Reproductive and Sexual Health Handbook

Male sexual function consists of three components: 

libido or sex drive arousal and the ability to achieve and maintain an erection orgasm and ejaculation

An overview of the normal male sexual response is shown in Figure 18.1.

Figure 18.1 Normal male sexual response

Libido disorders may present as hypoactive desire disorder, inhibited desire or desire discrepancy.

Low testosterone can be a cause of low desire but so can many medical conditions, relationship problems and psychological disorders. The most common ejaculation disorder is premature ejaculation (PE). Other ejaculation disorders include erectile dysfunction (ED), inhibited or delayed ejaculation, and retrograde ejaculation.

The penis consists of two spongy erection tissues called corpora cavernosa that extend along the penile shaft and anchor onto the pubic rami (see Figure 18.2). Each corpus has a central cavernosal artery which increases blood flow during an erection and together with associated smooth muscle dilatation in the cavernosal tissues, creates a large pressure against the surrounding tunica albuginea which compresses the draining emissary veins. Thus, the blood flow results in tumescence and the compression of the veins makes the erection rigid. The spongy tissue surrounding the urethra is called the corpus spongiosum and distally becomes the glans penis, which becomes tumescent but not rigid.

Erection is a neurovascular event under hormonal control. It includes arterial dilatation, trabecular smooth muscle relaxation and activation of the corporeal veno-occlusive mechanism.

Normal changes to erectile function occur with ageing and include:

longer time to achieve erection more difficult to sustain erection more tactile stimulation required to gain full erection less intense orgasm reduced ejaculation volume longer refractory period

Figure 18.2 The penis

Erectile dysfunction (ED) is a common condition affecting 1 in 5 men over the age of 40 years.⁽¹⁾ Erectile dysfunction is defined as the persistent inability to achieve and/or maintain a penile erection sufficient for satisfactory sexual activity and intercourse. It may affect physical and psychosocial health, and may have a significant impact on the quality of life (QoL) of sufferers and their partners.

There are multiple causes for erectile dysfunction, and often more than one factor may be present in any one individual.

Factors that can be important in relation to ED include:

cardiovascular risk factors such as hypertension, medications used to manage hypertension, dyslipidaemias, diabetes types 1 and 2, coronary artery disease (CAD) and peripheral arterial occlusive disease (PAOD) endocrine factors such as thyroid disease, adrenal disease, hyperprolactinaemia, hypogonadism (primary and secondary) neurological disease such as cerebral disease, spinal disease, multiple sclerosis, autonomic neuropathy other medical conditions such as renal insufficiency, chronic liver disease, respiratory disease (chronic obstructive pulmonary disease (COPD), sleep apnoea) local penile factors such as cavernous myopathy and fibrosis, Peyronie’s disease, post traumatic (pelvic fracture, perineal trauma, spinal cord or cerebral trauma) lifestyle factors such as high stress with increased sympathetic tone, sedentary lifestyle, obesity, smoking, alcohol, recreational drug use psychogenic factors

Ejaculation is controlled by the ejaculation centre in the medial pre-optic nucleus of the hypothalamus.

The most common ejaculation problem in men is premature ejaculation (PE), also known as rapid ejaculation, which has a varying incidence of between 10-20 per cent.  PE is regarded as a neuro-biological condition.⁽⁴⁾

The incidence of inhibited ejaculation (IE), or delayed or retarded ejaculation, varies between 5-10 per cent.

Retrograde ejaculation, where the ejaculate enters the bladder due to incomplete closure of the bladder neck, often occurs after surgery for benign prostate hyperplasia. It may also occur as a result of autonomic neuropathy in men with diabetes or in neurological conditions such as multiple sclerosis (MS).

Premature and inhibited ejaculations, as well as pain associated with ejaculation, are discussed further below.

