CLINICAL UPDATE

By Dr David Millar , WA Sexual Health Centre .

Tel 93891400

Biomarker or hidden association

From a doctor ’ s perspective , ED is as important a biomarker as BP , BMI or PSA .

It may be the first indicator of vascular disease – the most common cause of ED is endothelial dysfunction and atherosclerosis of the penile arteries . Exactly the same process is almost certainly occurring in the carotid , peripheral and cerebral arteries . Many Cardiologists consider ED as a marker of CAD until proven otherwise .

ED also has a close association with diabetes , metabolic syndrome , lower urinary tract symptoms ( LUTS ), sleep apnoea and androgen deficiency .

From a psychological perspective there is bidirectional relationship with depression and anxiety . Understandably , ED can profoundly affect relationships and lead to various avoidance strategies by the males ( watching late night NCIS repeats , working late ), which in turn can lead to all manner of negative conclusions by their partner . In fact , sometimes it is the partner who triggers the initial consult for ED .

What does the ED sufferer think ?

From a man ’ s perspective , the greatest fears around ED are :

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For married men , the ability to overcome ED is as much to do with maintaining their relationship as it is about sex . These men say the problem is on their minds constantly and nearly half ( 43 % in this study ) admit that even the thought of sex can make them anxious ( 2 ) .

Barriers to seeking help

There are many things that stand in the way of men seeking professional help . They are ashamed , feel inadequate , isolated , or a failure and do not discuss the problem with their friends , family or workmates . Moreira ED et al ( 3 ) found that only 20 % of Caucasian males approached their doctor with the problem and even smaller percentages of Asian males did so . Some will discuss the problem with their partners who often instigate medical help . The remainder surf the Internet , receive all manner of disinformation and can end up taking counterfeit PDE5-I medications with

varying degrees of the real compound and all manner of potentially dangerous fill-in chemicals . Some on-line “ services ” lock men into expensive contracts often with nonproprietary products .

Overcoming barriers by making ED acceptable

Initially , it is important to reassure the man that the problem is very common (“ you ’ re not

alone , a fair number of your mates have the same problem ”), that there is a physiological basis and that there are effective lifestyle changes and treatments .

We talk about blockage of arteries due to diabetes , hypertension and hyperlipidaemia , which can easily lead the conversation to “ do you know that the smallest and often first artery to become narrowed is the penile artery ?”

It is important to address any psychogenic component ( performance anxiety ) as this is likely to be a part of or , particularly in younger patients , the major factor . A phrase like , “ Did you know that adrenaline is the greatest erection killer on the planet ?” again gives a physiological basis .

If PDE5-I medications are prescribed it is important to consider the relevance of “ making dates ” versus the need of the man for spontaneity ( e . g . re-starting dating ) to determine if the drug is used on demand or on a once-a-day basis e . g . Cialis 5mg .

Important scenarios not to miss

The take home point is that ED is an opportunity for increasing our level of care for men and their relationships . Five not-to-miss situations and how to begin a conversation are :

1 . Newly diagnosed or existing patient with hypertension , hyperlipidaemia or diabetes : “ We need to consider the effect on all arteries including the heart and penis , have you any heart problems , chest pain or problems with erections ?”

2 . Patient with sleep apnoea or significant LUTS : “ There is a close association with this and erection problems , so are you experiencing any hassles there ?”

3 . Patient presents with anxiety or depression : “ Doctors are aware depression and anxiety often go hand-in-hand with erection problems – is this an issue for you ?”

4 . Patient asks for Viagra or its equivalent ( often as they are getting up to leave ): “ Okay , it is safe for me to do this , I will give you samples if you will come back in 1 – 2 weeks to see how they are working . And for me to help you find the cause , please book a long consultation .”

5 . If you prefer to refer once ED is uncovered , a Sexual Health Clinic is appropriate : “ These people know how sensitive a matter this is and if you want , are happy to include your partner in things , in confidence , of course .”

References : 1 . Chew KK et al . J Sex Med 2008 ; 5 ( 1 ): 60-9 2 . Galaxy Research . Erection problems : Voice of the Patient survey , 2011 . Prepared for Eli Lilly Australia . 3 . Moreira ED , et al . Int J Clin Pract 2005 ; 59 ( 1 ): 1 – 16 . �

FACTS : Erectile Dysfunction

Competing interests declaration : Dr Millar is a member of the Eli Lilly advisory board for Sexual Health and Androgen Therapy . Nil else . medicalforum 45