In Memoriam: Dr. Graham Jackson

G.Jackson

In Memoriam: Dr. Graham Jackson

We bear tragic and unexpected news, of a great man and legend in his field. Dr Graham Jackson, sadly, and prematurely, died on the 28th April 2016. He had a debilitating illness which he fought bravely, and without complaint, working and sending messages, right up to the very last minute.

He was a Consultant Cardiologist at London Bridge Hospital, London, and BMI Shirley Oaks Hospital in Croydon, Surrey. Graham’s NHS medical base was as a senior cardiologist at Guy’s and St Thomas’ Hospitals.

His special interest included the detection, management and treatment of sexual dysfunction in cardiac patients. He was the first cardiologist to establish a clinic specifically for patients with sexual dysfunction and cardiovascular disease in the UK.

He was the principal UK investigator in several lipid lowering trials including PROVE-IT and published widely on sex and the heart and on the perils of counterfeit medicines.

He was a member of the International Society for Sexual Medicine Standards Committee and a prominent speaker at the American Heart Association, the American College of Cardiology, and the British/European Society of Cardiology/World Congress of Cardiology meetings, and at many meetings nationally and internationally on sexual problems in cardiac patients.

In 2010 he was appointed president of the World Congress of Men’s Health and continued as president in 2011. He was on the board of the International Society of Men’s Health.

He has for many years been advocating the need for aggressive cardiac risk reduction in men with erectile dysfunction (ED) and no cardiac symptoms, using ED as a means of reducing subsequent cardiac events. He was editor of the book series Difficult Cardiology and has authored numerous books, including Angina in Practice; Sex, the Heart and Erectile Dysfunction; and The Practical Management of Ischaemic Heart Disease. The fourth edition of his book for patients, Heart Health at your Fingertips, was published in 2009. He has published more than 400 papers on cardiology and general medicine and was a well-respected member of several editorial boards. He was also emeritus editor of the International Journal of Clinical Practice after 22 years as editor-in-chief, and chairman of the Sexual Advice Association (www.sexualadviceassociation.co.uk), a role he loved and really cared about.

His death has shocked and saddened us all and our thoughts are with his family, friends and colleagues who will miss his humour, goodwill, sound advice and caring nature. He is irreplaceable and a great loss to the field of medicine.

New app addresses sexual health issues in the UK

Sexual Advice Association aims to overcome the communication barriers around discussing sexual problems; 50% of people will experience sex-related problems in their life

The Sexual Advice Association, a UK charity focussed on improving sexual function and wellbeing, today announced the launch of a free smartphone app designed to allow people to ask the questions about their sex lives that they didn’t feel comfortable asking before. The SMART app provides an option for people to get expert advice to address their concerns about sexual problems, in their own time and in complete privacy.

Designed by health professionals for use by men and women anywhere in the world, the SMART app provides anonymous access to a range of validated tests and questionnaires to assess people’s concerns about their sexual health and provide information, guidance and sound advice. Completely secure, it covers issue such as lack of sex drive, erectile dysfunction and premature ejaculation, and can be used by individuals, couples together or by one partner on behalf of another.

Sexual problems will affect around 50% of men and women in the UK at some point in their lives, and can be an early indicator of underlying health problems, but only about a quarter of people with a problem seek help from a health professional.

“The fact is that the British people are still not comfortable talking about sexual health,” said Mike Kirby, SAA Trustee and professor of men’s health at the University of Hertfordshire and the London Prostate Centre. “Not only does this have a negative impact on relationships, but sexual health issues like erectile dysfunction can also be indicators of underlying health issues like heart disease and diabetes. The SMART app gives people a new option for addressing their concerns privately and securely.”

“The SMART app lets people take the first steps in addressing sexual health issues in the privacy of their own home, and helps remove the doubt and misinformation associated with searching the internet,” said Victoria Lehmann, SAA Trustee and sex and relationship therapist at London Urology Associates. “It can also help reassure people that nothing may be wrong and can also help give them the right words if they do need to seek professional help.”

The SMART app:

  • Contains comprehensive information and advice relating to a wide array of sexual issues affecting men, women and couples.
  • Is PIN protected, so people can explore their sexual health concerns in complete privacy.
  • Is completely private. All information entered into the app is anonymous, so personal data is fully protected.
  • Can be downloaded for free and used across the world by anyone with an iOS or Android smartphone.
  • Is available for download from the App Store and Google Play.
The SMART SAA app shown on Android and iOS (iPhone) devices
The SMART SAA app shown on Android and iOS (iPhone) devices

About the Sexual Advice Association
Founded in 1995, the Sexual Advice Association is a charitable organisation created to help improve the sexual function and wellbeing of men and women, and to raise awareness of the extent to which sexual conditions affect the general population.

As the only national patient association of its kind, the Sexual Advice Association is committed to helping and supporting people, and partners of people, with all forms of sexual problems by raising awareness about sexual functioning and wellbeing; providing information and education on male and female sexual problems, and; improving the public’s understanding of the seriousness and causes of male and female sexual disorders. The charity runs a confidential helpline and email enquiry service: +44 (0)207 486 7262 or [email protected]

For more information, or to download the app, visit www.sexualadviceassociation.co.uk

Notes to editors:

Download images relating to this story: www.sexualadviceassociation.co.uk/gallery/

Supporting information:

Erectile dysfunction: https://sexualadviceassociation.co.uk/erectile-dysfunction/

Women’s sexual problems: https://sexualadviceassociation.co.uk/womens-sexual-problems/

As a charitable organisation, the SAA relies on grants and donations to cover its costs. All donations to the SAA are gratefully received and can be made at: www.sexualadviceassociation.co.uk/donate/

All SAA Trustees are available to answer questions relating to this story.

Prof. Mike Kirby and Victoria Lehmann are both Trustees of the Sexual Advice Association and experts in the field of sexual health. Together they co-authored the book Sleeping with ED, published by National Services for Health Improvement.

No personal identification information is collected by the app at any point, although some anonymous test data is shared with the Sexual Advice Association for research purposes.

The cost of development of the app was covered in part by American Medical Systems and Pfizer Inc. No data from the app is shared with either party and there is no promotion or recommendation of any commercial products within the app.

Media contact:

Danny Sullivan
OOKII Company
[email protected]
+44 (0)772 497 4255

Vaginal dryness and the menopause

What is the menopause?

The menopause is when a woman’s periods stop permanently because the ovaries no longer produce oestrogen or release eggs. This may occur naturally or as a result of the ovaries being removed by surgery, or damaged by chemotherapy or radiation. A natural menopause is usually confirmed by a year of no periods.

The time before your last period, when your hormone levels are falling, is known as the ‘perimenopause’. This usually starts in the mid to late 40’s and lasts about 4 years. In the UK, the average age at which the menopause occurs naturally is 51, and it happens about 2 years earlier in smokers. If it happens before the age of 40, it is considered premature.

The start of the perimenopause is marked by changes in the menstrual cycle. These include changes the amount of time between bleeds (which may shorten or lengthen) and changes in the amount and duration of bleeding. Then periods start to be missed altogether.

Women in the perimenopause report a variety of different symptoms. These include hot flushes, night sweats, difficulty sleeping, tiredness, mood changes, memory loss, joint and muscle pain, breast tenderness, urinary incontinence, vaginal dryness, a lack of interest in sex, headache and weight gain. However, not all of these symptoms appear to be specifically related to the hormonal changes that occur during the perimenopause. For example, trouble sleeping may be due to bothersome hot flushes and night sweats, memory loss and tiredness may be due to trouble sleeping or frequent hot flushes, and a lack of interest in sex may be due vaginal dryness causing pain during sex.

Menopause symptoms usually continue for around 4 years after the last menstrual period, but in about 10% of women, they may last up to 12 years. However, every woman experiences the menopause differently. Your symptoms may be severe and distressing, or mild and short-lived, or you may have no symptoms at all. Women who have had a hysterectomy (surgical removal of the uterus/womb) can still experience menopause symptoms.

How does it affect the vagina?

Reduced oestrogen levels may cause a number of changes in the vagina, including thinning of the walls, reduced elasticity, reduced blood flow and reduced lubrication (‘wetness’). Changes in vaginal fluid promote the growth of ‘bad’ bacteria and increase the risk of both vaginal and urinary tract infections.

Vaginal symptoms as a result of these changes may include dryness, itching, discomfort and pain during or after sex (see our factsheet ‘Pain during/after sex’ for more information on this). However, these symptoms may not appear until many years after the last menstrual period.

In women, testosterone is also produced in the ovaries and it is linked to female sexual function. A lack of sexual desire (also known as a lack of ‘sex drive’ or ‘libido’) may be associated with a drop in testosterone levels. A lack of sexual desire may in turn cause a lack of sexual arousal (not feeling ‘turned on’), which may include a lack of vaginal lubrication. A lack of testosterone may be more noticeable in women who have had their ovaries removed by surgery (oo-phorectomy), as their testosterone levels suddenly fall.

