Partner Sexual Health Problems

Content written by Irwin Goldstein, MD

Couples share their sexual dysfunctions. Can a woman develop a sexual dysfunction exclusively because of her partner’s sexual problem? There are limited scientific data on the topic. Based on the information available, the answer is probably yes. The data are less clear for women without sexual dysfunction who have women partners with sexual dysfunction, however women who are with men with erectile dysfunction or premature ejaculation may indeed have their own sexual function adversely affected.

Erectile dysfunction was the most frequently cited reason for cessation of sexual activity in a sample of over 500 otherwise healthy women. In another study, the sexual function was compared between almost 40 women whose men had erectile dysfunction and almost 50 women whose men did not. Women’s sexual arousal, lubrication, orgasm, satisfaction, and pain were significantly diminished among women with men who had erectile dysfunction in comparison to women in the control group. An additional study was performed on almost 300 women in 8 countries whose male partners had erectile dysfunction. Women whose partners had erectile dysfunction reported a lower frequency of sexual activity currently, compared with before their partner developed erectile difficulties. Significantly fewer women reported that they experienced “almost always” or “most times” sexual desire, sexual arousal, orgasm or sexual satisfaction currently, compared with before their partners developed erectile difficulties. In addition, women had the lowest frequency of orgasm and the lowest satisfaction with sexual experience when their male partners had the severest form of erectile dysfunction. Women whose partners were current users of phosphodiesterase type 5 inhibitor therapy, e.g., sildenafil, reported significantly greater frequency of desire, arousal, and orgasm than did women whose partners were not current phosphodiesterase type 5 inhibitor users.

Further, a trial was performed in women whose male partners had erectile dysfunction but the female partner did not have sexual dysfunction. Compared to the women whose men with erectile dysfunction were treated with placebo, women whose partners were randomized to receive the active drug had significantly higher sexual quality of life, sexual desire, arousal, lubrication, orgasm, and satisfaction. Women’s sexual function improvements correlated with treatment related improvements of their partner’s erectile function. Clinical management of sexual dysfunctions should emphasize both members of the couple.

Another erectile problem men suffer from is Peyronie’s disease, which is characterized by a hard lump or plaque that forms on the surface of the erection chamber lining, deep under the skin. Peyronie’s disease symptoms include penile pain during erection, penile curvature and loss of penile length during erection and erectile dysfunction. Peyronie’s disease may be related to the female partner superior position sexual activity. If the female partner misses with her penetration and brings her body weight to bear on the penile erection, the excessive force borne to the erection causes localized inflammation and injury to the tunica. In some cases, this can lead to tunica inflammation, with subsequent scarring eventually causing penile curvature during erection. The bend in the penis may make sexual intercourse penetration difficult, or may cause pain to the partner upon penetration.

Premature ejaculation is a very common male sexual dysfunction, affecting approximately 25% of men. Premature ejaculation may be objectively determined using a stopwatch to record intravaginal ejaculatory latency time, defined as the time between vaginal intromission and intravaginal ejaculation. It has been suggested that an intravaginal ejaculatory latency time of 2 minutes or less may serve as a criterion for defining premature ejaculation.

One study compared the mean intravaginal ejaculatory latency time of 200 men with premature ejaculation to almost 1400 men without premature ejaculation. The intravaginal ejaculatory latency time was 1.8 minutes in the former and 7.3 minutes in the latter. Women whose men had premature ejaculation were found to significantly differ from women whose men did not have premature ejaculation, in terms of decreased satisfaction with sexual intercourse and increased interpersonal difficulty and distress.

In summary, couples’ sexual problems and sexual solutions are shared. There are data documenting that women, whose male partners have erectile dysfunction and/or premature ejaculation, can develop their own sexual dysfunction based on their male partners’ sexual problems.What can be done about your male partner’s sexual dysfunction? There are many FDA-approved treatment options for men with erectile dysfunction. Erectile dysfunction is the persistent or repeated inability, for at least 3 months duration, to attain and/or maintain an erection sufficient for satisfactory sexual performance. It is a significant and common medical problem. If your partner has erectile dysfunction, he should see a healthcare professional and, if needed, a sexual medicine specialist.

