Ejaculation Problems

DELAYED EJACULATION AND ANEJACULATION (INABILITY TO EJACULATE)

A difficulty to achieve orgasm/ejaculation is uncommon but can be significantly distressing to men and their partners who may believe he is less aroused by them, which, is one cause.
Other causes include:

Medical causes include diabetes mellitus. Prostatic surgery can cause retrograde ejaculation i.e. into the bladder but there is generally still the pleasure of orgasm.
Medications such as antidepressants and beta-blockers.
Excessive masturbation and porn addiction
Excessive stress

Psychosexual therapy to reduce inhibitions can be effective for many patients.
Nasal oxytocin sprays can help in a few cases as they are medications that raise the dopamine (promotes ejaculation) levels. These drugs were not designed to treat delayed ejaculation but are an option.

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48-year old Keith was pushed by his wife Natalia to seek help for low sexual desire. For the past 9 months he had not instigated sex with her and she was beginning to believe that he had met another partner. She is 10 years younger than him, retains a very healthy libido and was considering leaving him.

Keith shared that despite loving his wife and still finding her very attractive, he no longer felt the urge for sex. There was no difficulty with attaining or maintaining full erections. He reported having very low energy levels with fatigue in the afternoon, absent morning erections, difficulty to concentrate at work, marked mood swings and poor motivation. The grumpiness and reduced help around the house was causing major friction. He used to attend a gym on a regular basis but ceased because he no longer felt benefits from exercise and had muscle pains for several days after.

There was no significant medical history and he was not taking any medication. He was not overweight. Testicular volume was lower than normal with no history of previous trauma or infection to the testicles recalled.

Subsequent early-morning blood tests revealed that Keith had low testosterone levels. Elevated pituitary hormone levels revealed that despite increased stimulation from the pituitary gland, the testes were no longer able to produce adequate testosterone (primary hypogonadism).

Testosterone has a profound effect on sexual function, brain function, muscle mass, bone density and other parts of the body. While no cause for Keith’s low testosterone levels were evident (as occurs in 50% of cases), his quality of life was clearly suffering because of the low levels.

He was commenced on testosterone replacement with a preparation applied to the skin each day and within 3 weeks described feeling like a new man with resolution of all symptoms. Natalia was absolutely delighted saying “I have my man back”.

Note: There is controversy even amongst the medical profession as to whether or not testosterone replacement therapy is indicated and/or safe. Around the world the consensus is that indeed testosterone replacement is indicated in men with a clinical picture of low testosterone and associated low testosterone levels. Full assessment is therefore required along with education before commencing men on replacement as this is a lifetime decision and requiring continued monitoring.

21-year-old furniture maker, Mark, presented with a history of premature ejaculation beginning with his first sexual partners. Mark confided that he always ejaculated less than 60 seconds after penetrating a partner, had no control over this and the problem was causing him major distress. A number of relationships had ended because he was unable to satisfy his partners and he described feeling like a total failure. Techniques such as the stop – start technique and getting drunk before sex had very little benefit.

Mark was congratulated for having the courage to address his problem, and was informed that up to 30% of men have PE in their lives and that effective treatments exist. He was transformed.

We discussed that the cause of lifetime premature ejaculation is primarily an imbalance between two neurotransmitters (chemicals within the brain) and that this runs in families. Dopamine pushes us towards ejaculation and serotonin blocks ejaculation. In PE the serotonin level is low making it impossible to prevent ejaculation even with various physical exercises.

After hearing the treatment options, Mark elected to commence a daily SSRI which after three weeks allowed him to last over five minutes before ejaculation. On review he was ecstatic.

We went through various relaxation techniques such as breathing meditation and mindfulness as means to take further control over the time to ejaculation with a view to tapering him off medication, if possible, in the future.

Andrew’s wife Emanuella encouraged him to make an appointment with us for erectile dysfunction.

18 months ago he found it increasingly difficult to attain an erection sufficiently hard for satisfactory sex which he and Emanuella last had three months ago. Initially he had a full response to Viagra 100 mg and Cialis 20 mg, but these gradually became ineffective over 12 months. Andrew was becoming increasingly distressed at being unable to satisfy Emmanuella and was avoiding physical intimacy.

Andrew is a 62-year-old Construction Engineer working long hours in a stressful environment. He quit smoking 15 years ago after 25 years of 20 cigarettes per day. With a relatively sedentary job he was 15 kg overweight and had been on medication for diabetes for the past five years which he confided was poorly controlled. He was also on medication to treat elevated cholesterol levels.

