Sexual Problems In Women,women, Problems,sexual,

A-PDF Merger DEMO : Purchase from www.A-PDF.com to remove the watermark

Sexual Problems in Women Topic Overview What are sexual problems?

A sexual problem means that sex is not satisfying or positive for you. In women, common sexual problems include feeling little or no interest in sex, having problems getting aroused, or having trouble with orgasm. For some women, pain during intercourse is a problem. Most women have a sexual problem at one time or another. For some women, the problem is ongoing. But your symptoms are only a sexual problem if they bother you or cause problems in your relationship. There is no "normal" level of sexual response, because it is different for every woman. You may also find that what is normal at one stage of your life changes at another stage or age. For example, it's common for an exhausted mother of a baby to have little interest in sex. And it's common for both women and men to have less intense sex drives as they age. This is linked in part to hormone changes in the body. What are some causes of sexual problems in women?

Female sexuality is complex. At its core is a need for closeness and intimacy. Women also have physical needs. When there is a problem in either the emotional or physical part of your life, you can have sexual problems. Some common causes include: • • • •

Emotional causes, such as stress, relationship problems, depression or anxiety, a memory of sexual trauma, and unhappiness with your body. Physical causes, such as hormone problems, pain from an injury or other problem, and certain conditions such as diabetes or arthritis. Aging, which can cause changes in the vagina , such as dryness and stiffening. Certain medicines that can cause sexual problems. These include medicines for depression, blood pressure, and diabetes.

What are the symptoms?

Sexual problems can include: • • • •

Having less desire for sex. Having trouble feeling aroused. Not being able to have an orgasm. Having pain during intercourse.

How are sexual problems in women diagnosed?

Women often recognize a sexual problem when they notice a change in desire or sexual satisfaction. When this happens, it helps to look at what is and isn't working in the body and in life. For example: • • • • •

Are you ill, or do you take a medicine that can lower your sexual desire or response? Are you stressed or often very tired? Do you have a caring, respectful connection with a partner? Do you and your partner have the time and privacy to relax together? Do you have painful memories about sex or intimacy?

Your doctor can help you decide what to do. He or she will ask questions, do a physical exam, and talk to you about possible causes. Some women find it hard to talk to their doctor about sexual problems at first. Sometimes it helps to write out what you want to say beforehand. For example, you could say something like “For the past few months, I haven't enjoyed sex as much as I used to.” Or you could say "Ever since I started taking that medicine, I haven't felt like having sex.” How are they treated?

Treatment for sexual problems depends on what is causing the problem. There may be one or more issues causing the problems. Many sexual problems can be worked out after you know the cause or causes. Sex involves emotional, physical, and relationship issues. Successful treatment requires a high level of comfort between you and your doctor. Ideally, you and your partner will also be able to talk openly about sexual concerns. Treatment may include treating health problems, getting communication counseling, and learning about things you can practice at home. For example, you might take a warm bath to relax, have plenty of foreplay before sex, or try different positions during sex.

Sexual Problems in Women

Cause A woman's sexuality is a complex mix of mental, emotional, and physical signals. A problem in one area can grow to involve others. For example, a physical problem can lead to fear of pain, and the fear can lead to guilt about its effect on your partner. So the causes of sexual problems in women are often interrelated.

Psychological causes may be related to past or current physical or emotional problems. These mental and emotional causes include: • • • • • • • •

Stress.

Marital or relationship discord. Previous pelvic trauma. Involuntary and often painful contractions of the vagina (vaginismus), sometimes linked to memories of pelvic trauma or abuse. Depression. Fears that illnesses, such as cancer, or surgery, such as a mastectomy or hysterectomy, will make sexual activity unpleasant for the woman or her partner. Unhappiness with body image. Anxiety.

Physical causes can be normal hormonal changes, injuries, medical procedures, or other medical problems. Physical causes include: •

•

•

Hormonal changes such as those related to the menstrual cycle, use of birth control pills or hormone therapy, pregnancy, recovery from pregnancy, perimenopause, and postmenopause. Pain during intercourse. This may result from: o Physical changes from surgery, radiation therapy, or other medical procedures. o An injury. o A physical abnormality. o Vaginal dryness. o Painful, involuntary contractions of the vaginal muscles (vaginismus). This is sometimes linked to the body's "memory" of pelvic trauma or abuse. o Genital herpes. o A vaginal infection (vaginitis). Medical conditions, including diabetes, arthritis, urinary incontinence, urinary tract infection, stroke, coronary artery disease, hypertension, atherosclerosis, multiple sclerosis, hypothyroidism, endometriosis, or a nervous system problem (neurological disorder).

Aging may cause a decrease in sexual desire and changes in the vagina. These changes include: • • • • •

Increased vaginal sensitivity, so that the vagina may be easily bruised or chafed. Narrowing, shortening, and/or stiffening of the vagina, causing pain during intercourse (dyspareunia). A reduction in lubrication and a lengthening of the time needed to lubricate the vagina. More time needed to feel sexually aroused. Orgasms that do not last as long they once did.

Medication use can sometimes decrease sexual desire and arousal. Such medications include: • • •

Blood pressure and diabetes medicines, such as diuretics, alpha-blockers, and calcium channel blockers. Antidepressants. These include tricyclics and selective serotonin reuptake inhibitors (SSRIs). Antihistamines, which are allergy medicines.

• • •

Opioids and tranquilizers. Opioids are used to treat pain. Tranquilizers are used to calm the nervous system. Appetite suppressants. These are also known as diet pills. Chemotherapy for cancer.

Losing a partner is a common life event that can lead a woman to be less sexually active and satisfied. This is not a "sexual problem," but it can leave you with unmet needs for intimacy. Cultural and societal factors may play a role in a woman's sexual health. Inadequate health services and/or a lack of sex education may result in a woman's lack of knowledge about sexual behavior. In addition, a woman may feel unable to meet the societal standards of attractiveness or sexuality, or she may believe herself to be incapable of meeting family and cultural expectations of a woman's role in life.1 Drinking alcohol to excess may increase the time it takes for a woman to reach orgasm. In addition, some women who feel sexually inadequate when sober may drink to mask those feelings temporarily. Alcohol can play a role in creating a cycle of drinking and sexual problems.

Symptoms Symptoms of sexual problems can include: • • • •

A decrease in the level of desire, which might be expressed by fewer sexual fantasies or thoughts and a reluctance to engage in sexual activity. A decrease in the level of arousal. A woman may notice that she feels unreceptive to sexual suggestions and is not able to feel or maintain sexual excitement. An inability to reach orgasm after sexual stimulation. (For most women, the clitoris is the main site of orgasm. Not all women have vaginal orgasms.) Pain during intercourse.

