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