Approximately 50% of men Andrew’s age have erectile dysfunction, he was greatly relieved to hear that he was not the only one. Causes of ED include blockage of the small arteries to the penis, nerve damage, low testosterone, medications, dysfunction of the mechanism that normally seals blood within the penis and performance anxiety. Any stress such as fear of failure results in the release of adrenaline which rapidly causes deflation.

It was explained to Andrew that the cause is very likely to be a mix of arterial blockage and secondary performance anxiety. As blockages can occur in arteries to other organs such as the heart, vascular ED is referred to as the “canary in the pants”. Andrew was asked to have a CT coronary artery calcium score to exclude signs of blockage to the coronary arteries.

We discussed the severe toxic nature of fat within the belly and the urgency to reduce his weight with a supervised diet and regular aerobic exercise such as walking at a moderate pace for 45 minutes, 3 – 4 times per week. He agreed to see his GP to discuss better control of diabetes. We also discussed relaxation techniques such as mindfulness and for Andrew to re-prioritise time for work and play.

He was interested to know that Renova low intensity shockwave therapy can stimulate the body to produce new healthy arteries and wished to research this further. In the meantime he was taught self-injection of the penis which produced fully satisfactory erections. Emanuella had no problem for the need for penile injection to restore sexual intimacy. In fact he arrived home one evening, opened the fridge for a beer and found an injection syringe drawn up ready to go with a little bow placed around it.

Dr Yin Min Hew is the Medical Director of Perth Men’s Health. As a UK trained specialist in Sexual Health Medicine, Yin Min has been involved in managing STD and HIV. He strongly feels that sexual health is an important aspect in life and that providing a safe and comfortable zone to discuss the issues is crucial to the overall wellbeing of a person.

Areas of Specialty include:

Sexually Transmitted Diseases (STD)

Chlamydia
Gonorrhoea
Syphilis
HIV Medicine
Genital warts and genital herpes
Hepatitis B and C
Mycoplasma genitalium

HIV Preventative Medicine

Pre-exposure Prophylaxis for HIV (PrEP)

Male Sexual Dysfunction

Erectile dysfunction (inability to achieve and/or maintain an erection)
Premature ejaculation (coming too quickly)
Delayed ejaculation
Loss of libido (lack of desire for sex)
Peyronie’s Disease
Sexual rehabilitation following prostate surgery

Relationship Counselling

Nick has worked as a nurse on surgical wards since 2009. His role involves the pre and post-operative care of patients who have undergone urological and gynaecological procedures. Nick has a keen interest in urology, in particular procedures relating to the prostate. Nick joins the practice to manage the sexual recovery aspects of patients that have undergone prostate surgery. Not only will he assist with the teaching/educating components of rehabilitation, he will also assist with other treatments that relate to men’s sexual health. Nick is available to speak with you on a Monday, Wednesday and Friday.

Teaching/Education

Penile rehabilitation post prostate surgery
Testosterone replacement therapy (TRT)
Intracavernosal injection (ICI)

Treatments

Renova shock wave treatment

Patrizia and Wilma are our dedicated receptionists.

John came in with his wife Belinda at the recommendation of his Urologist, two weeks prior to robotic assisted laparoscopic prostatectomy. They had largely come to grips with the diagnosis, the decision to proceed with surgery and John was undergoing a Physiotherapist supervised pelvic floor exercise program. They were unsure as to why they had come in prior to surgery to discuss erectile function as they had resigned themselves to the possibility that sexual intercourse would no longer be a component of their close and loving relationship.

Both were in their late 50s and prior to diagnosis they enjoyed sex on a regular basis. John shared that he had no erectile dysfunction and retained a healthy libido . The only significant medical history was of abdominal obesity and borderline diabetes. Lifestyle was healthy in all aspects. Examination of the penis and testes was completely normal.

They had been told by their surgeon that nerves would have to be sacrificed on one side of the prostate because of their closeness to the cancer but that nerve sparing on the other side was likely. We discussed the fact that, while these nerves would not be cut, they are incredibly fragile and almost always become bruised in the process of being kept out of harm’s way. This nerve damage results in severe erectile dysfunction until the nerves regenerate, which if it occurs, takes from 12 to 18 months.

They were informed that John was having approximately 6 erections every night to preserve erectile tissue health and elasticity and that these would cease after surgery because of the nerve damage. We then went over a program to maintain erectile tissue health and elasticity while we wait to see what degree of nerve regeneration occurs.

