Male sexual response

This article was written by Dr O’Mahony to send out to patients prior to a consultation. It specifically covers the contentious issues over cost and who can have what on the NHS etc. It also allows the patient to consider some homework and be involved in the final decisions. It was on the BBC Choice website in 2002 but the site was removed after the Daily Mail complained about using taxpayers money to peddle soft porn on the BBC. (Sat 30th Nov 2002).

Dr Colm O’Mahony, Countess of Chester NHS Trust. CH21Ul. 01244-363097

INTRODUCTION

So, what’s normal for men? Most young men have no problem getting an erection. Their sex drive is usually so high that it overcomes any religious or other shame inducing conditioning, to let them masturbate successfully as teenagers. There was a time when this was considered a serious moral issue and, indeed, the medical profession weighed in with dire warnings of all of the serious illnesses that would befall men who engaged in this “unhealthy” practice. Of course, masturbation is a normal part of growing up, but I am still constantly surprised at how many men I see who have guilt and religious hang-ups about the practice.

HOW LONG DOES IT TAKE FROM ERECTION TO ORGASM & EJACULATION, & WHAT’S THE NORMAL?

There is no normal. Even for the same man, sometimes it can take just a minute or less to reach orgasm, whether he wants to or not, and on other occasions it can seem to take forever.

For a normal erection to develop, a man must be thinking sexual thoughts to start the process. In many young men, this is enough to produce erection, but as men get older they also need sexual stimulation as well as erotic thoughts. The blood vessels to the penis dilate up under nerve stimulation and the penis fills with blood, and it drains away very slowly, hence an erection. The head of the penis has a slightly different supply and sometimes men find that the head of the penis may not be as rigid as the rest. This is a normal occasional feature. With enough sexual stimulation, a point is reached where orgasm and ejaculation becomes inevitable. A tiny amount of fluid moves from the testes into the tubes, most of the fluid is produced by the prostate gland and the seminal vesicles and other glands along the way. Muscular contractions of the water passage produce the pleasurable sensations and the semen is ejaculated out of the end of the penis. If it’s been a while since the previous ejaculation, and the stimulation is exciting enough, there can be a lot of fluid ejaculated and this can even spurt out on occasions. At other times, the muscular contractions are not as strong and the semen just trickles out. Again, these are all completely normal and simply depends on the intensity of the experience and the time since the previous orgasm. In some cultures, semen is regarded as a precious fluid and men try to conserve it by concentrating on the muscular contractions and suppressing them. This technique, according to some men, allows them to be multi-orgasmic. A recent book by Mantak Chia and Douglas Abrams Arrava, called Multi-orgasmic man explains this in great detail. However, I remain unconvinced.

As men get older, it takes longer to develop an erection and it takes longer to reach orgasm. Erections are also not usually as rigid as in the late teen years, and for some men this can begin to cause problems, even at an early age. It is not unusual for a young man to be even nervous or embarrassed at some time when he is with a girl and finds he can’t get or retain his erection. What happens next depends on his attitude to this event. If he is embarrassed and humiliated, the next time he is in a sexual situation he will be worried that the erection might not work again and, of course, that worry can be enough to make sure it won’t and now panic sets in. This is called a “fear of failure”, which can be very difficult to shake off. Obviously, these men are still able to masturbate and still wake up with early morning erections, etc., so all of the mechanisms are intact. It’s just that the sexual situation with a partner has now become a stressful and panic laden event. In the majority of cases, with a regular partner that they become comfortable with, sexual desire usually wins through, and after a couple of successful episodes the problem disappears. In some men, however, it can become very significant and they may need professional help to get back on track. This help can be as simple as a discussion with a friend, practice nurse or their GP, or sometimes devices or drugs are needed.

More commonly, erection problems develop in the 40’s or later. This is because the blood vessels supplying various organs in the body get narrower as men get older. This process is accelerated by lack of exercise, being overweight, cigarette smoking, excess alcohol, etc. These factors also cause high blood pressure, angina and heart attacks. At 40, at least one in ten men have significant erection problems and over the age of 50 it’s almost 50%. There will always be times, even in the healthiest of men, when fatigue, tiredness or just not being in the mood prevents a proper erection developing or if one does develop it fades quickly. Men should be able to take the occasional failure in their stride without letting it get to them. They should, however, have no embarrassment about going for help if the problem becomes significant or begins to interfere with their relationship. A visit to the doctor is important to out-rule common but serious conditions such as diabetes. In men who are diabetic, the blood vessels can get narrower at an earlier age and sometimes nerves can be damaged, so that they can experience erection problems much earlier than men who don’t have diabetes.