Of the vaginal symptoms that occur with the menopause, a lack of lubrication during sex is often the first to be noticed. Vaginal lubrication plays an important role during sex and women are usually expected to produce a moderate amount. Women have reported that they prefer sexual intercourse to feel ‘wetter’, feel more able to orgasm when sex is wetter, and think that their partner prefers sex that feels more wet than dry.

In an American study, vaginal discomfort related to menopausal changes caused 58% of women to avoid sex, with 59% finding sex painful and 64% reporting a loss of libido. Around 30% of women and men in the study said vaginal discomfort was the reason they stopped having sex altogether.

Research conducted in the United States and Europe has shown that moderate to severe vaginal symptoms may reduce a woman’s quality of life as much as serious conditions like arthritis, asthma, chronic lung disease and irritable bowel syndrome.

However, many women don’t seek help for vaginal symptoms. And unlike the other menopause symptoms, which tend to reduce in the years following the last period,
Vaginal dryness is likely to get worse if it is not treated.

How is it diagnosed?

Your doctor can probably tell if you are perimenopausal or menopausal depending on your age, menstrual cycle and symptoms. Diagnosis may be more difficult if you are taking hormonal treatments (e.g. to treat heavy periods).

They might need to examine you. This may include examination of your external genitals or ‘vulva’, which includes the opening of the vagina, the fleshy lips surrounding this and the clitoris. They may also examine the inside of your vagina with gloved fingers and/or a speculum (a plastic instrument which is inserted into the vagina and gently widened to allow better visual examination).

Your doctor may want to do a ‘swab’ or urine test to check for infection. A ‘swab’ is where a kind of cotton bud on a long stick is rolled over the skin on the inside or the outside of the vagina to collect discharge or skin cells and then sent away to the laboratory to see what bacteria are present. They may also want do blood tests to check your hormones/general health.

If your doctor is not confident in diagnosing or treating you, or they think you require more tests, they may refer you to a gynaecologist or other specialist at your local hospital.

How is vaginal dryness treated?

Hormonal treatments

If the menopause is responsible for your lack of lubrication, you may benefit from hormone replacement therapy (HRT).

Oestrogen can be given either systemically to increase levels throughout the whole body, or vaginally to increase levels in this area only.

Systemic oestrogen will also help other menopausal symptoms such as hot flushes. If you have a uterus/womb, this should be combined with another hormone called progesterone. If you have had a hysterectomy, you can take systemic oestrogen alone. Systemic HRT can be taken orally as a tablet, inserted under the skin as an implant, or applied topically as a patch or skin gel.

Vaginal oestrogens may be more suitable if a lack of lubrication is the main issue for you, or if you are unable to take systemic HRT for medical reasons. They can also be used with systemic HRT. These preparations are inserted into the vagina and come as a pessary, ring or cream. Vaginal HRT contains low doses of oestrogen and does not need to be combined with progesterone.

Research has shown that in women using vaginal oestrogen therapy to treat vaginal discomfort, 58% found sex less painful, 41% found sex more satisfying and 29% found it improved their sex life. What’s more, 57% of men looked forward to having sex because of their partner’s vaginal oestrogen therapy.

Several studies have shown a benefit of testosterone therapy in women who have been through the menopause, but mainly in those using oestrogen. In the UK, the only licensed testosterone treatment for many years was an implant put under the skin using local anaesthetic. Testosterone gel and testosterone patches have also been used, but the patches have been withdrawn and the gel is not licensed for use in women.

Tibolone (Livial®) is often classed as a type of systemic HRT. It is a man-made steroid with similar effects to the female hormones oestrogen and progesterone as well as testosterone. It can improve menopausal symptoms and a lack of sexual desire.

It is important to remember that although HRT offers numerous health benefits, it is also associated with some risks, particularly when used systemically. Ask your doctor to discuss these with you.

Complementary and unregulated preparations

There is some evidence that complementary therapies and unregulated preparations may relieve menopause symptoms. Examples include isoflavones, black cohosh and St. John’s Wort. However, many different preparations are available, their safety is uncertain, and they may interact with other medicines.

Vaginal lubricants and moisturisers

If vaginal dryness is a problem, this may be improved with lubricants and moisturisers. These products can be used alone or in addition to vaginal oestrogen.

Vaginal lubricants are used at the time of sexual intercourse. There are many different kinds available and they can be bought over-the-counter. Some are also available on prescription. They may be water-based (e.g. KY® Jelly), silicone-based (e.g. Replens™ Silky Smooth Personal Lubricant) or oil-based (e.g. peach kernel or sweet almond oils). The oil-based products may damage the latex in condoms, and it’s important to remember this if you want to prevent a pregnancy or sexually transmitted infection (STI). Some lubricants may feel better and last longer than others, so it is worth trying the different types to see which works best for you.

Vaginal moisturisers (e.g. Replens™ MD Longer Lasting Vaginal Moisturiser) help retain moisture in the vagina. These can be applied regularly and at least 2 hours before sex. They are available over-the-counter or on prescription.

Cognitive behavioural therapy

If your menopause symptoms are affecting your mood or causing you anxiety, you may benefit from Cognitive behavioural therapy (CBT). This is a type of ‘talking therapy.’ Your doctor may be able to refer you for CBT on the NHS, or you can pay to see a therapist privately – ask your doctor if they can recommend someone locally, otherwise you can find a register of accredited CBT therapists in the UK on the British Association for Behavioural & Cognitive Psychotherapies (BABCP) website www.babcp.com and a directory of chartered psychologists, some of whom specialise in CBT, on The British Psychological Society (BPS) website www.bps.org.uk

If you are experiencing sexual problems, as a result of the menopause or otherwise, you may benefit from sex therapy (see the following section on this). Some sex therapists also offer CBT.

Sex therapy

Sex therapy is talking therapy where an individual or couple work with an experienced therapist to assess and treat their sexual and/or relationship problems. Together they will identify factors that trigger the problems and design a specific treatment programme to resolve or reduce their impact.

Sex therapy is considered highly effective in addressing the main causes and contributing factors of sexual difficulties. And it helps people to develop healthier attitudes towards sex, improve sexual intimacy, become more confident sexually, and improve communication within the relationship.

Sex therapy can also be used in combination with other forms of treatment. Your GP or another health professional on the NHS may be able to refer you for sex therapy (depending on area), or you can contact a therapist directly and pay privately. It is important to make sure that they are qualified and are registered with an appropriate professional body. You can find more information on sex therapy in our factsheets ‘Sex therapy’ and ‘How to find, choose and benefit from counselling support’
How can you help yourself?

You may be able to improve some of your menopause symptoms yourself by eating a healthy, balanced diet, maintaining a healthy weight and exercising regularly (for more information see our factsheets, ‘The Mediterranean diet’, ‘Body Mass Index (BMI)’ and ‘Physical activity’).

Finally, having sex is good for you! Sexual activity has been shown to reduce vaginal changes associated with the menopause and women who have sex report fewer vaginal symptoms than those who do not (see our factsheet on ‘Lack of sexual desire/arousal’ for self-help tips on increasing a lack of sexual desire and/or arousal).

What is the Take Home Message?

Menopause-related vaginal dryness should not mean an end to all sexual activity – effective treatments are available

Where can you get more information?

The Sexual Advice Association is here to help. We cannot give individual medical advice, but we can answer your questions on any sexual problems and put you in touch withlocal specialist practitioners. We also have a number of factsheets and booklets on sexual problems and related issues for men and women that can be downloaded from our website or requested. Please feel free to email us or phone our Helpline (our contact details are at the bottom of this page).

You can also visit the NHS Choices website at www.nhs.uk for information and advice on many different health and lifestyle topics.

Further reading

Download or request our factsheet ‘Explaining sexual problems to your GP’

Donate

By donating to the Sexual Advice Association, you will know that you are helping improve the lives of people living with sexual problems. If you are interested in donating, please click here or contact us for more information (details at the bottom of this page).

Thinking About Sex Day: February 14th

Launched by the Sexual Advice Association, Thinking About Sex Day (TASD) is designed to encourage everyone to think about the physical and psychological issues surrounding sexual activity.

Pain during or after sex

What is it?

Pain felt during or after sex is known as dyspareunia (pronounced dys- par- eu- nia). Occasional dyspareunia is normal, with deep penetration for example. But this becomes a problem if it is felt often, stops a woman from having or enjoying sexual intercourse and/or causes her distress.

Dyspareunia is one of the most common gynaecological complaints, thought to affect between 8-22% of women. It may also be one of the most difficult gynaecological problems to assess and treat successfully.

Dyspareunia may be classed as superficial (felt in the tissues around the entrance of the vagina) or deep (felt deeper within the pelvis on penile thrusting), depending on the site of the pain. Dyspareunia may have been present from the time a woman first started having sex or it may have developed later in life.

