THE PHYSICIAN'S ROLE IN DEALING WITH MEN'S SEXUAL HEALTH CONCERNS.
Abstract: Sexual health issues should be a part of all medical exchanges between physicians and their male patient. Many patients are hesitant to initiate discussions regarding sexual problems, and physicians tend not to ask about sexual health as a matter of routine. Common difficulties include premature and delayed ejaculation, lack of desire and erectile dysfunction.
Subject: Sex research (Research)
Sexual disorders (Care and treatment)
Impotence (Care and treatment)
Men (Health aspects)
Premature ejaculation (Care and treatment)
Author: Holzapfel, Stephen
Pub Date: 09/22/1998
Publication: Name: The Canadian Journal of Human Sexuality Publisher: SIECCAN, The Sex Information and Education Council of Canada Audience: Academic Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 1998 SIECCAN, The Sex Information and Education Council of Canada ISSN: 1188-4517
Issue: Date: Fall, 1998 Source Volume: 7 Source Issue: 3
Geographic: Geographic Scope: Canada Geographic Code: 1CANA Canada
Accession Number: 53867966
Full Text: ABSTRACT: Although sexual health concerns are common in men of all ages, many men are reluctant to bring up sexual health issues with their physicians, and many physicians do not routinely inquire about these important aspects of their patient's health and well-being. This paper suggests ways physicians can effectively manage male sexual health problems with particular emphasis on low sexual desire, rapid ejaculation, delayed ejaculation, and erectile difficulties. It describes an integrated approach that incorporates medical, psychological, and couple factors. Case studies involving heterosexual couples in which the male partner presented with a sexual dysfunction are outlined.

Key words: Physicians Male sexual health Patient concerns Sex therapy

INTRODUCTION

There are many reasons why doctors should raise and discuss sexual health topics with their male patients. Erectile difficulties, rapid ejaculation, lack of desire, and anxieties about performance are associated with medical conditions for which a man might routinely consult a physician (diabetes, stroke, emphysema, heart disease, stress). Indeed, sexual symptoms may be indicators of other health problems (Diokno, Brown & Herzog, 1990; Wabrek & Bruchell, 1980). Research suggests that men expect their physicians to address sexual concerns, and prefer physicians over other health professionals for discussion of such issues should this be necessary (Metz & Siefert, 1990). It appears that sexual concerns are under-diagnosed by physicians. For example, Read, King and Watson (1997) found that although 70% of a sample of male patients felt sexual health issues were appropriate for discussion with their general practitioners, and 35% reported one or more sexual concern, only 2% had a notation on their charts indicating consultation about a sexual concern. This missed opportunity is important, because properly trained physicians can have a positive impact on their patient's well-being through effective diagnosis, treatment, and/or referral of sexual health problems (Holzapfel, 1993).

The literature indicates a continuing high prevalence of sexual problems in men, particularly among older men (Feldman, Goldstein, Hatzichristou, Krane, & McKinlay, 1994; Laumann, Gagnon, Michaels, & Michael, 1994; Moore, 1980; Spector & Carey, 1990). Since such difficulties can have a concomitant negative effect on relationships and individual well-being, the role of physicians in diagnosis and treatment warrants attention. This is particularly so in the current context of public discussion of new oral medications for erectile difficulties (sildenafil, e.g., Viagra[TM]) (Goldstein, Lue, Padma-Nathan & Rosen, 1998). The demand to prescribe and explain this and other such medical interventions may lead physicians who have been traditionally hesitant to address sexual concerns of patients (Bowman, 1989) to now do so more fully and directly. This will mean discussing the varied medical, psychological, and interpersonal factors that can cause, reinforce or accompany sexual difficulties. It may also mean more frequent referral to or consultation with sex therapists, as patients seek help for underlying psychological and/or relationship issues that have been brought to the surface by the man's desired or actual use of erection-enhancing medication (Guirguis, 1998).

This paper discusses ways that physicians can include sexual health care in the management of their male patients, identifies some of the obstacles they may encounter in attempting to do so, and suggests ways to avoid or overcome the most common pitfalls. Since men generally present to physicians with conditions that have an impact on desire, arousal and/or orgasm, my examples generally emerge from a biomedical condition and broaden to encompass psychological well-being, relationships, and other dimensions of sexual health.

HOW PREVALENT ARE THE COMMON SEXUAL CONCERNS THAT PHYSICIANS MAY SEE IN PRACTICE?

In their recent review of empirically validated outcome studies on treatment of sexual dysfunction in both sexes, Heimen and Meston (1997) cite the National Health and Social Life Survey (Laumann et al., 1994) as the only national randomly sampled U.S. population study of the prevalence of sexual dysfunction in both sexes. Since there have been no similar large-scale population studies of the prevalence of sexual problems in Canada, researchers have tended to generalize from U.S. data (e.g., Feldman et al., 1994; Spector & Carey, 1990). Such comparisons may be unreliable, but in the interest of a rough estimate, Laumann et al. (1994) found in a sample of over 3,400 women and men 18-59 years of age that rapid ejaculation (39%), performance anxiety (17%) and lack of sexual interest (16%) were the most commonly reported sexual problems among men. Among the sexual problems for which men seek medical care, erectile difficulties predominate. Not surprisingly, the prevalence of such difficulties increases with age. Feldman et al. (1994) found that 52% of a sample of healthy 40-70 year old men reported they had some level of erectile difficulty. The presence of the symptom need not imply that the man perceives this as a major problem; however, the number of those that do suggests that such issues have a large impact on male sexual health, and that physicians address only a fraction of the readily treatable and preventable medical, personal, and relationship consequences.

