Urology Nurses Online: ARTICLES

Jeff Albaugh, BSN, RN Patient Care Coordinator, Center for Urology, Northwestern Memorial Hospital
Chicago, IL.

Jean Lewis, BSN, RN, CANP Urology Nurse Practitioner and Coordinator, Erectile Disfunction Clinic, Veterans Affairs Medical Center
Minneapolis, MN.

It is estimated that as many as 30 million men in the United States suffer from erectile dysfunction (ED). Because ED is so widespread, especially among the older population, it is imperative that this disorder be recognized as an important and manageable health problem.

Objectives

This educational activity is designed for nurses and other health care professionals who care for and educate patients and health care workers regarding erectile dysfunction. The multiple choice examination that follows is designed to test your achievement of the following educational objectives. After studying this offering, you will be able to:
1. Describe the urologic condition of erectile dysfunction.
2. Provide support for the client with erectile dysfunction through interview, counseling, and monitoring of treatment.

With the advent of new pharmacologic discoveries for treating erectile dysfunction (ED), the number of men seeking treatment has skyrocketed in the past few years. However, managing the patient with ED presents a unique challenge for todayís health care providers. It is our intention that this continuing education article will further your knowledge of ED management in the hopes of increasing your role and value within your practice setting.
Erectile dysfunction, commonly known as impotence, is defined as the consistent inability to achieve and/or sustain an erection satisfactory for sexual activity (NIH Consensus Development Panel on Impotence, 1993). It is the most common sexual disorder in men. A common, treatable medical condition, ED affects an estimated 30 million men in the United States alone or one in 10 men worldwide (Benet & Melman, 1995). According to one landmark medical study, ED affects about half the men aged 40 to 70 in the United States to some degree (Feldman, Goldstein, Hatzichristou, Krane, & McKinlay, 1994). Yet, data suggest that less than 10% of these men actually receive treatment. Due to the personal nature of the problem, many men choose to suffer in silence making it difficult to attain accurate statistics of men afflicted with ED. More men are experiencing impotence as the baby boomer generation ages. Awareness of ED is increasing with the advent of oral agents, which has increased the number of men seeking help for this problem. According to a report in Newsweek (Leland, 1997), "Each new drug, with its attendant publicity, brings more men into the game. Some urologists expect the number of men seeking treatment to double in the coming years" (p. 64).
Many physicians are not aware of the many treatment options available, so patients have been either under treated or not treated at all. In addition, some health care providers are not comfortable addressing the topic with their patients.

Etiology

There are many causes of ED (see Table 1). Although in the past ED was believed to primarily have a psychologic origin, it has now been shown that the majority of cases (>70%) have a physiologic origin. The physiologic etiology may be vascular, neurogenic, hormonal, mixed etiologies; or related to cavernosal abnormalities, cavernosal or local nerve damage, or drugs.
Blood flow can be impaired by the same factors that cause arterial clogging associated with coronary artery disease. Smoking is a key risk factor as well as high cholesterol diet, arteriosclerosis, congestive heart failure, and diabetes.
Neurologic disease may cause erectile dysfunction. Spinal cord injury can interrupt the sympathetic and parasympathetic pathways that are essential to erectile function. Neurologic dysfunction caused by stroke, multiple sclerosis, head injury, or Parkinsonís disease may also cause ED. Structural deformities (such as peyrones and epispadias) may contribute to ED. An interruption in the nerves related to injury (cycling, horseback riding) or iatrogenic causes (radical prostatectomy, revascularization surgery, renal transplant, pelvic irradiation) may cause ED. Hormone deficiency may account for a small percentage of ED cases. Testosterone, LH, and prolactin levels can be assessed. Certain drugs have been associated with ED (see Table 2) including alcohol, anti-androgens, estrogens, anticholinergics, antidepressants, psychotropics, some antihypertensives (beta blockers, sympatholytics), nicotine, cocaine, histamine 2 receptor blockers, ketoconazole, lipid-lowering agents, marijuana, narcotics, cytotoxic drugs, diuretics, and spironolactone (Greiner & Weigel, 1996).