What are the causes?

These may be physical (in the body), psychological (in the mind) or a mixture of both.

Physical causes of superficial dyspareunia include:

  • Skin conditions (e.g. allergy to the latex, plastic or spermicide in condoms, allergy to semen, eczema, Lichen sclerosus, Lichen planus)
  • Infectious conditions (e.g. frequent thrush, sexually transmitted infections, urinary tract infection)
  • Lack of lubrication (causes include a lack of sexual arousal, hormone problems, some prescription medicines and radiotherapy to the pelvis)
  • Vulvodynia (long-term burning or itching pain without obvious medical cause that affects the external genitals or ‘vulva’)
  • Interstitial cystitis (inflammation of the bladder which may cause pain in the pelvis or abdomen/tummy)
  • Structural problems causing obstruction (e.g. injury/scarring from episiotomy, trauma from giving birth or female circumcision, an abnormal hymen, a cyst or abscess)
  • Muscular problems (e.g. vaginismus – a severe tightening of the vaginal muscles during penetration)

Physical causes of deep dyspareunia include:

  • Infectious/inflammatory conditions (e.g. pelvic inflammatory disease, endometriosis, inflammation of the cervix, blockage of the fallopian tubes)
  • Structural problems (e.g. uterine fibroids or pelvic adhesions following surgery or radiotherapy)
  • Muscular problems (e.g. spasm of the pelvic floor muscles)
  • Irritable bowel syndrome
  • Lack of lubrication

Dyspareunia may also be caused by sexual position, as some allow deeper penetration than others.

Psychological issues

Regardless of the cause, if sex is painful, it is likely to cause you emotional as well as physical distress. And psychological issues, such as anxiety, relationship problems and a history of sexual abuse/violence may contribute to, or even be responsible for, the symptoms of dyspareunia.

How is it diagnosed?

Many symptoms of dyspareunia are non-specific, which means they may be caused by a number of different conditions (not all of which are included in this factsheet). It is therefore important that you see your doctor, so they can try and find out what is causing the problem and plan the best treatment approach.

Your doctor is likely to ask you about your pain, your lifestyle and any other medical and/or psychological issues. They will almost certainly need to examine you, to see you have any obvious physical cause/s for the pain. This is likely to include examination of your external genitals or ‘vulva’, which includes the opening of the vagina, the fleshy lips surrounding this and the clitoris. They may apply pressure to certain areas to see where you feel the pain. You may also need an internal examination of the inside of your vagina. Your doctor may do this with gloved fingers and/or a speculum (a plastic instrument which is inserted into the vagina and gently widened to allow better visual examination).

Your doctor may want to do a ‘swab’ or urine test to check for infection. A ‘swab’ is
where a kind of cotton bud on a long stick is rolled over the skin on the inside or the outside of the vagina to collect discharge or skin cells and then sent away to the laboratory to see what bacteria are present. They may also want do blood tests to check your hormones/general health.

If your doctor is not confident in diagnosing or treating you, or they think you require more tests, they may refer you to a gynaecologist or other specialist at your local hospital.

More about the causes and how they are treated

Skin conditions

If you are allergic to something that touches your skin, you may get localised symptoms (e.g. redness, swelling, pain and itching) in the affected area/s. But some people have more serious reactions that affect their whole body (they may develop hives, swelling, difficulty breathing and anaphylaxis, which can be life threatening).

If you have an allergy to, or are irritated by latex, plastic or spermicide, you should be able to get condoms that are less likely to cause a reaction. Ask your pharmacist for advice on this. If you are allergic to latex or spermicide, you will not be able to use a contraceptive diaphragm, as these are made of latex and should be used with a spermicide. If you have an allergy to semen, you should not get any symptoms when you use a condom.

If you have eczema as a result of allergy or irritation (contact dermatitis), you and your doctor will need to identify what may be causing the problem and remove it. Treatment usually involves topical steroid creams/ointments. Ice packs (e.g. frozen peas) applied for a short time (to cool the area not freeze it!) and antihistamines can be used to relieve the itching.

Skin conditions like Lichen sclerosus and Lichen planus may be treated with topical steroid creams/ointments. If the problem is internal, you may need steroid suppositories (inserted into the vagina). Oral treatment (tablets) may be required if the other treatments don’t work. These products should be prescribed by a doctor.

Infectious conditions

Thrush may be passed on through sexual contact or it may develop for other reasons (e.g. during pregnancy, from wearing tight clothing, from taking antibiotics, using products that cause irritation to the vagina). Antifungal treatment for thrush can be taken orally as a tablet (e.g. fluconazole/Diflucan®), applied topically as a cream (e.g. clotrimazole/Canesten® cream) or used internally as a pessary (e.g. clotrimazole/Canesten® pessary). These products are available on prescription or over-the-counter at the pharmacy. If your partner has thrush, they will need to be treated too.

The symptoms of a sexually transmitted infection (STI) vary depending on which type it is, but they may include a fever or flu-like symptoms, unusual vaginal discharge, genital itching, burning, pain or discomfort, lower abdominal/pelvic pain, swollen lymph glands, pain when passing water, pain and/or bleeding during or after sex, and bleeding between periods.

Pelvic inflammatory disease (PID) is a general term for infection of the upper genital tract, which includes the uterus/womb, fallopian tubes and ovaries. The infection (often chlamydia) is usually transmitted during sex. If it is not treated early, PID may damage the fallopian tubes, which increases the risk of ectopic pregnancy (where the pregnancy develops outside of the uterus/womb) and infertility.

If you are worried you have an STI but don’t want to see your GP, you can visit a Genito-Urinary Medicine (GUM) clinic. You can find more information on STIs and search for local GUM clinics on the Family Planning Association (FPA) website www.fpa.org.uk and the British Association for Sexual Health and HIV (BASHH) website www.bashh.org. Remember that using a condom can reduce your risk of catching an STI.

A urinary tract infection (UTI), also known as ‘cystitis’, may cause pain in the bladder area, pain when passing water, a need to pass water often, blood in the urine, urine that is dark in colour or strong smelling and a fever (38ºC or more). Your doctor can test your urine to see if you have an infection. If a UTI is mild, it may clear up within a few days without the need for antibiotics. If it is severe and/or doesn’t clear up quickly, it should be treated with antibiotics. If you suffer from frequent UTIs, you may be able to reduce these by:

  • Drinking cranberry juice or taking cranberry tablets
  • Drinking plenty of bland fluids (e.g. 3-4 pints of water, milk or weak tea) to help flush germs out of the bladder and urinary tract
  • Keeping yourself very clean ‘down below’ by using a separate flannel to wash yourself night and morning
  • Using plain water only for washing
  • Always wiping from ‘front to back’ after opening your bowels
  • Avoiding bubble baths, talcum powder, vaginal deodorants & feminine wipes
  • Avoiding having a bath every day. A shallow bath is better than a deep one and a shower is better still
  • Passing water immediately after having sex

Lack of lubrication

If a lack of sexual arousal (not feeling ‘turned on’), is responsible for your lack of lubrication, increasing the amount of foreplay and delaying penetration until you are really ‘ready’ may help increase vaginal lubrication and reduce pain with intercourse. (see our factsheet ‘Lack of sexual desire/arousal’ for more information).

Vaginal dryness is common during and after the menopause due to reduced levels of the hormone oestrogen. Oestrogen deficiency can be treated with hormone replacement therapy (HRT – see our factsheet ‘Vaginal dryness and the menopause’ for more information). Thyroid problems resulting in high or low levels of the hormone thyroxine have also been associated with lubrication problems. Thyroid problems can be treated with medication or surgery.

Some prescription medicines may reduce vaginal lubrication. Examples include oral contraceptives, some antidepressants and some medicines for treating high blood pressure. If you are worried about this, talk to your doctor as alternatives may be available.

A lack of vaginal lubrication may also be associated with psychological issues, such as relationship worries, depression, anxiety and low self-esteem. If this is the case, you may benefit from sex therapy (see the following section on this).

Vaginal dryness may be improved with lubricants and moisturisers (see our factsheet ‘Sexual problems in women’ for more information).

Vulvodynia

There are two types of vulvodynia. Unprovoked vulvodynia is where the pain occurs spontaneously (i.e. is not caused by pressure or local contact) and this can affect any part of the vulva. Provoked vulvodynia (also known as vestibulodynia) commonly occurs around the entrance to the vagina (vestibule), where the pain is caused by sexual or non-sexual touch (by sexual intercourse, inserting tampons, tight clothing, cycling etc.) Urinary tract or bowel problems, such as interstitial cystitis or irritable bowel syndrome are often associated with provoked vulvodynia.

