In this session, Professor Suks Minhas, Consultant Urologist and Andrologist at Imperial College London discussed male sexual dysfunction, its definition, causes, and ways to treat it.
Professor Suks Minhas is a consultant urologist and andrologist at Imperial College, London. He looks at many patients with fertility problems and with male sexual dysfunction. He is a urologist or andrologist and works at Imperial College in London.
From a patient’s perspective, male sexual dysfunction is an issue that can occur at any phase of the sexual response cycle, and there are various types of sexual dysfunctions. These include both erection concerns, commonly referred to as impotence, though now more commonly called erectile dysfunction, and ejaculation concerns. For couples trying to conceive, these issues can be particularly concerning. In some cases, sex may become more regimented, leading to difficulties in achieving erections, as well as challenges in maintaining them. Additionally, issues surrounding ejaculation can arise, with some men experiencing the inability to ejaculate.
The professor explains that male sexual dysfunction is widespread. There are different phases to the normal sexual male response. Generally, sexual stimulation causes the penis to become tumescent or more erect. As arousal increases, it typically leads to penetrative sex or some form of sexual function, followed by orgasm and the production of ejaculatory fluid. After ejaculation, the penis usually goes down and becomes detumescence, as it is commonly called.
It is important to be aware that erection problems are very common, despite a common misconception that they are not. Many patients feel embarrassed about this issue. However, the professor explains that the worldwide prevalence of erection concerns is very high, with approximately 152 million men affected in 1995, and this number is projected to rise to 322 million by 2025. Therefore, it is a very common problem.
The professor explains that there are quite a lot of causes of erectile dysfunction, which is defined as the inability to maintain or sustain an erection adequate for intercourse. Common causes include diabetes, with about 70% of men who are diabetic experiencing some form of erectile problem. Vascular causes are also significant, as problems with blood flow can influence the penis, much like how heart conditions affect the heart. Endocrine issues, such as problems with hormonal function, including testosterone imbalances, can also cause erectile problems. Neurological issues, such as spinal cord injuries or surgeries that disrupt the nerves of the penis, can lead to erectile dysfunction as well. Additionally, surgeries in the pelvis area that damage nerves, and certain medications, can also impact erectile function. It is important to ask patients about all these potential causes when addressing erectile dysfunction.
Professor Suks explains that the risk of erectile dysfunction increases with age. Approximately 50% of men between the ages of 40 and 70 will experience some degree of erectile problem, ranging from minimal issues to complete erectile dysfunction. This makes erectile dysfunction very common, and it is significant to highlight this to patients, so they don’t feel alone in facing the problem.
There are many drugs available on the market for erection problems. Some of the most well-known are Viagra and Cialis. In fact, Viagra, also known as Sildenafil, is now available over the counter.
The causes of erectile dysfunction are varied. As previously mentioned by the professor, smoking is a common factor, but it is also important to consider psychological issues, such as depression. Patients who are feeling down may also experience difficulties in achieving an erection. It’s crucial to remember that there are both physical and psychological factors at play when men present with erectile dysfunction. These issues need to be assessed thoroughly, especially in the context of fertility. Additionally, hormone-related problems should also be considered in the evaluation.
With the slide above, the professor highlights how common the problem is, and that’s very significant. For 50% of men at that age, that’s quite a profound problem.
Using an anatomy drawing, the professor illustrates the bladder, prostate, and the nerves that supply the penis. He explains that in some men who have undergone surgery, the nerves, and blood supply to the penis can be damaged. This can occur when certain organs are removed for the treatment of various diseases.
The professor explains that erections occur due to stimulation to the brain, which can be triggered by various factors such as visual stimuli, imagination, and tactile responses. These stimuli increase blood flow to the penis, leading to an erection.
The professor explains that when an erection occurs, neural or nerve impulses are transmitted from the brain, primarily from the centre of the brain, down to the spinal cord. These impulses travel to the lumbar-sacral area, which is the lower part of the spinal cord, and provide nerve input to the penis, leading to an erection. There are specific nerves involved in this process, known as the parasympathetic system, which promotes erection. On the other hand, the sympathetic system controls the cessation of the erection. These two systems work in balance to maintain an erection.
When men then ejaculate, there are two phases. They get stimulated when they have an erection, then the muscles contract, the vas deferens, which propels sperm into the urethra, which is where the water pipe where men pass urine from, and from there men get contractions of the muscle, which then expels the ejaculate, that’s called the expulsion phase that’s when there’s fluid that comes out the penis.
