Dr Michael Lowy is a sexual health physician specialising in men’s health conditions, sexual medicine and counselling. He is specifically trained in the treatment of male sexual dysfunction (libido, erection, ejaculation disorders), relationship and sexual problems affecting individuals and couples.
Dr Michael Lowy practices in Woolloomooloo, Sydney at The Male Clinic.
Dr Michael Lowy MBBS, MPM, FAChSHM, FECSM
Dr Lowy obtained his original medical degree from the University of NSW. He is a Fellow of the Australasian Chapter of Sexual Health Medicine and obtained a Master of Psychological Medicine from the University of NSW. Dr Lowy is also a Fellow of the European Committee in Sexual Medicine.
Areas of Speciality
- Erectile Dysfunction
- Ejaculation Problems
- Libido disorders
- Androgen deficiency
- Peyronie’s Disease
- Sexual Rehabilitation
- Prostate Disease
- The Ageing Male
- Relationship Issues
- Mindfulness approach to sexual dysfunction treatments
Dr Lowy has worked in the specialty of sexual medicine since 1992, with an interest in the physical and psychological causes and treatments.
In addition to his clinical work, Dr Lowy has been an investigator in numerous clinical drug trials of medical treatments for male sexual dysfunction. He has been a member of a number of pharmaceutical industry clinical advisory boards.
Dr Lowy is a lecturer in Men’s Health at the University of NSW, Notre Dame University, Sydney University and Family Planning NSW. He is a founding member of the Society of Australian Sexologists (SAS) and has been awarded a life membership of ASSERT NSW.
Dr Margaret Redelman, OAM, MBBS (Uni NSW), M Psychotherapy (Uni NSW), trained in sexuality in the USA and worked in Sexually Transmitted Diseases Clinics, Family Planning Clinics and General Practice for many years. She has a Master’s Degree in Psychotherapy.
Dr Margaret Redelman works as a Sex Therapist and a Relationship Therapist in private practice in Bondi Junction as well as The Male Clinic in Woolloomooloo, Sydney.
Her work covers positive male and female sexuality, sexual dysfunctions, and the interpersonal relationships of both heterosexual and homosexual couples.
Dr Redelman is a guest lecturer and public speaker on topics of sexuality. She has published articles on sexuality in accredited medical journals and participated in research for the treatment of male and female sexual function.
She is on the executive committee of SAS (Society for Australian Sexologists) and has full clinical accreditation from SAS as a Psychosexual Therapist. She has held multiple executive positions in the Sexual Health field including President of SAS NSW in 2014 to 2016, President of the Asia-Oceania Federation for Sexology (AOFS) 2012 to 2014, President of the 13th AOFS Conference held in Brisbane in 2014, President of the 6th Sexual Dysfunction Conference, Sydney in 2014, Convenor of the Australasian Sexual Health Alliance (ASHA) Conference in Darwin in 2013, national President of ASSERT (Australian Society Sexuality Educators Researchers and Therapists) from 2004 to 2009 and President of the 18th World Association for Sexual Health (WAS) Congress held in Sydney in 2007.
- Sexual & relationship counselling
- Assessment and treatment of male sexual dysfunction, hormone and prostate disorders
- Medico-legal assessment of sexual dysfunction
- Clinical research of sexual dysfunction
- Women’s sexual health
The Male Clinic can organise the following investigations:
- Penile arterial blood flow studies (Duplex Doppler ultra-sound)
- Cavernosography to assess veno-occlusive dysfunction
- Close liaison with associated specialists in urology
Definition of ED
Erectile dysfunction (ED) is defined as the inability to achieve and/or maintain an erection that is suitable for sexual intercourse. Erectile dysfunction is often referred to as “impotence”. However this term is no longer used. It is important to distinguish erectile dysfunction from other forms of sexual problems such as low libido or premature ejaculation.
How an erection occurs
An erection is obtained by the spongy tissues in the penis becoming engorged with blood. This vascular process is initiated by a signal from the brain that travels down the spinal cord through the pelvis directing blood vessels in the penis to dilate. There are chemical factors involved in this vascular process and the mechanism that traps the blood in the penis is known as the veno-occlusive mechanism. When this does not work effectively the leakage of blood is known as “venous leakage”. This may occur as a psychological issue when anxiety is present during sexual activity or as a consequence of the physical changes of ageing and the effects of other medical conditions such as diabetes and coronary artery disease.
The causes of ED
The causes of ED may involve problems with the brain and nervous system, the arteries and veins in the penis and the penile spongy tissues (cavernosal tissues). Conditions such as high cholesterol, high blood pressure, diabetes and obstructive sleep apnoea may be associated with erectile dysfunction. Some medications used to treat these medical conditions may affect the erection process and these include blood pressure and cholesterol lowering tablets. Medications should never be stopped if is it suspected they are contributing to ED but the concern over the potential effect on sexual function should be raised with your treating doctor.
Peyronie’s disease may affect erections with the presence of painful scar tissue resulting in curvature of the erection. Excessive alcohol intake and substance abuse are other known factors. ED may occur after surgery to the abdomen, pelvis and prostate. ED can also associated in older men who have urinary changes from benign prostate enlargement. For further information, see the document on Peyronie’s disease.
ED due to psychological causes is called performance anxiety, often seen in younger men but can be present across all age groups. It may involve anxiety and lack of confidence at the beginning of a sexual relationship or may present with difficulty maintaining the erection when applying a condom. The anxiety with erections can result from relationship stress or other stresses like financial issues or as a result of other sexual issues such as premature ejaculation. Performance anxiety can improve in time but may require education and counselling and the use of medication.
Erections and ageing
The presence of ED in a younger man is often due to psychological causes but in some cases due to a congenital anomaly of the penile erection tissues or blood vessels, this is called veno-occlusive dysfunction or “venous leakage”. ED is an increasing issue in older men. About 1 in 3 men over the age of 50 complain of erectile difficulties. It is important to stress that the change in erections with age is not necessarily a physical disorder requiring treatment, often an understanding of the nature of these changes is sufficient treatment alone. The firmness of the erection changes with age and the time taken (the refractory period) to re-engage in sexual activity increases in time with age.
Investigation of ED
As ED may be associated with vascular conditions particularly present in the older man, it is thus important to carry out a full general health check including the heart. Overnight erection testing may assist in establishing in a younger man whether the cause is physical or psychological. It is usual for a man to experience during rapid eye movement sleep between 3 to 5 erections each night. High cholesterol and high glucose are checked with blood tests, which can also check the health of the liver, kidneys, iron stores, thyroid, prostate as well the level of the male hormone testosterone. Men with suspected venous leak undergo Duplex Doppler ultrasound scan of the penile blood flow to check the status of the arteries and erection tissues and a procedure called cavernosography or cavernosogram to view the site of the venous leakage and check penile pressures.
