Erectile dysfunction: a multidisciplinary approach

On Friday, 8th November 2019 the Greater Manchester Mental Health (GMMH) NHS Foundation Trust psychosexual team facilitated their third multi-disciplinary conference ‘Erectile dysfunction: a multidisciplinary approach’. Following the success of two previous conferences focusing on female sexual disorders, this was the first conference facilitated by the team to focus on a male sexual disorders. Delegates who attended were indeed multi-disciplinary, including psychosexual therapists, psychologists, psychiatrists, GPs, urologists, nurses and physiotherapists.

The first speakers of the day were Malcolm Firth (pictured left) and Gill Brisk, also members of the GMMH psychosexual team. Malcolm, a psychosexual therapist with a background in social work, university teaching and service development in primary and secondary care mental health settings, opened with presentations of erectile dysfunction and outlined the assessment process, including physical checks, psychogenic versus organic erectile dysfunction, predisposing, and precipitating and maintaining factors. He followed this with a brief description of performance anxiety. He then presented the case of a single heterosexual male, age fifty-six, with a long history of intermittent erectile dysfunction plus rapid ejaculation. Formulation noted performance anxiety, problems with trust and emotional intimacy, and belief in spontaneous sex as optimal. Three treatment sessions helped to normalise his performance related problem, confronted his beliefs around spontaneous sex being the ‘gold standard’, and encouraged acceptance of the effects of ageing. 

Gill (pictured right), a psychosexual therapist with a background in relationship counselling, is also part of the team who facilitate a community domestic abuse programme for perpetrators of abuse started by Relate in 2008. Gill presented the case of a client with performance anxiety and avoidance, which was precipitated by a trauma.  The psychosexual therapy was paused for eye movement desensitisation and reprocessing (EMDR) targeted at the trauma, which appeared to improve things slightly. The client was considering trialling a temporary period of taking a PDE5-inhibitor and then he stopped attending appointments. She opened a discussion around the notion that sometimes non-attendance can be anxiety-driven avoidance taken one step further.

Next to speak was Konstantinos Nikolaou (pictured left), a men’s health physiotherapist with extensive experience in musculoskeletal disorders and strength and conditioning to treat male pelvic floor dysfunctions. Konstantinos is employed by one of the most popular pelvic clinics in Birmingham, the Harborne Physiotherapy Clinic. His caseload includes male pelvic pain, athletic pelvic pain, post-prostatectomy, hard flaccid syndromes and erectile dysfunctions. In his talk, he spoke about how the process of achieving and maintaining an erection is known to be multifactorial; one of the major factors to this function being the pelvic floor muscles.

He explained how the coordination of bulbospongiosus and ischiocavernosus muscles facilitate erection and ejaculation, and how different conditions can affect their function such as chronic prostatitis, chronic pelvic pain syndrome, radical prostatectomy, anxiety and depression. These conditions can either cause weakness and hypoactivity or increased muscle resting tone, and physiotherapy plays a crucial role in the early identification of the source of the symptoms through detailed assessment. He outlined the growing evidence that suggests that pelvic floor muscle training can be effective in treating erectile dysfunction. Motor control retraining, breathing exercises, correction of maladaptive patterns and pelvic floor muscle strengthening exercises can improve the function of type one and two muscle fibres, which are accountable for creating and maintaining an erection.

Next to speak was Dr Ged Smith (pictured right), a family therapist of more than 20 years’ experience who currently works in both CAMHS and Adult Services within two NHS Trusts in Merseyside. Ged invited us to think about how men struggle to know how to act as fathers to their children or carers of their partners or each other, when bombarded with images that privilege control and reason, dominance and achievement. He invited us to consider how we need to change the ways societies operate to liberate us all from these strictures. Masculinity (for example) is an invented construct, not anything that is natural or essentialist, with costs that are high for both men and women in terms of physical and mental health, and this plays out in the bedroom with the pressures of sexual performance on men. Patriarchy is still a dominant force in our lives, and yet the idea of power that this gives men is an illusion that confuses us all and makes life harder for both men and women. Ged shared his belief that sexual dysfunction is more often psychological/cultural than medical.  

