Integrating New Biomedical Treatments into the Assessment and Management of Erectile Dysfunction
Basson, Rosemary, The Canadian Journal of Human Sexuality
ABSTRACT: There is a growing awareness and use of effective biomedical treatments for erectile dysfunction (ED). Although often originating partly from pathophysiological factors, ED has interpersonal and psychosocial implications for men and their partners. This paper draws attention to the need for clinicians to address the affective and cognitive factors that can be both causes and consequences of ED. A review of the treatment outcome literature supports the need for an integrated approach to the treatment of ED that employs biomedical treatments in the context of overall sexual health and interpersonal relationships.
Key words: Erectile dysfunction Bio-psychosocial Intracavernosal injections Sildenafil MUSE VEDs
Erectile dysfunction (ED) is currently understood to result from a variety of potentially interacting neurological, vascular, pharmacological, hormonal, affective, cognitive, behavioural and lifestyle factors (National Institute of Health, 1993). The NIH's definition of ED as the "inability of the male to achieve an erect penis as part of the overall multifaceted process of male sexual function" makes it clear that sexual interaction is more than intercourse, and invites a broader consideration of the psychological, interpersonal, and societal aspects of male sexuality. This multidimensional conceptualization of ED is welcome because it clarifies the fact that the presence of an organic basis for erectile difficulties does not preclude the additional involvement of significant affective and cognitive issues that can have a further impact on a man's sexual well-being and that of his partner (Buvat, Buvat-Herbaut, Lemaire, Marcolin & Quittelier, 1990).
The temptation to bypass these psychological and relationship issues in dealing with ED has grown as new understandings of the physiology and pathophysiology of erection continue to emerge. Clinicians are often encouraged to focus on penile function by the men themselves, who typically state that their relationship is fine. Women partners of men with ED tend to give lower ratings of the relationship, perhaps because they have different expectations and/or are more willing to address difficulties (Hawton & Catalan, 1986). This willingness to discuss problem areas (e.g., insufficient emotional intimacy) makes partner interviews a useful source of insights that can lead to modification of a diagnosis and/or treatment plan formulated after an interview with the man presenting with ED (Tiefer & Melman, 1983). Despite strong evidence that relationship issues are involved in precipitating, maintaining, and potentially recovering from ED (Althof & Turner, 1992; Hawton & Catalan, 1986), many reported interventions appear to focus primarily or exclusively on the penis. This may explain, in part, the high discontinuation rates with some treatments.
The International Index of Erectile Function (IIEF) questionnaire provides a variety of criteria upon which to assess erectile function (e.g., Rosen et al., 1997). Clinicians will find this level of precision beneficial in the assessment and treatment of erectile dysfunction. Three items in the questionnaire, overall satisfaction with sex life, satisfaction with sexual relationship, and feelings of confidence about getting and maintaining an erection, address the psychosexual and relationship issues alluded to above. Since these issues are sometimes obscured by the terminology used to classify ED, it is useful to clarify our understanding of these terms.
The term "organic ED" is often used in the literature to refer to erectile problems that are thought to arise primarily from a biological impairment (e.g. neurological, vascular, endocrine, pharmacological, or surgical). "Psychogenic ED" implies erectile problems arising predominantly from psychological, interpersonal, or social factors (e.g., performance anxiety, stress, relationship conflicts). …