Sexual dysfunction in men

GPs endeavour to provide complete holistic healthcare for our patients. While we deal competently with most areas of health, sexual health – and in particular male sexual health – is often overlooked or very cursorily considered. This is despite the fact that sexual health and function are important determinants of quality of life. Dysfunction can lead to reduced fulfilment in many aspects of life including one’s emotional, social, and intellectual, as well as one’s sexual life. Consequently, ignoring or giving scant attention to sexual health can lead to a large and important gap in the care we deliver to our patients and result in a significant deviation from our complete care ideal.

Where do we start?

Evidence suggests that there is an increasing prevalence of male sexual dysfunction in our population, not least because of an ageing population. There are undeniable detrimental effects on personal and interpersonal relationships. The question for us working in primary care is how to deal with this issue in our practices.

We are all aware of the links between erectile dysfunction (ED) and cardiovascular disease, haemochromatosis, renal failure and a host of other physical conditions, and we may well congratulate ourselves when asking about sexual dysfunction in this cohort of patients. 

However, there is a significant cohort of patients with issues like ED and particularly premature ejaculation (PE) with whom we fail to address the topic in any way.

My view is that what is fundamental to recognising, evaluating and treating these common conditions is that we develop and incorporate protocols and tools into our daily routine practice that will address male sexual function. Only this way can it become as normal to ask a male about sexual function as it is to ask about other physical functions.

Firstly we, as doctors, must normalise it. We must have a standard approach to history-taking. Any new patient, when filling in a health questionnaire, should be routinely asked about sexual health and activity.

Trainers should begin to teach specifically about male sexual function, and not just in passing in relation to other physical problems. This training should probably start early at undergraduate level. For example, one German university has an undergraduate programme for sexual function, and our medical schools should consider introducing similar programmes here.

Establishing male health clinics with specific questionnaires and advertising may be helpful. Even if they are initially not well attended, acknowledging issues around male sexual function and showing an interest in treating them will lead men to feel more comfortable and able to approach their GP regarding their sexual issues.

We must make it as easy as possible for men to raise sexual issues, and the availability of public health information on these topics would be helpful. Discussing sexual function with our male patients should become a normal part of our practice. 

Every practitioner needs to find a way of forming the question in their own consulting style. We have no difficulty or issue with asking about urinary issues, bowel problems, etc. so if we overcome our initial inhibitions, questions about sexual function should become as second nature as those about other bodily functions. Suggested questions might include:

• When did you last have sex?
• Are you satisfied with your sexual activity?
• Are you experiencing any difficulties or decreased satisfaction in your sex life?

It is a challenge for all GPs to find the most sensitive way to approach these issues and it is certainly an issue which has to be individualised. How we discuss sexual function with an elderly man who is in for a routine prescription may be different to how we discuss it with a single 20-year-old with anxiety issues. 

It is up to us as doctors to find the best way, and to incorporate it as part of our routine daily work. What we must not do, is to NOT enquire at all regarding our male patients’ sexual function.

Erectile dysfunction

Erectile dysfunction (ED), also referred to as impotence, is defined as the inability of the man to achieve and maintain an erection sufficient for mutually satisfactory intercourse with his partner. It is a common condition with an increasing incidence in older age groups. It has been found to be four times more common in men in their 60s compared to those in their 40s,¹ and it has been estimated that up to half of all men between the ages of 40-70 can display some degree of ED.

Given that penile erection results from the hydraulic effect of blood entering and being retained in the sponge-like tissues of the penis, it is unsurprising that many cardiovascular disorders and diseases which impact on our cardiovasculature are associated with ED.

These vascular factors include: CVD; atherosclerosis (approximately 50% of cases); hypertension; diabetes mellitus; hyperlipidaemia; smoking; surgery or radiotherapy to the pelvis or retroperitoneum; and trauma. 

