Although not usually the main topic of conversation around the dinner table or in a pub, problems with their sex lives are a source of major distress to large numbers of men. These difficulties are commonly related either to an inability to achieve an erection adequate for a satisfying sex life or to problems with ejaculation.
With regard to erectile dysfunction (ED) for many years it has been known that, in the Western world, by the age of 50 approximately 10% of men have completely lost their ability to achieve an erection and a further 20 – 30% have some significant difficulty. Whilst in years gone by men found this problem too embarrassing to discuss with their doctors, changing social practices together and the advent of better treatments has resulted in far less reticence. General practitioners are much more willing to discuss sexual problems and almost all UK urological departments are able to give specialist advice.
Achieving a satisfactory erection is a complex physiological event and difficulties may be broadly classified as due to organic or inorganic, i.e. psychological, factors. Particularly common organic causes of ED include diabetes, vascular or neurological diseases and major surgery especially operations performed in the pelvis. In addition there are a huge number of drugs that may have ED as a side-effect. Of note is the fact that although there is increasing interest in low testosterone as a potential cause of ED for most men there is little evidence that testosterone replacement improves erections. Some of the more obvious psychological causes of ED include stress, anxiety and depression.
One interesting condition that probably affects 1-2% of men and which can occur at any age is Peyronies disease. Francois de la Peyronie was physician to Louis XIII of France and he described the condition that bears his name in 1743. However it was undoubtedly it was present long before this. For example there are descriptions of the third century Roman emperor Theodosius waking with a bend in his penis that caused him to urinate into his face. The cause of Peyronies disease is unknown but it is probably caused by microscopic inflammation of tissue within the penis. This results in collagen, or scar tissue, being deposited which can have various consequences. First a lump may appear – whilst invariably alarming for the patient this lump is always benign. In the early stages it may be painful but again the pain will resolve within months. Of more concern is the fact that the scarring of one side of the penis results in men developing a bend in their erection. This can vary from very mild (causing no difficulty) to so severe that penetrative sex is physically impossible. In extreme cases the scarring can spread through the penis making erections themselves difficult to achieve.
The inflammation that gives rise to Peyronies disease burns itself out within 12-18 months. Unfortunately there are no treatments which speed this process up nor any which can lessen its effects on the penis. Doctors therefore have to advise patients to wait to see how the condition develops. If at the end of the day there is only a slight bend of the erection no further treatment is justified. However when the bend is severe surgery may be required to straighten the penis.
For most men there is little value in special investigations as to the cause of ED as the management follow well-defined pathways. Perhaps the major leap forward in treatment was the advent of Viagra (or sildenafil) in 1998 – the first tablet effective for the condition. Since then three other tablets have become available and approximately 70% of men benefit from them. Should they be ineffective there are other drugs which usually help and failing that it is possible to improve the situation surgically by implanting prostheses into the penis. It is fair to say that in this age it is almost always possible to restore a man’s erection if he is willing to try all of the available treatments.
Problems with ejaculation are increasingly recognised but, unfortunately, more difficult to manage. This is partly because the physiological processes which give rise to ejaculation are not well understood (they are completely different to those which cause erections). Therefore there are fewer drugs or other strategies which we know to be effective. Having said that it is often sensible to seek specialist advice as there may be ways of, if not curing, improving the man’s or the couple’s experience.
Content provided by Krishna Sethia DM, FRCS.