Why Does Most Erectile Dysfunction Go Untreated?
Erectile dysfunction (ED) is a common condition, affecting 18 million men in the United States.1 The combined prevalence of minimal, moderate, and complete impotence is 52%, according to the Male Aging Study.2 Yet despite its commonness, most patients with ED receive little or no treatment, according to a study presented at the 28th Annual European Association of Urology (EAU) Congress in March, 2013.3
The researchers conducted a large-scale investigation of ED treatment, using 12-month data derived from a payor data set consisting of 87,600,000 males, of whom 6,228,509 had a diagnosis of ED. Patients were considered "treated" if they filled a prescription for a phosphodiesterase type 5 inhibitor (PDE5i), injection or urethral prostaglandins, or androgen replacement therapy (ART). "Untreated" patients received the diagnosis but did not fill a prescription.
Of those diagnosed with ED, only 25.4% were treated, most commonly with PDE5i (75.2%) and ART (30.6%). Less than 2% received prostaglandin therapy. Treatment frequency was higher for comorbid hypogonadism (51% treated) and lower for comorbid prostate cancer (15% treated), but otherwise did not vary significantly with other associated comorbidities.
Below, Kevin McVary, MD, Professor and Chair of Urology, Southern Illinois University School of Medicine, Springfield, Ill., and one of the authors of the study, discusses the implications of his group's research and findings.
What motivated your group to embark on this study?
We were concerned about male sexual health and the vast number of men who suffer from ED but go untreated. We were aware that undertreatment is common, but previous research was derived from small studies involving small populations. We wanted to investigate large-scale data and see if we could glean factors that drive nonadherence and undertreatment.
Were you surprised by the study findings?
We were actually shocked by the results. The Male Aging Study,2 conducted in the 1990s, found that most men went untreated for ED. But we assumed that this undertreatment was due to the absence of effective medications. Moreover, physicians in those days did not ask about ED. Some were uncomfortable and felt patients would be embarrassed to discuss it, others did not think it was important, and others were too busy or harried to take time to inquire. But since then, a great deal of provider education has taken place, so an increasing number of physicians are initiating a discussion with male patients regarding potential ED. Indeed, our study findings confirm this—the number of ED diagnoses in the data set shows that physicians are asking about ED, but patients are not following through on treatment recommendations.
Why do you think so many patients do not follow through on treatment recommendations?
We can't necessarily derive that answer from claims data. Since the study took place over a one-year period, it's only a snapshot. For example, some men may have received a diagnosis in the years preceding the study, filled their prescription, and developed side effects leading to discontinuation at that time. But they still carry the diagnosis of ED on their claims data and for study purposes are regarded as "untreated."
Additionally, many men may not have been in a relationship during the study period, so they may not have regarded medication as relevant to their lives at that time. We know that some men are embarrassed about their need for "artificial" assistance in achieving or maintaining an erection, or their partners are opposed or uncomfortable, so they don't fill prescriptions. Other men cannot afford the medication.
Another reason—especially in the older population—is that patients with multiple comorbidities are already taking medications for hypertension or elevated cholesterol, or other conditions that typically affect older adults. Many patients reach a saturation point when it comes to medications, and don't want to add another to their already complicated regimen.
Do you have plans to conduct future studies on this subject?
My colleagues and I are planning to investigate community cohorts rather than insurance claims. We would like to go to the 75% of untreated patients and ask why they have not followed through on their treatment plans. This will give us hard data, rather than speculation. Once we understand the real motives of these patients, strategies can be developed to address their concerns.
1. Selvin E, Burnett AL, Platz EA. Prevalence and risk factors for erectile dysfunction in the US. Am J Med. 2007;120(2):151-157.
2. Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol. 1994;151:54-61.
3. Cakir O, Aurora H, Helfant T, McVary T. The frequencies and characteristics of men receiving medical intervention for erectile dysfunction: Analysis of 6.2 million patients. Abstract Nr: 126; 28th Annual EAU Congress, 15 to 19 March 2013; Milan, Italy.