A Year Without Sex September 1, 2013 Ask Dr. G, General Questions, Sexual Function Q: I am a married lady and it has been a year since our marriage. Sadly, my hubby and I still cannot have successful sexual intercourse. I think I may have a small vaginal opening. Every time my husband attempts intimacy, I automatically push him away. I didn’t realise this until he mentioned it recently. I feel so guilty as I can’t fulfill my responsibility as a wife. I have a sense of fear and rejection about intercourse, even before my engagement. I don’t have any past history of physical or emotional disability, apart from suffering from a prolapse disc at L5-S1. Do I have so called vaginismus or does the prolapse discs causes these problems? Miserable lady A: I am sorry to hear your ordeal in the past year. I usually help men with sexual dysfunctions. But it is an absolute honor to offer you advice too. Vaginismus is the inability to engage in any form of vaginal penetration including sexual intercourse, insertion of tampons or even gynecological examinations. It is associated with the reflex and spasm of the pubococcygeus muscle in the pelvis that makes vaginal intercourse painful and often impossible. Contrary to common belief, such sexual dysfunction is not associated with small vagina opening, after all this is also the birth canal. Vaginismus is more common than what is perceived in the society. In recent epidemiological investigations, it is reported to be around 6%, but others had also reported it to be as high as 47%. Vaginismus is usually classified as either primary or secondary. The former affects women who have never engaged in penetrative intercourse and the latter developed later in life, despite initial successful relationship. Primary vaginismus can be associated with common medical conditions such vaginitis, Urinary tract infection or yeast infection. Other common association can also be psychological problems such as history of sexual assault and domestic violence. Although the disc prolapse may cause pelvic muscle problems, it is usually nerve 2, 3 and 4 that can cause vaginismus. I think it is crucial for you and your husband to see the doctor together. A right therapist and a supportive husband will see you through this difficult time. The treatment usually is multimodal in nature, which includes vaginal dilation, psychological support plus neuro-modulation. I really hope you see light at the end of the tunnel and no longer feel miserable. You never know, a baby may also be coming following a successful treatment. Cheer up!! Q: My purpose of writing to you is to seek your medical/professional advice regarding Premature Ejaculation and Erectile Dysfunction (PE n ED). I had full Blood tests (yearly checking) including Testosterone (8.31ng/ml) on Dec.2012. All the other blood parameters I tested were normal. I do not suffer from any ill health and I currently consume multi vitamins, Ginkgo and various supplements. Incidentally, I also had a few testosterone jabs (less than10). Malacca Man. Dear Malacca Man, It has been an absolute delight reading your email. I am sorry to hear that your sex life has been plague with compromised erectile rigidity and shortened interval of Intercourse. I am also sorry to inform you that the treatment you have received so far (The Testosterone Injections) may not do much to improve the impairment in your performance either. Premature ejaculation (PE) is essentially a sexual dysfunction caused by the decrease in signaling agents in the brain that have the function to inhibit ejaculation. PE can be primary (life long sufferer) or secondary (Acquired later in life). In fact, the causes of such defects in different individuals are completely unknown. I guess you are one of the unfortunate ones! Don’t be despair; there is a new treatment available now. On the other hand, erectile dysfunction (ED) is mostly lifestyle induced. Hypertension, diabetes, smoking, stress and depression are the common causes of such problem. Although many men may think they are free of ill health, your risks factors may be brewing unknowingly! I think it may be a good idea to start treatment for ED on the first instance. It is real shame you have all three common sexual dysfunctions including low testosterone. My suggestion is to treat one condition at a time, and I think the low libido should be the last to treat, as the low testosterone may be an effect rather than cause of your sexual impairment. It is indeed tough being a man, I wish you good luck! Q: I am in my mid twenties and have been having urethral discharge for more than a month. It reduces during the course of antibiotics, but recurs the day after I stop taking the antibiotics. The urethral discharge culture and sensitivity, urinary microscopic examination, and syphilis examination all came out negative. It has been really bothering me. Mr. Help A: I read your email with a heavy heart. On one hand, I would like to assume a fine young gentleman in his mid twenties would be too innocent to have the curse of Sexual transmitted infection (STI). On the other hand, knowing you tested for Syphilis in your blood tests, I make assumption you have already