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

1. 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

2. 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

3. Erectile DysfunctionMassachusetts Male Aging Study (N=1709) Teaching Tips: The most extensive information on ED prevalence is based on studies conducted in the  United States. The prevalence of ED in the United States was carefully evaluated in the Massachusetts  Male Aging Study (MMAS).1 Conducted from 1987 to 1989 in 11 cities, the MMAS was a random sample survey of  non-institutionalized men, aged 40 to 70 years. The survey included a self-administered sexual activity questionnaire and interviews in which  information was collected on SES, and physical and psychological health status. Of 1709 men surveyed: 1290 (75%) provided complete responses. Results 52% of men reported some degree of ED1 25% reported moderate ED 17% minimal dysfunction 10% complete dysfunction Age correlated strongly with ED The National Institutes of Health (NIH) Consensus Panel reported that ED may affect as  many as 30 million men in the United States.2 Facilitator Tips: References: 1. Feldman HA, Goldstein I, Hatzichristou DG et al., J Urol 1994; 151:54-61. 2. NIH Consensus Development Panel on Impotence. JAMA 1993; 270(1):83-90.Teaching Tips: The most extensive information on ED prevalence is based on studies conducted in the United States. The prevalence of ED in the United States was carefully evaluated in the Massachusetts Male Aging Study (MMAS).1 Conducted from 1987 to 1989 in 11 cities, the MMAS was a random sample survey of non-institutionalized men, aged 40 to 70 years. The survey included a self-administered sexual activity questionnaire and interviews in which information was collected on SES, and physical and psychological health status. Of 1709 men surveyed: 1290 (75%) provided complete responses. Results 52% of men reported some degree of ED1 25% reported moderate ED 17% minimal dysfunction 10% complete dysfunction Age correlated strongly with ED The National Institutes of Health (NIH) Consensus Panel reported that ED may affect as many as 30 million men in the United States.2 Facilitator Tips: References: 1. Feldman HA, Goldstein I, Hatzichristou DG et al., J Urol 1994; 151:54-61. 2. NIH Consensus Development Panel on Impotence. JAMA 1993; 270(1):83-90.

5. History of Medical Therapies There has been substantial evolution of treatments for erectile dysfunction (ED) over the last 40 years. In the 1960s, sex therapy was the only viable treatment for men with ED. Penile prostheses and revascularization therapy became available in the 1970s, and vacuum constriction devices and penile injection therapies were developed in the 1980s. Intracavernous injection of prostaglandin E1 (PGE1, alprostadil) was first approved by the Food and Drug Administration (FDA) for the treatment of ED in 1995, and an intraurethral system for administration of PGE1 was approved for use in 1996. Sildenafil, the first oral selective phosphodiesterase 5 (PDE5) inhibitor, was approved for the treatment of ED in 1998.  A number of new agents for the treatment of ED are now on the horizon. These include the new PDE5 inhibitors (IC351 and vardenafil), apomorphine, an oral phentolamine formulation, and topical PGE1.There has been substantial evolution of treatments for erectile dysfunction (ED) over the last 40 years. In the 1960s, sex therapy was the only viable treatment for men with ED. Penile prostheses and revascularization therapy became available in the 1970s, and vacuum constriction devices and penile injection therapies were developed in the 1980s. Intracavernous injection of prostaglandin E1 (PGE1, alprostadil) was first approved by the Food and Drug Administration (FDA) for the treatment of ED in 1995, and an intraurethral system for administration of PGE1 was approved for use in 1996. Sildenafil, the first oral selective phosphodiesterase 5 (PDE5) inhibitor, was approved for the treatment of ED in 1998.  A number of new agents for the treatment of ED are now on the horizon. These include the new PDE5 inhibitors (IC351 and vardenafil), apomorphine, an oral phentolamine formulation, and topical PGE1.

6. Therapeutic OptionsPatient Preferences

7. Cascade of Treatment Seeking Cascade of Treatment Seeking Although by no means prospective, it is nonetheless longitudinal in nature,and it gives an interesting snapshot of what appears to be a group of men who are not very satisfied with their treatment experience. Note that each percentage depicted in each subsequent bar is contained in the previous one; these are percentages of the total sample - not ‘% of %”Cascade of Treatment Seeking Although by no means prospective, it is nonetheless longitudinal in nature,and it gives an interesting snapshot of what appears to be a group of men who are not very satisfied with their treatment experience. Note that each percentage depicted in each subsequent bar is contained in the previous one; these are percentages of the total sample - not ‘% of %”

8. 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 patient’s problem may be due not only to organic elements but also to psychological causes .

9. 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.

10. 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

11. 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.

12. 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.

13. Clinic Organization Urologist Endocrinologist Sexologist Nurse Research

14. 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

15. 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

16. 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.

17. 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

18. Clinical Process

19. 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.

20. 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

21. 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.

22. Case example 2 - treatment Bio-T low 1.8 (N=2.3-14) 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

23. 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.

24. 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

26. 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.

27. Case example 4 29- year-old male, child onset diabetic Separated, dates a woman with a child - parents don’t approve. , self-esteem low. Mild pyeronies’s 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.

28. 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

29. 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

30. Conclusion The multidisciplinary approach achieves all these objectives easily