Great expectations: Understanding the needs of your patients with erectile dysfunction
Erectile dysfunction (ED) is a common condition defined as the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance.1 It is one of the most common complaints in men’s sexual medicine, affecting both physical and psychosocial health and having a significant impact on the patient and partner’s quality of life.1 Moreover, ED is commonly associated with other comorbid conditions, including hypertension, dyslipidaemia and diabetes mellitus.1
Management of ED should include a detailed medical and sexual history of the patient. A discussion of the patient and partner’s preference and treatment goals is also essential to better tailor treatment and improve patient satisfaction and adherence to treatment.2 Lifestyle modification and management of risk factor should first precede pharmacotherapy, while first-line treatment with oral phosphodiesterase type 5 inhibitors (PDE5i) are well established for the management of patients with ED.1
Survey of sexual habits of men with ED
Results from a recent global health survey of 1,458 men from across 7 countries taking medication for their ED, identified 5 key sexual habits. In general, most men across the world taking medication for their ED plan their sexual intercourse up to several hours in advance and engage in sexual intercourse a median of 6 times per month (Figure 1).3
Key findings from the global sexual habits survey identified:3
· 83% of men taking ED treatment always or sometimes plan their sexual intercourse in advance.
· When men taking ED medication plan for sexual intercourse, 71% will plan up to several hours in advance.
· 96% of men taking an ED medication have sexual intercourse within 4 hours of dosing.
· Men taking oral ED treatment engage in a median frequency of 6 sexual encounters per month.
· At least 90% of men surveyed perceive rigid erections and low side-effects as the most important attributes of a treatment for ED.
Expert commentary by Dr Jaime Songco
What are your thoughts on the recent findings from the global sexual habits survey?
The findings from this survey show that most men with ED know when they will engage in sexual activity.3 We also know that men who are receiving treatment for their ED are aware of their condition and therefore make greater efforts to plan their sexual activity.
It is really important that physicians first understand what the patient’s needs are and what they are looking to achieve with treatment, along with the intricacies of their relationship and their partner’s needs before deciding on the kind of treatment the patient requires. The findings are particularly relevant because physicians should be defining treatment goals based on individual patient factors, especially if treatment is anticipated to be long term.
How should physicians apply this finding to the management of their patients with ED?
We know that there are some differences between the various oral PDE5i’s that may be more suited to some patient’s goals. For example, sildenafil is rapidly absorbed in the system and has an onset-of-action between 30–60 minutes after administration and can be effective for up to 12 hours.1,4 However, this may be reduced after a high fat meal.1,4 Other PDE5i’s in comparison, may have a shorter onset of action and a longer duration of efficacy.2
As the majority of men with ED are planning their sexual encounters in advance, sildenafil is a suitable treatment option. When it comes to selecting a treatment with regards to potency, sildenafil continues to be one of the most potent PDE5i based on clinical and anecdotal data, which are important for improving patient confidence, satisfaction and adherence.5–8
What are the important factors to consider when initiating first-line treatment?
Prior to initiating treatment, it is important to first take a thorough patient history and perform a physical examination to identify the cause of ED, the severity of ED and the presence of any comorbid conditions. In my practice, I openly engage the couple to discuss their expectations, dosing instructions and any potential side-effects with treatment.
Oral medications are often the first-line treatment for men with ED.1 For most of my patients with ED, I will typically start treatment on sildenafil, which is recommended to be given at a dose of 50 mg once-daily and can be dose-adjusted down to 25 mg or up to 100 mg as needed, such as for those patients with more severe ED and a baseline erection hardness score (EHS) of grade 1.4,9 In my experience, there is a low risk of side effects with PDE5i’s and these can often be maintained with dose adjustment. None of my patients have experienced adverse effects that have prevented them from continuing treatment.
Why is managing ED important?
There are plenty of data that discuss the psychosocial and mental impact of ED on patients.10,11 Therefore, when we are able to effectively manage a patient’s ED, we also help to improve their overall well-being. Patients who are more sexually active are more well-balanced, have better confidence, self-esteem, self-control and have happier relationships.11
I would advise physicians to engage in discussions of sexual issues with both their patients and their partner because this can give great insight into the best way to manage their condition. Most patients who are able to have these open discussions have had better experiences and are more satisfied with treatment.
1. Hatzimouratidis K, et al. Guidelines on male sexual dysfunction: Erectile dysfunction and premature ejaculation. The Netherlands: European Association of Urology; 2015. Available at http://uroweb.org/wp-content/uploads/14-Male-Sexual-Dysfunction_LR1.pdf. Accessed 6 July 2017.
2. Corona G, et al. Phosphodiesterase type 5 (PDE5) inhibitors in erectile dysfunction: the proper drug for the proper patient. J Sex Med 2011;8:3418–3432.
3. Mulhall JP, et al. Understanding the sexual habits of men taking medication for erectile dysfunction (ED): Survey results from 7 countries. J Urol 2016;195(4S):e951.
4. Viagra [Full Prescribing Information]. Available at: http://www.mims.com/indonesia/drug/info/viagra/?type=full#Dosage. Accessed 27 July 2017.
5. Chen L, et al. Phosphodiesterase 5 inhibitors for the treatment of erectile dysfunction: A trade-off network meta-analysis. Eur Urol 2015;68:674–680.
6. Hatzimouratidis K. Sildenafil in the treatment of erectile dysfunction: An overview of the clinical evidence. Clin Interv Aging 2006;1:403–414.
7. Cappelleri JC, et al. Association between the erectile dysfunction inventory of treatment satisfaction and the self-esteem and relationship questionnaire following treatment with sildenafil citrate for men with erectile dysfunction. Value Health 2005;8 Suppl 1:S54–S60.
8. Giannitsas K, et al. Preference for and adherence to oral phosphodiesterase-5 inhibitors in the treatment of erectile dysfunction. Patient Prefer Adherence 2008;2:149–155.
9. Mulhall JP, et al. Erection hardness: A unifying factor for defining response in the treatment of erectile dysfunction. Urology 2006;68(3 Suppl):17–25.
10. Dean J, et al. Psychological, social, and behavioural benefits for men following effective erectile dysfunction (ED) treatment: Men who enjoy better sex experience improved psychological well-being. Eur Urol Supplement 2006;5:773–778.
11. McCabe MP and Althof SE. A systematic review of the psychosocial outcomes associated with erectile dysfunction: Does the impact of erectile dysfunction extend beyond a man’s inability to have sex? J Sex Med 2014;11:347–363.