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http://www.primarypsychiatry.com/aspx/article_pf.as.
Erectile Dysfunction
Kevan R. Wylie, MD, FRCPsych DSM, and Anna Machin Primary Psychiatry. 2007;14(2):65-71 Dr. Wylie is consultant psychiatrist and consultant in sexual medicine and Ms. Machin is student doctorat the University of Sheffield in England.
Disclosure: Dr. Wylie is a consultant to Bayer, Eli Lilly, Futura, Pfizer, Plethora Solutions, Proctor andGamble, and SSL; on the speaker’s bureaus of Bayer, Eli Lilly, Pfizer, and Proctor and Gamble; andreceives research support from Futura and Schering. Ms. Machin reports no affiliation with or financialinterest in any organization that may pose a conflict of interest. Please direct all correspondence to: Kevan R. Wylie, MD, FRCPsych DSM, Consultant in SexualMedicine and Consultant Psychiatrist, Porterbrook Clinic, 75 Osborne Rd, Sheffield S11 9BF, UK; Tel:44-114-271-8674; Fax: 44-114-271-8693; E-mail: k.r.wylie@sheffield.ac.uk.
Focus Points
• Erectile dysfunction can be a sentinel marker for diabetes mellitus, cardiovascular disease, andhypogonadic states.
• Major depressive disorder and anxiety often contribute to erectile dysfunction.
• Multifactorial interventions are often required for maximal resolution of symptoms.
Abstract
Erectile dysfunction is a common condition and is recognized as an important marker for underlyingvascular and other disease states. A thorough evaluation with selected investigations will allow theclinician to offer a range of effective therapies and interventions. The evidence for psychologicinterventions is described along with a description of other treatment options. Integrated assessmentand therapeutic options allow for high success and patient satisfaction. Introduction
Erectile dysfuncion is defined as the inability to achieve or maintain an erection sufficient for sexualactivity. The effect of erectile dysfunction on patients and their partners can be devastating. Routinelyaddressing patient sexual health is feasible for primary care physicians (PCPs), and a brief patient questionnaire is an excellent tool for PCPs to initiate communication on the topic.
A cross-sectional, population-based, nationally representative survey in a general community setting http://www.primarypsychiatry.com/aspx/article_pf.as.
estimated the overall prevalence of erectile dysfunction as 22%. Using targeted phone lists to createequivalent representation among Hispanic (n=676), Caucasian (n=901), and African-American (n=596)males ≥40 years of age, the survey found prevalence rates of 21.9% for Caucasian men, 24.4% forAfrican-American men, and 19.9% for Hispanic men, with the odds ratio rising with increased age.
For all racial groups, probability of erectile dysfunction increased with diabetes, hypertension, andmoderate-to-severe lower urinary tract symptoms (LUTS). For Hispanic men, moderate LUTS,hypertension, major depressive disorder (MDD), and an age ≥60 years increased erectile dysfunctionprobability. In Caucasian men, probability increased for patients with diabetes and those ≥70 years ofage. Severe LUTS increased probability of erectile dysfunction for African-American men. Probabilitydecreased overall in patients who exercise and had college experience versus those who only had ahigh school education. Probability decreased in Hispanic men with high school or college-leveleducation, and in African-American men who exercised and had high-quality relationships. Alcoholintake was also associated with high probability of erectile dysfunction in the African-Americanpopulation.
Components in the etiology of erectile dysfunction is multifactorial. Common vascular diseasesassociated with erectile dysfunction are atherosclerosis, heart disease, hypertension, hyperlipidemia,and diabetes mellitus. Endothelial dysfunction is recognized as the common denominator. Asendothelium is present throughout the arterial tree, dysfunction at one point that is symptomatic oferectile dysfunction may be a marker for silent problems elsewhere (such as in the coronary arteries).
