Summary

Erectile dysfunction (ED) is a condition affecting a significant number of male populations and is a concern of a lot of patients and the community. While a detailed exploration of the physical-psycho-social information is crucial in the management of these patients, the limited time period during a typical physician-based public clinic consultation may not be able to achieve this goal. With the help of a nurse-led pre-assessment clinic, a more detailed medical and psycho-social assessment, as well as patient education can be performed in a non-hurry and comfortable environment. This information will definitely benefit the physician and patients by formulating the treatment plan of ED. The opportunities to screen for associated medical condition will also help to improve the overall men’s health in the community.

摘要

勃起功能障礙(ED)是一種常見男性的疾病，波及相當數 量的男性，也引起眾多患者和人群的關注。患者詳盡的軀體手 — 心理 — 社會資料對治療至關重要，但通常公立診所的醫 生的接診時間有限，可能無法達到這一目標。如果由護士先行 進行預評估，就能夠在從容、輕鬆的環境中對患者進行較細緻 的醫療及心理-社會評估和教育，這些資訊有助於醫生和患者 制定出針對勃起功能障礙的治療方案。同時也可以就相關疾病 進行篩查，有利提高社區男性人群健康的總體水平。

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Introduction

Erectile dysfunction (ED), also known as “impotence”, is defined as the inability to achieve or maintain an erection sufficient for satisfactory sexual performance.¹ In a recent questionnaire interview of 1506 Hong Kong male of age 26 to 70 year old, the reported overall prevalence of ED was 36.7%.² In the past, the condition was once a taboo subject and many would consider it a psychological problem or a natural consequence of ageing. However, since the introduction of the ground-breaking oral medication in 1998 and the i n c r e a s e d u n d e r s t a n d i n g o f t h e u n d e r l y i n g pathophysiology and association with other medical conditions, there is now an ever increasing demand for proper management of this condition from the public.

During the management of a patient with ED, we do not merely aim at helping him to have a rigid penis for vaginal penetration. There are many other areas that we need to consider during our assessment. The identification and treatment of reversible medical and non-medical causes is important and may allow complete recovery of the patient even without drugs. Psychosocial stress, especially in the local community, will certainly affect the performance of some patients, and these factors may need to be addressed before the patient can obtain a good treatment response. Moreover, a satisfactory sexual relationship between the couple relies not only on enjoyable sexual intercourse, but also on having marital harmony. Therefore exploring and resolving underlying tension between the couple can also improve their sexual life. In addition, detailed explanation of available treatments, including efficacy, side effects and cost to patients before making treatment decision can be most helpful. Finally, the maintenance of good and trustful relationship between the health care provider and patient is crucial to avoid misunderstanding, and to foster better cooperation and obtain the optimal treatment outcomes.

Many doctors, however, still find it difficult to deal with this sensitive, yet important condition in our traditional busy clinic settin g.³ Therefore, a nursespecialist, with specialized training in the management of ED, may be the alternative person that can help in the management of these patients. Since year 2002, we have established the first nurse-led Men’s Health Preassessment Clinic in Hong Kong to receive patients with sexual dysfunction. Up to this year, we have managed more than 600 male patients, referred from either primary care physicians or by other specialty doctors. Therefore, we would like to share our experience and offer some practical tips in managing this common clinical condition from a nursing perspective in an urological centre.

Men’s health pre-assessment clinic in Prince of Wales Hospital

In the traditional physician-based clinic model, patients would be assessed by doctors during their first consultation. After history taking and physical examination, investigations would be arranged. Patients would then come back later for review of investigation results and subsequent formulation of treatment plan. However, due to the constraints of the local busy public clinic setting, which usually allows only 10 ~ 15 minutes for each consultation, it may be difficult for doctors to have detailed discussion about patients’ problems, especially the potential psychosocial component. Also, the information provided on possible underlying aetiology and management options may not be comprehensive and adequate. In order to improve the standard of care, we decided to establish a nurse-led Men’s Health Preassessment Clinic. The aim of this clinic is to provide a more relaxing environment to patients for more in-depth discussion about their sexual problems. We hope that the information and advice provided will facilitate subsequent assessment by urologists and in turn improve the quality of management.

