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.

Sex and aging – Men’s issues

Will sex change as you get older?

The issues surrounding sex in older people are still not openly discussed. Older people have been stereotyped as asexual and devoid of feelings or emotion, but this of course is wrong. The way people express themselves sexually varies widely. While sex in older couples is likely to be different to that in younger couples, it doesn’t have to be any less pleasurable.

Today men and women are living longer, healthier lives. As a result of this improvement in health, many older couples continue to enjoy intimacy and sex. A global study showed that sexual desire and sexual activity are common in middle-aged and elderly people of both sexes and these continue into old age. Over 80% of men and 65% of women aged 40-80 years had had intercourse in the last year. However, sexual problems were common in both sexes and few people sought help for these.

Older couples who have been in long-term relationships do not necessarily find it easier than anyone else when it comes to discussing sexual difficulties (see our factsheet ‘Explaining sexual problems to your GP’).

Will you still be able to have sex as you get older?

The ageing process causes many normal changes in the body, some of which affect sexual desire (‘sex drive’) and response. But sexuality extends beyond the genitals. Often couples can find new ways to stimulate each other, such as reading erotic literature or watching erotic videos. Being able to talk to your partner and discuss sexual desires, fantasies and experimentation is important.

Some men may notice that it takes them longer to get aroused (‘turned on’) and develop an erection, and their erections may not seem as hard. The sensation of ejaculation may be reduced, the orgasm may not feel as powerful as it once did, and smaller amounts of semen may be produced. The length of time between erections can increase and just thinking about sex may no longer be enough. Reduced sensitivity may mean more direct physical stimulation of the penis is required for a longer time. Ejaculation may take longer to achieve, but this can be a positive side of getting older as it may give more satisfaction to the partner. While some men may notice that their desire for sex reduces with age, others may remain sexually active throughout their life.

If you are finding it more difficult to get and keep an erection, you are not alone. Half of men between the ages of 40 and 70 years will experience this to some degree. However, help is available. Your GP may be able to prescribe one of the oral drugs (tablets) that can help erectile dysfunction (ED), known as phosphodiesterase (pronounced phos- pho- di- es- ter- ase) inhibitors (PDE5i). If these drugs do not work or are not suitable for you, there are other options available, such as penile injections, urethral pellets, topical creams, vacuum pump devices and surgical implants (see our factsheets ‘Oral treatment for erectile dysfunction’, ‘Injection, urethral and topical treatments for erectile dysfunction’, ‘Vacuum pump treatment for erectile dysfunction’. You may also want to consider sex therapy (see the following section on ‘Sex therapy’). Do not buy drugs online, as they may be fakes!

Does illness affect sex?

Yes, it can. As people grow older, they are more likely to experience disabling conditions and illnesses that can affect their sex lives. These may have physical effects (in the body) and psychological effects (in the mind).

Painful physical problems like arthritis may make it difficult to find a comfortable position for having sex. Neurological problems such as Parkinson’s disease may reduce sexual desire and cause erectile problems, as may some drugs. Diabetes may also cause erectile difficulties.

The psychological effects of illness can also affect sexual function, especially if a life-threatening or life-limiting illness has been diagnosed, or the illness affects a person’s appearance and/or self esteem. Cardiovascular problems such as high blood pressure, heart disease or a previous stroke may make you nervous about having sex.

Illness can also change a couple’s relationship in other ways, as previously independent people become dependent on their partner/carer. One partner may feel it is inappropriate to still have sexual desire if their partner is ill. While for many carers, the sheer stress and exhaustion of the role may reduce their desire. Lifestyle can also affect how you see yourself. Retirement and children leaving home is viewed by some as an end of a chapter in their lives, whereas for others it can mean the freeing up of time for each other.

Lifestyle factors can also play a part. Smoking, excessive alcohol consumption, recreational drug use, poor diet and a lack of exercise can all contribute to sexual problems.

If you find that illness is preventing you from enjoying sex with your partner, it is sensible to see your GP. They should be able to offer you help and advice or refer you for sex therapy (see the following section on ‘Sex therapy’).

If you are a widower: Is it wrong to look for love again?

