Sexual Health For Adults

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Sexual Health

Sexuality is a big part of being human. Love, affection and sexual intimacy all play a role in healthy relationships. They also contribute to your sense of well-being. A number of disorders can affect the ability to have or enjoy sex in both men and women.

Factors that can affect sexual health include

The World Health Organization defines sexual health as a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.

National Institute of Health

Benefits of love and sex

 Besides a heart full of love and a big smile, romance can bring some positive health benefits.

Some scientific studies suggest that a loving relationship, physical touch and sex can bring health benefits such as lower blood pressure. Of course, no relationship can guarantee health and happiness, but cupid's arrow can send you some health boosts.

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Sex is good for your heart

Want to get healthy and have fun at the same time? Anything that exercises your heart is good for you, including sex. Sexual arousal sends the heart rate higher and the number of beats per minute reaches its peak during orgasm.  

But, as with most exercise, it depends how vigorously you do it. Some studies show that the average peak heart rate at orgasm is the same as during light exercise, such as walking upstairs. That's not enough to keep most people fit and healthy.

Adults should do at least 150 minutes (two and a half hours) of moderate-intensity aerobic activity, such as cycling or fast walking, every week.

Unless you're lucky enough to have 150 minutes of orgasms a week, try cycling, brisk walking or dancing.

Having heart disease doesn't have to hold you back in the bedroom. Experts advise that you can usually have sex as long as you can do the everyday activities that have the same impact on your heart without causing chest pain, such as walking up two flights of stairs.

Source: Rerkpattanapipat P, Stanek MS, MN Kotler. Sex and the heart: What is the role of the cardiologist? European Heart Journal 2001;22: 201-208.

A hug keeps tension away

Embracing someone special can lower blood pressure, according to researchers. In one experiment, couples who held each other's hands for 10 minutes followed by a 20-second hug had healthier reactions to subsequent stress, such as public speaking.

Compared with couples who rested quietly without touching, the huggers had: 

  • lower heart rate 

  • lower blood pressure

  • smaller heart rate increases

So give your partner a hug – it may help to keep your blood pressure healthy.

Similar effects have been found for non-sexual stroking, although this appears to only reduce blood pressure in women who are stroked, not men.

Source: Grewen KM, Anderson BJ, Girdler SS, Light KC. Warm partner contact is related to lower cardiovascular reactivity. Behavioural Medicine, 2003;29:123-30.

Sex can be a stress buster

Workload too high? Hot and bothered after the morning journey to work? Sex could help you beat the stresses of 21st century living, according to a small study of 46 men and women.

Participants kept a diary of sexual activity, recording penetrative sex, non-penetrative sex and masturbation.

In stress tests, including public speaking and doing mental arithmetic out loud, the people who had no sex at all had the highest stress levels.

People who only had penetrative sex had the smallest rise in blood pressure. This shows that they coped better with stress. 

Plenty of people find that intimacy or orgasm without penetration helps them feel relaxed, as do exercise or meditation. It doesn't have to be penetrative sex; it's whatever works for you.

Try these 10 stress busters.

Source: Brody S. Blood pressure reactivity to stress is better for people who recently had penile-vaginal intercourse than for people who had other or no sexual activity. Biological Psychology, 2006;71:214-22.

Weekly sex might help fend off illness

There's a link between how often you have sex and how strong your immune system is, researchers say.

A study in Pennsylvania found that students who had sex once or twice a week had higher levels of an important illness-fighting substance in their bodies.

Immunoglobulin A (IgA) was 30% higher in those who had sex once or twice a week than in those who had no sex at all. However, the lowest levels were in people who had sex more than twice a week.

But don't devise a sex calendar just yet. More research is needed before it can be proved that weekly sex helps your immune system. Another study found that stroking a dog resulted in raised IgA levels in students (resting quietly or stroking a stuffed dog didn't).

Sources: Charnetski CJ, Brennan FX. Sexual frequency and salivary immunoglobulin A (IgA). Psychology Report, 2004;94:839-44.

Charnetski CJ, Riggers S, Brennan FX. Effect of petting a dog on immune system function. Psychology Report, 2004;95:1087-91.

People who have sex feel healthier

It could be that people who feel healthier have more sex, but there seems to be a link between sexual activity and your sense of wellbeing.

A study of 3,000 Americans aged 57 to 85 showed that those who were having sex rated their general health higher than those who weren't.

And it's not just sex, it's love too. People who were in a close relationship or married were more likely to say they felt in "very good" or "excellent" health than just "good" or "poor". It seems that emotional and social support can boost our sense of wellbeing.

Find out about five steps to mental wellbeing. 

Source: Lindau ST, Schumm LP, Laumann EO, et al. A Study of Sexuality and Health among Older Adults in the United States. New England Journal of Medicine. 2007;357:762-74.

Loving support reduces risk of angina and ulcer

A happy marriage can help to fend off angina and stomach ulcers – at least, it can if you're a man.

One study of 10,000 men found that those who felt "loved and supported" by their spouse had a reduced risk of angina. This was the case even if they had other risk factors, such as being older or having raised blood pressure.

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Similarly, a study of 8,000 men found there was more chance of them getting a duodenal ulcer if they:

  • had family problems 

  • didn't feel loved and supported by their wife

  • didn't retaliate when hurt by colleagues – in other words, they repressed their anger (researchers called this their "coping style")

Researchers suggest that stress, lack of social support and coping style can all affect a man's likelihood of developing an ulcer.

Sources: Medalie JH, Goldbourt U. Angina pectoris among 10,000 men. II. Psychosocial and other risk factors as evidenced by a multivariate analysis of a five-year incidence study. American Journal of Medicine, 1976;60:910-21.

Medalie JH, Stange KC, Zyzanski SJ, Goldbourt U. The importance of biopsychosocial factors in the development of duodenal ulcer in a cohort of middle-aged men. American Journal of Epidemiology, 1992;136:1280-7.

And if you're single…

Spending an evening with friends is good for your health, too.

One 10-year study of 1,500 people over 70 years old found that those with stronger friendship networks lived longer than those with fewer friends.

Researchers thought this could be because friends may have a positive influence on lifestyle choices, such as smoking or exercise, and offer emotional support.

Source: Giles LC, Glonek GF, Luszcz MA, Andrews GR. Effect of social networks on 10-year survival in very old Australians: the Australian longitudinal study of aging. Journal of Epidemiology and Community Health, 2005;59:574-9.

Or celibate…

A life without sex is no bar to excellent health. A long-term study into the health and ageing of a group of nearly 700 older nuns found that many are keeping active and living well into their 90s and past 100.

Since 1986, participants in The Nun Study have had yearly checks on their physical and mental abilities. Researchers have used convent records to obtain their social, family and educational background.

While they've found some links between lifestyle and dementia (for example, higher education or positive emotions in early life might cut the risk of dementia), this isn't linked to sexual activity.

If you do have sex, using a condom will protect you and your partner against sexually transmitted infections (STIs) and unplanned pregnancy. 

A healthy sex life

A sexual psychotherapist gives advice on how to have a healthy and fulfilling sexual relationship.

Source: NHS Choices, UK

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Sexual arousal in women

 During arousal and sex, there are various stages of physical response. Researchers have identified four stages of sexual response in women and men: arousal, plateau, orgasm and resolution. This article describes what happens in a woman's body when she is sexually aroused.

Stage 1: excitement or arousal

When a woman becomes aroused (turned on), the blood vessels in her genitals dilate. There is increased blood flow in the vaginal walls, which causes fluid to pass through them. This is the main source of lubrication, which makes the vagina wet.

The external genitalia or vulva (including the clitoris, vaginal opening, and inner and outer lips or labia) become engorged (swollen) due to the increased blood supply. Inside the body, the top of the vagina expands.

The pulse and breathing quicken, and blood pressure rises. A woman may become flushed, especially on the chest and neck, due to the blood vessels dilating.

Stage 2: plateau

Blood flow to the lower third of the vagina reaches its limit, and causes the lower area of the vagina to become swollen and firm. This is called the introitus, sometimes known as the orgasmic platform, and undergoes rhythmic contractions during orgasm. 

A woman’s breasts may increase in size by up to 25%, and blood flow to the area around the nipple (the areola) increases, making the nipples look less erect.

As a woman gets closer to orgasm, her clitoris pulls back against the pubic bone and seems to disappear. Continuous stimulation is needed in this phase to build up enough sexual excitement for orgasm. 

Stage 3: orgasm

Orgasm is the intense and pleasurable release of sexual tension that has built up in the earlier stages, characterised by contractions (0.8 seconds apart) of the genital muscles, including the introitus. Read more here: what is an orgasm? 

Most women don’t experience the recovery period that men do after an orgasm. A woman may have another orgasm if she's stimulated again.

Not all women have an orgasm every time they have sex. For most women, foreplay is an important role in an orgasm occurring. This can include stroking erogenous zones and stimulating the clitoris.  

Stage 4: resolution

This is when the woman's body slowly returns to its normal state. Swelling reduces, and breathing and heart rate slow down. 

Female ejaculation

Female ejaculation is an uncommon condition where a woman expels clear fluid from her vagina during sex. In this video, an expert explains more and members of the public give their thoughts. Part of the embarrassing conditions series.

Source: NHS Choices, UK

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Sexual Arousal in Men

Researchers have identified four stages of sexual response in men and women: arousal, plateau, orgasm and resolution.

Stage 1: excitement or arousal

A man gets an erection with physical or psychological stimulation, or both. This causes more blood to flow into three spongy areas (called corpora) that run along the length of his penis. The skin is loose and mobile, allowing his penis to grow. His scrotum (the bag of skin holding the testicles) becomes tighter, so his testicles are drawn up towards the body.

Stage 2: plateau

The glans (head) of his penis gets wider and the blood vessels in and around the penis fill with blood. This causes the colour to deepen and his testicles to grow up to 50% larger.

His testicles continue to rise, and a warm feeling around the perineum (area between the testicles and anus) develops. His heart rate increases, blood pressure rises, breathing becomes quicker, and his thighs and buttocks tighten. He's getting close to orgasm.

Stage 3: orgasm and ejaculation

A series of contractions force semen into the urethra (the tube along which urine and semen come out of the penis). These contractions occur in the pelvic floor muscles, in the vas deferens (tube that carries sperm from the testicles to the penis), and also in the seminal vesicles and the prostate gland, which both add fluid to the sperm. This mix of sperm (5%) and fluid (95%) is called semen.  

These contractions are part of orgasm, and the man reaches a point where he can’t stop ejaculation from happening. Contractions of the prostate gland and the pelvic floor muscles then lead to ejaculation, when semen is forced out of the penis.

Stage 4: resolution

The man now has a recovery phase, when the penis and testicles shrink back to their normal size. He is breathing heavily and fast, his heart is beating rapidly, and he might be sweating.

There's a period of time after ejaculation when another orgasm isn’t possible. This varies between men, from a few minutes to a few hours or even days. The time generally gets longer as men get older.

If a man gets aroused but doesn’t ejaculate, this resolution stage can take longer, and his testicles and pelvis might ache.

You can find out more about penis health, including how to wash a penis and penis size.

If you are worried about your health have a look at the Man MOT, a confidential, online surgery where you can talk to a GP anonymously.

Source: NHS Choices, UK

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Some Good sex tips

If you want to make the most of your sex life, these sex tips are a good way to start.

As long as you're talking and listening to each other, you're well on the way to a healthy sex life. However, even the most contented lovers can have fun trying new things; here are a few ideas.

1. Build anticipation

Agree on a period of time, say one week, when you won’t have orgasms or penetrative sex. At first, allow only kissing and holding each other. Gradually move on to touching and stroking each other, masturbation, oral sex (what is oral sex?) or whatever feels right for you. Avoid orgasm. At the end of the week, allow yourselves the pleasure of orgasm, through any kind of sex you like. This week may help heighten your senses to all the other wonderful feelings you can share when you’re having sex.

2. Massage

Massage can help you have very sensual sex. As part of foreplay, it's a great way to start things off slowly, and relax into the feel of each other’s skin as your arousal intensifies.

However, a simple massage that doesn’t lead to sex can also work wonders for your sex life. A non-sexual massage will familiarise (or refamiliarise) you with your partner’s body, reduce stress and reaffirm the intimacy between you. If you don’t want a massage to lead to sex, discuss this with your partner so you can avoid any misunderstanding. Read more about why it's good to talk about sex. 

3. The senses

Good sex can embrace all the senses, not just touch. Scented oil for a massage (don't get oil on a latex condom as this can damage it), music and candles for soft lighting can all be erotic, as well as listening to your partner’s breathing and the sounds that they make. Taste each other as you kiss. If you both want to, you could mix food and sex – feed each other something delicious and juicy, such as strawberries.

4. Whisper

Whether it’s sweet nothings or your sexy intentions, whispering things to each other can add an extra thrill. It doesn’t have to be during foreplay or sex. A sexy phone call leave both of you looking forward to the event for hours or days.

This works with texts and emails too, but make sure you send them to the right person, and remember that your employer has the right to access your work email.

5. Masturbation

Masturbation, by yourself or with your partner, can be a bonus for your sex life. Exploring your own body and sexual responses means that you can share this knowledge with your partner. Masturbating your partner can help you learn more about what turns them on. It can also be a useful option if one of you doesn’t feel like full penetrative sex, or if you have different levels of desire. Talk about this with your partner.

6. Sex toys

If you and your partner both feel comfortable, using sex toys can be an arousing thing to do together. Some people use vibrators (and more) as an enjoyable part of their sex life. If you’ve never thought about using sex toys before, how do you feel about trying them? You can buy them online or in sex shops. Find out more: are sex toys safe?

7. Read a book

There are many books that have exercises and ideas to help you achieve a fulfilling sex life, whatever your age, gender, sexual orientation or taste. If you’ve never thought about buying a book about sex, why not do it now? You might wish you’d done it years ago.  

8. Share fantasies and desires

Everyone has unique fantasies, tastes and preferences when it comes to sex. From earlobes to ankles, hairline to hips, pirates to picnics, don’t be afraid to talk about them. If you and your partner know about each other’s turn-ons, you can make the most of them.

9. Keep it clean

We’re talking about your general hygiene. You don’t have to keep yourself super-scrubbed: a certain amount of sweat is fine, as long as it isn’t overwhelming. But be respectful towards your partner, and wash every day to prevent nasty smells and tastes. For specifics, read more about keeping your vagina clean and how to wash a penis.

10. Relax

Sex with a loving partner can be one of the most beautiful and intense experiences in life. Sometimes the best sex happens when you’re not worrying about making it exciting or orgasmic. Relax with your partner, and great sex may find you. 

Try some relaxation tips to relieve stress.

Source: NHS Choices, UK

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6 Complaints Sex Therapists Hear All The Time

You can’t return to the honeymoon phase but you can get your sex life back.

03/17/2016 03:52 pm ET

Brittany Wong Divorce Editor, The Huffington Post

Sex therapist Celeste Hirschman knows there’s no one-size-fits-all answer to couples’ erotic problems. What she can suggest to all couples that come into her office, however, is a new, more open-minded approach to sex.

“I tell them, you will need to explore your own turn ons and find out what turns your partner on and then see where the two of you overlap and where you might be willing to learn, expand and try out different experiences,” Hirschman, the co-author of Making Love Real: The Intelligent Couple’s Guide to Lasting Intimacy and Passion, told HuffPost. 

Chris Black via Getty Images

Below, she and other sex therapists share the most common bedroom problems couples grapple with.

“I commonly hear this statement from married women at their first session with me. I reframe this dilemma as a discrepancy in the couple’s definition of what ‘sex’ means. Most often the ‘high desire partner’ defines it as intercourse. The goal is orgasm and good sex is defined as a good performance. I see hope in the wife’s eyes as I begin to shift the definition into the pleasure model of sex, that is: sexuality is energy and can be expressed in so many ways not limited to genital performance. The goal is pleasure and the vehicle of pleasure is touch with no particular activity or outcome expected. It is not a matter of chemistry and plumbing working properly, but a matter of connection, relaxation and feeling safe. Hearing this is often very freeing for both partners.” — Linda E. Savage, a psychologist, sex educator and author of Reclaiming Goddess Sexuality

“Many couples I see think that an affair has to end the relationship, but affairs can often be a catalyst or wake-up call that can get couples talking again after years of stagnation. While it can be very painful to be cheated on, the most important thing to remember is that the person cheating is rarely doing it on purpose to hurt their partner. It is possible to recover from an affair and find a place of trust, honesty and connection again. It just takes a lot of love and empathy to get through the hurt to a deeper understanding with one another.” — Celeste Hirschman

“The most common sexual problem that men deal with is not erectile dysfunction, but premature ejaculation. Most men who suffer from PE are doing so in silent desperation, experiencing shame and frustration when commonly touted behavioral interventions such as the ‘stop-start’ and ‘squeeze’ methods fail. As one woman complained to her partner of the stop-start method, ‘Are we having sex or parking a car?’ There’s no cure for PE, but there are ways to manage it. First off, even if a guy could last as long as he wants, it doesn’t mean that lasting longer results in a woman’s orgasm. Most women respond to clitoral stimulation more than vaginal penetration. I always advise men to focus on outercourse more than intercourse.“ — Ian Kerner, a sex therapist and New York Times-bestselling author of She Comes First: The Thinking Man’s Guide to Pleasuring a Woman

“The truth is, you cannot go back to the way sex is in the honeymoon period, but you can move forward to something equally amazing or perhaps even better. If you stop looking at sex as something that is just supposed to happen between the two of you without any communication or creativity, it is possible to find out what will make your sex life hot again.” — Celeste Hirschman

“When I hear couples have lost their sexual connection, the work begins: Over the course of many weeks, homework assignments are first focused on creating the safe and secure connection. The assignments focus on touch experiences that allow the couple to connect through safe touch, a kind of kinesthetic mindfulness. Once they can be completely relaxed and connected with no agenda, they gradually focus on expanding pleasure in completely new ways, including spiritual sex practices if they so desire.” — Linda E. Savage

“Most of the couples I work with actually bristle at the idea of scheduling sex; they feel like desire should emerge spontaneously, but actually desire is ‘responsive,’ meaning that it doesn’t just emerge. What does desire respond to? Arousal. I often give couples the homework of creating ‘willingess windows’ — a 20 minute period where you commit to generating arousal (physiological, psychological or both) without the expectation or demand of sex. What are some of the activities that couples choose to generate in these willingness windows? It’s a range: kissing, making out, hugging, dancing like fools, mutual massages, watching porn together, reading erotica, there’s actually very few limits on what you can consensually get going in 20 minutes. It’s better to be the couple that schedules arousal, and potentially sex, then the couple that lets sex fall to the bottom of the to-do list.”  — Ian Kerner

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Source: Huffington Post

Male sexual problems

It’s estimated that one in 10 men has a problem related to having sex, such as premature ejaculation or erectile dysfunction. Dr John Tomlinson of The Sexual Advice Association explains some of the causes, and where to seek help.

“Sexual dysfunction in a man is when he's not able to perform properly,” says Dr Tomlinson. “The main problem is being unable to get an erection. It’s much more common than people realise. In the 20-40 age group it affects around 7-8% of men, in the 40-50 age group it affects 11%. In the over-60s it affects 40%, and more than half of men over 70.”

It can affect any man, whether he is straight, gay, bisexual or transgender. Read more about erectile dysfunction (impotence) and premature ejaculation.

Erectile dysfunction (impotence)

This is when a man can’t get, or keep, an erection. Most men experience it at some time in their life. “It only becomes a problem when the man or his partner considers it a problem,” says Dr Tomlinson. 

What causes erectile dysfunction?

“A variety of things cause it. Some psychological and some physical,” says Dr Tomlinson. "Psychological issues tend to affect younger men, such as first night nerves and so on. Often, these problems don’t persist. But there can be more serious psychological problems about sex that need the help of a psychosexual therapist.”

Worries about work, money, your relationship, family, and even worrying about not getting an erection, can all be factors.