Thus, a patient with erectile dysfunction is a vascular patient until proven otherwise.
dysfunction may precede a chronic or acute presentation of chest pain by an average of 3 years. Menwith these common vascular conditions are nearly four times more likely to develop complete erectile dysfunction. Veno-occlusive disorder, previously called venous leak, is the other main vascularetiology for erectile dysfunction.
Neurologic conditions associated with erectile dysfunction are multiple sclerosis, diabetes mellitus,alcoholic neuropathy, spinal cord injury, and Parkinson’s disease. Endocrine problems include lowtestosterone, high prolactin, and thyroid dysfunction. Common psychiatric disorders include anxiety,MDD, and drug and alcohol dependence. Surgical procedures, especially those performed on therectum and prostate, may affect sexual function. Medications, particularly cardiovascular andpsychiatric, can have a profound effect on erectile function.
Psychological factors in the etiology of erectile dysfunction include obsessive personality traits;developmental factors include early sexual experiences and sexual trauma; and maintaining factorsinclude poor body image, self-esteem, and confidence. Health problems, relationship problems, and lifechanges are also factors in the development of erectile dysfunction. Chronic health problems,vocational issues, and other contextual factors, such as children or elderly parents in the home and other factors which cause lack of privacy, are described by Althof and colleagues. Assessment
Assessment involves a detailed medical, surgical, psychiatric, psychological, psychosexual, and relationship history. In approximately two-thirds of cases, a combination of contributory factors willexist and the number of cases that are solely due to psychological or organic factors will be in the minority. The most frequently used questionnaire is the International Index of Erectile Function.
Scores from the index define erectile dysfunction as mild, moderate, or severe. A physical examinationis an essential component of sexual dysfunction evaluation in every case. Examinations should focusmainly on the cardiovascular, gonadal, and neurologic systems, and initial investigations should includefasting glucose, lipid profile, and morning testosterone. When concurrent symptoms of low sexual desire are present, prolactin should also be measured.
appropriate in some cases and could include nocturnal penile tumescence and rigidity monitoring(utilizing RigiScan), Doppler ultrasound of the cavernous arteries, and nerve conduction studies.
Evidence suggests that some men who have a predominantly psychogenic etiology for erectiledysfunction should be informed that an erection is possible using physiologic measurements. Evidence http://www.primarypsychiatry.com/aspx/article_pf.as.
of the occurance of a normal erection is often sufficient for the patient to either begin psychological therapy or be sufficiently reassured that no serious physical causes are present.
mixed etiology of erectile dysfunction, clinicians may find it necessary to facilitate an erection using anerectogenic agent or a vacuum device. When the cause is psychological in origin, production of anactive erection that can be observed by the patient and his partner may be helpful in moving the “stuckcouple system” forward, because the end goal for the couple—achieving and maintaining an erection—is confirmed as achievable using one or more treatment pathways.
Psychiatric Concerns
Erectile dysfunction and MDD often co-exist and can be compounding conditions. Sildenafil has beenshown to be efficacious for erectile dysfunction in men with mild-to-moderate MDD. Treatment of erectile dysfunction improves depressive symptoms and quality of life.
orgasm improved when compared to placebo in men with erectile dysfunction and MDD who were also taking a selective serotonin reuptake inhibitor (SSRI).
The added value of improving compliance with medication and avoiding reduction to a subtherapeutic dose of antidepressant is important to avoid thelikelihood of depressive symptoms and drug-induced erectile dysfunction worsening MDD. For men with psychotic symptoms, many medications may also substantially impair sexual function.
Treatment Options
Physical treatment often provides the opportunity to explore psychological factors in detail with patientsduring the process of reviewing treatment effects. In addition, when psychological factors are believedto be maintaining the problem, reduction of performance and anticipatory anxiety by restoring sexualfunction using a physical treatment can often have a considerable impact in regenerating spontaneoussexual activity.
Except under certain contraindications, it is prudent for the patient to choose his preferred treatment.
Clinical experience shows that this method is most likely to be effective, regardless of the mostappropriate treatment being chosen given the considerable psychological contribution toward sexualfunction in most cases.
