Men are more likely than women to present for treatment of sexual problems. However, men find sexual problems difficult to discuss and, if they perceive that their problems are being dismissed, may choose not to seek further help. When physicians spend time with patients and their partners in discussing sexual problems, effective treatment is often the result. Gregoire reviews the challenges associated with assessing and managing sexual problems in men.

Sexual dysfunction can be classified in the clinical setting as a continuum in frequency and severity, different from the fixed classifications in the International Classification of Diseases, 10th ed. (ICD-10) [ICD-9 in the United States] and the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV). The distinction between organic and psychogenic etiologies is artificial, and comorbidities of sexual dysfunction are common. For example, about one half of men with low sexual desire have another sexual dysfunction, and 20 percent of men with erectile dysfunction have low sexual desire. For a list of features that help identify sexual problems in men, see the accompanying table. Partner issues also are important because in as many as one third of patients with sexual problems, the partner also has a sexual dysfunction. The three most common areas of sexual dysfunction in men are inhibited sexual desire, erectile dysfunction and ejaculatory difficulties.

Inhibited sexual desire is difficult to define. It is more commonly reported in women than in men and becomes a source of relationship conflict, although often it is impossible to tell which is the cause and which is the consequence. Inhibited sexual desire is associated with other sexual dysfunctions. The lifetime prevalence of depression and anxiety disorders is increased in patients with inhibited sexual desire. Many physical factors are thought to play a role in this problem, such as the effects of illness, alcoholism, liver disease and medication side effect. Most outcome studies indicate poor patient response to psychologic intervention for inhibited desire.

Erectile dysfunction affects up to 15 percent of men and increases with age. Some degree of dysfunction affects 40 percent of men 40 years of age and older and increases to 70 percent in men 70 years of age and older. In most men, the cause is some combination of psychologic and organic factors. Sildenafil represents an important medical treatment advance in these patients and their partners, but concerns about cost and potential misuse merit further investigation.

Premature ejaculation is defined as the inability to control ejaculation sufficiently to permit both partners to enjoy sexual intercourse. About 20 percent of men have this problem, although often no underlying physical cause can be identified. Sometimes the problem is a shortened period before ejaculation because of the need for prolonged stimulation to achieve an erection. Premature ejaculation is more common in younger men and often resolves with increasing experience. Anxiety often plays a role. Psychologic and drug therapy with sertraline can be effective, but reported success rates are conflicting, which suggests that the benefits are not maintained. Retarded or absent ejaculation often is caused by medications, most commonly antidepressant and antipsychotic drugs. Treatment focuses on reducing anxiety, increasing genital stimulation and lowering the dosage of the offending medication, if possible.

The author concludes that talking with the patient and the partner may clarify important aspects of the problem and increase the likelihood of successful management. Discussion about the issues may be therapeutic in itself. Simple interventions such as education, reassurance, contraceptive advice or assistance with basic problem solving and counseling can resolve simple problems. When problems persist despite interventions or basic pharmacotherapy, referral to a subspecialist may be helpful.

editor's note: Physicians have long recognized that sexual habits are potential risk factors for transmission of infectious diseases, including several types of hepatitis and human immunodeficiency virus (HIV) infection. Speaking with patients about sexual matters, however, remains a difficult task. The inability to have satisfactory physical relationships is recognized as a potential source of morbidity in men who report increased anxiety and depression, loss of self-esteem and relationship difficulties when normal sexual functioning is disturbed. As physicians, we need to try to reduce the distress connected with our patients' self-perceived sexual inadequacies and help them achieve more satisfactory intimate encounters. This can be accomplished with basic sex counseling, advice about healthier lifestyles and medical interventions. Discussing sexual issues with our patients will become easier if we make it a habit to ask and if we do so in an open, non-judgmental manner that encourages an open response. Once a problem is identified, appropriate evaluation and treatment or referral to an appropriate consultant can be initiated. The result will be a happier and more functional patient and an improved physician-patient relationship.—r.s.