1. Engaging Men with Sexual Difficulties in Rural General Practice A biopsychosocial model
Dr Raie Goodwach
Malvern Psychotherapy Centre
1232 Malvern Rd Malvern Vic 3144 Ph
On behalf of Andrology Australia

2. The Facts 1 in 5 men – erectile difficulties
1 in 4 men – premature ejaculation
1 in 4 men - lack of libido [HSDD]
Ref: Andrology Australia Website, Oct 2005

3. Suffering in silence Men don’t talk to doctors about SD’s
Doctors don’t talk about SD’s with pts
Rx of medical aspects by all GP’s is primary goal.
Doctors need to feel comfortable to initiate discussion about sexual concerns
Aust study*: 1/3 surveyed: ED. Only 1/3 Rxed
European study**: When ED discussed, 80% pt initiated
Aust study***:Fewer than 1 in 3 men with ED discuss problems with their doctors
*Chew, int.J.Impot.Res Survey of 1240 men, av age 56 yrs
***Holden, C. Lancet 366, 2005
** Martin-Morales. J Sex Med Survey of 7824 men

4. Why patients don’t talk about sex
Shame, embarrassment
Belief the problem is inevitable due to age/ illness/ medication
Feel bad about their body eg post-prostatectomy/ colostomy
Lack of knowledge that Rx possible
Sensitive to doctor’s reluctance
Partner resistance

5. Doctors need to be pro-active
Many pts untreated – quality of life
ED: predictor of CVD/ microvascular
High risk of SD due to illness, medication, relationship difficulties

6. Why doctors don’t talk to pts about sexual difficulties
Sexual history hasn’t traditionally been part of medical history
We laugh when we’re anxious and we laugh most about sex & death
Lack of time – takes time to listen to intimate concerns
Knowledge – what to do beyond PDE5 inhibitors/ low dose antidepressants
How to deal with low libido, ED not due to microvascular disease, or PE without drugs. When it’s not “strictly medical”
Respect pt’s privacy – cf respectful question
Stereotyping – pt too old/ sick for sex
Own issues re sex/ personal/ relationship problems
How to talk to pts about sex

7. What makes us uncomfortable
Lack of knowledge
Lack of practice
Personal values and beliefs
What is “normal”
“Many men of your age/ with your condition experience sexual difficulties. If you have any difficulties, I am happy to discuss them”

8. Role of Rural GP Biopsychosocial model
Clinical assessment, Rx options & follow-up
Most helpful thing is to ask, listen & help pt decide best Rx
Best Rx individually tailored
Steady relationship / casual sex
Relationship supportive/ not
Pt wants medication/ not
Partner supportive of Rx: medication/ behaviour Rx
GP time/ interest to deal with difficulty
Referral options
Even when the cause is medical, SD cause distress

9. Male Sexual Difficulties - nomenclature
Erectile dysfunction
Premature ejaculation
Lack of libido - HSDD
Retarded ejaculation
Retrograde ejaculation
Anorgasmia/ anejaculation
Performance based, mechanistic descriptions
Sexual desire & activity much more complex

10. Rx of Sexual Difficulties
Pharmacotherapy - it’s medical OR it can be fixed w medication.
Oral, injectable, nasal spray
There’s great satisfaction prescribing Rx & seeing immediate results
Behaviour therapy – Masters & Johnson – learnt habit
Mechanical devices, surgery
Psychosexual Rx – biopsychosexual model

11. Choice of Rx Fix the problem: treat the symptom
Medical Rx when symptom is result of medical illness or S/E of medication
“Magic cure” confusion. Medication treats symptom regardless of cause. Drugs treat impotence but do little to boost self-esteem or improve relationships.*
Behaviour Rx if partners co-operative
Psychosexual Rx: what’s the symptom about? Bio-psycho-social model
Int J Impot Rse 2007;19:

12. Psychosexual therapy
1.Encourage pt to talk about difficulties & anxieties
2.Translate language of the body (symptom) into words, so pt learns to talk about, rather than enact distress.
3. Soma (body)  psyche (mind)
4.Understand the symptom in context of their lives & relationships
5.Provides opportunity for individual & interpersonal growth & a deepening of relationship

