Engaging Men with Sexual Difficulties in Rural General Practice A biopsychosocial model

1. Engaging Men with Sexual Difficulties in Rural General PracticeA biopsychosocial model Dr Raie Goodwach Malvern Psychotherapy Centre 1232 Malvern Rd Malvern Vic 3144 Ph 98244322 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. 2000. Survey of 1240 men, av age 56 yrs • ** Martin-Morales. J Sex Med 2005. Survey of 7824 men • ***Holden, C. Lancet 366, 2005

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 GPBiopsychosocial 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: 418-23

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 • Pharmacotherapy • – PDE5 inhibitors (oral) • - prostoglandins, papaverine et al (injections) • - implants • Behaviour Rx - Masters & Johnson 2. (Bio)psychosexual therapy - broader focus Symptomis 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 18-30 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: • 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 • 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) 25-50 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 25-75 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