Presentation of sexual problems in general practice is often not direct. A patient may prefer to see a locum or registrar, feeling embarrassed in front of a doctor they know well.
As with other emotional problems, the patient may present, often repeatedly, with a minor physical symptom in an attempt to find the right environment in which they can divulge their difficulty.
Patients may also present with a somatisation, for example pelvic pain. It might take a while to unravel the truth unless the doctor asks about sexual difficulties.
There are particular 'danger zones' where sexual problems may be more frequent, for example after childbirth, gynaecological surgery, menopause, bereavement, major illness and major life events. These issues may have a profound effect on the patient's partner as well as the patient.
Doctors need to use and understand colloquial language when describing sexual problems and body parts.
2. Problems in women
It is essential to exclude physical problems before diagnosing a psychosexual difficulty.
In women this will usually require a genital examination to exclude gynaecological disease. It may also reveal conditions such as vulval eczema, lichen sclerosus or atrophic vaginitis.
During the course of the examination the doctor can tell a lot from the patient's demeanour. She may be nervous or be relaxed and appear 'detached' from the process.
As well as using the genital examination to check for any physical problems, it may also give an insight into patients' attitude towards their sexuality. This information can be reflected back to the patient and sometimes extrapolation made into their sexual life.
Vaginismus is the involuntary contraction of the vaginal wall muscles, usually in response to the fear of physical pain. The muscle contraction is itself painful, therefore setting up a vicious cycle. It is usually impossible to examine a woman fully or insert a speculum.
The patient and her partner may think that she is 'too small' or that there is a blockage. With sensitivity the woman can be shown how to relax and contract her pelvic muscles and therefore become in touch with what is happening.
Sometimes encouraging self-examination or the use of dilators can help. This is often a slow process that can be done while trying to address the reasons for the fear of penetration.
3. Problems in men
In men with erectile dysfunction (ED) it is essential to exclude diabetes, hypertension, cardiovascular disease or the effect of drugs and alcohol. If a man can masturbate and the ED with his partner has started suddenly, it is less likely to be a physical problem.
Strong morning erections reduce the likelihood of a physical cause, but lack of morning erections can still indicate a psychological difficulty.
If there is loss of libido, tiredness or other signs of androgen deficiency, it is worthwhile taking a hormone profile. Examination may reveal undisclosed problems such as a hernia, varicocele or Peyronie's disease.
The man may also disclose previously unspoken fears about his genitals. If there are any urinary symptoms, a rectal examination and PSA screen may be indicated.
In both sexes the problem may be mixed. Physical difficulties can lead to secondary psychosexual issues and vice versa. It is important to use open-ended questions and stick to the patient's agenda when discussing the problem, keeping an open mind with no theory of causality.
As well as excluding physical problems, it is important to ensure that the patient does not have depression or any other mental illness.
|Common types of sexual difficulties|
Having made the diagnosis, it can be helpful to know why the patient attended at this time and if they came of their own accord or were sent by their partner. The latter suggests a poor prognosis.
A long formal history is usually not necessary, although enquiry about sexual assault may sometimes be relevant.
Sometimes a couple will present. It is often easier to identify who has the actual problem and work with them individually. Working with both members of a couple together or separately can be complicated.
It is important to establish whether there is a relationship problem. Relationship problems most commonly lead to loss of libido but can also cause other types of psychosexual difficulty. Giving simple insight to the patient may help because they may not have connected their relationship difficulty with something that seems to be physical.
GPs often feel that they have neither the skills nor the time to work with relationship difficulties and referral to Relate or a counsellor might be more appropriate.
Working with an individual, the doctor can make use of the doctor-patient relationship. For example, if you notice anger or anxiety, this can be extrapolated into the patient's sexual life.
Together with a physical examination and reassurance of 'normality', brief interpretive therapy is possible within the time constraints of general practice.
- Dr Denman is a GP in Oxford and a member of the Institute of Psychosexual Medicine
- The Institute of Psychosexual Medicine - A training organisation for doctors. www.ipm.org.uk
- Relate - Therapists see clients with relationship and sexual problems, mainly working with couples in a behavioural way. Self referral is encouraged. www.relate.org.uk
- College of Sexual and Relationship Therapists (COSRT previously known as BASRT) www.cosrt.org.uk