Reviving intimacy: managing Erectile Dysfunction in Primary Care

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE" as well as other institutions such as the British Association of the Urological Surgeons, as well as the American and European Urology Associations. Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by any of them. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go through clinical guidance and advice on erectile dysfunction provided by the following institutions: · BAUS- British Association of Urological Surgeons · AUA- American Urology Association · EAU- European Association of Urology · NICE- National Institute for Health and Care Excellence I will summarise the guidance from a Primary Care perspective only. I am not giving medical advice; this podcast is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement. There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The guidelines can be found here: · BAUS: https://www.baus.org.uk/patients/conditions/3/erectile_dysfunction_impotence · NICE : https://cks.nice.org.uk/topics/erectile-dysfunction/ · EAU: https://www.europeanurology.com/article/S0302-2838(21)01813-3/fulltext · AUA : https://www.bing.com/ck/a?!&&p=c5356f703dad5a45JmltdHM9MTY5Njg5NjAwMCZpZ3VpZD0xM2M1MGRhYS1mMDZkLTZlM2EtMWIzYi0wMTRhZjQ2ZDZkYjcmaW5zaWQ9NTI1OQ&ptn=3&hsh=3&fclid=13c50daa-f06d-6e3a-1b3b-014af46d6db7&psq=erectile+dysfunction+american+guideline&u=a1aHR0cHM6Ly93d3cuYXVhbmV0Lm9yZy9kb2N1bWVudHMvR3VpZGVsaW5lcy9QREYvRUQtSlUucGRm&ntb=1 The shortened Sexual Health Inventory for Men (SHIM/IIEF-5) can be found here: · https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/SHIM.pdf Thumbnail photo: · Image by Drazen Zigic on Freepik · a href="https://www.freepik.com/free-photo/young-man-having-headache-holding-his-head-pain-home_26343730.htm#query=upset%20men&position=1&from_view=search&track=ais"Image by Drazen Zigic/a on Freepik Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through Transcript Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through clinical guidance and advice on erectile dysfunction. For this I have looked at guidance by the: · BAUS- British Association of Urological Surgeons · AUA- American Urology Association · EAU- European Association of Urology · NICE- National Institute for Health and Care Excellence · As well as other local NHS Hospital Trusts protocols available in the London area. I will summarise the guidance from a Primary Care perspective only. So let’s jump into it. Erectile dysfunction is seen in 50 - 55% of men between 40 and 70 years old. It is often associated with obesity, high blood pressure, high cholesterol and diabetes and most treatable causes can be identified by a clinical history, physical examination and routine blood tests. And we will start by taking a detailed sexual history. It is advisable to use validated patient questionnaires, such as the shortened Sexual Health Inventory for Men (SHIM/IIEF-5), to assess the presence, severity, and impact of erectile dysfunction. A link to this questionnaire can be found in the episode description. Otherwise, we will ask about: · onset, duration, and quality of erections; · whether night-time or early-morning erections are still present · whether there are problems with their sex drive or libido, arousal, and orgasm; · whether there are symptoms of premature ejaculation or symptoms of prostatic obstruction because they are often associated with erectile dysfunction and · whether the relationship with their partner is affected. We will then ask about lifestyle factors such as their: · Job and work pressures · Ability to exercise · Smoking and alcohol and · Drug consumption And we will then look at their past medical history for other medical conditions which may be contributing to it. We must remember that ED can be a marker for cardiovascular disease. Then we will perform a general physical examination checking their: · BP, heart rate, · Height, weight and waist circumference, · peripheral pulses and the nerve reflexes in their legs. · We will also look for any abnormality of the penis or testicles and · We will check for gynecomastia or possible signs of hypogonadism. · Rectal examination may be performed to assess the anal tone and to examine the prostate. After this we should do a few routine tests that will normally include: · HbA1c, lipid profile, and fasting morning testosterone level (that is, before 11AM) in all men. · Other blood tests such as a FBC, renal, liver and thyroid function tests, and PSA can be done depending on our clinical judgement. · We should also consider urinalysis to test for glycosuria and haematuria If the free testosterone level is low or borderline, we will repeat it together with FSH, LH, sex hormone binding globulin, and prolactin levels. If on repeat testing, testosterone is still low and LH is high, then we are talking about primary hypogonadism, whereas if testosterone is low and LH is also low, then it would be secondary hypogonadism. When considering the possible cause, we should bear in mind that a physical cause normally has a gradual onset of symptoms, lack of tumescence, and low-to-normal libido, whereas a psychogenic cause normally has a sudden onset, low libido, and good quality spontaneous or self-stimulated erections. A psychological component, often called "performance anxiety", is common in men with ED, as well as relationship issues; stress; anxiety; and depression. However, a purely psychological problem is seen in only 10%. Of the 90% of men who have an underlying physical cause, the main abnormalities found are: · Up to 40% of men may have cardiovascular disease, for example, heart disease, hypertension and peripheral artery disease · Up to 33% of men may have diabetes · Up to 11% of men may have hormonal or drug problems. Examples of o Hormonal problems are hyperprolactinaemia and hypogonadism and o Drugs commonly associated with ED are: § Antihypertensives and diuretics, § Antipsychotics and antidepressants, § Antihistamines, § methadone and § recreational drugs such as heroin and cocaine. § If a drug cause is suspected, we will consider stopping or switching the medication, depending on our clinical judgement. · Around 10% of men may have neurological disorders, for example, MS, Parkinson's disease, stroke, or other diseases of the spinal cord or central nervous system · Up to 3-5% of men may have a history of pelvic surgery or trauma and · Between 1 to 3% of men will have anatomical abnormalities like phimosis, short penile frenulum, Peyronie’s disease, inflammation, penile curvature and prostate cancer When it comes to treatment in Primary care, we