enter the big bad world of STI’s. Lets assume you are no angel; the most likely cause of your discharge is chlamydia. The constant transparent discharge from the urethral and pain on urination are two common symptoms one would experience. The symptoms usually emerge a week after risky unprotected sexual intimacy, including oral sex. As the discharge from the urethral is colorless, many would also assume it is harmless. Not so, I’m afraid. This will continue to plague you until you get the right antibiotics. Talking about the right antibiotics, one have to assume you are on the wrong type or dosage of treatment if the discharge recurs after treatment. Chlamydia treatment is very specific, and the bacteria have also built up significant antibiotic resistance in Asia. The effective antibiotic should be intravenous ceftriaxone, high dose oral azithromycin or a week course of doxycycline. I know you would argue the urine microscopy has been negative! The fact is chlamydia is an obligate intracellular organism that may not be detected easily. I think, you have no choice but to cough up the cash to do the more accurate (and expensive) DNA PCR tests to confirm the infection. Having said all that, I also would like to believe the discharge be non sexual. It this was the case; the discharge is simply physiological in nature. This may either be pro-semen, which is a secretion that emergences with sexual excitation. Alternatively, this may also be prostatorrhoea, which is a natural secretion from the prostate upon staining. I guess only you would know which side of the fence you are on. Q: My partner and I had a wonderful relationship and our sex lives was pretty good. However, for the last couple of months, my partner has experienced significant loss of sexual desire and this has affected our relationship somewhat. Can you please advice us what would be the cause, as we cannot pinpoint the etiology of decline in the libido? He even lost the interest to self-pleasure. More worryingly, he also mentioned how the orgasmic intensity had declined tremendously. I wonder if you could also advise us the treatment options for loss of libido? Will this be permanent? Loving Partner A: I am so pleased having received such a caring letter from you regarding your partner. The strength of your relationship is open communication. It is rare to have partners opening up to talk about desires and pleasure in the bedroom. Many would endure the displeasure and misery for many years; others may even walk out of a relationship. From what I have gathered, your partner has lost his libido (both intimacy and self pleasure) and intensity of orgasm in the last two months. For most, this caused by non-organic issues such as stress at work or lack of sleep. Other causes may also be the lack of sexual excitements in life. Of course, there are also medical issues including sedentary lifestyle, late onset hypogonadism, prostatitis or hypothyroidism that may dampen your flames of intimacy. Clearly, you and your partner are worried about this change. I recommend for you to see a doctor and run some tests to ensure all his functions are spot on. I also believe your doctor can also play a role being the mediator to actively listen to both of you, regarding likes and dislikes behind the bedroom door. Stretch your imaginations; let him tell you all his fantasy and explore all possibilities. I am sure what you experience is a transient hiccup all relationships go through intermittently, After all, to ensure the longevity of the partnership, something fresh from time to time can only add to the spice of life. Good luck and keep the passionate flame burning. Q: Would appreciate if you can provide some advise on the following: I have done a blood test recently and my total bilirubin reading is high at 36 umol/l as compared to normal of <17 My last year total bilirubin reading was also high at 34 umol/l I was told this is related to gall bladder. I have removed my gall bladder in 1997 due to gallstones. Bill Dear Bill, I am not sure you are aware that Dr. G gives advice to readers on issues related to men or sexual in nature. Well, I guess you are also a man, why not? I am reasonably sure that you have a condition called the Gilbert’s Syndrome. This is the most common hereditary cause of elevated bilirubin, which can affect up to 10% of the general population. The great news is, it is mostly harmless and will require no treatment. The aetiology of Gilbert’ is the elevated unconjugated bilirubin in the blood stream caused by the reduced activity of an enzyme glucuronyltransferase. Gilbert’s syndrome usually has the level of bilirubin from 20uM to 90uM, compared to the normal range that is less than 20uM. The definitive diagnosis of the condition can be made by the DNA analysis of the genetic mutation. Of course, there are other causes of elevated bilirubin including heamolysis, hepatitis or splenomegaly. I assume you have seen a doctor to rule them out. It has been an absolute pleasure answering your questions. At least it ensure me my non-sexual medical knowledge is still intact. Please free to ask sexual questions too! 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