NCP Erectile Dysfunction

Erectile Dysfunction (ED)

Impotence

Male erectile dysfunction (ED) replaces the term impotence. The problem involves the inability to achieve or maintain an erection suitable to complete sexual intercourse. Due to innovative laboratory testing and research in hemodynamics, neurophysiology, and pharmacology of penile erection, there is a better understanding of ED. Erection involves neurological, hormonal, arterial, cavernosal, and psychological factors. A disruption in any one of these factors can cause the dysfunction. Improved diagnostic tests, therefore, can differentiate the types of ED.

Neurogenic disorders can be caused by disease or dysfunction of the brain, spinal cord, nerve endings, and receptors. These disorders could include spinal cord injury, cerebrovascular accident, Parkinson’s disease, peripheral neuropathy, trauma of the prostate, or rectal surgery. Diabetes mellitus is the most common hormonal disease associated with ED. Other hormonal disease processes include hyperthyroidism, hypothyroidism, Cushing syndrome, and Addison’s disease. With arterial disorders, the time required to reach full erection gradually increases with systemic arterial insufficiency. This may result in partial erection or in difficulty maintaining an erection. Penile artery disease may improve with surgical repair of the arteries, but diseases such as arteriosclerosis or diabetes do not respond surgically. Cavernosal disorders are caused by an insufficient venous occlusion mechanism. Disorders such as Peyronie’s disease, penile tumor, scleroderma, and penile contusion may affect erection. Other causes of ED may include specific drugs or interactions of drugs. Almost all antihypertensive drugs have been implicated in ED. Other drugs that affect erection include antidepressants, marijuana, alcohol, and narcotics.

In diagnosing and treating ED, it is necessary to obtain a detailed medical and sexual history and a thorough physical examination. Including the patient’s partner assists in obtaining a history, planning treatment, and obtaining a successful outcome. A routine workup for ED may include basic laboratory tests such as a complete blood count, urinalysis, fasting blood glucose, serum creatinine, serum testosterone, thyroid-stimulating hormone, and prolactin. Further testing is conducted according to the patient’s health, motivation, and desired treatment. Once the cause of ED is determined, treatment options may include 5-phosphodiesterase (5PDE) inhibitors such as sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra); hormonal therapy; a vacuum device; transurethral or intracavernous injections of vasodilators; or a penile prosthesis.

This care plan addresses the care of a patient diagnosed with ED as well as treatment modalities.

Nursing Diagnosis

Sexual Dysfunction

Common Related Factors

Defining Characteristics

Arterial diseases Low testosterone levels Neurological diseases Psychological factors	Reported sexual difficulties Change in sexual behavior activities Change in relationship with sexual partner Use of medications and/or devices to enhance sexual performance
Common Expected Outcome Patient adapts sexual techniques and engages in sexual activity with assistive devices, as needed.	NOC Outcomes Sexual Functioning; Knowledge: Disease Process; Treatment Regimen NIC Interventions Teaching: Disease Process, Medications, Psychomotor Skills; Sexual Counseling

Ongoing Assessment

Actions/Interventions	Rationale
Obtain the patient’s medical, surgical, and sexual history, noting normal and problematic patterns of functioning.	Gradual problems with sexual function may occur with advancing age or as the result of disease problems. Sexual problems can result from neurological, hormonal, arterial, cavernosal, and psychological factors, and/or surgical procedures.
If in a specialty area, consider administering the International Index of Erectile Function tool before and after treatment.	Comparing before-and-after treatment response may provide an objective measurable indication of improvement.
Determine the patient’s and significant other’s current knowledge, understanding, and expectations.	Men are often embarrassed or hesitant to discuss sexual problems. A lack of information or having misinformation may add to the patient’s problem.
Explore physical causes (e.g., diabetes, hormonal insufficiency, heart disease, and drug side effects).	ED often occurs as a result of a disease process or drug side effects.