We all need to be loved and wanted, and these needs do not lessen over time. However, you may find you are looking for a different kind of relationship than when you were younger. You may just require companionship and someone to share your favourite TV programmes with. If you are looking to rekindle your love life you may feel awkward and embarrassed, not knowing where or how to start. These are perfectly normal feelings, particularly if your partner had a long illness, or you have feelings of guilt and betrayal. It will help to talk to someone about those feelings. To help you to move forward in a new relationship, you may like to speak to your GP or contact a sex therapist (see the following section on ‘Sex therapy’). When sexuality is affected, it is often a matter of learning to adapt and adjust rather than accepting an end to all forms of sexual expression.

If you are embarrassed to seek help: What can you do?

The only person who will find this embarrassing is you. You have nothing to be afraid of and everything to gain by seeking help. Discussing sex later in life can sometimes be difficult, but there is no reason to think that because you are older, you cannot use all the services that are available to younger people. Sex is not abnormal after middle age and for many individuals it does not stop just because they are no longer able to conceive a child. Older age should not prevent you from seeking or receiving help from whatever source is most suitable for you. If you don’t want to discuss sexual problems with your GP, you can see a sex therapist (see the following section on ‘Sex therapy).

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 is the Take Home Message?

Sex is likely to change as you age but it does not necessarily need to stop – seek help if you need it

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

For more information download or request our factsheets ‘Erectile dysfunction’ and ‘Sex and the psychology of growing older’ 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

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.

How common is it?

It is very common; half of men between the ages of 40 and 70 years will have it to some degree. This means there are several million men in the UK suffering from ED and the numbers increase with age. Sadly, only a small percentage of sufferers actually receive treatment.

How is it caused?

Most men occasionally fail to get or keep an erection. This usually results from stress, tiredness, anxiety or excessive alcohol consumption and is nothing to worry about. However, worrying about it can increase the likelihood of it happening again due to ‘fear of failure’. Until about 20 years ago, ED was thought to be almost entirely due to psychological causes (in the mind). But we now know that physical causes (in the body) are more likely, and the most common of these is disease of the blood vessels which supply blood to the penis (atherosclerosis). However, most men with ED have a combination of psychological and physical causes, with one affecting the other.

Physical causes
Men whose ED is due to physical causes often experience a gradual onset of erectile problems, which usually occur with all sexual activities.

Physical causes of ED include:

  • Vasculogenic conditions (which affect blood flow to the penis) – including disease of the heart or blood vessels (cardiovascular disease (CVD)), high blood pressure, raised cholesterol and diabetes
  • Neurogenic conditions (which affect the nervous system) – including multiple sclerosis, Parkinson’s disease, stroke, diabetes and spinal injury or disorder
  • Hormonal conditions (which affect the hormones) – including an overactive thyroid gland, an underactive thyroid gland, hypogonadism (low testosterone level), Cushing’s syndrome (high cortisol level), a head or brain injury recently or in the past and subarachnoid haemorrhage or radiation to the head (these may cause hormonal changes, particularly a low testosterone)
  • Anatomical conditions (which affect the structure of the penis) – including Peyronie’s disease
  • Surgery and radiation therapy for bladder, prostate or rectal cancer
  • Injury to the penis
  • Side effect of prescribed drugs
  • Recreational drug use
  • Excessive alcohol consumption

ED is also more likely to occur in people who smoke, are overweight and/or are not active enough.

If atherosclerosis is the cause of your ED, this narrowing is likely to affect other blood vessels in the body as well, including the arteries that supply blood to the heart. This means ED can be an early warning sign of future heart problems, appearing some 3-5 years before a heart complaint. You may therefore be able to prevent a future heart problem from occurring if you see your doctor for treatment soon after your ED starts (see our factsheet ‘Erectile dysfunction and the heart’).

atherosclerosis
Atherosclerosis (narrowing) of an artery

Hormone problems may be a more common cause of ED than once thought. The most frequently seen of these is reduced testosterone (male sex hormone), which can occur in men of all ages, including the elderly. The current guidance on the use of testosterone replacement therapy in men recommends that that when they first see a doctor for ED and/or reduced libido (‘sex drive’), they should have their testosterone measured in the morning on at least two occasions (see our factsheet ‘Testosterone deficiency’).