Currently in our centre, all patients referred with sexual dysfunction will be directed to this pre-assessment clinic and be assessed by our nursing staff prior to their first consultation by urologists. This clinic assessment usually lasts for around 45 minutes to one hour, and each session is attended by one nurse-specialist who assesses up to a maximum of five cases a day. The patient’s partners are also encouraged to come with the patient. During the first part of the assessment session, a 20-minute video is shown to the patients for the background information and about basic treatment for ED. Thereafter, a detailed individualized assessment is performed by nurses, which include basic assessment of the sexual dysfunction, as well as any co-morbidity (including previous surgery or trauma, cardiovascular conditions, psychological conditions etc). Selfadministered questionnaires, International Index of Erectile Function (IIEF), will also be performed for quantifying the severity of the condition and for monitoring of treatment response.⁴ Basic education on life-style modification and treatment options are also given. At the end, basic investigations, including fasting lipid, sugar, renal function test, testosterone level and electrocardiogram, are arranged. An appointment is then made for the patient to be seen by an urologist in about two-week time for clarification of information, physical examination and review of investigation results. Finally a treatment plan will be formulated at the end of consultation. By this approach, while the total number of physician consultations is decreased, the quality of patient assessment and information provided is improved, which in turn provides better patient care in the current overloaded urology service.

Basis of the pre-assessment clinic

The basis of this pre-assessment clinic is to provide a relaxed and unhurried environment for the patient, which encourages them to have more comfortable dialogue about their problems. The longer consultation time allows opportunities to explore potential psychosocial and marital problems related to sexual dysfunction, and appropriate advice can then be given. In particular, the nursing staff, which is usually a female, can provide advice to male patients on marital problems from a feminine point of view. Moreover, the resources and time provided during this consultation allow patients to have a better understanding of their condition and the treatment options. Hence a more realistic management target and better treatment planning can be formulated .

During the interview in the pre-assessment clinic, one of the key to success is to be non-judgmental and open-minded during the conversations between nursing staffs and patients. Tone, language and appropriate terminology are very important. Table 1 shows the B.E.T.T.E.R. model which was introduced by Mick et al, and is a good guideline for the attitude of the staff during the assessment.⁵ The model reminds us to raise the subject matter gently and ensures patient’s confidence in the care-provider.

Ass essment of sexual dysfunc t ion and it s underlying causes

When a patient is referred for sexual dysfunction, he may actually be suffering from other sexual problems including problems with sex drive or libido, premature ejaculation, or penile deformity, etc. Therefore, a detailed description and clarification of the nature of the sexual dysfunction is important during the initial assessment. Onset and duration of the symptoms, as well as any associated precipitating events may provide clues to the underlying causes. It is also essential to clarify the patients’ concerns and expectations from the consultation.

As reflected in the need for comprehensive history, potential causes of ED are numerous, and often multifactorial in individual cases. (Table 2) These can be broadly classified into organic or psychological causes. The latter ones tend to have a more abrupt onset, be related to stressors or important life-events, have variable performance level, preserved morning erection, etc. Organic causes can be systemic and related to hormonal influence (e.g. hypogonadism, thyrotoxicosis, etc), medical conditions (e.g. renal failure, liver failure, etc) or drug-related (Table 3). Local causes can be related to underlying neurological deficits (e.g. previous pelvic surgery, diabetic neuropathy, etc), vascular insufficiency (traumatic or atherosclerotic) or cavernous or venous dysfunction (e.g. congenital abnormal venous leakage). Therefore, comprehensive evaluation of the past medical and drug histories may provide clues for the possible underlying aetiology of the erectile dysfunction, and some of them may be readily reversible. At the end of the pre-assessment and physical examination by the urologist, patient¡¯s blood is taken for serum testosterone level to rule out hypogonadism;⁶ and other blood tests, such as liver function test, thyroid function test may be ordered and be performed when clinically indicated.

