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GPs go forth

Erectile dysfunction query raised by widower's new relationship

Dr Melanie Wynne-Jones discusses

Dr Melanie Wynne-Jones discusses

Case history

Mr Jones, who is 73, looks embarrassed. With difficulty, he tells you that his wife died of lung cancer last year, but he has met a 'nice lady' with whom he would like to start a physical relationship. Unfortunately, their first attempt was unsuccessful due to his erectile dysfunction. He wonders whether anything can be done.

Are you OK with this?

Mr Jones is embarrassed – if he thinks you are, too, he may feel judged or give up, so you need to show empathy and signal that this is an acceptable topic for discussion.

But talking to patients about sex can sometimes be difficult, especially if we have our own issues. For example, we may feel shocked that someone could start another relationship 'so soon', or we may be experiencing problems in our own sexual relationship.

Some patients' problems relate to sexual preferences or behaviour that make us uncomfortable, or we may find it difficult to discuss sex with someone much older, younger, or of one particular gender.

Being self-aware and dealing with our own feelings is important, as in many consultations. If necessary, you could suggest Mr Jones consults another, 'more expert' doctor in the practice, and reflect on the situation later.

What is causing Mr Jones's erectile dysfunction?

The three most likely explanations are performance anxiety, vascular problems and unresolved grief issues. Telling Mr Jones the cause may be physical or emotional, but you will probably be able to help, is positive and you can decide jointly which area to discuss first.

If you were also his wife's GP you would already know something about their relationship and her final illness, although nothing should be assumed. He may not wish to discuss her today; if he does, you could ask what she was like, how her illness progressed, and how it affected him at the time, afterwards, and now. This may tell you whether guilt, grief or other people's attitudes (for example his children's) are relevant.

You may need to explore this in greater depth; he may be depressed, drinking too much, or need formal bereavement counselling. You may even uncover longer-term sexual or relationship problems that affected his marriage, too. On the other hand he may have made a reasonable recovery, and be ready for his new relationship.

What are the physical causes of ED?

One in 10 men suffers from ED at some stage in their lives, and 50 per cent of men over 40 have problems at least occasionally. In one survey, one in five men felt they couldn't even speak to their partners, and a quarter said ED had led to separation or divorce. How did Mr Jones's new partner react?

ED was once thought of as a mainly psychological problem, and stress and depression can certainly trigger ED, but in at least four out of five cases there is a contributory physical problem. Loss of morning erections, or an inability to get an erection at any time, suggest a physical cause such as:

  • Vascular disease – as many as two out of three men with CVD suffer from ED prior to their first cardiovascular event
  • Diabetes
  • Spinal cord damage
  • Other neurological disease, such as multiple sclerosis
  • Prostatectomy
  • Excessive alcohol intake
  • Liver or renal failure
  • Medication including ß-blockers, thiazides and antidepressants

What should you look for in ED?

Ask about Mr Jones's general physical health; does he have any cardiovascular, neurological or urological symptoms? Does he smoke, drink or use other drugs? Has he ever had a sexually transmitted infection? Men who have repeated ED should be asked about problems with desire, orgasm and ejaculation, the situations where ED occurred and whether the onset has been abrupt or gradual.

It may be appropriate to examine him now, or to defer examination because of time or Mr Jones's preference. You'll need to check his pulse, blood pressure and abdomen; examine his testicles, prostate, and the circulation and neurology in his legs. Dipstick his urine, and carry out blood tests for liver, renal and thyroid function, glucose, lipids, PSA and testosterone levels if appropriate. These may prompt referral for further investigations.

What help can you offer?

Any abnormal findings such as diabetes or hypertension will need treatment in their own right. His JBS2 cardiovascular risk assessment may suggest that he would benefit from medication to lower his cholesterol. Improving his general health, cutting his alcohol intake and stress levels, or improving his lifestyle, will benefit him generally and may cure his ED.

If this doesn't work (and unless he takes nitrates or has seriously unstable cardiovascular disease) Mr Jones should be able to take phosphodiesterase type-5 inhibitors such as sildenafil, tadalafil or vardenafil. These release nitric oxide, promoting erection, but don't work without sexual stimulation.

Advise your patient that some men need to take the strongest dose or use the drug several times before the full effect is reached. Suggesting he tries the medication alone first may give him confidence, but it's often worth seeking the partner's views and support when prescribing any form of ED treatment. Treatment is free for men with specific physical diseases (see BNF).

It's possible to buy PDE5s over the internet, but unless reputable online pharmacies are used, patients risk buying expensive or even dangerous counterfeit drugs. Alternative treatments include intra-urethral alprostadil, intracavernosal alprostadil injections, vacuum devices and penile prostheses. Testosterone supplements are sometimes indicated. These treatments are usually initiated in secondary care.

Melanie Wynne-Jones is a GP trainer in Marple, Stockport

Key points

  • Sex-related problems can trigger complex emotions in doctors as well as their patients
  • Starting a new sexual relationship after bereavement may be difficult
  • ED is common and distressing
  • Physical factors contribute to the majority of cases of ED in the over-40s and it may be a harbinger of serious cardiovascular disease
  • PDE5 drugs are generally safe and effective but some patients prefer other treatments

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