Management of Erectile Dysfunction: The Role of Stress & Mental Health

[Dr. Jose Silva]
I want to talk about the couples aspect at some point later in the episode but let's start with that individual person. That is usually the ones that we see in the office. What do you talk about on your first visit?

[Mark Goldberg]
On the first visit, it's usually a lot of assessment questions. The starting point of any therapy process is, really, establishing rapport. When a patient comes in or when a- I call them clients. -when a client comes in, and they're coming, really, under the context of a sexual dysfunction, it's really important that we normalize the challenges that they're going through, that we establish a comfortable environment, that we ask questions, we make sure that we're asking permission about getting involved in different aspects of their life, because we're doing this very quickly.

Oftentimes, unfolds in the first 10 to 15 minutes, we're already talking about sexual function challenges. Generally speaking, in my practice, it's rare that somebody is seeing us without having been to at least a primary care physician, if not a urologist, before coming in. It does happen from time to time, but we do our utmost that we can to ensure that somebody has been medically cleared.

To that end, we generally are just doing a basic check-in on the medical front in terms of what has been done, who they've spoken with, if there was any testing done, any medication. We're asking about that, but we don't consider ourselves to be the first line for medical assessment or what not. We just want to make sure that, however they got to us, they've had proper medical checkings. That usually is the first piece of the assessment.

We then will go through a much more broad-- We call a psychosocial assessment. We want to understand who this person is, what their backdrop is, relationship status, how long the problem's been going on. We also want to assess just where the problem is taking place. How often? Is it just with a partner? Is it happening when they're on their own? Times of day, specific triggers.

We try to be as quick and as thorough as we can to try to see what are the specific conditions where erectile dysfunction seems to be present or seems to be more exacerbated or whatnot. We will also ask questions about general mental health, and we may, if it's relevant, get into topics pertaining to family of origin as well.

[Dr. Jose Silva]
Yes, like you mentioned, I have patients, I'm sure them as well, that they say, "Hey, during the week, I'm working, having good erections. Then I go on vacation, I start having spontaneous erections, good sex with my wife or my partner," whatever. How do you explain to the patient, hey, you need time to recharge?

[Mark Goldberg]
It really depends on the patient. For some patients, they really want a solution, or like being able to have better erections during the week, or they want to be able to do this when they're not on vacation. For other patients, they just feel relief understanding what is going on, understanding that the stress is actually having an impact. For some of them, they're actually okay, their relationships are okay to have sex on the weekends or when there's an opportunity.

It's just a matter of helping them just come to an understanding or come to terms with the reality that if you have a very stressful work life or what not, that can have an impact on erection, so it really depends, also, on what each client's goals or what each patient's goals are.

[Dr. Jose Silva]
You mentioned that patient that wants immediate relief. Do you offer some immediate relief, or do you go to a urologist and get some pills? What do you tell that patient?

[Mark Goldberg]
If a patient is insistent on immediate release, I let them know that there are medical interventions that probably can provide more immediate relief. I do think that, sometimes, even the mental stress of not having that immediate relief sometimes warrants a medical intervention just to help this person be able to be in a much more calm and healthy state of mind.

I do not offer immediate relief because the mind is very tricky, very complex in many ways, and I think there's enough snake oil out there in the erectile dysfunction space and, generally, in the sexual function space that I don't think it's doing patients a service to offer them some kind of immediate, "We'll have you fixed within the hour." That being said, younger patients do tend to see results pretty quickly, even from the psychogenic process. I think that has to do with just their physically more fit bodies are just better positioned to be able to make those kinds of changes, but no, we don't offer anything immediate.

[Dr. Jose Silva]
That patient that says, okay, I'm going to work with you, let's start a process, what are your recommendations for that patient? Let's say most patients that I see that might be psychogenic is usually overwork, working two jobs, or working shifts at night, during the day they sleep. How do you tell them, hey, you need to change the way you function on a daily basis?

[Mark Goldberg]
That's a great question. I think with the patient base that I see that tends to be, let's say, a more rare presentation that it is a single factor event that's driving it. It tends to be more complex where there also is-- There's work stress, but it's also spilling over into the relationship. It tends to actually be a bit of a more complex picture. Sometimes it's as easy as saying, "Well, you need to cut back on work," and the response to that is, "That's just not possible."

Okay, so now we're on to those next steps where we have to work within the confines of this person's reality. A lot of times, there's enough factors that, I think, can be addressed both in terms of a person's relationship, their own internal psychology, that they can both maintain a challenging lifestyle and still be able to carve out space to decompress and have enough mental bandwidth to be able to have the kind of sexual function that they want.