If you have ED and ride a bike for more than three hours a week, your doctor may recommend you try a period without cycling to see if this helps improve things. It is important to make sure you are sitting in the correct position with a properly fitted, comfortable seat – some are specifically designed to relieve pressure on the blood vessels and nerves supplying the penis.

Psychological causes
A psychological cause of ED is more likely if:

  • Your erection is fine except with your partner
  • You are suffering stress and anxiety from work or home (money or family)
  • There are marital rows and dissatisfaction (which may also cause premature ejaculation)
  • You are depressed
  • Failing once is followed by fear of subsequent failure
  • Your partner has sexual problems
  • You are bored sexually
  • You are worried about your sexual orientation
  • You have suffered previous sexual abuse

When should you seek help?

If you have been suffering with ED for more than a few weeks, it is wise to see your doctor, because it may be a warning sign of other more serious health problems.

Many men find it very difficult to talk about such a personal problem as being unable to get an erection and may put off asking for help for 2 years or more. However, GPs are trained to deal with ED and in the end it’s usually not as embarrassing as was feared.

How is it diagnosed?

To diagnose the cause(s) of your ED, your doctor will ask you about your sexual history, diet and lifestyle. You will have an assessment, which includes measurement of your height, weight and waist. You will also need a medical, which includes:

  • Heart and lungs check
  • Blood pressure check
  • A quick check of your genitals to rule out any obvious physical abnormality
  • Cholesterol check
  • Diabetes test
  • A morning check of your testosterone (see our factsheet ‘Testosterone deficiency’)

If you have symptoms of an enlarged prostate gland, such as a weak stream and/or urgent and/or frequent urination, your doctor may also need to examine your prostate.

If you do not want to talk to your GP about ED, you can visit a genitourinary medicine (GUM) clinic. Their details can be found on the British Association for Sexual Health and
HIV (BASHH) website www.bashh.org You can also see a sex therapist (see the following section on ‘Sex therapy’)

How is it treated?

ED treatment involves tackling the cause of the problem, whether this is physical, psychological or a mixture of both. There have been major advances in the treatment of ED and most sufferers can now be treated effectively.

If atherosclerosis is causing your ED, your doctor may recommend some lifestyle changes, which will also improve your general health and help protect your heart. These include:

  • Stopping smoking
  • Limiting the amount of alcohol you drink to no more than 14 units a week
  • Losing weight if you are overweight (see out factsheet ‘Body Mass Index (BMI)’)
  • Eating a healthy Mediterranean-style diet (see out factsheet ‘The Mediterranean diet’)
  • Taking moderate daily exercise
  • Trying to reduce stress and anxiety

Your doctor may also prescribe medications to treat atherosclerosis (such as cholesterol-lowering statins and drugs to lower your blood pressure).

If lifestyle changes fail to improve things, tablets are usually the first line treatment. These are called phosphodiesterase (pronounced phos- pho- di- es- ter- ase) inhibitors (PDE5i) and include tadalafil (Cialis®), vardenafil (Levitra®), sildenafil (Viagra®) and avanafil (Spedra®). PDE5i work for many men but they will not cause an erection unless the man is mentally AND physically stimulated (see our factsheet ‘Oral treatment for erectile dysfunction’).

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. There are two types of alprostadil injections available, 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 help you get an erection while the other helps trap the blood there 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 painful 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 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 may be required if you are found to have low levels of this hormone (see our factsheet ‘Testosterone deficiency’).

Surgically implanted devices (penile prostheses), which strengthen the penis from inside, are available for the very few men who cannot get an erection in any other way.

Research has suggested that a small number of men with ED may benefit from exercises to strengthen the pelvic floor muscles. These lie underneath the bladder and back passage, and at the base of the penis. If your doctor thinks this approach may benefit you, they will refer you to a physiotherapist.

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’.

Will your age affect your treatment?

While you are more likely to suffer with ED as you get older, it is your attitude not your age that is the biggest barrier in treating the condition. While some older men and their partners accept loss of erectile function as a normal part of ageing and do not want treatment, others are unhappy about losing such an important part of their lives. It is perfectly normal for men and women to continue an active sex life way into old age and no one should be denied treatment for ED just because they are considered too old. Don’t be put off, you need to stay as fit and healthy as you can. If you have a partner, it is important to talk to them and also make sure that your doctor is aware of your treatment. Men in their 90’s are now seeking treatment for ED and usually respond to one of the available options.

