The Role of the Primary Care Clinician in the Management of Erectile Dysfunction

OPTIMIZING THE MANAGEMENT OF ED The Role of the Primary Care Clinician in the Management of Erectile Dysfunction Richard Sadovsky, MD Department of Family Practice, State University of New York–Brooklyn Health Sciences Center, Brooklyn, NY Although many medical problems commonly seen in the primary care clinician’s office are associated with ED, the majority of men do not discuss sexual difficulties and activities with their clinician. Patients are, however, appreciative of the clinician’s willingness to listen and initiate discussions. Often a new level of patient-doctor relationship is thereby reached, which provides for comanagement of sexual and other disorders. The acronym “ALLOW" defines a 5-step proactive management plan for the primary care clinician to follow in order to improve his or her flexibility and sensitivity of response to the patient’s ED; at the same time, “ALLOW" helps the clinician to recognize possible limitations in managing sexual health problems. More overall communication has been related to greater patient satisfaction, which in turn results in patients who are more involved in following through on their care, who have increased confidence in their clinician, and who continue to see one physician for their health care needs. [Rev Urol. 2002;4(suppl 3):S54–S63] © 2002 MedReviews, LLC Key words: Primary care clinician • Erectile dysfunction • Sexual health • Sex therapy rimary care clinicians are the first point of contact with the health care system for many people. The nature of this care may be episodic or involve only a single visit initiated to meet a specific need; but usually the primary care clinician provides continuous and comprehensive care for patients, using a biopsychosocial model. This care often involves learning more about a patient than only their chief complaints and most superficial needs. Sometimes, it even sounds as if primary care clinicians are expected to do everything! The health care giver role is often expanded to that of advisor, social worker, advocate through the health care system, religious counselor, confidant, P S54 VOL. 4 SUPPL. 3 2002 REVIEWS IN UROLOGY Role of the PCP in Management of ED Table 1 Factors Affecting a Primary Care Clinician’s Priorities • Problems with high morbidity and mortality • Disabling conditions • Standards of care and guidelines • Patient demands • Personal areas of interest of the clinician • Quality-of-life issues and, of course, trusted clinician. This care is provided by a variety of health care givers that includes nurse practitioners, physicians' assistants, family physicians, internists, and gynecologists. The approaches may vary, and the scope of inquiry and treatment may depend on local law and care standards in various communities. The values and roles of individual practitioners are also complex, because they may depend on the individual clinician's value system and practice model.1 However, the priorities in determining what issues will be addressed during a visit or a course of care are generally similar for all primary care clinicians (Table 1). Most primary care clinicians will first address problems with high morbidity and mortality, disabling conditions, and conditions for which there are clear standards of care and perhaps well-established management guidelines. The demands of their patient and the personal interest of the clinician will also affect the issues that the clinician addresses. Generally, issues that involve quality of life fall into a lower-priority category. This is perhaps so because patients may not feel that they are important, or because the clinician does not consider improving quality of life to be a high priority. This is especially true when the quality-oflife issue involves more personal problems and more difficult language. of men with ED still do not initiate the discussion of sexual difficulties. They fear their own, or the physician’s, embarrassment, or that their concerns will not be taken seriously.2 Discussing Sex in the Office Both patients and clinicians have difficulty bringing up sexual matters. Until now, clinicians have been asking patients about sexual partners and sexual practices in order to screen for the risk of sexually transmitted diseases, including human immunodeficiency virus infection and hepatitis B and C. Now, by routinely asking male patients about erectile dysfunction (ED), the potential to improve the patient’s sexual life, self-esteem, and relationships can be optimized. Recent publicity about male sexual health and the availability of an oral medication to improve erectile function have made discussions about sexual activities somewhat more common between clinicians and their male patients, but the majority Barriers to Men Seeking Support for Sexual Health Men are often hesitant to discuss sexual