Overview of male sexual dysfunction
- Glenn R Cunningham, MD
Glenn R Cunningham, MD
- Distinguished Professor Emeritus, Department of Medicine
- Baylor College of Medicine
- Raymond C Rosen, PhD
Raymond C Rosen, PhD
- Chief Scientist
- New England Research Institutes, Inc.
- Section Editors
- Peter J Snyder, MD
Peter J Snyder, MD
- Editor-in-Chief — Endocrinology
- Section Editor — Pituitary Disease; Male Reproductive Endocrinology
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Michael P O'Leary, MD, MPH
Michael P O'Leary, MD, MPH
- Section Editor — Urology
- Professor of Surgery, Harvard Medical School
- Senior Urologic Surgeon, Brigham and Women's Hospital
Male sexual dysfunction has long been known to be common. Of late, knowledge of normal male sexual function and the causes of sexual dysfunction have become better understood, and more effective treatments are available.
This topic review will provide an overview of normal and abnormal sexual function in men. Male sexual dysfunction includes erectile dysfunction (ED), diminished libido, and abnormal ejaculation. The evaluation and treatment of men with sexual dysfunction and sexual dysfunction associated with selective serotonin reuptake inhibitors (SSRIs) are discussed separately. (See "Evaluation of male sexual dysfunction" and "Treatment of male sexual dysfunction" and "Sexual dysfunction caused by selective serotonin reuptake inhibitors (SSRIs): Management".)
PHYSIOLOGY OF MALE SEXUAL FUNCTION
Normal male sexual function requires interactions among vascular, neurologic, hormonal, and psychological systems. The initial obligatory event required for male sexual activity, the acquisition and maintenance of penile erection, is primarily a vascular phenomenon, triggered by neurologic signals and facilitated only in the presence of an appropriate hormonal milieu and psychological mindset.
●Psychogenic erections are triggered by neural impulses originating in discrete loci of the central and peripheral nervous systems . Sexual images may originate in response to erotic visual or auditory stimuli or be generated via fantasy. The centrally perceived sensual input is relayed by neural signals to a spinal cord neural center located at T-11 to L-2 (the thoracolumbar erection center). From there, neural impulses flow to the pelvic vascular bed, redirecting blood into the corpora cavernosa.
●Reflex erections are created by tactile stimulus to the penis or genital area which activates a reflex arc with sacral roots originating at S-2 to S-4 (the sacral erection center). Psychogenic erections are more common during man's early sexually active years, whereas reflex erectile activity dominates during his mature years.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Krane RJ, Goldstein I, Saenz de Tejada I. Impotence. N Engl J Med 1989; 321:1648.
- Karacan I, Williams RL, Thornby JI, Salis PJ. Sleep-related penile tumescence as a function of age. Am J Psychiatry 1975; 132:932.
- Sommer F, Schwarzer U, Klotz T, et al. Erectile dysfunction in cyclists. Is there any difference in penile blood flow during cycling in an upright versus a reclining position? Eur Urol 2001; 39:720.
- Jeremy JY, Ballard SA, Naylor AM, et al. Effects of sildenafil, a type-5 cGMP phosphodiesterase inhibitor, and papaverine on cyclic GMP and cyclic AMP levels in the rabbit corpus cavernosum in vitro. Br J Urol 1997; 79:958.
- Virag R, Bouilly P, Frydman D. Is impotence an arterial disorder? A study of arterial risk factors in 440 impotent men. Lancet 1985; 1:181.
- Saenz de Tejada I, Goldstein I, Azadzoi K, et al. Impaired neurogenic and endothelium-mediated relaxation of penile smooth muscle from diabetic men with impotence. N Engl J Med 1989; 320:1025.
- Santen RJ, Bardin CW. Episodic luteinizing hormone secretion in man. Pulse analysis, clinical interpretation, physiologic mechanisms. J Clin Invest 1973; 52:2617.
- Bancroft J, Wu FC. Changes in erectile responsiveness during androgen replacement therapy. Arch Sex Behav 1983; 12:59.
- Mills TM, Wiedmeier VT, Stopper VS. Androgen maintenance of erectile function in the rat penis. Biol Reprod 1992; 46:342.