The final speaker for the morning was Elaine Robinson (pictured left) who has worked as a Urology Specialist Nurse at Manchester Royal Infirmary for 20 years, managing a nurse-led erectile dysfunction clinic in conjunction with two Urology Consultant Surgeons. Elaine gave an overview of her role at the clinic, which receives referrals from both primary and secondary care. She explained that she sees her role as an investigator, educator and teacher giving instruction both practically and theoretically on how to get the maximum effect from the treatments prescribed and supporting patients through their journey. With education and information, patients can appreciate that erectile dysfunction is multifactorial with contributing factors that can include lifestyle, co-morbities and medication. Treatment options take a holistic approach: psychological, medication (oral, intra urethral, injectable or vacuum therapy) and reassessment of patients is needed to achieve successful treatments options and outcomes. Elaine emphasised the importance of working in partnership with patients, GPs, psychological support and secondary care to ensure patients achieve the best outcome for their erectile dysfunction.

The afternoon speakers commenced with Emma Mathews (pictured above), who works as a therapist within the GMMH psychosexual team; she is also a cognitive behavioural and EMDR therapist. Emma’s presentation focused on erectile dysfunction from a performance anxiety perspective. As psychosexual therapy often focuses on behavioural interventions, both solo and partnered, Emma wanted to talk about cognitive based interventions that can be used with clients when behavioural interventions are not sufficient to facilitate change. Many single male clients present for psychosexual therapy and, if their problem only occurs during partnered sexual encounters, treatment can be limited from a behavioural perspective. She presented a maintenance model developed to demonstrate to clients how erectile dysfunction is maintained from a cognitive, behavioural and relational perspective and discussed various interventions that can be used by therapists to address unhelpful beliefs, cognitive distortions and unhelpful safety behaviours. She included a case presentation relating to a single heterosexual thirty-year-old male client with erectile dysfunction and low self-esteem, and demonstrated how she used the interventions outlined within the treatment plan to work with this client.

The second speaker of the afternoon was Professor Ian Pearce (pictured above), currently clinical head of the surgical division at Manchester Royal Infirmary. Ian has developed a large tertiary practice in andrology with the largest Peyronie’s disease and penile implant practice outside of London. His presentation addressed the various causes of male erectile dysfunction, highlighting the major independent risk factors of age, diabetes, hypertension and peripheral vascular disease amongst others. The importance of identifying modifiable risk factors in the patient’s assessment was stressed, as was the need for a detailed sexual history and validated assessment in the form of an IIEF questionnaire. Relevant investigations including an early morning fasting hormone profile were detailed, and each potential therapeutic option was discussed from lifestyle modification and oral pharmacotherapy through to injections, vacuum devices and topical cream and onto surgical prosthetic implantation. The need for thorough patient counselling at the onset of the patient journey and the need in the current era to explain all treatment options to facilitate patient and clinician joint decision making was focused on, with the final take home message being that patients no longer have to exhaust all other options prior to being considered for a penile implant but should have this option offered at an early stage.

The final speaker for the day was Ian Baker (pictured above). Ian’s experience gained as a relational and psychosexual therapist led him to work within the field of Sex Addiction Therapy. He also trained and works with Specialist Treatment Organisation for the Prevention of Sexual Offending (STOPSO), working with those who have been charged with watching indecent images of children. Ian’s presentation looked at the problem of PIED (porn induced erectile dysfunction), the influence of unrestrained access to erotica on adolescents, and an overview of the porn industry and its influence on children from early adolescence, including the consequences of being exposed to supernormal stimuli relating to sexual images from an early age, often before or at the start of puberty. Ian presented some sobering statistics from PornHub and spoke of the influence of porn not only in terms of sexual dysfunction but also as a cause of higher levels of body dissatisfaction, greater self-objectification, sexist beliefs and greater tolerance of sexual violence toward women. He went on to talk about how therapists are increasingly seeing young men with erectile dysfunction; a 2018 UK survey of 2000 men found one in two men under the age of thirty have erectile problems, this figure was under 2% in 2002, before the first tube porn sites were introduced in 2006.

The conference was a great success, with positive feedback from delegates who not only had the opportunity to gain wider knowledge in the area of erectile dysfunction from other disciplines, but also had an excellent opportunity to network, collect resources and contribute their own knowledge and experience during the animated Q&A sessions that followed each speaker. The GMMH psychosexual team are proactive and passionate about promoting multi-disciplinary working, and to receive information on future events email the team – emma.mathews@gmmh.nhs.uk or gillian.brisk@gmmh.nhs.uk

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