Size Isn't Everything by Men's Health Forum

SIZE ISN’T EVERYTHING Penis Health Made Easy

Erections • Orgasms • Peeing • Prostates • Testicles • Foreskins • THE LOT

TIME TO RAISE IT Backed by an alliance of different organisations and individuals, Time to Raise It is a movement that aims to challenge the lack of honest and open representation when it comes to the reality of sex, love, erection problems and intimacy today; remove the sense of isolation for men and their partners through honest conversation and sharing; and reconnect men and their partners to each other and to sex. facebook.com/TimetoRaiseIt

MEN’S HEALTH FORUM The Men’s Health Forum’s Man Manuals contain easy-to-read information on a wide range of men’s health subjects. Founded in 1994, the MHF is the independent voice for the health and wellbeing of men and boys in England, Scotland and Wales. Our goal is the best possible physical and mental health and wellbeing for all men and boys. Size Isn’t Everything © Men’s Health Forum All rights reserved. You must not reproduce or transmit any part of this booklet in any form or in any way without written permission from the Men’s Health Forum. This includes photocopying or scanning it. Printed in the UK. ISBN: 978-0-85761-032-4 (PDF version) Men’s Health Forum, 49-51 East Road, London N1 6AH Registered charity number 1087375 Company limited by guarantee number 4142349 – England

+44 (0)20 7922 7908 www.menshealthforum.org.uk

A full list of references is available at: menshealthforum.org.uk/MMreferences The MHF encourages your feedback at: menshealthforum.org.uk/MMfeedback

CONTENTS SIZE ISN’T EVERYTHING…

Masturbation 20

Introduction 4

Sex (with someone else!)

Looking After Your Knob

Ejaculation 25

Size 9

Sperm 28

Shape 11

Peeing 30

Foreskins 13

Testicles 33

Erections 15

What next?

Written and edited by Jim Pollard (jimpollard.co.uk) • Cartoons by John Byrne. Thanks to all the men who helped with this booklet, especially those who shared their stories. Some names have been changed. Thanks to the advisory team: Dr John Chisholm, Dr Su Wang, Sara Richards, Sarah Louise Ryan and Brook (brook.org.uk) and all those health professionals who helped with the booklet. Sponsored by Viatris. First published: June 2021 • Next revision: June 2023 This is a booklet about penis health. It is not about sex and relationships. If we do refer to these, most of the examples are drawn from heterosexual couplings. However, the basic info applies to all men regardless of partner preference. There’s more on gay men’s health in our manual ‘Man To Man’.

INTRODUCTION Over the years, the Men’s Health Forum has probably been asked more questions about the male tackle than about everything else combined. This booklet will answer the most common. Whatever your age, the key message is not to remain silent. Read the booklet, learn more and, if you want support, ask for it.

A FEW TECHNICAL TERMS

The penis is basically three cylinders of spongy erectile tissue full of blood vessels. The urethra, the body’s outlet tube for both sperm and urine (although only one at a time), passes through the middle of the smallest of these - the corpus spongiosum - which is found on the underside of the penis. The corpus spongiosum expands at the tip to form the head of the penis called the glans. The glans is protected by the foreskin.

The penis, as you have probably discovered, is used for peeing, making babies and generally enjoying. You’re very lucky to have one, so take care of it. Understanding your tackle will improve your sex life, your relationships and your health in general. However, the human body is not a machine. It doesn’t always do what we want it to do and that applies to the penis too. As with any other health problem, it won’t get better if you ignore it. We need to talk about it. There is a close relationship between traditional ideas about masculinity and poor health. The more we believe all that ‘strong and silent’ ‘boys don’t cry’ stuff, the poorer our health outcomes will be. This particularly applies to penis health. Some guys think they’re not real men if they don’t have a big penis or don’t get an erection every five minutes. Pornography exploits these ideas and may even make us more likely to believe them. But these ideas are not only untrue and unhealthy, they can also make you unhappy. Sex isn’t about performance, it’s about pleasure. If talking to your partner or talking to a doctor helps, why wouldn’t you do it? The truth is that nobody cares whether your dick is a quarter of an inch shorter than average or a quarter of an inch longer. Good sex, good relationships, good fun - these are all far more important.

FUN FOR ALL Sex is to be enjoyed by all involved. (Porn can distort this.) That means consent: everyone clearly and freely communicating that they want to carry on. Consent cannot be given by people who are underage, drunk, drugged, intoxicated, asleep or unconscious. Sex without consent is illegal.

FEELING GOOD

TALKING ABOUT IT Nobody is saying it is easy to talk about your knob. But we owe it to ourselves, and to future generations, to do so. Talking helps tackle challenges, silence can create them. A good example is erection problems (EPs). About five million men in the UK experience these – not just older men, but guys in their 20s-30s too. Yet the research shows that less than half (46%) have opened up to their partner(s) and nearly a third (27%) haven’t spoken to anyone at all. Not getting it up is getting people down. Some men take up to two years to address their EPs. In that time, there could be wider mental and physical health challenges that are going unchecked. EPs have a negative impact on men’s self-esteem. A third (31%) feel ‘inadequate’ leading to feelings of anxiety (27%), depression (19%) and lack of confidence (23%). The point is, if you’re feeling like this, you’re not alone. The Men’s Health Forum is a co-founder of the Time to Raise It movement which calls for openness and realism when it comes to sex, love and intimacy (see page 2). In short, let’s talk about it. Most couples agree (72% say we need to speak more openly about EPs). Whatever the issue, your GP has heard it all before. So have sexual health clinics. Most partners will welcome your honesty and the courage it takes.

