Breaking the silence: helping men with erectile dysfunction

CARE OF THE OLDER PERSON 

Breaking the silence: 

helping men with erectile dysfunction 

Ian Peate 

Ian Peate is Professor of Nursing and Independent Consultant 

Erectüe dysfunction does not discriminate and, 

while prevalence increases with advancing age, 

men of all ages, ethnic and socioeconomic groups 

may, at some point in their Uves, experience some form of 

erectile dysfunction. 

Erectile dysfunction is one aspect on a spectrum of sexual 

dysfunctions men may experience.The role and function of 

the community nurse is wide and varied, and, as such, it is 

Ukely that he or she will be required to care for men who 

have a problem with the ability to inidate and sustain an 

erection for sexual activity. The community nurse, working 

with various populations, can provide increased awareness 

and understanding of the condition to patients and partners, 

the media and other interested parties. 

Sexual health 

Sex is an important part of Hfe and relationships, and all people 

have a right to enjoy a fiilfilling sexual life; good sexual 

health (sexual health fi-ee fiom disease) is one way in which 

people achieve this right. Just as health means different things 

to different people, so too does sexual health. It is important 

to work towards a definidon of sexual health in order to 

provide care in a consistent and effecdve way to those who 

may have problems with their sexual health. 

Sexual health, according to theWorld Health Organization 

(WHO, 2002), can be described as: 

'A state of physical, mental and social well-being 

in relation to sexuality. It requires a positive 

ABSTRACT 

Erectile dysfunction is a condition that is often under-reported. This article 

provides the community nurse with a brief overview of erectile dysfunction 

in the context of sexual health and its importance to wellbeing. The article 

outlines issues concerning epidemiology, the possible causes of erectile 

dysfunction and the impact the condition can have on the man's quality 

of life. Often men with erectile dysfunction report being stigmatised, 

feeling shame and experiencing guilt. The role of the community nurse 

in assessing, making a diagnosis and helping the man with the condition 

is described. The article emphasises the fact that in order to offer care 

effectively and competently the community nurse must be up to date and 

knowledgeable concerning the condition. 

I 

KEYWORDS 

Sexual health • Assessment •- Cardiovascular disease 

Email: iati@ianpeatc.com 

and respectful approach to sexuality and sexual 

relationships, as well as the possibility of having 

pleasurable and safe sexual experiences, free of 

coercion, discrimination and violence.' 

The Royal College of Nursing (RCN) provides a similar 

definition, suggesdng that sexual health is: 

'The physical, emotional, psychological, social and 

cultural well being of a person's sexual identity, 

and the capacity and freedom to enjoy and express 

sexuality without exploitation, oppression, physical 

or emotional harm.' (RCN, 2000) 

Both definitions address sexual health as being holistic 

in nature, i.e. encompassing the bio-psychosocial aspects 

of the person and how sexual health is associated with the 

individual and society. For one person, being free from 

a sexually transmitted infection (STI) might mean good 

sexual health, while for another being in a secure and comfortable 

relationship with another person(s) might mean 

good sexual health for them. 

Irrespective of how the man expresses his own personal 

sexual health, the community nurse should strive to offer 

him care that is supportive and responsive to his expressed 

needs and concerns. The Nursing and Midwifery Council 

(NMC) requires that all nurses treat people as individuals 

and respect their dignity (NMC, 2008). Nurses must not 

discriminate in any way against those in their care; their 

role is encapsulated by treating people kindly and considerately, 

helping people to access relevant health and socialcare 

information, and providing them with the support that 

they may need. 

Normal erectile function 

Erection can occur throughout Ufe. The mechanisms associated 

with achieving and maintaining an erecdon sufficient 

for sexual activity are complex and involve a variety of 

integrated actions. An interacdon of neural, vascular, and biochemical 

activity results in normal erectile function. Sexual 

arousal occurs through physical and psychological stimuladon, 

for example, sight, touch, smell and thought, sdmulating 

the parasympathedc nervous system (see Figure 1). Figure 2 

considers the cellular perspective of the erection pathway. 

