Hello,

I can understand that you are quite anxious and worried about your sexual problem. Firtly, I would like to calrify that as long as you are able to get an erection, masturbate and ejaculate, you don't have impotency. Impotency is a condition where there is failure to get an erection. From the description of your symptoms, your predominant problem seems to be premature ejaculation along with poor quality of erection.

Actually, premature ejaculation is a very common problem in young males and many men start having doubts and fears before marriage regarding this issue and their future sexual performance in married life.

Now, like the previous doctor has mentioned, the first and most important step in the management of sexual problems is a comprehensive evaluation. This will include a detailed medical, sexual, personal and social history, a thorough physical examination (including a nervous system examination and checking blood pressure) and certain investigations, as per the necessity. In your case, I'm not sure what all investigations have been done, but I would suggest the following basic investigations: hemoglobin, blood sugars, urea, creatinine, lipid profile, thyroid profile.

Regarding the testosterone and vitamin D levels which you have already done, the testosterone level is just below the normal limits, but the vitamin D levels are quite low. I would suggest that you have a repeat of the testosterone levels - better to have morning (8am to 10 am) levels tested, because testosterone levels can be variable from day-to-day, and levels also change throughout the day, particularly in younger men. Testosterone levels are also affected by protein levels in the blood. Sometimes low levels of protein will cause measurements of total testosterone to be low. You may also need other hormone tests like FSH / LH, GnRH and Prolactin levels. So, I would not rush into testosterone replacement treatment before getting a clear picture. But regarding the vitamin D levels, you will definitely need further treatment with vitamin D injections.

Now, the good news is that in more than 90% of persons with the problem of premature ejaculation, there is no medical abnormality causing this. Most of the times, the underlying causes are the following:
1) Subconscious anxiety / fears / doubts about inadequate sexual performance (called as "performance anxiety")
and / or
2) A sensitization or hypersensitive response of the penis

Treatment of premature ejaculation problem is behavioural techniques as well as medication, in some cases. Usually medication is kept only as the last resort as most of the problems will resolve with proper behavioural techniques.

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 reducing this hypersensitivity and 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 definitely increase your time taken for orgasm.

3) One more problem responsible for 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 and ejaculation occurs. The way to tackle this is not to rush into masturbation quickly, but wait till you get fully aroused.

4) There are also certain medication like Dapoxetine (Prilyxet), which can help you with this specific problem of premature ejaculation. 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 avoid alcohol and smoking and eat a healthy & balanced diet, exercise regularly and try to stay positive and stress-free.

So, in conclusion...
- Don't get too alarmed by the low testosterone test results. Repeat the test (in the morning time) and take the other tests which I have suggested.
- Have a thorough physical examination - including genital and nervous system examination.
- Get treatment for the low vitamin D deficiency.
- Practice the sexual techniques which I have suggested
- Get rid of your anxiety, doubts and fears regarding your sexual performance. You can try yoga or meditation to relax your mind and relieve the anxiety.
- Further medication for your sexual problem can be decided after the evaluation results.

Wish you all the best.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist & Sexologist

---

Hello again,

I have reviewed your reports in detail. Except for the low vitamin D level, there is nothing seriously concerning. Like I had mentioned before, the total testosterone levels is just in the lower range of the normal limits, and the free testosterone (which is a much more reliable indicator of testosterone levels) is within the normal range. So, my personal opinion is that you don't have to worry much about the hormone levels.

I would advise you to continue to take the calcitriol supplements and try the psychological and sexual techniques which I have suggested. You can also try Dapoxetine, as it is an approved and safe drug for the treatment of premature ejaculation. With these remedial measures, your problem should most likely get resolved. In case it still persists, then you have to consult a sexologist in person for a more detailed evaluation and further management.

Wish you all the best.

Regards,
Dr. Jonas Sundarakumar
Consultant Psychiatrist & Sexologist

---

Hello again,

Dapoxetine tablets (available in India as Prilyxet) can be taken at a dose of 30mg. It is advisable to take it as "on-demand" or whenever needed only - 1 to 2 hours before intended sexual activity. The dosage should not exceed more than one tablet per 24 hours. It usually takes 2 weeks for the medication to become fully effective, so you have to be patient till then.

Don't forget to try the sexual techniques also and to keep your mind relaxed and free of anxiety.

Best wishes,
Dr. Jonas Sundarakumar
Consultant Psychiatrist & Sexologist

(Kindly close this query and leave a review if you are happy with the answer.)

---