Combination Therapy Guidelines Who How and When

There are two alternative models for CT: both will likely be adopted within the framework of sexual medicine, by different clinicians. First, working alone, PCPs, urologists, psychiatrists, and eventually gynecologists will integrate sex counseling with their sexual pharmaceutical armamentarium to treat SD. "Sex counseling" in this situation, is utilizing sex therapy strategies and techniques to overcome psychosocial resistance to sexual function and satisfaction (20). In a second model, the above clinicians will collaborate with nonphysician MHPs (sex therapists), resolving SD(s) through a coordinated multidisciplinary team approach to treatment. The clinical combinations will vary according to the presenting symptoms, as well as the varying expertise of these health care providers. The utilization of these two different models will require three steps. (i) The clinician first consulted by the patient will consider their interest, training, and competence. (ii) The bio-psychosocial severity and complexity of the SD as a manifestation of both psychosocial and organic factors will be evaluated. (iii) The clinician in consideration of the two previous criteria, together with patient preference, will determine who initiates treatment, as well as, how and when to refer. The guidelines for managing the relative severity of the dysfunction will essentially be expanded, but continue to match the type of treatment algorithm described in "The Process of Care" and other step-change approaches (42).

Categorizing Psychosocial Obstacles to Treatment

Whether or not a physician works alone, as in the first model, or as part of a multi-disciplinary team, as in the second, will be partially determined by the psychosocial complexity of the case. This CT model adapts Althof and Lieblum's "Proposed Integrated Model for Treating Erectile Dysfunction" (15,40). However, it must be emphasized that this author is advocating a CT model for all SD. The treating clinician would diagnose the patient(s) as suffering from mild, moderate, or severe PSOs to successful restoration of sexual function and satisfaction. This characterization would be based on an assessment of all the available information obtained during the evaluation. This would include an assessment of the issues/factors described in this chapter's earlier section on "Psychosocial Barriers to Success." This assessment would essentially include the psychosocial (cognitive, behavioral, cultural, and contextual) factors predisposing, precipitating, and maintaining the SD. This would be a dynamic diagnosis, continuously reevaluated as treatment progressed. The consulted clinician would continue treatment and/or make referrals on the basis of progress obtained. These PSOs are categorized as follows:

1. Mild PSOs: No significant or mild obstacles to successful medical treatment.

2. Moderate PSOs: Some significant obstacles to successful medical treatment.

3. Severe PSOs: Substantial to overwhelming obstacles to successful medical treatment.

Sexual Dysfunction Treatment Guidelines

Although no objective data determines the criteria for diagnosing these three PSO categories, they will become a useful heuristic device to help clinicians know when to refer. For instance, "Severe" PSOs may require psychotherapeutic and/ or psychopharmacologic intervention prior to the initiation of treatment utilizing sexual pharmaceuticals in order to restore sexual functioning and satisfaction. Most nonmedical MHPs will collaborate with physicians to augment their own treatments, as sexual pharmaceuticals are likely to provide an ever-increasing role in MHP's treatment strategies and armamentarium for SD (15,17,20,43). Additionally, this treatment matrix will provide a useful tool for sex therapist physicians (usually psychiatrists), when deciding whether to treat themselves, or seek collaborative assistance. The matrix determining who might treat is presented in Table 2.1.

Table 2.1 SD Management Guidelines Based on PSO Severity

Mild PSO

Moderate PSO

Severe PSO

Physician sex coach

Frequently

Often

Rarely

Multidisciplinary team

Frequently

Frequently

Frequently

PSOs = Psychosocial obstacles.

PSOs = Psychosocial obstacles.

The following discussion illustrates how Table 2.1 could be used in clinical practice. Clearly, a multidisciplinary team including a sex therapist and multiple medical specialists could attempt to treat almost every case. Although severe cases would usually require a greater number of office visits with lower success rates, than moderate or mild cases. However, a team is a very laborintensive approach and frequently unrealistic, both economically and geographically in terms of available expertise and manpower. However, in the first two cells, which reflect common scenarios in clinical practice, a physician who first evaluates a patient suffering from SD, could integrate sex counseling with their sexual pharmaceuticals, often resulting in a successful outcome.

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Dealing With Erectile Dysfunction

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