SortEDin10 Top Tips for Nurses
This guide has been written by Lorraine Grover, Clinical Nurse Therapist in Sexual Wellbeing to help provide nurses with a practical guide to managing patients with diabetes mellitus and erectile dysfunction (ED).
The role of nurses in identifying the risk of ED through co-morbidities is vital, particularly with GPs having less time to address such conditions and provide the service necessary to reassure these patients. Nurses need to be proactive in asking men with diabetes about ED. NICE guidelines state that all patients with Type 2 diabetes should be reviewed annually for ED 34.
There are approximately 2.3 million men living with ED in the UK, but it is estimated that only 10% are being treated 42
ED affects 50% of men between the age of 40-7014 and over half of all men with diabetes may be affected by ED10
Despite this, as many as 80% of men with diabetes have never been provided with information regarding sexual health / sexual relationship issues associated with diabetes 11
Sexual activity may be a normal part of life to varying degrees for patients in (or not in) a relationship. Those who are presently not in a relationship may wish to do so, but avoid it due to their sexual difficulties. Being able to help and support a patient in this intimate area of their life can be very rewarding for all concerned. When talking to a patient about sexual issues it conveys that you are comfortable to do so. It can help them understand that you see it as an important part of their health and wellbeing.
Asking questions regarding sexual function should become routine, and thereby ‘normalised’ in history taking. Starting to ask about sexual function for the first time can be seen to be difficult. It is important to use words to ask about sexual function that you and the patient understand.
I have found the following to be helpful. The three words which can make this easier are ‘In my experience’ for example:
“In my experience patients with diabetes can have sexual difficulties such as erectile dysfunction, let me know if that happens as there is help that can be given”.
It can help to alleviate anxiety and potential suffering, as it gives the opportunity for the patient to talk about it either ‘there and then’ or next time. It informs patients that you understand that there may be sexual difficulties and you are able to help. You may need to clarify what ED means.
There can be ambiguity when asking about ED and other terms can be used such as ‘Is everything OK down there?’
44% of men say they would not consult their GP/nurse if they experienced erection problems 24. ED is a really embarrassing topic for most men and they are unlikely to mention any problems themselves. It is really important to make patients feel comfortable and encourage them to discuss any problems they might be experiencing.
Talking about sexual issues requires privacy. Be thoughtful as to where you have the conversation. To help ignite the conversation having posters or leaflets in waiting or clinical rooms can help. This will add to providing an environment where help and advice can be obtained and discussion can be routine. Using questionnaires in clinics for patients to complete such as the Sexual Health Inventory for Men (SHIM) or the International Index of Erectile Function (IIEF) can initiate the conversation 40.
A lack of confidence and self esteem may exist in men with erectile dysfunction. This may impact in several areas of their life such as relationship(s), and work, not only sexual activity.
The World Health Organization (WHO) declaration on sexual health states; ‘There exist fundamental rights for the individual, including the right to sexual health and a capacity to enjoy and control sexual and reproductive behaviour in accordance with a social personal ethic’ 24. If you are starting to ask patients about their sexual function, you may need to have confidence in yourself! Initially this may seem daunting but as you gain confidence it will become easier.
Some of the medical conditions that can commonly affect ED and other areas of sexual function include cardiovascular disease, diabetes, spinal injuries and some cancers. ED is also a side-effect of some medicines, including diuretics, antihypertensives, steroids and antidepressants 35. Some of these medical conditions can co-exist, so it is important that patients’ overall medical situation is considered. An overriding effect that can be overlooked is that even if there is a medical cause for the ED, it can certainly have an impact on the psychological wellbeing of the man. This should not be overlooked and a combined medical treatment, sex therapy and couple therapy should be considered wherever possible.
It can be beneficial to have sex therapy as an adjunct to treatment with pharmacotherapies to enhance and improve the situation. There are three oral medications that have revolutionised the treatment of men with ED. Often these drugs are now widely prescribed as a first option for treatment. They are known as phosphodiesterase type 5 inhibitors (PDE5is), and are Levitra® (vardenafil) 4, Viagra® (sildenafil citrate) 38 and Cialis® (tadalafil) 13. Patients may tolerate and respond differently to all three drugs; therefore it is essential to find the treatment which works best for them.
Low testosterone levels can cause ED and also prevent PDE5is working properly. The British Society for Sexual Medicine (BSSM) Guidelines on The Management of Erectile Dysfunction state that all patients presenting with ED should have their serum testosterone levels measured (taken between 8 and 11 am) and if low, this measurement should be repeated on a further morning blood sample 18.
Other treatment options may involve MUSE® (intraurethral alprostadil) 30, Caverject Dual Chamber® 39 or Viridal Duo® (intraurethral alprostadil) 49, a vacuum constriction device or penile implants.
It is helpful for patients to have an understanding as to the contributory factors of their ED. Managing patients may start by discussing potential lifestyle change and how this can be of benefit. Factors which patients can modify themselves such as stopping smoking, improving diabetes control, weight reduction and improve communication with sexual partner can be of great benefit.
Treatment with pharmacotherapy may be first line, BUT having additional psychosexual input can have considerable additional benefit. Initiating sexual stimulation for PDE5is to be effective can be daunting if it has not happened for several months or years! First dose efficacy has been reported as the most important treatment attribute, alongside speed of action, by men with ED 23.
Patients may have been embarrassed to seek help, or not known who to ask advice from in the past regarding their erectile dysfunction, the first opportunity of offering management and treatment is important.
After discussing sexual function, in particular ED, you may have a good understanding of how to manage the situation yourself or feel ‘out of your depth’. To enhance the consultation further you may direct them to other areas where additional advice can be obtained either with fact sheets or help lines i.e. The Sexual Advice Association (SAA) (www.sda.uk.net) Diabetes UK (www.diabetes.org.uk), Relate (www.relate.org.uk), British Association of Sex and Relationship Therapists (www.bssm.org.uk). Forming links with other members of staff in your department or region who are able to help can be of great benefit.
Having a reading or viewing list of books/DVD which you can recommend to patients is helpful.
Patients who are not in a relationship should not be denied discussion regarding their sexual function. Age should not be a barrier. Partners may ‘sabotage’ treatment for various reasons. Asking partners (when they are present) ‘do they have any concerns regarding treatments discussed?’ can be extremely helpful. There are still myths and misconceptions regarding the use of PDE5is and cardiac disease. Patients who are known to have a ‘stable’ cardiac condition can be assessed for treatment with a PDE5i. The Princeton II Guidelines include an algorithm for assessing cardiac risk 28.
Knowing if the patient used the pharmacotherapy correctly is important. In particular, when oral pharmacotherapy is used, asking if the maximum dose of drug was tried with sexual stimulation can affect a positive outcome.