Educating Physicians to Treat Erectile Dysfunction Patients: Development and Evaluation of a Course on Communication and Management Strategies

Steps to construct educational interventions on sexual dysfunction for healthcare professionals and patients. Experiences from the SECRET research study-group

Objectives

To design an educational intervention on sexual dysfunction for patients suffering from schizophrenia and diabetes based on patients' and other relevant stakeholders' preferences, and to offer transparency into the basic decision-making process behind a final design.

Methods

We conducted a three-part investigation to explore theory, preferences, and feasibility based on literature searches and interviews with patients, healthcare professionals, heads of Assertive Community Treatment Centres and experts. Based on a content analysis of this material, a draft of the intervention was developed. The draft was quality-checked by involvement of stakeholder representatives and refined to its final design.

Results

The intervention evolved into having two components: One intervention for patients and one for healthcare professionals. In patient education, meeting peers and predictability were important factors. For healthcare professionals, daily clinical activities were prioritised.

Conclusions

We present a framework for an educational intervention about sexual dysfunction, schizophrenia and diabetes targeting both patients and healthcare professionals.

Innovation

The transparency of the design process underlying the interventions allows for reproduction and eases further refinement, extension, and adjustment if implemented in other contexts.

Gaps in sexual health content of healthcare professional curriculum: a systematic review of educational interventions

BACKGROUND

Sexual health care, including assessment and patient teaching, is part of comprehensive patient care. Health professional (medical and nursing) students' education in sexual health lacks uniformity in content and assessment skills.

OBJECTIVES

The current systematic review aimed to assess sexual health educational curriculum for health professional students regarding the educational content, duration, and evaluation of these educational interventions.

METHODS

This systematic review followed the preferred reporting guidelines for systematic reviews. A comprehensive search was conducted between May-August, 2023 across four databases (PubMed, Scopus, CINAHL, EMBASE), outlining 614 sources. Following the screening process, 36 educational intervention studies were deemed eligible for inclusion. The quality assessment of these studies was conducted using The Effective Public Health Project tool, which was found appropriate for evaluating this type of research.

RESULTS

The studies had a global representation, with most studies conducted in the US. Limited nursing educational interventions were found. Three main categories emerged from the analysis of the educational interventions: one-time interventions, workshops, and semester courses. These categories differed in terms of their duration. Upon evaluating the educational intervention programs, it was found that the majority relied on participant self-reporting, while only a few included objective evaluations.

CONCLUSIONS

This review revealed inconsistencies in educational content for healthcare professional students and may impact their clinical skills, particularly in sexual health. The variation in content, duration, and evaluation methods created challenges in assessing the interventions. The lack of standardized sexual health education highlighted a significant gap, raising concerns about students' ultimate proficiency in this area. Bridging this divide is essential by integrating comprehensive sexual health content and assessment skills into the health professional curriculum.

Breaking the Ice of Erectile Dysfunction Taboo: A Focus on Clinician–Patient Communication

Erectile dysfunction is a common yet complex problem facing men and their partners worldwide. It continues to be an under reported issue despites its high prevalence and negative impact as well as the availability of successful treatment. One of the main reasons for such a problem is the stigma surrounding it as a complaint and the deep-seated fear to discuss it. This paper aims to highlight the reasons behind the taboo and dilemma behind erectile dysfunction reporting and discusses means to overcome this stigma focusing on clinician–patient communication.

Teaching Sexual History Taking in Health Care Using Online Technology: A PLISSIT-Plus Zoom Approach During the Coronavirus Disease 2019 Shutdown

Aim

Cancellation of university classes during the coronavirus disease 2019 pandemic challenges teaching inperson sexual history–taking skills to medical, physician assistant, and nursing students. We used commercial online electronic services for medical students to learn sexual history–taking skills.

