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Vasoactive Intracavernous Pharmacotherapy—The Nursing Role in Teaching Self-Injection Therapy
0022-534 7/87 /1385-1198$02.00/0
THE
Vol. 138, November
JOURNAL OF UROLOGY
Copyright© 1987 by The Williams & Wilkins Co.
Printed in U.S.A.
VASOACTIVE INTRACAVERNOUS PHARMACOTHERAPY-THE NURSING ROLE IN TEACHING SELF-INJECTION THERAPY LINDA M. DUFFY, ABRAHAM AMI SIDI
AND
PAUL H. LANGE
From the Urology Section, Veterans Administration Medical Center and Department of Urologic Surgery, University of Minnesota Health Sciences Center, Minneapolis, Minnesota
ABSTRACT
Our physician-nurse team management of a program in vasoactive intracavernous pharmacotherapy to treat male impotence has provided a high degree of patient and partner satisfaction. Nurses participate in the assessment of the ability of a patient or partner to master the self-injection technique, and the potential of a couple for compliance with and commitment to the program, all of which are key factors for successful home therapy. A nurse also teaches the self-injection technique. Audiovisual materials and handouts are used as teaching aids to ensure that complete and consistent information is given. The patient or partner is required to perform a self-injection under nursing supervision before a prescription for home use is written. Initial followup visits are scheduled with a nurse at 1 to 2-week intervals. At these visits the nurse identifies possible patient errors in self-injection technique, dose or frequency, and answers questions about the therapy. After the couple has mastered and is comfortable with home injection, followup appointments are scheduled with the physician at 4-week intervals to monitor for possible changes in response to treatment and for an examination of the phallus. (J. UrQl., 138: 1198-1200, 1987) Vasoactive intracavernous pharmacotherapy is a dynamic new program in nonoperative management of impotence. 1- 7 The medications most commonly used for vasoactive intracavernous pharmacotherapy to date, papaverine hydrochloride and phen tolamine mesylate, have been used therapeutically for other conditions for many years. When injected into the intracorporeal space these drugs cause dilatation of arterial walls and consequent tissue engorgement. In addition, they retard venous return, which traps the blood, and causes sustained tumescence and rigidity of the penis. These actions mimic the normal physiology of penile erection. 8 Vasoactive intracavernous pharmacotherapy does not cure impotence by reversing the underlying problem and restoring potency. Instead, it is an amazingly successful technique that stimulates a temporary but satisfactory erection for sexual intercourse. The ability to achieve an erection usually is present within 15 minutes after injection. The quality and duration of the erection depend upon the dose of drug administered, the underlying cause of impotence and the availability of sexual stimulation. 1 This dependence on sexual stimulation makes the evaluation of proper drug dosage most difficult within the clinic setting. Because vasoactive intracavernous pharmacotherapy has been used for only a short period, questions concerning the possible developme:tJ.t of drug tolerance, tissue changes within the corpora cavernosa or systemic side effects remain unanswered.
only minimal doses of drugs. However, those with vascular problems needed larger doses. To date there have been few short-term or long-term local side effects from papaverine and phentolamine. Nine patients reported a sustained erection (priapism). 2 Zorgniotti and Lefleur reported similar experiences in their initial trials with 62 patients.6 Priapism, or erection lasting longer than 8 hours is the most obvious and traumatic complication of this treatment and it generally can be prevented by careful titration of the dosage. This is important especially for men with neurological impotence. Eight patients have had intrapenile induration at the injection site. A biopsy of the injection site taken during insertion of a penile prosthesis in 1 patient showed a thick tunica albuginea with histological evidence of fibrosis. This condition did not affect the quality of response to vasoactive intracavernous pharmacotherapy in this patient but he was excluded from further injection therapy to prevent the development of more extensive local fibrosis. These findings underscore the need for careful monthly followup that includes palpation of the phallus. The diagnostic evaluation of impotence before vasoactive intracavernous pharmacotherapy is similar to that required for penile prosthesis implantation. For vasoactive intracavernous pharmacotherapy, emphasis is placed on results of Doppler blood flow studies and psychological evaluation. 1• 2 Before treatment our patients are asked to sign a consent form that has been approved by the Human Studies Subcommittee at our institutions.
