Erectile dysfunction (ED) is defined as the inability to achieve and/or maintain an erection that is suitable for penetration. 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.

ED is an increasing issue in older men. About one third of 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 ability to re-engage in sexual activity increases up to a number of days. An erection is obtained by a process of 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 commonly occurs when anxiety is present during sexual activity or as a consequence of age and the effects of other medical conditions.

The presence of ED in a younger man is often due to psychological causes or in some cases due to a congenital anomaly in the penile erection tissue or blood vessels.

The causes of ED may involve issues around the brain and nervous system, the arteries and veins in the penis and the actual penile spongy tissues. Some medications used to treat medical conditions may affect the erection process and these include blood pressure and cholesterol lowering tablets. Conditions such as high cholesterol, high blood pressure, diabetes and obstructive sleep apnoea may be associated with erectile dysfunction. Peyronie’s disease may affect erections. Excessive alcohol intake and substance abuse are other known factors. Treatment of erectile dysfunction may simply involve counselling and explanation of the normal anatomy and physiology of erections. Counselling will certainly benefit relationship issues that may be a cause of or result in erection problems.

Premature Ejaculation

— Introduction

Premature ejaculation (PE) is the commonest male sexual dysfunction and is defined as ejaculation before the person wishes it, often within 1 to 2 minutes after penetration though it can occur before or on penetration.

PE present since commencing sexual activity is a primary disorder and is associated with a hypersensitive ejaculatory reflex now believed to arise from serotonin receptor sites in the brain. PE may also arise as a secondary disorder at any stage and can be associated with performance anxiety or psychological trauma. 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.

— Treatment

Treatment to slow down ejaculation time is not always appropriate due to the man's expectation of how long ejaculation time should be. Consideration should be given to these expectations and other factors such as the state of the relationship. Sometimes communication and simple adjustment of the couple's sexual technique is adequate therapy.

An established exercise treatment is Seman's stop-start technique. This involves 3 stages of stimulation of the erection to the point before ejaculatory inevitability and then temporarily withdrawing to allow arousal to subside, when the stimulation is recommenced. The stages involve use of a dry hand, lubricated hand and finally vaginal penetration.

Seman's manoeuvre was modified by Masters and Johnson who devised the squeeze technique. The partner firmly squeezes the frenulum and ridge of the penis for 10 seconds to reduce the ejaculatory sensation. This can occur just before penetration or at any time.

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 available level of testosterone resulting in a natural decline in libido in the older years. However it has been found that an older man’s libido may not necessarily be related to his level of testosterone.

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.

The most important androgen in men is testosterone. Androgens are the sex steroids or hormones that produce changes in body shape and sexual characteristics typical of men after puberty. Androgens play a major role in the reproductive and sexual function of the adult male. The equivalent sex steroid produced by women is oestrogen.

Androgen deficiency occurs when reduced levels of testosterone arise from a lack of hormonal drive from the brain or problems with the testes. Replacement of testosterone may be given to such men and this is usually continued for life. About 1 in 200 men under 60 years of age suffer from androgen deficiency. However as men age, testosterone levels begin to fall from the age of 40 years. It is believed that by the age of 65 years, 10% of men will have androgen deficiency and by the age of 70 this figure will have risen to over 20%. 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.

Men with low testosterone complain of a number of symptoms including easy fatigue, low energy levels, low mood, irritability, poor concentration and reduced libido. Low testosterone may also contribute to erectile problems though androgen deficiency is an uncommon cause of this. 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. Low testosterone levels are also a risk factor for the development of osteoporosis.

Main objectives of our a health check/assessment

• To improve and maintain your wellbeing in the short and long term.
• To ensure you maintain your physical independence in the long term.
• To prevent the onset of disease, including cancer.
• To detect disease early, including cancer.

Ultimately, our objective is for you to have peace of mind that any health problem or imbalance has been identified early and addressed appropriately.

What the health check covers

Detection and prevention of:

• Nutritional imbalances.
• Excess body weight.
• Disease of your heart and arteries (cardiovascular disease - build-up of plaque in your arteries).
• High blood pressure (hypertension).
• Abnormal blood fats (dyslipidaemia).
• Abnormal blood sugar (insulin resistance/pre-diabetes/diabetes).
• Prostate problems.
• Weak bones (osteoporosis), calcium and vitamin D deficiencies.
• Screening for cancer, in particular skin, testicles, prostate, bowel.
• Sexual difficulties, in particular erection and ejaculation problems (optional).
• Sexually transmitted infections (optional).
• Immunisations

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 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.

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 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. Penile injection therapy 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 a physical cause when penile blood vessels are affected by the plaque.

No treatment is required with minimal deformity, no pain and no discomfort. There is no consensus on the best treatments for Peyronie’s disease. Many treatments are anecdotal and not evidence based.

The main treatments for prostate cancer are radical prostatectomy (open, laparoscopic, robotic), radiotherapy, brachytherapy and HIFU.

The sexual dysfunctions that may occur after these treatments include erectile dysfunction, loss of ejaculation, shortened penis and passing of urine during orgasm. Loss of libido occurs particularly when anti-androgen hormone therapy is used.

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).

Surgery tends to result in immediate loss of erections, whereas the other 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 12 to 18 months.

Erections can be induced within 2 to 3 weeks of surgery with penile injection therapy using prostaglandin E1 (PGE1). The penis is injected with a low dose of PGE1, about 2.5 to 5 mcg once or twice a week, whether sexual activity occurs or not. The early and regular "exercising" of the penis to erection has been shown to expedite the return of erections (but only when the nerves have been saved).

PGE1 injection treatment has been safely used for many years but sometimes its use is painful due to a "chemical" pain. Care must be taken with the amount injected to avoid a prolonged erection 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 PGE1 therapy, oral treatment can be tried about every 3 months.