LOOKING AFTER YOUR KNOB DO I NEED TO CLEAN MY PENIS? Yes. Wash it every day with warm water when you’re having a shower or a bath. If you have a foreskin, you should pull it back and wash under it. The penis produces its own natural lubricant but, without regular cleaning, it builds up into a cheesy-looking substance called smegma: a breeding ground for bacteria. It’s natural to have some bacteria on your skin but too much on your knob can cause balanitis. Balanitis, which literally means inflammation of the acorn, can be painful. Frequent washing with plain soap and a couple of handfuls of salt in the bath should sort it out. If not, see your GP. Balanitis may also be caused by perfumes in soaps and gels or sex with a woman with thrush. Look after the groin area too. Jock itch, caused by the same tinea fungus as athlete’s foot, thrives in warm, moist conditions - a good description of the average bloke’s pants. Wash with unperfumed soaps, dry thoroughly and, superheroes take note, avoid tight nylon underpants. Talk to your pharmacist or see your GP if problems persist. There are simple treatments available.

I’VE GOT LUMPS / BUMPS / SPOTS ON MY KNOB. Bumps, bends, visible veins… most of these are quite normal. Small skin-coloured spots around the head of the penis, for example, are called pearly penile papules, while Fordyce spots are a yellower colour. Both harmless. A red, sore penis head could be balanitis.

If you’ve had unprotected sex, you may have a sexually-transmitted infection (STI) - see page 23. Very rarely, lumps could be something more serious, so if you are worried, talk to a GP.

CAN THE PENIS BREAK? Theoretically, yes. But it’s very rare. It can ‘fracture’ if it bashes into an immovable object (such as a pubic bone) when erect. It will be painful, probably purple and look a bit like the aubergine emoji. See a doctor immediately. It can be treated but, if ignored, can lead to long-term difficulties including erection problems.

FAQS: SIZE DOES SIZE MATTER? Limp penises may come in all shapes and sizes but erect, they’re pretty much the same (between about five and six-and-a-quarter inches long). In fact, the biggest survey to date - and when it comes to research, size (of the sample) does matter - found the average international erection to be 5.16 inches. Not that it matters: the vagina, for example, can expand or contract to take anything from a tampon to a baby. Penis girth (circumference) may matter a little more when it comes to stimulating a partner, but even that is no biggie (average erect girth is about four and a half inches). Sex is always about more than penetration, anyway. Genuine problems that might stop you enjoying sex or taking a piss are rare and usually picked up when you’re a baby. If you’ve passed that stage, you’re probably good to go. If you’re worried about your penis size, have a proper look at it. When you look at your penis normally you’re looking down on it. Even basketball players look small from above. Hold a mirror at the side and have a proper look. Honestly, very, very few men have willies that are too small or too big to have great sex with. There is a condition which affects perhaps 1 in 660 male babies called XXY or Klinefelter’s syndrome where men have an extra X chromosome. It may cause a smaller than average penis (and more often smaller than average testicles). It can also reduce fertility. You can read about Klinefelter’s on the Men’s Health Forum website.

WHAT ABOUT PENIS ENLARGEMENT? Trying to enlarge your penis is expensive, generally dangerous and almost certainly won’t work. Enlargement operations tend to make your penis look bigger when limp but not when erect. Plus, all surgery has risks. You only have one knob and it cannot be replaced. We don’t generally give advice but, in this case, we will: don’t be a dick.

AT WHAT AGE IS THE KNOB FULLY DEVELOPED? Puberty usually starts at 9-14 and lasts around five years. Penises grow at about half an inch a year from 11 to 15 and then grow more slowly. Growth usually stops by the age of 18 or 19.

DOES IT CHANGE AS YOU GET OLDER? Not really. It may shrink a little. But are you sure it’s your penis shrinking and not your stomach expanding? As with other penis problems as you age, significant reduction in size should be seen as a warning sign of other potentially more dangerous conditions. Talk to your GP. Reduced blood flow to the penis or reduced testosterone could be the explanation and these conditions can be treated. Peyronie’s disease (see page 11) becomes more common as you age. The penis may also become less sensitive, meaning you need a little more stimulation to get erect and reach orgasm.

FAQS: SHAPE WHY IS MY ERECT PENIS BENT? Some bend upwards is normal but, if it’s so bent that it makes sex uncomfortable, it could be a condition called Peyronie’s disease. Ask your GP about it.

WHAT ARE THE MAIN SYMPTOMS OF PEYRONIE’S? Hard lumps, known as plaques, form - usually on the top of the shaft, causing the penis to bend upward. (A plaque on the underside causes it to bend downward.) It can be difficult to get an erection (the plaques may obstruct blood flow in the penis) and, when erect, the thickened area may be painful. The pain and the bending of the penis may physically prevent sexual intercourse. All this can cause anxiety, which affects both erections and sex itself. Peyronie’s disease is not uncommon (it affects perhaps 6-10% of men). Men aged 40-70 are at most risk but it has been seen in men in their 30s.

Doctors are not sure what causes Peyronie’s. While injury (even something as simple as turning over in bed with an erection) may cause some cases, most cases develop slowly and after no apparent trauma. There is some evidence of a family link — a man with relatives affected by Peyronie’s is more vulnerable to developing it. The lumps in Peyronie’s disease are benign and not linked to cancer of the penis. Nor is it caused by sexually-transmitted infections.

