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Erectile dysfunction in diabetes: Providing a nurse-led referral service

Margaret Boyd

Erectile dysfunction (ED) is defined as the inability to achieve an erection that is adequate for intercourse to the mutual satisfaction of both partners (Eardley et al, 1999). At least 50% of men with diabetes will suffer from ED at some time in their life (Fraser, 2004). An audit was undertaken to ascertain the prevalence of ED in the male population with diabetes attending the Royal Infirmary of Edinburgh, to identify groups potentially most at risk of developing this condition and to qualify the need for a nurse-led ED referral service.

Erectile dysfunction (ED) has always been a taboo subject that is avoided both by healthcare professionals and their patients (Cummings, 2006). Unfortunately, it is the most common sexual problem experienced by men with diabetes and some would suggest the incidence may be as high as 60% of men over the age of 60 years (Williams and Pickup, 2005). There are several physical factors which may contribute to ED in men with diabetes, including autonomic neuropathy, vascular disease associated with diabetes and endothelial dysfunction (Eardley, 2003). ED can also have a huge impact on personal relationships and, in the author’s opinon, it is important to encourage the individual’s partner to attend the sessions too.

Initial audit
A total of 180 men attending the routine diabetes review clinic at the Royal Infirmary of Edinburgh between August 2005 and January 2006, completed an anonymous 14-point questionnaire, see Box 1. HbA1c results were collected by matching the date of birth given as part of the questionnaire to individuals on the clinic’s registry and using any recorded HbA1c result.

Audit results
In total, 180 men completed the questionnaire (110 with type 2 diabetes, 70 with type 1 diabetes) and 51.1% (n=92) felt they had a problem either obtaining or maintaining an erection suitable for sexual intercourse. This group had a mean age of 57.6 (SD: 8.3) years and were significantly more likely to have type 2 diabetes than type 1 diabetes (P=0.001). A positive correlation between the duration of diabetes and frequency of ED was observed (r=0.354, P=0.002), however, surprisingly, no association was noted between ED and poor glycaemic control (HbA1c in men with ED: 8.14%; HbA1c in men without ED: 7.75%). Most importantly, in the author’s opinion, was that almost 80% of men with ED were not receiving treatment for the condition but were keen to seek help if it were offered. See Box 2 for full details of the audit findings for the respondents who reported ED.

Service redesign
The data collected from the questionnaire audit highlighted the need to provide a service to men with diabetes and ED. It was also apparent that a referral service was required due to the lack of available referral facilities. Current referral options were either to the local sexual dysfunction clinic at the Royal Infirmary of Edinburgh, which has a waiting time of around 7 months, or to the Urology Department at the Western General Hospital, Edinburgh. In the past, doctors had a tendancy to write to GPs and ask them to prescribe a PDE 5 inhibitor. In this scenario, the individual was generally given a tablet with no education, drug titration or follow up. Understandably, they then reported that the tablets were ineffective. Consequently, the multidisciplinary team at the Royal Infirmary of Edinburgh were more than happy to support the establishment of a nurse-led ED clinic. 

The data also provided evidence for a business plan to apply for funding for the first year. Initially, funds came from a pharmaceutical company and enabled the establishment of the clinic.

Training
Prior to starting the clinic, the author identified that she needed to undertake a degree of training. While she spoke about ED during education sessions as one of the possible long-term complications of diabetes, she needed to learn what caused ED and how to help individuals with the condition with appropriate  and safe treatments.

Pharmaceutical representatives were approached to provide information about specific therapies for ED as well as patient information leaflets and demonstration aids for use in the clinic. Furthermore, they invited the author to symposiums and education sessions addressing ED in diabetes. This helped the author to understand how each therapy worked, what doses were appropriate, contraindications and possible side effects to ensure safe and effective treatment. An ‘educated educator’ also ensured that clinic attendees were educated appropriately with regards to their chosen therapy.  

The author attended the Royal College of Nursing-accredited course NEED (Nurse Education in Erectile Dysfunction), which proved invaluable both in terms of education provision and as an opportunity to network with other healthcare professionals with similar interests. 

The author observed ED clinics to gather ideas for good practice with regards to conducting an ED consultation and administering test doses of intracavernosal injections. This partnership with other healthcare professionals also provided contacts to call on should further help or advice be required.

The referral process
When discussing the long-term complications of diabetes with men during education sessions, educators made the attendees aware that ED is a very common problem associated with diabetes. In the author’s opinion it has proven important to put the individual at ease by using language they understand and ensuring they fully comprehend what is being asked during assessment to ensure the correct information is recorded. This intended to help men with diabetes and ED understand that they are not alone in experiencing the condition and can be a good gateway to discussing the subject. 

These education sessions were undertaken when individuals attended for insulin conversion or to improve glycaemic control on a one-to-one basis and were for both new and returning men. Staff were happier to discuss ED with individuals during these sessions as they were aware of the referral service and they would not have to deal with the problem alone. 

Protocol
Following the audit to qualify the problem and the education to fully understand its management, the author then designed a protocol for a nurse-led ED referral clinic. This was reviewed and approved by a consultant physician. The full protocol is shown in Box 3 and the rationale for its various components are detailed below. For each clinic visit, a one-hour time slot is allocated.

Blood test 
Blood tests to assess testosterone levels are essential regardless of whether or not the individual feels his libido is intact. This is because it is important to check the hormone profile of each man regardless of age. Younger men with an exceptionally low testosterone levels (for example, those aged 30–40 years with free testosterone levels calculated to be below the normal parameters of 10–30nmol/l) are referred to the endocrinology department for possible testosterone replacement therapy. Those with an abnormally high prolactin level, which is not drug related, are also referred to an endocrinologist for further investigations.