Therapeutic Interventions

Actions/Interventions	Rationale
Provide privacy and be nonjudgmental during interactions with the patient and significant other.	Privacy facilitates development of a trusting relationship. Men may not feel comfortable discussing their sexuality with others, especially a female nurse. A confident, matter-of-fact, and knowledgeable approach by the nurse will instill confidence in working with patients. Respecting the individual and treating his concerns as normal may foster greater acceptance of the problem and reduce anxiety.
Explain the need to share concerns with the significant other.	Men with ED commonly isolate themselves from others because of shame, embarrassment, and stress.
Correct misinformation about sexuality and ED.	Misinformation about ED may prevent the patient from seeking help for treatable problems. Many men may accept ED as a natural result of aging. Providing accurate information about ED may decrease the patient’s unrealistic expectations.
Encourage the patient to include his significant other in discussions of treatment and teaching sessions.	Both partners have a vested interest in working toward an acceptable and successful treatment plan. Patience and cooperation are needed from each person.
Teach the importance of rest before sexual activity.	Patients may have a more meaningful experience if not excessively tired.
Encourage use of a nonnarcotic pain medication before sexual activity.	Pain inhibits sexual activity; however, narcotic use may cause dysfunction.
Refer the patient to appropriate resources such as primary care provider, urologist, clinical specialist, sexual counselor, or family counselor.	Changes in sexual function may have adverse effects on the couple’s relationship. Specialists are needed for complex situations.
Refer the patient to self-help and support groups.	Participation in support groups may allow the couple to realize that others have the same problem and they may use this as a means to find alternatives or suggestions for specific treatment modalities.
Teach the possible side effects of drug therapies (e.g., antidepressants, cardiac drugs, narcotics, some H2-receptor antagonists, some nonsteroidal antiinflammatory drugs, and alcohol).	Some drugs may impair sexual function; these need to be reported to the primary care provider.
Teach diabetics the importance of diabetic control.	Altered glucose levels may change sexual function due to associated neuropathies and accelerated peripheral vascular disease.
Explain use of 5PDE treatment of ED.	This drug enhances the effects of nitric oxide released during sexual stimulation, promoting blood flow and subsequent erection.
·     Explain contraindications of its use with patients receiving nitrates (e.g., nitroglycerin, isosorbides).	The combination of PDE inhibitors and nitrates can cause a sudden drop in blood pressure that may result in sudden death, myocardial infarction, or cardiovascular collapse.
·     Instruct the patient to take the 5PDE from 30 minutes to 4 hours before sexual activity, and not more than once daily.	Sildenafil is not effective in the absence of sexual stimulation.
·     Advise the patient that 5PDE is not indicated for use in women.	Research has not proven this drug to be effective in women.
·     Instruct the patient to notify his health care professional if erection lasts longer than 4 to 6 hours.	Priapism is a serious side effect and needs to be alleviated before permanent damage occurs.
·     Inform the patient that these medications do not protect against sexually transmitted infections (STIs).	Proper use of condoms is needed to prevent STIs.
Teach regarding androgen replacement therapy with testosterone:	Treatment is based on evaluation of serum testosterone levels. It is contraindicated in men with cancer of the prostate.
·     Teach about drug interactions.	Androgens may enhance warfarin, oral hypoglycemic agents, and insulin.
·     Assess weight weekly.	Testosterone increases the incidence of edema.
·     Assess for secondary sex characteristics.	Secondary sex characteristics may include an increase in penile size, excessive growth of body hair, and priapism.
·     Monitor laboratory values:
·     Hemoglobin and hematocrit	Increased hemoglobin and hematocrit may be a side effect of the drug.
·     Hepatic functions	Drug may cause liver damage.
·     Cholesterol	Drug may increase or decrease cholesterol levels.
·     Glucose	Drug may cause alterations in blood glucose levels.
Teach administration of alprostadil urethral suppositories.	Intraurethral alprostadil is absorbed from the urethra and transported throughout the erectile bodies, causing vasodilation. This is effective in about 40% of patients.
·     Instruct the patient to urinate before insertion.	A moist urethra makes administration of the suppository easier.
·     Inform the patient that each foil pouch contains a suppository inside an applicator.	Save the foil pouch to dispose of the applicator.
·     Teach the patient to insert the suppository while standing or sitting, stretching the penis upward.	This straightens and opens the urethra.
·     Instruct the patient to slowly insert the applicator into the urethra.	This prevents damage to the urethra.
·     Instruct the patient to push down on the applicator until it stops and hold it in position for 5 seconds.	Body temperature will help to release the suppository from the applicator.
·     Instruct the patient to gently rock the applicator back and forth.	Rocking separates the suppository from the applicator.
