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Managing erectile dysfunction

Key learning points:

 - Recognising the common causes of erectile dysfunction

 - Assessing erectile dysfunction

 - Treatment options and treatment optimisation 

Erectile dysfunction (ED) is the inability of a man to get a penile erection that is of sufficient quality to gain and maintain for sexual performance.1 ED occurs in approximately 8% of 40-year-old men, increasing to 40% of 60-year-old men.2 The aetiology of ED is commonly caused by changes to blood flow, although there are neurological and psychogenic causes as well. Irrespective of the cause ED, the consequences affect his self-esteem, body image and relationships. 

ED can be an early indication of cardiovascular disease (CVD),3 with the mean time between onset of ED and first cardiovascular event at 3.5 years.4 Risk factors for ED and CVD are shared, and include obesity, diabetes mellitus, physical inactivity, smoking, dyslipidaemia and hypertension5 ED has been linked to poor adherence with, for example, cardiovascular medication,6 and therefore it is critical for nurses to identify men who have, or are at risk of developing, ED and offer advice and treatment.7

Identifying ED

The common perception is that men who suffer with ED are too shy or embarrassed to ask for help, but the literature does not support this contention.8 To facilitate conversations, a poster in the waiting area alerts the patient that the subject is not taboo,9 although patients can also be directed to websites that can be used as both information giving and symptom awareness (see Resources), that can be used to facilitate discussions. 

Assessment

A comprehensive history will enable accurate diagnosis and selection of the most appropriate treatment. Further investigations are also needed to establish if the patient has undiagnosed diabetes, hypertension or other physical cause for ED (eg. hypogonadism). 

Management plan

All patients will need a hormone, lipid and glucose assessment before deciding the treatment option to recommend. In addition, fitness for sexual activity will need to be established. The physical 'demand' for sexual activity is similar to climbing two flights of stairs or mowing a small patch of lawn10. If a patient is unable to undertake these activities or if they have had a recent (ie. within three months) cardiac or vascular event, they should refrain from sexual activity. 

Treatment options

Psychosexual counselling

Counselling, in some format, is needed for all men with ED. All individuals have conditions for sexual activity; for example, confidence, trust that their partner will not criticise them, absence of pain, etc, and these conditions have to be met before a man can get an erection. There are various forms of sex therapy but not all men will need or benefit from a formal referral. What needs to be reinforced is that sex is a form of communication; poor communication or reduced intimacy with a sexual partner will increase pressure to perform and will adversely affect the quality an erection.

Phosphodiesterase type 5 inhibitors (PDE5I)

The PDE5Is are Sildenafil Citrate (Viagra), Sildenafil (Generic), Tadalafil (Cialis), and Vardenafil (Levitra). Sildenafil Citrate, Sildenafil (generic) and Vardenafil are available 'on demand' (o/d) only whereas Tadalafil is available both 'on demand' and as a daily dose. Daily dosing with Tadalafil is reserved for men with a high demand for sexual activity (>2 encounters per week) and the 5mg o/d dose has been found to improve sexual satisfaction.11 Recently, Tadalafil o/d has been licensed for treating both ED and lower urinary tract symptoms (LUTS).12

Patients should be advised that these medicines will only work with sexual stimulation; without some form of sexual stimulation, an erection will not be achieved. Furthermore these medicines are unlikely to work first time and therefore they should be taken between six and 10 different occasions to establish efficacy (unless the side effects are intolerable).

The common side effects of PDE5Is include: headache, visual changes, dizziness, facial flushing, muscle pains, stuffy nose. Any patient who reports changes to vision should refrain from continuing with PDE5Is until they have sought further advice. For men who cannot take PDE5Is alternative options may be considered. 

Alprostadil 

There are two preparations of Alprostadil; medicated urethral system for erections (MUSE), which is a urethral pellet, and intracavernosal injections (ICI) where the medication is injected directly into the penis (corpus cavernosa). Neither preparation should be given to someone with low blood pressure (systolic less than 90 mmHg or diastolic less than 60mmHg) as the potential side effect of Alprostadil is hypotension.

Vacuum erection devices

Vacuum devices are cylinders that are placed over the penis and the air removed, creating suction that draws the penis into the tubing. Once tumescence is achieved, a constriction band is placed on the base of the penis, maintaining the erection after the vacuum has been removed.

Penile prostheses

If the pharmacological and vacuum therapies have been unsuccessful, or if the patient prefers, prosthesis can be considered. This requires surgery to replace the corpus cavernosa with malleable rods or fluid filled chambers that can be inflated/deflated 'on demand'. Although the shaft of the penis will be firm, the tip can be soft, making penetration difficult for some. Success rates for penile prosthesis have been reported as high as 90%.14

Optimisation of PDE5Is

Not all PDE5Is work in the same way and patients/partners should ideally select the medication that they think fits in with their sex life. Once the decision to take a PDE5I has been made, patients should attempt to engage in regular sexual activity (eg. 2-3 times per week), which will help to overcome the inevitable performance anxiety and pressure to perform that these men have.  

