Integrating erectile dysfunction treatment into primary care practice

Breaking the Ice of Erectile Dysfunction Taboo: A Focus on Clinician–Patient Communication

Erectile dysfunction is a common yet complex problem facing men and their partners worldwide. It continues to be an under reported issue despites its high prevalence and negative impact as well as the availability of successful treatment. One of the main reasons for such a problem is the stigma surrounding it as a complaint and the deep-seated fear to discuss it. This paper aims to highlight the reasons behind the taboo and dilemma behind erectile dysfunction reporting and discusses means to overcome this stigma focusing on clinician–patient communication.

Partner's Perspective on Long-term Sexual Dysfunction After Prostate Cancer Treatment

OBJECTIVE

Prostate cancer is the most common type of male cancer in the United States and the negative effect of prostate cancer treatment on sexual function has been well documented. The objective of this study was to examine the long-term impact of sexual dysfunction on spouses or partners of prostate cancer survivors.

METHODS

A total of 742 spouses of prostate cancer survivors was mailed surveys by the Michigan Public Health Institute, of which 379 were returned (51%). Nine surveys were excluded owing to study ineligibility. Spouses responding to the survey completed a combination of modified items from the Sexual Adjustment Questionnaire and researcher-developed items.

RESULTS

Over 75% of spouses reported a decline in sex life quality after treatment. Communication about sexual issues between survivors and their health care providers was rated as good to excellent by 54.7% of partners, whereas 35.1% reported it as fair to poor. Approximately 60% of physicians initially recommended some form of sexual treatment. However, despite the persistence of sexual dysfunction, only 7% of the prostate cancer survivors were currently receiving treatment. Only 4.1% of health care providers referred the survivor to a sex therapist.

CONCLUSIONS

Physicians need to understand the importance of the open, ongoing communication with prostate cancer survivors about sexual issues because sexual dysfunction seems to continue indefinitely after completion of treatment. Research on the effectiveness of behavioral interventions in restoring sexual health is critically needed for this population, especially as first-line sexual aids and medications are often not satisfactory solutions.

Sexual history taking and sexually transmitted infection screening in patients initiating erectile dysfunction medication therapy

BACKGROUND

Erectile dysfunction medications are being prescribed frequently; however, little is known about the amount of sexual health screening occurring in this setting.

METHODS

A retrospective cohort study evaluating sexual health and sexually transmitted infection screening occurring in veterans receiving initial erectile dysfunction medication prescription was conducted.

RESULTS

A total of 252 patients received initial erectile dysfunction medication prescriptions between October 1, 2009, and December 31, 2009; had at least 1 health care provider visit 12 months before the date of initial prescription; and had no documentation of previous erectile dysfunction medication use. Approximately 3% of these patients had any aspect of a sexual history recorded in the 24 months surrounding initial erectile dysfunction medication prescription. Sexually transmitted infection screening was 9.9% for syphilis, 4.8% for HIV, and 4.3% for gonorrhea/chlamydia before prescription, with only a slight increase in HIV screening after prescription.

CONCLUSIONS

Minimal sexual health assessment is being performed during the time surrounding initial prescription of erectile dysfunction medication. Further work needs to evaluate patient and provider barriers to basic elements of sexual health care, such as taking sexual histories or screening for sexually transmitted infections.

A population-based survey of sexual activity, sexual problems and associated help-seeking behavior patterns in mature adults in the United States of America

To study sexual activity, the prevalence of sexual dysfunction and related help-seeking behaviors among mature adults in the United States of America, a telephone survey was conducted in 2001-2002. A total of 1491 individuals (742 men/749 women) aged 40-80 years completed the survey. Overall, 79.4% of men and 69.3% of women had engaged in sexual intercourse during the 12 months preceding the interview. Early ejaculation (26.2%) and erectile difficulties (22.5%) were the most common male sexual problems. A lack of sexual interest (33.2%) and lubrication difficulties (21.5%) were the most common female sexual problems. Less than 25% of men and women with a sexual problem had sought help for their sexual problem(s) from a health professional. Many men and women in the United States report continued sexual interest and activity into middle age and beyond. Although a number of sexual problems are highly prevalent, few people seek medical help.

