Asking the Questions and Offering Solutions: The Ongoing Dialogue Between the Primary Care Physician and the Patient With Erectile Dysfunction

TREATING ERECTILE DYSFUNCTION Asking the Questions and Offering Solutions: The Ongoing Dialogue Between the Primary Care Physician and the Patient With Erectile Dysfunction Richard Sadovsky, MD SUNY-Downstate Medical Center, Brooklyn, NY Primary care physicians are becoming more involved in inquiry about and management of erectile dysfunction (ED). This relatively new occurrence is appropriate considering that the presence of ED may signal potentially serious medical conditions and that ED is a condition with true morbidity. Addressing sexual issues in the office setting requires a comforting and secure atmosphere in which patients can easily discuss their problems. Because many men are hesitant to approach physicians with their sexual problems, clinicians need to be proactive by asking direct questions, either verbally or in a written history format. The clinician who learns of a patient’s ED should acknowledge it as a legitimate problem and either work with the patient on a management plan or refer him to a physician more prepared to successfully manage the condition. Clinicians who choose to treat men with ED can achieve higher success rates by including the partner in the discussions and treatment planning and by offering some basic sex counseling. These efforts require additional learning on the part of the clinician, but the rewards of managing sexual dysfunction include happier and healthier patients and improved patient-partner relationships. [Rev Urol. 2003;5(suppl 7):S35-S48] © 2003 MedReviews, LLC Key words: Impotence • Erectile dysfunction • Sexual health • Sex counseling • Sexual history • Men’s health rimary health care for adults is provided by a variety of clinicians, including nurse practitioners, physicians’ assistants, family physicians, internists, and gynecologists. Most primary care physicians will routinely address disorders associated with high morbidity and mortality, disabling conditions, conditions for which there are clear standards of care and, perhaps, those with well-established P VOL. 5 SUPPL. 7 2003 REVIEWS IN UROLOGY S35 ED Questions and Solutions continued management guidelines. The demands of the patient and the personal interest of the clinician will also affect the issues that the clinician chooses to address. Issues that involve quality of life have traditionally fallen into a slightly lower-priority category. Patients may not feel that these issues are important, or clinicians may not recognize “improving quality of life" as help patients with sexual dysfunction should be high. Several factors make primary care the ideal setting for discussions about sexual issues. First, longitudinal and personal relationships with patients are assets in discussing and resolving sexual problems; second, the multifactorial issues surrounding ED are appropriately evaluable by the patient’s clinician; and third, the Men with ED often experience a variety of psychosocial stresses, including a loss of self-esteem, anger, and a diminished sense of masculinity and health status. being a high priority. This is especially true when the quality-of-life issue involves highly personal matters and more difficult language. Social taboos about discussing sex or considering sex a legitimate personal need also hinder communication about sexual dysfunction. Clinicians avoid discussing sexual concerns even when a problem is suspected, commonly citing lack of knowledge and skills as a reason. They may be concerned that a sexual dysfunction like erectile dysfunction (ED) will become a complex, time-consuming condition that cannot be managed properly under pressures of current reimbursement methods. Recent years have seen a change in attitudes about sexual health among clinicians and in society in general. General sexual dissatisfaction is highly prevalent among men, with 75% noting at least 1 problem with dissatisfaction, avoidance, infrequency, or lack of communication.1 Specific sexual dysfunction is also prevalent, reported in approximately one third of men older than 18 years; premature ejaculation is the most common sexual dysfunction reported by men, followed by ED.1,2 The motivation for primary care physicians to S36 VOL. 5 SUPPL. 7 2003 long-term follow-up needed to ensure that a sexual dysfunction is resolved is well suited to primary care. Most insurance carriers provide reimbursement for evaluation of ED, although patients should understand that there may be some limitations on payments for testing and treatment. Careful documentation of the need for tests will help ensure fair reimbursement. In general, reimbursement is more likely if the sexual dysfunction occurs secondary to an organic condition, such as diabetes, cardiovascular disease, or pelvic trauma. ED: More Than Just a Quality-of-Life Issue It is well documented that men with ED often experience a variety of psychosocial stresses, including a loss of self-esteem, anger, and a diminished sense of masculinity and health status. These issues have a marked effect on quality of life: men with ED record lower scores on standardized quality-of-life scales than a matched set of men without ED.3 Recently, however, ED has been found to be relevant to more than quality-of-life factors.4 As documented by Andrew McCullough, MD, and Gregory A. Broderick, MD, in their REVIEWS IN UROLOGY respective articles in this supplement, ED is likely to be a reliable marker of systemic vascular disease and endothelial dysfunction. This makes inquiry about ED in the primary care office a useful tool to identify at-risk patients with vascular disease that may not yet have become manifest by other symptoms or signs. ED may even be the first recognized evidence of the presence of vascular risk factors such as hypertension, hyperlipidemia, or diabetes. Further research is suggesting that the degree of ED severity is related to the degree of systemic vascular disease. Men with depression have been noted to have a higher incidence of ED than age-matched controls. Although the relationship between these 2 disorders is unclear, evidence is accumulating that concomitant treatment of both depression and ED in men with both disorders will improve depression scale scores to a greater extent than simply treating the depression and ignoring the ED.5 We are also learning that being part of a good relationship is not only a quality-of-life issue but can also promote good health. The popular idea that loving, supportive relationships can make you healthier, as often reported in the lay press, has been supported by clinical studies. The breakdown of a significant personal relationship is one of the most stressful life events and impacts general health, as well as quality of life. Although sex is not essential for supportive, healthy relationships, the amount of sexual intimacy in loving relationships has been correlated with relationship satisfaction.6 ED has been shown to negatively impact relationships, with one survey of men with ED noting that 80% of respondents indicated some form of relationship difficulty because of their ED and 12% saying that the ED Questions and Solutions condition prevented them from forming relationships.7 Close relationships seem to have