MALE HEALTH
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 complaint4
. 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.6
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. They are only available on NHS prescriptions under exception and must be endorsed ‘SLS’ (exception in men who meet the criteria listed in Part XI (b) of the Northern Ireland Drug Tariff)7
.
Alprostadil is a synthetic vasodilator chemically identical to the naturally occurring prostaglandin E1. It is a
38 - PHARMACY IN FOCUS
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 application. Initial use/ application must be done by a trained professional then the patient may be trained to correctly inject or insert alprostadil. If their 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 (8)-
In some men, certain medicines can cause erectile dysfunction, including:
• diuretics • antihypertensives • fibrates • antipsychotics • antidepressants • corticosteroids • H2-antagonists • anticonvulsants • antihistamines • anti-androgens • cytotoxics
Vacuum pumps are a physical means to achieve an erection. Some may be Swedish made however they do not work as an enlarger (no matter what Austin Powers says!). A vacuum pump consists of a clear plastic tube that is connected to a pump, which is either hand or battery operated.
The patient places their penis into the tube and pumps out the air, creating a vacuum. This causes blood to be drawn into the penis, making it erect. Once an erection is achieve the patient places a specially designed rubber ring around the base of the penis to keep the blood in place. This allows the patient to maintain an erection. It is recommended to maintain an erection for around 30 minutes before releasing the ring9
.
It is recommended to spend up to a week practising using the pump before engaging in sexual activity. This helps ensure smooth and efficient use of the pump when required.
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. Encouraging the patient to talk about their problems and feelings in a confidential and dependable environment can help them deal with their problems.
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 mindset. It is not the situation that causes the issues but the way in which they react to them9
.
Other treatments include the strengthening of the pelvic floor muscles. In a few cases patients have found this to be beneficial so it may be a useful exercise to some. Others suggest the use of complimentary therapies such as acupuncture, however there is no evidence to suggest they work and it is recommended to always refer back to G.P if a patient is considering the use of any complimentary therapies.
PRIAPISM:
Priapism is a very serious condition characterised by a sustained and painful erection usually lasting for more than 3-4 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 failed10
.
Priapism can be a potential side effect of the treatment for erectile dysfunction; however the risk is thought to be low at one in 1000 patients. Therefore the treatment greatly outweighs the risk.
WHAT CAN WE DO AS PHARMACISTS?
As pharmacists we are the easiest accessible of all healthcare professionals. This gives us the unique opportunity to engage with
our patients without the need for appointments. We can take the opportunity to engage with those who are prescribed ED treatment and offer them advice on lifestyle factors (advice on diet, losing weight, increasing exercise, reducing smoking and alcohol intake). The patient may be suitable for referral to medicines management or a smoking cessation programme. These opportunistic consultations also give the patient the chance to open up and discuss any queries or concerns they may have about their condition, the medication or potential side effects. This also offers the chance to signpost patients for counselling, if required. It is important for them to keep their heads up (pardon the pun!) and to retain a positive mental attitude.
Erectile dysfunction over the years may have been something to be embarrassed about or not considered a serious condition. It is important for this stigma to be removed and research has now shown that there is a physical cause (underlying conditions), rather than it ‘just in his head’. •
BIBLIOGRAPHY
1.
http://sexualadviceassociation.co.uk/ erectile-dysfunction/. Sexual Advice Associ- ation. [Online] 2. Urology, Cornell. how erection works.
https://www.cornellurology.com/clini- cal-conditions/erectile-dysfunction/how- erections-work/. [Online] 3. Scotland, Prostate.
http://www.prostate-
scotland.org.uk/assets/files/PS-27237-Spot- lightguide-Erectile%20Dysfunction_A5_ JC.pdf. [Online]
4. Association, Sexual Advice. Erectile dysfunction. http://sexualadviceassociation.
co.uk/erectile-dysfunction/. [Online] 5. Inform, NHS. http://www.nhsinform.
co.uk/health-library/articles/e/erectile-dys- function/introduction/. [Online] 6. Molecular Biology and Pharmacology of PDE-5—Inhibitor Therapy for Erectile Dysfunction. Francis, Jackie D. Corbin andSharron H. s6, Journal of Andrology : American Society of Andrology, 2 JAN 2013, Vol. 24. 7. Tariff, Northern Ireland. http://www.
hscbusiness.hscni.net/pdf/DT_Full_Au- gust_2016.pdf. [Online]
8. Causes, NHS UK ED. http://www.nhs. uk/Conditions/Erectile-dysfunction/Pages/
Causes.aspx. [Online] 9. NHS UK ED, Treatment. http://www.nhs. uk/Conditions/Erectile-dysfunction/Pages/
Treatment.aspx. [Online]
10. priapism, NHS Conditions-. http://
www.nhs.uk/conditions/Priapism/Pages/ Introduction.aspx. [Online]
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64