Physical reasons for erectile dysfunction include:

Medical conditions that cause erectile dysfunction

  • heart disease

  • diabetes

  • raised blood pressure  

  • raised cholesterol: this can lead to clogging of arteries, including the arteries in the penis, which are very narrow (1-2mm in diameter compared with around 10mm in the heart artery) 

  • low testosterone: testosterone levels fall as men get older, but not all men are affected by it. Those who are affected will have symptoms such as feeling tired and unfit, and loss of interest in (and inability to have) sex.

Drugs that cause erectile dysfunction

  • some prescription drugs: these can include medicines (such as beta-blockers) used to treat raised blood pressure, and antidepressants, antipsychotic drugs and anticonvulsant drugs

  • alcohol 

  • recreational drugs such as cannabis and cocaine 

  • smoking: nicotine affects the blood supply to the areas of the penis that cause erections 

What should I do if I have erectile dysfunction?

See your GP. He or she can give you a physical examination and carry out blood tests to identify the cause.

Erectile dysfunction can be an important signal to other issues. “It's associated with raised cholesterol, diabetes and raised blood pressure. Any of these can be a warning of future heart disease,” says Dr Tomlinson. Your doctor can ensure that you get the treatment you need.

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What's the treatment for impotence?

First, adjust any lifestyle factors that might be causing your problem.

“If you stop smoking, drinking too much or using recreational drugs, the problem should eventually go away. But it can take months,” says Dr Tomlinson. “There is no overnight cure.”

If you're prescribed blood pressure tablets or antidepressants, your doctor may be able to put you on a different kind.

Low testosterone can be treated with hormone replacement therapy, which should resolve erectile dysfunction as long as it's used together with erection-helping drugs. Other conditions, such as diabetes and high blood pressure, can be treated, which may improve erections. Find out more about erectile dysfunction treatment, including sildenafil cotrate (viagra). The Sexual Advice Association has useful factsheets on all of this.

Some men benefit from psychosexual therapy, which is a form of relationship therapy where you and your partner can discuss any sexual or emotional issues or concerns. You can contact the Sexual Advice Association, Relate, sexual health charity FPA or your GP to ask about psychosexual therapy.

Premature ejaculation

This is when a man ejaculates (comes) sooner than he wants to during sex. It's only a problem if it bothers him or his partner.  

You can see your GP or a psychosexual therapist for help.

What causes premature ejaculation?

"Either just being very excited with a new partner, or an acute sensitivity of the local nervous system, which triggers orgasm too suddenly," says Dr Tomlinson.

It can also be linked to anxiety about sexual performance, stress, unresolved issues in a relationship, or depression.

What should I do if I have premature ejaculation?

See your GP, or a psychosexual therapist. A therapist can teach you techniques to try to delay ejaculation.

What treatment is there?

“A lot of men and their partners don’t worry, and they work around it," says Dr Tomlinson. "But if you’re very unsatisfied, there are some things you can try.”

  • Have sex again soon after the man ejaculates. The second time, it will take longer to reach an orgasm. Older men might find this difficult as it may take too long to get a second erection. 

  • Creams (available from sex shops) can be put on the penis to numb sensation. “But this tends to transfer the numbing sensation to the partner, which they don't always like,” warns Dr Tomlinson. Some find using a condom useful.

  • The man’s partner can squeeze his penis in a certain way to prevent him ejaculating. “A man needs an extremely willing partner to do this, and some partners don’t feel comfortable with it,” says Dr Tomlinson. 

  • Antidepressants called selective serotonin reuptake inhibitors (SSRIs) can slow ejaculation, but only for a year or so. “We’ll try every other treatment first before starting on drugs,” says Dr Tomlinson. 

  • Psychotherapy might help in terms of relaxing or exploring problems in the relationship. Find out what a sex therapist does.

Dr Tomlinson is editor of The ABC of Sexual Health (published by Wiley-Blackwell).

The Sexual Advice Association helpline is 0207 486 7262.

Find out about other sexual problems, such as retarded ejaculation and retrograde ejaculation.

If you are worried about your health have a look at the Man MOT, a confidential online surgery where you can talk to a GP anonymously.

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About Ejaculation problems

Ejaculation problems, such as premature ejaculation, are common sexual problems in men.

The three main problems are:

These are described in more detail below.

Premature ejaculation

Premature ejaculation is the most common ejaculation problem. It is where the male ejaculates too quickly during sexual intercourse.

Many men are unsure about how long ‘normal’ sex should last before ejaculation. A study looking at 500 couples from five different countries found the average time between a man putting his penis into his partner’s vagina and ejaculation was around five-and-a-half minutes.

However, it's up to the individual and his partner to decide whether or not they're happy with the time it takes for him to ejaculate. There is no definition of how long intercourse should last.

Occasional episodes of premature ejaculation are common and not a cause for concern. However, if you're finding that around half of your attempts to have intercourse result in premature ejaculation, it might help to get treatment.

Most men with this problem won't have always had it – they'll have previously ejaculated normally. This may be referred to as 'secondary' premature ejaculation.

It's less common for the man to have always experienced premature ejaculation (since becoming sexually active) – this is known as 'primary' or lifelong premature ejaculation. It affects around one in 50 men in England. In most cases of lifelong premature ejaculation:

Delayed ejaculation

Delayed ejaculation (male orgasmic disorder) is classed as either:

There is no set definition to describe ‘how long is too long’, but a persistent (and unwanted) delay of ejaculation that lasts for 30 to 60 minutes may suggest delayed ejaculation.

Alternatively, if you are unable to achieve ejaculation at least half the times you have sex, you may have delayed ejaculation.

As with premature ejaculation, delayed ejaculation can be either acquired or lifelong. Lifelong delayed ejaculation is less common and affects an estimated one in 1,000 men.

Delayed ejaculation can occur in all sexual situations, or just in certain situations – for example, you may be able to ejaculate normally when masturbating, but not during sex. When delayed ejaculation only happens in certain situations, there's usually a psychological cause.

Retrograde ejaculation

Retrograde ejaculation is a rarer type of ejaculation problem. It happens when sperm travels backwards and enters the bladder instead of coming out of the end of the urethra (the tube through which urine passes).

The main symptoms of retrograde ejaculation include:

Men with retrograde ejaculation still experience the feeling of an orgasm and the condition does not pose a danger to health. However, it can affect the ability to father a child (read about infertility).

Treating ejaculation problems

Premature ejaculation can be treated with medication, such as the selective serotonin reuptake inhibitors (SSRIs) type of antidepressant, which can help delay ejaculating.

Couples therapy, a form of counselling, can be useful in coming up with techniques for partners to practice to help delay ejaculation.

Recommended treatments for delayed ejaculation depend on the underlying cause. If it is thought to be a side effect of medication, switching to an alternative medication will help. However, if the cause is thought to be psychological, counselling may be recommended.

Most men do not require treatment for retrograde ejaculation because they are still able to enjoy a healthy sex life and the condition does not affect their health. In some cases, medication may be used to help restore normal ejaculation.

However, if you want to have children, you may need fertility treatment to extract a sample of sperm.

Read more about treating ejaculation problems.

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What causes ejaculation problems?

Ejaculation problems are complex and can be caused by a number of things, including:

Some researchers think certain men are more prone to premature ejaculation because of their biological make-up, such as having an unusually sensitive penis.

Retrograde ejaculation is caused by damage to nerves or muscles that surround the neck of the bladder (the point where the urethra connects to the bladder). This damage can often occur as a complication of prostate or bladder surgery.

Read more about the causes of ejaculation problems.

Who is affected

Premature ejaculation is the most common type of ejaculation problem.

A number of surveys have found around one in three men reported being affected by premature ejaculation. The true figure is probably much higher as many men are reluctant to admit they have this problem.

While less common, delayed ejaculation is probably more of a problem then most people realise. One study found around one in 20 people had problems achieving an orgasm over the course of a month during the past year.

Although retrograde ejaculation is rare, it can be a common complication of some types of surgery, such as prostate surgery, or in men with certain health conditions that can damage the nerves, such as diabetes or multiple sclerosis.

Involve your partner

If you are having problems with your sex life and are seeking treatment, it is usually recommended you involve your partner as much as possible.

Communicating your concerns can often go a long way to helping to resolve them. And in some cases your partner may also have their own problems that are contributing towards problems with your sex life.

For example some women are unable to reach climax during ‘normal’ intercourse and require manual or oral stimulation.

Read more about why talking about sex is important.

Blood in your semen

Finding blood in your semen (haematospermia) can be alarming. However, in most cases it's not serious and will pass within a few days.

The most likely cause is infection of your urethra (urethritis) and prostate (prostatitis).

See your GP if the symptoms persist, or visit your local genito-urinary medicine (GUM) clinic because the causes may be more serious.

Read more about blood in the semen.

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The male midlife crisis

The male midlife crisis is something people joke about, but it can be distressing for those going through it

Source: NHS Choices, UK

Men's Health: The Secret to Better Erections

The Secret to Better Erections

Publication: Bottom Line Personal.
Source Steven Lamm, MD 

If you’re like most middle-aged and older men, you want better erections—erections that are reliable and hard. But better sex is only one of the benefits of better erections…

Surprising fact: A man’s erection is an important barometer of his health. Erectile dysfunction (ED)—when a man can’t get or keep an erection firm enough for sexual intercourse—often is an early warning sign of heart disease. An erection requires healthy blood vessels, nerves and hormones.

Important scientific evidence: A seven-year study of more than 4,000 middle-aged and older men, published in The Journal of the American Medical Association, showed that those who had ED at the beginning of the study or developed it during the study had a 45% higher risk of developing heart disease.

Unfortunately, ED affects roughly half of American men over age 60 (and many younger men)—most of whom have cardiovascular disease or one or more risk factors for developing it, such as high cholesterol, high blood pressure, insulin resistance, diabetes or obesity.

Of course, you can take an ED drug (such as Viagra, Cialis or Levitra) for the problem. But that won’t take care of the underlying health issues. Plus, no man wants to be dependent on ED drugs…they’re not without risk (blindness is a rare but possible side effect)…and they don’t always work.

Here’s what you need to know to preserve or restore your erections—and the health of your body—naturally…

EXERCISE

Erections owe most of their hardness to nitric oxide, a molecule that signals blood vessels to relax, allowing blood to enter and pool in the penis. The body’s most effective way of stimulating nitric oxide formation is exercise—even mild exercise, such as walking.

Scientific evidence: In a study of 180 men ages 40 to 70, published in International Journal of Impotence Research, those who were sedentary were 10 times more likely to develop ED than those who were physically active.

My recommendation: 10,000 steps a day, which you can achieve through everyday physical activity (typically 4,000 to 5,000 steps) and a brisk walk of 4,000 to 6,000 steps (about two to three miles, or 30 to 45 minutes).

Start with 5,000 steps daily for one week. Increase to 6,000 steps daily the second week…and to 7,000 the third week…until you reach 10,000. Maintain that level. You can find an accurate pedometer—typically at a cost of $20 to $30—at your local sporting-goods store or on the Internet at www.DigiWalker.com.

ERECTION-ENHANCING FOODS

Your sexual performance is greatly impacted by the foods you eat. My recommendations…

Reduce the fats in your diet. Fatty foods lead to clogged arteries, which prevent blood flow from reaching the penis. Cut back on saturated fats such as egg yolks, butter, cream, fatty red meats and palm oil.

Eat more fruits and vegetables. They reduce cholesterol and improve blood flow to the penis.

Eat whole grains, nuts and seeds. They provide an important basis for cardiovascular and penile health.

Spice up your foods. Chili peppers stimulate the nervous system, helping with sexual arousal. Ginger has long been considered a sexual stimulant and an overall tonic for general health.

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BEST SUPPLEMENTS

Several supplements can help restore erections…

L-arginine and Pycnogenol. The amino acid L-arginine (found in meat, whole grains, fish, nuts and milk) is converted to nitric oxide in the body. But most men don’t get enough in their diets, so I often recommend an L-arginine supplement Caution: Talk to your doctor before you take L-arginine, especially if you have low blood pressure, herpes, gastric ulcer, liver disease or kidney disease.

L-arginine works best when combined with Pycnogenol, a patented amalgam of more than three dozen antioxidants extracted from the bark of the French pine tree. Together, the supplement allows for better nitric oxide production and utilization.

Scientific research: In a study of men with mild-to-moderate ED, published in Phytotherapy Research, taking a supplement with L-arginine and Pycnogenol for eight weeks improved erections and satisfaction with sex.

Typical dose: A daily dose of the supplement Prelox Blue, which contains a blend of Pycnogenol and L-arginine.

Omega-3 fatty acids (fish oil). Found in oily fish such as salmon and sardines, omega-3s can reduce plaque inside artery walls…decrease blood clotting…lower triglyceride (blood fat) levels…and decrease both blood pressure and blood vessel inflammation. Omega-3s are the nutritional building blocks of heart and penis health.

Typical dose: 2,000 milligrams (mg) daily, taken with a meal.

Horny goat weed (Epimedium sagittatum). This Chinese herb perks up sexual desire.

Scientific evidence: I conducted two studies on Exotica H-G-W, a brand of horny goat weed. The first study showed that the supplement enhanced sexual satisfaction in three out of five men. The second study—in which men took horny goat weed capsules one hour before sexual activity—resulted in a significant increase in hardness in two-thirds of the participants.

Typical dose: Two capsules daily, totaling 500 mg of horny goat weed. My patients take it for six weeks and then start to taper off. You can use it intermittently after that.

TESTOSTERONE SELF-CARE

Testosterone—the predominantly male hormone that helps drive sexual desire and performance—declines with age. But most of that decline is caused by lifestyle—poor sleep, relentless stress and belly fat. My recommendations…

Sleep seven to eight hours a night. Going to bed at the same time every night (say, 11:00 pm) and getting up at the same time every morning (say, 6:30 am) is one of the best habits for deep, refreshing sleep.

Add strength-training to your routine. Whether it’s in the gym or at home with resistance bands, building and maintaining muscle are key to producing plenty of testosterone.

Breathe. Take a few slow, deep breaths a few times a day every single day—it does wonders for relieving tension and anxiety.

VISUALIZE FOR SEX SUCCESS

How do you prepare for an upcoming sexual encounter, especially if you didn’t do so well in a previous effort and don’t feel confident?

Sex is a physical act—and just as athletes practice visualization techniques so they can perform optimally, you can use the same techniques to build confidence in your bedroom “performance.”

First, relax—lie on your back on a mat or a rug with your arms at your sides and take a deep breath. Hold it for a moment, then exhale. Lie still, and continue breathing slowly.

Once you are relaxed, picture yourself about to have sex. Patiently go through the step-by-step sequence of events. Imagine every aspect of the session, including the sights, sounds and smells associated with sex. Try to rehearse the action in your mind just as you would actually perform it. It’s all about mental practice. When the time comes for the actual moment, your confidence will be higher.

Source: Steven Lamm, MD, a practicing internist, faculty member at New York University School of Medicine and director of Men’s Health for the NYU Medical Center, both in New York City. He has been named director of NYU’s men’s health center opening in January 2014. Dr. Lamm is author of The Hardness Factor: How to Achieve Your Best Health and Fitness At Any Age (Harper). His most recent book is No Guts, No Glory (Basic).

Publication: Bottom Line Personal.

Source Steven Lamm, MD 

www.DrStevenLamm.com

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Female sexual problems

Many women have problems with sex at some stage in their life. Here's a look at some forms of female sexual dysfunction (FSD) and advice on where to get help if FSD affects you.

According to the Sexual Advice Association, sexual problems affect around 50% of women and become more common as women get older.

Dysfunction can include loss of desire, loss of arousal, problems with orgasm, and pain during sex.

To identify the reasons behind sexual dysfunction, both physical and psychological factors have to be considered, including a woman's relationship with her partner.

Loss of desire

Loss of desire, or lack of sex drive, affects some women at certain times of life, such as during pregnancy or times of stress. But some women experience it all the time.

A lack of sex drive can have a range of physical or psychological causes, including diabetes, depression, relationship problems, hormone disorders, excessive alcohol and drug use, tiredness, and previous traumatic sexual experience.

Sex drive can also fall if a woman's natural testosterone levels drop. Testosterone is produced in the ovaries and adrenal glands, so levels can drop if these are removed or if they're not functioning properly.

Orgasm problems

These can be divided into two types: primary (when a woman has never had an orgasm) and secondary (when a woman has had an orgasm in the past but can't now).

Some women don't need to have an orgasm to enjoy sex, but an inability to reach orgasm can be a problem for some women and their partners.

Reasons why a woman can't have an orgasm can include fear or lack of knowledge about sex, being unable to "let go", not enough effective stimulation, relationship problems, mood disorders (such as depression), and previous traumatic sexual experience.

Research is being done into certain medical conditions that affect the blood and nerve supply to the clitoris to see whether this affects orgasm. Find out more in What is an orgasm?.

Psychosexual therapy can help a woman overcome orgasm problems. It involves exploring her feelings about sex, her relationship and herself.

Pain

Pain during sex (also called dyspareunia) is common after the menopause as oestrogen levels fall and the vagina feels dry. This can affect a woman's desire for sex, but there are creams that can help. Ask your GP or pharmacist.

Vaginismus is when muscles in or around the vagina go into spasm, making sexual intercourse painful or impossible. It can be very upsetting and distressing.

Vaginismus can occur if the woman associates sex with pain or being "wrong", if she's had vaginal trauma (such as childbirth or an episiotomy), relationship problems, fear of pregnancy, or painful conditions of the vagina and the surrounding area.

It can often be successfully treated by focusing on sex education, counselling and the use of vaginal trainers. Vaginal trainers are cylindrical shapes that are inserted into the vagina. A woman will gradually use larger sizes until the largest size can be inserted comfortably.

Getting help

To establish the cause of sexual dysfunction, a doctor or therapist will need to ask you questions about your medical, sexual and social history. Your GP can carry out tests for underlying medical conditions.

If your problem is related to lack of hormones such as testosterone or oestrogen, hormone replacement therapy (HRT) can help.

Treating other conditions such as diabetes or depression might also alleviate symptoms of sexual dysfunction.

In many cases, sexual therapy can help. Talk with your partner about your problem and see a therapist together if you can. Don't be embarrassed. Many people experience sexual dysfunction and there are ways to get help.

Your GP can refer you to a therapist, or you can see one privately. Look for a therapist who is a member of the College of Sexual and Relationship Therapists. This means they'll be fully qualified and will make sure you get a proper check-up of physical and psychological factors.

The Sexual Advice Association offers sexual health factsheets on topics ranging from loss of sex drive to talking to your GP about sexual problems, and ageing and sex.

More information
For more on sexual health, dysfunction and the menopause, read Sexual Health and the Menopause (RSM Press), edited by John Tomlinson, Margaret Rees and Tony Mander.

Source: NHS Choices, UK

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Sex advice for people with chronic pain

Sexual intercourse usually causes some degree of discomfort in people who suffer from chronic pain.

“If some part of the body is very painful, then, whether you’re a man or a woman, sex is bound to suffer. The extent to which your sex life is affected depends on how widespread the pain is and which part of your body is affected,” says Heather Wallace, chair of the charity and support group, Pain Concern.

The good news is that pain needn’t be the end of a fulfilling and satisfying sex life. In fact, research suggests that sexual activity, when comfortable, is often followed by several hours of pain relief.

The key is to return to some form of sexual activity as soon as possible. The longer you avoid sex, the bigger the fear of resuming sex becomes, and a downward spiral sets in. The lack of intimacy can damage your relationship.

Plan ahead for sex

If you live with chronic pain, spontaneous sex is never going to be easy. Planning and preparing for sex may not sound as romantic, but is a better way of achieving a satisfying sex life.

People often experience more pain at certain times of day. So it may help to have sex when your body is at its best, when your muscles are the least painful and your joints not so stiff and when you’re least tired.

Many people are most intimate just before going to sleep at night, but for people with chronic pain this can be the worst time. Instead, plan to spend time with your partner in the afternoon, or whichever time of day you feel the least pain.

Tips for more comfortable sex

If you take medication to control your pain, try to time sex for when your medicine’s therapeutic effect is at its peak.

Experiment with different positions that lessen physical strain, such as lying side by side.

It can help to warm the bed in advance with an electric blanket to ease muscle and joint discomfort.

Also, do some gentle stretches and use polyester or silk sheets to make it easier to turn and move in bed. 