a causal connection to some healthrelated outcomes. Social isolation, or the lack of relationships, has been associated with higher mortality rates.8 Loneliness from lack of a romantic partner has been shown to be a significant factor related to increased physician utilization, independent of depression, somatic complaints, and health status.9 Social support has been associated with increased coronary artery disease survival. Elderly men and women hospitalized for acute myocardial infarction who had no emotional support were more likely to die within 6 months than those with emotional support.10 Psychosocial support and social relationships have also been associated with an improved course of breast cancer among women and less susceptibility to colds and other infections.11,12 Experts knowledgeable about the positive link between intimate relationships and health strongly advise physicians to think of patients as “whole people" and to inquire about their relationships. Once it is recognized that ED is more than a quality-of-life issue, it is a simple step to acknowledge that ED is a common problem among patients seen in a primary care office. Some of the major diagnoses seen in the primary care setting represent risk factors for the development of ED, such as diabetes, dyslipidemia, hypertension, coronary artery disease, smoking-related illness, lower urinary tract symptoms associated with benign prostatic hyperplasia, depression, acute or chronic anxiety and stress, and obesity. Discussing Sexual Matters With Patients Patients with sexual concerns report feeling most comfortable discussing these issues with their family physician and expect to receive advice and treatment.2 Although more than 70% of adult patients in a large sample considered sexual matters to be an appropriate topic for the generalist clinician to discuss, and despite the fact that the rate of sexual dysfunction is 35% in adult men and 42% in adult women, evidence of discussion about sexual problems is present in as few as 2% of generalist clinicians’ notes.13 Introducing sexual activity as a legitimate topic for conversation with patients can be done passively or actively. Examples of passive approaches include leaving pamphlets about sex-related topics or self-evaluation material such as the of the physical examination. Questions about sexuality need to be sensitive to cultural, religious, and educational differences. Using terminology that is clear, simple, and respectful of the patient’s feelings can facilitate communication. Patients may present with symptoms of ED or have risk factors that prompt screening. Because men have an increased risk of ED as they age, screening all men older than 40 years may be wise. Screening is valuable to minimize the morbidity associated with the condition. Because the yield of screening is related to the frequency of ED in the population, men who should be screened include those older than 40 years; those with a predisposing comorbidity, such as Questions about sexuality need to be sensitive to cultural, religious, and educational differences. Sexual Health Inventory for Men (Table 1) in the waiting room and hanging educational posters in patient care areas. Including 1 or more questions about sexual activity in a printed history form completed by the patient requires more active patient participation. Of course, the patient must be willing to document that a problem exists. Clinicians initiate more of the verbal interaction than do patients and control the content, pace, and length of the interview. A truly active approach to initiating discussions about sexual activity is probably the most efficient technique (Table 2). Primary care physicians should become at ease with one of these more active approaches and incorporate it into discussions with patients. Questions about sexual matters are appropriate during the initial formal history taking, the review of systems, a follow-up visit, or appropriate stages cardiovascular disease, diabetes, or depression; and other patients who the clinician thinks may be having difficulty with physical intimacy. The man with vague somatic complaints may be in the office because of a sexual problem. Some primary care physicians find it easiest to incorporate questions about sexual activity routinely into the visits of all patients who are likely to be sexually active so that this dialogue becomes a regular and anticipated topic during office visits. Non-physician health care clinicians can act as front-line managers of ED or can augment the sexual dysfunction inquiry and management in the physician’s office.14 There are several ways to introduce the topic of sexual activity, and asking in more than one way may be useful. The main purpose of screening questions is to give the patient an opportunity to discuss sexual matters VOL. 5 SUPPL. 7 2003 REVIEWS IN UROLOGY S37 ED Questions and Solutions continued Table 1 Sexual Health Inventory for Men Over the past 6 months: 1. How do you rate your confidence that you could get and keep an erection? 1- Very low 2- Low 3- Moderate 4- High 5- Very high 2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)? 0- No sexual activity 1- Almost never or never 2- A few times (much less than half the time) 3- Sometimes (about half the time) 4- Most times (much more than half the time) 5- Almost always or always 3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? 0- Did not attempt intercourse 1- Almost never or never 2- A few times (much less than half the time) 3- Sometimes (about half the time) 4- Most times (much more than half the time) 5- Almost always or always 4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? 0- Did not attempt intercourse 1- Extremely difficult 2- Very difficult 3- Difficult 4- Slightly difficult 5- Not difficult 5. When you attempted sexual intercourse, how often was it satisfactory for you? 0- Did not attempt intercourse 1- Almost never or never 2- A few times (much less than half the time) 3- Sometimes (about half the time) 4- Most times (much more than half the time) 5- Almost always or always Calculate score by adding up the number circled for each question. Any score below 21 reveals to the physician that the patient may be suffering from erectile dysfunction. Adapted from Cappelleri JC et al. Clin Ther. 2001;23:1707-1719.18 S38 VOL. 5 SUPPL. 