In the majority of cases of ED, psychological factors are involved in either the development of the disorder or the maintenance of the problem. While recognising that many men would not seek a psychological approach to resolving the condition, an outline of performance anxiety about continued erectile failure and the effect this has on their partner and their relationship, is often appreciated by the man. Difficulties with communication and the development of suspicion and mistrust between partners may need discussion, recognition, and specific intervention.
One group of men will experience ED almost entirely related to disease processes. These men are likely to have good interpersonal relationships which, if longstanding, will have been maintained with communication, respect, and intimacy. They are unlikely to need much in the way of sex counselling (if any).
A second group of patients will have ED as a consequence of a disease state but where there are also contributory psychological factors. Acknowledging with the patient that the ED may be having an adverse effect on his overall sex life may facilitate an interaction with the man (and often his partner) to find ways to re-establish the desired sexual relationship. Sometimes this will involve provision of basic educational information and guidance to enhance the sexual relationship. It may also be appropriate to consider a more integrative approach with the short-term prescription of an erectogenic agent to help restore sexual confidence and function.
The third group of men includes those with the presence of other psychological morbidity such as dysthymia or mild depression, substance misuse, relational problems, or other sexual problems such as loss of desire or ejaculatory disturbance. These may require a more proactive input from the psychosexual therapist, which may incorporate psychosexual therapy, relationship therapy, often integrated with management from one or more mental health professionals for any associated mental health disorders.
In each of these three situations, an integrative approach by the assessing clinician to ensure adequate assessment of both psychological and physical contributing factors may lead to more efficacious outcomes while recognising that the interventions themselves may be multiple, rather than relying on one treatment and progressing in a linear fashion to alternatives because of failure of "first line therapy." Helping the man to start to use his preferred treatment choice (such as sildenafil) and integrating this into his sexual repertoire with his partner can help the man and the couple to restart their sexual lives together and regain not only a good erection, but also good sex.
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