Assessment of cardiovascular co-morbidity

Studies have shown that ED has similar risk factors as other cardiovascular diseases, like smoking, obesity, hypertension, sedentary lifestyle, diabetes, ageing and hyperlipidaemia.^{7, 8} More than two-thirds of men with hypertension who were studied had ED; ⁹ nearly twothirds of men with ED had dyslipidaemia and nearly half of men with ED had a positive stress test or had significant coronary heart conditio n.¹⁰ ED was also common in diabetes patients.¹¹ In fact, ED has now been regarded as an early sign of underlying cardiovascular disease.¹² Therefore, screening of these risk factors during the workup of ED may allow early recognition of these conditions and minimize future cardiovascular complications.

During our pre-assessment, smoking history is documented, blood pressure and body-mass index are measured. Fasting blood glucose and lipid level are also checked to exclude dysglycaemia and dyslipidaemia. Lastly, an electrocardiogram (ECG) is performed to screen for potential cardiac problems. These assessments are then reviewed by urologists later and appropriate referrals are made if abnormalities are detected.

Education and risk factor modification

It is not uncommon to encounter patients who come with lots of myths or misconceptions about ED and they may even expect a “miracle cure” of their problems. In the usual specialist clinics, there may not be enough time to provide adequate information or response to all the queries of patients. Our urology clinic is no exception. Therefore, the extra time provided during the nurse-led clinic in our Men’s Health Pre-assessment Clinic may allow an in-depth discussion about some of the basic information of the condition. Firstly, the video session helps to provide some basic understanding of the condition and possible interventions available. Then the one to one consultation with our nurse-specialists helps to clarify further questions on the condition. Besides education, this assessment also provides a golden opportunity to discuss with the patients on some of the modifiable risk factors, so that they could hopefully adopt a healthier lifestyle, e.g. quitting smoking, moderation of alcohol intake, balanced diet with moderate exercise for weight control, etc. As studies have suggested, modification of lifestyle alone, including increased exercise level by 200 kcal/day and weight reduction, can help to improve IIEF by 30% in 2 year s.13

Psychosocial supports and counselling

In the management of ED, it is essential to have a good understanding of the psychosocial function of the patients, as well as their partners. In our experience, the cause of ED is usually multi-factorial, and frequently a pre-existing mild ED can be aggravated by various psychological problems. For male patients, sexual dysfunction easily triggers the feeling of ageing, loss of masculine power, low self-esteem, loss of control over the body, etc. On the other hand, erectile function may further worsen due to these psychological stresses and performance anxiety. Moreover, if the partners do not show passionate understanding to one another, they may be thinking about having extramarital sex or when they lose interest in their partner, unnecessary marital conflicts may be created. This only makes the situation worse.

As a harmonious sexual life requires the contribution of both partners, we particularly stress the importance of involving the female partners in the management of ED. Therefore, we encourage patients to bring along their female partner during clinic visits. The assessment by a female nurse could ease some of the embarrassment of female partners and may also encourage them to express their view and concerns. It is essential to provide an open environment for the partners to discuss their sexual life and problems. Explanation of the medical condition may also help female partners to understand the patients better and relieve some possible tension related to the condition. Simple sexual counselling and education for individuals or couples on psychosocial factors like relationship problems, dysfunctional communication patterns or skills, sexual performance concerns and other co-morbid sexual conditions can also be provided during this consultation.

Advice on treatment options

Although ED is not “life-threatening”, its impact on the psychosocial well-being of an individual can still be significant. Managing ED is not simply getting a penis erected. An optimal treatment should be acceptable to both partners and ultimate success depends on a motivated patient, a supportive partner and willingness to try drugs and other means that can result in new approaches to sexual activity. Therefore good communication to eliminate misunderstanding and to foster cooperation cannot be stressed more.

