Loss of desire
	Physical disability
	Penis and erection problems
	Ejaculation difficulties
	ACTIVITY Ejaculation control
	Problems with testicles
	Prostate problems
	Infertility
	Sexually transmitted infections

Loss of desire

All men sometimes lose interest in sex. Loss of desire for sex can last for days, weeks, months or years. It mayor may not be seen as a problem by a man or his partner. Some men feel that sex is an essential part of their manhood. Other men feel that sex is not very important.

Loss of desire for sex can have a physical cause, such as illness, tiredness or poor diet, or an emotional cause, such as difficulties within a sexual relationship, or other worries. The best way to deal with it is usually through the 'talking cure' of counselling. Loss of desire is not usually treated medically, unless there is some obvious physical illness.

A common cause of loss of desire is depression. Many people become mildly depressed when they are anxious. It may be useful to explain to men that loss of desire due to anxiety is common, and that their desire will return when they feel more relaxed. It can help to talk to men and help them to deal with other issues that are making them feel anxious.

Problems relating to sex, such as ending an important sexual relationship, or confusion about sexuality, can cause a major emotional upset. Men are often reluctant to seek help about sex-related problems, and it is often hard for workers to recognise these problems. Men with sexual problems can therefore feel very isolated. A sense of isolation can lead to unhappiness and sometimes mental illness.

Celibacy 
Celibacy means not having sex, whether by choice or not. For some men it is a problem. There are no harmful effects from not having sex. However, some men who do not engage in sexual activity, for whatever reason, may be pitied or seen as socially inadequate and not 'a real man'. 

Becoming sexually active and becoming a man are often closely connected. Although most people have no sexual relationships during some periods in their lives, some men find lack of sex distressing. Men who have chosen to be celibate, for religious or other reasons, may be helpful in talking to men who are not having sex.

Physical disability

Disability can affect a man's sexual health in many ways, depending on the nature of the disability, attitude and ability of the individual, the attitude of society and what support is available.

 
 
Many disabled men have happy, normal sex lives, but many are prevented from doing so. Some disabilities, such as spinal injuries, limit the body's ability to function. Some disabilities make sex too tiring or painful. Many disabled men lack the confidence to develop sexual relationships because of their disability. However, many disabled men who cannot enjoy penetrative sex enjoy other sexual activities, such as oral sex, mutual masturbation, sensual touching, affection and emotional intimacy. 

It is important that disabled men and women are offered practical support, and counselling if they choose it, to feel more able to express their sexuality. (See Organisations on page 46).

Penis and erection problems

Penis problems 
Many men worry about the size and shape of their penis and may need some reassurance (see page 26). Serious medical problems with the penis are rare. 

A tight foreskin is a common problem. It makes it difficult and painful to pull the foreskin back over the top of the penis. It can make washing the penis difficult. After puberty, when a man has erections, a tight foreskin can be painful. It can be removed by circumcision (see page 26). 

Cancer of the penis is a serious disease, although very rare. The causes are not fully understood. It is possible that there is a link between penis cancer and the herpes virus (see page 44). There is also a possibility that cancer of the penis is linked to poor genital hygiene. Boys should be encouraged from an early age to wash their penis every day to protect themselves, and their sexual partners, against a range of infections (see page 30). Cancer of the penis usually affects older men. Early symptoms include an ulcer on the end of the penis, pain, bleeding and swollen glands. (It is important to remember that all of these symptoms are often caused by more common, and less serious, illnesses.) It is diagnosed by a biopsy (when some of the affected part of the penis is examined under a microscope). 

Priapism is a painful and permanent erection, which is not caused by sexual excitement, and does not disappear after ejaculation. It is rare and mostly affects men with sickle cell disease. It is important to treat it as early as possible, because it can lead to impotence if it is not treated. Treatment will depend on the cause, and should be dealt with by a specialist doctor. 
 

Erection difficulties ('impotence')  
 

Almost all men experience difficulty with erections at some time. They may have no erection, an erection for only a short time, or a partial or semi-rigid erection. Some men experience erection difficulties only under certain conditions or only with certain partners. Men can have erection difficulties at any age, but as they become older, it is more common for their erections to become less frequent and less rigid.

