Questions Asked by Men

Who should I talk with about my sexual dysfunction—it bothers me but I don’t know who can help me. Is there a particular kind of doctor for me to see?

You should speak with your primary care physician regarding your sexual health. If he or she does not have a broad enough knowledge base in this field, there are physicians who specialize in sexual medicine, some of whom see only men, some only women, and some who treat both.

How do I know if my problem is caused by physical or psychological difficulties?

Today in the vast majority of cases there are physical reasons causing a sexual dysfunction. Often, the psychological problems associated with these problems tend to be a result of the sexual dysfunction rather than causing it. It is difficult to have a sexual problem without experiencing some feelings of stress and other emotional reactions. These emotions can intensify an already existing problem. New treatments for sexual dysfunctions are effective in treating sexual difficulties regardless of whether they are caused by physical or psychological issues. Because most problems tend to have both physical and psychological components, it is generally a good idea to see a urologist in conjunction with a psychologist or sex therapist. A good sex therapist should refer you to a medical doctor for a comprehensive evaluation and a good medical doctor should also suggest that you see a sex therapist or psychologist for the emotional components.

I have had sexual dysfunction for years, but my wife of 40 years is not interested in sex, and I really don’t care. Should I be concerned?

Erectile dysfunction is very common, affecting 31% of all men. Sexual dysfunction is age-dependent and associated with multiple risks. Erectile dysfunction can be associated with significant loss of self-esteem, frustration, humiliation, anger, depression, and unwanted termination of relationship. However, erectile dysfunction may cause none of the above. It should only be treated if it is associated with personal distress.

Since I first developed an erection problem, my wife questions if I still find her attractive and even wonders if I am seeing another woman. What can I do?

After developing an erection problem many men find themselves withdrawing in various ways. They may communicate less or they stop showing affection to their partner. Because sexual contact has often resulted in failure, they are hesitant to initiate any sexual advances. As a result, the partner often feels unattractive or undesirable. Women may be concerned that sexual needs are being met outside the relationship. Even with an erection problem, it is important to be affectionate and caring with your partner. Communicate your feelings and let your partner know that you still care for her. Remember, not all sexual contact has to result in intercourse.

I’m a healthy man who exercises regularly and always had a good erection until recently. My doctor says my impotence must be psychological because I am so healthy, but I don’t feel like it’s in my head. Is it possible that it’s physical?

Erectile dysfunction is defined as the persistent, for a period of at least 3 months, inability to attain and/or maintain an erection for satisfactory sexual performance. It may be considered as mild, moderate or complete. It is quite possible that an otherwise healthy man can have physical causes for erectile dysfunction. Erectile dysfunction may be due to 1) failure to initiate the erection secondary to neurologic, psychologist or hormonal abnormalities; 2) failure to fill the erection chambers secondary to artery blockage or 3) failure to store blood in the erection chambers secondary to scarring of the erection chambers. A complete evaluation would include a history, physical, psychological evaluation, hormonal evaluation and specialized testing as needed.

My doctor told me to start exercising, so I bought a bicycle, but my life partner told me he read that riding a bike can cause impotence. Is this true?

Sitting on a seat you are sitting on your ischial tuberosities or sit bones. This is a safe region to bear your body weight on your sit bones. Fat and muscle lay over the sit bones and there are no associated nerves and arteries. In contrast, straddling a bike saddle forces the rider to bear the body weight on the perineum (hidden part of the penis). Compression of the perineum may lead to permanent nerve and artery damage, leading to numbness and sexual function, such as loss of erections. To avoid injury to the perineum while riding, it is recommended to use a noseless two cheek split seat. If sexual dysfunction occurs following riding, a full evaluation is indicated.

My penis curves to the left when erect. It’s embarrassing, and I’m only able to have intercourse in one position. On top of that, my girlfriend complains that it sometimes hurts her when we’re having sex. Can anything be done about it?

Curvature of the penis during erection may be either congenital (you were born that way) or acquired (usually due to Peryonie’s disease). The latter condition is associated with scarring of the lining layer of the erection chamber called the tunica albuguinea. The scarring is often the response to a previous injury of the erection during sexual activity.

My doctor gave me a prescription for Viagra but didn’t tell me how it works or how to take it. What do I do?

