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Assessing patients with actual or potential erectile dysfunction

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Martin J. Steggall, BSc, MSc, Dip Nursing, RN.

Lecturer in Applied Biological Science and Urology, City University, London, and Honorary Urology Specialist Nurse, Department of Urology, St. Bartholomew's Hospital, London

A local audit at the nurse-led erectile dysfunction (ED) clinic at St Bartholomew's Hospital, London, revealed startling data: the average time from onset of erection failure to seeking treatment was almost five years. All patients had been assessed using the Roper et al (2000) model of nursing; many had been treated for conditions ranging from hypertension to diabetes, but none were given information concerning a known side-effect or complication of their treatment - ED.

A local audit at the nurse-led erectile dysfunction (ED) clinic at St Bartholomew's Hospital, London, revealed startling data: the average time from onset of erection failure to seeking treatment was almost five years. All patients had been assessed using the Roper et al (2000) model of nursing; many had been treated for conditions ranging from hypertension to diabetes, but none were given information concerning a known side-effect or complication of their treatment - ED.

It is well known that antihypertensives can cause erection problems (Fogari and Zoppi, 2002); that diabetes accelerates atherosclerosis and therefore can affect arterial diameter (Sullivan et al, 2001); and that some surgery has the potential to cause erection failure through nerve or vascular damage or a change in body image (Hendry, 1995). It is essential, therefore, to assess patients and prevent delays in seeking treatment.

Incidence
ED is a common condition that is thought to have an annual incidence in men aged 40-69 of 26 per 1000 men (2.6%) (Meuleman, 2002). It can be defined as the inability of a man to gain an erection of sufficient quality for intercourse (Kirby and Eardley, 1991). ED supersedes the older term impotence, although this is still used by the lay public.

Causes
The causes of ED and the associated risk factors are often multiple, with psychological, neurological, endocrinological, vascular, traumatic and iatrogenic components, which are listed in Table 1. The exact role played by lifestyle/medical events has yet to be fully elucidated, although smoking, hypertension, hyperlipidaemia, diabetes mellitus and the presence of vascular disease have been proposed as potential risk factors, given their effects on the cardiovascular system (Sullivan et al, 2001)

It can be seen from Table 1 that a number of common medical conditions, for example diabetes mellitus and treatment for hypertension, are known to cause erectile dysfunction. Treatment for hypertension will lower blood pressure, therefore making it more difficult to gain an erection. Diabetes mellitus accelerates atherosclerosis, thereby narrowing arteries: since the corpus cavernosum is made up of small arteries, these are more likely to become blocked due to atheroma (Sullivan et al, 2001), resulting in erection problems.

Anatomy and physiology
The penis is made up of the urethra and three erectile bodies: two corpus cavernosa and the corpus spongiosum. There are two ligaments attaching the body of the penis to the pubic bone (Garcia et al, 1998).

Blood is delivered to the corpus cavernosa via the pudendal artery (Garcia et al, 1998). During erection the penis accumulates blood under pressure. Dilatation of the arteries is the initial event at the beginning of the erection, allowing blood into the penis at diastolic and systolic pressure. As blood fills the penis, the increased volume effectively compresses the venous drainage so that blood is held in the corpus cavernosa (Brewster et al, 2001). The system by which this occurs is known as the corporo-veno-occlusive mechanism. In addition to blood pressure, hormones and neurotransmitters are involved in maintaining the erection (Garcia et al, 1998).

The precise relationship between blood supply and nerve supply is unknown, but an additional key element is that of desire (Williams, 1989). Currently, opinion and treatment options focus on improving blood flow. Clearly, any medication or medical conditions that affect the tone or diameter of the arteries can affect the strength of the erection.

It is a myth that men can gain an erection 'anytime, anyplace, anywhere' (Williams, 1989). Conditions for intercourse are the same for men and women - there must be an element of desire to initiate the physical changes described above. Failure of desire or lack of libido that prevents erection is termed psychogenic ED, but this could be considered a 'normal' reaction if there are fears associated with intercourse or intimacy and is called performance anxiety (Hawton, 1985).

Psychogenic ED is self-perpetuating: each failure increases the associated anxiety levels and can lead to the continual failure to have erections (Hawton, 1985). This is thought to be the commonest cause of intermittent ED in young men, although it is usually secondary to organic dysfunction from middle age onwards (LoPiccolo, 1991).

Every erection failure experienced by the patient can exacerbate performance anxiety, but early intervention and treatment often helps to reduce this cycle of failure and leads to rapid resolution (Gupta, 1999). Therefore early identification of erection trouble, either actual or potential, by nurses will reduce this element of performance anxiety, and lead to swift intervention so that the patient can return to his normal sexual activity.

Drugs implicated in the development of erection failure are listed in Table 2 (Jackson et al, 1999).

