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Sexual
Questions You Wish You Could Ask Your Doctor… |
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The
doctor’s office is not always so sexy…
So often when we go to the
doctor, time with a physician is limited and it is challenging to ask
personal questions about sex. Fear, alienation from our bodies, ignorance
about the vast commonalities of sexual dysfunction and a host of other
social pressures make sharing and requesting sex information from a doctor
very difficult.
In
addition to our own discomfort, it's an unfortunate reality that most
doctors have had little or no sexuality education in medical school. Your
PCP and even your Gynecologist may have learned about reproductive organs,
but little regarding sex and sexual pleasure.
Most
importantly, if you do not tell your doctor about sexual problems, questions
or doubts, your health care may be incomplete. You may be at a higher
risk than you think for sexually transmitted infections or other problems
if your doctor does not know personal details about your sexual behavior.
Medical
Answers to Sex Questions
Questions
from Women
Questions
from Men
The Boston University Institute
for Sexual Medicine has been a leading institution in sexuality research
and health care. Below are their professional responses to common questions
about sexuality.
Learn
more from Boston
University and
BU
Center for Sexual Medicine
At Self Serve we believe communication
between partners and listening to your body’s needs can go a long
way. Many physiological sexual problems have to do with other aspects
of life. Keep an open mind in trying to improve your sex life. Medicine
and surgery are NOT always the answers. We are always pleased to see how
far one simple vibrator can take a person from defeated to orgasmic in
no time. Remember that there are many ways to look at sexual difficulties,
from medical advice to magazines to psychological theories. No one interpretation
is right for everyone. Explore…
Questions Asked by Women |
go to Questions
from Men
Q:
Who should I talk with about my sexual dysfunction - it bothers me but
I don’t know who can help me - is there a particular kind of doctor
for me to see?
A: You should speak with your primary care physician
or gynecologist (for women) regarding your sexual health. If he or she
does not have a broad enough knowledge base in this field, there are physicians
who specialize in sexual medicine, some of whom see only men, some only
women, and some who treat both.
Q:
I have not had intercourse for years, but my husband of 40 years is not
interested in sex, and neither am I. Should I be concerned?
A: Sexual dysfunction occurs in 43% of women. Sexual
dysfunction can be associated with significant loss of self-esteem, frustration,
humiliation, anger, depression, and unwanted termination of relationship.
However, sexual dysfunction may cause none of the above. It should only
be treated if it is associated with personal distress.
Q:
My partner has become increasingly frustrated with my lack of sexual interest.
I am afraid that my marriage won’t survive if my libido doesn’t
improve soon. What can I do?
A: Most treatments for low sexual desire are gradual
and improve the desire over a period of several months. Unfortunately,
stress in a relationship has often been building up for a long period
and the relationship may be at a breaking point before seeking professional
care. It can be very helpful to bring your partner with you whenever you
see the doctor. If this is impossible, bring your partner with you during
the initial office appointment. The more information that s/he receives
the better. Often knowing that there is a physical reason for this problem
helps the partner not to perceive the problem as a rejection or to take
it as overly personal. Also, if there is tension in your relationship
because of the lack of sexual activity consider couple or marital counseling.
This may be a helpful outlet to discuss the situation and to seek some
interim solutions.
Q:
I have three children and a husband I love very much, but I have absolutely
no interest in sex. My gynecologist suggested I leave the kids with my
parents and go away on a romantic weekend with my husband. I did that,
and it was a tender time, but I still had absolutely no interest in sex.
Why is that?
A: Desire is considered to be your needs and wants, thoughts
and fantasies, and hunger for sexual activity. Sexual desire disorder
is the persistent or recurrent deficiency (or absence) of sexual fantasies/thoughts,
and/or desire for receptivity to sexual activity, which causes personal
distress. Desire is related to many factors, including issues with your
present or past relationships, past sexual history, partner availability,
overall health, medications, and your hormonal status. A complete evaluation
for someone with consistent loss of desire would include a history, physical,
psychological evaluation and hormonal evaluation (estrogens and androgens,
including DHEA and testosterone).
Q:
Should I force myself to be sexually active with my partner even if I
am not in the mood?
A: This is an individual decision that only you can make.
