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The problem of erectile dysfunction following myocardial infarction

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Chris Jones, MSc.

Lecturer, Critical Care, School of Health Studies, Edge Hill College, University Hospital Aintree, Liverpool

The recent campaign of full-page press advertisements relating to erectile dysfunction (ED) illustrated that public attitudes to this distressing disorder may slowly be changing. That we now refer to this problem as ED and not its previous value-laden term 'impotence' is further evidence that ideas are evolving.

The recent campaign of full-page press advertisements relating to erectile dysfunction (ED) illustrated that public attitudes to this distressing disorder may slowly be changing. That we now refer to this problem as ED and not its previous value-laden term 'impotence' is further evidence that ideas are evolving.

The onset of ED has often been seen as an inevitable part of the ageing process - regrettable but unavoidable. Changed attitudes to this condition cannot arrive soon enough for the many men who have been unwilling or unable to broach the subject with either doctors or nurses.

ED and coronary artery disease
For many reasons, ED complicates the recovery of patients from myocardial infarction (MI). ED among patients with coronary artery disease (CAD) is not uncommon. One study found the probability of complete ED to be 39% among CAD patients who had received treatment (Feldman et al, 1994). Furthermore, ED is also a complication of the conditions that are primary risk factors for developing CAD, in particular diabetes, hypertension, dyslipidaemias and arteriosclerosis (Kirby, 1994). Even when a man receives appropriate medical attention for one of these conditions he may have problems to face: some of the highest incidences of complete ED occur in men with treated hypertension, treated heart disease and treated diabetes (Feldman et al, 1994). Smoking and stress are also implicated in the development of ED (Levine and Kloner, 2000).

Despite this knowledge, little attention is given to ED. For example, the National Service Framework for heart disease says nothing specific about ED and has only three rather vague references to 'sexual problems' in its remarks concerning rehabilitation (Department of Health, 2000).

This paper therefore intends to consider ED in patients recovering from myocardial infarction (MI).

Erectile dysfunction after MI
There can be few symptoms as disturbing for a man who is recovering from an MI than erectile dysfunction. Cardiac disease is likely to have had a profound effect on his psychological disposition. His job and expectations in life may have to be radically rethought. He may suffer lingering symptoms such as chest pain and breathlessness. He may feel depressed about an uncertain future. He may already resent his dependence on friends and family. And then he experiences ED.

ED may have a profound effect on his self-esteem and may complicate his rehabilitation. One urology nurse has put it this way: 'Loss of vaginal lubrication is an annoyance to a woman; loss of erectile function is a traumatic event to a man' (Intili and Nier, 1998).

MI and disruption to normal process of erection
The process of erection involves co-operation between mind and body and is described in some detail in Rampin and Giuliano's work (2000). It might be triggered in two ways (Figure 1):

- Pleasurable physical sensations or direct physical stimulation of the glans penis cause sensations to arise in the penis. These sensations are passed through the lower parts of the spinal cord to the brain. The brain issues parasympathetic stimulation to the blood vessels entering the penis, causing dilation and increased blood flow

- Parasympathetic activity may also be triggered by psychological stimulation alone. Dreams or sexually explicit material may provoke erection even when there has been no direct physical stimulation.

The blood vessels receiving this parasympathetic bombardment are usually kept tight and constrict blood flow to the penis. Under parasympathetic influence the vessels dilate and blood flows quickly into the penis. When the tissues of the penis engorge, they put pressure on the veins draining the penis and close them off. This causes the penis to fill and an erection to occur. Following ejaculation or a decrease in stimulation, the arteries supplying blood constrict and blood flows back out of the penis, resulting in detumescence.

In other words, erection is a complex activity involving motivational, psychological, neural, cerebral and vascular components. The failure of any or all of these mechanisms might produce erectile dysfunction. What is particularly of note here is that erection can be entirely psychogenic in origin. Just as psychological stimulation may cause arousal, psychological upset may prevent or diminish arousal. MI is a profound source of psychological and sexual upset (Friedman, 2000).

Physical and psychological causes of ED after MI
The traditional distinction of erectile dysfunction into organic and psychological aetiology is too simple, although it points to some interesting considerations.

If the patient states that the quality of his erections were gradually declining before his MI, or that his erections fail regardless of the context of his sexual activity, it is likely that there is some pre-existing physical cause underpinning his problem, such as poor blood supply to the penis. If, on the other hand, he reports that his erections were normal before his MI and that he loses a perfectly good erection in specific contexts, then it is unlikely that his problems are physical.

Low self-esteem and fear of chest pain or depression might have a leading role in his problem.

