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.

P

eyronie’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 be 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 in a sleep lab 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.

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 involves both 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 physiology
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.

Definition inhibited ejaculation
The definition of delayed ejaculation is the 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 genetic 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 arise as a side effect from 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 on the end of the penis or vibrating penile sleeves or a medical device called a Viberect may enhance ejaculation.

What are PDE5i?
The oral medications Viagra™ (sildenafil), Cialis™ (tadalafil), Levitra™ (vardenafil) and Spedra™ (avanafil) 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, called vasculogenic ED. 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. Spedra™ may become effective within 30-45 minutes and last up to 10 hours or more.

As all three medications come in different strengths, your doctor will advise the appropriate dose. The usual on demand dose of Viagra™ is 25mg, 50mg or 100mg, Levitra™ is 5mg, 10mg or 20mg, Cialis™ 10mg or 20mg and Spedra™ 50mg, 100mg, 200mg. The initial starting dose is usually the highest dose to obtain the best response, the dose can then be titrated down as required.

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 https://www.youtube.com/watch?v=KoIi7pmeQ6s.

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:

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. The incidence of these plaques occurs in about 1.5% of younger men and up to 6.5% in older men. 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. 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. Use of daily low dose PDE5i may help treat the Peyronie’s disease by increasing penile blood flow.

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 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 a 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.

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 (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.

Treatments
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.

The Renova
The Renova offers a non-invasive treatment using acoustic sound waves for ED in men.

• Renova is intended to treat Erectile Dysfunction (ED) symptoms in
  patients suffering from ED due to reduced penile blood flow
• The treatment consists of low intensity acoustic sound or shock
  waves applied with an applicator to the penis – 2 sites on the shaft
  and 2 on the perineum
• Pain free & no side effects
• Increases blood flow through new blood vessel formation in the
  erection tissues
• May improve the use of oral medication or eliminate the need
  altogether
• Benefits may be apparent in a few weeks
• Works best in men with vasculogenic ED
• May also benefit Peyronie’s disease and some painful prostate
  conditions called prostatodynia.

Reproductive and sexual health changes occur as a man gets older. These changes involve fertility, hormone levels, prostate health and erectile function.

Fertility
Sperm counts decline with age and the ability of an older man to father a child declines.

Hormones
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.

What is libido or sexual desire?
L

ibido, 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.

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.

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”.

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.

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.

Article published by Mandy Goldman, 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.