Question:
diagnosis and treatment of erectile dysfunction among family practice physicians
Answer:
To examine the philosophies and practices of the family
practitioner (FP) regarding the diagnosis and treatment of erectile dysfunction
(ED).
Methods. A prospective study by questionnaire of a group of FPs was performed.
The Spearman correlation coefficient and proportional odds regression analysis
were used to measure the relationship between the continuous variable and
ordinal-scale variables. The Goodman-Kruskal gamma test was used to measure the
strength of the association between the ordinal-scale variables.
Results. Eighty-five FPs completed the questionnaire. All respondents had at
least occasional discussions with their patients about ED. History taking,
physical examination, and laboratory data were the most common tools used for
diagnosis. Eighty-two percent of the FPs reported being either comfortable or
somewhat comfortable in making a diagnosis of ED; 93% believed that only
selected patients required more extensive diagnostic workups for ED. Sildenafil
was the most commonly used agent. All physicians referred patients with ED to
urologists at least occasionally. Most referred only after unsuccessful trials
with sildenafil. The relationship between the degree of managed care
penetration and the percentage of patients with ED referred for evaluation to a
urologist was not statistically significant (P = 0.402). The relationship
between the number of years in practice and the percentage of patients referred
to a urologist for treatment or evaluation was found to be a negative, but
statistically significant, relationship (P = 0.003).
Conclusions. FPs are now diagnosing and treating ED on a routine basis.
Referrals to urologists are likely to be made when they are no longer
comfortable treating the problem.
Erectile dysfunction (ED) is a common problem, and its diagnosis and treatment
have traditionally been an important aspect of urologic practice. The
prevalence of ED increases with age, 1 and a myriad of disease processes and
medications may cause or worsen the condition.
The family practitioner (FP) or internist is often the first physician the
patient has available to discuss ED. Indeed, the prevalence of sexual
complaints and disorders in patients seen by primary physicians has been
observed to be as high as 34%. 2 This implies that the patients who complain to
their primary physicians about ED will also likely seek treatment from them.
Nonsurgical alternatives for the treatment of ED have steadily evolved,
including vacuum erection devices, intracavernosal injection therapy,
intraurethral prostaglandin-E1 suppositories (MUSE), 3 and the oral agent
sildenafil citrate. 4 Some of these treatments, however, are probably more
appealing to the FP in terms of their complications and risks.
An investigation of the prevalence of ED complaints and the use of diagnostic
testing in primary physicians' practices has not been performed. Additionally,
the extent to which the contemporary armamentarium of treatments for ED are
accepted and used by FPs has not been investigated. It would also be useful to
know what type of ED cases this group of physicians refers to urologists. In an
effort to address these questions, we surveyed a group of FPs regarding their
practice and referral patterns to the urologist for the patient with ED.
A questionnaire was issued to a group of FPs attending a 5-day update course in
New Orleans in April 2000. Two hundred forty-eight FPs participated in the
course during the 5-day interval. However, the survey material was not
available to all participants, since many did not stay for the entire 5-day
course or chose not to participate in the urologic lectures. ED itself was not
specifically addressed as a lecture topic.
This questionnaire was included in the package of syllabus materials. It was
designed to inquire about FPs' approach to the evaluation and management of ED
and their referral practices to urologists for this condition (see Appendix).
This course was offered on a nationwide basis, but most participants were from
the southeastern United States.
Participation in the study was voluntary. No questionnaire was used in the
study if the participant expressed any concerns about the use of the data for
publication. No financial or other incentive techniques were used to encourage
study participation.
The measurement of the relationship between the continuous variables and most
of the ordinal-scaled variables was accomplished with the Spearman correlation
coefficient. The comparison between the comfort level in diagnosing ED and the
number of years of practice was performed using the proportional odds
regression analysis. To examine the relationship between the ordinal-scaled
variables, the Goodman-Kruskal gamma test was used to measure the strength of
the association. P values less than 0.05 were considered significant for all
statistical sampling.
One hundred ten surveys were issued and 85 completed (77% response). The mean
practice time in this group was 15.0 years. Sixty-one (72%) described their
practices as private, 16 (19%) as academic, and 8 (9%) as ''other.'' The
penetration of managed care within the FPs' practices was relatively evenly
distributed within the cohort (Fig. 1).
Seventy-five respondents (88%) believed that the proportion of male patients
older than 40 years of age who complained about ED in their practice was 30% or
less (sum of responses 1 and 2, survey question 4). All respondents had at
least occasional discussions with their patients about ED. Although only 13 of
the FPs (15%) reported routinely inquiring about ED of patients older than 40
years of age, more than one half (43 of 85; 51%) did inquire about ED to their
patients with identifiable risk factors.
History taking, physical examination, and laboratory data comprised the most
common tools used by this cohort of primary care physicians in diagnosing ED;
nocturnal penile tumescence studies and Doppler ultrasound were rarely used
(Fig. 2). Of 83 physicians, 69 (83% [2 FPs did not respond to the question])
reported being either comfortable or somewhat comfortable in diagnosing ED.