Among women, Laumann et al. (1994) found lack of sexual interest (33%) and orgasmic difficulties (24%) to be the most common concerns. These figures are worth noting because of the impact that one person's sexual problems can have in causing or reinforcing problems in the partner. Indeed, sexual function in couples is influenced by the interplay of relationship factors, each partner's psychological status, and each person's physical condition and health. Treatment of sexual difficulties and dysfunctions is most likely to be successful when each of these factors is addressed (Hanash, 1997). Sex therapy must therefore integrate marital and relationship therapy, psychotherapy, and the use of psychoactive medications and other medical therapies, including drug and surgical treatments.

WHY SHOULD DOCTORS RAISE AND DISCUSS SEXUAL HEALTH ISSUES WITH THEIR MALE PATIENTS?

The changing arena of public discussion and expectation about sexuality makes it increasingly important for physicians to engage patients on sexual health issues. The growing use of new biomedical methods in the treatment of sexual problems has placed physicians in the position of "gatekeepers" to access. Physicians are often more comfortable when the patient is an individual rather than a couple, and many feel insufficiently trained to do individual, let alone couple, counselling or therapy on sexual issues. That being said, physicians are quite used to providing brief, effective, educational and supportive counselling for patients and their partners for a variety of medical conditions (e.g., newly diagnosed diabetes mellitus, coronary artery disease). These skills can also be applied to sexual medicine.

Knowledge about sexual physiology has grown dramatically in the three decades since Masters and Johnson (1970) did their pioneering work. At that time, it was felt that sexual problems were primarily due to psychological and/or couple-relationship factors. This is not so today. One multidisciplinary assessment of couples dealing with sexual concerns found that physical/physiological factors were present for at least 33% of men and 10% of women presenting for sexual counselling (Catalan, Hawton, & Day, 1990). This suggests that physicians should look for medical factors when the presenting problem is sexual and vice versa. Medical conditions' affecting cardiovascular, endocrine, psychological and neurological function are among factors that can give rise to sexual problems (see Gajewski, 1998; Feldman et al., 1994). When this is the case, primary care physicians are in a good position to help patients identify and address the physical and psychological factors involved. This is what individuals and couples dealing with sexual dysfunction are looking for (Watters, Lamont, Askwith & Cohen, 1985).

In a now classic study, Ende, Rockwell and Glasgow (1984) undertook a controlled trial of sexual history-taking in a general medicine outpatient department. In contrast to the "usual care" physicians, the "study" physicians expressly asked patients if they had any sexual concerns. The study group uncovered new and important medical information in 26% of patient interviews, a discovery which resulted in changes to medical treatment in 16% of these patients.

Iatrogenic side effects of treatment for medical conditions is a common cause of erectile and desire problems for men (Medical Letter, 1992; Finger, Lund & Slagle, 1997; Gajewski, 1998). Patients will only rarely volunteer that they are having such sexual side effects, and physicians who do not ask may contribute to non-compliance with medication. A variety of medications, including drugs for cancer and heart disease, antipsychotics, and the serotonin-specific reuptake inhibitor (SSRI) antidepressants, have been shown to affect arousal, desire, and/or ejaculation in as many as 72% of patients (Lane, 1997; Modell, Katholi, Modell, & DePalma, 1997; Rosen, 1997). Physicians who address sexual issues with their patients may be able to uncover such side effects and suggest ways to deal with them (e.g., alter medication; adjust dose; accommodate effect by altering timing or dosage of medication; suggest alternate type of sexual activity).

Another important and often neglected role for physicians comes in identifying the effect of a partner's illness on a patient or vice versa. For example, a longitudinal study on men whose partners were to undergo treatment for cervical or endometrial cancer found that the men were in psychological crisis at the time of their partner's diagnosis, and that this gradually declined over the year following treatment to be replaced by psychosomatic symptoms and increased interpersonal and communication problems with their partners (Lalos, Jacobsson, Lalos, & Stendahl, 1995). Many of the men said they had only limited information about their partner's illness, and a majority said they had no one to talk to about this or about the impact of their partner's illness on them. A majority reported reduced sexual desire that lasted well past the initial crisis stage.

The changing age structure of the population is another reason for physicians to raise and discuss sexual issues. More people are living longer, and the absolute number and proportion of men and women over 65 is growing. Many seek to remain vigorous and active in later life, and quality of life concerns have thus become increasingly important in medical therapy (Croog, Levine & Testa, 1986). These concerns include sustained and satisfying sexual relationships.