problems with their clinicians and, in fact, consult family physicians for health-related problems less frequently than women do. This reduces men’s chances of recognizing and treating their disease and results in their receiving less preventive care, screening, and tests.3 Counseling rates for sensitive topics such as sexual health and emotional well-being are especially low in men.3 Research on help-seeking behavior in men has revealed that their pattern of seeking support tends to be indirect rather than straightforward and that personal barriers to bringing health concerns to a physician include a Table 2 Men’s Misconceptions About Erectile Dysfunction • Matters relating to sexual dysfunction are taboo. • Loss of erection is not a common problem, and their problem is unique. • Erectile dysfunction is a normal part of aging. • Inability to achieve erections is primarily a psychological problem and not a physical one. • Treatment options are generally lacking or are too invasive and risky to be pursued. • An erection is necessary to have sex. • An erection is indicative of sexual desire. • Erections should occur instantly, all the time. • Erections should get hard and stay hard until ejaculation • Erections are necessary to ejaculate. • Women like a large erection. • An erection occurs only once during a sexual attempt. • Losing an erection one time signifies impotence. • Firm erections are essential in a relationship. Sources: Burnett5; Weeks and Gambescia,6 pp 10–12. VOL. 4 SUPPL. 3 2002 REVIEWS IN UROLOGY S55 Role of the PCP in Management of ED continued sense of immunity, difficulty in relinquishing control, and a belief that seeking help is unacceptable.4 Other barriers identified include time and access, having to state a reason for a visit, and not having a male care provider.4 Clinicians often have a perception that men are less interested in prevention. All these factors, as well as misconceptions about ED, mitigate against the easy revelation of ED in the physician’s office (Table 2).5,6 David R. Sandman, co-author of the Commonwealth Study, “Out of Touch: American Men and the Health Care System," said, “Physicians can be more attuned to the special health concerns of their male patients and be more proactive in initiating communication."3 Although discussing ED may be embarrassing and difficult for the patient, most men are willing to discuss their sexual function with is present in as few as 2% of generalist clinicians’ notes.9 Clinicians may be concerned that ED will become a complex, time-consuming condition that cannot be managed properly under the pressures of current reimbursement methods, or they may feel that they will not be adequately reimbursed for their effort and time.10 Table 3 Risk Factors For Erectile Dysfunction ■ Vascular disease (hypertension, diabetes, hyperlipidemia) Renal failure Liver disease The Association Between ED and Common Health Problems Is a Good Reason for Primary Care Involvement It is estimated that 20–30 million men in the United States suffer from erection problems, but only 5%–10% actually seek treatment. The Massachusetts Male Aging Study demonstrated a 39% prevalence of ED among men between the ages of 40 and 50, 46% between the ages of 50 and 60, and almost 70% in men over Organic Multiple sclerosis Spinal cord injuries Substance abuse, including cigarette smoking Decreased androgen production Abnormal thyroid function Anemia Penile anomalies or disease (Peyronie's disease) ■ Psychogenic Anxiety or depressive disorder Concern about poor sexual function It is an unfortunate fact that, as surveys show, books, not health professionals, are the number one source of sex information reported by people age 45 and older. Previous traumatic sexual experience ■ primary care clinicians. It is an unfortunate fact that, as surveys show, books, not health professionals, are the number one source of sex information reported by people age 45 and older.7 Barriers to Clinicians Giving Support for Sexual Health Clinicians also avoid discussing sexual concerns, even when a problem is suspected, citing lack of knowledge and skills as a common reason.8 Although over 70% of adult patients in a large sample considered sexual matters to be an appropriate topic for the generalist clinician to discuss, and the rate of sexual dysfunction is estimated to be 35% for adult men and 42% for adult women, evidence of discussion about sexual problems S56 VOL. 4 SUPPL. 