In studies comparing Sildenafil citrate with Tadalafil15,16 patients tend to prefer the longer acting medication (Tadalafil) although in these studies more patients dropped out of the Tadalafil groups due to side effects (principally headache) compared to those taking Sildenafil.17 Since the introduction of generic Sildenafil, selection of treatment may be dependent on cost rather than the most appropriate medicine.

Eligibility for NHS treatment

Most men are ineligible to receive NHS treatment although since July 2013, generic Sildenafil has become available, which is much cheaper than other medication. There is an additional criteria (severe psychological distress)18 that can justify NHS treatment in men without, for example, diabetes mellitus, although there are no consensus definitions of severe distress.

Priapism

All men who receive treatment for ED should be advised of the risk of priapism. Priapism is an erection that is maintained after ejaculation and lasts for several hours. In this situation, damage can occur to the penis due to the trapping of blood in the corpus cavernosa. Although priapism is rare, patients should be advised that if they experience it, they need to:

 - Try and ejaculate again.

 - Have a warm bath or shower to promote vasodilatation.

 - Walk up/down stairs (to divert the blood to the legs).

If an erection is maintained for more than three hours, they should attend A&E for advice and/or treatment.

Summary

Erectile dysfunction is common and can be the first presentation of cardiovascular disease in some men. Men are not embarrassed to discuss their sexual problems and the sooner advice and treatment are sought, the 'better' the outcome in terms of resumption of sexual activity and stability within the relationship. Treatment options include PDE5Is, Alprostadil, vacuum devices, penile implants and counselling. Since the summer of 2013, generic Sildenafil has become available at a much reduced cost when compared to other available medication. This presents a complicating factor for the clinician, as men may be able to obtain this medication without a thorough assessment, thus potentially risking his health if a PDE5I is contra-indicated. Asking about ED is therefore an essential part of men's health.

 

Resources

Men's Health Answers

 

References 

1. National Institutes of Health Consensus Development Panel on Impotence. Impotence. Journal of the American Medical Association 1993;270(1):83-90

2. McKinlay JB. The Worldwide prevalence and epidemiology of erectile dysfunction. International Journal of Impotence Research 2000;12,Suppl 4, S6-11

3. Schwartz BG, Kloner RA. How to save a life during a clinic visit for erectile dysfunction by modifying cardiovascular risk factors. International Journal of Impotence Research 2009;21(6):327-35. 

4. Montorsi F, Briganti A, Salonia A. Erectile dysfunction prevalence, time of onset and association with risk factors in 300 consecutive patients with acute chest pain and angiography documented coronary artery disease. European Urology 2003;44(3):360-5.

5. Ponholzer A, Temmi C, Mock K, et al. Prevalence and risk factors for erectile dysfunction in 2869 men using a validated questionnaire. European Urology 2005;47(1):80-86. 

6. Voils CI, Sandelowski M, Dahm P, et al. Selective adherence to antihypertensive medications as a patient-driven means to preserving sexual potency. Patient preference and adherence, 2008;2:201.

7. Steggall M. Pharmacological management of erectile dysfunction. Nurse Prescribing 2012;10(7):339-44.

8. Laumann EO, Glasser DB, Neves RCS, et al. A population-based survey of sexual activity, sexual problems and associated help-seeking behaviour patterns in mature adults in the United States of America. International Journal of Impotence Research 2009;21(3):171-8.

9. Steggall MJ. Clinical management of erectile dysfunction. Trends in Urology, Gynaecology and Sexual Health 2009;14(6):14-7.

10. Sainz I, Amaya J, Garcia M. Erectile dysfunction in heart disease patients. International Journal of Impotence Research 2004;16(Supple 2): S13-7.

11. Seftel AD, Buvat J, Althof JG, et al. Improvements in confidence, sexual relationship and satisfaction measures: results of a randomised trial of Tadalafil 5mg taken once daily. International Journal of Impotence Research 2009;21(4):240-8. 

12. Porst H, Kim ED, Casabé AR, Mirone V, Secrest RJ, Xu L, Sundin DP, Viktrup L; for the LVHJ study team. Efficacy and Safety of Tadalafil Once Daily in the Treatment of Men With Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia: Results of an International Randomized, Double-Blind, Placebo-Controlled Trial. European Urology 2011;60(5):1105-13.

13. BNF. British National Formulary (September 2013) Number 66. London: British Medical Association and the Royal Pharmaceutical Society of Great Britain; 2013. 

14. Cummings M. Are there any alternative approaches to drug therapy? Managing Erectile Dysfunction. Altman, St. Albans. 2006;59-65

15. Health Service Circular HSC 1999/148 Treatment for impotence. Department of Health London. 

16. Keitz AV, Rajfer J, Segal S, et al. A multicentre, randomised, double-blind crossover study to evaluate patient preference between Tadalafil and Sildenafil. European Urology 2003;45:499-509.

17. Eardley I, Mirone V, Montorsi F, et al. An open-label, multicentre, randomised trial comparing Sildenafil Citrate and Tadalafil for treating erectile dysfunction in men naïve to phosphodiesterase type 5 inhibitor therapy. British Journal of Urology International 2005;96(9):1323-32. 

18. Health Service Circular HSC 1999/177 Treatment for impotence: patients with severe distress. Department of Health. London.