The treatment of ED
Counselling: Treatment of erectile dysfunction may simply involve counselling and explanation of the normal anatomy and physiology of erections. Counselling can benefit relationship issues that may be contributing to the erection problems.
Oral medication: A common and popular treatment these days is the use of oral medications known as PDE5 inhibitors. The products available on the Australian market include Viagra™, Cialis™ or Levitra™ tablets. These medications are taken as required 1-2 hours before planned sexual intercourse. These medications are effective in most situations but cannot be used if the patient is not fit enough to engage in sexual intercourse or is on nitrate medication. For further information, see document on PDE5 inhibitors.
Penile injections: When oral medication is not effective, penile injection therapy may work. The injection is self administered into the shaft of the penis, the dose needs to be carefully regulated so that a prolonged erection (priapism) does not occur. The injection medication may consist of a single chemical called prostaglandin (PGE1) or alprostadil known as Caverject Impulse™ available by a doctor’s prescription through a regular pharmacy. If the single medication injection is not adequate, then a compounded triple mixture that contains PGE1, phentolamine and papaverine is obtained through an approved compounding chemist. Priapism is defined as an erection lasting more than 4 hours and is treated with the application of ice packs and the taking of pseudo-ephedrine tablets (Sudafed™). Occasionally a visit is required to the local emergency room to drain the priapism.
Vacuum device: A less invasive treatment is the use of a vacuum erection device that allows an erection to occur by creating a vacuum with a plastic cylinder placed over the flaccid penis. The induced erection is then held in place by a constricting band placed around the base of the penis for a maximum time of 30 minutes.
Shock wave therapy: Low intensity extra corporeal acoustic shock wave therapy is a recent innovation relying on the effects of sound waves when applied to the shaft of the penis creating new blood vessels (angiogenesis). Shock wave therapy works best in men with ED arising from penile blood flow changes (vasculogenic ED). It may change a poor PDE5i responder to an improved PDE5i responder.
Surgery: In some cases regular treatments are not effective and a final treatment option is to insert a penile prosthesis or implant which is an internally placed hydraulic device that has no obvious external appearance of the genitals. This operation is performed by a urologist.
Vascular surgery is mainly performed in younger men when trauma has damaged the blood vessels leading to the genitals. Some men with venous leakage may benefit from erectile restoration vein surgery or vein stripping surgery.
The intention of this informatioin is for educational purpose only and not to be used as a guide for self-management. Consult with your specialist or GP.
Definition of PE
The most common ejaculation dysfunction is premature ejaculation which is defined as ejaculation which always or nearly always occurs prior to or within about one minute of penetration. This is associated with the inability to delay ejaculation on all or nearly all penetrations. The definition also involves the presence of negative personal consequences such as distress, bother, frustration and/or the avoidance of sexual intimacy. So the definition always involves the ejaculation time and the amount of distress to the man and his partner.
The prevalence of premature ejaculation in most communities is between 20 and 30%. Research has shown that the average ejaculation time is 5.4 minutes, though most men ejaculate within 5-15 minutes.
Ejaculation involves emission controlled by the hypogastric nerves at T12 to L1 and expulsion involving the pudendal nerve at S1 to S3. It involves a number of chemicals including dopamine, serotonin and prolactin. The stages of normal ejaculatory physiology consist of emission where the bladder neck closes, ejection of the seminal fluid associated with coordinated pelvic floor contractions and the pleasurable sensation of orgasm.
PE causes and types
Premature ejaculation has four subsets:
- Primary lifelong PE usually occurs in younger men with an ejaculation time of less than 1-1.5 minutes. Primary PE is a neurobiological condition associated with changes in the hypothalamus of the brain, associated with a hypersensitive ejaculatory reflex now believed to arise from serotonin receptor sites in the brain.
- Secondary or acquired PE occurs in older men and can be associated with erectile dysfunction or various life stressors. The ejaculation time is around 2-3 minutes. Secondary PE can be associated with anxiety and other medical conditions such as erectile dysfunction, prostatitis and hyperthyroidism. PE resulting from anxiety often has a situational component, such as when starting a new relationship. Men with PE will usually have better control over their ejaculation time with masturbation. Older men who develop erection problems may develop PE as a compensatory mechanism.
- The third category is called natural variable PE where ejaculation time is inconsistent in that sometimes it is quick and sometimes it takes longer but the essence of this condition is that ejaculation time is unpredictable.
- The last category is a subjective condition called PE like ejaculation syndrome where the ejaculation time is “normal” though the man for various psychological reasons believes he is too fast though on questioning he may last anywhere between 10 and 30 minutes.
Treatment of PE
Treatment of premature ejaculation involves psychological, pharmacological, sexology and behavioural approaches. Even though there may not be a psychological cause of the PE, any man having this condition may develop a secondary performance anxiety that can benefit from psychological help. When considering treatment, consideration should be given to the man’s expectations of how long he should last as well as other factors such as the state of the relationship. Sometimes communication between the couple and simple adjustment of the couple’s sexual technique is adequate therapy.
The classic behavioural exercise is the stop start technique which involves repetitive stimulation of the penis each time stopping short of the point of ejaculatory inevitability allowing the arousal to temporarily subside. Over time this repetitive stimulation pushes back the point of ejaculation though it does require persistence and commitment over some months. The stop start technique can be carried out in 3 stages involving use of a dry hand, lubricated hand and finally penetration.
Another ejaculation delaying technique is the squeeze technique where the tip of the penis is firmly squeezed for about 10-15 seconds just before penetration.
Medication: The use of an anaesthetic spray combined with a condom may delay ejaculation. Stud Spray™ is available without a prescription from a pharmacy but must not be used without a condom. Pelvic floor exercises are said to improve erection quality and improve control of ejaculation. The only approved medication for the treatment of PE is dapoxetine (Priligy™). This medication is a short acting SSRI anti-depressant medication that is taken as a single dose between 1 and 3 hours before planned sexual activity. SSRI medication can be used off label on a daily basis though the medication must be taken daily without interruption for up to 1-2 years.
Sex therapy and counselling can help PE even if the cause is physiological as the inevitable secondary psychological component can be treated which can help improve the outcome.
Mindfulness exercises may help treat performance anxiety, erectile dysfunction and premature ejaculation. This involves putting aside a 15-20 minute session about 2 or 3 times a week but not at a time when stressed or tired. Using yoga type relaxing breathing techniques during mindfulness exercises can be helpful. The idea is to create an erotic focus not just in the genital region but other pleasurable areas of the body. These exercises can be done on ones own or together with a partner. These exercises begin with clearing one’s mind of everyday life hassles and stressors. The genitals can be touched but are not necessarily the focus of the exercise though the stop start exercise for PE can be incorporated into this routine. Please view the separate document on mindfulness exercises.
