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Straight talking: bringing up erectile dysfunction

Many cases of erectile dysfunction (ED) remain undiagnosed due to the client's embarrassment, or reluctance to consult a physician, or a belief that ED is a normal part of the ageing process. A recent study suggested that up to 70% of cases go untreated.(1) ED is closely related to most of the chronic diseases managed in general practice, and GP income is closely related to reaching clearly defined targets in these chronic diseases, as laid down in the current GMS contract.

Why ask about erectile dysfunction?
Several large studies have shown that ED is a strong predictor for cardiovascular disease in men.(1-3) Despite clear evidence that ED is present in over 50% of patients with diabetes, over 35% of hypertensive patients and up to 70% of men with depression, questioning about ED is still not a routine part of chronic disease management.(1,4,5) In many cases the drug treatment for these conditions may make the problem worse - for example, thiazides, β-blockers and selective serotonin-receptor inhibitor (SSRI) antidepressants. The average length of time that a UK male has ED before diagnosis is made is two to three years, despite regular contact with healthcare professionals during that period.(1) Recent evidence suggests that, in the early stages, endothelial dysfunction rather than arteriosclerosis is the major pathology.(6) At this stage ED may be reversible with lifestyle modification and early management of the underlying causes.(7,8) If left untreated, irreversible degenerative changes occur, particularly in patients with diabetes, and response rates to therapy are much lower.(2) Early intervention could have important long-term health and economic benefits as the drug management of established ED is potentially expensive, both if funded by the NHS or privately by the patient.(8)
In patients suffering from depression, commonly associated with ED, several placebo-controlled studies have shown that treating the ED rather than the depression leads to significant improvements in depression scores, self-esteem and relationships.(9) Such an approach is usually welcomed by the patient and his partner because of the stigma associated with
depression.(9)
Although patients are embarrassed to talk about ED, many would welcome the initiation of such a discussion by a healthcare professional.(4,6) More patients could be diagnosed and treated for ED if questionnaires or another screening method were used to assess erectile function in men presenting with conditions, such as diabetes, obesity, depression or cardiovascular disorders.(1)

Why do we not ask about erectile dysfunction?
Few studies have looked at the attitudes of healthcare professionals in this respect, but Dean and Hackett identified several potential factors:(10)

  • Lack of knowledge of sexual function largely related to deficiencies in undergraduate and postgraduate training.
  • Embarrassment or a fear that it might upset the patient.
  • Lack of time.
  • Fear of opening a "Pandora's box".
  • Other possible factors, particularly related to the GMS contract.

Many healthcare professionals might be concerned about the potentially expensive therapy and its cost implications that they would have to justify to their PCT. The complex regulations related to NHS prescriptions under schedule 2 have not helped in this respect.(11)

How to ask the question - striking up a conversation
During the course of a chronic disease visit, the simple way to approach the subject is with an open-ended question, such as:
"Many patients with medical problems, such as XXX, notice difficulties with erections. Is this is a problem for you?"
In many cases this question will be greeted with a look of relief from the patient as if a burden has been lifted. The computer records should then record that the question has been asked, which will allow for searches and audits to be carried out in future.
Positive responses can be followed up with five key questions that can easily be included in a routine consultation:

  • How long has the problem been present? Short duration suggests the possibility of reversing the process, especially if the underlying problem can be addressed, such as obesity, dyslipidaemia, smoking or relationship issues.
  • Is the problem consistent, intermittent or situational? Persistent, progressive symptoms strongly suggest vascular disease and the need for further investigations.
  • What does your partner think about the problem? Involvement of the partner at an early stage leads to better results. The partner may have a sexual problem herself. Remember that vaginal dryness is particularly common in postmenopausal women. A reluctant partner will usually defeat the best efforts of clinician and patient. Sometimes after a divorce or bereavement ED can prevent a man from commencing a relationship or confiding in others.
  • Is loss of libido present? This might suggest hypogonadism. Premature ejaculation (PE) may be present. The golden rule is to treat the ED first. Often the PE will improve sufficiently, but sometimes it may also need to be treated.
  • What would you like to achieve from treatment? It is important to agree realistic goals with the couple at an early stage.