Don't forget cuddling and kissing

Touching and being touched increases feelings of intimacy. Try touching, cuddling, massaging and kissing, without intercourse as your goal. Take a shower together or massage each other in turn if one of you has a bath.

Talk to your partner about sex if you have chronic pain

Talk openly and honestly to your partner about how pain affects your enjoyment of sex and what you want and need from your relationship and each other.

Pick the right moment to have this conversation. It may be better to talk about it over dinner or while out walking, for example, rather than while in bed or in an intimate situation.

Ask for help if pain is affecting your sex life

If your pain is so severe that sex seems out of the question, talk to your doctor. For example, you may need a different or stronger pain control plan. If necessary, your doctor can refer you for professional sexual counselling.

Source: NHS Choices, UK

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Does a woman always bleed when she has sex for the first time?

No, not always. When a woman has penetrative sex for the first time, she may bleed and feel some pain because of her hymen breaking.

The hymen is a very thin piece of skin that partially covers (and sometimes completely covers) the entrance to the vagina. It usually breaks during sexual intercourse if it hasn’t already broken before this.

The hymen can break quite easily before a woman has sex for the first time, through:

A woman may not know that her hymen has broken because it doesn’t always cause pain or noticeable bleeding.

If a woman's hymen breaks before she has had sex, it does not mean that she isn't a virgin.

It is therefore normal for a woman not to bleed the first time she has sex.

Bleeding during sex can also be caused by vaginal dryness, insertion of objects such as sex toys, or rough sex. Read more about this in Further information.

If you regularly get bleeding during or after sex, get advice from your GP.  

Further information:

Source: NHS Choices, UK

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Does anal sex have any health risks?

Like most sexual activities, anal sex carries the risk of passing on sexually transmitted infections (STIs).

What is anal sex?

Anal sex is any type of sexual activity that involves the anal area (bottom). This includes:

What are the main risks of anal sex?

Penetrative anal sex has a higher risk of spreading STIs than many other types of sexual activity. This is because the lining of the anus is thin and can easily be damaged, which makes it more vulnerable to infection.

STIs that can be passed on through anal sex include:

Some infections caused by bacteria or viruses can be passed on through oral–anal sex, such as hepatitis A or E. coli.

It's also possible to pass on an STI by inserting a finger into someone’s anus.

How can I make anal sex safer?

Use condoms to help protect you against STIs when you have penetrative anal sex.

Use a water-based lubricant, which is available from pharmacies. Oil-based lubricants (such as lotion and moisturiser) can cause latex condoms to break or fail. Get tips on using condoms properly.

Male and female couples should use a new condom if they have vaginal sex straight after anal sex. This is to avoid transferring bacteria from the anus to the vagina, which may lead to a urinary infection.

Read the answers to more questions about sexual health.

Further information:

Source: NHS Choices, UK

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When can I have sex again after a heart attack?

After recovering from a heart attack, you can have sex as soon as you feel ready. For most people, this is usually around 4-6 weeks.

No increased risk

People are often concerned about having sex after a heart attack because they think it might be too strenuous.

However, there's no evidence to suggest that having sex increases your risk of having another heart attack. Once you’ve recovered, you’re no more likely to trigger another heart attack by having sex than someone who has never had a heart attack.

Regular exercise and physical activity are good for the heart and, for most people, continue to be recommended after a heart attack. Like any form of physical activity, having sex can make your heart work harder by increasing your heart rate and blood pressure.

When you’re ready to start having sex again, you may find the following advice from the British Heart Foundation useful:

When to seek medical advice

Consult your GP if you get chest pain (angina) during sex.

After having a heart attack, some men experience problems getting or maintaining an erection (erectile dysfunction or impotence). These problems can be caused by emotional stress or, in rare cases, by medication such as beta-blockers. However, impotence can also have other causes.

Speak to your GP who will be able to investigate what is causing your problems and advise you about any treatment you may need.

 Further information:

Source: NHS Choices, UK

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Women's Health: Select Topics for Women

Keeping your vagina clean and healthy

The vagina is designed to keep itself clean with the help of natural secretions (discharge). Find out how to help your vagina keep clean and healthy – and why you don’t need douches or vaginal wipes.

The vagina is a tube of muscle inside a woman’s body that runs from the cervix (the opening of the womb) to the vaginal opening. The external sex organs, which are called the vulva, surround the vaginal opening.

Looking after your everyday health can help keep your vagina in good shape, says Dr Suzy Elneil, consultant in urogynaecology at University College Hospital, London, and spokesperson for Wellbeing of Women. “Generally, good vaginal health is maintained by making sure you’re in good general health,” she explains. “This includes healthy diet and exercise. Normal exercise helps maintain good vaginal function, as walking and running helps the pelvic floor to tone up and helps ensure good general health.”

Find out more about having a healthy diet, exercise and keeping fit, and pelvic floor exercises.

Vaginal secretions or discharge

Other than your period as part of your natural menstrual cycle, it’s normal to produce clear or white secretions (discharge) from your vagina. This mucus is produced naturally from the neck of the womb, known as the cervix.

“Vaginal discharge is not ‘always a bad sign’,” says Dr Elneil. “There is a myth that copious clear or white discharge is associated with sexually transmitted infections. Changes in the amount of discharge can be 100% hormonal – in other words, linked to the menstrual cycle, pregnancy or menopause.”

The character and amount of vaginal discharge varies throughout your menstrual cycle. Around the time that your ovary releases an egg (ovulation), your discharge usually becomes thicker and stretchy, like raw egg white.

Healthy discharge doesn’t have a strong smell or colour. You may feel an uncomfortable wetness, but you shouldn’t have any itching or soreness around your vagina. If there are any changes to your discharge that aren’t normal for you, such as a change in colour or if it starts to smell or itch, see your GP as you might have an infection.

You can find out more about vaginal discharge, pregnancy and the menopause.

Bacteria in the vagina

There are lots of bacteria inside the vagina, and they’re there to protect it. Professor Ronnie Lamont, spokesperson for the Royal College of Obstetricians and Gynaecologists, says: “The vagina contains more bacteria than anywhere else in the body after the bowel, but the bacteria are there for a reason.”

The good bacteria inside the vagina:

  • provide "numerical dominance": they outnumber other potential harmful bacteria that might enter the vagina

  • help to keep the vagina’s pH balance (how acidic the vagina is) at an even level, which helps to keep the balance of bacteria healthy

  • can produce bacteriocins (naturally occurring antibiotics) to reduce or kill other bacteria entering the vagina

  • produce a substance that stops invading bacteria sticking to the vagina walls, which prevents bacteria from invading the tissues

If the balance of bacteria is disturbed, this can lead to infection and inflammation. Bacteria called lactobacilli help to keep the vagina’s pH balance at its normal low level (less than pH 4.5), which also prevents the growth of other organisms. If the pH of the vagina increases (in other words, if it gets less acidic), the quality or amount of lactobacilli can fall and other bacteria can multiply. This can result in infections such as bacterial vaginosis or thrush, which can cause symptoms including itching, irritation and abnormal discharge.

Washing your vagina

It’s a good idea to avoid perfumed soaps, gels and antiseptics as these can affect the healthy balance of bacteria and pH levels in the vagina, and cause irritation.

Use plain, unperfumed soaps to wash the area around the vagina (the vulva) gently every day. The vagina will clean itself inside your body with natural vaginal secretions (discharge). “During your period, washing more than once a day may be helpful,” says Dr Elneil, who points out that keeping the perineal area (between the vagina and anus) clean is important too. “Good perineal hygiene is necessary, by washing that area at least once a day using your normal bathing routines.”

“All women are different,” says Professor Lamont. “Some may wash with perfumed soap and not notice any problems. But if a woman has vulval irritation or symptoms, then one of the first things you can do is to use non-allergenic, plain soaps to see if that helps.”

Vaginal douches

A douche flushes water up into the vagina, clearing out vaginal secretions. Some women use a douche to "clean" the vagina, but using a douche can disrupt the normal vaginal bacteria so it isn't recommended that you use one.

“I can’t think of any circumstances where douches are helpful, because all they do is wash out everything that’s in the vagina, including all the healthy bacteria,” explains Professor Lamont.

There is no evidence that douching protects against STIs or vaginal infections, and it may even increase the risk.

Scented wipes and vaginal deodorants

These perfumed products can disrupt the vagina’s healthy, natural balance. “If nature had intended the vagina to smell like roses or lavender, it would have made the vagina smell like roses or lavender,” says Professor Lamont.

Washing with water and a plain soap should be all you need to keep your vagina healthy. It’s normal for the vagina to have a scent. “Vaginal odour can change at different times of the reproductive cycle and shouldn’t always be thought of as being a sign of infection or illness,” says Dr Elneil.

If you’re worried about the way your vagina smells, if the smell is unpleasant, or you’re using perfumed products to cover up your vagina’s smell, you should see your GP. You might have an infection that needs treatment.

The most common cause of unusual vaginal discharge is bacterial vaginosis, which can cause an unpleasant smell. It’s easily treated with antibiotics, so see your GP if you’re worried.

You can find out more about symptoms of bacterial vaginosis, symptoms of thrush and symptoms that could signal a sexually transmitted infection.

Safer sex

Some bacteria and viruses can get into the vagina during sex. These include the bugs that cause chlamydia, gonorrhoea, genital herpes, genital warts, syphilis and HIV. You can protect your vagina against these infections by using a condom every time you have sex.

Find out some tips about using condoms.

Cervical screening

All women aged from 25 to 64 are invited for cervical screening. Being screened regularly means that any abnormal changes in the cervix can be identified early on and, if necessary, treated to stop cancer developing. Find out more about cervical screening.

Source: NHS Choices, UK

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Can you have sex during a period?

Yes, you can. However, some people may feel uncomfortable having sex during a woman's monthly period because it can be messy, and the presence of blood can be off-putting. Some people may also oppose it on religious grounds.

There are a few risks associated with having sex during menstruation. HIV and a few other sexually transmitted infections (STIs) may be passed on more easily during a woman's period (both from the woman to the man and vice versa). To avoid catching HIV or other STIs, you should always use a condom when you have sex.

It’s very unlikely, but you can still get pregnant if you have unprotected sex during your period if you ovulate early. This is because sperm can survive inside a woman’s body for up to seven days. Although the risk is small, it could happen.

Further information:

 Is my vagina normal?

Vaginas are designed to help us have and enjoy sex, have periods and have babies. But what’s normal and what’s not? Find out how vaginas can be different.

Dr Suzy Elneil, consultant in urogynaecology and uro-neurology at University College Hospital, London, has worked with a lot of women. “Like people, vaginas are completely individual,” she says. “No two are the same.”

Don’t compare yourself to anyone else – what someone else’s vagina looks like is normal for them, but won’t necessarily be what’s normal for you. Yours is unique.

The vagina and vulva

Some of a woman’s sexual organs are inside the body (such as the womb, ovaries and vagina) and some are outside. The external organs are known as the vulva. This includes the opening of the vagina, the inner and outer lips (labia) and the clitoris, which is located at the top of the vagina.

The vagina is a tube about 8cm (3in) long, which leads from the cervix (the neck of the womb) down to the vulva, where it opens between the legs. The vagina is very elastic so it can easily stretch around a man’s penis or around a baby during labour.

“Vaginas vary in shape, size and colour,” says Dr Elneil. “Some are small and ovoid (egg-shaped), some are large and cylindrical, and the colours can vary from light pink to a deep brownish red-pink. The important thing is that the vagina functions normally.”

Pelvic floor exercises can help keep your vagina in shape. “These are good for maintaining good pelvic floor tone and can improve sexual function,” she adds. “Normal exercise also helps maintain good vaginal function, as walking and running helps the pelvic floor tone up and helps ensure good general health.” Find out about pelvic floor exercises, including how to do them.

Should I worry about the size of my labia?

Some women worry about the size of their labia (the lips outside the vagina), but there isn’t usually any cause for concern. Labia vary from woman to woman, so don’t judge yours by anyone else’s standards.

“Large labia are only a medical problem if it affects the woman’s working, social or sporting life,” explains Dr Elneil. “Size is really not a problem per se, for most women. However, for cyclists, the length and size of the labia can affect their ability to sit comfortably on the seat, but this is a rare problem.”

If you're worried, talk to your GP.

Vaginal discharge

It’s normal to have vaginal discharge (mucus or secretions), and the texture and amount of discharge can vary throughout your menstrual cycle. If your normal vaginal discharge becomes different, for example if it changes colour or smells, this could be a sign of infection so see your GP.

Vaginal itching

A healthy vagina shouldn’t be itchy. Itching can be a sign of thrush or other infection, but it can also have other causes.

“Itching can be part of a generalised skin problem, such as eczema,” Dr Elneil says. “Or it can be a sign of benign or malignant (cancerous) changes to the skin, such as lichen sclerosus or vaginal intra-epithelial neoplasia. All need treatment, so if the itch persists for more than a month, get it checked by a GP or gynaecologist. They need to see the vulva, perineum (between the vagina and anus) and the vagina directly.”

Further information

Keeping your vagina clean and healthy

Changes to the vagina after childbirth

Periods: do I need a doctor?

Do I need a cervical screening test if I'm not sexually active?

Answer: YES

Source: NHS Choices, UK

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Vaginal discharge 

Introduction 

It's normal and healthy to produce a clear or white discharge from your vagina.

This mucus is produced naturally from the neck of the womb, known as the cervix.

The amount of vaginal discharge varies throughout your menstrual cycle (brown discharge is usually the end of your period) and most pregnant women will get a "pregnancy discharge".

Healthy discharge doesn't have a strong smell or colour. You may feel an uncomfortable wetness, but you shouldn't have any itching or soreness around your vagina.

How do I know if my discharge is unhealthy?

Any sudden change to your discharge may indicate a vaginal infection. You should be aware of how your discharge naturally varies throughout your cycle and what isn't normal, but obvious warning signs of infection are:

If you're not sure whether your discharge is normal and are worried about it, see your GP or nurse. Read about sexual health for general information and advice.

Common causes of abnormal discharge

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There are many possible causes of abnormal vaginal discharge, but it's usually a sign of infection. The infection is often caused by something that upsets the natural balance of bacteria or yeast in your vagina, such as washing inside the vagina, or it may be sexually transmitted.

The most common causes are:

The guide below may help you identify the cause of your discharge. However, it's important to see your GP for a proper diagnosis and advice on how to treat the infection.

Watery or white vaginal discharge with intense itchiness

If your discharge is thin and watery, or thick and white (like cottage cheese), you may have thrush. This common fungal infection causes intense itchiness and soreness around your vagina. The discharge may smell slightly yeasty, but doesn't have a strong smell.

Almost all women get thrush from time to time and it's not sexually transmitted. It's easily treated with antifungal medicine, which can be bought over the counter from your pharmacist.

White or grey fishy-smelling discharge

If your vaginal discharge is grey or develops a strong fishy smell, particularly after sexual intercourse, you could have bacterial vaginosis (BV). BV is an imbalance in the normal bacteria found in your vagina. It doesn't usually cause itching or irritation.

Like thrush, BV is very common and isn't sexually transmitted. It's easily treated with antibiotics. See your GP for a prescription.

Green, yellow or frothy discharge

Trichomoniasis is a common STI caused by a tiny parasite. It can make your vaginal discharge frothy, yellow or green. You may have a lot of discharge, which may also have an unpleasant fishy smell. Other possible symptoms are soreness, swelling and itching around the vagina, and pain when passing urine.

Trichomoniasis is easily treated with an antibiotic called metronidazole, which your GP will prescribe. If you have trichomoniasis, visit a local GUM or sexual health clinic as it can exist alongside other STIs

Abnormal discharge with pain or bleeding

See your GP or go to a genitourinary medicine (GUM) clinic as soon as possible if your vaginal discharge is abnormal and you have:

You may have chlamydia or gonorrhoea (both STIs). Gonorrhoea can make your discharge turn green, although often the pain or bleeding are more noticeable. Both conditions are treated with antibiotics.

Untreated gonorrhoea or chlamydia may spread upwards and lead to pelvic inflammatory disease, a serious infection of the womb, fallopian tubes or ovaries

Abnormal discharge with blisters around the genitals

Genital herpes can cause painful, red blisters or sores to appear around your genitals, as well as an abnormal vaginal discharge. See your GP or go to a genitourinary medicine (GUM) clinic as soon as possible. You may be offered a course of antiviral tablets, which stop the herpes virus multiplying, but the symptoms may have a tendency to return.

Young girls and post-menopausal women

It's unusual for young girls to have abnormal vaginal discharge before they've gone through puberty. If this happens, they should see a GP. A common cause is a type of vulvitis (inflammation of the vulval area), caused by a streptococcal infection.

Abnormal discharge is also unusual in older women. If you've gone through the menopause and suddenly notice an abnormal vaginal discharge, see your doctor as soon as possible. Possible causes include:

It's also important to rule out cervical cancer or endometrial cancer.

Cleaning your vagina

The vagina is self-cleansing, so there is no need to wash inside it (called douching). Douching can upset the natural balance of bacteria and fungi in your vagina and lead to thrush or bacterial vaginosis.

Vaginal soreness and abnormal vaginal discharge can also be caused by overusing perfumed soaps, bubble baths and shower gels. Never clean your vagina with anything strongly perfumed. Use a mild soap and warm water to gently wash around your genitals.

Source: NHS Choices, UK

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Vagina changes after childbirth

The vagina naturally changes after giving birth, and might feel wider, dry or sore for some time. Find out what to expect and the ways you can help speed recovery.

When you give birth, the baby travels through the cervix and out through the vagina (also called the birth canal). The entrance to the vagina must stretch to allow the baby through. Sometimes the skin between the vagina and anus (the perineum) might tear or be cut by a doctor or midwife to allow the baby out. This is called an episiotomy.

After having a baby, it’s not unusual for women to feel that their vagina is more loose or dry than usual, and to have perineal pain or pain during sex. This page lists a few of the changes you might notice and tips on what you can do.

Wider vagina

Your vagina might look wider than it did before, according to Dr Suzy Elneil, consultant in urogynaecology at University College Hospital, London. “The vagina can feel looser, softer and more ‘open’,” she says. It may also look and feel bruised or swollen. This is normal, and the swelling and openness should start to reduce a few days after your baby is born.

Your vagina will probably not return completely to its pre-birth shape, but this shouldn’t be a problem. If you’re worried, talk to your health visitor or GP.

“We always recommend pelvic floor exercises,” Dr Elneil says. Pelvic floor exercises (sometimes called Kegel exercises) help to tone the vaginal muscles and your pelvic floor muscles. This will help to prevent incontinence (urine leaking) and can help your vagina feel firmer. It's not uncommon for women to experience incontinence after childbirth, but pelvic floor exercises can help limit this. They can also help sex feel better.

You can do pelvic floor exercises anywhere and at any time, either sitting or standing up:

  • Squeeze and draw in your anus at the same time, and close up and draw your vagina upwards.

  • Do it quickly, tightening and releasing the muscles immediately.

  • Then do it slowly, holding the contractions for as long as you can (but not more than 10 seconds) before you relax.

  • Repeat each exercise 10 times, four to six times a day.

You may find it helps to imagine you’re stopping a bowel movement, holding in a tampon or stopping yourself urinating.

You could fit the exercises in while washing up, queuing in the supermarket or watching TV.

Dryness in the vagina

It’s normal for the vagina to feel drier than usual after childbirth. This is linked to the lower levels of oestrogen in your body compared to when you were pregnant.

For breastfeeding mothers, levels of oestrogen are lower than in those who aren’t breastfeeding and the dryness can be more marked. “Once you stop breastfeeding and your periods have returned, the levels of oestrogen revert to pre-pregnancy levels,” says Dr Elneil. "If you’ve noticed dryness, it should improve."

If the dryness bothers you, talk to your health visitor or GP. If you’ve started having sex again and the dryness is causing problems, you can use a lubricant – you can buy lubricant in pharmacies, supermarkets or online. If you’re using latex condoms, make sure the lubricant is water-based, because oil-based products (such as moisturiser and lotion) can make latex condoms tear or rip.

Try to talk about this with your partner if it’s causing problems in your sex life. That way, you can deal with it together rather than worrying about it on your own.

