In short
Men’s sexual problems fall into three categories, and men are routinely treated for the wrong one.
- Erections: getting one, or keeping one. Affects up to a third of adult men.
- Desire: a separate problem, affecting an estimated 5 to 10 per cent, with its own causes.
- Ejaculation: too soon, too late, or absent. Each with its own treatment.
All three can coexist. Sorting out which is primary is the first and most useful step, and it happens in the history rather than in a laboratory.
Treatment Overview
The three categories
| Erectile dysfunction | Vascular, neurological, local penile, hormonal, drug induced or psychological causes |
| Low desire | Testosterone deficiency, stress, relationship issues, depression, systemic illness, and a range of prescription and recreational drugs |
| Ejaculatory disorders | Premature, delayed and retrograde ejaculation, each with different causes and treatments |
Why they get confused
Because they coexist. Men with erectile dysfunction can lose desire as a consequence of the erectile problem, and the chronology is what separates cause from effect.
Most men who present with erectile dysfunction do not report low desire, which is a useful signal in itself. When both are present, whichever came first is usually the one to treat.
The cardiovascular thread running through all of it
Erectile dysfunction shares risk factors and mechanism with cardiovascular disease, and men presenting with it are at higher risk of later cardiovascular events. In one national survey they had twice the rate of undiagnosed diabetes.
So the assessment includes glucose, lipids, blood pressure and thyroid function, and cardiac risk is graded before treatment. High risk means cardiology review first, intermediate risk means an exercise test first.
Ejaculatory problems, briefly
- Premature ejaculation: within about one to two minutes, with consistent inability to delay and marked distress. All three parts are needed. Treated with SSRIs, topical anaesthetics or psychotherapy depending on the cause
- Delayed ejaculation: most men ejaculate within five to six minutes. Beyond 25 to 30 minutes with distress qualifies. Often caused by antidepressants or by alpha blockers such as tamsulosin, silodosin or alfuzosin
- Retrograde ejaculation: little or no fluid. Follows prostate surgery or long standing diabetes, and can present as infertility
What testing is done?
Glucose or HbA1c, full blood count, liver and kidney function, thyroid, lipids and total testosterone in men with erectile dysfunction. In men with low desire, prolactin and oestradiol are added.
A low testosterone is repeated with LH and prolactin before treatment. Nocturnal erection testing in a sleep laboratory is no longer routine, and penile ultrasound is reserved for specific indications.
Who Is a Good Candidate?
- You have more than one problem and want them sorted out in one appointment
- You have been treated for erections when the actual problem was desire, or the reverse
- Ejaculation timing has changed, in either direction
- You have diabetes, high blood pressure or high cholesterol, or you smoke
- You want the cardiovascular side taken as seriously as the sexual side
- Chest discomfort or breathlessness on exertion, which needs cardiac assessment before any treatment
- You take nitrates in any form, which is an absolute contraindication to the standard tablets
- Little or no fluid at ejaculation, a bend in the penis, or shrinking testicles, all of which need proper assessment
What Happens During the Consultation
-
1
Which of the three, and in what order they appeared
Erections, desire, ejaculation, or more than one. The chronology separates the primary problem from its consequences, and it does more work than any test.
-
2
Risk factors, medication and relationship
Cardiovascular risk factors identified and treated in their own right. Antidepressants, alpha blockers and opioids asked about specifically. Interpersonal conflict raised, because it is common and rarely volunteered.
-
3
Examination and the right bloods
Pulses, penile plaques, testicular size, breast tissue and hair pattern. Glucose, blood count, liver and kidney function, thyroid, lipids and testosterone, with prolactin and oestradiol added where desire is the issue.
-
4
Cardiac risk graded, then a plan for each problem
Low, intermediate or high. Then treatment for each problem in the right order, with a baseline score recorded so improvement can be measured rather than guessed at.
Program Structure & Follow-Up
How multiple problems are handled
In order, not simultaneously, so that it is clear what worked.