HOW DO YOU TREAT PEYRONIE’S DISEASE? It may go away. It may never get serious enough to need treatment. It may respond to non-surgical interventions. However, in more severe cases, if the problem has lasted over a year and intercourse remains difficult, surgery may be discussed. In its mild form, Peyronie’s disease heals by itself in 6-15 months. Many doctors therefore suggest that men wait before having surgery.

CAN YOU GET PENIS CANCER? Yes. But it is very rare. It is linked to the virus HPV (one of several good reasons for young men to be vaccinated) and the risk increases with age. Build-up of smegma (see page 7) under the foreskin may be a factor, so wash your penis thoroughly every day. The main symptoms are: > A lesion (lump) on the penis, which may look like a wart or spot; occasionally the lesion may be painful. > A painless sore on the penis. > Pain and bleeding may occur with more advanced disease. See your GP or sexual health clinic if you’re concerned.

FAQS: FORESKINS MY FORESKIN IS TIGHT. SHOULD I GET CIRCUMCISED? Probably not. Frequent, careful, lubricated masturbation can help with slight tightness. Your GP can also advise on creams, stretching techniques and possible procedures. A last resort for the condition - known as phimosis - is full or partial circumcision but, like all surgery, that comes with risks. There is between a 1 in 10 and a 1 in 50 chance of bleeding or infection. A tight foreskin may also be linked to a short frenulum (frenulum breve). The frenulum (or banjo string) is the fold of skin joining the underside of the glans with the inner surface of the foreskin. A short one can make intercourse painful and even tear. Again there are treatments, exercises and procedures short of a circumcision to consider.

DOES CIRCUMCISION AFFECT SEX AND SENSITIVITY? Give it a bit of thought. Circumcision in men involves the cutting off of the foreskin protecting the head (or glans) of the penis. As the only moving part of the penis, the foreskin facilitates sexual activity. It contains nerve endings that play a part in sexual pleasure and its glands produce lubricants that help protect both the head of the penis and the female vagina. Certainly, the cornflakes man, Dr John Harvey Kellogg who popularised circumcision in the USA, felt it would discourage the ‘self-polluting’ crime of masturbation. (Circumcised men report that this is not the case - lubricants can help.) The NHS lists ‘permanent reduction in sensation in the head of the penis, particularly during sex’ and ‘tenderness around the scar’ among the possible complications from circumcision.

I’M NOT SURE ABOUT CIRCUMCISION. If you’re considering circumcision, get genuine independent advice. There are some strong views for and against out there. This is tied up with the fact that many non-medical circumcisions are carried out on religious or cultural grounds on babies or children without their permission. The foreskin is perfectly healthy and harmless and, like any other human tissue, should only be removed for a good reason. Whatever your personal views on what constitutes good reason, remember that no surgery is without risk and that circumcision is surgery in a very delicate place that can affect both physical and psychological well-being. Many men are happy with their circumcisions but others are very unhappy. The organisation 15 Square (Norm UK) provides information and advice on phimosis and unwanted circumcision.

FAQS: ERECTIONS WHAT CAUSES AN ERECTION? Well, whatever turns you on basically, but the science is this: Erections occur when the small muscles in your penis, which are usually tightly contracted, relax and let blood start flowing in. The spongy tissue in the penis fills with blood and expands, pushing against the veins and closing them so the blood cannot drain out again. (Well, you did ask.) When you’re younger, it can seem like pretty much anything can cause an erection, even a purely physical stimulus like riding on a bus. Nothing to worry about.

EARLY-WARNING SYSTEM Erection problems can be an early-warning system for wider problems, a barometer of your health. Like the heart, the penis is a vascular organ - it is made up of vessels carrying blood. Because the arteries in the penis are much smaller than those in the heart, damage can occur here first—often years before heart disease symptoms. In other words, erection problems can be a warning of heart problems to come. (Men in their 40s with erection problems have an 80% risk of developing heart problems within 10 years.) This also means that everything that is good for your heart - a healthy diet, not carrying too much weight, exercise, fresh air and a relaxed attitude - is also good for your penis health.

WHY CAN’T I GET AN ERECTION? Erection problems (EPs) or erectile dysfunction (ED) affect most men at some time (about 1 in 10 of us at any given moment). Often the cause is physical: > diabetes (over 50% of men with diabetes have erection problems) > blocked arteries or high blood pressure (see ‘early warning’ box) > drinking too much alcohol > drug side-effects > spinal cord injury > multiple sclerosis > hormone problems > prostate problem, or other surgery in this area. However, if you can’t get an erection with your partner but can when masturbating or during the night, there’s a good chance your EPs have lifestyle or psychological causes: > relationship problems or sexual boredom > tiredness, stress, depression, low self-esteem or performance anxiety > excessive porn (called Porn-Induced Erectile Dysfunction or PIED) > sexual identity problem. Not always getting an erection when you want one is normal. But, if it starts happening regularly, it’s important to see a health professional because some of the causes of EPs can be very serious indeed: heart disease, diabetes, depression. Or they could be a side-effect of other medication. Seeing a health professional means you can treat the erection problems and the underlying causes.

