Sexual dysfunction

Accompanying the deviation, and at the point where the angulation occurs, you will probably be able to feel a firm plaque. This often is tender and may make intercourse painful.

The cause of it is uncertain. It nearly always starts in early middle age or older and, therefore, there may be a degenerative aspect to it. For many years it has been thought that the repeated minor traumas which occur during intercourse are the underlying reason for the trouble and, in particular, it has been thought that the pressure of the female pubic bone on the dorsum of the penis is important. However, doubts have now been expressed about this theory and recently the idea that the root cause of the trouble may lie not in trauma but in changes to the blood supply to the penis. Evidence for this latter theory includes the demonstration that arterial disease is 30 per cent more common in patients with Peyronie’s disease than in other men. There is also evidence of an occasional association between it and diabetes in a portion of patients, and also raised levels of cholesterol. The treatment is usually surgical but is usually not recommended unless the deviation is such that penetration becomes impossible.

Does the size of penis indicate if the male has hypogonadism? I want to marry; how can I decide I have not got hypogonadism? Name and address withheld

The size of the penis is only one indication of a low level of testosterone and, if this was the cause of a small penis it would be associated with other obvious evidence of this, in particular, small and soft testicles. The man too would either have unusually sparse amounts of body hair or a female pattern to the pubic hair. The size of penises varies considerably from man to man and there are both racial and familial patterns to this. An anxiety about penile size is very common. One of the reasons is that men usually see their penis from above, which makes it look smaller. If somebody is anxious to find out if they have hypogonadism, there are four very useful biochemical tests, which can be carried out on a blood sample. The testosterone level should be measured, the SHBG (sex hormone binding globulin) level must be assessed as this gives an idea of how much of the testosterone the testicles are producing is in a form which can be utilised by the body, the FSH (this is a hormone produced by the pituitary which determines how hard the testicles are having to work to produce the testosterone). And, finally, it is worthwhile measuring the prolactin, another hormone produced by the pituitary, which has an affect on sexual function.

In many years of experience working in a genito-urinary clinic, the overwhelming majority of men I saw who were convinced that their penis was abnormally small had absolutely normal penises and normal hormone levels. If it is going to be reassuring it is always worthwhile having these different hormone levels estimated.

Are there any short or long term adverse effects of taking Viagra twice a month? Name and address withheld

Special care is needed if someone is taking Viagra if they have any form of heart disease, which might make excessive sexual activity inadvisable. Men can undertake sexual intercourse if they can climb a couple of flights of stairs without becoming breathless. People taking Viagra should also know that their liver function is normal, so that the Viagra may be adequately metabolised, and they should not take it after a stroke or recent heart attack.

It is absolutely contra-indicated if anyone is taking any of the nitrate drugs, amylnitrite or ritonavir for angina or other form of coronary arterial pain. Care has to be taken too with Viagra if other drugs which are metabolised along the same pathways in the liver are being taken at the same time. Your own doctor would have warned you about these when he wrote out your prescription. If you are unwise enough to buy it off the internet, the drugs you have to be particularly careful about are erythromycin, a commonly used antibiotic; cimetidine, one of the drugs treating indigestion; an antifungal, Ketoconazole; and the alpha-blockers for heart disease. Even grapefruit juice can affect its metabolism.

If you don’t have any adverse affects from Viagra, you don’t have any form of disabling heart disease, you are not taking nitrates for angina and you are not taking the two drugs we mentioned, Viagra twice a month will do you no harm at all. There certainly would be no particularly long-term adverse affects from it, always provided of course you have normal liver function.

Could you advise on failure to ejaculate, as distinct from erection difficulty? How does it relate to age, medication, and how can it be dealt with? We are a long married couple nearing 70, husband on medication for high blood pressure, which seems to prevent ejaculation. Name and address withheld

Failure to ejaculate, or delayed ejaculation despite having normal erections, is a common problem which particularly affects older people. It certainly has a relationship to age, as it is thought that the penile skin becomes less sensitive with age as the nerve supply to it begins to degenerate.

Likewise medication, including medication given for high blood pressure, or self-administered medication in the form of rather too much alcohol, will also delay ejaculation and sometimes even prevent it.

Apart from not having too many glasses of wine and trying different drugs to treat high blood pressure, the usual advice is to try different positions for intercourse, so that greater pressure is applied to your penis on penetration and during intercourse. Some men find that penetration from behind achieves this but it is, to a certain extent, a matter of trial and error. Likewise, if you are being handled by your wife, she will have to grip your penis more firmly to achieve the same result as she would have done 15 years earlier. One frequent problem which I have come across over the years is that some women hold their husband’s penis between their thumb and forefinger, which doesn’t provide so much contact as if it is grasped with the whole hand. My advice, therefore, is to discuss other pills to treat your blood pressure, to experiment with different positions and to rest assured that this is a common problem in older men.

