Focus | Clinical

Male sexual dysfunction

Clinical diagnosis and management
strategies for common sexual problems

Alice Nicol, Eric Chung MALE SEXUAL FUNCTION is a complex distress.12,14 In contrast to anejaculation,
biopsychosocial process that can be where ejaculation is absent during orgasm,
influenced by neurological, vascular, retrograde ejaculation occurs when
Background
Male sexual dysfunction (MSD) can affect
endocrine, psychological, interpersonal semen enters the bladder instead of being
males of all ages. The most common and sociocultural factors.1,2 Sexual released into the penis during orgasm.13,15
problems associated with sexual function is important for physical, Orgasmic dysfunction is the diminished
dysfunction include low sexual desire, psychosocial and emotional wellbeing1 intensity of an orgasm or an inability to
erectile dysfunction, Peyronie’s disease and serves as a marker for overall achieve orgasm during sexual stimulation
and disorders of ejaculation and orgasm. general health.3 Male sexual dysfunction and can coexist with ejaculatory
Each of these male sexual problems can
(MSD) can largely be divided into low disorders.5,13,15
be difficult to treat, and some males may
have more than one form of
libido, erectile dysfunction, Peyronie’s
sexual dysfunction. disease and ejaculatory and orgasmic
disorders.1,4,5 It is estimated that a third Relevant markers of MSD and
Objective of males will experience one form of MSD general health
This review article provides an overview
in their lifetimes.1 While it is common that psychiatric
of the clinical assessment and evidence-
based management strategies for MSD Low libido or hypoactive sexual desire disorders and related pharmacological
problems. Emphasis is placed on a disorder is defined as a decrease in sexual treatments are associated with MSD,
practical set of recommendations thoughts and desires for sexual activity,1,6 the presence of MSD could be an
relevant to general practice. and its prevalence can vary depending on important marker for underlying health.
exact definitions, methods of assessment Erectile dysfunction is more common
Discussion
Comprehensive clinical history-taking, and population demographics.6 Erectile with increasing age and in those with
tailored physical examination and relevant dysfunction is defined as difficulty multiple medical comorbidities, including
laboratory testing can provide relevant achieving or maintaining an erection.3,7–9 metabolic syndrome and chronic medical
clues for MSD diagnosis. Modifying In contrast, males with Peyronie’s disease illness.2,3,8 It serves as an important marker
lifestyle behaviours, managing reversible report penile curvature, deformity, pain of future cardiovascular risk, and literature
risk factors and optimising existing
and length loss, with ensuing erectile has shown that the risks of cardiovascular
medical conditions are important first-
line management options. Medical
dysfunction in advanced cases.10,11 disease and death increase steadily with
therapy can be initiated by general Ejaculatory disorders can be divided the severity of erectile dysfunction.3,8 In
practitioners (GPs) with subsequent into premature ejaculation, delayed addition, there is a strong association
referrals to a relevant non-GP specialist(s) ejaculation, anejaculation and retrograde between erectile dysfunction and lower
if patients do not respond and/or require ejaculation.12–15 Premature ejaculation is urinary tract symptoms/benign prostatic
surgical interventions. defined as the inability to control or delay hyperplasia.3 Male hypogonadism, which
ejaculation, resulting in psychosexual is defined as a pathological disorder of the

© The Royal Australian College of General Practitioners 2023 Reprinted from AJGP Vol. 52, No. 1–2, Jan–Feb 2023   41
Focus | Clinical Male sexual dysfunction: Clinical diagnosis and management strategies for common sexual problems

