Male Sexual Dysfunction

Male sexual dysfunction includes the following: decreased Libido, Erectile dysfunction (ED), ejaculatory disorders and disorders of orgasm. All types of sexual dysfunction increase with age.

Libido is the medical term for sexual drive or the desire for sex and decreased libido can occur in 5-15% of adult males. Libido is influenced by biological, psychological and social factors. Sex hormonal levels, stress and depression, endocrine conditions such as hypothyroidism, drugs such as antidepressants,antipsychotic, opioids, beta blockers, substances such as smoking and alcohol can affect libido.

Erectile dysfunction refers to the inability to attain and maintain a sufficiently rigid penis to permit penetrative sexual intercourse. It is very common and is estimated to affect 50% of all men between the ages of 40-70 yrs sometime during their lifetime. Common causes for ED are Vascular (arterial and venous), neurogenic, hormonal and psychogenic. Erections are Neuro vascular events provoked by thoughts, visual images or dreams.

Erections start when the mind is stimulated by erotic thoughts, visual stimuli or sounds. These electric discharges from the brain stimulate the erection centre in the lower spinal cord (segments T11-L2). Impulses generating from this area, stimulate vasodilation of the blood vessels flowing into the penile muscles. Rapid filling of the penis leads to compression of the penile veins until it leads to the attainment of an erection. When nitric oxide (vasodilatory mediator) is metabolised and also in stimulation of the Noradrenaline system, vasoconstriction occurs and the blood flow into the penis is reduced with subsequent drainage of blood out of the penis and loss of erection (detumescence). Therefore attaining an erection requires appropriate Mental and psychological function, intact neurological pathways, open blood vessels and hormonal activities. Erections can also happen to penile stimulation and spontaneously during sleep (normally 3-4times per night)

Ejaculatory disorders could be premature ejaculation, retrograde ejaculation, delayed ejaculation, anejaculation and anorgasmia. Premature ejaculation refers to when the man ejaculates within a minute of vaginal penetration or sooner than desired. It can occur in upto 30% of men. Retrograde ejaculation refers to backwards discharge of semen during intercourse into the bladder which then comes out during urination. This is one of the causes for infertility and may not require treatment unless fertility is desired. Ejaculation occurring after a reasonable period of sexual activity is called delayed ejaculation. Anejaculation is when there is no ejaculation after sexual stimulation and may be associated with anorgasmia.

What is required to find the cause for male sexual dysfunction?

1. A thorough medical history including a history of diabetes, hypertension, prostate disease, obesity, dyslipidaemia, depression, chronic kidney disease, sleep apnoea, substance abuse and medications (including off label medications) used. A detailed sexual history of the patient, including that of sexual preference, frequency of dysfunction and the circumstances associated with dysfunction needs to be elicited. History of injury to hip or genitals or pelvic surgery may be causative. A history of spontaneous erections occurring at night would make a vascular or neurological disease unlikely and a psychological cause more likely.

2. A thorough medical examination including examination of the genitals and a rectal examination to examine the prostate gland would be needed.

3. A thorough psychological assessment by an experienced counsellor.

4. To do appropriate tests such as general screening tests (CBC, ESR, RFT-E, LFT, Lipid profile, Hba1c, urine complete, stools complete and an ECG. More specific tests might include Thyroid function tests, Testosterone and LH assays, Penile Doppler and Ultrasound whole abdomen and Rectal ultrasound in select cases.

There are 5 broad categories that cause male sexual dysfunction. They include 1.Systemic diseases such as Diabetes, hypertension, heart disease, chronic kidney disease, 2.Psychological causes, 3.medicines (25% of all causes) 4.endocrine disease such as thyroid dysfunction and androgen deficiencies and 5.Neurological causes such as spinal cord diseases, multiple sclerosis and dementia.