By definition, sexual problems are symptoms that are distressing for you and/or your relationship with a partner. If you have a symptom that you are not troubled by and that isn't causing a relationship problem, then it is not considered to be a sexual problem. Most women have a sexual problem at one time or another. For some women, the problem is long-term. Surveys of the general population in the United States found that many women occasionally have sexual problems and worries, including:2 • • • • • • •

Concerns about sexuality (6 out of 10 women). Lack of interest in sex (3 out of 10 women). Sex not always being pleasurable (2 out of 10 women). Pain with intercourse (1 to 2 out of 10 women). Difficulty becoming aroused (5 out of 10 women). Difficulty reaching orgasm (5 out of 10 women). Not being able to have an orgasm (2 to 3 out of 10 women).

How common are sexual problems in women? A sexual problem is a decrease in or lack of sexual satisfaction. By definition, a sexual problem is distressing to a woman and/or her relationship with a partner. (What is distressing to one woman may not be a concern for another woman.) Most women are troubled by a sexual problem at one time or another. For some women, it can be a long-term problem. Surveys of the general population in the United States found that many women occasionally have sexual problems and worries, including:1 • • • • • • •

Concerns about sexuality (6 out of 10 women). Lack of interest in sex (3 out of 10 women). Sex not always being pleasurable (2 out of 10 women). Pain with intercourse (1 to 2 out of 10 women). Difficulty becoming aroused (5 out of 10 women). Difficulty reaching orgasm (5 out of 10 women). Not being able to have an orgasm (2 to 3 out of 10 women).

Prevention Women have varied and interrelated reasons for desiring sexual activity and feeling sexually fulfilled. A woman's sexuality is influenced by her physical, psychological, and emotional states. Some causes of sexual problems, such as medical conditions, may not be within your control. But your emotional and psychological states are as important as your physical state in influencing your sexuality. You can take the following steps to help your sexual well-being. • • • • • • •

Look after your overall health—both your physical health and your emotional health. Practice communicating your needs and desires to your partner. Become familiar with your own patterns and methods of sexual arousal, perhaps through masturbation. Try to separate your sexual life from the stresses of daily life, such as economic, career, and partner tensions. Understand that many women do not always have orgasms during sex and that mutual pleasure can be a satisfying focus of sexual intimacy. Use plentiful lubrication for your vagina to avoid the most common cause of painful intercourse. Enjoy tenderness and closeness, and avoid expectations of reaching goals such as great sexual performances.

What Increases Your Risk Risk factors for sexual problems include a current or long-term history of: • • • •

Exhaustion, often from round-the-clock care of a baby or small children and/or parenting and having a job. Normal hormonal changes linked to pregnancy, recovery from pregnancy, menopause, or aging. Emotional or stress-related problems, such as personal relationship tensions or economic concerns. Taking certain medicines that decrease a woman's desire for sex.

•

•

Health problems that cause pain during sex or decrease a woman's ability to engage in and enjoy sexual activity. Such health problems include: o Neurologic diseases such as stroke, spinal cord injury, and Parkinson's disease. o Surgery that affects a woman's pelvic organs or genitals. o Endocrine diseases such as diabetes or liver disease. o Peripheral arterial disease. Sexual trauma, such as rape or childhood abuse.

Exams and Tests Women often begin the process of diagnosing a sexual problem by noticing an absence of sexual desire or satisfaction. Your health professional will work with you to identify your symptoms and the history of those symptoms by: • •

Asking questions about your complete medical history, including any history of childhood sexual abuse or adult sexual assault, and your current sexual activity. Doing a physical exam.

Your doctor will use the information from the history and examination to determine the cause of your sexual concerns. Throughout the appointment and future treatment of a sexual problem, your doctor should establish an encouraging atmosphere for you to discuss your concerns. All of your communications about your sexual concerns should be maintained in a professional, confidential, and nonjudgmental manner. See a list of questions you might be asked by your doctor.

What to Think About

By definition, a sexual problem is a sex-related stressor for you and/or your relationship with a partner. If you have a symptom that you are not troubled by and that isn't causing a relationship problem, then it is not considered to be a problem.

Treatment Overview Many sexual problems can be managed when you understand what is causing them. Effective management requires a high level of comfort between you and your health professional, and possibly your partner. Because a sexual problem often has multiple causes, treatments cannot be universally applied—what works for one woman may not work for another. An effective plan will address and manage the cause and then build and strengthen intimate communication between you and your partner. The best results will help you find methods of having a satisfying sexual life.

Treatment may include: • • • • •

Medical treatment for any underlying cause. Education about your body, your sexual signals and receptors, and changes in sexuality as you get older. Communication counseling for you and your partner. Psychological therapy. Sex therapy.

Treatment for decrease of sexual desire

A decrease in your level of desire might be expressed by fewer sexual thoughts and/or a reluctance to engage in sexual activity. Treatment for physical causes can include: • • • •

•

Changing from a medicine that has been curbing your interest in sex. Relieving pain, illness, or sleep problems that are curbing your interest in sex. Hormone therapy with estrogen. After menopause, low levels of estrogen in the body cause vaginal dryness. This can be painful during sex. Estrogen reverses this. Testosterone with estrogen. Normally, a woman's testosterone slowly declines with age. It drops suddenly when a woman has surgery to remove the ovaries (oophorectomy, causing surgical menopause). Testosterone with estrogen is sometimes used after natural or surgical menopause to improve sex drive. When taken in too high a dose, testosterone causes male-type side effects, such as a deepening voice, thinning scalp hair, and growth of facial and body hair. Testosterone risks are not fully researched. Exercise, to improve your mood and increase natural testosterone levels.

Your doctor can treat physical or hormonal causes, and you can work on other facets of sexual desire. For example: • • •

•

Changing your setting and routine can improve your time together. Do you have enough privacy and time? Are you interested in trying something new? Having a partner you feel comfortable and nonstressed with plays a big part in your desire level. Getting counseling as a couple can help strengthen your emotional connection with your partner. Improving a stressed relationship is likely to improve your sexual relationship. It is normal to lack desire for a partner who forces sex or is verbally abusive or physically violent. For more information, see the topic Domestic Violence.

Treatment for decrease of sexual arousal

A decrease in the level of arousal might be noticed as an inability to feel or maintain sexual excitement. A woman's sexual arousal often is enhanced by, and is sometimes dependent on, stimulation in areas other than the genital area, especially the breasts. Treatment for a decrease in your sexual arousal may include: • • • •

Increasing the level of intimacy and sexual arousal with your partner before penetration. Liberal use of vaginal lubricants. Masturbation, possibly with the aid of a vibrator and/or with your partner. Education about the role that emotions play in sexual arousal.