13. Psychosexual history Describe the problem & your understanding of it
What was it like growing up in your family?
How did you find out about sex?
Family’s attitudes & beliefs about sex
Brief outline of life history, including school, friendships, work
Medical & surgical history
Relationship history
Sexual history
Physical/ sexual abuse
What is life like now? Work, relationships, any problems perceived
Why now? (may have had symptom for yrs)

14. Biopsychosexual therapy
Investigate & Rx medical problems
Education: learn about body fn – it’s not “just psychological”
Recognise & respect own thoughts & feelings – it’s not “just physical”
Deal with anxieties
Enjoyment & confidence in sexuality
Integration of mind & body
Experiencing – feeling – thinking
Enjoying sex – not just “doing it”

15. Erectile dysfunction/ difficulties
Inability to maintain erection sufficient for I/C
1 in 5 men over 40 yrs
*** Sentinel symptom for diabetes, CVD – microvascular disease
“It is common for men with diabetes/ high BP / heart disease to experience erectile problems. I can help you if you are having problems”

16. Erectile difficulties: 1 in 5 men
Metabolic: diabetes, HT, high cholesterol, obesity, chronic renal failure, sleep apnoea
Vascular: atherosclerosis – reduced blood flow
Neurological: spinal cord injury, MS, Parkinson’s, Alzheimer’s
Urogenital: Peyronie’s, pelvic trauma, prostate CA,
pelvic surgery (prostate, bowel), long-distance bike riding
Lifestyle: Recreational drugs, alcohol, smoking
Prescribed medication for HT, cholesterol, depression (SSRI’s)
Psychosocial issues: performance anxiety, depression, relationship problems, financial/work pressures –
Anything which makes a man feel “less of a man”

17. Cultural notions – psychosocial meaning
Erections:
Masculinity
Success
Impotence – erectile dysfunction – erectile difficulties
Shame
Loss
Inadequacy
Strong culture of silence
Even when there is a physical cause, need support & counselling
Extensive advertising of PDE5 inhibitors has both normalised and medicalised ED

18. Erectile difficulties - diagnosis
Early morning erections
Sudden/ gradual onset
With partner/ by self
O/E: BP, HR, waist circumference, pulses, urogenital, focused neurological
Baseline investigations: fasting glu, cholesterol/lipid profile, FBE
If indicated: LFT, testosterone (hypogonadism), prolactin (pituitary fn), LH, TSH, urinanalysis

19. Rx decision-making Cause: organic, psychosocial or combined
Patient & partner preference
Benefits, risks and costs of Rx options
Referral options

20. Assessment & Rx 1st line:
Address risk factors – esp C/V. Losing wt in obese, Rx illness eg diabetes, HT
2nd line:
Restore fn: Oral agents (PDE5 inhibitors)/ vacuum devices
Psychosexual Rx – incl education/ behaviour therapy
3rd line:
Consider specialist referral
Intracavernosal vasoactive drugs
4th line
Surgical Rx – implants

21. Rx 1. Fix the symptom 2. (Bio)psychosexual therapy - broader focus
Pharmacotherapy
– PDE5 inhibitors (oral)
- prostoglandins, papaverine et al (injections)
- implants
Behaviour Rx - Masters & Johnson
2. (Bio)psychosexual therapy - broader focus
Symptom is addressed & Rxed, but is not whole focus
Address pt’s concerns
Look for meaning of symptom in pt’s life

22. Prejudices?
Mr Smith, a wheezy 79 y.o. widower, lives in an old age facility
Presents for R/v bronchitis
As he leaves surgery, mumbles about his “pecker” not performing
Do you…

23. Do you…
Wish he hadn’t told you/ pretend you didn’t hear – the waiting room’s full
Wonder what a “pecker” is
Think “His wife is dead!”
Reassure him that most old men’s peckers don’t work too well
Think – “he’s nudging 80 – and he’s in an old people’s home – surely he’s not….where would it be performing….?”
Tell him it’s important he told you (? As opposed to being glad he told you) and set aside time to discuss it
Prescribe a PDE5 inhibitor

24. Let’s talk about sex Many pts at high risk for ED Elderly
Midlife – smoking, drinking, chronic illness, medication, work & relationship stresses
Young – alcohol, smoking, recreational drugs
To whom would you want to talk to about sex?
To whom would you prefer not to talk about sex?
How do you open a discussion with them about sex?
Eg Some people find as they get older…
Health: Many people after MI have problems with sex…
Any S/E’s w new medication? Any problems sexually?