Communication with your partner before this point may be preferable. Some
women do have sex out of a sense of obligation while other women find
this too difficult if they are not in the mood. The important thing is
to talk about the lack of intimacy in the relationship. By doing this,
many couples can find other ways to maintain the emotional and physical
intimacy of their relationship. If intercourse is uncomfortable, are there
other sexual acts that are more acceptable and enjoyable? Are there non-sexual
ways to keep the emotional closeness in a relationship? These are important
questions that couples should discuss. If not, there is a danger that
each individual will find him or herself becoming emotionally distant
from the other.
Q:
My doctor told me to start exercising, so I bought a bicycle, but I heard
that riding a bike can cause sexual problems. Is this true?
A: Sitting on a seat you are sitting on your ischial
tuberosities or sit bones. This is a safe region to bear your body weight
on your sit bones. Fat and muscle lay over the sit bones and there are
no associated nerves and arteries. In contrast, straddling a bike saddle
forces the rider to bear the body weight on the perineum (hidden part
of the labia and clitoris). Compression of the perineum may lead to permanent
nerve damage, leading to numbness and sexual dysfunction, such as loss
of ability to have orgasm. To avoid injury to the perineum while riding,
it is recommended to use a noseless two cheek split seat. If sexual dysfunction
occurs following riding, a full evaluation is indicated.
Q:
I’ve been married to a wonderful lover for 10 years but have never
had an orgasm. Is there anything that can be done?
A: The short answer: Try a vibrator! Orgasmic dysfunction
is defined as the persistent or recurrent difficulty, delay in or absence
of attaining orgasm following sufficient sexual stimulation and arousal,
which causes personal distress. It is a sensory reflex that is initiated
by stimulation of the genitals, with neurologic information passing into
the spinal cord and then into the brain (septum of the thalamus). After
appropriate stimulation is received in the brain, a spreading discharge
of chemicals is released spreading upward to higher levels of the brain
resulting in pleasure and spreading downward initiating motor stimulation
resulting in ejaculation. In general, therefore, problems with orgasm
are due to neurologic issues such as MS, injury from a bicycle saddle,
hormonal issues or aging or inhibition of the reflex from psychologic
stress, such as psychologic trauma or abuse. Partner issues such as premature
ejaculation may also result in anorgasmia. A complete evaluation for someone
with consistent anorgasmia would include a history, physical, psychological
evaluation, hormonal evaluation (estrogens and androgens, including DHEA
and testosterone) as well as neurologic assessment of genital sensation.
If neurologic assessment if abnormal, a practical strategy to increase
sensation is to use a vibrator.
Q:
My boyfriend broke up with me because sex was so painful I kept saying
no and he finally got too frustrated. He bought lubricated condoms, but
it didn’t help. Is there any hope for me? I am depressed about the
whole situation.
A: Dyspareunia is defined as the recurrent or persistent
genital pain associated with sexual intercourse. Recent population studies
of women with sexual dysfunction have shown that approximately 14% of
women have dyspareunia. Based on US population statistics, this translates
into 20,000,000 American women with dyspareunia. Biologic and psychologic
disorders may result in dyspareunia. Psychologic issues include history
of trauma and abuse, past experiences and partner issues. Biologic issues
include disorders of the clitoris such as clitoral neuroma, clitoral phimosis,
clitoral fibroepithelioma, disorders of the urethra such as urethral prolapse,
disorders of the labia such as dermatitis, disorders of the vestibule
such as vestibular adenitis (vulvar vestibulitis) and vulvodynia, disorders
of the pelvic floor such as vaginismus (pelvic floor spasm), disorders
of the vagina, uterus and ovaries, such as endometriosis, fibroids and
ovarian cysts. Patients with dyspareunia need a detailed history and physical
examination, psychological evaluation and hormonal evaluation. Management
requires specific diagnosis of the cause of the dyspareunia. In cases
of vulvar vestibulitis, conservative management is tried for a period
of time such as 3 months. Conservative management may include relaxation
biofeedback exercises, pain management with agents such as Neurontin or
topical lidocaine ointment, and hormonal management. Surgical management
may follow failed attempts at conservative treatment.
Q:
Can women with complete spinal cord injuries have an orgasm?