There are very complex factors that can affect ejaculation. For example, painful ejaculation can occur due to inflammation of the organs or the prostate. Sometimes, issues like stones or blockages can cause problems with the ejaculate, leading to fertility issues. Another issue is premature ejaculation, which can occur when men ejaculate too early, even before engaging in sexual activity with their partner. This can also lead to dissatisfaction for their partner if ejaculation occurs too soon. Generally, premature ejaculation is considered when the time to ejaculation is less than a minute. However, there is a wide range of responses in terms of how long men take to ejaculate, with the average time being about five minutes.
The professor defines premature ejaculation as a significant sexual dysfunction that many men experience, and it is often perceived as a major problem. Frequently, men who struggle with erectile dysfunction may feel the need to ejaculate earlier, as they fear they will lose their erections. This sense of urgency leads them to ejaculate quickly, which is often driven more by psychological factors than physical ones.
Premature ejaculation is quite common, affecting almost a third of men at various ages, with the prevalence increasing as they get older. Studies conducted in Europe show surprising variations in how often men experience this issue, depending on the country and the cultural context. The prevalence rates differ significantly based on factors such as who is reporting the condition, the country in question, and the specific study being conducted. Cultural and religious factors can also influence the frequency and reporting of premature ejaculation.
Premature ejaculation is classified into two types: lifelong and acquired. Lifelong premature ejaculation refers to men who have experienced it throughout most of their lives. Some men acquire the condition later, often due to erection problems. In such cases, they may be concerned that their erection will subside, which leads them to ejaculate prematurely. It is important to note that, in many cases, the cause of premature ejaculation is psychological, a factor that must be emphasized.
When men experience early ejaculation or perceive it as a problem, it is important to remember that their partner also needs to be involved in the conversation. In some cases, treatment is necessary, and occasionally, patients are referred to for psychological and behavioural therapy. This type of therapy has been shown to have a very positive effect in helping men manage early ejaculation.
In some cases, men who cannot maintain control over early ejaculation, even with psychological therapy, may require medication. Medications, such as antidepressants, are sometimes prescribed, not because the patient is depressed, but because these drugs increase the levels of serotonin, which has a damping effect on the reflex between the brain and spinal cord that triggers early ejaculation. One specific drug, called dapoxetine, can be used in this scenario, but the patient must be properly evaluated before being prescribed this medication.
It is important to recognize that there are various treatments available for early ejaculation, including behavioural therapy or psychotherapy. In addition, local anaesthetics are sometimes used, and medications such as dapoxetine, which is a short-acting SSRI, can be prescribed. These drugs work by increasing serotonin levels, helping to manage the condition.
One such drug is dapoxetine, along with various other medications that are sometimes used. For these medications, it is important to consult with a doctor before taking them. An assessment is necessary to ensure that you can safely use these types of drugs.
Another important issue to consider about sexual dysfunction, particularly erectile dysfunction, is that it might be a sign of underlying vascular disease or cardiac disease. Earlier, the professor mentioned that the penis, like a muscle, can serve as a barometer of overall health. Interestingly, something called metabolic syndrome is related to low testosterone levels, which can lead to obesity and can also affect fertility. This is significant because low testosterone levels can impact hormone levels in the body, further influencing overall health and fertility.
Testosterone is not only important for secondary sexual characteristics such as body hair, but also plays a role in increasing blood count, muscle bulk, and sexual function, particularly in terms of erections. However, men need to be aware of a common misconception: that if their testosterone levels are low, boosting testosterone will improve fertility. This is not the case. Administering testosterone, whether sperm production is normal or abnormal, can suppress it, acting like a male contraceptive. Therefore, men should never administer testosterone to themselves if they want to have children; it should always be prescribed by a doctor.
Professor Suks explains that men with increased weight often experience central adiposity, or increased fat around the waist, which can lower testosterone levels. This reduction in testosterone can affect overall erectile function and predispose individuals to cardiovascular diseases, such as insulin resistance, which increases the risk of diabetes. This highlights the importance of not ignoring erectile dysfunction and sexual dysfunction, as they may be indicative of underlying health conditions. While the frequency of these issues increases with age, younger men in their 20s generally experience erectile dysfunction more due to psychological factors than physical ones. However, it is still essential to rule out potential physical causes.
