Patricia Allen, MA, DipN (Lond), RM, RGN.
Clinical Nurse Specialist, Andrology Service, Urology Department, Royal Hallamshire Hospital, Sheffield
Erectile dysfunction (ED) is the inability to achieve and maintain an erection adequate for satisfactory sexual performance (NIH Consensus Conference, 1993). In the past, it was thought to be the result of psychological problems - psychogenic ED - but we now realise that in most men the condition is organic and caused primarily by underlying physical problems (Spector and Carey, 1990) (Box 1). Most men with organic ED develop psychological problems and are said to have mixed ED. The risk increases with age, but it is not a normal part of ageing.
To distinguish organic ED from psychogenic ED it is essential to take a detailed patient history (Box 2). This, with the patient’s age, may indicate the need for a more detailed physical examination by a doctor. Most patients need blood pressure measurement and examination of the genitals to exclude abnormalities of the testicles, shaft of the penis and foreskin. A few men will require referral to secondary care (Box 3).
Basic investigations include tests for glucose, prolactin, free testosterone and sex-hormone binding globulin levels. If testosterone levels are low, a sample should be taken to test for luteinising hormone, follicle-stimulating hormone and testosterone. Dipstick urine testing assesses blood and protein components.
Oral treatments apomorphine SL (Uprima) or sildenafil (Viagra) are now generally the first-choice treatment for most men.
Apomorphine SL is a dopamine receptor agonist that acts on the central nervous system to enhance the erectile process. In most patients who respond, erection is facilitated within 20 minutes of taking it, which can help restore the spontaneity for a more natural sex life (Heaton et al, 2002). Sildenafil is a phosphodiesterase-5 (PDE-5) inhibitor. It promotes and amplifies cavernosal muscle relaxation, improving penile blood flow. An erection is achieved within 30-60 minutes of oral administration.
The most common side-effects associated with apomorphine SL are headache, nausea and dizziness (Montors, 2002) while sildenafil can cause headache, flushing, altered colour vision and indigestion (Goldstein et al, 1998). Unlike apomorphine SL, sildenafil is contraindicated in men taking nitrates.
Alprostadil, in intracavernosal (Caverject, Viridal Duo) or transurethral (MUSE) formulations, is often chosen as a second- or third-line treatment when oral treatment is ineffective or contraindicated (Rosen, 2000), or is the first-line treatment through patient choice. Usually mild penile pain on injection and fibrosis are associated with intracavernosal alprostadil (Porst, 1997), while penile and urethral pain are reported with transurethral pellets (Padma-Nathan, 1997).
Priapism is not generally associated with apomorphine SL or sildenafil, but can occur with both formulations of alprostadil (Padma-Nathan, 1997). Warn patients to seek urgent treatment if this happens.
Devices and surgery
Vacuum devices consist of a cylinder fitted over the penis, attached to a pump. Air is pumped out, causing the penis to fill with blood and become erect. A constriction ring is fitted at the penis base to maintain erection.
Semi-rigid or inflatable penile implants are the alternative for men who are unsuitable or do not respond to other treatments. Implants can succeed in selected patients, but the devices can break down and become infected, necessitating removal (Moore, 1988).
Careful follow-up is essential. Most patients in our clinic are treated successfully after three to four visits, but for others it can take longer. Nurses should stress that other therapies are available and that patients get in touch if they have any concerns.
How to approach the patient
- Men with erectile dysfunction should be given the time and privacy to discuss their problem. This may be difficult in primary care, and patients may be more relaxed if the ED clinic is held outside regular surgery hours. Never make assumptions based on your own experience or attitudes.
- Do not assume that older men and their partners do not want penetrative sex. Similarly, when discussing the man’s relationship, it is unwise to assume that his partner is necessarily female.
- Although a man may make the initial approach, it is helpful to see both the patient and his partner. Not only may partners feel hurt that their partner does not trust them with such intimate concerns, but they may themselves have physical or psychological sexual problems that need to be addressed (Riley and Riley, 2000).
