Integrating Partners into Erectile Dysfunction Treatment: Improving the Sexual Experience for the Couple

J. Dean; E. Rubio-Aurioles; M. McCabe; I. Eardley; M. Speakman; J. Buvat; I. Sáenz de Tejada; W. Fisher

Disclosures

Int J Clin Pract. 2008;62(1):127-133. 

In This Article

Summary and Introduction

Introduction: Erectile dysfunction (ED) is a common condition estimated to affect more than 150 million men worldwide. ED should be regarded as a shared sexual problem which has significant detrimental effects both on the men who experience this condition and on their partners.
Evidence to support partner involvement in ED therapy: Evidence shows that the partner plays a key supportive role in the man's ED treatment and in successful long-term ED therapy. Including the partner in consultations may highlight discordant attitudes and communication problems between couple members which may indicate treatment acceptance or rejection, or realistic or unrealistic treatment expectations.
Options for partner involvement in ED therapy: Most patients with ED consult their physician in the absence of their partner. Therefore, involving the partner in therapy can be challenging. Two options which physicians should consider are: encouraging the patient to bring the partner into the office and, often more realistically, seeking information about, and providing information to, the partner, via the patient.
Objectives: The objective of these recommendations is to provide practical guidance on treating couples affected by ED, and suggest techniques that may be helpful in integrating the partner into the process of ED treatment.
What's known: Erectile dysfunction (ED) has significant detrimental effects both on the men who experience this condition and their partners. Evidence shows that the partner plays a key supportive role in the man's ED treatment and in successful long-term ED therapy. However, most patients with ED consult their physician in the absence of their partner. Therefore, involving the partner in therapy can be challenging.
What's new: These recommendations are the first to present suggestions to help primary care physicians, and other professionals treating men with ED, to better understand the role of the partner in this condition and in its successful treatment. Techniques are suggested that may be helpful in integrating the partner into the process of ED treatment, and a number of tools are provided to help the physician assess the interaction between patient and partner.

Our objective is to present suggestions to help primary care physicians, and other professionals treating men with erectile dysfunction (ED), to better understand the role of the partner in this condition and in its successful treatment. It is acknowledged that there may be situations where integrating the partner into treatment for ED is not appropriate or possible. At the same time, however, encouraging the patient to choose to include the partner in the treatment process will generally be beneficial, and may help to improve treatment success and restore a satisfactory sexual experience for both members of the couple.

The recommendations outlined in this paper provide guidance on treating couples affected by ED, and suggest techniques that may be helpful in integrating the partner into the process of ED treatment. For simplicity, we have largely discussed issues relating to heterosexual couples, but many of the suggestions may also be useful in the treatment of same-sex couples. In addition, it is clear that a number of social, cultural and religious factors need to be considered in the management of patients and partners affected by ED on individual and country levels, although these issues have not specifically been discussed here.

Why Integrate the Partner Into Erectile Dysfunction Treatment? In 1970, Masters and Johnson articulated the view that sexual response is an interaction between two people, and insisted that male or female sexual dysfunction involves both partners in the relationship. Therapy should, therefore, involve both partners to be successful.[1] More recent research has shown that ED has a significant negative impact on both the man and his partner and may be a considerable source of distress for both couple members.[2] Chevret et al. developed and validated the Index of Sexual Life (ISL) questionnaire, designed to measure women's sexual satisfaction and desire in relation to their partner's ED.[3,4] Findings indicated that partners of men with ED reported a significantly decreased sexual drive and sexual satisfaction, compared with partners of men without ED.

The Female Experience of Men's Attitudes to Life Events and Sexuality (FEMALES) study demonstrated a decline in sexual desire, levels of arousal, orgasm frequency and satisfaction among women partners of men with ED, compared with prior to the onset of their partner's condition.[5] Moreover, studies that have explored female sexual dysfunction suggest women partners of men with ED are themselves more likely to have sexual dysfunction or to cease sexual activity entirely.[6,7,8] The Nurses Sexuality Study, carried out among a community sample of American-registered nurses, found that women who reported a partner with ED showed significantly lower Female Sexual Function Index (FSFI) scores than women who did not report ED in their partner.[9] These studies suggest that, as women show lower levels of sexual functioning if their partner has ED, they should be included in ED treatment.