HOW CAN PHYSICIANS BE MOST EFFECTIVE IN ADDRESSING THE SEXUAL CONCERNS OF THEIR PATIENTS?

Physicians come to the task of counselling patients about sexuality with the same spectrum of early learning, personal experience, comfort or discomfort, attitudes and values as their patients. To the extent that social taboos have made it difficult for many of us to openly discuss what is generally thought to be a private area, reticence on both parts is not surprising or uncommon.

Physicians may fear that asking sexuality-related questions, even when they are pertinent to the presenting problem, may open a "Pandora's Box" of issues that will expose patients to emotional pain on the one hand, and expose the physician's possible inability to help on the other. That being said, most patients' sexual concerns can be met with the provision of information and practical suggestions for interventions. One study found that 80% of such problems can be dealt with in the primary care physician's office, with only 8% requiring referral (Kligman, 1991).

Given the great amount of information that medical students and residents need to digest in their training, sexual health care courses and content may be variable, too brief, and vulnerable to curriculum change in the face of "more pressing" topics. The time demands of practice may reinforce the tendency to skip over topics that, if not raised by the patient, will not have to be addressed.

Nevertheless even a few simple screening questions that acknowledge the patient as a sexual being may give permission to raise such topics on future visits. These include:

* Are you currently in a relationship?

* Are you sexually active?

* Have you had sex with men, women or both?

* Many people have sexual concerns. I wonder what yours might be?

I have already noted that inclusion of such questions as part of any routine check-up can yield useful medical information (Ende et al., 1984). However, sexual health topics can be raised in the context of discussions about obviously related issues such as contraception, STD prevention or men's interactions with their children in relation to sex education. Referral to reading on selected topics can be a starting point for subsequent discussion.

Medical training appears to place heavier emphasis on some sexual health topics than others. Major public health issues such as HIV/AIDs and STD prevention, sexual assault/sexual violence, child sexual abuse, and teen pregnancy prevention, may thus get more attention than sexuality in couple relationships, sexuality and aging, gay/lesbian/ bisexual issues or sexuality in illness and disability. Each of these latter areas has its own constellation of sexual health issues that may warrant attention with male patients.

For example, Cornelson (1998) describes some of the characteristic sexual health issues that gay and bisexual men may face specifically because of their sexual orientation. Being gay or bisexual in our heterosexist, and often homophobic, culture can make it difficult to access supportive health care, particularly for younger men in smaller communities who are dealing with the prospect of coming out to family and friends. Many gays will avoid regular health care for fear of discrimination. The added pressure of social stigmatization can increase their risk of depression, substance abuse and suicide attempts (Bagley & Tremblay, 1997; Faulkner & Cranston, 1998). In some settings, access to HIV/ STD prevention, hepatitis B vaccination, and related sexual health care and counselling may be restricted.

IDENTIFYING AND TREATING MALE SEXUAL PROBLEMS IN MEDICAL PRACTICE

The link between medical conditions and sexual problems is a key area in which physicians are increasingly expected to intervene. Since the literature indicates that men look to physicians as their preferred source of help with these issues (Metz & Siefert, 1990), I want to identify the needs and expectations that patients bring, and the circumstances under which physicians might treat, refer to a specialist in sex therapy or do both.

While the medicalization of the treatment of erectile difficulties has shifted the focus of this aspect of male sexual health care to penile function, it is also important for physicians to address the context of sex for men and their partners. The actions, reactions, and expectations of both partners have an impact on blood flow to the penis, and patients will benefit when physicians integrate the emotional and relationship aspects that can cause or reinforce sexual concerns (Basson, 1998).

Many single men with sexual dysfunctions have great difficulties in establishing intimate relationships. Concerns about rejection by potential partners due to sexual incompetence can overwhelm a man's attempts at dating. Sexual and social avoidance may serve to magnify erectile, ejaculatory or other sexual difficulties. In one study of single men with such concerns, group therapy that combined sexual therapy with interpersonal skills training improved sexual and relationship function in 70% of the men, with comparable or greater levels of improvement reported at one year of follow-up (Stravynski et al., 1997).

The following sections describe issues related to the diagnosis and treatment of reduced sexual desire, erectile difficulties, and rapid and delayed ejaculation. The accompanying case studies give examples of the issues that physicians may encounter in practice. The names and other potentially identifying characteristics of the patients have been changed. Space limitations preclude detailed examination of treatment methodology. Because these examples come from a family physician who specializes in sex therapy, they probably reflect a greater level of involvement in such issues than is usual for physicians. However, they also reflect a large unmet need for treatment, and a domain in which physician training and practice is therefore welcome. I have chosen to deal with male sexual dysfunctions and their sequelae because they require many of the interviewing and counselling skills used in addressing other sexual health issues that physicians often encounter (see Metz & Miner, 1998; Cornelson, 1998; Gajewski, 1998).

