In the second part of our series on sexual dysfunction, the authors look at erectile dysfunction, Peyronie’s disease and hypoactive desire disorder.
Dr Odunayo Kalejaiye Urology SpR, Professor Raj Persad Consultant Urologist, Honorary Professor of Urology. Dr Jon Rees GP Partner,Department of Urology North Bristol NHS Trust
In this second part of the series, we will explore the other common sexual dysfunctions.This includes erectile dysfunction (ED), Peyronie’s disease and hypoactive desire disorder.
ED is defined as the persistent inability to attain and/or maintain erection sufficient for satisfactory sexual performance.1 The Massachusetts Male Aging Study (MMAS) was one of the first studies to estimate the incidence of ED.1 It reported an annual incidence per 1,000 of 12.4 in men aged 40-49 and 25.9 in men aged 40-69. A more contemporary study found that one in four newly diagnosed cases of ED was in men aged 40 years or less.2 In addition, young men had significantly lower rates of co-morbidities, lower BMI but more frequently reported smoking and illicit drug use2. The rates of severe ED were 48.8% versus 40% in older men.
Severe ED was defined using the International Index of Erectile Function (IIEF) questionnaire. This validated questionnaire consists of 15 questions which assess the five domains of sexual function. Severe ED is a score of ten or less with a score of 26-30 indicating normal erectile function. ED is significantly associated with diabetes, heart disease, hypertension, smoking and obesity. The correction of risk factors has been shown in multiple studies to improve erectile function. The presence of ED in a young man should always alert the physician to the possibility of future risk of cardiovascular disease (CVD). ED may precede clinically overt CVD by two-five years, therefore offering a window of opportunity for early risk modification.3
- Presenting complaint:
- Clarify nature of problem
- Duration: lifelong vs new
- Onset: gradual vs sudden
- Organic vs psychogenic (see table 2)
- Severity (consider IIEF-questionnaire [www.baus.org.uk/Resources/BAUS/Documents/.../iief.pdf])
- Precipitating or exacerbating factors
- Relationship problems
- Any associated sexual problems
- Drug history: illicit or prescription drugs
- Psycho-social history
- Underlying condition (see above)
- Exclude hypogonadism.
- Psychosexual counselling
- Correction of risk factors
- Oral medications.
Correction of risk factors
The mainstay of oral medications is the use of phosphodiesterase-5 inhibitors (PDE-5i). The three most commonly used PDE-5is are sildenafil, tadalafil and vardenafil. They each have different pharmacokinetic and side effect profiles. It is important prior to starting them to counsel the patient about their appropriate usage, side effects and interactions with fatty meals. The PDE-5i chosen should be patient dependant; for example those who desire spontaneity may be best managed with tadalafil with its long duration of action while sildenafil is associated with the hardest erections. We recommend using the maximum dose on commencement of treatment and trialling more than one PDE-5i before labelling the patient as a non-responder. Non-surgical options include a vacuum device and the administration of alprostadil. The vacuum device provides negative pressure to the penis to produce an artificial erection. The efficacy is estimated to be 90% although men may complain of a cold erection, penile pain or numbness. Alprostadil is synthetic prostaglandin E which may be administered intracavernosally or intraurethrally. Men will need to be taught how to administer the drug and warned of potential adverse events. The efficacy of intraurethral injection is estimated to be 85%.
The indications for the provision of PDE-5i on the NHS include distress caused by ED, pelvic surgery, diabetes, renal dialysis and neurological disease.
Hypoactive sexual desire disorder (HSDD)
HSDD is the most common sexual dysfunction experienced by psychiatric outpatients.9 Schizophrenia, depression and their drug treatments may all be associated with HSDD. The drugs which may adversely affect desire include tricyclic antidepressants (TCA) and selective serotonin uptake inhibitors (SSRIs). HSDD may result in non-compliance which may subsequently lead to relapse of the man’s psychiatric condition. It is therefore vitally important that sexual function is assessed at baseline and during treatment.9
- Diabetes mellitus
- Cardiovascular morbidity and mortality.12
Peyronie’s disease (PD)
- Acute inflammatory
- Quiescent chronic fibrotic
Men should ideally be reviewed both on their own and with their partner to determine and manage any relationship problems and psychological or psychiatric ill health. Sexual dysfunction may be the presenting symptom of serious underlying conditions such as diabetes, hypogonadism or major depression. It may also be taken as an early warning of future ill health in the form of the metabolic syndrome and cardiac disease. This may allow the opportunity to modify and reduce risk factors to lower future disease possibly with early referral to cardiology. It also provides an opportunity for reassurance regarding what is normal and that sexual function varies over time. The clinician should use unambiguous questions covering desire, spontaneous and stimulated erections, ejaculation and orgasm. Psychotherapy and counselling is an important aspect of treatment.
This is a common problem and only a small number present to clinicians. Therefore a systematic and sympathetic approach is required. The clinician must be comfortable discussing all aspects of sexual function.
2. Capogrosso P, Colicchia M, Ventimiglia E et al. JSM 2013; 10(7): 1833-41
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5. Esposito K, Giugliano F, Di Palo C, et al. JAMA 2004; 291:2978–84.
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8. Glina S, Sharlip ID, Hellstrom WJG. J Sex Med 2013; 10:115–19.
9. Meuleman E, Van Lankveld. BJUI 2005; 95: 291-6
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11. Wijesinha S, Piterman L, Kirby C. Australian family physician 2013; 42(5): 276-8
12. Isidori A, Buvat J, Corona G et al. EU 2014; 65: 99-112
13. Hatzimouratidis K, Eardley I, Giuliano F et al. EU 2012; 62: 543-52
14. Carson C, Levine L. BJUI 2014; 113: 704-13