• •

Counseling, to help adjust expectations of sexual activity. If too much pressure is put on partners to perform, arousal may be reduced. Medicine or treatment changes for other conditions, if needed to eliminate side effects that decrease arousal.

Treatment for an inability to reach orgasm

A woman may seek treatment because she has never experienced an orgasm, is experiencing long delays in reaching orgasm, or has become unable to reach orgasm. Treatment usually begins with changing any medicine that is known to affect orgasm. (Talk to your doctor before you stop any medicine you are taking.) It is also important to understand what a normal sexual stimulation phase would be for that woman. If a woman is experiencing a delay or absence of orgasm after adequate sexual stimulation, therapy often centers on guided home treatment, which may include:6 • • •

•

Talking and listening to each other more. This includes talking openly about sex, what each of you needs, and what you want to do differently together. Reframing expectations, so that sexual intimacy is focused on mutual pleasure instead of a perceived need to achieve orgasm.7 Increasing sexual stimulation through masturbation, possibly with the use of a vibrator and with your partner. This can also include doing exercises to develop muscular control (contraction and relaxation) of the pelvic muscles. Decreasing inhibition with fantasizing, distractions, and/or listening to music.

Treatment for pain during intercourse

Pain during intercourse often is caused by a physical reason, such as vaginal dryness or infection. This is why treatment must start with determining the underlying cause of a sexual problem. If a physical condition is the cause, treatment of that condition may eliminate the pain. But pain during intercourse may have more than one cause, including psychological causes such as anxiety or the memory of sexual assault.2 •

•

•

Pain that occurs during initial penetration by the penis may be caused by involuntary contractions of the vagina (vaginismus). Vaginismus is more common in young, inexperienced women and is sometimes related to a lack of education or preparedness for sexual intercourse.8 Treatment may include a program of progressive muscle relaxation and gradual vaginal dilation, possibly including psychotherapy. But pain during initial penetration also may be caused by vaginal irritation or an anatomical condition. If so, getting rid of the pain will require treating the physical reason. After menopause, it is common to have vaginal dryness. This can cause pain during initial penetration or after intercourse has begun and the penis is in the vagina. Try using liberal amounts of vaginal lubricant. If this does not work as well as you need, talk to your doctor about vaginal estrogen, which can reverse vaginal dryness and sensitivity. If the pain is caused by the deep thrusting of the penis, the cause may be a pelvic disease, but it may also be caused by an inability to relax. An open and trusting relationship with your health professional will enable you to explore the cause of the pain and decide on a course of treatment.

Treatment for aging and menopause-related sexual problems

It is common for a woman's sexual desire to decrease gradually as she ages. In some cases this decrease is caused by the lack of a partner. But women continue to be sexually interested and to have the capability for sexual pleasure throughout their lives.2 Hormonal changes may be a cause of decreased sexual function in older women. During and after menopause, levels of the hormones estrogen, progesterone, and testosterone in a woman's body decline. •

•

•

Nonprescription water-based products are available that provide vaginal lubrication. These products are typically available at pharmacies, usually near the condoms, and include Astroglide, Replens, and K-Y Jelly. Vaginal estrogen therapy can reduce vaginal dryness and irritation and increase the blood flow in the vagina. If you have only vaginal symptoms (and not hot flashes, for example), you can use a low-dose estrogen cream, ring, or tablet in your vagina. Many women find that using cream or a tablet twice a week is often enough. Systemic estrogen therapy is a high enough dose that it affects your whole body and can help with several menopausal symptoms. If you have symptoms that affect your physical and mental well-being, talk to your doctor about the risks and benefits of taking daily estrogen. Estrogen therapy can be oral (pills), vaginal, or transdermal (with a patch). Estrogen therapy may affect sexual desire, arousal, and enjoyment, as well as the capability to reach an orgasm.2 But taking daily estrogen without progestin can cause cancer of the lining of the uterus (endometrial cancer). Therefore, a woman who has a uterus and wishes to take systemic hormones usually takes estrogen in combination with progestin to protect her uterus. This is called estrogen-progestin therapy, also known as hormone replacement therapy.

therapy helps some postmenopausal women who have a low sex drive, especially those who have had their ovaries removed. Surgery to remove the ovaries (oophorectomy) causes sudden menopause—testosterone and estrogen, and sometimes sex drive, suddenly drop. (Normally, testosterone slowly declines with age.) Some postmenopausal women take testosterone to improve sexual desire and responsiveness and to increase the frequency of sexual fantasies and interest.

Testosterone

Possible side effects of testosterone therapy are a concern and are not fully known. • •

•

Common side effects of taking too high a dose of testosterone include acne, facial hair, loss of hair, deepening of the voice, and liver damage. Taking testosterone by mouth (orally) can have a bad effect on your cholesterol levels. (At this time, a dosage for women is only available in pill form. A patch or gel may be available in the future.) No studies have yet looked at the risks and benefits of taking testosterone for longer than 6 months. The long-term effects of testosterone therapy in women are not known.

If you are considering taking testosterone supplements, talk to your doctor about these potential side effects. Make sure you are taking the lowest possible dose and are carefully monitored for side effects while taking testosterone.2 Decreased testosterone is a less common cause of sexual problems than the public might think. Studies do not report a benefit from testosterone therapy for most women.9

What To Think About Over time, an untreated sexual problem can increase its impact on your quality of life. As the cause of a sexual problem creates discomfort and dissatisfaction, sexual activity may become a tense and unwelcome experience.

Home Treatment Treatment of sexual problems is guided by you, your partner, and your health professional. You may find that it depends largely on changes you try at home. Techniques you can learn and practice at home include: • • • • • • • • •

Increasing the level of intimacy and sexual arousal with your partner before penetration (plentiful foreplay). Good communication with your partner. Liberal use of vaginal lubricants. Experimenting with different positions for intercourse to find the most comfortable ones. Masturbation, possibly with the aid of a vibrator and/or with your partner. Exercises to develop muscular control of contraction and relaxation of the pelvic muscles. Enjoying sensual massage and other pleasurable physical activities without sexual intercourse. Decreasing inhibition with fantasizing, distractions, listening to music, or using erotic videos or books. Taking a warm bath and reducing anxieties before sexual activity.

You can improve pelvic floor muscle strength using Kegel exercises or vaginal weights. •

•

To do a Kegel, you tighten the same muscles you use to control urine flow. Hold for 3 seconds, then relax for 3 seconds, repeating 10 to 15 times. Try to do a set of Kegels 3 or more times a day. You can use a vaginal weight to strengthen the vaginal wall muscles. You do this by holding it inside the vagina while standing upright for 15 minutes. Over time, you become strong enough to hold a heavier weight.