25. Referral Patient request
GP decision: training – experience – interest – time
Endocrinologist: complex endocrine, vascular, neurological problems
Urologist: pelvic or perineal trauma, penile deformities, pts for penile implants
Psychosexual therapy: relationship difficulties, psychological difficulties

26. Premature ejaculation
1 in 4 men
Lack of ejaculatory control
Ejaculate sooner than desired, causing distress to one or both partners
Masters & Johnson: Ejaculate B4 partner achieves orgasm in > 50% sexual encounters
Alfred Kinsey (1950’s): ¾ of men ejaculate within 2 minutes of penetration in ½ sexual encounters
Within 2 minutes
Av time to ejaculation for yo: 6 ½ mins

27. PE is confusing The symptom is expressed in one body
Not a problem if by himself
Affects both people
May reflect problems in person or b/w partners
Primary or secondary
It’s not “just in the body”
It’s not “just in the mind”
It’s in the “mind-body”

28. Science Emission: Expulsion:
Deposition of seminal fluid from ampullary vasa deferens, seminal vesicles & prostate gland into posterior urethra (Bohlen et al 2000)
Controlled by sympathetic motor neurons
Expulsion:
Closure of bladder neck followed by rhythmic contractions of urethra by pelvic-perineal & bulbospongiosus muscle & intermittent relaxation of external sphincter urethrae (Master & Turek 2001)
Controlled by somatic & autonomic neurons

29. Rx Fix the symptom Not recommended Pharmacotherapy – oral SSRI’s
clomipramine nasal sprays (not generally available)
Behaviour therapy – Masters & Johnson
Pt & partner work together to gain mastery over symptom
Only works if couple can co-operate & have been properly instructed
Not recommended
Reduce penile sensation – anaesthetic gels/creams, lignocaine ointment (Stud), double condoms, latex sheaths
Cocaine, cough mixtures (pseudoephedrine)
Viagra, cialis

30. Oral pharmacotherapy Medication can be effective
? Genetic basis to primary ED
Tricyclics: Clomipramine (Anafranil) 25-50mg/day or 6 hrs B4 coitus
SSRI’s: Paroxetine (Aropax) 10-40mg/day or 20 mg 4 hrs B4 I/C
Fluoxetine (Prozac) 5-20 mg/day
Sertraline (Zoloft) mg/day
In trial: Dapoxetine – as need basis 1-3 hrs B4 I/C
First drug specifically for PE
In trial: from < 1 minute:
30mg 2.45 min; 60 mg  3.5min
Start low & titrate slow. Trial for 3-6 mths then slowly titrate down to cessation. If PE occurs, trial again. If one drug not effective, trial another.

31. Traditional Behaviour Rx
Masters & Johnson “Squeeze” technique
Needs highly co-operative partners
Helen Singer Kaplan modified it to deal with Ucs problems which “got in the way”

32. Psychosexual Rx Listen, explain, encourage
Muscle explanation: 4-10 secs b/w 1st sensing urge to ejaculate & ejaculation
Options – Rx based on pt & partner preferences
Medication
Modified Masters & Johnson – “squeeze” & “stop-start” techniques, 3 x 3 approach
Use the physical to explore the subjective
Talk

33. Modified Masters & Johnson
3 x 3 approach
Each step, 3 times on 3 separate occasions
Set aside 30 mins (at least) each time
Each time, take turns, 3 times each, to “be pleasured” and to “do the pleasuring”
When male “pleasures” female: he caresses her, 1st non-sexually, then when she’s ready, sexually. She tells him what she likes/ what feels good/not. Opportunity for him to learn to be a better lover. Opportunity for both to learn to speak up about likes and dislikes.