The intention of this informatioin is for educational purpose only and not to be used as a guide for self-management. Consult with your specialist or GP.
Definition inhibited ejaculation
The definition of delayed ejaculation is persistent or recurrent delay or difficulty or absence of orgasm after sufficient sexual stimulation. A well known US sexologist Stan Althof has described three causes of delayed ejaculation, these being insufficient stimulation, psychic conflict and masturbation and desire disorders.
Physiology of inhibited ejaculation
Just as some men are born with premature ejaculation, some men are born with delayed ejaculation as simply part of their makeup. However this problem can appear as a normal part of ageing, in the presence of reduced testosterone level and as a result of diabetes and excessive alcohol intake. Excessive use of porn in some men can habituate their masturbatory style to the point where they struggle to ejaculate in a realistic non-fantasy sexual situation. Also unusual masturbatory techniques can also result in conditioned habituation where the erect penis cannot achieve enough stimulation with penetration.
Inhibited ejaculation may also be a complication of the use of anti-depressant SSRI medication and can be a result of any form of radical pelvic surgery including removal of prostate cancer by radical prostatectomy.
Men who are unable to ejaculate vaginally are often referred to fertility specialists in order for conception to occur. This situation can be stressful for couples where fertility is sought.
Treatment inhibited ejaculation
Sex therapy always remains an important part of any treatment of delayed ejaculation. This includes coming to terms with how ageing changes sexual function and adjusting sexual technique to deal with these changes. Using vibrators to the end of the penis or vibrating penile sleeves or a device called a Viberect may enhance ejaculation.
Bearing in mind that the average ejaculation time is 5.4 minutes, men who struggle to reach an orgasm and persist for a longer period than their partner is willing to be involved in, risk of losing their erection and thus creating an unsatisfactory sexual situation. It is thus encouraged that during sexual intercourse when the partner has reached a point of satisfaction, the man withdraws and seeks to reach a climax with other methods such as with a vibrator or manual stimulation.
There are some medications that may enhance ejaculation such as cabergoline (Dostinix), Buproprion™, oxytocin, Periactin™, Busipirone™, amantadine (Symmetrel™), Sudafed™, Edronax™ and Reboxitine™. These medications are not always effective and only available by a doctor’s prescription. Patients should be encouraged not to buy these medication over the internet, as despite these medications being cheaper and available without a prescription when purchased online, they are counterfeit, possibly containing unknown substances and potentially poisonous and also unlikely to be effective.
Other ejaculation problems can be anejaculation (total absence of orgasm and ejaculation), anorgasmia (no orgasm but ejaculation may occur) and retrograde ejaculation. Often after surgery for benign prostate disease retrograde ejaculation causes the ejaculate to go into the bladder due to changes at the bladder neck and is not expelled externally. This may also occur in chronic conditions affecting the autonomic nervous system such as diabetes and multiple sclerosis. Tamulosin (Flowmaxtra™) used in men with lower urinary tract symptoms commonly cause anejaculation. To investigate these ejaculation disorders an ultrasound of the seminal vesicles and prostate is carried out.
The intention of this information is for educational purpose only and not to be used as a guide for self-management. Consult with your specialist or GP.
What are PDE5i?
The oral medications Viagra™ (sildenafil), Cialis™ (tadalafil) and Levitra™ (vardenafil) belong to a group of medicines called phosphodiesterase type 5 inhibitors (PDE5i). These medications are a treatment for erectile dysfunction. They work through the nitric oxide and cyclic GMP metabolic pathways to enhance penile blood flow. These medications do not increase libido though they may be less effective in the presence of low testosterone. These medications work best in the presence of sexual stimulation.
PDE5 inhibitors were developed for the treatment of older men with penile blood flow problems resulting in erectile dysfunction. These days younger men without blood flow problems are taking PDE5 inhibitors where the sexual problem may be related to performance anxiety or lack of confidence. These medications are also very effective in this situation but should be considered a short term solution and prescribed in association with counselling.
How are they taken?
The PDE5 inhibitors should be taken about 1-2 hours before planned sexual activity. Sexual stimulation is required to activate the relaxation of the penile blood sinusoids (internal blood containing spaces) allowing blood to engorge the penis. These medications may be less effective or take longer to work if taken during a heavy meal or in association with alcohol intake, so on the first few attempts, take the medication before a meal or at least 2 hours afterwards. Taking the medication at least on 5 different occasions is required before the effectiveness can be ascertained.
The different types of PDE5i
Viagra and Levitra are usually effective after one hour and have a window of opportunity between 4-6 hours. Cialis may take up to 2 hours to become effective but the window of opportunity may last up to 36 hours or even longer. The usual on demand dose of Viagra is 50mg or 100mg, Levitra is 10mg or 20mg and Cialis also 10mg or 20mg.
As all three medications come in different strengths, your doctor will advise the appropriate dose. Viagra is now off patent and a number of generic variations are available on the market, these usually carry the name Sildenafil.
Cialis also comes in the form of a low dose daily medication in a dose of 5mg a day. This tablet is indicated for men who have difficulty planning sexual activity with on demand medication. By taking a tablet each day at the same time, sexual activity can be undertaken at any time without planning. It is also used in sexual rehabilitation after radical prostatectomy where the taking of daily medication encourages preservation of erectile tissue whilst waiting for healing of the damaged erection nerves and as a single treatment when erectile dysfunction and lower urinary tract symptoms present together.
Side effects of PDE5i
All the PDE5 inhibitors have similar side effects, the commonest being facial flushing, blocked nose and headache. Another side effect is gastric reflux (heart burn). Viagra™ has a rare side effect affecting colour vision and Cialis has a rare side effect of low back pain and muscular pain in the legs. Often the side effects are mild and may lessen over time. These medications have proven to be safe when taken in the long term.
PDE5 inhibitors should not be taken by any man who is not fit enough to engage in sexual activity, particularly by men who have unstable cardiovascular disease. Any man taking nitrate medication which is a treatment for heart pain known as angina, is not allowed to take these medications. The recreational drug amyl nitrate poppers is a nitrate medication and is thus also not allowed to be taken together with PDE5 inhibitors.
Please note that PDE5 inhibitors are not licensed for use in women.
Many men purchase these types of medications over the internet. These are called counterfeit medications. These medications are unsafe and may contain unknown and poisonous substances and there are documented cases of fatalities from consuming counterfeit internet sourced medications. It is strongly advised that prescribed medications should only be purchased from an Australian pharmacy.
The intention of this information is for educational purpose only and not to be used as a guide for self-management. Consult with your specialist or GP.
Penile injections are said to be more effective than oral medication particularly in cases of poor arterial inflow or excessive leaking of blood out of the penis, known as venous leakage. Erectile dysfunction not responding to oral medication can be seen in the presence of chronic medical conditions such as diabetes, after prostate cancer treatment and the result of ageing.