Soreness and stitches in the perineum

“The vaginal area can feel painful or sore in the immediate period after childbirth,” says Dr Elneil. “This usually improves within 6-12 weeks after the birth. We always recommend pelvic floor exercises to help make the situation better in this case, too.”

Your perineum can feel sore, especially if your skin tore or you needed stitches to repair a tear or episiotomy after giving birth. Painkillers can help, but if you’re breastfeeding talk to your midwife, GP or pharmacist before you buy any over-the-counter painkillers. It’s important to keep the perineal area clean, so always wash your hands before and after changing your sanitary pads and make sure you change them as soon as you need to. Have a bath or shower every day to keep your perineum clean.

If you’re worried about how your stitches are healing, talk to your health visitor or GP – this is especially important if you have a lot of pain or discomfort, or you notice a smell.

Depending on the size of the wound, you might have a scar when the tear or cut is healed. 

Pain during sex

There’s no right or wrong time to start having sex again after you’ve had a baby. Don’t rush into it. If sex hurts, it won’t be pleasurable. If your vagina feels dry, try a lubricant during sex to see if that helps.

If you have discomfort around your perineum, it might be worth your health visitor or GP having a look to check that it’s healing in the right way.

It’s not unusual to feel less like having sex than you used to – you’ve given birth, you’re looking after a tiny baby and you’re probably feeling very tired. It's important to talk about this with your partner, rather than just avoiding sex. If you both know what the situation is, you can deal with it together.

If you continue to feel pain during sex, talk to your GP.

Don’t forget to think about contraception after having a baby – it’s possible to get pregnant three weeks after giving birth.

Source: NHS Choices, UK

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Loss of Libido or Sexual Interest

Introduction 

Loss of libido (sex drive) is a common problem affecting up to one in five men – and even more women – at some point in their life.

It's often linked to professional and personal stress, or important life-changing events such as pregnancy, childbirth or breastfeeding.

However, an unexpected loss of libido – especially when it lasts for a long time or keeps returning – can also indicate an underlying personal, medical or lifestyle problem, which can be upsetting to both partners in a relationship.

If you're concerned about your libido, especially if your diminished sex drive distresses you or affects your relationship, make an appointment to see your GP to discuss any underlying causes and possible medical or psychological treatments.

Doctors at your nearest family planning clinic, Integrated Sexual Health clinic, or Contraceptive and Sexual Health (CASH) clinic may also be able to help.

In the meantime, you may find the following information useful. It explains some of the most common reasons for loss of libido.

Relationship problems

The first thing you should consider is whether you're happy in your relationship. Do you have any doubts or worries that may be the real reason for your loss of sexual desire?

If you've been in a relationship for a long time, you may have become overfamiliar with your partner and feel a degree of erotic dissatisfaction. This is quite common and can have a negative effect on your sex drive.

Relationship problems are among the most common causes of loss of libido. For help and advice, you may find it useful to contact the relationship support charity Relate.

Another thing to consider is whether the problem is a performance issue that makes sex difficult or unfulfilling. For example, many men experience ejaculation problems or erectile dysfunction, and women can experience painful sex or vaginismus (when the muscles around the vagina tighten involuntarily before penetration). See your GP if these problems are an issue, as they're often treatable.

Your GP may feel you will benefit from psychosexual counselling. This is a form of relationship therapy where you and your partner can discuss any sexual or emotional issues that may be contributing to your loss of libido. Read let's talk about sex for more information about this.

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Stress, anxiety and exhaustion

Stress, anxiety and exhaustion can be all-consuming and have a major impact on your happiness. If you feel you're constantly tired, stressed or anxious, you may need to make some lifestyle changes or speak to your GP for advice.

For more information and advice, you may find some of the following pages useful:

Depression

Depression is very different from simply feeling unhappy, miserable or fed up for a short while. It's a serious illness where you may have feelings of extreme sadness that can last for a long time. These feelings are severe enough to interfere with your daily life, including your sex life.

You're probably depressed if you're feeling low or hopeless, or you've lost interest or pleasure in doing things you used to enjoy. In this case it's really important to see your GP. They may feel you'll benefit from antidepressants.

However, low sex drive can also be a side effect of many antidepressants. Speak to your GP if you're already taking antidepressants and think they may be causing your problems, as you may be able to switch to a different medication.

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Drugs and alcohol

Drinking excess amounts of alcohol can reduce your sex drive, so it's a good idea to moderate your intake to no more than three to four units a day if you're a man, and no more than two to three units a day if you're a woman.

Read more about alcohol misuse and find out how to get support for a drinking problem.

Drug misuse is also linked to a loss of sex drive. Read more about drugs for information and advice.

Getting older

Many people lose some interest in sex as they get older, mainly as a result of falling levels of sex hormones, age-related health problems, or the side effects of medication.

Older men especially can develop low testosterone levels, which can cause fatigue, depression and a reduced sex drive.

Speak to your GP if you're concerned about this. They may carry out a blood test to check your testosterone level and can tell you about treatments if your level is low.

As women start to approach the menopause, levels of the female hormone oestrogen begin to fall, which can affect libido. Women can also suffer from low testosterone levels, especially after a hysterectomy. Testosterone is another hormone that can affect sex drive.

Speak to your GP if you're concerned the menopause may be having an effect on your libido. They may be able to offer you a trial of hormone replacement therapy (HRT) if it's suitable for you.

Hormonal problems

Less commonly, low libido may be caused by an underactive thyroid. This is where your thyroid gland (located in the neck) doesn't produce enough hormones. Common signs of an underactive thyroid are tiredness, weight gain and feeling depressed.

An underactive thyroid is easily treated by taking hormone tablets to replace the hormones your thyroid isn't making. Learn more about treating underactive thyroid.

A hormonal problem called hyperprolactinaemia can also have a negative effect on your sex drive. This is where you have a raised level of a substance called prolactin in your blood.

Contraception

Some women have reported a decreased sex drive while using some types of hormonal contraception, such as:

However, side effects of these contraceptives tend to improve within a few months and they're generally well tolerated.

Speak to your GP or local contraceptive (or family planning) clinic if you're worried your contraception is causing a loss of libido. They may suggest trying an alternative method.

Read more about choosing a method of contraception.

Other medical conditions

Long-term (chronic) medical conditions such as cardiovascular disease, diabetes and obesity can also have a negative effect on your libido.

Medication

Certain medications can sometimes reduce libido, such as:

See your GP if you're worried that medication you're taking is responsible for your reduced sex drive. They can review your medication and switch your prescription to something less likely to affect your libido if necessary.

NHS Choice: National Health Services.

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Wellbutrin And Sex Drive: Does Bupropion Increase Libido? Ask your doctor!

Good Sex Tips

Good sex can embrace all the senses, not just touch. Scented oil for a massage, music and candles for soft lighting can all be erotic, as well as listening to your partner's breathing and the sounds they make.

If you want to make the most of your sex life, these sex tips are a good way to start.

Talking and listening to each other about your feelings, preferences and desires can bring you closer together and make sex more enjoyable.

But even the most contented lovers can have fun trying new things. Here are a few ideas.

1. Build anticipation

Agree on a period of time – say one week, or whatever works for you – when you won't have orgasms or penetrative sex. At first, allow only kissing and holding each other. Gradually move on to touching and stroking each other, masturbation, oral sex, or whatever feels right for you. Avoid orgasm.

At the end of the agreed waiting period, allow yourselves the pleasure of orgasm through any kind of sex you like. This week may help heighten your senses to all the other wonderful feelings you can share when you're making love.

2. Massage

Massage can help you have very sensual sex. As part of foreplay, it's a great way to start things off slowly and relax into the feel of each other's skin as your arousal intensifies.

But a simple massage that doesn't lead to sex can also work wonders for your sex life. A non-sexual massage will familiarise (or refamiliarise) you with your partner's body, reduce stress, and reaffirm the intimacy between you.

If you don't want a massage to lead to sex, discuss this with your partner so you can avoid any misunderstanding.

Read more about why it's good to talk about sex.

3. The senses

Good sex can embrace all the senses, not just touch. Scented oil for a massage, music and candles for soft lighting can all be erotic, as well as listening to your partner's breathing and the sounds they make. But remember not to get oil on a latex condom, as this can damage it.

Taste each other as you kiss. If you both want to, you could mix food and sex – feed each other something delicious and juicy, such as strawberries.

4. Whisper

Whether it's sweet nothings or your sexy intentions, whispering things to each other can add an extra thrill. It doesn't have to be during foreplay or sex. Foreplay can start during the day with a sexy phone call or text – this could leave both of you looking forward to the event for hours or days.

This works with texts and emails, too – but make sure you send them to the right person, and remember that your employer has the right to access your work email.

5. Masturbation

Masturbation, by yourself or with your partner, can be a bonus for your sex life. Exploring your own body and sexual responses means you can share this knowledge with your partner.

Masturbating your partner can help you learn more about what turns them on. It can also be an option if one of you doesn't feel like full sex. Talk about this with your partner.

6. Sex toys

If you and your partner both feel comfortable, using sex toys can be an arousing thing to do together. Some people use vibrators (and more) as an enjoyable part of their sex life. If you've never thought about using sex toys before, how do you feel about trying them?

You can buy them online or in sex shops. You don't have to spend a fortune on toys – you can get creative. Soft hair brushes can feel great against the skin, and making your own games up can be fun.

Find out more in Are sex toys safe?

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7. Read a book

There are many books that have exercises and ideas to help you achieve a fulfilling sex life, whatever your age, gender, sexual orientation or taste.

If you've never thought about buying a book about sex, why not do it now? You might wish you'd done it years ago.

8. Share fantasies and desires

Everyone has unique fantasies, tastes and preferences when it comes to sex. From earlobes to ankles, hairline to hips, pirates to picnics, don't be afraid to talk about them.

If you and your partner know about each other's turn-ons, you can make the most of them.

9. Keep it clean

We're talking about your general hygiene. You don't have to keep yourself super-scrubbed: a certain amount of sweat is fine, as long as it isn't overwhelming.

But be respectful towards your partner, and wash every day to prevent nasty smells and tastes. For specifics, read more about keeping your vagina clean and how to wash your penis.

10. Relax

Sex with a loving partner can be one of the most beautiful and intense experiences in life.

Sometimes the best sex happens when you're not worrying about making it exciting or orgasmic. Relax with your partner and great sex may find you.  

Try some relaxation tips to relieve stress.

Page last reviewed: 03/06/2017
Next review due: 03/06/2020

Source: NHS Choices, UK

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Female genital mutilation

Introduction 

Female genital mutilation (sometimes referred to as female circumcision) refers to procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons. The practice is illegal in the UK.

It has been estimated that over 20,000 girls under the age of 15 are at risk of female genital mutilation (FGM) in the UK each year, and that 66,000 women in the UK are living with the consequences of FGM. However, the true extent is unknown, due to the "hidden" nature of the crime.

The girls may be taken to their countries of origin so that FGM can be carried out during the summer holidays, allowing them time to "heal" before they return to school. There are also worries that some girls may have FGM performed in the UK.

In February 2014, the UK government announced plans to part-fund a new study into how many women and girls living in England and Wales are affected by FGM. This was part of a wider commitment to preventing FGM during the International Day of Zero Tolerance for Female Genital Mutilation. Read the 2014 Government declaration on female genital mutilation for details on other steps being taken.

Forms of mutilation

FGM is usually carried out on young girls between infancy and the age of 15, most commonly before puberty starts.

The procedure is traditionally carried out by a woman with no medical training. Anaesthetics and antiseptic treatments are not generally used, and the practice is usually carried out using knives, scissors, scalpels, pieces of glass or razor blades. Girls may have to be forcibly restrained.

There are four main types of FGM:

  • Type 1 – clitoridectomy – removing part or all of the clitoris.

  • Type 2 – excision – removing part or all of the clitoris and the inner labia (lips that surround the vagina), with or without removal of the labia majora (larger outer lips).

  • Type 3 – infibulation – narrowing of the vaginal opening by creating a seal, formed by cutting and repositioning the labia.

  • Other harmful procedures to the female genitals, which include pricking, piercing, cutting, scraping and burning the area.

Effects of FGM

There are no health benefits to FGM. Removing and damaging healthy and normal female genital tissue interferes with the natural functions of girls' and women's bodies.

Immediate effects

  • severe pain

  • shock 

  • bleeding

  • wound infections, including tetanus and gangrene, as well as blood-borne viruses such as HIV, hepatitis B and hepatitis C

  • inability to urinate

  • injury to vulval tissues surrounding the entrance to the vagina 

  • damage to other organs nearby, such as the urethra (where urine passes) and the bowel 

FGM can sometimes cause death.

Long-term consequences

  • chronic vaginal and pelvic infections

  • abnormal periods

  • difficulty passing urine, and persistent urine infections

  • kidney impairment and possible kidney failure

  • damage to the reproductive system, including infertility

  • cysts and the formation of scar tissue

  • complications in pregnancy and newborn deaths 

  • pain during sex and lack of pleasurable sensation

  • psychological damage, including low libido, depression and anxiety (see below) 

  • flashbacks during pregnancy and childbirth

  • the need for later surgery to open the lower vagina for sexual intercourse and childbirth

Psychological and mental health problems

Case histories and personal accounts taken from women indicate that FGM is an extremely traumatic experience for girls and women, which stays with them for the rest of their lives.

Young women receiving psychological counselling in the UK report feelings of betrayal by parents, as well as regret and anger.

The legal situation

FGM is illegal in the UK. It is also illegal to arrange for a child to be taken abroad for FGM. If caught, offenders face a large fine and a prison sentence of up to 14 years.

What you can do

If you are worried about someone who is at risk of FGM or has had FGM, you must share this information with social care or the police. It is then their responsibility to investigate and protect any girls or women involved.

Read our page on useful links for FGM, which has information on organisations you can go to for help.

Health professionals

If you are a health or social care professional who may come into contact with girls and women at risk of FGM, you can read the Multi-Agency Practice Guidelines on Female Genital Mutilation (HMG 2011) (PDF, 1.63Mb).

These guidelines contain detailed advice and guidance in relation to the protection of girls who may be at risk of FGM, as well as the care and treatment of women who have already undergone FGM.

Other useful resources are listed in the useful links section on this page.

Surgical 'reversal'

Surgery can be performed to open up the lower vagina. This is sometimes called "reversal", although it cannot restore sensitive tissue that has been removed.

Surgery may be necessary for women who are unable to have intercourse, as the vagina is too narrow. In addition, some pregnant women who have had FGM will need to have their lower vagina opened up before labour, to allow a safer birth.

FGM increases the risk of the vagina tearing during delivery, which causes damage and can lead to heavy bleeding. It can also increase the risk of the baby dying during, or just after birth.

Surgery is best performed before pregnancy, or at least within the second trimester of pregnancy (between about 13 and 28 weeks).

Some women may be reluctant to undergo reversal until labour starts, because this may be normal practice in their country of origin.

Surgery involves making a careful incision along the scar tissue that has closed up the entrance to the vagina, to expose the underlying vagina. 

Adequate pain relief is essential – the procedure is usually performed under local anaesthetic in the outpatient clinic. However, a small number of women will need either a general or spinal anaesthetic (injection in the back), which would normally involve a one-day stay in hospital. 

Where does FGM happen?

FGM is prevalent in Africa, the Middle East and Asia.

In the UK, FGM tends to occur in areas with larger populations of communities who practise FGM, such as first-generation immigrants, refugees and asylum seekers. These areas include London, Cardiff, Manchester, Sheffield, Northampton, Birmingham, Oxford, Crawley, Reading, Slough and Milton Keynes.

Why is it done?

FGM is carried out for cultural, religious and social reasons within families and communities.

For example, it is often considered a necessary part of raising a girl properly, and as a way to prepare her for adulthood and marriage. FGM is often motivated by the belief that it is beneficial for the girl or woman. Many communities believe it will reduce a woman's libido and discourage sexual activity before marriage.

Female genital mutilation (FGM)

FGM is an unnecessary and illegal practice that causes significant physical, mental and emotional harm. Find out what FGM is and where to find help if you or someone you know is at risk of having FGM.

Key points

  • Over 66,000 women and girls living in Britain have experienced FGM.

  • FGM is illegal – it is an offence for anyone to perform FGM in the UK or to arrange for a girl to be taken abroad for it. 

  • FGM causes long-lasting physical and psychological damage.

  • There are a number of specialist clinics in the NHS that offer a range of healthcare services for women and girls who have been subjected to FGM, including reversal surgery. In some areas women can attend without referral, but in other areas a GP referral letter is required.

Statement opposing female genital mutilation

The school summer holidays in particular are when many young girls are taken abroad, often to their family's birth country, to have FGM performed. The FGM statement highlights the fact that FGM is a serious criminal offence in the UK, with a maximum penalty of 14 years in prison.

If you're worried about FGM, print out this statement, take it with you abroad and show it to your family. Keep the declaration in your passport, purse or bag, and carry it with you all the time. 

Download the 2014 FGM statement (PDF, 156kb)

If you work with FGM-practising communities, you may wish to order printed copies for your healthcare setting, youth club or community group. Please e-mail: FGMEnquiries@homeoffice.gsi.gov.uk stating the number of copies required and a postal address for them to be sent to.

FGM resources

Find useful links and organisations about female genital mutilation (FGM), including resources for health professionals

Source: NHS Choices, UK

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Erectile Dysfunction and Male Sexual Problems

Male sexual problems

It’s estimated that one in 10 men has a problem related to having sex, such as premature ejaculation or erectile dysfunction. Dr John Tomlinson of The Sexual Advice Association explains some of the causes, and where to seek help.

“Sexual dysfunction in a man is when he's not able to perform properly,” says Dr Tomlinson. “The main problem is being unable to get an erection. It’s much more common than people realise. In the 20-40 age group it affects around 7-8% of men, in the 40-50 age group it affects 11%. In the over-60s it affects 40%, and more than half of men over 70.”

It can affect any man, whether he is straight, gay, bisexual or transgender. Read more about erectile dysfunction (impotence) and premature ejaculation.

Erectile dysfunction (impotence)

This is when a man can’t get, or keep, an erection. Most men experience it at some time in their life. “It only becomes a problem when the man or his partner considers it a problem,” says Dr Tomlinson. 

What causes erectile dysfunction?

“A variety of things cause it. Some psychological and some physical,” says Dr Tomlinson. "Psychological issues tend to affect younger men, such as first night nerves and so on. Often, these problems don’t persist. But there can be more serious psychological problems about sex that need the help of a psychosexual therapist.”

Worries about work, money, your relationship, family, and even worrying about not getting an erection, can all be factors.

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Physical reasons for erectile dysfunction include:

Medical conditions that cause erectile dysfunction

  • heart disease

  • diabetes

  • raised blood pressure  

  • raised cholesterol: this can lead to clogging of arteries, including the arteries in the penis, which are very narrow (1-2mm in diameter compared with around 10mm in the heart artery) 

  • low testosterone: testosterone levels fall as men get older, but not all men are affected by it. Those who are affected will have symptoms such as feeling tired and unfit, and loss of interest in (and inability to have) sex.

Drugs that cause erectile dysfunction

  • some prescription drugs: these can include medicines (such as beta-blockers) used to treat raised blood pressure, and antidepressants, antipsychotic drugs and anticonvulsant drugs

  • alcohol 

  • recreational drugs such as cannabis and cocaine 

  • smoking: nicotine affects the blood supply to the areas of the penis that cause erections 

What should I do if I have erectile dysfunction?

See your GP. He or she can give you a physical examination and carry out blood tests to identify the cause.

Erectile dysfunction can be an important signal to other issues. “It's associated with raised cholesterol, diabetes and raised blood pressure. Any of these can be a warning of future heart disease,” says Dr Tomlinson. Your doctor can ensure that you get the treatment you need. 

What's the treatment for impotence?

First, adjust any lifestyle factors that might be causing your problem.

“If you stop smoking, drinking too much or using recreational drugs, the problem should eventually go away. But it can take months,” says Dr Tomlinson. “There is no overnight cure.”

If you're prescribed blood pressure tablets or antidepressants, your doctor may be able to put you on a different kind.