34. Modified Masters & Johnson
When female active: she stimulates his penis till he tells her to squeeze (no penetrative sex)
Step 1: Penis erect, B4 he feels urge to ejaculate
Squeeze as long & as hard as it takes: 6-15 secs
Step 2: Instead of squeezing, she just stops stimulating
Step 3: Penetration: female on top, she moves, man inactive
3a: Gets off, squeeze / stop
3b: just stops (stays on)
Step 4: Man starts and stops, starts and stops till ready to ejaculate

35. Modified Masters & Johnson
Men who don’t have a problem with PE “stop” and “start” as part of ordinary rhythm of lasting as long as they want, only thrusting ctsly when ready to ejaculate
Helpful as a technique when couple able to co-operate. Otherwise, it highlights their disagreements and difficulties, which can then be talked about
This way, using a behavioural technique (the physical) to inform us about relationship (interpersonal)

36. Psychosexual therapy
Become confident with own body – it’s not “just psychological”
Recognise & respect own thoughts & feelings – it’s not “just physical”
Enjoyment of and confidence in sexuality
Integration of body & mind

37. Chris
18 yo apprentice carpenter
Wants to satisfy his girlfriend

38. Derek, aged 52 Self-referred via Andrology Australia website
PE forever
When young, could “go twice” therefore not a problem
Divorced after 15 yrs. Used to last 2-3 mins. Didn’t matter, cos wife not interested in sex.
Current partner 18 mths. She’s “…ed off” with the whole business”. At start of relationship lasted 1-2 mins, now 30 secs.
Tried “stop-start”. Not exciting for her.
Given anaesthetic cream by clinic doctor – “it sort of worked, but dreadful, unpleasant, took away all sensation”
Viagra kept erection up, but disgusting to ejaculate then still have erection with no feeling.

39. Derek – possibilities for Rx
Educate – ejaculatory process
Invite partner in/ Treat by himself
Medication – SSRI
3 x 3 explain in detail with what to do so she feels nurtured too
3 x 3 by himself
Discuss his anxieties in relationship

40. Retrograde ejaculation
Muscle at opening of bladder doesn’t close semen back into bladder. Little/ no semen from penis during ejaculation. 1st urination after sex cloudy
Normal/ decreased orgasmic sensation
Harmless
Causes:
Surgery to prostate or bladder neck
Diabetes, multiple sclerosis, spinal cord injury
Antihypertensives
Rx:
Counseling
Fertility specialist for assisted reproductive techniques
Imipramine hydrochloride mg tds

41. Delayed ejaculation/ anorgasmia
Only with I/C OR during masturbation as well
Some men experience orgasm even though don’t ejaculate
Causes:
Physical: spinal cord injury, major lymph node surgery, diabetes, MS, traumatic injury to pelvis
Medication: SSRI’s
Relationship difficulties – delayed
Anorgasmia – rarely no medical cause
Check testosterone levels
Change medication/ drug holidays
Vibrator/electical stimulation to promote reflex ejaculation if want baby
Longterm psychotherapy

42. Painful ejaculation Pain in perineum or urethra and urethral meatus
Culture urine & semen
Cystoscopy
Rx: prostatits, urethritis – disease-specific
If no infection: physiotherapist/ psychotherapist

43. Lack of libido - HSDD
Traditionally female symptom: “I’ve got a headache”
1 in 4 men
Medical – chronic illness, chronic pain, androgen deficiency
Medication – antidepressants, antihypertensives
Drugs, alcoholism, cocaine, marijuana
Lifestyle – too little/ too much exercise, obesity
Eg after cancer surgery: chronic illness, chronic pain, fatigue, body image problems
A mind-body manifestation of lack of “aliveness” in the relationship or in the person himself
Depression, relationship difficulties, latent homosexuality

44. Lack of libido – not interested in sex
When not caused by ill-health/ medication
Something is lacking, but it’s not something quantifiable called “libido”
What is the person unhappy/ resentful about?
In himself / in the relationship?
Feeling alive, aliveness in the relationship

45. Lack of libido - What’s it about?
If symptom not related to ill-health/ medication…
Withdrawing emotionally
Body expresses anger/ resentment when person can’t verbally
Doesn’t consciously know what’s wrong– somehow just not interested in sex” (as if it has nothing to do with anything else)
Body expresses: I don’t want to be close to you.”
Lack of physical contact experienced by partner as rejection (they get the message, but don’t know why). Sex is about feeling wanted.
NB may have “lack of libido” with one partner but lots of “libido” with another

46. Sexual symptoms When the body does the talking
Sexual, medical & psychosocial history
Focused physical examination
Diagnostic tests
Review. Rx choice depends on doctor’s & pt’s understanding of what’s causing the symptom
(Bio)Psychosexual Rx: Medical issues need medical Rx. Beyond that, learn to talk about, rather than enact difficulties. Pt & partner dialogue.
Medication is a choice, not the only option