Delaying-ejaculationMany men have heard about the myth of the male menopause and most of us in the business believe that that’s just what it is – a myth! Testosterone levels do get lower as men get older, but generally speaking, if there’s enough testosterone on board to produce stubble on a daily basis, and if sexual desire is present, there is little point in measuring testosterone levels. If you are having a blood test at the GP’s surgery for testosterone, it is best to have it done in the morning, when the levels are at their highest. It’s incredibly uncommon for erection problems to be attributed to a low testosterone level. In the UK testosterone is rarely used as a treatment for erection difficulties in most reputable clinics.

If you are concerned that you wish to delay ejaculation please read the article Delaying Ejaculation which has a lot of useful advice and techniques you can try with your partner.

TREATMENTS FOR ERECTILE DYSFUNCTION

Counselling – All men who get significant erectile dysfunction do develop psychological disturbance as a result. Not being able to develop a satisfactory erection really knocks a man’s confidence. They find it difficult to still consider themselves a proper man. They are reminded on an hourly basis of their inadequacy. Every newspaper or television programme or conversation with colleagues throws up some reminder of their inability. Each attempt at intercourse just results in embarrassment and humiliation, and the psychological baggage builds up. It obviously reaches a stage where they stop trying as the pain is too much, and of course, they also stop doing the affectionate bits, and the partner doesn’t know what on earth is going on. These men lose out from the comfort of a close relationship and it can affect them in every aspect of their life, i.e. They can become depressed, they can lose confidence in business, and their whole attitude to life can change. The unfortunate partner can do nothing to help and constant reassurance that it is not all that important only increases his frustration and desperation. It IS all that important to him! In fact, his annoyance with her efforts to help eventually lessen her sympathy and the relationship becomes cold. I find most men are greatly relieved to hear me describe all of these symptoms that they are undergoing. It’s a completely normal male reaction to erectile dysfunction. Sometimes these men haven’t realised the depths to which they have sunk until the problem is actually cured and then they get all their confidence back, and in the space of a few weeks, when the problem is resolved, they only then realise how much it had impacted on them.

PARTNER ISSUES

When erection problems develop, a man’s partner is often at a loss. She doesn’t know how to help and if she does try she can be met with annoyance or even hostility. She, of course, thinks he doesn’t find her as attractive, or that there is something else going on. No matter how much she reassures him that she still loves him and enjoys their sexual episodes together, he is unconvinced and for some men not being able to get an erection means – no sex and that’s it. What many men can’t understand is that women can have a perfectly good orgasm even when there’s not an erect penis for miles around. It’s relatively easy for a man to have a sexual experience with his partner and bring her to orgasm whether it’s by manual touching, oral sex, vibrator, or whatever, so that although the erection is not satisfactory there can still be a good experience. Many men are still able to have an orgasm and ejaculate even though the penis is not fully erect or even semi erect. It is important to continue the intimacy and the sexual touching, even during the difficult times, so that both people in relationships still feel the love and affection of each other. It greatly compounds the problem if the man withdraws from any affectionate touching or holding, as this creates a passionless relationship, and couples can live on in quiet desperation for many years if not indefinitely. Sadly, this was how the majority of couples used to handle erectile dysfunction.

BOOK LIST

I always recommend a book list. I usually tailor the recommended books to the individual patient but, in general, the books are aimed at improving communication with their partner, understanding themselves, and understanding the part sex plays in their relationship. Typical books would be: Two books written by John Gray – one is called Men are from Mars, Women are from Venus; the other book is – Mars & Venus in the Bedroom. There is a very good self-psychology book written by Robin Skynner & John Cleese – called Families and How to Survive them.

A lovely book on improving self-esteem by Tony Humphreys – called Self Esteem: A guide to your child’s education. There are also books that explain the causes and treatments, by Kell & Dinsmore – Impotence – A guide for men of all ages or Kell & Griffiths – Sexual Health for Men. A book published in 2004 by Michael Metz and Barry McCarthy called “How to Regain Confidence & Enjoy Great Sex (Coping with Erectile Dysfunction)” is superb.

ORAL TREATMENTS

There are three popular drugs currently available for erection problems. They are Viagra, Cialis and Levitra. These drugs have revolutionised the management of ED and the vast majority of men will have success with one or other of these. One point has to be emphasised over and over again, however, and that is, that patients shouldn’t just try one or two of these and then give up. There needs to be a proper trial of therapy of these drugs before deciding whether they are suitable or work for that individual. In my practice I always prescribe at least 12 initially and then tell the patient to select a suitable 3 week period when there is no hassle at home or in-laws or children staying, etc. Then they take 3 a week for three weeks, and let them notice the changes in ability to have erections. They often notice the return of early morning erections and more spontaneous erection activity, and the confidence comes back. Many patients who have been referred to me as oral treatment failures have simply not had this trial of therapy to properly assess the drug’s ability to work for them.