Different types of penile injections
Penile injections are self administered by the man and are available in two forms. The first is Caverject Impulse™ which is available in two strengths, 10mcg and 20mcg. These are obtained with a doctor’s prescription through a local pharmacy. Different doses can be adjusted via a dial mechanism on the Caverject Impulse™ syringe. Video instruction on the correct use of injecting can be found on www.cject.com.au or www.caverject.com.
The second form of penile injection is available through compounding chemists who have a special licence to manufacture injection medications. These are generally known as Trimix and usually involve a combination of alprostadil, phentolamine and papaverine. The medication comes in a multi dose vial and the appropriate dose is calculated with discussion with your doctor. These compounded injections usually require refrigeration and have a short expiry date.
Side effects of penile injections
Penile injections are a very effective treatment of erectile dysfunction, particularly in the more severe cases.
The known side effects are:
- Post injection pain, this is a chemical pain that occurs 1-2 hours after the injection. It should be noted that the actual insertion of the needle at the time of injecting is not as painful as expected.
- Penile scarring can occur from regular injecting and is minimised by maximising a good injecting technique.
- Priapism or prolonged erection is a known risk of penile injection therapy. This can be minimised by initiating a low first dose and increasing the dose slowly until the required response is obtained. Priapism is treated by applying cold packs to the penis plus the taking of Sudafed™ cold remedy tablets which act as a blood constrictor. If the erection persists more than 2-4 hours then a visit to the local emergency room to deliver an antidote or drain the prolonged erection. Occasionally surgical drainage is required.
Men who use penile injections are advised not to use the injection more than 1-3 times a week and never more than once in 24 hours. Men who use penile injections should be regularly reviewed, at least every 6-12 months to check for penile scarring and to check on their injecting technique. Penile injections should only be used after full evaluation and instruction by your doctor, urologist or sexual health physician.
The intention of this information is for educational purpose only and not to be used as a guide for self-management. Consult with your specialist or GP.
Definition Peyronie’s Disease
Peyronie’s disease is a localised area of abnormal scar tissue or fibrosis that appears as a plaque or nodule in the penis. These plaques occur in about 1% of men over 50 years of age. A plaque is initially tender but when mature is painless and often associated with curvature of the erection. Most plaques occur on the top of the penis. Patients present with pain, a lump in the penis, a curvature of the erection or erectile dysfunction.
Physiology of Peyronie’s Disease
Peyronie’s disease has two distinct phases. The acute phase lasts 12-18 months and may be associated with pain during erection. Nodules form and a curvature may slowly develop. The chronic phase involves thickening of the scar tissue and the absence of pain. The curvature may improve, stay the same or deteriorate. The presence of calcification indicates a poorer outcome.
These plaques may arise without any known cause or may arise from mild trauma associated with mechanical strain of the erect penis during intercourse. This effect is commonly seen with the partner in the superior position. The exaggerated localised scarring response may be genetic (HLAB27) and associated with scarring in the hands, a condition known as Dupytren’s contracture. Penile injection therapy and men who have undergone radical prostatectomy may also predispose to this scarring.
Erection problems may occur in 20% of men with Peyronie’s disease. This may arise from a performance anxiety due to the pain and visible bend or due to a physical cause when penile blood vessels are affected by the plaque.
Treatment of Peyronie’s Disease
No treatment is required when there is minimal deformity, no pain and no discomfort. There is no consensus on the best treatments for the acute phase of Peyronie’s disease. Many treatments are anecdotal and not evidence based. However it is apparent that men experience a degree of depression where counselling is recommended.
Oral medication: When the plaque presents as a painful lump, the pain may be improved by oral medication using colchicine tablets (an anti-inflammatory used for the treatment of gout). Vitamin E can be taken orally and also applied to the skin of the penis. Oral proteins
l-carnitine and l-arginine are also used. An oral prescription medication oxypentifylline (Trental™) has been trialled overseas with some apparent benefit. Topical applications have not been proven to be that effective.
Injection medication: Various chemicals have been injected into the plaque such as cortisone, verapamil and interferon. A new injectable collagenase injection Xiaflex™ is now available in Australia. Xiaflex™ has been shown to reduce the curvature. Penile traction devices may assist to improve the shortening and curvature that are often a component of Peyronie’s disease.
Surgical treatment: Four surgical procedures are available to straighten the penis if the bend in the erection interferes with penetrative intercourse. However, surgery will not improve the rigidity of the erection if there is already a pre-existing problem with the rigidity. Surgery is only considered if the Peyronie’s plaque is stable and not causing further penile curvature.
The first procedure is a plication operation (Nesbitt procedure). It involves bending the penis straight with sutures but will cause some shortening of the penis.
The second procedure involves incision of the plaque with or without grafting of autologous or synthetic material. This is more complex and has slower recovery but has the benefit of preserving penile length.
The third procedure is the insertion of a penile implant and bending the penis straight. Occasionally grafting may also be incorporated as part of this procedure. The most severe cases whereby the penis is severely bent require complete dismemberment of the penile structures and then reconstructing it with synthetic material over a penile prosthesis.
Low intensity extra corporeal acoustic shock wave therapy has a controversial role in the treatment of Peyronie’s Disease but has been shown to have some benefit in reducing curvature is some cases. Shock wave therapy’s main use is in the treatment of vasculogenic ED.
What is the prostate?
The prostate is a variable sized gland located in the male pelvis, usually the size of a walnut measuring 3-4cm long and 3-5cm wide. On average the gland weighs about 20gm. The prostate surrounds the urethra which carries urine from the bladder to the penis. The seminal vesicles attach to the prostate and produce material that mixes with the prostatic fluid to form semen. The tubes from the testicles carry sperm to the prostate where the sperm are mixed with the prostate and the seminal vesicle fluid. The fluid is then ejaculated during orgasm by a connection to the urethra called the ejaculatory ducts.
Three main prostate disorders
Prostate disease is a term used to describe any medical problem involving the prostate gland. Common prostate problems experienced by men include:
- Prostatitis is inflammation and swelling of the prostate gland, occurs mainly in younger men.
- Benign prostatic hyperplasia (BPH) is a benign enlargement of the prostate gland, occurs as men age.
- Prostate cancer occurs in men after 40-45 year of age, it is the most common form of cancer in men in Australia.
Prostatitis is a difficult to treat inflammation of the prostate gland in younger men. Often bacteria can’t be identified, so the condition is then described as non-bacterial prostatitis, even though antibiotics may be used for treatment. Prostatitis may present with pain on urination, pain on ejaculation and a chronic pelvic/genital discomfort.
BPH is one of the most common diseases affecting the prostate and is the most common benign tumour in men as they get older. This condition is present in 50% of men over 50 years.