This risk of cardiovascular disease increases as men get older and this is because erectile dysfunction shares the same risk factors as cardiovascular disease. The next slide shows the relationship between low testosterone and this metabolic syndrome, which is central adiposity, which increases the risk of cardiac disease.
The process of achieving an erection is complex, involving both blood and nerve supply to the penis. There are various spinal pathways involved in this process, and any disruption to these pathways can lead to erection problems. This highlights the importance of understanding how different factors can impact erectile function.
Professor explains that the penis functions like a muscle tube, which is responsible for achieving rigidity during sexual arousal. As men become sexually stimulated, the nerves are activated, and blood flow is directed into the penis, which has two muscle bulks that dilate and become filled with blood. This process leads to an erection. However, if there is insufficient blood flow to the penis, it will not become rigid, and this can also impact the ability to maintain the erection. Therefore, blood flow is crucial for erectile function, and it can be affected by conditions like cardiovascular disease.
There are several drugs and medications available to treat erectile dysfunction, and their choice depends on the patient’s preference. Some of these drugs are short-acting, while others have a longer duration of action. Sildenafil citrate, available over the counter (OTC), is short-acting and works quickly. However, it is important to note that it should be taken on an empty stomach, and alcohol should be avoided. On the other hand, tadalafil, known as Cialis, is no longer acting. It takes about two hours to start working but can remain in the body for 24 to 36 hours. Many people prefer this drug for its more spontaneous effects. Other options include vardenafil and avanafil.
Often, men undergo prostate operations, which are important for sexual function and fertility. These procedures can lead to problems with erections, loss of ejaculation, and sometimes men even report that their penis has become smaller. This is significant because, as men age, prostate surgery, often required for prostate cancer, can have these effects on sexual health.
Some men have discussed the use of shockwave therapy, a relatively new treatment where shock waves are directed at the penis. According to studies, this method can help create new blood vessels. This treatment is available and sometimes works effectively when used in combination with medications like Viagra and Cialis.
Professor Suks explains Injection therapies and creams applied to the penis, as well as the use of pellets, can be effective but are still associated with some problems. One significant issue is that, with some of these medications, a man can experience an erection that does not go down, a condition known as priapism, which is considered a surgical emergency. Additionally, injections can sometimes cause bending of the penis or pain at the injection site. While these treatments are not without risks, they can work very well. One of the most common drugs used for men in this context is called PG-1, a prostaglandin.
Very occasionally, men may not respond to treatments for erectile dysfunction, and in such cases, surgical intervention may be required. This typically involves the insertion of implants, which are rods that replace the muscle in the penis. Since erections are caused by the dilation of the muscle tubes in the penis, these implants serve as replacements for them. There are two main types of implants: the semi-rigid, or malleable, implant, which keeps the penis in a constant state of erection that can be bent down when necessary, and the inflatable device. The inflatable device consists of a pump placed in the scrotum, a reservoir in the abdomen containing fluid, and two tubes that can be inflated to simulate an erection. The fluid is pumped into the tubes to expand them, and the implant can be deflated by releasing the fluid. This device effectively replaces the natural erectile mechanism.
To conclude, Professor Suks emphasizes the fertility-related issues he and other professionals often encounter in men. One common problem is low testosterone, but more frequently, when men are trying to conceive with their partners, issues arise with erectile dysfunction. This is often psychological, particularly when men try too hard during ovulation, leading to a decrease in erection quality. Some men also experience difficulty with ejaculation, which can sometimes be delayed. This is particularly significant for patients undergoing IVF treatments.
Before IVF, doctors often ask patients if they can ejaculate, as sperm may need to be frozen beforehand. Therefore, it’s essential to take a thorough sexual history when discussing treatments for erectile dysfunction, as these issues can affect fertility. Furthermore, couples often assume they are having sex at the right time and with sufficient frequency, but they may not be meeting often enough due to factors like travel or fatigue. It’s important to ask these questions to fully understand the challenges couples may be facing in their efforts to conceive.
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Testosterone is crucial not only in puberty, where it causes the development of pubic hair and a deeper voice but also in sexual function. It affects the chemicals involved in causing an erection, making it essential for erectile function. Interestingly, studies have shown that low testosterone levels can precede erectile problems, although there is some controversy about what level specifically triggers these issues. In general, testosterone is measured in men with erectile dysfunction, as it plays an important role physically and physiologically. It also impacts traits like deep voice, body hair, and masculinity.
