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The physicians "time crunch" can be managed, when brief counseling of the SD patient is sufficient. If the partner's support for successful resolution of the SD is not present, then active steps must be taken to evoke it. Sometimes, a conjoint referral for adjunctive treatment to a sex therapist for the partner may also be required (20). Of course, the more problematic the relationship, the more profound the marital strife, the less likely that patient-partner sex education will be able to successfully augment treatment in and of itself. Inevitably, a referral to a MHP would be required, albeit not necessarily accepted successfully. Additionally, there are numerous organically determined reasons making referral to a multiplicity of medical specialists (urologists, gynecologists, neurologists, psychopharmacologists, endocrinologists, etc.) necessary and appropriate. However, elaborating all of them is beyond the scope of this chapter.

Integration vs. Collaboration

Does a multidimensional understanding of a SD always require a multidisciplin-ary team approach? Clearly, the answer is no. When there is a question of collaboration vs. integration within an individual clinician; how does one decide whether to be a multitalented physician or part of a multidisciplinary team?

There are a variety of sexual medicine thought leaders conversant with both organic and psychosocial predisposing, precipitating, and maintaining factors of SD, including some notable PCPs, psychiatrists, and urologists. Additionally, there is a convergence towards a bio-psychosocial consensus initially reflected by the "Process of Care Guidelines," and elaborate upon, in the published Proceedings of the WHO 2nd International Consultation on Erectile and Sexual Dysfunction (40,42). These publications are the result of multidisciplinary cooperation, with collaborative knowledge being appreciated, independent of specialty of origin. These consensus reports, speak to the importance of integrating medical, surgical, and psychosocial treatments for SD. Sometimes, the physician's treatment is only partially successful, and the lack of psychosocial sensitivity causes an exacerbation of the problem. This may be corrected. Reciprocally, psychotherapists may be fairly criticized for failing to refer quickly enough for medical consultation, in order to benefit from incorporating a sexual pharmaceutical to speed-up the recovery process and reduce the time and cost of treatment. Discussed subsequently is Roberto's ED case, treated by the author and two different urologists; when an expert sexual medicine physician, who had adequate time and motivation, may have managed equally well.

Case Study: Roberto

A 32-year-old Italian man was suffering from primary ED. Roberto had "two hypospadias operations" at ages 3 and 6. He reported "at 8 years old, circumcision removed 'excess skin'." He remembered friends teasing, about his urinating from the "underside." He had primary ED and 2 years ago (as a visiting student), he consulted a US urologist who prescribed sildenafil. The urologist reportedly told Roberto that he would never function normally, because of his congenital hypospadius. Roberto left that consultation devastated, fearing he was sexually handicapped for life. No great surprise, the sildenafil did not work when he used it with masturbation. He was afraid to date women. The same urologist observed on follow-up that Roberto seemed depressed and was not using the sildenafil, or dating. He referred Roberto to the author. Accurate information incorporated within a cognitive-behavioral sex therapy, improved Roberto's self-esteem, reduced his fear of rejection, decreased performance anxiety, and encouraged dating. His confidence was increased through his masturbation, augmented with sildenafil and fantasy. It worked! He began dating and had erections with foreplay.

Vacationing in Italy, Roberto began a sexual relationship with a woman. He went to an Italian urologist who complemented his sex therapy progress, and provided him with samples of sildenafil, vardenafil, and tadalafil. All worked wonderfully, but he preferred tadalafil, because of the 36 h duration of action. He reported that his new girlfriend supposedly "had six orgasms in 27 years with all her boyfriends; yet with me, she had five in one day." He suspected, she knew, he used "sex drugs." They reportedly had sex twice daily. Back in the

USA, he used 1/3, of a 100 mg sildenafil and fantasy about sex in Italy, to masturbate successfully. Roberto was gradually weaned from the sildenafil when he masturbated. When his girlfriend visited 6 months later, he initially used low dose sildenafil successfully. Then, she seduced him one night when he had no medication available. She remained with him in the US. Reportedly, they now have twice weekly coitus, fully weaned from medication, for the past 5 months. The author will see him again in 2 months for follow-up to minimize relapse potential. Roberto recognizes, "it is mostly in the brain." He wisely said, "If we break up or in a period of stress, okay let me take a pill a couple of times. I will use it as a crutch once in a while. When I feel less secure or very stressed."

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