Men and sex: the medical angle

Men's health physician Dr Michael Lowy summarises the latest developments in men's sexual health.

The two major advances in male health over the last 2 decades have been in the assessment and treatment of erectile dysfunction and prostate disease. These two areas both involve a part of the male anatomy that is the essence of being male, the uro-genital system. Any involvement of the genitals in a male health problem can be a source of great concern.

The origin of male sexuality has a significant history. Sexuality amongst men and women in times long past was a much simpler matter. The driving force of sex was to reproduce the species with the best possible genes. The forebears of modern man were designed to achieve erections as quickly as possible after finding a receptive female, to ejaculate as quickly as possible to be less vulnerable to outside attack and then lose the erection as quickly as possible in order not to have a liability whilst moving away quickly. This brief but repetitive sexual act was very much a young man's activity due to the short life span in that era.

Sex in modern times is less about reproduction but more about relationships and communication. Most sexual activity involves a union between a couple where reproduction generally is not intended. In addition, couples are engaging in sexual activity at a much older age as longevity increases. The physical ability of the aging male to achieve and maintain erections diminishes with increasing years, purely as a mechanical blood flow issue.

Blood flow is what an erection is all about. Blood enters the flaccid penis after a neurological signal from the brain via the spinal cord releases a chemical neuro-transmitter to cause dilation of arteries which makes blood flow into the penis. The next stage is the trapping of the blood in the erect penis to maintain a rigid erection. This complex process is called veno-occlusion and is essentially a valve effect. A faulty "valve" allows blood to leave too early and this is called venous leakage.

Venous leakage may occur in medical conditions such as diabetes, high cholesterol, high blood pressure and as a consequence of aging. Sometimes anxiety in a sexual situation may result in venous leakage and this is known as performance anxiety. Any problem with achieving or maintaining an erection is called erectile dysfunction, a condition once more popularly known as impotence.

Modern treatments abound and a treating professional is advised to have a holistic approach. Issues such as sexual education, general psychological status, the nature of the relationship and sexual technique are important to address, as well as the relevant medical problems and the medications the patient may be on. Rarely does a man with an erection problem have a single cause, there is often a mixture of primary physical and secondary psychological problems.

It is important to point out that erectile problems are a separate issue from ejaculation and libido (sex drive) problems, though they may all present together. The loss of libido associated with changes in an aging male's testosterone (male hormone) level is an area under current research. The treatment is more complex than just replacing the testosterone, because many older men with a normal libido have low testosterone levels. Researchers are looking at muscle mass and bone density changes rather than libido as possible parameters for treating the older man with testosterone supplements.

Men and women have differing sexual needs which is taken into consideration when treating sexual problems. A man's sexual drive is testosterone driven. This puts the focus of the sexual act on the genitals. While low amounts of testosterone do play a role in female sexual interest, a woman's sexual arousal is more generalised and involves stimulation from all the sensual areas of the body.

Psycho-sexual counseling is useful. In the book "Men & Sex" there are numerous exercises that can be carried out solo or with a partner to improve the quality of the erection by improving the man's confidence. However, many men are eager to go for treatments that are quick, and these can be found in penile injection therapy or oral medication. A relatively painless "prick" into the shaft of the penis with an injectable medicine called Caverject™ results in an erection in around 10 minutes. Otherwise the man can swallow a Viagra™ tablet and 1 hour later engage in sexual activity. There are pluses and minuses for these treatments and a doctor should be consulted. A prescription is required for both.

Other treatments include vacuum erection device, penile implant and the soon to be released intra-urethral application of an erection inducing medication known as MUSE™ (Medicated Urethral System for Erection).

Another sexual problem that affects many men of all ages is premature ejaculation. There is little consensus on how quick is quick, but generally if ejaculation occurs too soon for the satisfaction of the man or his partner, then help is appropriate. There are excellent treatments available for this condition and again professional help is recommended, including exercises in the book "Men & Sex". A final word for men who are concerned by premature ejaculation - it is not a problem in your head, but a problem of the penis, and can be treated. Premature ejaculation is often erroneously considered purely an anxiety condition. While such problems may co-exist, the problem essentially concerns hyperexcitability of penile nerves, and it is usually treatable at a penis level, rather than delving into psychological matters.

Prostate disease has also benefited from modern medicine. Men over 50 may begin to experience symptoms of an enlarging prostate. This may present as difficulty urinating, a weak stream, a sense of urgency and getting up more often at night to go to the toilet. Mostly this slowly enlarging prostate is benign and often can just be observed. If treatment is required, there are new prostate shrinking medications now available and surgery is advancing with new techniques to widen the urine passage through the prostate.

Because many men fear prostate cancer, they avoid going to the doctor if they have urinary symptoms. The good news is that most urinary symptoms are due to benign prostate enlargement. If it is a cancer, the earlier the diagnosis the better the outlook. A relatively simple prostate test for all men over 50 is a yearly rectal examination of the prostate (a 10 second procedure with a gloved finger). This gives an idea of the size and shape of the prostate. Some men also have a blood test known as PSA. This may indicate the presence of prostate cancer. If there is a family history of prostate cancer, then testing is advised earlier from the age of 40.

Treatments for prostate cancer have also improved, and these include surgery, radiotherapy, hormones and implantation of radio-active pellets. The improvements in the assessment and treatment of all types of prostate disease are still influenced by men being proactive in having regular prostate checks and presenting earlier when urine symptoms occur.

Up to 50% of men of any age group may have a sexual issue. This percentage may be even higher in the man over 50 regarding issues relating to prostate function, a gland that generally enlarges as a man ages. If sexual and prostate problems were addressed and treated with the same importance as say heart, blood pressure and cholesterol problems, then men would be truly treated in a holistic manner. Men's health will be greatly improved when they become more confident to discuss these delicate issues amongst themselves or with their doctors.

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