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Men’s Health-Erectile Dysfunction


Chlamydiae are sensitive to various antibiotics including tetracycline and erythromycin. Tetracyclines are also effective against mycoplasmal infections. No effective single dose treatment is available. Penicillins and other beta lactams are ineffective. Standard practice is to treat patients on the demonstration of cervicitis or urethritis or on the basis of a contact history.

Patients should avoid sexual intercourse until treatment is completed. The importance of compliance with treatment should be stressed.

The recommended treatment for NGU or NGC is a tetracycline (e.g. doxycycline 100 mg twice daily taken with food or milk for 10 days). Regimens for treatment of PID are detailed on pp. 14-15. The sequelae of these infections can be serious and treatment should not be delayed until laboratory investigations are complete.

Tetracyclines are contraindicated in pregnancy and children of 8 years of age or less.
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The diagnosis of chlamydia is commonly presumptive but should be confirmed using laboratory tests. Direct detection using commercially available immunofluorescence or ELISA monoclonal antibody techniques permits rapid diagnosis. False positive and negative results occur; false positive results can be a problem, particularly in patients who deny risk of sexually transmitted infection. Results must be interpreted having regard to the clinical context

Chlamydiae are obligate intracellular parasites; isolation requires tissue culture techniques and takes 3 or 4 days. Direct tests are not as sensitive as culture but are reliable and much less expensive. Culture is only available from a few laboratories.

Serology is of limited value. Complement fixation tests for antibody are not very specific and have largely been superseded. ELISA and immunofluorescence techniques detect chlamydial group antibodies. Microimmunofluorescence tests can detect type specific antibodies. Seroconversion or a 4-fold increase in titre in serum samples collected 2 weeks apart indicates acute infection. A high titre of IgG antibodies and the presence of IgM antibodies probably indicate current infection. Negative serology may be of value in excluding chlamydial infectioa
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In our eagerness to correct the old misconceptions, we do need to be wary of falling into the trap of replacing one assumption with another — that all older people want to continue to be sexually active and that every one of us will have sexual needs until the day we die. One thing is true. We are all individuals. Some people will keep their interest in sex as they get older, but there are others who are quite happy to lose the urge as other aspects of their lives take precedence. Of course there are still others who never liked it much anyway and that’s not likely to change.

What might change is the way you want to express your sexual feelings. Harold is in his sixties. He explains, ‘In many respects the peaks of intense sexual feelings are not as keen as in my younger years and I’ve certainly slowed up. Although I still have orgasms, touching, companionship and just being close have become much more important than in my youth.’

One of the inevitabilities of growing old is the prospect of separation from your partner because of illness or death. Losing the person who has shared your most intimate moments is devastating. If you ask someone who is recently widowed what they miss the most, it’s often the little things like the Sunday morning cup of tea, or curling up on the lounge to watch television, asking their opinion on a flower arrangement or tucking up in bed together on a stormy night.

Molly, widowed at fifty-two, and now in her seventies frankly says, ‘I’d vomit if another man touched me. When I was young I was brought up to believe that you had one partner for life arid if anything happened to him that was the end of your sex life for good. You just can’t change the sort of ingrained idea that it would be somehow unfaithful to his memory to start seeing someone else. My friends tried to match-make me with any Tom, Dick or Harry but I just wasn’t interested. I found the most difficult time to cope was in bed at night. I would just miss knowing he was lying next to me in the bed. Sometimes even now I wake up and think I can hear him breathing. I was grieving so much at the time that sex was the last thing on my mind. When I started getting over the grief I never seemed to get my interest back. When I get miserable I get by with a hot bath and putting lots of pillows in the bed. I get a lot of affection and love from my daughter and my grandchildren.’

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Some forms of sexual activity are more strenuous than others and a crisis like this can be an incentive to exploring new ways of sexual expression, like massage, oral sex or manual stimulation of yourself or your partner.

It has been only in fairly recent years that medical researchers have taken a close look at the way different types of surgery affect sexual attitudes and behavior. As our understanding grows, a number of features keep cropping up. Sexuality is an integral part of most people’s lives and just because someone doesn’t ask questions or talk about their concerns doesn’t mean they don’t want to know. In facing a crisis like cancer or other surgery, there needs to be detailed information on what to expect afterwards: physically, emotionally and sexually. An important step in overall patient care has been the emergence of specialized counsellors and nursing staff who are aware of the issues and who have the time and the skills to talk them through with people facing them.

