Erectile dysfunction (ED) is a more common occurrence than most people think. Defined as the inability to get and maintain an erection that is sufficient for satisfactory sexual intercourse, ED is experienced at least once by about half of men between the ages of 40 and 70 years.
So what actually causes ED?
Numerous factors may contribute, but there are four main types of physical condition that can result in ED:
-Vasculogenic conditions (eg, atherosclerosis, high blood pressure, diabetes and high cholesterol)
-Neurogenic conditions (such as multiple sclerosis, Parkinson’s disease or stroke)
-Hormonal conditions (including hypogonadism and hypo- or hyperthyroidism)
-Anatomical conditions (including Peyronie’s disease [a condition affecting the tissue of the penis], and hypospadias [abnormal development of the urethra])
-Psychological factors can also contribute to ED. These include anxiety, depression and emotional problems, ranging from a lack of sexual knowledge to a history of sexual abuse. ED itself can cause anxiety and this can worsens symptoms so the problem can multiply after an initial occurrence.
There is a small risk of an initial occurrence of ED causing long-term psychological problems.
There are also more trivial and short-term causes, such a tiredness, excessive alcohol intake or the use of recreational drugs. And, of course, some medicines can cause ED, including antihypertensives (eg, enalapril) and antidepressants (eg, fluoxetine).
Why is it important?
Talking about ED is important because the problem can have far reaching consequences. Aside from the possibility that underlying health conditions remain undiagnosed, ED can create issues with self-esteem and heightened anxiety around sexual activity. This, in turn, can affect relationships. Sometimes men who are reluctant to share or acknowledge the problem avoid having a sexual relationship with their partner, resulting in frustration and confusion. So it is important that men address their problem with both their doctor or pharmacist and with their partner, as soon as possible — the earlier the problem is identified and treated, the less likely it is to damage the relationship. Early management can also be useful in stopping the development of heightened anxiety.
Dealing with patients affected by ED
When talking to someone about ED, the best approach is one of discretion and understanding. You can often determine from a person’s demeanour, whether or not he is embarrassed. Some men will display a certain level of bravado over the issue so it can be difficult to assess how serious the problem is, although I have found that discussing sensitive matters and getting the information that is needed is often easier with such patients.
Other men will be a lot more cautious about broaching the subject, and it is important to reassure them from the outset, that ED is a common problem — more common than they think — because this removes some of the embarrassment of discussing it. Telling them that there may be underlying health reasons for the problem can encourage them to be more forthcoming with details.
It is also important to go through the possible causes of ED. Although some men may be unwilling to discuss exact details of their problem, if they are armed with the knowledge that it may disappear if they make certain lifestyle changes or treat an underlying condition, it can make the difference between them seeking further advice and treatment, or not. The following advice, where appropriate, can help, as well as promoting general good health:
– Lose weight
– Give up smoking
– Take regular exercise
– Cut down on alcohol consumption
– Do not use illegal drugs
– To establish what might be causing ED, a simple question I find useful is: is the ED circumstantial or is it always a problem?
If ED occurs all the time, the causes are likely to be physical, but if it happens only now and again, psychological reasons are likely to blame. I provide treatments for ED from my pharmacy under a patient group direction but if ED has lasted more than a few weeks, GP referral is necessary.
Suspected underlying health conditions need investigation. For example, GPs will conduct physical examinations and may order thyroid function tests. Any underlying conditions should treated first because this may resolve the problem.
Although ED can be distressing, it is often simple to treat. The availability of phoshodiesterase type 5 inhibitors — sildenafil (viagra), tadalafil (cialis) and vardenafil (levitra) — has led to a decline in the use of the more invasive alprostadil products (ie, Caverject injection and Muse intraurethral pellets).
An erection is achieved through the release of nitric oxide in the corpus cavernosum of the penis. This binds to guanylate cyclase receptors, resulting in increased levels of cyclic guanosine monophosphate and causing smooth muscle relaxation. This leads to vasodilation and increased blood flow into the spongy tissue of the penis, allowing an erection once the man is aroused. PDE5 breaks down cGMP and in men with ED it is broken down too quickly to achieve an erection. Inhibition of the PDE5 enzyme allows sufficient levels of cGMP to be maintained for an erection. The three available PDE5 inhibitors are compared in the Panel.
The most common side effect caused by this group of drugs is a headache, with up to one in 10 being affected. Other common side effects include hot flushes, indigestion, blocked, or runny nose, back pain and temporary disturbances of colour vision. There are few serious side effects, but men should be made aware of them and that they must seek help should they occur. These include loss of vision or hearing, chest pain with nausea and discomfort, and a continuous painful erection lasting four hours or more.
In my practice, I have found treatment is particularly successful in cases where just one episode of ED has had a follow on psychological impact. Treatment is short-term, providing a confidence boost.
Regardless of whether or not pharmacists choose to provide treatments under a PGD, they should be prepared to talk about ED. They should be able to answer frequently asked questions, such as:
How do medicines for ED work and will they be suitable for me?
Will I always need to take these medicines?
What can I tell my partner?
And when they cannot provide the answers, pharmacists can play a useful role in signposting men (and couples) to helpful support organisations such as Relate (www.relate.org.uk) and the Men’s Health Forum (www.menshealthforum.org.uk).
Learning on “Dealing with difficult discussions” is available from the Centre for Pharmacy Postgraduate Education.