Low testosterone can be treated with hormone replacement therapy, which should resolve erectile dysfunction as long as it's used together with erection-helping drugs. Other conditions, such as diabetes and high blood pressure, can be treated, which may improve erections. Find out more about erectile dysfunction treatment, including sildenafil cotrate (viagra). The Sexual Advice Association has useful factsheets on all of this.

Some men benefit from psychosexual therapy, which is a form of relationship therapy where you and your partner can discuss any sexual or emotional issues or concerns. You can contact the Sexual Advice Association, Relate, sexual health charity FPA or your GP to ask about psychosexual therapy.

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Premature ejaculation

This is when a man ejaculates (comes) sooner than he wants to during sex. It's only a problem if it bothers him or his partner.  

You can see your GP or a psychosexual therapist for help.

What causes premature ejaculation?

"Either just being very excited with a new partner, or an acute sensitivity of the local nervous system, which triggers orgasm too suddenly," says Dr Tomlinson.

It can also be linked to anxiety about sexual performance, stress, unresolved issues in a relationship, or depression.

What should I do if I have premature ejaculation?

See your GP, or a psychosexual therapist. A therapist can teach you techniques to try to delay ejaculation.

What treatment is there?

“A lot of men and their partners don’t worry, and they work around it," says Dr Tomlinson. "But if you’re very unsatisfied, there are some things you can try.”

  • Have sex again soon after the man ejaculates. The second time, it will take longer to reach an orgasm. Older men might find this difficult as it may take too long to get a second erection. 

  • Creams (available from sex shops) can be put on the penis to numb sensation. “But this tends to transfer the numbing sensation to the partner, which they don't always like,” warns Dr Tomlinson. Some find using a condom useful.

  • The man’s partner can squeeze his penis in a certain way to prevent him ejaculating. “A man needs an extremely willing partner to do this, and some partners don’t feel comfortable with it,” says Dr Tomlinson. 

  • Antidepressants called selective serotonin reuptake inhibitors (SSRIs) can slow ejaculation, but only for a year or so. “We’ll try every other treatment first before starting on drugs,” says Dr Tomlinson. 

  • Psychotherapy might help in terms of relaxing or exploring problems in the relationship. Find out what a sex therapist does.

Dr Tomlinson is editor of The ABC of Sexual Health (published by Wiley-Blackwell).

The Sexual Advice Association helpline is 0207 486 7262.

Find out about other sexual problems, such as retarded ejaculation and retrograde ejaculation.

If you are worried about your health have a look at the Man MOT, a confidential online surgery where you can talk to a GP anonymously.

Source: NHS Choices, UK

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Erectile dysfunction (impotence)

Introduction 

Erectile dysfunction (ED), also known as impotence, is the inability to get and maintain an erection.

Erectile dysfunction is a very common condition, particularly in older men. It is estimated that half of all men between the ages of 40 and 70 will have it to some degree.

When to see your GP

See your GP if you have erectile dysfunction for more than a few weeks. They will assess your general state of health because the condition can be the first sign of more serious health conditions, such as heart disease (when the heart’s blood supply is blocked or interrupted).

Why does erectile dysfunction happen?

Erectile dysfunction can have a range of causes, both physical and psychological. Physical causes include:

Psychological causes of ED include:

Sometimes erectile dysfunction only occurs in certain situations. For example, you may be able to get an erection during masturbation, or you may find that you sometimes wake up with an erection but you are unable to get an erection with your sexual partner.

If this is the case, it is likely the underlying cause of erectile dysfunction is psychological (stress related). If you are unable to get an erection under any circumstances, it is likely that the underlying cause is physical.

Erectile dysfunction can also be a side-effect of using certain medicines.

Read more about the causes of erectile dysfunction.

Diagnosis

Although you may be embarrassed, it's important to get a diagnosis so that the cause can be identified.

Your GP can usually diagnose erectile dysfunction. This will involve answering questions about your symptoms, as well as a physical examination and some simple tests.

Read more about diagnosing erectile dysfunction.

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How is erectile dysfunction treated?

Erectile dysfunction is primarily treated by tackling the cause of the problem, whether this is physical or psychological.

The narrowing of the arteries (called atherosclerosis) is one of the most common causes of ED. In these cases your GP may suggest lifestyle changes, such as losing weight, to try to reduce your risk of cardiovascular disease. This may help to relieve your symptoms as well as improving your general health.

You may also be given medication to treat atherosclerosis, such as cholesterol-lowering statins and drugs to reduce your blood pressure.

A number of treatments have been successful in the treatment of erectile dysfunction. Medication, such as sildenafil (sold as Viagra), can be used to manage it in at least two-thirds of cases. Vacuum pumps that encourage blood to flow to the penis and cause an erection are also successful in 90% of cases.

Psychological treatments include cognitive behavioural therapy (CBT) and sex therapy.

Overall, treatments for erectile dysfunction have improved significantly in recent years. Most men are eventually able to have sex again.

Read more about treating erectile dysfunction.

Causes of erectile dysfunction 

Erectile dysfunction (ED) can have many causes, such as certain medical conditions, medications and stress.

It's important to identify the cause of erectile dysfunction and treat any underlying conditions.

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Erections

When a man becomes sexually excited (aroused), his brain sends signals to the nerves in his penis. The nerves increase the blood flow to the penis, causing the tissue to expand and harden.

Anything that interferes with the nervous system or the blood circulation could lead to erectile dysfunction.

Anything that affects the level of sexual desire (libido) can also cause erectile dysfunction because a reduced libido makes it more difficult for the brain to trigger an erection. Psychological conditions, such as depression, can reduce libido, as can changes in hormone levels (chemicals produced by the body).

Physical causes

There are four main types of health conditions that can cause physical problems resulting in erectile dysfunction. These are:

Injuries and surgery

Penis injuries or surgical treatment of the penis, pelvis or surrounding areas can sometimes lead to erectile dysfunction.

Erectile dysfunction is also thought to occur in up to 15-25% of people who experience a severe head injury.

Vasculogenic conditions

Examples of vasculogenic conditions that cause erectile dysfunction include:

Erectile dysfunction is strongly associated with cardiovascular disease. For this reason, it may be one of the first causes your GP considers when making a diagnosis and planning your treatment.

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Neurogenic conditions

Examples of neurogenic conditions that cause erectile dysfunction include:

Hormonal conditions

Examples of hormonal conditions that cause erectile dysfunction include:

Anatomical conditions

Peyronie's disease, which affects the tissue of the penis, is an example of an anatomical condition that can cause erectile dysfunction.

Medicine 

In some men, certain medicines can cause erectile dysfunction, including:

Speak to your GP if you are concerned that a prescribed medicine is causing erectile dysfunction. Alternative medication may be available. However, it is important never to stop taking a prescribed medicine unless you are advised to do so by a qualified healthcare professional who is responsible for your care.

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Psychological causes

Possible psychological causes of erectile dysfunction include:

Erectile dysfunction can often have both physical and psychological causes. For example, if you have diabetes, it may be difficult for you to get an erection, which may cause you to become anxious about the situation. The combination of diabetes and anxiety may lead to an episode of erectile dysfunction.

There are many emotional issues that may also affect your physical ability to get or maintain an erection. These include:

Other causes

Other possible causes of erectile dysfunction include:

Cycling

Men who cycle for more than three hours per week may be recommended to try a period without cycling to see if this helps improve erectile dysfunction.

Riding in the correct position with a properly fitted seat may also help to prevent regular cycling from leading to erectile dysfunction.

Increased risk

There are some things that can make erectile dysfunction more likely. These are very similar to the risks of cardiovascular disease and include:

  • lack of exercise or physical activity 

  • obesity

  • smoking

  • high cholesterol

Erectile dysfunction itself can also be a sign of cardiovascular diseases

Source: NHS Choices, UK

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Understanding Erectile Dysfunction

What is erectile dysfunction (ED)?

ED is the inability to get or keep an erection firm enough for sexual intercourse. ED can be a total inability to achieve an erection, an inconsistent ability to do so, or a tendency to sustain only brief erections.

ED is sometimes called impotence, but that word is being used less often so that it will not be confused with other, nonmedical meanings of the term.

The National Institutes of Health estimates that ED affects as many as 30 million men in the United States.1 Incidence increases with age: About 4 percent of men in their 50s and nearly 17 percent of men in their 60s experience a total inability to achieve an erection. The incidence jumps to 47 percent for men older than 75.2 But ED is not an inevitable part of aging. ED is treatable at any age.

1National Institutes of Health (NIH) Consensus Conference. NIH Consensus Development Panel on Impotence. Impotence. Journal of the American Medical Association. 1993;270:83-90.

2Saigal CS, Wessells H, Wilt T. Predictors and prevalence of erectile dysfunction in a racially diverse population. Archives of Internal Medicine. 2006;166:207-212.

How does an erection occur?

Two chambers called the corpora cavernosa run the length of the penis (see Figure 1). A spongy tissue fills the chambers. The corpora cavernosa are surrounded by a membrane, called the tunica albuginea. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa and is surrounded by the corpus spongiosum.

An erection begins with sensory or mental stimulation, or both. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in through the arteries and fill the spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The tunica albuginea helps trap the blood in the corpora cavernosa, thereby sustaining the erection. The erection ends when muscles in the penis contract to stop the inflow of blood and open the veins for blood outflow.

Figure 1. Arteries and veins of the penis

Arteries (top) and veins (bottom) penetrate the corpora cavernosa and the corpus spongiosum. An erection occurs when relaxed muscles allow the corpora cavernosa to fill with excess blood fed by the arteries, while drainage of blood through the veins is blocked by the tunica albuginea.

What causes ED?

ED usually has a physical cause, such as disease, injury, or side effects of drugs. Any disorder that causes injury to the nerves or impairs blood flow in the penis has the potential to cause ED.

Because an erection requires a precise sequence of events, ED can occur when any of the events is disrupted. The sequence includes nerve impulses in the brain, spinal column, and area around the penis, and response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa.

Damage to nerves, arteries, smooth muscles, and fibrous tissues, often as a result of disease, is the most common cause of ED. Diseases—such as diabetes, high blood pressure, nerve disease or nerve damage, multiple sclerosis, atherosclerosis, and heart disease—account for the majority of ED cases. Patients should be thoroughly evaluated for these conditions before they begin any form of treatment for ED.

Lifestyle choices that contribute to heart disease and vascular problems also raise the risk of ED. Smoking, drinking alcohol excessively, being overweight, and not exercising are possible causes of ED.

Surgery—especially radical prostate and bladder surgery for cancer—can also injure nerves and arteries near the penis, causing ED. Injury to the penis, spinal cord, prostate, bladder, and pelvis can lead to ED by harming nerves, smooth muscles, arteries, and the fibrous tissues of the corpora cavernosa.

In addition, ED can be a side effect of many common medicines such as blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine, an ulcer drug.

Psychological factors such as stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure can also cause ED. Even when ED has a physical cause, psychological factors may make the condition worse.

Hormonal abnormalities, such as low levels of testosterone, are a less frequent cause of ED.

How is ED diagnosed?

Patient History

A person's medical and sexual histories help define the degree and nature of ED. The medical history can disclose diseases that lead to ED, and a simple recounting of sexual activity might identify problems with sexual desire, erection, ejaculation, or orgasm.

Use of certain prescription or illegal drugs can suggest a chemical cause because drug effects are a frequent cause of ED.

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Physical Examination

A physical examination can give clues to systemic problems. For example, if the penis is not sensitive to physical touch, a problem in the nervous system may be the cause. Abnormal secondary sex characteristics, such as unusual hair pattern or breast enlargement, can point to hormonal problems, which would mean the endocrine system is involved. The doctor might discover a circulatory problem by observing decreased pulses in the wrist or ankles. And unusual characteristics of the penis itself could suggest the source of the problem—for example, a penis that bends or curves when erect could be the result of Peyronie’s disease.

Laboratory Tests

Several laboratory tests can help diagnose ED. Tests for systemic diseases include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. Measuring the amount of available testosterone in the blood can yield information about problems with the endocrine system and may explain why a patient has decreased sexual desire.

Other Tests

Monitoring erections that occur during sleep—nocturnal erections—can help rule out certain psychological causes of ED. Healthy men have involuntary erections during sleep. If nocturnal erections do not occur, then ED is likely to have a physical rather than a psychological cause. Tests for nocturnal erections are not completely reliable, however. Scientists have not standardized such tests and have not determined when they should be conducted for best results.

Psychosocial Examination

A psychosocial examination, using an interview and a questionnaire, can reveal psychological factors. A man's sexual partner may also be interviewed to determine expectations and perceptions during sexual intercourse.

How is ED treated?

Most doctors suggest that treatments proceed from least to most invasive. Making a few healthy lifestyle changes may solve the problem. Quitting smoking, reducing alcohol consumption, losing excess weight, and increasing physical activity may help some men regain sexual function.

Cutting back on or replacing medicines that could be causing ED is considered next. For example, if a patient thinks a particular blood pressure medicine is causing problems with erection, he should tell his doctor and ask whether he can try a different class of blood pressure medicine.

Psychotherapy and behavior modifications in selected patients are considered next if indicated, followed by oral or locally injected drugs, vacuum devices, and surgically implanted devices. In rare cases, surgery involving veins or arteries may be considered.

Psychotherapy

Experts often treat psychologically based ED using techniques that decrease the anxiety associated with intercourse. The patient's partner can help with the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety during treatment for ED from physical causes.

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Drug Therapy

Drugs for treating ED can be taken orally, injected directly into the penis, or inserted into the urethra at the tip of the penis.

Oral Medications
In March 1998, the U.S. Food and Drug Administration (FDA) approved sildenafil (Viagra), the first pill to treat ED. Since that time, vardenafil hydrochloride (Levitra) and tadalafil (Cialis) have also been approved. Additional oral medicines are being tested for safety and effectiveness.

Viagra, Levitra, and Cialis all belong to a class of drugs called phosphodiesterase (PDE) inhibitors. Taken an hour before sexual activity, these drugs work by enhancing the effects of nitric oxide, a chemical that relaxes smooth muscles in the penis during sexual stimulation and allows increased blood flow.

The recommended dose for Viagra is 50 milligrams (mg), and the doctor may adjust this dose to 100 mg or 25 mg, depending on the patient. The recommended dose for either Levitra or Cialis is 10 mg, and the doctor may adjust this dose to 20 mg if 10 mg is insufficient. Lower doses of 5 mg and 2.5 mg are available for patients who take other medicines or have conditions that may decrease the body's ability to use the drug. The 5 mg and 2.5 mg doses of Cialis are FDA-approved for daily use.

None of these PDE inhibitors should be used more than once a day. Men who take nitrate-based drugs such as nitroglycerin pills for heart problems should not use any of the three drugs because the combination can cause a sudden drop in blood pressure. Also, men should tell their doctor if they take any drugs called alpha-blockers, which are used to treat prostate enlargement or high blood pressure. The doctor may need to adjust the ED prescription. Taking a PDE inhibitor and an alpha-blocker within 4 hours of each other can cause a sudden drop in blood pressure. A small number of men have experienced vision or hearing loss after taking a PDE inhibitor. Men who experience vision or hearing loss should seek prompt medical attention.

Oral testosterone can reduce ED in some men with low levels of natural testosterone, but it is often ineffective and may cause liver damage. Patients also have claimed that other oral drugs—including yohimbine hydrochloride, dopamine and serotonin agonists, and trazodone—are effective, but the results of scientific studies to substantiate these claims have been inconsistent. Improvements observed following use of these drugs may be examples of the placebo effect—that is, a change that results simply from the patient’s belief that an improvement will occur.

Injectable Medications
While oral medicines improve the response to sexual stimulation, they do not trigger an automatic erection as injections do. Many men achieve stronger erections by injecting drugs into the penis, causing it to become engorged with blood. Drugs such as papaverine hydrochloride, phentolamine, and alprostadil widen blood vessels. The injectable form of alprostadil is marketed as Caverject. These drugs may create unwanted side effects, however, including scarring of the penis and persistent erection, known as priapism. Nitroglycerin ointment, a muscle relaxant, can sometimes enhance an erection when rubbed on the penis.

A system for inserting a pellet of alprostadil into the urethra uses a prefilled applicator to deliver the pellet about an inch into the urethra. The pellet form of alprostadil is marketed as MUSE. An erection will begin within 8 to 10 minutes and may last 30 to 60 minutes. The most common side effects are aching in the penis, testicles, and area between the penis and rectum; a warm or burning sensation in the urethra; redness from increased blood flow to the penis; and minor urethral bleeding or spotting.

Research on drugs for treating ED is expanding rapidly. Patients should ask their doctor about the latest advances.

Vacuum Devices

Mechanical vacuum devices cause an erection by creating a partial vacuum, which draws blood into the corpora cavernosa, engorging and expanding the penis. The devices have three components: a plastic cylinder, into which the penis is placed; a pump, which draws air out of the cylinder; and an elastic ring, which is moved from the end of the cylinder to the base of the penis as the cylinder is removed. The elastic ring maintains the erection during intercourse by preventing blood from flowing back into the body (see Figure 2). The elastic ring can remain in place up to 30 minutes. The ring should be removed after that time to restore normal circulation and to avoid skin irritation.

Couples may find that using a vacuum device requires some practice or adjustment. An erection achieved with a vacuum device may not feel like an erection achieved naturally. The penis may feel cold or numb and have a purple color. Bruising on the shaft of the penis may occur, but the bruises are usually painless and disappear in a few days. Ejaculation may be weakened because the elastic ring blocks some of the semen from traveling through the urethra, but the pleasure of orgasm is usually not affected.

Figure 2. Vacuum device

A vacuum device causes an erection by creating a partial vacuum around the penis, which draws blood into the corpora cavernosa.

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Surgery

Surgery usually has one of three goals:

Implanted devices, known as prostheses, can restore erection in many men with ED.

Malleable implants usually consist of paired rods, which are inserted surgically into the corpora cavernosa. The user manually adjusts the position of the penis and, therefore, the rods. Adjustment does not affect the width or length of the penis.

Inflatable implants consist of paired cylinders, which are surgically inserted inside the penis and can be expanded using pressurized fluid (see Figure 3). Tubes connect the cylinders to a fluid reservoir and a pump, which are also surgically implanted. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. The pump causes fluid to flow from a reservoir residing in the lower pelvis to two cylinders residing in the penis. Inflatable implants can expand the length and width of the penis to some degree. They also leave the penis in a more natural state than malleable implants do when not inflated.

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Once a man has either a malleable or inflatable implant, he must use the device to have an erection. Possible problems with implants include mechanical breakdown and infection, although mechanical problems have decreased in recent years because of technological advances.

Figure 3. Surgical implant

With an inflatable implant, an erection is produced by squeezing a small pump implanted in the scrotum. The cylinders expand to create the erection.

Surgery to repair arteries can reduce ED caused by obstructions that block the flow of blood. The best candidates for such surgery are young men with discrete blockage of an artery because of an injury to the groin or fracture of the pelvis. The procedure is usually unsuccessful in older men with widespread blockage.

Surgery to veins that allow blood to leave the penis usually involves an opposite procedure—intentional blockage. Blocking off veins, called ligation, can reduce the leakage of blood that diminishes the rigidity of the penis during an erection. However, experts have raised questions about the long-term effectiveness of this procedure, and it is rarely done.

Points to Remember

Hope through Research

Advances in suppositories, injectable medications, implants, and vacuum devices have expanded the options for men seeking treatment for ED. These advances have also helped increase the number of men seeking treatment. Gene therapy for ED is now being tested in several centers and may offer a long-lasting therapeutic approach for ED.

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) sponsors programs aimed at understanding and treating ED. The NIDDK's Division of Kidney, Urologic, and Hematologic Diseases supported the researchers who developed Viagra and continue to support basic research into the mechanisms of an erection and the diseases that impair normal function at the cellular and molecular levels, including diabetes and high blood pressure.

Participants in clinical trials can play a more active role in their own health care, gain access to new research treatments before they are widely available, and help others by contributing to medical research. For information about current studies, visit www.ClinicalTrials.gov.