Viagra is indicated for the treatment for erectile dysfunction. Its official role is as an enzyme inhibitor, but practically speaking it acts as a signal amplifier. This means that once the signal of sexual stimulation is received by the penis, the resultant erection will be maximized because of the use of the medication. Viagra comes in 3 strengths, 25, 50 and 100 mg. For most healthy people Viagra can be started at 100 mg and, if it is effective, the dosage can be decreased. For individuals with cardiac or liver conditions, or people taking medications for AIDS, or a medication such as erythromycin, it is recommended to start the dose at either 25 or 50 mg. Viagra must not be used if the patient takes nitroglycerin, a common medication used for men with chest pains such as angina. Viagra should be taken on an empty stomach, and the use of alcohol be minimal. One needs to wait at least one hour after taking Viagra, but the signal amplification effect lasts, in most patients, between 8 and 12 hours, therefore, in many men, the medication can be taken hours before planned sexual activity to allow for sexual spontaneity. Traditional side effects include headache, facial flushing, nasal congestion and stomach pains. Certain patients with eye problems such as retinitis pigmentosa should not use Viagra. Viagra should only be used after consultation with a physician. After a period of use, it is recommended to return to your physician to discuss the results of the treatment. Viagra is not the only treatment option for men with erectile dysfunction. There are other mechanical, pharmacological and surgical treatments that can restore erectile function.

My doctor gave me Viagra but it didn’t really help. Is there anything else I can try?

Often Viagra does not work because of improper use: if appropriate the highest strength should be used, the pill taken on an empty stomach with minimal alcohol use, taken at least one hour before use, and sexual stimulation is needed. If Viagra doesn’t work after an appropriate use of several pills at the highest strength your physician recommends, contemporary understanding would suggest that you obtain hormone blood tests, such as DHEA and testosterone. If your hormone levels are below normal, hormone replacement may be given and Viagra tried again. Sexual counseling by a certified sex therapist should be considered. Other therapies for the treatment of erectile dysfunction include Levitra and Cialis, the vacuum constriction device, insertion of a medicated pellet into the urethra (MUSE), self-injection therapy and penile prosthesis insertion. In selected cases of men less than 45 years of age, especially where the impotence is due to trauma to the perineal (crotch) area, penile revascularization surgery may be considered.

I hear there are new medications coming out to treat impotence. What are they, and how do work?

Levitra became available in the U.S. in August, 2003 to treat men with ED. Cialis became available as of December 2003. Like Viagra, they are signal amplifiers of the sexual stimulated erectile response. There are biochemical and pharmacokinetic differences among the 3 pills. Head-to-head comparison trials among the 3 drugs will help us understand when to use these new medications.

I’m 35 years old with impotence. Levitra works, but I don’t want to be dependent on pills for the next 40 years. Is there anything I can do?

In selected cases of impotence, penile bypass surgery may be effective. In cases where the hormonal, neurologic and psychologic evaluations are normal, an underlying vascular problem may be suspected. In those vascular cases where the blood trapping system is normal (veno-occlusive function), the vascular abnormality is limited to a blocked artery. Performing bypass surgery for blocked arteries in the heart, legs, kidney and brain are commonplace. Penile bypass surgery was first described in 1973. In selected centers in the United States penile bypass surgery has proven to be safe and effective, especially for young men whose ED is associated with a history of blunt pelvic/penile/perineal trauma.

I have been impotent for five years. I tried pills, pellets and shots, and nothing has worked. My doctor says I need an implant but I don’t understand what he means. Can you explain what it is and how it works?

Penile implants are silicone or silicone-like devices that are surgically implanted into the erection chambers of the penis to provide appropriate penile rigidity. There are basically two types of devices: an inflatable and a non-inflatable device. The inflatable device usually consists of 3 pieces: a pump, two cylinders and a reservoir. The cylinders are implanted into the erection chambers, the pump is placed into the scrotum, and the reservoir is implanted deep into the pelvis near the bladder. Usually a single incision is required to implant the entire device. Since all the component parts are internally placed and none are visible, gently squeezing the pump in the scrotum transfers fluid from the reservoir into the cylinders creating the erection. Once the sexual activity has terminated, gently squeezing the deflate mechanism near the bulb of the pump results in fluid form the cylinders returning to the reservoir. The first penile implant was placed in 1973, and over 20,000 per year are inserted. The success rate exceeds 80%, thus making this treatment the most successful of all the treatments for erectile dysfunction. Since placement of the implant requires surgery, and permanent injury to the erectile tissue, implant treatment is considered an irreversible therapy. Complications of this surgery include penile implant infection (1-2% of cases), device malfunction (2-3%), surgery or anesthesia complications (‹ 1%) and inappropriate patient expectations (5%).

I’m a prostate cancer survivor and have not recovered my ability to have erections yet. Viagra didn’t help, so what can I do?

During surgical removal of the prostate for cancer (radical prostatectomy), it is common that the nerves to the penis are injured. Under conditions where there is nerve injury, Viagra should not be expected to improve erectile function since it is a signal amplifier. If no signal can be transmitted to the penis, Viagra cannot be expected to work. Under normal physiological circumstances, neurologic sexual stimulation results in release of chemicals (i.e. neurotransmitters) in the erectile tissue that initiate the erectile process. This mechanism can be mimicked by injecting similar chemicals directly into the erectile tissue by an insulin needle (30 gauge). Self-injection therapy for the treatment of ED has been practiced since 1983. Traditional vasoactive drugs presently in use include papaverine hydrochloride, phentolamine mesylate, and/or prostaglandin E1. FDA approved treatments for self-injection therapy include Caverject and Edex. In many cases individualized combinations of vasoactive drugs have been found to be safe and effective. Complications of self-injection therapy include prolonged erection (1-3 % of cases), clinically significant pain (5-10 %), and bruising at the injection site (20 %).