hypothalamic–pituitary–testicular axis and validated questionnaires can provide additional hormonal evaluation (eg thyroid
biochemical low total testosterone level, additional useful information.8 function, prolactin and estradiol), penile
can be associated with cardiometabolic It is important to ascertain the exact colour duplex ultrasonography or semen
complications and ensuing erectile MSD, potential causative (contributing) analysis (post-orgasm urine analysis
dysfunction, low libido, delayed factors and relevant modifiable factors. for retrograde ejaculation) – can be
ejaculation and anorgasmia.1,4,5,16 1–5,15,17
Potential aetiologies such as undertaken by a urologist.1,8
This article provides an overview of the medications, psychological stress, mental
current understanding of and management wellbeing, medical comorbidities,
strategies for MSD. A Medline literature medications, partner-specific issues and Management strategies
search for English language articles was tobacco, drug and alcohol consumption Management strategies are listed in Box 1.
performed using the following keywords: should be explored (Table 1).2,3,8,15 Modifying lifestyle behaviours, managing
‘low sexual desire’, ‘erectile dysfunction’, reversible risk factors and optimising
‘Peyronie’s disease’, ‘ejaculatory disorder’ Physical examination existing medical conditions are important
and ‘orgasmic disorders’. Relevant General physical examination should be first-line management options before
clinical guidelines are summarised in this undertaken with an emphasis on body pharmacotherapy (Table 2) and should be
narrative review. Given the broad scope of habitus (secondary sexual characteristics), performed in a holistic, patient-centred
this review paper, emphasis is placed on cardiovascular system and neurological approach.1–8
relevant clinical assessment and a practical status. A focused examination of the Psychosexual counselling is an
set of recommendations pertinent to male genitalia includes palpation of important consideration since the
general practice. testes size (based on an orchidometer) psychogenic component is common;
and a stretched penis for size and ideally it should be done with the
plaques.4,7,8,10 It is important to maintain patient’s partner. It can assist to reduce
Diagnostic assessment the patient’s privacy, confidentiality and psychological distress, aid in patient
Clinical history comfort, preferably in the presence of education and improve treatment
Patient history remains an integral part of a chaperone.1,8 compliance.1,2,5
evaluating patients presenting with MSD
given that these dysfunctions represent Laboratory testing Low libido
self-reported conditions and many lack Initial evaluation is recommended Testosterone therapy is generally
confirmatory diagnostic tests.1–5,15,17 with blood tests for cardiometabolic recommended for males with low
Emphasis is placed on an open dialogue factors such as fasting glucose, glycated libido and those with proven male
in a face-to-face consultation and being haemoglobin, lipid profile and hormone hypogonadism.5,15,16,18 Topical gel and
mindful of the patient’s sexual concerns profile, in fasting state and collected in the intramuscular testosterone therapy are
with sensitivity towards the patient’s early morning.1,3,4,7,8 Further screening generally recommended in preference
unique ethnic, cultural and personal tests to exclude or confirm underlying to oral tablets and patches. Furthermore,
background.1,8 Completion of relevant aetiologies or comorbid conditions – with it is advised that other endocrinological

Table 1. Relevant history-taking

Sexual history Medical history Medications history Psychosocial history

• Onset • Cardiovascular diseases • Antihypertensives • Smoking

• Context • Peripheral vascular disease • Anti-arrythmias • Alcohol
• Severity • Diabetes mellitus • Antidepressants • Illicit substance
• Libido • Pelvic trauma, surgery • Anxiolytics • Mental health (eg anxiety
• Penile problems or radiotherapy • Hormonal therapy (eg androgen or depression)

• Morning and/or • Endocrine conditions deprivation therapy) • Social stressors

spontaneous erections • Neurological conditions • Anti-epileptics • Relationship problem(s)
• Ability to have sexual
intercourse
• Use of medications or
sexual aids
• Pornographic materials
• Childhood sexual abuse and
religious or sociocultural beliefs

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Male sexual dysfunction: Clinical diagnosis and management strategies for common sexual problems Focus | Clinical

Table 2. Approved pharmacotherapy to treat male sexual dysfunction

Medication Administration Starting dose and maximum dose Special comments

Male hypogonadism (with low libido)

Testosterone 1% (in gel sachet Topical therapy; daily use One sachet or two pumps daily • Approved on PBS if patients
50 mg/5 g or actuation pump (increase to two sachets or four meet specific criteria
12.5 mg/actuation) pumps as required)

Testosterone 2% (in actuation Topical therapy; daily use One pump daily (increase to two • Approved on PBS if patients
pump 23 mg/actuation) pumps as required) meet specific criteria

Testosterone esters Intramuscular therapy Once every two weekly (dose and • Not approved on PBS
(250 mg/mL) duration can be altered as required)

Testosterone enanthate Intramuscular therapy Once every two weekly (dose and • Not approved on PBS
(250 mg/mL) duration can be altered as required)

Testosterone undecanoate Intramuscular therapy Once every three monthly • Approved on PBS if patients
(1000 mg/4 mL) meet specific criteria

Erectile dysfunction

Sildenafil Oral therapy; 30 minutes Starting dose 25–50 mg • Medication half-life

before sex Maximum dose 100 mg approximately four hours
• Absorption affected by food
and alcohol