Some doctors worry about giving Viagra, Cialis or Levitra to patients who have a cardiovascular history. In my opinion, the boost in confidence, the enhancement of the quality of life, the results from restoring erections easily outweigh the tiny increased risk that there may be from the mild physical activity associated with intercourse with a regular partner. As one such patient said to me – Dr O’Mahony – I know there’s a bit of stress involved in having sex, but have you ever tried having sex without an erection? You are there whacking away for ages doing your best, she’s doing her best, you nearly get it in, it comes out, it starts to fade – the whole thing turns into an emotionally charged humiliating event – Now Doc, that’s what I call stress ! With the Viagra, I just take the tablet, we have sex, we have a lovely time, it’s all over in 5-10 minutes and everybody is happy! Where’s the danger? The main contra-indication with Viagra is that it cannot be taken in patients who are treating angina with drugs containing nitrates, i.e. GTN spray.

VIAGRA

This drug has been a massive success story. It was developed by Pfizer Laboratories and initially was being tried as an anti-anginal drug, where men were taking this tablet on a daily basis. The effects on erectile dysfunction were a surprise bonus. Further sophisticated scientific analysis discovered that this drug was blocking an enzyme that is found predominantly in the arteries of the penis, to allow erections to develop and stay erect. The drug is extremely successful in men with all types of erectile dysfunction. The usual dosage is 50 mg and the medication has to be taken at least an hour before sexual activity, and it’s best taken on an empty tummy. If it’s taken shortly after a heavy meal, it takes the drug longer to be absorbed. There is a saying that “a curry kills it”! Many men, however, describe its effects kicking in within half an hour. The drug will only work if it’s coupled with sexual thoughts and sexual stimulation. Men who have very poor blood supply or nerve damage to the penis; i.e. men who don’t get early morning erections or any spontaneous erections may not be successful with Viagra. Some ability to produce some erection is usually needed for the drug to be able to work. Like all of these oral treatments, several goes of the drug are needed before deciding whether it’s the ideal treatment for any individual patient. It’s unfortunate that some patients will just try these once or twice.

The embarrassment of the whole thing can cause so much anxiety that the drug may not work, and they then lose heart, and stop. It’s important to try Viagra and other drugs for at least eight doses over a relatively short period, say 3 weeks, to fully assess its effects. The drug is absolutely safe, even in patients who have had cardiovascular problems. Obviously, the man needs to be reasonably fit enough to have intercourse, but the physical activity involved in sexual intercourse has been calculated as the same as walking for one mile on the flat in twenty minutes.

The patent expired for Viagra in June 2013, so there are generic versions available or the price of Viagra itself may come down, so for patients paying for private prescriptions that will be welcome. The chemical name for Viagra is ‘Sildenafil’, so if the doctor writes that on the prescription the chemist will issue the cheapest version.

CIALIS
This drug has a similar method of action to Viagra, so most of the above information applies to Cialis. However, it stays in the system for much longer. This may help take some of the planning out of the situation. Some men find it embarrassing that they have to organise when they are going to have sex, and this drug may restore the spontaneity. It can be taken with or without food. It comes in 2 strengths – 20mg and 10mg – both the same price. It becomes effective in about 50% of men within half an hour. The drug stays in the system at effective levels for about 2 days (officially it’s 36 hours!). Again it is important that at a few doses are tried i.e. eight doses over a 3 week period is a good idea. Trials suggest it is as successful as Viagra and the side effects are similar. Commonest is headache and facial flushing but these decrease with further doses. Again, No nitrates allowed.

ONCE DAILY Cialis: With increasing use of these drugs it became obvious that some patients needed a ‘loading dose ‘for the drug to work well. Some men reported that if they took the drug for a day or two before they actually needed it the erection seemed to work better. Studies were done using a low dose of Cialis every day and this suits some men who prefer to be able to have sex without the detailed forward planning. This system seems to suit younger men who might be having sex more than once a week.

LEVITRA
Another Viagra type drug. Duration of action is similar to Viagra. Can be taken with or without food but activity may be delayed if taken with a high fat meal. Scientifically it is very selective for the target enzyme and has been marketed as possibly having superior efficacy in difficult to treat patient groups. A new formulation that dissolves in the mouth is now available. (Orodispersible 10 mg).

