General principles

The purpose of clinical assessment is to identify and agree the nature of the individual’s/couple’s problem(s), why i t has occurred, their aims for treatment outcome, and whether this may realistically be achieved with biomedical or pysychotherapeutic interventions. These are summarized in Figure 12. The ‘diagnosis’ of the causes of a complex, multifactorial problem requires a holistic approach, considering biomedical, psychological, behavioral , partner , and relationship issues.

Working with individuals and with couples

When assessing a sexual problem, it is almost always desirable to see both partners in a sexual relationship, even if there only seems to be one person affected. The partner can provide important additional information and may also need help with their own sexual problems. Co-existing problems in both partners are common, and may be an obstacle to successful treatment. Sexual dysfunctions in women are a common problem, affecting perhaps 40% of women, although only around 20% have sought help. Problems with desire, genital and subjective arousal, orgasm, and sexual pain have been described. Their assessment and management is beyond the scope of this book. However, these problems are important: they can cause significant distress, may have a negative impact upon ED treatment outcome, and, importantly, are amenable to treatment.

Women with concerns over sexual function may benefit from a holistic biomedical and psychosexual evaluation, and should be strongly encouraged to seek professional help. Postmenopausal women who are partners of men with ED and who have not had intercourse for some time may notice impaired vaginal lubrication and elasticity. This is often due to estrogen deficiency-related atrophic vaginitis. They should be warned that this might occur and be made aware that they should seek treatment if necessary. This advice should be given concurrently with any ED treatment , rather than waiting for the problem to emerge. In practice, many men are reluctant to involve their partners and, not infrequently, the partner does not wish to attend. There are frequently perfectly valid reasons for this but, occasionally, the absence of a partner may indicate that they are unwilling to allow resumptions of sexual intercourse. It is very important to ask men attending alone about their general relationship satisfaction and to solicit information about their view of their partner’s perception of their problem. Sometimes, men with ED will admit that they have not told their partner that they are seeking treatment and suggest that they ‘want it to be a surprise’ for them. This may Mell be the case for a partner who has not had intercourse for several years and is suddenly confronted with an unwelcome erect penis. While i t might not be appropriate to insist that a man tells his partner that he is seeking ED treatment , he should be strongly encouraged to do so. Taking a sexual history presents different challenges to the physician, not least because most physicians have had little or no training or experience in doing so.

Medications are available that can substantially delay ejaculation. The familiar 5-PDE inhibitors (Viagra, Levitra and Cialis) that are commonly used for erectile dysfunction, may have a role in the treatment of P.E. in men with acquired P.E. secondary to erectile dysfunction.

Anti-depressants of the S.S.R.I. class (selective serotonin reuptake inhibitors) have been clearly demonstrated to delay ejaculation. These medications can have undesirable side effects such as decreased libido, sleepiness, insomnia, headache, nausea and dry mouth. You are generally started on a low dose for two weeks with an increase in dose if necessary for the next two weeks. Once an effective dosage is achieved, you can use the medication on a situational basis, 3-4 hours prior to sexual intercourse.

The most commonly used medications are:

• Anafranil (Clomipramine): 25-50mg
• Paxil (Paroxetine): 20-40mg
• Zoloft (Sertraline): 25-100mg
• Prozac (Fluoxetine): 5-60mg

A new medication, Dapoxetine (30/60mg), is currently in investigational trials.

Insofar as most cases of P.E. have an underlying psychological basis, it may be beneficial to seek the aid of a sexual therapist who can help manage the problem with counseling sessions. This can be done in conjunction with some of the aforementioned techniques in order to bring about a quicker resolution.

Peripheral Nerve Injury Peripheral nerve injury is another important cause of ED, especially in patients undergoing prostatectomy. Other causes of peripheral nerve injury include bicycle riding and acute pelvic trauma. Several authors have reported genital numbness and increased the incidence of ED among cyclists. The pathophysiological basis for ED in cyclists is thought to be neurogenic as well as vasculogenic.

A recent systematic review of the literature found that the reported incidence of ED after radical prostatectomy with nerve sparing technique varies widely due to methodology. 50% and 34% for bilateral and unilateral nervesparing surgery, respectively.

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Nerve-sparing techniques are based on the seminal study by Walsh and Donkers in which they identified the path of the nerves to the corpus cavernosa.
They identified the branches of the pelvic plexus traveling through the urogenital diaphragm adjacent to the prostatic capsule and then adjacent to and through the wall of the membranous urethra. Not surprisingly, they found that men with tumors that did not invade the prostatic capsule and were amenable to salvage of this structure had reduced rates of ED.

Recovery and improvement in erectile function after radical prostatectomy has been reported to continue up to and beyond 2 years postoperation, perhaps indicating healing of injured nerves.
Loss of erectile function is also related to anatomical changes in the penis, specifically fibrosis of the penis due to prolonged lack of tumescence. In animal models, histological changes occurring after nerve injury are prevented by regular pharmacologically induced erections.

Psychogenic Risk The number of cases of ED attributed purely to psychogenic etiology have greatly declined in the past several decades. Younger men who complain of ED are more likely to have a psychogenic component than older men. Psychogenic ED is generally classified into generalized and situational pathologies and further subclassified.

This classification scheme has been criticized as it fails to account for advances in neurobiology that have linked certain psychiatric illnesses with neurochemical and neurohormonal derangement. Depression Depression and ED are often comorbid conditions. Several epidemiologic studies report men with ED are more likely to report depression, and that this association is independent of associated comorbidities, demographic factors and medications. In a study of men diagnosed with Major Depressive Disorder but not yet treated, almost half had trouble sustaining an erection and reported decreased sexual desire