The issue of male sexual dysfunction often causes men to feel anxious and hesitant to consult anyone. In reality, sexual dysfunction is a common physical, vascular, and neurological condition in medicine (Burnett et al., 2018), which can be diagnosed and rehabilitated to a functional state. This article will explain what sexual dysfunction is, its causes, preliminary self-checks, as well as proper management and prevention methods, helping men regain confidence and quality of life.

What Is Sexual Dysfunction? Understanding Erectile Dysfunction (ED)

Erectile Dysfunction (ED) or sexual dysfunction is a condition where the penis cannot achieve a sufficient erection or maintain it long enough to complete sexual intercourse (Salonia et al., 2021). This condition can occur in men of all ages, not limited to older adults.

Sexual Dysfunction: What Are the Causes?

Male sexual dysfunction usually stems from a combination of physical, vascular, neurological, hormonal, lifestyle, and emotional factors. Properly identifying the root causes helps physicians plan targeted treatments. The main groups include:

Physical Causes (Organic Causes):

- Vascular (Vasogenic): A highly frequent physical cause, arising from Endothelial Dysfunction or Atherosclerosis. This results in insufficient blood flow to the penile tissues (Corpora Cavernosa). Often found in patients with diabetes, high blood pressure, high cholesterol, and cardiovascular diseases.
- Neurological (Neurogenic): Caused by abnormalities in the nerves that send erection signals, such as in patients who have had prostate surgery, pelvic surgery, spinal cord injuries, or neurological conditions like Parkinson’s disease.
- Endocrine and Hormonal: Caused by Late-Onset Hypogonadism (LOH), affecting both sexual desire (Libido) and the production of Nitric Oxide in the blood vessels (Onyeji & Clavijo, 2022).
- Structural (Anatomic/Structural): Such as Peyronie’s Disease, which causes the penis to curve or become painful during an erection.

Psychological and Fatigue Causes (Psychogenic Causes): Stemming from stress, anxiety, depression, or performance anxiety, as well as lifestyle factors like lack of sleep, heavy smoking, and alcohol consumption. Symptoms often occur suddenly or in particular situations, while morning erections remain regular, or erections are fine during masturbation.

A frequent situation today involves working-age men seeking consultation for erectile issues in their 30s or incomplete erections due to heavy workloads, accumulated stress, and inadequate rest. After thorough physical, blood sugar, lipid, and hormone evaluations at Bangkok Hospital, vascular and physical health often appears normal. The primary issue stems from fatigue and temporary autonomic nervous system failure due to stress. With appropriate lifestyle modifications and care, function can return to normal without requiring long-term medication.

Symptoms of male sexual dysfunction can present in various severity levels, with observable signs including:

Inability to achieve an erection: Cannot achieve an erection at all, even with adequate sexual stimulation.
Incomplete erections: Can achieve some rigidity, but insufficient for penetration, or loss of firmness before completion.
Reduced sexual desire: A noticeable decrease in sexual interest, which may relate to male hormone deficiency.

How to Perform a Preliminary Self-Check for Sexual Dysfunction

Before consulting a urologist, men can observe initial changes as follows:

Observe morning erections (Nocturnal/Morning Erection): Normally, the body experiences erections during sleep and upon waking (around 3 to 5 times a night). If these disappear for several weeks, it may be a warning sign of vascular or neurological irregularities.
Assess rigidity during penetration: Check if the firmness is sufficient for intercourse, which can be evaluated using the Erection Hardness Score (EHS):
- EHS Level 1: The penis enlarges but is not firm (like a sponge).
- EHS Level 2: Firm but insufficient for penetration (like a peeled banana).
- EHS Level 3: Firm enough for penetration but not fully hard (like an unpeeled banana).
- EHS Level 4: Fully firm and rigid (like a cucumber).
Observe responses during masturbation: If erections are fine during self-stimulation but problematic with a partner, this often indicates psychological factors and anxiety.