ARE ERECTION PROBLEMS THE RESULT OF AGE? Not necessarily. There is a correlation between age and erection problems (about 40% of men have EPs in their 40s; about 70% in their 70s and so on). But it’s not inevitable. Increasingly, young men are affected. A quarter of British men under the age of 35 have experienced EPs.

WHAT CAN I DO ABOUT IT? All the usual things. Lose weight if you’re carrying too much. Quit smoking and any recreational drugs. Nicotine interferes with the flow of blood to the penis, making an erection less likely. Men who smoke are about twice as likely to develop EPs as non-smokers. Go easy on alcohol. Exercise every day. And reduce stress and anxiety. If you’re a frequent motorcyclist or cyclist (3 hours a week or more) then perhaps take a break from your bike and see if that helps. Hiding EPs from your partner complicates things and making excuses to avoid sex tends only to confuse, leading to feelings of rejection and even suspicions that you’re having an affair. Better to be as open and honest as possible with your partner and ask for support. Place less emphasis on penetration and more on other forms of sexual intimacy. Cuddling, kissing, licking, massaging and masturbating together will keep you emotionally close to your partner. Avoid herbal supplements or so-called aphrodisiacs. You can’t be sure what you’re buying and they are very unlikely to work. Most of all, don’t blame yourself. It’s a health problem and not a reflection of you as a person. Don’t be tempted to blame your partner either.

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THE ‘CAN DO’ APPROACH Try the CAN DO approach to mental wellbeing. This is based on five proven, evidence-based things that anyone can do. They are: C - connecting with others (text a mate, join a club, call someone) A - getting active (take some exercise, have a walk, do some DIY) N - noticing more around you in the moment you’re living in D - discovering or learning more (read a book, take up a new hobby) O - offering, giving or just doing something for others We CAN DO a lot to boost our mental wellbeing. (And our erections too.)

WHAT ABOUT DRUGS TO HELP YOU GET ERECTIONS? Medicine to help treat erection problems is now available from the pharmacy counter without the need for a prescription. That’s good news. But you must talk to the pharmacist or a GP beforehand. If you only deal with the symptom - no erection - without looking at the cause, you may be ignoring life-threatening problems like heart disease. You need a professional to rule these out. The drugs, called Phosphodiesterase-5 inhibitors, help relax the blood vessels in the penis, allowing blood to flow in. They don’t work unless you’re also sexually stimulated. There can be side-effects - most commonly headaches and facial flushing - and they must not be used if you’re also taking medicines containing nitrates (commonly prescribed for angina).

AND THE PSYCHOLOGICAL SIDE? Talking to your partner, pharmacist, health professional or someone else you trust may help. The waiting list for talking therapies on the NHS is long. If you decide to approach a private counsellor or sex therapist, make sure they’re members of the British Association of Counselling and Psychotherapy, the College of Sexual and Relationship Therapists (COSRT) or the Institute of Psychosexual Medicine. The charity Relate also provides sex therapy for a fee.

I’VE GOT AN ERECTION ALL THE TIME. If your penis becomes hard for long periods or when you’re not sexually excited, you may have a condition called priapism. It’s painful and requires prompt treatment to avoid the risk of permanent damage to the penis and erection problems in the future. Home treatments include: trying to pee, a warm bath or shower, drinking lots of water, a walk or exercising (try squats or running on the spot). Take painkillers if need be, but avoid ice packs or sex (that won’t work). Any man whose erection continues for four hours or more should see a doctor. Most cases of priapism have no obvious cause but, in those that do, it is

usually a reaction to drugs, especially those prescribed to treat erection problems, but also to some antidepressants or blood thinners. Or to recreational drugs like cannabis. Or, it may be related to sickle-cell anaemia, childhood leukaemia or other drug disorders. Injuries (to the penis or to the area underneath the penis known as the perineum or to the spinal cord) may also be a cause. In rare cases, cancers may affect the penis and prevent the outflow of blood. A blocked or ruptured blood vessel can also affect blood flow in the penis. The point is, whatever the cause, it can permanently damage your penis, so see a doctor.

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Champ, age 27 I first started experiencing EPs when I was in my early 20s following a really bad break-up. I thought the best way to get over my ex was to be intimate with someone new, but each time I tried, my body didn’t want to play ball. This really got me down – I was meant to be a man in his ‘prime’. I felt a pressure to perform and then would beat myself up when I couldn’t. I didn’t tell anyone for a long time – mainly because I was embarrassed, but also because no-one else seemed to be having problems. I felt completely alone. But when I did eventually open up to my friends, they helped me to see that I struggled to be intimate because I was getting over a messy break-up and it was pretty normal to experience a lack of libido. If more people spoke about these sorts of issues or it was seen more in the media, I don’t think people would take so long to sort them out.

FAQS: MASTURBATION IS IT OK TO MASTURBATE? It is and it’s fine. It will help you understand your body and your sexuality and what turns you on better. This may help you communicate with your partner more easily, enjoy sex more and avoid sex-related psychological problems. Masturbating with your partner is a really good way to show each other what you like. Frequent orgasms help reduce the risk of prostate cancer, while masturbation reduces the likelihood of phimosis, a tightness of the foreskin. (It may even cure a tight foreskin if you have that problem.) It also releases stress and can boost mood and help sleep. A health warning: you only have one penis, so handle with care. It is a delicate body part designed to go into other delicate body parts. Don’t stick it in anything else or stick anything else into it.