3 2002 age 70.11 The percentage of men with moderate and severe ED and those unable to have satisfactory sexual relations, increases as men progress from 40 to 70 years of age. Although associated with age, ED is not, however, an inevitable result of aging. Healthy men often continue to have satisfactory erectile function throughout their lifetimes. Many medical problems commonly seen in the primary care clinician’s office are associated with ED (Table 3). For example, vascular disease, especially with hyperlipidemia, diabetes, and hypertension, is associated with ED. The combination of these conditions with aging increases the ED risk in older men. This association of ED with common neurologic and vascular pathology encourages using the pres- REVIEWS IN UROLOGY Iatrogenic Certain medications (antiandrogens, antidepressants, diuretics, -blockers, digoxin) Pelvic surgery Prostate surgery Vascular bypass surgery ence and degree of ED as a “screening test" for these disorders when they have not already been recognized. Other hormonal and metabolic problems, including primary or secondary hypogonadism, hypothyroidism, chronic renal failure, and hepatic failure, also negatively impact on erectile function. The abuse of substances such as alcohol or other “recreational" drugs is a major contributor to dysfunction. Smoking, a known cause of arterio-occlusive Role of the PCP in Management of ED Table 4 Reasons Why Primary Care Clinicians Should Ask Questions About Sex • It provides an opportunity to give advice about prevention of sexually transmitted diseases. • Disrupted sexual function may be a symptom of disease or a side effect of treatment. • Past sexual history may help explain the present condition. • Sexual issues are important at all stages of the life cycle. • Sexual dysfunctions are common. • Sexual function is related to good health. Source: Maurice,14 pp 16–17. disease, is clearly a cofactor and is probably an independent etiologic factor itself. Psychogenic disorders— for example, depression, dysphoria, and anxiety states—have an increased incidence of multiple sexual dysfunctions, including erectile difficulties. Iatrogenic ED can be caused by nerve-disrupting pelvic or prostate surgery, inadequate glycemic, blood pressure, or lipid control, as well as by many of the medications commonly used in primary care.12,13 Antihypertensives, notably diuretics and central-acting agents, can cause ED, as can digoxin, psychopharmacologic agents, and antitestosterone hormonal agents (such as leuprolide). More Primary Care Clinicians Are Interested in Managing Sexual Issues Recent years have seen a change in attitude among clinicians and society in general regarding discussions about sexual activity. Primary care clinicians should be greatly motivated to inquire about a patient’s sexual activity (Table 4).14 Experiencing a sexual dysfunction is highly associated with a number of unsatisfying personal experiences and relationships. Men with ED demonstrate a diminished quality of life when measured as low physical satisfaction, low emotional satisfaction, and low levels of general happiness.15 Reports of low self-esteem and relationship difficulties indicate the effect of ED on function and on satisfaction with daily-life activities. There are also some preliminary reports that sexual dysfunction can contribute to the initiation of clinical anxiety and depression syndromes. Successful treatment of ED in men who were also known to be depressed clinically has been shown to improve depressive symptoms and quality of life.16 Intimate relationships appear to be important factors in maintaining health.17 Warm relationships and emotional support have been associated with a decreased rate of midlife diseases, a lower rate of mortality within 6 months following an acute myocardial infarction, and an improved ability to resist infection by regulation of the immune system.18–20 The significance of proximity, security, and love demonstrates the fact that intimacy can be thought of as a basic need. Sexual thoughts, sexual feelings, and sexual desire persist into advanced age for most individuals, and ED has been found to interfere with quality of life, possibly leading to depression, poor self-image, and poor self-esteem.21,22 Healthy relationships can be encouraged by many factors, including good communication, personal awareness, sharing, loving, and good sex.23 The more that clinicians learn about the importance of satisfactory sexual activity—and adequate erections in particular—the more they find that ED looks like a condition with real morbidity. This should raise the priority level of management of ED in the clinician’s office. Primary care clinicians are recognizing that 1) the longitudinal and personal relationship they have with the patient is an asset in discussing and resolving sexual problems; 2) the multifactorial issues around ED are appropriately evaluable by the patient’s clinician; and 3) the long-term follow-up in order to be certain that a sexual dysfunction is resolved is well suited to primary care. Screening for ED Screening male patients for ED is valuable in order to minimize the morbidity of ED. For screening to be useful it must 1) utilize a tool that is reliable; 2) achieve early identification so as to enhance the likelihood of resolution; and 3) provide a yield that is higher in value than its costs. Because the yield of screening is related to the frequency of ED in the population, men who should be screened are those over 40 years of age, those with a predisposing comorbidity, such as cardiovascular disease, diabetes, or depression, or anyone who the clinician feels may be having difficulty with physical intimacy. A man with vague somatic complaints may be in the office because of a sexual problem. As men often avoid routine visits, sex may be the motivator and actual reason for the visit. A partner may be the initial source of information about a man’s ED because many men hesitate to bring problems to the doctor’s attention. Patients with sexual con- VOL. 4 SUPPL. 