Dr Carl Shakespeare consultant cardiologist  
consultant cardiologist
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arrowMale Sexual Dysfunction
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Male Sexual Dysfunction or Erectile Dysfunction:

Sexual dysfunctionin the male principally involves loss in libido, a failure in developing an erection, a failure of maintaining an erection, or premature ejaculation.

A loss in libido means that one becomes less interested in having sex. Of course this may result in erection problems. Reduced libido is mostly related to fatigue, stress, intercurrent illness, or psycho-social reasons. These issues need to be excluded before considering erectile failure as the primary problem.

Erectile function is dependent on a series of physiological reactions. The initial stimulus is the sexual urge that promotes nerve activation that enlarges the blood vessels in the penis (engorgement). The vessels act as a reservoir, with increasing blood being trapped, resulting in penis enlargement. Inherent to the ability of trapping the blood is a nerve mechanism of preventing the blood escaping. After orgasm, the trapping reflex ends, and blood then leaves the penis so it reduces in size.

If there are problems of engorgement then the penis will not enlarge. This would occur with any damage to the nerve reflexes stimulating the blood vessels. Similarly, if there is damage to the inner lining of the vessels which is responsible for enlargement, then it will not engorge. Equally if there are problems trapping the blood supply by nerve damage so blood escapes, it will not engorge. Also, if the entrapment does not last long enough, then the erection cannot be maintained.


Failure of developing an erection or maintaining one are related to each other, and broadly considered as impotence. Although psychological issues are important, the main causes for it are usually physical. Obvious neurological causes include spinal injury and multiple sclerosis. More commonly, erectile dysfunction can be considered a potential marker of vascular disease. Potential causes include undiagnosed diabetes, hypertension, high cholesterol and smoking. These disease processes result in either damage to the underlying vessel wall (called the endothelium), or to the nerve reflexes. Patients frequently blame their medication (especially blood pressure pills) for erectile dysfunction. Infact it is probably the underlying blood pressure that damages the vessels in the first place that caused the problem, but medication may have compounded the problem. Remember, treatment of the underlying cause is imperative, as progressive damage will occur. We can always treat the erectile dysfunction as well.

Treatment of Erectile Dysfunction:
Initially searching for an underlying cause is important. This will involve measuring blood pressure, blood sugar and cholesterol. Assessment of baseline male sex hormones (androgens) and pituitary prolactin is usually made. In addition exclude local urological causes is important. Examining for anatomical deformities or prostate disease is mandatory, and also involves blood tests for excluding prostate cancer (PSA test). Lifestyle causes need to be excluded, such as determining whether the problem is primarily a loss in libido. Alcohol and smoking are key lifestyle issues to be modified. If neither these factors are modified, then even specific medication may not work either. In the case of medication either precipitating or inducing the symptoms, a change in medication may alleviate the problem.

Psychological causes account for about a third of cases, and should always be considered. Detailed questions about other emotive issues may unlock the problem. Patients may have underlying anger, depression, and have a fear of failure. Similarly, the sex partner may suffer feelings of rejection and suspicion.  In addition, if there are minor erectile problems, then anxiety about performing may worsen the problem. From this point of view, patience and reassurance from the sexual partner is important.

For most patients, treatment with tablets works in at least two thirds of cases. Before considering medication, excluding underlying coronary disease is necessary, and consultation with a cardiologist recommended. Certain medications may interfere with the erectile dysfunction treatment drugs. This includes: nitrates, nicorandil, and certain HIV treatment drugs.

As to actual medication, Sildenafil (also known as Viagra) is the most frequently used. This is a short acting medication that takes about 45 minutes to work. Longer acting drugs include Tadalafil and Vardenafil. Patients have high expectation when first using the medication, and should be cautioned that it may not work the first time. Patience and reassurance is required. In addition, patients should be reminded this is not a mechanical process, and all the romance and foreplay applies to the sexual act just as normal. Any side effects such as dizziness, collapse and chest pain should be reported to a doctor. Generally, one starts with a low dose, but that can be increased.

For patients with no improvement in function or ill effects of the tablets, further discussion with a doctor is recommended. Consideration of other treatments can then be considered. One other successful treatment modality includes an injection into the penis itself before sex is anticipated. This is not painful as it sounds, and has excellent results. Alternatively various mechanical devices to aid engorgement can be applied. Advice and education from a urology or erectile dysfunction service is necessary for such treatment modalities.