Commonly prescribed medicines that can cause sexual dysfunction in men are:

1. Antidepressants – SSRIs

2. Antihypertensives medications: Betablockers, Amlodepine, Chlorthalidone, Enalapril and Doxazosin.

3. Antiandrogens – Androgen deprivation therapy

4. Others- Clonidine, methyldopa, ketoconazole and Spironolactone.

Treatment of Male sexual dysfunction

1. Lifestyle changes – advice patient to stop using recreational drugs including alcohol and cigarettes and help him with Deaddiction. Weight loss and physical activity will also help improve the situation.

2. Professional counselling – counselling patient with partner by a sex therapist may be helpful.

3. To stop medicines that can cause sexual dysfunction.

4. To correct androgen deficiencies and other endocrine disorders ( Thyroid, Prolactin and Estradiol). To stop antiandrogens including Finasteride and Dutasteride if possible.

5. To provide a prescription for a phosphodiesterase 5 inhibitor – Sildenafil, Tadalafil etc.

6. To consider surgery – penile prosthesis

7. Other therapies – use of a vaccine device, intraurethral alprostadil suppository etc. Premature ejaculation can be treated with counselling and use of Lignocaine/Prilocainegel on penis before intercourse.

Patient stories: One gentleman who was 70 yrs old and was on treatment for benign prostatic hypertrophy on Urimax F (Tamsulosin and Finasteride) came to me with a history of erectile dysfunction. I suggested that he change his Tamsulosin to Alfuzocin, stopped the Finasteride and also gave him a prescription for Tadalafil.

Patient 2 was a 50 year old who was on SSRI antidepressant and who reported loss of libido. I asked him to change his Escitolopram to Mirtazapine with good effect.

Patient 3 was a retired banker who had had presented with dullness, slurred speech and memory deficits. Investigations had shown low sodium, hypopituitarism, hypogonadism and atypical tuberculosis.1 yr after recovery he was started on Testosterone injections for lack of libido and ED and reported good improvement in his complaints.

Male sexual dysfunction has many effective therapies but often needs a multidisciplinary approach to providing the best care.

What are the 5 medically proven things that you can do to live longer?

There are many people in this world who would love to live upto a 100 yrs of age. My own grandfather was very keen to live to see a 100 but unfortunately died 4 months past his 99th birthday. The average lifespan of an Indian has been constantly increasing over the last 30 yrs. In medical college I had learned that the life expectancy at birth of the average Indian male was 56 yrs (in 1988) but it has risen to 69.6 years in 2019. WOW! The Indian male can today expect to live 13-14 yrs longer than 30 yrs ago! Of course the Indian lady has always lived much longer than the man! I have always been curious about longevity ever since I heard my 7th grade classmate claim that his grandfather was 90 yrs old because he took one Badaam (Almond) a day, everyday! I had asked another grandfather what his secret to his long life was and he had replied, “no worries, hahaha”! I have read many books by current authors who claim their methods will get you to live upto 120 yrs but none of them,I am sure are even a day older than 60! Surely it wouldn’t be prudent of me to wait 60 yrs to know if there were right! It so happened that one day as I was shifting my books from the old cupboard to a new one, I stumbled upon a book that was with me for many years but had never been leafed through. And to my surprise, the author a physician/cardiologist mentioned that there were only 5 things proven with reasonable certainty in published medical literature that could prolong life. Hold your breath folks, the answer is coming up shortly…………..

1. Non-smoking – didn’t your mother tell you “never to smoke”, didn’t she tell you that it causes cancer, heart attacks, strokes, kidney failure and impotence!! Smoking is injurious to your health and your dynasty! That is a no brainer, NOT smoking will help you live longer and better.

2. Modest (daily) Alcohol consumption – hail Bacchus, the God of good times! May every party start with salutations to you. The important word to watch out is MODEST alcohol intake. Modest alcohol refers to 3 units (1 unit = 30ml) for men and 2 units for women a day. The daily intake recommendations are intended for societies where it is normal for people to drink daily. Like the French who may drink a glass of wine with lunch and even be allowed to fly a plane for Air France!If you are a teetotaller,I wouldn’t recommend that you start drinking for health! It is also recommended that you don’t add your daily quota for a binge during the weekend.That is sure to make Bacchus unhappy and shorten your lifespan.