7 2003 REVIEWS IN UROLOGY in a non-threatening manner. It is best to develop a technique that can be comfortably used with most patients, although sometimes a flexible approach is needed depending on factors such as patient age and cultural background, the clinician’s familiarity with the patient, the timing of the inquiry during the visit, and the flow and dynamics of the specific visit. A word about confidentiality is often helpful. Communication is enhanced by placing the sexual history in an appropriate context in the history taking, such as during discussion of the social history or the review of systems. Open-ended questions, such as “Can you tell me a little about your sexual activities?" “Have you been sexually active with a partner in the past 6 months?" or simply "How’s your sex life?" encourage the patient to speak more openly. Men with chronic illnesses or risk factors for ED should be asked, “How has your illness affected your sex life?" This question may be preceded by a brief statement recognizing the importance of sexual activity to a person’s health: “In order to protect your health, I need to ask you some questions about your sexual life. Are you romantically or sexually involved with anyone?" Occasionally, a question about “concerns" is useful, as it is both open-ended and problemoriented15: “Do you or your partner have any sexual concerns?" Offering specific examples may also be useful— for example, “Do you or your partner have any sexual difficulties or concerns, such as with your interest level, erections, or ejaculation?" Questions that can be answered with a simple “yes" or “no" should be avoided, as these will close off discussion.16 Another useful technique is to use a permission-giving question that tells the patient you will not be sur- ED Questions and Solutions prised if he reports a problem and that demonstrates respect and sensitivity. An example of this would be to say to a patient with diabetes, “Many of my male patients with diabetes report some difficulty having an erection. Have you noticed any problems?" This allows the patient to answer openly without anticipating that the physician will be surprised or shocked by his answer. Using synonyms such as “getting hard" or “coming" may help the patient understand the question better. Encouraging a patient’s response with “facilitating" gestures such as good eye contact and nodding affirmatively, as well as summing up what the patient has told you and expressing optimism that the problem can be resolved, improves communication. The evaluation of ED follows the same pattern as does evaluation of any medical symptom. This includes pertinent history taking, physical examination, and laboratory tests. The history, however, must include a sexual history. A well-organized brief sex history can be an effective diagnostic tool. Questions generally review the phases of male sexual response and sexual pain. Because of the specificity of the necessary workup and the planned treatment, careful distinction of the patient’s actual symptoms is essential, especially when there is a problem in more than one phase of sexual activity. For example, men may tell the physician that they have ED, but the erection problem may be a symptom of low libido or ejaculatory problems. Marian Dunn, PhD, director of the Center for Human Sexuality at the Downstate Medical Center in Brooklyn, NY, has suggested specific ways to elicit useful details about sexual activity and different stages of sexual response. She notes that it is better to not accept the patient’s label for a disorder without first question- Table 2 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 patients’ responses. • Promote an optimistic attitude. Taking a sexual history • Routinely ask all patients about their sexual history. • Add sexual health questions to patient history forms. • Use a screening test (eg, SHIM) to uncover erectile dysfunction when performing a comprehensive evaluation. • Give patients the opportunity to discuss sexual problems they now have or may have in the future. • Discuss sexually transmitted disease prevention. Ask questions to clarify the problem more precisely • How severe is the problem? • What caused the problem? • How long has the problem existed? SHIM, Sexual Health Inventory for Men. ing him and getting a clear picture of the complaint. Often, less-educated patients misuse medical or technical terminology. For desire-phase disorder, an appropriate question would be “Do you still feel in the mood/feel desire/have sexual thoughts or fantasies?" Synonyms such as libido, interest, drive, appetite, urge, lust, and instinct may be helpful. Desire disorder is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as persistent deficiency (or absence) of sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty.17 If a man reports a loss of desire, it is necessary to establish whether it is secondary to the ED or preceded it. ED preceded by loss of desire can signal hormonal problems, relationship difficulties, medication adverse effects, or depression. It is difficult for most men to maintain an erection if they feel no desire. For arousal/erection difficulties, ask “Do you have trouble getting or keeping an erection/getting or keeping hard or both?" ED is defined by the DSM-IV as a persistent inability to attain, or to maintain until completion of the sexual activity, an adequate erection, which causes marked distress or interpersonal difficulty.17 If the patient acknowledges an erectile difficulty, ask about its onset and frequency, its relationship to medical treatments or medications, and stressful life events. Because some men VOL. 5 SUPPL. 7 2003 REVIEWS IN UROLOGY S39 ED Questions and Solutions continued confuse ED with premature ejaculation, asking if the erection is lost before or after ejaculation can clarify the problem. Orgasm/ejaculatory phase problems can be reviewed by asking “Do you feel you ejaculate/come too quickly?" The DSM-IV definition of premature (rapid) ejaculation is persistent ejaculation with minimal stimulation before, on, or shortly after penetration and before it is desired, causing marked distress or interpersonal difficulties.17 It is not unusual for ED to develop in a man who has been disappointed by and become increasingly anxious about quick ejaculations. “Do you ever have difficulty reaching orgasm or ejaculating?" is a question up with an erection before having to urinate? 2) If you experiment and touch yourself when your partner is not around, can you get an erection? 3) Can you get an erection at any time of night or day, during any form of sexual activity, with any partner? A positive response to these questions indicates stress or anxiety as the trigger of the ED rather than a physical cause or a medication adverse effect. These patients may benefit from sexual counseling by you or a knowledgeable therapist. Ruling out organic causes requires a history taking that defines the circumstances of the problem, a physical examination and laboratory tests that look for clinical disorders Retrograde ejaculations may lead to psychogenic ED because of a man’s worry over a lack of visible ejaculate. to evaluate for delayed or retrograde ejaculation. Male orgasmic disorder is defined in the DSM-IV as persistent delay in, or absence of, orgasm after a normal excitation phase, causing marked distress or interpersonal difficulty.17 Retrograde ejaculations, for example, may lead to psychogenic ED because of a man’s worry over a lack of visible ejaculate. Some medications can cause delayed ejaculation. To reveal Peyronie’s disease or pain disorders, ask about “a bend to the penis" or pain during or after sexual activity. If the primary care physician plans to further manage the sexual disorder, it is helpful to obtain additional information about the characteristics of the specific problem. The first step is to determine whether the problem is psychogenic or organic. An easy method of distinguishing most psychogenic ED disorders from potentially organically induced disorders is to ask 3 questions: 1) Do you ever wake S40 VOL. 5 SUPPL. 