MALE HEALTH ERECTILE DYSFUNCTION By Gareth McCabe


ERECTILE DYSFUNCTION (ED) IS A CONDITION WHERE THERE IS AN INABILITY TO GET AND MAINTAIN AN ERECTION LONG ENOUGH TO HAVE SEXUAL INTERCOURSE. IT IS A VERY COMMON CONDITION AFFECTING HALF OF MEN BETWEEN THE AGES OF 40 AND 70 YEARS TO SOME DEGREE.


I


f we are honest, most men occasionally fail to get or keep an erection which usually results from


stress, tiredness, anxiety or excessive alcohol consumption and is nothing to worry about. However, once it does become a common occurrence, then it would be an indicator for referral to a GP.


CAUSES OF ED


The causes can be classed as either physical or psychological. The main cause in 40-70 year olds can be attributed to an underlying medical condition. See below the list of physical conditions that can lead to ED:


• Vasculogenic conditions: cardiovascular disease (CVD), hypertension, hyperlipidaemia/ arthrosclerosis and diabetes


• Neurogenic conditions: multiple sclerosis, Parkinson’s disease, stroke, diabetes and spinal injury or disorder


• Hormonal conditions: Hypo- and hyperthyroidism, hypogonadism (low testosterone level), Cushing’s syndrome (high cortisol level)


• Surgery and radiation therapy for bladder, prostate or rectal cancer


• Injury to the penis • Side effect of prescribed drugs • Recreational drug use • Excessive alcohol consumption


Possible psychological causes of ED include:


• stress • anxiety • depression, and • relationship problems.


Erectile dysfunction is more common and has a greater likelihood of


happening to those who are overweight, smoke and are not active enough. It is worth noting that ED can be the first sign of future heart problems, especially if the diagnosis is that of atherosclerosis. The narrowing associated with atherosclerosis, that affects the penis, is likely to affect the blood vessels elsewhere in the body, including the arteries that supply the heart. This means ED can be an early warning sign of future heart problems, appearing three-five years before a heart complaint.


Therefore seeing a GP sooner rather than later regarding ED can potentially cut the risk of future CVD.


TREATMENT FOR ED


Erectile dysfunction usually responds well to a combination of lifestyle measures (such as weight loss, smoking cessation, and reducing alcohol consumption) and drug treatment. Phosphodiesterase-5 (PDE-5) inhibitors are recommended first-line, regardless of suspected cause (provided there are no contraindications or interactions).


Available PDE-5 inhibitors include:


• sildenafil (Viagra) • tadalafil (Cialis) • vardenafil (Levitra) • avanafil (Spedra)


PDE-5 inhibitors enhance erectile function during sexual stimulation by penetrating into smooth muscle cells and inhibiting PDE-5. This inhibition decreases the degradation of a molecule called cyclic guanosine monophosphate (cGMP). This increases relaxation of the smooth muscle, resulting in increased blood flow, allowing an erection to occur. Through competitive inhibition of PDE-


5, sildenafil (and others in its class) cause accumulation of the cell cGMP, which triggers an erection.


They are recommended to be taken 30-60 minutes before desired activity. In order for them to work, the sexual desire and stimulation must occur. Sildenafil, vardenafil and avanafil work for approximately eight hours, whereas tadalafil lasts for up to 36 hours and is more suitable if the patient requires treatment for a longer period of time, for example, over a weekend. It may take longer to notice the effects if the tablet is taken with food, so it’s best to take it on an empty stomach.


These inhibitors are only available on NHS prescriptions under exception and must be endorsed ‘SLS’ (exception in men who meet the criteria listed in Part 12 of the Scottish Drug Tariff)7. Alprostadil is a synthetic vasodilator chemically identical to the naturally occurring prostaglandin E1. It is a vasodilating agent acting on the smooth muscle of the penis. Through this relaxation there is an improved blood flow into the penis.


There are three formulations of alprostadil – topical (Vitaros), intracavernosal (Caverject, Viridal Duo) and urethral (MUSE) application (must be endorsed ‘SLS’). The most commonly used are the intracavernosal and urethral applicationInitial use/application must be done by a trained professional then the patient may be trained to correctly inject or insert alprostadil. If the patient’s partner is pregnant, they must use a condom during sex if using the urethral application. The onset of action for these formulations is between five to fifteen minutes and can last up to an hour depending on the dose given.


DRUGS THAT MAY CAUSE ED:


In some men, certain medicines can cause erectile dysfunction, including: • diuretics


• antihypertensives • fibrates


• antipsychotics • antidepressants • corticosteroids


• H2-antagonists • anticonvulsants • antihistamines • anti-androgens • cytotoxics Psychological treatments are available for those that have an underlying psychological cause for their ED. Depending on the root cause, such as anxiety or depression, the patient may benefit from counselling. They may also benefit from cognitive behaviour therapy (CBT).


CBT is another form of counselling and is based on the principle that the way someone feels is partly dependent on the way they think about things. CBT helps them realise that their problems are often created by their mind-set. It is not the situation that causes the issues but the way in which they react to them.


PRIAPISM


Priapism is a very serious condition characterised by a sustained and painful erection usually lasting for more than three-four hours. It is a medical emergency and anyone presenting with the condition should be referred immediately for medical assistance. If it is not treated within 24 hours, then permanent damage to the penis can occur. Initial treatment for priapism is aspiration which uses a needle and syringe to physically remove the blood from the penis. Surgery is only recommended if other treatments have failed. Priapism can be a potential side effect of the treatment for erectile dysfunction; however the risk is thought to be low as low as one in 1000 patients. Therefore the treatment greatly outweighs the risk.


WHAT CAN WE DO AS PHARMACISTS?


As pharmacists, we can discuss ED treatment and offer patients advice on lifestyle factors (advice on diet, losing weight, increasing exercise, reducing smoking and alcohol intake). This can lead to potential medicines management and smoking cessation clients. It also offers the chance to signpost patients for counselling, if required. •


SCOTTISH PHARMACIST - 43


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