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OVERVIEW — As men and their health care providers have become more comfortable talking about sexual problems and new treatments have been developed, it is possible for men to remain sexually active well into their 70s and beyond.
Sexual problems in men include:
●An inability to acquire or maintain an erection satisfactory for sexual intercourse (also called erectile dysfunction or ED)
●A lack of interest in sex (diminished libido)
●Premature ejaculation
●Delayed or inhibited ejaculation
●Penile curvature (Peyronie's disease)
This article discusses some common sexual problems and their treatment. If you are having problems with sex, talk to your health care provider. They can help.
ERECTILE DYSFUNCTION
Causes — Erectile dysfunction (ED) is the term used to describe the inability to get or maintain an erection.
Limited blood flow — Anything that limits blood flow to the penis can cause ED. The most common conditions that limit blood flow include cigarette smoking, diabetes, high blood pressure, obesity, and normal aging. In addition, many commonly prescribed medications, such as medications used to treat high blood pressure, can interfere with sexual function. Reduced blood flow in the penile arteries can happen before decreased blood flow to other vital organs (such as the heart) begins. Therefore, men with ED should be evaluated for any other cardiovascular risk factors. Studies have demonstrated that ED could be the first sign of developing a heart attack in the future. In fact, one study found that of those men who develop new-onset ED, 15 percent will have a cardiovascular event within the next seven years.
Neurological causes — ED can be caused by a stroke, penile trauma, diseases such as diabetes, spinal cord injury, or prostate surgery that damage nerves to the penis.
Medications — A large number of drugs that affect the nervous system and some that lower testosterone levels or inhibit testosterone action can cause ED. Opioids that are taken for chronic pain can also cause ED. Blood pressure medications, such as beta blockers, and antidepressants are commonly associated with ED.
Psychologic causes — Depression, performance anxiety, and lack of focus are common causes of what is known as "psychogenic" ED.
●Depression – Loss of libido and lack of interest in sexual activity are common symptoms of depression. ED is, in itself, a depressing experience for many men. Many men choose to accept a decline in sexual function as a natural consequence of aging. Because of shame or embarrassment, they do not discuss this problem with their health care provider. This is unfortunate because it is often possible to determine the cause(s) of sexual problems and many options are available to treat ED.
●Performance anxiety – Performance anxiety may develop in men who suddenly experience one or more erectile failures during intercourse. The focus of the sexual act shifts from a sensual experience to one filled with anxiety. During later attempts to have sex, the inability to acquire and maintain an erection becomes the focus of the sexual experience.
Diagnosis — Seeing a health care provider is the best way to find out what is causing your problems and how to address them.
In order to determine the cause of the dysfunction, the provider will take a sexual history, do a physical examination, and order blood tests to determine if conditions such as diabetes or low testosterone levels are contributing to your sexual problems. Sometimes more specialized tests, such as using medication to cause an erection and then evaluating penile blood flow with ultrasound, can also provide useful information. (See 'Testing' below.)
Sexual history — The provider will ask personal questions about your sex life to help determine the cause of the condition. While this might feel awkward, it is important to answer these questions honestly and provide as much detail as possible.
The provider will want to know if:
●ED developed slowly or happened suddenly
●There are erections during the night or in the morning when he first wakes up
●You experience ED with masturbation or only with a partner
●There are relationship problems with your partner(s)
●You have any risk factors for ED, such as a history of smoking, diabetes, obesity, high blood pressure, high cholesterol levels, alcohol or drug abuse, or depression
●You have already tried any medications to treat your ED
Physical examination — In addition to doing a basic physical examination, the provider may:
●Check pulses in the groin and feet
●Check the breasts for abnormal swelling, a condition called "gynecomastia"
●Examine the penis
●Check the testicles' size and for any abnormal testicular masses
●Check the prostate
Testing — Your provider may order tests to measure levels of testosterone, cholesterol, blood sugar, and thyroid hormones in your blood. Abnormally low testosterone and either low or elevated levels of thyroid hormones can cause sexual problems. All men with sexual problems should have blood tests.
If it turns out that you have a hormone imbalance, these tests may help to diagnose a more serious problem, such as growth in the pituitary gland or malfunction of the gonads. Even the most experienced health care providers cannot determine hormone levels by asking about the history and performing a physical examination; blood testing is necessary.
Treatments — The goal of treating ED is to enable a man to achieve and maintain an erection so that he can have sexual intercourse. Depending upon the cause of ED, treatment may include one or more of the following:
Lifestyle changes — Improving diet, exercise, and sleep and reducing stress can all potentially improve sexual problems such as ED and low libido.
