What you need to know on sexual dysfunction in men
Sexual medicine consultant Professor Alan Riley answers Dr Julian Spinks questions on premature ejaculation, anorgasmia and side-effects of medication
Sexual medicine consultant Professor Alan Riley answers Dr Julian Spinks questions on premature ejaculation, anorgasmia and side-effects of medication
1. What's the best approach when dealing with a younger patient suffering from premature ejaculation?
Treatments in use, but not evidence-based, include applying local anaesthetic to the penile glans, SSRIs, phosphodiesterase type 5 (PDE5) inhibitors and psychotherapy.
The best approach in the younger patient is behaviour therapy, usually employing the ‘stop-start' technique. This requires the man – or his partner – to stimulate his penis and stop just before the feeling of imminent ejaculation. He then repeats this up to five times before ejaculating.
Once ejaculatory control has been achieved, it is important for the couple to incorporate one of these techniques into their lovemaking on a regular basis to reduce the risk of relapse.
2. What are the most common reasons for anorgasmia in a man and how would you go about treating it?
Anorgasmia and anejaculation usually, but not always, co-exist. The cause can be physical or psychological. The most common physical causes are the side-effects of antidepressants, pelvic surgery or trauma, spinal cord injury, diabetes and hypogonadism.
A man with lifelong anejaculation could have congenital abnormality of his internal reproductive ducts.
Psychogenic anorgasmia and anejaculation are most frequently situational – the man can ejaculate on his own but not with his partner. This often happens when the man has conditioned himself to a method of masturbation that cannot easily be used during sexual intercourse. Other psychological causes include fear of pregnancy, fear of the vagina and unresolved power struggles in the relationship.
The first step is to take a full history, review medication and do a clinical examination and investigations for hypogonadism.
The surgical and traumatic causes are irreversible and the patient and his partner may benefit from sex therapy aimed at increasing sexual pleasure by non-genital stimulation. If they wish to conceive, electro-ejaculation is an option.
In the absence of physical causes, sex therapy and psychotherapy are usually effective. The therapy programme will include sex education, stimulation techniques (possibly with a vibrator), masturbation reconditioning and desensitising the patient against the causative inhibitions.
3. In the absence of obvious clinical pointers, is loss of sex drive ever the result of unsuspected physical illness? How should this problem be approached?
It is important to question the patient about what exactly he means by loss of sexual drive. He may have noticed that he initiates intercourse and/or masturbates less frequently and has fewer sexual thoughts and fantasies. These are markers of biological sexual drive.
Alternatively, he may still have these but no longer has the desire to make love with his regular partner – in which case his biological drive is intact and he has psychological or relationship problems.
The man whose biological sex drive is reduced should always be considered to have a physical cause until proved otherwise. He requires a full assessment, looking for signs of hypogonadism, thyroid, liver and renal diseases. Additional investigations and clinical management will depend on the results. Depression must not be overlooked as it can be both a cause and consequence of loss of sexual drive.
4. Patients on antidepressants, or other psychotropic medication, often complain of a variety of sexual dysfunctions – and it can be difficult to know if it is the medication or the psychiatric problem itself that is the cause. Do you have any advice on these situations?
This is a difficult clinical problem. Is the sexual dysfunction caused by the psychiatric condition being treated, the medication being taken or some other condition? The most helpful approach is to carefully consider the temporal relationships between the onset of the sexual dysfunction, the onset of the psychiatric condition and the prescription of the medication. Obviously if the sexual dysfunction was present before medication was started, the drug isn't implicated. If it started within a month of taking the medication, the chance is that there is a causal relationship. If the onset of sexual dysfunction occurs after the first month of medication, then there is unlikely to be a causal relationship.
A patient who had not previously admitted a sexual dysfunction may blame a pre-existing problem on the medication. It is all too easy to attribute sexual dysfunction to the patient's psychiatric condition or medication when in fact it has another cause, so a thorough assessment is always required.
5. What proportion of ED cases have a physical rather than psychological cause? Are there any key elements in the history and examination that can help point to the likely cause of the dysfunction?
