September 2023 correspondence

To quote a previously published article about focussing on male sexual dysfunction (MSD), ‘Erectile dysfunction (ED) is much more than prescribing a pill’.¹ With regards to the published article ‘Male sexual dysfunction: Clinical diagnosis and management strategies for common sexual problems’ by Nicol and Chung in the January–February 2023 issue of AJGP,² it quotes a traditional biopsychosocial rather than newer bio-neuromusculoskeletal approach, thereby failing to integrate a neglected piece of the puzzle, the pelvic floor and the autonomic nervous system (ANS) into male sexual dysfunction.³

General practitioners (GPs) need to be aware of the evolved knowledge of the role of the pelvic floor in normal sexual function, neuro-psychophysiology of sex, how pelvic floor autonomic tone relates to MSD and why pelvic floor and breathwork are important first-line sexology skills for all men.

Although the article acknowledges the importance of psychosexual therapies, it focusses mainly on traditional urological and drug treatments. More recent evidence, however, suggests rehabilitation using pelvic floor training to normalise pelvic muscle tone and improve muscle relaxation as an important non-drug treatment for MSD.⁴ Therefore, a ‘holistic management’ strategy would be to include pelvic floor training as an important component of management strategies.

Although it is acknowledged that there is no natural owner of sex therapy, sexology skills and psychosexual therapies and counselling are still recommended first-line treatment strategies, especially for psychogenic erectile dysfunction and acquired premature ejaculation (PE).⁵

GPs can consider the option of psychosexual therapies, pelvic floor programs and sexology skills programs within chronic disease management planning to ensure an appropriate mix of allied health professionals are involved when managing men’s sexual disorders.

Thank you for publishing articles on MSD. Managing sexual dysfunction is an important yet understated component of patients’ quality of life that GPs manage within chronic care diseases such as diabetes, depression, anxiety and heart disease.

Author

Suzan Bekir MBBS (Hons1), FRACGP, General Practitioner, Cooper Street Clinic, Double Bay, NSW

References

1. Shoshany O, Katz DJ, Love C. Much more than prescribing a pill - Assessment and treatment of erectile dysfunction by the general practitioner. Aust Fam Physician 2017;46(9):634–39.
2. Nicol A, Chung E. Male sexual dysfunction: Clinical diagnosis and management strategies for common sexual problems. Aust J Gen Pract 2023;52(1–2):41–45. doi: 10.31128/AJGP-09-22-6559.
3. Cohen D, Gonzalez J, Goldstein I. The role of pelvic floor muscles in male sexual dysfunction and pelvic pain. Sex Med Rev 2016;4(1):53–62. doi: 10.1016/j.sxmr.2015.10.001.
4. Yaacov D, Nelinger G, Kalichman L. The effect of pelvic floor rehabilitation on males with sexual dysfunction: A narrative review. Sex Med Rev 2022;10(1):162–67. doi: 10.1016/j.sxmr.2021.02.001.
5. Ramanathan V, Redelman M. Sexual dysfunctions and sex therapy: The role of a general practitioner. Aust J Gen Pract 2020;49(7):412–15. doi: 10.31128/AJGP-02-20-5230.

Reply

We thank the writer for engaging with our our paper titled ‘Male sexual dysfunction: Clinical diagnosis and management strategies for common sexual problems’.¹ We agree with their suggestion that there is more than just a ‘simple’ (traditional) biopsychosocial model to erectile dysfunction and other innovative concepts such as applying a bio-muscular-skeletal approach to target other relevant organ systems such as the pelvic floor musculature and autonomic nervous system, which are equally important in the overall management of male sexual dysfunction (MSD).^2–4 The male sexual function is important for physical, psychosocial, and emotional wellbeing, and the presence of MSD could be an important marker for overall general health beyond just a simple disorder of the penis.^5,6

Non-medical therapy remains the first-line management in MSD, and potential causative (contributing) factors and relevant modifiable factors such as medications, psychological stress, mental-wellbeing, medical comorbidities, medications, partner-specific issues, and tobacco, drug, and alcohol consumption, should be explored and addressed.^5,6 Referral to well-trained psychosexual therapists such as those provided by the GP Mental Health Treatment Plan (GPMHTP) and concomitant input from allied health professionals through the Enhanced Primary Care within Chronic Disease Management (CDM) are certainly appropriate and should be instituted if clinically relevant to ensure a more holistic approach and improve treatment compliance. Nonetheless, pharmacotherapy remains the cornerstone in managing MSD as most patients generally request and/or prefer a drug to ‘fix’ their sexual problems.⁷

This review paper aims to highlight the contemporary understandings and management strategies for MSD with an emphasis on relevant clinical assessment and providing a practical set of recommendations pertinent to general practice.¹ General practitioners should always try to modify lifestyle behaviours, address reversible risk factors, and optimise existing medical conditions in patients before instituting medical therapy based on the patient’s needs and goals for treatment.⁵Referrals to the relevant specialists are certainly appropriate if patients do not respond and/or seek expert input.

Authors

Alice Nicol MBBS, Surgical Registrar, Department of Urology, Princess Alexandra Hospital, University of Queensland, Brisbane, Qld

Eric Chung MBBS, FRACS (Urol), Professor of Surgery, Department of Urology, Princess Alexandra Hospital, University of Queensland, Brisbane Qld; Professor of Surgery, Department of Urology, Macquarie University Hospital, Sydney, NSW; Director, AndroUrology Centre, Brisbane, Qld

References

1. Nicol A, Chung E. Male sexual dysfunction: Clinical diagnosis and management strategies for common sexual problems. Aust J Gen Pract 2023;52(1–2): 41–45. doi: 10.31128/AJGP-09-22-6559.
2. Wu C, Kovac JR. Models for erectile dysfunction and their importance to novel drug discovery. Expert Opin Drug Discov 2016;11(2):185–96. doi: 10.1517/17460441.2016.1126243.
3. Chung E, De Young L, Brock GB. Investigative models in erectile dysfunction: A state-of-the-art review of current animal models. J Sex Med 2011;8(12):3291–305. doi: 10.1111/j.1743-6109.2011.02505.x.
4. Kandeel FR, Koussa VK, Swerdloff RS. Male sexual function and its disorders: Physiology, pathophysiology, clinical investigation, and treatment. Endocr Rev 2001;22(3):342–88. doi: 10.1210/edrv.22.3.0430.
5. Chung E, Lowy M, Gillman M, Love C, Katz D, Neilsen G. Urological Society of Australia and New Zealand (USANZ) and Australasian Chapter of Sexual Health Medicine (AChSHM) for the Royal Australasian College of Physicians (RACP) clinical guidelines on the management of erectile dysfunction. Med J Aust 2022;217(6):318–24. doi: 10.5694/mja2.51694.4
6. Salonia A, Bettocchi C, Boeri L, et al; EAU Working Group on Male Sexual and Reproductive Health. European Association of Urology Guidelines on Sexual and Reproductive Health - 2021 update: Male sexual dysfunction. Eur Urol 2021;80(3):333–57. doi: 10.1016/j.eururo.2021.06.007.
7. Hatzimouratidis K, Salonia A, Adaikan G, et al. Pharmacotherapy for erectile dysfunction: Recommendations from the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med 2016;13(4):465–88. doi: 10.1016/j.jsxm.2016.01.016.