Symptoms of BPH: The symptoms involve noticeable changes in urination due to the effects of enlargement of the prostate around the urethra, called lower urinary tract symptoms (LUTS). The urinary symptoms may be voiding (weak stream, dribbling, intermittency and inadequate emptying) or storage (urgency, frequency, nocturia and incontinence).
Assessment of BPH: The prostate can be assessed by a digital rectal examination (DRE) where a gloved and lubricated finger is inserted into the anus. The back of the prostate can thus be felt and an assessment of its size may be possible. This digital examination may also feel a cancerous lump though not all prostate cancers are palpable in this manner.
The PSA blood test (prostate specific antigen) is an important marker of prostate cancer though it is not cancer specific. It is very sensitive to the detection of prostate cancer, however it isn’t very specific in the sense it is not able to tell how aggressive the cancer is. It may also be raised in benign enlargement or prostatitis. Normal values for PSA blood test results are available for different age groups.
Treatment of BPH: Treatments for BPH range from watchful waiting to medication to surgery. Medications derived from plants have shown some benefit, for example, Saw Palmetto. Prescription medications may reduce the prostate size thus improving symptoms, yet often this is only a temporary relief. These medications include alpha blockers, 5 alpha reductase inhibitors and a combination of both. LUTS can be also associated with symptoms of an overactive bladder, and if primary treatments are not effective then oral anti-cholinergic medications can assist. However, sudden occurrence of overactive bladder symptoms can mean an insidious cause such as bladder cancer.
Treatments for BPH causing bladder outlet obstruction can be divided into cavitating (creation of a new channel) or non cavitating (no creation of a new channel).
Cavitating treatments include transurethral resection of the prostate (TURP) or HoLEP (holmium laser enucleation of the prostate). This involves removal of obstructive prostate tissue with an electrical blade or laser. Newer modalities of laser (greenlight) or heat treatment do not seem to create as large a channel as TURP/HoLEP but benefit from less bleeding .
A new treatment for BPH is the Urolift™ which can be performed as a day stay and most men will return to normal activities within a week. The Urolift™ uses implants to essentially stent apart the prostate that is blocking the urethra. Your urologist will discuss the most appropriate treatment for you.
Prostate cancer is the commonest cancer in men. It usually does not present with urinary symptoms unlike BPH. Prostate cancer has an increased incidence in men who have a close relative diagnosed with this condition or in men who have an African American heritage. It may be diagnosed by routine testing with the PSA blood test and DRE (digital rectal exam). Recently the use of high strength 3T MRI (magnetic resonance imaging) can assist with precision of diagnosis.
Prostate cancer needs confirmation by a biopsy and this can be done in a variety of ways. Transrectal ultrasound guided prostate biopsy (TRUS) requires the use of a rectal ultrasound probe to guide biopsy needles into the prostate. This can be done either awake using local anaesthetic or asleep with a general anaesthetic. Transperineal (TP) ultrasound guided prostate biopsy (TP) is similar to TRUS except the needles are placed through the perineum (skin between the scrotum and anus). The latter requires day stay in hospital and a general anaesthetic but has less risk of infective complications. If a patient has had an MRI, a computer can extrapolate areas to an ultrasound image and a biopsy this way is called a MRI/US fusion biopsy. Recently, a robot (Biobot) can be used to in conjunction with MRI and US fusion techniques to target areas of interest transperineally and via only two needle punctures. The most accurate way to target the smallest area of concern in a prostate is via MRI ingantry guided prostate biopsies. This will require both a dedicated MRI radiologist and a Urologist to guide the needle into the prostate. Once confirmed, the aggressiveness of the cancer is measured by the Gleason score.
Treatment of prostate cancer is complex and the decision on the most appropriate treatment involves many factors, the grade and stage of the cancer and importantly, the patient’s own preferences. If the cancer has the potential for cure then the choices are active surveillance, seed brachytherapy, external beam radiotherapy, or radical prostatectomy (open or robotic). If the cancer is incurable then treatment is usually with hormones or chemotherapy. Your urologist will discuss the most appropriate treatment with you for prostate cancer.
Definition sexual rehabilitation
Sexual rehabilitation is a process to restore sexual function that is often affected by prostate cancer treatments, which are surgery, either open or robotic radical prostatectomy, radiation therapy, brachytherapy or androgen deprivation therapy (ADT).
Sexual changes and outcomes
The sexual dysfunctions that may occur after these treatments include erectile dysfunction, loss of ejaculation, shortened penis and climacturia (passing of urine during orgasm). Loss of libido occurs particularly with ADT.
The outcome of sexual function after treatment depends on the age of the patient, the level of sexual function present before treatment and in the case of surgery, the sparing of the nerve bundles (better outcome if both sides are spared). Even if the erection nerves are spared, nerve paralysis also called neuropraxia may delay return of natural erectile function. Neuropraxia often occurs after surgery, hopefully a temporary situation.
Surgery tends to result in immediate loss of erections, whereas radiation and hormone deprivation treatments may result in a delayed loss of erections, up to 6 months after treatment. Sexual rehabilitation addresses these sexual dysfunctions, especially erectile dysfunction, that men may experience as a result of treatment for prostate cancer. It is an important part of the holistic care of men undergoing treatment.
There is evidence that the earlier the erectile dysfunction is treated, the better the chance of a return of erections. If natural erectile function returns after treatment, the quality of the erections may not be as good as in the past. Erections may take up to 3 years to recover, but usually an indication of the outcome is seen at 18 to 24 months.
Penile injections: erections can be induced within 2 to 3 weeks of surgery with penile injection therapy using alprostadil (Caverject Impulse™) or compounded alprostadil, phentolamine and papaverine known as Trimix. The penis is initially injected with a low dose of alprostadil, about 2.5 to 5 mcg once or twice a week. The early and regular “exercising” of the penis to erection has been shown to expedite the return of erections (but only when the erection nerves have been saved). This exercising regime can be with your partner or by yourself.
Penile injection treatment has been safely used for many years but sometimes its use is painful due to a “chemical post-injection pain”. Care must be taken with the amount injected to avoid a prolonged erection known as priapism and there is a risk of scarring occurring in the penile tissues.
This “exercising” regime allows oxygenation of the erection tissues thus minimising the risk of deterioration of these tissues due to lack of use and low oxygen (hypoxia) levels. If there appears to be an improvement in natural erections whilst on injection therapy, oral treatment can be tried about every 3 months.
Oral medications: the oral treatments are known as PDE5 inhibitors, there are 3 available (Viagra™, Levitra™ and Cialis™). The tablets are swallowed about 1 hour before planned sexual activity when used on an as required basis. But initially they are usually taken daily and later that may be changed to an as required basis. However during the first few months after surgery, these oral tablets may not have the same erection inducing effect that injections have, but some men may prefer tablets to injections at the early stage of recovery, either due to personal preference or not being ready to engage in sexual activity.