ED clinic
A routine audit of the St Bartholomew's ED clinic in 2001 revealed that the average time before treatment was sought was 57 months (+/-52 months) and the mean age of the patient was 57.5 years (+/-11.4 years). Most referrals were received from the urology department, but our clinic has now expanded to receive direct referrals from GPs, diabetologists and other specialties and all professional groups. Table 3 gives the common aetiologies.

A common finding was that those patients with an organic cause to their dysfunction also had significant psychogenic factors that influenced the condition and its treatment.

Nursing assessment: expressing sexuality
According to the Roper et al (2000) model of nursing, society has become more permissive and sexuality is now discussed openly with fewer taboos surrounding discussion about sex or sexuality than in previous generations. However, this view of sexuality may be exaggerated. These perceptions can often lead to unfavourable comparisons between media representations of sexuality and patient experiences, which may make patients embarrassed to discuss this activity of living. Although the Roper et al model states that the observant nurse will perceive cues which are expressions of sexuality, or indicators of anxieties related to the activity of living of expressing sexuality, this is still frequently not discussed. Often the assessment of this activity of living is recorded in the notes as as 'Not discussed', 'Married' or 'Lives alone'.

Over the past 10 years there has been an increase in the number of men who have sought advice from our urology department about a presenting sexual problem. We believe this reflects media images and discussion of sexuality. Publicity about solutions to sexual problems such as sildenafil (Viagra) has also enabled men to seek help. However, as noted, there is still a five-year gap between onset of problems and receiving treatment, which demonstrates that, despite the myth that our society is open about sexuality, there are enormous barriers of embarrassment and fear of humiliation that may delay men seeking help. Our data are consistent with published evidence citing delay in treatment until the condition had disrupted the individual's lifestyle (Wagner et al, 2002).

Admission to hospital
Hospitalisation for any reason can raise significant fears and anxieties in patients. Some surgery will have an impact on body image, whereas the treatment for certain diseases can cause unwanted side-effects (Blackmore, 1989). Both present a challenge to the nurse caring for the patient. In the light of the conditions and medications listed, many patients are at risk of developing ED. We contend that specific questioning may be of greater benefit for the patient with or potentially suffering from ED. Direct referral to the ED services would not need to include any information other than the patient's name and address.

Using the Roper et al model, assessing 'Expressing sexuality' would not require a full psychosexual assessment, but more data other than 'Married' or 'Lives alone'. Questions could include: 'I notice that you are taking drug X (Table 2). Some men can have difficulty with erections following taking this medicine, have you had any trouble?' Alternatively, the patient may be undergoing a specific operation that may affect this activity of living. Questions such as 'Are you aware that some men have difficulty gaining or sustaining an erection or ejaculating after this operation?' could then be asked. This strategy can also be applied in a community setting during diabetic/ blood pressure reviews.

Detailed assessment is not required but, given the consequences of delay between onset of erection failure and seeking treatment, this is an opportunity for patient education and health promotion. Patients need to be given information concerning what to do if they experience problems and who to contact. They should ask their GP to refer them to the local ED clinic for assessment, advice and treatment (if wanted).

Specialist practice
Assessment in the ED clinic comprises a medical/ surgical history followed by specific questioning concerning the type of problem. The assessment guide has been reproduced in Table 4. This assessment tool gives an insight into organic and psychogenic causes of erection failure and helps to guide management. A common finding is that medical colleagues often 'polarise' patients by attributing their ED to organic or psychogenic causes. We believe that such an approach fails patients with mixed-aetiology ED because it denies the effects that anxiety or undiagnosed organic disease can have.

A hormone profile looking at luteinising hormone (LH), follicle-stimulating hormone (FSH), testosterone and sex hormone-binding globulin (SHBG) is routinely taken. Although derangements in these levels are rare, they require treatment if identified.

For a certain group of men ED is a form of communication, a way of signalling to themselves, or to others, that something needs attention in their personal or emotional lives (Gann, 1995) It is commonly an expression of negative feelings such as sadness, anger, guilt or worry, particularly for those men who do not express their feelings verbally (Williams, 1989). All these states are known to have an inhibiting effect on the erectile mechanism (Williams, 1989). Unless these issues are also addressed during the consultation, the medication may provide an erection, but does not always help the man to achieve his goals in terms of having a mutually satisfying sexual relationship with a partner.

Erection failure is not always precipitated by a crisis in the presenting patient's life (Hawton, 1985). Where there is a partner it is also important to explore the partner's situation and feelings about the sexual relationship. For many men loss of erections is a response to anger or negative feelings perceived in the partner (Hawton, 1985).

The following case studies illustrate the complexity of ED management.

Case study 1 - John Brown, aged 56, was referred to the ED clinic with loss of erections for two to three years without any medical or known psychogenic reason identified in his history. He was initially prescribed sildenafil (Viagra) by the urological consultant who saw him in the general clinic. This had not helped him. On further exploration it was discovered that his wife had experienced a period of illness and surgery and the patient had been her main carer. ED had occurred during a time when sexual intercourse was not possible and the subsequent ED maintained the 'no sex' rules.