What should you and your male partner do about his erectile dysfunction? He should undergo a comprehensive medical and psychosexual history, physical examination, and laboratory testing, just as is required for a woman being treated for sexual health problems. Laboratory tests may include sex steroid hormones, blood flow or genital sensation testing. Your partner may need exercise testing to see if there are any early signs of blockage in other arteries, such as in the heart. He may need to change his diet and consider a Mediterranean diet. He may need to start a daily exercise program and consider stopping smoking. He may need counseling with you to address relationship factors, such as excessive marital tension. The sexual health problem should be characterized, and the need for additional testing and referral assessed. Your partner’s needs and your needs as a member of the couple, both your expectations and your priorities, are key elements in the management process. Healthcare providers in general, and specifically sexual medicine healthcare providers, can offer evidence-based treatment options if your partner has erectile dysfunction.Sex therapy may be provided to your partner alone or ideally with both you and your partner as a couple. Sex therapy addresses specific psychological or interpersonal factors that are likely to enhance your partner’s and your sexual functioning. Factors that frequently interfere with sexual satisfaction are relationship distress, sexual performance concerns, and dysfunctional communication patterns. Independent, brief sex therapy consists of in-session discussion and at-home exercises specific for your partner and for your couple relationship. Cognitive-behavioral interventions are used predominantly, and include such strategies as behavioral rehearsal, cognitive restructuring/reframing, systematic sensitization, anger management, thought stopping techniques, control and perception of control, self-esteem enhancement, goal setting, active listening, strategies for coping with stress, and modification of life-style, such as getting better sleep, better nutrition, and more exercise. Sex therapy can be used in conjunction with oral phosphodiesterase type 5 inhibitors, constriction devices or other medical/surgical treatments. This modified form of sex therapy can address the psychological reactions to the medical treatment, which may be perceived as an unnatural or unacceptable means of achieving sexual gratification.

Oral phosphodiesterase type 5 inhibitors are FDA approved for the treatment of erectile dysfunction. They are administered on demand, in appropriate dosages, and are effective in facilitating the initiation and maintenance of erections following sexual stimulation approximately 30–45 minutes after administration. No notable effects on erections are observed in the absence of sexual stimulation. Phosphodiesterase type 5 inhibitors are effective across a broad range of causes of erectile dysfunction, including psychologic, medication-related, vascular, and neurologic. Side effects include headaches, flushing, upset stomach, nasal congestion, and back or leg pain. Phosphodiesterase type 5 inhibitors are contraindicated for men receiving nitrate therapy, including short or long acting agents, delivered by oral, sublingual, transnasal or topical administration.

Vacuum constriction device therapy is a well-established, non-invasive therapy that is FDA approved for over-the-counter distribution. Vacuum constriction device therapy may represent an attractive treatment alternative if your male partner does not desire the use of medications, such as oral phosphodiesterase type 5 inhibitors. The vacuum constriction device applies a negative pressure to your partner’s penis thus drawing in blood. The blood is then retained by the application of an elastic constriction band at the base of the penis. The side effects associated with vacuum device therapy include penile pain, numbness, bruising, and delayed ejaculation.

Testosterone therapy should be pursued, especially if your partner has consistently low values of “unbound” testosterone documented on repeated blood testing. The “calculated free testosterone” values, as determined by measuring the total testosterone, the sex hormone binding globulin, and the albumin levels, should be higher than 5 ng/dl. The syndrome of low biologically available testosterone, with symptoms such as fatigue or low interest, is called hypogonadism or androgen insufficiency. The most common form of testosterone therapy is by topical delivery of an FDA approved gel, although testosterone may be administered by intramuscular injection. Testosterone therapy should be used selectively and carefully. Your male partner will need to undergo a digital rectal examination and a blood test called “PSA” or prostate specific antigen prior to any testosterone therapy. It is contraindicated to administer testosterone to a man with prostate cancer, as the testosterone can encourage the growth of a pre-existing prostate cancer. If the rectal examination and the PSA blood tests are initially normal, your male partner will need to have repeated examinations and blood tests during regular follow-up visits while on testosterone therapy. Often, giving testosterone therapy will improve the effects of the phosphodiesterase type 5 inhibitors in facilitating, initiating, and maintaining erections, although this effect takes months to be appreciated.

Intraurethral administration of alprostadil is another FDA approved therapy option for erectile dysfunction. The alprostadil is in the form of a semi-solid pellet that is placed in the male urethra with a special inserter device, prior to sexual activity. Approximately 50% of men achieve successful intercourse with this system in the home situation. Side effects associated with the intraurethral administration of alprostadil include penile pain and, more uncommonly, prolonged erections. In addition to local side effects, intraurethral alprostadil may cause systemic effects, particularly hypotension, in a small number of cases.