There is also a growing body of evidence that positive thinking can have a powerful impact on the outcome of many different illnesses, including cancers. If a person can face an uncertain future with a degree of optimism that they will still be able to enjoy life, and that includes their sexuality, then the implications will be far-reaching. It may well be a matter of survival.

A social worker who counsels patients with heart disease told me, ‘I generally find that if a couple’s sexual relationship was good before the cardiac event, it will be good again. I must say I worry about the older men with much younger partners, particularly if the relationship is fairly recent. They tend to be more anxious about whether they will be able to perform as well as before. I always bring up the issue of sexuality because we can’t assume that because someone doesn’t ask, they don’t want to know. This is particularly true of women. You know, there are literally no studies that look at the sexual attitudes of women in this situation, so I have to rely on experience.’

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Heart disease is the foremost killer in the Western world, thanks to smoking, high blood pressure and fatty diets. Although a heart attack is predictable in many people because they collect risk factors like football cards, for many it comes as a bolt out of the blue. Coronary artery bypass surgery is now more commonplace than having your tonsils out, but that is not to say it’s a breeze. Quite often a heart attack or heart surgery is the first time a person comes face to face with their own mortality, or faces the prospect of losing their partner. During the early weeks after the event, the foremost thing on your mind has to be your immediate survival and even if the question of resuming sex did occur to you, it’s hard to get the opportunity to ask.

Ward rounds before discharge from hospital have to be seen to be believed. You might have the surgeon, the registrar, a resident or two, the physiotherapist,”, dietician, occupational therapist, ward pharmacist, nurses, spouse and assorted relatives crowded around the bed discussing anything from your latest cardiac echo to a warning about never smoking again. ‘Any questions, Mrs Jones?’ ‘Well, Doctor, my husband and I were actually wondering whether a big orgasm might bust my stitches and kill me?’ is probably not the first question to spring to your lips under the circumstances. Many people are sent home wondering whether they will ever be able to have sex again.

Jack is a man in his late sixties. Married for forty years, he had recently undergone heart surgery. He told me, ‘We had always enjoyed a good, relaxed sex life. In fact the last twenty years have been better than the first twenty. After the operation I knew I would be able to do it, but I didn’t know if it would be normal. For the first few weeks I was too tired to really even think about it but as I got stronger we thought it was time to give it a go. I had to reassure my wife that it wasn’t going to hurt me. You see, I had asked my doctor if it would be alright, and he said that when I could walk up two flights of stairs I wouldn’t have any problems with sex. At first the chest wound made sex uncomfortable in some positions, so we tried out some different positions to see what was best. Anyway, we took it slowly and now after a couple of months things are pretty much back to normal.’ He smiled warmly at his wife. ‘Yes, we’re doing alright.’

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There is no doubt that most cultures see the breast as a symbol of femininity and the loss of a breast is frequently mourned because of this. Surgeons try to be as conservative as possible but where the priority is longterm survival, and hopefully a cure, the cosmetics take a back seat. Losing a breast can cause a massive psychological reaction, so it is now a relatively common practice for the cancer surgeon to work with a plastic surgeon to reconstruct the breast at the time of the mastectomy. Nonetheless, many women notice a change in their sexual behavior after a mastectomy. This seems to be particularly true of women who rely a lot on breast and nipple stimulation for arousal or orgasm. Sensate focus exercises also come in handy here. The different touching techniques used on other areas of your body stimulate the erotic feelings that build towards orgasm. In the case of mastectomy, it takes the emphasis away from the breasts by discovering other parts of the skin that will give you a similar response.

The loss of a breast can also mean a loss of self-confidence and a reluctance to initiate sex. Rita was forty-two when her breast cancer was diagnosed. ‘I was devastated. I thought they must have put the wrong name on the mammogram. The whole ordeal felt like some terrible nightmare. Matthew and I

had always had a great sex life. We married late and I suppose we were making up for lost time or something. He was always a big breast man and he always said how much he loved the fact that I was well-endowed. When I heard I had to have a mastectomy I thought, “Well that’s it then, he won’t have any interest in me sexually any more. This will turn him right off.” The strange thing was that it was me who had the trouble with sex. I couldn’t bear to let him see me without a shirt on, and I would freeze if his hands went anywhere near my chest. He said it really didn’t matter to him, he was just so glad he still had me. He was so patient and so gentle, I don’t know how I would have coped on my own.’