CLINICAL BACKGROUND
CLINICAL PROTOCOL
A total of 200 men 35 to 75 years old who were impotent for a variety of reasons participated in our vasoactive intracavernous pharmacotherapy trial during the last 12 months. The test protocol and treatment of complications have been reported previously, and injections were effective in approximately 80 per cent of the men. 1- 3 The dose of drugs required varied from patient to patient. Men who were impotent because of a neurological problem, such as multiple sclerosis or spinal cord injury, but who did have an intact vascular system required
After the initial drug injection patients with partners were instructed to return home and attempt sexual intercourse. They also were given a data sheet to complete and return at the next clinic visit. The data requested included time of injection, dose of medication, time of onset and duration of erection, quality of erection in terms of rigidity on a scale of O to 100 per cent (O per cent-none, 50 per cent-quality adequate for vaginal penetration with assistance and 100 per cent-normal), ability for penetration and intercourse, and local and systemic side effects. This information assisted in determining what we considered an appropriate dosage (that is, that which enabled a
Accepted for publication April 28, 1987.
1198
NURSING ROLE IN VASOACTIVE INTRACAVERNOUS PHARMACOTHERAPY
patient to obtain an erection adequate for satisfactory intercourse but that was not sustained beyond 3 hours). THE NURSING ROLE IN VASOACTIVE INTRACAVERNOUS PHARMACOTHERAPY
The nursing role is important in the development and implementation of a successful self-injection program in vasoactive intracavernous pharmacotherapy. Nurses have a significant role in patient assessment, teaching and progress evaluation. Assessment before teaching. Teaching of self-injection is begun once it has been established that vasoactive intracavernous pharmacotherapy is working for an individual and he has passed psychological testing. Assessment of patients for selfinjection includes an evaluation of physical response to the medication, realistic expectations of treatment and tendency for compliance. It is of utmost importance that the men and their partners understand the benefits and limitations of vasoactive intracavernous pharmacotherapy. An erection sufficient for penetration and intercourse is the obvious benefit. No direct effect on orgasm and ejaculation can be anticipated, and this must be explained to the couples. In addition, the couples must not view a return to sexual functioning as a quick fix for all relationship issues, for example long-standing marital conflict or the depression and frustration accompanying alcoholic behavior. The danger of noncompliance in the vasoactive intracavernous pharmacotherapy program is the opposite of that usually observed in other therapies. For most therapies involving selfadministered medications noncompliance involves not taking the medication, which leads to poor control or exacerbation of the health problem. In vasoactive intracavernous pharmacotherapy noncompliance could mean taking the medication more often or in greater amounts than indicated by the physician to be safe. This could induce priapism or local complications, or it may produce psychological problems for the patient or partner. In all cases we attempt to control for this variable by limiting the amount of medication arid the number of syringes provided. Successful self-injection candidates also must demonstrate several specific skills, such as the ability to verbalize principles of vasoactive intracavernous pharmacotherapy, manual dexterity sufficient for syringe handling and injection, visual acuity adequate to measure the proper dose of medication and to find the proper injection site, and ability to return to the clinic for followup visits. If a patient is unable to perform self-injection a willing partner can be instructed instead. Plan for teaching. Several factors must be considered when a vasoactive intracavernous pharmacotherapy self-injection instruction program is planned. Information must be accurate, complete and presented in a consistent manner. Participants must be given the opportunity to practice their new skill with the same type of equipment that will be supplied for home use. Because of the number of patients a completely 1-to-1 instruction approach is not feasible. However, the sensitive nature of the topic does not allow for group learning. An audiovisual presentation followed by distribution of written handouts can decrease the instruction time enormously. These prepared learning aids guarantee that complete and consistent information is given to each person regardless of environmental and staff variables. Documentation of the teaching program and the nurse's evaluation of patient ability to proceed at home are an important part of self-injection instruction. Documentation provides information for other health care professionals and is evidence of informed consent. The teaching process. Patients are taught the traditional method to draw up the medication; an insulin syringe with a 30-gauge, half-inch needle has worked well for us. Emphasis is placed on accuracy and aseptic technique. When this is mastered patients are taught the self-injection technique. The penis should be grasped on either side of the meatus with the thumb