Having the partner present in the office during consultation can also highlight discordant attitudes and communication problems between couple members that may indicate treatment acceptance or rejection, or realistic or unrealistic expectations of treatment.[10] Studies have shown that the partner's attitudes affect the man's uptake and adherence to therapy,[11] and that successful long-term ED therapy is more likely with the involvement and support of the partner.[12] It has been suggested that partner preferences for different treatment options should always be carefully considered and that any ED treatment should be chosen and accepted by both the patient and his partner, or it will not be used.[13,14]

The woman partner may be able to contribute important information on the history of the man's ED, and describe changes in patterns of erectile function.[10] It has also been reported that problems experienced by the partner or difficulties within the relationship may contribute to the development of ED, or may perpetuate this sexual dysfunction in the man.[15] However, most patients with ED consult their physician in the absence of their partner. Partner involvement therefore presents a challenge for the physician. Two options should be considered: attempting to bring the partner into the office and, often more realistically, seeking information about, and providing information to, the partner, via the patient (e.g. using specific clinical questions about the partner's awareness of treatment options and feelings about them, about patient-partner communication in this area, and via educational leaflets, brochures, etc. targeting both the patient and partner).

Evidence to Support Integrating the Partner Into Erectile Dysfunction Treatment. A number of randomised, controlled studies have demonstrated a significant improvement in sexual function, satisfaction and sexual quality of life in both the man and his untreated woman partner following vardenafil treatment of men for ED.[11,16,17] In a recent trial using sildenafil, untreated women partners of men with ED also reported an increased frequency of satisfactory sexual intercourse, enjoyment, and some measures of desire, arousal and orgasm following treatment of the man.[18]

There is a negative treatment-seeking cascade among men with ED. The Men's Attitudes to Life Events and Sexuality (MALES) phase II study showed that some 58% of men with ED had spoken with their physician about their sexual dysfunction but only 16% were currently using oral phosphodiesterase type 5 (PDE-5) inhibitor therapy.[19] Other studies suggest that treatment discontinuation rates for PDE-5 inhibitors may be as high as 19.5-47.3%.[20,21,22,23] Integrating the female partner into the treatment plan may play a key role in improving adherence rates and improving the sexual quality of life of both members of the couple.

Many experts feel that physicians have a moral and ethical responsibility to assess and to treat, where possible, sexual problems affecting both partners, and acknowledge that these problems often occur within the context of a couple relationship. In treating one member of the couple, the physician should ensure that the other member has the opportunity to have their needs assessed and met as much as possible. In some cases, the physician may feel that they lack the knowledge and skills needed to address the partner and their concerns, or it may be culturally unacceptable for the physician to treat someone of the opposite gender. In these cases, the physician has a responsibility to propose to refer the partner, or the couple, to an appropriate source of high quality healthcare.

Possible Barriers to Partner Integration. Integrating the partner into a couple-based approach to the management of ED is often useful. However, as highlighted above, there may be certain situations where integrating the partner into treatment may not be appropriate or possible. Barriers to partner integration may result from a number of interpersonal, cultural, social, ethnic and religious factors.

Couples who are likely to have the best long-term treatment outcomes and the lowest rates of discontinuation are those where the woman partner wishes to be involved in treatment and the patient wants her to be involved.[2,24,25,26] These couples usually have a strong relationship with good levels of communication. In some cases, the patient may prefer to have the involvement of his partner but she is unsupportive. This lack of support may be a result of unresolved problems in the relationship, the woman's belief that ED is solely the man's problem, or an excessive sense of embarrassment and shame, or aversion to sex in the woman partner. In this case, relationship or sexual issues need to be addressed (e.g. through counselling). The woman may also benefit from education about the benefits of partner support in achieving long-term treatment success.[27] Educating the woman about different treatment options to enable her to express her preference may reduce the risk of resistance to treatment.

In other couples, the patient may not want to involve his partner in therapy. The reasons for this may be cultural (e.g. where the man assumes a traditional, male-dominant sexual role in the relationship), or due to a lack of communication between couple members. In some cases, couples may benefit from education to help them both understand the condition more fully and for the patient to recognise the benefits of partner support.[28,29] Counselling, either individually or for the couple as a whole, may also be beneficial. The situation where the patient does not want to involve his partner and his partner is unsupportive does not allow for partner involvement, and treatment for ED may be least likely to be effective in these cases.

Another common barrier to partner integration involves constraints on clinician time and expertise. The physician may be able to gain information about the partner indirectly, by asking the patient questions about the partner's interest and/or concerns about treatment, her menopausal status, and the couple's recent history of sexual activity. It may then be possible to suggest that the patient bring the partner into the office, to convey information to the partner by way of the patient, or to suggest patient-partner discussion of treatment issues and to offer physician consultation to the couple in the event it is needed.

Development of Recommendations and Physician Tools. Discussions were held with eight expert panel members to develop practical tools for integrating the partner into ED treatment. The recommendations developed by the panel were then presented to a wider group of 35 experts from countries worldwide, and modifications made in response to the feedback received. The expert panel included members from various disciplinary backgrounds and included family physicians, general physicians, psychologists, researchers, sexual and reproductive medicine physicians, sexual psychotherapists and urologists. All participants had significant professional experience in ED management or had published multiple peer-reviewed studies on this topic.

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