Drugs and alcohol — Ask your doctor if one of your medications could be contributing to your ED. In some cases, there are different medications you could use instead. Quitting smoking and reducing or stopping alcohol can also be beneficial. If you are having trouble quitting smoking or cutting back on alcohol, your doctor can help.
Phosphodiesterase-5 inhibitors — Phosphodiesterase-5 (PDE-5) inhibitors work by increasing chemicals that allow the penis to become and remain erect. PDE-5 inhibitors open the blood vessels in the penis and allow more blood flow to come into the penis. They help a man to achieve an erection after sexual stimulation, but the medication does not increase sexual desire. These medications require sexual stimulation to cause an erection.
PDE-5 inhibitors are effective in restoring sexual function in up to 70 percent of men. They work best in men with psychogenic impotence (see 'Psychologic causes' above), though they can be used in men with other types of ED as well. In men with conditions that affect the blood vessels (such as diabetes), PDE-5 inhibitors are often effective. The success rate in men who have undergone prostate cancer surgery is between 25 and 30 percent.
Sildenafil — Sildenafil (brand name: Viagra) should be taken on an empty stomach one hour before planned sexual intercourse. Its effect lasts for approximately four hours; this refers to the timeframe that erection is possible if sexual stimulation occurs, not the duration of the erection. Only one dose should be taken per 24 hours.
Vardenafil, tadalafil, and avanafil — Vardenafil (brand name: Levitra), tadalafil (brand name: Cialis), and avanafil (brand name: Stendra) are PDE-5 inhibitors used to treat ED. Like sildenafil, men who take vardenafil may have an erection (in response to sexual stimulation) as soon as 30 minutes and for up to four hours after taking a vardenafil tablet (this refers to the timeframe that erection is possible if sexual stimulation occurs, not the duration of erection). No more than one dose should be taken per 24 hours.
Men who take tadalafil may have an erection within one hour (in response to sexual stimulation) and may be able to get an erection up to 36 hours after each dose (this refers to the timeframe that erection is possible, not the duration of erection). No more than one dose should be taken every 24 hours. Tadalafil can also be taken every day as a low-dose pill. Daily tadalafil can be helpful for men who respond poorly to an "on demand" PDE-5 inhibitor. It also may be prescribed for men with lower urinary tract symptoms (LUTS) as well as ED. Avanafil onset of action is as early as 15 minutes, which is somewhat faster than the other three PDE-5 inhibitors.
Use of PDE-5 inhibitors
●Side effects – Side effects of PDE-5 inhibitors include headache, flushed (red) skin, indigestion, and dizziness. Sildenafil may cause distorted (blue-tinged) vision. Side effects are generally short lived and resolve spontaneously.
●Drug interactions – Men who use nitrates (nitroglycerin) in any form, either on a regular basis or only as needed for chest pain, should never use PDE-5 inhibitors. Taking PDE-5 inhibitors and nitrates can lead to dangerously low blood pressure. PDE-5 inhibitors do not cause heart attacks.
Anyone who has used a PDE-5 inhibitor and then develops cardiac problems and requires nitrate medications should NOT use the PDE-5 inhibitor in the future. If you develop chest pain, contact your health care provider or go to the emergency department immediately. If you take tadalafil, wait at least 48 hours before taking a nitrate.
Certain medications (including erythromycin, ketoconazole, protease inhibitors, rifampin, phenytoin, and grapefruit juice) can alter the duration of time that sildenafil, vardenafil, and tadalafil remain in the blood stream, which can cause additional side effects. Your health care provider or pharmacist can provide specific information.
Medications such as doxazosin (brand name: Cardura) and terazosin (brand name: Hytrin), used to treat LUTS caused by an enlarged prostate (called benign prostatic hyperplasia [BPH]) should be used very cautiously with any of the PDE-5 inhibitors; the combination of these drugs can cause very low blood pressure. However, tamsulosin (brand name: Flomax), also prescribed for bothersome urinary symptoms caused by BPH, is safe to take with tadalafil as it does not cause a dangerous decline in blood pressure. It is not known if tamsulosin is safe to take with sildenafil or vardenafil. (See "Patient education: Benign prostatic hyperplasia (BPH) (Beyond the Basics)".)
Safety — It is not yet proven that sildenafil is safe for these groups:
●Men who have had a heart attack, stroke, or life-threatening irregular heartbeats (called arrhythmia) within the last six months
●Men with untreated low or high blood pressure
●Men with retinitis pigmentosa, a progressive eye disorder that can lead to blindness
Resuming sexual activity after a prolonged period of inactivity is similar to beginning a new exercise routine. Men considering a PDE-5 medication should be able to participate in an activity that is approximately equal to the energy required for sex. To assess whether your heart can tolerate sexual activity, your health care provider might ask if you are able to walk 1 mile in 20 minutes or climb up 2 flights of stairs in 10 seconds. These activities assess the degree of conditioning one would theoretically need to engage in sexual activity. Depending on your health, your provider may recommend exercise treadmill testing to ensure that sexual activity will be safe.
