Male Sexual Health

Erectile Dysfunction

Erectile dysfunction is the inability to achieve and maintain an erection sufficient for satisfactory sexual intercourse. It is estimated to affect 20 to 30 million men in the US and is definitely age-related.

It may result from any one of the following factors: psychological, neurologic, hormonal, arterial, and venous. Recently it has become quite clear that, in many cases, erectile dysfunction can be a "silent marker" for the later development of cardiovascular disease.

Low Testosterone

The normal male produces approximately five grams of testosterone daily, generally in a pulsatile fashion with the highest levels seen early in the morning. As men age, there is a progressive decline in testosterone production, with an average decrease of 1% yearly after age 50. While the terminology has yet to be firmly established, with such terms as andropause, male menopause or partial androgen deficiency in the aging male being used, we know that this is a real health issues affecting millions of men. The drop in testosterone can be due to a decrease in testicular production, or related to the hormones that regulate testosterone production.

When testing for testosterone, it is important to understand the relationship of testosterone to the proteins that circulate in the body. Most testosterone is attached, or “bound” to the proteins albumin and sex-hormone binding globulin (SHBG), that significantly limit the body’s ability to process testosterone. As men age, and their levels of SHBG increase, there is less testosterone available to be processed by the body.

Testosterone plays an important role in many bodily functions, and is not simply important for erectile function. In the brain, it influences libido or sex drive, male aggression, mood and thinking. Testosterone can improve verbal memory and visual-spatial skills. It as also been shown to decrease fatigue and depression in men with low levels. It is responsible for muscle strength and growth, and stimulates stem cells and blood cells in bones and kidneys. Penile growth, erections, sperm production, and prostatic growth and function all depend on testosterone. It also causes body hair growth, balding, and drives beard growth. Thus, testosterone makes us who we are, and influences how we look.

If, during your evaluation with Dr. Kaufman, your testosterone levels are low, he will present the various treatment options available to you for supplementation.

Testosterone Supplementation

Risks and Side Effects

Men with a history of prostate cancer or breast cancer are absolutely not candidates for testosterone therapy. The testosterone can make both of these hormonally sensitive cancers grow more rapidly. 
Other negative effects may include:

Fluid Retention
It is possible, especially within the first few months of treatment, for a man to retain fluid. Studies of healthy older men have shown problems with fluid retention leading to ankle or leg swelling, worsening of high blood pressure, or congestive heart failure. It is unclear whether there would be an effect in men who are ill, for example, those with congestive heart failure.

Liver Toxicity
There have been no reports of liver toxicity from transdermal testosterone replacement. However, oral testosterone replacement can cause significant liver problems. Interestingly, every manufacturer (even those producing transdermal testosterone) mentions the possibility of liver problems. This should be taken into account.

Problems with Fertility
Spermatogenesis (the production of sperm) in all men is dependent on production of testosterone by the testes. If testosterone is given from outside the testes (exogenous testosterone), as in testosterone replacement therapy, the testes will then stop producing their own testosterone. This will actually shut down sperm production either significantly or completely in almost all men. This may be a temporary or permanent effect. It is very important that younger men who still plan to have a family take this into account. Some men have "banked" their sperm (for more information on this subject visit www.SpermBankDirectory.com). Other men have delayed testosterone replacement until they have finished having children. It is important that any man considering a family be very careful in starting testosterone treatment of any kind.

Sleep Apnea
Sleep apnea is a condition in which an individual stops breathing for periods of time while sleeping. This can have significant medical effects. There have been reports that increased testosterone levels exacerbate pre-existing sleep apnea. However, a recent 36-month trial of testosterone therapy in older men reported no effect of treatment on apneic or hypoapneic episodes.

Tender Breasts or Enlargement of Breasts
This may occur in some older men who are on testosterone therapy. This may be due to the conversion of testosterone to estrogen. Breast tissue in both men and women is very estrogen sensitive. Sometimes, this side effect can be overcome by decreasing the testosterone dose.