Giving the patient a five-question "Sexual Health Inventory in Men" (SHIM) can help them to focus on the precise problem. These are self-completed sheets freely available from the manufacturers of ED medications. They also provide an excellent method of measuring changes over time and therapeutic responses.
If time restraint is a problem, an information sheet can be provided and a follow-up appointment arranged. Baseline examinations should consist of a lipid profile, fasting blood glucose (if not already available) and morning testosterone, before the next consultation.

One treatment per week not enough
The government schedule 2 regulations have had a major negative impact on the UK management of ED. Few understand their complexity and many myths are allowed to prevail, such as "we are only allowed to provide one treatment per week". This is simply not true as the regulations state that: "It is anticipated that one treatment per week will be appropriate for the majority of patients … Where more is required, the physician shall prescribe according to clinical need."(12)
The guidelines also recommend that GPs refer to specialists if the patient suggests they are in "severe distress".(13) Recent studies that use well-validated assessments demonstrate that severe distress is present in over 88% of newly presenting patients with ED, compared with 5% of the general population.(14) Modern treatments have also been shown to be highly effective in relieving severe distress. Failing to ask about ED is potentially missing a major opportunity to deal with an important cause of distress in the lives of our patients and their families.

References

  1. Kubin M, Wagner G, Fugl-Meyer AR. Epidemiology of erectile dysfunction. Int J Impot Res 2003;15:63-71.
  2. Hood S, Robertson I. Erectile dysfunction: a significant health need in patients with coronary heart disease. Scott Med J 2004;49:97-8.
  3. Thompson I, Tangen CM, Goodman PJ. Erectile dysfunction and subsequent cardiovascular disease. JAMA 2005;294:2943-50.
  4. Giuliano FA, Leriche A, Jaudinot EO, de Gendre AS. Prevalence of erectile dysfunction among 7689 patients with diabetes or hypertension, or both. Urology 2004;64:1196-201.
  5. Roose SP. Depression: links with ischemic heart disease and erectile dysfunction. J Clin Psychiatry 2003;64 Suppl 10:26-30.
  6. Montorsi P. Is erectile dysfunction the tip of the iceberg of a systemic vascular disorder? Eur Urol 2003;44:352-6.
  7. Saltzman E, Guay A, Jacobsen J. Improvement in organic erectile dysfunction in men with elevated cholesterol levels: a clinical observation. Urology 2004;172:242-8.
  8. Derby CA, Mohr BA, Goldstein I, Feldman HA, Johannes CB, McKinlay JB. Modifiable risk factors and erectile dysfunction: can lifestyle changes modify risk? Urology 2000;56:302-6.
  9. Seidman SN, Roose SP, Menza MA, Shabsigh R, Rosen RC. Treatment of erectile dysfunction in men with depressive symptoms: results of a placebo-controlled trial with sildenafil citrate. Am J Psychiatry 2001;158:1623-30.
  10. Dean J, Hackett G. The knowledge and attitudes of UK primary care physicians to sexual problems. Poster MP 42. ESSM.London 2004.
  11. Hackett G. Schedule 11-impact on treating erectile dysfunction. Br J Diab Vasc Dis 2002;2(4):315-8.
  12. HSC 1999/115. Treatment of impotence. Available from:http://www.dh.gov.uk
  13. HSC 1999/148. Treatment for impotence. Available from:http://www.dh.gov.uk
  14. Fugl-Meyer K,  Stothard D, Belger M, et al. The effect of tadalafil on psychosocial outcomes in Swedish men with erectile distress: a multi-centre, non-randomised open-label clinical study. Int J Clin Pract (ahead of print Nov 2006).