Male Sexual Problems

What Are Male Sexual Problems?

Sexual behavior and response requires the complicated intertwining of environmental, physical (both anatomical and hormonal), and psychological factors. Problems with sexual functioning are common, affecting more than half of all couples at some time. Though sexual dysfunction rarely threatens physical health, it can take a heavy psychological toll, bringing on depression, anxiety, and debilitating feelings of inadequacy. Many sexual problems are really symptoms of other more serious heath disorders.

Determining which factors are affecting your ability to enjoy your sexuality can be very difficult and will require great patience from you, your partner, and your healthcare provider. Problems may be difficult to resolve without expert help, especially because misinformation and embarrassment are leading causes of sexual dysfunction.

If your sexual problem only occurs under a particular set of circumstances, or only with certain sexual partners, then your condition is considered to be "situational" rather than "generalized" (occurring regardless of the circumstances or partner). If you've had normal sexual functioning in the past, but then develop a sexual problem, you have an "acquired" rather than "lifelong" difficulty.

The major categories of sexual dysfunction in men include:

• Erectile dysfunction (sometimes called impotence): the inability to have or maintain an erection sufficient for sexual functioning.
• Premature ejaculation: an inability to delay orgasm and ejaculation, such that it occurs very early in the course of sexual contact, leaving the other partner dissatisfied.
• Male orgasmic disorder: an inability to reach orgasm (climax) with a partner; or the inability to achieve orgasm without lengthy sexual contact; or the inability to have an orgasm during intercourse. In some cases, orgasm can be achieved only through masturbation or oral sex.
• Inhibited or hypoactive sexual desire: a disinterest in sexual contact or complete lack of sexual desire.
• Retrograde ejaculation, in which the semen, rather than emerging from the end of the penis, moves backward into the bladder during orgasm.
• Priapism, a prolonged erection unaccompanied by sexual desire; this rare condition is potentially dangerous and requires immediate medical attention.

Many of these sexual conditions will occur occasionally, during the course of a man's sexual life. In fact, some researchers only consider a diagnosis of sexual dysfunction if the problem occurs in 25% of all attempted sexual encounters.

What Causes Them?

Because the sexual response is so complex, involving multiple factors, there are many causes of sexual dysfunction. Sometimes simple lack of information is to blame. An erection involves the nervous and vascular systems (the network of arteries and veins) and appropriate levels of hormones, so problems with any of these systems can interfere with sexual functioning. Common problems include the following:

• Hypogonadism, in which the testicles do not produce enough testosterone.
• Thyroid disorders (both hyperthyroidism and hypothyroidism)
• Adrenal lesions (Cushing's syndrome)
• Noncancerous pituitary growths that increase levels of a hormone called prolactin
• Diseases that affect the nervous system, including strokes, spinal cord injuries, multiple sclerosis, long-standing diabetes, and Parkinson's disease
• Damage following pelvic surgery (such as prostate, colon or bladder surgery)
• Conditions that affect the penis directly, such as Peyronie's disease (penile curvature) or injury to the penis itself or to the arteries, veins, or nerves that supply the penis
• Any serious and debilitating diseases that result in intense fatigue, including emphysema, chronic bronchitis, heart disease, cirrhosis, cancer, and kidney failure

Premature ejaculation (PE) is usually not due to physical causes, although the problem is sometimes linked to a neurological disorder, prostate infections, or urethritis. Possible psychological causes include:

• Anxiety
• Guilt feelings about sex
• Ambivalence toward women
• Learned behavior pattern of rapid ejaculation seen with frequent masturbation or infrequent sexual activity

Erection problems can be caused by

• Blockages in the aorta (the large artery that carries oxygen-rich blood from the heart) that disturb normal blood flow to the penis (aortic occlusion)
• Atherosclerosis in arteries leading to the penis
• Damage to arteries or nerves after radiation treatment
• Leaky veins
• Conditions or behaviors that increase the risk of vascular disease, such as smoking, high blood pressure, diabetes, and high cholesterol or the medications to treat these and other disorders

Painful intercourse usually has physical causes such as these:

• An infection of the prostate, urethra, or testes, which can be initiated by sexually transmitted diseases, such as chlamydia and genital herpes
• An allergic reaction to spermicide or condoms
• Peyronie's disease, fibrous plaques on the upper side of the penis that often produce a painful bend during erection
• Arthritis of the lower back

Lack of sexual desire may be due to any of these factors:

• Physical illness
• Hormonal abnormality (usually low testosterone levels)
• Medications that affect libido
• Psychological causes, including depression or interpersonal problems, which a therapist may help identify

Retrograde ejaculation may occur in men from these causes:

• Prostate or urethral surgery
• Medication that keeps the bladder open
• Diabetes -- a disease that can injure the nerves that normally close the bladder during ejaculation

Can Medication Cause Sexual Problems?

