Breaking the silence: helping men with erectile dysfunction

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CARE OFTHE OLDER PERSON 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 or his partner • Use of drugs '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 or his partner • Use of drugs 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
CARE OF THE OLDER PERSON 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 316 British Journal of Community Nursing Vol 17, No 7
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