Erectile Dysfunction And Cardiovascular Disease Health And Social Care Essay
Cardiovascular disease (CVD) is a disease of the heart and circulatory system (BHF, 2008). Examples are myocardial infarction, coronary heart disease, stroke, heart failure, hypertension and peripheral vascular diseases (BHF, 2008). According to BHF statistics, CVD is the main cause of disability and death in United Kingdom (UK) and accounts for 198,000 deaths each year. In addition, it is the leading cause of premature deaths, that is, deaths below the age of 75 years. In 2006 for example there were 53,000 premature deaths in UK (BHF, 2008). It also cost UK £26 billion annually in terms of direct cost, loss of production and informal cost (Jowett and Thompson, 2007, P1). CVD has a significant impact on patients' family, social, economic, physical and psychological lives. In addition, their sexual lives are affected.
This topic was chosen because though research has come out clearly that, ED is an early sign of CVD, it has not received the much needed attention due to several factors such as lack of information, the attitude of patients and that of the health professionals. This essay will explore the relationship between ED and CVD and analyse whether effective reporting, assessment and management of ED will reduce the prevalence of CVD. Recommendations on what should be done to improve reporting, assessment and management will then be given.
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ED is the persistent difficulty in achieving, sustaining and or maintaining an erection long enough to attain satisfactory sexual activities (Wylie, 2007). It affects 50% of men aged 40-70 years and 3 times higher in men over 70 (Feldman et al, 2000). It has significant effects on one's self esteem leading to isolation and depression as well as relationships break downs (DiMeo, 2006). Its sufferers do not want to talk about it as they feel embarrassed (Baldwin, Ginsberg and Harkaway, 2003). The causes can be organic or psychological (Hood and Kirby, 2004). It has been further explained that the organic ED can result from neurological, hormonal or vascular factors as well as drug-related causes. Conditions such as hypertension, diabetes and vascular diseases that affect the arterial blood supply impair erection and the ability to sustain an erection long enough for sexual activity. This raised the question whether there is a relationship between ED and CVD.
According to Duffy (2008) the physiology and psychology process that make up sexuality can be affected by the presence of chronic diseases of which CVD is part. It is therefore not surprising patients with CVD do have ED.
Haro et al (2006) performed observational study on 1362 patients suffering from ED in UK. It was found out that 32% were having CVD. Though there was a recall bias with this study, it emphasises there is relationship between CVD and ED. Ma et al (2008), also studied 3,206 Chinese men with ED and it was shown the incidence of CVD was twice as much higher than those without ED. Although the sample was large it might not be a true reflection for UK due to geographical and ethnic reasons. Hodges et al (2007) assessed the temporal relationship between ED and CVD on 207 patients with history of CVD and 165 as control group across UK. It was found out 66% of CVD group has ED. The sample number was small and from 16 general practices may not reflect the true picture in UK.
Though these researches have their limitations, they still enforce the link between ED and CVD. As Solomon et al, (2003) stated a patient can start with ED and end up with CVD or vice versa with the incidence ranging from 39% to 64%. Jackson et al (2002) asserted that they commonly coexist and share the same risk factors namely obesity, smoking, hyperlipidaemia, sedentary lifestyle, age with the common factor being endothelial dysfunction.
Kirby, Jackson and Simonsen (2005) explained that the endothelium that lines the luminal of blood vessels helps with the smooth flow of blood and produces Nitric Oxide which prevents the formation of atheroma and blood clots as well as preventing unstable atheroma plaque from rupturing. According to Kirby et al, it also has a vasodilatation effect allowing the vessels to dilate enough to allow blood flow. Impairment to any of this function causes narrowing or blocking of the vessels which affect the blood supply to the area. The authors further stated that, the penile arteries are affected early since they have smaller diameters. If no remedy is given to stop the theroma from forming equally the large ones will also be affected. This explains why ED can precede CVD although not all patients with ED end up with CVD when the cause of ED is due to structure abnormalities and trauma to pelvic area and spinal cord (Hood and Kirby, 2004). There is therefore the need to intervene with lifestyle modification advice and medication.
Apart from the endothelium dysfunction, it is well documented that some antihypertensive drugs such as non-selective as non-selective beta-blockers, thiazide diuretics, calcium channel inhibitors and angiotensin11 antagonists used to treat patients with hypertension cause ED (Shiri et al, 2007). This implies that most patients have implicated all antihypertensive drugs to caused ED. Benue, Haafkens, Agyemang, Schuster and Williams (2008) found out some patients believe these drugs are harmful to the body especially the male organ which affect their sexual performance. As a result of this most patients do not take their medication, making it difficult to control their blood pressure. It has been observed in the clinical area that some patients between the ages of 40-60 who have high blood pressure readings are difficult to control despite potent drugs and life style modification advise. This needs to be looked into to ascertain the cause. The consequence of this non-adherence is stroke, atrial fibrillation, myocardial infarction and others (Garner, 2010).