Many medications have been implicated in sexual dysfunction, causing inhibited sexual desire and/or erectile dysfunction, such as:

• Drugs to treat high blood pressure
• Diuretics (including thiazides and spironolactone)
• Histamine blockers
• The antifungal agent ketoconazole
• Antidepressant medications
• Common over-the-counter preparations (particularly antihistamines and decongestants)
• Antipsychotic medications
• Sedatives
• Medications used to treat anxiety
• Drugs of abuse, including alcohol, methadone and heroin, and tobacco

Psychological Factors in Sexual Problems

Psychological factors play an important role. You may find it difficult to enjoy a sexual relationship if:

• You are under a lot of stress
• Your relationship is troubled
• You have a history of traumatic sexual encounters (rape or incest)
• You were raised in a family with strict sexual taboos
• You're afraid of getting your partner pregnant or of contracting a sexually-transmitted disease
• You have negative feelings (including guilt, anger, fear, low self-esteem, and anxiety)
• You are depressed
• You are severely fatigued

Environmental Factors in Sexual Problems

Environmental factors may interfere with sexual functioning. You may find it difficult to enjoy sex if there is no safe, private place to relax and allow yourself to become sexual, or if fatigue due to an overly busy work and personal life robs you of the energy to participate sexually. Parents may find it difficult to find the time to be sexually intimate, given the demands/presence of their children. Knowledge about AIDS, the difficulties of striving for "safer sex," and the psychological effects of discrimination are just a few of the factors that can give rise to anxieties for gay men.

Testosterone

A testosterone test checks the level of this male hormone (androgen) in the blood. Testosterone affects sexual features and development. In men, it is made in large amounts by the testicles. In both men and women, testosterone is made in small amounts by the adrenal glands; and, in women, by the ovaries.

The pituitary gland controls the level of testosterone in the body. When the testosterone level is low, the pituitary gland releases a hormone called luteinizing hormone (LH). This hormone tells the testicles to make more testosterone. See an illustration of the pituitary gland.

Before puberty, the testosterone level in boys is normally low. Testosterone increases during puberty. This causes boys to develop a deeper voice, get bigger muscles, make sperm, and get facial and body hair. The level of testosterone is the highest around age 40, then gradually becomes less in older men.

Most of the testosterone in the blood is bound to a protein called sex hormone binding globulin (SHBG). Testosterone that is not bound ("free") can also be checked if a man is having sexual problems.

Why it is Done

A testosterone test is done to:

• See why a man is having problems in fathering a child (infertility). A low amount of testosterone can lead to low sperm counts.
• Check a man's sexual problems. A low level of testosterone may lower a man's sex drive or not allow him to have an erection (erectile dysfunction).
• See whether a high level of testosterone is causing a boy younger than age 10 to have early signs of puberty.
• Find out why a woman is developing male features, such as excessive facial and body hair (hirsutism) and a deep voice.
• Find out why a woman is having irregular menstrual periods.
• See if testosterone-lowering medicines are working in a man with advanced prostate cancer.
• Find the cause of osteoporosis in a man.

How to Prepare

You do not need to do anything before you have this test. Your doctor may want you to do a morning blood test, when testosterone levels are highest.

How it is Done

The health professional taking a sample of blood will:

• Wrap an elastic band around your upper arm to stop the flow of blood. This makes the veins below the band larger so it is easier to put a needle into the vein.
• Clean the needle site with alcohol.
• Put the needle into the vein. More than one needle stick may be needed.
• Attach a tube to the needle to fill it with blood.
• Remove the band from your arm when enough blood is collected.
• Put a gauze pad or cotton ball over the needle site as the needle is removed.
• Put pressure to the site and then a bandage.

How it Feels

The blood sample is taken from a vein in your arm. An elastic band is wrapped around your upper arm. It may feel tight. You may feel nothing at all from the needle, or you may feel a quick sting or pinch.

Risks

There is very little chance of a problem from having blood sample taken from a vein.

• You may get a small bruise at the site. You can lower the chance of bruising by keeping pressure on the site for several minutes.
• In rare cases, the vein may become swollen after the blood sample is taken. This problem is called phlebitis. A warm compress can be used several times a day to treat this.
• Ongoing bleeding can be a problem for people with bleeding disorders. Aspirin, warfarin (Coumadin), and other blood-thinning medicines can make bleeding more likely. If you have bleeding or clotting problems, or if you take blood-thinning medicine, tell your doctor before your blood sample is taken.

Results

A testosterone test checks the level of this male hormone (androgen) in the blood.

Normal

Normal values may vary from lab to lab. Your doctor will have your test results in 1 to 2 days.

Total Testosterone
Age	Male	Female
7 months to 9 years	Less than 30 ng/dL	Less than 30 ng/dL
10 to 13 years	Less than 300 ng/dL	Less than 40 ng/dL
14 to 15 years	170 to 540 ng/dL	Less than 60 ng/dL
16 to 19 years	250 to 910 ng/dL	Less than 70 ng/dL
20 years and older	280 to 1080 ng/dL	Less than 70 ng/dL

Normal free testosterone level is 0.3 to 2 pg/mL.

