Sexual Problems in Men

Common sexual problems in men include erectile dysfunction (impotence or ED), premature ejaculation, and loss of libido.

Common sexual problems in men include erectile dysfunction (impotence or ED), premature ejaculation, and loss of libido. 

Sexual health is an important part of a man's life, no matter his age, civil status, or sexual orientation. It is also an important part of a couple's foundation and contributes to the quality of life. Sexual problems in men are very common and impact sexual health. Many problems with sexual health can be treated. Therefore, it is important for a man to discuss these issues with a physician.

The definition of sexual dysfunction is the inability to have a satisfactory sexual relationship. This definition depends on each person's own interpretation on what he judges satisfactory. In general, sexual dysfunction can affect the quality of life and, even more importantly, can be the first symptom of another medical or psychological problem. Any sexual complaint should be taken seriously and evaluated.

Sexual activity involves coordination between various systems of the body. Hormones and neurological pathways must be in sync for sexual desire to be present. Blood vessels, nerves, and penile integrity must all be present for an adequate erection and its maintenance during the sexual relation. Muscles and nerves coordinate ejaculation achieved when the physiological passageway for sperm (from the testicles to the urethra) is present. Orgasm is a complex phenomenon that isn't completely understood, but it involves the coordination of muscles and nerves. When sexual dysfunction is present, the physician must evaluate all the possible problems in this chain of events.

Types of sexual dysfunction include disorders involving sexual desire or libido, erection, ejaculation, and orgasm. They will be described separately, but understand that some medical conditions can affect two or more disorders at the same time.

Evaluation of sexual dysfunction starts with a detailed medical, sexual, and psychological history, followed by a thorough physical examination. The second step must not be overlooked because sexual dysfunction can have many causes. Sometimes, the patient's partner can also contribute to the evaluation and could provide useful information as well.

A detailed medical, psychological, and sexual history is acquired during the interview with the physician. Some of the questions that are asked can be intimate and might cause you to feel too shy to answer thoroughly. It is imperative to give the proper information, even though it is understandable that it can take time to be comfortable talking about this. Having a good relationship with your physician is always helpful.

Some of the questions the doctor could ask might concern the frequency of sexual relations, your sexual orientation, if the frequency or quality of sexual relations are satisfying, and your number of sexual partners, among others. They will also inquire about nonsexual-related complaints.

A complete physical examination is performed including assessing the pulses in the legs and a thorough examination of the external genitalia (penis, scrotum, and perineum) and their reflexes.

One of the possible tests is a nocturnal tumescence test to evaluate nocturnal erections. Your physician might also ask for tests for penile blood vessel function or some tests of the nervous system to help differentiate between possible causes of sexual dysfunction.

Treatment depends greatly on the exact cause of the sexual problem.

• If the cause is psychological, help from a psychiatrist or psychologist can be helpful. Often in this situation, cognitive behavioral therapy is the treatment used. Sometimes the treatment will include couples therapy.
• If the cause of the diminished libido is from medications being taken, sometimes there are alternative medications without sexual side effects. For others, hormonal replacement may be suggested.

Talk to your doctor about any changes in libido you have experienced.

The definition of low libido is when sexual desire is diminished or absent. The definition also varies according to the patient's level of satisfaction of his own sexual desire. Some men can be very fulfilled with what some men consider scarce sexual activity.

Sexual desire problems affect a small percentage of men in the general population. Libido is mainly a hormonal and brain phenomenon. Sexual desire requires normal levels of testosterone (male hormone) in the blood and a certain attraction for the partner in question.

Symptoms of low libido may include:

• Lack of desire to initiate sex
• Inability to attain an erection

If the patient experiences an episode of erectile dysfunction without any previous sexual symptoms and adequate nocturnal erection, the cause is probably psychogenic and not physiological. It is also important to specify whether the low libido is new in onset or if the patient has always felt this way about sex.

Many causes have been identified as contributing to the diminishment of sexual desire. They include:

• Medications (SSRIs, anti-androgens, 5-alpha-reductase inhibitors, opioid analgesics)
• Alcoholism
• Depression
• Fatigue
• Hypoactive sexual disorder
• Recreational drugs
• Relationship problems
• Other sexual dysfunction (fear of humiliation)
• Sexual aversion disorder
• Systemic illness
• Testosterone deficiency
• Stress
• Lack of time
• History of sexual abuse
• Hormonal problems such as hyperthyroidism

Risk factors for low libido in men include:

• Age because testosterone concentration will decrease over the years
• Alcohol consumption
• Malnourishment
• Smoking
• Drug consumption
• Conditions requiring medication that lowers testosterone, depression, benign prostatic hyperplasia (BPH), pain, and prostate cancer

Erectile dysfunction (ED) is the inability to acquire or maintain a satisfactory erection. The prevalence of erectile dysfunction varies according to the patient's age. About 16% of men from 50 to 59 years of age will suffer from erectile dysfunction and 44% of those aged 70 to 75 years will, too.

