Medical Chroniclehosted a product webinar on the topic: Managing erectile dysfunction – from Primary care to Specialist. This webinar was sponsored by Eli Lilly.  

Dr Kgomotso Mathabe (urologist) and Dr Julien Trokis (diabetologist) discussed the treatment outline of the ED patient

Dr Kgomotso Mathabe and Dr Julien Trokis recently presented the treatment outline of erectile dysfunction patients in the context of primary care and specialist care as well as the management of comorbid diseases that accompany the diagnosis. This webinar was made possible by Eli Lilly. 

Dr Julien Trokis is a diabetologist who, besides running a busy diabetes clinic, Diabetes Care Centre, Cape Gate, also runs a large clinical trial centre, and has been an investigator in over 80 clinical trials, approximately half of which were as principal investigator. Due to his special interest in diabetic kidney disease, he has been the national principal investigator for South Africa in two large international clinical trials in diabetic kidney disease. 

Dr Kgomotso Mathabe is a specialist urologist practicing at Steve Biko Academic Hospital. In 2011 she became the first woman to qualify as a Urologist from the University of the Witwatersrand and the second black woman Urologist in South Africa. 

The following article is based on their presentations.  

Erectile dysfunction (ED) affects 34%-45% of men with diabetes, and 40% of men >60 years with diabetes have complete ED. 

ED negatively impacts the quality of life, and it is recommended to screen all adult men with diabetes regularly as part of sexual function history. 

Risk factors for ED 

  • Age 
  • Smoking 
  • Glucose control 
  • Diabetes 
  • Metabolic syndrome 
  • Hypercholesterolemia  
  • Hypertension  
  • Sedentary lifestyle  
  • Heart disease 
  • Surgery (prostate, bladder, colon, rectal) 
  • Medications 
  • Spinal cord injury 
  • Hypogonadism. 

 Recommendations 

    1. All adult men with diabetes should be regularly screened for ED with a sexual function history  
    2. A phosphodiesterase type 5 (PDE5) inhibitor should be offered as first-line therapy to men with diabetes and ED in either an on-demand or daily-use dosing regimen 
    3. Men with diabetes and ED who do not respond to PDE5 inhibitors should be investigated for hypogonadism with measurement of a morning serum total testosterone level, drawn before 11 am 
    4. Referral to a specialist in ED should be considered for eugonadal men who do not respond to PDE5 inhibitors or for whom the use of PDE5 inhibitors is contraindicated. 

 

Custodian of the processes 

The pivotal role of the primary level of care is the coordination of care and establishing a relationship with the patient, possibly over many years. History taking should include an overview of family circumstances including stressors and finances. 

This is the anchor point for various specialities, managing the patient holistically not just treating an aspect of their person. The primary caregiver should also be aware of polypharmacy, especially if the patient is also seeing a specialist.  

GPs often need to advocate for the patient, including to medical aids. 

In terms of what can be done at the primary level, this includes the basics plus some special investigations (for if the patient sees a specialist, with all the results). The patient might be able to see a specialist only once, instead of a return visit at extra cost. 

The primary caregiver should do the following, using the mnemonic, HELP: 

      • History 
      • Examination 
      • Leads/ special investigations 
      • Plan. 

Screening tools

The International Index of Erectile Function (IIEF): in the abbreviated form involves five questions. The Sexual Health Inventory for Men (SHIM) is another option and these can be given to all adult males while in the waiting room. 

Beyond primary level 

Beyond the primary care level, there are a variety of specialists available for referral, depending on the needs of the individual: urologist, physician, endocrinologist, cardiologist, psychologist, sexologist or others, based on the needs of the patient. 

The role of the urologist 

The urologist will look at the sexual function: male sexual dysfunction in ED, premature ejaculation, and dyspareunia. Fertility and other genitourinary conditions such as hypogonadism, benign prostatic hyperplasia, and prostate cancer will also be assessed. 

The urologist assessment might include:  

      • Young patients who have always had difficulty (psychosexual history is important) 
      • Patients with a history of trauma (isolated vessel injury) 
      • Abnormal testes or penis found on examination 
      • Initial screening tests indicate a significant abnormality 
      • Patients who have failed to respond to treatment. 

Hypogonadism 

Hypogonadism is distinguished by low testosterone. It is a congenital or disorder of sexual differentiation. It can be acquired before puberty, if acquired after puberty it is part of andropause/ testosterone deficiency syndrome. 

Testosterone replacement in the hypogonadic patient 

Aspects to pay attention to include: 

      • Formulations and frequency of administration 
      • Effects and side effects 
      • Ideal formulation: testosterone undecanoate 
      • Triggers for initiation of therapy 
      • Investigations before initiation of therapy 
      • Follow-up on therapy. 

Treatment options, beyond the holistic management of primary level care, include pharmaceutical and surgical options. World Health Organization guidelines advocate a stepwise approach. When deciding on which PDE5 inhibitor to use, considerations include safety in terms of contraindications and drug interactions. To achieve treatment success, it is important to manage the expectations of the couple, allaying concerns and myths. 

Safety concerns with PDE5 inhibitors 

In terms of cardiovascular safety, all PDE5 inhibitors are contraindicated in:  

      1. Patients who have suffered from a myocardial infarction, stroke, or life-threatening arrhythmia within the last six months 
      2. Patients with resting hypotension (blood pressure <90/50mmHg) or hypertension (blood pressure >170/100mmHg) 
      3. Patients with unstable angina, angina with sexual intercourse, or congestive heart failure categorised as New York Heart Association Class IV (106,194-196).  

Kidney or hepatic dysfunction may require dose adjustments or warnings. 

Drug interactions with PDE5 inhibitors 

Nitrates are contraindicated with PDE5 inhibitors, as are antihypertensive drugs. In general, the adverse event profile of a PDE5 inhibitor is not worsened by a background of antihypertensive medication, even when the patient is taking several antihypertensive agents. In terms of α-blocker interactions, all PDE5 inhibitors show some interaction with α-blockers, which under some conditions, may result in orthostatic hypotension. 

Drugs that inhibit the CYP34A pathway will inhibit the metabolic breakdown of PDE5 inhibitors, thus increasing the PDE5 inhibitor’s blood levels. Therefore, lower doses of PDE5 inhibitors are necessary. However, other agents may induce CYP3A4 and enhance the breakdown of PDE5Is, so that higher doses of PDE5Is are then required.   

Choice of PDE5 inhibitors 

Factors that may affect the choice of PDE5 inhibitors include medication-related, in terms of efficacy, reliability and rigidity. Safety, tolerability, reputation, duration of treatment and cost also play a role. 

Patient-related factors include age, marital status, culture, finances, comorbidities and expectations. 

As a physician, you would base your decision on experience, familiarity and expertise. 

Take-home messages  

    • Not all patients with ED need a referral to a specialist 
    • Primary level care is pivotal in the management of these patients 
    • The decision of which specialist to refer to made by primary care physician 
    • ED is an evolving condition with modifiable risk factors 
    • Stick to the basics: HELP 
    • Medicate when indicated 
    • Reassess effectiveness, side effects and worsening condition.