Medical Sexual Dysfunction Treatment

Current sexual dysfunction treatment emphasizes Shared Decision-Making and personalized medicine, in accordance with the American Urological Association (AUA) and European Association of Urology (EAU) (Burnett et al., 2018; Salonia et al., 2021):

Lifestyle Modification & Counseling

Modifying vascular risk factors is a fundamental foundation of treatment, including moderate to vigorous aerobic exercise for at least 160 minutes per week, weight management, smoking cessation, and psychosexual therapy for those with psychological factors.

Oral PDE5 Inhibitors

For patients aged 50 to 60 and older, who often experience lower testosterone levels, narrowed blood vessels, and nerve degradation, physicians will provide testosterone alongside erection-supporting medication. Oral medications have relatively low side effects, such as occasional headaches and hot flashes, using one tablet per sexual intercourse. Importantly, this medication must not be taken with ischemic heart disease medications or nitrates, as it can cause life-threatening side effects.

Testosterone Replacement Therapy (TRT)

In cases where laboratory tests confirm low blood testosterone levels (Total Testosterone < 346 ng/dL or about 12 nmol/L) (EAU Guideline 2026, TAMS guidelines) accompanied by clinical symptoms, physicians will consider hormone replacement (such as injections or topical gels). This helps increase sexual drive and enhances the response to oral PDE5i medications (Onyeji & Clavijo, 2022; Salonia et al., 2021).

Low-Intensity Extracorporeal Shockwave Therapy (Li-ESWT)

Utilizing low-frequency sound waves to stimulate penile tissue, promoting the release of growth factors to encourage blood vessel formation (Neovascularization) and restore existing endothelial function. This helps achieve natural erections and is suitable for patients with early to moderate vascular deterioration.

Vacuum Erection Device (VED)

Using a vacuum device over the penis to create negative pressure, drawing blood in to create an erection, followed by placing a constriction ring at the base of the penis to maintain rigidity (should not be left on for more than 30 minutes). Suitable for those who cannot take medication.

Side effects to be aware of:

Skin symptoms: The penile skin may darken, feel cold at the tip, or experience temporary numbness during use.
Bruising: Small pinpoint hemorrhages under the skin may occur if the suction is too high.
Dry Orgasm: Semen may not ejaculate during climax because the constriction ring compresses the urethra, but it is not dangerous and will flow normally after removing the ring.
Important precaution: Never wear the constriction ring for more than 30 minutes, as it may cause tissue ischemia. Those taking blood thinners should be particularly careful.

Intracavernosal Injection (ICI) or Urethral Suppositories

Using vasodilators (such as Alprostadil/PGE1 or BiMix/TriMix mixtures) injected directly into the penile tissue, or using a suppository inserted into the urethra before intercourse. This helps achieve an erection without emotional stimulation. Suitable for those who do not respond to oral medications or post-prostate surgery patients.

Side effects to be aware of:

Pain/Irritation: May feel a dull ache in the penis or burning in the urethra (for suppositories).
Bruising and bleeding: Small bruises or bleeding spots may occur at the injection site.
Fibrosis: Repeated injections in the same spot over time can cause subcutaneous fibrosis or penile curvature.
Important precaution (Emergency): Risk of severe prolonged erections (Priapism). If an erection lasts longer than 4 hours, it is an emergency requiring immediate medical attention to prevent permanent tissue damage.

Penile Prosthesis Implantation

Surgically implanting a penile prosthesis into the penile tissue (Corpora Cavernosa) is an option for patients who do not respond to other treatments or have severe vascular and tissue damage. Divided into two main types:

Malleable/Semi-rigid Rods: Bendable silicone rods that are more accessible in price. Can be manually bent upward for intercourse and bent downward to conceal.
3-Piece Inflatable Penile Prosthesis (IPP): Consists of inflatable cylinders, a pump in the scrotum, and a fluid reservoir in the pelvis, offering a natural feel and appearance. When needed, simply press the pump to send fluid into the cylinders for an erection, and press to release the fluid back after completion.