3 2002 REVIEWS IN UROLOGY S57 Role of the PCP in Management of ED continued Table 5 Techniques for Discussing Sexual Matters ■ Your approach sets the tone Take the initiative Use language that is simple and direct Maintain a sense of privacy and confidentiality Keep your attitude nonjudgmental, caring, and respectful Provide explanations and allow for questions Acknowledge and explore the patient’s responses ■ Promote an optimistic attitude cerns report feeling most comfortable discussing these issues with their family clinician and expect to receive advice and treatment.24 one or more questions about sexual activity in a printed history form that is completed by the patient elicits more active participation from the patient by requiring his willingness to document that a problem exists. A truly active approach is probably the most efficient technique for initiating discussions about sexual activity (Tables 5 and 6). Clinicians can develop ease with one or more of these more active inquiry techniques and incorporate them into discussions with patients.25 The main purpose of the question is to give the patient an opportunity to discuss sexual matters in a nonthreatening manner. A word about the confidentiality of the information being discussed is often helpful. Communication is enhanced by placing the sexual history in an appropriate context during the historytaking, for example, when the social history is discussed or a review of systems is performed. Questions about sexuality need to Asking About Sexual Activity Incorporating screening into the primary care practice becomes easier when the clinician adopts a policy of briefly asking questions about sexual activity with all patients. Making a habit of asking these questions decreases anxiety, encourages the “routinization" of sex discussions, thereby reducing possible embarrassment, and makes screening for sexual dysfunction more efficient. Patients will feel that sexual concerns can be raised at any time. The introduction of sexual activity as a legitimate topic for conversation with patients can be done passively or actively. A passive approach would be to leave pamphlets about sexrelated topics or self-evaluation material, such as the Sexual Health Inventory for Men, in the waiting room or to hang educational posters in patient-care areas. Inclusion of S58 VOL. 4 SUPPL. 3 2002 REVIEWS IN UROLOGY be sensitive to cultural, religious, and educational differences. Using terminology that is clear, simple, and respectful of the patient’s feelings can facilitate communication. Using synonyms such as “getting hard" or “coming" may help the patient better understand questions about erections. Encouraging a patient’s response with “facilitating" gestures such as good eye contact, nodding affirmatively, or summing up what the patient has told you are all helpful. Asking sexual partners about each other’s sexual function is often very useful. Women ranked “partner sexual difficulties" as a common sexual concern.26 If both members of a couple are in the office, it becomes easy to introduce the topic by asking, “How are you two doing together? ... How are you doing with sex?" If only one member of a couple is available, questions can still be asked about the present patient as well as the partner. When a sexual dysfunction is identi- Table 6 Questions to Initiate Discussions About Sexual Activity ■ Open-ended questions “So, how are you doing with sex lately?" “Are you satisfied with your sexual activity?" “Rate your recent sexual activity on a scale of 1–10." (Follow-up with, “What would make it a 10?)