Sexual difficulties and help-seeking among mature adults in Australia: results from the Global Study of Sexual Attitudes and Behaviours

Background: The Global Study of Sexual Attitudes and Behaviours was a survey of 27 500 men and women in 29 countries. Here we report the sexual activity, the prevalence of sexual difficulties and related help-seeking behaviour among participants in Australia. Methods: A telephone survey was conducted in Australia in 2001–2002, with interviews based on a standardised questionnaire. A total of 1500 individuals (750 men and 750 women) aged 40 to 80 years completed the survey. The questionnaire covered demographic information, overall health, and sexual behaviours, attitudes and beliefs. Results: Overall, 83% of men and 74% of women had engaged in sexual intercourse during the 12 months preceding the interview, and 38% of all men and 29% of all women engaged in sexual intercourse more than once a week. Early ejaculation (23%), erectile difficulties (21%) and a lack of sexual interest (18%) were the most common male sexual difficulties. The most frequently reported female sexual difficulties were: lack of sexual interest (33%), lubrication difficulties (26%) and an inability to reach orgasm (25%). Older age was a significant predictor of male erectile difficulties and of lubrication difficulties in women. Only a minority of men and women had sought help for their sexual difficulty(ies) from a health professional. Conclusions: Many middle-aged and older adults in Australia report continued sexual interest and sexual activity. Several sexual difficulties are highly prevalent in this population, but those experiencing these difficulties rarely seek medical help. This may be because they do not perceive such difficulties as serious or sufficiently upsetting.

Comorbid conditions in men with ED before and after ED diagnosis: a retrospective database study

Although erectile dysfunction (ED) has been considered a complication of other medical conditions, clinicians and researchers suggest that ED may serve as a clinical marker of vascular health. This retrospective claims study examined the prevalence of predefined comorbid conditions in men with ED (N=301 994) in the 12 months before and the 6 months following ED diagnosis. Consistent with previous research, comorbid conditions were prevalent among men with ED. Comorbid conditions were most often diagnosed before an ED diagnosis, although new diagnoses in the 6 months following an ED diagnosis were common and occured more frequently than new diagnoses in a matched sample of men without ED during the same period. Differences by age, region and insurance coverage for ED medications were also examined. Findings support previous research that suggests ED may serve as a marker for previously undetected comorbid conditions.

Prevalence of sexual problems and related help-seeking behaviors among mature adults in Brazil: data from the global study of sexual attitudes and behaviors

CONTEXT AND OBJECTIVE

Relatively little is known about the usual frequency of sexual activity and how older individuals cope with sexual problems. The objective was to study sexual activity, prevalence of sexual problems and related help-seeking behaviors among middle-aged and older men and women in Brazil.

DESIGN AND SETTING

Population survey, by Fundação Oswaldo Cruz.

METHODS

Interviews were held with 1,199 Brazilians aged 40-80 years (471 men and 728 women). The standardized questionnaire investigated demographics, general health, sexual behavior, attitudes and beliefs.

RESULTS

Overall, 92.6% of men and 58.3% of women had had sexual intercourse during the preceding year. More than half of the men and women had done so more than once a week. Early ejaculation (30.3%) was the commonest male sexual problem, followed by inability to reach orgasm (14.0%), erectile difficulties (13.1%) and lack of sexual interest (11.2%). For women, the commonest sexual problems were lubrication difficulties (23.4%) and lack of sexual interest (22.7%). Depression was a significant correlate of sexual problems, for men and women. More women than men had sought help for sexual problem(s) from a healthcare professional.

CONCLUSIONS

The findings highlight the importance of encouraging greater use of available healthcare services, including consultation with a medical doctor regarding sexual health. This should not only enable men and women to maintain satisfactory sexual function well into their later years, but may also result in overall improvement in the quality of healthcare.

Risk factors for early syphilis among gay and bisexual men seen in an STD clinic: San Francisco, 2002-2003

BACKGROUND

Substantial increases in syphilis among gay and bisexual men have been reported in San Francisco.

GOAL

To identify risk factors for early syphilis infection among gay and bisexual men attending the San Francisco municipal STD clinic (City Clinic).

