Standardized Procedure Worksheet – Erectile Dysfunction

Definition

Disease or condition: The selected condition I will focus on is erectile dysfunction (ED) in older adults. Erectile dysfunction is the failure to maintain or achieve a rigid penile erection appropriate for satisfactory sexual intercourse (American Urology Association, 2023).
Pathophysiology: Erectile dysfunction is mostly caused by many factors. Any disease process that affects the Peniel nerves, arteries, hormone levels, corporal endothelium, smooth muscle tissue, or tunica albuginea can cause erectile dysfunction. These disorders include hyperlipidemia, hypertension, diabetes mellitus, and cardiovascular disease, among other diseases (Irwin, 2019). Also, primary psychological and lifestyle issues contribute to erectile dysfunction. In older patients, erectile dysfunction is mostly linked to age-related changes in neural, vascular, and hormonal systems. These disorders lead to decreased penile blood flow, elevated sympathetic tone, and reduced nitric oxide production, leading to erectile dysfunction (American Urology Association, 2023)
Incidence and prevalence: In the United States, approximately 52% of men aged between 40 and 70 years have erectile dysfunction (Goldstein et al., 2019). About 30 million men in the US and 150 million men in the world suffer from the disorder (American Urology Association, 2023)

The prevalence of the disease is associated with age and the presence of underlying diseases such as diabetes, cardiovascular disease, and hypogonadism. According to statistics, there is an average prevalence of 52%, with the incidence increasing with age. 40% of men at the age of 40 are affected, while 70% report having the disorder by the age of 70 (American Urology Association, 2023).

Scholarly source:

American Urology Association. (2023). Erectile Dysfunction (ED) Guideline – American Urological Association. Www.auanet.org. https://www.auanet.org/guidelines-and-quality/guidelines/erectile-dysfunction-(ed)-guideline

Assessment

Symptoms: Common symptoms or subjective findings consistent with erectile dysfunction include reduced sexual desire or interest, difficulty maintaining or achieving an erection, and psychological distress associated with sexual performance (American Urology Association, 2023).
Physical Exam: Physical examination for erectile dysfunction patients focuses on underlying factors that contribute to the disorder, like obesity, hormonal imbalance, or hypertension. The physical examination is focused on the endocrine, genitourinary, neurological, and vascular systems. The assessment should include an examination of concomitant or previous penile abnormalities like hypospadias, Peyronie’s disease, and congenital curvature. Vital signs, including resting blood pressure and heart rate, should be measured. Also, waist circumference or Basal Metabolic Index should be undertaken to assess the comorbid conditions of patients (American Urology Association, 2023).

In Florida, nurse practitioners have autonomy in their practice which allows them to treat, diagnose, and manage patients themselves within their scope of practice. However, physician collaboration is required;

If the condition of the patient is complex; hence, there is a need for a comprehensive evaluation.
If there is an underlying medical condition that needs medical management
Prescription of specific medication to treat erectile dysfunction.

Scholarly source

Diagnostic tests

Testing: Laboratory testing should be specific to the patient’s risk factors and complaints. Tests taken include:

Lipid profile
HbA1c or fasting blood glucose
Early morning total testosterone test
Nocturnal penile tumescence and rigidity test
Intracavernous injection test
Dynamic duplex ultrasound of the penis
Arteriography and dynamic infusion cavernosometry/cavernosography (American Urology Association, 2023).

Expected results

The lipid profile would show elevated LDL cholesterol and low HDL cholesterol, which indicates vascular issues that cause erectile dysfunction.
Elevated fasting blood sugar or HbA1c suggests diabetes, which is associated with erectile dysfunction.
Low total testosterone levels indicate erectile dysfunction
The absence of nocturnal erections or low rigidity and tumescence indicates a physiological cause of erectile dysfunction
Lack of response to intracavernous injection suggests a neurological or vascular cause of ED
Abnormal arterial or venous blood flow in the ultrasound may indicate vascular factors causing erectile dysfunction (American Urology Association, 2023)

Scholarly source:

Management

First-line medications

The recommended first-line medications are the PDE5 inhibitors:

Sildenafil

Generic name: Viagra

Dosage: Taken orally, 50mg PRN (Center for Drug Evaluation and Research, n.d)

Major contraindications: Unstable angina, resting hypotension, myocardial infarction, congestive cardiac failure

Major drug-drug interactions: Nicorandil, alpha-blockers, and organic nitrates, including nitroglycerine, isosorbide dinitrate, and isosorbide mononitrate

Tadalafil

Generic name: Cialis

Dosage: Taken orally, 5mg daily or 10mg-20mg PRN

Major contraindications: Unstable angina, resting hypotension, myocardial infarction, congestive cardiac failure