* *L. Kuritsky, personal communication, October 28, 2001. ■ Permission-giving questions “Many of my male patients your age have noticed some change in their sexual function. How about you?" “Many men with diabetes note some problems getting an erection. Are you noticing anything different?" ■ Asking the partner “How has sex been lately?" “How has _____ been functioning?" ■ Asking men with chronic illnesses “How has your illness affected your sex life?" Role of the PCP in Management of ED fied, talking to the partner can reveal a different picture that may substantially affect management, and the discussion can have a therapeutic effect in itself.27 The Next Step After Identifying ED The primary care clinician who identifies the patient with ED has accomplished much. This information can be used to 1) refer the patient to an appropriate clinician; 2) open up further discussion to confirm whether or not ED is the primary sexual problem or whether it is secondary to a difficulty with some other phase of the male sexual cycle, such as libido or ejaculation; and/or 3) work with the patient on a management plan. “ALLOW" The primary care clinician’s flexibility of response to the patient’s ED is described by the acronym “ALLOW" (Figure 1). ALLOW defines a management plan that acknowledges the need for all primary care clinicians to inquire about sexual activity while recognizing the limitations and varied interest of many clinicians in actually managing problems. Step 1 of ALLOW involves “Asking" the patient about sexual activity. There are many ways to ask, and some have been identified above. Step 2 includes “Legitimizing" the patient’s problems and acknowledging that sexual dysfunction is an important issue. An initial impression that the problem is being dismissed can considerably delay or prevent a patient from seeking further help.28 Step 3, “Limitations," invites the clinician to evaluate his or her own interest and ability to work with patients who report a sexual problem. Based on this self-evaluation, the clinician takes the next step, and the clinician has now done “ALL" for the patient. Step 4 can then be a referral to an appropriate subspecialist to further investigate and treat the patient’s sexual issues, or the primary care clinician can “Open up the issues for further discussion” and diagnostic evaluation. Step Figure 1. “ALLOW" your patient to discuss sexual dysfunction: a management plan Step 1. A—Ask Step 2. L—Legitimize Step 3. L—Limitations Step 4. O—Open up for further discussion Step 5. Refer W—Work together to develop a treatment plan 5 involves “Working with the patient to identify an appropriate goal and a mutually acceptable treatment.” Optimism is an essential dialog enhancer as well as management tool for clinicians to use in responding to sex issues. Patients often seek help after the problem has been around for a long time, and they need encouragement to discuss it and encouragement to believe that it can be resolved. Management Options The evaluation and treatment of men with ED are discussed in other articles in this supplement. Specific treatment regimens for ED are varied, ranging from oral medications, transurethral suppositories, intracavernosal injection, vacuum devices, and surgery. Treatment plans need to be goal-oriented and ideally aimed at satisfying the needs of both the man and his partner. The treatment options remain the same regardless of the etiology of the ED and are prescribed to provide satisfactory erections to virtually every man who desires them. Optimal results require counseling and emotional support from the clinician, often actively involving the partner. Involving Partners Partner issues vary widely. Patients may be having sex with one partner, multiple partners, partners of the opposite sex, partners of the same sex, or both. Issues around partner choice, partner participation in sexual activity, and partner physiology may impact on erectile function. In some situations, the postmenopausal partner of the man with ED may have vaginal dryness caused by estrogen changes. Vaginal dryness can also result from diabetes or medication side effects. The woman and her partner can misinterpret the loss of lubrication as a sign of her diminished VOL. 4 SUPPL. 3 2002 REVIEWS IN UROLOGY S59 Role of the PCP in Management of ED continued Table 7 Principles of Basic Sex Therapy for the Primary Care Clinician ■ Content Reduce performance anxiety Improve communication between partners Educate about sex and dysfunction (verbal or bibliotherapy) Dispel sexual myths ■ Techniques Use cognitive therapy—change negative thoughts to positive thoughts Ask specific questions Create a sexual environment Develop sexual skills Encourage sensate focus exercises Increase awareness of sexual feelings Help patients to learn to lose and regain an erection and make the transition to intercourse Integrate medical and psychological treatments Sources: Weeks and Gambescia,6 pp 119–43; Rosen.29 interest. When vaginal dryness or vaginal atrophy leads to pain, women quickly lose interest in continued sexual activity. The use of topical lubricants or estrogen replacement therapy for the woman may be essential to be physiologically prepared for the increased sexual activity. Encouraging Relationships Relationship factors often play a role in ED. Early in relationships, partners try to please and be sensitive to one another. As time goes by, these efforts may be abandoned, and sex becomes perfunctory in both form and function. Clinicians can encourage couples to renew intimacy and sensuality in the relationship and to extend foreplay for each other. Communication difficulties within the relationship can often inhibit satisfactory sex. Criticism is often easier than frank discussion. S60 VOL. 4 SUPPL. 