Clinical Review

Veterans’ Satisfaction With Erectile Dysfunction Treatment

Limited alternatives and lack of knowledge of behavioral methods shown to improve erectile functioning lead many veterans to continue erectile dysfunction treatment despite a lack of satisfaction.

Fed Pract. 2016 May;33(5):33-37

Author(s):

Joleen C. Sussman, PhD

Heather M. Smith, PhD, ABPP

Sadie E. Larsen, PhD

Katherine E. Reiter, MS

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References

1. Grover SA, Lowensteyn I, Kaouache M, et al. The prevalence of erectile dysfunction in the primary care setting: importance of risk factors for diabetes and vascular disease. Arch Intern Med. 2006;166(2):213-219.

2. Miller K. In the war on impotence, the VA deploys Viagra and Cialis. Bloomberg Business Week. January 17, 2013. http://www.businessweek.com/articles/2013-01-17/in-the-war-on-impotence-the-va-deploys-viagra-and-cialis. Accessed April 7, 2016.

3. Phosphodiesterase Type 5 Inhibitors for the Treatment of BPH/LUTS and Penile Rehabilitation: Evidence Summary and Recommendations - December 2014. U.S. Department of Veterans Affairs website. http://www.pbm.va.gov/clinicalguidance/clinicalrecommendations/PDE5I_BPH_LUTS_Evidence_Summary_and_Recommendations.pdf. Accessed April 29, 2016.

4. Laumann EO, Glasser DB, Neves RC, Moreira ED Jr; GSSAB Investigators’ Group. A population-based survey of sexual activity, sexual problems and associated help-seeking behavior patterns in mature adults in the United States of America. Int J Impot Res. 2009;21(3):171-178.

5. Baumgartner MK, Hermanns T, Cohen A, et al. Patients’ knowledge about risk factors for erectile dysfunction is poor. J Sex Med. 2008;5(10):2399-2404.

6. Esposito K, Ciotola M, Giugliano F, et al. Effects of intensive lifestyle changes on erectile dysfunction in men. J Sex Med. 2009;6(1):243-250.

7. Macdowall W, Parker R, Nanchahal K, et al. ‘Talking of Sex’: developing and piloting a sexual health communication tool for use in primary care. Patient Educ Couns. 2010;81(3):332-337.

8. Ng CJ, Low WY, Tan NC, Choo WY. The role of general practitioners in the management of erectile dysfunction-a qualitative study. Int J Impot Res. 2004;16(1):60-63.

9. Tsimtsiou Z, Hatzimouratidis K, Nakopoulou E, Kyrana E, Salpigidis G, Hatzichristou D. Predictors of physicians’ involvement in addressing sexual health issues. J Sex Med. 2006;3(4):583-588.

10. Moreira ED Jr., Kim SC, Glasser D, Gingell C. Sexual activity, prevalence of sexual problems, and associated help-seeking patterns in men and women aged 40-80 years in Korea: data from the Global Study of Sexual Attitudes and Behaviors (GSSAB). J Sex Med. 2006;3(2):201-211.

11. Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Peña BM. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 1999;11(6):319-326.

12. Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology. 1997;49(6):822-830.

13. Impotence [Erectile Dysfunction] Quiz: Test Your Medical IQ of ED. MedicineNet website. http://www.medicinenet.com/impotence_erectile_dysfunction_quiz/quiz.htm. Accessed April 20, 2016.

14. Ponholzer A, Temml C, Mock K, Marszalek M, Obermayr R, Madersbacher S. Prevalence and risk factors for erectile dysfunction in 2869 men using a validated questionnaire. Eur Urol. 2005;47(1):80-86.

15. Althof SE, Corty EW, Levine SB, et al. EDITS: development of questionnaires for evaluating satisfaction with treatments for erectile dysfunction. Urology. 1999;53(4):793-799.

16. Lewis R, Bennett CJ, Borkon WD, et al. Patient and partner satisfaction with Viagra (sildenafil citrate) treatment as determined by the Erectile Dysfunction Inventory of Treatment Satisfaction Questionnaire. Urology. 2001;57(5):960-965.

17. Raina R, Lakin MM, Agarwal A, et al. Long-term effect of sildenafil citrate on erectile dysfunction after radical prostatectomy: 3-year follow-up. Urology. 2003;62(1):110-115.

18. Safarinejad MR, Kolahi AA, Ghaedi G. Safety and efficacy of sildenafil citrate in treating erectile dysfunction in patients with combat-related post-traumatic stress disorder: a double-blind, randomized and placebo-controlled study. BJU Int. 2009; 104(3):376-383.