Testosterone is the most important androgen (male sex hormone) in men and is secreted in a circadian rhythm. It is important for libido, as well as conferring many other health benefits. In men, 95 per cent of testosterone is produced in the testes and 5 per cent from the adrenal glands. Women have a much lower level of testosterone, with 50 per cent produced in the ovaries and 50 per cent in the adrenal glands. ⁽¹⁾

The prostate gland contributes to seminal fluid production and anatomically sits at the gateway to the bladder.

The main prostate conditions include:

prostatitis in younger men benign prostate hyperplasia (BPH) often associated with lower urinary tract symptoms which result in obstructive/voiding symptoms (such as a weak stream, post urination dribble) or irritative/storage symptoms (such as urgency, frequency, nocturia) affects quality of life symptoms are evaluated according to the International Prostate Symptom Score prostate cancer risk begins at 40 years with a family history or African American background risk in general population starts at around 45-50 years

Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland. It is the most common prostate disease which increases in incidence as a patient ages.⁽¹¹⁾

Benign Prostate Hyperplasia (BPH):

Lower urinary tract symptoms and erectile dysfunction are often connected and are said to be due to bladder detrusor muscle overactivity BPH is the main cause of lower urinary tract symptoms in men BPH incidence is 1 in 7 men aged 40-49 years and 1 in 4 men >70 years metabolic syndrome also leads to lower urinary tract symptoms/erectile dysfunction due to increased sympathetic activity resulting in reduced nitric oxide that reduces vasodilatation through the cGMP system BPH occurs mainly in the transition zone of the prostate; 85 per cent of prostate cancer occurs mainly in the peripheral zone

Prostate cancer is a condition that causes abnormal cells to develop within the prostate gland. These cells grow, divide and multiply, creating a tumour, and sometimes spread to other parts of the body.

With the exception of some forms of skin cancer, prostate cancer is the most common type of cancer in Australian men. ⁽¹²⁾ Prevalence of prostate cancer unchanged overtime. Increased incidence due to PSA testing.⁽¹³⁾ Early prostate cancer doesn’t have any noticeable symptoms. For example, problems with urinating are most likely caused by non-cancerous prostate conditions, i.e. benign prostate (BPH) or prostatitis.⁽¹²⁾ Incidental prostate cancer detected at autopsy increases with each decade; up to 59 per cent by age >79 years.⁽¹⁴⁾ One in six men in Australia are at risk of developing cancer by the age of 85.⁽¹⁵⁾ The five year survival rate for prostate cancer is 95 per cent.⁽¹⁶⁾

Differential diagnoses of testicular lumps include:

testicular cancer benign lumps epididymal cysts spermatocele hydatid of Morgagni hydrocele

Examination of the testes and local lymph nodes is important. It may be difficult to distinguish between testicular and epididymal cysts. Lumps in the epididymis are rarely cancer. Lumps in the testes are nearly always cancer. When a patient presents with a testicular or scrotal lump, it needs to be investigated by scrotal ultrasound.

Testicular cancer is a condition where abnormal cells develop in the testicle. These cells then grow, divide and multiply, creating a growth or tumour. It will usually appear as a painless lump on the testicle. Many lumps are found to be fluid-filled cysts (growths), rather than cancer. Testicular cancer has a cure rate of over 95 per cent, and is uncommon.⁽¹⁹⁾

If the patient is between 20 and 40, they’re in the age group with the highest risk of developing testicular cancer. Testicular cancer is the second most common cancer among men aged 20 – 40.⁽¹⁹⁾

There is insufficient evidence to recommend routine screening for testicular cancer, however, opportunistic examination can be considered in those at higher risk (e.g. those with a history of cryptorchidism (undescended testes), orchidopexy, testicular atrophy, or previous testicular cancer).Healthy Male

Clinical summary guides International Prostate Symptom Score (I-PSS)

Cancer council

Prostate cancer guidelines

European Association of Urology

Prostate cancer guidelines Other guidelines

International Society for Sexual Medicine

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