In men who have a benign prostate disease (BPH), the enlarged prostate may, in fact, interfere with this ejaculatory process, and if they are using certain prostate medications for their prostate enlargement (medications known as alpha blockers, such as Flomax, Uroxatral, Hytrin, or Cardura) or if they’ve had surgery for the prostate, the bladder neck will not close properly and they will experience retrograde ejaculation. This is a condition where the semen, rather than traveling out through the urethra and ejaculate, passes back into the bladder and is then passed out in the first urination after orgasm. Patients who have this problem because of medications can stop the medication, and it is fully reversible.
However, patients who have had surgery for benign prostate enlargement (such as TURP, green light laser, microwave therapy) cannot generally be cured of this, as it is a structural problem. It is surprisingly common for patients not to be informed that after radical prostatectomy and after radiation therapy that there will be significant interference with their ejaculation. For the majority of older men, this is not a major concern, as they are not interested in fertility, and most older men do not assign any major significance to the production of semen. However, in younger men, the production of semen and the process of ejaculation may for some be significant contributors to sexual satisfaction, and the loss of this may impact upon the quality of their sexual lives. This is not a physical process,but more a psychological one. It is very common to produce a tiny amount of clear sticky fluid at urethral meatus (opening of the urethra). This should be of no concern, as this fluid (known as pre-cum) is fluid that is produced by glands inside the urethra which are not interfered with by surgery or radiation. Most importantly, this fluid contains no sperm.
Orgasm is, in the words of Captain James Kirk, the final frontier. Little is known about the physiology of orgasm in comparison to the physiology of erection or ejaculation. Orgasm is a brain event and it has been shown at the time of orgasm that men and women have brain activity that is as close to a seizure as possible without there being an actual seizure. The ability to achieve orgasm, as well as its intensity, is mediated by many different factors, predominantly psychological, but some physical. Most patients after radical prostatectomy and radiation therapy achieve an orgasm, although many will say that it is different, particularly after surgery. Indeed, interestingly, about 10% of them will say that their orgasm intensity is better after surgery than before. What is surprising to most people is that, even in the complete absence of any erection whatsoever, they are capable of achieving an orgasm, and this is routine. I will discuss problems with orgasm later on in Chapter 8.
V. How Libido Works
Libido is yet another brain event. (The brain is the biggest sex organ after all!) The most important factor for libido in men is the presence of testosterone. This is also somewhat true for women and may be a reason as to why women lose their sex drive after menopause. The next chapter deals with testosterone in far greater detail, but in the absence of testosterone, there is a significant reduction in sex drive.There are other factors,of course, which impact upon this. There are some men, for example, who have perfectly normal testosterone levels who constitutionally have a low sex drive. Whether this is related to prior sexual experiences or cultural factors is not well defined. How much testosterone is actually needed for sex drive is not well understood, but if a man over the course of his third, fourth and fifth decades of life has a significant reduction in his testosterone level, this will manifest in a variety of ways, one of which is low sex drive.
Saying this, the majority of men reporting low sex drive do not, in fact, have low testosterone, but have psychological reasons for this. A testosterone level is easy to check. It is an early morning blood test for which a man does not need to fast. It is generally recommended that the blood work be performed as early as possible in the morning, but certainly before 10 o’clock. The reason for this is that there is a circadian rhythm of testosterone production, with the levels being highest in the morning and lowest in the late afternoon.
Any external stressor or psychological disorder (such as depression and anxiety) and certain medications, in particular those that interfere with testosterone and those that have an impact upon the brain (for example, those used for depression and psychotic disorders), can negatively impact a man’s sex drive. In the general population, one of the most common reasons for loss of sex drive is, in fact, erectile dysfunction. It is very common for men who have erection problems over the course of time to lose their sex drive. This is explained very simply through avoidance behavior. Men do not like to pursue activities at which they fail, and when a man fails to get an erection that satisfies him and his partner, he will avoid sexual scenarios. For many men that includes intimacy activities, such as kissing, cuddling and hugging, because there is a concern for men that these activities will lead to sexual relations, which is an anxiety-inducing event for men with erectile dysfunction. Thus, when a man presents with low sex drive, the routine response from the physician should be to have an early morning testosterone level checked. If this is normal, then it is safe to presume that the man’s libido problems are psychologically based, and the decision should be made whether that patient should be seeing a psychologist or if there is an obvious reason that can be corrected by the physician. If the testosterone level is low, then a comprehensive discussion should be held with the patient regarding the pros and cons, risks and benefits of testosterone supplementation. In the patient with a diagnosis of prostate cancer, this is an extremely complicated discussion. See Chapter 15 for a detailed discussion of this.
VI. Sexual Difficulties are Common
It is estimated that 50% of men over the age of 40 have erectile dysfunction. This is defined as the persistent inability to get and/or keep an erection sufficient for satisfactory sexual relations. The older a man gets, and the more medical problems he has (in particular, conditions such as high blood pressure, diabetes, high cholesterol, coronary artery disease and cigarette smoking exposure), the more likely he is to develop erectile dysfunction. Erectile dysfunction rates are estimated to be approximately 20% at 40 years of age and 70% at 75 years of age, with about 5% of 40–year-olds being completely unable to have sexual intercourse and 25% of 75–year-olds likewise. In contrast to what most people think, most men who have erectile dysfunction do not have a complete inability to have sexual intercourse. Indeed in the ED drug (Viagra, Levitra and Cialis) trials, something in the range of 25 to 30% of attempts before a man went on the trial drug resulted in the ability to have intercourse. However, the presence of erectile dysfunction is associated with a dramatic reduction in the man’s quality of life, which doesn’t just affect his function in the bedroom, but also affects his self-esteem and self-confidence and may carry over into his activities of daily living.
By far, the medical condition that is worst to have for erectile function is diabetes. Diabetes affects not just the blood vessels, but the erection nerves also, causing failure of the nerves to function properly and the health of the erectile tissue, which undergoes scarring. All of these issues cause problems with erection.
Other causes of erectile dysfunction include hormone problems, such as low testosterone and thyroid disease, neurological problems such as Parkinson’s disease, stroke, and lumbar disc disease, medications (in particular blood