 
Physical causes of erection difficulties include vascular problems (blood vessels in the penis), alcohol, drugs (both medicinal and recreational), smoking, blood pressure, diabetes, thyroid problems, some cancers, and some illnesses such as multiple sclerosis.

Erection difficulties often have emotional causes. These may be temporary, such as the shock of losing a job or getting divorced. They maybe more complex and longer term, such as a belief that sex is 'dirty' or wrong. Emotional causes are often connected to men's childhood conditioning and early experiences of sex. Problems with erections are often linked to difficulties in a relationship. 

Many men feel under pressure to use sex as a way of proving their manhood. This is common, but can be very damaging. The more pressure a man puts on himself to have an erection and be a 'real man', the more difficult it will be.

Treatments There are several ways of dealing with erection difficulties, depending on the cause. Erection difficulties are often due to causes that are not physical, and cannot be dealt with by medical methods. Professional counselling, or talking informally to someone, is often the best way to help. 

Treatments for erection difficulties with a physical cause are expensive and not widely available:
 

	injection into the penis, with drugs or hormones, to cause a temporary erection
	drugs which cause temporary erections, such as Viagra
	surgery to increase blood flow to the penis
	penile implants give the man a small but permanent erection
	inserting a small bulb into the scrotum, which can be squeezed to create an erection.

Ejaculation difficulties

Premature ejaculation 
A common sexual difficulty for men is not being able to control when they ejaculate (have an orgasm or 'come'). Premature ejaculation means ejaculating within a few seconds of penetration. Some men may ejaculate in response to only a slight touch, or just by thinking about sex. Premature ejaculation usually has an emotional cause, and is not related to any physical condition. 

It is sometimes said that premature ejaculation is common among younger men with less sexual experience. In fact, it can affect men of all ages. Premature ejaculation is not a problem if the man and his partner are not concerned about it. However, men usually want to exercise some control over when they have an orgasm, so that their partners have time to reach orgasm. 

Premature ejaculation is often caused by the pressure to 'perform', or other emotional difficulties. For example, if a man has been taught that sex is shameful he may feel pressured into getting it over with quickly. Many men are nervous when they have sex with a new partner, and have a premature ejaculation. Lack of privacy, or fear of being discovered having sex, also make premature ejaculation more likely. 

Treatment There are several simple techniques that can be taught to men to help them increase control over when they ejaculate. 
 

	Encourage the man to relax and understand his body better, and recognise the signs that he is near to ejaculation (see Activity, below).
	Using a condom when having sex can reduce sensitivity of the penis, and give a man more ability to control his ejaculation.

It is not helpful to advise men to 'think about something else' while having sex, to help them delay their ejaculation. This can stop them from enjoying the sex and can make it less pleasurable for their partner.

 
 

ACTIVITY EJACULATION CONTROL This activity is designed to help a: man who has problems with premature ejaculation. It involves masturbating to a set of specific instructions. The man needs somewhere quiet, private and comfortable, and time to practise. The aim is for him to gain greater awareness of his sexual response, so that he will be better able to control when to ejaculate with a partner. Start masturbating and keep going until you reach a point at which you feel you are about to ejaculate. When you are very excited and just about to come to orgasm, stop masturbating and notice how you feel. You will soon lose the urge to ejaculate and will lose your erection either partially or completely. When your desire to have an orgasm has gone completely, start masturbating again and repeat the process of stopping before the point of ejaculation. If you feel like ejaculating almost immediately, wait a bit longer before going on.  The more you do this exercise, the better control you will develop over your ejaculation, as you become more aware of your sexual responses. A greater awareness of your own feelings means that you will be able to recognise when you are nearing the point of ejaculation with a partner, and choose whether to slow things down and delay orgasm.

 
 
Delayed ejaculation 
Delayed ejaculation is when a man has an erection, but cannot move on to orgasm. This happens from time to time with some men, but for others it can be a long-term problem. 