1199
and forefinger. The glans should be held firmly so that the penis does not slip during the procedure. The foreskin must be retracted in uncircumcised men. The penis should be stretched forward tautly and then positioned to one side with the restraining hand resting against the thigh. The safe injection area is the proximal-lateral aspect of the penile shaft relatively close to the pubis. The patient or partner should be taught to identify anatomical landmarks, that is meatus, urethral groove and corporeal body (fig. 1). The injection area should not have significant superficial veins and it must be cleansed with alcohol or povidone-iodine. The syringe should be held like a cigarette in the dominant hand between the second and third fingers, and the thumb should be placed on the syringe phalange, not on the plunger (fig. 2). The injecting hand should rest on the opposite thigh to give support and to reduce the possibility of traumatic extraneous movements. Penetration of the needle into the penis must be at 90 degrees to the skin to ensure access to the corpus. An angle of 45 degrees or less risks injection of the urethra or penile neurovascular bundle. Once the needle is within the corpus the thumb is moved to the plunger and the medication is injected slowly. After injection the patient must apply pressure to the site for up to 1 minute to prevent swelling or bruising. Some patients may be unable to see the penis because of the size of the abdomen. In this case practice in front of a mirror can facilitate the process. Occasionally, unusual resistance is encountered when attempting to insert the needle or when the medication is injected. When this occurs it is best to remove the needle and to inject at a different site. Couples should be informed of the consequences of improper injection. If the urethra is injected there will be burning and, possibly, slight hematuria at the next
FIG. 1. Anatomy of penis
1200
DUFFY, SIDI AND LANGE
should include a review of the injection process and the results obtained, examination of the penis, collection of data forms, liver function studies and, if appropriate, occasional demonstration of the technique to a nurse. CONCLUSION
The diagnosis and treatment of impotence are becoming more sophisticated, and patient and partner satisfaction with treatment is increasing. Nurse education, counseling and support to each couple on an individual basis is valuable to vasoactive intracavernous pharmacotherapy and any impotence treatment program. REFERENCES 1. Sidi, A. A., Cameron, J. S., Duffy, L. M. and Lange, P. H.:
FIG. 2. Proper injection technique 2.
voiding. If a superficial vessel is punctured swelling, bruising and pain at the site may occur to various degrees. In both situations the quality of the response will be affected. It is possible that there will be no erection. It is crucial to assure patients that injection of the urethra or a superficial blood vessel causes no permanent injury and does not require a call to the physician. Couples should be advised not to attempt injection again the same day but to wait the usual interval. Patients also should be informed about priapism, to date the most severe possible side effect of vasoactive intracavernous pharmacotherapy. We instruct patients to report an erection lasting longer than 6 hours. Management of a sustained erection has been discussed previously. 1- 3 Evaluation of patient teaching. Vasoactive intracavernous pharmacotherapy patients should be evaluated at frequent intervals to assess the progress in the home situation. Followup
3.
4. 5. 6. 7. 8.
Intracavernous drug-induced erections in the management of male erectile dysfunction: experience with 100 patients. J. Urol., 135: 704, 1986. Sidi, A. A. and Lange, P.H.: Recent advances in the diagnosis and management of impotence. Urol. Clin. N. Amer., 13: 489, 1986. Sidi, A. A., Cameron, J. S., Dykstra, D. D., Reinberg, Y. and Lange, P.H.: Vasoactive intracavernous pharmacotherapy for the treatment of erectile impotence in men with spinal cord injury. J. Urol., 138: 539, 1987. Brindley, G. S.: Cavernosal alpha-blockade: a new technique for investigating and treating erectile impotence. Brit. J. Psychiat., 143: 332, 1983. Goldstein, I., Payton, T. R., de Tejada, I. S. and Krane, R. J.: Pharmacologic erections: role in the treatment of neurologic impotence. J. Urol., part 2, 133: 261A, abstract 591, 1985. Zorgniotti, A. W. and Lefleur, R. S.: Auto-injection of the corpus cavernosum with a vasoactive drug combination for vasculogenic impotence. J. Urol., 133: 39, 1985. Virag, R., Frydman, D., Legman, M. and Virag, H.: Intracavernous injection of papaverine as a diagnostic and therapeutic method in erectile failure. Angiology, 35: 79, 1984. Juenemann, K.-P., Lue, T. F., Fournier, G. R., Jr. and Tanagho, E. A.: Hemodynamics of papaverine- and phentolamine-induced penile erection in monkeys and dogs. J. Urol., 136: 158, 1986.