REDUCED SEXUAL DESIRE

Decreased sexual desire is among the most common of sexual dysfunctions for both men and women, with 1 in 3 women and 1 in 7 men meeting the criteria for Inhibited Sexual Desire (McCarthy, 1997). Men's interest in sex declines gradually beyond the fifth decade of life, though at least a quarter of men are still interested in regular sexual activity (more often than monthly) into their eighties. Men are more likely to complain of decreased erectile function than decreased desire, though both may be present. Desire disturbances are more likely to cause difficulties when there is a sudden change in sexual frequency for a couple, rather than a gradual decline. Many older couples adjust to an absence of intercourse in the later decades of their lives together and continue to remain close physically and emotionally, while for others it is a concern. Men are often too embarrassed to bring up the topic with their physician even if it is of concern to them.

Decreased desire is frequently due to relationship strife, but has many medical causes as well (see Case 1). Sex demands some level of physical exertion. As physical stamina is drained through deconditioning and illness, desire can be adversely affected. Medication effects are common, including those from polypharmacy, especially for chronic illness in the elderly (Metz & Miner, 1998; Gajewski, 1998). Yet sexual function can remain a dominant concern even for patients dealing with severe end-stage illnesses, such as advanced heart failure (Jaarsma, Dracup, Walden & Stevenson, 1996). With New York Heart Classifications of stage III and IV, 73% of patients reported decreased, or absent, sexual desire, and 81% reported functional problems in sexual performance. In patients awaiting heart transplantation (where many might feel sexual concerns would be extraneous or superficial concerns), decreased sexual function was 1 of the 5 most distressing symptoms they faced (Grady, Jalowiec, Grusk, White-Williams & Robinson, 1992).

Case 1 Decreased Desire and Erectile Dysfunction

Janet, a 35 year old lawyer, saw her family physician for a check-up and pap smear. She had known her doctor for many years. The encounter went uneven(fully until she asked about Janet's marriage of three years, upon which Janet began to cry. Janet had known Michael for two years before deciding to get married. They enjoyed a positive sex life with neither of them having any concerns either prior to or after the wedding. Both had had intercourse before they met and neither had experienced previous sexual difficulties. After the first year of married life, their sexual frequency had gradually declined, a fact which Janet had ascribed to the normal course of events. By the end of the second year, they were having sex less than once every two months, and on these infrequent occasions, Michael found it increasingly difficult to have or maintain an erection. This difficulty, which had led him to withdraw more and more from intimacy with Janet, had led her to fear that Michael did not find her attractive, and that he might be having an affair.

Janet's doctor suggested that Michael see a physician, something he had not done in many years. On examination, he was found to be fit with no obvious abnormalities. He was not depressed, although he was concerned about wanting to please Janet. He denied any affairs and said, in fact, that he felt he had no interest in sex with anyone. He was embarrassed at not getting erections with Janet, but had also noticed fewer with masturbation, and none on waking for the last two years.

Janet had urged Michael to make the appointment and had accompanied him. A brief assessment revealed a couple in which each partner cared for, and was concerned about the other. There was no apparent marital discord that could explain their loss of sexual contact and/or Michael's gradually appearing lack of desire and arousal.

Laboratory investigations (see Buvat & Lemaire, 1997, for details of endocrine screening for erectile problems) showed a low normal free testosterone, normal thyroid indices, and a grossly elevated prolactin level. He was diagnosed as having hyperprolactinemia secondary to a pituitary tumour, which caused a mild lowering of his testosterone, though not out of the normal range. His luteinizing and follicle stimulating hormones were all low normal. An MRI scan revealed a 1.5 cm tumour in his pituitary gland. This was removed neurosurgically, and by 3 months thereafter he and Janet had gradually resumed sexual activity once every 1-2 weeks.

Men at risk for lowered desire from such conditions need physicians to give them the invitation to raise these issues since they seldom bring up their concerns unprompted. Routine questioning about sexual concerns can reveal such problems. Patients whose diagnoses and/or medications can have an impact on sexual desire offer physicians an obvious avenue to raising and exploring this and related sexual health issues (see Case 2).

Case 2 Infertility and Decreased Desire

Mohammed and Fatima, a couple in their late thirties who have been married for 10 years, immigrated to Canada from the Asian subcontinent 3 years ago. They have been trying to get pregnant for the last 2 years.

They had met only twice before an arranged marriage set up by their families, and neither had had sexual intercourse before they married. Sex had been good initially, and then gradually more and more infrequent over the years. This was attributed to Mohammed's absences while working abroad to support the family. On coming to Canada, he had been working two jobs while Fatima was taking English language courses. They had been suffering under increasing tension since coming to Canada, due to financial pressures, social isolation, and difficulties in adjusting to a new society. Fatima was increasingly blaming Mohammed for these problems, and for the virtual absence of sex in their relationship. She had gone to her doctor to discuss fertility concerns, for which she blamed herself. They had not had intercourse in over a year. She was otherwise well.

Mohammed agreed to be seen as part of a work-up for Fatima's infertility. He was aware of a decline in his sexual interest, but this did not particularly concern him, except for the pressure from Fatima to have a baby. His medical review and exam was normal, although he had gained about 40 lbs since coming to Canada. He felt tired, but blamed this on working two jobs. He did not appear depressed. His penis and testes were normal, his neurological exam showed mildly slowed reflexes.