Methods

A total of 174 medical students viewed a lecture on sexual history taking and the PLISSIT model (Permission, Limited Information, Specific Suggestion, Intensive Therapy) and were then randomized into dyads. They arranged a time to meet online on Zoom with their partner, chose a simple sexual history case-history (male or female) from a small selection, and recorded the 5- to 6-minute sexual history within a 1-week time frame. Each student played a “provider” or “patient” and then switched roles with a new case. One of the course tutors, all sexual health practitioners, downloaded 10 videos randomly assigned to them asynchronously and viewed and commented on the interaction of each “provider” along with comments on what to improve in the sexual history. 2 weeks later after the remainder of the lectures in the course, a second, more complex set of 8 cases were provided, so students could move at their comfort pace and choose 1.

Main Outcome Measure

Students were required to make 1 online post and 1 comment on another student's post for each case, on the experience, and associated issues arising, positive or negative. All comments were downloaded and analyzed by theme.

Results

Major themes included developing comfort in using sexual language, using simpler sexual terms suitable for patients, feeling confidence and mastery, excitement using technology developing clinical skills, surprise watching their performances and body language, observation of how they appeared to the “patient,” organizing sexual histories and incorporating PLISSIT model, ability to ask about context and relationships, and seeing the exercise as building on existing clinical skills training. Some expressed anxiety and nervousness, which by the second case had largely or completely dissipated.

Conclusion

A readily replicable, secure, cheap cloud-based model to integrate sexual history training asynchronously was provided, with tutors’ comments, and student skills development, and performance evaluated.

Ross MW, Newstrom N, Coleman E. Teaching Sexual History Taking in Health Care Using Online Technology: A PLISSIT-Plus Zoom Approach During the Coronavirus Disease 2019 Shutdown. Sex Med 2021;9:100290

Nursing interventions on sexual health: validation of the NISH Scale in baccalaureate nursing students in Taiwan

INTRODUCTION

No widely accepted tool is available to assess nursing interventions on patient's sexual health among nursing students. Consequently, nursing school faculty cannot determine the sexual healthcare-related skills of nursing students.

AIM

The aim of this article was to develop and test a scale to assess nursing interventions on sexual health.

METHODS

A 19-item instrument Nursing Interventions on Sexual Health (NISH) was developed using 10 semi-structured interviews of senior nursing students, expert review, and comparative analysis of text and field notes. A total of 198 senior nursing students were recruited from two nursing schools in central Taiwan to test the instrument. Exploratory factor analysis (EFA) was used to measure construct validity and Cronbach's alpha to measure internal consistency.

MAIN OUTCOME MEASURES

Validity and reliability of the NISH scale based on the Permission, Limited Information, Specific Suggestion, and Intensive Therapy (PLISSIT) model.

RESULTS

Three factors (permission, limited information, and specific suggestion) were retained after EFA of the 19 items of NISH. Cronbach's alpha for the subscales increased from 0.71-0.93 to 0.74-0.94 and from 0.93 to 0.95 for the total scale, with 72.42% of the cumulative variance explained by these three factors. Nursing students' age (P=0.019) correlated positively with total score.

CONCLUSIONS

NISH is a useful and reliable scale for assessing the frequency of PLISSIT-related behaviors used by nursing students to address patient's sexual health concerns. Nursing faculties can use this scale to assess students' performance and find their omitted behaviors in clinical practice regarding sexual health care.

Predictors of physicians' attitudes toward sharing information with patients and addressing psychosocial needs: a cross-sectional study in Greece

Sharing information with patients and addressing their psychosocial needs are recognized as fundamental practices of patient-centered physicians. Our study explored predictors of physicians' patient-centered attitudes and yielded a better understanding of the relative influences of job satisfaction, employment status, specialty, previous communication skills training, and sociodemographic factors. Physicians who participated in 13 identical workshops offered throughout Greece were invited to complete a battery of anonymous questionnaires (demographics, job satisfaction scale, Patient-Practitioner Orientation Scale-Sharing subscale, and Physician Belief Scale). Prediction models were used to identify predictors of patient-centered attitudes. In total, 400 fully completed questionnaires were returned (response rate 79.8%). Job satisfaction, previous training in communication skills, younger age and lower socioeconomic status were predictors of positive attitudes toward sharing information with patients. Job satisfaction, previous training in communication skills, and stronger religious beliefs were predictors of higher psychosocial orientation. Job satisfaction and training in communication skills should be ensured in the effort to develop and maintain patient-centered attitudes in physicians. Religious beliefs, age, and socioeconomic status should be taken into consideration in the effort to help physicians become aware of their biases.