SPEDRA

Spedra is the latest of this type of drug to come on to the market. Its marketed as a ‘fast acting’ PDE5 inhibitor. Spedra is rapidly absorbed with a fast onset of action; it is effective for up to 6 hours and is not particularly affected by food.

UPRIMA
This interesting drug has a completely different method of action to Viagra. It works on the areas in the brain that initiate the sexual response. The quoted success rates for Uprima are not as high as Viagra, but it does have an interesting advantage in that it’s absorbed very quickly. The tablet is put under the tongue and it’s absorbed in that fashion, it reaches peak levels in about 15 minutes. It’s not interfered with by food and, again – like Viagra, at least eight goes of the drug over a three week period should be tried before deciding whether it’s suitable for that individual or not. This drug is not interfered with by nitrates, so patients with angina on nitrates can take this drug. However in view of poor sales it is no longer manufactured in UK, so it can’t be prescribed.

L-ARGININE, YOHIMBINE & OTHER SUPPLEMENTS

Many drugs and compounds have been claimed to be effective in erectile dysfunction. However, controlled trials, using dummy drugs (placebo) have been conducted and don’t appear to show any significant benefit. Having said that, if a patient tells me these drugs work for him, I say – Well you just carry right on using them – good for you!

TESTOSTERONE

It’s rare for low testosterone to be major contributing factor to erectile dysfunction. The medical attitudes to testosterone vary. In the United States it is considered a useful treatment, but in the United Kingdom, by and large it’s not used readily. However if the levels are repeatedly low then it is good practice to restore the levels to normal.

PENILE INJECTIONS

This may sound outrageous and unbelievable, but I have shown over 500 men how to inject their penises without any difficulty. The needle is tiny – they just have to put the needle in at either side of the penis and inject a small amount of a compound called prostaglandin. This dilates up the blood vessels and depending on how much they inject, an erection develops. This is an excellent way of producing erection, even in men who have had failures or problems with all the other treatments. The right dose for each man must be worked out slowly, because if too much is injected the patient can end up with a very hard penis for several hours. This might sound like a good idea, but believe me, it isn’t. If the penis is erect and doesn’t go down at any stage over a 4-hour period, it is a medical emergency and the patients will need to come into Casualty and have blood removed from the penis by another needle. This is an extremely uncommon occurrence and to my mind this has never happened to a single patient of mine. I emphasise to all the patients that they should work out a sensible dose that gives them an erection for at least half an hour, but not longer than an hour or more, and they should never exceed this dose.

MUSE Medicated urethral system for erection

This is a small plastic device that allows a little pellet of the drug prostaglandin to be placed into the urethra (water passage). This pellet dissolves and the chemical gets into the penis producing an erection. It’s a bit like the injection system, except there’s no needle. The success rates are not as high as with the injection process or with the oral tablets, but some patients find it ideal for them.

VITAROS cream

This is like MUSE above but is in a cream/gel form and very easy to use. The gel is carefully ‘dropped’ into the tip of the penis. This web site gives all the detail needed.

vitaros

VACUUM DEVICES


There’s a whole range of vacuum devices available and the price varies from around £100 to £250 for these. Since July 2002, some of these have become available on an NHS prescription, from general practice but NOT hospital, provided the man falls into one of the categories that allows them free treatment for erectile dysfunction (more of that later). One system called Genesis have a website www.genmedhealth.com . There is also the Osbon Erecaid vacuum therapy system – accessible on www.mediplus.co.uk. They have a unique erection maintenance ring that a lot of patients like. Owen Mumford also do devices. They work by creating a vacuum that draws blood into the penis and then an elastic ring is slipped off over the base of the penis, as tightly near the body as possible. This keeps the blood in the penis and allows a reasonable erection for as long as the elastic is left on. Obviously, the advantage of these is that they are completely safe and once you have paid the price for the initial device there’s no more cost involved.

LUBRICANTS


It is important to use a good lubricant when there is questionable rigidity. Some men find that they get a reasonable erection, but when they go on and try to put it into their partner it just buckles up, causing dismay and disappearance. If a really good lubricant is used then even a soft penis can slide into the vagina – no problem. We have 2 lubricants in this clinic. One is called Sensilube – a water based lubricant available in all chemists and most supermarkets. The second one is Millennium glide, a silicone based lubricant that coats the area (www.idlube.com). This works well on the dry skin of the penis if the man prefers to put on the lubricant. Some couples use both and term “glide and slide” has been coined to describe this pleasant experience!