3. Vigorous daily exercise for at least 30 mins. Daily deliberate exercise ensures that your heart, lungs, all muscles and joints of the body are well oiled and in good condition. Surely you must have heard that “all work and no play makes Jack a dull man”! I would recommend gradually increasing your exercise quota to an hour every day targeting 7 days a week. The intensity can vary depending on you freshness/fatigue levels! Exercising in the evenings have the benefit that you don’t have to spend much time warming up.

4. To achieve your ideal body weight – I have seen many people who go to the gym who are very happy with their physical prowess but are in denial of the fact that they are overweight. So how do you calculate your ideal body weight (IBW)? The simplest way is to subtract 100 from your height in centimetres. I am 185cm in height and so my ideal weight is 185-100=85kg. There is another way to calculate using the BMI. The BMI is calculated by dividing the weight in kilogram by the square of the height in meters. Using my values ……..

The Americans (AHA) have recently reduced the upper value of the ideal BMI for Indians to 23.5 (how dare they!) So to calculate your ideal weight using the recommended BMI value, you will need to do the following sum – 23.5 X 1.85X1.85 = 80.42Kg. So according to the AHA, I would be 4.6 kg overweight! So all I have to do now is to eat less and exercise more to achieve my ideal body weight and live longer – Oh what a beautiful idea Sirji!

5. The last one! The Ideal diet – to eat more fruits and vegetables. It used to be said that “an apple a day keeps the doctor away”. That was appropriate for the days when the average Indian male lived upto the age of 56. But not anymore!! I ask some of my young patients if their parents and grandparents are alive and most would answer in the negative. When I ask them why they had passed on, they would often reply “of old age” and when I ask how old they were, the reply would come “65”! 65 yrs is young by me as I had 3 grandparents alive with me until 10 yrs ago. We need to eat right to live long. The WHO recommends that one consumes nearly 800 gms of fruits and vegetables every day. For a family of 4, it would be 3.2kg of fruits and vegetables every day! This does not happen in even the most affluent families. I think that is important to eat more fruits and vegetables of every colour every day. Salads salads salads is the way to go!

So, these are the 5 proven secrets to a long life. You may want to “Live Young and Live Free” my friend but I pray that you will Live well, Live long……….my best wishes!


1. For the last 10 yrs I have been VEGAN. I would recommend a few documentaries on Netflix for you to see. Athletes and Medical doctors recommending similar things for your improved health.

Forks over knives

Game Changers

What the Health

2. Living Longer, Living Better – Dr. Harold H Opie

3. Prevent and Reverse Heart disease – Dr. Caldwell Esselstyn Jr. My respects for this gentleman are sky high for not just be a great doctor but more for his being a Gold medal winner in Rowing at the 1956 Olympic Games! And by the way, Bill Clinton endorse his programme for cardiac health!

How do you tell if your chest pain is serious!

Recently I had a friend come to my clinic with a history of severe chest pain which started off at night and was so severe that she had to go to the hospital nearby for treatment. Apart from the pains what was most terrifying was that she was alone and she was afraid that she was having a heart attack. Luckily, her ECG at the ER was normal, her pain subsided with antacid therapy and she was sent back home. I write this article to tell you how to analyse your pain and what you must do. Of course if you are unable to analyse what you are going through or if the pain is very severe, I would advise you to go straight to the hospital and not lose time pondering as to the cause of the pain.

What are the Alarm signs in a person with a chest pain, things that would require you to go to the ER immediately?

1.Compressive chest pain with severe sweating.

2.Chest pain with severe dizziness

3.Chest pain with new onset breathlessness.

4.Chest pain followed by fainting or loss of consciousness.

