These men often have other health problems. Here’s how urologists should address comorbidities.
It’s increasingly clear that erectile dysfunction (ED) is strongly linked to a range of underlying ailments including systemic vascular disease, diabetes, and obesity. These disorders, in turn, are associated with diet, exercise, and other lifestyle and emotional factors. Dealing with these interrelated issues goes beyond prescribing erection-enabling devices and drugs, and time often is limited.
Consequently, to what extent should busy urologists be-come involved in counseling pa-tients about these broader issues? Renal & Urology News discussed the issue with two highly respected urologists: Robert Kessler, MD, professor of urology at Stanford University School of Medicine in Palo Alto, Calif., and Natan Bar-Chama, MD, associate professor of urology at the Barbara and Maurice Deane Prostate Health and Research Center at Mount Sinai School of Medicine in New York.
Q: Many experts believe the presence of ED should prompt assessment of a patient’s risk of CVD and the presence of occult systemic vascular disease. What is the urologist’s assessment responsibility?
Dr. Kessler: To save time, have patients fill out a questionnaire in the waiting room or mail it to them when they schedule their appointment. Get their entire medical history, including what surgeries they’ve had. If I know a patient has had a penile implant, for example, I know phosphodiesterase-5 (PDE-5) inhibitors won’t work. If a patient has a history of severe diabetes and had stents put in because of atherosclerosis, I won’t spend as much time focusing on psychological problems. I also take a personal and family history from each new patient. If the patient has a referring physician, I ask the patient whether his doctor recently performed a workup that included a lipid panel, ECG, and serum glucose level test. If not, I send a letter to the patient’s primary care physician (PCP) suggesting that she or he perform such an evaluation. If the patient has no current PCP, I either order serum glucose and lipid tests, or suggest referral to an internist. In my referral letter I request evaluation for CVD, possible diabetes, and so on.
Dr. Bar-Chama: Today, urologists as well as the broader medical community better appreciate the linkage between ED and CVD. ED is often a manisfestation of endothelial dysfunction and is now con-sidered an independent risk factor for future adverse cardiovascular events. Therefore, we need to promote awareness of this association to our patients and medical colleagues. We must appreciate our limitations; we are not trained to treat CVD. However, we can proactively establish the diagnosis of dyslipidemia, hypertension, and endothelial dysfunction in our ED pa-tients. We can say, “Look it’s obvious you’re overweight, your blood pressure is elevated, you’re not exercising, and according to my ED evaluation your cholesterol profile and BMI are abnormal.” Our medical colleagues as well as our patients with ED often respond better to an abnormal lab test than to vague warnings about overall health.
Q: Many things, including alcohol, recreational drug use, and poor nutrition can contribute to ED. Should urologists counsel patients about these issues?
Dr. Kessler: Absolutely. If patients have high BP I always tell them that they may be able to get off BP medication if they follow a good diet and exercise program, starting with brisk walking for 30-45 minutes at least three or four days a week. If they need help with diet, I refer them. Sometimes PCPs feel urologists are impinging on their authority, so in my letter to the PCP I might say, “I’ve spoken to the patient and asked him to get referral to a nutritionist from you.” I do not rely on the patient to ask the PCP for a referral; and if they have no PCP, I provide a referral.
Dr. Bar-Chama: In addition to obtaining a medical and social history, all urologists, when appropriate, should determine an ED patient’s BP, weight, height, and testosterone level. The urologist should also find out if the patient is smoking and exercising. The next level of testing may be to assess for lipid abnormalities, early diabetes, and endothelial dysfunction. At this point, however, we’re entering an arena where it would be helpful to have another medical discipline involved. Very few urology practices are set up to perform such comprehensive assessments. We should look at treating ED patients as an opportunity to establish referral relationships with PCPs and other specialists. At the Mount Sinai Men’s Wellness Program, we are able to expand our ED evaluation as part of a comprehensive workup. I see patients together with an internist/endocrinologist one day each week. It comforts me to know that my ED patients are being evaluated for diabetes, hypogonadism, and cardiovascular risk by a physician who lives and breathes these diseases, and can offer state-of-the-art testing and treatment. A urologist who doesn’t currently have such an arrangement could suggest to a PCP colleague that he or she come into their office one afternoon a month to see patients who would benefit from this comprehensive approach to treating ED.
Q: To what extent should urologists get involved in discussing patients’ sex lives?
Dr. Kessler: To a major extent. I sometimes see patients who have not had intercourse with their partners for a long time, and as we talk, it becomes clear to me that there are major relationship issues. Sometimes I’ll say, “If I could give you a magic pill that would give you a good erection, would you want to have intercourse with your partner?” Often he will respond, “Not really.” I tell the patient he and his partner should be on the same page. On the other hand, if a man doesn’t have a current partner, treatment may be very worthwhile because if he knows he can perform, he can often go out and find a partner.