Web-based survey on the effect of digital storytelling on empowering women to seek help for urogenital atrophy

OBJECTIVE

To evaluate an online digital story aimed to empower women suffering from urogenital atrophy to seek health professional advice.

STUDY DESIGN

A questionnaire evaluating a digital story on the UK-based menopause website www.menopausematters.co.uk. Main outcome measure Answers to questions on empowerment.

RESULTS

A total of 539 responses were obtained over the 62 weeks that the questionnaire was online. In women who had not previously sought help for urogenital atrophy, 145 were too embarrassed and 105 did not want to bother the health professional. Having watched the video, 73% (n = 105/143) of women who had been too embarrassed to discuss their symptoms with their doctor would now do so and 87% (n = 89/102) of women who had not wanted to bother their doctor would also make an appointment. Ninety-six percent (n = 138/144) of women would be willing to try treatment. Over two-thirds of women favoured webcast information to written information; however, postmenopausal women were less likely than peri- or premenopausal to favour this method of presenting health information.

CONCLUSION

Using digital stories for health promotion is a new area for research. Our data provide preliminary evidence that women can feel more empowered to seek help for urogenital atrophy using digital storytelling.

The future of sex therapy: specialization or marginalization?

Sex therapy's claims to specialization may be exaggerated and ultimately damaging to the integrated treatment of sexual dysfunction. In fact, sex therapy does not have a unified underlying theory, a unique set of practices, or an empirically demonstrated efficacious treatment outcome. Paradoxically, the practice of sex therapy has gained widespread professional and popular acceptance since the publication in 1970 of Human Sexual Inadequacy by Masters and Johnson. Consequences of the widespread acceptance of this supposed specialization include the marginalization of sex therapy from other forms of treatment and the perpetuation of the notion that sex therapy is a special form of therapy requiring highly specialized training. This specialization focus also helps to perpetuate societal discomfort with sexuality. The very modest empirical success of most so-called sex therapy interventions and the lack of theoretical development suggest that sex therapy needs a recalibration in order to survive. It is suggested that the treatment of sexual dysfunction be integrated into the general psychotherapy enterprise and into a multidisciplinary biopsychosocial framework.

Web-based survey on the effect of menopause on women's libido in a computer-literate population

Objective

The objective of this study is to use the internet to survey the effect of menopause on women's experience of libido.

Study design

A questionnaire incorporating the Brief Profile of Female Sexual Function (B-PFSF) on a UK menopause website.

Main outcome measure

Questions on reduced libido, distress, level of help sought and treatment.

Results

Eighty-four percent of women ( n = 2112/2527) felt that an active sex life was important. One thousand and fifty-one perimenopausal and 560 postmenopausal women reported reduced libido causing distress with 23% and 35% discussing this with health professionals. Eighteen percent perimenopausal and 30% postmenopausal women had tried non-testosterone hormone replacement therapy with 34% and 37%, respectively, finding it helpful. Testosterone was deemed useful in some perimenopausal ( n = 6/17) and postmenopausal ( n = 23/50) women. Twenty-seven percent premenopausal, 38% perimenopausal and 56% postmenopausal women reported vaginal dryness with 78% peri- and 87% postmenopausal women believing it a factor causing reduced libido. Twenty-two percent premenopausal, 28% perimenopausal and 46% postmenopausal women had discussed this with health professionals and 17%, 36% and 55%, respectively, were on treatment. Women in all reproductive epochs completed the B-PFSF (a validated tool for postmenopausal women only).