A: Until a few years ago, there was a common belief that
men and women with complete injuries were not capable of achieving a physiological
orgasm. Instead, memories of the past, feelings of closeness and a sense
of well-being were described as an "emotional orgasm" and were
offered as a substitute to a physical orgasm. The research done by Marca
Sipski, M.D. at Kessler Rehabilitation Center and at the University of
Miami has clearly demonstrated otherwise. This ground breaking research
is worth reviewing by women who see this as important. Although the physical
reasons for this are still unclear, many women of all levels and with
complete injuries can be orgasmic under the right conditions. Some of
the factors that have been found to correlate with the ability to have
an orgasm are: comfort with one’s body, persistence, knowledge about
one’s sexuality and intensity of stimulation. To date, no studies
have demonstrated similar results for men with spinal cord injuries.
Q:
Do Viagra, Levitra or Cialis improve sexual functioning for women with
spinal cord injury?
A: Research is still trying to answer this question and
a multi center SCI study is currently underway. Early studies with women
did show that Viagra was no better than a placebo for women who had low
desire and poor lubrication. Currently, the new studies with women have
been redesigned to exclude women with poor desire. Thus, in addition to
the SCI studies now underway, Pfizer is exploring the impact of Viagra
on women with poor lubrication and normal desire. It is just a matter
of time before oral medications to improve women’s sexual functioning
make their debut. Today however, we just don’t have the answers.
Questions Asked by Men
| go to Questions
from Women
Q:
Who should I talk with about my sexual dysfunction - it bothers me but
I don’t know who can help me - is there a particular kind of doctor
for me to see?
A: You should speak with your primary care physician
regarding your sexual health. If he or she does not have a broad enough
knowledge base in this field, there are physicians who specialize in sexual
medicine, some of whom see only men, some only women, and some who treat
both.
Q:
How do I know if my problem is caused by physical or psychological difficulties?
A: Today in the vast majority of cases there are physical
reasons causing a sexual dysfunction. Often, the psychological problems
associated with these problems tend to be a result of the sexual dysfunction
rather than causing it. It is difficult to have a sexual problem without
experiencing some feelings of stress and other emotional reactions. These
emotions can intensify an already existing problem. New treatments for
sexual dysfunctions are effective in treating sexual difficulties regardless
of whether they are caused by physical or psychological issues. Because
most problems tend to have both physical and psychological components,
it is generally a good idea to see a urologist in conjunction with a psychologist
or sex therapist. A good sex therapist should refer you to a medical doctor
for a comprehensive evaluation and a good medical doctor should also suggest
that you see a sex therapist or psychologist for the emotional components.
Q:
I have had sexual dysfunction for years, but my wife of 40 years is not
interested in sex, and I really don't care. Should I be concerned?
A: Erectile dysfunction is very common, affecting 31%
of all men. Sexual dysfunction is age-dependent and associated with multiple
risks. Erectile dysfunction can be associated with significant loss of
self-esteem, frustration, humiliation, anger, depression, and unwanted
termination of relationship. However, erectile dysfunction may cause none
of the above. It should only be treated if it is associated with personal
distress.
Q:
Since I first developed an erection problem, my wife questions if I still
find her attractive and even wonders if I am seeing another woman. What
can I do?
A: After developing an erection problem many men find
themselves withdrawing in various ways. They may communicate less or they
stop showing affection to their partner. Because sexual contact has often
resulted in failure, they are hesitant to initiate any sexual advances.
As a result, the partner often feels unattractive or undesirable. Women
may be concerned that sexual needs are being met outside the relationship.
Even with an erection problem, it is important to be affectionate and
caring with your partner. Communicate your feelings and let your partner
know that you still care for her. Remember, not all sexual contact has
to result in intercourse.
Q:
I’m a healthy man who exercises regularly and always had a good
erection until recently. My doctor says my impotence must be psychological
because I am so healthy, but I don’t feel like it’s in my
head. Is it possible that it's physical?
A: Erectile dysfunction is defined as the persistent,
for a period of at least 3 months, inability to attain and/or maintain
an erection for satisfactory sexual performance. It may be considered
as mild, moderate or complete. It is quite possible that an otherwise
healthy man can have physical causes for erectile dysfunction. Erectile
dysfunction may be due to 1) failure to initiate the erection secondary
to neurologic, psychologist or hormonal abnormalities; 2) failure to fill
the erection chambers secondary to artery blockage or 3) failure to store
blood in the erection chambers secondary to scarring of the erection chambers.
