Specific Aspects of Erectile Dysfunction in Sexology

Original Research Specific aspects of erectile dysfunction in sexology

JJ Borra´s-Valls1* and R Gonzalez-Correales1

1Instituto de Psicologı´a Sexologı´a y Medicina ESPILL, Valencia, Spain

The sexology of erectile dysfunction (ED) is approached from a perspective that integrates medical, psychological, and social aspects. This article reviews the clinical intervention in sexology beginning with the diagnostic evaluation, where the organic and psychological factors (predisposing, precipitating, and perpetuating) contributing to ED are determined. A description of the differential diagnosis process follows, which establishes the relevance of organic factors in order to organize therapeutic strategies. There are three possible treatment processes: psychological intervention with the patient, intervention on the partner relationship, or intervention with the partner. Referral criteria are also described, such as when patients with ED should be referred to a sexologist, and to whom sexologists should refer patients with ED. International Journal of Impotence Research (2004) 16, S3–S6. doi:10.1038/sj.ijir.3901235

Keywords: sexology; erectile dysfunction; treatment; etiology

Introduction problem rather than pathology to refer to ED and other sexual heath problems.2

Sexology is defined as the study of sex and sexual relations and their evolutionary, physiological, Evaluation of ED in sexology developmental, and sociological aspects.1 The problem of erectile dysfunction (ED) is addressed in sexology by integrating biological, psychological, From the patient’s first complaint of ED, the evaluation and socioeducational aspects from the sexual health process is to identify the etiology of ED as precisely as perspective of the person. possible, by making a differential diagnosis between Traditionally, etiologic factors of ED have been organic and psychogenic causes. Determining the classified as organic, psychogenic, or mixed. This cause of ED will help to develop an effective therapy.3 way of classifying ED is relatively useful for Since the more general aspects of the interview organizing our intervention, although it is com- are discussed in the core document, we will pletely arbitrary. Strictly speaking, a penis that does emphasize the aspects specific to intervention from not respond with an erection to an ‘effective’ a sexologic perspective. stimulation may be a consequence of what we call organic factors. However, every ED problem is Nonspecific clinical manifestations that may detect ‘psycho-organic,’ because it affects the man as a ED. The first element in the evaluation is to whole (both physically and psychologically) as well identify clinical manifestations of ED. A variety of as his partner and the couple’s relationship. psychosomatic disorders may be associated with Furthermore, there are socioeducational aspects that ED, such as headache, nonspecific malaise, lumbal- influence sexual behavior, which have considerable gia, gastrointestinal disturbances, stress, anxiety, importance on how the sexual encounter is experi- and depression. These problems are frequent causes enced. These are considerations that have led the for repeated outpatient visits to primary care and/or World Health Organization (WHO) working group psychological services. These symptoms may be on sexual health to propose the generic term sexual presented by the man with ED, his partner, or both.