19. U.S. Department of Veterans Affairs, Veterans Health Administration. VHA Handbook 1120.02: Health promotion and disease prevention core program requirements. U.S. Department of Veterans Affairs website. http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2763. Published July 5, 2012. Accessed April 7, 2016.

A majority of men (70%) aged ≥ 70 years report erectile dysfunction (ED) in primary care settings.¹ Further, the cost of ED medication is increasing: nationally, the VA spent $71.7 million on ED medications in 2013, triple the amount from 2006,² despite a 2011 VA mandate limiting ED medication prescriptions to 4 doses per month per veteran.³ Unfortunately, although ED is common and costly, only about 12% of men in the community report being asked about their sexual health by their primary care provider (PCP) in the past 3 years.⁴ Further, little emphasis seems to be placed on preventive care. For example, men with ED in primary care clinics are unaware of ED risk factors such as hypertension, smoking, and obesity; indeed, only 17% of a large community sample could name 1 risk factor for ED.⁵ This is problematic because diet and exercise improve erectile functioning,yet men may not realize they can reduce ED through behavioral and lifestyle change.⁶

In addition, there is little research that investigates veterans’ satisfaction with ED treatment and its effectiveness. The taboo nature of talking about erections and sexual health may partially relate to the lack of research. When surveyed, PCPs noted that they do not talk about ED routinely with patients for reasons that include time constraints, lack of experience managing sexual problems, viewing ED medication as a lifestyle drug, perceiving ED as a nonserious concern, discomfort discussing the topic for both male and female PCPs, and viewing ED discussions as the responsibility of providers of the opposite gender.^7-9

Given the dearth of ED research within the veteran population, the purpose of the current study was to (1) explore the level of treatment satisfaction of veterans prescribed an ED medication, phosphodiesterase type 5 inhibitor (PDE5); (2) assess patients’ perception of discussions with their PCPs about sexual health concerns; and (3) provide preliminary data on veterans’ knowledge of ED risk factors and identify possible areas for preventive education. This study was intended to highlight areas for further investigation to improve ED treatment satisfaction among veterans.

Methods

The authors conducted an anonymous survey with veterans who were prescribed an ED medication within the previous 12 months. In 2012, researchers obtained 8,000 names of veterans prescribed a PDE5 medication at the Clement J. Zablocki VA Medical Center (CJZVAMC) in Milwaukee, Wisconsin, and randomly selected 1,000 persons to mail a research survey to be returned anonymously. Three hundred ten surveys were returned, a 31% response rate, which was similar (32%) to a comparable large ED survey study, in which the participants were randomly selected to participate and also were not recruited by their PCP.¹⁰ Because 13 participants were excluded due to incomplete surveys or obtaining primary medical care services outside the VA, the current sample consisted of 297 participants. The CJZVAMC institutional review board approved the study in March 2013, and de-identified data were collected from March 2013 to March 2014.

The authors assessed demographics and treatment information, including whether veterans had talked with their PCP about sexual concerns.

Of the 297 participants, 55% were aged > 65 years. Racial/ethnic groups reflected the veteran population at CJZVAMC, with 78% identifying as European American, 17% as African American, 2% as Hispanic American, 2% as biracial, and 1% as Asian American or American Indian. Eighty-one percent were identified as Christian, and 10% reported no religious preference. Sixty-seven percent reported having a current sexual partner.

Measures

The International Index of Erectile Function (IIEF-5), an abridged version of a longer, 15-item instrument, was administered to assess participants’ erectile function.^11,12 The IIEF-5 consists of 5 items that ask about participants’ erectile functioning over the past 6 months. Participants responded to items on a 1 to 5 scale ranging from “almost never/never” to “almost always/always”. Items were summed to create a total score that could range from 5 to 25. Total scores reflect erectile functioning and satisfaction, with low scores indicating greater dysfunction. This measure has shown high sensitivity (.98) and specificity (.88).¹¹ Cut scores for the current study were consistent with the literature: mild ED = 17-21; mild-to-moderate ED = 12-16; moderate ED = 8-11; and severe ED = 5-7.¹³ Reliability in this sample was α = .93.

The authors were unable to find a validated measure assessing men’s knowledge of ED risk factors in the literature. Therefore, participants’ knowledge of ED risk factors was assessed using an online nonvalidated questionnaire entitled “Impotence [Erectile Dysfunction] Quiz: Test Your Medical IQ of ED” from www.emedicinehelp.com.¹³ Questions assess knowledge of specific risk factors (eg, age, obesity, depression, prostate cancer), symptoms, incidence rate, treatments, normal erectile functioning, and implications of ED. The questionnaire contains 16 items (3 true/false and 13 multiple choice items), and the total score corresponds to the percentage correct. According to the online version, the average score is 11 items correct (69%).¹³