Psychological Interventions
Many psychological interventions may be advantageous in even the most complex and organic cases.
Couples therapy may be indicated where there is marked discord within the general relationship.
Psychotherapy aims to restore patient potency to an optimal level given the limits of physical well-being Literature suggests a wide variety of therapies from the simplicity of improving communication to a more complex program of combined psychotherapies, or a combinationof psychotherapies and medical intervention.
Communication and Negotiation
evaluated 449 men with erectile dysfunction, 429 partners of erectile dysfunction patients, and 389 PCPs using questionnaires. Some patients reported that they hadcommunicated about erectile dysfunction on a high frequency, whereas others had eithercommunicated about erectile dysfunction on a low frequency, or had not communicated about thecondition. The authors reported positive responses regarding communicating about erectile dysfunctionand negative responses regarding failing to communicate about erectile dysfunction. The authors http://www.primarypsychiatry.com/aspx/article_pf.as.
concluded that communication is important in the acceptance of erectile dysfunction and can havetherapeutic value.
stress the importance of communication by suggesting that psychiatrists should perform a “general intervention” in patients with erectile dysfunction. This should includereassurance, the provision of appropriate sexual information, and the modification or correction of anysexual myths that the patient may hold.
Education
Studies have proposed that education can enhance the effect of erectile dysfunction therapies or could compared the effect of sildenafil versus sildenafil and psychoeducation in 83 couples. The 60–90-minute psychoeducation workshop had a behavioralmotivational theme and was accompanied by written educational material, which contained goals fortreatment, a communication homework assignment, referral sources, and references forself-improvement books. The authors found that despite there being no difference in treatmentoutcome (eg, increase in potency) between the two groups, couples who took the psychoeducationworkshop reported a higher level of satisfaction with treatment and increased communication about sexthan couples in the medication-only group. Psychodynamic Therapy
Psychodynamic therapy is typically used for individual patients rather than couples, and seeks to findpast experiences related to causation. In particular, psychodynamic therapists would examine the possibility of an unresolved Oedipal complex in patients with erectile dysfunction.
combined psychodynamic psychotherapy with virtual reality in an attempt to treat erectile dysfunction. Therapy consisted of 12 sessions of 1-hour duration over the course of 25 weeks. The firstsession involved acoustic therapy, the second session used psychotherapy, and sessions 3–12alternated between acoustic therapy and virtual reality experiences. Virtual reality consisted ofscenarios developed to arouse memories and emotions within the patient, which could be discussedwith the therapist afterward. The process aimed to rebuild sexual identity, which the authorshypothesized was initially acquired in the early years of life. The patients’ partners were also offeredthree sessions to identify problems. Of 50 study patients with erectile dysfunction solely due topsychogenic causes, erectile dysfunction improved or was resolved in 76% of patients. Forty-fivepercent of the 60 patients with erectile dysfunction of mixed causation found improvement in theirsymptoms or remission. These results remained after 6 months.
Cognitive Therapy
Cognitive therapists perform either singles or couples therapy to tackle faulty scripts or beliefs that interfere with erectile response, and replace them with more adaptive cognitive strategies.
Behavioral Therapy
Behavioral therapists aim to eliminate performance anxiety and increase confidence to treat erectile In one study, 37 men with erectile dysfunction were evaluated.
partners, 23 of the men completed six sessions of couples therapy consisting of Modified Modern SexTherapy and Behavioral Systems Couple Therapy. The study found improvement in 20 of the coupleswhom completed therapy (14 couples had excellent or moderate outcomes) and no improvement inthree couples. http://www.primarypsychiatry.com/aspx/article_pf.as.
suggested that therapists must explain the origins of erectile dysfunction to the couple through simple education. Use of techniques established by Masters and Johnson banning of sexual intimacy, nongenital sensate focus, genital sensate focus, and vaginal penetration)are encouraged. The study also highlighted several potential limitations to this treatment method,including situational erectile dysfunction, single men, unwilling or embarrassed partners, and religionsthat forbid masturbation.