Conclusions

An active sex life was deemed to be important but many women were not seeking help for menopause-related reduced libido causing distress. For many, vaginal changes contributed to their symptoms. In those seeking advice, treatment was commonly not prescribed. Health professionals must ask appropriate direct questions to all women, especially as part of menopausal assessment. A need for the B-PFSF to be validated in non-postmenopausal women was also indicated.

Does educational status affect a patient's behavior toward erectile dysfunction?

INTRODUCTION

Educational status has been investigated rarely as a potential factor affecting the behavior of patients with new onset erectile dysfunction (ED) toward seeking first medical help and subsequent compliance with prescribed phosphodiesterase type 5 inhibitor (PDE5) therapy.

AIM

To test whether the educational status of patients with new onset ED and naïve to PDE5 therapy may have a significant impact on the delay before seeking first medical help (DSH) and compliance with the suggested PDE5.

MAIN OUTCOME MEASURES

Assessing DSH and compliance with PDE5 in new onset ED patients according to their educational status by means of detailed logistic regression analyses.

METHODS

Data from 302 consecutive patients with new onset ED and naïve to PDE5s were comprehensively analyzed. Patients were segregated according to their educational status into low (elementary and/or secondary school education) and high (high school and/or university degrees) educational levels. Complete data were available for 231 assessable patients. Univariate (UVA) and multivariate (MVA) logistic regression analyses addressed the association between educational status and DSH after adjusting for age, relationship status, and Sexual Health Inventory for Men score. Likewise, UVA and MVA were performed to test the association between educational status and patient compliance with PDE5 at the 9-month median follow-up.

RESULTS

Median DSH was 24 months (range 1-350; mean 38.1 +/- 42.8). The lower the educational status, the shorter the DSH (P = 0.03). In contrast, a significantly (P < 0.0001) greater proportion of patients with a higher educational status showed compliance with the suggested PDE5 at the 9-month follow-up. Overall, educational status was not an independent predictor of either DSH or patient compliance with PDE5 therapy.

CONCLUSIONS

After adjusting for other variables, our findings suggest that in new onset ED patients, educational status does not independently affect the DSH and patient compliance with PDE5 therapy.

Integrated sildenafil and cognitive-behavior sex therapy for psychogenic erectile dysfunction: a pilot study

INTRODUCTION

Men with psychogenic erectile dysfunction (ED) present a challenge to physicians. Treatment with pharmacological agents alone does not address the complexities of the causative or resulting psychological issues.

AIM

To evaluate the effectiveness of an integrative treatment protocol (ITP) with sildenafil and cognitive-behavior sex therapy (CBST) compared with sildenafil alone for men with psychogenic ED.

MAIN OUTCOME MEASURES

Change from baseline on the International Index of Erectile Function (IIEF) in the domains of erectile function and sexual satisfaction to demonstrate improved sexual functioning and confidence.

METHODS

Men with psychogenic ED and female partners were randomized to receive either sildenafil alone or an ITP with sildenafil and CBST for the first 4 weeks. In the last 4 weeks, couples in the sildenafil group added CBST sessions to their regimen; patients in the ITP group continued the combined therapy. The IIEF questionnaire was used to compare erectile function and overall satisfaction serially at pretreatment, 4, and 8 weeks. Couples who met the success criteria in both domains after the first 4 weeks received no further treatment.

RESULTS

Fifty-three couples constituted the study population. After the first 4 weeks of sildenafil and ITP, 48% of men met criteria for success on erectile function and 65.5% for satisfaction compared to men on sildenafil alone with 29% and 37.5% success rates, respectively. After the last 4 weeks, integration of CBST with sildenafil resulted in a 58% success rate for erectile function which was comparable to the 66% rate for the initial drug/ITP group; satisfaction rates for men were 45% and 75%, respectively.