7 2003 that can negatively impact sexual function, and a careful review for potentially causative medication or drug use. The second characteristic to determine is whether the problem is lifelong or acquired. Dysfunctions that are recently acquired are more amenable to briefer treatments, whereas those that are lifelong often require further psychotherapy or clinical investigation. The third characteristic to determine is whether the dysfunction is generalized or situational. Situational problems hint at difficulties with specific partners or in specific situations, which implies a psychogenic etiology. Gender differences between a female clinician and a male patient may initially cause some discomfort, but many men report feeling more comfortable discussing sexual issues with female physicians. Being polite and respectful, yet displaying an appropriate level of interest in the patient’s REVIEWS IN UROLOGY personal life, is the best overall approach to encouraging conversation about sexual activity. If a written evaluation tool seems easier, the Sexual Health Inventory for Men is a good way to learn about erectile function in a standardized, written manner. This 5-item questionnaire provides an excellent objective standard of the quality of erection (see Table 1).18 Discussions About Sex Can Improve Patient Satisfaction The goal of all clinicians and patients is to improve outcomes that result from clinician-patient encounters. Discussing psychosocial issues in the clinician’s office has been linked in empirical studies with favorable patient outcomes.19 Clinicians who engage patients in some discussion about psychosocial topics in addition to their immediate clinical problems promote openness and display caring, often improving patient satisfaction with the visit.20 Patients with emotional distress that is recognized by the physician report stronger relationships with their physician than do patients whose emotional distress is not addressed. Discussing sexual matters with patients and helping them resolve problems is a satisfying activity for primary care physicians. Patients are often grateful following discussions about sexual matters, and that gratitude can manifest as increased enthusiasm about improving their health and increased loyalty to the clinician. The value of the interaction is enhanced when it is initiated by the physician, facilitating the problem-solving process for the patient. This “afflictive" communication style, including friendliness, interest, empathy, a nonjudgmental attitude, and a social orientation, is associated with significantly higher patient satisfaction.21 ED Questions and Solutions Table 3 Why Men Do Not Seek Help: 3 Themes • Support: Men get support regarding health concerns from female partners, rarely from male friends. Support seeking is indirect rather than straightforward. • Help seeking: Men are influenced by perceived vulnerability, fear, and denial. They seek help for specific problems rather than for general health concerns. • Barriers: Men may have a sense of immunity and immortality, difficulty giving up control, or a belief that seeking help is unacceptable. Lack of time and access, having to give a reason for a medical visit, and lack of a male care provider are also barriers to seeking help. Adapted from Tudiver F, Talbot Y. J Fam Pract. 1999;48:47-52.23 Men Need Encouragement to Discuss ED Men consult family physicians for health-related problems less frequently than do women, reducing the chance of disease recognition and treatment.22 Research has revealed several key themes to explain this behavior, including support seeking, help seeking, and barriers (Table 3).23 Other potential barriers to action include poor relationships with doctors, lack of time and access to health care, having to state a reason for the visit, and not having a male health care provider. This research on male reticence to discuss health concerns with a health professional supports the strong role of the female partner in health-seeking behavior. This reticence results in men receiving less preventive care, screening, and testing. Counseling rates for sensitive topics such as sexual health and emotional well-being are especially low. David Sandman, coauthor of the Commonwealth Study, said “Physicians can be more attuned to the special health concerns of their male patients and be more proactive in initiating communication."24 When men do present to the clinician’s office, they often offer general or no complaints and wait for the clinician to find out why they are really there. Men are often hesitant to discuss sexual problems with their physician because of embarrassment, ignorance or misinformation, and lack of financial means. They often think that they are beyond help. It is unfortunate that surveys indicate that books, not health professionals, are the number one source of sex information reported by persons aged 45 years and older.24 The sexual difficulties of disabled male patients are often overlooked. Physical injury and physiologic trauma from a disabling condition can affect sexual function. These disabling conditions can be congenital or acquired. Management of these 2 different types of disability requires sensitivity and care. Patients who become disabled in adulthood are much more aware of what they have lost. Loss of erectile function is the most common sexual problem among disabled male patients.25 Discussion about sexual activity is essential for patients with any type of disability. Conversations With Partners Asking sexual partners about each other’s sexual function is often useful. Women rank “partner sexual difficulties" as a common sexual concern.26 If both members of a couple are in the office, it is 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 about both partners can still be asked. Discussions with partners can be both diagnostic and therapeutic. When a sexual dysfunction is identified, talking with the partner can reveal a different picture, which may substantially affect management and can have a therapeutic effect.27 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 of partner choice, partner participation in sexual activity, and partner physiology may impact erectile function. Postmenopausal partners 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 interest. When vaginal dryness or vaginal atrophy leads to pain, women quickly lose interest in continued sexual activity. All of the emotional components of a good relationship contribute to continued sexual satisfaction. 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. It is important to encourage partners to give each other positive and constructive feedback on sexual preferences. A partner might say, “I really enjoy it when VOL. 5 SUPPL. 7 2003 REVIEWS IN UROLOGY S41 ED Questions and Solutions continued you touch me lightly" or “It really feels great when you do that." If partners are shy, they can make sounds of pleasure to cue the partner that what they are doing feels 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 may occur. If partners are able to be lighthearted, they are always relevant in times of illness. In general, discussions about sexuality occur most easily when the clinician initiates questions about sexuality that do not assume heterosexuality. Asking, “Do you have sex with men, women, or both?" is a common way of demonstrating acceptance of varying sexual orientations. Using the term “partner" rather than “spouse" or “wife" conveys the fact that the The use of topical lubricants or estrogen replacement therapy for the woman may be essential. 