studied 69 single men and compared interpersonal difficulties-orientated therapy, sexual dysfunction-orientated therapy, a combination of the two therapies, and assessmentonly. Patients who received therapy had 19 sessions of 90-minute duration. Interpersonaldifficulties-orientated therapy was based on social skills training that consisted of behavior-modificationtechniques (eg, description of desired behavior, modeling, role rehearsal, self monitoring, anddiscussion). Sexual dysfunction-orientated therapy involved masturbation exercises, instruction insensate focus, stop-start and squeeze techniques, sensory awareness exercises, sexual misconceptiondiscussion and correction, and practice in disclosing sexual inadequacy fears. Outcomes were superiorfor patients who received interpersonal difficulties-orientated therapy alone or in combination with othertherapies than patients who received sexual dysfunction-orientated therapy alone. The authorsconcluded that treatments focusing on interpersonal difficulties had better efficacy than those focusing on sexual dysfunction in single men. Maurice provides an excellent summary of some of these interventions within clinical scenarios.
Creative-Dynamic Image Synthesis
Creative-dynamic image synthesis has its base in neurolinguistic programming and utilizes emotions, memories, words, and drawing to overcome problems.
creative-dynamic image synthesis, oral yohimbine, and placebo in 69 erectile dysfunction patientswhere no organic cause for erectile dysfunction had been identified. Patients in image synthesisattended sessions alone and were asked to draw a picture representing their impotence and then apicture representing their aggression. Afterward, patients were asked to integrate these two picturesusing memory, emotion, and self-induced trance and draw a corresponding picture. With the therapists’guidance, patients then applied three to four powerful positive key phrases to this picture. Thiscompleted image was to be taken home by the patient and focused on three times a day to helpovercome erectile dysfunction. The authors claimed that this process could be performed within 4–15sessions. At 6 months post-therapy, potency was found to be increased by 75% in patients whoperformed image synthesis compared to 55% in patients who took oral yohimbine and 30% for thosetaking placebo.
Humanistic Therapy
proposed the use of experiential psychotherapy. In this therapy model, patients attend alone and describe a strong experience or memory. The therapist encourages the patient to welcomefeelings that this experience or memory may arouse in an attempt bring the experience “into reach.”The aim of therapy is for the patient to “become” the experience, thus becoming what is deeper withinthem, which is a process called actualization. The goal for this method is for the client to changedramatically by this process and for the original problems to cease to exist. Systemic Therapy
Systemic therapists find that erectile dysfunction is often related to a couple’s emotional relationship.
discussed tools that a systemic therapist may use to treat erectile dysfunction, but stated that medical interventions should be used if indicated. The authors said thatsystemic therapists should use a curious, respecting, empathic, understanding, and hopeful approachto explore a couple’s meaning systems as well as provide a calm and safe environment for any crisis http://www.primarypsychiatry.com/aspx/article_pf.as.
that may arise. The therapist should also work on building communication between the couple, allowingempowerment, anger diffusion, and time to discuss any guilt or ambivalence present. Homework tasksare an essential feature of this therapeutic approach, with bibliotherapy being a good start foreducation. Couples could try to “connect and caress,” brainstorm activities, and have “date nights.”Sensate focus can also be used. Other important areas for discussion include the “loss of the erectiledysfunction” and “future focus.” highlighted the importance of a systemic approach by describing that in many men with erectile dysfunction there is significant sexual dysfunction in the partner that predates the onset of hissymptoms. Integrated Therapies
presented a combined cognitive-behavioral approach in erectile dysfunction treatment that uses bibliotherapy, education, cognitive restructuring, and script adaptation to overcome unrealisticexpectations and sexual ignorance. Self-hypnosis and fantasy training procedures are also indicated,along with positive imagery training with or without masturbation. Rosen also noted the importance ofinterpersonal and systemic approaches in the management of sexual dysfunction. The use of a combined approach is supported by other studies.
advocated an integrative approach with a focus on cognitive-behavioral therapy (CBT) and counseling. They found that sexual psychotherapy should be short, motivational,and active in producing a change in thought and behavior. They suggested several questions that atherapist should ask during the initial meeting with the couple, including which areas of sexuality are orare not present in the relationship, what does erectile dysfunction inhibit, and what does it protect.