The couple presented as wanting a baby. There was some marital tension present but, based on their culture, they felt they had no option other than staying together. Fatima appeared trapped, with limited options, while Mohammed was trying to carry the financial and emotional burden for the couple.

Laboratory investigations revealed normal prolactin and testosterone levels. His thyroid stimulating hormone level was elevated, thus indicating moderately decreased thyroid activity. Other tests for liver and renal function were within normal limits.

Thyroid replacement therapy was started. Mohammed's desire increased over the first month of talking the medication to the point of having sex about once weekly. The couple were helped in connecting to community resources from their own culture, a solution which helped both feel less alone. Fatima found work with a group of women from her province back home.

After three months the levothyroxine prescription ran out, and Mohammed's desire waned over a period of three weeks. On restarting medication, he regained his desire gradually. This experience reinforced his intention to continue with the medication uninterrupted. The couple went on to have two successful pregnancies.

ERECTILE DYSFUNCTION

The management of erectile dysfunction has historically been polarized between treating "organic" and "psychogenic" causes. Initial treatments for erectile dysfunction were based on individual psychotherapy (Freud, 1905/1963), followed in the 1970s with the evolution of couple sex therapy (Kaplan, 1981). With our increasing understanding of the mechanisms of erection, therapeutic options have become more medicalized and now include injection of prostaglandin (Gingell, 1998; Jeunemann, Manning, Krautschick & Alken, 1996), intraurethral alprostadil (e.g., MUSE; Padma-Nathan et al., 1997), and phosphodiesterase inhibitors of which sildenafil (Viagra[TM]) is the first to be used clinically (Eardley, 1998; Goldstein et al., 1998).

The enthusiasm for these newer therapies has frequently overshadowed the need for treating these men in the context of their couple relationships and individual lives. Drug therapy can frequently help produce erections independent of whether the cause of the erectile problem was organic or psychogenic. While this can be reassuring for some men with psychogenic erectile difficulties, this therapy alone does little to address other psychological issues. The reality is that men with erectile dysfunction, whatever the cause, are likely to experience some anxiety about their sexual function. It follows that treatment of erectile dysfunction should address couple issues since failure to do so can limit success in improving the couple's sex life, even when erectile function is restored (Hanash, 1997; see also Basson, 1998).

Couple factors are frequently important in treating erectile dysfunction. The partner may be supportive of the man's search for an effective therapy or may sabotage solutions for personal reasons. "Solving" the erection problem may reveal other issues, including the partner's physical and emotional state around sexuality. Given that erectile dysfunction is often an age-related phenomenon, many partners of these men may themselves be perimenopausal or menopausal. If sexual intercourse has been absent from these relationships for a number of years, then the women are likely to suffer from dyspareunia due to their vaginal atrophy. Although this issue could be addressed with estrogen supplementation either parallel to or even before the restoration of erections, it is the overall perspective of the partner, not just vaginal function, that is important (see Case 3).

Case 3 Erectile Dysfunction

Maria, aged 62, and John, aged 67, were generally in good health, though John required Enalapril (Vasotec[TM]) 40 mg and Hydrochlorothiazide (HydoDiuril[TM]) 25 mg daily to control his blood pressure. Maria had generally been well, and was taking no medication. She had recently recovered well from an episode of Bell's palsy (unilateral facial weakness). During a checkup after the Bell's Palsy, she was asked about her sexual function, and she revealed that they had not had sex in the last 8 years of their marriage because of his erectile problems. The few times they had managed to have intercourse in the initial years of their relationship had generally been less than satisfactory. This concerned her, but she had never discussed this with anyone, it was embarrassing for her, and "besides doctor, what could be done?" Maria was invited to bring her husband to the next appointment.

John was initially upset that Maria had discussed "private matters" outside of the marriage. He was reassured when he learned that erectile dysfunction was a common consequence of having hypertension. His past health revealed that he had never smoked, had no diabetes nor high cholesterol, but that his father had had a heart attack at age fifty. John's erections had been normal until his late forties, when he started having gradual erectile problems with his first wife Barbara. He had attributed this decline to Barbara's having developed breast cancer from which she died when John was in his mid-fifties. He had complete erectile dysfunction in the last few years of their marriage. This problem persisted with two subsequent partners prior to his meeting Maria. Physical examination showed him to look fit, with a well controlled blood pressure of 135/85. His genitals were normal. Otherwise his examination showed no evidence of cardiovascular, endocrine or neurological problems. Laboratory testing showed normal blood sugar, free testosterone, prolactin, thyroid, liver function and cholesterol.

Options of using injection therapy, vacuum tumescence devices, and the possibility of a penile implant were discussed with the couple, and John chose injection therapy, which provided a moderate to good erection with 15-20 ug of prostaglandin[E.sub.1] (Caverject[TM]). They were both excited to try this at home.