Pros and precautions to note:

High efficiency: Satisfaction rates from patients and partners reach up to over 90 to 95%. Users can control the duration of the erection as desired.
Natural function: Does not affect tactile sensation, climax, or ejaculation.

Important precaution: This is a permanent surgery that cannot be reverted to natural erections. There is a risk of infection around the device (1 to 2%), and it requires specialized urological surgeons for the procedure.

How to Prevent Sexual Dysfunction

Preventing sexual dysfunction can be done by maintaining vascular and physical health:

Avoid risk factors: Stop smoking, limit heavy alcohol consumption, and reduce high-fat foods.
Control underlying conditions: Get annual health checkups to keep blood pressure, cholesterol, and blood sugar levels within normal ranges.
Exercise regularly: Focus on cardiovascular exercises to help the circulatory system function well.
Manage stress and get enough rest: Keep the mind clear and sleep at least 7 to 8 hours a day.

What to Know About Using Penile Vasodilators Properly

Viagra (Sildenafil) or other PDE5i medications like Tadalafil and Vardenafil are specially controlled drugs with important considerations:

Requires sexual stimulation to work: The medication does not act as an aphrodisiac, but helps blood vessels dilate upon emotional and neurological stimulation.
Different onset times: Sildenafil and Vardenafil act rapidly (take 30 to 60 minutes before intercourse) and last about 4 to 8 hours, while Tadalafil can last up to 24 to 36 hours.
Important contraindication: Strictly do not use it together with nitrates or sublingual heart disease medications.
Possible side effects: Such as headaches, facial flushing, hot flashes, nasal congestion, or indigestion. If an erection lasts longer than 4 hours (Priapism), it is a urological emergency requiring immediate medical attention to prevent permanent penile tissue damage.

Urology Center at Bangkok Hospital for Men’s Health Care

Sexual dysfunction is a treatable health issue. The Urology Center at Bangkok Hospital provides consultations, diagnosis of root causes (such as penile doppler ultrasound with intracavernous injection), and care for those experiencing sexual dysfunction in Bangkok. Treatments range from hormone adjustment and shockwave therapy to surgical options, performed by urological surgeons and andrologists. The service standard emphasizes patient privacy, helping individuals regain confidence in their lives.

Summary

Sexual dysfunction is not just an emotional issue but an indicator of overall vascular and physical health. Observing abnormalities, whether it is an inability to achieve an erection or experiencing erection issues in your 30s, and promptly seeking a diagnostic evaluation from specialized physicians will help resolve the issue directly and properly, allowing a return to a good quality of life.

Frequently Asked Questions

1. Can younger men experience sexual dysfunction?

It is possible. In young or working-age men (such as those in their 30s), the issue often does not arise from age-related vascular deterioration but from accumulated stress, lack of sleep, performance anxiety, or risk behaviors like smoking, alcohol consumption, and lack of exercise. However, further examination may be necessary in some cases, and consulting a specialized physician is recommended.

2. Does frequent masturbation cause sexual dysfunction?

Medically, masturbation is not a direct cause of sexual dysfunction or vascular damage. However, doing it so frequently that the body becomes exhausted, or if it leads to accumulated anxiety, it may affect responsiveness and emotional connection during intercourse with a partner.

3. Can sexual dysfunction medication be purchased over the counter?

It is strictly not recommended to purchase these medications on your own. This group of drugs has significant contraindications, especially for individuals with underlying medical conditions or those taking nitrates. Using this medication without a physician’s supervision can be life-threatening.

4. Can sexual dysfunction be completely resolved?

Function can be restored to normal or near normal depending on the cause. If caused by lifestyle, stress, or hormones, lifestyle modifications and specific treatments will help normalize function. If caused by chronic vascular disease, disease control and rehabilitative technologies like Shockwave therapy, along with physician care, will help restore function safely.