Delayed ejaculation can have physical causes, such as alcohol, drugs or exhaustion. If there is no obvious physical cause, emotional causes are possible. These may include worry about a man's sexual performance and a feeling that he must prove himself as a 'good lover' or boredom, anger or fear.

Treatment Emotional causes of delayed ejaculation are best dealt with by talking with a sympathetic listener, and relaxing and learning more about the man's sexual response.

Problems with testicles

Men can help to prevent medical problems with their testicles by checking them regularly (see page 31). 

Any new lumps, hardening, heaviness or general feeling of discomfort in the testicles could indicate:
 

	a hernia (caused by muscle strain or injury)
	a hydrocele (a collection of fluid around the testicle which causes swelling)
	a cyst (a small pocket in the testicle which contains fluid)
	a torsion or twist in the testicle which brings on a painful swelling
	cancer of the testicles (this is rare).

A man may feel aching in his testicles if he has been sexually aroused for some time but has not ejaculated. This is not harmful and soon passes.

Treatment Because of the range of possible causes of testicle problems, men with testicle problems should get medical advice. Some conditions can be dangerous if they are not treated. Testicular cancer can be cured if it is detected and treated early.

Prostate problems

Many men suffer from prostate gland problems, especially older men. The prostate gland (see diagram on page 24) encircles the urethra, the tube through which semen and urine pass out of the penis. Problems are usually caused by the prostate becoming enlarged, which can make it difficult to urinate (pass water). An enlarged prostate gland has no specific physical effects on a man's sexual functioning. 

The most likely symptoms of prostate enlargement include: 
 

	a slow flow of urine
	delay in starting urination
	dribbling at the end of urination
	frequent urination
	need to urinate at night
	sometimes a complete inability to urinate.

A man should always go to a doctor if symptoms persist. Some of these symptoms can be a sign of prostate cancer. However, enlargement of the prostate gland is usually not caused by cancer. It is important not to scare men into assuming that prostate enlargement means they have cancer. Fear of cancer may prevent them from seeking help. 

Treatment A doctor's initial advice may be to 'wait and watch'. This should only be done on medical advice. It means monitoring the condition to see if the man can safely live with the prostate enlargement without medical intervention. Many men can manage without treatment.

If prostate enlargement causes problems, surgery is the most usual medical treatment offered. It involves removal of prostate tissue. Drug treatments are another option. However, the drugs have side effects, they need to be taken for a long time, and they are probably not as effective as surgery. 

If prostate enlargement is due to cancer and the cancer is only in the prostate gland, the chances of cure are good, provided that medical treatment is available and affordable. Radiotherapy, hormone therapy or complete surgical removal of the prostate gland are the most common treatments. 

If the cancer has spread to other parts of the body, a cure may not be possible. This is one reason why it is important for men to seek help as soon as they notice any changes or problems in their prostate gland. Early treatment can save lives.

Infertility

Sexually transmitted infections Infertility means being physically unable to have children. It can occur in both men and women. A man may also be 'sub-fertile', which means that he has low numbers of sperm, and therefore a lower chance of his sperm being able to fertilise an egg (see page 28). 

About one in ten couples who try to have children are unable to do so. In about 40 per cent of couples who cannot have children, the man is infertile or sub-fertile. In another 40 per cent of couples, it is the woman who is infertile. In the remaining 20 per cent of couples, the cause of infertility cannot be identified. Women are often blamed when a couple cannot have children. It is important that health workers explain that both men and women can have problems with fertility. 

Men can have fertility problems for a number of reasons: 
 

	difficulty in producing sperm
	low numbers of healthy sperm
	blocked tube which carries the sperm (the vas deferens, see diagram on page 24)
	an inability to ejaculate because of erection difficulties or physical damage
	a sexually transmitted infection, such as syphilis or gonorrhoea (see page 44).

Treatment Good overall health plays a part in maintaining fertility, but not much can be done if a man has a low sperm count. Male infertility or sub-fertility cannot be easily treated. Sometimes drug treatment or surgery can be offered if the numbers of sperm are not too low. 

