THE CASE
Eric M,* a 36-year-old new patient, visits a primary care clinic for a check-up accompanied by his wife. A thorough history and physical exam reveal no concerns. He is active and a nonsmoker, drinks only socially, takes no medications, and reports no concerning symptoms. At the end of the visit, though, he says he has been experiencing erectile dysfunction for the past 6 months. What began as intermittent difficulty maintaining erections now “happens a lot.” He is distressed and says, “It just came out of the blue.” The patient’s wife then says she believes men cannot achieve erections if they are having an affair. When the chagrined patient simply asks for “those pills,” his wife says in a raised voice, “He’s a liar!”
● How would you proceed with this patient?
*The patient’s name has been changed to protect his identity.
Some family physicians may feel ill-equipped to talk about sexual and relational problems and lack the skills to effectively counsel on these matters.1 Despite the fact that more than 70% of adult patients want to discuss sexual topics with their family physician, sexual problems are documented in as few as 2% of patient notes.2 One of the most commonly noted sexual health concerns is erectile dysfunction (ED), estimated to occur in 35% of men ages 40 to 70.3 Many ED cases have psychological antecedents including stress, depression, performance anxiety, pornography addiction, and relationship concerns.4,5
Assessing ED. The inability to achieve or maintain an erection needed for satisfactory sexual activity is typically diagnosed through symptom self-report and with thorough history taking and physical examination.6 However, more objective scales can be used. In particular, the International Index of Erectile Function, a 15-question scale, is useful for both diagnosis and treatment monitoring (www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/iief.pdf).7 Common contributors to ED can be vascular (eg, hypertension), neurologic (eg, multiple sclerosis), psychological (noted earlier), or hormonal (eg, thyroid imbalances).6 In this article, we focus on the relationship context in which ED exists. A review of medical evaluation and management can be found elsewhere.8
Key relational questions
It’s important to address ED as a shared sexual problem that has significant detrimental effects for both heterosexual and same-sex relationships.9 Encourage patients to bring their partner to appointments so a relational assessment may be conducted.10 Ask them both about their satisfaction with the sexual relationship. Questions such as, “Are you both satisfied with your sex life?” or “Do you or your partner have any sexual concerns?”2 can shed light on the couples’ sexual health. This encourages a unified approach to the issue instead of casting things as largely the responsibility of the symptom bearer.
Identify norms that are specific to the couple. Patients from a variety of cultures prefer that their clinicians initiate the conversation about ED.11,12 We specifically recommend that clinicians, using relationally focused questions, inquire about sexual norms and desires that may be situated in culture, family of origin, or gender (TABLE 1).
Continue to: Treating ED within a relationship