Recommandations aux médecins généralistes pour la prise en charge de première intention de la dysfonction érectile (réactualisation 2010)

Practices and knowledge of general practitioners on erectile dysfunction: A practice survey

INTRODUCTION

Erectile dysfunction (ED) is a common and underestimated sexual disorder. This sexual concern, which should raise the suspicion of an underlying coronary artery disease, is rarely broached by general practitioners (GPs). The aim of this work was to establish an inventory of the practices and knowledge of general practitioners when faced with a case of ED.

METHODS

This survey is a descriptive cross-sectional epidemiological study targeting GPs' practice. Answers were collected through a self-questionnaire, "KIKI SAIT?", online that explored: demographic data, level of practice and theoretical knowledge regarding ED.

RESULTS

One hundred and seventy-seven GPs took part in this study. Regarding their practice, 80.2% of doctors expected the patient to bring up the subject. Few clinicians managed ED according to recommendations of the French Association of Urology. More than 30% referred the patient to a urologist, cardiologist or endocrinologist. In total, 57.6% of practitioners prescribed a phosphodiesterase 5 inhibitor (PDE5I) as first-line treatment. Regarding their knowledge, 67.8% of doctors considered their level of knowledge about PDE5I to be poor, 96.6% about intracavernosal injections, 88.7% about vacuum devices and 91% about penis rings. The main obstacle retained was the lack of medical knowledge (71.2%). Clinicians who rarely consulted for ED were less confident in explaining possible treatments (25/63 versus 18/113, P<0.001).

CONCLUSION

Strengthening initial training and providing a practical algorithm for the management of ED could be useful to help general practitioners detect ED, which could be a sentinel of coronary heart disease.

LEVEL OF EVIDENCE: 4

Doctors Talking About Sexuality: What Are the Patients' Feelings?

INTRODUCTION

Many medical practitioners avoid discussing the subject of sexuality with their patients because they are afraid of invading their privacy.

AIM

This study was carried out to discover what patients feel when asked about their sexuality by their GP.

METHODS

A qualitative study was carried out that involved 96 patients aged 18 to 86. The patients were recruited from 4 medical offices in the South of France. A substitute general practitioner asked the patients, "How is your sexuality these days?" during routine consultations. The patients were then asked how they felt about that question in semi-structured interviews.

MAIN OUTCOME MEASURES

This study highlights the existence of a discrepancy between physicians' beliefs and patients' expectations. Indeed, physicians fear that they would embarrass their patients if they address the subject of sexual intimacy. As it turns out, 93% of the patients would have welcomed that question.

RESULTS

34 patients (35%) were surprised by the question. 7 patients (7%) found the question unwelcome. 89 patients (93%) had a neutral or positive feeling. 78 patients (81%) deemed that sexual history should form an integral part of GP consultations (50% were in favor of systematic screenings for sexual dysfunctions, while 31% preferred targeted screenings). 2 patients (2%) found that the question had boosted their confidence and strengthened the doctor-patient relationship.

CONCLUSION

Most patients do not deem that their GP is invading their privacy if the GP touches upon the subject of sexuality, even if the patient's visit was for a different reason. Before addressing the issue, the GP must ensure that an appropriate framework of trust, care, and empathy is in place. If this framework is present, the patient will be able to overcome his/her feelings of surprise and know that there is a safe space to talk freely about this topic. Zéler A, Troadec C. Doctors Talking About Sexuality: What Are the Patients' Feelings?. Sex Med 2020;8:599-607.

The impact of drugs on male fertility: a review

Beside cytotoxic drugs, other drugs can impact men's fertility through various mechanisms. Via the modification of the hypothalamic-pituitary-gonadal axis hormones or by non-hormonal mechanisms, drugs may directly and indirectly induce sexual dysfunction and spermatogenesis impairment and alteration of epididymal maturation. This systematic literature review summarizes existing data about the negative impact and associations of pharmacological treatments on male fertility (excluding cytotoxic drugs), with a view to making these data more readily available for medical staff. In most cases, these effects on spermatogenesis/sperm maturation/sexual function are reversible after the discontinuation of the drug. When a reprotoxic treatment cannot be stopped and/or when the impact on semen parameters/sperm DNA is potentially irreversible (Sulfasalazine Azathioprine, Mycophenolate mofetil and Methotrexate), the cryopreservation of spermatozoa before treatment must be proposed. Deleterious impacts on fertility of drugs with very good or good level of evidence (Testosterone, Sulfasalazine, Anabolic steroids, Cyproterone acetate, Opioids, Tramadol, GhRH analogues and Sartan) are developed.

[Efficacy and tolerance of PDE-5 in the treatment of erectile dysfunction in schizophrenic patients: A literature review]

INTRODUCTION

Sexual dysfunction is an important public health problem in men and is associated with reduced quality of life. It is more common in patients with schizophrenia. It is well-established that antipsychotic drugs cause sexual dysfunction with consequences on the quality of life of patients, adherence to treatment, and public health costs. Phosphodiesterase type 5 inhibitors (PDE5 inhibitors) are indicated for the management of erectile dysfunction. However, there is little information on such treatment in schizophrenic patients. This literature review aimed to summarize the current data on the efficacy and tolerability of PDE-5 inhibitors in the erectile dysfunction in schizophrenic patients.