This scenario illustrates that expressing sexuality must also be considered in female patients, given the potential change in personal relationships that illness can cause.

Case example 2 - Peter Green, aged 31, presented with erection failure for the past six years. His medical history included diabetes mellitus treated with insulin. Sildenafil had apparently failed and he was referred for teaching on how to use the injection system. With injection therapy it is possible to have an erection without going through the cycle of desire and erection. During closer questioning Mr Green was found to have a loss of desire brought on by anxieties about gaining an erection. This loss of libido was managed using combined medical and psychosexual therapy. Sildenafil provided the 'medical' component whereas self-focus exercises provided the 'psychosexual' element.

This is a relatively common finding - patients are referred with organic disease but are found to have psychogenic failure. This approach led to successful management of the erection failure without resorting to injection therapy. The role of the nurse in this instance was to combine two 'models', medical and psychological, and use both to reach a successful outcome. The medication needs to be used within the context of the sexual cycle of desire-arousal-lovemaking, rather than just as a mechanical device.

Treatment
Irrespective of cause, there are only seven treatments available for ED, which are listed in Table 5.

The efficacy of these treatments can be variable and dependent on patient motivation (Gupta, 1999). There is also anecdotal evidence indicating that time taken to teach injection technique or application of these options can improve patient acceptability and efficacy.

Not all patients can be treated by NHS prescription. The Government has restricted NHS prescriptions to conditions and circumstances listed in Table 5 (DoH, 1999). Those patients who do not fulfil these criteria must seek a private prescription from their GP. Treatment options for this group of patients often become influenced by cost. Before April 2002 vacuum pumps were not included in the approved medications/treatment for NHS prescriptions, but this anomaly has now been corrected.

The Department of Health guidelines (1999) for the prescription of these medications includes research from Johnson et al (1994), who report that the average number of times that the 40-60-year-old age group have intercourse is once a week, and therefore suggest that GPs prescribe to reflect this.

Unfortunately, such guidelines fail to recognise the effect that delayed treatment and performance anxiety has on these groups of patients. As the average time to seek treatment is five years, taking a tablet such as sildenafil will be unlikely to have a successful effect on the first few attempts at intercourse since the individual will be under extreme pressure to 'perform' on the first few occasions.

Recent evidence from Heaton et al (2002) indicates that it is the sixth dose of apomorphine hydrochloride that is most likely to be efficacious. Therefore, rigid adherence to the prescribing guidelines will have implications on successful and rapid outcome, possibly exacerbating fear of failure and performance anxiety.

Patients in this clinic are advised to take medication more than once a week, using the rationale that this will reduce the anxiety related to the expected efficacy of the medication and pressure to perform. This rationale often results in criticism from some colleagues that patients are told how often to have intercourse, but this is clearly not the case. In our experience, treatment is more likely to be successful when the patient and his partner are relaxed; such a regimen often helps to achieve this.

Conclusion
A consistent barrier to seeking treatment for ED is embarrassment and lack of clear referral procedures. Patients are assessed on admission to the ward and discharge plans made. We contend that ED should be specifically targeted given the incidence and causes defined. Management in the ward or community setting is not required, but swift referral to the ED clinic should be made. Early referral reduces the impact of performance anxiety, which is of major importance in treating erection failure.

This paper has demonstrated that approaching assessment and treatment from the purely medical view is to deny an important aspect of erectile dysfunction and limits its successful outcome. Some strategies have been outlined to identify men at risk of developing erectile dysfunction and the need for effective communication between the nurse and patient.

Recommendations for practice
- Identify whether the patient has or may develop ED as a result of treatment by focused questioning

- Offer direct referral or contact details in case the patient wishes to talk about problems in the future

- Use an holistic approach to management that is medical and psychosocial

- Patients must be partners in treatment - the patient must be committed to treatment for any treatment programme to be effective

- Re-assess patients until successful treatment has been found.

Names of patients have been changed

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Fogari, R., Zoppi, A. (2002)Effects of antihypertensive therapy on sexual activity in hypertensive men. Current Hypertension Reports 4: 3, 202-210.

Gann, S.Y. (1995)A functionalist view of erectile insufficiency (unpublished dissertation for Diploma in Psychosexual Therapy). London: British Association of Sexual and Marital Therapists.

Garcia, E.L., Iribarren, I.M., de Tajada, I.S. (1998)An update on the physiology of erection. In: Morales, A. (ed.). Erectile Dysfunction. London: Martin Dunitz.

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LoPiccolo, J. (1991)Psychological evaluation of erection failure (Chapter 13). In: Kirby, R.S., Carson, C.C. and Webster, G.D. (eds). Impotence: Diagnosis and management of male erectile dysfunction. Oxford: Butterworth Heinemann.

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Wagner, G. The Lyon Arms Group, Claes, H., Costa, P., et al. (2002)A shared care approach to the management of erectile dysfunction in the community. International Journal of Impotence Research 14: 189-194.

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