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Finally, psychological fear and anxiety of having another episode during sexual activity is a concern for CVD patients and their partners (Steinke, 2000). Some patients do attempt and fail while others stay away. Ability of a male to perform sexual activity satisfactorily confirms and confers on him his manhood and identity, (Pontin, Porter and McDonagh, 2002). Therefore, if a male is unable to function sexually, it affects the role he plays as a man in the world, feeling his identity is taken away. It can affect the way he views society, dissatisfied with life and stressful (Jack, 2005). The consequences of low self esteem, social stigma, feeling of loss of manhood, isolation, and poor relationship and partner break down according to Doggett-Jones (2007) can lead to disorders such as anxiety and depression which affects libido and self-image. This accounts for increasing numbers of CVD patients suffering from depression (Garner, 2010). Instead of dealing with the underlying ED these patients are put on antidepressants which also contribute to ED making their situation worse off (Seftel, Sun and Swindle, 2004).
Duffy (2008) likewise stated that sexuality is an integral part of one's existence, a vital aspect of humanity and essential determinant factor of one's health status. Lehman (2005) also defined sexuality as an individual's self-concept expressed as sexual feelings, attitudes, beliefs and behaviour. These imply that sexual activity is part of one's health and therefore if that aspect is not functioning, it affects that patient's general health and quality of life. The above illustrations show patients are significantly affected by ED which may lead to CVD hence the need for effective assessment and prompt treatment. Therefore the benefits of treating ED are reduction in CVD risk, disease, depression, positive effect on partner relationship and general well being (Goldstein, 2000).
Surprisingly, higher percentage of patients do not report or seek help and health professionals do not talk about it either (Hacket, 2009). Some of the factors that hinder patients from reporting ED are shame, embarrassment, religious beliefs, culture, perceived inability to get solution from the health care setting and fear of possible negative judgement by health professionals (Marwick, 1999). Patients also think sexuality issues are not medical issues to be raised at consultation. They feel that health professionals do not have time; they are not interested and not competent. Elderly patients accept it as part of the aging process while the young ones think it will resolve with time, (Wimberly, Hogben, Moore-Ruffin, Moore and Fry-Johnson, 2006). Also, Bandenburg and Bitzer (2009) added that patients were worried doctors will dismiss the issue of sex as well as doctors not comfortable in dealing with it. In my clinical area culture, religious beliefs and language are the barriers for reporting as the practice has a high percentage number of ethnic minority.
Another consideration is that, patients have poor knowledge on ED and the educated and young patients seek information from the internet and media (Baumgartner et al, 2008; Wittenberg & Gerger, 2009). Most of the information may not be accurate, be outdated and scary. However, Goldstein, Lines, Pyke and Scheld (2009) supported the fact that there is much awareness and openness about ED yet most of these patients report late when the ED is very severe others will not discuss such problem with their physicians and will not seek help.
Similarly health professionals also do not talk about this issue due to lack of time, ED is a sensitive issue that needs time for discussion. It is also due to lack of adequate training and skills in dealing with sexual issues. Shabsigh, Perelman, Laumann and Lockhart (2004) explained further that dealing with sexual issues need adequate knowledge, skills and communication which is lacking by some professionals. Also sexual issues need a multidisciplinary team approach and if that service or support is not readily available, no discussion is done. Lack of easy and simple treatment options for ED also deter doctors to talk about sex (Bandenburge and Britzer, 2009). However some doctors ask about sexual issues not for routine purposes but when it pertains to the actual consultation (Wimberly, Hogben, Moore-Ruffin, Moore and Fry-Johnson, 2006). In the clinical area for example, time is the major issue as 10 minutes appointment slot for doctors and 15 minutes for nurse. This is a sensitive issue that should not be dealt with in a rush.
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Health professionals are thus not giving the patients the needed information and not creating the needed awareness about ED, the course, treatment and prevention. Patients need to be educated and given adequate information to alert them of the need to report ED promptly for investigation and treatment in order to avoid further complications like CVD. As Billups et al (2005) put it, identifying ED early and treating leads to the prevention of CVD.