Dr. Bar-Chama: When dealing with personal issues like sexual function, it’s important to establish an understanding of the individual’s expectations and relationship status so you can offer effective therapy. On my intake form and in my discussions, I routinely inquire about these issues. Patients are asked, “Do you have a steady partner? How many years have you been together? Is your partner interested in having your sexual issues treated? How often are you sexually active? What are your expectations of ED therapy?”
Q: ED develops in as many as 80% of men with diabetes. Should urologists help patients manage their diabetes?
Dr. Kessler: Absolutely not. I caution urologists against treating diabetes, although they should make sure patients are getting treatment for it elsewhere. The same is true for blood pressure. Some patients will say, “I recently started on blood pressure medication, and within a week I developed ED. Can you switch me off it?” It’s not my area of expertise and I’m not qualified to do that.
Dr. Bar-Chama: A urologist who sees any ED patient with an abnormal BMI or glucose level should realize that this patient is at risk for diabetes and may already have pre-diabetes. However, we are not qualified to treat this. Nevertheless, alerting the patient to his increased risk is practicing good medicine. If the patient is told he needs to see another MD at a separate location, we often lose the opportunity to address these comorbidities effectively. I try to schedule patients for a follow-up appointment on days that the internist/endocrinologist is available. I tell patients, “You’re here anyway; so let’s attempt to deal with these issues.”
Q: What, if anything, should urologists do to monitor and treat depression in ED patients?
Dr. Kessler: Most urologists are good at evaluating depression; 90% of patients with severe depression will have ED, and if they are on antidepressant medication, that can make the ED worse. Of course, it can work both ways. Men with ED often develop depression. If the urologist picks up on a patient’s depression, it is not unreasonable to ask his PCP to refer him to a psychotherapist—or the urologist can do the referral directly.
Dr. Bar-Chama: Every patient with ED has psychological issues. The notion that there is a clear split between organic and psychogenic is outdated medicine. I work closely with a psychologist and a psychiatrist, and offer their skills routinely to my patients. We can often initiate successful PDE-5 inhibitor therapy first, and then the patient’s ability to deal with psychological issues will be markedly enhanced. Urologists are result-focused; we anticipate that the next time we see our ED patient, he will have made progress. If a tangible improvement is ob-served, a referral to the psychologist has a better chance of success. However, there are situations where intervention by a psychiatrist or psychologist is needed immediately, and the referral should not be delayed. These cases tend to be exceptions.
Q: Both ED and CVD are now thought to share a common denominator: endothelial dysfunction. What role does endothelial dysfunction play in ED?
Dr. Kessler: Endothelial cells in the penis can play a major role in improving or limiting erectile function. In patients with early diabetes who do not yet have ED, there may be medication in the future that can protect the endothelium.
Dr. Bar-Chama: Once a patient has endothelial dysfunction, its manifestations are broad and can include CVD, diabetes, and ED. We are currently screening patients for endothelial dysfunction in the office using an FDA-approved computer-based device called the Endo-PAT 2000, made by Itamar Medical Ltd. This new technology assesses endothelial function by measuring PATTM (Peripheral Arterial Tone) before and after brachial artery compression. The test takes about 30 minutes to perform by a trained nurse or medical assistant. Men with ED and no overt CV risk factors often have abnormal endothelial function compared to their age-matched cohorts without ED. As a urologist, I can’t take responsibility for treating underlying cardiovascular conditions; however, I can say to the patient, “Let’s talk about how we can optimize your overall health.”
Q: CVD and related comorbidities affect a disproportionately large number of African American and Hispanic men. To what extent should this information guide urologists in caring for minority patients?
Dr. Kessler: You need to take the same kind of medical, family, and social history for every patient, but be aware of group differences. African Americans have a higher incidence of prostate cancer, for example, so the patient’s internist should start PSA testing at age 40 instead of 50.
Dr. Bar-Chama: Minority patients are often seen by the medical community at a later stage of numerous disease processes. Disease severity as well as prevalence is higher in minority populations. Regardless of race or ethnicity, all ED patients should be screened for confounding and linked diseases. The linkage may also be greater in the minority population because of diminished access to quality health care.
Q: Will urologists be doing more lifestyle and emotional counseling in the future?
Dr. Kessler: Any physician should be comfortable talking about patients’ lifestyles. When patients come for other reasons, such as circumcision or vasectomy, but are overweight, I counsel them to lose weight. I say, “I know you’re coming in for a vasectomy, but you also want to be around for your grandchildren. If you need some help with your weight, let me know; I’ll give you names of people you can see.”
Dr. Bar-Chama: Urologists are an integral part of men’s wellness; some domains of urology—ED, voiding dysfunction, cancer detection and treatment—are critical to overall quality of life. Men’s wellness is best achieved using a multidisciplinary approach where urology is integrated with other specialties, including internal medicine, cardiology, endocrinology, and psychology. We are often the initial medical encounter for the ED patient. However, we must broaden our horizons and create an environment in which diagnosis and treatment for the comorbidities often encountered with ED are treated as well.