Blood pressure
By checking blood pressure, it may be possible to identify the need for changes to antihypertensive drugs, which are known to contribute to erectile problems (for example beta blockers). Uncontrolled blood pressure is addressed: the Scottish Intercollegiate Guideline Network (SIGN) suggest blood pressure targets for all people with diabetes to be below 140/80mmHg (SIGN, 2001). If an man with ED has suboptimal blood pressure, it would be recorded and would be detailed in a letter to his GP when informing the GP of the consultation.

HbA1c
HbA1c is checked and suboptimal glycaemic control (preferably around 7% but certainly below 7.5% [SIGN, 2001]) is addressed by advising on how it can be improved via pharmacological or lifestyle modifications. Target HbA1c should be maintained to prevent the onset and progression of long-term complications.

Weight
Weight is checked and with exercise being the main recommendation to help with weight loss if overweight. The additional benefits of exercise on improvement of ED are outlined: Eardley (2003) suggests that exercise is beneficial  for sexual function and the cardiovascular benefits of exercise have been frequently observed. A consultation with a dietitian is offered for those who need additional assistance in diet management.

Medical examination
A past medical history is taken paying particular attention to cardiac problems and current medications are noted. The effects of smoking and excessive alcohol on ED are discussed and are discouraged. 

Prior to referal the clinic requires that a physical examination is undertaken by a doctor to rule out alternative sources of the dysfunction, for example, Peyronie’s disease. If an examination has not been carried out or, for example, if the patient complains about an abnormality, the diabetes registrar will assist the nurse with a physical examination during the appointment.

Treatment
After assessment, psychosexual counselling is offered if deemed appropriate and a referral to a counsellor can be made. There is a long waiting list for psychosexual counselling, around 7 months at Royal Infirmary of Edinburgh, but one which is possibly less at other sexual health clinics in the area. This service is free and consists of several visits by the couple to the counsellor. The man with ED may also see a counsellor on a private basis. Private funding of counselling can result in an appointment being made with a much shorter waiting time.

Current available pharmacological therapies are discussed in detail, including the action and duration of each agent, administration methods, titration guidelines and possible side effects. At present, pharmacotherapies offered in the author’s clinic include sildenafil citrate (Viagra, Pfizer), tadalafil (Cialis, Eli Lilly & Company), vardenafil (Levitra, Bayer Healthcare) and alprostadil (Caverject, Pfizer; Muse, Meda Pharmaceuticals). See Box 6 for more information. Dose titration is recommended for all of the above therapies to achieve a satisfactory erection which should last approximately half an hour to one hour.

All of the above therapies may cause a priapism:  a prolonged erection of >4 hours in duration. If this occurs, exercise or a cold shower can often diminish the symptoms. If the erection persists, advise the individual to go to their local A&E: the proceedure used to reduce the erection will be insertion of a butterfly needle into each side of the penis to draw approx 20ml of blood.

Vacuum devices and constriction bands can be used in men who are unable to maintain their erection either with or without the use of a PDE-5 inhibitor (see Figures 4 and 5). The constriction band may stay in situ for a maximum of 30 minutes. As per the instruction leaflet, caution should be taken when any individual is taking antiplatelet therapy and these devices should not be used in conjunction with warfarin.

Vacuum erection devices enables the individual to obtain an erection which is then maintained with a constriction band. Erections can feel cold to partner and may pivot at the base of the penis. Caution is once again advised with antiplatelet therapy.

Each individual is given a choice of treatment options and invited back for follow up after 2 months. Contact details are given if further help or advice are required in the interim.

Outcomes
Locally, the existing facilities for treating ED had extremely long waiting lists of around 7 months. The new nurse-led ED clinic run by the author runs for 4 hours per week and men referred with ED are now able to be given an appointment for initial assessment within a month. 

Referrals were initially taken from members of the multidisciplinary team within the secondary care setting. However, this service has now been extended so that primary care practitioners can refer men with diabetes for education, assessment and treatment of ED. Individuals can also self refer. The author has noted that the multidisciplinary team are happier to approach the subject of ED with their patients in the knowledge that the individual can be referred on for assessment and appropriate treatment.

To date, 14 months after the nurse-led ED clinic opened, 79 men with diabetes and ED have reported successful outcomes at their follow-up appointment.

REFERENCES:

Cummings M (2006) Managing Erectile Dysfunction. Altman Publishing, St Albans 
DoH (1990) National Health Service and Community Care Act 1990 (c. 19). Available at:http://www.opsi.gov.uk/ACTS/acts1990/ukpga_19900019_en_2#pt1 (accessed 15.11.2007)
Eardley I, Sethia K and Dean J (1999) Erectile Dysfunction: A Guide to Management in Primary Care. Mosby-Wolfe, London
Eardley I (2003) Therapy for Erectile Dysfunction: Pocketbook. Taylor & Francis, Reading
Fraser M (2004) Erectile dysfunction in diabetes: An Introduction. Diabetes Digest 3(suppl)
Mayo Clinic Staff (2006) Testosterone therapy: The answer for aging men? http://www.mayoclinic.com/health/testosterone-therapy/MC00030 (accessed 15.11.2007)
Secretary of State for Health (1999) Directions under the National Health Service and Community Care Act 1990 Schedule 2 Paragraph 6(2). Available at:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsLegislation/DH_4117087 (accessed 15.11.2007)
SIGN (2001) Management of Diabetes: SIGN Publication No. 55. Available at:http://www.sign.ac.uk/guidelines/fulltext/55/section5.html (accessed 15.11.2007)
Trigwell P (2005) Helping People with Sexual Problems – A Practical Approach for Clinicians. Elsevier, Oxford 
Williams G, Pickup JC (2005) Handbook of Diabetes 3rd Edition. Blackwell Publishing, Oxford

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