Both physical and psychological factors play significant roles in causing ED but it is difficult to accurately ascribe the proportion that each play.
For example, just because a man has diabetes it doesn't necessarily mean he has organic ED – although he would often be classified as such.
His ED could actually be caused by any of the psychological or relationship problems that could cause ED in a man without diabetes. Frequently, organic and psycho-logical factors co-exist in men with ED.
The presence of organic diseases should be sought by history, examination and investigation in all men who present with ED as it can be the presenting symptom of serious disease. But there are pointers in the history that suggest the probable classification. These are summarised in the table above.
6. What is the place of testosterone replacement therapy in the treatment of either lack of sexual drive or ED? What are the risks?
Testosterone deficiency is associated with depression and significant life-threatening metabolic abnormalities including osteoporosis, atherogenic lipid profile, type 2 diabetes and metabolic syndrome and all patients with these symptoms should be screened for hypogonadism.
Testosterone deficiency is also a cause for non-response to PDE5 inhibitors.
Testosterone replacement (TR) in hypogonadal men improves these sexual symptoms – providing no additional factors are involved – and reverses the metabolic effects of low testosterone.
But there are risks. Testosterone promotes existing prostatic cancer but does not cause it. It also increases prostate volume and hence may increase urinary symptoms in some, but not all, men.
Cardiovascular risks of TR have probably been exaggerated in the past. No increases in angina, myocardial infarction and stroke have been reported in TR studies, but large-scale placebo-controlled studies are needed before we can be certain.
7. When using PDE5 inhibitors such as sildenafil, is it best to start with a low dose and titrate upwards or initiate with a higher dose?
Opinions differ. Some clinicians say it is best to titrate upwards because this prevents patients being exposed to more drug than they need.
Others consider it better to titrate downwards. This regimen results in more patients responding at the initialising dose, but some patients who respond are reluctant to reduce the dose.
I personally think it's better to start with an intermediate dose and titrate upwards or downwards depending on the patient's response and toleration.
When metabolic clearance of the drug is expected to be impaired – with hepatic insufficiency for instance – the patient should be started on the lowest dose.
8. Is it safe to use PDE5 inhibitors in patients with stable ischaemic heart disease who are not taking regular nitrates and what should they do if they develop chest pain after taking the drug?
As ED and ischaemic heart disease both result from endothelial dysfunction, it's not surprising these conditions frequently co-exist.
Stable ischaemic heart disease is not a contraindication to these drugs, providing at least six weeks has elapsed since a myocardial infarction and the man does not use nitrates. The patient will need reassurance on the safety of these drugs in view of adverse publicity.
Long-term safety data confirm that the PDE5 inhibitors do not increase the overall cardiovascular risk in men with diagnosed cardiovascular disease.
Chest pain after taking the drug can occur either before, during or after sexual intercourse. When it occurs before intercourse it could be triggered by fear and anxiety engendered by the thought that intercourse will cause angina.
Chest pain associated with intercourse could be effort-induced.
When the drug is first prescribed the clinician should assess the patient's effort tolerance. If he can walk one mile in 20 minutes on the level or play a round of golf, he should well be able to have sexual intercourse with a regular partner, though more vigorous sex requires more effort.
If chest pain is experienced, the man should stop intercourse, sit or stand up (to reduce preload) and wait for it to settle. If this fails to resolve the pain rapidly, he should seek emergency medical advice.
9. What's your clinical opinion of Cialis Once-a-Day? Are there any data on the risks associated with taking a PDE5 inhibitor continuously?
People have their own individual patterns of sexual behaviour and treatment and dosing preferences and no single treatment will satisfy the needs of all patients. So I welcome all new treatment regimens providing they are safe and effective.
To a great extent the long half-life of tadalafil has enabled dissociation of sexual activity from dosing, allowing greater spontaneity, which has been shown to enhance satisfaction. Having to take a tablet – albeit many hours before sex is planned – is an irritation for some couples. Cialis Once-a-Day allows sex to be as spontaneous as it would be if the man did not require ED medication.
