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Charalambos Vlachopoulos1st Department of Cardiology, Hippokration Hospital, Athens Medical School, Profiti Elia 24, Athens 14575, GreeceGraham JacksonGuy's and St.
Erectile dysfunction is defined as the inability to attain or maintain a penile erection sufficient for satisfactory sexual performance. Table 1 offers elements for distinction between organic and psychogenic disease.7 Of note is that in cases of organic origin, a psychogenic component may co-exist. It is an important component of the quality of life and it also confers an independent risk for future cardiovascular events.
While this review deals exclusively with sexual health of men, female sexual health and its potential relation with CVD is also an interesting, yet underexplored, field.
Cases of ED may be classified as predominantly organic in nature, predominantly psychogenic, or mixed.
Although, erectile dysfunction is profoundly stressful for most men, affecting self image, behaviour, and relationships, some do not regard it as a health priority. The usual 3-year time period between the onset of erectile dysfunction symptoms and a cardiovascular event offers an opportunity for risk mitigation. Many of the men were uninformed about erectile dysfunction and were unprepared for it, and the majority neither helped themselves nor asked for help. Thus, sexual function should be incorporated into cardiovascular disease risk assessment for all men. Owing to the relationship of vasculogenic ED with CVD, it is important to distinguish men with predominantly vasculogenic ED from those with predominantly psychogenic ED or non-vasculogenic organic ED. A comprehensive approach to cardiovascular risk reduction (comprising of both lifestyle changes and pharmacological treatment) improves overall vascular health, including sexual function. Evidence of ageism was strong.Conclusions Unlike patients with prostate cancer, men with colorectal cancer are not routinely offered information and treatment for erectile dysfunction. Proper sexual counselling improves the quality of life and increases adherence to medication. Greater coordination of care and consistent strategies are needed to tackle the unmet needs of this widely diverse patient group. This review explores the critical connection between erectile dysfunction and cardiovascular disease and evaluates how this relationship may influence clinical practice. Currently, clinicians are inadvertently neglecting, misleading, and offending such patients; better training could improve this situation, as might the reorganisation of services. Algorithms for the management of patient with erectile dysfunction according to the risk for sexual activity and future cardiovascular events are proposed. To date there has been little published research describing the experiences of erectile dysfunction in men with colorectal cancer,8 or their views and preferences about information, services, and treatment. We carried out a qualitative study to describe the experiences of men with erectile dysfunction after surgery for colorectal cancer and to ascertain whether or not the provision of information could be improved so that it is “flexible, responsive to individual’s coping strategies and information choices.”23MethodsWe carried out a prevalence study of erectile dysfunction among 378 paticipants who had a diagnosis of colorectal cancer between January 1998 and December 2008 and were treated in the same hospital trust in the West Midlands.
From the 167 men who agreed to be interviewed we selected those from a variety of backgrounds and with differing treatment histories to ensure a broad range of views and experiences of erectile dysfunction and to include minority views.24 We used purposive sampling to select 28 men who had received treatment for colorectal cancer. Analysis occurred concurrently with data collection so that emerging topics could be explored in later interviews. We gave the participants a choice of venue (own home or healthcare location) and sex of interviewer. Frequent discussions within the team ensured thorough and consistent coding and led to the development of an extensive thematic framework, including both manifest (explicit) and latent themes. All the men chose a female interviewer, therefore BH carried out the interviews, which lasted between 10 and 126 minutes (mean 40 minutes). Most of the participants were married, white, and heterosexual; they varied considerably in age and International Index of Erectile Function score (table 1?).
Most had undergone colorectal cancer surgery (n=24) and chemotherapy (n=20), some had radiotherapy (n=13), and some had a stoma (n=13). The cancer site was unknown in six, diffuse in one, above the rectosigmoid junction in 12, and below the rectosigmoid junction in nine. As four men did not have erectile dysfunction, the results concentrate on the experience of the other 24 who did.Table 1 ?Characteristics of participants (n=28).
All had received treatment for colorectal cancer.Fig 1?Thematic frameworkCausal beliefs and experience of erectile dysfunctionA range of beliefs were expressed about the causes of erectile dysfunction (table 2? and box 2). For three, erectile dysfunction had predated colorectal cancer (owing to prostate or long term health problems).

