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Human sexual function is complex and multidimensional, with physiologic and psychological components. The common sexual dysfunctions in men have significant overlap. Low sexual desire in men includes a lack of interest in thinking about sex or in being sexual, alone or with a partner. Sexual health counseling often is helpful. Physicians should prescribe supplemental testosterone only if it is clearly indicated. (Sexual dysfunction is an off-label use of testosterone.) Supplementation is not beneficial for men with a normal total testosterone level. Erectile dysfunction (ED) is the consistent or recurrent inability to attain or maintain a penile erection sufficient for sexual satisfaction. The cause typically is multifactorial. The oral phosphodiesterase type 5 inhibitors are the first-line pharmacotherapies for most patients with ED. Their use is contraindicated in patients taking nitrates. Peyronie disease is an acquired penile abnormality that causes curvature or other deformities of the erect penis. Premature ejaculation is defined as a lack of ejaculatory control that is associated with distress. All pharmacotherapies for premature ejaculation are used off label. First-line treatment options include daily selective serotonin reuptake inhibitors (eg, paroxetine), on-demand clomipramine, and topical penile anesthetics. Psychotherapeutic and physical therapies also have been shown to be effective.

Case 4. Ali is a 57-year-old man who reports difficulty maintaining an erection that is satisfactory for intercourse. This has been occurring for approximately the past year. He has one female partner who is postmenopausal.

General Approach

Human sexual function is complex and multidimensional, with physiologic and psychological components. The common sexual dysfunctions in men have significant overlap, and affected men often have more than one type of dysfunction.

Many patients find it challenging to discuss their sexual lives, so establishing rapport is essential, followed by direct and empathic questioning. Use of neutral, inclusive language and a sensitive tone during documentation of the history may prevent patient perception of moral or religious judgment.118 Likewise, avoidance of assumptions, such as about the sex of the patient’s partner, may help the patient feel comfortable.

Sexual dysfunctions often are multifactorial, so a patient-centered biopsychosocial approach can help the clinician identify various contributing factors.119 Obtaining a thorough sexual, social, and medical history is key to the diagnosis and effective management of sexual dysfunctions. The goals of the conversation are to learn about patient concerns, assess the biologic and psychosocial factors that might affect those concerns, and determine treatment goals.

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