A complete evaluation would include a history, physical, psychological
evaluation, hormonal evaluation and specialized testing as needed.
Q:
My doctor told me to start exercising, so I bought a bicycle, but my life
partner told me he read that riding a bike can cause impotence. Is this
true?
A: Sitting on a seat you are sitting on your ischial
tuberosities or sit bones. This is a safe region to bear your body weight
on your sit bones. Fat and muscle lay over the sit bones and there are
no associated nerves and arteries. In contrast, straddling a bike saddle
forces the rider to bear the body weight on the perineum (hidden part
of the penis). Compression of the perineum may lead to permanent nerve
and artery damage, leading to numbness and sexual function, such as loss
of erections. To avoid injury to the perineum while riding, it is recommended
to use a noseless two cheek split seat. If sexual dysfunction occurs following
riding, a full evaluation is indicated.
Q:
My penis curves to the left when erect. It’s embarrassing, and I’m
only able to have intercourse in one position. On top of that, my girlfriend
complains that it sometimes hurts her when we're having sex. Can anything
be done about it?
A: Curvature of the penis during erection may be either
congenital (you were born that way) or acquired (usually due to Peryonie's
disease). The latter condition is associated with scarring of the lining
layer of the erection chamber called the tunica albuguinea. The scarring
is often the response to a previous injury of the erection during sexual
activity.
Q:
My doctor gave me a prescription for Viagra but didn't tell me how it
works or how to take it. What do I do?
A: Viagra is indicated for the treatment for erectile
dysfunction. Its official role is as an enzyme inhibitor, but practically
speaking it acts as a signal amplifier. This means that once the signal
of sexual stimulation is received by the penis, the resultant erection
will be maximized because of the use of the medication. Viagra comes in
3 strengths, 25, 50 and 100 mg. For most healthy people Viagra can be
started at 100 mg and, if it is effective, the dosage can be decreased.
For individuals with cardiac or liver conditions, or people taking medications
for AIDS, or a medication such as erythromycin, it is recommended to start
the dose at either 25 or 50 mg. Viagra must not be used if the patient
takes nitroglycerin, a common medication used for men with chest pains
such as angina. Viagra should be taken on an empty stomach, and the use
of alcohol be minimal. One needs to wait at least one hour after taking
Viagra, but the signal amplification effect lasts, in most patients, between
8 and 12 hours, therefore, in many men, the medication can be taken hours
before planned sexual activity to allow for sexual spontaneity. Traditional
side effects include headache, facial flushing, nasal congestion and stomach
pains. Certain patients with eye problems such as retinitis pigmentosa
should not use Viagra. Viagra should only be used after consultation with
a physician. After a period of use, it is recommended to return to your
physician to discuss the results of the treatment. Viagra is not the only
treatment option for men with erectile dysfunction. There are other mechanical,
pharmacological and surgical treatments that can restore erectile function.
Q:
My doctor gave me Viagra but it didn’t really help. Is there anything
else I can try?
A: Often Viagra does not work because of improper use:
if appropriate the highest strength should be used, the pill taken on
an empty stomach with minimal alcohol use, taken at least one hour before
use, and sexual stimulation is needed. If Viagra doesn't work after an
appropriate use of several pills at the highest strength your physician
recommends, contemporary understanding would suggest that you obtain hormone
blood tests, such as DHEA and testosterone. If your hormone levels are
below normal, hormone replacement may be given and Viagra tried again.
Sexual counseling by a certified sex therapist should be considered. Other
therapies for the treatment of erectile dysfunction include Levitra and
Cialis, the vacuum constriction device, insertion of a medicated pellet
into the urethra (MUSE), self-injection therapy and penile prosthesis
insertion. In selected cases of men less than 45 years of age, especially
where the impotence is due to trauma to the perineal (crotch) area, penile
revascularization surgery may be considered.
Q:
I hear there are new medications coming out to treat impotence. What are
they, and how do work?
A: Levitra became available in the U.S. in August, 2003
to treat men with ED. Cialis became available as of December 2003. Like
Viagra, they are signal amplifiers of the sexual stimulated erectile response.