There are three types of erections -- those caused by tactile stimulation, those caused by mental stimulation, and those that men experience while sleeping. This classification can be important when the cause of erectile dysfunction is yet to be determined.

In order to have an erection, men need stimuli; they need blood arriving from the arteries and have veins capable of locking the blood in place. Each of the numerous steps in this system can fail making erectile dysfunction a complex problem for investigation.

Erectile dysfunction will cause the penis to be unable to acquire or maintain a satisfactory erection. It is important to specify to the doctor the rapidity of onset, the presence of nocturnal erections, and the quality of the erection if it can be attained but not maintained. The quality of an erection can be judged according to the rigidity and the functionality (Is the penis erect enough to allow for vaginal penetration?).

Erectile dysfunction with sudden onset and no previous history of sexual dysfunction suggests a psychogenic cause, unless there was a previous surgery or a genital trauma. The loss of nocturnal erections will suggest a neurologic or vascular cause. Finally, when an erection is not sustained, its loss may be due to an underlying psychological cause or vascular problem. Talk to your doctor if you have noticed any problems with your erectile function.

There are numerous potential causes of erectile dysfunction.

Neurologic causes include:

• Stroke
• Spinal cord or back injury
• Multiple sclerosis
• Dementia
• Pelvic trauma
• Prostate surgery (even with nerve-sparing surgeries it can take up to 24 months to regain normal sexual function)
• Priapism
• Nervous system tumor
• Epilepsy
• Diabetic neuropathy

Vascular causes include:

• Arteriovenous fistula
• Diabetes
• Atherosclerosis
• Congenital anomaly

Hormonal causes include:

• Low testosterone blood level (The patient can achieve an erection but it won't always be turgid enough for vaginal penetration.)
• Hyperprolactinemia
• Hyperthyroidism
• Hypothyroidism
• Cushing's disease
• Addison's disease

Pharmacological causes include:

• Antidepressants (mainly SSRIs)
• Spironolactone
• Sympathetic blockers (clonidine, guanethidine, or methyldopa)
• Thiazide diuretics
• Ketoconazole
• Cimetidine

Penile dysfunction causes include:

• Peyronie's disease

Psychiatric causes include:

• Loss of feeling toward the other person
• Stress
• Fear of non-performance

Functional causes include:

• Bicycling irritating the nerves and tissue of the penis

The risk factors for erectile dysfunction include:

• Obesity
• Smoking
• Diabetes
• High blood pressure
• High cholesterol
• Cardiovascular disease
• Medication use
• Obstructive sleep apnea
• Restless leg syndrome
• Systemic sclerosis (scleroderma)
• Peyronie's disease
• Prostate cancer treatment

Nowadays, there are many options for men who suffer from erectile dysfunction. Before suggesting pharmacological help, the doctor may suggest a change in lifestyle habits. Since many causes of erectile dysfunction are disorders in which lifestyle changes will have a positive effect, addressing these issues can be helpful. Therefore, regular exercise, a healthy diet, smoking cessation, and limiting alcohol consumption can all have an impact on erectile function. Lifestyle changes can also include the use of a more genitalia-friendly bicycle seat.

There are many nonsurgical treatments available for erectile dysfunction.

Oral pharmacological treatment

The first line of pharmacological treatment is a class of medication called phosphodiesterase (PDE-5) inhibitors. This class includes sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis). They will improve the ability to attain and maintain the erection, but sexual stimulation is still required for this medication to work. It should be taken some time before the sexual act is planned, but has a long timeframe of action. Side effects include visual disturbances, flushing, back pain, and muscle pain. Most side effects will abate with time. Usually, there will be no side effects at all. If you are taking nitrates, phosphodiesterase inhibitors are not recommended since both medications taken simultaneously could cause severe hypotension (excessive low blood pressure).

Other types of oral medication are available. Apomorphine will enhance penile erection. And there are others. You should ask your doctor for other types of medication if the first one didn't work. Other treatment options should also be discussed.

Transurethral therapy

Another type of pharmacological solution is a liquid that can be applied in the urethra that manages to improve erection. The erection can be maintained by applying an elastic band at the base of the penis.

Intracavernous injection

Injections at the base of the penis (intracavernous) can help attain and maintain an erection. There are various types of solutions that can be injected -- papaverine, alprostadil, and drug combinations. These injections are considered the most effective treatments for erectile dysfunction. They are also convenient for the patients who don't tolerate the oral therapies.

Side effects include priapism (prolonged and painful erection) and fibrosis (scarring) but they are rare. There are ways to prevent these side effects (especially the prolonged and painful erection). The patient must follow the training and recommendations given at the beginning of this type of therapy. Contraindications for intracavernous injections include sickle cell anemia, schizophrenia, and severe psychiatric disorder.