Neurological factors that may impact on ED include central causes such as Parkinson’s disease, stroke, multiple sclerosis (MS), tumours, traumatic brain injury (causing hypothalamic-pituitary deficiency), cerebrovascular disease, intervertebral disc disease, spinal cord disease or injury; and peripheral causes such as: polyneuropathy, peripheral neuropathy, diabetes mellitus, alcoholism, uraemia, and surgery (for example of pelvis or retroperitoneum).

Hormonal factors include hypogonadism, hyperprolactinaemia, thyroid disease and Cushing’s disease, while anatomical factors include Peyronie’s disease and micropenis or other penile anomalies.

Practitioners also need to be aware of the multitude of drugs that can be a factor in ED. These include antihypertensives, beta-blockers, diuretics, antidepressants (both tricyclics and SSRIs), antipsychotics (phenothiazines, risperidone), hormonal agents such as cyproterone acetate and luteinising hormone-releasing hormone analogues, anticonvulsants (phenytoin, carbamazepine), antihistamines, recreational drugs and H2 antagonists (cimetidine and ranitidine).

The psychogenic factors that can influence ED include general psychosexual factors such as disorders of sexual intimacy or lack of arousability, situational factors (partner, performance or stress), and frequency of intercourse (ie. maintaining a regular frequency of intercourse can reduce the risk of ED); and psychiatric illnesses such as generalised anxiety disorder, depression, psychosis and alcoholism. 

ED of itself can often cause severe psychological effects as well as relationship difficulties. In attempting to differentiate between cause and effect in these instances, careful history-taking should assist.

Premature ejaculation

While there are varied definitions of what constitutes premature ejaculation (PE), experts at the International Society for Sexual Medicine have defined the condition as ejaculation which occurs, or nearly always occurs, within one minute of penetration.² PE encompasses the inability to delay ejaculation on all, or nearly all occasions, and often results in negative personal consequences such as distress, frustration and/or avoidance of sexual intimacy. PE is considered to be a common male sexual dysfunction and has been estimated to affect approximately 30% of males worldwide.³

Most cases of PE have no clear cause. This has given rise to many theories being put forward regarding possible causes. Premature ejaculation may only occur in certain sexual situations, with a new partner, or following a prolonged period of sexual abstinence. 

It is also associated with anxiety, guilt and depression. Some cases may be related to hormonal problems, or the side-effects of certain medicines. 

Thinking on PE has changed from considering it a single psychological disorder to a more recent recognition that it is a more complex condition. We now also have a better understanding of the physiological basis of the condition. 

Despite its prevalence and the considerable negative psychosocial consequences of PE on the patient’s life and that of their partner, it remains significantly underdiagnosed and undertreated. 

Erectile dysfunction fares marginally better due to the well-established and documented links between ED and cardiovascular risk, but it also often remains unrecognised and untreated in the consultation room.

Role of the GP

As GPs, we need to ask ourselves why we may be undertreating this condition. Why is it that we may fail to recognise, evaluate and appropriately treat erectile dysfunction? Sexual dysfunction is extremely common in men and even though we are aware of the association with certain physical disorders, we continue to underdiagnose. 

In one study of men between the ages of 40-70, 52% reported some degree of erectile difficulty and 10% reported complete ED.⁴ In another study, the NHSLS, 28.5% of men aged 18-59 reported PE.⁵

Who needs care?

While the obvious focus in these cases of sexual dysfunction is on the male, it is important to remember that the partner plays an integral role in the presentation, treatment, and management of these conditions. Successful assessment and treatment may often involve the couple.

Both ED and PE can have a significant negative psychological effect on the man and their partner and greatly affect their relationship. Men may experience anxiety, lowered self-esteem and even feelings of depression. Female partners can experience similar feelings for obvious reasons, including:

• When sex is over, so (often) is intimacy, and this has a detrimental effect on the relationship
• With erectile dysfunction, the female often feels she is responsible.⁶ She may feel unattractive and unwanted
• With premature ejaculation, the female often feels that the male is responsible. The female may feel that the male is impatient and selfish and not interested in solving their relationship problem.