Two chambers in the penis, the corpus cavernosa, contain 

sinusoids: these fiH with blood and enlarge to become rigid 

when smooth muscle is relaxed. Blood flow out of the penis 

is momentarily stopped (veno-occlusion) to maintain the 

310 British Journal of Community Nursing Vol 17, No 7

CARE OFTHE OLDER PERSON 

4. Rigid erecdon 

5. Detumescent 

The significant biochemical event in erectue fiancdon is an 

increase in the amount of cyclic guanosine monophosphate; 

this causes smooth-muscle relaxation and permits an erection 

to occur. This process is mediated hy nitric oxide, produced 

by neurons and elsewhere, acting as a gaseous messenger 

molecule. 

Figure 7. The penis 

Corpus cavemosum 

erection. Neural control is complex; in general, the sympathetic 

nervous system inhibits, and the parasympathetic 

system excites erectue function. The central nervous system 

can induce erections without peripheral stimuK, e.g. in nocturnal 

erections. There are five phases associated with erectile 

response: 

1. Latent 

2. Tumescent 

3. FuU erection 

Erectile dysfunction 

Erectile dysfuncdon is defined as 'inability to achieve or 

maintain a penile erection sufficient for sadsfactory sexual 

performance' (NIH Consensus Conference on Impotence, 

1993). Three events are required to take place for the erection 

to occur and to be maintained: 

• First is sexual arousal 

• Second is the brain's communication ofthe sexual arousal 

to the nervous system (activating blood flow) 

• Thirdly, relaxation of the blood vessels that supply blood 

to the penis must occur, allowing the erection. 

If anything occurs that affects any of the three events 

above — arousal, nervous system response or the vascular 

system response — or the interplay between them, then the 

consequence can be erectile dysfunction. Erectile dysflinction 

should not he confused with other sexual dysfunction 

conditions, such as loss of libido or premature ejaculation. 

Causes of erectile dysfunction 

Given the complexities associated with erection, it is not 

surprising that a variety of diverse conditions can result in 

Smooth - muscle 

realaxation (erection) 

Figure 2. The 

erection at 

cellular level 



Psychogenic causes 

• Anxiety 

• Stress 

• Guilt about sex (arising 

from religion, family, 

culture) 

• Fatigue 

• Relationship problems 

(associated with power, 

trust, intimacy) 

• Feelings about partner 

(influences sexual 

response) 

• Depression 

• Sexual situation, where 

the act takes place, time, 

choice of person 

• Anxiety about performance, 

size 

uses of erectile dysfunction 

' Physical and non-physical 

causes of erectile dysfunction 

can and do interact 

'Too much alcohol,for 

example, may alter sexual 

response, resulting in 

anxiety about attaining an 

erection 

' Anxiety worsens erectile 

dysfunction 

Physical causes - 

•Vascular conditions 

• Neurological conditions 

•Alcohol 

• Medications (for example, major tranquillisers, 

antidepressants, endocrine drugs, antihypertensives, 

cimetidine, digoxin, metoclopramide, 

phenytoin, carbamazepine) 

• Diabetes mellitus 

• Abnormal nerve function 

• Hormone disorders 

• Prostatectomy 

• Pelvic/abdominal surgical procedures 

• Radiotherapy 

• Peyronie's disease 

• Recreational drug use 

• Smoking and diet (as contributing factors) 

Source: Adapted from Carson and Dean, 2007; Rané and Fraser, 2007; Carson and McMahon, 2008 

erectile disorders. Eardley (2002) suggests that there are a 

number of ways of classifying the pathophysiological causes 

of erectile dysfunction: 

• Vascular 

• Neurogenic 

• Endocrinological 

• Psychogenic 

• Cellular 

• Iatriogenic. 

Table 1 outlines some of the causes of erectile dysfunction. 

Often there may be more than one cause present 

at the same time. The role of the community nurse is to 

undertake a holistic assessment with the aim of making a 

diagnosis and offering the man treatment and support. 