CAN YOU MASTURBATE TOO MUCH? Anything that is pleasurable can be addictive and masturbation is no different. If it begins to interfere with the rest of your life and you’re becoming more interested in it than in real relationships with real people, you need to be careful. Are you using it to deal with difficult feelings? Are you doing it in inappropriate places? Do you feel bad about yourself afterwards? Take a break. If you can’t stop, you need to.

WHAT ABOUT PORN? We have different attitudes to porn. Whatever your views, it is important to be aware of the potential downsides.

A lot of porn only shows certain types and shapes of bodies. A lot only shows certain kinds of sex. A lot is humiliating and abusive to those taking part. All of this can distort what we find attractive and lead to unrealistic and unhealthy ideas about what real people having real sex is really about. Plus, there is increasing evidence that porn can be addictive and encourage you to seek out more. So, handle with care. All of this can affect your attitudes to other people and spoil your relationships with them. If you’re becoming more interested in porn than in real sex with real people in real relationships, seek help. There are online resources to help with sex addiction in all its forms. Both thelaurelcentre.co.uk and yourbrainonporn.com include free resources. There are also organisations such as Sex Addicts Anonymous. You shouldn’t need porn to masturbate. If you do, it may be a sign you’re becoming dependent.

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Kyle, age 35 Masturbation may be healthy, but that doesn’t mean the stuff you use to help you do it is. I’d noticed I was using porn more often and starting to look at ‘harder’ stuff. I didn’t like what it was doing to me, so I decided to quit for a month. There was initial relief at the lifting of a burden of secret shame that I didn’t even know I was carrying. I realised the damage it had done to my self-esteem. But midway through the month it got tough. Couldn’t sleep. Couldn’t concentrate. I felt like I’d drunk too much coffee. My body, deprived of its dopamine hits, was going cold turkey. Like gambling or social media and all these other kicks we get online, the porn sites know exactly how to pull you in. I had no idea I’d become physically addicted. I haven’t gone back and my relationship has benefited as a result. If you’re a porn user, give up for a month. You’ll be surprised.

FAQS: SEX WHAT IS SAFE SEX? Assuming you don’t want to stop sex with other people altogether, it’s about using condoms. These prevent pregnancy and help prevent most sexually-transmitted infections (STIs). Other forms of contraception - like the pill - may stop pregnancy but not STIs. So it’s as simple as this: if you don’t know someone else’s sexual history, use a condom - whatever sort of sex you’re having. If a condom breaks, the NHS website can direct you to the nearest emergency contraception service.

HOW DO I USE A CONDOM? They come in different sizes, shapes, thicknesses and flavours. Lengths vary by 2-3 centimetres, circumferences by a centimetre or more, so experiment to see which you like. For anal sex, go for a thicker condom. Choose one that has the European CE or BSI kite mark and check the ‘use by’ date as condoms deteriorate with age. Practice putting one on on your own. There are umpteen videos to show you if you’re not sure. Condoms are a lot less hassle than an unwanted pregnancy or a sexually-transmitted infection which, if left untreated, may kill you. It’s a myth that they affect sexual performance — in fact, they may prolong it. Some condoms can irritate the vagina. This can be overcome with a little lubricant (not oil-based as this can split latex condoms). In the rare case of latex allergy or overwhelming urge to use your favourite oil-based lubricant, use polyurethane condoms.

Condoms are widely available. Your local contraception/family planning clinic or sexual health clinic may even have some free.

MY PENIS / BALLS ACHE AFTER SEX. This could be down to lack of lubrication, over-vigorous sex or delaying ejaculation too long. Avoiding all these should help, but see your GP if it starts happening regularly.

HOW CAN I RECOGNISE AN STI? Sexually-transmitted infections (STIs) can be caught through vaginal, oral or anal sex. Or skin-to-skin contact. Some STIs are increasing rapidly. Common symptoms include: > a yellow discharge from your penis > swollen tender testicles > irritation of your penis > pain when peeing. Your GP can help. Or, for something more anonymous, try a specialist sexual health clinic. Many STIs can be treated if caught early, usually with antibiotics. Some STIs such as chlamydia may not have any symptoms, while the only signs of HIV or hepatitis may be a short flu-like illness. All are serious diseases. So get yourself tested if you’ve had unsafe sex. The best way to avoid an STI is through safer sex.

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Jack, age 19 I know how to put on a condom with my eyes closed now. It makes you look experienced, competent and caring - a guy who knows what he’s doing and gives a shit about others. Those things are a turn-on for her and I last longer too. What’s not to like?

I’VE LOST INTEREST IN SEX. Your interest in sex (libido) is a complicated mix of emotions and hormones. Ups and downs with time and age are normal. Libido can also be reduced by: > tiredness, stress, depression and/or relationship problems > the side-effects of drink or drugs (including legal drugs such as antidepressants and medications for blood pressure or prostate problems) > hormonal changes (as men age, levels of testosterone go down) > medical conditions such as heart disease, diabetes or an underactive thyroid. If you’re concerned about any of these, see your GP.

FAQS: EJACULATION WHAT IS IN CUM? When you come or ejaculate, white semen comes out of the end of your penis. It can happen during sex, during masturbation or during the night in a wet dream. All normal. Only about 10% of this is sperm. The rest is mostly fluid from the seminal vesicles and prostate including citric acid, amino acids, fructose, potassium and zinc (not exactly a health food, but could be worse). There are 20 million or more sperm per millilitre of semen and the average ejaculation is two to three millilitres.