Penile self-injection therapy uses the FDA approved drug prostaglandin E1. The drug is injected directly into the side of the penis into the erection chamber, prior to sexual activity, with a small gauge insulin-like needle and syringe. If your partner needs this therapy, he will need to be trained by a healthcare provider as to the correct techniques for self-administration. Often, the woman injects the penis if the man is unable to do this. Penile self-injection therapy is remarkably effective in most cases of biologically-based erectile dysfunction. In general, penile self-injection therapy with alprostadil is effective in 70% to 80% of patients, although discontinuation rates are very high in most studies. In addition to prostaglandin E1 therapy, various combinations of prostaglandin E1, phentolamine, and/or papaverine are widely used for self-injection therapy. Side effects of penile self-injection therapy include primarily local penile events, such as prolonged erections or priapism (<1%) and pain (5% to 20%), as well as scar tissue formation with chronic use. Penile self-injection therapy should not be used if your partner is receiving the anti-depressant medication monoamine oxidase inhibitor. Penile self-injection therapy continues to be widely used and is a safe and effective non-surgical treatment for erectile dysfunction, especially when simpler, less invasive treatments are either not effective or not indicated.

Surgical implantation of a semi-rigid or inflatable penile prosthesis is highly invasive and associated with potential complications, such as infection in 1% to 5% of cases or mechanical failure. Penile prosthesis insertion is an irreversible treatment option, generally reserved for select cases of severe, treatment-refractory erectile dysfunction, such as Peyronie’s Disease, priapism or after radical prostatectomy. Despite the invasiveness, numerous studies have shown penile prostheses to be associated with high rates of sexual satisfaction for both partners. The inflatable penile prosthesis provides a more aesthetic erection and better concealment than the semi-rigid prosthesis. Penile prostheses provide an effective surgical solution for erectile dysfunction, particularly in those patients for whom other forms of therapy are ineffective.

Penile microsurgical revascularization surgery may correct erectile dysfunction, particularly in young men (aged <40–45 years) with a history of pelvic and/or perineal trauma, such as from a fall onto a bicycle bar or kick in the crotch. If a localized arterial blockage is determined to exist, a revascularization procedure employing a new artery source (e.g., the inferior epigastric artery) to deliver blood to the erection artery of the penis is a treatment option. Penile revascularization is associated with a 60% to 70% long-term (5-year) success rate and few complications.

What if your male partner has premature ejaculation? While there are no FDA-approved treatments for premature ejaculation at this time, most healthcare providers or sexual medicine specialists will use the following treatment options alone or in combination. First, a desensitizing agent such as topical lidocaine is used to reduce penile sensation. Usually the desensitizing agent is applied in conjunction with a condom, to avoid drug transfer to the woman’s genital tissues. It is important to see if the desensitizing agent used may adversely affect the integrity of the condom, if contraception is important. The idea is that less penile sensation will lower the likelihood of premature ejaculation. Second, an anti-depressant that is a selective serotonin reuptake inhibitor is used daily. At present there are no selective serotonin reuptake inhibitors FDA approved for the treatment of premature ejaculation. There are many different selective serotonin reuptake inhibitors available for treatment of depression, most of which can be used off-label for premature ejaculation. The idea is that serotonin is a specific centrally acting inhibitor of sexual activity, especially ejaculation and orgasm. Correct daily dosing of the selective serotonin reuptake inhibitor can increase the intravaginal ejaculatory latency time. Third, an oral phosphodiesterase type 5 inhibitor can be used. The idea is that if your partner has an early ejaculation, he will be able to obtain a second erection earlier by using a phosphodiesterase type 5 inhibitor. As a last treatment option, penile self-injection therapy may be used, resulting in an erection that will last post-ejaculation. As in all cases of sexual dysfunction, consultation with a sexual medicine specialist may be needed.

In summary, sexual problems and sexual solutions are shared. Management of sexual health problems requires the use of evidence-based, rational, clear, and specific guidelines for diagnosing and treating men and women with sexual health problems. The treatment of a sexual dysfunction in one partner may heighten the awareness of a sexual health issue in the other. Both you and your partner should undergo general medical and psychosocial evaluation by a healthcare provider or by a sexual medicine specialist at regular intervals. Follow up is intended to assess the progress of current therapy. A sound and trusting relationship among you, your partner, and your healthcare provider is the key to success in a sexual medicine treatment program. Sexual health is an important element in the physical and psychological wellbeing of most individuals and couples.