Diagnosis Sexual Dysfunction
Men are…well…complicated!

This Case of the Year is an actual patient of The Turek Clinics.

A 13th century Franciscan friar named William of Occam proposed a way of thinking that is popular even today. Occam’s Razor states that simpler solutions are more likely to be correct than complex ones. Alternatively viewed, if one theory explains all observations, then that’s probably the right one. This heuristic has guided my career as professor, physician and surgeon. And it came in handy yet again in the case of the man with many-sided sexual dysfunction.

Where to Start?

The patient in question appeared more youthful than a man in his 6th decade. He was engaging and delightful, but also very troubled. His sexual dysfunction had been around for decades and had gotten worse. It involved erectile dysfunction, loss of sex drive, early or premature ejaculation, altered orgasm and painful ejaculation. Most recently, orgasm was no longer pleasurable but felt like someone was “pulling the skin off my body.” He had been to urologists, psychologists and sex therapists, but all for naught. “Doc, I know that there’s a lot going on with me, but you’re my only hope,” he stated earnestly at our first meeting.

We quickly ruled out relatively common conditions and corrected what we could: there was no prostatitis or other infections and no blockages, masses or hernias. I quickly fixed the erections with pills, but other symptoms persisted. The need for early ejaculation, I figured, might be a response to an underlying desire to end sex quickly for some reason. The recently altered orgasm could also be due to distraction during sex. But what was so distracting about sex? And what’s up with painful ejaculation?

Listen and Observe

The best clue came from his physical exam. He was born with an undescended testicle on one side which was brought down surgically when he was 11 years old. Not unusual. Except that on exam, the testicle was situated high in the scrotum, next to the penis, and fixed there by scar tissue, right smack in front of the pubic bone. The scrotum on that side was essentially empty. And he withdrew violently when I went to examine his genitals, like being kicked instead of examined.

“It’s really sensitive down there, Doc,” he stated apologetically.
“Does it hurt with sex?” I asked.
“Yea, enough that I’d rather not have any…,” he replied.

Sea Legs for Sex

Peeling away his layers of sexual symptoms, it occurred to me that this pain might be the root cause of all of them. You can imagine that a testicle fixed against the pubic bone could be forced against it with every pelvic thrust of sex and hurt like hell. How fun is that? Certainly, it could lead to the desire to finish sex quickly (premature ejaculation), erectile dysfunction (pain stimulates the wrong nervous system), altered orgasm (sensation of pain mixed with pleasure) and loss of sex drive (avoidance of pain). So, I figured, the pain’s the thing that’s underlying all this.

Based on this, I offered him over-the-counter pain pills (ibuprofen) to take before sex. And the sex got better. And the erections improved. And the desire returned. But not completely. After this trial, I offered to remove the smaller, misplaced testicle completely and replace it with natural-feeling testicular implant placed right where it’s supposed to be: within the scrotum alongside its brother. He agreed to this.

Within 3 weeks of surgery, he was a new man. The pain was gone. He could touch the area and move freely without feeling uncomfortable. He also liked having two matching balls in their corner pockets. And erections were now occurring without pills. He even wanted sex again.  Of course, after 30 years of painful sex, progress on this front might take more time. But by the subtle smile on his face, I knew that his sea legs for sex had returned. Amazing but true that 600-year-old ideas, like Occam’s razor, still have relevance today.

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