Finding out that he is infertile can be shocking for a man. He may feel that he is to blame, or he may not believe the results of a medical test. Fertility is often strongly linked with sexual performance and a sense of manhood. A man who is infertile may fear losing his status within the community. Infertility may also affect his identity much more deeply, especially where religion and culture emphasise the fathering of children as a central activity in a man's life. 

Some women may find infertility of their partner very difficult to accept. Some may be sympathetic, but some may be unable to feel any sympathy towards their male partners. It is important to offer men the chance to talk about their feelings. Counselling for both partners, either separately or together, can be helpful.

Sexually transmitted infections

Sexually transmitted infections (STIs) have an enormous impact on people's health worldwide. The World Health Organization estimates that one in ten sexually active people have an STI. Most STIs can be easily cured if treated ill time. Untreated infections, however, can grow much worse, and can cause pain, illness, infertility and even death. Some STIs can cause harm to babies born to women with STIs. For example, gonorrhoea can cause eye problems and in some cases blindness. Syphilis can be transmitted to the child and cause death. HIV can be passed from mother to child before or during birth, or during breastfeeding. 
 

Very few men attend STI clinics for regular check-ups, even where these facilities exist. Men often leave sexual health problems until they are suffering discomfort or pain. Delaying treatment usually means that the problem gets worse, which can make treatment harder and less effective. It also increases the risk of infecting partners. STIs are transmitted more easily from men to women than from women to men.

It is very important to encourage men to find out about STIs and ask for advice and treatment when they need it. It is also important to encourage people with suspected STIs to ask their partners to have a check-up. Anyone finding out that they have an infection from their partner may be shocked. Contacting partners needs to be done sensitively. 

HIV is a virus that can lead to a range of illnesses some years after a person is infected. There is no cure for HIV. However, people with HIV can stay healthy for longer if they are treated for infections early. Some drugs are now available which reduce the level of the HIV virus in the body (anti-viral drugs, or anti-retroviral therapy). These drugs must be continued once started. They are expensive, but are becoming increasingly available in some countries. Anyone with HIV can pass the HIV virus on to sexual partners, even if they are still healthy, or are taking anti-viral drugs. 

Most STIs affect the male and female reproductive organ or rectum. Some STIs, including syphilis, hepatitis Band HIV, can affect other parts of the body, for example, the eyes, nervous system or liver.

Common STI signs and symptoms include:
 

	urethral and vaginal discharge
	pain when urinating or during intercourse
	genital ulcer
	lower abdominal pain
	genital itching
	painful swelling in the lymph glands in the groin
	painful swelling of the scrotum.

If STIs are not treated, they can result in serious problems, such as infertility in both men and women. STIs that cause open sores, such as syphilis, chancroid and genital herpes, are not only dangerous in themselves but also greatly increase the risk of HIV transmission. 

STIs can easily be diagnosed using laboratory tests. However, these require expensive equipment that is not available in most places. Results of tests can take several days. Some people do not to return to obtain their test results, or to have treatment. In many countries, health workers are being encouraged to diagnose and treat people with an STI, by identifying the main groups of symptoms (syndromes) commonly associated with these STIs (syndromic management).

MEN AND STIs  

 

	Start teaching boys and young men about sex and STIs before they start having sex. Providing information about risks, treatment, and prevention works better than leaving boys in ignorance and fear!
	Provide clear and explicit information; anything unclear may increase boys' and men's fears.
	Let boys and men know where to get help. If possible, organise a visit to a health facility where people with STIs are treated, as part of sex education lessons.
	Design posters and leaflets which explain in detail what happens at health facilities where people with STIs are treated.
	If a man is unwilling to seek help for a suspected STI, offer to go to the clinic with him. Feeling ashamed or isolated is a major barrier to seeking treatment.
	If men are worried about seeking treatment, arrange to talk with staff at clinics to see how services could be made more 'men-friendly'.
	If men are having difficulty talking to their partners about the risk of STIs, ask them to practise by talking with you first.
	Remember that STIs are transmitted through oral and anal sex, as well as vaginal sex. Train health workers to recognise anal STI symptoms.