MATERIAL AND METHODS

PubMed, PsycInfo and Cochrane databases were searched for studies published until August 2014.

RESULTS

Only 6 studies met the inclusion criteria. Three were randomized, double-blind, cross-over, placebo-controlled trials and three were open studies. Various scales were used to measure erectile and orgasmic function, desire, satisfaction during intercourse, overall satisfaction, quality of life and intensity of schizophrenic symptoms. In the 3 randomized studies (one with sildenafil 25-50 mg, one with lodenafil carbonate 80 mg/j and the last one with tadalafil 10 mg), the rate of participants who completed the trial was high (around 95 %). All three included patients with schizophrenia or schizophrenia spectrum disorders. Patients reported significant improvement on sexual dysfunction. However, no statistical difference was reported between lodenafil and placebo, on different scales, suggesting a very important placebo effect in patients with schizophrenia. All three found a good tolerance of PDE-5 inhibitors. Side effects were rare and were mainly nasal congestion, headaches, nausea and dizziness. There were no major side effects or drug interactions. Considering the 3 open studies, 2 involved sildenafil and one tadalafil. All concluded in improved erectile and orgasmic function, desire, satisfaction during intercourse, overall satisfaction, and even the quality of life when it was studied. However, very few patients were included.

DISCUSSION

Little data are available on the use of PDE5 inhibitors in schizophrenic patients. The 6 studies included few patients which reduces the power and the scope of their conclusions. There is also an important bias due to the use of self-questionnaires. The methodologies of the studies differ in many aspects which limits the comparability. Inclusion and exclusion criteria, drugs used and scales varied among the studies. However, the management of erectile disorder seems to be a consistent target in an integrative approach for the overall well-being of schizophrenic patients. PDE-5 inhibitors appear to be safe and could improve erectile function in schizophrenic patients.

CONCLUSION

In total, the current data suggest efficiency and good tolerance of the use of PDE-5 inhibitors in schizophrenic patients with erectile dysfunction. However, further studies focusing on PDE-5 inhibitors are needed to more deeply assess their efficacy and safety in patients with schizophrenia.

Impact of a first treatment with phosphodiesterase inhibitors on men and partners' quality of sexual life: results of a prospective study in primary care

INTRODUCTION

Phosphodiesterase type 5 inhibitors (PDE5is) as oral treatment for erectile dysfunction (ED) facilitate the management of ED in primary care. Still, compliance is low and general practitioners (GPs) do not always feel confident with this pathology. AIM.: The aim of this paper is to evaluate the impact of a first treatment with PDE5i on the patient and his partner and the management of ED by GPs.

METHODS

The Evaluation après traitement de la dyfonction erectile, du bien-êtré émotionnel d'un patient en fonction de la rigidité de son érection survey was a longitudinal, observational French study with prospective collection of data from the GP, the patient, and his partner at baseline and after 3 months of treatment. GPs benefited from a short educational session before starting the survey.

MAIN OUTCOME MEASURES

The main outcome measures are the Erection Hardness Score (EHS), Self-Esteem and Relationship (SEAR) questionnaire, Index of Sexual Life (ISL), and Erectile Dysfunction Inventory of Treatment Satisfaction.

RESULTS

A total of 478 men aged 19-80 years (mean 57 years) were included in the survey by 229 GPs. Before treatment, EHS was mostly grade 1 (28%) or 2 (44%). At the end of the survey, an improvement was reported for 88% of the patients and 58% achieved maximum score EHS 4 (penis completely hard and fully rigid). Mean SEAR scores significantly increased after 3 months for self-esteem, overall and sexual relationship, and more notably with greater improvement in EHS (P < 0.001). Improvement in partners' ISL scores was significantly higher with greater improvement in EHS (P < 0.001) and in SEAR score for self-esteem. The safety profile of PDE5i was good with few adverse events, mostly headaches. More than 80% of the participating GPs considered that the survey had changed their management of ED.

CONCLUSION

After 3 months of treatment with PDE5i, a significant improvement in self-esteem was observed in patients with ED, associated with improvement in erection.

[Importance of patient's choice in the treatment of erectile dysfunction]

Erectile dysfunction (ED) affects nearly one out of two men over age 45. ED is known to alter the quality of life of patients, and to affect significantly their sexual life and relations, as well as those of their female partners. Phosphodiesterase 5 inhibitors (PDE5) inhibitors currently represent the reference treatment for ED, because of their efficacy and good tolerability. The presence of erectile disorders capable of altering considerably the life of a couple makes it necessary to find ways for patients and their partners to get more involved in the treatment choices. A "customized" solution responding to patient's needs and resulting from a decision shared with the patient and his partner will allow a better compliance and efficacy of the treatment.