The tablets may result in a softer erection not firm enough for penetration, but sexual play is encouraged as part of the “exercise” concept. An orgasm is entirely possible with a soft erection or indeed with no erection when adequate stimulation to the penis occurs. But there is some evidence that just by taking PDE5 inhibitors even without an erection occurring, there may be benefit in prevention of deterioration of the erection tissues.
The common side effects include flushing of the face, headache and blocked nose. PDE5 inhibitors cannot be taken by men who are on cardiac medication known as nitrates.
Vacuum device: another treatment choice is the use of a vacuum erection device which is a non invasive method involving placement of a cylinder over the penis. Air is extracted by a pump which results in the formation of an erection that is held in place by a rubber constriction ring. The vacuum device is also used to “exercise” the penis without the rings as a daily or second daily routine for a few minutes. The constrictions rings can be used with the device to create and hold the erection to allow sexual intercourse to occur.
Penile implant: the surgical insertion of a penile implant or prothesis is considered when all other treatments have proven ineffective. This hydraulic device allows an erection suitable for penetrative intercourse to occur with the simple activation of a pump discreetly placed in the scrotum.
Sexual rehabilitation is a process to restore erectile function following prostate cancer treatment. After surgery, the loss of the erection is immediate and the return of that function can be a slow and unpredictable process. Brachytherapy and radiation treatment have a delayed onset of erectile dysfunction. Each rehabilitation program is individually designed and regular review is required as adjustments in treatments are often made. The outcome depends on many factors surrounding the nature of the surgery plus age and pre-surgery sexual functioning. Sometimes the final outcome of the return of erectile function 2 to 3 years after surgery may not be as good as the situation beforehand, even when nerve sparing surgery has been carried out. Persistence and repetition of the recommended exercises in a regular routine may improve the outcome. If you do not have partner it is still important to carry out the treatment program on your own. However if you are in a relationship, do not forget the sexual needs of your partner. If your erections are not firm enough for penetration, consider non-penetrative sexual activity known as outercourse. Negotiate with your partner over the exercises that you can both participate in and discuss what level of sexual activity you both wish to achieve. Your treating doctor or sex therapist can always assist with these decisions.
The intention of this informatioin is for educational purpose only and not to be used as a guide for self-management. Consult with your specialist or GP.
What is testosterone and what does it do?
Testosterone is a male sex hormone also known as an androgen. Testosterone produces changes in body shape and sexual characteristics typical of men after puberty and maintains adult male features and stimulates the testes to produce sperm. Androgens play a major role in the reproductive and sexual function of the adult male. The equivalent sex steroid produced by women is oestrogen.
Testosterone is also important for the growth of bones and muscles and stimulates the bone marrow to make red blood cells as well as affecting mood and libido. It is secreted in a circadian rhythm. Testosterone is produced in the testes under the control of Luteinising Hormone (LH) that is secreted by the pituitary gland. Testes also produce sperm that is under control of both FSH, also secreted by the pituitary gland, and testosterone produced in the testes (but not by exogenous testosterone – injections or topical solutions, which does not stimulate spermatogenesis). This means that the body’s natural production of testosterone is involved with sperm production, but any external testosterone treatment will suppress sperm production.
Testosterone or androgen deficiency
Androgen deficiency is a condition in which tissues do not have enough exposure to androgens with normal function. Low testosterone is also known as hypogonadism and may be the result of primary (testes) and secondary (brain) causes. Primary causes arise from the testes and secondary causes arise from the pituitary region of the brain. Primary hypogonadism can be seen in young men with Klinefelter’s syndrome which results from an extra sex chromosome (XXY). Primary hypogonadism can also occur in cases of undescended testes or when the testes have been removed either due to trauma, inflammation or cancer treatment. Ageing also decreases the function of the testes, as does long term alcohol consumption.
Secondary hypogonadism may arise from chronic health conditions such as haemochromatosis, sarcoidosis or a tumour of the pituitary gland called prolactinoma. A chronic health condition such as obstructive sleep apnoea may also impact on the testosterone level resulting from changes at the pituitary level.
Total testosterone in the blood is a measure of testosterone lightly bound to albumin and closely bound to sex hormone binding globulin (SHBG) as well as free testosterone. Sex hormone binding globulin increases with ageing but decreases with obesity. Levels of testosterone are highest in men between the ages of 20 and 30 years and fall gradually with age about 0.3% per year after the age of 40. About 1 in 200 men under 60 years of age suffer from androgen deficiency. However at the age of 65 years 10% of men are deficient in androgen and this increases to 20% by 70 years. Men’s testosterone levels fall much more gradually and over a longer period of time, unlike women, whose oestrogen levels fall rapidly when they go through the menopause.
Symptoms of testosterone deficiency
Deficiency of testosterone can present as reduced libido, decreasing size of the testes, absence of sperm, hot flushes and sweats, reduced shaving and enlargement of the breasts. Non specific signs and symptoms consist of decreased energy and increased fatigue, depressed mood, reduced muscle mass and strength, reduced bone density, poor concentration and memory, sleep disturbance and increasing body fat. Low testosterone may also contribute to erectile problems though androgen deficiency is an uncommon cause of this.
Late onset hypogonadism (LOH) also known as adult onset hypogonadism is a controversial diagnosis where the levels of testosterone that naturally fall with age are somewhat accelerated. As men age, the amount of body fat increases and muscle mass and strength decreases. A fall in testosterone levels is likely to contribute to these conditions. However any medical condition can accelerate this decline such as diabetes or obesity and the current recommendations are to treat the secondary causes first before considering treating the low testosterone with medication. It is important to note that sleep apnoea may be associated with low testosterone, it is always important to treat the sleep apnoea first before consideration of a testosterone treatment program. Any components of metabolic syndrome which include diabetes, obesity, high blood pressure and high cholesterol should always be treated first. These significant medical illnesses that can cause a fall in the level of testosterone usually recover when the illness has been treated.
Another name for LOH is “male menopause” and again, due to the controversy surrounding this condition, it is not regarded as a legitimate diagnosis. However replacing testosterone in older men who have a proven and documented very low testosterone has been shown to have a number of benefits on body fat, muscle, cholesterol and bone density as well as an improvement in quality of life.
How is low testosterone diagnosed
Low testosterone is diagnosed by assessment of clinical symptoms, physical examination and investigations. The testes may be reduced in size. Blood tests addresses LH, FSH, total testosterone, sex hormone binding globulin, prolactin and calculated free testosterone as well as thyroid and iron stores (ferritin).
In Australia the level of testosterone that can be treated to obtain a subsidised authority prescription is less than 6nmol/L or higher if the LH is raised. It should be noted that in other parts of the world this level is higher though it is possible in Australia to treat testosterone with a private prescription if the clinical and biochemical assessments concur with a diagnosis of hypogonadism.