Epidemiology 

There have been a number of large epidemiological studies 

carried out globally that demonstrate a high prevalence and 

incidence of erectile dysfunction. The Massachusetts Male 

Aging Study (MMAS) (the most often cited study) conducted 

in 1994 reveals the prevalence of erectile dysfunction to 

be 52% in non-institutionalised men aged 40—70 years, in the 

Boston area; 17.2%, 25.2% and 9.6% for minimal, moderate 

and complete erectile dysñmction, respectively (Feldman et 

al, 1994). A study undertaken in the UK of men aged 18-75 

showed a rate of 39% for Hfetime erectile dysfunction, with 

a current prevalence of 26% (Dunn et al, 1998). In these 

studies there is an age-related increase in erectile dysflmcdon. 

Making a diagnosis of erectile 


The NMC (2004) requires all specialist community public 

health nurses to collect and structure data and information 

on the health and weUbeing and related needs of a defined 

population.The nurse has to be able to analyse, interpret and 

communicate data and information with the aim of improving 

health and social weUbeing: this also applies to the health 

and weUbeing of men. One aspect of the community nurse's 

role is to undertake a range of screening activities (NMC, 

2004), for example, screening patients for undiagnosed 

cardiovascular disease. Part of this activity is to undertake a 

detailed health-care assessment, which would also include an 

assessment of the man's sexual function. An in-depth physical 

and psychological assessment is required in order to make 

an accurate diagnosis. FuU physical, psychological and sexual 

health histories are prerequisites. 

The nurse should obtain a detailed description of the 

problem, including the duration of symptoms as weU as the 

original cause(s) of the problem (see Table 1). The British 

Society of Sexual Medicine (BSSM) (2008) suggests that 

other factors that should be identified and recorded will 

include: ' .•.'_;! _. f«ii?. ''h: 

• Any subsequent investigations 

• Treatment interventions along with the response achieved 

• An expression of tumescence and rigidity with quality of 

morning awakening erections, and spontaneous, masturbatory 

or partner-related activity erections 

• Sexual desire, ejaculatory and orgasmic dysfunction 

• Previous erectile capacity 

• Issues around any sexual aversion or sexual pain 

• Partner issues e.g. menopause or vaginal pain. 

The detailed assessment requires the nurse to encourage 

the man, in a respectful and sensitive manner, to clarify any 

problems he may have related to his sexual function. Other 

considerations that the nurse needs to think about when 

making a diagnosis are those factors related to precipitation, 

predisposing and maintenance factors (BSSM, 2008) (see 

Table 2). 

Any coexisting medical, psychiatric and surgical history 

should also be recorded, as well as the man's current rela- 



Table 2. Some factors to consider when rnaking a diagnosis 

Precipitation 

• Lack of sexual knowledge 

• Negative previous sexual 

experience(s) 

• Relafionship problems 

• Religious or cultural beliefs 

• Restrictive upbringing 

^_____ 

• Confusion concerning sexual or 

gender preference 

• Sexual abuse 

• Physical or mental healfh problems 

• Ofher sexual problems in fhe man 

or his partner 

• Use of drugs 

Predisposing 

• New relationship 

• Acufe relafionship problems 

• Family or social pressures 

• Pregnancy and childbirth 

• Other major life events 

• Partner's menopause 

• Acute physical or mental health 

problems 

• Lack of knowledge concerning the 

usual changes of ageing 

• Ofher sexual problems in the man 



'ource: Adapted from Carson and Dean, 2007; : BSSM, 2008; Carson and McMahon, 2008 

Maintenance 

' Problems with relationship(s) 

• Poor communication between 

partners 

' Knowledge deficit concerning 

treatment options 

• Long term physical or mental 

health problems 

' Ofher sexual problems in the man 



tionship status (single, married, in a long-term relationship); 

a history of previous sexual partners and relationships will 

also he required. Sexual orientation and gender identity 

should also be noted. The nurse must also ask the patient 

ahout alcohol, smoking and illicit drug use. 

Validated questionnaires are available that will help the 

nurse to make the consultation more objective: for example, 

the International Index of Erectile Function (IIEF) 

(Rosen et al, 1997) or the validated shorter version ofthe 

SHIM (Sexual Health Inventory for Men) (Cappelleri and 

Rosen, 2005) help to assess sexual function, and also the 

impact of treatments and interventions. These tools are only 

an adjunct to a detailed history and physical examination, 

however, they do not replace them. 