They returned for follow-up 2 weeks later looking upset. John had been able to self-inject and successfully achieve a satisfactory erection. Maria was not able to get aroused and lubricated in the haste with which they had attempted intercourse, with the resulting pain stopping the sexual encounter. Subsequent attempts were similar, even though they focused more on Maria. On examination, Maria had moderately severe vaginal atrophy. She was also angry with John, though she had not been able to express this to him directly. She revealed that her previous marriage had been an unhappy one, and sex had generally not pleased her, though she denied any painful intercourse previously. The couple was treated with Maria's receiving intravaginal estrogen followed by oral combination hormone replacement with estrogen and progesterone. Over 4-6 sessions, the couple worked on a number of communication issues. John became more aware of Maria's concerns, something he had never bothered to do before. Maria was surprised at John's interest, and ability to change in response to her more direct requests. The couple eventually established comfort with the injection procedure and enjoyed intercourse once every 1-2 weeks.

Goldstein et al.'s (1998) study on using sildenafil in men with erectile dysfunction found a 69% success rate in attempts at intercourse. Partners were questioned only to corroborate the men's self-report data. There have been no data reported on the effect of sildenafil on the partner's sexual satisfaction, though the high rate (92%) of continued participation in an open label extension trial showed that the men, at least, appreciated having the drug available to them. It is anticipated that the advent of this less invasive treatment for erectile dysfunction, when properly integrated in an overall treatment plan, will improve outcomes (see Basson, 1998). Hopefully, compliance and long-term results for couples will also improve.

Sildenafil has shifted the management of erectile dysfunction from a specialist focus to that of the family physician (see Casey, 1998). Besides helping produce better erections, the prescribing of an oral sexual medication gives the physician the opportunity to help explore the man's sexual relationship, and support him in dealing with the individual and couple issues that are often present. Many men will choose to only use medications, while others will benefit from pursuing further therapy (such as individual, marital or sex therapy) for their problems.

PREMATURE OR RAPID EJACULATION

Premature or rapid ejaculation is the most common of the male sexual difficulties with an incidence as high as 3138% (Read, King & Watson, 1997; Spector & Carey, 1990). The possible causes and treatments are varied and have been extensively reviewed (Grenier & Byers, 1995, 1997; Metz, Pryor, Nesvacil, Abuzzahab & Koznar, 1997; Rowland & Slob, 1997). Defining premature or "rapid" ejaculation is not merely a timing issue, but rather involves an interplay between both members of a couple, with some partners's wanting longer intercourse than others. Rapid ejaculation is not present when both members of the couple are happy with the length of time that intercourse lasts. Rapid ejaculation is correlated with female sexual problems, such as preorgasmia.

Rapid ejaculation is generally thought of as a psychogenic problem induced by performance anxiety. Most sex therapies focus on decreasing anxiety through "non-demand sensate focus" massage and graduated masturbation "stop-start" exercises to help the man become aware of the point of ejaculatory inevitability. Introducing the partner in the exercises, and step-by-step reintroduction of vaginal containment of the penis (the "silent vagina") with increased thrusting is the mainstay of traditional therapy (Zilbergeld, 1992).

The advent of serotonin-specific reuptake inhibitor (SSRI) antidepressants has led to new treatments for rapid ejaculation (see Case 4). While justly criticized for their detrimental effect on desire, erectile function, and causing delayed ejaculation in sexually healthy men (Modell et al., 1997), they have proven their effectiveness in the treatment of rapid ejaculation (Balon, 1996; Kim & Seo, 1998; Lee, Song, Kim & Choi, 1996; Waldinger, Hengevel & Zwinderman, 1997).

Case 4 Rapid Ejaculation

Gordon, aged 57, and Flora, aged 42, had been married for 6 months when they sought help for Gordon's rapid ejaculation. This was described as occurring within about 15-30 seconds of insertion, and occasionally before insertion. Gordon had tried drinking alcohol to delay ejaculation, but the slightly longer duration of intercourse came at the cost of reduced firmness and predictability of erection. Both were very frustrated, with Gordon worried that Flora would leave the marriage.

Gordon had previously been married to Jean for 25 years and had two adult children. Gordon felt he had had no sexual problems previously with Jean. They had been virgins when they had met and knew little about sex. The marriage had been strained for most of the time, with no sex for the last 10 years. Gordon had met Flora and "had been seduced" by her at a business meeting. Sex had been unsatisfactory initially, but improved somewhat over the following months, when Gordon decided to leave the marriage for Flora. He felt uncomfortable pleasing Flora with oral or manual sex, and she wished for more intercourse.

Flora had never been married, but had had a series of long-term relationships, two of which had been with married men. Her mother had died when she was seven, and her father was frequently away on business, leaving much of her rearing to a governess. Flora left home at 18 to study at university and only rarely saw her father again. She stated that she liked sex and enjoyed the attention of men; this was what made their current situation so difficult. She presented in a coquettish and seductive manner, while Gordon evidenced discomfort both with his rapid ejaculation and with Flora's manner in the interview.