- A treatable cause is removed first, such as a medication or an untreated thyroid problem
- Where desire and erections are both affected and testosterone is low, replacement usually goes alongside a PDE5 inhibitor rather than instead of one
- Where the pattern is anxiety, counselling is the preferred treatment rather than the fallback
Review points
| Erectile treatment | Reviewed for effect, instruction and side effects. Dose goes up before the drug is changed |
| Testosterone | Diagnosis confirmed first, then desire reviewed, with ongoing monitoring |
| Medication change | Four to six weeks to judge |
| Cardiovascular risk | Managed on its own schedule, because it outlasts the sexual problem |
What counts as improvement
A defined change on a validated score rather than an impression: two points for mild erectile dysfunction, five for moderate and seven for severe. That is why a baseline is taken before anything starts.
If the first treatment does not work
Retrying with proper instruction rescues about 25 to 30 per cent of apparent non responders. Beyond that there are second line options, usually starting with a vacuum device because it is non invasive and less expensive than injections.
Benefits, Limits & Safety
What is realistically achievable
Erections respond well: successful intercourse in 68 to 69 per cent of men on treatment against 33 to 35 per cent on placebo.
Desire responds where there is a specific cause to remove or correct. Ejaculatory problems respond variably, with premature ejaculation better served than delayed ejaculation, for which treatment options are limited and all off label.
What treatment will not do
- It will not increase desire in a man whose testosterone is normal
- It will not resolve a relationship problem, which will be named rather than prescribed around
- It will not make treatment safe if you take nitrates
The lifestyle side, which is not filler
Aerobic exercise improved erectile function against placebo in a meta analysis of 11 trials, and exercise of 18 MET hours a week or more was associated with better sexual function.
Weight loss including after bariatric surgery raises testosterone and improves erections, stopping smoking helps, and treating sleep apnoea improved erectile function in some studies.
What is not offered
Prescriptions without assessment, treatment before the cardiac question is settled, testosterone on a single borderline result, and shockwave or platelet based therapies marketed as regenerative.
Erections respond well
Successful intercourse in 68 to 69 per cent of men on treatment against 33 to 35 per cent on placebo, with similar results in men with diabetes.
One problem at a time
Treated in order rather than simultaneously, with a validated baseline score so improvement is a defined change rather than an impression.
Settled before treatment
Nitrates in any form rule out the standard tablets. High cardiac risk needs cardiology review and intermediate risk an exercise test first.
Cost & Program Investment
The consultation and the blood panel are quoted before anything is ordered. The panel is a standard one rather than a specialist hormone screen, with prolactin and oestradiol added where desire is the problem. Medication is an ordinary prescription at pharmacy prices, with no subscription and no minimum course. Where a cardiac test or a referral is needed first, it is arranged and quoted rather than skipped.
Frequently Asked Questions
Yes, and they are handled in order rather than at once, so it is clear what worked. Establishing which came first usually identifies which is the primary problem.
No. Most men with erectile dysfunction do not report low desire. They have different causes and different treatments, and treating one as the other is the usual mistake.
Because erectile dysfunction and cardiovascular disease share the same mechanism, and ED usually comes first. Sexual activity is also exertion, and the standard tablets are absolutely contraindicated with nitrates.
Premature ejaculation means within about one to two minutes, together with a consistent inability to delay it and marked distress. All three parts are needed for the diagnosis.
Sometimes. It is frequently caused by antidepressants or by alpha blockers used for prostate symptoms, in which case reviewing the medication helps. Oral treatment options are limited and all off label, but sex therapy can be effective.
No. It improves desire reliably where deficiency is confirmed, but it is less effective for erections and is usually given alongside a tablet rather than instead of one. In men with normal levels it does not help.
Entirely. Nothing goes to an employer, insurer or anyone else without your explicit instruction, and consultations are in English or German.
Evidence
Where this information comes from
Every figure on this page is taken from the sources below. All of them are free to read, so you can check them yourself.
This page is general medical information and does not replace a personal consultation. Trial results are averages across large groups, not a prediction for any one person.