Vragen naar de onbekende weg. De seksuele anamnese in de medische praktijk [Sexual history-taking in medical practice: the elephant in the room?].

• Recently, the Dutch College of General Practitioners released a Practice Guideline on Sexual Problems which provides clear directives for the diagnosis and management of various sexual disorders in men and women. Patients who are managed in general practice and in outpatient clinics might experience distress related to sexual problems due to their age, medical condition or treatment, or distress related to problems in establishing and maintaining intimate relationships. We present two clinical cases. The first case is a woman aged 44 years with breast cancer treated by mastectomy and adjuvant tamoxifen. The second case is a man aged 54 years with heart failure due to myocardial infarction and resultant loss of physical strength. Both cases illustrate that taking a short sexual history could result in the right treatment and patient satisfaction, without having to go into detail about very intimate and private matters.Case description The first case presents a woman, 44 years of age, with breast cancer treated by mastectomy and adjuvant tamoxifen. During follow up at the oncology clinic, she addressed complaints such as fatigue, mood swings, and sleep problems. The oncologist suspected a depressive disorder and referred the patient to the general practitioner (GP) in order to get support or treatment. The GP diagnosed a mild depressive disorder due to mild problems in her relationship caused by minimal emotional support from her partner. Treatment by a psychologist was advised but because its reimbursement was lacking, the patient decided to refrain. During consultation a year later, the oncology nurse practitioner asked her for her mood problems and asked whether sexual problems might cause her some burden. The patient was relieved to address her problems of decreased sexual desire and dyspareunia. The nurse gave education about the negative but reversible effect of tamoxifen. However, feelings of guilt towards her husband made her persist in having intercourse without satisfaction and therefore the patient was referred to a sexologist, who provided adequate treatment. The second case presents a man, 54 years of age, with heart failure due to a myocardial infarction, leading to loss of physical strength. He is prescribed cardiac medication that might have negative influence on his sexual response, his BMI has been increased, and his alcohol consumption has increased. In addition he had to give up his job and his sports activities. He visited his GP asking for medication to treat his erectile dysfunction. The GP suspected a predominantly somatic cause of his erectile dysfunction and started medication. The result was disappointing, even after increasing the dosage. About a year later, while consulting his cardiologist, the man addressed his sexual problem. After asking only a few questions, it became clear that he still had reasonable erections in some situations. The cardiologist explained that there was apparently still some residual erectile function and advised him to improve his lifestyle in preventing further deterioration of his erectile function. Ultimately this proved to be a good treatment option. Consideration Health care workers can address the importance of sexuality and intimate relationship in the quality of life for the chronically ill, cancer patients, and the elderly, in a basic but effective way. The Dutch Guideline Sexual Complaints provides a basis for diagnosis and management for sexual dysfunctions.

Ämnesord

MEDICIN OCH HÄLSOVETENSKAP  -- Klinisk medicin -- Allmänmedicin (hsv//swe)

MEDICAL AND HEALTH SCIENCES  -- Clinical Medicine -- General Practice (hsv//eng)

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