The most frequent sexual problems in men are not getting or keeping an erection and premature ejaculation.
Erectile Dysfunction
Loss of erection, also referred to as erectile dysfunction, involves the man’s inability to get and maintain an erection. Like other sexual dysfunctions, erectile dysfunction can be primary, secondary, situational, or total. Occasional, isolated episodes of the inability to attain or maintain an erection are not considered dysfunctional; these are regarded as normal occurrences. To be classified as an erectile dysfunction, the erection difficulty should last continuously for a period of at least 3 months.
Erectile dysfunction may be caused by physiological conditions. Such biological causes include blockage in the arteries, diabetes, neurological disorders, alcohol or other drug abuse, chronic disease (kidney or liver failure), pelvic surgery, and neurological disorders. Smoking is also related to erectile dysfunction; the more frequent the smoking, the more likely the erectile dysfunction.
Psychosocial factors associated with erectile dysfunction include depression, fear (e.g., of unwanted pregnancy, intimacy, HIV infection, or other STIs), guilt, and relationship dissatisfaction. For example, the man who is having an affair may feel guilty. This guilt may lead to difficulty in achieving or maintaining an erection when having sex with one’s primary partner and/or the extradyadic partner.
Anxiety may also inhibit the man’s ability to create and maintain an erection. One source of anxiety is performance pressure, which may be self-imposed or imposed by a partner. In self-imposed performance anxiety, the man constantly checks (mentally or visually) (spectatoring) to see that he is erect. Such self-monitoring creates anxiety, since the man fears that he may not be erect.
Partner-imposed performance pressure involves the partner communicating to the man that he must get and stay erect to be regarded as a good lover. Such pressure usually increases the man’s anxiety, thus ensuring no erection. Whether self- or partner-imposed, the anxiety associated with performance pressure results in a vicious cycle—anxiety, erectile difficulty, embarrassment, followed by anxiety, erectile difficulty, and so on.
Performance anxiety may also be related to alcohol use. After consuming more than a few drinks, the man may initiate sex but may become anxious after failing to achieve an erection (too much alcohol will interfere with erection). Although alcohol may be responsible for his initial failure, his erection difficulties continue because of his anxiety.
Treatment of erectile dysfunction (like treatment of other sexual dysfunctions) depends on the cause(s) of the problem. When erection difficulties are caused by psychosocial factors, treatment may include improving the relationship with the partner and/or resolving the man’s fear, guilt, or anxiety (i.e., performance pressure) about sexual activity. These goals may be accomplished through couple counseling, re-education, and sensate focus exercises.
A sex therapist would instruct the man and his partner to temporarily refrain from engaging in intercourse so as to remove the pressure to attain or maintain an erection. During this period, the man is encouraged to pleasure his partner in ways that do not require him to have an erection (e.g., cunnilingus or manual stimulation of partner). Once the man is relieved of the pressure to perform and learns alternative ways to satisfy his partner, his erection difficulties (if caused by psychosocial factors) often disappear. Most therapists bypass these exercises and refer their patients to a physician who my prescribe Viagra, Cialis, or Levitra, discussed below.
Increasingly, physicians are prescribing Viagra, Cialis or Levitra which increases blood flow to the penis and results in an erection when the penis is stimulated. About 80 percent of men experiencing erectile dysfunction report restored potency as a consequence of one of these medications. Cialis can be taken 12 hours prior to sex and last for 24 to 36 hours. The man does not have a constant erection but may become erect with stimulation.
Men with low libido as well as erectile dysfunction may also benefit from testosterone replacement therapy (TRT). Once a low testosterone level (20% of men over age 60 have low levels) is confirmed by a blood test, testosterone supplements in the form of a gel, patch, or injection may be given. A physician should be consulted. Potential risks include an increase in prostate size and changes in blood levels of cholesterol.
Rapid Ejaculation
Often referred to as premature ejaculation, rapid ejaculation is defined as recurrent ejaculation with minimal sexual stimulation before, upon, or shortly after penetration and before the person wishes it. Whether a man ejaculates too soon is a matter of definition, depending on his and his partner’s desires. Some partners define a rapid ejaculation in positive terms. One woman said she felt pleased that her partner was so excited by her that he “couldn’t control himself.” Another said, “The sooner he ejaculates, the sooner it’s over with, and the sooner the better.” Other women prefer that their partner delay ejaculation. Some women regard a pattern of rapid ejaculation as indicative of selfishness in their partner.
The cause of rapid ejaculation may be biological, psychogenic, or both. Some men are thought to have a constitutionally hypersensitive sympathetic nervous system that predisposes them to rapid ejaculation. Psychogenic factors include psychological distress, such as shame, or psychological constitution, such as being obsessive-compulsive.
A common treatment for premature ejaculation is for the man to ejaculate often. In general, the greater the number of ejaculations a man has in one 24-hour period, the longer he will be able to delay each subsequent ejaculation.