Anatomy and Physiology

To best understand ED, it is helpful to first understand the anatomy and physiology of a normal erection. Understanding how the normal erection occurs dramatically changed the way ED is treated today. Erections are the result of a neurovascular event triggered by cognitive or tactile stimulation. Psychogenic and hormonal factors play a role in achieving an erection as well (Meredith, 1995).
An erection begins with a tactile or psychogenic stimulus that is processed in the brain. Specifically, the nuclei of the temporal lobe, cingulate gyrus, gyrus rectus of the cerebral cortex, hypothalamus, hippocampus, and mammillary bodies affect the erectile response in animals and humans (Siroky & Krane, 1983). Sympathetic and parasympathetic impulses from the spinal cord contribute to smooth muscle relaxation and the inflow of blood. Chemical mediators are used to cause the essential relaxation of tissue and perfusion of the erectile cylinders. Nitric oxide and its second messenger cyclic guanosine monophosphate (cGMP) are the primary noncholinergic-nonadrenergic and cholinergic mediators for the relaxation of the cavernosal smooth muscle (Boolell, Gepi-Attee, Gingell, & Allen, 1996). The erection occurs because of the engorgement within the corposa cavernosa.
There are three erectile cylinders within the penis (see Figure 1). The corpus spongiosum contains the urethra. The paired cylinders, called the corpora cavernosa, are capable of enlarging as engorgement with arterial blood occurs. The penile artery arises from the pudendal artery and splits into the dorsal, spongiosal, and cavernosal arteries. The deep, superficial, and intermediate veins drain the penis. As the erectile cylinders are engorged they press up against the veins to prevent leakage of blood back into the body. It is by this mechanism that an erection is maintained.
Some normal changes occur in the aging male. As a man matures, his sperm count and the amount of semen will decrease. The ejaculate will no longer be propelled with the same force. Men may experience a delay in reaching climax and an increased refractory period between erections. The rigidity of erections may be slightly decreased along with a decrease in the time an erection can be maintained. However, men should still have sufficient rigidity for penetration.
Potency may be affected by hormone levels. The primary hormone involved is testosterone. Testosterone can influence sexual drive, but it is not well understood how it affects erectile function. The normal serum range is 240 to 850 ng/dl. The pituitary gland produces luteinizing hormone and prolactin. Luteinizing hormone stimulates the testicles to produce testosterone while prolactin blocks the effects of testosterone.