How is low testosterone treated
There are many different types of medications and these include oral tablets, injections, patches, creams and gels. Treatment with testosterone must always be monitored as there is a risk of increasing the blood thickness (hematocrit) and aggravating sleep apnoea though there is no evidence that testosterone may result in prostate cancer. Testosterone treatment is usually continued for life.
Finally a word of warning about the illegal use of testosterone and related steroid medications, which are often obtained through the black market for the purposes of muscle enhancement in a gym setting. These medications may not be genuine and thus increase the risk of further health problems. They will also suppress the body’s own natural production of testosterone which may take 6 to 12 months to recover, or in some instances, never recover, thus then requiring life time testosterone supplementation.
What is libido or sexual desire?
Libido, also known as sexual desire, is a reflection of a person’s sexual behaviour and desire to engage in sexual activity. Libido arises from the effect of the hormone testosterone which is generally known as “the male hormone” but is responsible for sexual desire in both men and women. Testosterone is responsible for the peak in sexual interest in men around the age of 20 and women in their mid-thirties.
The ageing process in men and women reduces the bio-availability of testosterone resulting in a natural decline in libido in the older years. However a man’s libido may not necessarily be related to his level of testosterone as there are other factors that can influence sexual desire such as the status of the relationship and psychological and other medical health problems.
Low or high libido
Libido problems usually present as low desire but sometimes excessive desire can be the issue. These problems may present as a lifelong issue that has always been present or occur only in some situations. Another common desire issue is desire discrepancy where the difference of desire within a relationship creates problems within that relationship.
A common cause of low libido is not related to lack of production of testosterone but rather due to relationship problems, such as when a decision is required for a long term commitment in a new relationship. Any medical condition as well as excessive alcohol intake may contribute to reduced libido. Lack of sexual activity and stimulation may have a negative effect on testosterone production. Any damage to the testes in the male or ovaries in the female will affect testosterone production. This can be seen in the removal of such organs or damage from chemotherapy for treatment of cancer. Stress, anxiety, low mood and chronic fatigue are also very common causes of low libido.
Assessment and treatment
An assessment of libido problems requires investigation of medical, psychological and relationship aspects. It is important to involve the couple in the assessment. Medical treatment if required may involve use of testosterone supplementation, usually in the form of daily applications or long acting depot injection. There are pharmaceutical guidelines that provide the level of testosterone in men that qualifies for a subsidised authority prescription. There are no approved guidelines for testosterone treatment in women.
Counselling for libido problems comes under the domain of relationship counsellors, sex therapists and psychologists.
Reproductive and sexual health changes occur as a man gets older. These changes involve fertility, hormone levels, prostate health and erectile function.
Sperm counts decline with age and the ability of an older man to father a child declines.
Testosterone levels begin to slowly fall from the age of 40 years onwards.
The fall is not as dramatic as the drop in oestrogen that occurs in women at the menopause. Whilst low testosterone may result in a decreased libido, ageing men are at risk of osteoporosis and decreased muscle mass.
Tiredness and irritability may also be a feature of low testosterone.
Ongoing research is aimed at establishing at what level men should be treated with testosterone and at what dose. There is still no general consensus on this issue at this moment in time.
The commonest change with the prostate gland in the ageing man is benign enlargement. This may affect urine flow. A less common change is prostate cancer which may present with the same symptoms as benign prostate disease or no symptoms at all. Regular prostate checks over the age of 50 years is recommended.
Erectile dysfunction increases with age. This may be exacerbated by the presence of medical conditions such as high blood pressure, high cholesterol and diabetes. Many new treatments have been developed for erectile dysfunction.
Roughly half the world’s population is female so it is worthwhile to understand the factors that determine good female sexuality, what some of the difficulties are and what can be done about them.
In general, women only have a relatively small amount of the libido hormone testosterone so that sexual interest and behaviour may be significantly influenced by personal wellbeing, relationship dynamics, context of the sexual activity, appropriateness of the sexual behaviour, sexual beliefs and sexual education. Women may be more affected by negative factors such as lack of time, fatigue, anger and resentment and lack of intimacy than men.
Among younger women lack of sex education and experience, shyness and insecurity about their bodies and lack of assertiveness may be major contributors to difficulties. Later, tiredness, poor relationships and anger become more relevant and then with menopause, hormonal factors, health issues, longevity of the relationship and partner health and sexual function issues become significant. However, each woman and each couple are unique in how contributory factors come together and play out.
The main female sexual difficulties are:
- Inhibited sexual desire and desire discrepancy in the couple
- Orgasmic difficulties
- Vaginismus and pain disorders
- Body dysmorphic disorders
Management of each of these difficulties requires specific strategies based on understanding the individual’s sexual, psychological and relationship history.
Inhibited sexual desire has to be evaluated understanding the broad range of normal female sexual desire which at one end may be that the woman is responsive to a male on a few occasions early in the relationship adequate for impregnation. And at the other end is the woman who wants and is initiatory daily. Nature is not particularly interested in recreational sexual activity. In the desire discrepancy situation both partners may be sexually, medically and psychologically normal and it is the difference between them that is the “patient”.
Orgasmic difficulties mainly require behavioural sexual techniques and encouragement to overcome inhibitory behaviours. The vast majority of women are capable of reaching orgasm given the opportunity to discover their individual pathway. While synchronous multi-orgasms may not be achievable by everyone it is always possible to improve one’s experience.
Pain disorders/dyspareunia need to be properly medically evaluated and relevant causes treated, before corrective behavioural and psychological therapies are instituted. Vaginismus needs a very empathic history and then supportive behavioural sex therapy. Optimally, the partner should be included in the management and his needs also considered.
With menopause and age related changes there needs to be a proper medical evaluation of the hormonal and anatomical situation before corrective advice is given. It is unusual for medical difficulties to be present in isolation from psychological and relationship issues.
Increasingly we are seeing more and more women being unhappy with not only their bodies but also the look of their genitals. There has been an exponential increase in labial and vaginal surgery which cannot be justified on medical grounds and in some cases has resulted in very damaging outcomes. An informed decision about the look and function of our sexual organs is important before surgical steps are taken.
If you are unhappy or worried about any aspect of your sexuality or relationship seek help early so that you can get the best possible out of your life.
An intimate relationship involves the interaction between two (or more people) engaged with each other in more than just the social sense. There are many aspects to how a couple relate with each other in the context of their relationship. Examples may be whether the couple are involved in an intimate non-sexual relationship or a sexual relationship or whether the couple are same sex or opposite sex. A good relationship is often the foundation stone for a mutually satisfying sexual relationship.
Relationships are not always easy and often require compromise by both members of the partnership. Desire discrepancy is an example of differing sexual needs within a relationship which usually requires a negotiated compromise solution for the long term contentment of the two individuals. There are many factors, both positive and negative, involved in the attraction between two people so forming a relationship may not be easy or without stress.