Tadalafil Oral therapy; 60 minutes Starting dose 10–20 mg • Medication half-life

before sex Maximum dose 20 mg approximately 17.5 hours
• Absorption not affected by
food and alcohol

Tadalafil daily Oral therapy; daily use 5 mg • Medication half-life

approximately 17.5 hours
• Absorption not affected by
food and alcohol

Avanafil Oral therapy; 30 minutes Starting dose 100 mg • Medication half-life

before sex Maximum dose 200 mg approximately 6–17 hours
• Absorption not affected by
food and alcohol

Vardenafil Oral therapy; 30 minutes Starting dose 10 mg • Medication half-life

before sex Maximum dose 20 mg approximately four hours
• Absorption affected by food
and alcohol

Alprostadil Intracavernosal therapy; Starting dose 10 μg • Medication half-life

30 minutes before sex (in syringe system) approximately 10 minutes
Maximum dose 20 μg • Risk of priapism (10%)

Premature ejaculation

Dapoxetine Oral medication; 30 minutes Starting dose 30 mg • Medication half-life

before sex Maximum dose 60 mg approximately six hours
• Absorption affected by alcohol
but not food

PBS, Pharmaceutical Benefits Scheme

© The Royal Australian College of General Practitioners 2023 Reprinted from AJGP Vol. 52, No. 1–2, Jan–Feb 2023   43
Focus | Clinical Male sexual dysfunction: Clinical diagnosis and management strategies for common sexual problems

conditions (eg hyperprolactinaemia, low-intensity shockwave therapy and heightened arousal), while those with
thyroid dysfunction or diabetes) should penile injection of stem cells or platelet- delayed orgasm might benefit from sexual
be excluded or managed expectantly.5,6 rich plasma, is not recommended since counselling on arousal methods, genital
Appropriate therapy for anxiety or these methods lack long-term efficacy stimulation or role-playing to increase
depression may also improve libido.1,8 and safety records and are not properly sexual intimacy.15,22
regulated by the government.8,21 A mechanical device that provides
Erectile dysfunction penile vibratory stimulation has been
Oral phosphodiesterase type 5 (PDE5) Peyronie’s disease shown to improve penile sensitivity and,
inhibitor medication remains the standard The current evidence regarding the in turn, assist with delayed ejaculation and
of care and is considered the first-line clinical efficacy of oral medication in orgasmic dysfunction.12,14 For those with
pharmacological intervention.1,3,7,8,19 Peyronie’s disease is lacking, and these retrograde ejaculation or delayed orgasms,
While PDE5 inhibitor medications are medications are used off-label.10,11 electroejaculation is a viable option to
often effective, well tolerated and safe Penile traction therapy can be a useful retrieve semen for fertility purposes.4,13
when prescribed appropriately, their adjunct but requires patient adherence. Topical anaesthetic agents (eg lignocaine
use should be cautioned in males with Intralesional injection therapy is not gel applied to the glans penis) can
unstable angina or who are currently widely offered in Australia, and the only prolong ejaculation and increase sexual
taking nitrates therapy and follow careful approved Peyronie’s disease medication, satisfaction, but a condom should be
discussion about the pros and cons of collagenase Clostridium histolyticum, has used to avoid numbness to the partner’s
medications.3,7,8,19 For patients with been withdrawn from the market.10,11 genitals.15,22 Dapoxetine, a short-acting
hypogonadism, restoring testosterone Penile reconstructive surgery remains selective serotonin reuptake inhibitor
levels will improve PDE5 inhibitor efficacy the most effective treatment for Peyronie’s (SSRI), is the only approved medication
and salvage PDE5 non-responders.8,19 disease, but patients should wait until the for premature ejaculation.15,22 However,
Intracavernous injection (ICI) of disease is stable with no penile pain.10,11 various tricyclic antidepressants, SSRIs
vasoactive agents such as prostaglandin Patients should be counselled on expected and tramadol have been used off-label
E1 (also known as alprostadil) is surgical outcomes and potential risks, to delay ejaculatory latency time, but
recommended as second-line therapy in such as recurrence of deformity, penile these medications may be costly and can
males who did not respond to oral PDE5 length loss, altered sensation and erectile inadvertently cause erectile dysfunction
inhibitor treatment, and the prescription dysfunction.10,11 For those with pre-existing or orgasmic dysfunction.12,14,15,22
of these ICI medications should include erectile dysfunction, a concurrent penile Sympathomimetic agents (eg imipramine
a detailed discussion with the patient prosthesis implant is recommended.20 or pseudoephedrine) can cause a
that consists of technical instruction and contraction of the bladder neck, which
education about priapism.7,8,19 Vacuum Ejaculatory and orgasmic dysfunctions prevents the ejaculate from flowing
constriction devices can provide passive The best treatment approach for into the bladder, but these medications
engorgement of the corpora cavernosa, ejaculatory and orgasmic dysfunctions can cause hypertension or urinary
and a constriction ring can be placed is a multimodal approach, with problems.12,14,15 Testosterone therapy is
at the base of the penis to maintain an pharmacological, psychological effective to improve orgasm in patients
erection.7,8,19 For patients who do not and behavioural techniques used in with hypogonadism.8,16,18 Other off-label
respond to or tolerate PDE5 inhibitor combination.12,14,15,22 Behavioural uses of medications such as bupropion,
medications or are keen on more definitive techniques for premature ejaculation cyproheptadine or cabergoline have
treatment, a penile prosthesis implant include the stop-start technique (patients been shown in selected studies to treat
can be offered following appropriate cease genital stimulation until arousal delayed ejaculation and improve orgasm
consultation with a urologist.8,20 The sensation subsides) or squeeze technique and sexual satisfaction, although further
role of regenerative therapy, such as (squeezing of the glans prepuce during studies are warranted for their long-term
efficacy and safety.15,23