STUDY

Cross-sectional, self-administered, behavioral survey of gay and bisexual men attending City Clinic between November 2002 and March 2003 linked with electronic medical record data.

RESULTS

Among 1318 gay and bisexual men surveyed, 53 (4.0%) were diagnosed with early syphilis. The final multivariate model included nonwhite race (OR = 2.1 [1.1-4.4]), HIV-infection (OR = 3.9 [2.0-7.7]), using both methamphetamine and sildenafil (Viagra(R)) (OR = 6.2 [2.6-14.9]), using methamphetamine without sildenafil (OR = 3.2 [1.3-7.6]), using sildenafil without methamphetamines (OR = 0.9 [0.3-2.9]), stronger gay community affiliation (OR = 2.3 [1.2-4.6]), and having recent Internet partners (OR = 2.1 [1.0-4.3]).

CONCLUSIONS

Syphilis prevention efforts should address methamphetamine and sildenafil use among gay and bisexual men and require strong and substantive involvement with the gay community to address syphilis in San Francisco.

A study of the management of erectile dysfunction in general practice

BACKGROUND AND OBJECTIVES

The Department of Health issued guidelines for the NHS treatment of erectile dysfunction (ED) with phosphodiesterase type 5 inhibitors (PDE 5 inhibitors) in 1999. There has been an increasing trend in the prescribing of PDE 5 inhibitors within Bebington and West Wirral Primary Care Trust (PCT) over the 3-year period from February 2001 to January 2004. The objective of the study was to investigate implementation of Government guidelines on prescribing of PDE 5 inhibitors for ED and the cost of prescribing outside these guidelines.

METHODS

Practice data were collected for all patients prescribed a PDE 5 inhibitor in 16 surgeries within Bebington and West Wirral Primary Care Trust, from November 2002 to December 2003. The data were evaluated with respect to adherence to UK Government guidelines. Analysis was made on the cost to the PCT with respect to treatment provided outside the guidelines.

RESULTS AND DISCUSSION

Prescribing for 78% of patients was within Government guidelines. With respect to frequency of prescribing, 89% of patients in the PCT received less than or equal to the recommended frequency of one tablet per week. The percentage range for practices was 67-100%. The cost to the PCT for PDE 5 inhibitor treatment provided outside the guidelines was 19,060 pounds sterling over the period of study.

CONCLUSION

Prescribers generally follow Government guidelines, however, stricter adherence to guidelines could result in more efficient use of National Health Service resources.

Prevalence of female sexual dysfunction symptoms and its relationship to quality of life: A Japanese female cohort study

OBJECTIVES

To clarify the age prevalence of female sexual dysfunction and the factors that contribute to the varying frequency of sexual intercourse and satisfaction with sexual life in Japanese women.

METHODS

Of 8956 participants (median age 57 years, range 17 to 88) in a Japanese female cohort study, 5042 (56.3%) responded. We evaluated 2095 women aged 30 to 69 years (median 48) who completed a questionnaire that queried about their sexual life.

RESULTS

When women in their 30s were compared with those in their 60s, we found that the prevalence of the symptom of orgasmic disorder, sexual desire disorder, arousal disorder, and lubrication disorder had increased significantly from 15.2% to 32.2%, 27.7% to 57.9%, 29.7% to 57.9%, and 12.5% to 51.2%, respectively. Multivariate analysis showed that the rigidity of the partner's erection, orgasm, and arousal contributed significantly to sexual frequency and foreplay and orgasm to satisfaction with sexual life.

CONCLUSIONS

The prevalence of female sexual dysfunction increased with age. The results of multivariate analysis indicated that favorable sexual function is important to maintain the opportunity for sexual intercourse in both men and women and that foreplay and orgasm are essential for satisfactory sexual life in women.

Clinical Evaluation and Management Strategy for Sexual Dysfunction in Men and Women

INTRODUCTION

The optimal approach for identification and evaluation of the sexual problems in men and women in primary care or general medicine practice has not been consensed.

AIM

To provide recommendations/guidelines concerning state-of-the-art knowledge for clinical evaluation and management strategies in the evaluation and treatment of sexual dysfunction in men and women, emphasizing evidence-based medicine and a patient-centered framework.