Increased Red Blood Cell Concentration (Polycythemia)
One of the most important side effects of testosterone replacement therapy can be an increase in the red blood cell mass and hemoglobin levels. This is particularly true of older men. Increased blood cell mass may increase thromboembolic events (heart attacks, strokes, or peripheral clotting in the veins). Men who develop increased hematocrit can decrease testosterone replacement or donate blood to decrease their blood cell mass.

Prostate Growth
The growth of the prostate can have a negative effect on men in two ways. First, the prostate may increase in size (benign prostatic hyperplasia or BPH). This may cause problems with urination. Second, it may promote the growth of cancerous prostate cells. It is important to remember that prostate cancer is a common cancer for older men and is the second most common cause of cancer deaths in older men.

Decreasing testosterone levels has been a method used to treat diseases related to both the "benign" and the cancerous groups of cells, but it is still unclear whether testosterone therapy for the older man places him at increased risk of developing prostate disease (i.e., whether testosterone replacement therapy makes benign prostatic hyperplasia progress or makes previously unknown prostate cancer spread).

The vast majority of studies following PSA (prostate specific antigen made by both cancer cells at a higher rate and benign prostate cells) show that it does not increase significantly with testosterone therapy. All of the short-term studies have shown no negative effects on prostate size, maximum urination flow rates, and prostate symptom scores. It appears that testosterone replacement therapy has little short-term effect on the prostate. Long-term data, however, is not yet available.

  • Lifestyle (smoking, drinking, drugs, lack of exercise) 
  • Psychological (stress, anxiety, depression) 
  • Disease (diabetes, blood pressure, cholesterol, obesity) 
  • Use of certain medications (antidepressants, antihypertensives, antiepileptics)

A male sexual dysfunction specialist can identify the cause of the problem and recommend appropriate treatments.

Ejaculatory Disorders

Premature Ejaculation

While it was once thought that premature ejaculation was purely a psychological problem, it is now clear that certain physical problems contribute to this extremely common problem. While it is not always clear what the cause may be, increased understanding of the condition has greatly expanded the treatment options available to men who are suffering with this highly stressful problem.

For many couples, this issue has caused a significant stress in their relationship, and unfortunately men only seek help as a last resort. It is important for both partners involved to realize that this is more often a physical problem which is not caused by a lack of interest in the partner. Very often, having both partners present at the initial consultation is beneficial when coming up with a treatment plan.

When you visit with Dr. Kaufman, your consultation will include an extensive medical and sexual history, as well as a physical exam. Occasionally, certain blood tests will be ordered as part of the medical work-up. 
Treatment for premature ejaculation is often multi-modal, with a combination of behavioral modifications and medical therapy. Newer medications are being introduced and there is constant research in the field at this time. When you meet with Dr. Kaufman, you will work together to come up with a suitable treatment plan that will be tailored to your individual needs.

Peyronie's Disease

Peyronie’s disease is a disorder in which scar tissue, called a plaque, forms in the penis—the male organ used for urination and sex. The plaque builds up inside the tissues of a thick, elastic membrane called the tunica albuginea. The most common area for the plaque is on the top or bottom of the penis. As the plaque builds up, the penis will curve or bend, which can cause painful erections. Curves in the penis can make sexual intercourse painful, difficult, or impossible. Peyronie’s disease begins with inflammation, or swelling, which can become a hard scar.

The plaque that develops in Peyronie’s disease is not the same plaque that can develop in a person’s arteries. The plaque seen in Peyronie’s disease is benign, or noncancerous, and is not a tumor. Peyronie’s disease is not contagious or caused by any known transmittable disease.

Early researchers thought Peyronie’s disease was a form of impotence, now called erectile dysfunction (ED). ED happens when a man is unable to achieve or keep an erection firm enough for sexual intercourse. Some men with Peyronie’s disease may have ED. Usually men with Peyronie’s disease are referred to a urologist—a doctor who specializes in sexual and urinary problems.

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