Sexual medicine: erectile, ejaculatory, desire and pain problems and how specialist care works

Sexual medicine is a field of practice rather than a single organ specialty. It brings together urology, gynaecology, endocrinology, sexual and reproductive health, psychiatry and psychology, and psychosexual therapy. The British Society for Sexual Medicine describes its focus as the basic science of sexual function and dysfunction and the clinical aspects of diagnosis and treatment of sexual problems in men and women, taking a holistic approach.

The people involved depend on the problem. Many difficulties are first assessed by a GP or in a sexual health clinic, and the NHS notes that sexual health clinics treat sexual health problems, including erection problems, often with walk-in services. More complex cases are seen by urologists, gynaecologists, endocrinologists, or doctors with training in sexual medicine, along with psychosexual therapists who are accredited counsellors or clinicians. The NHS says sex therapists should be members of professional bodies such as the College of Sexual and Relationship Therapists or the Institute of Psychosexual Medicine.

Because sexual difficulties are common and often feel difficult to discuss, a good service is straightforward and non-judgemental, and sees the person alone or with a partner depending on preference.

• Erectile dysfunction, meaning being unable to get or keep an erection long enough for sex. The NHS says occasional failures are common and usually caused by stress, tiredness or alcohol, and that persistent problems may reflect physical or psychological conditions.

• Premature and delayed ejaculation, and difficulty reaching orgasm.

• Low sex drive (loss of libido), which the NHS says has many causes, including relationship problems, stress, depression, hormonal changes, medicines such as some for high blood pressure or antidepressants, and long-term conditions.

• Painful sex (dyspareunia) and vaginismus, where vaginal muscles tighten involuntarily and make penetration painful or impossible, which is more common in women in their late teens to early thirties according to the NHS.

• Peyronie's disease and other penile conditions affecting erection or intercourse.

• Sexual difficulties after cancer, pelvic surgery, childbirth, spinal injury or menopause, and those related to hormone changes including low testosterone.

Assessment starts with a conversation about the problem, how it began, whether it occurs in all situations, relationships, mood, medicines, alcohol and smoking. The NHS says that for erectile dysfunction a doctor or nurse may ask about lifestyle and relationships, do basic health checks such as blood pressure, examine the genitals and, if there are urinary symptoms, may examine the prostate. Blood tests, commonly for glucose or HbA1c, cholesterol and sometimes testosterone, look for underlying causes.

Erectile dysfunction can be an early sign of cardiovascular disease, so assessment usually includes heart risk factors. For sexual pain in women, the NHS says a GP may ask to examine the vagina, can offer a female doctor and a chaperone, and rules out infection or other causes. Further investigation depends on the findings, and specialist tests are uncommon.

Questionnaires are sometimes used to gauge severity and track progress. Where the cause is clearly psychological or relational, referral for psychosexual therapy is a first-line option rather than a last resort.

Treatment aims at causes as well as symptoms. Lifestyle changes can help: the NHS lists losing weight if overweight, stopping smoking, a healthy diet, exercise, reducing stress and anxiety and limiting alcohol. Medicines may be changed if they contribute, and conditions such as high blood pressure, high cholesterol or hormone problems are treated.

For erectile dysfunction the NHS says the main treatments are PDE-5 inhibitors (sildenafil, tadalafil, vardenafil and avanafil), with sildenafil available on prescription or from a pharmacy, and vacuum pumps that may not always be available on the NHS. Other options in specialist care include injections into the penis and penile implants for selected people, and some centres offer newer approaches such as shockwave therapy, where the evidence is still limited so it is worth asking what is known about benefit. For vaginismus the NHS lists psychosexual therapy, relaxation techniques, pelvic floor exercises, sensate focus and vaginal trainers. For low desire, treatment depends on cause and may include therapy, treating depression, reviewing medicines or hormone replacement around menopause.

Psychosexual therapy involves talking and structured exercises, usually over several sessions, and can be done alone or with a partner. The NHS notes there can be a long wait for counselling and therapy on the NHS, and that people can pay privately.

On the NHS, the first step is a GP or a sexual health clinic. A GP can start treatment for many problems and refer to urology, gynaecology, endocrinology or psychosexual services for complex or persistent difficulties. Provision and waiting times vary, and some treatments such as vacuum pumps or injections are not available everywhere.

Private care is available through urologists, gynaecologists, sexual medicine physicians and psychosexual therapists, and online services. Check registration of doctors with the GMC and of therapists with a recognised professional body, and be wary of services that offer treatment without proper assessment. The NHS advises checking that online pharmacies are registered with the General Pharmaceutical Council and online doctors with the Care Quality Commission, because counterfeit medicines are sold online.

• What might be causing this, and are any tests needed to look for underlying conditions?

• What are the treatment options, how do they work, and what are the side effects and interactions with my other medicines?

• Would psychosexual therapy help, and is it available on the NHS locally or only privately?

• Can my partner be included, and how is confidentiality handled?

• How long should I try a treatment before deciding it is not working?

• Seek urgent help for a painful erection lasting more than 4 hours, sudden severe testicular pain, or sexual symptoms with chest pain or severe breathlessness.