Patient and/or partner seeks medical attention for *Correspondence: JJ Borra´s Valls, MD, PhD, Instituto de ED. When the man with ED, his partner, or both Psicologı´a, Sexologı´a y Medicina ESPILL, C/ Serpis, 8 pta. seek medical attention for ED, one of the key focuses 2a, 46021 Valencia, Spain. of the interview should be to establish the diagnosis E-mail: [email protected] of this dysfunction. Erectile dysfunction in sexology JJ Borra´s-Valls and R Gonzalez-Correales S4 It is a key point at this stage not to equate the Lack of perception of sexual sensations: dis- reason for consultation (the complaint presented to connecting from excitation or even sexual us) with the diagnosis. Couples often transfer other desire by acting as a spectator during love- conflicts to their sexual life, or the man may making (spectator role); manifest erection problems when the primary cause Insecurity that soon extends to other areas of the is, for example, lack of desire or a problem with the man’s life. partner. Other factors such as low sexual desire, Addressing the perpetuating factors through sexo- premature ejaculation, delayed ejaculation, or part- logical support is fundamental because treatment of ner dysfunctions such as hypoactive sexual desire, predisposing and precipitating psychogenic factors anorgasmia, and so on, may coexist. This is why it is 4 and organic causes alone may not be effective over essential to establish the primary diagnosis. the long term owing to the occurrence of relapses. To avoid relapses, it is essential to treat perpetuating Psychogenic factors. With respect to psychogenic psychogenic factors, which may become the only causes of ED, one of the keys to sex therapy is 5 cause sustaining ED when the other factors have consideration of temporal criteria. We can thus been resolved and the problem persists. distinguish among the following: Predisposing psychogenic factors. The presence Differential diagnosis. It is vital to know the of these factors may facilitate the occurrence of relevance of organic factors to perform sex therapy ED. The most common factors are aimed at restoring erectile function. The patient Antisex messages during childhood; interview remains the instrument that will provide Problematic family environment; us with these answers. ED is considered to be Inadequate sexual information; situational if: False sexual beliefs; Inadequate or traumatic first sexual experiences; the absence or lack of erection does not occur at all Early insecurity in sexual role; times when the man has sexual relations, and/or Fear of commitment; an erection is achieved with masturbation, and/or Fear of intimacy; if the man maintains sexual relations with more Anxious personality; than one partner and ED occurs only with one or Low self-esteem. certain partners, and/or Precipitating psychogenic factors. The presence he has erections after dreams, on waking, and/or of these factors may result in ED. In addition, the he has nocturnal erections (during rapid eye combination of precipitating factors may aggra- movement (REM) sleep phases). vate the condition. The most common factors are: In this case, unless the patient reports that he General disturbance in relationship; awakens on some occasions and this has been Partner sexual dysfunction; confirmed, we may need to resort to diagnostic tools Partner infidelity; such as the stamp (a strip of stamps that is placed Demanding partner; around the penis at night—a break in the strip Unreasonable expectations; indicates an erection, although not quantifiable) or Prior chance failure; similar tests, polygraphic recordings of nocturnal Traumatic sexual experience; penile tumescence, or Rigiscan. Reaction to organic causes; If ED is situational, we should institute sex Increased overall anxiety; therapy, focusing on the psychogenic and relation- Depression. ship components that may be present. If we cannot Perpetuating psychogenic factors. The presence rule out the presence of organic factors, we should of these factors contributes to ED as an automatic treat ED along with the psychogenic factors that are response to sexual stimulation. In any case, the always present. psychogenic component is always present as a If the man has a sexual desire disorder and this is perpetuating factor of ED. The following may act our principal diagnosis, ED being simultaneous or as perpetuating factors because of their constant secondary to inhibited sexual desire, we may need presence: to conduct a more in-depth endocrinological assess- Fear of sexual relations, failure, lack of re- ment with a hormone profile (testosterone, prolactin sponse, loss of erection, penetration, and so on; (PRL), luteinizing hormone (LH) and thyroid hor- Anxiety about the idea of having intercourse or mones); a referral to the endocrinologist may then be actual intercourse; appropriate. Typically, the specialist treats only the Vulnerability of the man to his partner’s attitude endocrine disease, and thus the patient or partner about ED; will continue to require simultaneous or subsequent Feelings of guilt; sexual support, orientation, or therapy. Poor communication with partner; If the diagnosis is ED and there is no lack of sexual Little foreplay; desire, we begin treatment with drugs (sildenafil,