Medications Because a woman's sexuality encompasses physical, emotional, and psychological factors, the causes of sexual problems are often complex and interrelated. Medications may be used in treating certain conditions that contribute to sexual problems.

Medication Choices Estrogen. If you only have vaginal dryness and irritation (and not other symptoms such as hot flashes), you can use a limited amount of estrogen in a cream, tablet, or ring in the vagina. The daily estrogen makes your tissue less thin and sensitive and more moist. Many women find that using a cream or tablet twice a week is enough. This may increase vaginal tone and lubrication, which will decrease vulvar dryness, irritation, and shrinkage (atrophy).

If you also have other menopausal symptoms that affect physical and mental well-being, talk to your doctor about taking daily (systemic) estrogen therapy. Estrogen can increase the blood flow in the vagina , as well as reduce hot flashes and other symptoms of menopause. Estrogen therapy or estrogen-progestin therapy can be oral (pills), vaginal, or transdermal (with a patch). In a small number of women, hormone therapy causes heart disease, breast cancer, ovarian cancer, dangerous blood clots, stroke, and dementia. Talk to your doctor about whether this therapy is right for you. Testosterone. This hormone may play a part in a woman's sex drive and satisfaction. The ovaries make testosterone throughout a woman's lifetime. Women have the most testosterone in early adulthood. Testosterone levels drop by half between the early 20s and the early 40s. In women who have their ovaries removed (oophorectomy), testosterone drops by 50%.10 If you have had an oophorectomy, your doctor may suggest trying testosterone therapy. But the U.S. Food and Drug Administration (FDA) has not approved any testosterone therapy for women.

What To Think About The methyltestosterone-estrogen formula called Estratest is not approved by the FDA. The company that makes it markets it for moderate to severe menopausal symptoms. It is also prescribed to some menopausal women to improve sexual desire and response. But Estratest is made with methyltestosterone, which the body uses differently than testosterone. It does not directly raise the amount of testosterone in your body. And taking a testosterone by mouth does put you at risk for problems with your liver and possibly your heart. Using a patch or cream does not. At this time, there is no testosterone pill, patch, or cream approved for women—those made for men have too high a dose for women. Side effects of too much testosterone include acne, facial hair, and loss of hair and a deepening of the voice, which may be permanent. No studies have looked at the benefits and risks of taking testosterone for longer than 6 months. The long-term effects of testosterone therapy in women are not known.10 Sildenafil (Viagra) is used to treat erectile dysfunction in men. The maker of this medicine has decided not to market it for improving women's sexual desire and arousal. This was based on research showing that sildenafil was not effective for most women. The maker has commented that women's sexuality is a complex mix of physical, emotional, and relationship factors, and it is not as simple to treat with a medicine as male erectile dysfunction is.11 Currently no medications are approved by the FDA to treat female sexual problems, although several paths are being studied, including stimulation of certain molecules (receptors) in the brain and increasing blood flow to the genitals. It is still too early in the process to know whether any of these medications will prove to be effective and safe treatment options

Surgery One type of sexual problem in women is pain during intercourse. Pain often is caused by a physical reason, such as injury or anatomical problems. If examinations and tests confirm that a physical condition is causing pain during intercourse, treatment of that condition may

get rid of the pain. In some cases, such as with the medical condition endometriosis, surgery may be recommended.

Surgery Choices There is no surgical treatment for sexual problems unless pain is caused by endometriosis or another medical condition.

What To Think About Certain surgical procedures may cause sexual problems. For example, it is common for a woman who has had her breast or breasts removed (mastectomy) or has had her uterus and ovaries removed (hysterectomy and oophorectomy) to report decreased sexual desire afterward. Sexual therapy may be recommended after surgery to assist you and your partner in developing methods to stimulate sexual arousal and achieve sexual satisfaction.

Other Treatment Studies of alternative medicines for sexual problems are limited, but some of them show possible benefits. These include studies of herbal supplements and devices.

Other Treatment Choices ArginMax, a nutritional supplement containing ginseng, ginkgo, damiana, and other ingredients, is the subject of a small study. Early reports show improvement in sexual desire. Studies on ArginMax continue.13 Ginkgo biloba may be helpful for women who lack sexual interest and response while taking antidepressants.14Ginkgo improves blood circulation throughout the body. But if you are taking a blood thinner, such as daily aspirin or warfarin, ginkgo may not be for you. Talk to your doctor about whether ginkgo is safe for you—it may increase the effect of a blood thinner. DHEA. Like testosterone, DHEA (dehydroepiandrosterone) is an androgen made in the body. Over-the-counter DHEA:15 •

• •

When taken by mouth, has the same risks of liver damage and negative effects on your cholesterol levels as oral testosterone. It also has the same unwanted hair growth and acne side effects. This is because the body turns DHEA into testosterone. Is not known to improve sexual well-being in healthy women. Is not regulated by the government, so you cannot know for sure how much you are taking. Some DHEA supplements contain less DHEA than the labels claim. Others contain more than the labels claim.

Vaginal weights can strengthen the pelvic floor and vaginal muscles. They usually come in five sizes. Start with the smallest weight, and work up to the largest over time. Insert a weight into your vagina, then hold it in place while standing upright for 15 minutes. Your muscles will feel the urge to tighten and hold it in. After a few days, the vaginal muscles become strong enough that they no longer feel an urge to hold the weight. This is when you use the next larger weight. Once you've used all five weights, keep your muscles toned by using the largest weight for 5 to 7 days in a row, each month.

Also under study is the EROS-Clitoral Therapy Device (CTD), in which a small batteryoperated device is used to stimulate engorgement of the clitoris as a way to increase a woman's sexual arousal and satisfaction. Early studies report improved ability to achieve 9, 16 orgasm. Studies on EROS-CTD continue.

What To Think About Researchers continue to look for treatments for raising sexual desire, arousal, and satisfaction. Some products, such as different vitamins and herbs, are promoted as natural treatments for sexual problems. But most of these products have not been subject to the same kind of rigorous scientific testing for safety and effectiveness that standard medical treatments must go through before they are approved in the United States. Be sure to talk with your doctor about which therapies might be best for you. If you decide to use an alternative medication or supplement, follow these precautions. •

• •

Talk with your doctor before taking an alternative medicine or supplement, especially if you are pregnant or trying to become pregnant, you take prescription medicines, or you have another health problem. As with all conventional medicines and supplements, it is important to follow the directions on the label. Do not exceed the maximum recommended dose.

Sexuality and Physical Changes With Aging Topic Overview Sex and sexuality communicate a great deal: affection, love, esteem, warmth, sharing, and bonding. These gifts are as much the right of older adults as they are of those who are much younger. Three aspects of sexuality are covered in this topic: the changes that come with aging, suggestions on how to adjust to these changes, and information about sexually transmitted diseases. In most healthy adults, pleasure and interest in sex do not diminish with age. Age alone is no reason to change the sexual practices that you have enjoyed throughout your life. However, you may have to make a few minor adjustments to accommodate any physical limitations you may have or the effects of certain illnesses or medications.