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?

ED may be a warning of a future heart problem – heed the warning because your life may depend on it – 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.

Ejaculation Problems

What are they?

There are 4 ejaculation problems that can affect men:

  • Premature ejaculation
  • Delayed ejaculation
  • Retrograde ejaculation
  • Anejaculation

Premature ejaculation

Premature ejaculation (PE) is when a man ejaculates or ‘comes’ sooner than he or his partner wishes on all or nearly all occasions. It usually happens before, or within about one minute of, vaginal penetration.  But just thinking about something sexually stimulating can trigger ejaculation and sometimes it happens before any direct stimulation of the penis occurs. The important thing to remember is that if ejaculation occurs sooner than the man and/or his partner wishes and this is causing distress, bother, frustration and/or the avoidance of sexual intimacy, then it can be considered ‘premature’.

How common is it?
PE is one of the most common, aggravating, sexual problems affecting men. It can occur at any age and under any situation, but it is most common in younger men, particularly those their teens and twenties. It is often due more to the novelty of the sexual experience (new partner or different situation) than to the man’s age, although most men will experience it at some time. Estimates of how many men are affected by PE vary widely, ranging from just 5% up to 31%.

How is it caused?
Most cases of PE are caused simply by being unable to control the ejaculatory response.  Erection problems may play a part, as some men ejaculate early if they think they might lose their erection. There are also some conditions in older men that may interfere with ejaculation, such as changes in the prostate gland, disease of the blood vessels (atherosclerosis), diabetes and neurological disorders.

Early sexual experiences may be important in shaping future ejaculatory habits. Initial nervousness and hurry, such as in having sex in the back of a car, one-night stands, fear of discovery or of being heard at home through the wall and other unsatisfactory early sexual experiences, may lead to a pattern of PE.

Another common cause of PE is relationship problems. Stress in a relationship may come from sexually demanding partners, unrealistic expectations, different needs and desires in a couple, dissatisfaction, lack of communication and trust, outside affairs, a partner who also has a sexual problem and an excessive desire to please a partner. Unkind remarks made at the time may make matters worse and can lead to a cycle of failure and anxiety.

How can you delay ejaculation?
Many men can help themselves to delay ejaculation, but some may need help. Discuss the problem with your partner first, to find out what she needs and how she feels. A simple self-help method that can be effective is called the ‘stop/start technique’. This can be done by the man alone or with his partner, whichever is preferred.

  • Step 1: Gradually start stimulation of the penis (a lubricant helps), stopping just before you think you are about to ejaculate (the point of no return!)
  • Step 2: Rest, with no stimulation for 30 to 60 seconds, until the need to ejaculate passes
  • Step 3: Begin rubbing the penis again, stopping or reducing the stimulation until the need to ejaculate passes. Rest, as above
  • Step 4: Repeat the above steps 4 or 5 times, until you begin to recognise when you are about to ejaculate. Allow ejaculation to occur. This needs to be done regularly for a couple of weeks

This ‘stop/start technique’ can be changed to include your partner and is then called the ‘squeeze technique’. Your partner masturbates you up to the point of no return, then firmly squeezes the penis where the glans (knob) joins the shaft using the thumb and forefinger. The sensation of being about to ejaculate will reduce. There may be some softening of your erection, until stimulation begins again. This technique is a bit more difficult to master. A couple will need to be really committed if either of these techniques are to work.

Do ‘delay sprays’ work?
Delay sprays contain local anaesthetics. These can reduce the sensitivity of the glans of the penis, but you may not feel yourself ejaculating either.  The most commonly used spray contains lidocaine and can be prescribed by your doctor.

Research has shown that an anaesthetic spray applied to the penis 5 minutes before intercourse helped men with lifelong PE last 6 times longer, with few side effects. It increased the time of intercourse from 0.6 minutes to 3.8 minutes, while the placebo treatment (that contained no active ingredient) only increased the time from 0.6 minutes to 1.1 minute.