5. Chest pain with a low or a very high Blood pressure or with low oximeter readings ( < 92%)or with a high pulse rate (>100bpm)

Lets look at the common causes of chest pain, see how they present typically.

1. Cardiac pain – Pain arising due to a heart attack or angina is typically central, compressive, it could radiate to the left shoulder, arm, jaw or ear and is associated with severe sweating, nausea or vomiting, dizziness and breathlessness. The key words would be pain and sweating. This pain is usually worse on exertion and could be relieved by rest. The typical patient is a middle aged to elderly man who has cardiac risk factors such as obesity, cigarette smoking, high cholesterol levels, diabetes, high blood pressure etc. Postmenopausal women are at higher risk for a heart attack compared to premenopausal women. Also women may have a heart attack with atypical symptoms and even without pain!

2.Acid reflux can also give pain behind the sternal (breast) bone. The pain could be sharp or dull, localised or diffuse. The pain could also be burning and be associated with bile/bitter water rash to the mouth. This is worse after a meal and on lying down in bed after food.

3. Chest pain due to Gas! Pain due to gas is usually sharp localised to a small area and can move quickly from one part of the chest to another or even the back. It could feel like a catch in the chest or like being stabbed and make breathing difficult. This pain usually happens after a meal and is relieved by belching/burping. The key words would be moving pain and relief by belching.

4.Pleuritic chest pain -this pain is sharp and felt on the side of the chest. It worsens on deep breathing coughing and sneezing. This is usually caused by irritation of the pleura , which is the covering of the lung and it occurs when there is a pneumonic infection of the lung. This could be associated with cough, phlegm production and breathlessness. The key words would be chest pain on deep breathing.

5. Musculoskeletal chest pain- this pain can be quite severe localised and can increase on movements, deep breathing and local pressure (which is diagnostic) If the pain increased on pressing the affected part of the chest, it is highly unlikely to be from the heart or the lung and must be from the muscles and bone of the chest. Localised pain on touch and pressure on the side of the sternal bone (2nd Costo-chondral junction is called Tietze syndrome). The key words would be localised chest pain worse on local compression. Similar pain can also happen after a rib fracture.

Other cause for chest pain:

1. Mitral valve prolapse syndrome is characterised by repeated sharp pricking anterior chest pain which may be associated with palpitations and anxiety. It affects women more often than men.

2. Sudden sharp “pleuritic” chest pain with breathlessness and low Oximeter reading could be an Acute Pulmonary Embolism. The usual patient is a woman on contraceptive pills or an elderly person who has made a long haul flight (Economy class syndrome) and has developed a Deep venous thrombosis (DVT). This could also be due to a Pneumothorax. (Punctured lung)

3. Herpes Zoster – the pain of herpes zoster can precede the typical rash by a few days. The pain is severe lancinating continuous and may have a pleuritic component i.e., it worsens on deep breathing.

So what should you do if you develop a chest pain?

1. The first thing would be to check your pulse rate, oximeter reading and your Blood pressure. These equipments are now available in nearly household. If the parameters are very abnormal, it would be sensible to go to the hospital immediately.

2. If you have any alarm signs – a hospital visit is a must urgently.

Spinal Pain – how to tell what kind of a pain it is, so you can get the right medicines for relief!

The vertebral column is made up of 33 vertebral spinal bones stacked one on top of the other like carrom coins. Each vertebral bone is separated from the one above and below by a intervertebral disc which functions as a cushion or a shock absorber.

Each vertebra is made up of a body, pedicle, transverse process, articular process (facet) and spinous process.

The body of each vertebral bone is separated from its fellow above and below by the intervertebral disc in the front and the inferior articular process of the upper vertebra sits on the superior articular facets of the lower vertebra forming the Facet joints. The opening at the centre of the bone is called the Vertebral foramen through which the spinal cord passes. The spinal nerves exit sideways in between the vertebral bones.