Medical treatments include topical preparations which are applied to the affected area (e.g. steroids, lidocaine or oestrogen), injectable medications (e.g. lidocaine) and oral medications that are taken by mouth (e.g. some types of anticonvulsant and antidepressant). Pelvic floor physiotherapy or psychological/talking therapy (e.g. sex therapy) may also help (see the following sections on ‘Physiotherapy’ and ‘Sex therapy’). Surgery may be required as a last resort.

Making small changes in your life may reduce the likelihood of vulvodynia. These include:

  • Minimising pressure/friction on the vulva (e.g. sitting, cycling, horse riding)
  • Washing the vulva no more than once per day using mild soaps
  • Avoiding scented products
  • Avoiding shaving around the vulva
  • Using 100% cotton underwear
  • Using gentle washing powders/liquids
  • Avoiding wearing clothes that are too tight
  • Avoiding chlorinated pools/hot tubs (alternatively, applying petroleum jelly to the vulva before their use may provide protection from chlorine)
  • Removing wet swimming costumes and exercise clothes quickly
  • Trying to find a sexual position that is comfortable (you may be better off on top)
  • Trying a water based lubricant
  • Experimenting with different sexual positions/speeds
  • Passing water straight after intercourse
  • Trying an oral medication (tablet) for treating thrush rather than a cream/pessary

Interstitial cystitis

Also known as ‘painful bladder syndrome’, symptoms include a sudden, strong need to pass water, needing to pass water more often (night and day) and severe pain in the pelvis or abdomen/tummy. It is not caused by infection and can be difficult to treat.

Lifestyle changes are usually tried first. These include:

  • Reducing stress
  • Avoiding certain foods/drinks
  • Stopping smoking
  • Limiting fluid intake
  • Making regular trips to the toilet

Your GP or specialist can give you more information on these. If lifestyle changes don’t solve the problem, medication may be required. Some people require physiotherapy (see the following section on this), psychological/talking therapy (e.g. ‘Sex therapy’ – see the following section on this), surgery or other procedures.

Endometriosis

Endometriosis is where cells like those lining the uterus grow elsewhere in the body. These cells behave in the same way as those in the uterus and follow the menstrual cycle, so each month they build up, break down, then bleed. However, while the blood of a period can leave the uterus through the vagina, it can’t leave from anywhere else in the body. This is a long-term, debilitating condition which causes painful and/or heavy periods. It may also lead to tiredness, depression, sexual problems and infertility. It affects women and girls of childbearing age.
If your doctor thinks you may have endometriosis, he will probably refer you to a gynaecologist for further tests. The results of these tests will determine if you need medical or surgical treatment. Medical treatment usually involves pain relief and/or hormonal treatment.

Inflammation of the cervix

Also known as ‘cervicitis’, this may be caused by sensitivities, allergies or infections (often transmitted during sex). Cervicitis may not cause any symptoms, but if it is not diagnosed and treated, it can lead to other problems such as PID. The most common symptoms include vaginal discharge and bleeding after sex or between periods. Infections are usually treated with antibiotics.

Blockage of the fallopian tubes

The fallopian tubes link the ovaries to the uterus. If they are blocked an egg may not be able to pass through and fertility will be affected. Blockages may be caused by pelvic infections (e.g. PID) which are often transmitted during sex, surgery to the pelvis or abdomen, and ectopic pregnancy. Surgery may be required to treat this.
Structural problems

Structural problems causing blockage or pain may require surgery. Your doctor or specialist will be able to advise you on this.

Muscular problems

For more information on vaginismus, see out factsheet ‘Vaginismus’. Problems affecting the muscles of the pelvic floor may be best treated by a physiotherapist (see the following section on ‘Physiotherapy’).

Irritable bowel syndrome

Irritable bowel syndrome (IBS) describes a variety of unexplained symptoms relating to disturbance in the bowel. Symptoms may include abdominal pain and spasms (often relived by going to the toilet), sharp pain in the back passage, diarrhoea or constipation, swelling of the abdomen, rumbling noises and wind.

Treatment may involve lifestyle changes (e.g. IBS-friendly diet, more exercise and stress reduction), medications (e.g. antimotility agents to stop diarrhoea, laxatives to prevent constipation and antispasmodics or low dose antidepressants to stop the cramps/pain) and/or psychological/talking therapy (e.g. ‘Sex therapy’ – see the following section on this)

Psychological problems

If psychological problems are causing or contributing to your dyspareunia, they may be best treated with sex therapy (see the following section on this). However, it is important that you see your doctor so they can investigate the cause of your pain and check if you have any health problems that require medical treatment.

Physiotherapy

If your doctor thinks physiotherapy may help you, they can refer you for this on the NHS. Alternatively, you may be able to self-refer and arrange to see an NHS physiotherapist without going through your doctor (depending on area ).You can also pay to see a physiotherapist privately (check that they have experience of treating your problem, they are fully qualified, and they are registered with both a recognised professional body, such as the Chartered Society of Physiotherapy (CSP), and the Health and Care Professions Council (HCPC).

Sex therapy

Sex therapy is talking therapy where an individual or couple work with an experienced therapist to assess and treat their sexual and/or relationship problems. Together they will identify factors that trigger the problems and design a specific treatment programme to resolve or reduce their impact.
Sex therapy is considered highly effective in addressing the main causes and contributing factors of sexual difficulties. And it helps people to develop healthier attitudes towards sex, improve sexual intimacy, become more confident sexually, and improve communication within the relationship.
Sex therapy can also be used in combination with other forms of treatment. Your GP or another health professional on the NHS may be able to refer you for sex therapy (depending on area), or you can contact a therapist directly and pay privately. It is important to make sure that they are qualified and are registered with an appropriate professional body. You can find more information on sex therapy in our factsheets ‘Sex therapy’ and ‘How to find, choose and benefit from counselling support’

What is the Take Home Message?

Sex-related pain may be caused by physical and/or psychological problems – don’t ignore it, seek advice early

Where can you get more information?

The Sexual Advice Association is here to help. We cannot give individual medical advice, but we can answer your questions on any sexual problems and put you in touch with local specialist practitioners. We also have a number of factsheets and booklets on sexual problems and related issues for men and women that can be downloaded from our website or requested. Please feel free to email us or phone our Helpline (our contact details are at the bottom of this page).

You can also visit the NHS Choices website at www.nhs.uk for information and advice on many different health and lifestyle topics.

Further reading

Download or request our factsheets ‘Problems with orgasm’ and ‘Explaining sexual problems to your GP’

Donate

By donating to the Sexual Advice Association, you will know that you are helping improve the lives of people living with sexual problems. If you are interested in donating, please click here or contact us for more information (details at the bottom of this page).

Thinking About Sex Day: February 14th

Launched by the Sexual Advice Association, Thinking About Sex Day (TASD) is designed to encourage everyone to think about the physical and psychological issues surrounding sexual activity.

What men (and their partners) should know

  • Erectile dysfunction (ED), or problems with getting and keeping an erection, can act as a warning sign for a number of health problems, including:
    • Hidden disease of the heart and blood vessels (cardiovascular disease (CVD))
    • Raised cholesterol
    • High blood pressure
    • Diabetes

If you have ED, you should also be checked for these other conditions (see our factsheet ‘Erectile dysfunction’)

  • A raised cholesterol, unless treated and reduced, can damage the blood vessels (arteries) that supply blood to the heart and the penis. If the penis is affected, this can lead to ED
  • High blood pressure is a major risk factor for CVD
  • Around two-thirds of men with high blood pressure also have some form of ED
  • ED can be an early warning sign of future heart problems, appearing some 3-5 years before a heart complaint (see our factsheet ‘Erectile dysfunction and the heart’)
  • If you are under the age of 30, and otherwise fit and healthy, difficulty getting an erection is usually due to psychological causes (in the mind), such as stress. In this age group erectile problems are rarely due to physical causes (in the body)
  • A phosphodiesterase (pronounced phos- pho- di- es- ter- ase) inhibitor (PDE5i), such as Viagra®, will not give a man an erection unless he is mentally AND physically stimulated. This becomes more important as he get older (see our factsheet ‘Oral treatment for erectile dysfunction’)
  • Older men with ED that does not improve with PDE5i treatment often have low testosterone levels. Low testosterone can be easily corrected with testosterone replacement therapy (TRT) (see our factsheet ‘Testosterone deficiency’)
  • You should not take a PDE5i if you are already taking nitrates (in the form of a spray for angina, some tablets for the heart, or the recreational drugs known as ‘poppers’ (Amyl nitrite)). As this combination can make the blood pressure drop too low
  • Compared with younger men, those aged 55 years and over tend to have less firm erections, produce smaller amounts of semen and have less intense ejaculations. They also have a longer recovery period after ejaculation (see our factsheet ‘Sex and aging – Men’s issues’)
  • Many sexual problems are caused by a combination of physical issues (in the body) and psychological issues (in the mind). These require very different treatments
  • Lifestyle changes can help improve ED AND general health. These include:
    • Stopping smoking (see our booklet ‘Sex and smoking’)
    • Taking regular physical activity
    • Losing weight if you are overweight (see our factsheet ‘Body Mass Index (BMI)’)
    • Eating a healthy Mediterranean-style diet (including large amounts of plant foods, moderate amounts of fish and wine, and small amounts of animal products and sweets) (see our factsheet ‘The Mediterranean diet’)
    • Limiting alcohol intake (Government guidelines recommend that men and women do not regularly drink more than 14 units of alcohol per week
  • Don’t forget that women can have sexual problems too (see our factsheet ‘Women’s sexual problems’)
  • It is helpful if men with ED are assessed with their partners. This way, the partner can be involved in any treatment decisions, and if they have any sexual problems themselves, these can be identified and addressed

Where can you get more information?