One interesting way of teasing out the psychological influences in a patient's ED is to enquire whether or not he has morning or nocturnal spontaneous erections. If the patient reports such spontaneous erections, his erectile problems are likely to be due primarily to psychological causes.

Causes of ED in MI patients
The phenomena of CAD, depression and erectile dysfunction have, in one study, been linked. The author argues that depression causes MI, that MI causes ED, and that ED leads to depression. He refers to this phenomenon as a 'self-reinforcing triad' (Goldstein, 2000a).

Post-infarct loss of libido - The patient who has survived an MI might undergo a loss of sex drive for numerous reasons. The fact of being ill may make someone disinclined to have sex, but to have had what many patients might perceive as a 'near-death experience' might terrify a person and overwhelm his libido. The patient may be undergoing a form of bereavement and may feel that his youth has come to an abrupt halt. There may also be other more complex reasons. Depression has long been reported to be a psychological complication of MI (Roose and Seidman, 2000). One of the signs of depression is that once pleasurable activities are no longer enjoyable. If the patient is taking antidepressants, this may independently contribute to loss of libido and ED (Buffum, 1986).

CAD risk factors and testosterone - A cause of ED in elderly patients is abnormally low testosterone levels. Low testosterone will erode a man's sex drive, but is rare in younger men. The incidence of low testosterone corresponds with the appearance of central adiposity in men (Barret-Connor and Khaw, 1988). That is to say, the lower the testosterone levels the higher the waist-hip ratio. A high waist-hip ratio has been associated with CAD (Barret-Connor and Khaw, 1988). Testosterone has also been seen to decline in men with diabetes (Barret-Connor et al, 1990) and in those with hypertension (Khaw and Barret-Connor, 1988).

Cigarette smoking has been shown to increase oestrogen levels in men, which could antagonise the effect of testosterone (Barret-Connor and Khaw, 1987).

CAD and disruption of control of erection - The mechanism of erection is mediated by complex nervous interactions (Rampin and Giuliano, 2000), and any condition that interferes with these impulses may lead to ED. Disruption of these pathways is uncommon in MI patients, but those who also have or develop diabetes may develop neuropathy throughout the body and there is no reason why the penis will be spared this debilitating complication. Depression and anxiety may also disrupt the flow of parasympathetic stimulation, keeping the penis in a dormant state due to sympathetic tone.

CAD and disseminated arteriopathy - In 1985 Virag et al raised the question of the vascular contribution to erectile dysfunction. In their paper 'Is impotence an arterial disorder?' (1985), they argued that the person with risk factors for MI (smoking, diabetes, hyperlipidaemia and hypertension) is likely to have arteriopathy, and the process that may cause problems in his heart may manifest itself elsewhere, including in the iliac arteries. The arteries supplying the penis may have begun the process of sclerotic change and the penis may not have access to enough blood for proper function. Further studies have suggested that the man presenting with primary ED may on investigation be found to have as yet undiagnosed ischaemic heart disease (Virag et al, 1985). Men complaining of erectile dysfunction to urologists have been shown to have abnormal cholesterol concentrations. Other investigations have revealed that, in this group, over 90% had evidence of penile arterial disease when examined with Doppler ultrasound (Levine and Kloner, 2000).

Medication-induced erectile dysfunction - Erectile dysfunction caused by drugs is one of the most common presentations of the condition. Many of the problems experienced by the patient will be due to drugs prescribed for the treatment of his cardiac condition. Antihypertensive drugs, for example, are well known to produce erectile dysfunction, as are some diuretics. Beta-blockers are renowned for causing problems. Cardioactive drugs also have the tendency to diminish circulating testosterone. Digoxin is notable here. An excellent description of the effect of digoxin on sexual function is given on an Internet site by Dr I. Goldstein (2000b), a member of the Princeton Consensus Panel on the Management of Sexual Dysfunction in Patients with Cardiovascular Disease in the USA.

Helping men with ED
There are several ways in which nurses can help men with ED tackle the underlying problems.

Depression - One of the most important psychogenic causes of ED is depression, and the relationship between the two has been extensively described (Intili and Nier, 1998). Depressed people are at a higher risk of CAD (Goldstein, 2000a), and depression may also independently cause ED (Roose and Seidman, 2000). The mechanism involved is thought to be sympathetic activation, which antagonises the neural and vascular component of the process of erection. Of course, the relationship between ED and depression is complex.

