Clinical Review

Veterans’ Satisfaction With Erectile Dysfunction Treatment

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

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 single item asked participants to identify behavioral changes they had tried to improve their erectile functioning. Options included taking medications at a different time, and/or decreasing tobacco, caffeine, or alcohol consumption. The Erectile Dysfunction Inventory of Treatment Satisfaction – Patient Version (EDITS) is an 11-item questionnaire administered to assess participants’ satisfaction with their medical treatment of ED.¹⁴ Items assess treatment satisfaction, ease of use, confidence in ability to perform, partner satisfaction, and naturalness of erections achieved during treatment. These items are rated on a scale ranging from 0 (dissatisfaction) to 4 (high satisfaction) and then summed, with total scores ranging from 0 (extremely dissatisfied) to 100 (extremely satisfied). The measure displayed high internal consistency (α = .90) and high test-retest reliability (r = .98).¹⁴ Several studies have used cutoff scores of 0 = very dissatisfied; 25 = dissatisfied; 50 = neither satisfied nor dissatisfied; 75 = satisfied; and 100 = very satisfied.^15,16 These cut scores and classifiers were used in the current study; reliability was α = .92.

The authors further explored reasons for veteran dissatisfaction with ED treatment by asking participants to respond to a single item: “Why are you dissatisfied with your erectile dysfunction treatment?” They could indicate that they were satisfied or circle all options for dissatisfaction that applied (“I would like to receive more pills per month,” “The treatment does not work well,” or “I want more information about erectile dysfunction and treatment”), or write in a response. The authors inquired about the number of pills prescribed to ascertain whether dissatisfaction was due to VA-specific policies vs veterans’ understanding of ED and effectiveness of treatment, which providers have more ability to improve.

In addition to the quantitative data obtained from the completed surveys, unsolicited responses from participants to the principal investigator via phone calls, and letters regarding treatment satisfaction were gathered. The second author conducted a basic exploratory content analysis of these unsolicited responses to group them into themes related to this study, such as satisfaction or dissatisfaction with ED treatment.

Results

The authors first assessed levels of ED and satisfaction with treatment in the sample. On average, participants reported mild-to-moderate erectile dysfunction (M = 13.1; SD = 5.7), which is higher than that of the general population and consistent with samples of men referred for ED treatment.^17,18 Satisfaction levels were slightly above neutral on the EDITS questionnaire (M = 58.3%; SD = 24.5). In response to a separate single-item question regarding reasons for dissatisfaction, only 6.4% of veterans reported being satisfied with their ED treatment.

According to respondents, the primary reasons for dissatisfaction were wanting more medication (46%), finding the treatment ineffective (26.7%), and desiring more information (24%). Further, ED severity was negatively correlated with satisfaction with ED treatment (r = .72, P < .01; note that higher scores correspond to less severe ED on this measure). However, despite moderate-to-low levels of satisfaction, 79.2% of patients planned to continue with their ED treatment (59.3% very likely and 19.9% moderately likely).

The authors also assessed participants’ communication with PCPs about their sexual functioning. Twenty-five percent reported not talking with their PCP about sexual concerns (despite all having been prescribed an ED medication in the past year). In this sample, talking with one’s PCP was not related to increased knowledge of ED risk factors (t [294] = .32, ns). Those who talked to their PCP tended to be less satisfied with treatment (M = 56.2; SD = 24.5) than those who did not talk to their PCP (M = 64.7; SD = 23.3; t (213) = -2.2; P = .03), likely because those who felt their treatment was working for them felt less need to talk to their provider. Indeed, those who talked to their PCP trended to have more severe levels of ED (M = 12.7; SD = 5.8) than those who did not (M = 14.2; SD = 5.3; t [285] = -1.91; P = .057; note that higher scores correspond to less severe ED on this measure). Finally, adults aged > 65 years were less likely to talk to their PCP than were younger adults (69% vs 81%); χ² (1, N = 291) = 5.57; P = .018.

Generally, the level of knowledge of ED risk factors was lower than the average of respondents to the original online survey (62% vs 69%).¹³ Younger adults were slightly more knowledgeable (M = 64%; SD = 13) than were older adults (M = 60%; SD = 15), t (288.08) = 2.01; P = .046).