Nonarteritic ischemic optic neuropathy or NAION, a condition associated with loss of vision, has been reported in a few men who have taken sildenafil and tadalafil. Most of these cases occurred in men with underlying nerve or blood vessel disease. Contact your health care provider if you are taking a PDE-5 inhibitor and develop sudden vision loss in one or both eyes.
Purchasing medications for erectile dysfunction — A number of sources claim to sell medications such as Viagra, Cialis, Levitra, or herbal supplements for ED through the internet or by mail for a reduced cost, often without a prescription. These sources are not known to be safe or reliable, and it is not possible to know whether the pills from these sources contain the actual drug or are counterfeit.
It's important to avoid potentially unreliable sources for any medication. Community pharmacies or reputable web-based pharmacies are the most reliable source for all types of medications. Talk to your doctor or nurse if you have concerns about affording your medication.
Penile self-injection — With penile self-injection, the person injects a medication (alprostadil or papaverine) into the corpora cavernosa (the two chambers of the penis that are filled with spongy tissue and blood). This causes an erection by allowing the blood vessels within the penis to expand so that the penis first swells and then stiffens to create a fully rigid erection (figure 1). The erection created by penile injection occurs without sexual stimulation (different from the erection that occurs after taking sildenafil, vardenafil, or tadalafil).
It takes some training for men to feel comfortable with this type of therapy. Under the guidance of urologists, men are shown how to make the skin on the penis sterile and how to inject the medication properly (figure 2). The first injection should be done in the office under direct supervision. Although this treatment works well for erections, many men eventually stop using it because of discomfort from the injections.
Side effects — Pain is the most common side effect. Men often say that this is the reason they discontinue this type of treatment.
There is also a small risk that the penis will remain erect after intercourse. This occurs in 6 percent of men who use alprostadil and approximately 11 percent of those who use papaverine. Prolonged erection, called "priapism," that lasts longer than four hours is a medical emergency. Contact your health care provider immediately if this happens. An emergency procedure must be done as soon as possible to empty the blood that is trapped in the penis. An erection that lasts longer than 48 hours often results in scarring of the tissue inside the penis.
Intraurethral alprostadil (MUSE) — This treatment uses the same medication (alprostadil) as penile self-injection. Instead of injecting it, the man inserts a device with an alprostadil pellet (suppository) into the urethra. The urethra is the opening in the center of the penis from which urine flows. The alprostadil is then absorbed into the erectile bodies (corpus cavernosum) to create an erection. Currently MUSE is not readily available from most pharmacies.
Side effects — Side effects include pain as the blood vessels in the penis widen and swell to create the erection. Other side effects include bleeding from the urethra and lightheadedness. The first dose should be given in a health care provider's office to make there are no side effects. Problems like prolonged erection and scarring on the outside of the penis are less common than with self-injection therapy.
Vacuum-assisted erection devices — There are several products on the market that involve placing the penis in a plastic cylinder and creating a vacuum around the penis. This increases blood flow into the penis. A rigid ring is placed at the base of the penis (near the body) to hold the blood inside the penis, allowing it to remain erect. Vacuum devices successfully create erections in as many as 67 percent of cases. Satisfaction with vacuum-assisted erections varies between 25 and 49 percent.
Vacuum-assisted devices require that a man be able to hold and pump the unit. It may take a week or more for the device to work effectively. After a man is accustomed to using the device, he can usually create an erection that is rigid enough for penetration and sexual intercourse. He will not be able to ejaculate because the ring that holds blood in the penis also compresses the urethra, preventing semen from exiting. The ability to have an orgasm is not affected by the ring.
Penile prostheses — A penile prosthesis is a device that is surgically implanted and inflates to allow the penis to become erect (figure 3). Penile prostheses can be semi-rigid rods or inflatable cylinders that are inserted into the corpora cavernosa. Penile prostheses are used less frequently because of the popularity of PDE-5 inhibitors and penile injection therapies. For men who do not respond to these therapies or who find vacuum erection therapy distasteful, penile prostheses are an option.
Side effects — Side effects of prosthetic devices include the possibility of infection, erosion, pain, and mechanical failure. Mechanical failure may require surgically removing the prosthesis and implanting a new one.