I COME TOO QUICKLY. There are no rules about how long a man is supposed to ‘last’. Some times last longer than others. It’s the intimacy that counts. Having said that, if ejaculation times are bothering you a lot, it can be helped with treatment. You may hear it called premature ejaculation (PE). It’s common and often caused by stress or anxiety, but there are sometimes physical causes (including prostate or thyroid problems).

HOW DO YOU TREAT PREMATURE EJACULATION? Some simple suggestions: > a thicker condom > your partner on top (gravity may help) > ejaculate more often - perhaps masturbate an hour or two before sex

> don’t focus on intercourse - perhaps avoid penetration until your partner has already had an orgasm > talk to your partner about it > learn some relaxation exercises. If those don’t help, here are a couple of ’retraining’ techniques you can try: > Stop-start. You stimulate your penis (or ask your partner to do it for you) until you’re near the point of ejaculation. Then stop and rest for 30-60 seconds before stimulating your penis again. Repeat this process five or six times. > Squeeze. You stimulate your penis (or ask your partner to do it for you) until you’re near the point of ejaculation. This time, you or your partner firmly squeeze around your penis just below the glans (head) — put your thumb on the underside of the penis in the indent where the head meets the shaft (the frenulum) and your first and second fingers on the other side of the penis, just above and below the ridge that separates the head from the shaft. The squeeze has the effect of preventing ejaculation. A doctor may suggest a local anaesthetic gel or spray applied to the penis. This is not always effective and some men are allergic. Moreover, the gel may be transferred to your partner during sex and anaesthetise their sensitive parts. More likely, doctors will try drugs called SSRIs. These are usually prescribed for depression but as a side-effect, they can slow down ejaculation. There is also now an SSRI specifically designed to treat premature ejaculation: dapoxetine. The drugs used to treat erection problems (Phosphodiesterase-5 inhibitors) can also help. But get advice before using them. All drugs are best reserved for use when retraining techniques have failed.

I CAN’T EJACULATE. As with premature ejaculation, frequent delayed ejaculation is often psychological but it can have physical causes or be the side-effect of a medication. It happens from time to time. If it happens regularly, talk to your GP.

I’VE GOT BLOOD IN MY SEMEN. IS IT SERIOUS? This is can be very scary but is usually harmless. A bit of rough sex or masturbation can cause it. Only one case in five has an obvious cause, but very rarely it can be a sign of something more serious so see a doctor if it happens more than once.

THE GREAT SPERM RACE

Sperm are tadpole-shaped and about 0.05mm long. From puberty onwards, at least 1,000 sperm a minute are manufactured in the testicles. They take about two-and-a-half months to mature and spend the last couple of weeks in the epididymis. The epididymis is a microscopically narrow tube six metres long folded into a space of 5cm - an engineering masterpiece. Just before you come, the sperm travel along two narrow tubes of muscle called vas deferens. These meet with the seminal vesicles which are behind the bladder just above the prostate gland. The seminal vesicles and the prostate gland add their own secretions to the semen. These fluids are alkaline which protect the sperm from the acid in the vagina. At orgasm, the semen is propelled from two ejaculatory ducts along the urethra which runs the length of the penis and out of the urethral opening. Sperm swim at six inches a second but at the point of ejaculation, they are propelled a lot faster - about 28mph along with the rest of the seminal fluid. Two minutes after entering the female, they’re at the cervix and five minutes later at the fallopian tubes. During the most fertile part of the female menstrual cycle (when the egg is released - usually between the 12th and 18th day), this journey is much easier because at this time there is plenty of fertile mucus around for the sperm to live off. They can - non-condom users may like to take a seat - survive like this for a week. The average ejaculation contains 200-300 million sperm, but it only takes one to fertilise the egg. (Just as well as only about 40 of them will get anywhere near the end of the race.) As well as fertilising the egg, the sperm contains the chromosomes which will determine the baby’s sex.

FAQS: SPERM ARE SPERM COUNTS FALLING? Probably. A systematic review of the research published in 2017 concluded that between 1973 and 2011, sperm counts in the West fell by over 50% (although this analysis is not without its critics). Plastics and other ‘everyday, everywhere’ chemicals appear to disrupt the hormones. These chemicals are better regulated in the EU than in the USA, but are still a concern. As with anything to do with the environment, old habits and vested economic interests means change is slow. For about one in three couples who are struggling to get pregnant, sperm is a factor. It’s not just about numbers, quality matters too. Are the little wrigglers mobile enough to reach and penetrate the egg? All of these can contribute to a poor sperm quality: > a structural problem - having blocked or missing tubes; > a hormone problem - low testosterone or Klinefelter’s syndrome, for example; > testicle problems - such as an undescended testicle as a baby, enlarged veins (varicoceles), previous surgery or simply the testicles having become too hot; > an infection - STIs (such as chlamydia or gonorrhoea) or prostatitis (an infection of the prostate gland); > drug abuse - such as alcohol, smoking, cannabis, cocaine and anabolic steroids; > treatment side-effects - testosterone-replacement therapy, chemotherapy for cancer, some antibiotics and some antidepressants;

> weight - a key factor, with the odds of infertility increasing by 10% for every 9 kg (20 pounds) a man is overweight. If you’re concerned about your fertility, don’t mess around with home sperm-testing kits or similar, get it done properly. See your GP. You can improve your fertility by exercising, eating a healthy diet, maintaining a healthy weight, and avoiding fags, drugs and too much booze. All good things which will improve your general health too. Keeping your balls cool may also help. The ideal temperature for sperm production is around 34ºC. This is 3ºC below normal body temperature (37ºC), which is the main reason your testicles are outside your body in the first place. Avoid hot tubs and laptops on the lap, for example; consider looser pants.