For More Information

American Urological Association
1000 Corporate Boulevard
Linthicum, MD 21090
Phone: 1–866–RING–AUA (1–866–746–4282) or 410–689–3700
Fax: 410–689–3800
Email: aua@auanet.org
Internet: www.auanet.org

American Association of Sexuality Educators, Counselors, and Therapists
P.O. Box 1960
Ashland, VA 23005–1960
Phone: 804–752–0026
Fax: 804–752–0056
Email: aasect@aasect.org

Acknowledgments

Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. This publication was originally reviewed by Arnold Melman, M.D., Montefiore Medical Center, Bronx, NY, and Mark Hirsch, M.D., U.S. Food and Drug Administration.

This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired.

NIH Publication No. 09–3923

Source: NKUDIC, NIDDK, NIH

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What I need to know about Erectile Dysfunction

On this page:

What is erectile dysfunction (ED)?

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Erectile dysfunction* is when you cannot get or keep an erection firm enough to have sex. You may have ED if you

ED is sometimes called impotence; however, doctors use this term less often now.

*See the Pronunciation Guide for tips on how to say the words in bold type.

How does an erection occur?
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An erection occurs when blood flow into the penis increases, making the penis larger and firmer. Hormones, blood vessels, nerves, and muscles all work together to cause an erection. When your brain senses a sexual urge, it starts an erection by sending nerve signals to the penis. Touch may cause this urge. Other triggers may be things you see or hear, or sexual images or thoughts.
When your brain senses a sexual urge, it starts an erection by sending nerve signals to the penis.

The nerve signals cause the muscles in the penis to relax and let blood flow into the spongy tissue in the penis. Blood collects in this tissue like water filling a sponge. The penis becomes larger and firmer, like a blown-up balloon. The veins then shut off to keep blood from flowing out. An erection requires healthy blood vessels.

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After orgasm or when the man is no longer aroused, the veins open up and blood flows back into the body.

What causes erectile dysfunction?
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Erectile dysfunction often has more than one cause. Many diseases can damage nerves, arteries, and muscles. Some can lead to ED, such as

Unhealthy lifestyle choices, such as smoking, drinking too much alcohol, using illegal drugs, being overweight, and not exercising, can lead to ED.

Mental health problems such as the following can also cause or worsen ED:

Even when ED has a physical cause, mental health problems can make ED worse. For example, a physical problem may slow your sexual arousal, which may make you more nervous and worsen your ED.

In addition, ED can be a side effect of many common medicines. A small number of ED cases result from low testosterone, a male hormone.

Who gets erectile dysfunction?
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Erectile dysfunction affects men of all races and in all parts of the world. Men are more likely to have ED as they get older. For example, ED occurs in

What other problems can erectile dysfunction cause?
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How does my doctor find the cause of my erectile dysfunction?
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To find the cause of your ED, your doctor may

Medical and Sexual History

Your doctor will ask general questions about your health, as well as specific questions about your erection problems and your relationship with your sexual partner. Your doctor might ask you questions such as

The answers to these questions will help your doctor understand the problem.

Bring a list of all the medicines you take, or the actual medicines, to show to your doctor.

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Mental Health Questions

Your doctor may ask you questions about your mental health. For example, the doctor may ask if you feel nervous or depressed. He or she may also ask you to answer questions on paper. The doctor may also ask your sexual partner questions to get more information about the problem.

Physical Exam

A physical exam can help your doctor find the cause of your ED. As part of the exam, the doctor will examine your testes and penis, take your blood pressure, and check for problems with your blood flow.

Blood Tests

A blood test involves drawing your blood at a doctor’s office or a commercial facility and sending the sample to a lab for analysis. Blood tests can show possible causes of ED, such as diabetes, clogged blood vessels, or chronic kidney disease. Low levels of testosterone in your blood can explain why you may have lost interest in sex.

Nighttime Erection Test

During a nighttime erection test, you wear a plastic band around your penis to test whether you have nighttime erections. The band easily breaks if your penis expands. This test shows if you had at least one erection during the night. Another test uses an electronic device that can record the number of erections, how long they last, and how firm they are. A man normally has three to five erections during the night while he sleeps. If you do have an erection, it probably means that your ED is more likely a mental health issue. If you do not have these erections, you probably have nerve damage or poor blood flow to your penis. You may do this test in your home or in a special sleep lab.

Injection Test

During an injection test, the doctor will inject a medicine into your penis to cause an erection. If the erection is not firm or does not last, it may mean you have a problem with blood flow. This test most often takes place in the doctor’s office.

Doppler Penile Ultrasound

An x-ray technician most often performs a Doppler penile ultrasound in a doctor’s office or an outpatient center. During a Doppler penile ultrasound, the x-ray technician or doctor lightly passes a device over your penis to create images of blood vessels in your penis. An injection is used to create an erection. The images can show if you have a blood flow problem. The pictures appear on a computer screen. A radiologist—a doctor who specializes in medical imaging—looks at the images to find possible problems.

How is erectile dysfunction treated?

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Your doctor can offer you a number of treatments for ED. For many men, the answer is as simple as taking a pill. Other men have to try two or three options before they find a treatment that works for them. Don’t give up if the first treatment doesn’t work. Finding the right treatment can take time. You may want to talk with your sexual partner about which treatment fits you best as a couple.

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A doctor can treat ED by

Treating the Cause of Your Erectile Dysfunction

The first step is to treat any health problems that may be causing your ED. Untreated diabetes or high blood pressure may be part of the cause of your ED.

Lifestyle changes. For some men, the following lifestyle changes help:

Changing medicines you take to treat other health problems. Talk with your doctor about all the medicines you are taking, including over-the-counter medicines. The doctor may find that a medicine you are taking is causing your ED. Your doctor may be able to give you another medicine that works in a different way, or your doctor may tell you to try a lower dose of your medicine.

Counseling. Counseling can help couples deal with the emotional effects of ED. Some couples find that counseling adds to the medical treatment by making their relationship stronger.

Prescribing Medicines to Treat Your Erectile Dysfunction

Depending on which medicine your doctor gives you, you may take it by mouth or by putting it directly into your penis.

Medicine by mouth. Your doctor may be able to prescribe a pill to treat ED. Common medicines include

If your health is generally good, your doctor may prescribe one of these medicines. You should not take any of these pills to treat ED if you take any nitrates, a type of heart medicine. All ED pills work by increasing blood flow to the penis. They do not cause automatic erections. Talk with your doctor about when to take the pill. You may need to experiment to find out how soon the pill takes effect.

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Other forms of medicine. Taking a pill doesn’t work for all men. You may need to use medicine that goes directly into your penis. You may use an injection into the shaft of your penis, or you may use medicine placed in your urethra, at the tip of your penis. The urethra is the tube that carries urine and semen outside of the body. Your doctor will teach you how to use the medicines. They most often cause an erection within minutes. These medicines can be successful, even if other treatments fail.

Prescribing a Vacuum Device

Another way to create an erection is to use a device with a specially designed vacuum tube. You put your penis into the tube, which is connected to a pump. As air is pumped out of the tube, blood flows into your penis and makes it larger and firmer. You then move a specially designed elastic ring from the end of the tube to the base of your penis to keep the blood from flowing back into your body. You may find that using a vacuum device requires some practice.

Performing Surgery

If the other options fail, you may need surgery to treat ED.

Implanted devices. A urologist can place a device that fills with fluid or a device with bendable rods inside the penis to create an erection.

One kind of implant uses two cylinders that fill with fluid like a balloon. Tubing connects the cylinders to a small ball that holds the fluid. You fill the cylinders by squeezing a small pump that the urologist places under the skin of the scrotum, in front of your testes. The pump causes fluid to flow into the two cylinders in your penis, making it hard. The fluid can make the penis slightly longer and wider. An implant that uses fluids instead of bendable rods leaves the penis in a more natural state when not in use.

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Implanted Devices

Implants that bend most often have two rods that the urologist places side by side in your penis during surgery. You use your hands to adjust the position of the rods to make your penis straight. Your penis does not get larger. After sex, you bend the rods down.

Implanted devices do not affect the way sex feels or the ability to have an orgasm.

Once you have an implanted device, you must use the device to have an erection every time. Talk with your doctor about the pros and cons of having an implanted device.

Surgery to repair blood vessels. Doctors treat some cases of ED with surgery to repair the blood vessels that carry blood to the penis. This type of surgery is more likely to work in men younger than 30.

How can I prevent erectile dysfunction?
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You can prevent many of the causes of ED by making healthy lifestyle choices. Following a healthy diet may help prevent ED. Quitting smoking and getting physical activity are also important ways to prevent ED.

Physical activity increases blood flow throughout your body, including your penis. Talk with your doctor before starting new activities. If you have not been active, start slow, with easier activities such as walking at a normal pace or gardening. Then you can work up to harder activities such as walking briskly or swimming. Try to aim for at least 30 minutes of activity most days of the week.

Eating, Diet, and Nutrition
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To prevent ED, you should eat a healthy diet of whole-grain foods, fruits and vegetables, low-fat dairy foods, and lean meats. A diet that causes you to be overweight and have heart and blood vessel disease can also lead to ED. You should avoid foods high in fat and sodium, the main part of salt. You should also avoid smoking, drinking too much alcohol, or using illegal drugs.

Points to Remember
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Hope through Research
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The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) sponsors programs aimed at understanding and treating ED. One team of researchers is exploring the effect of weight loss on ED in men who are obese and sexual dysfunction in women who are obese. One group of participants in the study received bariatric surgery or a lap band procedure to bring about weight loss. Another group lost weight through counseling and behavior change. At the beginning of the study, participants filled out surveys that measured erectile or sexual function. Four years after surgery or weight loss counseling, they will retake the surveys. The Changes in Sexual Function Following Bariatric Surgery study, funded under National Institutes of Health (NIH) clinical trial number NCT00670098, will test the theory that weight loss can improve erectile function.

Other investigators are studying how better control of blood sugar and blood pressure in diabetes could help reduce the chances of developing ED.

Clinical trials are research studies involving people. Clinical trials look at safe and effective new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. To learn more about clinical trials, why they matter, and how to participate, visit the NIH Clinical Research Trials and You website at www.nih.gov/health/clinicaltrials. For information about current studies, visit www.ClinicalTrials.gov.

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Pronunciation Guide
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avanafil (av-AN-uh-fil)

ejaculate (ee-JAK-yoo-layt)

erectile dysfunction (ee-REK-tyl) (diss-FUHNK-shuhn)

erection (ee-REK-shuhn)

impotence (IM-puh-tenss)

multiple sclerosis (MUL-tih-puhl) (skleh-ROH-siss)

penis (PEE-niss)

prostate (PROSS-tayt)

radiation (RAY-dee-AY-shuhn)

sildenafil (sil-DEN-uh-fil)

tadalafil (tuh-DAL-uh-fil)

testes (TESS-teez)

testosterone (tess-TOSS-tuh-rohn)

urethra (yoo-REE-thruh)

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vardenafil (var-DEN-uh-fil)

For More Information

Urology Care Foundation
1000 Corporate Boulevard
Linthicum, MD 21090
Phone: 1–800–828–7866 or 410–689–3700
Fax: 410–689–3998
Email: info@urologycarefoundation.org

Acknowledgments

Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. Tom Lue, M.D., University of California San Francisco, and Hunter Wessells, M.D., University of Washington, reviewed the current version of this booklet.

Thank you also to the following individuals for facilitating field-testing of the original version of this publication:

Kay Longhi, Research Coordinator
Harborview Medical Center, Seattle

Kevin McVary, M.D.
Northwestern University

Hunter Wessells, M.D.
University of Washington

Source: NIDDK, NIH

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Peyronie's Disease

On this page:

What is Peyronie’s disease?

Peyronie’s disease is a disorder in which scar tissue, called a plaque, forms in the penis—the male organ used for urination and sex. The plaque builds up inside the tissues of a thick, elastic membrane called the tunica albuginea. The most common area for the plaque is on the top or bottom of the penis. As the plaque builds up, the penis will curve or bend, which can cause painful erections. Curves in the penis can make sexual intercourse painful, difficult, or impossible. Peyronie’s disease begins with inflammation, or swelling, which can become a hard scar.

The plaque that develops in Peyronie’s disease is not the same plaque that can develop in a person’s arteries. The plaque seen in Peyronie’s disease is benign, or noncancerous, and is not a tumor. Peyronie’s disease is not contagious or caused by any known transmittable disease.

Early researchers thought Peyronie’s disease was a form of impotence, now called erectile dysfunction (ED). ED happens when a man is unable to achieve or keep an erection firm enough for sexual intercourse. Some men with Peyronie’s disease may have ED. Usually men with Peyronie’s disease are referred to a urologist—a doctor who specializes in sexual and urinary problems.

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How does an erection occur?

An erection occurs when blood flow increases into the penis, making it expand and become firm. Two long chambers inside the penis, called the corpora cavernosa, contain a spongy tissue that draws blood into the chambers. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The tunica albuginea encases the corpora cavernosa. The urethra, which is the tube that carries urine and semen outside of the body, runs along the underside of the corpora cavernosa in the middle of a third chamber called the corpus spongiosum.

An erection requires a precise sequence of events:

What causes Peyronie’s disease?

Medical experts do not know the exact cause of Peyronie’s disease. Many believe that Peyronie’s disease may be the result of

Injury to the Penis

Medical experts believe that hitting or bending the penis may injure the tissues inside. A man may injure the penis during sex, athletic activity, or an accident. Injury ruptures blood vessels, which leads to bleeding and swelling inside the layers of the tunica albuginea. Swelling inside the penis will block blood flow through the layers of tissue inside the penis. When the blood can’t flow normally, clots can form and trap immune system cells. As the injury heals, the immune system cells may release substances that lead to the formation of too much scar tissue. The scar tissue builds up and forms a plaque inside the penis. The plaque reduces the elasticity of tissues and flexibility of the penis during erection, leading to curvature. The plaque may further harden because of calcification––the process in which calcium builds up in body tissue.

Autoimmune Disease

Some medical experts believe that Peyronie’s disease may be part of an autoimmune disease. Normally, the immune system is the body’s way of protecting itself from infection by identifying and destroying bacteria, viruses, and other potentially harmful foreign substances. Men who have autoimmune diseases may develop Peyronie’s disease when the immune system attacks cells in the penis. This can lead to inflammation in the penis and can cause scarring. Medical experts do not know what causes autoimmune diseases. Some of the autoimmune diseases associated with Peyronie’s disease affect connective tissues. Connective tissue is specialized tissue that supports, joins, or separates different types of tissues and organs of the body.

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How common is Peyronie’s disease?

Researchers estimate that Peyronie’s disease may affect 1 to 23 percent of men between 40 and 70 years of age. However, the actual occurrence of Peyronie’s disease may be higher due to men’s embarrassment and health care providers’ limited reporting. The disease is rare in young men, although it has been reported in men in their 30s.1 The chance of developing Peyronie’s disease increases with age.2

Peyronie’s disease. Urology Care Foundation website. www.urologyhealth.org/urology/index.cfm?article=115 leaving site icon. Updated March 2013. Accessed May 14, 2014.

Montague D, Angermeier K, Chopra A, contributors. Peyronie disease. MD Consult website. www.mdconsult.com/das/pdxmd/body/405480262-4/1418355225?type=med&eid=9-u1.0-_1_mt_1016342 leaving site icon. Updated March 7, 2012. Accessed May 14, 2014.

Who is more likely to develop Peyronie’s disease?

The following factors may increase a man’s chance of developing Peyronie’s disease:

Vigorous Sexual and Nonsexual Activities

Men whose sexual or nonsexual activities cause microscopic injury to the penis are more likely to develop Peyronie’s disease.

Connective Tissue and Autoimmune Disorders

Men who have certain connective tissue and autoimmune disorders may have a higher chance of developing Peyronie’s disease. A common example is a condition known as Dupuytren’s disease, an abnormal cordlike thickening across the palm of the hand. Dupuytren’s disease is also known as Dupuytren’s contracture. Although Dupuytren’s disease is fairly common in older men, only about 15 percent of men with Peyronie’s disease will also have Dupuytren’s disease.2 Other connective tissue disorders associated with Peyronie’s disease include

Autoimmune disorders associated with Peyronie’s disease include

Family History of Peyronie’s Disease

Medical experts believe that Peyronie’s disease may run in some families. For example, a man whose father or brother has Peyronie’s disease may have an increased chance of getting the disease.

Aging

The chance of getting Peyronie’s disease increases with age. Age-related changes in the elasticity of tissues in the penis may cause it to be more easily injured and less likely to heal well.

What are the signs and symptoms of Peyronie’s disease?

The signs and symptoms of Peyronie’s disease may include

Symptoms of Peyronie’s disease range from mild to severe. Symptoms may develop slowly or appear quickly. In many cases, the pain decreases over time, although the curve in the penis may remain. In milder cases, symptoms may go away without causing a permanent curve.

What are the complications of Peyronie’s disease?

Complications of Peyronie’s disease may include

How is Peyronie’s disease diagnosed?

A urologist diagnoses Peyronie’s disease based on

Medical and Family History

Taking a medical and family history is one of the first things a urologist may do to help diagnose Peyronie’s disease. He or she will ask the man to provide a medical and family history, which may include the following questions:

Physical Exam

A physical exam may help diagnose Peyronie’s disease. During a physical exam, a urologist usually examines the man’s body, including the penis.

A urologist can usually feel the plaque in the penis with or without an erection. Sometimes the urologist will need to examine the penis during an erection. The urologist will give the man an injectable medication to cause an erection.

Imaging Tests

To help pinpoint the location of the plaque buildup inside the penis, a urologist may perform

For both tests, a specially trained technician performs the procedure in a health care provider’s office, an outpatient center, or a hospital, and a radiologist—a doctor who specializes in medical imaging—interprets the images. The patient does not need anesthesia.

Ultrasound. Ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure.

X ray. An x ray is a picture created by using radiation and recorded on film or on a computer. The amount of radiation used is small. The man will lie on a table or stand during the x ray, and the technician may ask the man to change positions for additional pictures.

How is Peyronie’s disease treated?

A urologist may treat Peyronie’s disease with nonsurgical treatments or surgery.

The goal of treatment is to reduce pain and restore and maintain the ability to have intercourse. Men with small plaques, minimal penile curvature, no pain, and satisfactory sexual function may not need treatment until symptoms get worse. Peyronie’s disease often resolves on its own without treatment.

A urologist may recommend changes in a man’s lifestyle to reduce the risk of ED associated with Peyronie’s disease.

Nonsurgical Treatments

Nonsurgical treatments include medications and medical therapies.

Medications. A urologist may prescribe medications aimed at decreasing a man’s penile curvature, plaque size, and inflammation. A man may take prescribed medications to treat Peyronie’s disease orally––by mouth––or a urologist may inject medications directly into the plaque. Verapamil is one type of topical medication that a man may apply to the skin over the plaque.

To date, collagenase is the first and only medication specifically approved for Peyronie’s disease.

Medical therapies. A urologist may use medical therapies to break up scar tissue and decrease plaque size and curvature. Therapies to break up scar tissue may include

A urologist may use iontophoresis––painless, low-level electric current that delivers medications through the skin over the plaque––to decrease plaque size and curvature.

A urologist may use mechanical traction and vacuum devices aimed at stretching or bending the penis to reduce curvature.

Surgery

A urologist may recommend surgery to remove plaque or help straighten the penis during an erection. Medical experts recommend surgery for long-term cases when

Some men may develop complications after surgery, and sometimes surgery does not correct the effects of Peyronie’s disease––such as shortening of the penis. Some surgical methods can cause shortening of the penis. Medical experts suggest waiting 1 year or more from the onset of symptoms before having surgery because the course of Peyronie’s disease is different in each man.

A urologist may recommend the following surgeries:

A urologist performs these surgeries in a hospital.

Lifestyle Changes

A man can make healthy lifestyle changes to reduce the chance of ED associated with Peyronie’s disease by

Read more in Erectile Dysfunction at www.urologic.niddk.nih.gov.

How can Peyronie’s disease be prevented?

Researchers do not know how to prevent Peyronie’s disease.

Eating, Diet, and Nutrition

Researchers have not found that eating, diet, and nutrition play a role in causing or preventing Peyronie’s disease.