References

Burnett, A. L., Nehra, A., Breau, R. H., Culkin, D. J., Faraday, M. M., Hakim, L. S., Heidelbaugh, J., Khera, M., McVary, K. T., Miner, M. M., Nelson, C. J., Sadeghi-Nejad, H., Seftel, A. D., & Shindel, A. W. (2018). Erectile Dysfunction: AUA Guideline. Journal of Urology, 200(3), 633–641. https://doi.org/10.1016/j.juro.2018.05.004
Onyeji, I. C., & Clavijo, R. I. (2022). Testosterone replacement therapy and erectile dysfunction. International Journal of Impotence Research, 34(7), 698–703. https://doi.org/10.1038/s41443-021-00512-w
Salonia, A., Bettocchi, C., Boeri, L., Capogrosso, P., Carvalho, J., Cilesiz, N. C., Cocci, A., Corona, G., Dimitropoulos, K., Gül, M., Hatzichristodoulou, G., Jones, T. H., Kadioglu, A., Martínez Salamanca, J. I., Milenkovic, U., Modgil, V., Russo, G. I., Serefoglu, E. C., Tharakan, T., Verze, P., & Minhas, S. (2021). European Association of Urology Guidelines on Sexual and Reproductive Health—2021 Update: Male Sexual Dysfunction. European Urology, 80(3), 333–357. https://doi.org/10.1016/j.eururo.2021.06.007

What Is Sexual Dysfunction? Understanding Erectile Dysfunction (ED)

Sexual Dysfunction: What Are the Causes?

Physical Causes (Organic Causes):

- Vascular (Vasogenic): A highly frequent physical cause, arising from Endothelial Dysfunction or Atherosclerosis. This results in insufficient blood flow to the penile tissues (Corpora Cavernosa). Often found in patients with diabetes, high blood pressure, high cholesterol, and cardiovascular diseases.
- Neurological (Neurogenic): Caused by abnormalities in the nerves that send erection signals, such as in patients who have had prostate surgery, pelvic surgery, spinal cord injuries, or neurological conditions like Parkinson’s disease.
- Endocrine and Hormonal: Caused by Late-Onset Hypogonadism (LOH), affecting both sexual desire (Libido) and the production of Nitric Oxide in the blood vessels (Onyeji & Clavijo, 2022).
- Structural (Anatomic/Structural): Such as Peyronie’s Disease, which causes the penis to curve or become painful during an erection.

Psychological and Fatigue Causes (Psychogenic Causes): Stemming from stress, anxiety, depression, or performance anxiety, as well as lifestyle factors like lack of sleep, heavy smoking, and alcohol consumption. Symptoms often occur suddenly or in particular situations, while morning erections remain regular, or erections are fine during masturbation.

Symptoms of male sexual dysfunction can present in various severity levels, with observable signs including:

Inability to achieve an erection: Cannot achieve an erection at all, even with adequate sexual stimulation.
Incomplete erections: Can achieve some rigidity, but insufficient for penetration, or loss of firmness before completion.
Reduced sexual desire: A noticeable decrease in sexual interest, which may relate to male hormone deficiency.

How to Perform a Preliminary Self-Check for Sexual Dysfunction

Before consulting a urologist, men can observe initial changes as follows:

Observe morning erections (Nocturnal/Morning Erection): Normally, the body experiences erections during sleep and upon waking (around 3 to 5 times a night). If these disappear for several weeks, it may be a warning sign of vascular or neurological irregularities.
Assess rigidity during penetration: Check if the firmness is sufficient for intercourse, which can be evaluated using the Erection Hardness Score (EHS):
- EHS Level 1: The penis enlarges but is not firm (like a sponge).
- EHS Level 2: Firm but insufficient for penetration (like a peeled banana).
- EHS Level 3: Firm enough for penetration but not fully hard (like an unpeeled banana).
- EHS Level 4: Fully firm and rigid (like a cucumber).
Observe responses during masturbation: If erections are fine during self-stimulation but problematic with a partner, this often indicates psychological factors and anxiety.