SEXUALLY TRANSMITTED INFECTIONS INFECTION SIGNS AND SYMPTOMS TREATMENT Human immunodeficiency virus (HIV)  HIV is a virus that is carried in blood, semen or vaginal fluid. It can be transmitted through: - unprotected sexual intercourse - exchange of blood (such as transfusions or shared injecting equipment) - mother-to-child transmission during pregnancy, delivery or breastfeeding.  HIV is not transmitted through everyday contact such as kissing, toilet seats, sharing towels or eating utensils, or through mosquitoes. HIV itself has no symptoms. HIV damages the immune system, making people more vulnerable to a wide range of infections. Some people may develop flu-like symptoms shortly after infection. Most people who have HIV remain healthy for several years with no serious symptoms. HIV-related problems may then develop, such as dry coughs, night sweats, thrush and sudden weight loss. More serious illness may then develop, such as shingles (herpes zoster), persistent diarrhoea, tuberculosis and other illnesses which would normally be easy to treat. This phase is known as Acquired Immune Deficiency Syndrome (AIDS). Someone with HIV can remain healthy for many years. It is believed that overall good health, a healthy diet and good health care may delay the onset of illness. Anti-viral drugs can reduce viral load (the amount of HIV in the body). These drugs, taken in combination therapy, enable people with HIV to live for much longer. The anti-viral drug, zidovudine, can reduce the risk of HIV transmission from mother to child, if taken by pregnant women before and during delivery. Gonorrhoea (the clap) Caused by the bacteria N. gonorrhoeae. Transmitted through unprotected vaginal, anal or oral sex. Yellowy-white discharge from the penis, pain when urinating. The symptoms may disappear after a few days, but the person remains infectious. If left untreated, gonorrhoea can inflame testicles, which can lead to infertility. Women may have symptoms similar to men, or often no symptoms. If untreated, gonorrhea in women can lead to upper reproductive tract infections, and cause infection to babies during birth, leading to eye infections or blindness. Treated with a single dose of antibiotics such as ceftriaxone, ciprofloxacin, cefixime or spectinomycin (kanamycin or trimethoprim where gonorrhoea is resistant to other drugs). In most areas, penicillin is no longer effective against gonorrhoea. Many men and women with gonorrhoea also have chlamydia, which has similar symptoms. Treatment for both gonorrhoea and chlamydia is recommended if a man or woman has urethral or vaginal discharge. Chlamydia  Caused by the bacteria Chlamydia trachomitis. Transmitted through unprotected vaginal, anal or oral sex. Common signs in men include: thin watery discharge from the penis and burning sensation when urinating or during sex. Chlamydia often has no visible signs in women so is undetected and untreated, increasing the risk of reproductive tract infections. Symptoms in women may include bleeding after sex and pain in the abdomen. Chlamydia can cause infection in babies during birth, leading to eye infections or blindness. Treated with a short course of antibiotics such as doxycycline or tetracycline (erythromycin for pregnant women). Chlamydia is often present in men who have gonorrhoea. It is advisable to treat men and women with gonorrhoea for chlamydia as well. Chlamydia can be detected by a blood test or sample taken from the area that may have been infected. Syphilis  Caused by bacteria Treponema pallidum. Transmitted through unprotected vaginal, anal or oral sex. Painless ulcers on the penis, vagina or anus, which appear two to four weeks after infection. Without treatment, the ulcers disappear after six to eight weeks. Then the secondary stage develops. Symptoms include: fever, enlarged lymph glands, headache and rash. If the disease is still left untreated, it may cause blindness, heart problems and dementia (confusion). Syphilis can be passed from a pregnant woman to her baby. Treated with short course of benzathine penicillin, or, for the rare cases of allergy, doxycycline (erythromycin for pregnant women). Chancroid Caused by bacteria Haemophilus ducreyii. Transmitted through unprotected vaginal, anal or oral sex Painful ulcers on the penis, vulva or anus, similar to syphilis ulcers. Treated with short course of antibiotics such as erythromycin, ceftriaxone, ciprofloxacin or trimethoprim. If chancroid is common locally, a person with genital ulcers should be treated for both syphilis and chancroid.