All relationships benefit from good effective communication and commitment to making the relationship succeed. All relationships require ongoing maintenance and attention to succeed happily for 50 years. Couples also benefit from time alone. Children may pose extra stress on intimate relationships as time becomes limited, energy is depleted and differences of opinion on parenting techniques arise. It is also important for each member to have time out to pursue their own interests, but not to the detriment of the relationship.
Over time sexual needs may change in relationships so the importance of ongoing respect, affection and attention to each partner must always be emphasised. There are many self help books available which address the many issues that most couples may face at one time or another. Sometimes the problems prove too difficult to manage without outside help. Relationship or couples counselling may then be an appropriate
Mindfulness exercises are a special type of relaxation technique that helps you stay in the present moment, rather than dwelling on the past or worrying about the future. Worries about everyday issues and stresses can inhibit sexual enjoyment. By helping you stay in the present moment mindfulness has a positive impact on stress and anxiety in everyday life as well as in sexual situations.
Mindfulness exercises involve relaxation and breathing awareness that should be practised daily. For those who practice yoga or meditation will be familiar with the mindful breathing process where the focus is on awareness of body sensations. It is easy to become distracted during the mindfulness exercises and this is dealt with by acknowledging the distraction and returning to the exercise.
During mindfulness sexual practice, the distraction is often negative thoughts about fears about sexual performance (erection and ejaculation issues). When this happens bring your attention back to the nice sensations you are feeling rather than what you cannot achieve. Pleasure is absolutely possible without an erection or orgasm, these are not compulsory for sexual enjoyment.
Specific sexual mindfulness exercises can be done with a partner or by oneself. It is commenced with the mindfulness breathing exercises which clears the mind and helps reduce distraction and straying thoughts.
Physical stimulation involves experiencing pleasurable sensations through the entire body and not just the genitals. An erotic focus allows erotic sensations and feelings to be developed. Shift stimulation from the penis to other parts of the body and back to the penis again. Allow the erection to rise and fall – the experience of deliberately losing an erection in a sexually stimulating situation through these exercises allows you to stop being so anxious when loss of erection occurs. Being distracted or anxious when you lose your erection may inhibit your arousal and impair your ability to regain an erection. As you become more adept at these exercises your confidence that you can arouse yourself, get a firm erection, control ejaculation and stay calm if your penis goes down will improve.
Article published by Mandy Goldman, President, Cancer Counselling Professionals:
Men and women often lose interest in sex when they feel their lives are being threatened by illness. Loss of sexual function in the presence of a chronic medical condition may arise more from the treatment of the condition than the actual illness itself. In addition the level of sexual functioning present before the onset of the illness determines the eventual level of return of sexual function.
At first concern for survival is so great that sex is far down the list. Loss of desire may be a result of worry, fear, depression or anxiety. It may also be caused by physical problems such as nausea, pain, fatigue or hormone imbalance.
Sex and sexuality are important parts of everyday life. There is a difference between the two. Sex is thought of as an activity—something you do with a partner. Sexuality is more about the way people feel and is linked to your need for caring and closeness, playfulness and pleasure.
Feelings about sexuality affect our zest for living, our self-image, and our relationships with others. Yet patients rarely talk to their doctors about how they may feel as a sexual being or how the medical treatment may affect their sex lives. Many of us feel awkward talking about these matters even to a close sex partner. Many people with a chronic illness, including cancer, worry that their partner may be turned off by changes in their bodies. Or the partners worry that they may hurt the ill person during sex.
Good quality sex is possible in the face of medical conditions including diabetes, heart disease and cancer. This is true notwithstanding that many medications have a variety of side effects. Many people with chronic illnesses continue to have sex, and some have exceptionally good sex. Loving expression is possible almost regardless of what kind of physical condition you are in.
Serious illness, potent medication often known to inhibit sexual desire and exhaustion may be enough justification to stop having sex altogether. Yet, if you want to have sex you can deal with these situations and enjoy great lovemaking. You may have to change how and when you have sex, but all in all it can be worked out.
Many sexual problems that people have after cancer treatment will not last long. Pain with erection or ejaculation after pelvic surgery or radiation is likely to go away. The stress of treatment can also reduce hormone levels temporarily which may reduce desire or cause erection difficulties until hormone levels return to normal. As one feels more in control of one’s body, self-confidence returns and one’s sex life often improves.
Sexuality for the man with cancer
Some cancer treatments can cause lifelong change in a man’s sexual function. This may depend of the type of treatment that was required as well as the individual response and recovery. For example after a radical prostatectomy for prostate cancer where nerve sparing was possible, a reasonable sexual recovery may be possible.
Dealing with short-term problems: As men age or go through health problems, feelings of sexual excitement no longer lead to an instant erection. There are simple strategies that may help; perhaps you may just need more time or more stroking to get aroused. Perhaps you have not found the right kind of caressing. A hand held vibrator can provide intense stimulation. Sexual fantasy, looking at erotic stories or pictures may help. The more excited you are, the easier it is to reach orgasm. The first orgasm after cancer treatment may occur while asleep during a sexual dream. Sleep erections are not affected by mood or state of mind and may give an indication of the best erection your body can produce.
Sexuality for the woman with cancer
No matter what kind of cancer treatment you have you will still be able to feel pleasure from touching. Few treatments (other than those affecting the brain or spinal cord) damage the nerves and muscles involved in feeling pleasure from touch and reaching orgasm. For example women who have pain in their vagina due to pelvic surgery or radiotherapy or dryness due to menopausal symptoms or lack of oestrogen can often reach orgasm through stroking of their breasts and outer genitals. Sexual touching is often satisfying even if some aspects of sexuality have changed.
Many couples have a somewhat narrow view of what is normal in sex. If both partners cannot reach orgasm with penetrative sex they feel cheated. This may be a chance to learn new ways to give and receive sexual pleasure. Touching, stroking and cuddling can be pleasurable. Try touching yourself. You may need to practice having orgasms alone before going back to sex with a partner.
In some cases a woman may need to try different positions or types of genital touching.
Remember if you are in a sexual relationship and one of you has a problem it affects both of you. Dealing with the problem works best when your partner can be part of the solution. If sex becomes difficult, the physical expression of caring remains an important way of sharing closeness and can bring much pleasure.
Sydney Men’s Health now located at The Male Clinic:
THE MALE CLINIC
SUITE 2, LEVEL 6
75 CROWN STREET
WOOLLOOMOOLOO NSW 2011
The Male Clinic is located within the East Sydney Private Hospital (formerly known as the City Ford building). The building is situated between Crown and Riley Streets close to William Street.
The Male Clinic is located a 10 minute walk from either Kings Cross or Museum train stations. There are regular bus routes along William Street.
There is a Wilson car park within the building and the Domain Car Park is a short walk down Riley Street. There is limited street parking.