Box 1. Key points on management strategies

Conclusion
• Modifying lifestyle behaviours Comprehensive clinical assessment with
• Managing reversible risk factors, including medications relevant laboratory testing is important
• Optimising existing medical conditions to assess for MSD. Modifying lifestyle
• Psychosexual counselling behaviours, managing reversible risk
• Mechanical devices (for certain types of male sexual dysfunction) factors, and optimising existing medical
• Pharmacotherapy (refer to Table 2)
conditions are important first-line
management. Medical therapy can
• Surgery (for males with erectile dysfunction)
be initiated by general practitioners

44   Reprinted from AJGP Vol. 52, No. 1–2, Jan–Feb 2023 © The Royal Australian College of General Practitioners 2023
Male sexual dysfunction: Clinical diagnosis and management strategies for common sexual problems Focus | Clinical

(GPs) with appropriate referrals to 10. Chung E, Gillman M, Tuckey J, La Bianca S,

Love C. A clinical pathway for the management of
relevant non-GP specialists if patients Peyronie’s disease: Integrating clinical guidelines
do not respond and/or require surgical from the International Society of Sexual Medicine,
American Urological Association and European
interventions. Urological Association. BJU Int 2020;126 Suppl
1:12–17. doi: 10.1111/bju.15057.
11. Chung E, Ralph D, Kagioglu A, et al. Evidence-
Authors based management guidelines on Peyronie’s
Alice Nicol MBBS, Surgical Registrar, Department of disease. J Sex Med 2016;13(6):905–23.
Urology, Princess Alexandra Hospital, University of doi: 10.1016/j.jsxm.2016.04.062.
Queensland, Brisbane, Qld 12. Shindel AW, Althof SE, Carrier S, et al. Disorders
Eric Chung MBBS, FRACS (Urol), Professor of Surgery, of ejaculation: An AUA/SMSNA Guideline.
Department of Urology, Princess Alexandra Hospital, J Urol 2022;207(3):504–12. doi: 10.1097/
University of Queensland, Brisbane Qld; Professor JU.0000000000002392.
of Surgery, Department of Urology, Macquarie 13. Alwaal A, Breyer BN, Lue TF. Normal male sexual
University Hospital, Sydney NSW Australia; Director, function: Emphasis on orgasm and ejaculation.
AndroUrology Centre, Brisbane, Qld Fertil Steril 2015;104(5):1051–60. doi: 10.1016/j.
Competing interests: None. fertnstert.2015.08.033.
Funding: None. 14. Althof SE, McMahon CG, Waldinger MD, et al.
Provenance and peer review: Commissioned, An update of the International Society of Sexual
externally peer reviewed. Medicine’s guidelines for the diagnosis and
treatment of premature ejaculation (PE). Sex Med
Correspondence to:
2014;2(2):60–90. doi: 10.1002/sm2.28.
[email protected]
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© The Royal Australian College of General Practitioners 2023 Reprinted from AJGP Vol. 52, No. 1–2, Jan–Feb 2023   45
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