The Multidisciplinary Approach to the Management of Male Erectile Dysfunction Combining Sex Therapy with PDE-5 inhibitors.

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The Multidisciplinary Approach to the Management
of Male Erectile Dysfunction Combining Sex
Therapy with PDE-5 inhibitors.

• Dorota Niedziela M.A., I.W.Kuzmarov M.D.,
  A.Skamene M.D., D.Eiley M.D., J.Bell R.N., S.
  Boudreau R.N., K.White R.N.
• The West Island Sexual Dysfunction Clinic

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Plan

• Introduction
• Incidence and Epidemiology of ED
• Review of Approach to treatment of ED
• Medical model
• Psychological approach
• Review of the Approach in a Multidisciplinary
  Clinic
• Clinic organization
• Role of each health care professional
• Interaction of health professionals
• ILLUSTRATIVE CASE HISTORIES

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Erectile DysfunctionMassachusetts Male Aging
Study (N1709)
Feldman HA et al., J Urol 1994 15154-61.
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History of Medical Therapies
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Therapeutic OptionsPatient Preferences

Cologne survey of 8,000 men
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Cascade of Treatment Seeking
Men
n 2,912 Men who self-reported ED
MALES 2001
Rosen, et al, Curr Med Res Opin. 200420607-617.
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ED FACTS

• Success rates for ED treatments using mechanical
  methods are 80, these success rates decline in
  the long term to less than 50.Reports have
  estimated that as many as 70 of men drop out of
  medical treatment, success of that treatment is
  only short term, declines dramatically with
  sustained use.
• The medical model targets only the organic
  component of ED.
• Erectile dysfunction (ED) is a complex phenomenon
  and that the patients problem may be due not
  only to organic elements but also to
  psychological causes .

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History of Sex Therapy

• 1920s Freud explain ED in terms of regression
• of unresolved conflicts into
  unconscious
• mind (1923).
• 1950s Behavioral therapy is presented where a
• sexual behavior is a learning
  process.
• In 1958, Wolpe elaborated systematic
• desensitization strategy.
• 1970s Masters and Johnson proposed
• short term program in which patients
  
• received body-work sessions
  followed
• by discussion sessions.
• 1980s Meichenbaum and Beck defined a
• cognitive-behavioral therapy.

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OTHER FACTS

• The success rates for psychosexual therapies may
  range from 40 to 90.
• Cognitive-behavioral therapy will use a
  functional analysis to understand psychogenic ED.
  It will act upon behavior and ideas that
  undermine a healthy sexual attitude.
• Sexocorporelle therapy will evaluate different
  muscular tensions, breathing, movement and rhythm
  within a sexual experience.
• Systemic approach, which see sexuality as a part
  of the couple patterns, communication, intimacy

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OTHER FACTS

• The current treatments often fail because they do
  not capture the complexity of ED. Treatment plans
  are typically constructed to target either the
  psychogenic or organic symptoms.
• ED is a synergism of psychological and physical
  factors.
• A visible organic component is often accompanied
  by fear, anxiety or other psychological
  reactions. A psychogenic basis for impotence
  necessarily involves a visible organic component,
  such as an inability to develop or maintain an
  erection.

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The benefits of a multidisciplinary approach to ED

• The multidisciplinary approach is more likely to
  evaluate all aspects of the sexual problem and to
  correctly diagnose the type of ED psychogenic,
  organic, mixed psychogenic and organic.
• The outcome of therapy is heavily dependent on
  the correct diagnosis.
• The multidisciplinary approach will than study
  all the information and propose a specific
  treatment for patient sex therapy, PDE-5
  inhibitors or both.

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Clinic Organization

• Urologist
• Endocrinologist
• Sexologist
• Nurse
• Research

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Primary IntakeUROLOGY

• History and Physical examination
• SHIM(5) and ADAM Score
• DRE
• Serum T FSH LH Prolactin,TSH,PSA
• Total and bio-available
• Cholesterol lipid profile, Blood sugar
• Urology special testing
• Penile Doppler
• PDE-5 Inhibitor Trial
• LUTS (BPH, prostatitis..)
• Uroflow
• Cystoscopy
• Urinalysis urine culture

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Role of Endocrinologist

• Evaluate the medication that can be associated
  with ED
• Evaluate the hormonal status of the patient
  (Testosterone, thyroid, pituitary etc..)
• Evaluate other factors (DM, HTA,CAD-cholesterol
  etc..)
• Evaluate metabolic syndrome
• Monitor hormone therapy

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Role Of Sex Therapist

• Clinical sexology makes it possible to identify
  and treat different problems related to human
  sexuality ED, PE, lack of sexual desire,
  vaginism, dyspareunia, sexual identity and
  orientation problems, sexual abuse
• Do specific psychological testes STAI, BDI,
  Dyadic adjustment Scale, PAIR-M, IIEF, FSFI...
• Help merge organic PDE-5 or HRT with
  psychological needs of the couple/individual.