- Lindau ST, Gavrilova N. Sex, health, and years of sexually active life gained due to good health: evidence from two US population based cross sectional surveys of ageing. BMJ 2010; 340:c810.
- McVary KT. Clinical practice. Erectile dysfunction. N Engl J Med 2007; 357:2472.
- Feldman HA, Goldstein I, Hatzichristou DG, et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol 1994; 151:54.
- Araujo AB, Mohr BA, McKinlay JB. Changes in sexual function in middle-aged and older men: longitudinal data from the Massachusetts Male Aging Study. J Am Geriatr Soc 2004; 52:1502.
- Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999; 281:537.
- Bacon CG, Mittleman MA, Kawachi I, et al. Sexual function in men older than 50 years of age: results from the health professionals follow-up study. Ann Intern Med 2003; 139:161.
- Lindau ST, Schumm LP, Laumann EO, et al. A study of sexuality and health among older adults in the United States. N Engl J Med 2007; 357:762.
- Selvin E, Burnett AL, Platz EA. Prevalence and risk factors for erectile dysfunction in the US. Am J Med 2007; 120:151.
- Rosen RC, Fisher WA, Eardley I, et al. The multinational Men's Attitudes to Life Events and Sexuality (MALES) study: I. Prevalence of erectile dysfunction and related health concerns in the general population. Curr Med Res Opin 2004; 20:607.
- Esposito K, Giugliano F, Di Palo C, et al. Effect of lifestyle changes on erectile dysfunction in obese men: a randomized controlled trial. JAMA 2004; 291:2978.
- Koskimäki J, Shiri R, Tammela T, et al. Regular intercourse protects against erectile dysfunction: Tampere Aging Male Urologic Study. Am J Med 2008; 121:592.
- Fung MM, Bettencourt R, Barrett-Connor E. Heart disease risk factors predict erectile dysfunction 25 years later: the Rancho Bernardo Study. J Am Coll Cardiol 2004; 43:1405.
- Sullivan ME, Keoghane SR, Miller MA. Vascular risk factors and erectile dysfunction. BJU Int 2001; 87:838.
- Chiurlia E, D'Amico R, Ratti C, et al. Subclinical coronary artery atherosclerosis in patients with erectile dysfunction. J Am Coll Cardiol 2005; 46:1503.
- Mannino DM, Klevens RM, Flanders WD. Cigarette smoking: an independent risk factor for impotence? Am J Epidemiol 1994; 140:1003.
- Saigal CS, Wessells H, Pace J, et al. Predictors and prevalence of erectile dysfunction in a racially diverse population. Arch Intern Med 2006; 166:207.
- Grover SA, Lowensteyn I, Kaouache M, et al. The prevalence of erectile dysfunction in the primary care setting: importance of risk factors for diabetes and vascular disease. Arch Intern Med 2006; 166:213.
- Budweiser S, Enderlein S, Jörres RA, et al. Sleep apnea is an independent correlate of erectile and sexual dysfunction. J Sex Med 2009; 6:3147.
- Budweiser S, Luigart R, Jörres RA, et al. Long-term changes of sexual function in men with obstructive sleep apnea after initiation of continuous positive airway pressure. J Sex Med 2013; 10:524.
- Li Y, Batool-Anwar S, Kim S, et al. Prospective study of restless legs syndrome and risk of erectile dysfunction. Am J Epidemiol 2013; 177:1097.
- McCulloch DK, Campbell IW, Wu FC, et al. The prevalence of diabetic impotence. Diabetologia 1980; 18:279.
- Kalter-Leibovici O, Wainstein J, Ziv A, et al. Clinical, socioeconomic, and lifestyle parameters associated with erectile dysfunction among diabetic men. Diabetes Care 2005; 28:1739.
- Gazzaruso C, Solerte SB, Pujia A, et al. Erectile dysfunction as a predictor of cardiovascular events and death in diabetic patients with angiographically proven asymptomatic coronary artery disease: a potential protective role for statins and 5-phosphodiesterase inhibitors. J Am Coll Cardiol 2008; 51:2040.
- Ma RC, So WY, Yang X, et al. Erectile dysfunction predicts coronary heart disease in type 2 diabetes. J Am Coll Cardiol 2008; 51:2045.