I’m 62 years old, happily married, can no longer get an erection but cannot take the pills for ED. I remember seeing an ad for a vacuum device for impotence. Is this safe? Should I try it?

A vacuum device consists of a cylinder, a pump and a constriction ring. After the penis is placed within the cylinder and the cylinder pushed against the pubic bone to create a seal, the pump creates a negative pressure which draws blood into the erection chambers. The constriction ring is then placed at the base of the penis to trap the blood inside, thus maintaining the erection. The constriction ring should be left in place for a limited time period, approximately half an hour. Vacuum constriction therapy is a safe and effective therapy that does not involve drugs or surgery. It often requires a technical support staff to address questions regarding its proper use. Complications of vacuum constrictive therapy include bruising (‹5 % of cases) and clinically significant pain (5 %).

My girlfriend says I come so fast she barely has time to get excited let alone have an orgasm. Is there any help for me?

Although it is difficult to define premature ejaculation, it is the most common sexual dysfunction, exceeding the frequency of erectile dysfunction. Premature ejaculation traditionally has been managed by the sex therapist using exercises such as squeeze technique, relaxation exercise, and desensitization techniques. Recently pharmacologic therapies have been used with success. SSRI’s such as Zoloft and topical lidocaine have been helpful. Side effects of SSRI’s include light-headedness and drowsiness.

Everyone always brags about how long they can make sex last, but I want to hide when they have that discussion. I take so long to reach orgasm that my wife complains of how sore she is. I wind up having to masturbate, but that takes forever. Are there any tricks to reaching orgasm sooner?

Orgasm is a sensory reflex that is initiated by stimulation of the genitals, with neurologic information passing into the spinal cord and then into the brain (septum of the thalamus). After appropriate stimulation is received in the brain, a spreading discharge of chemicals is released spreading upward to higher levels of the brain resulting in pleasure and spreading downward initiating motor stimulation resulting in ejaculation. In general, therefore, problems with orgasm are due to neurologic issues such as MS, injury from a bicycle saddle, hormonal issues, or aging, or inhibition of the reflex from psychologic stress, such as psychologic trauma or abuse. A complete evaluation for someone with consistent anorgasmia would include a history, physical, psychological evaluation, hormonal evaluation as well as neurologic assessment of genital sensation. If neurologic assessment is abnormal, a practical strategy to increase sensation is to use vibrator devices.

I am a 25-year-old man with a spinal cord injury. Since getting injured, I can never quite reach an orgasm. Is there anything I can do that would get me closer to an orgasm?

The ability to ejaculate and have an orgasm is a complex neuromuscular process that is adversely affected by a SCI. Following injury, it is not unusual for individuals to have significant difficulties in reaching orgasm. In most cases, loss of sensation and inadequate stimulation contribute to the problem. Thus increasing stimulation, especially in areas where sensation may be spared, is a worthwhile pursuit. Many individuals find that using a vibrator with adjustable amplitude can provide the level of stimulation necessary for ejaculation and orgasm. Increasing visual and auditory stimulation may also be helpful in enhancing the level of arousal. In addition, some experts believe that regular and frequent sexual activity may increase the likelihood of restored ejaculatory functioning. Ongoing sexual activity maintains the integrity of the various chambers and arteries of the penis. Remember when using a vibrator; be especially careful of autonomic dysreflexia.

Does sexual functioning improve over time since spinal cord injury?

There is no precise answer to this question although many people do report positive changes over a period of years since injury. For example, it is not unusual for some men to report having an ejaculation or an orgasm for the first time several years after injury. Other men notice gradual improvements in the quality of their erections. Being sexually active on a frequent basis may be the most helpful tool in improving your sexual functioning over time. Frequent sexual activity tends to maintain good blood flow to the genitals and contributes to the integrity of penile tissue. Many of the early studies with Viagra demonstrated the long term benefits of frequent engorgement of the cavernosal arteries and corporal chambers. There is truth to the old saying, “use it or lose it!”

So much changed after my injury. Can guys with spinal cord injury really enjoy sex?

Early after injury the idea of resuming a positive sexual life can be overwhelming. Some men tend to avoid sexual activity because of embarrassment regarding their body, poor self esteem or the fear of failure. On the other hand, some men see this as a challenge to be conquered, learn as much as they can and take advantage of every opportunity to be intimate. Over time and with confidence about their sexual abilities, these men enjoy long lasting relationships and frequent sexual intimacy. It is possible to have a great sex life after an injury but it doesn’t develop without a personal commitment to make it happen. Having an enjoyable sex life requires time, practice, and the knowledge that sex is an important part of life not to be missed.