Author bio | Disclosures “I can’t make love to my wife anymore...” These were the words of a patient during a routine diabetes consultation at my clinic. The patient had a history of myocardial infarction and was (rightly) worried about the risks of taking sildenafil (Viagra®), which he had previously been prescribed. In this instance, it was clear that the patient was reaching out for help to preserve his psychological health, quality of life, and relationship with his wife. The encounter inspired this view from the clinic as I recognized, all too well, that initiating the conversation about sexual dysfunction is seldom this straightforward for clinician or patient. The communication divide Barriers for patients It is both unsurprising and understandable that many patients are reluctant to discuss sexual health problems such as erectile dysfunction (ED) during routine visits. The perception that the issue represents a failure on the part of the individual can be a powerful deterrent, despite the prevalence of sexual dysfunction in people with diabetes. Hence, I believe that it is crucial that we – the healthcare team as a whole – take the initiative to at least start a dialog with our patients to bridge the communication divide that arises around sexual health problems. "...it is good practice to suggest having the partner accompany the patient to the urology consultation..." Symbolic image with models Monkey Business/stock.adobe.com × Barriers for clinicians In my experience, ED rarely features as a discussion topic for busy primary care providers. Some are concerned that ED is too complex to manage properly under the time pressure, while others feel that they lack the appropriate knowledge and skills to address the issue. In spite of this, I strongly believe that primary care providers have an important role in initiating open communication, with a view to establishing an effective treatment plan with a specialist. Bridging the gap “Other than what you are coming in for, are there any sexual health concerns you would like to discuss?” A quick review of a patient’s medical record can highlight conditions and medications associated with ED; this insight can serve as a useful prompt for the question above. By posing a similar question casually, at the start of the visit, you invite the patient to “meet in the middle” and give way to the prospect of an in-depth and honest discussion about their concerns, with the possibility of arriving at an initial plan for treatment. Treatment options Advances in medicine have yielded a multitude of treatment options to fit the needs and comfort level of patients at different ages with various preferences. Summarized below are some of the main options available to patients with ED, in the USA. Common ED treatments Oral medications Sildenafil (Viagra®) Vardenafil (Levitra®) Tadalafil (Cialis®) Urethral suppository Alprostadil (MUSE®) Injection Alprostadil (Caverject Impulse®) Non-pharmacological options Constriction bands Vacuum pumps Penile support sleeves Penile implant Patients faced with such a wide variety of treatment options are likely to require an in-depth discussion to support them in making an informed choice. While the responsibility for guiding the patient typically lies beyond primary care, clinicians in this position have a vital responsibility to educate the patient and facilitate the kind of open communication that will eventually lead to a urology referral. The referral and beyond Comprehensive approaches for treating ED will normally be guided by a urologist. With their specialized training on the condition, and diverse interdisciplinary connections, urology teams are best placed to oversee a diabetes patient’s chosen/recommended treatment for ED. I have found that it is good practice to suggest having the partner accompany the patient to the urology consultation. In this way the treatment decision, which potentially impacts the dynamics of the couple, can be made as a team and bring them closer to their desired outcome(s). Putting communication into practice For the aforementioned patient, open communication was established. I, as a Certified Diabetes Educator (CDE), was able to provide the appropriate educational resources for him to consider, thus encouraging him to continue seeking a treatment option that would best suit him. Open communication – between patient and clinician, and between patient and partner – is the first and most fundamental step in tackling issues associated with ED and regaining sexual health in diabetes. Recommended reading Roszler J, Rice D. Sex and Diabetes: For Him and For Her. Alexander, VA, USA: American Diabetes Association, 2007. Hackett GI. What do patients expect from erectile dysfunction therapy? Eur Urol 2002; 1(8): 4–11. Sadovsky R. The role of the primary care clinician in the management of erectile dysfunction. Rev Urol 2002; 4(Suppl 3): S54–S63.