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. The use of topical lubricants or estrogen replacement therapy for the woman may be essential. It does no good for the man to receive treatment for ED if the partner is not physiologically prepared for the increased sexual activity and experiences pain. It is always valuable to include the partner in discussions about sexual activity with the patient so that both can learn about and plan treatment together. Successful treatment of ED is most likely to occur when couples have a good relationship and are able to communicate their positive and negative feelings to each other.28 Many men may prefer to be evaluated and treated for ED alone, but when a man has a regular partner, patient education may convince him of the importance of including his partner in further management. Ask About Sexual Orientation Knowing about a patient’s sexuality is important to the clinician who is truly interested in the patient’s health and happiness. A person’s life stresses and support systems are S42 VOL. 5 SUPPL. 7 2003 clinician is not making any assumptions regarding sexual orientation. Gay men are more likely to confide important information and to follow a provider’s advice if they feel accepted and understood. The provider’s technical knowledge may be of little value if the gay patient feels uncomfortable, judged, or misunderstood. Offering to keep information about sexual orientation out of the medical record may be a welcome relief for some patients. Homosexual patients must be able to involve partners or other support people in examinations and treatment decisions. Dr Dunn has taught many health care clinicians about the impact of sexual orientation on patients’ concerns, their willingness to communicate with health care providers, and how to improve treatment outcomes. She has emphasized the need to create a welcoming environment even before contact with the health care provider. For example, one can post a sign in the waiting room reading, “We do not discriminate on the basis of race, sex, or sexual orientation." In addition, literature targeted at and/or provided by the gay, lesbian, and bisexual communities may be placed in the waiting room. Clinicians need to learn about the REVIEWS IN UROLOGY full range of human sexuality so that patients will not suffer because of provider ignorance. Referral to knowledgeable professionals is appropriate when the situation becomes more complex. Understanding and acceptance of differences does not automatically suggest approval, but failure to deal sensitively with sexual matters predisposes the patient to potential harm by omission or inappropriate treatment. Dealing with ED among gay male patients is not much different than among heterosexual men. The issues causing ED remain the same, as do the emotional and relationship consequences. Managing ED among gay men involves the same inquiry, evaluation steps, and treatment discussion as with other patients, and discussions with partners can be constructive. The only variations may be differing life stresses, and these issues can be handled by the sensitive and aware clinician. The Next Step After Identifying ED The primary care physician who identifies a patient with ED has accomplished much. This information can be used to: • Initiate evaluation for psychological and organic comorbid conditions, including risk factors for neurovascular disease. • Refer the patient to an appropriate clinician. • Open up further discussion to determine whether ED is the primary sexual problem or is secondary to a difficulty with some other phase of the sexual cycle, such as libido or ejaculation. • Work with the patient on a management plan. This flexibility of response to the patient’s ED is illustrated by the acronym ALLOW (Figure 1). This ED Questions and Solutions management plan acknowledges the need for all primary care clinicians to inquire about sexual activity, while recognizing the limitations and varied interest of clinicians in actually managing problems. Step 1 involves asking the patient about sexual activity. Step 2 includes legitimizing the patient’s problems and acknowledging that sexual dysfunction is an important issue. An initial impression that his problem is being dismissed can considerably delay or prevent a patient from seeking further help. Step 3 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 has done it “ALL" for the patient. Step 4 can be referral to an appropriate specialist to further investigate and treat the patient’s sexual problems, or the primary care clinician can open up the issue for further dissection and diagnostic evaluation. Step 5 involves working with the patient to identify an appropriate goal and mutually acceptable treatment. Basic Sex Counseling in the Primary Care Office Basic sex therapy can be provided by the primary care physician. Sex therapy involves teaching ways to improve sexual technique and helping the patient concentrate on pleasure rather than simply the achievement of an erection. This may be achieved by providing the patient or, ideally, both partners with information about sexual concerns, sexual practices, and sexual response and by attempting to reduce performance anxiety (Table 4). Encourage partners to discuss what they enjoy about sex. More specific suggestions can be offered at the next level of sex therapy, such as encouraging couples to renew intimacy and sensuality in the Figure 1. The “ALLOW" management plan acknowledges the need for all primary care physicians to inquire about sexual activity, while recognizing the limitations and varied interest of clinicians in actually managing problems. "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. W—Work together to develop a treatment plan relationship and to extend foreplay for each other. The clinician needs to have some specific knowledge about sexual performance and response to provide this level of counseling. The most detailed level of therapy often requires the assistance of a sex therapist and should be considered when the patient has been unable to understand or implement any of the more basic suggestions or when the counseling interventions have not worked. The physician can help reduce performance anxiety in several ways. When sensuality, extended foreplay, and a focus on pleasure rather than erection is encouraged, greater arousal is possible. Often, couples need to be encouraged to rekindle the sense of courtship and romance that existed earlier in their relationship. When recommending new treatments, clinicians can reduce patient anxiety by explaining that treatments often take time to be fully effective and that most couples need time to comfortably integrate the new treatment into their sex lives. A Useful Structure for Brief Therapy: The P-LI-SS-IT Model The P-LI-SS-IT model, developed by Annon,29 offers a structure that is Refer useful in organizing an approach to brief sex counseling. P-LI-SS-IT is an acronym used to describe 4 different levels of counseling: permission, limited information, specific suggestions, and intensive therapy. The model moves from the simplest level of intervention, permission, to the most complex level of intervention requiring the most skill, intensive therapy. The first 3 intervention levels can be implemented by any health care practitioner. Intensive therapy requires special training in sex therapy. Permission “Permission giving" is meant to help the patient feel better about thoughts, feelings, and reactions. Many persons wonder whether their sexual responses, fantasies, and past or present behaviors are “normal." Permissiongiving statements, usually accompanied by an inquiry, encourage questions and elicit concerns. Examples of permission-giving statements include, “Many couples have questions or concerns about sex during pregnancy. What questions do you have?" or “Most men who have had a heart attack are worried about VOL. 5 SUPPL. 