Revascularization — Revascularization (a procedure to restore blood flow) is reserved for young men who have experienced pelvic trauma. Revascularization of penile arteries is rarely successful for chronic vascular insufficiency (a condition in which the blood vessels do not work effectively, so blood flow throughout the body is impaired).
Testosterone replacement therapy — Testosterone therapy is prescribed if a man's testes do not make enough of the hormone testosterone. It is of no benefit in improving sexual function in men whose bodies make normal amounts of testosterone. Testosterone levels are measured with blood tests.
Men with low blood testosterone levels may have diminished libido (sex drive), ED, decreased muscle mass, increased fat, and they are at increased risk for thinning of the bones (osteoporosis). Treatment is designed to increase a man's testosterone level, libido, erectile function, and muscle mass; bone density usually improves as testosterone levels return to normal. Current guidelines suggest that testosterone should not be used by itself as first-line therapy to treat ED. Testosterone can be used with a PDE-5 inhibitor as testosterone has been shown to increase the efficacy of the PDE-5 inhibitor. (See "Patient education: Androgen replacement in men (The Basics)" and "Patient education: Low testosterone in men (The Basics)".)
Psychotherapy and psychoactive medications — Depression and anxiety can cause ED. Often these problems can be treated using psychological counseling, antidepressant drugs, or both. If you are struggling with performance anxiety, your health care provider may refer you to a certified sexual therapy counselor.
Medications are used to treat both depression and anxiety. They are very effective, though some (especially those of the serotonin reuptake inhibitor [SSRI] class) can cause decreased sex drive and ED. On the other hand, some antidepressant drugs can cause delayed ejaculation, which can be helpful for men with premature ejaculation. (See "Patient education: Depression treatment options for adults (Beyond the Basics)".)
DISORDERS OF EJACULATION
Premature ejaculation — Premature ejaculation is defined as ejaculation that occurs too early, before the man is ready. This can cause distress in the man and/or his partner. Premature ejaculation causes the penis to become flaccid (limp), making penetration more difficult.
Treatments — Antidepressant drugs prolong the time between arousal and ejaculation in some men. These are regarded as the most successful treatment for premature ejaculation. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), such as sertraline and paroxetine. The tricyclic antidepressant clomipramine has been reported to be more effective than SSRIs, although it can cause dry mouth. These medications can be taken on a regular (daily) basis; intermittent use (three to four hours before planned sex) works well for some men.
Other treatment options include topical lidocaine (to decrease sensation) and sex therapy.
Delayed or inhibited ejaculation — In this condition, men have no difficulty acquiring and maintaining an erection but are unable to climax (orgasm) and ejaculate. This can occur with some antidepressant medications (SSRIs). Adjusting the medication dose is often helpful. Sex therapy can also be helpful in men suffering from this condition.
PEYRONIE'S DISEASE — Up to 7 percent of men can experience an abnormal curvature of their penis when it is erect. This is known as Peyronie's disease. The most common cause of Peyronie's disease is penile trauma that occurs during sexual intercourse. The penis develops a scar, and this scar then causes the penis to bend when it is erect. Significant penile curvatures can result in pain, poor erections, and an inability to engage in sexual intercourse. If the penis bends more than 60 degrees, this usually means the man is unable to have intercourse. Many men are extremely distressed by this curvature of their penis.
Treatments — There is currently only one US Food and Drug Administration (FDA)-approved treatment, known as collagenase (brand name: Xiaflex) injections. These injections are placed directly into the penile plaque, and they help remove the scar tissue. Studies have found that men typically experience a 30 to 40 percent improvement in penile curvature after completing this type of therapy.
WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Sex problems in males (The Basics)
Patient education: Recovery after coronary artery bypass graft surgery (CABG) (The Basics)
Patient education: Paraplegia and quadriplegia (The Basics)
Patient education: Sex as you get older (The Basics)
Patient education: Androgen replacement in men (The Basics)
Patient education: Low testosterone in men (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Benign prostatic hyperplasia (BPH) (Beyond the Basics)
Patient education: Depression treatment options for adults (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Symptom management of multiple sclerosis in adults
Approach to older men with low testosterone
Evaluation of male sexual dysfunction
Side effects of androgen deprivation therapy
Epidemiology and etiologies of male sexual dysfunction
Sexual activity in patients with cardiovascular disease
Sexual dysfunction caused by selective serotonin reuptake inhibitors (SSRIs): Management
Surgical treatment of erectile dysfunction
Treatment of male sexual dysfunction
The following organizations also provide reliable health information.
●National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
●National Institute of Diabetes and Digestive and Kidney Diseases
●Urology Care Foundation
●Hormone Health Network
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