Points to Remember

Hope through Research

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) conducts and supports a variety of research in kidney diseases and urinary tract disorders. The knowledge gained from these studies is advancing scientific understanding of why kidney diseases and urinary tract disorders develop and is leading to improved methods of diagnosing, treating, and preventing them.

Clinical trials are research studies involving people. Clinical trials look at safe and effective new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. To learn more about clinical trials, why they matter, and how to participate, visit the NIH Clinical Research Trials and You website at www.nih.gov/health/clinicaltrials. For information about current studies, visit www.ClinicalTrials.gov.

Acknowledgments

Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. This publication was originally reviewed by Arnold Melman, M.D., Montefiore Medical Center, Bronx, NY, and Tom F. Lue, M.D., University of California, San Francisco. Tom F. Lue, M.D., University of California, San Francisco, reviewed the updated version of this publication.

NIH Publication No. 14–3902

Source: NKUDIC, NIDDK, NIH

Erectile Dysfunction and Male Sexual Problems

Erectile dysfunction (impotence)

Introduction 

Erectile dysfunction (ED), also known as impotence, is the inability to get and maintain an erection.

Erectile dysfunction is a very common condition, particularly in older men. It is estimated that half of all men between the ages of 40 and 70 will have it to some degree.

When to see your GP

See your GP if you have erectile dysfunction for more than a few weeks. They will assess your general state of health because the condition can be the first sign of more serious health conditions, such as heart disease (when the heart’s blood supply is blocked or interrupted).

Why does erectile dysfunction happen?

Erectile dysfunction can have a range of causes, both physical and psychological. Physical causes include:

Psychological causes of ED include:

Sometimes erectile dysfunction only occurs in certain situations. For example, you may be able to get an erection during masturbation, or you may find that you sometimes wake up with an erection but you are unable to get an erection with your sexual partner.

If this is the case, it is likely the underlying cause of erectile dysfunction is psychological (stress related). If you are unable to get an erection under any circumstances, it is likely that the underlying cause is physical.

Erectile dysfunction can also be a side-effect of using certain medicines.

Read more about the causes of erectile dysfunction.

Diagnosis

Although you may be embarrassed, it's important to get a diagnosis so that the cause can be identified.

Your GP can usually diagnose erectile dysfunction. This will involve answering questions about your symptoms, as well as a physical examination and some simple tests.

Read more about diagnosing erectile dysfunction.

How is erectile dysfunction treated?

Erectile dysfunction is primarily treated by tackling the cause of the problem, whether this is physical or psychological.

The narrowing of the arteries (called atherosclerosis) is one of the most common causes of ED. In these cases your GP may suggest lifestyle changes, such as losing weight, to try to reduce your risk of cardiovascular disease. This may help to relieve your symptoms as well as improving your general health.

You may also be given medication to treat atherosclerosis, such as cholesterol-lowering statins and drugs to reduce your blood pressure.

A number of treatments have been successful in the treatment of erectile dysfunction. Medication, such as sildenafil (sold as Viagra), can be used to manage it in at least two-thirds of cases. Vacuum pumps that encourage blood to flow to the penis and cause an erection are also successful in 90% of cases.

Psychological treatments include cognitive behavioural therapy (CBT) and sex therapy.

Overall, treatments for erectile dysfunction have improved significantly in recent years. Most men are eventually able to have sex again.

Read more about treating erectile dysfunction.

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Causes of erectile dysfunction 

Erectile dysfunction (ED) can have many causes, such as certain medical conditions, medications and stress.

It's important to identify the cause of erectile dysfunction and treat any underlying conditions.

Erections

When a man becomes sexually excited (aroused), his brain sends signals to the nerves in his penis. The nerves increase the blood flow to the penis, causing the tissue to expand and harden.

Anything that interferes with the nervous system or the blood circulation could lead to erectile dysfunction.

Anything that affects the level of sexual desire (libido) can also cause erectile dysfunction because a reduced libido makes it more difficult for the brain to trigger an erection. Psychological conditions, such as depression, can reduce libido, as can changes in hormone levels (chemicals produced by the body).

Physical causes

There are four main types of health conditions that can cause physical problems resulting in erectile dysfunction. These are:

Injuries and surgery

Penis injuries or surgical treatment of the penis, pelvis or surrounding areas can sometimes lead to erectile dysfunction.

Erectile dysfunction is also thought to occur in up to 15-25% of people who experience a severe head injury.

Vasculogenic conditions

Examples of vasculogenic conditions that cause erectile dysfunction include:

Erectile dysfunction is strongly associated with cardiovascular disease. For this reason, it may be one of the first causes your GP considers when making a diagnosis and planning your treatment.

Neurogenic conditions

Examples of neurogenic conditions that cause erectile dysfunction include:

Hormonal conditions

Examples of hormonal conditions that cause erectile dysfunction include:

Anatomical conditions

Peyronie's disease, which affects the tissue of the penis, is an example of an anatomical condition that can cause erectile dysfunction.

Medicine 

In some men, certain medicines can cause erectile dysfunction, including:

Speak to your GP if you are concerned that a prescribed medicine is causing erectile dysfunction. Alternative medication may be available. However, it is important never to stop taking a prescribed medicine unless you are advised to do so by a qualified healthcare professional who is responsible for your care.

Psychological causes

Possible psychological causes of erectile dysfunction include:

Erectile dysfunction can often have both physical and psychological causes. For example, if you have diabetes, it may be difficult for you to get an erection, which may cause you to become anxious about the situation. The combination of diabetes and anxiety may lead to an episode of erectile dysfunction.

There are many emotional issues that may also affect your physical ability to get or maintain an erection. These include:

Other causes

Other possible causes of erectile dysfunction include:

Cycling

Men who cycle for more than three hours per week may be recommended to try a period without cycling to see if this helps improve erectile dysfunction.

Riding in the correct position with a properly fitted seat may also help to prevent regular cycling from leading to erectile dysfunction.

Increased risk

There are some things that can make erectile dysfunction more likely. These are very similar to the risks of cardiovascular disease and include:

  • lack of exercise or physical activity 

  • obesity

  • smoking

  • high cholesterol

Erectile dysfunction itself can also be a sign of cardiovascular disease.

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Diagnosing Erectile Dysfunction 

Erectile dysfunction (ED) can often be diagnosed by your GP. They will talk to you about your situation and may carry out a physical examination.

Your GP may ask you about:

If you do not want to talk to your GP about erectile dysfunction, you can visit a genitourinary medicine (GUM) clinic. You can find your nearest GUM clinic on the British Association for Sexual Health and HIV (BASHH) website.

Sexual history

You'll also be asked about your sexual history. Try not to be embarrassed because erectile dysfunction is a common problem. You can request a male GP at your surgery if you prefer.

You may be asked about:

Erectile dysfunction that happens all the time may suggest an underlying physical cause.

Erectile dysfunction that only occurs when you are attempting to have sex may suggest an underlying psychological (mental) cause.

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Assessing your cardiovascular health

Your GP may assess your cardiovascular health. Narrowed blood vessels are a common cause of erectile dysfunction and linked with cardiovascular disease (conditions that affect the heart and blood flow).

Your GP may:

Physical examinations and tests

A physical examination of your penis may be carried out to rule out anatomical causes (conditions that affect the physical structure of your penis).

If you have symptoms of an enlarged prostate, such as weak or irregular urination, a digital rectal examination (DRE) may be suggested. 

Blood tests can also check for underlying health conditions. For example, measuring the levels of hormones such as testosterone can rule out hormonal conditions, such as hypogonadism (an abnormally low level of testosterone).

Further testing

In some cases you may be referred to a specialist for further testing. This might be the case if you are unusually young to be experiencing erectile dysfunction as it's rare in men under 40 years of age. 

Intracavernous injection test

An intracavernous injection test involves injecting a man-made (synthetic) hormone into your penis to increase the blood flow. This helps assess any abnormalities in your penis and plan surgery. 

If the injection doesn't result in an erection it may indicate a problem with the blood supply to your penis. In some cases, you may also need an ultrasound scan.

Arteriography and dynamic infusion cavernosometry or cavernosography

These specialised tests involve injecting dye into the blood vessels of your penis and studying the dye on a scanner. These are likely to be used if you are being considered for surgery or if a problem has been detected with your blood vessels.

Psychological assessment

If the cause of your erectile dysfunction is thought to be psychological, you may be reffered for a psychological assessment.

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Treating erectile dysfunction 

If you have erectile dysfunction (ED), treatment will depend on what's causing it.

Read on to learn about the different treatments you may be offered.

You can also read a summary of the pros and cons of these treatment options, allowing you to compare your treatment options.

Treating underlying conditions

If your erectile dysfunction is caused by an underlying health condition, such as heart disease or diabetes, that condition may need to be treated first. In some cases, treating the underlying cause may also resolve the problem.

If you are taking medication that can cause erectile dysfunction, there may be an alternative. It is important never to stop taking a prescribed medication unless you are advised to do so by your GP or another qualified healthcare professional responsible for your care.

Lifestyle changes

Erectile dysfunction can often be improved by making changes to your lifestyle, such as:

As well as helping to improve your erectile dysfunction, these changes can also improve your general health and may help to reduce your risk of cardiovascular disease (conditions that affect your heart and blood vessels).

Read more about preventing cardiovascular disease.  

Phosphodiesterase-5 (PDE-5) inhibitors

Phosphodiesterase-5 (PDE-5) inhibitors are one of the most widely used and effective types of medication for treating erectile dysfunction. They work by temporarily increasing the blood flow to your penis.

In England, four PDE-5 inhibitors are available for treating erectile dysfunction. They are:

Sildenafil, vardenafil and avanafil work for about eight hours and they are designed to work 'on demand'. Tadalafil lasts for up to 36 hours and is more suitable if you require treatment for a longer period of time, for example, over a weekend.

Depending on the type of PDE-5 inhibitor you are taking and the dose, it should take about 30-60 minutes before it starts to work. With sildenafil, vardenafil and avanafil, you should be able to have sex from one to 10 hours after taking the medicine. After taking tadalafil, the effects will last for up to 36 hours.

It may take longer to notice the effects if the tablet is taken with food, so it's best to take it on an empty stomach. You can then eat after an hour without affecting the medicine.

Only take one tablet within a 24-hour period.

Your GP should explain the benefits of each medication and how it works. The choice may depend on:

There have been many studies to test the effectiveness of these medications. In general, at least two-thirds of men report having improved erections after taking one of these medicines.

If you do not find that PDE-5 inhibitors are effective it may be because:

These medications are triggered by sexual stimulation, so you also need to be aroused for it to work.

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Warnings

PDE-5 inhibitors should be used with caution in men who have cardiovascular disease, such as coronary heart disease. However, sexual activity is also likely to be beneficial for your cardiovascular health. You should discuss the risks and benefits with your GP.

PDE-5 inhibitors should also be used with caution in men who have anatomical problems with their penis, such as Peyronie's disease (a condition that affects the tissue of the penis).

PDE-5 inhibitors should also be used with caution in men who:

Do not take PDE-5 inhibitors if you are also taking medicines or recreational drugs that contain nitrates. The combination of the two substances can have a dangerous effect on your heart.

Organic nitrates are often used to treat angina, and butyl nitrate is a recreational drug that is more commonly known as 'poppers'.

You are also warned not to take PDE-5 inhibitors if you:

Side effects

PDE-5 inhibitors can cause some side effects, including:

See the medicines information for erectile dysfunction.

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NHS prescriptions

Your GP can prescribe sildenafil to anyone with erectile dysfunction as long as it is safe to do so (see warnings above). Other PDE-5 inhibitors may only be prescribed based on your individual circumstances.

In some cases you may need to pay the full cost of the medication. The exact price will depend on the dosage and your local pharmacy but four PDE-5 tablets usually cost between £17 and £30.

Read more about help with prescription costs.

Men with the following medical conditions are entitled to NHS prescriptions for PDE-5 inhibitors:

Men who are receiving or have received certain medical treatments may also be entitled to NHS prescriptions for PDE-5 inhibitors. These treatments include:

In certain circumstances, some specialist centres may provide an NHS prescription for PDE-5 inhibitors. For example, if ED is causing you severe distress.

Vacuum pumps

A vacuum pump consists of a clear plastic tube that is connected to a pump, which is either hand or battery operated.

You place your penis in the tube and pump out all of the air. This creates a vacuum that causes the blood to fill your penis, making it erect. You then place a rubber ring around the base of your penis to keep the blood in place, allowing you to maintain an erection for around 30 minutes.

It may take several attempts to learn how to use the pump correctly, but they are usually effective. After using a vacuum pump, nine out of 10 men are able to have sex, regardless of the cause of their ED.

Considerations 

You should not use a vacuum pump if you have a bleeding disorder or if you are taking anticoagulant medicines, which reduce the ability of your blood to clot.

Side effects of vacuum pumps include pain or bruising, although these occur in less than a third of men.

Men who qualify for NHS prescriptions for erectile dysfunction treatments may be able to get a vacuum pump on the NHS (see above for more details). However, some men will need to buy one.

The Sexual Advice Association produces a number of factsheets, including one on vacuum pumps that provides details of companies that supply them.

Alprostadil

If your erectile dysfunction doesn't respond to treatment, or you are unable or unwilling to use PDE-5 inhibitors or a vacuum pump, you may be given a medicine called alprostadil. This is a synthetic (man-made) hormone that helps to stimulate blood flow to the penis.

Alprostadil is available as:

You may be trained to correctly inject or insert alprostadil. If your partner is pregnant, use a condom during sex if you are inserting alprostadil into your urethra.

Alprostadil will usually produce an erection after five to 15 minutes. How long the erection lasts will depend on the dose.

In men who did not respond to PDE-5 inhibitors, alprostadil injections were successful in 85 out of 100 men. Alprostadil inserted into the urethra is successful for up to two-thirds of men.

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Warnings

Alprostadil should not be used:

Urethral application may also not be used in:

Side effects

Alprostadil can cause some side effects including:

See the Alprostadil medicines information for more information about this medicine.

NHS prescriptions

As with PDE-5 inhibitors, NHS prescriptions for alprostadil may only be available for men with particular health conditions or those receiving some types of medical treatments. If you need to pay the full prescription cost, a single injection of alprostadil costs around £8 to £22, depending on the dose. A single dose of alprostadil for urethral application is around £10. 

Hormone therapy

If a hormonal condition is causing erectile dysfunction, you may be referred to an endocrinologist (who specialises in the treatment of hormonal conditions).

Hormones are chemicals produced by the body. Many hormonal conditions can be treated using injections of synthetic (man-made) hormones to restore normal hormone levels.

Surgery

Surgery for erectile dysfunction is usually only recommended if all other treatment methods have failed. It may also be considered in:

In the past, surgery was used if there was clear evidence of a blockage to the blood supply of the penis. The surgeon could unblock the blood vessels to restore a normal supply of blood. However, research now suggests that the long-term results of this type of surgery are poor, so it's unlikely to be used.

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Penile implants

Penile implants are a type of surgery that may be considered. These can be:

Penile implants are not usually available on the NHS and inflatable implants may be very expensive. However, around three-quarters of men report being satisfied with the results of this type of surgery.

Complications

As with all types of surgery, having penile implants inserted carries a risk of infection. If you take preventative antibiotics, the rate of infection is around two or three in 100. Mechanical problems with the implants may occur within five years in five per cent of cases. 

Psychological treatments

If your erectile dysfunction has an underlying psychological cause then you may benefit from a type of treatment called sensate focus.

If conditions such as anxiety or depression are causing your erectile dysfunction, you may benefit from counselling (a talking therapy).

Sensate focus

Sensate focus is a type of sex therapy that you and your partner complete together. It starts with you both agreeing not to have sex for a number of weeks or months. During this time, you can still touch each other, but not in the genital area (or a woman’s breasts). The idea is to explore your bodies knowing that you will not have sex.

After the agreed period of time has passed, you can gradually begin touching each other’s genital areas. You can also begin to use your mouth to touch your partner, for example, licking or kissing, them. This can build up to include penetrative sex.

You can find out more about sensate focus from the College of Sexual and Relationship Therapists (COSRT).

Psychosexual counselling

Psychosexual counselling is a form of relationship therapy where you and your partner can discuss any sexual or emotional issues that may be contributing to your erectile dysfunction. By talking about the issues, you may be able to reduce any anxiety that you have and overcome your erectile dysfunction.

The counsellor can also provide you with some practical advice about sex, such as how to make effective use of other treatments for erectile dysfunction to improve your sex life.

For information and advice about sexual arousal, read about good sex.

Psychosexual counselling may take time to work and the results achieved have been mixed.

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Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is another form of counselling that may be useful if you have erectile dysfunction. CBT is based on the principle that the way you feel is partly dependent on the way you think about things. CBT helps you realise that your problems are often created by your mindset. It is not the situation itself that is making you unhappy, but how you think about it and react to it.

Your CBT therapist can help you to identify any unhelpful or unrealistic thoughts that may be contributing to your erectile dysfunction – for example, to do with:

Your CBT therapist will be able to help you to adopt more realistic and helpful thoughts about these issues.

Read more about cognitive behavioural therapy.

Pelvic floor muscle exercises

Some studies have suggested that, in a few cases, it may be beneficial to exercise your pelvic floor muscles. These are a group of muscles around the underside of the bladder and rectum, as well as at the base of the penis.

Pelvic floor muscle exercise involves strengthening and training the muscles used to control the anus (back passage) and urinate. If your GP feels this type of exercise could be beneficial, then you may want to discuss it with a physiotherapist to learn it correctly.

By strengthening and training these muscles, you may be able to reduce the symptoms of erectile dysfunction.

Complementary therapies

Some complementary therapies, such as acupuncture, have claimed to treat erectile dysfunction. However, there is little evidence they are useful.

In some cases, they may even include ingredients that could interact with other medications and cause side effects.

Always speak to your GP before using any complementary therapies.

Counselling may be required if the underlying cause of your erectile dysfunction is psychological  

Managing ED on the internet

As erectile dysfunction (ED) can be an embarrassing problem, some men are tempted to look for treatment on their own. It is possible to buy medication over the internet, but you should always exercise caution as there are many sites that offer counterfeit medicines. These medications are not regulated and the amount of active ingredients in them can vary. They could cause unpleasant side effects or they may not be suitable for you.

Always ensure that any online doctor service is registered with the Care Quality Commission (CQC) , that all doctors are registered with the General Medical Council (GMC) and that any prescribed medicines come from a pharmacy which is registered in the UK.

It is also possible that an underlying health condition may be causing your erectile dysfunction and getting this diagnosed and treated may resolve your symptoms. Therefore, always see your GP for a full check-up.

Take a look at a simple guide to the pros and cons of different treatments for erectile dysfunction

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Ejaculation problems

Introduction 

Ejaculation problems, such as premature ejaculation, are common sexual problems in men.

The three main problems are:

  • premature ejaculation 

  • delayed ejaculation 

  • retrograde ejaculation 

These are described in more detail below.

Premature ejaculation

Premature ejaculation is the most common ejaculation problem. It is where the male ejaculates too quickly during sexual intercourse.

Many men are unsure about how long ‘normal’ sex should last before ejaculation. A study looking at 500 couples from five different countries found the average time between a man putting his penis into his partner’s vagina and ejaculation was around five-and-a-half minutes.

However, it's up to the individual and his partner to decide whether or not they're happy with the time it takes for him to ejaculate. There is no definition of how long intercourse should last.

Occasional episodes of premature ejaculation are common and not a cause for concern. However, if you're finding that around half of your attempts to have intercourse result in premature ejaculation, it might help to get treatment.

Most men with this problem won't have always had it – they'll have previously ejaculated normally. This may be referred to as 'secondary' premature ejaculation.

It's less common for the man to have always experienced premature ejaculation (since becoming sexually active) – this is known as 'primary' or lifelong premature ejaculation. It affects around one in 50 men in England. In most cases of lifelong premature ejaculation:

  • there is an inability to delay ejaculation during sex every time or most times

  • the condition causes feelings of shame or frustration and impacts on quality of life, causing the man to avoid sexual intimacy

Delayed ejaculation

Delayed ejaculation (male orgasmic disorder) is classed as either:

  • experiencing a significant delay before ejaculation is possible

  • being unable to ejaculate at all even though the male wants to and his erection is normal

There is no set definition to describe ‘how long is too long’, but a persistent (and unwanted) delay of ejaculation that lasts for 30 to 60 minutes may suggest delayed ejaculation.