METHODS

An International Consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five continents developed in a process over a 2-year period. Concerning the Clinical Evaluation and Management Strategies Committee, there were 12 experts from five countries.

MAIN OUTCOME MEASURE

Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation and debate.

RESULTS

Three concepts underlie sexual medicine management: (i) adoption of a patient-centered framework for evaluation and treatment; (ii) application of the principles of evidence-based medicine in diagnostic and treatment planning; and (iii) use of a unified management approach in men and women. When taken together, these three principles provide a balanced and integrated approach to sexual dysfunction management. Common algorithms for diagnosis and management of men and women with sexual dysfunction, brief sexual symptom checklists, basics in history and physical examination, indications for specialized referral and development of a follow-up strategy are presented.

CONCLUSIONS

More research is needed in understanding the role of evidence-based and patient-centered medicine in the clinical evaluation and management strategies of men and women with sexual dysfunction.

Medical therapy for benign prostatic hyperplasia: sexual dysfunction and impact on quality of life

Therapies for benign prostatic hyperplasia (BPH) may either improve or exacerbate sexual function with an ensuing impact on quality of life. Here we review a total of 73 papers on medical therapies for BPH with a focus on the effects of different pharmacological agents on sexual function. For example, certain alpha(1)-adrenergic receptor blockers may improve erectile function; however, ejaculatory dysfunction with one of these agents, tamsulosin, occurs at a rate of 4-18%, rising to 30% with long-term use. In addition, treatment with the 5 alpha-reductase inhibitor finasteride is associated with problems of ejaculation (2.1-7.7%), erection (4.9-15.8%), and libido (3.1-5.4%). Such significant and undesirable complications in relation to sexual function produce a well-documented negative impact on quality of life. Thus, optimal treatment for men with BPH requires the use of agents that demonstrate efficacy and safety with fewer sexual side effects.

Anxiety and erectile dysfunction: a global approach to ED enhances results and quality of life

Anxiety plays a major role in the development of the problems associated with erectile dysfunction (ED). Psychological and behavioural responses to ED can lead to a vicious cycle of increased uneasiness, distance and conflicts. This in turn leads to a lower frequency of sexual encounters, less time spent together and lack of communication between partners in a relationship. In this review, methods to decrease sexual anxiety are discussed. Primary care psychosexual counselling including a detailed explanation of ED, reassurance to the patient and proposal of a solution for ED are outlined. A multidisciplinary approach to ED therapy is recommended using psychosexual counselling in conjuction with pharmacotherapy.

Adult-onset idiopathic hypogonadotropic hypogonadism presented with erectile and ejaculatory disorder

A 37-year-old man who had fathered a child five years previously presented with erectile and ejaculatory disorder. Endocrinological examinations revealed isolated luteinizing hormone-releasing hormone (LHRH) deficiency of hypothalamus, resulting in hypogonadotropic hypogonadism, and no causative abnormality was detected in imaging studies, including magnetic resonance imaging (MRI). Having a diagnosis of adult-onset hypogonadotropic hypogonadism, the patient received pulsatile subcutaneous administration of gonadotropin-releasing hormone (GnRH). Sperm analysis and serum level of testosterone improved to normal in a few months. His wife became pregnant using artificial insemination with her husband's semen 15 months after the beginning of the treatment.

A new tool for predicting erectile dysfunction

The Sexual Health Inventory for Men (SHIM) is an effective way to assess erectile difficulty (ED). Despite documented efficacy, however, many physicians may be reluctant to incorporate it into clinical practice because of the intimate nature of the questionnaire. In an attempt to devise and test an easy-to-use computer-based SHIM score indicator for office use, more than 30,000 SHIM questionnaires were administered to men visiting physicians' offices in 2000. Information about age, current smoking status, diabetes, depression, hypertension, prostate disease, and cholesterol levels was also collected. A logistic regression model with a sensitivity of 81.8% and a specificity of 57.7% was created to predict the likelihood of ED in a patient scoring below 21 (SHIM definition). This model was built into a highly graphic Windows-based program. The SHIM score indicator is a convenient way to rapidly identify patients at high risk for ED who should be further assessed.