Management Erectile Dysfunction 2018.ppt

The presentation outlines the nursing management of a client with erectile dysfunction

1. Erectile Dysfunction
GPR teaching
January 2017

2. Case study
53 year old gentleman presents with impotence.
What do you do?

3. Background to ED
How common:
-1 in 5(8% <40years and 56% >70years)
How often treated:
-10% only: Rx 78% success rates
Remember to ask all pts with diabetes, CVD, medications etc.
Predictor of CVD:
-Often presents 3-5 years prior to onset of CVD
“the penis is the barometer of the cardiovascular system”

4. History: What do you need to cover?
Discuss in pairs
Then write summary list on board

5. Cause:
80% organic component but most combination
Features suggestive of psychogenic factors:
sudden onset
early collapse of erection
good quality or “better” spontaneous, self stimulated or waking erections
premature ejaculation or inability to ejaculate
problems or changes in relationship
major life events
psychological problems
Features suggestive of organic cause:
gradual onset
normal ejaculation
normal sex drive (except hypogonadal men)
risk factor in medical history (especially CVS, endocrine and neurological)
operations, radiotherapy or trauma to pelvis or scrotum
current drug recognised to be linked with erectile dysfunction
smoking, high alcohol consumption, use of recreational or body building drugs

6. History: What do you need to cover?
Clarify history: acute/slow onset, libido (and partner),
EMEs, other partners, etc.
Depression
Endocrine changes: hair growth, small testes
Medical history:
neurological/endocrine/cardiovascular/DM
Medications: Next slide
Alcohol/smoking/other drugs

8. Examination?
Make personal lists
Discuss as a group

9. Examination
blood pressure and ?CV system
?examination of genitalia: Guidelines
recommend:
to include checking for abnormalities in testicular
size, fibrosis in shaft of penis, and retractable
foreskin

10. Investigations?
Make personal lists
Discuss as a group

11. Investigations:
Exclude diabetes: HbA1c, urinalysis
Lipids, (FBC, LFTs, TFTs if indicated)
Testosterone – 8-11am sample
>12 normal; 8-12 borderline; <8 low

12. Testosterone deficiency
What will you do if the result is low?
1.Repeat with FSH/LH/PRL (consider referral for MRI
pituitary if under 5)
2.Offer treatment if low/borderline
3.Prior to treatment check DRE and PSA
4.Offer gel (daily) or injections (6w then 3mly)
5.Assess success at 3m and monitor PSA/FBC
Possible CV benefits of treating, but ?possible risks

13. Treatment of ED: What would you offer?
And what would you tell the patient?
Discuss in pairs

14. Treatment: What would you offer?
1. Psychosexual counselling
Based on reducing anxiety and increasing confidence.
Over 50% effective IF motivated. Availability?
2. PDE5 Inhibitors:
Drug Speed of onset of action Duration of action
Sildenafil (Viagra) 30 to 40 minutes 4 hours
Vardenafil (Levitra) 20 minutes 4 hours
Tadalafil (Cialis) 30 to 40 minutes 24 to 36 hours
3. Other options

15. PDE5 Inhibitors
Effective: 50-90%
Cost consideration? (next slide)
Side-effects: headaches, flushing, dyspepsia
Safe in CVD except if on nitrates inc GTN or MI in last
month
Consider trial (50mg then higher/lower dose)
Sometimes only one packet is needed…
Timing: 1 hr before (or tadalafil can also be used daily
if needed at least twice weekly…)

16. NHS prescribable for…
DM, MS, PD, polio, prostate Ca, severe pelvic or spinal
cord injury, spina bifida.
Dialysis for renal failure
PHx: Radical pelvic surgery, prostatectomy (inc
TURP), kidney transplant
Receiving ED Rx on NHS prior to September 1996
Severe distress!? (specialists only)
“significant disruption to activities or marked effect on mood or relationships”!Irrelevant

17. Other treatment options:
 Vacuum device – 1
st
line option?!
?80% effective, low side-effects BUT cumbersome and uncomfortable
 Transurethral alprostadil – 2
nd
line:
Medicated urethral system for erection (MUSE)
2/3 effective, uncomfortable, requires dexterity
NEW: Alpostadil cream to apply on tip of penis
“Intracavernosal, intraurethral or topical application of alprostadil is recommended as
second-line therapy under careful medical supervision”
 Intracavernosal alprostadil injection – 2
nd
line
2/3 effective, fast onset, recovery of spontaneous erections in some BUT
invasive, pain, fibrosis, requires dexterity
 Prosthesis – 3
rd
line
High effective rates and long term results but invasive, sepsis and other
complications, cosmetic.
 Evidence for Ginseng and Yohimbine…

18. When to refer:
young patients who have always had erectile difficulty
patients with a history of trauma
patients in whom an abnormality of the testes or penis
is found on examination
patients in whom the initial screening tests have
indicated an important abnormality

19. Useful reference
British Society for Sexual Medicine Guidelines on the Management of
Erectile Dysfunction
Geoff Hackett et al
The Journal of Sexual Medicine
Volume 5, Issue 8, pages 1841–1865, August 2008