·     Tell the patient to remove the applicator while the penis is in upright position.	This facilitates removal and reduces trauma.
·     Instruct the patient to roll the penis firmly between both hands for 10 seconds.	This ensures the medication is distributed along the walls of the urethra and reduces discomfort.
·     Tell the patient that an erection should begin in 5 to 10 minutes with a duration of 30 to 60 minutes.	The patient needs to be prepared.
·     Alprostadil should not be used more than twice a day.	This prevents complications.
·     Alprostadil does not have contraceptive properties, nor will it protect against sexually transmitted infections (STIs).	This information allows the patient to coordinate drug use with sexual activity.
·     Educate the patient about common and serious side effects and contraindications.	Serious side effects include priapism, which is rare, and hypotension, which can occur in about 3% of users. Common reactions include penile pain, urethral pain, and/or bleeding. Contraindications include intercourse with a pregnant woman while using intraurethral alprostadil and use by men with penile deformities.
·     Recommend that suppositories be stored in the refrigerator.	Exposure to temperatures above 85°F makes alprostadil ineffective.
Teach intracorporeal injection therapy (papaverine or alprostadil).	Injection directly into the penis with these medications causes erection and is often used in conjunction with phentolamine (Regitine). The drug acts locally on penile tissue, causing dilation and trapping blood flow in the cavernous bodies to maintain an erection that lasts 30 minutes to 4 hours.
·     Teach procedure to correctly draw medication into syringe.	Accurate dosage is key.
·     Teach the patient to place two fingers under the penis and thumb on top. He may hold the penis against the side of the leg to provide support.	The patient may need assistance in mastering this psychomotor technique.
·     Instruct the patient not to twist or turn the shaft of the penis.	This helps ensure the injection will be administered at the correct anatomical site.
·     Teach the patient to clean the injection site with alcohol.	This prevents localized infection.
·     Instruct the patient to inject medication into the side of the penis near the base closer to the body, using either hand to inject.	This treatment may not be appropriate for men with poor fine-motor control or impaired vision.
·     Instruct the patient regarding proper disposal of the syringe.	Never reuse a syringe; it may be contaminated.
·     Inform the patient to alternate sides for injections.	This prevents fibrosis of the corpus cavernosa.
·     If using alprostadil, instruct the patient to return drug to proper storage as soon as possible.	Drug must be protected from heat and light.
·     Teach the patient to record results of the medication and report them to the health care provider.	If results are not satisfactory, the dosage may need to be altered.
·     Teach side effects of papaverine:
·     Priapism (erection lasting longer than 6 hours)	Priapism generally responds to aspiration and irrigation of the penis.
·     Limit injections to three times a week	This prevents complications.
·     Instruct on the side effects of alprostadil.	Drug requires guidelines similar to papaverine. There are minimal side effects because the drug occurs naturally in the body.
Teach use of vacuum devices:	This is a viable option for poor surgical candidates. The device is obtained by prescription.
·     Lubricate the cylinder.	This facilitates penile entry.
·     Apply suction to create a vacuum in the cylinder.	Pressure from the vacuum draws blood into the corporeal bodies.
·     Slip the penile ring or tourniquet to the base of the penis.	This causes vasoconstriction and maintains penile engorgement.
·     Gently remove the cylinder, and the patient is ready for sexual activity.	Once an erection is achieved and the compression device is placed at the base of the penis, the blood is trapped in the corporeal bodies.
·     Remove the ring within 30 to 40 minutes.	Prolonged use causes penile tissue damage.
Provide information about penile implants:	Penile implants may be rigid, semirigid, or inflatable. They are used to create an erection sufficient for performing intercourse with ED. Many factors such as insurance, physical capabilities, and surgical risk influence the selection of this method of treatment. Alprostadil is contraindicated in men with penile implants. Future genitourinary and/or prostatic procedures may be more difficult because of penile implants.
·     Inform the patient of the types and names of prosthetic penile implants.	Patients need written information about the style and model of their implant.
·     Explain correct operation of the device. Allow for return demonstration.	The patient needs to be able to follow the correct technique for inflation and deflation of the device.
·     Explain the need for lubrication before penetration with intercourse.	Erosion of penile tissue covering the implant can occur with inadequate lubrication.
·     Avoid use for at least 6 to 8 weeks after implantation or until pain subsides.	Complications can occur if the device is used before complete surgical wound healing.
·     Refer to support groups and sexual counselors.	It takes patience and time to master the use of implants. The patient may benefit from talking with men who have had successful implants.