Educating and giving of adequate information on drugs is also very vital. Health professionals should explain to patients there are newer antihypertensive drugs which have positive effect on erectile function and may decrease the incidence of ED. Example are losartan, non-selective beta-blockers and doxazosin (Khan et al, 2002). Also Erdmann (2009) argued that beta blockers do not cause ED but rather the underlying disease such hypertension and diabetes. The various medical treatments for ED are also potent and safe (Kloner, 2008). Examples of treatments are oral tablets, injections, intraurethral, prosthesis and surgical intervention. Giving patients accurate information on their medication will allay some of these fears and improve compliance.
Good intervention for patients with ED will restore sexual function and ultimately improve their cardiovascular health (Walczak et al (2002). Both patients and health professionals need to update themselves with new evidence that sexual activity does not put stress on the heart and therefore patients with CVD can have sex (Marwick, 2002). However, there is the need for careful assessment to ascertain patient's CVD condition is stable before commencing them on ED treatment (Jackson et al 2006). This therefore puts huge responsibilities on nurses who run CVD clinics in the general practice to equip themselves with adequate knowledge and skills in dealing with sexual issues.
Despite the fact that ED is under reported, under diagnosed and under treated (Baldwin,Ginsberg and Harkaway, 2003), two to three million men in UK between the age of 40-70 are known to have been affected by ED (Riley,2002). If these patients will report for appropriate assessment, treatment and be given accurate information on ED it will reduce a significant number of patients from getting CVD and its associated complications and prevent avoidable deaths (Jowett and Thompson, 2007, P3). Montorsi et al (2003) and Thompson et alÂ (2005) had showed that it takes 38.8 to 60 months for men with ED to have CVD event. This demonstrates that health professionals have significant amount of years to assess and manage patients with ED to minimise their risk of getting CVD event. This can be done by creating awareness about the course of ED and CVD, available treatments, giving of accurate information on treatment both medically and lifestyle modification and where to seek help. This may improve compliance and increase reporting.
According to Bedell, Duperval and Goldberg (2002), patients are happy if health professionals initial the topic and approach it in an appropriate way. Also inquiry made during consultation and booking double appointment for the next visit will encourage patients to come back to seek help. Derby et al (2000) emphasised that despite the fact that men are slow to adhere to advice on healthy lifestyle changes irrespective of adequate explanation, they are quick to adapt to change when it is regarding correcting erectile problems. This shows that men are concerned about ED. Providing national and local guidelines on ED to guide health professionals and also adding it to clinical indicators will remind staff to ask the question. Adding it to nursing and medical school curriculum will equip health professional the needs skills and confidence to deal with sexual health issues. There should be Multidisciplinary approach in managing ED among Urologist, Psychiatrist and Cardiologist as these conditions co-exist for effective management. Likewise there should be a randomised control trials research into the ED as a risk factor, and the effect of language barrier in managing ED among ethnic minority groups to improve their care. Besides, the partners of ED patients suffer psychologically and therefore needs psycho sexual counselling to understand the partner and give him the need support.
It has been realised that ED is a sensitive issue that play a major part in identifying CVD patients early which is important in reducing CVD morbidity and mortality (Jowett and Thompson, 2007, P3), research in this area is limited. Also it is not among the National Service Framework for coronary heart disease (2000), National Institute for Clinical Excellence CVD guidelines and clinical indicators for CVD. If much attention is given to ED as the other risk factors, will it improve care given to patients with CVD in terms of identifying those at high risk early and also give appropriate advice and treatment in order to minimise premature death in UK? It is evident that given much attention to ED as the other risks such as smoking, obesity, alcohol, exercise will improve CVD management and identify those at risk early.
In conclusion, ED and CVD are inter-related. Evidence has shown that ED can be an early sign of CVD. ED is cause by endothelial dysfunction, CVD medication and psychological impact. This has been affecting their quality of life, their family and the nation as a whole. Also it affects the management of patients with CVD in terms of adherence to drugs. Despite the availability of potent treatment to help these patients, significant numbers of them refuse to talk about and do not seek help due to lack of knowledge and accurate information, likewise the Health professionals caring for them. Accurate information and educating both patients and health professionals is necessary in order to gain insight to current evidence about ED, drugs and CVD as well as enlighten patients to come out to seek help. Effective assessment and treatment of those at risk of CVD will go a long way to minimise CVD morbidity and mortality rates as well as premature deaths in the UK. As Jowett and Thompson, (2007, P3) put it, these fatal deaths and disabilities caused by CVD are treatable and can also be prevented if identified early.
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