Alternatively, if you are unable to achieve ejaculation at least half the times you have sex, you may have delayed ejaculation.

As with premature ejaculation, delayed ejaculation can be either acquired or lifelong. Lifelong delayed ejaculation is less common and affects an estimated one in 1,000 men.

Delayed ejaculation can occur in all sexual situations, or just in certain situations – for example, you may be able to ejaculate normally when masturbating, but not during sex. When delayed ejaculation only happens in certain situations, there's usually a psychological cause.

Retrograde ejaculation

Retrograde ejaculation is a rarer type of ejaculation problem. It happens when sperm travels backwards and enters the bladder instead of coming out of the end of the urethra (the tube through which urine passes).

The main symptoms of retrograde ejaculation include:

  • producing no semen, or only a small amount, during ejaculation

  • producing cloudy urine (because of the semen in it) when you first go to the toilet after having sex

Men with retrograde ejaculation still experience the feeling of an orgasm and the condition does not pose a danger to health. However, it can affect the ability to father a child (read about infertility).

Treating ejaculation problems

Premature ejaculation can be treated with medication, such as the selective serotonin reuptake inhibitors (SSRIs) type of antidepressant, which can help delay ejaculating.

Couples therapy, a form of counselling, can be useful in coming up with techniques for partners to practice to help delay ejaculation.

Recommended treatments for delayed ejaculation depend on the underlying cause. If it is thought to be a side effect of medication, switching to an alternative medication will help. However, if the cause is thought to be psychological, counselling may be recommended.

Most men do not require treatment for retrograde ejaculation because they are still able to enjoy a healthy sex life and the condition does not affect their health. In some cases, medication may be used to help restore normal ejaculation.

However, if you want to have children, you may need fertility treatment to extract a sample of sperm.

Read more about treating ejaculation problems.

What causes ejaculation problems?

Ejaculation problems are complex and can be caused by a number of things, including:

  • stress

  • relationship problems

  • anxiety – such as a man being anxious that he will lose his erection (erectile dysfunction), causing him to ‘rush’ the intercourse

  • previous traumatic sexual experiences

  • depression

  • some medical conditions or medicines – for example, diabetes can cause delayed ejaculation

Some researchers think certain men are more prone to premature ejaculation because of their biological make-up, such as having an unusually sensitive penis.

Retrograde ejaculation is caused by damage to nerves or muscles that surround the neck of the bladder (the point where the urethra connects to the bladder). This damage can often occur as a complication of prostate or bladder surgery.

Read more about the causes of ejaculation problems.

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Who is affected

Premature ejaculation is the most common type of ejaculation problem.

A number of surveys have found around one in three men reported being affected by premature ejaculation. The true figure is probably much higher as many men are reluctant to admit they have this problem.

While less common, delayed ejaculation is probably more of a problem then most people realise. One study found around one in 20 people had problems achieving an orgasm over the course of a month during the past year.

Although retrograde ejaculation is rare, it can be a common complication of some types of surgery, such as prostate surgery, or in men with certain health conditions that can damage the nerves, such as diabetes or multiple sclerosis.

Involve your partner

If you are having problems with your sex life and are seeking treatment, it is usually recommended you involve your partner as much as possible.

Communicating your concerns can often go a long way to helping to resolve them. And in some cases your partner may also have their own problems that are contributing towards problems with your sex life.

For example some women are unable to reach climax during ‘normal’ intercourse and require manual or oral stimulation.

Read more about why talking about sex is important.

Blood in your semen

Finding blood in your semen (haematospermia) can be alarming. However, in most cases it's not serious and will pass within a few days.

The most likely cause is infection of your urethra (urethritis) and prostate (prostatitis).

See your GP if the symptoms persist, or visit your local genito-urinary medicine (GUM) clinic because the causes may be more serious.

Read more about blood in the semen.

Causes of ejaculation problems 

Causes of ejaculation problems vary depending on the person and the type of problem.

An ejaculation problem can often have physical and psychological causes. For example, if a man has previously had a health condition that made it difficult to maintain an erection, it may now cause anxiety, leading to premature ejaculation.

Primary (lifelong) premature ejaculation

A number of possible causes are discussed below.

Conditioning

Many doctors believe early sexual experiences can influence future sexual behaviour. For example, if a teenager conditions himself to ejaculate quickly to avoid being caught masturbating, it may later be difficult to break the habit.

Traumatic sexual experiences

A traumatic sexual experience at an early age can sometimes lead to lifelong sexual anxiety and premature ejaculation. Experiences can range from being caught masturbating to sexual abuse.

Upbringing

Men who have had a strict upbringing, where sexual activity is only considered appropriate in certain circumstances, such as after marriage, may find it difficult to relax during sex, or be unable to let go of the belief that sex is wrong or sinful.

Biological reasons

A number of recent studies suggest biology may play a role in some cases of primary premature ejaculation.

Changes to the normal pattern of nerve signals in some men affected by erectile dysfunction could result in their penis being extra sensitive, meaning it takes much less stimulation to cause ejaculation.

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Genetic influences

Studies have recently suggested men with a first-degree relative (father, brother or son) who experiences premature ejaculation are more likely to have the problem themselves. But a definite genetic association has not yet been proved.

Secondary (acquired) premature ejaculation

Acquired premature ejaculation (where premature ejaculation develops in a man who has previously had a history of normal ejaculation) can be caused by both psychological and physical factors.

Common physical causes include:

  • diabetes 

  • multiple sclerosis 

  • prostate disease 

  • high blood pressure 

  • thyroid problems – an overactive or underactive thyroid gland 

  • using recreational drugs

  • drinking too much alcohol

The recommended daily levels of alcohol consumption are three to four units of alcohol for men, and two to three units for women.

A unit of alcohol is equal to about half a pint of normal strength lager, a small glass of wine, or a pub measure (25ml) of spirits.

Common psychological causes include:

  • depression 

  • stress 

  • unresolved problems, conflicts or issues within a sexual and emotional relationship

  • anxiety about sexual performance (this is often a contributory factor at the start of a new sexual relationship, or when a man has had previous problems with sexual performance)

Delayed ejaculation

Like premature ejaculation, delayed ejaculation can be caused by psychological and physical factors.

Possible psychological causes of delayed ejaculation are similar to those of premature ejaculation – for example, early sexual trauma, strict upbringing, relationship problems, stress, and depression.

Physical causes of delayed ejaculation include:

  • diabetes (usually only type 1 diabetes)

  • spinal cord injuries

  • multiple sclerosis

  • surgery to the bladder or prostate gland

  • increasing age

Many medicines are known to cause delayed ejaculation, including:

  • antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs)

  • medications used to treat high blood pressure (hypertension), such as beta-blockers

  • antipsychotics, which are medications used to treat episodes of psychosis 

  • muscle relaxants, such as balcofen, which is widely used to treat motor neurone disease and multiple sclerosis

  • powerful painkillers, such as methadone (which is also widely used to treat people addicted to heroin)

Retrograde ejaculation

Retrograde ejaculation is caused by damage to the nerves or muscles that surround the neck of the bladder (the point where the urethra connects to the bladder).

Usually when you ejaculate, semen is pushed out of your testicles and up through your urethra (the tube that semen and urine pass through). It is prevented from entering your bladder by the muscles around the neck of the bladder, which close tightly at the moment of orgasm.

However, damage to the surrounding muscles or nerves can stop the bladder neck closing, causing the semen to move into the bladder rather than up through the urethra.

Prostate gland or bladder surgery is the most common cause of retrograde ejaculation. Other causes are diabetes, multiple sclerosis, and a class of medicines known as alpha blockers, which are often used to treat high blood pressure (hypertension).

Diagnosing ejaculation problems 

If you have an ejaculation problem, you will usually become aware of it through your own sexual behaviour or discussion with your partner. The next step is to visit your GP who will discuss the problem with you and either examine you or refer you to a specialist.

Family and medical history

Depending on the nature of your problem, you may be asked questions about your family medical history and any underlying health conditions you may have, such as:

  • diabetes

  • heart disease

  • high blood pressure (hypertension)

You will also be asked about your sexual and emotional health. While you may find it embarrassing to talk about, answering questions about the type and pattern of your symptoms is an important step towards making sure that you receive the most effective treatment.

Read more about the symptoms associated with ejaculation problems.

Your GP or specialist will want to know if you have had an injury or surgery to your pelvic area, what medications you are taking, and about aspects of your lifestyle, such as how much alcohol you drink.

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Further testing

A rectal examination may be carried out in people over 50 years old to check for an enlarged prostate gland. Your blood pressure and heart rate may also be measured.

Blood and urine samples may be taken to check your hormone and cholesterol levels. Your GP, or specialist, may also carry out a visual examination of the pelvic area to check for injury or infection.

Treating ejaculation problems 

If you have ejaculation problems caused by physical conditions, your GP should be able to suggest possible treatment options.

Treating ejaculation problems caused by psychological factors can be more challenging, but most men who persevere with treatment have successful outcomes.

Premature ejaculation

Self-help

There are a number of things you can try yourself before seeking medical help, such as:

  • masturbating an hour or two before having sex

  • using a thick condom to help decrease sensation

  • taking a deep breath to briefly shut down the ejaculatory reflex (an automatic reflex of the body during which ejaculation occurs)

  • having sex with your partner on top (to allow them to pull away when you are close to ejaculating)

  • taking breaks during sex and thinking about something boring

Couples therapy

If you are in a long-term relationship, you may benefit from having couples therapy. The purpose of couples therapy is two-fold.

First, couples are encouraged to explore issues that may be affecting their relationship, and given advice about how to resolve them.

Second, couples are shown techniques that can help the man to ‘unlearn’ the habit of premature ejaculation. The two most popular techniques are the ‘squeeze technique’ and the ‘stop-go technique’.

In the squeeze technique, the woman begins masturbating the man. When the man feels that he is almost at the point of ejaculation, he signals to the woman. The woman stops masturbating him, and squeezes the head of his penis for between 10 to 20 seconds. She then lets go and waits for another 30 seconds before resuming masturbation. This process is carried out several times before ejaculation is allowed to occur.

The stop-go technique is similar to the squeeze technique except that the woman does not squeeze the penis. Once the man feels more confident about delaying ejaculation, the couple can begin to have sexual intercourse, stopping and starting as required.

These techniques may sound simple, but they do require a lot of practice.

Medication to treat premature ejaculation

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are primarily designed to treat depression, but they also have the useful side effect of delaying ejaculation. Although SSRIs are not licensed to treat premature ejaculation, they are increasingly being prescribed for this use.

SSRIs used for this purpose include:

  • paroxetine

  • sertraline

  • fluoxetine

Some men with premature ejaculation may experience an improvement in their symptoms as soon as treatment begins. However, you will usually need to take the medication for one to two weeks before you notice the full effects of the treatment.

Common side effects of SSRIs include:

  • fatigue

  • feeling sick and being sick

  • diarrhoea 

  • excessive sweating

However, these are usually mild and should improve after two to three weeks.

Dapoxetine

An SSRI, known as dapoxetine, has been specifically designed to treat premature ejaculation.

From November 2013, dapoxetine (Priligy) became the first medication to be licensed for premature ejaculation in the UK and local NHS authorities can choose to prescribe it on the NHS.

Dapoxetine acts much faster than the SSRIs mentioned above and can be used 'on demand'. If you are prescribed dapoxetine, you will usually be advised to take it one to three hours before having sex, but not more than once a day.

Dapoxetine is not suitable for all men diagnosed with premature ejaculation. For example, it is not recommended for some men with heart, kidney and liver problems. Dapoxetine can also interact with other medications, such as other antidepressants.

Common side effects of dapoxetine include headaches, dizziness and feeling sick.

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Topical anaesthetics and condoms

The use of topical anaesthetics such as lidocaine or prilocaine can be helpful but can be transferred and absorbed to the vagina, causing decreased sensation. Condoms can also be used and are effective, particularly when combined with local anaesthesia.

Delayed ejaculation

Sex therapy

Sex therapy is a form of counselling that uses a combination of psychotherapy and structured changes in your sex life. This can help to increase your feeling of enjoyment during sex, and help make ejaculation easier.

Some clinical commisioning groups (CCGs) provide a sex therapy service on the NHS, but others do not. Therefore, levels of availability can vary widely depending on where you live.

You can also pay privately for sex therapy. Prices for a single session can vary from around £50 to £80. For information about private sex therapists in your local area you should visit the College of Sexual and Relationship Therapists website.

The relationship counselling service Relate also offers sex therapy at a number of its centres; you would be expected to pay for each session.

During sex therapy, you will have the opportunity to discuss any emotional or psychological issues related to your sexuality and relationship, in a non-judgemental way.

Activities may also be recommended for you to try at home while you are having sex with your partner (you should never be asked to take part in any sexual activities during a session with the therapist).

These may include:

  • viewing erotic material before having sex, such as videos and magazines, to increase the feeling of sexual stimulation

  • erotic fantasies and ‘sex games’ to make your lovemaking more exciting

  • using lubricating creams or gels to make the physical act of sex more comfortable and relaxing

  • using sexual aids, such as vibrators, to increase pleasure

Read more information about what a sex therapist can do.

Switching medication

There are a number of medications that can be used if it is thought SSRIs are responsible for causing delayed ejaculation. These include:

  • amantadine – a medication originally designed to treat viral infections

  • buproprion – a medication originally designed to help people stop smoking

  • yohimbine – a medication originally designed to treat erectile dysfunction

These medications help block some of the chemical effects of SSRIs that are thought to contribute towards delayed ejaculation.

Retrograde ejaculation

Most men do not require treatment for retrograde ejaculation because they are still able to enjoy a healthy sex life and the condition does not have adverse effects on their health.

If retrograde ejaculation is caused by using a certain medication then normal ejaculation will usually return once the medication is stopped. Speak to your GP before you stop taking prescibed medication.

If treatment is required (usually because of wanting to father a child), medicines can be used to strengthen the muscles around the bladder neck. Pseudoephedrine (a medicine commonly used as a decongestant) has proved to be effective in treating retrograde ejaculation caused by diabetes or surgery.

However, if the retrograde ejaculation has been caused by significant muscle or nerve damage, treatment may not be possible.

Men who want to have children can have sperm taken from their urine for use in artificial insemination or in-vitro fertilisation (IVF).

Buying medication on the internet

Many medications mentioned here are available from commercial websites on the internet, including medications not licensed for use in the UK. However, using these websites to purchase medication is not recommended.

Medication such as SSRIs can have a wide range of side effects so it is important to take it under the supervision of a healthcare professional. You'll need guidance about whether the medication is suitable for you, the correct dose to take and any interactions with other medicines.

Also, medications ordered on the internet could be out-of-date, diluted or fake, making them dangerous to your health.

The Royal Pharmaceutical Society of Great Britain (RPSGB) has a code of ethics for all online pharmacies to help you ensure a website is reputable.

Source: NHS Choices, UK

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Treating low testosterone levels

Men naturally lose testosterone as they age, but there are "low-t" treatments available.

treating low testosterone


Published: December, 2016

Testosterone is the hormone that gives men their manliness. Produced by the testicles, it is responsible for male characteristics like a deep voice, muscular build, and facial hair. Testosterone also fosters the production of red blood cells, boosts mood, keeps bones strong, and aids thinking ability. Lack of testosterone, often nicknamed, low-t, can cause unwanted symptoms.

Testosterone levels peak by early adulthood and drop as you age—about 1% to 2% a year beginning in the 40s. As men reach their 50s and beyond, this may lead to signs and symptoms, such as impotence or changes in sexual desire, depression or anxiety, reduced muscle mass, less energy, weight gain, anemia, and hot flashes. While falling testosterone levels are a normal part of aging, certain conditions can hasten the decline. Low t symptoms include:

  • injury or infection

  • chemotherapy or radiation treatment for cancer

  • medications, especially hormones used to treat prostate cancer and corticosteroid drugs

  • chronic illness

  • stress

  • alcoholism

  • obesity

Millions of men use testosterone replacement therapy to restore low levels and feel more alert, energetic, mentally sharp, and sexually functional. But it's not that simple. A man's general health also affects his testosterone levels. For instance, being overweight, having diabetes or thyroid problems, and taking certain medications, such as glucocorticoids and other steroids, can affect levels. Therefore, simply having low-t levels does not always call for taking extra testosterone.

Diagnosing low testosterone

Doctors diagnose low testosterone based on a physical exam, a review of symptoms, and the results of multiple blood tests since levels can fluctuate daily.

If your doctor diagnoses low testosterone, other tests may be considered before therapy. For example, low-t can speed bone loss, so your doctor may recommend a bone density test to see whether you also need treatment for osteoporosis.

Prostate cancer is another concern, as testosterone can fuel its growth. As a result, the Endocrine Society recommends against testosterone supplementation for men in certain situations, including those who:

  • have prostate or breast cancer

  • have an elevated blood level of prostate-specific antigen (a blood test used to screen for prostate cancer)

  • have a prostate nodule that can be felt during a rectal exam.

Other circumstances in which testosterone supplementation is not recommended include:

  • a plan to become a father in the near-term

  • an elevated red blood cell count

  • severe, untreated sleep apnea

  • severe lower urinary tract symptoms

  • poorly controlled heart failure

  • heart attack or stroke within the last 6 months

  • a tendency to form blood clots (a condition called thrombophilia)

Testosterone therapy for low levels

In most cases, men need to have both low levels of testosterone in their blood and several symptoms of low testosterone to go on therapy.

It is possible to have low levels and not experience symptoms. But if you do not have any key symptoms, especially fatigue and sexual dysfunction, which are the most common, it is not recommended you go on the therapy given the uncertainty about long-term safety.

Even if your levels are low and you have symptoms, low-t therapy is not always the first course of action. If your doctor can identify the source for declining levels—for instance, weight gain or a particular medication—he or she may first address that problem.

If you and your doctor think testosterone replacement therapy is right for you, there are a variety of delivery methods to consider, as found in the Harvard Special Health Report Men's Health: Fifty and Forward.

  • Skin patch. A patch is applied once every 24 hours, in the evening, and releases small amounts of the hormone into the skin.

  • Gels. Topical gels are spread daily onto the skin over both upper arms, shoulders, or thighs. It is important to wash your hands after applying and to cover the treated area with clothing to prevent exposing others to testosterone.

  • Oral therapy. Capsules are swallowed or tablets are attached to your gum or inner cheek twice a day. Testosterone is then absorbed into the bloodstream.

  • Pellets. These are implanted under the skin, usually around the hips or buttocks, and slowly release testosterone. They are replaced every three to six months.

  • Injections. Various formulations are injected every seven to 14 days. Testosterone levels can rise to high levels for a few days after the injection and then slowly come down, which can cause a roller-coaster effect, where mood and energy levels spike before trailing off.

Most men feel improvement in symptoms within four to six weeks of taking testosterone replacement therapy, although changes like increases in muscle mass may take from three to six months.

– By Matthew Solan
Executive Editor, Harvard Men's Health Watch
Harvard Health Publishing

Tips For Better Sex Life (WARNING: STRICTLY FOR ADULTS ONLY!)

  1. Amazing Sex Tips & Tricks for Her

  2. Complete Guide to Sexual Fulfilment

  3. 365 Sexual Positions

  4. A-Z Guide: Sexual Intimacy in Marriage

  5. Best Sex Ever: 69 Sensational Ideas

  6. Sexual Detox: A Guide for the Married Guy

  7. Sexual Behavior, Attraction, & Identity

  8. Relationships, Sex, and Other Stuff

  9. Safe Sex For Seniors

  10. Sex After Stroke

  11. Keeping Healthy Testosterone Levels

  12. Food and Sex Life

  13. Tips to a Better Sex Life

  14. The Intimate Guide to Crazy Good Sex

  15. Safe Sex For Seniors

  16. Sex After Stroke

  17. Love, Sex, and You

  18. Complete Idiote's Guide to Tantric Sex

  19. The 5 Sex Needs of Men and Women

  20. How to Talk to Your Kids About Sex

  21. Sex in Marriage

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