Male Sexual Dysfunction

Original Editor - Stacy Schiurring based on the course by Pierre Roscher
Top Contributors - Stacy Schiurring, Kim Jackson, Lucinda hampton and Jess Bell

This page aims to provide an introductory discussion of men's health physiotherapy with regards to male sexual dysfunction. Please note that further training is required through a reputable pelvic health education company before attempting the techniques discussed in this page. See the Resources section at the bottom of this page for links to pelvic and men's health special interest groups.

Introduction

Three parts of sexual activity

When treating sexual dysfunction, a medical professional must look at the broader prospective of the patient's sexual activity in order to accurately diagnose and treat the underlying causes of the dysfunction. Sexual activity includes a patient's physiological sexual functioning, their sexual identity, and their sexual relationship.

It is imperative to have open and respectful conversations with the patient regarding these very personal issues order to provide quality and appropriate care. A medical professional working in this specialized field must be inclusive and make all patients feel comfortable and respected. This extends from the words a therapist uses to describe a patient's sexual orientation, gender identity, and or expression, to how the clinic is setup to provide maximal privacy during patient evaluations, treatments, and consultations. Please read this article for recommendations on how to setup a men's health clinic.

Sexuality

Sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical, religious and spiritual factors.

Just as an understanding of pelvic anatomy is needed for proper pelvic floor physiotherapy, an understanding of appropriate terminology to use for gender identity and sexual orientation is needed when providing pelvic health physiotherapy. It is also important to use know the appropriate pronouns to use, especially when working with gender nonbinary and transgender patients. Please read this article for more in-depth information on sexual orientation, gender identity, and gender expression.

The term sex is used to refer to a person’s biological maleness or femaleness, and the term gender to the nonphysiological aspects of being male or female– the cultural expectations and roles for femininity and masculinity. This article will focus on male sexual dysfunction and how it can be addressed by men's health physiotherapy. The term “men” will refer to biological males and “women” for biological females for the remainder of this page.

Male Sexual Dysfunction

Normal sexual function in men relies on the complex interaction between biological, emotional, cognitive, behavioural, contextual and interpersonal factors.

There are multiple physiological processes involved in male sexual function to include:

• Sexual desire (libido)
• Erectile functioning
• Ejaculation
• Orgasmic ability and quality

When discussing sexual dysfunction, a physiotherapy patient interview may uncover a change or alteration in one of these four basic sexual functions. The treatment of male sexual dysfunction often requires a multidisciplinary approach, involving multiple treatment techniques and interventions from various healthcare and mental health providers.

Hypoactive Sexual Desire

Sexual desire relies on a variety of factors both physical and psychological. Testosterone levels play an important role in physiological libido.

Erectile Dysfunction

Erectile function forms an important part of a man’s sexual function, but it is only a part of the picture. A normal erection depends on a sequence of physiological, neural, vascular, metabolic and endocrine events.

There are different types of erections; reflexogenic, psychogenic and nocturnal:

• Reflexogenic erections occur when the penis is physically stimulated
• Psychogenic erections from other stimulation such as visual, auditory or psychological inputs.
• Nocturnal erections occur in men every night with about 5-8 per night and can last up to 30 minutes each.

Erectile dysfunction (ED) is a component of male sexual dysfunction and can be defined as the persistent inability to achieve or maintain an erection firm enough or lasting long enough to participate in sexual activities.

• Problems with erectile function can come from physical and psychological problems.
• When a man’s nocturnal erections stop it can be used as a diagnostic factor in determining a physical cause of the erectile dysfunction.
• The pelvic floor muscles, in particular, the bulbospongiosus and ischiocavernosus, play an important role in penile rigidity and injury or weakness can play a role in erectile dysfunction.

Aspects of erectile dysfunction:

1. ability to achieve an erection
2. ability to maintain an erection
3. ability to achieve adequate erection quality e.g. hardness

Ejaculation issues

Ejaculation occurs when the smooth muscle of the prostate contract and the urethra smooth muscles relax to allow the ejaculate to enter the urethra. Thereafter a strong involuntary contraction of the bulbospongiosus expels the ejaculate.

• The prostate is responsible for the production of seminal fluid which makes up the majority of the ejaculate.
• When the prostate is removed or affected by radiation there is often a significant loss or absence of ejaculate.

Types of ejaculation issues:

• Retrograde ejaculation results in a reduced volume of anterograde ejaculate during sexual climax or the detection of semen in the post-ejaculatory urine.Can be a consequence of a prostatectomy due to the removal of the internal urethral sphincter allowing semen to move into the bladder rather than into the urethra.
• Premature ejaculation is the most common type of ejaculation dysfunction. Involves ejaculation within 30 seconds of either sexual stimulation or penetration.
• Delayed ejaculation involves an extended amount of time needed prior to ejaculation.

Orgasmic Dysfunction

• Mediated by the autonomic nervous system but there is also cortical involvement.
• The pelvic floor muscles play an important role in orgasm.
• Damage to the nerves and spasm of the muscles can play a role in the orgasmic dysfunction.

Sexual Dysfunction Risk Factors

Health Conditions that increase risk of sexual dysfunction in men:

• Diabetes
• Cardiovascular disease
• Hypertension
• Hyperlipidemia
• Chronic kidney disease
• Cancer, especially prostate cancer
• Obesity, significant relationship with ED
• Drug side-effects

Lifestyle factors that increase risk of sexual dysfunction in men:

• Smoking

• Chronic alcohol abuse
• Exposure to heavy metals or pesticides
• Stress

Age also plays a factor in sexual dysfunction development. Younger patients tends to present with premature ejaculation, hard flaccid syndrome, pelvic pain, pain with orgasm. Older patients tend to present with ED and many of the above listed health conditions which increase their risk for developing sexual dysfunction such as cardiovascular disease or prostate issues.

Pathological mechanisms of male sexual dysfunction:

• Endothelial dysfunction
• Neurogenic factors
• Hormonal pathway
• Haemodynamic factors
• Psychosocial factors

Biopsychosocial Model and Healthcare Professional Training

Please read here for more in-depth information on the biopsychosocial model with regards to men's health. Please read here for more general information about the biopsychosocial model.

Sexual health needs are more neglected by medical professionals than mental health.A 2019 systematic review suggest that sexual health education provided by nurses to patients was affected by:

• Lack of knowledge about sexual health
• The healthcare providers' attitudes and beliefs that sexual health care is private and not a priority
• The healthcare providers’ comfort discussing sexual health
• Perceived barriers related to time, responsibility and organisational support

The healthcare providers' ability to comfortably and professionally ask in-depth questions with regards to a patient's sexual activity can be vital in providing appropriate pelvic health care and interventions. For example: when evaluating and treating a patient with complaints of ED, it is important to know if their sexual partner is male or female. This is due to the amount of penile quality needed to penetrate an anus vs a vagina.

Male Pelvic Floor Physiotherapy

Pelvic floor physiotherapy treatments and interventions are:

• conservative
• modifiable
• noninvasive
• non-pharmacological
• non-surgical
• can be used for a wide range of men's sexual health conditions

Resources

• https://www.prideinpractice.org/articles/transgender-pronouns-guide/
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