Without doubt, inclusion of the partner in the treatment process is important for success. Co-operation of the partner can enhance a man’s self-confidence skills, self-esteem and sense of masculinity, and generally assist the man to develop more ejaculatory control. This leads to an improvement in the couple’s sexual relationship as well as the broader aspects of the relationship.

An important concept in sexual therapy is that of ‘sexual equilibrium’.⁷ Any relationship is dynamic and reciprocal with a change in one partner inducing a change in the other. Consequently, any assessment of male sexual dysfunction and their relationship must take the partner into account.

However, sexual dysfunction is of course not confined to men within relationships. It also effects single males, and may well be the reason that they remain single. Recent studies⁸ have shown that young men with PE have 33% less sexual intercourse compared to normal controls and report a significant decrease in sexual enjoyment.

Other symptoms commonly reported in this study include:

• Decreased self-esteem
• Increased anxiety
• Increased embarrassment
• Difficulty maintaining and sustaining relationships
• Preoccupation with sexual relationships
• Deterring single men from starting relationships.

Sexual history-taking

Once it has been established that there may be an issue,  then are some very good tools to help establish the extent of the problem. The Self-Esteem and Relationship (SEAR) and the International Index of Erectile Function (IIEF-5) questionnaires are very useful tools in establishing the extent of the problem once it has been flagged.

The European Society for Sexual Medicine⁹ offers various resources and tools to help improve procedures for sexual history-taking. These tools are useful for undertaking a good quality consultation, particularly as it has been shown that at present, only 15% of GPs are competent in sexual history-taking.

Once the problem has been identified and discussed with use of a questionnaire, then further evaluation is required. With most men, while history-taking is of the upmost importance in undertaking an assessment, there will also be a need for a focused physical examination and several investigations such as lipids, blood sugar and serum testosterone. 

Extensive investigation is only required in a small number of cases, and it is through a detailed history-taking that we will most often recognise those who need to be sent for secondary and tertiary investigations.  

Treatment

The mainstay of treatment for any condition is recognising the underlying disorder and in that sense the history and background of sexual dysfunction must be understood and investigated.

Erectile dysfunction

Treatment options for consideration in this condition include counselling, medication, external vacuum devices, hormonal therapy, penile injection and implants. With drug therapies, the ideal treatment should be easy to administer, non-invasive, non painful, highly efficacious, and have minimum side-effects.

Current treatment of ED include several options of oral phosphodiesterase type 5 (PDE-5) inhibitor treatment. 

PDE-5 inhibitors are selective, competitive inhibitors of phosphodiesterase-5, the enzyme responsible for the breakdown of cGMP (cyclic guanosine monophosphate) in various tissues. PDE-5 inhibitors augment erection rather than initiate it, and therefore sexual stimulation is required. Clinical studies to date indicate that all PDE-5 inhibitors available are effective, absorbed rapidly from the GI tract, metabolised, and eliminated predominantly via cytochrome P450 (CYP3A4) in the liver. 

Each drug has unique pharmacological characteristics based on molecular structure, enzyme inhibition profile and pharmacokinetic properties.

Side-effects, drug interactions and contraindications are similar across this class of drugs. Typical side-effects of PDE-5 inhibitors are dose-dependant and include headache, facial flushing, nasal congestion and dyspepsia. Visual disturbances can occur with sildenafil, and back and muscle pain has been infrequently reported with tadalafil. Each PDE-5 inhibitor has a distinct selectivity that contributes to its safety profile. 

Assessment of cardiac fitness is mandatory before prescribing PDE-5s; avoid in patients using nitrate drugs for angina, including glyceryl trinitrate sprays.

Which PDE-5 inhibitor to prescribe depends on the individual’s needs, lifestyle and general health.

Premature ejaculation

Treatment to date has concentrated on: sexual therapy; couple communication; start/stop squeeze technique; and cognitive behavioural therapy.

