Approaching Intimacy Concerns in a 62-Year-Old Male
Begin this telehealth visit by directly initiating the conversation about sexual concerns, as most men are uncomfortable broaching this topic themselves, and conduct a comprehensive sexual, medical, and psychosocial history to determine if erectile dysfunction or other intimacy issues are present. 1
Initial Conversation Framework
Use the BETTER approach to structure your telehealth discussion: 1
- Bring up the topic directly: "Many men your age experience changes in their sexual function. What specific concerns brought you to schedule this visit?"
- Explain that intimacy concerns are common and treatable, affecting quality of life
- Tell the patient you can provide resources and treatment options
- Timing: Acknowledge this may be difficult to discuss, but addressing it improves outcomes
- Educate about potential causes and available interventions
- Record your assessment and plan
Essential History Components
Sexual History - Ask specifically about: 1
- Onset: Sudden (suggests psychogenic) vs. gradual (suggests organic/vascular) 2
- Pattern: Problems with attaining erection, maintaining erection, or both
- Situational factors: Does it occur only with partners, only in specific contexts, or all situations
- Morning/nocturnal erections: Presence suggests psychogenic component 1
- Masturbatory erections: Preserved function suggests psychogenic etiology 1
- Severity and degree of bother: Use validated questionnaires like Sexual Health Inventory for Men or Erection Hardness Score 1
- Prior treatments: What has been tried and response
Medical History - Screen for: 1
- Cardiovascular risk factors: Hypertension, diabetes, dyslipidemia, smoking, family history of vascular disease (ED is a risk marker for cardiovascular disease) 1
- Medications: Antihypertensives, antidepressants, opioids, hormone therapy 1
- Comorbidities: Depression, anxiety, relationship issues, substance use 1
- Prior surgeries: Particularly pelvic or prostate surgery 1
Psychosocial Assessment: 1
- Depression, anxiety, performance anxiety
- Relationship quality and partner concerns
- Alcohol or drug use
- Stress levels
Physical Examination Priorities
During a follow-up in-person visit (if needed), examine: 1
- Vital signs: Blood pressure and pulse
- Genital examination: Penile skin lesions, urethral meatus placement, palpate stretched penis from pubic bone to coronal sulcus for plaques or deformities (Peyronie's disease)
- Note: Digital rectal exam is NOT required for ED evaluation 1
Laboratory Testing
Order the following tests: 1
- Morning serum total testosterone (mandatory for all men with ED) 1
- Fasting glucose or HbA1c 1, 3
- Fasting lipid profile 1, 3
- Consider PSA if age-appropriate and not recently checked 3
Cardiovascular Risk Stratification
Critical safety assessment before treatment: 1
- Sexual activity equals walking 1 mile in 20 minutes or climbing 2 flights of stairs in 20 seconds 1
- If patient cannot perform these activities without symptoms, refer to cardiology BEFORE treating ED 1
- Counsel that ED is a risk marker for underlying cardiovascular disease requiring evaluation 1
Treatment Algorithm
First-Line: Lifestyle Modifications + PDE5 Inhibitors
Initiate simultaneously (not sequentially): 2
- Smoking cessation 2
- Weight loss if BMI >30 kg/m² 2
- Increase physical activity 1
- Reduce alcohol consumption 1
- Optimize glycemic control if diabetic 2
- Optimize blood pressure and lipid management 2
Pharmacotherapy - PDE5 Inhibitors (sildenafil, tadalafil, vardenafil, avanafil): 1, 2, 3
- Efficacy: 60-65% of men achieve successful intercourse 2, 3
- Dosing strategy: Start conservatively, titrate to maximum dose 1, 2
- Adequate trial: At least 5 separate occasions at maximum dose before declaring failure 1, 2
- If first PDE5i fails: Try a different PDE5i at maximum dose 1, 2
Critical instructions for maximizing efficacy: 1
- Take on empty stomach or light meal (fatty meals reduce absorption)
- Allow adequate time before sexual activity (sildenafil/vardenafil: 30-60 min; tadalafil: 30 min to 12 hours)
- Sexual stimulation is required for effect
- Avoid alcohol excess before use
Absolute contraindications: 2, 4
- Concurrent nitrate use (any form) 1, 2, 4
- Guanylate cyclase stimulators (riociguat) 2
- Recent stroke or myocardial infarction 4
- Unstable angina 4
Common side effects to discuss: 4
- Headache, flushing, nasal congestion, dyspepsia 4
- Visual changes (rare but seek immediate care) 4
- Sudden hearing loss (rare but seek immediate care) 4
- Priapism: If erection >4 hours, seek emergency care 4
Concurrent Mental Health Referral
For psychogenic ED or performance anxiety: 1, 2
- Refer to mental health professional or sex therapist concurrently with PDE5i initiation, not after failure 1, 2
- Address depression, anxiety, relationship conflict 1, 2
- Include partner in counseling when possible 1
- Cognitive behavioral therapy and social support frameworks are effective 1
Second-Line Therapies (After Two PDE5i Failures)
- Intraurethral alprostadil suppositories 1
- Intracavernous vasoactive drug injection therapy (alprostadil) 1, 3
- Vacuum erection devices 1, 5
Third-Line: Surgical Options
Penile prosthesis implantation: 2, 3, 5
- Reserved for patients who fail all medical therapies 2
- High satisfaction rates in appropriately selected patients 3
Common Pitfalls to Avoid
- Don't wait for the patient to bring up sexual concerns - physicians must initiate 1
- Don't declare PDE5i failure after 1-2 attempts - requires 5 trials at maximum dose 1, 2
- Don't forget to check for nitrate use - absolute contraindication with potentially fatal consequences 1, 2, 4
- Don't delay mental health referral - should occur concurrently with medical treatment, not sequentially 1, 2
- Don't overlook testosterone deficiency - check morning total testosterone in all men with ED 1
- Don't ignore cardiovascular risk - ED is a sentinel marker requiring cardiovascular evaluation 1
- Don't assume psychogenic ED doesn't need PDE5i - first-line treatment regardless of etiology 2