THE
Vol. 138, November
JOURNAL OF UROLOGY
Copyright© 1987 by The Williams & Wilkins Co.
Printed in U.S.A.
VASOACTIVE INTRACAVERNOUS PHARMACOTHERAPY-THE NURSING ROLE IN TEACHING SELF-INJECTION THERAPY LINDA M. DUFFY, ABRAHAM AMI SIDI
AND
PAUL H. LANGE
From the Urology Section, Veterans Administration Medical Center and Department of Urologic Surgery, University of Minnesota Health Sciences Center, Minneapolis, Minnesota
ABSTRACT
Our physician-nurse team management of a program in vasoactive intracavernous pharmacotherapy to treat male impotence has provided a high degree of patient and partner satisfaction. Nurses participate in the assessment of the ability of a patient or partner to master the self-injection technique, and the potential of a couple for compliance with and commitment to the program, all of which are key factors for successful home therapy. A nurse also teaches the self-injection technique. Audiovisual materials and handouts are used as teaching aids to ensure that complete and consistent information is given. The patient or partner is required to perform a self-injection under nursing supervision before a prescription for home use is written. Initial followup visits are scheduled with a nurse at 1 to 2-week intervals. At these visits the nurse identifies possible patient errors in self-injection technique, dose or frequency, and answers questions about the therapy. After the couple has mastered and is comfortable with home injection, followup appointments are scheduled with the physician at 4-week intervals to monitor for possible changes in response to treatment and for an examination of the phallus. (J. UrQl., 138: 1198-1200, 1987) Vasoactive intracavernous pharmacotherapy is a dynamic new program in nonoperative management of impotence. 1- 7 The medications most commonly used for vasoactive intracavernous pharmacotherapy to date, papaverine hydrochloride and phen tolamine mesylate, have been used therapeutically for other conditions for many years. When injected into the intracorporeal space these drugs cause dilatation of arterial walls and consequent tissue engorgement. In addition, they retard venous return, which traps the blood, and causes sustained tumescence and rigidity of the penis. These actions mimic the normal physiology of penile erection. 8 Vasoactive intracavernous pharmacotherapy does not cure impotence by reversing the underlying problem and restoring potency. Instead, it is an amazingly successful technique that stimulates a temporary but satisfactory erection for sexual intercourse. The ability to achieve an erection usually is present within 15 minutes after injection. The quality and duration of the erection depend upon the dose of drug administered, the underlying cause of impotence and the availability of sexual stimulation. 1 This dependence on sexual stimulation makes the evaluation of proper drug dosage most difficult within the clinic setting. Because vasoactive intracavernous pharmacotherapy has been used for only a short period, questions concerning the possible developme:tJ.t of drug tolerance, tissue changes within the corpora cavernosa or systemic side effects remain unanswered.
only minimal doses of drugs. However, those with vascular problems needed larger doses. To date there have been few short-term or long-term local side effects from papaverine and phentolamine. Nine patients reported a sustained erection (priapism). 2 Zorgniotti and Lefleur reported similar experiences in their initial trials with 62 patients.6 Priapism, or erection lasting longer than 8 hours is the most obvious and traumatic complication of this treatment and it generally can be prevented by careful titration of the dosage. This is important especially for men with neurological impotence. Eight patients have had intrapenile induration at the injection site. A biopsy of the injection site taken during insertion of a penile prosthesis in 1 patient showed a thick tunica albuginea with histological evidence of fibrosis. This condition did not affect the quality of response to vasoactive intracavernous pharmacotherapy in this patient but he was excluded from further injection therapy to prevent the development of more extensive local fibrosis. These findings underscore the need for careful monthly followup that includes palpation of the phallus. The diagnostic evaluation of impotence before vasoactive intracavernous pharmacotherapy is similar to that required for penile prosthesis implantation. For vasoactive intracavernous pharmacotherapy, emphasis is placed on results of Doppler blood flow studies and psychological evaluation. 1• 2 Before treatment our patients are asked to sign a consent form that has been approved by the Human Studies Subcommittee at our institutions.
