Erectile Dysfunction

Casebank History
1

Approach

GRIPS

Presenting Complaint

  • Patient: I’ve got an embarrassing problem
    – This is not the place where you directly offer confidentiality because pt is not embarrassed about something that you’ll discuss beyond medical team. Here patient is referring that he is embarrassed to talk with you about something. So your response is, “we’re professionals, we see all kinds of different problems in different patients, therefore, there is nothing to be embarrassed about.”
    – After this you can add confidentiality. “Whatever we’re discussing we remain confidential within our medical team.”
    – “Therefore, can you tell me what is bothering you?”
  • Patient: (Sharing directly) I’ve got problem with my erection.
  • Patient: (Sharing indirectly) Doctor, I can’t perform down there.
    – Here you need to clarify what they mean. “Can you tell me, what you mean by can’t perform down there.”

The Severity Of Erection:

  1. How would you rate your desire for sex on a scale 1 to 5, 1 being the lowest?
  2. How often you get erection when you want to have sex on a scale of 1 to 5?
  3. How often do to get hard enough to penetrate your partner on a scale 1 to 5?
  4. How often you manage to sustain an erection?
  5. Do you get morning erection?

Past and current relationships

  • How long have you been in your current relationship?
  • Did you have any similar problems in your previous relationship?

Causes of Erectile Dysfunction:

  1. Psychological Causes:
    – Any recent changes in relationship?
    – Sudden onset?
    – Decreased Libido?
    – Good quality spontaneous or self stimulated erection?
    – Major life event or stress?

  2. Medical Condition:
    – Hypertension?
    – Diabetes?
    – IHD?
    – ВРН?

  3. Lifestyle:
    – Alcohol
    – Smoking
    – Recreational drug

Examination

  1. BMI
  2. Examine Genitalia
  3. Digital rectal examination

Investigation:

  1. HbA1c or Fasting Glucose
  2. Lipid Profile
  3. Morning Testosterone

ICE

  • IDEAS: have you thought of anything that could be the cause?
    Was there any stress in your life before the problem starts?
  • CONCERNS: is there anything else you are worried about?
    P: I’m worried about my partner, she thinks I’m not interested any more.
  • EFFECT: has this affected your relationship with your partner?
    P: Yes, it’s affected.

Diagnosis

  • Erectile dysfunction due to the medication you’re receiving.

Scenario A

Erectile dysfunction due to beta blocker (Bisprolol)

You’re FY2 in GP.
The drug has started by GP.
Erectile dysfunction affects the relationship.

Management:

  1. Stop the beta blocker (bisprolol)
  2. Prescribe a different medication for hypertension (ACEls or Calcium channel blockers) depending on whether they are older than 55 or younger.
    Inform about ACEIs side effects: cough and affect kidney. Therefore, 2 week follow up, to investigate U&E.
  3. Offer Viagra
  4. Offer counselling for both partners, couple counselling.
  5. Offer Leaflets

Scenario B

FY2 in GP
Patient referred to cardiologist for heart problem (IHD, HF or LVD), consultant started beta blocker ( Bisprolol).
Developed erectile dysfunction & Raynaud phenomenon

Presenting Complaint

  • “Doctor, I want to stop taking this medications”
    – He doesn’t openly say the problem unless you asked them directly.
    – When you explore why he wants to stop the medication, he’ll say because he has pain in the finger and feels tired all the time.
    – Common error: thinking this is a end of life discussion because of the heart failure and refusing to take medications.
    – Here you should explore which medication is causing the side effects and what other side effects is caused by that medication. Hence, exploring other side effects of Bisprolol, which includes, SOB at night, erectile dysfunction, etc.

Management

  • Talk to cardiologist over call to get their advice before stopping bisprolol.
  • Explain that the cause is bisprolol and it will be stopped after talking to cardiologist.
  • Explain other side effects of beta blocker like wheeze and shortness of breath.
  • Offer viagra.

Scenario C

  • No obvious cause of erectile dysfunction
  • Perform examination and investigation as discussed.

Management

  • Offer viagra
  • Offer leaflets
  • Follow up in 6 to 8 weeks.
  • Exclude psychological :
  • if psychological, refer for the couple therapy.
7 Likes
2

Am I supposed to call cardiologist or I will refer to cardiologist for medication review?