should advise on sources of information and support as well as encouraging lifestyle improvements. In fact, losing weight and increasing exercise can dramatically improve erectile dysfunction. by up to 70%. We should obviously optimise the management of any underlying conditions and, if clinically appropriate, we should consider drug treatment with a phosphodiesterase-5 (PDE-5) inhibitor. However, before offering PDE-5 inhibitors we will need to do a cardiac risk stratification which will assess men into low-, intermediate-, or high-risk cardiovascular categories, depending on their risk factors and co-morbidities. Men at low risk would be asymptomatic doing moderate exercise, and may have controlled hypertension, mild stable angina, mild valvular heart disease and mild heart failure or may have had an uncomplicated MI or a successful revascularisation procedure Men with a more significant cardiac history will be at intermediate or high risk and we would normally arrange a referral to a cardiologist for advice and recommend stopping all sexual activity until the specialist assessment. The European Association of Urology estimates that sexual activity is equivalent to walking 1 mile on the flat in 20 min or briskly climbing two flights of stairs in 10 seconds. Men who can complete this level of exercise without symptoms are deemed to be low risk and those who would struggle would be referred to cardiology for further assessment, including an exercise ECG. Sexual activity is generally considered to be equivalent to 4 min of the Bruce treadmill protocol. We should refer to secondary care: · As an emergency if there is priapism (that is, painful prolonged erection for more than 4 hours following ED treatment). · To Urology if there is anatomical abnormality; young age or not responding to maximum tolerated dose of at least two PDE-5 inhibitors. · To Endocrinology if we suspect testosterone deficiency or hypogonadism. · To Cardiology if at high or intermediate cardiac risk of sexual activity and · To Psychosexual and relationship counselling, or mental health services if there is a psychogenic cause or severe mental health condition. Alternatively, if we decide to prescribe a PDE-5 inhibitor in Primary Care, we will: · Explain that these drugs will have no effect on their sex drive and that they require sexual stimulation to be effective · And that sildenafil 50 mg tablets (Viagra Connect®) can be purchased over-the-counter without a prescription. · We will warn, however, that ED medications are amongst the most commonly counterfeited medicines in Europe and that buying online should only be through legitimate sources like registered pharmacies · and we will advise about the importance of dose timing. o Sildenafil should be taken about one hour before planned sexual intercourse and the effect can last about 4-5 hours. We also need to explain that food intake can reduce the absorption of sildenafil by an average of one hour. o On the other hand, tadalafil for example needs to be taken only 30 minutes before sexual intercourse, has a duration of up to 36 hours and food ingestion has not effect on it. · We will also explain that PDE-5 inhibitors, except generic sildenafil, are not automatically prescribable on the NHS. Therefore, before prescribing it, we need assess whether the man qualifies for an NHS prescription and, if not, we will offer a private prescription. NHS prescriptions should be endorsed SLS if the man qualifies for NHS treatment because of: o diabetes, o Neurological conditions such as multiple sclerosis, Parkinson's disease, spina bifida etc, o prostate cancer, o pelvic trauma like in pelvic injuries, radical pelvic surgery or prostatectomy, o renal failure treated with dialysis or by transplant or o Is experiencing 'severe distress' as assessed by a specialist o However, as already mentioned, generic sildenafil does not need to be endorsed with 'SLS' for NHS prescribing. · Phosphodiesterase-5 (PDE-5) inhibitors are usually taken intermittently as needed, normally as one treatment dose per week on the NHS. However, if clinically appropriate, NICE says that a higher frequency may also be prescribed on the NHS. After the initial prescription: · we will follow-up the patient after 6–8 weeks, and, if there is a poor response, · we will consider increasing to the maximum dose, trying each PDE-5 inhibitor 4–8 times at the maximum tolerated dose before switching to an alternative. · We will suggest a trial of at least two different PDE-5 inhibitors taken sequentially before considering the patient as a 'non-responder'. · If taking tadalafil, we can consider increasing the dose frequency, such as switching to once daily (rather than 'on-demand') dosing depending on our clinical judgement. o The BNF states that tadalafil may be prescribed daily as a dose of 5 mg once daily, for patients who anticipate sexual activity at least twice a week, although the dose can be reduced to 2.5 mg once daily, depending on the response, · We also need to be aware that hypogonadism and a low testosterone level may result in a reduced response or non-response to phosphodiesterase-5 (PDE-5) inhibitors. I will now give just an overview of some prescribing information and, in terms of contraindications, we will not prescribe a phosphodiesterase-5 (PDE-5) inhibitor if there is: · Unstable angina or angina occurring during sexual intercourse. · Regular or intermittent use of nitrates in any form · Hypotension (that it, a systolic blood pressure below 90 mmHg). · A Recent MI or stroke or · A history of non-arteritic anterior ischaemic optic neuropathy (NAION). There are a number of other contraindications for specific PDE-5 inhibitors in renal or hepatic impairment and other cardiovascular conditions, so I would recommend looking at the specific recommendations for whichever drug you intend to prescribe. Equally, there is also a long list of cautions which we would need to check for each individual patient. In terms of drug interactions, there is a severe interaction with nitrates and concurrent use of PDE-5 inhibitors and nitrates, including nicorandil, or amyl nitrate (also known as 'poppers') are absolutely contraindicated due to the risk of hypotension. There is also an increased risk of hypotension with alpha-blockers and sacubitril/valsartan so caution is advised. Finally, just to mention that other treatments available for Erectile Dysfunction are: · Penile injections · Medicated urethral system for erection (MUSE) · Vacuum erection assistance devices (VEDs) · Vascular surgery/angioplasty and · Penile prostheses We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.