SHOULD I HAVE A VASECTOMY? A vasectomy is surgery in which the tubes carrying the sperm from the testicles to the seminal vessel are cut and heat sealed. As a result, when semen is ejaculated during sex, it contains no sperm. If you are sure you want no more children, a vasectomy is a 99.8% effective solution to unwanted pregnancy. But used properly, condoms are 98% effective. No surgery is without risk and some men - perhaps 10% have pain and other problems after vasectomies. Be aware that some men change their mind once in a new relationship and vasectomy reversal isn’t always successful. Remember too that a vasectomy does not prevent you from getting STIs, so you will need to use condoms with a new partner. Vasectomies are less common than they used to be. Partly it may be NHS cuts but partly men are less keen. Get advice and think it through.

FAQS: PEEING WHY DOES IT STING WHEN I PEE? This could be a mild urinary tract infection like cystitis or a sign of a prostate or kidney problem. It could also be a sign of a sexually-transmitted infection. If it persists, see your GP.

DO I PISS TOO OFTEN? Only you know what has been normal for you in the past and obviously, if you drink more, you will pee more but, as a very general rule of thumb, a man peeing 3-6 times a day and no more than once at night is doing OK. If you are peeing more often or have other symptoms such as pain, a slow start, a weak or intermittent flow, a trickly finish or a feeling that you haven’t finished when you have or you are peeing when you don’t intend to, then you should see your doctor. It may be a sign of something more serious like a prostate problem or diabetes.

TELL ME MORE ABOUT THE PROSTATE. The prostate is a small gland producing the thick, white fluid that gets mixed with sperm to create semen. It sits right next to the bladder. As we get older, it is normal for the prostate to grow, pushing on the bladder and causing peeing problems. All of these could be the sign of a prostate problem: > a weak flow when peeing > a flow which stops and starts

> having to wait before you start to go > having to pee more often than previously > a sudden urgent need to pee > peeing more often at night. An enlarged prostate doesn’t mean cancer. Often growth is benign. But you need to see your GP to check and get advice on the various treatments. Incontinence (peeing when you don’t want to) may also be a sign of prostate growth, but there are other causes too. See your GP.

WHY CAN’T I PEE IN PUBLIC? If you’ve ever been standing at a public urinal and found you couldn’t go, you’re not the only one. The condition even has a name: paruresis (also known as shy bladder syndrome). Paruresis is a social anxiety disorder which makes it difficult to pee in certain situations. It may just occur in urinals; it may happen whenever others are around, including at home. Talk to your GP who can rule out other causes like a prostate problem. Cognitive behavioural therapy (CBT) may help. For example, CBT is used in the workshops run by the UK Paruresis Trust. The Trust also have a website and forum.

“

Ken, age 60 I was always a bit worried about toilets and peeing. At pubs and clubs, any trouble would usually kick off in the bogs. I used to look for a cubicle. I suppose the final straw was when I was on a ferry and couldn’t go, not even in a cubicle. I went to see my GP. I saw a therapist. In the end, I plucked up the courage to go to a UK Paruresis Trust workshop. Absolutely liberating. If someone had told me that after the workshop I’d have been able to pee with someone standing next to me, I wouldn’t have believed them.

THERE’S BLOOD IN MY PEE Is it definitely blood? If you have not been drinking enough water, your urine can begin to look brown. Certain foods, like beetroot, or certain drugs can also make your urine change colour. A heavy work-out can cause the urine to look red. It’s not actually blood but, if it happens while you’re exercising or keeps happening, see your doctor. If it is blood, it could be a urinary tract infection or the sign of something such as a prostate problem. See your doctor and try to take a urine sample.

THE HOLE IN MY PENIS IS IN THE WRONG PLACE. If you’re not pissing out of the end of your penis, you may have undiagnosed hypospadias. It can be treated, improving both peeing and sexual function. Your GP can refer you to a specialist. Hypospadias is a congenital condition, which means you were born with it. The opening may be anywhere along the underside of the shaft or even at the root of the penis near the testicles. The usual estimate is that hypospadias affects about one in every 300 males but there is evidence that this is increasing. It usually runs in families. If a boy has hypospadias, his brothers have a one in twenty chance of also having it. The cause is unknown. Drug side-effects, hormones and, once again, man-made chemicals are all in the frame. Normally the penis develops in two halves, which fuse along the underside (this accounts for the line that runs along the underside of the penis from the scrotum to the end of the foreskin). This process is usually complete by the 15th week of gestation in the mother’s womb. If this process is interrupted, then hypospadias is the result. Infants with hypospadias should not be circumcised at birth because the foreskin is often used to provide tissue for the hypospadias repair. Severe hypospadias should have been noticed at birth and corrected by an operation at the age of 12-18 months. But babies with slight hypospadias do not always have an operation. However, even slight hypospadias can have physical and emotional consequences. Organisations like the Hypospadias UK Trust can provide support. In terms of sperm quality, a man with hypospadias has just as much chance of becoming a father as any other man.