It depends on several factors. What we need to remember is that when couples are trying for children, there is often a lot of pressure, which can play a significant psychological role in erectile dysfunction. This psychological factor is very important when it comes to losing an erection, which is defined as erectile dysfunction. Sometimes, thyroid problems can cause erectile dysfunction, and smoking can also contribute to it. However, the issue depends on your boyfriend’s age. In younger age groups, these factors might potentially cause problems, but as one gets older, they become more influential. So, depending on how old your boyfriend is, these factors might be more contributory.
From the age of 47, you would, of course, look at it and say, well, he’s getting middle age, and it happens to all of us. So, at this point, he should probably have an evaluation. Remember, we talked about the fact that roughly 40 to 50% of men in this age group experience erectile dysfunction. There are psychological causes, as we’ve already mentioned, particularly if you’re trying to have children. Stress, work problems, fatigue, or issues with compatibility, such as wanting to have intercourse at different times, could all be contributing factors. There are many aspects to consider, but the most important thing is also the risk of cardiovascular disease, high cholesterol, and diabetes, as these can potentially cause erectile dysfunction. Therefore, if this is a continuing problem, I would recommend that he be evaluated by his local general practitioner to determine whether there is an underlying issue related to blood flow. There are simple tests that can be done, including blood tests and a testosterone level assessment, especially at that age.
Well, that’s an interesting question. Next week, I am doing a talk on sperm acquisition, and I think that would fit very well with this topic, but I can answer it quickly now. So, one of the issues is that it depends on the cancer treatment. Generally, as modern technologies improve, we tend to freeze sperm before patients undergo chemotherapy or surgery. For example, I work a lot with testicular cancer, and we always freeze sperm before men have surgery, like testicle removal, or before they undergo chemotherapy. We usually hope that we’ve done this in advance.
The problem, however, is that certain types of cancer can affect fertility. It’s not just about chemotherapy or the removal of an organ; the cancer itself can also cause fertility issues. For instance, cancers like leukaemia and lymphoma can directly impact fertility in some men. In some cases, we have to perform operations before treatment if there is no sperm present, but we can also do surgeries afterwards to see if we can retrieve sperm.
These issues are often related to cancers like leukaemia, lymphoma, or chemotherapy treatments in childhood. We sometimes perform surgery to extract sperm directly from the testicles. So, not all men necessarily need to resort to sperm donation. They should be evaluated by an andrologist or fertility expert to determine whether sperm extraction from the testicles is feasible before moving on to donor sperm. Whether this is possible largely depends on the type of chemotherapy, the age at which the treatment occurred, and the specifics of the treatment itself.
That’s a very good question. Today I spent the day in the clinic talking to patients about abnormal forms of sperm, which is one of the biggest controversies in urology and infertility. The reason for this is that often, when we look at semen analysis results, patients go to a lab, and the labs can vary in their interpretation of abnormal forms. Remember, semen analysis can be done manually or by computer, and the preparation for the analysis is very different from lab to lab. Because of this, you don’t get uniformity in how the technique is applied.
It’s unusual to get isolated abnormal forms in a semen analysis. When you see a fertility problem, it typically means that all factors are usually affected. However, there are certain conditions, like globozoospermia, where all the sperm are globular, and this can result in low morphology on its own. However, isolated cases of what we term “teratospermia” or poor morphology are rare.
It’s important to remember that humans are quite strange in this regard; we can have up to 96% abnormal sperm forms, which is very high. If your partner has 3% normal forms, that isn’t bad at all. So, instead of focusing only on abnormal forms, we now tend to look at something called the total motile count, which is a measure of sperm motility—the number of moving sperm. This is often a better indicator of a couple’s fertility potential.
Abnormal forms are a controversial area, and we are moving away from using them on their own to predict fertility. More importantly, you could have a normal sperm count and still not be able to conceive. One issue to consider here is DNA damage, which might be important, but we can probably discuss that next time.
Now, as for ways to improve things—lifestyle modifications can be helpful. Losing weight and following a Mediterranean-type diet are beneficial. There’s also some evidence suggesting that taking antioxidants might improve semen parameters, particularly motility and abnormal forms. Supplements like selenium, zinc, and other antioxidants have shown some evidence of improving sperm quality, but the evidence remains controversial.