Common Physical Changes in Men •

• •

•

A man's sexual response begins to slow down after age 50. However, a man's sexual drive is more likely to be affected by his health and his attitude about sex and intimacy than by his age. It may take longer for a man to get an erection, and more time needs to pass between erections. Erections will be less firm. However, a man who has good blood flow to his penis will be able to have erections that are firm enough for sexual intercourse throughout his entire life. For more information, see the topic Erection Problems. Older men are able to delay ejaculation for a longer time.

Common Physical Changes in Women Most physical changes take place after menopause and are the result of decreased estrogen levels. These changes can be altered if a woman is taking hormone therapy. • • • •

It may take longer for a woman to become sexually excited. A woman's skin may feel more sensitive and irritable, making caressing and skin-toskin contact less pleasurable. The walls of the vagina become thinner and drier and are more easily irritated during sexual intercourse. Orgasms may be somewhat shorter than they used to be, and the contractions experienced during orgasm can be uncomfortable.

Not all women experience these problems. Those who do can experiment to find ways to enjoy sex despite these physical changes.

Cultural and Psychological Factors In addition to physical changes, there are cultural and psychological factors that affect sexuality in later years. For example, in our culture, sexuality is equated with youthful looks

and youthful vigor. Too many people seem to think that as a person ages, he or she becomes less desirable and less of a sexual being. Older adults may accept this stereotype and buy into the notion that they are not permitted or expected to be sexual. Joy in sex and loving knows no age barriers. Almost everyone has the capacity to find lifelong pleasure in sex. To believe in the myth that older people have no interest in sex is to miss out on wonderful possibilities. Being single through choice, divorce, or widowhood can present a problem as well. As you get older, you may not have as many people in your age group to choose from for partners. Women and men who are single may not know how to deal with their sexual feelings. Generally speaking, it is better to express your desires than to suppress them until you are no longer aware that they exist. Physical and emotional needs change with time and circumstance. Intimacy and sexuality may or may not be important to you. The issue here is one of choice. If you freely decide that sex is no longer right for you, then that is the correct decision. It is possible to live a fulfilling life without sex. However, if you choose to continue enjoying your sexuality, you deserve support and encouragement. You may still find uncharted sensual territories to explore.

Use It or Lose It: Staying Sexual Just as exercise is the key to maintaining fitness and health, having sex on a regular basis is the best way to maintain sexual capacity. And just as it's never too late to start an exercise program, it's never too late to start having sex. Many older people who have been celibate for years develop satisfying sexual practices within new loving relationships. For others, self-stimulation (masturbation) is common and poses no health risks or side effects.

Here are some additional considerations: • • •

•

To enhance sexual response, use more foreplay and direct contact with sexual organs. The mind is an erogenous zone. Fantasy and imagination help arouse some people. Try setting the mood with candlelight and soft music, or whatever else "turns you on." Many medications, especially high blood pressure medications, tranquilizers, and some heart medications, inhibit sexual response. Ask your doctor about these side effects. Your doctor may be able to reduce your dosage or prescribe different medications. Do not stop taking prescription medications without consulting your doctor first. Colostomies, mastectomies, and other procedures that involve changes in physical appearance need not put an end to sexual pleasure. Communicating openly about your fears and expectations can bring you and your partner closer together and help

•

•

•

•

•

you overcome barriers. If necessary, a little counseling for both of you can help you adjust. People who have heart conditions can enjoy full, satisfying sex lives. Most doctors recommend that you abstain from sex for only a brief time following a heart attack. If you have angina, ask your doctor about taking nitroglycerin before you have sex. Do not take Viagra if you are using nitroglycerin. If arthritis keeps you from enjoying sex, experiment with different positions. Try placing cushions under your hips. Also try home treatment for arthritis pain. For more information, see the topic Osteoarthritis. Use a water-based vaginal lubricant, such as Astroglide, K-Y Jelly, or Replens, to reduce vaginal dryness or irritation. Do not use petroleum jelly. A doctor can also prescribe a vaginal cream containing estrogen, which will help reverse the changes in the vaginal tissues. Drink alcohol only in moderation. Small amounts of alcohol may heighten your sexual responsiveness by squelching your inhibitions. Larger amounts of alcohol may actually decrease your sexual performance. Prescription medications that can enhance the sexual response are available. Some people find that herbs such as ginkgo biloba and ginseng enhance their sexual function. Both prescription drugs and herbal remedies carry the risk of side effects. Your health professional can help you decide whether these options are right for you.

Other Aspects of Sexuality Sexuality goes far beyond the physical act itself. It is part of who we are. It involves our needs for touch, affection, and intimacy.

Touch Touch is a wonderful and needed sensation. Babies who are not touched do not thrive. Children who are not touched develop emotional problems. Touch is important to older adults as well. Touch helps us feel connected with others and enhances our sexuality. • • •

Get a massage. Professional massages are wonderful, but simple shoulder and neck rubs feel great, too. Find a friend who will trade shoulder rubs with you. Look for hugs. Everybody needs them. Some people are a little shy about hugs, but it's okay to ask, "Would you like a hug?" Consider getting a pet. Caring for a pet can help meet your needs for touch. Some studies have shown that older people who have pets to care for live longer.

Affection

To give and receive affection is a wonderful feeling. If you like someone, be sure to let them know. If someone seems to like you, appreciate it. It is never too late to make new friends and strengthen bonds with longtime companions.

Intimacy

Intimacy is the capacity for a close physical or emotional connection with another person. Intimacy is a great protector against depression. Talking with a confidant can help ease life's problems. When you lose a loved one, intimacy may be what you miss most. You may not find someone to fully replace a loved one who died, but you can begin to rebuild intimacy in your life in the following ways: • • •

Turn to your children, siblings, or old and new friends. Look for another person who is in the same situation as you are. One of the richest benefits of support groups is that members often find intimacy with one another. Be available to others. Just as you need people, there are people who need you, too.

Sexually Transmitted Diseases Sexually transmitted diseases—also known as STDs or venereal diseases—are infections passed from person to person through sexual intercourse, genital contact, or contact with semen, vaginal fluids, or blood. Many of these diseases can also be spread by sharing needles and other items that may be contaminated with infected blood or body fluids. STDs can affect anyone, no matter what his or her age. Talk openly with your partner about STDs and take whatever precautions are necessary to protect yourself before you engage in any form of sexual contact. If you think you may have an STD, see your health professional

Erection Problems (Erectile Dysfunction) Topic Overview What are erection problems?