- Some men will not have a partner but this should not be a reason for refusing treatment. A man may not have a partner because his worries about his ED prevent him from forming intimate relationships. Alternatively, the man may be concerned that ED will blight a currently non-sexual relationship that he wishes to take further. It is also perfectly reasonable for men without partners to want to gain a sexual outlet in masturbation.
Nurses should explain to the patient that all NHS drug treatments for erectile dysfunction are covered by Schedule 11 regulations, which allow the Department of Health to compile a list of drugs that GPs may prescribe only in certain circumstances or for specific groups of patients.
Under Schedule 11, GPs are allowed to prescribe one NHS treatment a week to men who:
- Have had radical pelvic surgery
- Have had their prostate removed or have been treated for prostate cancer
- Have been treated for renal failure by transplant or dialysis
- Have spinal cord or severe pelvic injury
- Have diabetes
- Have conditions such as multiple sclerosis, Parkinson’s disease, spina bifida or poliomyelitis.
GPs can continue to prescribe ED treatment to men who do not fall into these categories but who were receiving treatment on September 14,1998.
Men who fall outside these guidelines or those wishing to have intercourse more often will have to obtain their treatment on private prescription.
Source: NHS Executive, 1999.
The nurse’s role
- For nurses who run chronic disease clinics, it is worth being proactive and bringing up the subject during routine appointments. Nurses can simply ask the man if he has any problems in his relationship. For patients with chronic disease, a more direct approach might be to mention that erectile problems are associated with the condition but that treatments are available.
- The final choice of treatment lies with the patient, and the nurse’s role is to give unbiased advice and help him make a choice that is best for him and, where applicable, his partner. However, it is important to make sure the patient has reasonable expectations since no treatment will solve all his relationship problems. For this reason, treatment goals should be agreed at the outset and psychosexual therapy or relationship counselling arranged as appropriate.
Goldstein, I., Lue, T.F., Padma-Nathan, H. et al.Oral sildenafil in the treatment of erectile dysfunction: New England Journal of Medicine 1998; 338: 1397-1404.
Heaton, J.P., Dean, J., Sleep, D.J. (2002)Sequential administration enhances the effect of apomorphine SL in men with erectile dysfunction. International Journal of Impotence Research 14: 1, 61-64.
Montors, F. (2002)The role of Amorphine SL in the treatment of erectile dysfunction. European Urology Supplement 1: 4-11.
Moore, K.T.H. (1988)Penile implants. British Journal of Sexual Medicine. Jan: 26-33.
NIH Consensus Conference (1993)Impotence. NIH Consensus Development Panel on Impotence. Journal of the American Medical Association 270: 83-91.
NHS Executive. (1999)Treatment of impotence. Health and Safety Commission 1999/115. London: NHSE, 7 May 1999.
Padma-Nathan, H., Hellstrom, H., Kaiser, F. et al. (1997)Treatment of men with erectile dysfunction with transurethral alprostadil. New England Journal of Medicine 336: 1-7.
Porst, H. (1997)Transurethral alprostadil with MUSE US intracavernous alprostadil: A comparative study of 103 partners with erectile dysfunction. International Journal of Impotence Research 9: 187-192.
Ralph, D., McNicholas, T. (Erectile Dysfunction Alliance) (2000)UK management guidelines for erectile dysfunction. British Medical Journal 321: 499-503.
Riley, A., Riley, E. (2000)Behavioural and clinical findings in couples where the man presents with erectile disorder: a retrospective study. International Journal of Clinical Practice 54: 4, 220-224.
Rosen, R.C. (2000)Management of complicated and treatment refractory ED: Clinical issues and guidelines. Special Lecture. International Journal of Impotence Research 12: Suppl 3, 559-560.
Spector, I.P., Carey, M.P. (1990)Incidence and prevalence of the sexual dysfunctions: A critical review of the empirical literature. Archives of Sexual Behaviour 19: 389-408.
Wiles, P.G. (1992)Erectile impotence in diabetic men: aetiology investigation and management. Diabetic Medicine 9: 888-892.