SEXUALLY TRANSMITTED INFECTIONS INFECTION SIGNS AND SYMPTOMS TREATMENT Genital herpes Caused by the Herpes simplex virus. Transmitted through close bodily contact. This includes vaginal, anal or oral sex or skin contact if blisters are present. Can be transmitted to a baby during birth if the mother has blisters Small, painful blisters on the penis, rectum or mouth which fill with a liquid and then burst;  flu-like symptoms; itchiness around genitals. Ulcers heal within two to three weeks. Many people have no further symptoms. Some people experience frequent occurrences, perhaps less severe than the first one.  Once someone has the herpes virus, there is no way of getting rid of it by medical treatment. In many people, herpes episodes become less frequent with time. Acyclovir (ointment or tablets) can help to shorten the length of the attack. Genital warts  Caused by human papilloma virus. Transmitted through close bodily contact, most commonly vaginal, anal or oral sex. Small, fleshy and soft lumps which appear on their own or in clumps on the inside of the penis or around the anus. Sometimes they are difficult to see. They can cause irritation and discomfort. It can take several months for the warts to appear after a person becomes infected. External warts treated by a paint-on ointment. Internal warts need freezing treatment at hospital. If left un treated, the warts spread rapidly. It is thought that the virus increases risk of cervical cancer in women.  Trichomoniasis ('trich') Caused by protozoa (single-cell organism). Transmitted through close bodily contact and unprotected vaginal intercourse, but not anal or oral sex. Thin, greenish discharge from penis. Sometimes pain when urinating. Men can have no symptoms and still be infectious. Trich is not dangerous if left untreated but many people with trich also have gonorrhoea, which can lead to serious problems if left untreated. There is some evidence that infection with trich increases the risk of co-infection with other STIs. Treated with a short course of antibiotics, such as metronidazole. Thrush  Yeast infection, caused by Candida albicans which occurs naturally in women's vaginas but sometimes grows more than normal. Takes advantage of weakened defences, either in a particular part of the body or generally. Too little or too much washing is a common causative factor. Occurs in babies, and in adults who are tired, stressed, taking antibiotics, diabetic or with a damaged immune system, sometimes because of HIV infection. Men can get the yeast trapped under their foreskin and then pass it on during sex. White coating growing in moist parts of the body, such as the vagina or throat, or under the foreskin. Causes redness and itching. People with HIV often get severe, recurring thrush in the mouth, digestive tract and genitals. Can be serious as it can interfere with eating or breathing. Treated with anti-fungal drugs in tablet or cream, such as fluconazole. live yoghurt applied to affected areas can prevent and treat thrush. Some people recommend avoiding sweet or starchy foods. Risk of thrush can be reduced in HIV-positive people if they take weekly doses of fluconazole. Pubic lice ('crabs')  Small insects that lay their eggs in pubic hair. Pass between people during close bodily contact, including sex. Small brown lice and white eggs visible in pubic hair. Cause severe itching.  Lice killed with liquid solution applied to the pubic area, left on for a short time and then washed off. Scabies  Small parasites that live on the skin, usually the fingers, armpits, abdomen, thighs, penis or scrotum. Transmitted through close bodily contact, including sleeping next to a person with scabies, or from contact with infected clothes or bedding. Causes a red, very itchy rash on the affected area. If left untreated, scabies will spread rapidly over the body and be very uncomfortable. Can lead to sores. Whole body is treated with benzene hydrochloride lotion or crotamiton cream, left on for 24 hours and then washed off. Sheets and clothes should be boiled. All members of the house-hold must be simultaneously treated. Hepatitis B  Virus which can be transmitted through vaginal, anal or oral sex, or through exchange of blood (such as sharing needles or syringes, or blood transfusion). It is much more infectious than HIV.  Symptoms may never develop, or may develop after some time. Liver becomes inflamed, causing jaundice, vomiting and loss of appetite. Symptoms can be mild to very serious, and can cause death.  There is no cure but symptoms can be relieved with medication. There is an effective vaccine for those who might be at high risk of coming into contact with the virus, such as health workers.