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General principles

The purpose of clinical assessment is to identify and agree the nature of the individual’s/couple’s problem(s), why i t has occurred, their aims for treatment outcome, and whether this may realistically be achieved with biomedical or pysychotherapeutic interventions. These are summarized in Figure 12. The ‘diagnosis’ of the causes of a complex, multifactorial problem requires a holistic approach, considering biomedical, psychological, behavioral , partner , and relationship issues.

Working with individuals and with couples

When assessing a sexual problem, it is almost always desirable to see both partners in a sexual relationship, even if there only seems to be one person affected. The partner can provide important additional information and may also need help with their own sexual problems. Co-existing problems in both partners are common, and may be an obstacle to successful treatment. Sexual dysfunctions in women are a common problem, affecting perhaps 40% of women, although only around 20% have sought help. Problems with desire, genital and subjective arousal, orgasm, and sexual pain have been described. Their assessment and management is beyond the scope of this book. However, these problems are important: they can cause significant distress, may have a negative impact upon ED treatment outcome, and, importantly, are amenable to treatment.

Women with concerns over sexual function may benefit from a holistic biomedical and psychosexual evaluation, and should be strongly encouraged to seek professional help. Postmenopausal women who are partners of men with ED and who have not had intercourse for some time may notice impaired vaginal lubrication and elasticity. This is often due to estrogen deficiency-related atrophic vaginitis. They should be warned that this might occur and be made aware that they should seek treatment if necessary. This advice should be given concurrently with any ED treatment , rather than waiting for the problem to emerge. In practice, many men are reluctant to involve their partners and, not infrequently, the partner does not wish to attend. There are frequently perfectly valid reasons for this but, occasionally, the absence of a partner may indicate that they are unwilling to allow resumptions of sexual intercourse. It is very important to ask men attending alone about their general relationship satisfaction and to solicit information about their view of their partner’s perception of their problem. Sometimes, men with ED will admit that they have not told their partner that they are seeking treatment and suggest that they ‘want it to be a surprise’ for them. This may Mell be the case for a partner who has not had intercourse for several years and is suddenly confronted with an unwelcome erect penis. While i t might not be appropriate to insist that a man tells his partner that he is seeking ED treatment , he should be strongly encouraged to do so. Taking a sexual history presents different challenges to the physician, not least because most physicians have had little or no training or experience in doing so.