According to the BSSM (2008), erectile dysfuncdon and 

coronary heart disease have the same risk factors. It is important 

to note that coronary artery disease is frequently only 

one of the affected sites in a generalised arteriopathy that 

has the ability to impact on arterial blood inflow to the corpora 

cavernosum.The penile arteries are substantially smaller 

than the main coronary arteries, and erectile dysfunction 

frequently pre-dates coronary artery disease (Montorsi et al, 

2004), hence the need for the nurse to approach the assessment 

of the patient fi-om a hoUsdc perspective. 

Physical examination 

There is controversy concerning the need to perform a 

physical examination ofthe genitalia. The physical examination 

should focus on secondary sexual characteristics, an 

abdominal examination, major pulse examination, S2—4 

neurological assessment and external genitalia examination. 

This type of examination should be undertaken by a specialist 

skilled practitioner. The history gained from the man 

will direct the nurse to determine if a physical examination 

is required (see Table 3). 

The BSSM (2008) suggests that all patients should have a 

focused physical examination and a genital examination is 

recommended; this is essential if there is a history of rapid 

onset of pain, deviation ofthe penis during tumescence, the 

symptoms of hypogonadism or other current or past urological 

symptoms. If the nurse suspects Peyronie's disease 

this would merit assessment of the peripheral vasculature 

(Rané and Fraser, 2007). It is not obligatory to perform a 

digital rectal examination; however, this should be considered 

if there is evidence of genito-urinary or protracted 

secondary ejaculatory symptoms (Carson and McMahon, 

2008). Blood pressure, heart rate, waist circumference and 

weight should be measured. 

Other investigations may be indicated and are tailored 

to the needs of the patient after an in-depth assessment 

Table 3. Individual examination and assessment 

Assess general appearance. 

Are there signs of 

other illnesses: 

Assess secondary sexual 

characteristics: 

Assess genitalia: 

Assess physical parameters. 

Measure: 

• Depression 

•Thyroid problems 

• Parkinson's disease 

• Distribution of body hair (facial, pubic, 

body) 

• Muscle development 

• Distribution of body fat 

• Observe, palpate and examine penile 

shaft, foreskin (if present) 

• Any evidence of swelling, lumps, tenderness 

• Any evidence of sexually transmitted 

infection 

• Inspect and palpate scrotal sac and 

contents (what size are the testes developmentally) 

• Blood pressure 

• Heart rate 

•Waist circumference 

•Weight 

Source: Adapted from Carson and Dean, 2007; BSSM, 2008 

British Journal of Community Nursing Vol 17, No 7 315


has taken place, as weU as in response to the wishes of the 

patient. Carson and Dean (2007) have suggested that the 

foUowing should be performed for all men with erectue 

dysfunction, accompanied by a detailed cardiovascular 

assessment that includes: 

• Fasting glucose 

• Urinalysis for glucose 

• Total HDL and cholesterol and triglycérides 

• Total testosterone, sex hormone binding globulin and 

albumen 

• Prolactin 

• Prostate specific antigen 

Carson and McMahon (2008) suggest that in addition to 

the above, the foUowing specialist clinical investigations may 

be required: 

• Nocturnal penile tumescence rigidity testing 

• Colour Doppler imaging 

• Pharmacocavernosography 

• Pharmacoarteriography 

• Psychiatric evaluation 

• Vascular evaluation 

• Cardiac evaluation. 

Treatment and nursing care 

Eardley (2002) noted that, in the general population, the 

most common causes of erectUe dysfunction are vascular, 

with increasing evidence that the risk factors for atherosclerosis, 

specificaUy hypertension, smoking, hyperlipidaemia and 

diabetes, are aU associated with erectue dysfunction.There are 

two key consequences: 

Figure 3. Intercavernosal injection therapy 

1. Control of these risk factors would help to reduce the 

risk of erectile dysfunction 

2. When a man presents with erectile dysfunction the 

nurse must identify these risk factors, not only with the 

intention of improving the erectile dysfunction, but to also 

aim to prevent future cardiovascular sequelae. 