Assessment

A discussion of sexual health should be part of the health assessment. Sexual health is important to overall health. ED may signal serious underlying disease, for example, diabetes, hypertension, coronary artery disease, or peripheral vascular disease.
Clinicians should pay special attention to the sensitivity of the topic and to their patientsí comfort level in discussing sexual problems. The history taking is also an opportunity for the clinician to initiate patient and partner education and to facilitate communication. Outcomes related to this step in the evaluation should include characterization of the presenting problem, assessment of the need for additional testing, and decisions about referral or multidisciplinary involvement (Rosen et al., 1999). When evaluating for ED, during the first encounter between the physician and patient it is helpful if the partner can be present. If the partner is positive about supporting the patientís physical and emotional problems and is involved in the treatment decision, it will greatly affect the success of any interventions. General questions regarding the patientís medical health, diseases that he has experienced in the past, medications, past surgeries, allergies, family history, and health habits are best obtained through a questionnaire which can be given and completed by the patient before his appointment. Specific questions regarding the exact nature of his sexual dysfunction and success with partner/s should ideally be obtained during the direct history taking with the patient and his partner. A thorough explanation of normal aging changes is an important part of the therapeutic process. As a patient ages, his environment takes on a much more important role in success or failure of his erections under certain circumstances. A thorough explanation of all treatment options including cost should be discussed with the patient and his partner if available. Patient needs, expectations, and priorities are an essential element in this assessment, as patients vary greatly in their acceptance of medical treatment for sexual disorders.
Upon performing a physical examination, the genitalia, groin area, and peripheral pulses in the lower extremities should be inspected and assessed. The physical examination should be aimed at detecting signs of vascular, endocrine, neurologic deficit, and penile abnormality. In addition, the blood pressure should be checked and a neurologic evaluation of the genital region performed. The physical examination also provides an excellent opportunity for patient education and reassurance regarding normal genital anatomy. If the patient has not had a recent evaluation, certain basic laboratory studies ruling out concomitant processes which may contribute directly to the ED are certainly in order. The diagnostic workup may vary from region to region or urologist to urologist, but the recommended laboratory testing from the NIH Consensus Panel (1993) includes CBC with differential, fasting blood sugar or Hgb A1C, TSH, prolactin, and a lipid panel. If the patient has a very low or absent sexual drive, serum testosterone, free testosterone, and FSH, may be added. The question arises, in which patients should a serum testosterone level be measured? Testosterone should be measured in a patient who would be a candidate for replacement if the level was low. Excluded from this group would be patients with known prostatic cancer. PSA levels should be drawn following the guidelines of the American Urological Association (1996). More advanced testing, such as duplex ultrasound, rigiscan, dynamic infusion cavernosometry and cavernosography (DICC), or arteriography is done on a case by case basis.
Men experiencing erectile dysfunction often report increasing anxiety, loss of self-esteem, lack of self-confidence, change in quality of life, and tension and difficulty in their relationship with their partner. Instead of seeking treatment, some men resign themselves to the problem, which often leads to feelings of depression, embarrassment, shame, and frustration. Experts agree that good communication is the foundation for an enduring relationship. However, when couples encounter sexual difficulties, communication in the best of relationships can become strained or break down. Partners often feel inadequate and abandoned as the male avoids any situation that may lead to sexual activity. Some may fear they are no longer attractive or that they have done something to create the situation.
Overcoming ED is most successful when a man and his partner openly communicate, continue to demonstrate love and affection, reassure each other that they still care, and have a mutual desire to carry through with the treatment options.
There are various degrees of erectile dysfunction. Mild ED is described as having a successful erection 7 to 8 attempts out of 10, moderate as 4 to 6 attempts out of 10, and severe as 0 to 3 attempts out of 10. Most men experience occasional erectile failure at some time during their lives, especially during times of fatigue, stress, and excessive alcohol use. This is generally not something to worry about. However, when the problem persists or interferes with a manís normal sexual activity, medical advice should be sought.
Some men may see the condition as a natural part of aging. Although the likelihood of ED increases with age ñ39% at age 40, 65% over the age of 65 ñ it is not necessarily a consequence of aging (Feldman et al., 1994). Attitude, not age, is the biggest barrier in treating ED.

Management

Urologists and practitioners interested in treating men with ED and their partners can perform basic counseling regarding aging and environmental influences on sexual functioning. The couple can be counseled on the need for mutual stimulation and keeping the lines of communication open. When serious problems are present, the patient should be referred to a mental health professional or sex therapist.
Part of the treatment process should include patient and partner education, including basic review of the anatomy and physiology of the sexual response, normal aging changes, overview of relevant etiology and associated risk factors, lifestyle factors (for example, smoking, substance abuse), prescription drug effects, description of initial assessment and diagnostic testing results, and review of all treatment options, including potential risks and benefits. It is also a time for clarification of patient and partnerís expectations and treatment needs.
Most health care providers will suggest proceeding from the least invasive to the most invasive treatments if necessary. Step-wise therapy is a proposed treatment algorithm that incorporates a step-wise progression of therapeutic interventions for ED (Rosen et al., 1999). This model is based upon the four essential criteria of ease of administration, reversibility, invasiveness, and cost. Patient and partner preferences should also be strongly considered in all cases. First-line therapies may be used as single interventions or in combination. Second and third-line therapies are generally reserved for those patients who show insufficient response to or adverse effects from one or more first-line therapies.
In light of recent medical advances in treating ED, men no longer need to suffer from erectile dysfunction in silence. Men and their partners can usually be treated safely and effectively. Currently, there are a number of lifestyle changes and treatment options available for men with erectile dysfunction. These options, indications, contraindications, and results will be covered in a continuing education article in the February 2000 issue of Urologic Nursing with a focus on the newer treatment options.