A man has erection problems if he cannot get or keep an erection that is firm enough for him to have sex. Erection problems are also called erectile dysfunction or impotence. Erection problems can occur at any age. But they are more common in older men, who often have other health problems. Treatment can help both older and younger men. What causes erection problems?

Erection problems may be caused by physical problems, such as injury to nerves or loss of blood supply to the penis . They can also be linked to other health problems. These include diabetes, high blood pressure, high cholesterol, and atherosclerosis. Erection problems can also be linked to problems with the nervous system, such as multiple sclerosis and Parkinson's disease. Many medicines for other health problems may cause erection problems, but most do not. If you recently began taking a new medicine and started having erection problems, this could be a side effect of the medicine. Talk with your doctor. He or she may be able to change the dose or type of medicine you take. Men who drink too much alcohol, smoke, or use illegal drugs also are at risk for erection problems. Anxiety, stress,

or depression can cause erection problems.

Other causes include surgery, such as for prostate cancer, or injury to the pelvic area.

What are the symptoms?

The only symptom of an erection problem is being unable to get and keep an erection that is firm enough to have sex. But even with an erection problem, a man may still have sexual desire and be able to have an orgasm and to ejaculate. How are erection problems diagnosed?

Your doctor can find out if you have an erection problem by asking questions about your health and doing a physical exam. Your doctor will want to know if the problem happens all 1

the time or just from time to time. The exam, lab tests, and sometimes mental health tests can help find out the cause of the problem. How are they treated?

There are a number of treatments for erection problems. Doctors usually start with lifestyle changes and medicines. They usually don't advise surgery or other treatments unless those first steps don't help. Treatment can include: •

• •

• • •

Making lifestyle changes, such as avoiding tobacco, drugs, and alcohol. It may also help to talk about the issue with your partner, do sensual exercises, and get counseling. Finding and then stopping medicines that may be causing the problem. In some cases you can take a different medicine that does not cause erection problems. Taking prescription medicine that can help you get erections. These include pills such as sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra). Check with your doctor to see if it is safe for you to take one of these medicines with your other medicines. These can be dangerous if you have heart disease that requires you to take nitroglycerin or other medicines that contain nitrates. Taking medicines and getting counseling for depression or anxiety. Using vacuum devices or getting shots of medicine into the penis. Having surgery to place an implant in the penis.

Can you prevent erection problems?

Because erection problems are most often caused by a physical problem, it’s important to eat healthy foods and get enough exercise to help you stay in good health. To reduce your risk of having an erection problem, do not smoke, drink too much alcohol, or use illegal drugs. You may be able to avoid erection problems related to anxiety and stress by talking with your partner about your concerns. This may help you relax.

Cause (erectile dysfunction) may be caused by physical problems related to the blood vessels, nerves, and hormones or by psychological issues. Current evidence suggests that physical causes account for about 80% of erection problems.1

Erection problems

Normally, an erection occurs when your imagination or senses (vision, hearing, touch, smell, taste) are stimulated and you become aroused. Your central nervous system sends nerve impulses that increase blood flow to your penis. Blood fills the spongy chambers (corpora cavernosa) in the penis, causing them to expand and become rigid. Four requirements for a normal erection are: •

A properly functioning nervous system that sends the necessary signals to the penis. 2

• • •

An intact system of blood vessels (vascular system) to allow blood to flow into and out of the penis. Normal smooth muscle in the penis, which must relax so the penis can fill with blood and enlarge. The ability to trap the blood in the penis so that it stays firm.

Physical causes of erection problems include long-term (chronic) and short-term (acute) injuries and complications of prostate or other surgery that interfere with nerve impulses or blood flow to the penis. Physical problems are often the cause of erection difficulties in men age 50 or older. •

•

• • •

•

Problems with the blood vessels (vascular problems) may prevent blood from filling the penis or from remaining there long enough to maintain an erection. For example, longterm high blood pressure can cause damage to blood vessels and lead to erection problems. Problems with the nerves (neurologic problems) may prevent arousal signals from traveling from the brain and spinal cord to the penis. Nerve disorders such as Parkinson's disease, Alzheimer's disease, multiple sclerosis, and stroke may interfere with a man's ability to have an erection and may lower sexual desire. Nerve damage from diabetes, complications from surgery, and spinal cord injury also may cause problems. Problems with the structure of the penis or its surrounding tissues may prevent an erection. Hormonal factors, such as a low level of the hormone testosterone, may be involved in causing erection problems. Side effects of medications (for example, some of those taken for high blood pressure or depression) may include erection problems. In some cases it may be possible to change the dose of the medicine or to use another medicine. The use of tobacco, alcohol, or illegal drugs can lead to erection problems. Stopping or reducing the use of these substances may reduce the severity of a man's erection problem.

Activities that restrict blood flow to the penis also may result in erection problems. Some doctors have observed that men who regularly ride bicycles over long distances are more likely to have erection problems than men who ride only occasionally, especially if they ride on a narrow, unpadded saddle. But the possible link between bicycle riding and erection problems has not been proven. A vasectomy usually does not cause an erection problem. But pain after the operation may affect sexual performance for a time, and if a man was not comfortable with his decision to have a vasectomy, or is having second thoughts, it could affect him psychologically. Psychological causes of erection problems include depression (which also has a physical component), anxiety, stress, grief, or problems with current or past relationships. These interfere with the erection process by distracting the man from things that would normally arouse him. Erection problems in men younger than 40 who have no physical risk factors are more likely to be caused by psychological factors than physical causes. • •

Relationship problems can lead to erection problems. This may happen when a man has been widowed or loses sexual interest in a particular partner. Some men develop erection problems when they contemplate marriage. 3

•

Some men may have difficulty having sexual intercourse with their partner after their first child is born.

Erection Problems (Erectile Dysfunction)

Symptoms Symptoms of erection problems (erectile dysfunction) include being unable to: • • •

Have an erection at any time, either with masturbation or with a sex partner. Maintain an erection firm enough for sexual intercourse. Maintain an erection long enough to complete sexual intercourse.

Even with an erection problem, a man may still have sexual desire and be able to have an orgasm and to ejaculate.

What Happens Most men have occasional erection problems (erectile dysfunction). But when erection problems become persistent, they can affect your self-image, sex life, and relationship. When you have persistent erection problems, "performance anxiety" can worsen the problem. If you cannot maintain an erection that is firm enough for intercourse, or you have an orgasm before or immediately after entering your partner (premature ejaculation), you may feel frustrated and believe you are not pleasing your partner. All of these factors could influence how you view your relationship. Fortunately, many of the physical and psychological factors that cause erection problems respond to treatment.