My wife is aged 56 and for the past 18 months has had the symptoms of the menopause. How long is it likely to last? She has completely changed, ie, hot sweats, loss of libido, depressed, no interest in life, etc. Our GP’s attitude is: “You are on the change, get on with it.” Name and address withheld

The standard advice on treatment of the menopause is that it is still permissible to take HRT for a short time while the symptoms are at their worst, but that this should then be reasonably quickly tailed off, ie, a woman shouldn’t be taking it for more than a year or two.

Obviously if there is a contra-indication to HRT because of previous thromboembolic problems, smoking, etc, your own doctor would know about it. I would suggest that your wife has a chat with her GP about this, as he is the only person who will know all the circumstances and whether short-term HRT is warranted. The symptoms your wife describes are the classic ones for the menopause, and with HRT the recovery can be dramatic.

I am a 54-year-old, post-menopausal female and have been experiencing a lot of pain during intercourse. Apart from a few hot flushes, I had absolutely no problems during the menopause. I have been married for 26 years to a very patient husband. I never found intercourse particularly enjoyable, but now it is non-existent because it is so painful. I tried HRT patches for a few months but didn’t like them and, couldn’t see the point of paying £12/month for sex once a month. We’ve tried creams, which help somewhat during penetration, but I then suffer a very painful burning sensation when my husband reaches his climax (I never get that far). Is there anything else I could try to make it less painful, and therefore more enjoyable? I’ve tried talking to my doctor but don’t find it easy. Name and address withheld

After the menopause the female sexual response, as well as libido, may go in any one of three ways. In many women the sexual drive, which has been increasing with age as the level of testosterone to oestrogen increases, grows. In these women the normal response is for this desire to level off – to plateau out. In those who find the menopause and the end of reproductive life a distressing concept there is often a feeling of inadequacy, and these women may want sexual intercourse often, to reassure them that they are still desirable. Other women, who may be slightly depressed, and may have been growing more depressed over the years as oestrogen levels change, may find that once the menopause has arrived they have lost both libido and sexual response.

Whatever the sexual response, nearly all women develop a thinner lining to their vagina, and therefore one that is more easily inflamed and infected. Also the vagina itself usually shrinks in diameter. These local vaginal changes lead to superficial dyspareunia - pain in the vagina at penetration. Using HRT patches for a few months is effective, if expensive. Local hormone creams are not very useful unless you use them so regularly that your hormone levels are altered, in which case you might as well have had the patches. Lubrication creams and jellies, such as KY, are recommended, and it would also be worthwhile buying a dilator so that you can gradually re-expand your vagina.

I would therefore recommend the HRT patches, a dilator and a lubricant jelly. However, I would strongly suggest that even if you don’t find it easy talking to your doctor you have a chat about this, as only he/she will know your full circumstances. The occasional doctor also finds it difficult to talk about sex, in which case he/she could always send you to see an expert.

I am on a daily dose of Finast 5mg and Doxacard 2mg for my enlarged prostate. I am unable to get a full erection and am unable to sustain the half erection. Can this be due to medication, or is it due to my age (71), although till I started this medication I had no such problems? Can I do anything about it? Name and address withheld

I have spent some time looking up both Finast and Doxacard and neither, I’m afraid, is given in either the British standard list, nor in my edition of the international formulary. I suspect that the Finast is really Finasteride in one of its forms, which is sold in the UK as Proscar. It is a first-rate drug, used to treat benignly enlarged prostates.

There are three different ways of treating prostatic enlargement. A man can have a minor operation, in which the center of the prostate is cored out rather as an apple core is removed from an apple; this is known as a TURP. Or you can take one of two different types of drugs: the 5alpha-reductase inhibitors, which include Finasteride (Finasteride in some parts of the world is sold as Finastin); or a selective alpha-blocker. The Finasteride drug actually induces shrinkage of the enlarged prostatic tissue, whereas the selective alpha-blocker relaxes the muscles in the prostate and in this way allows the passage of urine.

Doxacard I cannot help you with, but it is perfectly true that any of these drugs may affect the quality of your erection, and also make it difficult to sustain an erection. If you find you are having this trouble with the Proscar, it might be worthwhile taking a selective alpha-blocker, but you need to talk to your urologist about this and explain your problem. Conversely, if you have no contra-indication to the use of one of the Viagra-type drugs [see above], you could also take Viagra, as well as your drugs, to treat prostatic hyperplasia (increase in the volume of the glandular tissue).

