SEXUAL DYSFUNCTION OF CHRONIC ILLNESS AND MANAGEMENT

Sexual dysfunction
Sexual dysfunction affects negatively quality of life.  An obvious component of sexual
dysfunction is that of erectile dysfunction, ED.  ED is defined as the persistent inability
to achieve and/or maintain an erection sufficient for satisfactory sexual activity. Age is
an important risk factor for ED. Sixteen per cent of Malaysian men aged 40 – 70 years
suffers from complete ED. Management  should  be aimed not only at treatment but also
at prevention of ED.  Despite having the first impotence clinic in GHKL in 1992, only
10% of Malaysian men with ED talked to the doctors and only 3.9% had received some
form of treatment.  Sildenafil (trade name Viagra) was found to be effective amongst
Malaysians in a double blind placebo controlled study published in 2000.  Even then,
Sarawakian men  sought advice regarding their ED after an average duration of 20
months.

Erection is a complex neurovascular event,  modified by psychological factors.  The comorbidities of ED are similar to those for ischaemic heart disease and strokes. ED should
be treated as part of total wellness of the patients by family doctor, taking into account
hypertension, ischaemic heart disease, dyslipidaemia, diabetes, psychological stresses,  
family factors, diet, exercise, smoking etc.

All such co-morbidities are common in chronic renal failure.  In addition, chronic renal
failure  is associated with hormonal imbalances involving testosterone and prolactin.
Studies of ED in chronic renal failure patients showed a prevalence of about 60% with
half of this suffering from severe ED.  Dialysis patients above the age of 50 have an
almost 70% chance of having ED.  In one study, it was found that the incidence of ED is
irrespective of social economic status and duration of haemodialysis.  In another  study,
63 out of 68 patients on peritoneal dialysis suffered from ED.

The treatment of ED has been revolutionised by the introduction of the phosphodiesterase
Type 5 inhibitor (PDE-5 I).  There are 3 main PDE-5 inhibitors currently being used,
namely,  Sildenafil, Vardenafil and Taladafil.   These medications can be taken ½ to 1
hour before sex; the effect of Sildenafil and Vardenafil last for 4 hours and that of
Taladafil for 36 hours.  They should not be taken on a full stomach.  Sexual and penile
stimulation is required as PDE-5 inhibitors enhance an erection but does not induce
an erection!   PDE-5 inhibitors are generally safe and the main contraindication is that
these medications should not be taken concurrently with any form of nitrates eg GTN,
Isordil, Imdur.  Taking PDE-5 I together with nitrates can result in hypotension. PDE-5 I
works in about 60% of ED patients, less if the patients have numerous untreated comorbidities.  The side effects of PDE-5 inhibitors include flushing, headache and nasal
congestion.  Another treatment is that of intra-penile injection of a vasodilator, e.g.
Caverject 20 mcg.  Over-dosage can result in prolonged erection viz priapism.   Any
erection more than 4 hours should be brought down, usually with penile aspiration or
injection of a dilute vasoconstrictor gradually e.g. Phenylephrine.   Other modalities
include penile rings to reduce venous leak and also vacuum pumps to increase blood flow
into the penis.  Finally, for patients with “end stage penile failure, ESPF”, a penile
prosthesis can be inserted by open surgery. Many traditional therapies are available but 2
these have not been tested with double blind placebo controlled trials.   Moreover, some
of these therapies (e.g. subcutaneous injections for penile lengthening) can have serious
side effects

The role of testosterone in erectile dysfunction has recently taken a more prominent role,
with the availability of long acting (3 months) injection testosterone.  There is some
association of  testosterone deficiency syndrome (TDS) with truncal obesity in men,
diabetes, hypertension, dyslipidaemia (metabolic syndrome).

The International Society for Sexual Medicine defines  premature ejaculation as
ejaculation which occurs within 1 minute of vaginal penetration and resulting in negative
personal consequences.  Premature ejaculation is probably more common than ED and
difficult to treat, especially if it is chronic. The treatment consists of physical methods
(e.g. squeeze technique) and the use of selective serotonin re-uptake inhibitors, SSRI, e.g.
Fluoxetine 20 mg 2 hours before sex.

Female sexual dysfunction (FSD) consists of impaired sexual interest (52%), orgasmic
dysfunction (19%), vaginismis (18%) and dyspareunia (4%).  Female sexual arousal 
disorder is  defined by WHO as the persistent inability to attend or maintain sexual 
excitement, express as a lack of genital lubrication or swelling response.  Chronic
illnesses including diabetes mellitus double the risk of FSD especially arousal difficulties,
pain during sex and infection.  Sildenafil does not treat FSD although it is postulated to
have some effect on clitoral erection and on the G-spot.

Fertility in patients with chronic illnesses is often decreased in part due to ED,
ejaculatory disorders and infection of the lower urinary & genital tract.  For patients with
ejaculatory problems, sperm can be harvested by post orgasm urine or electro-ejaculation.
Sperm can also be harvested nowadays from the testes and kept in sperm bank.  Modern
test tube baby techniques e.g. intracytoplasmic sperm injection (ISCI) can help many
subfertile couples.

SUMMARY:
ED is seen in about 60% of patients with chronic renal failure. Specific treatment with
PDE-5 I is effective in more than 60% of patients.  ED should be treated early together
with the co-morbidities viz hypertension, diabetes, ischaemic heart disease,
dyslipidaemia, mental health and testosterone deficiency syndrome.  Intra-penile
injection of vasodilators is useful in patients who do not respond to PDE-5 I.

NKF Annual Dialysis Meeting, Kuala Lumpur, 13th
December 2008