The rest of the men had become aware of erectile dysfunction at some point after surgery or adjuvant therapy although pinpointing the precise times of onset was difficult. Initial unawareness of erectile dysfunction stemmed from morbidity, the side effects of treatment (severe in some cases), and the shock from or preoccupation with having cancer. Some may also have associated erectile dysfunction with other treatment (blood pressure tablets, for example). After treatment, and following a period of recovery, most of the sample (n=19) attributed the onset of erectile dysfunction to the effects of treatments for colorectal cancer. Around half the men, however, believed that continuing erectile dysfunction was related to a range of psychological factors. I thought to myself, I said, “I can’t get a hard on” (312)It’s either the radio or the chemo.
I think it was the radiotherapy, and I think they’ve done some damage there (404)PsychologicalAnd I think the thing was that the harder I tried the worse it got, you know.
And because you are ill you lose the desire to have sex, if you like, it’s as simple as that.
When treatment stopped, however, the men described a diverse range of effects of erectile dysfunction on themselves and on their partners. Profound and stressful consequences were reported as erectile dysfunction challenged the men’s identity, affected mental and physical health, and undermined relationships (box 3). I’d like to sort of feel that I was a complete man really and you don’t feel like you’re a complete man really and it’s not a very nice feeling. It’s like, I don’t know, you can imagine how these women feel who have a breast op, they don’t feel they’re a complete woman I would imagine.
It’s only for peeing now, if you know what I mean (312)Because I mean in darkest moments you do think well I wonder if it was worth having to be like existing like this, it’s not really living (319)it’s very difficult to describe all the emotions and everything else that you go through and the pain that you suffer and the anguish and the frustration and everything else, all rolled into one. So the relationship, it hasn’t broke down yet but I suspect it will (264)we’ve had a couple or three goes in the last 12 months, that’s probably it.
Which is quite a bit of difference (328)because I’m not desperate for sex, I’m desperate to become well. And the other thing is probably in one sense probably the stock answer might be back “oh well, look at your age like,” you know, type of thing and “you’ve just had this operation, what do you expect” type of thing. I have probably expected that in my mind’s eye and think well okay it might be the norm, I don’t know. If it is then you just live with it (347)RiskBut I do feel that [consultant A] is so busy . Now I don’t want to ruffle anybody’s feathers and I’m reluctant to phone secretaries or make myself a nuisance because I do feel that he’s doing me a favour. He’s doing me a favour insomuch as he’s taking me back on again so I feel in that position (264)TemporalI link it all to all these things I’m taking and the operations and I’m just hoping that it’ll go. Notably, men who had received treatment appeared less reticent but otherwise shared most of the views of the men who had never asked for help.Reticence was the most common explanation for not seeking help.
This encompassed simple embarrassment (four men), a lack of confidence, a general fear of looking stupid, and waiting to be asked rather than raising the subject themselves. Four men expressed low expectations of clinicians (based on poor care experiences) and believed that responses would be offensive. Three men believed they had already had their “fair share” of care, and two stated that if they were “greedy” it meant that others would be deprived of care.The category of risk encompassed perceptions that clinicians in primary and secondary care were too busy (in general) and not interested in erectile dysfunction (in particular). Six men perceived that erectile dysfunction was not on the clinical agenda and therefore did not want to risk raising it in case this was deemed inappropriate. Three thought it might give offence to the clinician and feared that being “pushy” would undermine future care. Under the temporal reasons, four men were optimistically waiting for erectile dysfunction to resolve naturally, two were procrastinating, and three explained that it had been relatively unimportant while undergoing active cancer treatment and so had only recently emerged as a problem. Relevance was questioned by five men who did not believe that erectile dysfunction was a great concern to them or thought that it was irremediable. One was told by his general practitioner that he was not eligible for phosphodiesterase type 5 inhibitors (no surgery) and gave up at this point. Another was referred by an andrologist to his general practitioner for a new drug, which the general practitioner refused to prescribe (lost paperwork, perceived lack of knowledge, and unacceptable cost to the National Health Service). One had subsequently obtained the aphrodisiac horny goat weed from the internet (not efficacious).
Two of those who experienced a lack of benefit also reported increased rejection by partner and subsequent dejection (echoing views of some who had not sought treatment).