Finally, a word of warning. Remember that Proscar affects the level of the PSA – the guide to whether or not there is any malignant tissue present. Once a man starts to take Proscar he should double his PSA reading to derive the true one.

I am due to have an operation (prostatectomy) for the relief of a minor urinary problem, which I understand is quite common. However, I have recently been reading an article from Vision of Health, which advocates the benefits of supplements as opposed to surgery. Apparently this use of supplements is far more common in Europe than in either UK or America. Could you outline the risks involved in surgery, including the important risk of becoming impotent? Name and address withheld

I haven’t much faith in natural supplements for the relief of the symptoms of prostatic enlargement. If you can be certain that there is no evidence of malignancy about your enlarged prostate, and don’t want to have a prostatectomy, it is always worthwhile trying one of the 5alpha-reductase inhibitors, such as Finasteride (Proscar), or a selective alpha-blocker.

You have written that STDs can be transmitted through oral sex - can you elaborate? Name and address withheld

Yes, sexually transmitted diseases can be transmitted through oral sex. It has always been accepted that gonorrhoea and syphilis can be transmitted through oral sex. It then became obvious that chlamydia is also transmitted orally. There were some doctors who, for no very good reason, suggested that HIV couldn’t be handed on in this way. However, research a few years ago (initially in Sweden), showed that as many as one case in four with HIV in a particular trial had been transmitted orally. This was to be expected. Likewise hepatitis C and B can be spread orally.

The mucosal lining of the mouth, the genitalia and the eye are all very similar, and all three of these sites are possible sites for infection by STDs. It is now recommended generally that when having oral sex with a stranger the man should wear a condom, but this of course doesn’t overcome the problem when the sexual roles are reversed.

After many months of suffering from cystitis-type problems I went to see a private GP who diagnosed candida. The special diet I have been put on has helped, but the symptoms are still there. Are there any medical treatments for candida albicans? I have particular pain in the vagina area and am confused about where to get treatment, as opposed to the diet of pre/probiotics and cutting certain foods from my diet. My own GP denies that there is a problem. Name and address withheld

I have never had much confidence in the effectiveness of altering the diet as a means of controlling vaginal candidiasis. It may play a role in controlling it, but I would have thought no more than that. As you know, at any one time there is one chance in three that a woman will have a small amount of candida (thrush) present in her vagina, and it is only when this becomes profuse that the patient suffers pain and an irritating rash. Pre and probiotics may be useful too, but like altering the diet, only of limited help. I have always believed in pessaries, coupled with something taken by mouth. The pessaries I recommend are either gyno-daktarin, gyno-pevaril, or Canestan. To take by mouth, either diflucan or sporanox. This usually puts paid to it for a time, but it tends to come back.

It is often forgotten that it is as well to treat your partner at the same time. An application of Canestan cream to your partner before intercourse not only serves to treat him but also inserts the cream high into your vagina. Your partner should then apply more cream later to himself. The pain from thrush during intercourse is partly because the discharge of thrush is a very poor lubricant and tends to dilute your own natural lubrication.

I am thinking about having the snip. I wonder if you could advise on what follows. I watched a programme on TV about how when a man is apart from his partner he does not consciously know, but he is producing more sperm in case his partner has been copulating with another male. I believe this adds to sexual drive. I would like to know whether after the snip a male is still motivated in the same way. Name and address withheld

I sat on the government-appointed committee to inquire into the snip in the early 1970s, when it first became popular. I had been rather an advocate of it until I heard all the evidence, after which I thought that it shouldn’t be the first method of choice. A surprising number of men, for one reason or another, either want or need to have it reversed. This is possible, but by the time the reversal occurs they may already be producing an immune response to their own sperm. A surprising number of men, too, had persistent discomfort after the snip. Sometimes this was no more than a matter of bruising, and it soon passed away, and at other times some leakage of fluid had set up a reaction in the scrotum. Furthermore, all the animal research showed that those animals which had had a vasectomy done in earlier life tended to have smaller testes when older. One doesn’t know what, if any, effect this might have on libido and potency in older age. There was no convincing evidence that men who had a vasectomy were more likely to develop cancer of the prostate, but it was an idea which was mooted. Vasectomy remains a very good method of contraception for those partnerships where other methods are not suitable. But I have never recommended it as first choice.

A man who abstains from sex, or has less sex than usual, has a higher sperm count, but more of the sperm tend to be rather aged, and less active. I don’t think there is any magic way in which he produces more sperm to overcome any left behind by an extra-partnership relationship which has been indulged in by his female partner. Nor do I feel that a man’s sexual drive would necessarily be increased by his regular partner having sex with somebody else, and if it was, I feel certain the result would be psychological rather than physiological.

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