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
Evaluation of ED should include a detailed medical and sexual history of the patient. 1 A discussion of the patient and partner’s preference and treatment goals is essential to better tailor treatment and improve patient satisfaction and adherence to treatment.2 Lifestyle modification and management of risk factors should precede pharmacotherapy, while first-line treatment with oral phosphodiesterase type 5 inhibitors (PDE5i) is 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 five key sexual habits. 3 In general, most men across the world taking medication for 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 six 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.
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 response.2
As the majority of men with ED plan 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’s 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. 1 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 were treated with a PDE5i experienced improvements in general health, vitality, confidence, self-esteem, self-control and satisfaction with sexual 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 insights 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.
Abbreviated Prescribing Information4 Composition: Sildenafil Citrate.
Indications: For the treatment of erectile dysfunction, which is the inability to achieve or maintain a penile erection sufficient for satisfactory sexual performance. In order for sildenafil to be effective, sexual stimulation is required.
Recommended dosage: Use in adults: For most patients, the recommended dose is 50mg taken, as needed, approximately 1 hour before sexual activity. Based on effectiveness and toleration, the dose may be increased to a maximum dose of 100mg or decreased to 25mg. The maximum recommended daily dose is 100mg. The maximum dosing frequency is once per day.
Contraindications: Use of sildenafil is contraindicated in patients with a known hypersensitivity to any component of the tablet. Administration to patients who are concurrently using nitric oxide donors, organic nitrates or organic nitrites in any form either regularly or intermittently is therefore contraindicated.
Special warning and precautions for use: There is a degree of cardiac risk associated with sexual activity; therefore, cardiovascular status of patients should be considered prior to initiating treatment for erectile dysfunction. Sildenafil should not be used in men for whom sexual activity is inadvisable. Prior to prescribing sildenafil, physicians should consider whether patients with certain underlying conditions could be adversely affected by vasodilatory effects, especially in combinations with sexual activity. Non-arteritic anterior ischemic optic neuropathy (NAION) has been reported rarely post- marketing with the use of PDE-5 inhibitors. In case of sudden visual loss, patients should be advised to stop taking sildenafil and consult a physician immediately. Sildenafil should only be used if benefit outweighs risk in patients with history of NAION. In order to minimize the potential for developing postural hypotension, patients should be hemodynamically stable on alpha-blocker therapy prior to initiating sildenafil treatment, whereby lower doses should be considered. Administer sildenafil with caution in patients with inherited condition retinitis pigmentosa, bleeding disorders or active peptic ulceration, in patients with anatomical deformation of the penis or predisposed to priapism. In the event of an erection that persists longer than 4 hours, the patient should seek immediate medical assistance. Combinations with other PDE5 inhibitors is not recommended. In case of sudden decrease or loss of hearing, patients should be advised to stop taking sildenafil and consult a physician.
Common side effects: The most commonly reported adverse reactions were headache, diziness, vision blurred, vision disturbance, cyanopsia, hot flush, flushing, nasal congestion, nausea and dyspepsia.
Formulation and preparation: 50mg and 100mg tablets in packs of 1’s and 4’s.
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 July 6, 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. Pfizer (Malaysia) Viagra Prescribing Information. 23 September 2015.
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.