CLINICAL BACKGROUND
CLINICAL PROTOCOL
A total of 200 men 35 to 75 years old who were impotent for a variety of reasons participated in our vasoactive intracavernous pharmacotherapy trial during the last 12 months. The test protocol and treatment of complications have been reported previously, and injections were effective in approximately 80 per cent of the men. 1- 3 The dose of drugs required varied from patient to patient. Men who were impotent because of a neurological problem, such as multiple sclerosis or spinal cord injury, but who did have an intact vascular system required
After the initial drug injection patients with partners were instructed to return home and attempt sexual intercourse. They also were given a data sheet to complete and return at the next clinic visit. The data requested included time of injection, dose of medication, time of onset and duration of erection, quality of erection in terms of rigidity on a scale of O to 100 per cent (O per cent-none, 50 per cent-quality adequate for vaginal penetration with assistance and 100 per cent-normal), ability for penetration and intercourse, and local and systemic side effects. This information assisted in determining what we considered an appropriate dosage (that is, that which enabled a
Accepted for publication April 28, 1987.
1198
NURSING ROLE IN VASOACTIVE INTRACAVERNOUS PHARMACOTHERAPY
patient to obtain an erection adequate for satisfactory intercourse but that was not sustained beyond 3 hours). THE NURSING ROLE IN VASOACTIVE INTRACAVERNOUS PHARMACOTHERAPY
The nursing role is important in the development and implementation of a successful self-injection program in vasoactive intracavernous pharmacotherapy. Nurses have a significant role in patient assessment, teaching and progress evaluation. Assessment before teaching. Teaching of self-injection is begun once it has been established that vasoactive intracavernous pharmacotherapy is working for an individual and he has passed psychological testing. Assessment of patients for selfinjection includes an evaluation of physical response to the medication, realistic expectations of treatment and tendency for compliance. It is of utmost importance that the men and their partners understand the benefits and limitations of vasoactive intracavernous pharmacotherapy. An erection sufficient for penetration and intercourse is the obvious benefit. No direct effect on orgasm and ejaculation can be anticipated, and this must be explained to the couples. In addition, the couples must not view a return to sexual functioning as a quick fix for all relationship issues, for example long-standing marital conflict or the depression and frustration accompanying alcoholic behavior. The danger of noncompliance in the vasoactive intracavernous pharmacotherapy program is the opposite of that usually observed in other therapies. For most therapies involving selfadministered medications noncompliance involves not taking the medication, which leads to poor control or exacerbation of the health problem. In vasoactive intracavernous pharmacotherapy noncompliance could mean taking the medication more often or in greater amounts than indicated by the physician to be safe. This could induce priapism or local complications, or it may produce psychological problems for the patient or partner. In all cases we attempt to control for this variable by limiting the amount of medication arid the number of syringes provided. Successful self-injection candidates also must demonstrate several specific skills, such as the ability to verbalize principles of vasoactive intracavernous pharmacotherapy, manual dexterity sufficient for syringe handling and injection, visual acuity adequate to measure the proper dose of medication and to find the proper injection site, and ability to return to the clinic for followup visits. If a patient is unable to perform self-injection a willing partner can be instructed instead. Plan for teaching. Several factors must be considered when a vasoactive intracavernous pharmacotherapy self-injection instruction program is planned. Information must be accurate, complete and presented in a consistent manner. Participants must be given the opportunity to practice their new skill with the same type of equipment that will be supplied for home use. Because of the number of patients a completely 1-to-1 instruction approach is not feasible. However, the sensitive nature of the topic does not allow for group learning. An audiovisual presentation followed by distribution of written handouts can decrease the instruction time enormously. These prepared learning aids guarantee that complete and consistent information is given to each person regardless of environmental and staff variables. Documentation of the teaching program and the nurse's evaluation of patient ability to proceed at home are an important part of self-injection instruction. Documentation provides information for other health care professionals and is evidence of informed consent. The teaching process. Patients are taught the traditional method to draw up the medication; an insulin syringe with a 30-gauge, half-inch needle has worked well for us. Emphasis is placed on accuracy and aseptic technique. When this is mastered patients are taught the self-injection technique. The penis should be grasped on either side of the meatus with the thumb