CONCLUSIONS

CBST was shown to have a positive influence when used throughout the entire 8 weeks of the ITP or added to the sildenafil in the last 4 weeks. Although patients in both treatment regimens had significant improvements in the IIEF domain scores confirming efficacy of sildenafil, those in the CBST and drug regimen achieved higher rates of clinical success within the first 4 weeks of therapy.

ORIGINAL RESEARCH—PEYRONIE'S DISEASE: A Survey of Primary-Care Physicians and Urologists Regarding Peyronie's Disease

INTRODUCTION

Peyronie's disease (PD) is a connective tissue disorder with an uncertain etiology that causes penile deformity. The interest in PD and our understanding of the disorder has grown significantly in recent years. Data have shown that several previous beliefs regarding the prevalence, natural history, and treatment of PD were incorrect. The prevalence is significantly higher than the previously reported 1%, and most cases of PD do not spontaneously resolve.

AIM

To determine the extent to which newer information about PD has reached physicians who are likely to encounter men with PD and to determine practice patterns regarding this disorder.

METHODS

We created a survey of 20 questions and mailed it to primary-care physicians (PCPs) and urologists (UROs) in Illinois and Wisconsin.

MAIN OUTCOME MEASURES

Responses to individual survey items were totaled.

RESULTS

We received 152 responses from PCPs and 98 from UROs for response rates of 43% and 44%, respectively. Survey results revealed the following: 63% of PCPs and 41% of UROs thought the prevalence is less than 1%; 17% of PCPs and 38% of UROs believed PD spontaneously resolves in greater than 50% of cases; 17% of PCPs and 9% of UROs did not think PD occurs in men younger than 40 years of age; 48% of PCPs and 37% of UROs did not believe that PD is frequently associated with ED; 51% of PCPs and 1% of UROs were unsure if any effective medical or surgical treatment for PD existed.

CONCLUSION

These data suggest that many physicians who are very likely to encounter men with PD have incorrect assumptions about the disease, and this can negatively affect diagnosis and treatment of men with PD.

Erectile Dysfunctions in Patient–Physician Communication: Optimized Strategies for Addressing Sexual Issues and the Benefit of Using a Patient Questionnaire

INTRODUCTION

Erectile dysfunctions are prevalent but underdiagnosed and undertreated health problems. Communication barriers between patients and physicians are one of the main reasons for this and responsible for a low report rate of sexual dysfunction.

AIM

The main aim of the study was to investigate which phrasing and communication strategies gained the highest acceptance from physicians and their patients and were considered the most effective.

MAIN OUTCOME MEASURES

A documentation form on which each consultation was rated by the participating physicians.

METHODS

A large group of physicians was asked to hand out a short patient questionnaire to all male patients over 30 years. The physician was instructed to discuss the questionnaire with the patient and to ask him about sexual problems. A total of 1,191 physicians took part in the study that documented a total of 10,622 consultations with an average duration of 15 minutes.

RESULTS

The main results were: (i) the patient questionnaire found a high level of acceptance and 54% of discussions of sexual health were prompted by it; (ii) the patients' reaction to physicians addressing sexual health was positive in more than two-thirds of the sample and characterized by openness, willingness to communicate, and relief that their sexual problems had been addressed; (iii) from the physicians' perspective, the most favored communication strategies were a clear signaling of a willingness to talk, and addressing treatment possibilities or signaling that help was available; and (iv) the resulting discussion led to further diagnostic measures in 25% of patients and to further therapeutic measures in 60% of patients.

CONCLUSIONS

There are good grounds for concluding that: (i) addressing a patient's sexual health as part of a physician's everyday routine is feasible in terms of duration and content; and (ii) a short patient questionnaire is an excellent aid for patients and physicians for initiating communication on the topic.

Predictors of physicians' involvement in addressing sexual health issues

OBJECTIVES

Although the World Health Organization has declared that sexual health is an integral part of overall health, physicians seem to engage in taking the sexual health history less than their patients would desire. This study aimed at investigating the factors that predict physicians' involvement in addressing sexual health issues, including their attitudes toward the doctor-patient relationship, as well as sexual issues.