International Journal of Impotence Research Erectile dysfunction in sexology JJ Borra´s-Valls and R Gonzalez-Correales S5 tadalafil, vardenafil, apomorphine, and so on). If 2. When, after treating the organic components these treatment options do not restore erections, we underlying the lack of erection, the problem of should consider referral to another specialist to ED does not improve. This is the referral route for further investigate diagnosis and treatment. general physicians and specialists. 3. When, after treating the psychological and/or psychopathological components presented in Treatment of ED in sexology the man with ED, the problem of ED does not improve. This is the referral route for psycholo- Sex therapy is a specialized form of psychotherapy. gists and psychiatrists who are not sexologists. The essence of the therapeutic approach used in sexology is integration, which implies the use of When and to whom should sexologists refer patients both pharmacotherapy and psychotherapy. Psy- with ED? As sexologists are a diverse group in chotherapy integrates cognitive-behavioral and psy- terms of their basic training (physicians and/or chodynamic approaches.6 psychologists), referral should be made based on Depending on the basic training as a physician or these training differences. psychologist and specialized training in sexology, the clinical sexologist (or sex therapist) will use a Referral to the urologist/andrologist specialized in range of available resources.7 It should be noted that erectile function. By psychologist sexologists:Itis psychologist sexologists are not legally qualified to essential to know the organic cause of the problem access the pharmacological or surgical resources for referral to the appropriate specialist. In many intrinsic to medical training. On the other hand, cases, it is recommended to work cooperatively with physician sexologists often lack extensive training the referral physician, to determine the sexological in psychotherapy, and therefore, their intervention support required to alleviate the problem. Referral in ED may be ineffective when it is due to deeper should be considered when psychological causes. Sex therapy for ED may be categorized as follows: the contribution of an organic factor to ED cannot be ruled out and psychological or relationship Psychological intervention with the patient. Ad- causes are not detected; dressing predisposing, precipitating, and perpetu- after initiating treatment, the expected response is ating factors through cognitive restructuring, not obtained and not attributable to resistance to insight therapy, or other interventional modalities the treatment; according to the clinical orientation of the therapist. drugs are required as a diagnostic tool for ED; Intervention on the partner relationship (if re- drugs are required for treatment; quired). Addressing relationship problems, im- surgery (prosthesis) is required for treatment. proved communication, role conflicts, and so on. Intervention with the partner (if required). Sub- It should be kept in mind that pharmacological and/or surgical treatment, although effective to jective experience of problem, degree of involve- achieve an erection, often does not resolve the ment, sabotage mechanisms, and so on. problem of ED for the patient or partner. Therefore, The prescription of tasks to be performed with the pharmacological and/or surgical treatment should partner only is a basic resource in sex therapy. With be combined with sex therapy to resolve the regard to ED, the exercises performed in the privacy problem. of the home (the patient alone or with his partner) By physician sexologists: Based on their under- aim, in keeping with the premises of systematic lying medical specialty, as a general criterion, the desensitization in vivo, to help them face the patient should be referred to the urologist/androlo- anxiogenic stimulus under the most favorable con- gist specialized in ED who will ditions and with the lowest degree of anxiety. The suggested exercises should also be specific for each perform a more in-depth diagnostic assessment if patient, so that they result in an improvement in required, by conducting or coordinating a wide sexual performance and psychosexual well being. range of diagnostic tests such as intracavernous injection of vasoactive substances, echo-Doppler, nocturnal erection recording, cavernosometry– Referral criteria for ED cavernosography, somatosensory evoked poten- tials, electromyography, penile biothesiometry, pudendal artery arteriography, and so on; When should patients with ED be referred to a apply or coordinate with other specialists the use sexologist? of other therapeutic resources such as the sacral 1. When the professional (who is not a sex therapist) root stimulator, penile prostheses, and so on. learns that there is a psychological and/or partner conflict that is the only, or a significant compo- Referral to other specialists. By psychologist sex- nent, in the etiology of ED. ologists: When the use of psychoactive drugs is

International Journal of Impotence Research Erectile dysfunction in sexology JJ Borra´s-Valls and R Gonzalez-Correales S6 required in cases in which ED is accompanied by a privileged position to assist the patient with ED depressive states or anxiety, the patient should be and to coordinate the consultation process with referred for treatment. It is essential to consider that other medical specialists, psychologists, or psy- referral does not mean abandoning the patient but chotherapists who are pertinent for successful collaborating with other professionals to jointly treatment. perform the most effective intervention.

Conclusions References

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