Men's sexual problems and solutions

Several causes can be associated with the development of sexual dysfunction in men. Some of these include:

• Stress (related to work or life)
• Physiological problems
• Diabetes
• Drugs
• Injury
• Performance anxiety
• Alcohol (Read more: Side effects of alcohol on body)
• Relationship problems
• Low levels of testosterone
• Antidepressants
• High blood pressure
• Previous experiences
• Expectations and beliefs

Individual causes for each sexual problems are further explained in the sections below.

According to the American Sexual Health Association, male sexual disorders can be classified into three categories.

• Loss of libido or loss of sexual desire
• Erectile dysfunction
• Ejaculation problems: These include premature ejaculation, delayed and retrograde ejaculation.

In the course of this article, all these problems will be explained in detail along with the possible solutions for each.

After erectile dysfunction, ejaculatory problems are one of the most common sexual problems in men. Studies suggest that ejaculatory latency or the time taken for ejaculation varies in men; what is considered optimum by one might not be enough for another. Early or late ejaculation can be an issue of utter embarrassment for most men. Ejaculatory disorders can be of the following types:

• Premature ejaculation
• Delayed ejaculation
• Retrograde ejaculation

Let us explore all of these in detail.

Premature ejaculation

Premature ejaculation (PE) is usually characterised by an early and uncontrolled ejaculation that happens just before or after penetration. Intravaginal ejaculation latency time (IELT), that is, the time between ejaculation and penetration of less than 1 minute is generally marked as Premature ejaculation but an IELT between 1 to 1.5 minutes is also in the high-risk category for PE. PE has been reported in 4 to 40% of men in the world. It can either be lifelong, acquired, subjective or variable. Lifelong PE is defined as being consistent. However, this type of PE is associated with other problems like a premature erection. Some genetic and hormonal factors have been found to be the risk PE.

On the basis of Ejaculation time and complaint frequency, PE can be classified into the following categories:

Apart from the aforementioned causes, hormones have also been linked to PE. Low levels of prolactin are generally observed in men suffering from PE.

These factors play an important role in the diagnosis of PE.

Treatment

Depending on the type of the PE the treatment may vary, which is discussed as follows:

Lifelong PE

It is usually treated with the administration of SSRIs, which are inhibitors of the serotonin hormone. These drugs increase the time of ejaculation. But they have some side effects. While some men don’t need additional counselling, it is usually provided to explain to them the effects of the drug and the condition. Also, lifelong PE and the effect of treatment drugs need to be regularly monitored.

Acquired PE

The treatment of acquired PE mostly includes counselling and psychotherapy and may not require any drugs. However, depending on the individual condition, oral or topical drugs may be administered.

Subjective PE

Since this type is usually caused by normal variations in sexual functions,  it is essential that such men understand the underlying cause of their PE. Treatment of subjective PE, thus, primarily includes personal and couple counselling. SSRIs may or may not be prescribed.

Variable PE

This type of PE doesn’t require any treatment. In case of variable PE, psychological analysis is usually done to help the person find out and deal with the mental condition behind this problem.

Delayed ejaculation 

Quite opposite to premature ejaculation, delayed ejaculation refers to a condition wherein the person isn’t able to ejaculate or when the ejaculation time (IELT) is much longer than usual.

It is also variably known as inhibited ejaculation, idiopathic anejaculation (AE), inadequate ejaculation and retarded ejaculation. Although AE usually refers to a total inability to ejaculate.

According to the American Psychiatric Association, to confirm DE, a person should have at least one of the two conditions:

• Delay or inefficiency of ejaculation
• An absence of ejaculation in the past six months with no reduction in arousal.

There seems to be a conflict when it comes to defining the IELT time marking DE. According to the Journal of Sexual Medicine, the IELT for DE is 20-25 minutes. However, as per a study published in the Journal of Sex and Marital Therapy, IELT ranges from 4 to 10 minutes in normal men, so any deviation higher than this time frame could be considered DE.

Nonetheless, DE seems to be the least prevalent male sexual disorder with only 1% of men with lifelong DE and around 5% of men suffering from acquired DE.

Delayed ejaculation is normal with age but some other actors have also been associated with this condition. Here is a list of such factors*:

• Lack of confidence
• Guilt
• Religious beliefs
• Psychological problems like anxiety and depression
• High frequency or vigorous masturbation
• Dissatisfaction with love, relationship or partner
• Sexual fantasies that are different from the reality
• Lack of sexual desire
• Medications or drugs like SSRIs that delay ejaculation and antidepressants
• Individual genetics
• Low thyroid function
• Lack of prolactin hormone

*Note: The list isn’t comprehensive. The diagnosis depends on individual factors and clinical history.

Diagnosis

DE is usually diagnosed by a person’s sexual history and some clinical tests. History includes factors such as neurological disorders, masturbation, lack of orgasm, the frequency of intercourse, urinary or testicular problems, or cultural constraints.

While clinical examination usually includes examining vas deferens and epididymis, any abnormalities in the testes size and size of the penis, ability, or inability to feel testicular squeezing (normally that stimulates pain receptors), cremasteric reflex (reflex associated with stroking the inner thigh).

Further tests may be suggested by the physician to confirm any abnormality.

Treatment

Treatment of DE would depend on the individual cause and may include counselling if it is a psychological issue. However, in some cases, testosterone solution and dopamine (pleasure hormone of the body) agonist drugs may be prescribed to enhance sexual function. It is important to note that most of these drugs have some associated side effects which include inflammation, nausea, urinary problems, constipation and diarrhoea.

