Bobby Andres, a 48-year-old man, presents to your office with complaints of erectile dysfunction for about one year. He reports that sexual desire is present but that he has a lack of ability to achieve and maintain erection. Bobby notes that he has avoided physical affection with his wife in order to avoid the embarrassment of “not being able to perform.” He often falls asleep early so that he may avoid initiation of sexual contact. Bobby also states that he had a history of depression and anxiety, but his primary care doctor put him on sertraline and buspirone and that has taken care of those symptoms. He reports that he has been on those medications for two to three years.
From your perspective as Bobby’s psychiatric nurse practitioner, answer the following questions in a four-page double-spaced paper (not including the reference page), in APA format. Include at least three peer-reviewed, evidence-based references.
1. What screening tools could be used with Bobby to assess his complaints of sexual dysfunction?
2. What labs should be ordered for Bobby? Explain the rationale for each lab.
3. Pick one medication that could be used to help Bobby. Include brand and generic names, starting dose, tapering (if applicable), contraindications, needed lab work, and patient education.
4. What role (if any) do sertraline and buspirone have on sexual dysfunction? Would you change these medications? Why? Explain your rationale.
5. What referrals would you make for Bobby? Explain your rationale.
Solution to Erectile Dysfunction Case Study
Introduction: Erectile dysfunction (ED) is the failure to achieve an erection or maintain it for satisfactory sexual intercourse. The prevalence of ED increases with age beyond 40 years and comorbidities (Keks et al., 2019). Several underlying conditions cause ED. However, most patients with ED have a primary psychological condition, especially young men. The psychological impacts of ED on individuals include loss of self-esteem, depression, anxiety, and relationship issues, among others. Therefore, ED results in significant emotional damage to individuals and their partners, leading to low quality of life. This paper delves into various aspects of ED based on Bobby Andres’ case study.
Screening tools for Erectile dysfunction
The first tool that can be used to assess Bobby’s sexual dysfunction is the International Index of Erectile Dysfunction (IIEF). This tool is a clinician-rated 15-item questionnaire designed to assess sexual dysfunction lasting over four weeks in males. This tool evaluates five significant domains of sexual functions. These are erectile and orgasmic functioning, sexual desire, sexual intercourse satisfaction, and general satisfaction with the sexual act. Grover and Schouan (2020) contend that its wide use is due to a high degree of internal consistency for all the domains.
The second tool is Change in Sexual functioning Questionnaire (CSFQ). It is a structured questionnaire containing 14 items that compare sexual functioning before and after an event in males and females (Grover & Schouan, 2020). The event could be an illness or using certain medications. The male questionnaire assesses dysfunctions in erection, orgasm, ejaculation, and libido. Bobby developed ED after treatment with antidepressants. Therefore, these two scales are suitable for his screening.
Lab tests for Bobby
I would order blood hormone tests to evaluate early morning testosterone and prolactin levels. Abnormal testosterone levels outside the range of 50-1000 ng/dL indicate ED. An abnormal prolactin level in males- more than 15 ng/ mL is associated with erectile dysfunction and low sex drive (Grover & Schouan, 2020).
I would also order a urinalysis, which provides information on protein, sugar, and testosterone levels. A deviation from the normal measurements of these parameters indicates diabetes, renal disease, or testosterone deficiency, all of which can cause ED.
I would order a final diagnostic test of duplex ultrasound. This procedure used high-frequency sound waves to take pictures of body tissues. The tests in performed when the penis is soft and erect. To achieve an erection, a drug that stimulates erection is injected. Then the ultrasound evaluates the blood flow, assessing venous leak, atherosclerosis, or tissue scarring within the penis (Grover & Schouan, 2020).
Medication for Bobby
Bobby would significantly benefit from higher doses of buspirone while gradually tapering sertraline. Adequate evidence reveals that buspirone can counter erectile dysfunction due to the long-term use of selective serotonin reuptake inhibitors (sertraline) (Shmuts, Kay & Beck, 2020). Buspirone is the generic name, while the brand name is Buspar. The initial dose recommended for generalized anxiety disorder is 7.5 mg BD (Wilson & Tripp, 2018). Wilson and Tripp (2018) establish that the dosage can be increased every 2 to 3 days by 5 mg till the desired health outcome is achieved. The maximum recommended daily dosage is 60 mg per day.