Nursing Diagnosis

Situational Low Self-Esteem/Disturbed Body Image

Common Related Factors	Defining Characteristics
Sexual dysfunction Need for manipulation of genitalia by special devices	Expression of negative feelings about self and sexual capabilities Focus of behavior on changed body function or part Change in social behavior Expressions of shame Hesitancy to try new things Sadness Irritability
Common Expected Outcomes Patient begins to accept problem and verbalize positive aspects of self. Patient makes positive attempts to use ED treatment modalities to improve sexual performance and self-image.	NOC Outcomes Self-Esteem; Coping; Body Image NIC Interventions Self-Esteem Enhancement; Body Image Enhancement; Coping Enhancement

Ongoing Assessment

Actions/Interventions	Rationale
Assess and validate feelings about altered sexual function.	The extent of the problem is related more to the value or importance the patient places on sexual performance than to general feelings of sexuality.
Assess the primary cause for any self-negating statements.	There are many causes of ED, which may be the etiology of this coping problem. Other events may aggravate the problem (e.g., change in job, difficult family relationships) and may contribute to low self-esteem, requiring additional interventions. Problems within a relationship may not resolve with the ability to perform intercourse.
Assess perceived impact of ED on social behavior or personal relationships.	Young adult males may be particularly affected by a change in the structure or function of their bodies at a time when they are developing social and intimate relationships. Likewise, change in sexual performance during middle age and even late in life may be especially distressing for many individuals.
Assess useful coping mechanisms used in the past.	Successful adjustment is influenced by previous coping success; however, prior coping skills may not be adequate in the present situation.
Assess level of readiness to implement recommended ED treatments.	Adequate resolution of this problem requires accurate information and understanding of treatment options. Patients who are coping ineffectively may be unable to hear or assimilate needed information.

Therapeutic Interventions

Actions/Interventions	Rationale
Encourage the patient to verbalize feelings of the changes in his bodily function and appearance.	Verbalization of perceived or actual changes may help reduce anxiety and open doors for ongoing communication. It is worthwhile to encourage the patient to separate feelings about changes in body from feelings about self-worth.
Convey feelings of acceptance and understanding.	An honest relationship facilitates problem-solving and successful coping.
Encourage communication and expression of feelings of both partners through active listening.	Active listening reinforces the values and rights of each partner.
Encourage a problem-solving approach to ED.	Several treatment options are available. The patient may need assistance in evaluating the costs versus benefits of each.
Encourage the patient to patiently practice new methods to treat ED.	Change requires a willingness to tolerate unfamiliar behavior over time.
Encourage the patient to communicate with his significant other rather than to worry in silence.	This will facilitate shared involvement rather than a unilateral approach to a shared problem.
Encourage the significant other to genuinely accept and respect the patient in his attempts at new treatment modalities.	Self-worth is influenced by recognition of others.
Assist the patient in differentiating concepts of erection, ejaculation, fertility, and orgasm.	Prosthetic implants restore erectile capability but have no impact on ejaculation, fertility, or orgasm.
Encourage the patient to discuss his feelings regarding penile implants.	It is normal for patients to have both positive and negative feelings about implants. Body image changes may take months to resolve.
Provide information about lay groups and community services that may be available.	Lay persons in similar situations offer a different type of support, which is perceived as helpful.
Refer to appropriate Internet resources.	The National Kidney and Urologic Diseases Information Clearing House offers reliable and updated information.