- De Berardis G, Pellegrini F, Franciosi M, et al. Longitudinal assessment of quality of life in patients with type 2 diabetes and self-reported erectile dysfunction. Diabetes Care 2005; 28:2637.
- Giuliano FA, Leriche A, Jaudinot EO, de Gendre AS. Prevalence of erectile dysfunction among 7689 patients with diabetes or hypertension, or both. Urology 2004; 64:1196.
- Baumhäkel M, Böhm M. Erectile dysfunction correlates with left ventricular function and precedes cardiovascular events in cardiovascular high-risk patients. Int J Clin Pract 2007; 61:361.
- Min JK, Williams KA, Okwuosa TM, et al. Prediction of coronary heart disease by erectile dysfunction in men referred for nuclear stress testing. Arch Intern Med 2006; 166:201.
- Thompson IM, Tangen CM, Goodman PJ, et al. Erectile dysfunction and subsequent cardiovascular disease. JAMA 2005; 294:2996.
- Shamloul R, Ghanem H. Erectile dysfunction. Lancet 2013; 381:153.
- Wein AJ, Van Arsdalen KN. Drug-induced male sexual dysfunction. Urol Clin North Am 1988; 15:23.
- Slag MF, Morley JE, Elson MK, et al. Impotence in medical clinic outpatients. JAMA 1983; 249:1736.
- Comparison of propranolol and hydrochlorothiazide for the initial treatment of hypertension. II. Results of long-term therapy. Veterans Administration Cooperative Study Group on Antihypertensive Agents. JAMA 1982; 248:2004.
- Grimm RH Jr, Grandits GA, Prineas RJ, et al. Long-term effects on sexual function of five antihypertensive drugs and nutritional hygienic treatment in hypertensive men and women. Treatment of Mild Hypertension Study (TOMHS). Hypertension 1997; 29:8.
- Ko DT, Hebert PR, Coffey CS, et al. Beta-blocker therapy and symptoms of depression, fatigue, and sexual dysfunction. JAMA 2002; 288:351.
- Kirby RS, O'Leary MP, Carson C. Efficacy of extended-release doxazosin and doxazosin standard in patients with concomitant benign prostatic hyperplasia and sexual dysfunction. BJU Int 2005; 95:103.
- Cocores JA, Miller NS, Pottash AC, Gold MS. Sexual dysfunction in abusers of cocaine and alcohol. Am J Drug Alcohol Abuse 1988; 14:169.
- Schwarzer U, Sommer F, Klotz T, et al. Cycling and penile oxygen pressure: the type of saddle matters. Eur Urol 2002; 41:139.
- Kwan M, Greenleaf WJ, Mann J, et al. The nature of androgen action on male sexuality: a combined laboratory-self-report study on hypogonadal men. J Clin Endocrinol Metab 1983; 57:557.
- Wu FC, Tajar A, Pye SR, et al. Hypothalamic-pituitary-testicular axis disruptions in older men are differentially linked to age and modifiable risk factors: the European Male Aging Study. J Clin Endocrinol Metab 2008; 93:2737.
- Marberger M, Roehrborn CG, Marks LS, et al. Relationship among serum testosterone, sexual function, and response to treatment in men receiving dutasteride for benign prostatic hyperplasia. J Clin Endocrinol Metab 2006; 91:1323.
- Snyder PJ, Bhasin S, Cunningham GR, et al. Effects of Testosterone Treatment in Older Men. N Engl J Med 2016; 374:611.
- Brock G, Heiselman D, Maggi M, et al. Effect of Testosterone Solution 2% on Testosterone Concentration, Sex Drive and Energy in Hypogonadal Men: Results of a Placebo Controlled Study. J Urol 2016; 195:699.
- Rochira V, Balestrieri A, Madeo B, et al. Sildenafil improves sleep-related erections in hypogonadal men: evidence from a randomized, placebo-controlled, crossover study of a synergic role for both testosterone and sildenafil on penile erections. J Androl 2006; 27:165.