3 2002 It is important for the clinician to encourage partners to give each other positive and constructive feedback on sexual preferences (M. Dunn, personal communication, September 22, 1999). A partner might say, “I really enjoy it when you touch me lightly" or, “It really feels great when you do that." If people are shy, they can make sounds of pleasure to cue to the partner that what they are doing feels really good. Much can go wrong during sexual activity. Arousal may be delayed, the positions may be awkward, the desired response may not be achieved, and interruptions occur. If people are light-hearted, they are more likely to say, “It’s an off night, let’s try again tomorrow," rather than let the one less successful encounter inhibit future contacts. Other principles of basic sex therapy that can be incorporated into primary care practice are noted in Table 7.6,29 REVIEWS IN UROLOGY Making Lifestyle Changes Making healthy lifestyle changes can decrease the likelihood of the ED becoming worse and improve general physical health (Table 8). Patients need to understand that what is bad for the heart and the peripheral vascular system or the nervous system is also bad for the penis. Elimination of smoking tobacco is critical, as may be elimination of all other recreational drug use. The occurrence of ED in the smoking patient provides an opportune “teaching moment" to discuss the value of smoking cessation, and the potential to improve erectile function is a strong motivator for many patients. Dietary changes, including reducing cholesterol and fats, eliminating hyperglycemia when present, and decreasing salt intake when salt-sensitive hypertension is noted, all help to reduce the progression of vascular insufficiency. Exercise can increase cardiac output and improve peripheral circulation. Moderate exercise for sedentary middle-aged and older adults may minimize the small increase in relative risk of a myocardial infarction after sex noted in this population.30,31 Table 8 Lifestyle Counseling for Patients with Erectile Dysfunction • Stop smoking and/or substance abuse (including alcohol) • Reduce fat and cholesterol in diet • Exercise • Improve compliance with cardiovascular and diabetes medications • Reduce stress • Increase optimism about the potential resolution of erectile dysfunction Role of the PCP in Management of ED Adjusting Medications Changing medication regimens to remove causative agents can be tried when good alternatives are available and the clinical situation permits pharmacologic adjustments. Substituting an  adrenergic blocking agent for a thiazide or -blocking agent, weaning progress. Comparisons with baseline can be done by interview or by using the standardized, 5-item questionnaire, the Sexual Health Inventory for Men, which measures erectile function. Additional patient issues or problems can be addressed, as can the need for dosage titration for A trusting partnership enhances the likelihood of a successful therapeutic outcome. the patient from digoxin if the medication is not really necessary or lowering the dosage, or substituting bupropion, an antidepressant with minimal effect on sexual function for a tricyclic or selective serotonin reuptake inhibitor, may meet with some success. Changes in medications need to be individualized, depending on specific clinical circumstances. Follow-up Is an Essential Part of Management of Erectile Dysfunction If the clinician reviews the success or lack of success of treatment, any adverse effects, and dosage or treatment alterations, the patient is more likely to achieve his goal. Patients should be seen 1 month after the initiation of treatment to evaluate their patients receiving pharmacologic therapy. A trusting partnership enhances the likelihood of a successful therapeutic outcome. Consultation with subspecialists may be appropriate at varying intervals when the primary care clinician is managing a man with ED. The the primary care clinician who has good communication skills about sexual activity and is knowledgeable about first-line treatments. Urologists can be helpful in treating difficult or complex ED conditions or when the patient presents with anatomical problems such as Peyronie’s disease. An endocrinologist may be consulted to assist in managing men with difficultto-control diabetes, hypogonadism, or evidence of pituitary dysfunction. Sex therapists are practitioners in the medical or mental health field who, in addition to their basic clinical education, have had training in sex therapy, including evaluation and treatment options. Men with sexual dysfunction can learn techniques to have more