Because medications like Viagra and Cialis require significant nerve function we discussed why these would not be effective in achieving a full erection in the medium-term following surgery. Upon hearing that penile injection (virtually painless, simple to learn and safe) would allow a return to full erectile function within several months after surgery, they became quite exuberant. John admitted to being depressed at the thought of impotence following surgery because he enjoyed sexual intimacy with Belinda and distraught at being unable to satisfy her sexual needs.

He was apprehensive at the thought of self-injection but Belinda offered to inject him calling it a “new form of foreplay”.

We discussed the effect of his visceral obesity and borderline diabetes in causing blockage to the arteries of the penis over the next 12 – 18 months. I urged him therefore to undergo a supervised weight loss program to prevent this.

In the end they were delighted that they had come along to discuss penile rehabilitation prior to surgery and that options exist for them.

Chlamydia

the commonest STI that is easily passed in during sex.
causes pain on urinating or discharge
pain in the lower abdomen or testicles
abnormal vaginal discharge and pain during sex in females

Gonorrhoea

white or yellow discharge from penis and pain on urination
pain and tenderness on testis
vaginal discharge and abnormal bleeding in females

Syphilis

early stages cause painless or painful ulcers on genitals or mouth
sore can disappear after 5-6 weeks
secondary stages can give symptoms like rash on body, patchy hair loss, disturbed vision
late stages occur after many years and can cause serious conditions such as heart problems and paralysis

HIV

can be passed through unprotected sex, infected blood (i.e. sharing needles)
affects immune system making it less able to fight infections and disease
nonspecific symptoms – rash, flu like illness, sore throat, swollen glands on neck (seroconversion illness) initially
no cure for HIV but highly effective treatment to control the infection

Trichomoniasis

caused by parasite called Trichomonas vaginalis (TV)
In men, rarely causes symptoms – may experience pain or burning after passing urine or have an inflamed foreskin
in females, a frothy white watery discharge, itching or soreness of the vagina can be noticed

Genital Warts

fleshy growths, bumps or skin changes on genital area
caused by Human Papilloma virus (HPV)
occasional itching, soreness
spread via skin to skin contact

Genital Herpes

common virus caused by Herpes Simplex virus (HSV)
can develop painful small shallow ulcers on genital area
can also cause itching and tingling sensation and difficulty urinating
no cure but can be controlled with antiviral medication

Pre-exposure prophylaxis for HIV (PrEP)

The risk of HIV infection can be minimised by taking an oral tablet called Truvada (or equivalent) Based on multi international trials, this has proven to be efficient in reducing the acquisition of HIV in high risk situation if taken consistently before sex.
For more information, please arrange an appointment to discuss further.

Sam awoke one morning to find that his morning erection was bent upwards and slightly to the left side. He was understandably horrified. There had been no trauma to the penis with he and his partner, Mary, last having sex two days ago. On examining his penis, he could feel a small tender lump on the top of the penis. Sam did not alert Mary hoping the problem would go away.

The next time he and Mary attempted sexual intercourse he found it difficult to achieve vaginal penetration. They managed to have sexual intercourse, but she commented on the difficulty to penetrate and was shocked to see his bent penis. He was mortified.

“Dr Google” revealed that he most likely had Peyronie’s disease. A massive number of treatments were recommended on-line including surgery. Confusion and a heavy work schedule led to Sam avoiding no to see his GP until Mary urged him to do so, 8 months after the onset. His GP confirmed the diagnosis of Peyronie’s Disease? link to PD in conditions we treat and referred Sam to PMH.

Sam had the foresight to bring in 2-demensional photos of his erect penis, which, using a protractor revealed a 40-degree upwards curve commencing at the middle of the shaft and a 20 degrees curvature to the left side. He reported some difficulty to maintain a fully firm erection. Examination revealed a 1 x 2mm area of fibrosis (plaque) in the middle of the top of the shaft extending slightly to the left side.

We recommended that Sam begin a conservative course of treatment consisting of once daily Cialis 5mg, use of a vacuum erection device (VED) in a structured program and a 5-week course low intensity shockwave therapy. In his case, over a period of 3 months, the treatment resulted in removing the curve to the left side, reduction of the upward curvature to 20 degrees (measured by repeat photos) and a return to full erectile function. Sam was very satisfied with the outcome. As the problem was initially causing significant distress between, he and Mary, we referred him to a Psychologist with Sexology training at the beginning of the physical treatment for counselling and guidance. They reported major benefit from this.

Disclaimer: Not all patients will have the same degree of success with conservative treatment. Beginning a holistic, scientifically based treatment program is however a major psychological boost to patients such as Sam, especially with his wife’s support.