There are biochemical and pharmacokinetic differences among the 3 pills.
Head-to-head comparison trials among the 3 drugs will help us understand
when to use these new medications.
Q:
I'm 35 years old with impotence. Levitra works, but I don't want to be
dependent on pills for the next 40 years. Is there anything I can do?
A: In selected cases of impotence, penile bypass surgery
may be effective. In cases where the hormonal, neurologic and psychologic
evaluations are normal, an underlying vascular problem may be suspected.
In those vascular cases where the blood trapping system is normal (veno-occlusive
function), the vascular abnormality is limited to a blocked artery. Performing
bypass surgery for blocked arteries in the heart, legs, kidney and brain
are commonplace. Penile bypass surgery was first described in 1973. In
selected centers in the United States penile bypass surgery has proven
to be safe and effective, especially for young men whose ED is associated
with a history of blunt pelvic/penile/perineal trauma.
Q:
I have been impotent for 5 years. I tried pills, pellets and shots, and
nothing has worked. My doctor says I need an implant but I don't understand
what he means. Can you explain what it is and how it works?
A: Penile implants are silicone or silicone-like devices
that are surgically implanted into the erection chambers of the penis
to provide appropriate penile rigidity. There are basically two types
of devices: an inflatable and a non-inflatable device. The inflatable
device usually consists of 3 pieces: a pump, two cylinders and a reservoir.
The cylinders are implanted into the erection chambers, the pump is placed
into the scrotum, and the reservoir is implanted deep into the pelvis
near the bladder. Usually a single incision is required to implant the
entire device. Since all the component parts are internally placed and
none are visible, gently squeezing the pump in the scrotum transfers fluid
from the reservoir into the cylinders creating the erection. Once the
sexual activity has terminated, gently squeezing the deflate mechanism
near the bulb of the pump results in fluid form the cylinders returning
to the reservoir. The first penile implant was placed in 1973, and over
20,000 per year are inserted. The success rate exceeds 80 %, thus making
this treatment the most successful of all the treatments for erectile
dysfunction. Since placement of the implant requires surgery, and permanent
injury to the erectile tissue, implant treatment is considered an irreversible
therapy. Complications of this surgery include penile implant infection
(1-2 % of cases), device malfunction (2-3 %), surgery or anesthesia complications
(‹ 1 %) and inappropriate patient expectations (5 %).
Q:
I'm a prostate cancer survivor and have not recovered my ability to have
erections yet. Viagra didn't help, so what can I do?
A: During surgical removal of the prostate for cancer
(radical prostatectomy), it is common that the nerves to the penis are
injured. Under conditions where there is nerve injury, Viagra should not
be expected to improve erectile function since it is a signal amplifier.
If no signal can be transmitted to the penis, Viagra cannot be expected
to work. Under normal physiological circumstances, neurologic sexual stimulation
results in release of chemicals (i.e. neurotransmitters) in the erectile
tissue that initiate the erectile process. This mechanism can be mimicked
by injecting similar chemicals directly into the erectile tissue by an
insulin needle (30 gauge). Self-injection therapy for the treatment of
ED has been practiced since 1983. Traditional vasoactive drugs presently
in use include papaverine hydrochloride, phentolamine mesylate, and/or
prostaglandin E1. FDA approved treatments for self-injection therapy include
Caverject and Edex. In many cases individualized combinations of vasoactive
drugs have been found to be safe and effective. Complications of self-injection
therapy include prolonged erection (1-3 % of cases), clinically significant
pain (5-10 %), and bruising at the injection site (20 %).
Q:
I'm 62 years old, happily married, can no longer get an erection but cannot
take the pills for ED. I remember seeing an ad for a vacuum device for
impotence. Is this safe? Should I try it?
A: A vacuum device consists of a cylinder, a pump and
a constriction ring. After the penis is placed within the cylinder and
the cylinder pushed against the pubic bone to create a seal, the pump
creates a negative pressure which draws blood into the erection chambers.
The constriction ring is then placed at the base of the penis to trap
the blood inside, thus maintaining the erection. The constriction ring
should be left in place for a limited time period, approximately half
an hour. Vacuum constriction therapy is a safe and effective therapy that
does not involve drugs or surgery. It often requires a technical support
staff to address questions regarding its proper use. Complications of
vacuum constrictive therapy include bruising (‹5 % of cases) and
clinically significant pain (5 %).
