Difficulty having an erection or intercourse?
Many men experience challenges with having intercourse that they didn’t see coming. A lot of men worry that they have low testosterone levels and often want to have that checked first.
Erectile dysfunction is part of the group of conditions that make up sexual dysfunction.
Sexual dysfunction in men can be grouped into:
erectile dysfunction
Issues with ejaculation (including premature ejaculation) and
decreased libido
The inability to have or sustain an erection to allow satisfactory sexual intercourse is a common symptom, which affects one-third of all adult men. And it almost always causes a lot of worry and stress for each man.
Young men between the age of 18 and 50 are also seen in this group experiencing premature ejaculation. So, it’s a good for women to understand this also.
The causes for erectile dysfunction are many, but can be grouped into causes due to:
Psychological stress
Drugs that affect erections and libido
Problems with the endocrine system (diabetes, low production of hormones),
Organic disease due to underlying diseases such as
disease of the arteries and veins,
diseases affecting the nerves,
surgery within the pelvis,
diabetes,
Peyronei’s disease.
During the COVID pandemic I have seen a lot of young men who have had difficulty having intercourse, this has almost always been related to stress or anxiety.
Through discussion this can be traced back to symptoms of stress or anxiety in the past also.
Despite knowing that the difficulty with erection or loss of sex-drive is probably stress-related most men want to check if their testosterone levels are normal.
Some men just want their testosterone level checked, but I always recommend having a consultation face to face so that physical examination can be carried out to ensure there is no disease of the penis or the testicles or indeed anything within the abdomen itself.
Most young men are not taking any medications or drugs, but lots of older men are on medication for blood pressure or in some cases medication for depression, so this is something we would discuss in order to see if coming off the medication improves their ability to have intercourse.
Often for older men, particularly over the age of 45 if they are carrying extra weight around the abdomen then checking blood pressure and checking for diabetes is important as this can affect the ability to have an erection.
In terms of psychological causes, if depression and anxiety are the main drivers for the inability to have an erection to perform intercourse then it is really important to address this first. We refer most patients for a course of mindfulness-based therapy to improve their understanding of the link between depression or anxiety and the ability to have an erection; this proves very successful in the vast majority of people.
If you are not taking any medications, have no psychological issues, and do not have diabetes or pre-diabetes, then we have to look for other underlying conditions. These include but are not limited to vascular disease (this is particularly common if you are a smoker or have had a heart attack or stroke) and neurological disorders such as multiple sclerosis.
In cases where more in depth assessment is required and in order to start any treatment to improve sexual function I would always refer to a specialist Urologist for erectile dysfunction for onward management.
Low libido
There are many causes of low libdo all of which are potentially treatable. Low libido is often caused by medications, underlying chronic illness, depression/low mood/anxiety,or low testosterone; but, it can also be due to psychological causes.
Antidepressants can reduce libido and so it may be that treatment for depression of anxiety needs to be altered to find a different medication that does not affect libido.
Men who have or are taking finasteride for hair loss ( this can improve hair regrowth) can experience changes in libido and also ejaculation even after the medication has been stopped.
Alcohol intake: drinking regularly can for many men reduce libido and it is important to consider decreasing alcohol intake as a strategy for improving ones sexual health.
Low testosterone can cause low libido. It is important to also check other tests that reflect the pituitary gland function ( Prolactin, TSH) and eostrogen level.
Psychological causes are best managed with psychotherapy which proves very successful and can be a great support.
So What Kind Of Questions Will You Be Asked When You Come For Your GP Consultation?
What are the duration of your symptoms of not being able to have an erection?
Was the onset gradual or did it happen suddenly? Is it consistently not happening or does it just happen intermittently?
Are you having an early morning erection?
What is the quality of the erection when stimulated by yourself or your partner?
Can you sustain an erection once it has begun?
Is there a loss of libido ?
Is there an issue with ejuclation does it happen too early, is it delayed or is it painful?
Are you having any discharge from the penis or pain on passing urine?
Is your partner having any issues with intercourse ? They may be in the menopause or they may be experiencing some vaginal pain or dryness? If it’s a male partner they too may have some physical symptoms that need addressed.
The doctor will also assess your risk factors for heart disease, this is based on your body weight and body mass index, your blood pressure, whether you have diabetes or you smoke, whether you have a strong family history of heart disease, your cholesterol and if you have underlying inflammation due to another disease and if you are on any medications.
The doctor will always ask about anabolic steroids, if you smoke marijuana or tobacco and if you drink alcohol.
A physical examination will include blood pressure and a urine sample, examination of the abdomen, examination of the penis itself, the testes and we will take your height and weight to calculate your BMI.
Blood investigations:
These include an early morning testosterone level between 8:00 and 11:00 AM, prolactin level, PSA (for the prostate) and if the testosterone is low we would also check the FSH and LH levels which comes from the pituitary gland within the brain.
In summary:
A blood test alone will not answer all the questions related to difficulty having intercourse or an erection. It is best to have a consultation with a doctor in order to ask the above questions, have a physical examination and then decide if blood tests are needed.
Since the COVID pandemic I am seeing more men with concerns over their sexual function and the majority of them have been under a lot of stress which impacts the erectile process immensely. A few will have either an infection underlying or a low testosterone or underlying blood vessel disease usually due to smoking.
So before you make an appointment you can do some things yourself to decide the underlying cause.
If you are under stress, try to build some stress free time into your day. Even ten minutes before breakfast doing deep-breathing/meditation will help. Keep a diary or journal and write down how you’re doing each morning. COnsider abstaining from intercourse for 4 weeks while improving your mental health and then see where you are after that.Things may have improved.
Get your blood pressure checked, this can be done in a pharmacy or we can do it for you.
If you are overweight or unfit or both, then build ten minutes of exercise into your day. Whether you lose weight or not, becoming stronger and fitter will improve your blood pressure, your overall health and confidence. Again reassess things 4 weeks to see if there is any change.
If you are taking any medications that could affect having an erection, such as a blood pressure tablet or an anti-depressant, ask your doctor if there is an alternative that you could try and then again reassess things in about 4-6 weeks