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Role of the Nurse

• Teach how to apply the Testosterone patch or gel
• Perform penile Doppler studies
• Manage the caverject injection program
• Follow-up on dosage adjustments
• Perform research

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Clinical Process
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Case example 1

• 57- year- old male, single, dates young women.
• On PDE-5 inhibitor, but works only 50 of the
  time.
• Libido down.
• Obsessive behavior, negative anticipation.
• Disconnected from lower body, sexual energy.
• Restricted movements, upper lung breathing, body
  stiffness.

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Case example 1 - treatment

• Bio-available Testosterone normal, Thyroid normal
• Sex Therapy Evaluation and Management
• Study each sexual scripts to compare the
  influence of sexual stimulating thoughts and
  negative anticipation.
• Encourage PDE-5 use during the process
• Focus on physical sensations, lower body,
  pleasure of being touched.
• After 10 weeks
• PDE-5 occasional use with 100 efficacy
• Confidence level high
• No obsessive thoughts

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Case example 2

• 66- year- old male, in relationship for 10 years.
• Andropause, low libido and soft erection
• PDE-5 inhibitor works when used during
  masturbation sessions but does not work with
  partner - absent of genital stimulation.
• Normal DRE, PSA low
• Adam Score 10/10 positive
• Generalized anxiety.
• Fear of failure, inadequacy, negative evaluation.
• Important muscular tensions, upper lung breathing
  restricted movement and rhythm - rigid body.

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Case example 2 - treatment

• Bio-T low 1.8 (N2.3-14)
• Androgel recommended
• Penile Doppler venous leakage bilaterally
• Maintain use of PDE-5 inhibitor during and after
  the sex therapy stress management breathing,
  relaxation, triple-column technique.
• ? sexual anxieties, ? self-esteem.
• Introduce upper and lower release of the body -
  la bascule du haut et du bas du corps, increase
  body mobility and physical sensations. B-B?B-B

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Case example 3

• 56- year- old male, separated.
• diabetic, Hypertensive, MI- with stents placed.
• Morning erection, rigidity 3 on 10.
• Masturbation 2 to 3 times a week, works 50 of
  the time, rigidity 7 on 10 after 5 minutes of
  direct stimulation.
• Viagra 100 mgm failed pre-clinic
• Disconnected from lower body, total absence of
  muscular tension and movement. Not present in
  sexual pleasures.

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Case example 3

• Testosterone, bio-available T, FSH ,LH
  normal..Thyroid function normal
• Penile Doppler 3/10 erection after 20 minutes on
  prostoglandin injection
• Penile Doppler showed severe arterial
  insufficiency- L moderate on the RT
• Failed trial of levitra 20 mgm

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Urologist Prescribe caverject

Nurse Titrate dose To erection
Sex Therapy
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Case example 3 - treatment

• Make him understand the influence of sexual myths
  and believes on nervous system and sexual
  respond.
• B-B?B-B, S-I-E-B.
• Focus on physical sensations, 5senses.
• Learn to diffuse the sexual energy through the
  entire body and to focus in genital area using
  specific methods of breathing, movements and
  rhythm.
• Introduce upper and lower release of the body.

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Case example 4

• 29- year-old male, child onset diabetic
• Separated, dates a woman with a child - parents
  dont approve. , self-esteem low.
• Mild pyeroniess disease
• Worried about penile size, and fertility
• Morning erection
• Masturbation 2 to 3 times a week, rigidity 8 on
  10.
• Female active, male passive in sexuality
• Fear of failure, inadequacy, negative evaluation,
  rejection and abandonment, ? sexual anxieties,
• Disconnected from lower body, sexual energy.

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Case example 4 - treatment

• Normal testosterone FSH, LH
• Sugar high
• Penile Doppler normal
• Sperm count normal
• Thyroid low, will have this corrected .
• ? sexual anxieties, ? self-esteem.
• Focus on physical sensations, increase sexual
  energy in the lower body
• Identify sexual needs, take more control in
  sexual scripts, be more assertive

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Conclusion

• Because of the complexity of ED
• Interaction of different health professionals is
  important in the evaluation and management
• Communication and exchange of information is
  essential on an ongoing basis, on all aspects of
  the case.
• Many cases require multiple treatment approaches
  to the sexual health of the client and partner

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Conclusion

• The multidisciplinary approach achieves all these
  objectives easily