The initial treatment tried to reduce his performance pressure while exploring the couple interaction. Flora only gradually saw that Gordon's perception of the expectation he associated with her sexual demands was contributing to his rapid orgasms. Gordon slowly expanded his sexual repertoire and his comfort in stimulating Flora, while becoming more relaxed in letting her touch him. Stop-start masturbation exercises were of only limited benefit. Gordon was eventually able to maintain intercourse for a few minutes at a time but Flora found this very frustrating because Gordon often needed to stop moving just as she wanted more thrusting. Therapy ended on this disappointing note.

They returned for follow-up about two years later, at which point the SSRI antidepressants had become available. The use of 50 mg Zoloft[TM] allowed Gordon to gain better control of his ejaculation, to the point that he felt he could move freely with intercourse. Both were happier with this solution, though the pattern of their sexual interaction persisted with Gordon's feelings of sexual inadequacy being reinforced by Flora, albeit in somewhat attenuated form.

Kim and Seo (1998) compared fluoxetine (Prozac[TM]), sertraline (Zoloft[TM], and clomipramine (Anafranil[TM] and placebo in a double-blind study for the treatment of premature ejaculation. Clomipramine (a tricyclic antidepressant) lead to the greatest sexual satisfaction for the study subjects (52%), followed by sertraline (41.7%), fluoxetine (25%), and placebo (19.4%). Measures of satisfaction were statistically different between all groups. All drugs and placebo increased length of time of intercourse; sertraline 4.3 minutes, clomipramine 5.8 minutes. Fluoxetine at 2.3 minutes was no different from placebo at 2.3 minutes. Clomipramine had nearly twice the side effect rate of either fluoxetine or sertraline (64% vs. 36 and 33% respectively.)

Use of paroxetine (Paxil[TM]) in a double-blind, dose-response trial of 34 men improved quite severe premature ejaculation (mean of 13 seconds at baseline) to 5 minutes at 8 weeks on 20 mg; and 9 minutes on 40 mg (Waldinger, Hengevel & Zwinderman, 1997). There was strong partner agreement with these results. Improvements were seen within the first week of treatment, in contrast to the usual lag time of weeks seen in antidepressant effect. Patients complained of yawning, sweating, fatigue, nausea and dry mouth, all of which decreased over the trial. One patient had decreased erectile function, but none complained of any effects on sexual desire. This study can be criticized for not having included a placebo control group.

The number of studies that are placebo-controlled and double-blinded are currently small and have few subjects. Besides comparing new medications with each other and placebo control, long-term studies are needed to look at effectiveness of these treatments over time. How do different drug therapies compare with each other and with sex therapy alone? What does the combination of SSRIs and sex therapy add to the long-term sexual satisfaction of patients and their partners? While early sex therapy for rapid ejaculation reported success rates over 90% (Masters & Johnson, 1970), more recent long-term studies of outcomes after 3 years show poor maintenance of ejaculatory control and sexual satisfaction with sex therapy alone (Metz, Pryor, Nesvacil, Abbuzzahab, & Kozner, 1997).

The elucidation of serotonin-mediated central neurons is beginning to lead to a better understanding of the mechanisms of rapid ejaculation, at least in rats and monkeys (Robinson & Mishkin, 1966; Yells, Prendergast, Hendricks & Nakamura, 1994). These results are showing that rapid ejaculation is not simply a learned behaviour or anxiety, but similar to erectile dysfunction, involves the interplay of psychic and neurophysiological factors. Some couples will benefit from sex therapy alone, while others will need medication in combination with psychotherapy. Some men who will only accept pharmacotherapy can benefit from it, although the best treatment will likely involve an integration of both approaches (see Case 5).

Case 5 Erectile Dysfunction and Rapid Ejaculation

Bill is a 38 year old man who had experienced rapid ejaculation all of his adult life. This had generally been associated with variable erectile function since he first had intercourse at age 19. He had a few relationships, but became easily scared off, especially after a woman had commented, "Gee, that was fast." He had married Joanne, age 35, three years before, after a 6-month courtship which included limited sex play, but no intercourse, as the couple wanted to save "sex" until marriage. He was attracted to her and she seemed to care for him and did not seem to be demanding in the area of sex. Both partners were frustrated by the limitations posed by Bill's sexual problems. He was assessed in a male health clinic, where he was diagnosed as having vasculogenic impotence and premature ejaculation. He was prescribed prostaglandin injection therapy for his erectile dysfunction, and Prozac[TM] for his rapid ejaculation. He had problems in correctly injecting his penis, and would fluctuate between painful, prolonged erections and none at all. He was taught how to use an auto-injector, but grew more and more frustrated, and was at the point of giving up. He and Joanne were referred for counselling.

As a couple, they presented as caring for each other, but very frustrated. Joanne had tried to help Bill, to the point of doing the injection for him, but nothing seemed to work. She was growing increasingly resentful of "having to do all of the work". She wanted Bill "to get fixed". They both agreed that Bill was becoming more, rather than less, anxious.