The Sexual Advice Association is here to help. We cannot give individual medical advice, but we can answer your questions on any sexual problems and put you in touch with local specialist practitioners. We also have a number of factsheets and booklets on sexual problems and related issues for men and women that can be downloaded from our website or requested. Please feel free to email us or phone our Helpline (our contact details are at the bottom of this page).

You can also visit the NHS Choices website at www.nhs.uk for information and advice on many different health and lifestyle topics.

What is the take home message?

Sexual problems may be a warning sign of other health issues – heed the warning and get checked out!

Further reading

Download or request our booklet ‘Sex and the heart’ and/or our factsheet ‘Explaining sexual problems to your GP’.

Donate

By donating to the Sexual Advice Association, you will know that you are helping improve the lives of people living with sexual problems. If you are interested in donating, please click here or contact us for more information (details at the bottom of this page).

Thinking About Sex Day: February 14th

Launched by the Sexual Advice Association, Thinking About Sex Day (TASD) is designed to encourage everyone to think about the physical and psychological issues surrounding sexual activity.

Erectile dysfunction and the heart

What is the connection?

Erectile dysfunction (ED) is when you are unable to get or keep an erection suitable for sexual intercourse or another chosen sexual activity. The most common cause of ED is a lack of blood supply to the penis. The lining of the blood vessels (arteries) that supply blood to the penis is called the endothelium (pronounced en- do- thee- lee- um). This controls the speed with which blood enters the penis. If the endothelium does not work properly, blood can not enter fast enough or stay there long enough to get a firm erection that lasts sufficient time for satisfactory sexual intercourse (see our factsheet ‘Erectile dysfunction’).

With aging, particularly when combined with an unhealthy lifestyle, the arteries become narrowed and damaged by a process known as atherosclerosis, which is similar to a pipe furring up. The link between ED and disease of the coronary arteries (those that supply the heart) is that they share the same endothelium, so atherosclerosis in the penile arteries is also likely to be present in the coronary arteries. This is why up to two-thirds of men with coronary artery disease (CAD) also have ED. The problem is that over half the men with ED may have CAD they don’t know about. Finding and treating atherosclerosis early can help stop it from getting worse, so this is important.

Atherosclerosis (narrowing) of an artery
Atherosclerosis (narrowing) of an artery

Can ED come before CAD?

Yes! The arteries in the penis are smaller in diameter (1-2mm) than the coronary arteries (3-4mm). This means that while atherosclerosis in the coronary arteries may not currently be causing any heart problems, the same disease in the smaller penile arteries causes them to become narrowed earlier, leading to ED.

It takes longer for the bigger coronary arteries to be affected by the narrowing process, but if it is allowed to continue, a man with ED and no heart complaint may develop a heart complaint within 3-5 years of his ED starting. This is why the penis has been described as ‘the window to the hearts of man’. It means ED can help identify someone at future risk of a heart attack, giving us a chance to prevent it from occurring by lowering cholesterol and treating high blood pressure. The early detection and treatment of diabetes is also important.

What are the risk factors for ED and CAD?

They are the same. High blood pressure, raised cholesterol, cigarette smoking, obesity, diabetes, physical inactivity, low testosterone, depression and stress. So it is easy to see why ED and CAD often occur together – it is really a matter of which comes first.

What if you have ED and no sign of CAD?

It is very important to see your GP to assess your health and see if you have any of the risk factors described above. Lifestyle issues are important. Losing weight if needed, eating a healthy Mediterranean-style diet and increasing physical activity are the easiest changes to make, and these will benefit both ED and CAD (see our factsheets ‘Body Mass Index (BMI)’ and ‘The Mediterranean diet’).

By reducing your risk factors for ED and CAD, you reduce your chances of a serious health problem in the future. You may have had your ED successfully treated by tablets given to you by a friend or bought online, but getting your erection back without a check on the heart is asking for trouble.

Where can you get more information?

The Sexual Advice Association is here to help. We cannot give individual medical advice, but we can answer your questions on any sexual problems and put you in touch with local specialist practitioners. We also have a number of factsheets and booklets on sexual problems and related issues for men and women that can be downloaded from our website or requested. Please feel free to email us or phone our Helpline (our contact details are at the bottom of this page).

You can also visit the NHS Choices website at www.nhs.uk for information and advice on many different health and lifestyle topics.

Further reading

Download or request our factsheets ‘Erectile dysfunction’ and ‘Testosterone deficiency’ and/or our booklet ‘Sex and the heart’

Donate

By donating to the Sexual Advice Association, you will know that you are helping improve the lives of people living with sexual problems. If you are interested in donating, please click here or contact us for more information (details at the bottom of this page).

Thinking About Sex Day: February 14th

Launched by the Sexual Advice Association, Thinking About Sex Day (TASD) is designed to encourage everyone to think about the physical and psychological issues surrounding sexual activity.

Injection, urethral and topical treatments for erectile dysfunction

What is erectile dysfunction?

Erectile dysfunction (ED) is when you are unable to get or keep an erection suitable for sexual intercourse or another chosen sexual activity (see our factsheet ‘Erectile dysfunction’). This factsheet explains how injection, urethral and topical treatments can help men with ED.  These are used when oral treatments (tablets) do not work or are not suitable.

What is injection treatment?

The first injectable drugs commonly used in the UK for erection problems were papaverine and phentolamine, but these were not licensed for ED and have now been replaced by alprostadil. This is the same as a chemical that the penis produces naturally when it becomes erect.

Alprostadil has been used as an injection for the treatment of erection problems in the UK since 1994. It does not work as a tablet but can also be used as a pellet (MUSE®) or a cream (Vitaros®). In injection form, alprostadil relaxes the penile muscles and blood vessels. This allows more blood to flow into the penis and get trapped there, which helps you get and keep an erection. Alprostadil injections work in more than 80% of men who do not respond to tablets.

Two alprostadil products are currently available for injection – Caverject® and Viridal®.

They are available in a variety of dose strengths. The starting dose should be decided by your doctor. The usual dose is between 10 and 20 micrograms (mcg). These products are only available on prescription.

The patient (or his partner) is taught by a nurse or doctor how to inject the drug directly into the shaft of the penis when he wants an erection (up to a maximum of 3 times per week and not more than once daily). An erection usually follows within 20 minutes of the injection. Even though the thought of this brings tears to the eyes of some of the strongest men, the procedure is easy to learn and, surprisingly, it is not too uncomfortable. The erection should last up an hour; although very occasionally, it will last longer if the dose of alprostadil is too large (see the section below ‘What if my erection lasts too long?’).

Other possible side effects include occasional pain, a burning sensation, or a small nodule in the shaft of the penis which disappears if you change the injection site (it is best to change sides regularly). Men are advised to use a condom when using Viridal® if their partner is, may be, or could become pregnant. You should not use alprostadil injections if you have Peyronie’s disease (see our factsheet ‘Peyronie’s disease’), or if you have sickle cell anaemia, leukaemia, or multiple myeloma, as these may cause a prolonged erection.

Invicorp is another type of injection therapy used to treat ED.  It contains two active ingredients (aviptadil and phentolamine mesilate); one increases blood flow to the penis to help get an erection while the other helps trap the increased amount of blood in the penis to keep the erection. Invicorp may work well for men who have found little success with other ED treatments and some may find it less uncomfortable to use than alprostadil injections.

What is urethral treatment?

This treatment is based on the discovery that the urethra (the tube through which urine is passed) can absorb certain medications. The active ingredient in the ‘medicated urethral system for erection’ (MUSE®) is alprostadil, which has been used as an injection for many years (see the previous section).

For use in the urethra, alprostadil is made into a very small pellet, which is inserted using a special applicator. It should not be painful. It is best used just after passing urine, as the extra moisture helps the drug to be absorbed. The alprostadil then passes into the surrounding tissues of the penis, creating an erection. When MUSE® works, it takes between 5-10 minutes for an erection to occur and it should last for between 30-60 minutes. It can be used twice a day but not more than 7 times a week.