It is not altogether clear what might be done to combat depression. Antidepressants may make the ED component of the depression worse. What could improve a patient's depression might be that he understands that he is not alone and that ED is a common complication that is amenable to treatment. The importance of nurses talking about the situation is clearly obvious. In any discussion, however, the following points may have to be borne in mind. Many people do not regard the reduction of sexual activity as an altogether bad thing. Perhaps the patient does not like sex, or maybe the main relationship in the patient's life does not support an active sex life. It would be wrong to give a previously satisfied patient the idea that he was failing relative to his peers in not wanting sex (Dinsmore and Evans, 1999).

Either way, the patient requires reassurance even if only to prevent the psychological phenomenon of 'grandstanding': the tendency of men with erectile dysfunction to watch and evaluate their own performance. This process contributes to a sensation of panic in the man who feels he is 'failing' and this can only make his situation worse: the so-called 'cycle of failure' (Friedman, 2000).

It is clear that adequately addressing this problem in rehabilitation is essential. The patient should be given reassurance that he is not alone and his partner should be reassured that the problem does not lie with their relationship. This may not actually relieve the problem, but it may take away the sense of urgency from the situation.

Fear and anxiety - If a man's erectile dysfunction is caused by fear and anxiety, then the following advice might be of use. While it is true that men occasionally die during sex, in terms of putting your heart at risk, there is little to choose between sexual activity and something sedentary such as watching television. Sex is not the equivalent of running a marathon; it is more akin to experiencing anger (Muller, 2000). If the 'background risk' of MI is 1.0, then sex increases a person's risk to 1.01 over a year (Muller, 2000).

It is true that there is some degree of cardiac risk in engaging in sexual activity following an MI (Muller, 2000). Drory et al (1996) found that there was some ventricular ectopy during sex in men who had had an MI, but that this compared to that experienced during the performance of ordinary household tasks. Anyone who gets no pain from these activities has little to fear from sex (Stein, 2000).

Ignorance - Many men are unclear about what constitutes a diagnosis of ED or whether it can be treated. Cummings et al (1997) describes the ignorance about this topic in men with diabetes. There is no reason to believe that men who have had an MI are better informed.

Nursing care of the patient with ED
The subject of ED is often a difficult one for nurses to discuss with their patients. The man might be as old as the nurse's father or even grandparent and it might seem better all around to let the subject go. But the matter might also be of uppermost importance to the man in question and the problem might be one that is easy to resolve. One US nurse suggests a script that the nurse might use to break the ice (Intilli and Nier, 1998).

It could be that, among a team of rehabilitation nurses, one team member takes the lead interest in these matters, and initiates discussion on the subject. The UK guidelines for erectile dysfunction suggest employment of a specialist nurse for this problem area (Ralph and McNicholas, 2000). Duckworth (1997) gives an account of running such an ED clinic. Simply talking to a specialist nurse might be all that is required. The atmosphere in which these matters are discussed can be all important. For example, a man might not feel able to raise embarrassing questions at a busy outpatient's appointment where he is separated from the next patient by just a curtain.

Basic observations may also be used when assessing a patient with ED. For example, if the patient is hypertensive, this might be the beginning of the problem and the condition's treatment its end. Measurement of blood sugar is also recommended as a basic investigation because of the incidence of erectile dysfunction in men with diabetes (Ralph and McNicholas, 2000).

The post-MI patient and Viagra
Medical therapy has become very promising in this area. Kirby (1994) said: 'The appeal of a pill for restoring potency is attested by the enormous world-wide sales of homeopathic remedies claiming to have this effect.' Of course there is now oral medication that can achieve this objective.

One drug treatment is sildenafil citrate (Viagra), which has the effect of restoring function to men in many differing contexts. The drug has not been demonstrated to induce adverse cardiac reactions (Shakir et al, 2001). In men with cardiac disease it is therefore a safe and effective therapy. By its mode of action it can cause a moderate drop in blood pressure (Kloner, 2000) but not enough to cause any real problem, except in one subset of patients. Patients taking organic nitrates can have a drop in their blood pressure of up to 55mmHg because of the synergistic effects of sildenafil (Kloner, 2000).

For those patients taking non-nitrate antihypertensives, the position is less clear. There is a suggestion that there have been a number of adverse reactions among patients using non-nitrate antihypertensives but no clear picture has yet emerged (Cohen, 2000).

For those patients who cannot use sildenafil, there are other medications that may be suitable. Phentolamine (Vasomax), for example, is a treatment advocated in many US texts. This drug is an alpha-receptor blocker that simultaneously causes a moderate drop in blood pressure and an increase in sexual performance. Other pro-erectile drugs are said to be in development.

There are voluntary organisations that provide valuable information and advice for the patient. The Men's Health Forum produces accessible literature around all these problems, as does the Impotence Association. The addresses of these organisations are listed in Box 1.

