- 作者：Judy Chun ; MD* ; Cully C. Carson III ; MD*
- 刊名：Urologic Clinics of North America
- 出版年：2001
- 出版时间：1 May 2001
- 年：2001
- 卷：28
- 期：2
- 页码：249-258
- 全文大小：1226 K
The term impotence is an all-encompassing definition of male sexual dysfunction, including loss of sexual drive, orgasmic or ejaculatory dysfunction, and erectile dysfunction. Because of the negative connotations associated with this word, the preferred terminology is more descriptive and more physiologic: vasculogenic, endocrinologic, neurogenic, or psychogenic erectile dysfunction. In 1992 the National Institute of Health Consensus Panel set out to educate health care providers and improve public awareness on aspects of human sexuality and sexual dysfunction. They defined erectile dysfunction as the inability to achieve or maintain an erection sufficient for satisfactory sexual function. With increased publicity and education, the general view of erectile dysfunction has evolved over the past 2 decades from a humiliating psychogenic disorder to an organic medically treatable disease. The mass media further legitimized human sexuality and its problems as a health and quality-of-life issue with world coverage of sildenafil (Viagra; Pfizer US Pharmaceutical Group, New York, NY) in 1998. Although considerable advances have been made in the diagnosis and treatment of erectile dysfunction, the inadequate knowledge of health care providers on erectile dysfunction precludes them from initiating candid discussions with their patients. Many men are still reluctant to discuss erectile dysfunction; therefore, greater than 70 % of erectile dysfunction remains undiagnosed. The goal of this article is to assist the health care professional in establishing a comfortable physician-patient dialogue to evaluate erectile dysfunction clinically.
Despite the growing recognition that most erectile dysfunction is organic, a psychologic emotional aspect almost always accompanies it. Problems with human sexuality are inevitably associated with relationship issues, issues of self-esteem and gender, and deeply engrained moral values that must be added to the usual fears patients have about their body. Appropriate management and understanding of psychologic issues are essential for gaining trust and establishing patient rapport, the first step in assessing and treating patients with erectile dysfunction. If patients feel that their physician is comfortable with the subject, they will be less anxious and more likely to reveal important aspects of their sexuality. The general public is diverse in culture, class, language, and knowledge base. Physicians must be flexible and cognizant of the deeply seated values and beliefs of each individual.
The physician¨Cpatient dialogue takes place even before the face-to-face interview. The first impression that the patient constructs is framed by the treatment environment. The physician can help facilitate a comfortable nonthreatening environment by introducing a friendly, professional, and sensitive medical staff. A knowledgeable professional medical staff may be able to answer questions that the patient may be embarrassed to ask the physician. Another way to create a comfortable atmosphere is to introduce the patient to the subject of erectile dysfunction before the first personal interview. Baum provides the patient with educational materials by mail to reassure him that he is not the only man with this problem and that treatments are available. Another important facilitator is the standardized questionnaire on erectile dysfunction. The questionnaire introduces the patient to a personal unexplored topic by asking questions that may be difficult to answer initially on a one-to-one basis. The physician must remember that erectile dysfunction may be a topic that the patient has avoided talking about to their sexual partners, friends, or even their clergy. Reviewing the questionnaires and educational materials before the initial visit will give the patient and his partner time to get used to the subject and nomenclature. There is no substitute to extensive patient education to stimulate questions and discussions. Three standardized questionnaires currently are available for clinical assessment: (1) the Brief Male Sexual Function Inventory for Urology; (2) the International Index of Erectile Function (IIEF) and its short form, the Sexual Health Inventory for Men (SHIM); and (3) the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS). The Brief Male Sexual Function Inventory for Urology consists of 11 validated questions developed to measure sexual drive, erectile function, problem assessment, and overall satisfaction. It is a brief, self-administered questionnaire that is ideal for the office setting. The IIEF is a cross-culturally and psychometrically valid measure of male erectile dysfunction that is used widely in clinical trials of erectile dysfunction. The 15-item questionnaire distinguishes men with and without erectile dysfunction and grades the severity of erectile dysfunction from mild to severe based on a scale from 6 to 30. It examines specific domains of sexual function, including libido, erection, ejaculation, and overall satisfaction. The EDITS was developed to assess the patient and partner satisfaction after initiating treatment modalities and is more useful when assessing sexual satisfaction after treatment.