COSTS OF TREATMENT & WHAT’S AVAILABLE ON THE NHS

The Department of Health have decided that only certain groups of men can have treatment for erectile dysfunction on the NHS. These are patients who were receiving erectile dysfunction treatment prior to 14th September 1998; they will continue to be eligible. The following medical conditions are also entitled to free prescriptions – these are:

Diabetes / Multiple Sclerosis / Parkinson’s Disease / Poliomyelitis / Prostate Cancer / Prostatectomy / Radical Pelvic Surgery / Renal Failure – treated by dialysis or implant / Severe Pelvic Injury / Single Gene Neurological Disease / Spinal Cord Injury / Spina Bifida.

Obviously, the biggest group of these are patients with diabetes. The Department of Health recommends that they are allowed one treatment a week on the NHS initially, but information specifically states that if more than one treatment a week is needed that should also be prescribed on the NHS. (Health service circular number 1999/148 dated 30th June 1999)

Most patients, however, will see a doctor on the NHS, but be given a prescription and they will have to pay for the cost of the drugs at the Chemist. This definitely varies depending on which Chemist you go to, so it’s important to phone the Chemist beforehand and find out the price. You don’t want to be having that sort of discussion over the counter in a packed shop. As a guide, four tablets of 100 mg Viagra costs between £31 and £41. However if the doctor writes ‘sildenafil’ that is the generic name and its only about 80 pence per tablet.

Viagra, Cialis and Levitra, and other ED treatments can be purchased from Boots or Pharmacy2U. Their prices are very cheap and it’s an NHS service. The first prescription has to be posted, but then they keep a record and further prescriptions can then be ordered on line. You simply post them your prescription, with payment, and they post the drugs next day. If you GP or Specialist writes “Repeat x 10” on the prescription, then each time you need more, you just phone and pay — no need for another prescription or visit to the doctor!

  • Pharmacy2U Ltd, Deacon House, 1 Seacroft Avenue, Seacroft, Leeds LS14 6JD.
  • Website address: www.pharmacy2u.co.uk
  • Tel: 0870 787 6210
  • Boots the Chemist Ltd, 1 Town End Square, Walsall, West Midlands WS1 1NP.
  • Tel: 0845 121 9040
  • Website www.boots.com/pharmacy – go on to the prescription section and “order my prescription” medicine section and fill in the details.

The first prescription has to be posted, but then they keep a record and further prescriptions can then be ordered on line.

The first prescription has to be posted, but then they keep a record and further prescriptions can then be ordered on line.

Pharmacy2U Boots Pharmacy
Drug Name: Quantity Price Price
Cialis 20mg 4 £25.59 £24.46
Levitra 20mg 4 £23.50 £23.50
Viagra 100mg 4 £23.50 £23.50

Alternatively, Superdrug seems at the moment to have a national policy of NOT charging a fee for private prescriptions. So the patient only pays for the cost of the drugs. This makes it as cheap as the above prices. Phone beforehand just to make sure your drug is in stock. Again, if sildenafil is written on the prescription it is cheaper.

Other erectile dysfunction treatments can be purchased by mail or internet from Pharmacy2U or Boots.

Injection treatments cost around £13 each. Many men find that they get a lot of their confidence back after a couple of weeks or months of therapy and find they don’t need as much of the treatments as they thought they would, ie. some men even start cutting up the tablets or using less of the injections, and find that they don’t mind the odd failure as much, now that they know that there’s help at hand in the drawer, whether they decide to use it or not.

There tends to be long NHS waiting lists for erectile dysfunction and many patients opt to see someone privately. The cost for this varies throughout the United Kingdom, but in general, the initial consultation privately would be about £180 (depending on length of consultation and investigations) with a follow-up of about £80. In my practice I rarely need to see patients more than twice. Most private practitioners will see patients without a referral letter from their GP, but if a medication is prescribed, patients are strongly encouraged to allow their GP to be informed of this.

USEFUL WEBSITES

The Sexual Dysfunction Association (formerly the Impotence Association) have an excellent website with lots of information, usually accessible on www.sda.uk.net Sexual Dysfunction association helpline 0870 7743571. They also have a list of doctors who treat problems in your area.

Other excellent UK websites for stimulating your sex life are Blissbox – www.blissbox.com or www.lovehoney.com where there are excellent books, videos and sex toys.

DR COLM O’MAHONY, Consultant in Sexual Health, Department of Sexual Health, Countess of Chester Hospital NHS Trust, Liverpool Road, Chester CH2 1UL.

Telephone: (01244) 363097 Fax: (01244) 363095.

Email: colm.omahony@nhs.net

Private Practice at the Grosveror Nuffield Hospita,l Wrexham Rd, Chester. (01244) 680444

Updated July 2014