Major drug-drug interactions: Nicorandil, alpha-blockers and nitrates medication

Vardenafil

Generic name: Levitra

Dosage: Oral 10mg PRN

Major contraindications: Unstable angina, resting hypotension, myocardial infarction, congestive cardiac failure

Major drug-drug interactions: Nicorandil, alpha-blockers, and nitrates medication(American Urology Association, 2023)

Second-line medications

Alprostadil

Generic name: Levitra

Dosage: 200-300µg administered topically, 125-1000µg intra-urethral inserted

Major contraindications: Bleeding disorders, high risk of priapism, hypersensitivity

Major drug-drug interactions: Hydralazine, empagliflozin, and sildenafil (American Urology Association, 2023)

Other treatments

Psychosocial intervention and therapy: This includes Cognitive and Behavioral Therapy (CBT) and other modalities like marital therapy, sexual skills training, and psychosexual education. CBT aims at changing the dysfunction’s behavioral and cognitive patterns that impact erectile dysfunction and increasing modification during the disorder.
Hormonal treatment: Through an endocrinologist’s advice, testosterone therapy may be initiated for men with low testosterone levels and concomitant problems with their erectile dysfunction.

Use of Vacuum erection devices: These provide reflexive corpus cavernosum engorgement in combination with a constrictor ring put on the base of the penis to help retain blood in the penis (American Urology Association, 2023).

Follow-up

If a client reports recurrent or persistent symptoms after the first treatment, evaluating the patient’s psychological and medical status is important. Changing the management plan may be appropriate (American Urology Association, 2023).

Referral

Referral to a specialist or urologist may be considered if there is an indication of:

Lack of response to first-line treatment
Serious underlying medical condition
Complicated psychosocial factors contributing to ED (American Urology Association, 2023)

References

Center for Drug Evaluation and Research. (n.d.). Sildenafil (marketed as Viagra and Revatio) information. U.S. Food and Drug Administration. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/sildenafil-marketed-viagra-and-revatio-information

Goldstein, I., Goren, A., Li, V. W., Tang, W. Y., & Hassan, T. A. (2020). Epidemiology Update of Erectile Dysfunction in Eight Countries with High Burden. Sexual Medicine Reviews, 8(1), 48–58. https://doi.org/10.1016/j.sxmr.2019.06.008

Irwin, G. M. (2019). Erectile Dysfunction. Primary Care: Clinics in Office Practice, 46(2), 249–255. https://doi.org/10.1016/j.pop.2019.02.006

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Question

Standardized Procedure Worksheet – Erectile Dysfunction

Preparing the Assignment
Nurse practitioners provide high-quality, comprehensive care to clients in various healthcare settings. Standardized procedures may be used to help guide care. Boards of Nursing, such as CaliforniaLinks to an external site., provide resources to ensure that NPs provide quality care while functioning within their scope of practice. Identify the assigned topics listed by the first letter of your last name. For example, if your last name is Cromer, then your assigned topic is urinary incontinence in older adults.

First Letter of Your Last Name Topic
A – C urinary incontinence in the older adult
D – G urinary tract infections in community-dwelling older adults
H – K urinary tract infections in facility-dwelling older adults
L – O benign prostatic hyperplasia in older adults
P – R erectile dysfunction in older adults
S – V hormone replacement therapy for menopause
W – Z sexually transmitted infections in older adults
Include the following sections (detailed criteria listed below and in the Grading rubric). Use the standardized procedure template links to an external site. to complete the assignment.

Disorder or condition
Identify the selected disorder or condition.
Provide a basic description of the pathophysiology of the selected disorder or condition.
Provide a summary of the incidence and prevalence of the selected disorder or condition in the United States.
Provide a scholarly source.
Assessment
Identify common subjective findings (symptoms) consistent with the selected diagnosis.
Identify pertinent physical examination components and the expected exam findings consistent with the selected disorder or condition.
Identify your intended state of practice and whether physician collaboration is required, as it is in California. If collaboration is required, describe the circumstances that would require physician consultation.
Provide a scholarly source.
Diagnostic tests
List diagnostic tests appropriate for the selected disorder or condition.
List expected abnormal results consistent with the selected disorder or condition.
Provide a scholarly source.
Management: Present an evidence-based management plan for the selected disorder or condition.
Describe in detail the first-line prescribed medications recommended for the selected disorder or condition.
Describe in detail the second-line medication that should be prescribed IF the client had an allergy to first-line line treatment for the selected disorder or condition.
Identify medication details including
Trade and generic names for each medication
Typical dose for each medication
Major contraindications for use
Major drug-drug interactions
Identify other recommended treatments, if any, for the selected disorder or condition.
Discuss expected client follow-up. If the client called in with persistent or recurrent symptoms after initial treatment, describe the appropriate next action.
Describe indications for referral.