The first interaction the physician has with the patient is vital to establishing rapport and ease. The initial meeting should be in a quiet environment without any interruptions or a sense of haste. In this manner, the patient can perceive how comfortable the physician is in discussing the deeply vulnerable aspects of the patient's life. Many interviewers are uncomfortable with detailed sexuality questions because they feel inadequate in knowledge and experience themselves. They believe that an expert draws from and identifies with the patient from their own varied and exciting sexual experiences. This misunderstanding of what an expert interviewer should be creates anxiety and insecurity that is reflected in the interview. All professionals and patients have their own sexual experiences that are guided by values, beliefs, and opportunities. The role of the health care provider is not a moral one. During the physician¨Cpatient dialogue, the physician needs to realize that similar values and experiences are not essential for a successful interview; the listening, nonjudgmental interviewer tries to elicit and clarify the patient's sexual life and the problems that arise. Inevitably, the patient will wait to see the response he elicits with his troubled history. The interviewer who is prepared to hear and respond to disclosures of the most dull or the most unconventional sexual history with a professional calm will be rewarded with full trust and sincerity.
Another key to establishing rapport and gaining trust in the initial interview is to be at ease with the vocabulary. The knowledge base of patients and partners is varied, and the physician needs to be flexible and capable of communicating with the patient effectively. Sexual terminology can be described in layman's jargon without sounding condescending or degrading. The physician's voice should not reflect his or her own values or disapproval. The dialogue should be professional and objective, yet courteous and understanding. Another important interview skill is the ability to ask open-ended questions. This approach facilitates communication and allows the patient to explore and elaborate on his problems. By allowing the patient to express his emotions, the physician can perceive how the patient feels about his sexuality and what his outlook is. The process needs to take into account the fact that most men are depressed or anxious about having a potency problem, which can result in spillage to other aspects of life. The history given by the patient will most likely be complex and involve interrelated troubles.
An interview of the partner is essential in the evaluation of erectile dysfunction. The partner brings a different insight to the sexual difficulties and another viewpoint that may corroborate or contradict the facts obtained from the patient's interview. It is preferable to interview the partner separately after the patient interview to obtain information of relational and psychologic significance without the influence of the patient nearby. An independent assessment can be made of the partner's contribution to the sexual difficulty and of the partner's interest in treatment modalities. Such independent interviews are important and can alter the patient's diagnosis and treatment as much as 58 % of the time. There are six components that each partner brings into the sexual relationship: gender identity, orientation, intention, level of desire, ease of arousal, and the ability to have an orgasm. The first three components are fixed personality traits, whereas the last three are malleable and subject to life stressors. Life stressors, such as death, miscarriage, or financial change, can cause a disequilibrium that may manifest as sexual dysfunction. Couples who are compatible can adjust to these stressors and maintain sexual equilibrium.
A physician¨Cpatient dialogue that places patients at ease and that establishes trust takes practice. Introducing the subject of erectile dysfunction before the patient's arrival for the first interview allows the man to be aware of its commonality and of the possible questions ahead. By providing a professional, sensitive environment, the apprehensive man is less anxious and is placed at ease. When the physician is a good listener and remains objective, the patient is inclined to explore his emotions openly. By asking open-ended questions in a sincere manner, a detailed sexual history can be obtained. The comprehensive questioning not only provides needed information but assures the patient that the physician is taking the problem seriously. Erectile dysfunction affects men of all ages, and the questioning should be tailored to the individual. Having the patient fill out standardized questionnaires before the visit helps to guide the medical history. A young teen will most likely have issues with premature ejaculation or problems coping with sexuality, whereas an elderly male will most likely present with a delayed or decreased erectile response. Regardless of whether the patient is young or old, confidentiality is a priority, and patients are more likely to reveal important aspects of their sexuality if they feel that the physician takes them seriously and respects their privacy. These important interviewing skills can make the first meeting a success.