References

American Urological Association Erectile Dysfunction Clinical Guidelines Panel. (1996) The treatment of organic erectile dysfunction: A patientís guide. Baltimore, MD: American Urological Association.

Benet, A.E., & Melman, A. (1995) The epidemiology of erectile dysfunction. Urologic Clinics of North America, 22, 699-709.

Boolell, M., Gepi-Attee, S., Gingell, J.C., & Allen, M.J. (1996) Sildenafil, a novel effective oral therapy for male erectile dysfunction. British Journal of Urology, 78, 257-261.

Feldman, H.A., Goldstein, I., Hatzichristou, D.G., Krane, R.J., & McKinlay, J.B. (1994). Impotence and its medical and psychosocial correlates: Results of the Massachusetts Male Aging Study. Journal of Urology, 151, 54-61.

Greiner, K.A., & Weigel, J.W. (1996). Erectile dysfunction. American Family Urology, 54, 1675-1682.

Meredith, C. (1995). Erectile dysfunction. In K.A. Karlowicz (Ed.), Urologic nursing: Principals and practice (pp. 332-359). Philadelphia: W.B. Saunders.

Leland, J. (1997 November 17.). A pill for impotence? Newsweek.

NIH Consensus Development Panel on Impotence. (1993). Impotence. JAMA, 270, 83-90.

Rosen, R., Goldstein, I., Heiman, J., Korenman, S., Lakin, M., Lue, T., Montague, D., Padma-Nathan, H., Sadovsky, R., Segraves, R.T., & Shabsigh, R. (1999). Process of care model for the evaluation and treatment of erectile dysfunction. New Brunswick, NJ: University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School.

Siroky, M.B., & Krane, R.J. (1983). Neurophysiology of erection. Male sexual dysfunction. Boston: Little, Brown.

Neurogenic
Multiple sclerosis
Peripheral neuropathy
Radical prostatectomy
Spinal cord Injury
Stroke

Vascular
Cardiovascular or peripheral vascular disease
Congestive heart failure
Cigarette smoking
Diabetes mellitus
Trauma to perineum or pelvis

Hormonal
Decreased testosterone, LH, or increased prolactin

Psychogenic
Anxiety
Depression
Stress

Medications
(see Table 2)

Antihypertensives
Beta blockers: propranolol, atenolol
Diuretics: hydrochlorothiazide, amiloride, chlorthalidone, spironolactone
ACE inhibitors: enalapril, lisinopril
Centrally acting agents: clonidine, methyldopa
Peripherally acting agent: guanethidine
Miscellaneous: labetalol, reserpine

Antidepressants
Tricyclics: amoxapine, imipramine, clomipramine
Miscellaneous: bupropion, tranylcypromine, venlafaxine

Other Drugs
Antipsychotics: chlorpromazine, fluphenazine, lithium, thioridazine, sulpiride
Antianxiety: chlordiazepoxide
Antiarrhythmics: digoxin, phenytoin,
Anticonvulsants: acetazolamide, cabamazepine, phenytoin, phenobarbitol, primidone
Anticholinergics: atropine, dicyclomine, ipratropium, scopolamine
Histamine H2 antagonists: cimetidine, ranitidine, famotidine
Miscellaneous medications: clofibrate, dichlorphenamide, fenfluramine, ketoconazole, methadone, methazolamide, norethindrone, thiabendazole
Illicit and abused drugs: alcohol, amphetamines, cocaine, marijuana, tobacco

1. When a patient presents with an inability to maintain an erection, the health care provider may suspect a problem with:
a. Sexual drive.
b. Chemical mediators, nitric oxide, and cyclic guanosine monophosphate.
c. Sexual partnerís drive.
d. Acetylcholine and norepinephrine levels.

