Pharmacological Treatment Nonadherence in Men with Erectile Dysfunction

1
Pharmacological Treatment Nonadherence in Men
with Erectile Dysfunction

• Nicholas C. Larma, B.A.
• Predoctoral Intern
• Federal Medical Center, Rochester

Christopher D. Chuick, M.S. William Ming Liu,
Ph.D. University of Iowa
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Global Problems in Mens Health

• There exists a crisis in mens health. This
  crisis is best evidenced by the gender gap in
  life expectancy. Data from the National Vital
  Statistics Reports (U.S. Department of Health and
  Human Services, USDHHS, 2004) calculates this gap
  at 5.3 years with the average life expectancy for
  men at 74.5 years compared to 79.9 years for
  women. This gap increases for ethnic/racial
  minorities and in other countries. The gap in
  life expectancy is particularly perplexing given
  the fact that women outlived men an average of
  only one year in 1920 (USDHHS, 2004). Men also
  have higher mortality rates than women for 12 of
  the 15 leading causes of death and are at equal
  numbers to women for 2 of the leading causes.
  Again, these statistics are even bleaker for men
  of ethnic/racial minority status. This crisis is
  largely related to multiple factors associated
  with mens health.

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Factors Affecting Mens Health

• Research has indicated that men engage less
  frequently in health-promoting behaviors, exhibit
  a toxic pattern of denying illness, seek medical
  and psychological help far less than women, and
  are often noncompliant with treatment plans
  prescribed by health professionals (Courtenay,
  2003). This denial of mortality and unwillingness
  to seek help are socialized variables that plague
  masculinity.

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Erectile Dysfunction

• One health problem men face is Erectile
  Dysfunction (ED). This disorder is particularly
  useful to examine because it best highlights some
  of the factors that impair mens attainment of a
  positive health status. For example, one would
  think that men would be highly proactive in
  remedying their ED because sexual functioning is
  such a socialized staple of their masculinity and
  sense of self. However, mens behaviors in
  admitting a problem, seeking help and adhering to
  treatment plans contradicts the idea that they
  would be proactive in remedying their ED.

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Erectile Dysfunction Defined

• ED is defined as the persistent or repeated
  inability to achieve and/or sustain an erection
  sufficient for satisfactory sexual performance
  for a period of at least three months in the
  absence of an ejaculatory disorder (Goldstein,
  2004).

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Impact of Erectile Dysfunction

• Research indicates that men with ED are impacted
  in the following ways
• Feel sexually inadequate and a loss of manhood
• Emotional instability, including depression
• Diminished self-esteem and sexual
  self-confidence
• Less likely to marry and twice as likely to
  divorce
• Greater likelihood of diminished physical health.

Cameron, Rosen, Swindle, 2005 Esmail, Esmail,
Munro 2002 Pontin, Porter, McDonagh, 2002
Cogen Steinman, 1990
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Erectile Dysfunction

• ED affects 30 million U.S. men. Despite its
  prevalence, ED is often ignored and misdiagnosed
  because men are in denial of their problem and
  refuse to seek professional help. One study
  concluded that only 10 of men suffering from
  sexual dysfunction seek medical consultation for
  their problems (Laumann, Paik, Rosen, 1999).

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Treatment Nonadherence

• Despite the effectiveness and non-invasive
  nature of current oral medications (i.e., Viagra,
  Cialis, Levitra), preliminary statistics and
  anecdotal information suggest that approximately
  half of all men prescribed oral medication for ED
  voluntarily cease treatment. Mens nonadherence
  to treatment for ED is particularly interesting
  as current medication for ED is marketed to men
  for its restorative value in not only returning
  sexual functioning to premorbid levels, but in
  reclaiming their masculinity.

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Early Research of Nonadherence to Treatment of ED

• A qualitative study conducted on a Malaysian
  sample identified the following barriers to
  treating ED (Low, Ng, Tan, Chool, Tan, 2004).
• Physicians perception of ED as a less important
  disease.
• Physicians lacking experience treating ED.
• Patients discomfort for seeking medical help for
  ED.
• Patients unrealistic expectations regarding the
  efficacy of pharmacological treatment led to
  noncompliance.

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• One study to date has specifically examined
  pharmacological treatment nonadherence in men
  with ED (Son, Park, Kim, Paick, 2004). The
  authors followed 156 Asian men with ED whose
  erectile functioning was restored after being
  treated with Viagra. Six months following the
  first Viagra prescription, compliance to
  treatment was measured by either reviewing
  patient chart or through a brief telephone
  survey. The specific questions asked in the phone
  interview and the information taken from patient
  charts was not reported. The authors concluded
  that 54 (34.6) of the 156 Asian men sampled
  discontinued treatment with Viagra.