The development of sexual dysfunction following a myocardial infarction is an alarming and depressing turn of events, particularly for the younger patient. Unfortunately, it is also a common condition. Erectile dysfunction may compromise the man's perception of his quality of life, and the condition may also lead to psychosocial complications. It is therefore essential that the problem be addressed.

Helping men to address sexual problems such as erectile dysfunction will assist them in the process of physical and emotional recovery from MI. It will be a way of the man recovering his 'wholeness'. It will also start the process of medication adherence, and secondary prevention.

Barret-Connor, E., Khaw, K.T. (1987)Cigarette smoking and increased endogenous estrogen levels in men. American Journal of Epidemiology 126: 2, 187-192.

Barret-Connor, E., Khaw, K.T. (1988)Endogenous sex hormones and cardiovascular disease in men. Circulation 78: 3, 539-545.

Barret-Connor, E., Khaw, K.T., Yen, S.S. (1990)Endogenous sex hormone levels in older men with diabetes mellitus. American Journal of Epidemiology 132: 5, 895-901.

Buffum, J. (1986)Pharmacosexology update: prescription drugs and sexual functioning. Journal of Psychoactive Drugs 18: 2, 97-105.

Cohen, J.S. (2000)Sildenafil and non-nitrate antihypertensive medications (letter). Journal of the American Medical Association 283: 2, 201-202.

Cummings, M.H., Meeking, D., Warburton, F., Alexander W.D. (1997)The diabetic male's perception of erectile dysfunction. Practical Diabetes International 14: 4, 100-102.

Dinsmore, W., Evans, C. (1999)ABC of sexual health: erectile dysfunction. British Medical Journal 318: 387.

Department of Health. (2000)National Service Framework for Cardiac Rehabilitation. London: The Stationery Office.

Drory, Y., Filsman, E.Z., Shapiro, Y., Pines, A. (1996)Ventricular arrhythmias during sexual activity in patients with coronary artery disease. Chest 109: 922-924.

Duckworth, K. (1997)Running an erectile dysfunction clinic Professional Nurse 12: 11, 775-778.

Feldman, H.A., Goldstein, I., Hatzichristou, D.G. et al. (1994)Impotence and its medical and psychological correlates: results of the Massachusetts male ageing study. Journal of Urology 151: 54-61.

Friedman, S. (2000)Cardiac disease, anxiety and sexual functioning. American Journal of Cardiology 86: (suppl), 46F-50F.

Goldstein, I. (2000a)The mutually reinforcing triad of depressive symptoms cardiovascular disease and erectile dysfunction. American Journal of Cardiology 86: (suppl), 41F-45F.

Goldstein, I. (2000b)Treatment and pharmacotherapy for erectile dysfunction. Available at:

Intili, H., Nier, D. (1998)Self-esteem and depression in men who present with erectile dysfunction. Urologic Nursing 18: 3, 185-187.

Khaw, K.T., Barret-Connor, E. (1988)Blood pressure and endogenous testosterone in men: an inverse relationship Journal of Hypertension 6: 4, 329-332.

Kirby, R.S. (1994)Impotence: diagnosis and management of male erectile dysfunction. British Medical Journal 308: 957-961.

Kloner, R.A. (2000)Cardiovascular risk and sildenafil. American Journal of Cardiology 86: (suppl), 57F-61F.

Levine, L.A., Kloner, R.A. (2000)Importance of asking questions about erectile dysfunction. American Journal of Cardiology 86: 1210-1213.

Muller, J.E. (2000)Triggering of cardiac events by sexual activity: findings from a case crossover analysis. American Journal of Cardiology 86: (suppl), 14F-18F.

Ralph, D., McNicholas, T. (2000)UK management guidelines for erectile dysfunction. British Medical Journal 321: 499-503.

Rampin, O., Giuliano, F., (2000)Central control of the cardiovascular and erection systems: possible mechanisms and interactions. American Journal of Cardiology 86: (suppl), 19F-22F.

Roose, S.P., Seidman, S.N. (2000)Sexual activity and cardiac risk: is depression a contributing factor? American Journal of Cardiology 86: (suppl), 38F-40F.

Shakir, S.A., Wilton, L.V., Boshier, A. et al. (2001)Cardiovascular events in users of sildenafil: results from first phase of prescription event monitoring in England. British Medical Journal 322: 651-652.

Stein, R.A. (2000)Cardiovascular response to sexual activity. American Journal of Cardiology 86: (suppl), 27F-29F.

Virag, R., Bouilly, P., Frydman, D. (1985)Is impotence an arterial disorder? Lancet I: 181.

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