What Increases Your Risk Your risk of developing an erection problem (erectile dysfunction) increases with age.1, 2 • •

•

About half of the men between ages 40 and 70 report erection problems. More than 15 out of 100 men in their 40s report having a moderate erection problem. But twice as many (about 30 out of 100) men in their 70s say they have a moderate erection problem. While only about 5 out of 100 men in their 40s say their erection problems are severe, three times as many (15 out of 100) men in their 70s report severe problems.

Diseases, physical or psychological problems, and certain activities also may increase your risk. Diseases that affect blood vessels include: • • •

Diabetes. About half of men with diabetes develop erection problems. High blood pressure or other blood vessel diseases. High cholesterol or low HDL (high-density lipoprotein) cholesterol.

2

4

Diseases or procedures that affect nerves include: • • • • •

Diabetes. Multiple sclerosis. Stroke. Parkinson's disease.

Having had surgery involving the prostate, bladder, rectum, or urethra. These procedures may cause injury to nerves involved in achieving and maintaining an erection.

Other conditions include: • •

Thyroid problems. Low levels of the hormones needed for the normal development and function of the sex organs (hypogonadism), leading to low testosterone levels.

Injuries or treatment include: • • • •

Injury to the penis or pelvic region. Injury to the spinal cord or nerves to the penis. Pelvic surgery. Radiation in the pelvic area.

Medicines and other substances that increase your risk include: • • • •

Some medicines to treat high blood pressure or depression. Long-term (chronic) alcohol abuse. Drug abuse. Tobacco use.

Psychological risk factors include: • • • •

Depression. Anxiety or stress.

Relationship problems. A recent major life change (birth of a child, retirement, job change, loss or death of a partner, divorce, or marriage).

Activities that constrict blood flow to the penis—such as frequent long-distance bicycle riding on a hard, narrow saddle—may increase a man's risk of developing an erection problem. But experts continue to debate this issue. A vasectomy usually does not cause erection problems. But pain after the operation may affect sexual performance for a time, and if a man was not comfortable with his decision to have a vasectomy, or is having second thoughts, it could affect him psychologically.

Exams and Tests Because both physical and psychological factors are often involved, it may be difficult to diagnose the exact cause of your erection problem. 5

As part of the initial evaluation, your health professional may: • • • •

Review your risk factors for an erection problem. For more information, see the What Increases Your Risk section of this topic. Ask questions about your sexual function. Do a complete physical examination of the abdomen, penis, prostate, rectum, and testicles. Do laboratory tests for: o Testosterone. A low testosterone level may reduce sexual desire, leading to an erection problem. o Prolactin. A high level of prolactin (hyperprolactinemia) may indicate a small tumor in the brain, which can affect other hormone levels in the body. When hormone levels are affected, an erection problem may result. o Thyroid hormone. Either a high or low level of thyroid hormone may cause problems with sexual desire or erections. o Blood glucose. Elevated blood sugar (glucose) levels may indicate the presence of diabetes, which can contribute to erection problems.

At this point, oral medicines such as sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) are often recommended unless an easily treated cause (such as a medicine side effect or testosterone deficiency) has been identified. If oral medicines do not work or your doctor feels more testing is necessary, he or she may recommend: •

•

Specific tests for erection problems,

such as a nocturnal penile tumescence testing (rigidity test) and an intracavernosal injection test. These both help determine whether physical or psychological factors are causing your erection problem. A psychological evaluation, if a psychological issue is suspected.

An ultrasound may be done if your doctor suspects you have a circulation problem (peripheral arterial disease). Even if the blood vessels cannot be repaired, it may be helpful to know if you have this condition because it may mean you have a risk for other blood vessel (vascular) problems. In very rare instances, you may have angiography—an X-ray test of blood flow through an artery. Its usefulness is limited because treatment to repair the blood vessels that supply blood to the penis is appropriate for very few men.

Treatment Overview Treatment for an erection problem (erectile dysfunction) depends on the cause of the problem, which may be psychological, physical, or a combination of both. Erection problems that have one or more major physical causes also often have psychological factors that make the problem worse and make treatment more complicated. Many doctors take a stepwise approach to treating erection problems, using the least invasive treatments first. These steps are: 1. Discovering and then eliminating medications that may be causing your condition. In some cases a different medicine can be tried. 2. Trying an oral medicine. Medicines used for erection problems include phosphodiesterase-5 inhibitors such as sildenafil (Viagra), tadalafil (Cialis), and vardenafil 6

3. 4. 5. 6.

(Levitra). One of these medicines may be tried unless an easily treated cause—such as a medicine side effect or testosterone deficiency—has been identified. Getting counseling if a psychological cause is suspected. Trying medicines that are injected or inserted into the penis. Trying a vacuum device. Trying penile implant surgery.

Counseling (also called psychotherapy) or behavioral therapy may be appropriate even if your erection problem has a physical cause. It may be offered if your health professional suspects psychological issues play a role in your erection problems.

What To Think About It is important to involve your partner in your decision regardless of the treatment you choose. Oral medicines have revolutionized the treatment of erection problems, and they are commonly tried first before other medicine or surgery. Although phosphodiesterase-5 inhibitors have relatively few side effects, they can be dangerous in certain men. If you are taking nitrate-containing medications, such as nitroglycerin, you cannot use sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra). You also should not take certain alpha-blockers—used to lower blood pressure and to treat an enlarged prostate gland—with these medicines because of the risk of a dangerous drop in blood pressure. Check with your health professional to see whether you can take sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra) with your alpha-blocker. Many men overestimate how important being able to have erections is to their relationships. Some men find that once they are able to have erections again, the hassle of using the treatment is not worth the effort. Other men may find that being able to have erections doesn't change their relationship as much as they or their partners had expected.

Prevention You may be able to avoid erection problems (erectile dysfunction) related to anxiety and stress by taking a more relaxed approach to lovemaking. Talk to your partner about your problems and concerns. Sexual intimacy is a form of communication. If you and your partner talk about your lovemaking, it will help reduce your stress and anxiety, and you may become more relaxed. Erections may gradually become more difficult to get and maintain as you get older. But foreplay—erotic stimulation before intercourse—and the right environment can help increase your ability to have an erection, regardless of your age. Other things you can do that may reduce your risk for developing an erection problem include: • •

Quitting smoking. Avoiding use of alcohol and illegal drugs. 7

• • • • • •

Keeping your cholesterol level low to reduce the risk of hardening of the arteries (atherosclerosis). Treating high blood pressure. Keeping your blood sugar in a safe range if you have diabetes. Exercising regularly. Losing weight, especially if you are obese.3 Lowering stress in your life.