The vertebrae are supported and kept in alignment by strong ligaments.

And the ligaments are covered by muscle which not only support the spine but also move and turn it.

There are 4 types of pain that you can feel around the spine – Radicular pain, muscle spasm pain, Facet joint arthritic pain and muscle inflammation (tear) pain.

1. Radicular pain – is pain that runs along the direction of the nerve that is touched/compressed by the degenerative process of the spine as indicated in the diagram below.

Sciatica is a type of Radicular pain that runs down the back of the leg upto the toe. It is described as sudden shooting and electric shock like!

Anti neuritic treatment along with a week’s bed rest will reduce this pain

2. Muscle spasm are a dull continuous and distressing kind of pain which stops you from bending down. The pain is diffuse and the exact location cannot be shown to others.

Muscle relaxants work very well to reduce this discomfort. A variety of different medications are available.

3. Facet joint pain is usually sudden sharp and localised to a small area in the back.

This pain responds very well to anti inflammatory pain killers.

4. Muscle tear pain usually happens from severe stress to the spine leading to a muscle tear. The pain is localised to one muscle which is swollen and tender (pain generated by local pressure)

Anti inflammatory pain killers will work very well to reduce pain. Trapezitis is the term used to describe pain and tenderness of the Trapezius muscle in the neck and shoulder area.

Ice pack for acute pain and Hot fomentation once the severity of pain reduces is helpful.

Spinal support from a neck collar and Lumbar corset can also be quite helpful.

If you develop a little insight into your pain, you may be able to help your doctor prescribe the correct medicine for you.

Finally, once the back pain reduces with medicines and physiotherapy, regular core and neck strengthening exercises are the only way to keep back pain from any cause from recurring.

Common fevers of Chennai

Chennai (previously known as Madras), is the capital of this southern state of Tamil Nadu. The weather is so hot that the British have a dish named after this city called Chicken Madras. Despite being dry most of the year, many infectious disease are prevalent throughout the year, only that some are more common during the rainy season. Infections are an important reason for high temperatures in the city.

The 5 common endemic infections in Chennai are:

1. Malaria – Vivax malaria is seen more often compared to falciparum malaria and typically cause high fevers with intense shivering (rigors). A person suffering typically experiences a cold phase with shivering, a hot phase with high fever and a sweating phase with drenching sweating. This happens periodically once a day or once in 2-3 days.

2. Typhoid fever (Enteric fever) – this is food borne infection caused by salmonella gastroenteritis. This can present variously but what is usual is that there would be some degree of a gastrointestinal upset. The patient could present with fever,shivering, body pains, headache,rash etc.

3. Dengue Fever – is another mosquito borne viral infection spread by the day biting Aedes aegypti (tiger mosquito – with white stripes on it) which is believed to bite below the knee. Fever can be high with shivering and severe back pain. A rash is also possible in light skinned patients.

4. Leptospirosis or Rat fever is caused by a family of 400 bacteria and causes fever with severe body pains. Some subtypes can cause jaundice, bleeding tendencies along with the fever whereas some others can cause kidney failure. This bacteria enters the body when water contaminated by rat urine (containing the bacteria) comes in contact with the body of the patient.

5. Scrub Typhus -happens due to a organism called Rickettsia and is a mite borne infection. The bite usually occurs in people who travel to heavily wooded areas such as IIT Madras or Raj Bhavan. The fever can be very high and the patient can have a very severe headache. Usually a black ulcer is found in the flexures of the body (under the breasts and in the groins)

The number one fever in Chennai over the last 2 years has been Covid 19. Patients usually have a fever with upper respiratory symptoms such as a headache, sore throat, runny nose, sneezing and cough with some phlegm production. A small proportion of patients develop a severe immune mediated pneumonia during the second week of the infection.

Urine infections, Intestinal infections, Skin infections are other common causes for fever. These infections are usually easily treated.Early diagnosis will help ensuring an early cure and rapid return to normal living.