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One of the most common sexual difficulties for women is not being able to reach orgasm — all of the time, or some of the time. Perspective is also important here. If you have been led to believe the myth that sexual success means an orgasm with every sexual encounter, then you will believe you have a problem if you fall short of the 100 percent. Anxiety to achieve an orgasm can be self-defeating because the more anxious you are, the less likely you are to get there. This is the female version of performance anxiety.

Sexual technique makes a big difference. It can be embarrassing to admit that you think your sexual skills might need some sharpening. Whenever you bring up the subject of improving sexual technique there are some who criticize the emphasis on performance. Now while I’ll be the first to admit that technique isn’t everything, there is a lot to be said for the elements of sensuality and tactile finesse. While some people are what you’d call ‘naturals’ much of this can be learned or at least improved upon. The ham-fisted jump on, do your thing and go to sleep approach is hardly the formula for a lifetime of mutual sexual bliss. Similarly, people who are sexually inhibited and self-conscious may never be able to relax enough to discover their sexual potential. Sensate focus exercises can help here too. So can some of the reputable sex manuals and self-help videos. It’s been interesting over the last few years to see these move from under the counter of the local bookstore or down in the dark, back corner of the video library to the front shelves. They can show you anything from communication skills to different arousal techniques and intercourse positions you might not have thought to try. Above all, they are often a great way to start conversations between partners about sexuality and give you the opportunity to find out aspects of each other’s attitudes and needs you may never have discussed.

A common theme in many of the letters I receive is the concern that the woman is not able to orgasm during penetration. Now this is perceived by the correspondents as a sexual problem. One typical letter said, ‘My wife and I have been married for nearly a year and we still have a lot to learn about sex. We are both worried that she cannot seem to have an orgasm when I have my penis inside her, no matter how long I can last. I figure I must be doing something wrong.’ Once it is pointed out that this is in fact the normal course of events, that many women usually need something else like stimulation of the genitals with their; partner’s fingers or mouth (before, during, after or instead of intercourse), or the ‘woman on top’ position, then it needn’t be seen as a problem. Mind you, some men find it difficult to accept that a penis is not an essential for a woman to be sexually satisfied.

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In some cases sexual disinterest is a longterm prospect. Emotional factors are high on the list. Chronic depression or stress are frequently associated with loss of interest in sex. Alan became depressed after a series of business failures when he was in his thirties. ‘At the time I just wasn’t getting any sleep. I had so much on my plate that months would go by when I hardly thought about sex at all. It wasn’t until I saw the light at the end of the tunnel when things started to improve at work that I realized how little interest I had had in sex.’

How interested you are in sex depends heavily on the target of your affection. Sexual chemistry is a funny thing. ‘Chemistry’ implies a cocktail of ingredients — triggers — that set off another person’s sexual interest like a smile, a perfume, hair color, body movements. Romantic poets depend on it. No scientist has been able to explain it. It defies logical definition, yet it is such a vital element in any successful sexual relationship. Two people can be totally compatible as friends, enjoying each other’s company and sharing the same interests but if that intangible we call chemistry just isn’t there, then libido might be a bit evasive.

Being with the wrong partner can be the reason for a relatively lower interest in sex but consider the effect of partners being the wrong gender for you. The possibility that you are not interested in sex because you would actually prefer a partner of the same gender can be immensely confronting, particularly as it goes against the grain of a lifetime of conditioning. This rarely becomes an issue until strong sexual feelings are ignited by a person, an event, or a fantasy. And it can come as quite a shock, as it was for Kate.

‘I remember, as a teenager, having crushes on older girls at school but that wasn’t anything unusual amongst my friends. I started dating boys when I was about sixteen but I wasn’t really that keen on the whole process. When I met my husband we got on incredibly well together and I knew I was in love with him but I always had the feeling there was something missing. Although I didn’t avoid sex with him, I certainly didn’t initiate things very often. My girlfriends had always been very important to me but when I met Marie it was totally different. It sounds like a clich? but it was like I had been hit by a bolt of lightning. I remember being acutely aware of an intense sexual attraction between us and thinking, “I don’t want this to happen; it’s just too hard”, but it was impossible to stop the feelings. My libido felt like it was turbo-charged, and I realized this was what I really needed.

