Plan

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. ED: 52% (n=889) Men aged 40 to 70 years Complete: 10% (n=171) Moderate: 25% (n=427) No ED: 48% (n=820) Minimal:17%(n=291) Erectile DysfunctionMassachusetts Male Aging Study (N=1709) Feldman HA et al., J Urol 1994; 151:54-61.

5. 1970s Penile prostheses Revascularization therapy (1973) 1980s Penile injection (1983) Vacuum constriction device (1985) 1990s Intracavernous PGE1 (1995) Intraurethral PGE1 (1996) First oral PDE5 inhibitor (1998) 2001+ Newer PDE5 inhibitors Apomorphine Phentolamine Topical PGE1 History of Medical Therapies

6. Therapeutic OptionsPatient Preferences % Cologne survey of 8,000 men

7. Cascade of Treatment Seeking % Men n = 2,912 Men who self-reported ED MALES 2001 Rosen, et al, Curr Med Res Opin. 2004;20:607-617.

8. ED FACTS • Success rates for ED treatments using mechanical methods are 80%, thesesuccess 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, movementand 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. Urologist Sexologist Endocrinologist Nurse 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

25. Urologist Prescribe caverject Nurse Titrate dose To erection Sex Therapy

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