As weU as helping men with problems associated with the 

physical and psychological impact of erectile dysfunction, the 

nurse must also ensure that measures are put in place to deal 

with the potential cardiovascular consequences. 

Erectile dysfunction can have a significant impact on a 

man, his partner(s) and their relationships, ofi:en resulting 

in a reduction in self-esteem and poor quality of life. Men 

report feeling guilty and experiencing a sense of shame 

Table 4. Treatment ODtions 

^ Treatment option 

First line 

Second line 

Third line 

Description 

• Provision of education that reinforces sexual function, sexual responsiveness, sexual 

satisfaction and sexuality 

• Debunking of myths 

• Promotion of sex and the older person and intimacy 

• Consider referral to sexual and relationship therapist (psychosexual therapy) 

• Advice should be provided about lifestyle issues such as the harmful effects of cigarette 

smoking, use of alcohol and illicit drugs and the benefits of exercise 

• Depression and dyslipldemias if present should be addressed and corrected 

• Review and revision of current medications may be needed 

• Other therapeutic options may be indicated if there is evidence of other underlying 

pathology such as hypertension and coronary heart disease or poorly controlled diabetes 

• Administration of oral therapies such as sildenafil, tadalafil, vardenafil and sublingual 

apomorphine as required 

• Use of a vacuum tumescence device with a constriction ring 

• Administration of oral therapies such as sildenafil, tadalafil, vardenafil and sublingual 

apomorphine on a daily basis 

• Administration of intracavernosal injections such as alprostadil (see Figure 5) 

•Administration oftransurethral pellets, such as alprostadil 

• Penile implant surgery 

Source: BSSM, 2008; Carson and McMahon, 2008 

•Vascular reconstructive surgery 



(Engender Health, 2003), and the stigma associated with 

erectile dysfunction can cause the man to withdraw from 

intimacy. In some cases all forms of physical contact can 

become non-existent, resulting in emotional distress, causing 

stress and adding to the psychogenic component associated 

with erectile dysfunction. Treatment has the potential 

to resolve depression and improve the man's self esteem and 

overall quality of life and sense of weDbeing (Carson and 

McMahon, 2008). 

Currently, practitioners working in the primary care 

setting implement the guidance issued by the Department 

of Health (DH), in a number of Health Service Circulars 

(DH, 1999a; 1999b; 1999c), to determine the management 

and treatment of men with erectile dysfiinction.The circulars 

provide the community nurse with guidance on good 

practice for those men who qualify for treatment within 

the NHS. Further guidelines have heen produced hy the 

BSSM (2008); this guidance, while still adhering to the 

current DH circulars, is underpinned hy a more up-to-date 

evidence base. 

Regardless of the treatment plan chosen, the nurse has 

a duty to provide the man and (if appropriate) his partner 

with appropriate and adequate informadon to help 

him understand the reasons why erectile dysfiinction has 

occurred. Explaining to the man how his problem compares 

with the general population may help him feel less 

stigmatised, and debunking any myths associated with 

erectile dysfunction can provide an opportunity for him 

and his partner to understand each other's sexual needs and 

their sexuality and to chose the most appropriate treatment. 

There are a number of treatment options available for 

erectile dysfunction, and inany of these have been developed 

and revised over time, becoming more effective. 

Carson and McMahon (2008) consider treatment options 

from psychogenic and organic perspectives. The choice of 

treatment will depend on several factors, such as patient 

(and, if appropriate, partner) preference, severity of erectile 

dysfunction and the underlying cause. Rané and Fraser 

(2007) recommend a 'step ladder' approach to treatment, 

progressing from non-invasive talking therapies and drug 

therapies, to minimally invasive injection therapy {Figure 3) 

and vacuum devices, to invasive prosthetic surgery. Table 4 

provides an overview of treatment options. 