Lifestyle changes like reducing alcohol consumption, quitting smoking, and potentially taking antioxidants may help reduce the number of abnormal sperm forms. However, it’s important to note that the results can vary depending on the laboratory. I’ve seen patients with seemingly poor sperm parameters who have conceived naturally. Sometimes, couples do a semen analysis before trying to conceive, but this can open a bit of a “can of worms.” In these cases, they might already be concerned about the abnormality and wonder why they have an isolated problem. But often, it’s about timing. Infertility is defined as a couple who, after a year of unprotected intercourse, are still unable to conceive. About 75% of couples will conceive by the end of the first year, and 95% by the end of the second year.
So, we need to be careful not to over-diagnose, over-treat, or over-worry patients based on very small differences in sperm parameters.
I don’t know if you remember those slides—I’m sorry, they were a bit technical—but as you get older, you can see the percentage increase in the risk of erectile dysfunction. It’s interesting because it’s not just about the arteries; as you get older, you naturally develop more problems related to cardiac disease, which can affect the blood supply to the penis. But what’s even more interesting is that age also causes changes in the muscle of the penis. So, in itself, you could argue that erectile dysfunction is a normal part of ageing.
If you look at sexual activity as people get older, the number of times people have sex tends to decrease. Testosterone levels, interestingly, start to fall off around the age of 40. So, Catherine, you were asking about testosterone before, and it seems that erectile dysfunction and testosterone levels are interlinked. Testosterone has an impact not only on chemicals but also on the muscle bulk of the penis. So, yes, it is a normal part of ageing.
The question you asked, for example, about someone who’s had chemotherapy—it’s quite common for patients who undergo chemotherapy to experience azoospermia, meaning they don’t have sperm in the ejaculate. In these cases, we sometimes use a procedure called TESE, which stands for testicular exploration and sperm extraction. Essentially, we go into the “engine room,” which is the testicle, to extract sperm. There are specific circumstances under which we do this.
A brief overview would be that we generally perform this procedure in patients who don’t produce sperm in the ejaculate. This can be due to an obstruction, which is obstructive azoospermia, or it could be non-obstructive, and these are different types of scenarios. Non-obstructive azoospermia is often caused by chemotherapeutic agents, and in about 70% of cases, the cause is unexplained. However, there can also be genetic causes.
Now, in this operation, my preference is to use a technique called micro-TESE or microdissection testicular sperm extraction. This technique was invented by Peter Schlegel in New York. It involves opening the testicle like a book, which allows us to look for sperm. Interestingly, with this method, we can find sperm in about 50% of cases of non-obstructive azoospermia. However, we still don’t fully understand why sperm can be present in the testicle but not in the ejaculate. That’s a question we haven’t yet answered.
To clarify, yes, you can perform testicular exploration and sperm extraction. There are different types of sperm extraction techniques, but we tend to think that microdissection testicular sperm extraction, which is done under a microscope, is the best technique. It reduces the risk of damage, which is one of the reasons we prefer it.
Additionally, there are other reasons why you might perform testicular sperm extraction, such as in men who have a blockage that prevents sperm from being retrieved through needles or from the sperm tube at the back of the testicle, called the epididymis. In such cases, you would need to go directly into the testicle to extract sperm, which can then be used for ICSI treatment. The sperm can be frozen and used later for ICSI.
Yes, it does. I think there’s more and more emerging data on this topic. If you look at various studies, there is evidence to suggest that alcohol can impact fertility. We’ve conducted our own studies, which we haven’t published yet, and we found that drinking alcohol was associated with poorer IVF outcomes. However, we don’t yet know the full extent of alcohol’s effects on sperm. That said, within limits, it’s probably reasonable to have an occasional drink.
I wouldn’t tell someone to completely avoid alcohol because we don’t have conclusive evidence on that. But interestingly, in the small study we did, we found that people who drank alcohol had worse IVF outcomes. It’s important to note that this was a very small study, and we haven’t published it, so it should be treated with caution. There are also other studies in the literature reporting similar findings.
Some studies suggest that limiting alcohol intake to about five or six units per week might be optimal. If you’re trying to conceive and you’re motivated, it’s probably better to avoid alcohol.
Yes, so 76% is a normal, healthy number. The standard should be 40% and above when looking at the motile sperm—meaning how many sperm are moving in a sample. People also refer to progressive motility, which describes the sperm moving forward, for example, going from point A to point B.
However, there’s another concept I’ve mentioned before, which is the total motile count. This is slightly different from motility as a percentage. It refers to the total number of sperm in the sample that are moving, which you can calculate. This concept helps address the whole issue of abnormal forms.
A total motility of 76% would indicate that the total amount of moving sperm in the sample is 76%, which is a healthy number.