7 2003 REVIEWS IN UROLOGY S43 ED Questions and Solutions continued Table 4 Basic Sex Therapy Content • Reduce performance anxiety • Improve communication between partners • Educate about sex and dysfunction (verbal or bibliotherapy) • Dispel myths about sex Techniques • Cognitive therapy to change negative thoughts to positive thoughts • Asking specific questions • Creating a sexual environment • Develop sexual skills and sensate focus exercises, including: –Increasing awareness of sexual feelings –Learning to regain an erection after losing it –Transitioning to intercourse –Integrating medical and psychological treatments Adapted from Weeks GR, Gambescia N. Erectile Dysfunction: Integrating Couple Therapy, Sex Therapy and Medical Treatment. 200016; Rosen RC. Urol Clin North Am. 2001;28:269-278.34 resuming sex. What questions do you have?" or maybe “Since sexual health is related to overall health, I would like to ask how sex is going for you." Just asking about sexual health permits the patient to feel more comfortable about asking questions and discussing concerns. Of course, permission should not be given for the patient to be involved in potentially harmful sexual activities. Limited Information A clinician provides “limited information" usually in conjunction with permission giving. Factual information about sexual concerns, sexual practices, and sexual response is specifically directed to the problem or question presented by the patient. Patients often lack an understanding of normal sexual function. Many older men have misunderstandings about sexual function and changes that occur with aging (Table 5). Correcting myths and misinformation S44 VOL. 5 SUPPL. 7 2003 and teaching the patient about the body and how it works are part of this limited information (Table 6). The subtle physiologic changes that occur with age can have significant emotional ramifications if they are misunderstood. Both a man and his partner may be unaware of his need for more foreplay and penile stimulation, the loss of firmness of erections with aging, and the decreased need for climax for sexual satisfaction. An older man may interpret his lack of spontaneous erections as a sign of impending impotence or as a complication of a chronic illness. His partner may erroneously feel that she no longer attracts him or that he has lost interest in sexual activity. It is common for a cycle of anxiety, discouragement, and avoidance of sexuality to begin at this stage of life. Simple education can be provided through a variety of formats, such as printed or electronic materials and personal discussions. Some physicians REVIEWS IN UROLOGY have effectively used group meetings to educate about sexual function, which can be cost-effective and decrease the stigma and embarrassment associated with ED. Direct discussions, either individually or in groups, allow for more interaction and give patients the opportunity to ask questions.14 If viewed positively, the changes that occur with aging can make lovemaking last longer and involve deeper mutual involvement. Specific Suggestions At the third level of intervention, the physician offers the patient “specific suggestions" for improving sexual technique, achieving greater response, enhancing communication with a partner, or selecting positions and sexual activities in specific situations. To provide helpful suggestions, the physician needs to have some knowledge of sexual response and how a variety of health, illness, and disability states can affect or interfere with it. Advising the patient to talk with his partner about sexual issues that are important to him, or talking about “sexual scripts" (the format of lovemaking) that may have become boring or routine, can easily be done in the office setting. If patients find direct conversation with partners difficult, remind them that verbal and nonverbal cues that indicate pleasure can be erotic and encourage partners to repeat stimulating behaviors. A specific suggestion with regard to enhancing overall sexual response might be to encourage a patient to read a selfhelp book. Physicians are accustomed to giving directions and suggestions to patients, but listening to patients and encouraging them to develop their own suggestions and solutions may be more therapeutic. This leaves the patient with a greater sense of selfesteem and with an enhanced prob- ED Questions and Solutions lem-solving ability. It is better to offer 1 or 2 suggestions that can be implemented when setting specific long-term goals. Steps taken at this point in therapy can resolve short-term and more recent–onset problems. Table 5 Changes in Male Erectile Function Associated With Aging • More time and/or direct physical stimulation is necessary to achieve an erection. • Erections are not as hard as they used to be. Intensive Treatment This highly individualized treatment aimed at multiple and complex aspects of a sexual dysfunction can involve detailed focus on sexual relationships and specific techniques. It is more useful in situations of interpersonal and/or intrapsychic conflict and is most helpful for sexual problems that have existed for a long time. This level of therapy requires appropriate training and usually is best accomplished by a trained sex therapist or other mental health care professional. Lifestyle Changes May Improve Both ED and Other Health Parameters Identification of ED helps the physician encourage healthier activities that may impact cardiovascular risk. Men are often slow to adopt healthy lifestyles, even when a full explana- • It takes longer to get a second erection (lengthened refractory period). • Physiologic and psychogenic risk factors associated with ED are more likely. tune “teaching moment" to discuss the value of smoking cessation. Patients become more motivated to stop smoking when they understand the potential of halting progression of erectile problems and, possibly, improving erectile capacity. Dietary issues including reducing intake of cholesterol and fats, eliminating hyperglycemia when present, and decreasing salt intake when saltsensitive hypertension is noted all help reduce the progression of vascular insufficiency. Exercise can increase cardiac output and improve peripheral circulation. Moderate exercise for sedentary middle-aged and older men may minimize the small increase in relative risk of a myocar- Patients need to understand that what is bad for the heart and the peripheral vascular system or the nervous system is bad for the penis. tion about cardiovascular risk is offered. Patients need to understand that what is bad for the heart and the peripheral vascular system or the nervous system is bad for the penis. Associating healthier lifestyles