When using anaesthetic sprays, it is important to remember that you may transfer the anaesthetic to your partner and reduce her pleasurable sensations, so it’s best to use a condom.

Use of antidepressants
Some antidepressants are known to slow down ejaculation, but most of these are not licensed for the treatment of PE in the UK. However, if your doctor thinks it may help your PE, they may prescribe one of these drugs, usually a selective serotonin-reuptake inhibitor (SSRI) or clomipramine. One tablet is taken at night for a month. If that helps the PE, the treatment can then be taken when required, an hour before intercourse. There are side effects such as a dry mouth, occasional blurring of vision and sleepiness. It should only be taken at night and great care should be taken with driving or with using machinery the next day.

Dapoxetine (Priligy®) is the first drug treatment for PE to be licensed for use in the UK. It is a type of SSRI, but because it works much faster than those described above, it can be taken ‘on demand’ around 1 to 3 hours before sexual activity. It has been shown to significantly lengthen the time of intercourse. Dapoxetine is not generally recommended in men who are taking phosphodiesterase (pronounced phos- pho- di- es- ter- ase) inhibitors (PDE5i) such as Viagra®, because this combination may cause the blood pressure to drop. For this reason, these medicines should only be prescribed by a doctor who will take your health and other medications into consideration (see our factsheet ‘Oral treatment for erectile dysfunction’). Dapoxetine should not be combined with recreational drugs or alcohol. In trials, very common side effects included dizziness, headache and nausea, and common side effects included anxiety, insomnia, strange dreams, tremor, blurred vision, tinnitus, erectile dysfunction and reduced libido.

Other drug treatments may be available for PE, particularly if you also have erection problems. Talk to your doctor about your options. When taking any drug, particularly those that are not ‘essential’, you need to be sure that the benefits outweigh the risks and these should be discussed with your doctor.

Drug treatments for PE may be also prescribed in combination with sex therapy (see the following section on ‘Sex therapy’).

Delayed ejaculation

Delayed ejaculation (DE) is not anyone’s fault and it is not uncommon. With this problem, ejaculation is affected and the man finds it very difficult to ejaculate or ‘come’ even though he wants to and is receiving sufficient stimulation for this to occur.

How is it caused?
DE may be caused by physical problems (in the body) psychological problems (in the mind) or a mixture of both. Physical causes include severe diabetes, drug therapy and neurological problems, such as those caused by spinal cord injury, pelvic surgery, multiple sclerosis or alcoholism.

Psychological causes are more likely if you don’t have any of the above conditions. Some men may have unknowingly taught themselves to respond in a certain way or manner and ejaculation can only occur in this situation. For example, ejaculation may only happen with masturbation rather than intercourse, as some men get used to a certain type of manual stimulation and find it difficult to adjust to the change in sensations when with a partner. There may also be an underlying relationship problem.

How is it treated?
At the moment, there are no drug treatments approved for DE. Treatment usually involves sex therapy (see the following section on ‘Sex therapy’).

Retrograde ejaculation

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.

How is it caused?
The most common cause of retrograde ejaculation is surgery to the prostate or the bladder neck. Many men who have had a prostate operation will experience this.  Other causes include neurological problems caused by diabetes or multiple sclerosis, spinal cord injury, and some prescription medications (mainly for blood pressure control). The sensation of ejaculation may also be reduced.

How is it treated?
Treatment for this condition would only be considered if fertility was an issue.  If you find this condition distressing, you may benefit from sex therapy (see the following section on ‘Sex therapy’).

Anejaculation

Anejaculation is when you get the sensation of ejaculation but you don’t ejaculate at all. It is uncommon.

How is it caused?
The main cause is neurological damage resulting from spinal cord injury, major lymph node surgery, diabetes or multiple sclerosis. It may also be caused by a psychological problem.

How is it treated?
Anejaculation would only be treated if fertility was an issue. If you find this condition distressing, you may benefit from sex therapy (see the following section on ‘Sex therapy’).

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

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?

Ejaculation problems may result from physical and/or psychological causes – these require very different treatments.

Further reading

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

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.

Testosterone Deficiency

What is it?

Testosterone deficiency or ‘hypogonadism’ is when the body is unable to make enough testosterone to work normally.

