ED, ERECTILE DYSFUNCTION AND SEXUAL DISORDERS FOR OSTOMY AND UROSTOMY PATIENTS

ED, ERECTILE DYSFUNCTION AND SEXUAL DISORDERS FOR

OSTOMY AND UROSTOMY PATIENTS

INTRODUCTION:

Sexual function is among the most important body functions.  Dysfunction impacts negatively the quality of life.  Sexual function involves erectile function and ejaculation for the men. Female sexual function has similar components, in particular, lubrication and orgasm.  Fertility is among the end products of marital happiness.

ED, ERECTILE DYSFUNCTION:

An obvious component of sexual dysfunction is that of ED, erectile dysfunction. 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 of ED.  16% of Malaysian men aged 40 to 70 suffers from complete ED. Management should be aimed not at treatment but also prevention of ED.

Despite having the first Impotence Clinic in GHKL in 1992, only 10% of Malaysian men with ED ever talked to the doctors and even less undergo some form of treatment.  Sildenafil was the first commercially available medication, found to be effective amongst Malaysians in a double blind placebo controlled study published in 2000. Erection is a complex neurovascular event, modified by psychological factors.  ED should be treated as part of total wellness of the patients by the family doctor, taking into account hypertension, coronary artery disease, dyslipidaemia, diabetes, psychological stresses, diet, exercise, smoking etc.

All such co-morbidities are  common in ostomy and urostomy group of patients.   In addition, these patients may have chronic renal failure which is associated with hormonal imbalances involving testosterone and prolactin. Depending on the underlying pathology and the surgical procedure done, the prevalence of ED of about 60% in patients with underlying chronic illnesses.  Dialysis patients above the age of 50 have an almost 70% chance of having ED. 

There are limited scientific publications on the topic of sexual dysfunction in ostomy and urostomy patients.  One of the earliest publications in the British Journal of Urology 1992, 70: 33-39  found that 90% of male who were sexually active before surgery lost their ability to achieve an erection following radical cystectomy. Five of the 6 females treated by cystectomy also stopped having coitus postoperatively.  Patients with cancer tend to have a less active sexual life, as expected.  However, for patients who have operation  such that they do not need to use incontinence pads or catheters, have an increase in sexual activity. 

For patients with no cancer, the social function, social integration and fertility is good.  Therefore, evaluation of sexual function and fertility should be part of long term treatment. This includes patients with congenital lower tract abnormalities, e.g. bladder extrophy and also neuropathic conditions.  Patients who are younger than 60 and with benign conditions with a current partner tend to have a better recovery sexual function.  Clean intermittent catheterisation/incontinence should not affect sexual activity adversely. All aspects of sexual activity remains unchanged following cystectomy and neobladder formation as long as sexual activity is not affected by other medical conditions.  Even fertility can be preserved if the genitalia does not need to be removed.  Urinary leakage during sexual activity can be prevented by catheterisation before intercourse. Patients who have an external stoma and suffering from benign condition can be considered for urinary undiversion, to get rid of the stoma.  Female patients who are fertile can also get pregnant, although any Caesarean section will have to be jointly performed by the obstetrician and the urologist. 

The treatment of ED has been revolutionised by the introduction of the phosphodiesterase Type 5 inhibitor (PDE-5 I).  The main ones include Sildenafil, Vardenafil and Taladafil.  These medications can be taken ½ to 1 hour before sex and usually lasts for 4 hours except for Taladail which is 36 hours. 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 e.g. GTN, Isordil, Imdur.  Taking PDE-5 I together with nitrates can result in severe hypotension. PDE-5 I works in about 60% of patients, less if the patients have numerous co-morbidities e.g. diabetes.  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 20-40 mcg.  Over-dosage can result in prolonged erection, namely a 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 these have not been tested with double blind placebo controlled trials. 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 and topical Androgel to be applied daily, which is more physiological.  There is association between 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 psycho-sexual methods (e.g. squeeze technique) and the use of selective serotonin re-uptake inhibitors, SSRI, e.g. Fluoxetine 30 mg 2 hours before sex or off label use Tramadol. 

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, cancers, urostomata double the risk of FSD, especially arousal difficulties, pain during intercourse and infection. 

Fertility in patients with chronic illnesses is often decreased in part due erectile dysfunction and infection of the lower urinary and genital tract.  For patients with ejaculatory disorders, 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:

Erectile dysfunction is seen in up to 60% of patients with chronic illnesses including urostomy patients. However, many of them can be treated. Specific treatment and counselling  should be offered to these patients. ED should also be treated with the co-morbidities e.g. hypertension, diabetes, health and testosterone deficiency syndrome. and also lifestyle and dietary education.

A urethral catheter is obviously less effective as compared to a suprapubic catheter for sexual function.

 Presented for Malaysian Enterostomal Therapy ET  Nursing Program, SGH*

by Dr Clarence Lei Chang Moh, FRCS Urol, FEBU

Consultant Urologist

Adjunct Professor, Universiti Malaysia Sarawak

Honorary Consultant to SGH & HKL

16^th August 2017