Available data confirms it's as effective and as safe as prn dosing. Obviously large scale post-marketing surveillance data are not yet available. As with all treatments, patients should be clinically reviewed regularly. Hypertensive patients may require a downward adjustment of their antihypertensive therapy.
Health benefits such as cardioprotection and improvement in lower urinary tract symptoms associated with benign prostatic hypertrophy, may be a bonus with this new dosing regimen.
10. Is there still a place for intracavernosal or intraurethral treatments for erectile dysfunction?
Yes. They're regarded as second-line treatments, after PDE5 inhibitors. Intracavernosal injection therapy is generally more efficacious (up to 80% in general ED population and higher in patients without vascular disease) than intraurethral treatment (30-60%). Unlike the PDE5 inhibitors, these treatments do not require sexual stimulation for their effect – which has led to their use as a test for erectile potential.
11. Vacuum constriction devices seem to have fallen out of favour in recent years – do they still have any use?
This approach is effective, with satisfaction being reported in up to 90% of users but this satisfaction rate may be inflated by men who are no longer satisfied when they stop using the device.
Vacuum devices can be prescribed under Section 2 and in the long term provides a cost effective means to treating ED.
There are drawbacks. They induce tumescence but the penis does not become fully rigid. This can make intromission difficult, over come by manually supporting the penis to allow penetration. This also gets over the problem of the penis hinging at the constriction ring because the corpora cavernosa proximal to the ring do not get rigid.
Adverse effects include local pain, bruising, numbness and painful ejaculation caused by the constriction ring.
Partners sometimes report the penis feels cold because the blood supply is occluded by the constriction ring. In fact, skin necrosis has been reported and for this reason the ring should be removed within 30 minutes of application.
12. Who should be referred for advice regarding surgical options such as vascular surgery or penile prosthesis?
Very few patients require surgical intervention. Patients with significant penile deformity, such as caused by Peyronie's disease, and young men whose ED followed pelvic or penile trauma, who may have post traumatic arteriogenic ED, should be referred early for surgical opinion. Other patients should probably be referred only when all other treatments have failed or are unacceptable to the patient.
13. Which men should be offered psychological therapy for their sexual dysfunction, only those with predominantly psychological problems or would other men benefit?
Psychological therapy ranges from short-term sex counselling to one of the more intensive approaches such as CBT. The latter is required for men with non-organic ED. I have no doubt at all that most men being treated for ED would benefit from sexual counselling (ideally attending with their partners). The counselling would include sex education (including the effects of ageing on sexual responses) and advice on optimising sexual stimulation, use of lubricants and avoiding sexual boredom. Sexual counselling will also help the men's partners overcome their sexual difficulties. Couples who are experiencing relationship difficulties would benefit from relationship therapy.
I believe an integrated approach to treating ED, combining psychological and pharmacological therapies, should be encouraged.
Professor Alan Riley has specialised in sexual medicine for more than 40 years and was professor of sexual medicine at the University of Central Lancashire until his recent retirement
Competing interests Professor Riley has received fees for lectures and participation in advisory boards from Eli Lilly, Vectura, Pfizer and Johnson & JohnsonWhat I will do now What I will do now
Dr Julian Spinks considers the responses to his questions
There is some really useful information here.
I am struck by the balance between physical and psychological causes and their treatments.
I will be placing more emphasis on the psychological aspects of sexual dysfunction and using the table of pointers that suggest organic or psychological causes. If only access to counselling or CBT was as easy as writing a prescription.
I now have a better understanding of the options available for the treatment of ED and the availability of daily tadalafil looks to be a promising treatment for couples who may desire a more spontaneous love life.
There is the tantalising possibility of other health gains with this treatment but it may be too early to prescribe on this basis.
Two answers reassure me on safety grounds. The advice on PDE5 inhibitors in patients with stable ischaemic heart disease is both easy to apply and comforting for prescribers.
I will also be happier to prescribe testosterone replacement therapy for patients with low testosterone levels as risks seem low compared with the significant benefits.
Dr Julian Spinks is a GP in Rochester, Kent