- Buvat J, Montorsi F, Maggi M, et al. Hypogonadal men nonresponders to the PDE5 inhibitor tadalafil benefit from normalization of testosterone levels with a 1% hydroalcoholic testosterone gel in the treatment of erectile dysfunction (TADTEST study). J Sex Med 2011; 8:284.
- Spitzer M, Basaria S, Travison TG, et al. Effect of testosterone replacement on response to sildenafil citrate in men with erectile dysfunction: a parallel, randomized trial. Ann Intern Med 2012; 157:681.
- Spark RF, White RA, Connolly PB. Impotence is not always psychogenic. Newer insights into hypothalamic-pituitary-gonadal dysfunction. JAMA 1980; 243:750.
- De Rosa M, Zarrilli S, Vitale G, et al. Six months of treatment with cabergoline restores sexual potency in hyperprolactinemic males: an open longitudinal study monitoring nocturnal penile tumescence. J Clin Endocrinol Metab 2004; 89:621.
- Dhindsa S, Prabhakar S, Sethi M, et al. Frequent occurrence of hypogonadotropic hypogonadism in type 2 diabetes. J Clin Endocrinol Metab 2004; 89:5462.
- Althof SE, McMahon CG, Waldinger MD, et al. An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation (PE). J Sex Med 2014; 11:1392.
- Patrick DL, Althof SE, Pryor JL, et al. Premature ejaculation: an observational study of men and their partners. J Sex Med 2005; 2:358.
- Rosen RC, McMahon CG, Niederberger C, et al. Correlates to the clinical diagnosis of premature ejaculation: results from a large observational study of men and their partners. J Urol 2007; 177:1059.
- Rowland D, McMahon CG, Abdo C, et al. Disorders of orgasm and ejaculation in men. J Sex Med 2010; 7:1668.
- McMahon CG, Abdo C, Incrocci L, et al. Disorders of orgasm and ejaculation in men. J Sex Med 2004; 1:58.
- Waldinger MD, Rietschel M, Nöthen MM, et al. Familial occurrence of primary premature ejaculation. Psychiatr Genet 1998; 8:37.
- Waldinger MD. The neurobiological approach to premature ejaculation. J Urol 2002; 168:2359.
- Rowland DL, Patrick DL, Rothman M, Gagnon DD. The psychological burden of premature ejaculation. J Urol 2007; 177:1065.
- Hatzimouratidis K, Amar E, Eardley I, et al. Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. Eur Urol 2010; 57:804.
- Hatzimouratidis K, Hatzichristou D. Sexual dysfunctions: classifications and definitions. J Sex Med 2007; 4:241.
- Coolen LM, Allard J, Truitt WA, McKenna KE. Central regulation of ejaculation. Physiol Behav 2004; 83:203.
- Corona G, Jannini EA, Mannucci E, et al. Different testosterone levels are associated with ejaculatory dysfunction. J Sex Med 2008; 5:1991.
- Corona G, Mannucci E, Petrone L, et al. Psychobiological correlates of delayed ejaculation in male patients with sexual dysfunctions. J Androl 2006; 27:453.
- Blanker MH, Bosch JL, Groeneveld FP, et al. Erectile and ejaculatory dysfunction in a community-based sample of men 50 to 78 years old: prevalence, concern, and relation to sexual activity. Urology 2001; 57:763.
- Rosen RC, Giuliano F, Carson CC. Sexual dysfunction and lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH). Eur Urol 2005; 47:824.
- Rosen R, Altwein J, Boyle P, et al. Lower urinary tract symptoms and male sexual dysfunction: the multinational survey of the aging male (MSAM-7). Eur Urol 2003; 44:637.
- PHYSIOLOGY OF MALE SEXUAL FUNCTION
- Neural influences
- Role of blood flow and nitric oxide
- Hormonal influences
- Normal sexual activity with age
- SEXUAL DYSFUNCTION
- Decreased libido
- Erectile dysfunction
- - Prevalence
- - Risk factors
- Diabetes mellitus
- - Association with cardiovascular disease
- - Drugs
- - Psychosocial factors
- - Neurologic
- - Bicycling
- - Endocrine disorders
- Ejaculatory disorders
- - Premature ejaculation
- - Delayed ejaculation, anejaculation, and male anorgasmia
- INFORMATION FOR PATIENTS