While gradually increasing this dosage, sertraline dosages should be slowly tapered too. Keks et al. (2019) note the high risk of relapse associated with switching or stopping antipsychotics. Additionally, withdrawal symptoms such as cholinergic and dopaminergic effects depend on the antipsychotic drug. Keks et al. 2019 describe three-drug switching techniques to ensure patient safety. In this case, the cross titration technique is applicable as it has less risk of relapse. In this method, the first drug (sertraline) is gradually reduced while the second (buspirone) is gradually increased to therapeutic levels. This technique is common and provides a balance between reducing the risk of relapse and adverse effects during the overlap (Keks et al., 2019).
Buspirone use is strongly contraindicated in concomitant use with monoamine oxidase inhibitors (MAOI). Also, MAOIs should not be administered within 14 days before or after treatment with buspirone due to the high risk of developing serotonin syndrome and high blood pressure (Wilson & Tripp,2018). Lastly, it is contraindicated in a history of buspirone sensitivity.
Before initiating treatment, the patient should have an ECG to rule out arrhythmias and palpitation. These symptoms worsen with buspirone therapy as they are reaming the side effects (Wilson & Tripp, 2018).
Patients should minimize the amount of grapefruit juice they ingest per day when using buspirone. Grapefruit juice increases buspirone plasma concentrations. Also, due to unpredictable central nervous system effects in every individual, it is advisable not to operate any machinery or automobile until one is confident that the medication does not affect them seriously. Lastly, it is advisable to avoid drinking alcohol when on buspirone. More research is needed to ascertain the safety of using alcohol with buspirone.
The role of sertraline and buspirone on sexual dysfunction
Sertraline is an SSRI. Antidepressants in this category of drugs are associated with a common side effect of low sex drive and erectile dysfunction. When used concomitantly with buspirone, there are high efficacy levels in treating generalized anxiety disorder (Schmuts et al., 2020). Studies indicate that buspirone can treat erectile dysfunction associated with SSRIs. Also, studies suggest that it is safer to use the cross titration technique when switching medications as the first line of treatment. Failure to counter the unfavourable adverse effect will prompt the second-line approach, which is switching the antipsychotic drug (Keks et al., 2019). Therefore, in this case study, I would adjust the doses of each drug until the patient experiences an improvement in ED.
Referrals for Bobby
I would refer Bobby to a urologist for further relevant investigations and follow-up while on treatment. Urologists are best fit to make recommendations and manage health conditions associated with ED as they specialize in treating urinary and reproductive organs issues.
I would also refer Bobby and his partner to a sex therapist. Sex therapy is the most effective treatment of sexual dysfunctions, especially when the sexual partner participates (Ramanathan & Redelman, 2020). It entails cognitive-behavioural interventions, psychotherapy, couple interventions, and mindfulness techniques to help clients understand and improve their sexual dysfunctions (Ramanathan & Redelman, 2020). Sex therapy aims to restore maximum sexual function through various techniques listed above.
Sexual functioning is a multidimensional process that needs a sound body and state of mind and stable emotions. Since most antidepressants are associated with sexual dysfunctions, clinicians should provide adequate health education when initiating treatment, so the patients are mentally prepared and know why they are experiencing sexual dysfunction. Addressing sexual health concerns through medical interventions and sex therapy has immense benefits in improving the quality of life.
Grover, S., & Shouan, A. (2020). Assessment scales for sexual disorders—a review. Journal of Psychosexual Health, 2(2), 121-138. https://doi.org/10.1177/2631831820919581
Ramanathan, V., & Redelman, M. (2020). Sexual dysfunctions and sex therapy: The role of a general practitioner. Australian Journal of General Practice, 49(7), 412-415. doi: 10.31128/AJGP-02-20-5230
Shmuts, R., Kay, A., & Beck, M. (2020). Buspirone: A forgotten friend. Current Psychiatry, 19(1), 20. Retrieved from https://cdn.mdedge.com/files/s3fs-public/CP01901020.PDF
Wilson, T. K., & Tripp, J. (2018). Buspirone. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK531477/
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