In addition, one man had also tried “sticks put down the penis” (unsuccessfully) and another was persevering with a pump device:I have tried it [Viagra]. I said, I’d only just gone through chemo and all that, and I says, I can’t get an erection unless I have the Viagra and I said, it’s started destroying me, it’s doing my head in (312)Yeah, I didn’t like it. I tried it about twice, I couldn’t stand it [lack of spontaneity] (374)I’ve looked on the internet, they said that horny goat weed and things like this might work . Although most participants reported being given general information, more than half of the men who developed erectile dysfunction after treatment for colorectal cancer believed that they had not been warned specifically about erectile dysfunction:[erectile dysfunction] I presumed it to be an effect of chemotherapy which surprised me, I did some Googling and found that it was in fact most likely an effect from the surgery and to be honest I was annoyed that I didn’t know about it (24)However, all pointed out that they would still have had the treatment even if more adequately informed. Ten men recalled receiving verbal information from a nurse or doctor on possible erectile dysfunction, some of which was unintentionally offensive. I was more concerned about my bowel cancer and getting myself sorted out with that but you know, you sort of take it step by step and at the moment, this (erectile dysfunction) is the thing I’m trying to sort out (118)Some had reached a point in their recovery where they felt swindled:And that is part of the package which they really don’t tell you about. It’s like saying “well you’re going on the package holiday, there’s the hotel,” but they don’t tell you it’s half built at the back do they? Some men took part in our study specifically to ask for help and to get a sense of what the norms might be. No coordinated system of care for erectile dysfunction was apparent from accounts:Well, this is why I’ve been in two minds about it because—who is best to consult? Although for most men erectile dysfunction is profoundly stressful, affecting self image, behaviour, and relationships, some do not see it as a health priority.
Many of the men in our sample were uninformed about erectile dysfunction and were unprepared for it, and the majority neither helped themselves nor asked for help. Evidence of ageism was strong.Results in contextCare pathways for patients with prostate cancer are designed to ensure that information about erectile dysfunction is incorporated into routine care and that treatment is offered. Neither information on nor treatment for erectile dysfunction is routinely offered to men with colorectal cancer8; this may result from a lack of evidence on the effects of treatment or a lack of awareness among clinicians of the patient’s need for treatment. Unfamiliarity or discomfort may have resulted in men failing to be coherent or explicit when discussing their experiences or preferences. We suspect that men’s information needs change over time, but a longitudinal study would be needed to show this. In common with other qualitative studies we cannot assume that our sample is representative; rather we set out to describe a range of views and experiences.
However, comparison with the prevalence study population (table 1) shows that the participants who were interviewed were similar to the questionnaire respondents except that, because of the purposive sampling, they were slightly younger and less likely to be of white ethnicity.Implications for clinical practiceIn England inequalities in access to erectile dysfunction treatment currently exist.
Firstly, there is considerable potential for offending older men by making assumptions about their sexual behaviour or motivation. Older couples may not differ substantially from younger couples in sexual interest or activity.49 Secondly, phosphodiesterase type 5 inhibitors are not a panacea.
Thirdly, the majority of men are not going to ask for help with erectile dysfunction and therefore it may be necessary for someone in the clinical team to explore this sensitively but routinely. Based on the evidence that erectile dysfunction is stressful and distressing, we suggest that the opportunity needs to be created for men to voice their concerns. We have not, however, established precisely how to get men to acknowledge that erectile dysfunction is important, common, a legitimate concern (whatever the patient’s age or marital status), or acceptable as a topic of discussion with clinicians, and that addressing it is a reasonable component of healthcare for patients with colorectal cancer.The wide diversity of this patient group (but a general lack of information, understanding, and limited help seeking) calls for a more proactive coordination of care and consistent strategies to address unmet needs.
More work is needed to fully determine patients’ and clinicians’ views on the appropriate design and delivery of services. Previous work has shown that healthcare workers often avoid discussing erectile dysfunction because they have other priorities, may not recognise its importance to men’s health related quality of life, and feel embarrassed themselves about discussing sexual matters.6 20 Therefore we could speculate that responsibility needs to be explicitly given to a particular member of a team. Given appropriate training and support, colorectal clinical nurse specialists (a central part of most colorectal cancer care teams) could focus on the diverse needs of this variable population, incorporate the provision of information on erectile dysfunction into care before and after surgery, identify unmet needs, refer as necessary, monitor progress, and coordinate ongoing care. Oncology nurses in the United States and breast cancer nurses in the United Kingdom often have a similar role.6 A checklist (see web extra) is suggested by our descriptive framework (figure). Other practical solutions may also be possible.Future researchAlthough we did not interview the spouses or partners of patients, their perspectives were strongly present in several accounts. Purposive sampling enables the broad range of experience to emerge, but further work is needed to determine the true prevalence of the experiences and preferences uncovered here. A detailed assessment of the existing provision of information on erectile dysfunction is called for to determine what approaches are used in different centres and what impact these may have on men’s understanding.

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