MUSE® comes in a variety of dose strengths. The initial dose should be decided by you and your doctor. Patients usually start off on 500 micrograms (mcg), increasing to 1000 mcg.  This treatment works in up to two-thirds of men and seems particularly suitable for people with diabetes.

MUSE® has few side effects. If you are rough when inserting the applicator, you can scratch the lining of the urethra, which may cause pain or even a spot of blood. This is not harmful. Other possible side effects include headache, dizziness, and more rarely fainting – usually at the thought of sticking something up one’s urethra! Some men may feel a burning sensation that can last for an hour or two, but this should not interfere with intercourse. Very occasionally, your partner may have some internal itching or burning. If she is, or may be pregnant, you should use a condom. Rarely, your erection may last too long (see the section below ‘What if my erection lasts too long?’) You should not use MUSE® if you have Peyronie’s disease (see our factsheet ‘Peyronie’s disease’), or if you have sickle cell anaemia, leukaemia, or multiple myeloma, as these may cause a prolonged erection.

What is topical treatment?

Alprostadil is also available as a cream called Vitaros®.  This is applied to the opening (meatus) of the penis and the surrounding skin with a special applicator. It should be used 5 to 30 minutes before intercourse and improvements in erection should last between 1 and 2 hours. It should be used no more than 2-3 times a week and only once a day.

Rarely your erection may last too long (see the section below ‘What if my erection lasts too long?’). Other possible side effects include rash and discomfort. Occasionally your partner may have some internal itching or burning.  If they are pregnant, breastfeeding or of childbearing age, it is advised that you use a condom. You should not use Vitaros® if you have Peyronie’s disease (see our factsheet ‘Peyronie’s disease’), or if you have sickle cell anaemia, leukaemia, or multiple myeloma, as these may cause a prolonged erection.

What should you do if your erection lasts too long?

Following the use of these products, the erection usually goes down with ejaculation. If this does not happen, it may become uncomfortable and you will need to reduce it as soon as possible. Exercise such as running up and down stairs or cycling vigorously will usually work, or try taking a cold shower. An ice bag (such as frozen peas) wrapped around the penis for a short time may also be effective (but don’t overdo this – you want to cool the area not freeze it!). Otherwise, taking an over-the-counter decongestant medicine called Sudafed® (pseudoephedrine HCI) in tablet form may help. But check with the pharmacist that it is ok for you to take this if you have other health problems or are taking other medications. If your erection lasts longer than 4 hours, you should go to a hospital casualty unit or Accident and Emergency Department as soon as you can, because a long delay may damage the penis.

Where can you get more information?

The Sexual Advice Association is here to help. We cannot give individual medical advice, but we can answer your questions on any sexual problems and put you in touch with local specialist practitioners. We also have a number of factsheets and booklets on sexual problems and related issues for men and women that can be downloaded from our website or requested. Please feel free to email us or phone our Helpline (our contact details are at the bottom of this page).

You can also visit the NHS Choices website at www.nhs.uk/ for information and advice on many different health and lifestyle topics.

What is the Take Home Message?

Some treatments for ED are applied to the penis itself – they may be a good alternative if tablets do not work or are not suitable

Further reading

Download or request our factsheet ‘Oral treatment for erectile dysfunction’ and/or our booklet ‘Sex and growing older – Men

Donate

By donating to the Sexual Advice Association, you will know that you are helping improve the lives of people living with sexual problems. If you are interested in donating, please click here or contact us for more information (details at the bottom of this page).

Thinking About Sex Day: February 14th

Launched by the Sexual Advice Association, Thinking About Sex Day (TASD) is designed to encourage everyone to think about the physical and psychological issues surrounding sexual activity.

Erectile dysfunction when with a partner

What is erectile dysfunction when with a partner?

Erectile dysfunction (ED), when you are unable to get or keep an erection suitable for sexual intercourse or another chosen sexual activity, is a common problem for many men. It may be due to physical causes (in the body), psychological causes (in the mind) or a mixture of both (see our factsheet ‘Erectile dysfunction’).

This factsheet specifically covers ED which happens only or mostly when you are with a partner. If you can usually get an erection spontaneously or when you are masturbating alone, but you can’t get one when you are with someone else, then this factsheet should help.

What might be causing this problem?

All types of ED, including those that only happen with a partner, may be due to physical causes (in the body). In particular, ED can be an early sign of heart disease (see our factsheet ‘Erectile dysfunction and the heart’) or be associated with diabetes, so it’s important to have a thorough checkup by your GP

If you get the all clear physically, then the cause of your problem is likely to be psychological (in the mind). For example, you may be physically able to get aroused (‘turned on’), but when you are with a partner; your erection is affected by your mind and emotions, your feelings about yourself and/or your partner or partnership.

Possible psychological causes include:

  • Things you’ve learned in childhood about sex with a partner being shameful or wrong
  • An unhappy or traumatic sexual experience that means you are anxious when being sexual with a partner
  • Having sex with a partner you are not attracted to
  • Having sex with a gender you are not attracted to (for example having sex with a woman when you are more attracted to men)
  • A fear of being erect or climaxing when with someone else, or worry that you may be hurting your partner when penetrating them, particularly if your partner has had sexual health issues that might make this painful
  • A fear of emotional commitment (this is more likely if the problem happens with long-term partners)
  • A need for more emotional commitment then you’re getting (this is more likely if the problem happens with short-term partners)
  • A fading of love towards your partner (this is more likely if you were able to get an erection with this partner but now can’t)
  • Using pornography so much that it has become difficult for you to get aroused when having sex with a ‘real life’ partner
  • Worry that because you haven’t been able to get an erection with a partner in the past that you won’t be able to do so now
  • Pressure from a partner to ‘perform’

What should you do next?

If you haven’t already had a medical checkup, then have one. ED is associated with a number of health problems, and although it is less likely that the cause of your problem is only physical, medical issues may be making the problem worse. There are various options available for treating ED and your doctor can advise you on these (see our factsheets ‘Oral treatment for erectile dysfunction’, ‘Injection, urethral and topical treatments for erectile dysfunction’ and ‘Vacuum pump treatment for erectile dysfunction’.

You can also think about what psychological issues may be causing your problem. Begin by asking yourself how you feel about sex in general, about sex with partners in general, and about sex with this particular partner. If your erection problems usually happen within short-term relationships, then try to make friends with a partner and build up some trust before you have sex.

When you do have sex, tell your partner that you want to take things slowly, which will help remove the pressure to have an instant erection. Stop trying for an erection when you are with a partner, but focus instead on kissing and cuddling. At least for a while (maybe one month to start), stop trying to get an erection and simply enjoy being close, giving as well as receiving pleasure. If you do get an erection with a partner, don’t try to push things towards orgasm, just relax and let your erection come and go. Be interested in what is happening rather than trying to make something happen.

If you still are having problems, then even if you’re not aware of any unhappy feelings about sex, it may be helpful to see a sex therapist (see the following section on ‘Sex

therapy’). If you think your erection problems may be due to sexual issues that your partner is having, talk these through and perhaps agree to see a sex therapist together.

What is sex therapy?

Sex therapy is talking therapy where an individual or couple work with an experienced therapist to assess and treat their sexual and/or relationship problems. Together they will identify factors that trigger the problems and design a specific treatment programme to resolve or reduce their impact.

Sex therapy is considered highly effective in addressing the main causes and contributing factors of sexual difficulties. And it helps people to develop healthier attitudes towards sex, improve sexual intimacy, become more confident sexually, and improve communication within the relationship.

Sex therapy can also be used in combination with other forms of treatment. Your GP or another health professional on the NHS may be able to refer you for sex therapy (depending on area), or you can contact a therapist directly and pay privately. It is important to make sure that they are qualified and are registered with an appropriate professional body. You can find more information on sex therapy in our factsheets ‘Sex therapy’ and ‘How to find, choose and benefit from counselling support’

Does this problem mean there is something wrong with your relationship?

Even if you are finding it difficult to get an erection when with a partner, there may be nothing wrong with your relationship (see the previous section on ‘Sex therapy’).

What is the Take Home Message?

Being able to achieve an erection alone but not with a partner can be frustrating, but help is available.

Where can you get more information?

The Sexual Advice Association is here to help. We cannot give individual medical advice, but we can answer your questions on any sexual problems and put you in touch with local specialist practitioners. We also have a number of factsheets and booklets on sexual problems and related issues for men and women that can be downloaded from our website or requested. Please feel free to email us or phone our Helpline (our contact details are at the bottom of this page).
You can also visit the NHS Choices website at www.nhs.uk for information and advice on many different health and lifestyle topics.

Further reading

Download or request our factsheet ‘Explaining sexual problems to your GP’ and/or our booklet ‘Sex and growing older – Men’

Donate

By donating to the Sexual Advice Association, you will know that you are helping improve the lives of people living with sexual problems. If you are interested in donating, please click here or contact us for more information (details at the bottom of this page).