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.

Prostate disease is a term used to describe any medical problems involving the prostate gland. Common prostate problems experienced by men include:

• Prostatitis which is inflammation and swelling of the prostate gland.
• Benign prostatic hyperplasia (BPH) which is a benign (non-cancerous) enlargement of the prostate gland.
• Prostate cancer.

Prostatitis tends to be a condition in younger men. BPH commonly occurs as men age. Prostate cancer is now the most common form of cancer in men in Australia.

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. The symptoms involve noticeable changes in urination due to the effects of enlargement of the prostate around the urethra. The urinary symptoms may be obstructive (weak stream, dribbling, inadequate emptying) or irritative (urgency, frequency urination through the night). The prostate can be assessed by a digital rectal examination 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.

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.

Roughly half the world's population is female so it is worthwhile to understand the factors that will determine good female sexuality and what some of the difficulties are due to.

In general because females only have a small amount of the libido hormone testosterone, sexual interest and behaviour is more 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.

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 become significant.

The main female sexual difficulties are:

• Inhibited sexual desire and desire discrepancy.
• Orgasmic difficulties.
• Dyspareunia.
• Vaginismus and pain disorders.

A relationship may involve the interaction of two people, or may involve the way a person relates to a group of people such as work or sporting colleagues. There are many aspects of how a couple relate to each other in the context of their relationship. This depends on whether the couple are just good friends (as in good mates) or whether the couple are involved in a loving and sexual relationship. It also depends on whether the couple are same sex or opposite sex. A good relationship for a couple is the foundation stone for a mutually satisfying sexual relationship.

Relationships are not always equal and require much compromise by both members of the partnership. Desire discrepancy is an example of differing sexual needs within the relationship. There are many factors that determine the differences and similarities that attract two people to each other thus forming a relationship that may or may not flow smoothly.All relationships benefit from both good effective communication and commitment to making the relationship succeed. All relationships require ongoing maintenance and attention no matter how good or bad the situation is. Couples benefit from time alone, especially when children are present. Children pose extra stress on all relationships particularly over differences of opinion on parenting techniques. It is also important for each member to have time out to pursue his or her own interests but not to the detriment of the relationship.

Gay, lesbian and bisexual individuals have joys and difficulties, just like the rest . There are some specific issues that are more typical.

Gay Issues in Society

Some people seem to know they are different very early in life. For others, it comes bit by bit. Some get married and have kids before they admit to being strongly attracted to the same sex. Society doesn’t always tolerate difference, as it assumes that sex and gender are fixed at birth. A boy who feels different might seek refuge in playing sport and seem very tough. A girl who is attracted to other girls may seek solace in books or music. To admit to friends that you are different is scary. It’s even harder to admit it to yourself. And as for telling mum or dad- many of us just freak out!

For many people, there is a slow dawning, a realisation that they are different. Perhaps there’s one special person who appeals strongly to us. It doesn’t always happen dramatically or suddenly. It’s a shame that Hollywood movies don’t treat these issues well. There is a wide range of feelings one can have for other people.

Sexual orientation can be defined according to sexual attraction, sexual activity and/or sexual identity. The estimate of the proportion of the population that is gay or lesbian varies according to which of these three definitions (or combination thereof) is being used. Popular estimates still rely on data from the Kinsey Institute that estimate that 10 percent of the male population and 5 to 6 percent of the female population are exclusively or predominantly gay and lesbian, respectively.A recent US analysis (1996) of the limited data available estimated that in the US 9.8 per cent of men and 5 per cent of women report same-sex sexual behaviour since puberty; 7.7 per cent of men and 7.5 per cent of women report same-sex desire and 2.8 per cent of men and 1.4 per cent of women report homosexual or bisexual identity.There are no comparable Australian studies. However, recent Australian research reveals that between 8 and 11 per cent of young people are not unequivocally heterosexual.

Gay men

Gay men may present as men who identifies themselves as gay, bisexual men or non-gay identifying men who occasionally have sex with men (MSM).

Lesbians

Lesbians have received little attention in the sexual health literature.Rates of transmission and the prevalence of STIs among women who have sex with women (WSW) are unknown.Unlike studies of gay and other homosexually active men, there has been little research into the behavioural and cultural determinants of patterns and rates of STIs among lesbians and little accessible information regarding safer sex practices for WSW.

Lesbians have been shown to be more physically active than heterosexual women.This may lead to increased protection from diseases such as diabetes and heart disease and may offset the negative effects of risk factors such as obesity.

Bisexuals

Findings of a 1993 report from the Bisexual Men’s Association (GAMMA) identifies depression as a major mental health issue for bisexual men.Many bisexual men who remain in long term committed heterosexual relationships and continue to have sex with men may experience feelings of dishonesty, disloyalty and alienation, resulting in significant stress and depression. Bisexual men and women in heterosexual relationships may also have reduced access to support and health information.

Adolescents

The consequences of sexual orientation and gender identity discrimination on the health and wellbeing of Gay, Lesbian and Bisexual adolescents include increased rates of homelessness, due torejection by family and friends, increased and multiple risk-taking behaviors, including substance abuse and unsafe sex, earlier initiation into risk-taking behaviours, feelings of guilt and self-denial and in some instances internalised homophobia or transphobia, ncreased rates of depression, increased incidence of suicidal and self-harming behaviours.

Rural Gay Issues

The major sexual health issues for gay, lesbian and bisexual people in rural areas include lack of appropriate services, hostility to same-sex attraction, no peer support, lack of sympathetic GPs, issues to do with disclosure, a lack of safe sex messages and information in rural settings.

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.