Q:
My girlfriend says I come so fast she barely has time to get excited let
alone have an orgasm. Is there any help for me?
A: Although it is difficult to define premature ejaculation,
it is the most common sexual dysfunction, exceeding the frequency of erectile
dysfunction. Premature ejaculation traditionally has been managed by the
sex therapist using exercises such as squeeze technique, relaxation exercise,
and desensitization techniques. Recently pharmacologic therapies have
been used with success. SSRI's such as Zoloft and topical lidocaine have
been helpful. Side effects of SSRI's include light-headedness and drowsiness.
Q:
Everyone always brags about how long they can make sex last, but I want
to hide when they have that discussion. I take so long to reach orgasm
that my wife complains of how sore she is. I wind up having to masturbate,
but that takes forever. Are there any tricks to reaching orgasm sooner?
A: Orgasm is a sensory reflex that is initiated by stimulation
of the genitals, with neurologic information passing into the spinal cord
and then into the brain (septum of the thalamus). After appropriate stimulation
is received in the brain, a spreading discharge of chemicals is released
spreading upward to higher levels of the brain resulting in pleasure and
spreading downward initiating motor stimulation resulting in ejaculation.
In general, therefore, problems with orgasm are due to neurologic issues
such as MS, injury from a bicycle saddle, hormonal issues, or aging, or
inhibition of the reflex from psychologic stress, such as psychologic
trauma or abuse. A complete evaluation for someone with consistent anorgasmia
would include a history, physical, psychological evaluation, hormonal
evaluation as well as neurologic assessment of genital sensation. If neurologic
assessment is abnormal, a practical strategy to increase sensation is
to use vibrator devices.
Q:
I am a 25 year old man with a spinal cord injury. Since getting injured,
I can never quite reach an orgasm. Is there anything I can do that would
get me closer to an orgasm?
A: The ability to ejaculate and have an orgasm is a complex
neuromuscular process that is adversely affected by a SCI. Following injury,
it is not unusual for individuals to have significant difficulties in
reaching orgasm. In most cases, loss of sensation and inadequate stimulation
contribute to the problem. Thus increasing stimulation, especially in
areas where sensation may be spared, is a worthwhile pursuit. Many individuals
find that using a vibrator with adjustable amplitude can provide the level
of stimulation necessary for ejaculation and orgasm. Increasing visual
and auditory stimulation may also be helpful in enhancing the level of
arousal. In addition, some experts believe that regular and frequent sexual
activity may increase the likelihood of restored ejaculatory functioning.
Ongoing sexual activity maintains the integrity of the various chambers
and arteries of the penis. Remember when using a vibrator; be especially
careful of autonomic dysreflexia.
Q:
Does sexual functioning improve over time since spinal cord injury?
A: There is no precise answer to this question although
many people do report positive changes over a period of years since injury.
For example, it is not unusual for some men to report having an ejaculation
or an orgasm for the first time several years after injury. Other men
notice gradual improvements in the quality of their erections. Being sexually
active on a frequent basis may be the most helpful tool in improving your
sexual functioning over time. Frequent sexual activity tends to maintain
good blood flow to the genitals and contributes to the integrity of penile
tissue. Many of the early studies with Viagra demonstrated the long term
benefits of frequent engorgement of the cavernosal arteries and corporal
chambers. There is truth to the old saying, "use it or lose it!"
Q:
So much changed after my injury. Can guys with spinal cord injury really
enjoy sex?
A: Early after injury the idea of resuming a positive
sexual life can be overwhelming. Some men tend to avoid sexual activity
because of embarrassment regarding their body, poor self esteem or the
fear of failure. On the other hand, some men see this as a challenge to
be conquered, learn as much as they can and take advantage of every opportunity
to be intimate. Over time and with confidence about their sexual abilities,
these men enjoy long lasting relationships and frequent sexual intimacy.
It is possible to have a great sex life after an injury but it doesn’t
develop without a personal commitment to make it happen. Having an enjoyable
sex life requires time, practice, and the knowledge that sex is an important
part of life not to be missed.
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