Sexual Health and Wellness for Women and Men

Dr. Clifford D. Gluck Surgeon Hingham, Massachusetts

Dr. Clifford D. Gluck M.D. is a top Urologist in Dorchester, . With a passion for the field and an unwavering commitment to their specialty, Dr. Clifford D. Gluck M.D. is an expert in changing the lives of their patients for the better. Through their designated cause and expertise in the field, Dr. Clifford D. Gluck M.D.... more

I once received an anonymous letter at my office which changed my practice. As a urologist for 30 years, I have spent much of my career devoted to helping men with erectile dysfunction. It was after helping a man that I received the “anonymous” letter. Like a frightening ransom note, the letters were cut and pasted from magazines. The author was pleading with me to stop helping because, as a wife with her own difficulties, she was unable to participate in sex. She went on to question: what could I possibly offer to help her? 

Well, what could I do? I immediately started to educate myself about the often-ignored subject of female sexual dysfunction. Because half of my patients are women, I began to include an open-ended question about sexual health as part of a routine medical history. Suddenly, I was listening to multiple stories from women about their desires and concerns that had gone unmentioned for years or decades. More importantly, they were relieved and excited that a doctor should actually ask and be interested in their sexual health. The origins of the problems were varied, but the common goal was to restore a wonderful but missing part of their life.

Hormones, those chemical messengers which traverse our bodies to shepherd the normal processes of physiology, are provided to us on a time-limited basis by nature. As we age, both men and women undergo a natural decline in sex hormones. In women, this is called menopause, and the body stops making estrogen and progesterone. Testosterone, which is made from estrogen, also disappears. The result is a loss of libido, or sexual appetite, a shrinking and drying of the vaginal tissues, and a loss of sensitivity. Hot flashes, osteoporosis, loss of energy and muscle mass, and a slowing of the metabolism leading to weight gain and fat accumulation are also products of menopause. By replacing bio-identical hormones, the negative effects of menopause can be safely limited. For sexual health, the correction of hormone deficiencies will restore vaginal thickness and lubrication, improve libido, and elevate energy so that diet and exercise become meaningful and successful.

What about women who cannot or choose not to replace bioidentical hormones? Some women, notably those with a history of breast or uterine cancer, must avoid hormone replacement. Two effective solutions are Votiva and PRP. Votiva is a form of transcutaneous thermal controlled radiofrequency energy (TTCRF) which gently and painlessly rejuvenates vaginal tissues in 3 brief office visits. The feeling during the procedure has been compared to that of a hot stone massage. By precisely raising the local tissue temperatures for about 25 minutes, the vagina undergoes a process of collagenesis, whereby new collagen, elastin, nerve endings, and blood vessels are created.

Anatomical changes include more elasticity and accommodation for the overly tight vagina, and a firming up and restorative gripping capacity for the redundant or loose vagina. Women report the resolution of painful intercourse, dryness, and itching. Many experience relief from chronic urinary tract infections and incontinence. The cosmetic appearance of the labia can be improved with Votiva by creating a non-surgical labiaplasty. 

PRP, or platelet-rich plasma, is an autologous blood product, harvested from a patient and returned to the same patient. The platelets form a separate component of whole blood, apart from the red and white blood cells, and the plasma. Platelets are not actually cells themselves, but importantly contain elements which induce tissue repair. When an area of the body is injured, blood is released from the circulation into the injured area or organ. The platelets move in and stick to the injured areas as the blood plasma forms a fibrin net to fill in the broken spaces. As the platelets aggregate, they release several different growth factors, including Vascular Endothelial Growth Factor (VGEF), which induces the formation of new blood vessels, bringing oxygen and nutrients to the healing tissues.

PRP is created by using a person’s own blood. Blood is drawn from the arm and then treated to a one or two-step centrifugation in order to separate the platelets from the red and white cells. Generally, the platelets will be concentrated into plasma at 3-5 times their natural numbers. Because the donor is identical to the recipient, there is no real risk to the procedure, other than a bruise from the needle for injection.  

Using PRP for the vagina has been reported to enhance sexual sensation and pleasure. For women, the PRP is injected into the anterior vagina (the “G-spot”) and the clitoris.  Benefits can be felt almost immediately, but tissue transformation may go on for several days or weeks. Although a PRP injection is a single procedure, the benefits may last up to a year. Follow up injections can be done as needed. PRP can also complement other treatments including Votiva and Emsella.

Emsella is a specialized chair to deliver high intensity focused electromagnetic energy (HIFEM) to the pelvic floor during a 27 minute, fully clothed session. No special preparation is necessary. The treatment is often described as “intense and pleasurable” and sometimes likened to the feeling of orgasm. Much more effective than Kegel’s exercises, the muscles of the pelvic floor strengthen under the influence of the focused magnetic energy. This pelvic floor therapy results in improved pelvic blood flow and better sexual function, and will also improve bladder function and incontinence. It can be an adjunct to both PRP and Votiva.

I am grateful that I can offer hope to women for a problem that has been too often ignored. Like snowflakes, I find each person and each story is unique when examined carefully. There is no one correct solution to treat everybody, and arriving at that solution requires patience, listening, and a good physical exam. As a urologist, I am also tuned in to bladder health, and many bladder conditions such as incontinence, pain, or recurrent infections can also be helped by these treatments. Possibilities of stones, pelvic prolapse, and cancer must be discovered and addressed if present.