Most participants (79 of 85; 93%) believed that only selected patients required
more extensive diagnostic workups for ED. The relationship between the number
of years of practice and the comfort level in diagnosing ED was modeled using
the comfort level as the dependent variable and the number of years of practice
as the independent variable in a proportional odds regression analysis. The
odds ratio was 1.082. Therefore, for every 1-year increase in the number of
years of practice, the probability of being in a more comfortable category
increased 1.082 times. The proportional odds model was not used with other
dependent variables because the proportional odds assumption was not
reasonable.
The distribution of agents and devices that these FPs used to treat ED is
demonstrated in Figure 3. Sildenafil was the most commonly used treatment,
although some also prescribed vacuum erection devices. Few used the more
invasive techniques. Table I depicts the comfort level with each of the agents
prescribed. The disparate numbers of FPs using intraurethral prostaglandin-E1
suppositories or intracavernosal injection therapy versus sildenafil or vacuum
erection devices did not allow for statistically meaningful comparisons.
All FPs referred patients with ED to urologists at least occasionally; most (60
of 85; 70%) referred patients only after unsuccessful trials with sildenafil.
Of the 85 respondents, 50 (59%) referred patients with ED 25% of the time or
less (question 12; sum of responses 1 and 2). The relationship between the
percentage of practice that was managed care and the percentage of patients
with ED referred to a urologist was measured using the Goodman-Kruskal gamma
test. The gamma value was 0.108, which was not statistically significant (P =
0.402). The relationship between the number of years in practice and the
percentage of patients referred to a urologist for treatment or evaluation was
found to be negative, however (Spearman's rho -0.332; P = 0.003). Thus, the
more years in practice, the smaller the proportion of patients referred to a
urologist.
Comment
Our data suggest that most FPs deal with the diagnosis and management of ED
routinely and seem to be comfortable in doing so. Sildenafil was the most
common treatment used, although a minority also prescribed other therapies. We
also observed that although most FPs referred at least some patients with ED to
the urologist, the more experienced primary physicians felt the need to do so
less frequently. Similarly, the physicians who had been in practice longer were
more comfortable diagnosing ED. The degree of penetration of managed care,
however, did not seem to influence the referral patterns to urologists.
Increases in the public awareness of ED have likely brought many more patients
to physicians in search of help for the condition. Metz and Seifert 5 observed
in 1990 that although the vast majority of men reported some type of sexual
concerns, only 19% actually discussed these issues with their physician and
that they preferred it if the physician broached the topic first. Broekman et
al. 6 observed that 59% of FPs did not routinely inquire about ED. Perttula 7
recently reported in a retrospective review that FPs inquired about ED only if
risk factors were present. Our data, however, suggest that FPs are commonly
inquiring about male sexual dysfunction. Many ask their patients about ED
either routinely if they fall into appropriate age categories or if medical
risk factors can be identified.
The need for identifying the exact etiology of ED has become arguably less
important for most clinical situations. The Process of Care Model for Erectile
Dysfunction outlines a goal-oriented approach for the diagnosis and treatment
of ED. 8 This excludes specialized diagnostic testing in most patients and
instead focuses on the identification of a suitable treatment. The availability
of nonsurgical options for the treatment of ED has undoubtedly made this
approach feasible. Therefore, most FPs surveyed in this study appear to adhere
to this model in the diagnosis of ED, in accordance with what is now considered
standard urologic practice. The observed greater comfort level in diagnosing ED
among the FPs who had practiced longer may reflect a greater willingness to
inquire about this disease as they become more familiar with their patients.
Oral sildenafil therapy for ED has greatly simplified treatment in many
patients, and our data imply that this agent is well accepted and frequently
prescribed by FPs. This finding is further reflected in that most FPs in this
report only referred patients with ED to a urologist after sildenafil failed.
Similarly, we observed that the more experienced the FP, the less likely they
were to refer the problem to a urologist. Although some of these physicians
also reported prescribing other therapies, earlier studies have demonstrated a
reluctance on the part of FPs to use these more invasive options. 6 In some
instances, the FP may assist in the primary management of ED by identifying and
ameliorating certain medical risk factors (eg, smoking or antihypertensive
medications), rather than by simply prescribing treatment. The lack of an
observed relationship between the degree of managed care penetration and the
referral patterns to a urologist for ED may be a further reflection of the
increasing role assumed by the FP in the management of the disease in all
practice situations. Thus, an economic motivation for their referral patterns
was not apparent.
Conclusions
The results of our study suggest that ED represents an increasingly important
aspect of the medical care delivered by FPs. Most make some effort to identify
and diagnose the condition before referring the patient to a urologist. Oral
sildenafil citrate has probably decreased the reliance of many internists on
urologists in the management of ED, but many are still reluctant to prescribe
more invasive therapies, and these patients are probably still referred to a
urologist.