FAQS: TESTICLES MY BALLS ARE DIFFERENT SIZES. We’re all like that. It’s 100% normal. It helps to stop them bashing into each other, thus avoiding that ‘kicked in the balls’ feeling. Often men find that the right testicle is slightly larger, while the left hangs lower.

SHOULD I CHECK MY BALLS FOR LUMPS? Try to be aware of the weight, shape and size of your balls. If you notice a lump or an enlargement or have a sense of heaviness in your balls, see your GP. Testicular cancer is the most common cancer in younger men, but remains rare. It can be treated very successfully if caught early on.

WHAT OTHER TESTICLE PROBLEMS ARE THERE? Infections are possible in the epididymis and they’re not always STIs. You could get a build-up of fluid in the testicles (hydrocele), usually caused by an injury. Or a varicose vein in the testicle (varicocele). The most painful potential problem is a torsion when the cord which connects the testicle to your body becomes twisted. It’s most common in teenagers. See a doctor promptly as the twisting can cut off the blood supply.

I’M WORRIED ABOUT MY TESTOSTERONE LEVELS. Testosterone is the most important of the male hormones. (The ovaries produce it in lower levels in women.) It is responsible for muscle, bone and

sexual development as well as sex drive. At puberty, it makes the voice drop and the penis, testicles and facial and pubic hair grow. In the prostate gland, testosterone is broken down into the related hormone dihydro-testosterone which appears to be involved in both baldness and enlarged prostate. Testosterone levels fall slightly from the age of about 40 - perhaps about 1% a year. This may be more noticeable in men who had higher levels to begin with. Even so, at the age of 70, while testosterone production may be 30% below its peak, testosterone levels remain within the normal range in at least 75% of men. Lower testosterone levels may lead to loss of muscle tone and bone strength, an increase in weight and the risk of heart disease and diabetes. Whether reduced testosterone is also the cause of the sluggishness, loss of libido and depression that some middle-aged men experience is debatable. Certainly, low testosterone is very rarely the cause of erectile dysfunction. A genuinely, functionally low level of testosterone is called hypogonadism. For these men, testosterone replacement therapy (TRT) in the form of gels, injections or tablets can be used but there are side-effects. TRT can increase the risk of prostate disease, heart disease, liver disease and breast enlargement. It also makes you infertile. As with all medical treatments, it’s about balancing the pros and cons but, for now, the wider use of TRT is unproven and not recommended. Don’t self-prescribe.

CAN I BOOST TESTOSTERONE LEVELS NATURALLY? Yes. First, get a good night’s sleep. Then, take more exercise and have more sex to get the hormones going. Being overweight reduces the amount of testosterone available to the body, so losing weight and cutting down on fatty foods and alcohol may also help. Your general health will also benefit from all this. Address any vitamin or mineral deficiencies, especially in zinc and magnesium. Eat more seeds (particularly pumpkin and sunflower seeds), dark leafy greens, shellfish, beans, yoghurt, fish and lean meat. Ginseng and stinging nettles are also reputed to help. You might also consider which football team you support. Testosterone surges are linked to combat. Research suggests testosterone levels increase in the fans of winning teams and decrease in the fans of losing teams.

WHAT NEXT? So, there you have it: the male tackle. Not a lot to worry about really. All the healthy stuff you already know about around food, drink and physical activity is also very good for your penis health. And if there is a problem, it can nearly always be sorted by talking about it to the right person. There’s more on our website, including useful links and the opportunity to ask a question: www.menshealthforum.org.uk/knob

OTHER MAN MANUALS Man MOT: The Man Manual: Man MOT for the Mind: Beat Stress, Feel Better: Serious Drinking: Diabetes For Men: Man To Man:

www.menshealthforum.org.uk/MOT www.menshealthforum.org.uk/MM www.menshealthforum.org.uk/MMM www.menshealthforum.org.uk/BSFB www.menshealthforum.org.uk/SD www.menshealthforum.org.uk/DFM www.menshealthforum.org.uk/MTM

Jim Pollard’s book ‘Men’s Health’ is available from Haynes. Haynes donate 25p per copy to the Men’s Health Forum: haynes.com/mens-health All rights reserved. You must not reproduce or transmit any part of this booklet in any form or in any way without written permission from the Men’s Health Forum. This includes photocopying or scanning it. The authors and the publisher have taken care to make sure that the advice given in this edition is correct at the time of publication. We advise you to read and understand the instructions and information included with all medicines and to carefully consider whether a treatment is worth taking. The authors and the publisher have no legal responsibility for the results of treatments, misuse or overuse of the remedies in this book or their level of success in individual cases. The author and the publisher do not intend this book to be used instead of advice from a medical practitioner, which you should always get for any symptom or illness.

SIZE ISN’T EVERYTHING Over the years, the Men’s Health Forum has probably been asked more questions about the male tackle than about every other health topic combined. Size Isn’t Everything: Penis Health Made Easy answers the most common questions. Whatever your age, the key message is not to struggle in silence. Read the booklet. Learn more. Get support. > Size and shape

> Masturbation

> Sperm

> Foreskins

> Sex

> Peeing

> Erections

> Ejaculation

> Testicles

This short, punchy, easy-to-read booklet written by Jim Pollard is full of simple, practical information that will improve the health of pretty much anyone who owns a penis. Straightto-the-point info I can actually use to take control of my health

WARNING: Reading this booklet could seriously improve your health. ISBN: 978-0-85761-032-4 (PDF version) www.menshealthforum.org.uk