Male sexual problems doctors should know about

By Naveed Saleh, MD, MS
Published May 6, 2021

Key Takeaways

The following is the second installment in a two-part series on sexual dysfunction. This article focuses on sexual problems in men, while our previous article covered sexual dysfunction in women.  

Viagra—also dubbed “the little blue” pill—is one of the most widely recognized prescription drug names on the market. Who hasn’t at least heard of it?

The title of an article on says it all: “Viagra: How a Little Blue Pill Changed the World.” Also known by its generic name, sildenafil, Viagra was the first phosphodiesterase 5 (PDE5) inhibitor to get FDA approval for erectile dysfunction (ED) back in 1998. Since then, numerous new ED treatment options have become available, including vardenafil (Levitra, Staxyn); tadalafil (Cialis); and avanafil (Stendra).

Erectile dysfunction, or impotence, is the most common sex problem that men report to their physician—although not the only one—and it increases in frequency with age. ED is estimated to affect as many as 30 million men in the United States

Thanks to ongoing direct-to-consumer marketing campaigns from pharmaceutical companies, the topic of male sexual dysfunction has moved into the mainstream.  

“For many men, the stigma and embarrassment of talking to their doctor about ED has declined since the introduction of Viagra and other PDE5 inhibitors,” according to   

Physicians treating sexual health problems navigate a complex condition that includes physical and psychological components. Let’s have a look at male sexual dysfunction.

Types of male sexual dysfunction 

Although sexual dysfunction can occur at any age, it is most common in older men. Often, physicians can treat sexual dysfunction in men by targeting underlying causes. Here are the four common types of male sexual dysfunction.

Erectile dysfunction

According to the Family Practice Notebook, 38% of men aged 60-69 are diagnosed with ED, compared with 57% of men aged 70 or older. For those between the ages of 40-49, the incidence is much lower at 11%. Of note, men who have diabetes are three times more likely to develop ED than men who do not. 

Organic disease accounts for 80% of cases of ED, with arterial or venous disease causing 70% of cases. Anxiety, depression, heart disease, obesity, endocrine disorders, neurologic diseases like multiple sclerosis and Alzheimer, and medications (eg, antihypertensives, antidepressants) can all cause ED. Current studies have even shown that marijuana use may contribute to ED. 

Intriguingly, shift work sleep disorder (SWSD) is also related to ED, according to the results of a study published in the Journal of Sexual Medicine. Researchers surveyed 754 men, and after ruling out various covariates, including testosterone use, testosterone levels, PDE5 inhibitor use, and age. The researchers determined that shift workers have worse ED—with night shifts linked to the worst cases.

“These findings suggest that circadian rhythm disturbance may significantly impact erectile function,” the authors wrote. “While testosterone therapy may partly reverse the effects of SWSD, shift work is a potential risk factor for ED and should be assessed for as part of the evaluation of men with ED.”

Authors publishing in Nature Reviews Urology also found that disturbances to the circadian clock contribute to ED.

“Disruption of the circadian clock has been associated with pathological conditions including obesity, type 2 diabetes mellitus, cancer, depression and neurodegenerative diseases,” they wrote “Disturbed sleep patterns have now been associated with reduced erectile function. The mechanisms behind this effect are unclear but could include hypoxia signalling and low testosterone.”

Four categories of treatment for ED are currently available. The four previously mentioned oral medications (eg, sildenafil, vardenafil, tadalafil, avanafil) all have comparable efficacy. In patients who are non-responders to oral medications or experience adverse effects, intracavernosal injections (alprostadil, phentolamine, papaverine, atropine), as well as intraurethral suppositories (alprostadil), may work. Lastly, although penile implants are an invasive alternative, they boast the highest satisfaction rate of all treatments.

Regenerative treatments are on the horizon and may be an option. 

“There is clinical interest in employing regenerative therapies, including low-intensity extracorporeal shockwave therapy (Li-ESWT), platelet rich plasma (PRP), and stem cell therapy (SCT), in the treatment of ED as adjunct or alternative treatments,” wrote the authors of a review published in Therapeutic Advances in Urology. 

“Results of human studies are varied, although SCT treatments did result in increased erectile rigidity with some patients recovering the ability to achieve penetration. While these regenerative therapies show potential to augment the current treatment regimen for ED, there is a paucity of evidence to support the safety and efficacy of these treatments. Further research is necessary to define the role of these alternative therapies in the treatment of ED,” they concluded.

Decreased libido

As men age, libido can decrease. Libido can also decrease with long-term committed relationships. Sex contributes to well-being, and men with low libido often seek treatment. 

In those with low libido, doctors should perform a thorough history and physical exam to assess whether drugs (eg, antidepressants, blood pressure medications, illicit substances) contribute. Furthermore, systemic diseases such as HIV and cancer can play a role. It’s also important to test for decreased levels of serum testosterone.

Unfortunately, there is no magic bullet to treat decreased libido in men.

“There is no FDA approved ‘libido pill’ for men although there is a medical option for women with low sexual desire,” noted the authors of an article published by the Department of Urology at University of California-San Francisco. “If the man has another sexual problem that led to changes in libido, treatment of that condition may lead to a secondary improvement in sexual desire. If the changes in libido are associated with a specific medication, it may be worth stopping or changing the medication to an alternative agent.”

General health conditions that may predispose to changes in libido should be managed as appropriate (eg, men with obesity and or controlled diabetes should aim to lose weight and bring blood sugar levels under control). In some cases, this may lead to improvements in libido.

The authors added, “As low blood levels of testosterone are associated with low libido, supplementation may be appropriate in some cases. Testosterone supplementation is somewhat controversial so it should only be considered after careful consultation with a health care provider who is knowledgeable about this topic. Testosterone is helpful in many, but not all, cases of low libido.”

Premature ejaculation

Premature ejaculation (PE) is a common male sexual dysfunction that affects between 20% and 30% of men. It can be acquired or lifelong, with lifelong presentations occurring after first sexual intercourse. Lifelong PE refers to intravaginal ejaculatory latency times of 1 or 2 minutes or fewer, and occurs in between 2% and 5% of men.

The cause of PE is unknown, although anxiety, penile hypersensitivity, and serotonin receptor dysfunction have all been implicated.

First-line treatment for PE involves the use of SSRIs, which delay ejaculation. Topical anesthetics can also be applied between 20 and 30 minutes before intercourse. Other options include behavioral and cognitive therapies.

Delayed ejaculation

This condition is the most poorly understood of the male sexual dysfunctions. It can range in severity, with some men able to ejaculate while masturbating but not during vaginal intercourse. It affects between 1% and 4% of men. 

Causes can be psychological or physiological, including spinal cord injuries, multiple sclerosis, or diabetes. Relationship issues may also play a role. Medications that contribute to this disorder include beta blockers, muscle relaxants, and SSRIs.

No pharmacologic treatment exists for this condition. Cognitive behavioral sex therapy, however, may prove effective. Furthermore, penile stimulation with a vibrator may also result in ejaculation.

Bottom line

Having occasional erection problems is not necessarily cause for concern. However, ongoing erection issues can be a sign of sexual dysfunction and possibly an underlying medical attention. Clinicians should attain a robust history and physical examination and look for possible contributors.

Treatment of sexual dysfunction can be complex and often requires a multidisciplinary approach. Physicians should thus have a low threshold for appropriate referral to the proper specialists.

And remember, ED can also be caused by stress, relationship conflicts, depression, or anxiety—or the ED may be contributing to these problems—notes the Mayo Clinic. In these cases, physicians should consider referral to a psychologist or counselor. 

On a related topic, learn more about how vitamin D may improve sexual dysfunction in men.

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