In order to help the patient chose the right treatment 

option, the nurse must have an up-to-date and in-depth 

knowledge base. Not all treatment opdons will suit all men, 

and they all have side-effects and contraindications. There 

is no 'one size fits all' approach: each man must be assessed 

and treated as an individual. The information and advice 

that the nurse offers should he provided in such a way that 

the man understands the options, the advantages and drawhacks, 

with the intention of making an informed choice. 

Conclusion 

Erectile dysfunction can have devastating effects on individuals. 

Men report feelings of guilt and shame, and experience 

stigma associated with this condition that can lower 

self esteem and impact negatively on the person's sense of 

wellbeing. Community nurses are ideally placed to help 

men and, if appropriate, their partner(s) to come to terms 

with the condition and to select the most appropriate 

treatment option. In order to provide this information it 

is essential that the nurse is knowledgeable and up-to-date 

with contemporary approaches to the care and management 

of men with erectile dysfunction. 

BJCN 

Acknowledgements: I would like to thank Mrs Frances Cohen for 

her help and support. 

British Society for Sexual Medicine (2008) British Society for Sexual Medicine 

Guidelines on the Management of Erectue Dysfuncdon. J Sex Med 5(8): 

1841-^5 

Cappelleri JC, Rosen RC (2005) The Sexual Health Inventory for Men (SHIM): 

A 5-year Review of Research and Clinical Experience. Ini j hnpoc Res 17: 

307-19 

Carson CC, Dean JD (2007) Management of Erectile Dysfunction in Clinical Practice. 

Springer, London 

Carson CC, McMahon CG (2008) Erectile Dysfunction. 4th Edn. Health Press, 

Abingdon 

Department of Health (1999a) Health Service Circular/115. DH, London 

Department of Health (1999b) Health Service Circular/148. DH, London 

Department of Health (1999c) Heahh Service Circular HSC/U?. DH, London 

Dunn KM, Croft PR, Hackett GI (1998) Sexual Problems: A Study of the 

Prevalence and Need for Health Care in the General Population. Fam Pract 

15(6): 519-24 

Eardley I (2002) Pathophysiology of erectile dysfunction. BrJ Diabetes Vase Dis 

2(4): 272-6 

Engender Health (2003) Men's Reproductive Health Curriculum. 3: 

Management of Men's Reproductive Health Problems. http://tinyurl.coni/ 

dxx7x37 (Accessed 27 June 2012) 

Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB (1994) 

Impotence and its medical and psychosocial correlates: results of the 

Massachusetts Male Aging Study.J tjrol 151(1): 54-61 

Montorsi P, Ravagnani PM, Galli S et al (2004) Common grounds for erectile 

dysfunction and coronary artery disease. Curr Opin Urot 14(6): 361-5 

NIH Consensus Conference on Impotence (1993) NIH Consensus Development 

Panel on Impotence.J^Ai/1 270(1): 83-90 

Nursing and Midwifery Council (2004) Standards of Proficiency for Specialist 

Community Public Health Nurses. NMC, London 

Nursing and Midwifery Council (2008) The Code: Standards of Conduct, 

Performance and Ethics for Nurses and Midwives. NMC, London 

Rané A, Fraser M (2007) Erectile Dysfunction Digest. Merit Publishing 

International, West Palm Beach, Florida 

Rosen RC.Riley A, Wagner G, Osterloh IH, KirkpatnckJ, Mishra A (1997) The 

International Index of Erectile Function (IIEF):A multidimensional scale for 

assessment of erectile dysfunction. Urology 49(6): 822-30 

Royal College of Nursing (2000) Sexuality and Sexual Health in Nursing Practice. 

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World Health Organisation (2002) Gender and Human Rights - Sexual Heahh. 

WHO. Geneva 

LEARNING POINTS 

• Sex is an important aspect of many people's lives 

• Our understanding of erectile dysfunction continues to develop 

• The community nurse is ideally placed to help men (and their partners) 

who experience the physical and psychological impact erectile 

dysfunction can have on their lives and wellbeing 

• Any condition that damages endothelial function can result in erectile 


• Some men with erectile dysfunction will also have coexisting conditions 

such as hypertension, hyperlipidaemia, diabetes and depression 

British Journal of Community Nursing Vol 17, No 7 317

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