Regaining potency does not automatically translate into the couple resuming sexual intercourse. Psychological issues may render the best treatments futile. PDE-5 discontinuation or failure rates of 20-40% are not due to adverse events. Resistance to lovemaking is often emotional and the most common "mid-level" psychological causes of SD are relationship factors (15,20,23). As discussed previously, partner dynamics can help determine correct pharmaceutical selection on the basis of analysis of the couple's premorbid sexual script and relationship (50). Yet numerous partner related psychosexual issues may also adversely impact outcome.
Mild immediate causes of SD are often amenable to brief counseling in the physician's office. Still the most common mid-level relationship causes may present considerable difficulty for the nonpsychiatric physician treating SD within the context of a typically brief office visit. How might this challenge be met? The complexity of this conundrum can be reduced or resolved. The physician's challenge is not necessarily requiring an office visit with the partner, as many CME programs have advocated. Instead, the emphasis should be on evaluating the level of partner cooperation and support. Since Masters and Johnson, sex therapists have recognized that SD is a "couples problem," not just the identified patient's problem (2). However, almost equally long ago, this author and others noted that the key partner treatment issue was supportive cooperation, independent of actual attendance during the office visit (5,20). Generally speaking, encourage partner attendance with committed couples, allowing assessment and counseling for both. However, the issue is never forced. Treatment format is a psychotherapeutic issue and rapport is never sabotaged. Although conjoint consultation is a good policy, it is not always the right choice! A man or woman in a new dating relationship is probably better-off seeing the physician alone, than stressing a new relationship by insisting on a conjoint visit (20,54).
Although CME courses recommended that patient-partner-physician dialogue was best enhanced through patient-partner education during conjoint visits, there was anecdotal evidence that physicians were not regularly meeting with partners of SD patients. This author undertook a 2002 Internet survey of the Sexual Medicine Society of North America, member's practice patterns. These urologists are all sub-specialists in sexual medicine in general, and ED in particular. Although methodologically limited, the results were interesting. The data pointed to a striking disparity between urologist attitude and actual practice. An overwhelming 79% of the responding urologists considered partner cooperation with ED treatment "important," regardless of whether the partner actually attended sessions or not? Yet, only 39% of the responding urologists saw only one partner or less in their last five ED patient's office visits. Nor was there any contact by phone, e-mail, or other means between doctor and partners for 90% of the responding urologists, despite the vast majority of patients were married or coupled. However, there were good reasons for not having a conjoint visit, as long as the importance of partner issues in treatment success was understood. Indeed, many urologists reflected thoughtfully on the burden of the treater to not invade the privacy beyond what was freely accepted by the patient. Urologists noted that the men saw ED as their problem, and were not interested in involving their partner. These urologists gently encouraged partner attendance, but appropriately did not require it (20). So why are pharmaceutical ED treatments so effective? Does this data suggest that partner issues do not impact outcome? No, but it does support the thesis that "partner cooperation" is even more important than "partner attendance." Why are many physicians successful even when not seeing partners? Sex pharmaceuticals with sex counseling and education work for many people, if the partner was cooperative in the first place. Fortunately, many partners of both men and women are cooperative, which partially accounts for the high success rates of medical and surgical interventions. Indeed, most of the cooperation goes unexplored. The cooperation is assumed based on post hoc knowledge of success. Importantly, many women were cooperating with their partners, or facilitating sexual activity, independent of their knowledge of the use of a sexual aid or pharmaceutical. In other words, serendipitous matching of sexual pharmaceutical and previous sexual script equaled success: "we did, what we used to do, and it worked." (20,54).
The existence of large numbers of cooperative, supportive women who themselves have partners with mild to severe ED account for much of the success of many ED patients who see their physicians alone, for evaluation and subsequent pharmacotherapy. Many of these partners were never seen by the treating physician, nor was their attendance necessary for success. This is likely to be true for other male and female dysfunctions as well, depending on the degree of psychosocial barriers to success. Obviously, the most pleasant, supportive, cooperative partners would rarely be discouraged from attending office visits with any patient. Ironically, these same patients would probably have successful outcomes even if their partners never attended an office visit. However, good becomes better by evaluating, understanding, and incorporating key partner issues into the treatment process (54).
The patient-partner-clinician dialogue is best enhanced through patientpartner education. Partner attendance during the office visit would allow for such education. Yet, many clinicians do not regularly meet with partners of SD patients. Although working with couples was often recommended: sometimes there was no partner; sometimes the current sexual partner was not the spouse, raising legal, social, and moral sequella. The reality and cost/benefit of partner participation is a legitimate issue for both the couple and the clinician, and not always a manifestation of resistance. Finally, the patient's desire for his partner's attendance may be mitigated by a variety of intrapsychic and interpersonal factors, which, at least initially, must be respected and heeded (15,20).
There are other solutions. When evaluation or follow-up reveals significant relationship issues, counseling the individual alone may help, but interacting with the partner will often increase success rates. If the partner refuses to attend, or the patient is unwilling or reluctant to encourage them; seek contact with the partner by telephone. Ask to be called, or for permission to call the partner. Most partners find it difficult to resist speaking "just once," about "potential goals" or "what's wrong with their spouse." The contact provides opportunity for empathy and potential engagement in the treatment process, which may minimize resistance and improve further outcome. This effective approach could be modified depending on the clinician's interest and time constraints. Clinicians should counsel partners when necessary and possible. They need to be a resource in treating with medication, counseling, and educational materials. Education needs to be a greater part of SD practice, whether provided within a physician's practice or externally by other competent healthcare professionals. Success rates can be enhanced through patient-partner-clinician education, which will reduce the frequency of noncompliance and partner resistance, and minimize symptomatic relapse. Organic and psychological factors causing SD, and noncompliance with treatment, are on a multi-layered continuum. Although some partners will require direct professional intervention, many others could benefit from obtaining critical information from the SD patient and/or multiple media formats both private and public (20,54).
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