Counseling should be educational and provide simple explanations of male and female sexuality aswell as finding areas where possible changes can be made.
Integrated Therapies and Medical Treatments
Several studies support the use of psychotherapy combined with medical interventions.
stated that CBT should be used with adjuvant pharmacologic intervention.
Initially, the pharmacologic agents should be used to help overcome the effects of anxiety and quicklybegin psychotherapy. Agents should be reduced as self-confidence is gained. studied 30 men with erectile dysfunction who were randomly allocated to receive group psychotherapy and sildenafil, sildenafil only, or group psychotherapy only. The weeklypsychotherapy was time limited and theme based. The authors found an improvement in erectilefunction in all three groups. However, improvement was only significant in patients who received grouppsychotherapy either alone or with sildenafil. There was no statistical difference between patientsreceiving therapy and combination treatment, suggesting that psychotherapy was the major factor thatimproved erectile function. Another study examined integrating cognitive, behavioral, and psychodynamic approaches with Three methods were cognitive restructuring and insight therapy with the patient alone, improving communication and overcoming role conflicts and relationship problems with couples,and intervention with the partner alone. This latter method considered the partner’s subjectiveexperience, sabotage attempts, and their degree of involvement.
A further study of 45 men with erectile dysfunction compared psychotherapy plus vacuum constriction device treatment to psychotherapy alone.
Patients and their partners received between three and six 40–50-minute sessions of psychotherapy, integrating relationship therapy with Masters and Johnson’ssex therapy. Behavioral, cognitive, systemic, and brief-dynamic techniques were used. The studyconcluded that the early addition of a vacuum constriction device to psychotherapy in men with erectile http://www.primarypsychiatry.com/aspx/article_pf.as.
dysfunction led to an improvement in treatment outcome.
Pharmacologic
Non-Pharmacologic
Interventions
First-line treatments for patients with erectile dysfunction with difficulty either attaining or maintainingerection are oral phosphodiesterase type 5 (PDE-5) inhibitors, such as sildenafil, tadalafil, andvardenafil. All three oral PDE-5 inhibitors require sexual activity to initiate the sexual arousal process.
The overall effectiveness of these agents is approximately 80% in psychological cases andapproximately 50% in organic cases. Sildenafil, the first PDE-5 inhibitor, has become well establishedas an initial treatment. Patients start with a 50 mg dose taken 1 hour before anticipated sexual activity.
Sexual foreplay and activity are required for a full arousal response. Sildenafil is available in threedoses and can be tailored up to 100 mg or down to 25 mg depending on clinical response and sideeffects. The most common side effects are headache (16%), facial flushing (10%), and dyspepsia(7%). A mild and transient disturbance of color vision with a blue hue alongside increased sensitivity tolight is described by approximately 3% of men. Absorption is delayed by a full stomach. Sildenafil is asafe treatment for erectile disorder. It is contra-indicated in patients who are taking systemic oras-required nitrate medications (eg, glyceryl trinitrate sprays), as this causes intense and possibly fatalhypotension. Caution should also be taken when prescribing this and other agents in patients withcardiovascular disease, as moderate exercise may provoke untoward cardiac events. Tadalafil has a different selectivity for PDE subtypes when compared with sildenafil and vardenafil. Ithas an extended plasma release, with a half-life of approximately 17.5 hours. This allows patients tohave successful sexual intercourse for up to 24–36 hours after a dose of 20 mg (dosage can be 10 mgor 20 mg). Side effects are headache, dyspepsia, back pain, flushing, myalgia, and nasal congestion.
