CCE-CBD-220

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the likely causes of James’s erectile dysfunction, and what further assessments are needed?

• Prompt: What are the common physiological and psychological contributors to ED?
• Prompt: What further investigations are appropriate in this case?

Q2. How would you explain the link between erectile dysfunction and cardiovascular/metabolic health?

• Prompt: What is the significance of ED as a marker for cardiovascular disease?
• Prompt: How would you discuss this sensitively with James?

Q3. What are the treatment options for James’s erectile dysfunction?

• Prompt: What pharmacological and non-pharmacological approaches should be considered?
• Prompt: How would you address his concerns about medications?

Q4. How would you approach psychological and relationship concerns in this case?

• Prompt: How would you explore underlying stress, depression, or relationship strain?
• Prompt: When would you consider referral for counselling or sex therapy?

Q5. What preventive health advice would you provide regarding James’s overall well-being?

• Prompt: What lifestyle changes can improve both ED and long-term health?
• Prompt: What screening and follow-up measures are needed?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are the likely causes of James’s erectile dysfunction, and what further assessments are needed?

Erectile dysfunction (ED) is multifactorial, with vascular, metabolic, neurological, hormonal, and psychological contributors. In James’s case, key contributors include:

Likely Causes

1. Vascular disease: Hypertension, diabetes, and dyslipidaemia contribute to endothelial dysfunction and impaired blood flow.
2. Metabolic factors: Insulin resistance and obesity increase inflammatory and oxidative stress, worsening ED.
3. Hypogonadism: Low-normal testosterone may impact libido and erectile function.
4. Psychological factors: Relationship strain, performance anxiety, and low mood can exacerbate ED.
5. Medication side effects: Amlodipine and statins can contribute to ED.

Further Investigations

• Repeat morning testosterone (to confirm levels).
• Luteinising hormone (LH), follicle-stimulating hormone (FSH) (to assess for primary/secondary hypogonadism).
• Prolactin and thyroid function tests (to rule out endocrine causes).
• Doppler penile ultrasound (if vascular cause suspected).
• Mental health screening (assessing for depression/anxiety).

---

Q2: How would you explain the link between erectile dysfunction and cardiovascular/metabolic health?

Key Messages

• ED is often a warning sign of cardiovascular disease (CVD) due to underlying endothelial dysfunction.
• Studies show ED precedes major cardiac events by 3-5 years.
• Risk factors such as diabetes, hypertension, and dyslipidaemia impact both vascular health and erectile function.
• Treating underlying metabolic and cardiovascular risk factors improves both ED and long-term heart health.

Communication Approach

• Use layman’s terms: “Erections rely on healthy blood vessels, just like your heart.”
• Address concerns sensitively: “Many men experience ED; it’s not just about ageing but a sign we should assess your overall health.”
• Empower the patient: “Improving your metabolic health will not only help ED but also reduce your risk of heart disease and stroke.”

---

Q3: What are the treatment options for James’s erectile dysfunction?

Lifestyle Modifications (First-Line)

• Weight loss and regular exercise (improves endothelial function and testosterone).
• Optimising diabetes control (reduces vascular damage).
• Smoking cessation and reducing alcohol.

Pharmacological Options

• Phosphodiesterase-5 inhibitors (PDE5i):
  • Sildenafil (Viagra), Tadalafil (Cialis) improve erectile function by enhancing nitric oxide activity.
  • Contraindications: Use with nitrates or severe CVD.
• Testosterone replacement therapy (if indicated):
  • Consider if testosterone consistently low with symptoms.
• Review antihypertensives:
  • Consider switching from amlodipine to ACE inhibitors if contributing to ED.

Other Options

• Psychological support for performance anxiety or relationship strain.
• Penile injections or vacuum devices if oral medications fail.

---

Q4: How would you approach psychological and relationship concerns in this case?

Key Considerations

• ED impacts self-esteem and relationships; an empathetic, non-judgmental approach is essential.
• Explore mood symptoms: “Have you noticed changes in your energy, sleep, or enjoyment in activities?”
• Assess relationship strain: “How has this affected intimacy with your partner?”
• Discuss performance anxiety: Addressing anticipatory anxiety and expectations.

Management Strategies

• Counselling referral: Sexual health counselling or couples therapy.
• Cognitive behavioural therapy (CBT): Can address anxiety and self-confidence issues.
• Education on intimacy and communication: Encourage open dialogue with his partner.

---

Q5: What preventive health advice would you provide regarding James’s overall well-being?

Cardiovascular Prevention

• Target BP <130/80 mmHg and HbA1c <7.0%.
• Encourage Mediterranean diet: Reduces CVD and metabolic risks.
• Consider statin therapy review to optimise lipid control.

Men’s Health Screening

• PSA test: Discuss pros/cons of prostate cancer screening.
• Colorectal screening: If not yet done, recommend faecal occult blood test (FOBT).
• Vaccination: Ensure influenza, pneumococcal, and COVID-19 vaccinations are up to date.

Mental Health and Lifestyle

• Encourage strength training and aerobic exercise.
• Screen for depression/anxiety.
• Reduce sedentary time at work.

---

SUMMARY OF A COMPETENT ANSWER

• Recognises ED as a multifactorial issue, linked to vascular, metabolic, hormonal, and psychological causes.
• Orders appropriate investigations, including testosterone, metabolic workup, and mental health screening.
• Explains the link between ED and cardiovascular disease, providing clear, relatable explanations.
• Offers a structured treatment plan, including lifestyle, pharmacotherapy, and psychological support.
• Provides preventive health advice, addressing CVD risk, mental well-being, and screening measures.

PITFALLS

• Failing to recognise ED as a cardiovascular risk marker, missing an opportunity for prevention.
• Not addressing psychological and relationship factors, focusing only on medications.
• Prescribing PDE5 inhibitors without assessing contraindications, particularly CVD and medication interactions.
• Neglecting preventive health measures, such as diabetes control, lipid management, and screening.
• Inadequate counselling on lifestyle changes, missing a chance for long-term improvement.

REFERENCES

• RACGP Guidelines on Management of Erectile Dysfunction in General Practice
• Australian Heart Foundation on Erectile Dysfunction and Cardiovascular Risk
• Better Health Channel on Erectile Dysfunction and Men’s Health
• Endocrine Society of Australia on Testosterone Therapy Guidelines

---

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Engages patient in discussion of sensitive health issues.
1.2 Uses non-judgmental, patient-centred communication techniques.

2. Clinical Information Gathering and Interpretation

2.1 Elicits a thorough sexual, metabolic, and cardiovascular history.
2.2 Identifies risk factors contributing to erectile dysfunction (ED).

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises underlying causes of ED and associated comorbidities.
3.2 Determines appropriate investigations.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides evidence-based management of ED and related conditions.
4.2 Discusses pharmacological and non-pharmacological treatments.

5. Preventive and Population Health

5.1 Provides cardiovascular and metabolic health advice.

6. Professionalism

6.1 Ensures culturally sensitive and ethical discussion of sexual health.

7. General Practice Systems and Regulatory Requirements

7.1 Understands prescribing regulations for ED medications.

9. Managing Uncertainty

9.1 Recognises when specialist referral is required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies ED as a potential marker of cardiovascular disease.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD