Sexual Dysfunction: The Male Point of View -- Sheldon Marks, MD -- 05/14/03

Last Editorial Review: 10/19/2004

By Sheldon Marks
WebMD Live Events Transcript

Erectile dysfunction, male infertility, prostate problems -- whatever your concern, check out our discussion of the male side of sexual dysfunction. Sheldon Marks, MD, was our guest.

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome back to WebMD Live, Dr. Marks. What are the most common causes of erectile dysfunction (ED)?

Marks: The most common cause for problems with erection would be simply aging of the system. It's expected that as men age, their ability to obtain and maintain an erection will gradually reduce. There are a number of medical problems commonly associated with erectile dysfunction. These include diabetes, coronary artery disease, high blood pressure, elevated cholesterol, and of the lifestyle problems, smoking cigarettes is far and away the most common problem.

Moderator: So just sending off via Internet for Viagra isn't really a good solution?

Marks: No. Internet sales of Viagra scare me, because sometimes a problem with erection is the early warning sign of something far more serious and potentially life threatening. If a man has problems with erection, it is essential that he see a doctor for a baseline examination, discussion of other health issues and baseline laboratory tests. There is no way that an interview on the Internet can replace seeing your doctor. It is sad to think that there will be probably thousands of men who develop serious problems and possibly die, simply because they chose to buy their Viagra on the Internet rather than see their doctor.

It is essential to remember that problems with erection are really the symptom of something else that lead to the abnormality we call erectile dysfunction (ED) or impotence. It would be like treating a serious infection with Tylenol, because the Tylenol will control the fever but won't address the infection. Likewise, Viagra will treat the problem of ED, but won't do anything to treat the underlying cause.

Moderator: Medications you may be taking for another condition can cause ED as well, correct?

Marks: Correct. There are a number of medications that cause problems with erection. The most famous ones include Dimetidine, any of the antidepressants, and most of the medications for high blood pressure. Whenever a man comes in complaining of problems with erection, the first thing that I do is to look at the medications that he takes to see if any of those could be the cause or could be contributing to the problem. No one should ever stop or change their medication on their own. Rather, they should talk with their physician about the problem and their concerns, to see if other medications could safely treat the problem without the side effects of ED.

Member: My question has to do with medications and ED. I was taking Tenormin and Zoloft and Cimetedine. My doctor has since taken me off of Zoloft and Cimetedine and changed my blood pressure medication to Maxide. Can the effects of these medications be reversed and if so how long does it usually take?

Marks: When a man takes medications that cause ED, such as medicines for stomach ulcers, high blood pressure, antidepressants, etc., the effect on erectile function can usually come back, if it is the medication alone that leads to the problem. Oftentimes the problem requiring the medication contributes to the erectile dysfunction as well. For example:

  • Men with depression tend to have problems with erection, as well as an interest in sex, totally separate from the side effects of the antidepressant.
  • High blood pressure damages the blood vessels that are required for erection, so when we treat high blood pressure, oftentimes the damaged vessels are already present, in addition to the side effect of the medication.

In general, if a person still has problems one or two months after a change in medication, then perhaps the new medication may be playing a role as well. In my practice, I usually recommend changing one medication at a time to see if there is any improvement.

The biggest problem with this is that men tend to be very impatient, and when they finally accept that there is a problem, they want it corrected by that evening. Chances are, it has taken many months, and probably years, for the problem to develop, and sometimes it can take a while to identify the cause and treat it. The good news is that during this transition, most men can take medications like Viagra to help them while they are waiting to see if their erections improve naturally.

Moderator: Do stress and anxiety play a role in ED? Or are they the result?

Marks: Yes and yes. I describe the problem to my patients by explaining that the brain and the penis seem to function by a simple toggle switch. One works or the other; there is no in between. So if a man is nervous and thinking that he might have problems with erection, the odds are great that he will have problems with erection. Again, if the brain is working, the penis usually isn't. If the penis is working, the brain usually isn't -- unless we're talking about teenagers, where the brain doesn't work at all.

Member: For the last two weeks or so, I've not been able to ejaculate! I have no problem performing, so that's not the problem.

Marks: The inability to ejaculate, called anejaculation, can occur with a number of medications, as well as after certain surgeries, and sometimes as a manifestation of an underlying illness. Depending on the person's age, their health, and their medical history, that is what health problems they currently have and have had in the past, we would either be concerned enough to do further studies or sometimes simply reassure the man that this could be a temporary problem.

There are a number of medications that relax the bladder neck, so as the fluid during orgasm is pushed into the urethra, rather than follow the usual path down the long male urethra and out it follows the path of least resistance and can go backwards into the bladder. This is called retrograde ejaculation. There are a number of surgeries that can also cause this, primarily prostate, pelvic, and abdominal surgery that can damage or traumatize the nerve also causing anejaculation. This is something that probably should be evaluated by a urologist, especially if there is no obvious cause.

Member: Is there any thing out there to make your penis bigger?

Marks: If you want a larger penis you must elect different parents. The length of your penis is determined genetically and putting heavy weight on it or using creams or other devices will do nothing of significance.

Interestingly, there are studies that suggest that it's not the length that is critical to a man's partner's satisfaction, but rather the width/girth and most importantly, how it is used. I recall back in my residency in Boston seeing one day a man with a very large penis who couldn't keep a girlfriend and then the next patient was a man with a very small penis who was escorted to the appointment by two of the most beautiful women I had ever met. So it's not so much what you have, but it's how it's used. In general, it's important to remember that for women there are a tremendous number of non-sex factors prior to, during, and after [intercourse] that play into satisfaction and a happy relationship.

There are some men who are truly born with very small members, and there are some treatments that can help those men, but would be of no value to normal men. Many years ago penile enlargement surgery was very popular. This involved cutting a small ligament that holds the penis up, so that it appears, because it hangs down, to be longer, but really isn't.

Another problem that men describe is the famous shrinking penis, and really what this is, is nothing more than the man gaining weight at the base of his penis. I explain this to my patients like this: If one has a five-foot tree and you mound three feet of dirt alongside the trunk, the tree may look like a two-foot tree, but it really is still a five-foot tree. So the treatment for that is simply losing weight, and if it's a persistent problem, then a plastic surgeon, on rare occasions, could do liposuction at the base of the penis. In general, though, unless you have something truly abnormal, you should learn to play with the cards you are dealt.

Member: How can smoking be a factor in ED?

Marks: Smoking damages the very small, delicate blood vessels in the body. This is why men who smoke have more strokes, heart attacks, and vascular blood vessel problems. Remember that an erection is a blood-vessel process, and that if these small arteries that take the blood into the penis are damaged and lose their normal elasticity, then the blood flow into the penis is reduced and men commonly complain of slower onset, decreased rigidity, and early resolution -- all of which play into the erectile dysfunction.

I have seen young men, in their late 30s and early 40s, who have serious erection problems, and the only cause that we can find is the history of cigarette smoking. It's interesting that if you tell a young man that if he smokes he will have heart attacks, lung cancer, and strokes, he usually doesn't seem to care. But if you tell him he will lose his erection early in life, then he will suddenly listen to you and quit smoking.

Moderator: Can you discuss the effects of anabolic steroids on male performance?

Marks: When a man takes external body-building steroids beyond what would be medically correct dosing, that man's brain senses that there is plenty of testosterone in the blood stream. Because of this, it shuts down the body's own testosterone production. The longer a man takes the anabolic or body-building steroids, the longer his body will go in the shut-down mode. When this occurs we often see that the man's genitals, both penis and testicles, will dramatically shrink in size. Sometimes, when they stop the steroid, everything returns to normal; sometimes it doesn't, and the system can stay shut down forever. The super body builders that take the steroids are famous for having very, very small "packages." So in general, anabolic steroids may be great if you really want to have large biceps, but only if you are willing to essentially sacrifice your testicles, future fertility, and penile size for them.

Member: Is there any good way to increase testosterone?

Marks: Yes. The best way to improve your testosterone is through maintaining one's weight at a normal level, regular exercise, a healthy balanced diet, and intelligent lifestyle choices, such as moderation of alcohol and avoiding smoking. The critical question is, what is your testosterone level, and would boosting it make a difference? If you have questions, it is important to see your doctor and have some basic blood tests evaluated. These include:

  • Testosterone
  • Free testosterone
  • DHEA
  • Prolactin
  • Estradiol

These tests should be drawn between 8 a.m. and 10 a.m.

Sometimes it is not the testosterone that is the problem, but rather the balance between testosterone and estrogen that becomes altered. For example, as men gain weight in their abdomen the extra fat converts testosterone to estrogen. The estrogen causes additional fat accumulation, which causes more conversion of testosterone to estrogen, which causes more fat buildup, and so on. It is this change in the balance that can cause problems in men.

Sometimes it's the development of other hormone problems that change the interest in or the ability to have an erection. So if you suspect that there is a problem, it is very important to see your doctor. Many family practice and internal medicine doctors do not feel comfortable evaluating some of these problems, and may refer you to a urologist for further testing. The good news is that if there is an abnormality in your hormone level, it can usually be treated with medication.

It's important to know, though, that intelligent lifestyle choices are an essential part of these treatments, and there are no magic pills that alone will help you. Simply correcting a low testosterone may not be enough to improve your erection if you:

  • Drink too much
  • Eat too much
  • Eat the wrong food
  • Don't exercise
  • Smoke

Member: Is there treatment for premature ejaculation?

Marks: Yes. Interestingly, we found that men who take a category of antidepressants called SSRIs, such as Paxil, Celexa, Zoloft, and others, describe delayed ejaculation. So when a man complains of premature ejaculation, oftentimes taking a low dose of one of these medications on a daily basis will help dramatically. In addition, sexual counseling therapy has been shown to be helpful in working with couples. Most often premature ejaculation is a symptom seen in couples that are not sexually active frequently, so that the heightened level of excitement for the man moves things along a bit too fast for him. Usually there needs to be more emphasis on non-intercourse activity and contact in the couple.

Member: Can vitamins like B-12 help with sex drive and ED?

Marks: In general, for most men, there really isn't one particular vitamin that can help with erection. If you have a well-balanced diet, high in fresh fruits, fresh herbs, and fresh vegetables, it is extremely unlikely that you really need any vitamin supplements. That being said, it doesn't hurt to supplement an intelligent diet with certain vitamins and micronutrients.

As always, before you take any medication or any substances, you should talk with your doctor, as even over-the-counter vitamins can become quite deadly if taken in certain health situations or with certain medications.

Vitamin E serves as a mild blood thinner and some men have described improved erection when they take Vitamin E. This is especially one of the medications that can be dangerous, so talk with your doctor first. If you take Vitamin E, most men will think that if a little is good, a lot is better, and if a lot is better, then a huge dose is better yet. The truth is, that this actually can be very dangerous. So you should follow your doctor's instruction, especially with Vitamin E.

Ginko biloba has been reported to also be a mild blood thinner and may help improve the flow as well.

In general, if you are going to take vitamins, the B complex, as well as folic acid are good with the Vitamin E in combination with an intelligent diet. Most often I see men who want to take vitamins but still eat a double cheeseburger, two orders of curly fries with chili, and a strawberry shake and wonder why they don't get better.

Moderator: Dr. Marks, we are almost out of time. Before we wrap up for today, do you have any final comments for us?

Marks: Yes. Erectile dysfunction is very common but the good news is it is very easy to treat. It is essential that men realize that it could be an early warning sign of something far more serious, and they take the time to go to their doctor so that they can live a long, healthy, erect life.

Moderator: We are out of time. I'm sorry we couldn't get to all of your great questions. Thank you Sheldon Marks, MD, and thank you members for joining us today.

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