How common is it?

Men are more likely to develop hypogonadism as they get older. In the UK, it is thought to affect over 8% of men aged between 50 and 79 years.

Why is it important?

Testosterone is the most important sex hormone (androgen) in men. The body starts to produce testosterone during puberty and it is essential for the development and maintenance of male characteristics. Testosterone also has effects on sexual function and most major organs including the brain, kidneys, bone, muscle and skin.

Low testosterone levels increase a man’s risk of developing diseases of the heart and blood vessels (cardiovascular disease (CVD)), and increase his risk of death. A low testosterone can also significantly reduce a man’s quality of life.

What causes it?

Testosterone production is controlled by both the brain and the testes. In younger men, testosterone deficiency usually results from a problem in one of these areas. From the age of about 30 years, testosterone levels start to drop naturally. However, the production of testosterone doesn’t usually stop altogether and some men have higher levels than others as they age. The condition known as ‘late-onset hypogonadism’ is only associated with older age.

Older men are at increased risk of developing hypogonadism if they are obese or have the metabolic syndrome, diabetes, chronic obstructive pulmonary disease (COPD), inflammatory arthritis or kidney disease. It is also more likely to occur if they have had androgen deprivation therapy for prostate cancer, taken opiate drugs for a long time, have prostate disease or drink too much alcohol.

What are the symptoms?

Patients with hypogonadism often have no specific symptoms. They may lose their night time erections, find it difficult to get or keep an erection (which is known as erectile dysfunction (ED)), have low libido (‘sex drive’) and feel tired and/or depressed. Some men may notice they are losing muscle mass, becoming weaker and/or gaining weight. Other symptoms include hair loss from the face, armpit or pubic region, difficulty sleeping and hot flushes.

However, it is important to remember that many of these symptoms may be due to lifestyle or psychological issues (in the mind) rather than testosterone deficiency. For example, tiredness, weakness, reduced muscle mass and getting fatter may be caused by a lack of exercise and/or a poor diet. While low libido, ED, depression and difficulty sleeping may be caused by stress and/or anxiety. The lower your testosterone levels, the more likely you are to get symptoms

How is it diagnosed?

Hypogonadism is often identified when men see their doctor about, or are asked about, reduced libido and/or ED.

To diagnose hypogonadism that requires treatment, your doctor will consider your symptoms AND your testosterone levels. Men with ED, diabetes and suspected hypogonadism should always have their testosterone checked. Men who don’t respond to phosphodiesterase (pronounced phos- pho- di- es- ter- ase) inhibitors (PDE5i) such as Viagra®, (which are used for treating ED), should also have their testosterone checked. To measure your testosterone level you will need a blood test, which is done in the morning and usually repeated on another day.

Hypogonadism may not be diagnosed if men ignore their symptoms or put them down to other causes such as aging.

How is it treated?

If you are found to have hypogonadism that requires treatment, you will need testosterone replacement therapy (TRT). This can be given as a gel which is rubbed into the skin every day, or as a long-acting injection which is given every 6-12 weeks depending on how you respond to it.

TRT can provide a variety of benefits in men with hypogonadism. These include improvements in CVD, mood, libido and sexual function, as well a reduction in body fat and an increase in muscle mass. Such benefits are also likely to improve quality of life.

If you have ED, TRT may have the added bonus of improving the effects of drugs like Viagra®. (For more information see our factsheet ‘Oral treatment for erectile dysfunction’). This may be particularly important in men who have type 2 diabetes, as many of them do not get good results with these drugs.

However, TRT is also associated with some risks and your doctor should be able to discuss these with you. When thinking about using TRT, you and your doctor need to be sure that the benefits outweigh the possible risks. TRT may not be suitable for you if you have prostate cancer.

Once a man starts TRT he should see his doctor for regular check ups to make sure it is working well and not causing any problems. If he is not at increased risk of heart problems, and the testosterone level is stable, he should have a blood test every 6 to 12 months.

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?

Hypogonadism can significantly affect a man’s health and quality of life – but it can be easily treated.

Further reading

Download or request our booklet ‘Sex and the heart’ and/or our factsheet ‘Erectile dysfunction’.

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.