Retrograde ejaculation 

Retrograde ejaculation is an uncommon male sexual dysfunction, occurring in less than 2% of the cases. Sympathetic nerves are responsible for the expulsion of semen from the penis. It makes sure that the internal urethral sphincter (a muscle that closes or opens to let fluid pass through a certain point in the body) remains closed and the semen flows out instead of going back into the urethra. Any dysfunction in the sympathetic nerve would cause the semen to collect in the urethra. As a result, very less or no semen comes out with orgasms. This condition is defined as retrograde ejaculation (RE). However, there is no difficulty in arousal or erection.

Several factors can cause RE such as genetics, spinal injury, neck injury, bladder surgery. Diabetes mellitus and Parkinson’s has also been found to be associated with RE.

It is also associated with cloudiness in the urine which is due to the presence of semen. This is one of the diagnostic features of retrograde ejaculation.

Treatment

Treatment of RE includes certain drugs or surgery, depending on the individual case.

Oral drugs that mimic the function of sympathetic nerves are usually included in the treatment of RE. Additionally, anticholinergics, drugs that inhibit the function of parasympathetic nerves are also used for RE treatment. Needless to say, most of these drugs may have some of their own side effects and should be taken under the supervision of a doctor.

According to a study, sperms can also be obtained from the bladder after intercourse and inseminated artificially to alleviate fertility issues in couples.

Low libido

Low libido or sexual desire has been linked to a lack of sexual desire and arousal which is not independently caused by some chronic conditions or medications. The exact cause of this problem has not been known so far but over expectations and anxiety increase the risk.

Certain diseases, medicines and low levels of testosterone are also found to be associated with the condition. Medications like antidepressants inhibit the release of dopamine and prolactin, which are the sexual desire hormones in the body, thereby, sex drive is reduced. Additionally, age can also contribute to loss of interest in sex.

It is important to note that hypoactive sexual desire is sometimes mistaken for erectile dysfunction. For correct diagnosis, it is best that you mention your sexual history to the physician.

(Read more: Low libido in men causes)

Treatment

Since the cause of low libido is different in most people, there is no single medication or therapy for its treatment. Instead, psychotherapy is used to help the person understand the underlying cause of this problem. Couple therapies, wherein a couple is made to take a joint session with a psychiatrist to resolve the situation through an open discussion are also an option. Assignments are given to the couple which includes a defined set of sexual practices. This helps them understand the pattern of their sexual cycle (acceptance, arousal, orgasm).

A different set of therapies are employed for the management of anxiety and depression.

Apart from this, some hormone supplements and dopamine-enhancing drugs like amphetamines can also improve sexual desire. Hormone supplements are available commercially in the form of tablets, patches and creams in the market.

(Read more: How to improve libido)

Erectile dysfunction

Erectile dysfunction is a condition wherein a person is not able to achieve or hold an erection needed for the process of intercourse. It is one of the most common sexual disorders in men. Studies suggest that about 15% of men suffer from erectile dysfunction and this increases with age. About 70 % of men by the age of 70 have difficulty in maintaining an erection. Studies indicate various causes for this problem. These include:

• Vascular causes like high blood sugar, high blood pressure, and atherosclerosis.
• Hormonal, including testosterone deficiency, pituitary diseases or thyroid dysfunction.
• Physical problems like old age, hypospadias (a condition wherein the penis opening is on the underside instead of being on the tip), Scar tissue formation in penis that prevents erection.
• Neurological problems like epilepsy, stroke, trauma and diseases like Parkinson’s.
• Other factors like surgery or drugs.

Various physical and neurological factors play a role in an erection. There are specific areas in the brain that control sexual desire and erection. It is a function of the brain and spinal signalling pathways. Any interruption or inhibition of these signals would be directly associated with erectile dysfunction.

According to animal-based studies, activation of a specific arm of the nervous system (sympathetic) could inhibit erection.

Anxiety and depression increase the risk of this problem. Norepinephrine (stress hormone) has also been found to be associated with erectile dysfunction in some men.

Diagnosis

Usually, ED is diagnosed by the history of the patient along with certain lab tests.

While assessing the person’s medical history, factors like the onset, extent and duration of ED and psychological history are noted. Physical examination usually includes checking for any structural problems that might cause ED, this also includes cardiovascular conditions.

Laboratory tests done to evaluate erectile dysfunction include Lipid profile test, Haemoglobin A1C, levels of testosterone, free testosterone, follicle-stimulating hormone (FSH), luteinizing hormone, prolactin and sex hormone binding globulin tests. Sometimes thyroid functions are also tested for the levels of T4, T3 and TSH.

Further tests may be done to find specific causes for the problem.

Treatment

The treatment of ED depends on the exact cause and can thus be psychological or may require drug treatment or even a surgical procedure. It includes diet and lifestyle changes like quitting alcohol and smoking, sticking to a Mediterranean diet (high consumption of fresh vegetables and olive oil along with moderate consumption of proteins) and following a regular exercise routine.

ED due to hypogonadism (dysfunction of testes) has been found to be reduced by supplementing testosterone along with the standard drugs. Oral medications like sildenafil (Viagra), udenafil (zydena) and Vardenafil (Levitra) are also used for the treatment of ED.

(Read more: Male hypogonadism causes)

In case of the failure of oral treatment, intracavernosal injections are used which introduces drugs directly into the artery of the penis. Depending on the individual case, a combination of all of these may be used.

For those looking for alternative therapies, acupuncture has been found to be helpful in improving ED.