If women are from Venus and men are from Mars, can we agree that we all come from the same solar system? For men, treating their sexual wellness will also require a careful history and physical exam, and a routine blood test. Similar to menopause, men will typically lose testosterone as they age, and may arrive at “andropause” without understanding why they have gradually become more irritable, anxious, and less interested in a healthy sex life. Low testosterone may also cause erectile dysfunction, loss of muscle mass, loss of bone mass, and osteoporosis. Low testosterone leads to the accumulation of body and belly fat and may result in diabetes. Correcting testosterone is easily accomplished with a cream, a patch, or an injection that must be done under the care of a physician. Testosterone replacement therapy, or TRT, will quickly restore libido. But further treatment of sexual wellness usually involves correction of erectile dysfunction or ED.

The normal erection occurs when neurological signals from the thalamus, the emotional part of our brain, are transmitted via the spinal cord to the cavernous nerves, or “nerves of erection” in the pelvis. The nerves initiate the release of nitric oxide inside the vascular spaces of the corpora cavernosa, the paired erectile bodies which form the rigid shaft of the penis. Nitric oxide induces smooth muscle relaxation, leading to a widening of the lumen of blood vessels. As the corpora fill with blood, small drainage veins are shut down by the stiffening shaft, and the penis arrives at an erect steady state. Testosterone also plays a role in the formation of the erection, binding to receptors in the erectile tissues. 

So, in general, five things are necessary for a good erection: good blood flow to the penis, healthy tissues in the corpora cavernosa or “erectile bodies,” adequate testosterone levels, intact nerves leading to the penis, and adequate signals from the brain (a release of serotonin in the thalamus) to initiate an erection. An interruption in one or more of these items will lead to ED.

Nearly everyone has seen ads and commercials for medication for ED, or erectile dysfunction. The discovery of the usefulness of these medications was an unanticipated result of a clinical trial for a new drug for hypertension. The new drug was sildenafil, or Viagra, a PDE5 (phosphodiesterase 5) inhibitor. The new medication would promote an increase in nitric oxide in blood vessels, opening them wider to reduce blood pressure. One group of men in a double-blind study (meaning that neither the volunteers nor the investigators know who is taking the real medicine) received Viagra, while the control group got a placebo. At the end of the study, the men were asked to return the unused pills. The control group handed them over without question, but the Viagra group was unwilling to part with their pills due to a happy side effect: much better erections. The increased nitric oxide in the tissues of the corpora cavernosa was allowing more blood to flow into the penis to create an erection.

The PDE5 inhibitors, a class of drugs that now includes sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Stendra) are amazing and helpful adjuncts to treating ED. But sometimes, the pills alone are not enough, and their effectiveness may seem to wear off over time. Men wonder, am I becoming dependent on these pills, or immune to them? The answer is neither. The pills simply increase the nitric oxide content in the tissues.  It is the health of the tissues that are in question.

Regenerative medicine, to make the tissues of the corpora cavernosa in the penis healthier, is a new and exciting frontier. Like any other part of the body, the erectile tissues must get a frequent workout in order to stay healthy. Nature usually helps by creating a nocturnal erection during REM (rapid eye movement) sleep, the phase of sleep in which we dream. A morning erection occurs when a man awakens from a dream, during REM sleep. Sleep disorders can interfere with REM sleep, and thus prevent nocturnal erections. Unless one is able to induce frequent waking erections, the tissues may fall to disuse, atrophy, and fibrosis. Disease states such as diabetes, hypertension, and vascular disease also worsen the health of erectile tissue. Smoking and the constriction of blood vessels by the effect of nicotine is extremely harmful to erectile tissue. There is an ironic truth to the old adage of “use it or lose it.” 

PRP, platelet-rich plasma, is a safe and effective way to induce healing and improvement of damaged tissue. PRP can be used in the penis and may be immediately effective in restoring sensitivity, expansion, and the ability to maintain an erection. PRP can improve the responsiveness of tissues to PDE5 inhibitors. PRP can help regenerate nerves and may improve the length and enjoyment of orgasm. PRP can be safely used with other treatments, like low-intensity shock wave therapy (LISWT), Emsella pelvic floor therapy, vacuum erection devices (VED), and penile self-injection. PRP is the starting point for regenerative therapy for the corpora cavernosa. Other techniques including stem cells, exosomes, and placental derived growth factors are used by some physicians. While PRP is autologous, meaning it comes from your own body, other treatments may not. Always ask your doctor about any therapy you are considering, and make sure that you understand its safety and usefulness before you give consent.

Low-intensity shock wave therapy (LISWT) is another safe and effective way to treat ED. There are no “shocks” given during this treatment. 5000 pulses of mechanical energy are gently delivered to the shaft of the penis during a half-hour treatment. No anesthesia is necessary, and the sensation is not unpleasant. LISWT has been well studied and results in greater blood flow to the penis, as well as recruiting stem cells to the area. A natural regenerative process leads to improved hardness and control of the erection. Some men notice an increase in sensitivity or girth. Typically 6 sessions are adequate, but more can be increasingly effective. Follow up sessions may be done once or twice a year.

A new non-invasive technology for ED is high intensity focused electromagnetic energy (HIFEM). The Emsella chair uses this focused energy to stimulate and strengthen the muscles of the pelvic floor. It is a safe, relaxing and effective method of pelvic rehabilitation, sitting fully clothed for 6 sessions of 27 minutes each. Multiple studies of pelvic floor rehabilitation have shown its efficacy in treating ED. Other benefits are improved bladder control. Emsella is complementary to PRP and LISWT for treatment of ED.

Maintaining sexual wellness is an important part of maintaining overall health and wellness. Sexual activity is healthy: it activates multiple physiologic processes resulting in decreased stress, improved immunity, better cardiovascular health, and better urinary health. The bond between couples often strengthens when both partners are able to actively participate and enjoy a healthy sexual life together.  Better understanding of each other, and a fresh and improved outlook on life are often the happy result. My greatest reward is to help others live their best lives. Getting help is a simple and straightforward process once you are determined to take the first step to call for an appointment.