with preservation of normal erectile function or a possible improvement of impaired erectile function may motivate men to make healthier lifestyle decisions. Elimination of tobacco smoking is critical, as may be elimination of all other recreational drug use. The occurrence of ED in the smoking patient provides an oppor- dial infarction in this population.26,30 These recommendations will help men be healthier and, hopefully, happier, although their effect on erectile functioning may not be instantly apparent. Derby and associates31 studied the ability of changes in smoking, heavy drinking, sedentary lifestyle, and obesity to decrease ED symptoms and the risk of worsening ED. Only regular moderate to vigorous physical activity was shown to reduce the risk of ED32 and possibly even improve symptoms of ED.31 This is not sur- prising since the positive impacts of exercise on claudication, a common lower extremity symptom in patients with peripheral vascular disease, have been well documented.33 Improvement of claudicating symptoms through exercise may be explained by mechanisms that may also impact penile arterial flow, including measurable improvements in endothelial vasodilator function, muscle metabolism, blood viscosity, and inflammatory response. When clinically possible, medication changes to remove causative agents can be tried. Examples of this would be discontinuing a thiazide diuretic and substituting an -adrenergic blocker, or weaning a patient from digoxin if the medication is not really necessary. Antidepressantinduced sexual dysfunction can sometimes be managed by reducing drug dosages, altering timing of drug dosages, taking drug holidays, adding an adjunctive drug, or switching to an alternative antidepressant. These substitutions and eliminations may meet with some success but need to be individualized depending on clinical circumstances. Issues of Follow-up and Referral Follow-up is an essential part of the management of ED. Reviewing the success or lack of success of treatment, discussing any adverse effects, and considering dose or treatment alterations may help achieve the patient’s goal. Patients should be seen VOL. 5 SUPPL. 7 2003 REVIEWS IN UROLOGY S45 ED Questions and Solutions continued Table 6 Men’s Misconceptions About Erectile Dysfunction • Matters relating to sexual dysfunction are taboo. • Loss of erection is not a common problem; the problem is unique. • Erectile dysfunction is a normal part of aging. • Inability to achieve an erection 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. Adapted from Weeks GR, Gambescia N. Erectile Dysfunction: Integrating Couple Therapy, Sex Therapy and Medical Treatment. 200016; Burnett RL. Geriatrics. 1998;53:34-35, 39-40, 46-48.35 1 month after initiation of treatment to evaluate progress. Comparison to baseline can be done by verbal exchange or by using the Sexual Health Inventory for Men. Additional patient issues or problems can be addressed, as can the need for dosage titration for patients receiving pharmacologic therapy. A trusting partnership between clinician and patient enhances the likelihood of a successful therapeutic outcome. Consultation with subspecialists may be appropriate at varying intervals of ED management. The major factor is the primary care physician’s comfort in discussing and managing treatment. The obligation of the primary care physician is to recognize ED and make the patient feel comfortable about seeking help. However, the initial workup and treatment can be planned by a primary care physician with good communication skills S46 VOL. 5 SUPPL. 7 2003 who is knowledgeable about first-line therapies for sexual dysfunction. Common indications for referral to a specialist include significant penile anatomic disease, a younger patient with a history of pelvic or perineal trauma, cases requiring vascular or neurosurgical intervention, complicated endocrinopathies, complicated psychiatric or psychosocial problems, or patient or physician desire for further evaluation.7 Urologists can be helpful in difficult or complex cases of erectile dysfunction or when the patient presents with anatomical problems, such as Peyronie’s disease. An endocrinologist may be consulted when a patient has difficult-to-control diabetes, hypogonadism, or evidence of pituitary dysfunction. Sex therapists are practitioners in the medical or mental health fields, such as physicians, clergy members, and mental health professionals, REVIEWS IN UROLOGY who, in addition to their basic clinical education, have had training in sex therapy, including evaluation and treatment instruction. Sex therapists have more time to talk with the patient, to work with couples and suggest enhancement techniques, and to educate couples about the many ways of having pleasurable sexual relations without a firm erection. The American Association of Sex Educators, Counselors, and Therapists provides a directory of trained, certified sex therapists in each state (www.aasect.org/Home/). Most major teaching hospitals have a trained sex therapist on staff. Optimizing Primary Care Management of ED in the Future Primary care management of ED is generally successful, with the large majority of men who talk to their primary care physician about ED receiving, at minimum, preliminary advice and recommendations. Many primary care physicians have become comfortable initiating phosphodiesterase type-5 inhibitor therapy in men with ED and referring complex cases to appropriate specialists. As primary care physicians become even more involved in ED discussion and management, successful intervention for sexual problems will require additional professional education and more effective clinician-patient interactions. Further professional education will include information on the reasons for ED inquiry, such as amplification of the relationship between ED and neurovascular diseases and the role of ED as a “predictor" of atherosclerosis and/or endothelial dysfunction; clarification of the impact of the decrease on quality of life resulting from ED; the negative impact of sexual dysfunction on healthy relationships that enhance health and health outcomes; the potential value of ED ED Questions and Solutions as a clue to other conditions, including depression, benign prostatic hypertrophy, and relationship difficulties; and the appropriate role of testosterone evaluation in erectile problems. As clinicians begin to recognize ED as both a signal of potentially serious disorders and a condition with its own morbidity, inquiry about ED will become a higher priority. To enhance the management of sexual dysfunction, clinician education must focus on the following: • Better instructions for optimizing treatment outcomes • Development of clear follow-up protocols • The need to educate patients about the wide range of sexual response and changes that occur with aging and illness • Basic sex counseling concepts and techniques suitable for use in the primary care setting • Methods to enhance communication between primary care physicians and specialists, such as urologists and sex therapists More effective physician-patient interaction will require clinicians to be more patient-oriented and allow patients to comfortably bring up sexual issues. Clinician inquiry about sexual activity needs to become a routine part of the primary care history taking in order to identify risks of sexually transmitted disease as well as to allow for intervention in sexual dysfunction that negatively affects the patient or his relationship. More education on this topic is needed, beginning as early as professional school, to prepare clinicians to discuss sex comfortably and constructively. Although many patients are being rewarded with better sex lives by the increasing number of clinicians who are recognizing sexual health as a legitimate medical concern, efforts to universalize sexual health care in primary care need to continue. 