METHODS

Physicians participating in educational courses on erectile dysfunction were the study sample, and anonymously and optionally completed a battery of questionnaires. In addition to demographics and a questionnaire on their involvement in taking sexual histories, the beliefs about the doctor-patient relationship were measured by the Patient-Practitioner Orientation Scale, while the Physician Belief Scale was used as the measurement of the psychosocial aspects of patient care. Finally, participants completed the Derogatis Sexual Functioning Inventory--Attitude subscale, in order to determine the possible role of physicians' sexual attitudes.

RESULTS

Previous training in communication skills was found to be the strongest predictor for sexual history taking. Physicians addressing patients' psychosocial concerns were found to be more likely to ask for sexual health problems and to consider their management as less difficult. Other identified predictors of their involvement in sexual history taking were their medical specialty-possibly reflecting their level of education in sexual medicine--and having liberal sexual attitudes; female physicians and general practitioners reported more difficulty in dealing with sexual problems.

CONCLUSIONS

Physicians' training in communication skills seems to be fundamental for sexual history taking and the management of sexual problems, as it improves their level of comfort in dealing with sexual issues; exposure to sexual medicine courses, and psychosocial orientation, as well as physicians' personal sexual attitudes, are also important factors affecting their involvement in sexual medicine.

COMMENTARY: Subclinical Erectile Dysfunction: Proposal for a Novel Taxonomic Category in Sexual Medicine

The definition of erectile dysfunction currently used and accepted worldwide does not encompass all possible changes to male erection. Partial, temporary, or episodic absence of erection is not considered as true erectile dysfunction. This leads to a lack of diagnosis and therapy and perhaps even the risk of the subsequent development of overt impotence. The lack of an evidence-based diagnosis of such a condition may be due to the widespread, pernicious self-prescription of erection drugs, obtained from the illegal market. To define the pathological condition of men experiencing a lack of erection who are unaffected by erectile dysfunction, we propose herein a new taxonomic category, based on new sexological criteria. In addition, we suggest research into biochemical markers to define this condition, which we have named subclinical erectile dysfunction.

Phosphodiesterase type 5 inhibitors: the day after

OBJECTIVE

Review the literature on phosphodiesterase type 5 inhibitors (PDE5-Is), addressing critical issues in their current and future use, assessing unanswered questions, and identifying research needs.

METHODS

A MEDLINE search was conducted on PDE5-Is, with emphasis on clinical trials and experience, for interpretation and analysis of their present and future role.

RESULTS

Although approximately 40 million patients with erectile dysfunction have been treated successfully worldwide with the three available PDE5-Is, inappropriate instructions, lack of follow-up, and lack of patient-centered care models are the main reasons for "non-response," leading to drop-out rates of >50%. Patients with severe neurologic damage, diabetes mellitus, or severe vascular disease may be resistant to PDE5-Is. Preservation of corporal smooth muscle with chronic administration of PDE5-Is has been reported and substantial evidence indicates that these drugs have beneficial effects on endothelium and cardiovascular function; sildenafil has been approved for the treatment of idiopathic pulmonary hypertension. Improvement of lower urinary tract symptoms in men with benign prostatic hyperplasia after PDE5-I administration has been also suggested.

CONCLUSIONS

The data indicate the necessity for (1) exploration of the pharmacologic characteristics of the three PDE5-Is; (2) research on their pharmacologic differences because some actions seems to be drug-specific; (3) development of alternative management strategies, such as chronic, low, everyday doses of PDE5-Is, if the monthly cost is affordable; and (4) clinical trials on use of PDE5-Is to treat other chronic conditions. The door for innovative therapeutic approaches will open, specifically for cross-risk factor treatment with PDE5-Is or their use in combination treatments or new multimodal pills that take advantage of drugs that exert pleiotropic vascular actions.