Vacuum constriction device

This is a plastic cylinder connected to a vacuum-generating source that creates a negative pressure that draws the blood to the penis and makes way for an erection. An elastic band must be placed at the base of the penis to maintain the rigidity. The base of the penis will stay flaccid which might make the genitalia pivot. Side effects include ejaculatory problems, penile pain, and blood pooling because of ruptured blood vessels (ecchymosis or petechiae).

There are numerous surgical treatments available for erectile dysfunction.

Penile vascular surgery

Bypass surgery can be performed when there is an isolated artery occlusion disrupting blood flow in the penis. With any surgical procedure, it's necessary to consider the patient's surgical risk. Not all patients will be able to qualify for this type of intervention.

Prosthesis

Various types of prosthesis are available -- malleable, mechanical, and inflatable. The patient should discuss the type he would prefer with his physician. The majority of prostheses will need replacement after 10 to 15 years. Surgical complications include infection, mechanical failure, cylinder leaks, perforation, penile shortening, autoinflation, and pain.

Premature ejaculation is the most common of the ejaculatory disorders; approximately 20% to 30% of men will have premature ejaculation. Ejaculation problems involve the improper discharge of sperm, prostatic, and seminal vesicle fluid through the urethra.

There are three different types of premature ejaculation:

• Premature ejaculation is ejaculation after minimal or no physical stimulation.
• Retarded ejaculation is ejaculation after a long delay of physical stimulation.
• Retrograde ejaculation is orgasm without ejaculation, also called "dry" ejaculation.

Classically, premature ejaculation includes:

• Brief ejaculatory latency
• Loss of control
• Psychological distress in the patient and/or partner

Generally, premature ejaculators will only have about a minute or less of intravaginal time before they ejaculate.

Retarded ejaculation will present as a long delay of intravaginal time to the point where the patient will not be satisfied with the sexual relation.

Anejaculation or retrograde ejaculation is the experience of a dry orgasm. The semen doesn't go out of the urethra. It can either flow to the bladder instead or not be produced at all. Following the sexual act in the latter case, patients will notice the presence of semen in their first urine.

There are many potential causes of premature ejaculation. These include neurological causes that affect the following areas:

• Central control of ejaculation
• Innervations to the seminal tract
• Sensory innervation to the genitalia/prostate

Premature ejaculation may be caused by negative conditioning and penile hypersensitivity. Retarded ejaculation may be an early sign of diabetes or may develop following surgery for benign prostatic hyperplasia (BPH). Anejaculation (retrograde ejaculation) may be caused by radical prostatectomy, cystoprostatectomy (removal of the bladder and the rectum), or the use of certain medications such as alpha-blockers (tamsulosin) and antidepressants (SSRIs).

The treatment will vary according to the cause of premature ejaculation. Couples sexual therapy or psychological therapy can be useful when psychological causes are involved. Other nonpharmacological therapies include actively trying to "hold it in." Drug therapy has also proven to be successful. The medications used to treat premature ejaculation are selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs).

Disordered orgasm is the inability to reach an orgasm after adequate stimulation. Orgasm is still a phenomenon that is poorly understood.

The causes of disordered orgasm include:

• Psychiatric disorder
• Diabetic neuropathy
• Multiple sclerosis
• Complications from genital surgery
• Pelvic trauma
• Drugs (alpha-blockers, antidepressants)

Anorgasmia will be treated with psychiatric help or by treating the underlying cause.

Another category of sexual problem is sexual pain. A penile lesion, injury, or a skin disease can be the cause among others. Men's sexual pain occurs less frequently than women's.

There are normal changes in sexual function in the elderly. Older men can have the following symptoms of sexual dysfunction:

• Longer delay between stimulation and erection
• Erection is less turgid
• Ejaculation is less strong
• Ejaculatory volume is smaller
• Time between erections is longer
• Less sensitivity to tactile stimuli
• Lower testosterone
• Orgasm is attained more slowly

These phenomena can be experienced as patients grow old. Nevertheless, it can be addressed so that those affected can still have a very satisfactory sexual life.

Lifestyle changes can be useful to help treat or improve sexual dysfunction, but more importantly, they can have an impact before the development of the disease itself. You can prevent the incidence of sexual troubles by having a healthy lifestyle; exercise regularly, eat well, limit alcohol consumption, and quit smoking, if you are a smoker. Lifestyle changes take time and effort, but the results are worthwhile.

Prognosis varies according to the method of treatment and the underlying disease. Nowadays, many innovations have changed the face of male sexual dysfunction giving men multiple options regarding treatment. Not only do men have choices but the developing technologies and medications have also given men a voice to share their experience.

It's very important that you speak to your doctor about any concern regarding your sexual function or that of your partner.

Psychiatrists, psychologists, and sexologists can be involved in the management of sexual dysfunction. Psychiatrists or psychologists can especially help when the cause of the dysfunction is psychogenic. Therapies targeting cognition and behavior usually have good success rates. Sexologists can also contribute to these therapies.