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• The self-reported reasons for discontinuation
  include
• Lack of emotional readiness for restoration of
  normal sexual functioning (37 with 22.2 of
  partners and 14.8 of patients reporting lacking
  emotional readiness)
• Fear of possible side effects of Viagra (18.5)
• Reported recovery of spontaneous erection (i.e.,
  achievement of erection not requiring oral
  ingestion of Viagra prior to sexual activity,
  14.8)
• Postponement of Viagra due to treatment of
  comorbid disorder (11.1)
• Unwillingness to accept a drug-induced erection
  (7.4)
• Unacceptability of planned sexual activity, lack
  of sexual interest, and high drug cost yielding
  equal percentages (3.7).

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Current Study

• A variety of factors are identified as being
  potentially implicated in nonadherence to
  pharmacological treatments of ED. These factors
  are classified into the following three
  categories (a) patient variables, (b) partner
  variables, and (c) relational variables. These
  variables will be compared across two groups of
  men divided according to whether they continued
  or discontinued treatment with oral medications 6
  months after filling their initial prescription.
  Relational variables will be assessed through a
  survey measuring relational/marital satisfaction.

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Patient Variables

• History of erectile dysfunction
• History of treatment for ED
• Medication dosage and reported side-effects
• Restoration of naturally functioning erection
• Health status (including other comorbid
  disorders)
• Patient ability to afford medication
• Whether other treatment types of ED were sought
  out either during or after discontinuation of
  oral medication
• Quality of relationship with and confidence in
  physician

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Partner Variables

• Health status, including whether they are
  menopausal or experiencing their own sexual
  dysfunction
• Experiences related to being a partner of a man
  with erectile dysfunction
• Sexual desire and readiness for restoration of
  sexual activity
• Expectations for treatment, including perceived
  success
• Perceived involvement in treatment, including
  selection of treatment type, relationship with
  physician, and involvement in decisions regarding
  treatment self-administration
• Perceived influence over treatment adherence

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Outcome

• This study is primarily explorative in nature,
  as little research to date has examined this
  phenomenon or theorized about the factors related
  to pharmacological treatment nonadherence in men
  with ED. Thus, no specific predictions were made
  about the relations between these variables in
  either group. The findings from this study,
  however, are very pertinent to health
  professionals as it may aid prescribing
  physicians and psychologists who treat such men
  by identifying those factors most associated with
  treatment adherence. By identifying those factors
  associated with compliance of pharmacological
  treatment of ED, physicians and mental health
  professionals can assure that these factors are
  not overlooked and work together in evaluating
  and successfully treating ED.

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• This study is also particularly relevant given
  its exploration of nonadherence to a treatment
  that not only effectively restores sexual
  functioning for large percentages of men, but
  restores a core component of their masculinity.
  Given traditional socialized expectations of male
  sexuality, virility is a proof of masculinity.
  Nonetheless, there may be other factors more
  significant than restoration of sexual
  functioning that contribute to pharmacological
  treatment nonadherence. Understanding these
  factors potentially involved in this phenomenon
  may more globally enhance our understanding of
  medical and psychological help-seeking,
  engagement in health-promoting behaviors, denial
  of illness, and treatment adherence in men.

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References

• Cameron, A., Rosen, R.C., Swindle, R.W. (2005).
  Sexual and relationship characteristics among an
  internet-based sample of U.S. men with and
  without erectile dysfunction. Journal of Sex
  Marital Therapy, 31, 229-242.
• Cogen, R., Steinman, W. (1990). Sexual function
  and practice in elderly men of lower
  socioeconomic status. Journal of Family Practice,
  31, 162-166 Courtenay, W.H. (2003). Key
  determinants of the health and well-being of men
  and boys. International Journal of Mens health,
  2, 1-30.
• Esmail, S., Esmail, Y., Munro, B. (2002).
  Sexuality and disability, The role of health care
  professionals in providing options and
  alternatives for couples. Sexuality and
  Disability, 19, 267-283.
• Goldstein, I. (2004). Diagnosis of erectile
  dysfunction. Sexuality Disability, 22, 121-130.
• U.S. Department of Health and Human Services
  (2004, February). Health Behaviors of Adults
  United States, 1999-2001. Vital and Health
  Statistics, 10, 1-89.

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References

• Laumann, E.O., Paik, A., Rosen, R.C. (1999).
  Sexual dysfunction in the United States
  Prevalence and predictors. Journal of the
  American Medical Association, 281, 537-544.
• Low, W.Y., Ng, C.J., Tan, N.C., Choo1, W.Y., Tan,
  H.M. (2004). Management of erectile dysfunction
  Barriers faced by general practitioners. Asian
  Journal of Andrology, 6, 99-104.
• Pontin, D., Porter, T., McDonagh, R. (2002).
  Investigating the effect of erectile dysfunction
  on the lives of men A qualitative research
  study. Journal of Clinical Nursing, 11, 264272.
• Son, H., Park, K., Kim, S.W., Paick, J.S. (2004).
  Reasons for discontinuation of sildenafil citrate
  after successful restoration of erectile
  function. Asian Journal of Andrology, 6, 117-120.

Author Contact Information Nicholas C. Larma
nicholas-larma_at_uiowa.eduhttp//www.education.uiow
a.edu/counspsy/research.htm