In exploring Joanne's sexual history, she revealed that she had had two negative sexual experiences while studying at college. She felt she had been "pushed" into sex with her first partner, who ended the relationship soon afterwards. After a further positive relationship, she experienced what she felt was a "date rape". This lead her to avoid dating for several years before meeting Bill. She appreciated his warmth and lack of pressure for sex. She had learned how to pleasure herself as an adolescent, and found masturbation more satisfying than she currently found sex with Bill.

Sex therapy involved helping the couple understand each other's sexual fears and needs. Specifically, Joanne learned that Bill was not having rapid orgasms on purpose, and that he was not trying to hurt her. The couple learned how to reduce Bill's performance pressure by focusing on nonintercourse sex play, and initially by finding other ways to satisfy Joanne's sexual needs. Bill's Prozac[TM] was increased from 20 to 40 mg per day. As Bill's anxiety declined, he was able to focus on masturbatory "stop-start" exercises to gain some sense of mastery over his rapid ejaculation, even though his penis was not very firm with self-pleasuring. This behaviour was moulded, so that Joanne was able to also stimulate him manually without immediate ejaculation. At this point, injection therapy was resumed with greater success.

Joanne became upset that sex had become too much "erection focused", without the more sensual pleasuring that she had come to enjoy. The couple negotiated a balance of using injections no more than every other episode of lovemaking. This pleased Joanne, and helped reduce further Bill's anxiety, with improvement of some spontaneous erectile function.

DELAYED EJACULATION

Delayed ejaculation is more rare than rapid ejaculation, and affects perhaps 4-10% of men in their middle years (Frank, Anderson & Rubinstein, 1978; Spector & Carey, 1990). The introduction of SSRIs has lead to increasing numbers of men with delayed ejaculation. Men who suffer delayed ejaculation rarely seek help, and sometimes it may only be detected during the evaluation of other medical issues such as infertility (see Elliott, 1998, for a review of the sexual implications of infertility).

Delayed ejaculation is either primary or secondary, and either situational or global. Adult men who have never had an orgasm or wet dream need to be evaluated from an endocrine and neurological standpoint. Secondary delayed ejaculation necessitates a review of medications (Medical Letter, 1992; Finger, Lund & Slagle, 1997), other medical causes (trauma or other lesions to the nervous system such as stroke or multiple sclerosis), urological surgery, psychological and couple factors such as abuse, assault, or severe conflict.

Partners are often frustrated that the man cannot ejaculate, and will blame themselves for not being a good enough lover to bring him to orgasm. Alternatively, they blame the man for "withholding" his orgasm from them. These issues need to be explored with the couple, who should be offered education around the causes of the inability to ejaculate.

Current principles of therapy involve anxiety reduction, and stimulus intensification. Often men have situational orgasmic difficulties and can have an orgasm on their own. In moulding this behaviour in a desensitizing behavioural therapy, the partner can gradually become involved in his self-pleasuring. Eventually, the partner provides intense, direct stimulation to the penis sufficient to produce an orgasm manually, orally or with a vibrator. Once the man can have an orgasm with the partner present and participating, the next step of therapy is to maintain the ejaculatory ability with vaginal containment. Despite our increasing knowledge of the psychophysiology of erectile and ejaculatory mechanisms, the success rates in treating delayed ejaculation remain poor.

For couples wanting a child, fertility can be uncoupled from intercourse by having the partner provide a semen sample through masturbation to allow for insemination either using a 3 cc syringe at home alone or through direct insemination into the uterine cavity in a physician's office. Men who have para- or quadriplegia due to neck or back trauma can, at times, be stimulated to orgasm using either vibratory or other stimulation (see Elliott, 1998).

CONCLUSIONS

Physicians now have access to greater knowledge of sexual dysfunctions, and more options for their treatment. The challenge to the medical community is to translate this knowledge into coherent action that is effective and measurable over time as an improvement in the sexual quality of life for those men and their partners dealing with sexual problems.

As the medical understanding of the causes and management of sexual dysfunction continue to expand, so will demands on physicians for help. The prevalence of sexual problems means that all physicians working in primary care disciplines, be they family physicians, pediatricians, internists, gynecologists, urologists or psychiatrists, will be facing their patients' sexual concerns.

Currently, sexual health care is fragmented among many disciplines. The evidence is clear that an integrated approach to the management of sexual concerns leads to better outcomes. Multidisciplinary clinics to deal with sexual problems have been suggested as an option (Lewin & King, 1997). Sexual medicine as a medical specialty (Maurice, 1985) would thus integrate skills from the different health disciplines and help to bridge the gaps caused by the current fragmentation of care. Sexual medicine specialists would provide support to generalists, who would continue to offer the bulk of sexual health care to their patients. This model offers a basis for training medical students and graduate physicians to better deal with the sexual concerns of their patients.

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Correspondence concerning this paper should be addressed to Stephen Holzapfel, Department of Family and Community Medicine, Family Practice Health Centre, Women's College Hospital Campus, Sunnybrook and Women's College Health Sciences Centre, 60 Grosvenor St., Toronto, Ontario, MSS 1B6. Tel: 416-323-6064; Fax: 416323-7323; email: s.holzapfel@utoronto.ca.
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