Effects typically occur in <15% of patients and may not occur for the duration of action of this agent.
There is no delay in absorption of food in the stomach and no alteration of color vision. In patients onnitrate medications, the same caution must be applied as with sildenafil. Vardenafil has a profile similar to sildenafil and is available in 10 mg and 20 mg doses. It is welltolerated, with a low adverse-event profile, the most common being headache, flushing, dyspepsia, andrhinitis. Side effects occur in <15% of patients. A full review of all PDE-5 inhibitors is available Other oral agents include apomorphine, which has been withdrawn from the market, and yohimbine, which is an unlicensed preparation and available on a named-patient basis only.
In the small number of patients in whom there is biochemical and/or clinical evidence of low testosterone, supplementation is appropriate and can be effective in restoring normal function.
However, the latter is not inevitable and concurrent erectogenic agents may be required. PDE-5inhibitors may be ineffective where the testosterone levels are low.
For men where there is failure of sildenafil (or another PDE-5 inhibitor) therapy, medicationoptimization, counseling, and modification of associated risk factors can provide success. Failure maybe due to lack of efficacy or side effects. Inadequate instructions, follow-up, suboptimal dosing,insufficient time, number of dose attempts, and insufficient clarity about safety issues or concerns for the patient are all important factors that the clinician must attend to.
Second-line treatments include intra-urethral and intracavernosal agents as well as vacuum devices.
Medicated Urethral System for Erection (MUSE) is a device containing a small intra-urethral pellet thatis inserted into the end of the urethra to bring about penile erection. The normal starting dose is 250 µgand the dosage can be adjusted higher or lower depending on response. The most common side effectis a burning sensation and discomfort in the urethra. The erection takes approximately 10 minutes toevolve. Patient drop-out rate is high, which may reflect the need for skilled advice on how to make thisagent effective and the relatively-intrusive nature of this treatment option. Other side effects includeurethral bleeding and hypotension. Patients should have the first dose given with medical or nursingsupervision. The dosage is contraindicated when the patient’s partner is pregnant or is likely toconceive. There is some evidence that effectiveness may be improved by using MUSE in combination http://www.primarypsychiatry.com/aspx/article_pf.as.
with sildenafil or a constriction ring.
Intracavernosal injection (ICI) therapy, which injects alprostadil into the intracavernosal penile body, isextremely effective. The technique of injection must be taught using video and direct observation by anursing or medical technician. The dose should be cautiously increased in non-responders, as priapismmay occur. In patients with needle phobia or dexterity problems, auto-injecting devices are available.
Alprostadil is the most widely used agent and is effective in >80% of patients. Penile pain may occur.
Penile fibrosis and priapism are rare side effects. Although many cases of fibrosis will resolvespontaneously, clinicians should inform patients that this is a recognized side effect. The use of ICI isgenerally contraindicated in patients with penile plaques, including Peyronie’s disease. Other injectableagents include smooth-muscle relaxants papaverine, moxisylyte, and phentolamine. Combinations ofpapaverine, alprostadil, and “tri-mix” (alprostadil, papaverine, and phentolamine) are useful in moreresistant cases, which are typically patients with marked arterial disease. As some of these agents areunlicensed, patients must give informed consent and be made aware in advance of potentialcomplications such as priapism and fibrosis. Vasointestinal polypeptide is combined with phentolamine,which is also available on a named-patient basis. The most common side effects are facial flushing andtachycardia, but there is a lower incidence of pain when compared with intraurethral alprostadil.
