What pharmacists need to know about this common condition
Extending community pharmacy-based healthcare would enable more men living with erectile dysfunction to safely access effective medications, diagnostic services and support for lifestyle changes, say UK and US researchers.
Community pharmacists could provide a conveniently accessible setting to effectively interact with men who choose to consult with them, as well as other primary and secondary care professionals.
“There is evidence that many men are embarrassed to talk about their erection problems and do not know that erectile dysfunction is often caused by the same factors as events like heart attacks and strokes,” writes Professor David Taylor from the UCL School of Pharmacy in London, and colleagues, in Research in Social and Administrative Pharmacy.
“There is also evidence that community pharmacies and the other professionals working in them can offer acceptable points of first contact for men with erectile dysfunction, including those who have not previously discussed their condition with their doctors or any other health profession.”
Erectile dysfunction is a common male sexual dysfunction associated with reduced quality of life for patients and their partners.
It is also a predictor of overall cardiovascular health, and treatment with medication and psychotherapy remains the gold standard, according to Dr Christopher McMahon, author of a narrative review published in the MJA.
Dr McMahon, a sexual health physician at the Australian Centre for Sexual Health, Sydney, wrote that the prevalence of complete erectile dysfunction is about 5% among 40-year-old men, 10% among men in their 60s, 15% among men in their 70s, and 30-40% among men in their 80s.
“Erectile dysfunction is associated with increasing age, depression, obesity, lack of exercise, diabetes mellitus, hypertension, dyslipidaemia, cardiovascular disease, and lower urinary tract symptoms related to benign prostatic hyperplasia,” he writes.
Meanwhile the treatment options available for men with erectile dysfunction are “effective, safe and well tolerated”.
- Oral therapy – for example, on-demand or daily dosed phosphodiesterase type 5 inhibitors PDE5i such as sildenafil, tadalafil, vardenafil and avanafil
- Testosterone replacement therapy – for hypogonadism
- Psychosexual counselling
- Penile injection therapy – for example, alprostadil, including through intracavernosal injections
- Vacuum constriction devices
- Surgery – for example, penile implants, Peyronie surgical repair, vascular reconstructive surgery (usually reserved for young men with arterial trauma)
“Treatment with erectile dysfunction pharmacotherapy alone or in combination with graded psychosexual therapy is effective in improving and/or restoring sexual function in most men,” Dr McMahon concluded.
Looking into the role of pharmacists
Some pharmacists are already making waves in this field, working closely with medical practitioners to help men in complying with their medications to treat erectile dysfunction.
For example, Men’s Health Downunder, a pharmacist-run clinic for male urological issues which was recently named winner of the ACT Men’s Health Award, receives referrals from GPs, urologists, sexual health or family planning doctors all over Australia for patients.
While about half of the patients they now see are related to prostatectomies, the clinic has since expanded to include erectile dysfunction, Peyronie’s disease, incontinence and more.
Their primary role is to provide counselling, coupled with supply of medications.
“There’s certainly a supply element, which is typically intracavernosal injections such as Caverject and PDE5 inhibitors such as Cialis, and vacuum erection devices,” Bradley Butt, managing partner at Cooleman Court Pharmacy (part of the Life Pharmacy Group) and lead pharmacist at Men’s Health Downunder told AJP.
“The other component, which is the more bulky part of the time we spend in the consultations, is around counselling – so importance on compliance, how they’re to take medications, how it’s administered. If you’re injecting a needle into your penis you want to know what you’re doing.
“An initial consult runs for about 45 minutes with the patient, irrespective of what their concern is, in terms of gathering medical history, making sure their drugs are appropriate for the patient, and then running through what we have to run through in terms of outcomes and goals,” he says.
“The general consensus is that ‘the urologist was too busy to tell me, he just wrote me the script and said go and do it and didn’t give me much instruction, and here I am and I’m not quite sure what to do’.
“We’re able to offer a service where we can tell the patient exactly what to do and break down some of the barriers.”
Cooleman Court Pharmacy men’s health pharmacist Tim Stewart, said men’s health is an area he’s now passionate about, after “helping these gentlemen that weren’t getting much help elsewhere”.
“Having that slight expertise in that area and being able to really help them in all aspects of their health, specifically the ones they have difficulty talking about with other health professionals, seeing the difference that you can make in their life – it’s an area that’s easy to be passionate about,” he says.
“Pharmacy is particularly accessible for men’s health. Men are not likely to book in or to really set aside time to care of their own health, so having a pharmacy where you can literally walk in and there’s a pharmacist that’s able to sit down and have a chat with you about your health makes it really easily accessible for these guys,” says Mr Stewart.
Professor Taylor and colleagues suggest there is evidence that extending pharmacy-based primary health care provision can be helpful, cost-effective and increase appropriate treatment.
This includes not only treating erectile dysfunction but also tackling secondary factors.
Pharmacists can encourage men to make lifestyle changes such as quitting smoking and losing weight, they say, and there is evidence that pharmacist-led interventions for hypertension can lead to improved blood pressure control and reductions in blood pressure.
The researchers also argue that pharmacist interventions should extend to allowing better access to erectile dysfunction medications.
“The rationale for extending access to PDE5 inhibitor-based erectile dysfunction treatments via additional pharmacist-controlled routes is partly based on research indicating this should enhance health outcomes by encouraging a greater proportion of the men using PDE5 inhibitors to address to systemic causes of their reduced potency,” they write.
“Lack of professional advice and support can also deprive men who are living with erectile dysfunction of the opportunity to use treatments like anti-hypertensive medicines containing angiotensin-receptor blockers in an optimal manner.
“These medications protect the endothelial cells of blood vessels and can reduce the risk of erectile dysfunction while also lowering blood pressure.
“Such considerations, coupled with the reality that drugs such as sildenafil are already widely available without prescription via unregulated channels, underpin the case for extending community pharmacy supply in ways that an increasing proportion of men will find accessible and consistent with their needs and preferences.”
In September last year the Advisory Committee on Medicines Scheduling knocked back an application for sildenafil to be downscheduled to Schedule 3, finding that the pharmacy setting is not equipped to provide medical diagnosis for underlying conditions of erectile dysfunction.
“Risk of ED treatment without medical diagnosis or treatment of any underlying serious medical conditions (such as cardiovascular disease and diabetes) outweighs [the] benefit of making sildenafil available as a Schedule 3 medicine,” said the committee.
However another application has been submitted with the ruling to be handed down later this year.
The AMA has consistently opposed several applications to downschedule vardenafil and sildenafil.