satisfactory sex, even if their erections do not meet their expectations. The American The obligation of the primary care clinician is to recognize ED and make the patient feel comfortable about seeking help. major factor is the clinician’s comfort in discussing and managing treatment options. The obligation of the primary care clinician is to recognize ED and make the patient feel comfortable about seeking help. The initial workup and treatment can be planned by Association of Sex Educators, Counselors, and Therapists (telephone number: 319-895-8407) can provide a directory of trained, certified sex therapists in your state. Most major teaching hospitals have such a trained individual on their staffs. Main Points • By routinely asking male patients about erectile dysfunction (ED), the primary care clinician has the potential to optimize the patient’s sexual health, quality of life, self-esteem, and relationships. • The majority of men do not discuss sexual difficulties with their primary care clinician, which reduces their chances of receiving preventive care, screening, and tests, and recognizing and treating their disease. • Many medical problems commonly seen in the primary care clinician’s office are associated with ED, and the presence and degree of ED can be a “screening test" for these disorders. • The primary care clinician’s flexibility and sensitivity in responding to a patient’s ED is described by the acronym “ALLOW," which denotes a 5-step plan that enables the clinician to manage sexual issues while recognizing his or her limitations. Treatment plans need to be goal-oriented and aimed at satisfying the patient and his partner. • Recognizing and acknowledging a patient’s concerns about sexual dysfunction may have the benefit of increasing the patient’s satisfaction with his care and strengthening the doctor-patient relationship. VOL. 4 SUPPL. 3 2002 REVIEWS IN UROLOGY S61 Role of the PCP in Management of ED continued Identifying and Managing Sexual Problems Can Enhance a Practice A major way for the clinician to build a relationship is through the questions and answers that occur during the initial discussion and evaluation stage of the patient’s visit. Because at least 30% of men and 40% of women over age 18 have been estimated to be dissatisfied with sexual activity, sensitive inquires by the clinician, as well as follow-up discussions customized to a specific patient’s problem, will enhance communication and relationship between the clinician and patient. Patients are very appreciative of the clinician’s willingness to listen, and often a new level of patient-clinician relationship is reached in which conversation flows more easily and trust allows an enhanced comanagement of other clinical problems. This “affiliative" communication style, which includes friendliness, interest, empathy, a nonjudgmental attitude, and a social orientation, is associated with significantly higher patient satisfaction.32 More overall communication, including social conversation and partnership building, has also been related to greater patient satisfaction.33 Discussing sexual matters can add a sense of informality and, occasionally, humor into the clinical discussion, helping to level the relationship between clinician and patient and create patient value by solving the individual patient’s problems. Value is even more enhanced when the hassle of obtaining the solution is minimized for the patient because the clinician has initiated the discussion. Patients with emotional distress that has been recognized by the clinician report stronger relationships with their clinician than do patients whose emotional distress was not S62 VOL. 4 SUPPL. 3 2002 diagnosed.34 Therefore, although paying attention to patients’ concerns about sexual dysfunction may divert some time and energy away from other areas of medical attention, it may have the benefit of strengthening the doctor-patient relationship and increasing the patient’s satisfaction with his care. Patient satisfaction can result in 1) patients who follow instructions for care more carefully; 2) patients with increased confidence in and loyalty to the physician, resulting in word-of-mouth endorsements and increased referrals; 3) patients who pay their bills promptly; and 4) patients who continue to see one physician for their health care needs. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. REVIEWS IN UROLOGY Lamberts H, Hofmans-Okkes I. Values and roles in primary care. 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Sexual dysfunction in primary medical care: prevalence, characteristics and detection by the general practitioner. J Pub Health Med. 1997;19:387–391. Becker BL. Streamlined office management. Article consultant: Baum N. Patient Care. 1999;33(Supplement Spring):17–21. Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinley JB. Impotence and its medical and psychological correlates: results of the Massachusetts Male Aging Study. J Urol. 1994,151:54–61. Shabsigh R. Is a drug effect part of your patient's complaint of impotence? Contemp Urol. 1993,5:51–58. 13. Finger WW, Lung M, Stagle MA. Medications that may contribute to sexual disorders. J Fam Pract. 1997;44:33–43. 14. Maurice WL. Sexual Medicine in Primary Care. St Louis, MO: Mosby; 1999. 15. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States; prevalence and predictors. JAMA. 1999;281:537–544. 16. Seidman SN, Roose SP, Menza MA, et al. Treatment of erectile dysfunction in men with depressive symptoms: results of a placebo-controlled trial with sildenafil citrate. Am J Psychiatry. 2001;158:1628–1630. 17. Berkman LF. The role of social relations in health promotion. Psychosom Med. 1995:57;245–254. 18. Russek LG, Schwartz GE. Feelings of parental caring predict health status in midlife: a 35year follow-up of the Harvard Mastery of Stress Study. J Behav Med. 1997;20:1–13. 19. Berkman LF, Leo-Summers L, Horwitz RI. Emotional support and survival after myocardial infarction: a prospective, population-based study of the elderly. Ann Intern Med. 1992;117:1003–1009. 20. Cohen S, Doyle WJ, Skoner DP, Rabin BS, Gwaltney JM Jr. Social ties and susceptibility to the common cold. JAMA. 1997,277;1940–1944. 21. Althof S. Intimate relationships: a vital component of health. The Pfizer Journal. 2000;4:9. 22. Urological Sciences Research Foundation. Half of older Americans report they are sexually active. 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Dr. Sadovsky responded that he had been asked that question in the past, and he guessed that the preferred answer would be, “We asked the patient 2 months later, and they’re having better erections." The reality is that, unfortunately, the patient usually never brings it up again. “So, I guess," Dr. Sadovsky continued, “the bottom line of what we’d like when we send the patient to the urologist, is really not to hear about it again, because the patient’s problem has been resolved." Dr. Sadovsky went on to tell of a urologist in his community who sends back consultations about erectile dysfunction to Dr. Sadovsky’s office. That urologist not only writes what he’s done and his success, but he stamps “Confidential" on the back of the envelope, where the envelope gets glued. That urologist now gets every one of Dr. Sadovsky’s group’s difficult patients, because the urologist recognizes the importance of this issue, and is hinting that the office clerical staff shouldn’t open the mail. Dr. Steers was eager to move the discussion to the issue of laboratory testing of testosterone levels. He commented on the striking number of men for whom bioavailable levels of testosterone are low, and surmised that physicians should probably be treating more than they actually are. Dr. Sadovsky responded that clinicians should only do a test if the test is going to affect the clinician’s behavior. If somebody is going to urge the physician to do a fasting testosterone test, they should also show what the guidelines are, and how to respond to certain results. The problem, Dr. Carson offered, is that there is no established threshold. Obviously, everybody would treat 170 ng/dL testosterone. But what about a 325 ng/dL testosterone, obtained at 9 AM in a 45-year-old man with ED? The American Association of Clinical Endocrinologists has guidelines for this, which have been recently updated, but the guidelines are still unclear. We do know, Dr. Carson said, that an important marker for patients with ED is their testosterone. The physician can impact the life of some of these patients, and not only those with ED, but also those with cog- nitive problems, low muscle mass, etc, simply by replacing their testosterone. Dr. Sadovsky had this question: What do you tell the physician who, after hearing in a lecture that everyone should test men with ED for testosterone levels, counters that he did a testosterone test and it was borderline low? Dr. Carson’s response was, refer them. Repeat the test, and refer them, either to a urologist or an endocrinologist, but to somebody who has an interest in that area of medicine. Dr. Sadovsky agreed and wished, for the purpose of this meeting, there could be an agreement that testosterone tests should be part of the mandatory patient workup, which is not always what is advised when lectures are given. Dr. Steers commented that most urologists get serum testosterone levels measured. Dr. McCullough raised the point that, for the patient who has a normal testosterone, adding more testosterone is not going to improve his erectile function. Dr. Carson added that even for the man with low testosterone, function may not improve, or may take longer than expected, because the ultimate time to improvement of any of the symptoms of androgen deficiency is more than 90 days. VOL. 4 SUPPL. 3 2002 REVIEWS IN UROLOGY S63