Vacuum devices are noninvasive and effective in most men with erectile dysfunction, including thosewith vascular problems. A cylindrical tube is placed over the penis and a vacuum created by usingeither a hand-held or electrical pump draws air out of the cylinder. The negative pressure around theshaft of the penis draws blood into the erectile tissue, thereby creating an artificial erection. Aconstriction ring is placed around the base of the shaft of the penis before the tube is removed, whichmaintains the erection. The ring should not be used for >30 minutes at a time. The process is fairlyimmediate and the device may be used during foreplay by both partners if willing. Side effects include agradual discoloration and feeling of coldness to the penis while the ring is attached as well as thepossibility of bruising and difficulties with ejaculation. If the glans does not become firm, one option is toaugment this treatment with MUSE. This is a passive treatment and can be effective in non-respondersto most other treatments. When effective, vacuum devices remain the treatment of choice and paired When surgical disease has been identified using color Doppler ultrasound and typically followingtrauma (eg, pelvic injury, penile fracture, fistulae between the corpora cavernosa, and spongiosum, etc)in men <40 years of age, arterial reconstruction may be considered. The inferior epigastric artery isrerouted and anastomosed to the dorsal penile artery or vein. The success rate is approximately 65%.
Patients with proven veno-occlusive disorder are rarely suitable for surgical intervention. In patientswith severe arterial disease and/or Peyronie’s disease, when erections are not possible or there is aconsiderable bend in the penis, the use of penile prostheses (implants) may be beneficial. The patientand partner should be fully counseled with regard to the limited benefit that can be obtained. Malleablesemi-rigid implants and inflatable hydraulic implants are available, although there are cost implications.
The implant does not restore normal erectile processes but makes the penis rigid enough for sexualintercourse. The glans may remain flaccid. Long-term results are satisfactory in up to 90% of patients.
Patients with veno-occlusive disorder may find value in using penile rings, which act in an occlusive way once the original erection is attained.
Many men use these rings to strengthen the firmness and size of their erection regardless of any sexual dysfunction; thus, their use may be normalized forpatients. Patients should be advised not to wear them for >30 minutes at a time. Pelvic-floor traininghas also been reported as a useful treatment for mild veno-occlusive disorder and erectile dysfunction Dopamine, serotonin, and nitric oxide have an important role in sexual function, and antidepressants(including SSRIs) and antipsychotics that interfere with their transmission are likely to bring aboutsexual problems, including erectile dysfunction. A review of sexual dysfunction in depression and schizophrenia is provided by Baldwin and Mayers.
Conclusion
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A careful assessment that establishes the etiologic factors of erectile dysfunction, shares a decision
pathway on the appropriateness for further investigation, and describes therapy choices from which the
patient may select, will lead to a successful outcome. In more complicated or treatment-resistant cases,
there is a need for integrated assessment and intervention services that offer patients the best and
most appropriate treatment, whether it be physical, couples counseling, conjoint sex therapy, individual
psychotherapy, psychiatric intervention, or a combination of the above. PP
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Source: http://www.obenaus-psynet.de/2007-Wylie-Erectile.pdf

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Section 3-VACUUM EQUIPMENT DESCRIPTION RETAIL DISC FLOMAX WRC - WATER RING COMPACT PUMPS WRC2 - WATER RING VACUUM PUMP (2200 L/MIN @ 50KPA) WRC3 - WATER RING VACUUM PUMP (3000 L/MIN @ 50KPA)WRC4 - WATER RING VACUUM PUMP (4000 L/MIN @ 50KPA) FLOMAX - WATERING COMPOUND PUMPS WATER RING VACUUM PUMP 850 507 BLOWER PACKAGES (BELT DRIVE) 507 4000L SYSTEM 11KW UTILE VA

Ahi_friends_newsletter_2009-04

Azalea Health Innovations Friends Newsletter - May 2009* Welcome* Praxis EMR Version 5.0 Due Mid July 2009!* Medical Billing Tip: Billing for Injections* Azalea DrugWare™ Hello to all of our Azalea Health Innovations friends. We hope you enjoy this month's Newsletter. AHI wishes our readers a happy and prosperous spring!----------Praxis EMR Version 5.0 Due Mid July 2009!Praxis 5 will be amon

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