Thinking About Sex Day: February 14th

Launched by the Sexual Advice Association, Thinking About Sex Day (TASD) is designed to encourage everyone to think about the physical and psychological issues surrounding sexual activity.

Sexual problems in gay men

Why are these important?

It may be very difficult for a gay man to admit to having any problems with sex. After all, our sexuality is part of what makes us gay men. It is a myth that we are all sexual athletes, always ready for sex and always able to perform at a moment’s notice. But because this false view exists, we tend to measure ourselves against it.

If something goes wrong, some men feel they are ‘letting the side down’ if they ask for help. Asking for help with a sexual problem is the same as asking for help with any other medical problem and our needs are as important as anyone else’s.

What is erectile dysfunction?

Erections are funny things. When we were sixteen they seemed to happen all the time, even when they were not wanted. As we get older they don’t always appear, even when we want one most. Almost every man experiences a time when their erection is less strong than they would like, but sometimes it becomes a problem.

Erectile dysfunction (ED) is when you are unable to get or keep an erection suitable for sexual intercourse or another chosen sexual activity. If your erection is never OK (either with a partner or with masturbation, and is never there when you wake up), then it is likely to be a physical problem (in the body). If your erections are fine except with a partner, then it is more likely to be a psychological problem (in the mind). Often people have a combination of physical and psychological issues, which together cause problems.

Physical causes of ED include diabetes, multiple sclerosis and problems with the blood supply to the penis (importantly this may mean the blood supply to the heart will also be affected in the future, so if you have ED, it is wise to see your GP for a general health check.) Occasionally there is a problem with the male hormone, testosterone, especially

in older men. Drugs, both ‘prescribed’ and ‘recreational’, are a common cause of erectile difficulties (see our factsheet ‘Erectile dysfunction’).

Having a psychological problem with sex does not mean that there is anything else wrong with your mental health. Help is available for both the physical and psychological causes of sexual problems.

What are the medical treatments for ED?

There are drugs that can help with erection difficulties. Oral treatments (tablets) are called phosphodiesterase (pronounced phos- pho- di- es- ter- ase) inhibitors (PDE5i). They include sildenafil (Viagra®), tadalafil (Cialis®), vardenafil (Levitra®) and avanafil (Spedra®). They work for many men but will not cause an erection unless the man is mentally AND physically stimulated (see our factsheet ‘Oral treatment for erectile dysfunction’).

Men who have less firm erections may find their condom slips off. A PDE5i may help prevent this (and make sex safer) by producing a firmer erection.

You should not take a PDE5i if you are taking a medicine that contains nitrates, because this combination can cause the blood pressure to drop too low. Such medicines include sprays for angina, some tablets for the heart and the recreational drugs known as ‘poppers’ (Amyl nitrite)). Because ‘poppers’ may be used in a confined environment (such as a sauna) by someone other than the PDE5i user, the effect of the chemical spreading through the environment could potentially affect the PDE5i user. PDE5i should only be prescribed by a doctor who will take your health and other medications into consideration. Do not buy medicines online – they may be fakes!

A drug called alprostadil (which is the same as a chemical that the penis produces naturally when it becomes erect) can be injected into the shaft of the penis. This allows more blood to flow into the penis and get trapped there, which helps you get and keep an erection. Injection therapy is very successful in those men who do not respond to tablets. Two alprostadil products are currently available for injection – Caverject® and Viridal®.

Invicorp is another type of injection therapy used to treat ED. It contains two active ingredients (aviptadil and phentolamine mesilate); one increases blood flow to the penis to get an erection while the other traps the increased amount of blood in the penis to keep the erection. Invicorp may work well for men who have found little success with other ED treatments and some may find it less uncomfortable to use than alprostadil injections.

Another option is to insert a pellet (MUSE®) that contains alprostadil into the urethra (the tube through which you pass water) after urinating. The pellet dissolves and gives you an erection.
Alprostadil can also be used topically as a cream (Vitaros®) which is applied to the penis.
For more information on injection, urethral and topical treatments for ED, see our factsheet ‘Injection, urethral and topical treatments for erectile dysfunction’.

Vacuum pump devices draw blood into the penis to get an erection, and it is trapped there with a special ring at the base of the penis to keep the erection. These devices suit some people well (see our factsheet ‘Vacuum pump treatment for erectile dysfunction’).

Testosterone replacement therapy (TRT) may be required if you are found to have low levels of this hormone (see our factsheet ‘Testosterone deficiency’).

Surgically implanted devices, which strengthen the penis from inside, are available for the very few people for whom producing an erection is not possible in any other way.

What are ejaculation problems?

Difficulties controlling when you ejaculate or ‘come’ are increasingly common. Ejaculating too quickly is called ‘premature ejaculation’ (PE) and when it takes longer than you would like it to it is called ‘delayed ejaculation’ (DE). DE has been considered a rare problem, but it is being seen more often in gay men referred to specialist clinics.

Retrograde ejaculation is where you may not see any fluid (semen) after orgasm. If this happens, you may also have noticed that when you first pass water after intercourse it is cloudy. This is because the semen is being expelled backwards into the bladder. Anejaculation is when you get the sensation of ejaculation but you don’t ejaculate at all.

For more information, see our factsheet ‘Ejaculation problems’

What are problems with sexual desire?

A lack of sexual desire (or ‘sex drive’) is often described as a loss of libido. Occasionally ‘going off’ sex has a physical cause, such as low testosterone. If so, it can then usually be treated by a doctor. But if the initial tests are ok, it may be best treated by sex therapy (see the following section on ‘Sex therapy). If you have a regular partner it is often useful if he goes to some of the clinic visits with you.

What is sex therapy?

Sex therapy is talking therapy where an individual or couple work with an experienced therapist to assess and treat their sexual and/or relationship problems. Together they will identify factors that trigger the problems and design a specific treatment programme to resolve or reduce their impact.

Sex therapy is considered highly effective in addressing the main causes and contributing factors of sexual difficulties. And it helps people to develop healthier attitudes towards sex, improve sexual intimacy, become more confident sexually, and improve communication within the relationship.

Sex therapy can also be used in combination with other forms of treatment. Your GP or another health professional on the NHS may be able to refer you for sex therapy (depending on area), or you can contact a therapist directly and pay privately. It is important to make sure that they are qualified and are registered with an appropriate professional body. You can find more information on sex therapy in our factsheets ‘Sex therapy’ and ‘How to find, choose and benefit from counselling support.’

What about recreational drug use and sex?

There are increasing concerns about the link between ‘club drug’ use and high-risk sexual behaviours in a small number of gay men. This includes ‘chemsex’.

In the UK, the term ‘chemsex’ is used to describe consensual sex while under the influence of psychoactive drugs, mostly among gay men. This mainly involves the use of mephedrone, gamma-hydroxybutyric acid (GHB), gamma-butyrolactone (GBL) and crystal methamphetamine (crystal meth). These drugs may be used alone or in combination to fuel sex sessions lasting several hours or days with multiple partners.

There are serious health implications with this type of behaviour. You may become physically or psychologically dependent on the drugs. You may require treatment for mental health effects and/or drug treatment to support detoxification. You may take an overdose by mistake. Different drugs may interact with each other or with alcohol. Not sleeping or eating for days may harm your general health and wellbeing. Injecting drugs increases the risk of contracting HIV and hepatitis C, and unprotected sex (particularly with different partners) increases your risk of these and other sexually transmitted infections (STIs).

Gay men who are worried about their mental or physical health following ‘chemsex’ may delay or avoid accessing professional support due to fears of being judged or the person they see having a lack of knowledge about this practice. If you don’t want to talk to your GP, you can ask them to refer you to a sex therapist or a substance misuse treatment service or you can contact these yourself. See the previous section on ‘Sex therapy’ for more information on this. You can find information about local drug treatment services on the Frank website www.talktofrank.com Genito-Urinary Medicine (GUM) clinics/departments may also be able to help you, particularly if you are worried that you might have caught a STI (see the following section on ‘Where can you get help for sexual problems’?).

Where can you get help for sexual problems?

Most people with sexual problems are advised to seek help from their GP first, but many Genito-Urinary Medicine (GUM) clinics/departments can offer help. They should at least be able to direct you towards whatever services are available. Their details can be found on the British Association for Sexual Health and HIV (BASHH) website www.bashh.org

Finding good quality care that is also ‘gay friendly’ can be difficult. If you choose to find a sex therapist through gay media, make sure they are qualified and are registered with an appropriate professional body (see the previous section on ‘Sex therapy’)

What is the Take Home Message?

Sexual problems may be a warning sign of other health problems – heed the warning and get checked out

Where can you get more information?