High Values

• In men, a high level of testosterone may be caused by cancer of the testicles or adrenal glands.
• In boys younger than 10, a high level of testosterone may mean early (precocious) puberty, a tumor in the testicles, or an abnormal adrenal gland.
• In women, a high level of testosterone may be caused by cancer of the ovaries or adrenal glands or polycystic ovary syndrome (PCOS).

Low Values

• In men or boys who have gone through puberty, a low level of testosterone may be caused by a problem with the testicles, such as slow development of, an injury to, or a lack of testicles. It can also be caused from treatment with the female hormone estrogen, a problem with the pituitary gland, or many long-term (chronic) illnesses.
• A low testosterone level in men can also be caused by certain inherited diseases (such as Klinefelter syndrome or Down syndrome), liver disease (cirrhosis), or treatment for cancer of the prostate gland.
• Chronic alcohol use can cause a low testosterone level.

Hormone Therapy for Erectile Dysfunction

Testosterone is a hormone produced by the testicles and is responsible for the proper development of male sexual characteristics. Testosterone is also important for maintaining muscle bulk, adequate levels of red blood cells, bone growth, sense of well-being and sexual function.

Inadequate production of testosterone is not a common cause of erectile dysfunction; however, when ED does occur due to decreased testosterone production, testosterone replacement therapy may improve the problem.

What Causes Testosterone Deficiency?

As a man ages, the amount of testosterone in his body gradually declines. This natural decline starts after age 30 and continues throughout life. Other causes of lowered testosterone levels include:

• Injury or infection to the testicles
• Chemotherapy or radiation treatment for cancer
• Genetic abnormalities such as Klinefelter's Syndrome (extra X chromosome)
• Hemochromatosis (too much iron in the body)
• Dysfunction of the pituitary gland (a gland in the brain that produces many important hormones)
• Inflammatory diseases such as sarcoidosis (a condition that causes inflammation of the lungs)
• Medications, especially hormones used to treat prostate cancer and corticosteroid drugs
• Chronic illness
• Chronic kidney failure
• Liver cirrhosis
• Stress
• Alcoholism

The significance of testosterone decline is controversial and poorly understood.

What Are the Symptoms of Testosterone Deficiency?

Without adequate testosterone a man may lose his sex drive, experience erectile dysfunction, feel depressed, have a decreased sense of well-being, and have difficulty concentrating.

What Changes Occur in the Body Due to Testosterone Deficiency?

• Decrease in muscle mass, with an increase in body fat
• Changes in cholesterol levels
• Decrease in hemoglobin and possibly mild anemia
• Fragile bones (osteoporosis)
• Decrease in body hair

How Do I Find Out if I Have a Testosterone Deficiency?

The only accurate way to detect the condition is to have your doctor measure the amount of testosterone in your blood. Because testosterone levels fluctuate throughout the day, several measurements will need to be taken to detect a deficiency. Doctors prefer, if possible, to test levels early in the morning since this is when testosterone levels are at their highest.

How Is Testosterone Deficiency Treated?

Testosterone deficiency can be treated by

• Intramuscular injections, generally every two or three weeks
• Testosterone patch worn either on the body or on the scrotum (the sac that contains the testicles)
• Testosterone gel
• Mucoadhesive material applied above the teeth twice a day

Each of these options provides adequate levels of hormone replacement; however, they all have different advantages and disadvantages. Talk to your doctor to see which approach may be right for you.

Who Shouldn't Take Testosterone Replacement Therapy?

Men who have prostate cancer or breast cancer should not take testosterone replacement therapy. All men considering testosterone replacement therapy should undergo a thorough prostate cancer screening prior to starting this therapy.

What Are the Side Effects of Testosterone Replacement Therapy?

In general, hormone replacement therapy is safe. It is associated with some side effects, including:

• Acne or oily skin
• Mild fluid retention
• Stimulation of prostate tissue, with perhaps some increased urination symptoms such as a decreased stream or frequency
• Breast enlargement
• Worsening of sleep apnea (a sleep disorder that results in frequent night time awakenings and daytime sleepiness)
• Decreased testicular size

Laboratory abnormalities that can occur with hormone replacement include:

• Changes in cholesterol concentrations
• Increase in red blood cell count
• Decrease in sperm count, producing infertility (especially in younger men)

If you are taking hormone replacement therapy, regular follow-up appointments with your doctor are important.

Like any other medication, directions for administering testosterone should be followed exactly as your doctor orders. If you are unsure or have any questions about testosterone replacement therapy, ask your doctor.

Reviewed by the doctors at the Glickman Urological Institute at The Cleveland Clinic.

WebMD Medical Reference from MedicineNet Reviewed on January 31, 2005

 

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