In recent years, off-label use of selective serotonin re-uptake inhibitors (SSRIs) as a treatment has become commonplace. 

A more recent medication, dapoxetine, has been developed and is a licensed treatment for premature ejaculation. It is a short-acting SSRI. It is administered on demand, one to three hours prior to sexual activity. Reported side-effects are nausea, dizziness and headache.

Practice protocols for male sexual dysfunction

The development of practice protocols and use of questionnaires can prove to be extremely valuable resources in addressing the current unmet need in relation to male sexual dysfunction and can address the problem of these issues going undiagnosed and untreated. 

The development of diagnostic and treatment protocols can also help ensure that our prescribing practices are safe, for both ourselves and our patients. 

Treatment protocols provide useful guidelines in establishing individual drug dosages, frequency of use, and possible drug interactions.

The introduction of protocols would assist in minimising over-prescribing and the associated undesired consequence of unused drugs finding their way onto the informal street market. Similarly, use of protocols to discuss sexual issues in general practice and detect cases of sexual dysfunction could help reduce the practice of self-medication where patients purchase medication via the internet and other places.  

Obviously, self-medication presents a number of potential risks to the patients, including those associated with overdosage, interaction with other drugs, etc. The mixing of these drugs with recreational and dangerous drugs, in particular the use of PDE-5 inhibitors with ‘poppers’ or ‘amyl’ nitrate can have very serious consequences. Similarly, when men are forced to get their information and treatments from the internet and other sources, there is a risk that they may develop unrealistic sexual expectations that can result in the misuse or overuse of medications.

Conclusion

Male sexual dysfunction may often be unrecognised and untreated. It is a common condition and often associated with an ageing population, and thus an ever-increasing prevalence in the population

Sexual dysfunction can lead to reduced fulfilment in many aspects of life and have a significant adverse effect on the quality of both the individuals’ and their partners’ lives. 

We should consider discussing sexual matters more openly with our male patients and to use a number of tools available to assist us in doing so in our daily practice. Society has become more enlightened and the subject is also being discussed more openly and fully in the media. Men and women of all ages are seeking guidance in an effort to improve their relationships and experience satisfactory sex lives. 

As doctors who are interested in providing a holistic and quality service we should be willing to take up the challenge of assisting them.

References 

1. Johannes C et al. Incidence of erectile dysfunction in men 40-69 years old: longitudinal results from the Massachusetts Male Aging Study. J Urology 2000; 163: 460–463
2. Sharlip ID et al. The ISSM definition of premature ejaculation: a contemporary, evidence-based definition. J Urol, suppl., 2008; 179: 340, abstract 988-988
3. Carson C, Gunn K. Premature ejaculation: definition and prevalence. International Journal of Impotence Research 2006; 18, S5-S13
4. Araujo et al. Relation between psychosocial risk factors and incident erectile dysfunction: Prospective results from the Massachusetts Male Aging Study. American Journal of Epidemiology. Vol 152. Issue 6; 533-541
5. Laumann et al. National Health and Social Life Survey. 1992: [United States]. ICPSR06647-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2008-04-17
6. Rosen RC, Porst H, Montrosi OF. The premature ejaculation prevalence and attitudes (PEPA) survey: a multinational survey. J Sex Med 2004; 1(S1): 57-58 
7. Jannini EA, Lenzi A. Epidemiology of premature ejaculation. Curr Opin Urol 2005;15(6):399-403
8. McMahon CG et al. Efficacy and safety of dapoxetine for the treatment of premature ejaculation: integrated analysis of results from five phase 3 trials. J Ses Med 2011; 8: 524-539
9. European Society of Sexual Medicine. www.essm.org
10. Rosen RC, Cappelleri JC, Smith MD, et al: Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res 1999; 11:319-326
11. Guidelines on Male Sexual Dysfunction: Erectile dysfunction and premature ejaculation. European Association of Urology 2013