11. References 12. 1. 2. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281:537-544. Dunn KM, Croft PR, Hackett GI. Sexual problems: a study of prevalence and need for health 3. 4. 5. 6. 7. 8. 9. 10. 13. care in the general population. Fam Pract. 1998;15:519-524. Jonler M, Moon T, Brannan W, et al. The effect of age, ethnicity and geographical location on impotence and quality of life. Br J Urol. 1995:75:651-655. Sadovsky R, Mulhall J. The potential value of erectile dysfunction inquiry and management. Int J Clin Pract. 2003;57:601-608. 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;158:1623-1630. Birchler GR, Webb LJ. Discriminating interactive behaviors in happy and unhappy marriages. J Consult Clin Psychol. 1977;45:494-495. Dunn KM, Croft PR, Hackett GI. Association of sexual problems with social, psychological, and physical problems in men and women: a cross sectional population survey. J Epidemiol Community Health. 1999;53:144-148. Berkman LF. The role of social relations in health promotion. Psychosom Med. 1995;57:245-254. Geller J. Loneliness: an overlooked and costly health care risk factor. Minn Med. 2000;83:48-51. Friedmann E, Thomas AA. Pet ownership, social support, and one-year survival after acute myocardial infarction in the Cardiac Arrhythmia Suppression Trial (CAST). Am J Cardiol. 1995;76;17:1213-1217. Cohen S, Doyle WJ. Social ties and susceptibility to the common cold. JAMA. 1997;277:19401944. Speigel D. Psychosocial aspects of breast cancer treatment. Semin Oncol. 1997;24(suppl 1):S1-S36. Read S, King M, Watson J. Sexual dysfunction in primary medical care: prevalence, characteristics and detection by the general practitioner. J Pub Health Med. 1997;19:4:387-391. Main Points • The long-standing relationship often present between a primary care provider and patient, the ability of a primary care physician to address the varied issues surrounding sexual problems, and the amenability of the primary care setting to long-term follow-up make primary care the ideal setting for discussions about sexual issues. • Erectile dysfunction (ED) is more than a quality-of-life issue: ED may be a sign of systemic vascular disease or may be the first recognized evidence of vascular risk factors, such as hypertension, hyperlipidemia, or diabetes. • When talking about sexuality with patients, remember to be sensitive to differences in culture, religion, sexual orientation, and education. Using terminology that is clear, simple, and respectful of the patient’s feelings can facilitate communication, as can the use of open-ended questions, “facilitating" gestures, and conveyance of an optimistic attitude. • The evaluation of sexual dysfunction is the same as for any medical condition, including a pertinent history taking, physical examination, and appropriate laboratory tests; more thorough questioning by the clinician who plans to further manage sexual dysfunction should establish whether the problem is psychogenic or organic, lifelong or acquired, and generalized or situational. • Relationship issues have a definite role in ED, which is why it is useful to include a patient’s partner in discussions whenever possible. Successful treatment of ED is most likely when couples are able to communicate their feelings to each other. • The “ALLOW" management plan recognizes that, although the primary care physician and patient can often work together to manage ED, referral to a specialist is sometimes necessary. • The P-LI-SS-IT structure describes the 4 levels of counseling, from simplest to most complex: permission (eliciting the patient’s concerns), limited information (providing factual information), specific suggestions (coming up with solutions), and intensive therapy, which is done by a trained sex therapist. VOL. 5 SUPPL. 7 2003 REVIEWS IN UROLOGY S47 ED Questions and Solutions continued 14. 15. 16. 17. 18. 19. 20. S48 Albaugh J, Amargo I, Capelson R, et al. Health care clinicians in sexual health medicine: focus on erectile dysfunction. Urol Nurs. 2002;22:217231. Maurice WL. Sexual Medicine in Primary Care. St Louis, Mo: Mosby; 1999:50-51. Weeks GR, Gambescia N. Erectile Dysfunction: Integrating Couple Therapy, Sex Therapy and Medical Treatment. New York: WW Norton & Co; 2000. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. Arlington, Va: American Psychiatric Press; 1994. Cappelleri JC, Siegel RL, Glasser DB, et al. Relationship between patient self-assessment of erectile dysfunction and the Sexual Health Inventory for Men. Clin Ther. 2001;23:1707-1719. Beck RS, Daughtridge R, Sloane PD. Physicianpatient communication in the primary care office: a systematic review. J Am Board Fam Pract. 2002;15:25-38. Bertakis K, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract. 1991;32:175-181. VOL. 5 SUPPL. 7 2003 21. 22. 23. 24. 25. 26. 27. 28. REVIEWS IN UROLOGY Buller MK, Buller DB. Physicians’ communication style and patient satisfaction. J Health Soc Behav. 1987;28:375-388. Sandman D et al. The Commonwealth Fund 1998 Survey of Men’s and Women’s Health. New York: The Commonwealth Fund; 1998. Tudiver F, Talbot Y. Why don’t men seek help? Family physician’s perspectives on help-seeking behavior in men. J Fam Pract. 1999;48:47-52. Sheiton DL. Men avoid physician visits, often don’t know whom to see. Am Med News. 2000;43:14:1. Glass C, Soni B. ABC of sexual health: sexual problems of disabled patients. BMJ. 1999;318:518-521. Muller JE, Mittleman MA, Maclure M, et al. Triggering myocardial infarction by sexual activity: low absolute risk and prevention by regular physical exertion. JAMA. 1996;275:1405-1409. Ackerman MD, Carey MP. Psychology’s role in the assessment of erectile dysfunction: historical precedents, current knowledge, and methods. J Consult Clin Psychol. 1995;63:862-876. Dorey G. Partners’ perspective of erectile dys- 29. 30. 31. 32. 33. 34. 35. function: literature review. Br J Nurs. 2001; 10:187-195. Annon JS. The Behavioral Treatment of Sexual Problems: Brief Therapy. New York: Harper and Row; 1976. Gunnarsson OT, Judge JO. Exercise at midlife: how and why to prescribe it for sedentary patients. Geriatrics. 1997;52:71-80. Derby CA, Mohr BA, Goldstein I, et al. Modifiable risk factors and erectile dysfunction: can lifestyle changes modify risk? Urology. 2000;56:302-306. Pinnock CB, Stapleton AMF, Marshal VR. Erectile dysfunction in the community: a prevalence study. Med J Australia. 1999;171:353-357. Stewart KJ, Hiatt WR, Regensteiner JG, et al. Exercise training for claudication. N Engl J Med. 2002;347:1941-1951. Rosen RC. Psychogenic erectile dysfunction. Classification and management. Urol Clin North Am. 2001;28:269-278. Burnett AL. Erectile dysfunction: a practical approach for primary care. Geriatrics. 1998;53: 34-35, 39-40, 46-48.