2. Which change is a normal assessment finding in the aging male?
a. Decrease in sperm not semen volume.
b. Increased propulsion of ejaculate.
c. Delay in reaching climax.
d. Flaccidity of skin folds.

3. When providing patient teaching regarding erectile dysfunction, it is important to consider the effects of which over-the-counter drug?
a. Acetaminophen
b. Cimetidine
c. Aspirin
d. Calcium

4. Which condition disclosed during the patient history could be associated with erectile dysfunction?
a. Diabetes
b. Kidney stones.
c. Migraine headaches.
d. Rheumatoid arthritis.

5. When providing a public forum regarding erectile dysfunction, which risk factors might the health care provider suggest can also lead to ED?
a. Cardiovascular disorders.
b. Carcinogenic disorders.
c. Psychosomatic disorders.
d. Neurologic disorders.
6. A patient with erectile dysfunction should be cautioned before sexual activity to avoid:
a. Eating a heavy meal.
b. Exercise.
c. Spontaneity.
d. Alcohol consumption.

7. Taking the history for the erectile dysfunction patient is best accomplished:
a. With the client alone.
b. With the partner present whenever possible.
c. By a male health care provider.
d. By a female health care provider.

8. The diagnosis of erectile dysfunction requires:
a. The presence of a regular sexual part- ner.
b. A family history.
c. A thorough genital exam.
d. A nutritional assessment.

9. Pharmaceutical counseling may include that erectile dysfunction can be aggravated by many:
a. Cholesterol-lowering agents.
b. Short-acting tranquilizers.
c. Glucocorticoids.
d. Blood pressure medications.

10. In addition to erectile dysfunction, the patient may report:
a. Lack of self-confidence.
b. Freedom from sexual pressures.
c. Activity intolerance.
d. Decreased activity.

This article is approved by SUNA for 1.0 contact hour of continuing education in nursing.
Posttest Instructions

1. To receive continuing education credit for individual study after reading the article, check the appropriate box corresponding to the best answer on the answer form (a photocopy of the answer form is acceptable). Each question has only one correct answer. A passing score for this test is 8 correct answers (80%).

2. Send the answer form along with a check or money order payable to Urologic Nursing, CE Series, East Holly Avenue Box 56, Pitman, NJ 08071ó0056.

3. Test returns must be postmarked by December 31, 2001. If you pass the test, a certificate for 1.0 contact hour will be awarded and sent to you.




This activity for 1 contact hour has been provided by the Society of Urologic Nurses and Associates, which is accredited as an approver of continuing education (CE) in nursing by the American Nursesí Credentialing Centerís Commission on Accreditation (ANCC-COA). The SUNA is reciprocal in the states and specialty organizations that recognize the ANCC-COA accreditation process. SUNA is an approved provider of continuing education in the following states, California BRN #05556, and Iowa, BRN #169. The content of this program complies with chapter five of the Iowa Administrative Code as described in 5.3 (2)a. The ANCC-COA requires that all CE and participant records be kept on file at the National Office for a period of five years. Licenses in the states of CA, FL, and IA must retain this certificate for four years after the CE activity is completed. Other mandatory CE states may have different record requirements. Please be aware of your stateís procedure.




This article was reviewed and formatted for contact hour credit by Julia W. Aucoin, DNS, RN,C, SUNAEducation Director; and Catherine-Ann Lawrence, MA, RN, Editor.