Home Treatment In some cases you can treat occasional episodes of erection problems (erectile dysfunction) at home, without a health professional's help. But do involve your partner in the process, and don't be embarrassed about seeking professional help if erection problems are consistent and troublesome. You may be able to help yourself by: •

• • •

Changing lifestyle factors that may affect erections. These factors include alcohol, smoking, and using illegal drugs. Losing weight and exercising more has also been helpful for some men. Examining your relationships and life events. Talking with your partner. Trying sensual exercises with your partner.

Some men may try methods available in health food stores or through magazine advertisements. Most of these methods have never been medically proven to work, may be unsafe, and are often expensive. They are not recommended.

Medications Medicines that can help produce an erection may be used to treat erection problems (erectile dysfunction) that are caused by blood vessel (vascular), hormonal, nervous system, or psychological problems. They also may be used along with counseling to treat erection problems that have psychological causes. If erection problems could be caused by a prescribed medicine, it may be possible to change the dose or try another medicine. Do not change or stop taking any medicine without first talking with your health professional.

Medication Choices Commonly used oral medicines include: •

Phosphodiesterase-5 inhibitors (PDE-5 inhibitors)

such as sildenafil (Viagra), tadalafil

(Cialis), and vardenafil (Levitra). Other medicines that may be used include: • •

Injected medications. Intraurethral alprostadil (MUSE).

8

Hormones and other prolactin levels.

medicines may be prescribed for men who have low testosterone or high

What To Think About

PDE-5 inhibitors and heart problems Health experts have debated the use of PDE-5 inhibitors in men with heart disease, because deaths have been reported after use of sildenafil (Viagra). The 1999 American College of Cardiology/American Heart Association (ACC/AHA) Expert Consensus Document noted that PDE-5 inhibitors may be dangerous for people who:4 • • •

Have coronary artery disease (CAD). Have heart failure and low blood pressure. Are taking many different drugs for high blood pressure.

But several more recent studies have reported that some men with heart problems may be able to take PDE-5 inhibitors safely. Talk to your health professional about whether PDE-5 inhibitors are appropriate for you. • •

•

One study found no evidence of increased risk for heart attack or CAD in men who use sildenafil (Viagra).5 Another study in men with CAD reported that sildenafil (Viagra) does not lead to heart attack and that heart attacks and other cardiovascular problems reported after taking Viagra may be related more to the physical activity of intercourse than to the medicine.6 A study of 35 men found that Viagra is safe for men with moderate heart failure.7

Sexual activity is exercise. If you have a heart condition and have not been sexually active for a while, talk with your health professional to make sure you can engage in sexual activity safely. PDE-5 inhibitors should never be used if you may need to take a nitrate-containing medication, such as nitroglycerin. Taking nitroglycerin and a PDE-5 inhibitor within 24 hours of each other may greatly lower your blood pressure, which could lead to a heart attack, stroke, or death. If you are taking a PDE-5 inhibitor and are going to have a test for heart disease, be certain your doctor knows you are taking it. You should not take sildenafil (Viagra) or vardenafil (Levitra) for 24 hours before the test. Do not take tadalafil (Cialis) for at least 48 hours before the test. Then if you develop a problem during the test, it will be safe to use nitrate-containing medicines such as nitroglycerin.

9

Although oral medicines for erection problems can be purchased over the Internet, you should still talk with your health professional before using this medicine. This is especially important if you have a heart problem. If you are using a combination of drugs for high blood pressure, PDE-5 inhibitors could result in low blood pressure (hypotension). Also for this reason, you should not take alpha blockers—used to lower blood pressure and to treat an enlarged prostate—with these medicines without talking to your health professional; the combination could cause a dangerous drop in blood pressure.

Surgery In a few cases, surgery may be an option to treat erection problems (erectile dysfunction). Surgery will rarely be recommended before nonsurgical treatment and counseling have been tried. Surgery to repair the blood vessels of the penis may be an option for a small number of men younger than 40 who had an injury that caused poor blood flow to the penis. Surgery to repair blood vessels should only be done at a teaching hospital that has experts in this type of surgery. Surgery on the pelvic area, such as prostate or bladder surgery, can sometimes damage nerves there and cause erection problems. But this is much less common than it used to be. For example, a surgeon now may do a nerve-sparing radical prostatectomy as treatment for prostate cancer. Some surgeons do nerve grafts as part of surgery for prostate cancer when the nerves cannot be saved. In a nerve graft surgery, the surgeon takes nerves from another part of your body and uses them to replace nerves damaged during surgery.

Surgery Choices Penile implants Surgery on penile blood vessels

What To Think About Give careful consideration to nonsurgical options and to the possible risks of surgery. Include your partner in your decision. Doctors who specialize in conditions of the urinary tract (urologists) perform most penile implants. Specially trained urologic surgeons usually do blood vessel repair surgery.

Other Treatment Other treatments for erection problems (erectile dysfunction) include vacuum devices and counseling (psychotherapy).

Other Treatment Choices •

are useful for all types of erection problems—physical, psychological, or both. The device has a tube you place around the penis. You pump the device to

Vacuum devices

10

•

create a vacuum that leads to an erection. Then you place a band around the base of the penis to maintain the erection for up to 30 minutes. Counseling (psychotherapy) is recommended for men whose erection problems are caused, at least in part, by psychological factors. Psychological factors seem to be involved in many cases of erection problems. Treatment may include sex therapy, which focuses on methods to improve attitudes toward sex and specific sexual techniques. Counseling also may be used with medication treatment or vacuum devices for erection problems that have psychological and physical causes. Evidence shows that group therapy helps with erection problems in some men. Adding group therapy to treatment with sildenafil (Viagra) helped more than Viagra alone. Men who were taking part in group therapy also were more likely to keep taking their medicine.8

Although medicines are usually the main treatment for erection problems, some men try If you don't want to use medicine, or medicine doesn't work for you, you may want to talk with your doctor about some of the following options. Most of these treatments need more research before doctors can know if they work for sure.9

complementary therapies.

• • •

• • •

may work for some men with erection problems. Ginseng has been shown to work for some men with erection problems. But because it is sold as a dietary supplement, it is hard to know if you are getting the right amount. Some men take the amino acid L-arginine as a dietary supplement to try to treat erection problems. The amino acid increases the amount of nitric oxide in the blood, which relaxes blood vessels. In theory, L-arginine could improve erections. But Larginine may be harmful.10 Although the antidepressant medicine trazodone has been used for treating erection problems, there is no current evidence that it is effective for this purpose.1 Some men who have low zinc levels in their body have had success using zinc supplements to treat erection problems. But high doses of zinc can be dangerous. Some men have tried yohimbine to treat erection problems, but it is rarely used.

Acupuncture

What To Think About No matter what approach you use to treat an erection problem, including your partner in the decision is helpful and may improve results.

11