The Sexual Advice Association is here to help. We cannot give individual medical advice, but we can answer your questions on any sexual problems and put you in touch with local specialist practitioners. We also have a number of factsheets and booklets on sexual problems and related issues for men and women that can be downloaded from our website or requested. Please feel free to email us or phone our Helpline (our contact details are at the bottom of this page).

You can also visit the NHS Choices website at www.nhs.uk for information and advice on many different health and lifestyle topics.

Further reading

Download our booklet ‘Sex and the heart’ and/or our factsheet ‘Explaining sexual problems to your GP’

Donate

By donating to the Sexual Advice Association, you will know that you are helping improve the lives of people living with sexual problems. If you are interested in donating, please click here or contact us for more information (details at the bottom of this page).

Thinking About Sex Day: February 14th

Launched by the Sexual Advice Association, Thinking About Sex Day (TASD) is designed to encourage everyone to think about the physical and psychological issues surrounding sexual activity.

Oral treatment for erectile dysfunction

What is it?

Erectile dysfunction (ED) is when you are unable to get or keep an erection suitable for sexual intercourse or another chosen sexual activity (see our factsheet ‘Erectile dysfunction’).

Oral treatment for ED is taken by mouth as a tablet. There are four oral treatments currently available: sildenafil (Viagra®), tadalafil (Cialis®), vardenafil (Levitra®) and avanafil (Spedra®). They belong to a group of medicines called phosphodiesterase (pronounced phos- pho- di- es- ter- ase) inhibitors (PDE5i).  These treatments should only be prescribed by a doctor who will take your health and other medications into account. Do not buy medicines online – they may be fakes!

How does it work?

PDE5i are not aphrodisiacs and they do not increase sexual desire (‘sex drive’). For these treatments to be effective you need sexual stimulation (foreplay) as well as sexual desire. They will not give you an erection without this (taking a tablet and waiting for something to happen just does not work). If a man has normal erectile function, he does not need to take a PDE5i.

These medicines work by relaxing the blood vessels in the penis, allowing blood to flow into it, causing an erection.

Men who have less firm erections may find their condom slips off. A PDE5i may help prevent this (and make sex safer) by producing a firmer erection.

PDE5i are available in a variety of dose strengths. Many doctors start treatment with a dose in the middle range, which can be reduced or increased as required. The tablets are usually taken ‘on demand’, 30 – 60 minutes before sexual activity, but many men find it better to wait longer to have sex if possible. Don’t forget, you need to be mentally AND physically stimulated to get an erection.

After taking sildenafil, vardenafil or avanafil, they may continue to have an effect for up to 8-10 hours (many men claim to have a good erection the next morning). Tadalafil can have an effect up to 36 hours (earning it the nickname ‘the weekend’ pill). This is useful if things don’t work out for you immediately.

You should not take more than the maximum dose – you simply increase the side effects but not the good effects. You should not take more than one tablet a day. With sildenafil, vardenafil and avanafil, taking the tablets with food may delay and reduce their effects.  This is not a problem with tadalafil.  It is probably safest to avoid alcohol altogether when taking any of these medicines, as this combination may cause dizziness due to a drop in blood pressure.

PDE5i don’t work for everyone. If you haven’t had much success after taking the maximum dose on 8 different occasions, it may be worth asking your doctor if you can try one of the other tablets, as a change can sometimes work, or ask if you can try a daily dose of tadalafil 5mg instead.

It is a good idea to find out how the medicine works on you and what side effects it has, if any, before you drive or have sex with your partner.

What are the most common side effects?

PDE5i also make other blood vessels in the body dilate so you may get facial flushing or a headache. These effects are usually not severe and only temporary. They should not stop you having sex. You may also get a stuffy nose or indigestion, which usually goes with regular use or if the dose is reduced. Visual disturbances may be more likely with sildenafil. Muscle pain and backache may be more common with tadalafil. Backache may also be more likely with avanafil.  Rarely, your erection may last too long (see the section below ‘What if my erection lasts too long?’).

When should you avoid it?

  • If you are taking a medicine containing nitrates, because this combination can cause the blood pressure to drop too low (these include sprays for angina, some tablets for the heart and the recreational drugs known as ‘poppers’ (Amyl nitrite)). If you would like to try a PDE5i and you are taking a nitrate for another reason, talk to your doctor to see if it can be changed
  • If you are taking a different PDE5i, as this combination is not recommended
  • If you are a woman, as PDE5i have not been widely tested in women
  • If you have disease of the heart or blood vessels (cardiovascular disease (CVD)), you should check with your doctor when you get your first prescription that a PDE5i is safe for you to use. As a rough guide, if you do not have any symptoms (e.g. chest pain, irregular heartbeat, dizziness or excessive breathlessness) while walking 1 mile on the flat in 20 minutes, or when briskly climbing 2 flights of stairs in 10 seconds, it is likely to be safe for you to enjoy normal sexual activity

What if it does not work?

If oral treatment does not help you to get an erection, or your erection does not last long enough for you to enjoy your chosen sexual activity, you should tell your doctor. They may suggest help from a sex therapist (see our factsheet ‘Sex therapy’).  If you are an older man, your doctor may want to check your testosterone (see our factsheet ‘Testosterone deficiency’). There are also other effective treatment options available (see our factsheets ‘Injection, urethral and topical treatments for erectile dysfunction’ and ‘Vacuum pump treatment for erectile dysfunction’).

What should you do if your erection lasts too long?

Following the use of a PDE5i, the erection usually goes down with ejaculation. If this does not happen, it may become uncomfortable and you will need to reduce it as soon as possible. Exercise such as running up and down stairs or cycling vigorously will usually work, or try taking a cold shower. An ice bag (such as frozen peas) wrapped around the penis for a short time may also be effective (but don’t overdo this – you want to cool the area not freeze it!). Otherwise, taking an over-the-counter decongestant medicine called Sudafed® (pseudoephedrine HCI) in tablet form may help. But check with the pharmacist that it is ok for you to take this if you have other health problems or are taking other medications. If your erection lasts longer than 4 hours, you should go to a hospital casualty unit or Accident and Emergency Department as soon as you can, because a long delay may damage the penis.

What’s true and what’s not?

  • I take a tablet and get an instant erection – No, they require sexual desire AND sexual stimulation (foreplay) to work
  • ‘I took a tablet and stayed ‘up’ all night’ – The risk of a prolonged erection is very rare. This comment is often made as a result of the jokes that can be related to ED
  • I cannot take a PDE5i if I have a ‘heart problem’ – Not necessarily, particularly if your ‘heart problem’ is stable. Your doctor can check if you are ‘fit for sex’ and if there are any other reasons why you should not take these medications
  • These tablets can cause a heart attack – Heart problems and stroke have been reported with this type of medicine, but it is not clear if they occurred as a result of the patient already having risk factors for them, the drug itself, the sexual activity, or a combination of these or other factors. To reduce the risk of problems, your doctor should check if you are ‘fit for sex’ and if there are any other reasons why you should not take these medicines. It is important to remember that because the tablets dilate your blood vessels to help you get an erection, this may also cause your face to flush and your blood pressure to drop (not rise), and indigestion may feel like heart pain

Who can get it?

At the moment, sildenafil (the generic version of the branded Viagra®) can be prescribed on the NHS to anyone with ED as long as it is safe to do so. Oral treatment with other PDE5i

Is only available on an NHS prescription if you have certain medical conditions (including diabetes, multiple sclerosis, Parkinson’s disease, prostate cancer, spina bifida, polio and certain genetic conditions such as Huntingdon’s disease). PDE5i may also be prescribed on the NHS if you are receiving or have received certain treatments (including pelvic or prostate surgery, dialysis for kidney failure and kidney transplant), or if you are suffering severe distress as a result of your ED.  If you are not entitled to these treatments on the NHS, you may be able to pay for them privately. Ask your doctor or pharmacist for more information.

What is the Take Home Message?

Oral treatments for ED can be very successful, but they require sexual desire AND sexual stimulation to work

Where can you get more information?

The Sexual Advice Association is here to help. We cannot give individual medical advice, but we can answer your questions on any sexual problems and put you in touch with local specialist practitioners. We also have a number of factsheets and booklets on sexual problems and related issues for men and women that can be downloaded from our website or requested. Please feel free to email us or phone our Helpline (our contact details are at the bottom of this page).

You can also visit the NHS Choices website at www.nhs.uk for information and advice on many different health and lifestyle topics.

Further reading

Download or request our factsheets ‘Erectile dysfunction and the heart’ and/or ‘Explaining sexual problems to your GP

Donate

By donating to the Sexual Advice Association, you will know that you are helping improve the lives of people living with sexual problems. If you are interested in donating, please click here or contact us for more information (details at the bottom of this page).

Thinking About Sex Day: February 14th

Launched by the Sexual Advice Association, Thinking About Sex Day (TASD) is designed to encourage everyone to think about the physical and psychological issues surrounding sexual activity.