1199
and forefinger. The glans should be held firmly so that the penis does not slip during the procedure. The foreskin must be retracted in uncircumcised men. The penis should be stretched forward tautly and then positioned to one side with the restraining hand resting against the thigh. The safe injection area is the proximal-lateral aspect of the penile shaft relatively close to the pubis. The patient or partner should be taught to identify anatomical landmarks, that is meatus, urethral groove and corporeal body (fig. 1). The injection area should not have significant superficial veins and it must be cleansed with alcohol or povidone-iodine. The syringe should be held like a cigarette in the dominant hand between the second and third fingers, and the thumb should be placed on the syringe phalange, not on the plunger (fig. 2). The injecting hand should rest on the opposite thigh to give support and to reduce the possibility of traumatic extraneous movements. Penetration of the needle into the penis must be at 90 degrees to the skin to ensure access to the corpus. An angle of 45 degrees or less risks injection of the urethra or penile neurovascular bundle. Once the needle is within the corpus the thumb is moved to the plunger and the medication is injected slowly. After injection the patient must apply pressure to the site for up to 1 minute to prevent swelling or bruising. Some patients may be unable to see the penis because of the size of the abdomen. In this case practice in front of a mirror can facilitate the process. Occasionally, unusual resistance is encountered when attempting to insert the needle or when the medication is injected. When this occurs it is best to remove the needle and to inject at a different site. Couples should be informed of the consequences of improper injection. If the urethra is injected there will be burning and, possibly, slight hematuria at the next
FIG. 1. Anatomy of penis
1200
DUFFY, SIDI AND LANGE
should include a review of the injection process and the results obtained, examination of the penis, collection of data forms, liver function studies and, if appropriate, occasional demonstration of the technique to a nurse. CONCLUSION
The diagnosis and treatment of impotence are becoming more sophisticated, and patient and partner satisfaction with treatment is increasing. Nurse education, counseling and support to each couple on an individual basis is valuable to vasoactive intracavernous pharmacotherapy and any impotence treatment program. REFERENCES 1. Sidi, A. A., Cameron, J. S., Duffy, L. M. and Lange, P. H.:
FIG. 2. Proper injection technique 2.
voiding. If a superficial vessel is punctured swelling, bruising and pain at the site may occur to various degrees. In both situations the quality of the response will be affected. It is possible that there will be no erection. It is crucial to assure patients that injection of the urethra or a superficial blood vessel causes no permanent injury and does not require a call to the physician. Couples should be advised not to attempt injection again the same day but to wait the usual interval. Patients also should be informed about priapism, to date the most severe possible side effect of vasoactive intracavernous pharmacotherapy. We instruct patients to report an erection lasting longer than 6 hours. Management of a sustained erection has been discussed previously. 1- 3 Evaluation of patient teaching. Vasoactive intracavernous pharmacotherapy patients should be evaluated at frequent intervals to assess the progress in the home situation. Followup
3.
4. 5. 6. 7. 8.
Intracavernous drug-induced erections in the management of male erectile dysfunction: experience with 100 patients. J. Urol., 135: 704, 1986. Sidi, A. A. and Lange, P.H.: Recent advances in the diagnosis and management of impotence. Urol. Clin. N. Amer., 13: 489, 1986. Sidi, A. A., Cameron, J. S., Dykstra, D. D., Reinberg, Y. and Lange, P.H.: Vasoactive intracavernous pharmacotherapy for the treatment of erectile impotence in men with spinal cord injury. J. Urol., 138: 539, 1987. Brindley, G. S.: Cavernosal alpha-blockade: a new technique for investigating and treating erectile impotence. Brit. J. Psychiat., 143: 332, 1983. Goldstein, I., Payton, T. R., de Tejada, I. S. and Krane, R. J.: Pharmacologic erections: role in the treatment of neurologic impotence. J. Urol., part 2, 133: 261A, abstract 591, 1985. Zorgniotti, A. W. and Lefleur, R. S.: Auto-injection of the corpus cavernosum with a vasoactive drug combination for vasculogenic impotence. J. Urol., 133: 39, 1985. Virag, R., Frydman, D., Legman, M. and Virag, H.: Intracavernous injection of papaverine as a diagnostic and therapeutic method in erectile failure. Angiology, 35: 79, 1984. Juenemann, K.-P., Lue, T. F., Fournier, G. R., Jr. and Tanagho, E. A.: Hemodynamics of papaverine- and phentolamine-induced penile erection in monkeys and dogs. J. Urol., 136: 158, 1986.