Underlying causes, patients’ perspective on the condition and their preference would influence the choice of treatment. Personal, cultural, ethnic, religious and economic factors also have a significant impact. As discussed above, addressing modifiable risk factors like stress management, smoking cessation, weight reduction, etc, may already have a significant positive impact on the condition. Simple adjustment of dosage of medication for some of the concomitant medical conditions can also be of significant benefit. Obviously this has to be coordinated with the patient’s family doctor.

During the pre-assessment, basic information on available treatment options and their advantages and disadvantages are important. Simply for the urologist to pre scribe drug s o r su gges t d evic es or s urge ry sometimes result in treatment failure. Like many other medical treatment, the nursing part is important and also some explanation on how to take the drugs or d emo ns t ra t io n o f th e u sa g e o f n on -or a l med i ca l treatment via the educational video can have much successful outcomes. The nursing staffs can also provide detailed explanations on some enquiries from patients whenever required. This allows the patients and their partners to have a better understanding of the available treatment, such that they could have some prior discussion before they meet the urologist for treatment decision.

Drug treatment

If there is no obvious reversible factor that can be dealt with, some form of oral medication can be considered for the patients. Oral phosphodiesterase-5 inhibitors (PDE5i) are broadly acceptable as the firstline treatment for most patients, unless there are contraindications. The main advantages of PDE5i are t h e e a s e o f a d m i n i s t r a t i o n a n d i t s “ r e l a t i v e ” naturalness. There are three PDE5i available in the market with slight differences in pharmacokinetics characteristics (Table 4),¹³ and they all act peripherally to enhance but not initiate erections. As PDE5i are vasodilators, common side effects include facial flushing, headache, and nasal blockage, etc. Patients are told before-hand about these side effects and that they can usually tolerate them after a while of using these drugs; otherwise they should come back to our d o c t o r s a g a i n . I t i s a l s o v i t a l t o c h e c k f o r contraindications for prescription, like concomitant usage of nitrate and some types of alpha-adrenergic blocker. Our nurses can also explain exactly how the drugs should be taken and time allowance given to act before sex.

Other treatment

Besides oral medications, other local treatment options include intraurethral therapy (intraurethral prostaglandin cream), intracarvenosal injection therapy or vacuum constriction device therapy.¹ These are in d i c a t e d in c as e s o f f a i lu r e o f o r al t r e a tme n t , contraindications or intolerance of oral drugs or when there are individual preferences. But proper use of these devices needs adequate education and proper demonstration (by the educational video). Lastly, surgical treatment may be necessary when there are underlying vascular abnormality or structural penile abnormality and these have been discussed elsewhere in previous medical journals and need not be repeated here.

Conclusion

Erectile dysfunction is a commonly encountered urological problem. Despite the ease of current oral medical treatment, careful and comprehensive assessment is still necessary for the management of patients. However, due to the current resource limitation in physician-based service, a nurse-led preassessment clinic may help to provide a more relax and unhurried environment for proper patient assessment, education and counselling. The comprehensive information provided to patient, as well as their partner, on the disease nature and treatment approach will help them to decide on the most suitable treatment option. The environment may also help to explore potential psychosocial problems related to sexual dysfunction. The opportunity to screen for other coexisting cardiovascular risk factors may also help to identify undiagnosed conditions like hypertension, diabetes etc, and allow appropriate intervention and health care advice to improve the sexual and overall health of the patient.

Acknowledgement

We thank the Nursing Chapter of Hong Kong Urological Association in supporting the establishment of this pre-assessment clinic.

Key messages

1. The bas is of the pre-asse ssment clinic is to provide a relaxed and unhurried environment to the patient, which encourages them to have more comfortable dialogue about their problems.
2. The extra-time provided during the nurse-led clinic may allow an in-depth discussion about some of the basic information of ED, which will facilitate the subsequent decision on treatment planning and management.
3. ED has similar risk factors as other cardiovascular diseases, therefore, screening of these risk factors during the workup of ED may a llow e a rly recognition of these conditions and minimize future cardiovascular complications.
4. Female nursing staff may help to provide patients with the opinion from a female point-of-view to facilitate the understanding and communication between husbands (patients) and their wife.

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Reference