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Expert Forum: Hidden burdens of erectile dysfunction


“I would classify hidden burdens as things which we don't appreciate on the surface, or that aren't obvious that are associated with erectile dysfunction,” says John J. Mulcahy, MD, PhD.

In part 1 of this Expert Forum series on the hidden burdens of erectile dysfunction, moderator Arthur L. Burnett II, MD, MBA, and panelists Martin S. Gross, MD, John J. Mulcahy, MD, PhD, and Faysal Yafi, MD, FRCSC, give an overview of some of the burdens of this condition. Burnett is the Patrick C. Walsh Distinguished professor of urology and oncology at the Johns Hopkins University School of Medicine and the James Buchanan Brady Urological Institute in Baltimore, Maryland; Gross is an assistant professor of surgery at Dartmouth Geisel School of Medicine in Hanover, New Hampshire, Mulcahy is president of Mulcahy Consulting Inc, and Yafi is an associate professor of urology, chief of the Division Men’s Health and Reconstructive Urology, director of Men’s Health and Newport Urology and co-Director of the Eric S. Wisenbaugh GURS Fellowship in Male Reconstructive and Prosthetic Urology at the University of California, Irvine.


Burnett: By way of introduction, I'm Arthur Burnett [, MD, MBA], and I have some tremendous colleagues with me today for a presentation for Urology Times on the hidden burdens of erectile dysfunction. We thought this was a great topic and a very timely topic to address the burdens of erectile dysfunction, which may traverse various topic areas ranging from the biology of burdens to mental health aspects to even health care access, and the economics of erectile dysfunction. By way of overview, we'll discuss what are some of the hidden burdens, we'll discuss about how the health care system has some impact. We'll talk about health plan coverage, and considerations regarding various interventions, including penile prosthetics and what we want to consider here with regard to coverage across gender lines and health topics related to that. We'll also get into some discussion about employer health plans and exclusions and how that has affected the field. There'll be some discussion about the impact of direct-to-consumer marketing and traditional prescription plans and how that may influence how we go about managing erectile dysfunction. And then toward the end, I'd like to talk a little bit about how we can advise our fellow urologists about how we can consider managing erectile dysfunction in the face of these burdens, and what kind of additional work we need to consider in the field to move it all forward. I'd like to start maybe just by talking about what are the hidden burdens of erectile dysfunction?

Mulcahy: I would classify hidden burdens as things which we don't appreciate on the surface, or that aren't obvious that are associated with erectile dysfunction. Things that come to my mind are productivity in the workplace. A patient who has ED certainly isn't happy with it. Many times, he becomes depressed. When he becomes depressed, this also leads to problems at the workplace, where he doesn't function like he should. He isn't as productive as he should be; he ruminates and thinks of other things when he should be performing on the job. Also, it may extend to the home life. Certainly, sexual activity is a very basic part of the marital relationship. And when this isn't occurring, the spouse gets involved. Many times however, she's menopausal, and sexual activity isn't as prominent in her life as it was when they were first married, so to speak. But she sees that he gets upset because of it and she tries to become supportive, so in both of these arenas, the workplace and the home, it definitely has a secondary effect, not only in the inability to perform, but in affecting the patient's working life and his family life as well.

Gross: In the course of seeking treatment, there may be some reduced trust in the prescribers and by that I mean, so many of my patients have seen their primary care doctors and/or other providers who have prescribed them erectile dysfunction treatment options that haven't worked. And so they therefore stop talking about it with their PCP, then they may stop talking about other things as well. So for example, if your PCP prescribes you Viagra [sildenafil cirate], and it is not successful, you may not take it as seriously when they say, "And also, you should quit smoking, and maybe should try this diabetes medication, and perhaps you should get your cholesterol under better control." I think if treatment options for EDI are not successfully given, which is what the patient is predominantly coming in for to talk about, then perhaps they may have less confidence in their PCP or other provider's ability to give them other treatment options.

Yafi: And I'd also point out the costs of interventions. Pills are less of an issue now from a financial perspective, but injectables and surgery, certainly penile implants, may incur some high costs to the patients, which in turn, may cause some stress to the patient before they get their interventions because they're worried about whether they can afford it, especially in an economy like today where people's budgets are tight, but also on the backend when, unfortunately with a lot of insurance providers, there are a lot of hidden fees that the patients may not be necessarily aware of, and they get surprise bills. And this definitely causes a certain amount of stress to patients who will then be stressed about their finances. This may also put a strain on their relationship with their partner because of the financial burden of the interventions that they need to do to be able to be sexually active.

This transcription was edited for clarity.

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