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What sort of compromises are possible? Clearly, if the underlying problem is disharmony in the relationship then sorting out the reasons for that will go a long way. It’s fairly well accepted that men and women speak a different emotional language to each other. An exercise that some relationship therapists use is to have the two partners, in turn, tell each other what they need from the other. Only when the first partner feels they have expressed themselves, is the second partner asked what they understood about the other’s needs. It’s amazing how often the message gets mashed up in the translation. It’s a great way to highlight the reasons people so often feel as though they ‘can’t get through’ to their partner. I recently saw a poster that put it so well: ‘I know that you believe that you understand what you think I said but I am not sure you realize that what you heard is not what I meant.’

Work pressure or the demands of a young baby can mean that you are so tired by the end of the day that all you want to do is go to sleep. If you’re exhausted and your partner wants sex, it can feel like another chore to tack on to the day’s list.

Sally has two children under two. ‘It’s not as if I don’t fancy him any more. I often find myself thinking about making love to him during the day. The trouble is, by the time I survive the evening bathing, feeds and bedtime routine I am all out of energy and sex is the last thing on my mind.’ If the issue is tiredness or lack of time, one way around it is the ‘negotiated quickie’ … that means talking about different ways of satisfying one or both of you when time or inclination is in short supply. Just as you don’t feel like a four-course meal every night for dinner and a quick snack does the job, each lovemaking session need not be a major event worthy of a chapter in a romance novel. Expanding your repertoire of alternatives to intercourse can solve a lot of problems. There are times when, for example, a woman wants to make love but would prefer not to have intercourse, like on the heavy days of her period. Alternatives like oral sex or mutual masturbation can be useful compromises.

Traditionally, masturbation has had a bit of an image problem. Even nowadays, it is not exactly a compliment to call someone a wanker. So many people have grown up with guilt, inhibitions, anxieties and generally negative feelings about it. It is very common for one partner to feel threatened by the other masturbating, fearing that it is an insult to their attractiveness or their ability to satisfy their partner’s needs. Of course, others find it not only acceptable but a real turn-on and will learn more about their partner’s needs by watching them masturbate.

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One woman who has endured four miscarriages told me, ‘Anyone who thinks life doesn’t start at conception has never had a miscarriage. Actually, the first one wasn’t so bad. It didn’t really connect for me that it was a baby I had lost … more like a blood clot or something … and I explained to myself that there must have been something wrong with the baby. Nature’s way of getting rid of abnormal babies … you know what people say to try and make you feel better. After I had my first live baby, my attitude really changed. It was much more real then. I wanted a big family more than anything in the world but I had three miscarriages in two years. The first went to sixteen weeks and the next two only lasted twelve weeks. Each time I had a miscarriage it was as though I had lost a baby at full term. It’s impossible to describe the pain of the grief. Lying in the hospital ward with a drip in my arm before the curette, it was so lonely. The staff were trying to be really understanding, but to them miscarriages were so commonplace that they were just a routine. I thought if one more person says “Better luck next time” I will just scream! One strange thing that happened each time I got pregnant was that I became incredibly protective of myself and the baby as a unit. I wouldn’t let my husband anywhere near me. Sex was out of the question and my only priority was getting the pregnancy to term. I wouldn’t do anything that would disturb the baby. I would cringe even if he wanted to give me a cuddle because I’d think, “Oh no, he wants to do it!” I really felt like I was being attacked.’

The harder it has been to get pregnant or to take the pregnancy to full term, the stronger this siege mentality gets and it really is understandable. In fact women with a history of repeated miscarriages may well be advised to avoid intercourse for the first few months of the pregnancy as a precaution, although most will do so anyway as an instinct. This is one of those situations when it is important that the woman’s partner understands the reasons the advice has been given. That makes it a team effort for a common goal, rather than the man feeling totally shut out of the pregnancy. I’ve heard it said that the Freudian concept of ‘penis envy’ is just a decoy invented by men to take the attention away from their ‘womb envy’, an unfulfilled desire to experience pregnancy for themselves. The point here is that the more pregnancy is treated as a team effort the less likely you are to run into problems, and that means men being involved and informed as much as possible at every stage.

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