Hello and welcome to Healthcare Magic. Thanks for your query.

Let me first review the medication which you are on:

Cialis (Tadalafil) is a medication used to promote erection by enhancing the blood flow to the penis.
Distonex (Cabergoline) is a medication which increases the level of a neuro-chemical called dopamine, and thereby improves libido (sexual drive).
Clomid (Clomiphene) is an anti-estrogenic medication which acts by increasing the central hormones responsible for releasing testosterone and has been found effective in treating male hypogonadism.
Androgel (Testosterone gel) is basically a milder version of testosterone replacement therapy through a skin application.

In order to understand your current problems better, please provide the following clarifications...

- Out of the above mentioned medication, which ones are you currently taking and in what dosages?
- What exactly was your testosterone level?
- How is your sexual drive now?
- How severe is your premature ejaculation problem? How long are you able to sustain sexual intercourse?
- Now, does your erection problem happen once in a while only or very frequently?

Please get back to me with these clarifications, so that I can advise and guide you further.

Regards,
- Dr. Jonas Sundarakumar
Consultant Psychiatrist & Sexologist

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Hello again and thanks for the clarifications.

Now, for premature ejaculation there is a new medication called Dapoxetine (Prilyxet), which has been specifically marketed for the treatment of premature ejaculation. The usual anti-depressants which are given for this problem can have side effects of causing erectile dysfunction, sedation, etc. But Prilyxet is supposed to be specifically effective for PME, without the other side effects.

DAA (D-Aspartic Acid) is the latest hype among testosterone supplements and has been claimed to have positive effects. However, you must understand that this substance has not been thoroughly studied scientifically and not yet proven to be completely safe. There have been few reports of it causing mood fluctuations, aggression, etc. Also, some of these supplements, if taken for prolonged periods can even have an adverse impact on kidney functioning. So, regarding DAA, I would say that it's better to avoid, since the data regarding this is scientifically inconclusive. Moreover, your testosterone levels are only borderline and hence don't require any major supplementation. It would be advisable to repeat another testosterone level to determine if you really need any supplementation.

Now, you seem to have a lot of anxiety and fear about your sexual problems, and like you rightly mentioned, this anxiety and fear can very well be a major reason for your sexual dysfunction. I would also like to let you know that in more than 80% of cases of erectile dysfunction, psychological factors also play a major role in causing or aggravating the problem. Most of the times, the underlying subconscious anxiety / fears / doubts about inadequate sexual performance (called as "performance anxiety") or a hypersensitive response of the penis or inproper sexual arousal are the underlying causes for premature ejaculation.

I would suggest the following tips to overcome this problem:

1) Firstly get rid of thoughts that you may be sexually inadequate or your doubts that you may not be able to perform properly. Like I mentioned before, performance anxiety, feelings of sexual indequacy, self-doubts, guilt, past negative sexual experiences, poor communication / understanding with the partner, etc. can all affect sexual functioning and performance. So, removing the person's doubts and fears, and improving his self-confidence levels will definitely help in improving sexual performance. Remember that sex is not just a physical act but also a psychological process involving an expression of emotions, intimacy and love. So, just involve yourself in those feelings and stop focussing on your "performance" alone. Once you do that, then I assure you that your sexual performance will automatically improve.

Most importantly, performance anxiety soon becomes a "viscious cycle" That is, anxiety leads to poor performance and poor performance then leads to further anxiety and this keeps on increasing. So, the key is to break this cycle at some point of time and take control of yourself.

2) The second cause for pre-mature ejaculation is hypersensitivity of the penis to touch sensations. Now, there are certain specific sexual techniques which can reduce this hypersensitivity. The "stop-start technique" or "squeeze technique" have been proven to be successful in increasing the ejaculatory time.

In the stop-start technique, the penis is stimulated (by sexual intercourse or by masturbation) till a point when you feel close to orgasm. At that point, the stimulation is stopped for some time and after a small gap, it is continued. This process is repeated repeated a few times.

In the squeeze technique, the penis can be stimulated by hand (by masturbation or by your partner) till a point when you feel close to orgasm. At that point, the lower part of the head of the penis is squeezed tightly with the index finger and thumb around for a few seconds till the erection decreases. Then the stimulation is restarted and the process is repeated a few times.

Both these techniques, if practised regularly can increase your time taken for orgasm.

3) The third problem responsible for erections getting weak and early ejaculation is inadequate sexual arousal. When the person is not properly aroused, the blood flow to the penis is not maximal, and so, after a few strokes, the erection weakens. The way to tackle this is not to rush into intercourse quickly, but wait till you get fully aroused. So, increase and spice-up your foreplay. Make sure that you initiate penetration only after both of you are fully turned on. Good foreplay not only arouses you but also sparks off the mood in your partner. So, when she is also aroused and involved, then things keep flowing smoothly and effortlessly, and you don't have to be constantly anxious if you are satisfying your partner or not.

4) Improve your communication with your partner - this means both verbal as well as non-verbal communication. Each person has his or her own ways of getting sexually aroused or feeling sexual pleasure. So, this verbal and non-verbal communication will let each of the partners understand each other's needs and thereby make sex both relaxing and enjoyable.

5) Distract yourself stop "monitoring" your sexual performance. Try putting on some romantic music or mild lighting while you make love. Think about the things that turn you on. Taking your mind off of your sexual performance can remove the worries that are stopping you from getting excited.

6) There are also certain medication like Dapoxetine (Prilyxet), which can help you with this specific problem of premature ejaculation. Certain other medication can improve the blood flow to the penis and promote better erection, such as Sildenafil, Vardenafil and Tadalafil. But like I mentioned before, medication should be kept only as a last resort after trying the behavioural methods and sexual techniques.

It is also important to eat a healthy & balanced diet, exercise regularly and try to stay positive and stress-free.

Wish you all the best.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist & Sexologist

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Hello again,

1) Dapoxetine (Prilyxet) can be used whenever needed, 1 to 2 hours before sexual intercourse. If Dapoxetine is not available, then you can use Lustral i.e. Sertraline (25 to 50 mg)

2) Testosterone can cause side effects like baldness, shrinking of the testes, mood fluctuations, aggression, kidney problems (with long term use), etc. Moreover, testosterone supplementation will usually help only if you have significantly low levels of testosterone (which is not your case); moreover, taking them does not have any impact in improving your erection problems or premature ejaculation. If you are very particular about taking some form of testosterone supplement, then it would be relatively better to take natural supplements like DAA, rather than taking testosterone directly as injections.

3) Cialis (Tadalafil) also has to be used whenever needed only. But Cialis has a long duration of action of 2 to 3 days. So, even if you are having sexual intercourse daily, it is enough to take it once in 2 to 3 days.

I hope this information has been informative and beneficial to you. Kindly leave a positive review if you are satisfied with my answers.

Wish you all the best.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist & Sexologist

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