The aim of this study was to evaluate one possible reason why men do not seek help for erectile dysfunction. For this study, 500 men that visited their family doctors were stratified into one of three groups based on the reasons for their visits and their overall health statuses. A questionnaire was used to ask each participant about his willingness to seek help for erectile dysfunction should it occur during his lifetime. The statistical analysis of their answers showed that the men with serious chronic illnesses and malignancies were less interested in sexual activity, and they were less likely to seek help for erectile dysfunction when compared to otherwise healthy men and men with mild chronic diseases. Better patient education and reassurance could increase the proportion of men with chronic illnesses and malignancies who seek treatment for erectile dysfunction.
Erectile dysfunction is a common condition that affects many men. Previous epidemiological studies have shown very different prevalences based on the criteria that were used, but all of the researchers agreed that a significant number of active men are affected by erectile dysfunction [1,2,3]. Strangely enough, only a small proportion of these men seek advice and receive treatment for their conditions. Some studies have shown that only 10% of men with erectile problems are actually treated . Thus far, the reasons for this discrepancy between the erectile dysfunction prevalence rate and the treatment rate have been poorly studied. There are only a few reports in the literature, and they consist mainly of the subjective opinions of the authors. Better knowledge about the barriers to seeking treatment for erectile dysfunction could help develop strategies for raising awareness about the importance of an individual’s sexual wellbeing. This may increase the proportion of men who finally receive treatment.
The inability to attain or maintain a penile erection can be an isolated problem, but in many cases, men with erectile dysfunction also suffer from other illnesses . Some of these comorbidities can be directly related to erection problems, while others merely coexist without any causal relationship with erectile dysfunction. The presence of a coexisting illness could be one of the reasons why men tend to neglect their sexual health and their erectile difficulties remain untreated. In this study, we investigated this possibility to determine whether men with serious illnesses are less likely to seek help for erectile dysfunction.
Subjects and methods
The study was approved by the National Medical Ethics Committee of Republic of Slovenia and by the local Medical Ethics Committee at University Medical Centre Maribor. We conducted a survey among 500 male patients that visited their family doctors for any reason. The survey was conducted using a questionnaire that briefly described the purpose of the investigation and a request for collaboration. After obtaining the verbal approval of the patients, the questionnaire was administered, filled out by the patients and was returned to the family doctor. The survey was conducted by 10 family physicians during the same month to prevent bias due to seasonal illnesses. The questionnaires were offered to 50 consecutive male patients who visited each participating family doctor. Of the 500 questionnaires offered, 14 of the patients refused to participate, so we ended up with 486 completed questionnaires. The questionnaire itself is shown in Fig. 1.
Those men who completed the survey were divided into three groups based on the reasons for their visits to their family practitioners:
This group contained 176 patients who visited their doctors for preventive reasons, for acute illnesses with complete resolution and no expected consequences, for minor trauma or minor complaints that needed no specific treatment, and for observation or the planning of further diagnostic procedures. Table 1 shows the different reasons why the patients in group A visited their doctors.
This group contained 244 patients who visited their doctors due to existing chronic illnesses in which no serious acute complications were expected with standard treatment, and patients who could be categorized with an Eastern Cooperative Oncology Group (ECOG)/World Health Organization (WHO) performance status of 0 . Table 2 shows a list of the illnesses of the group B patients.
This group contained 66 patients with chronic illnesses affecting their wellbeing, patients who could be categorized with an ECOG/WHO performance status of 1  or greater, and all patients with malignancies in which there was the possibility of disease recurrence or progression despite standard treatment. Table 3 shows a list of the illnesses of the patients in group C.
According to the abovementioned criteria, group A had 176 participants with a mean age of 49.84 years old [range 36–75 years, standard deviation (SD) 10.03 years]. Group B consisted of 244 participants with a mean age of 59.49 years old (range 36–78 years, SD 8.23 years). Group C had 66 participants with a mean age of 62.31 years old (range 50–71 years, SD 5.92 years).
Implementation of the ANOVA one-way test with significance level of α = 0.05 and post-hoc paired-wise T-tests (α = 0.01) for three test groups A, B and C, indicates no statistically significant difference between test groups B and C and some statistically significant difference between pairs A,B and A,C with respect to average age. The average age of 49.84 years was observed in the group A, 59.49 years in the group B and 62.31 years in the group C.
The answers in the returned questionnaires were statistically analyzed, and a two-tailed z test was used to analyze the two questions. Statistical significance was proven if the odds for the verification of our hypothesis were greater than 95% (p < 0.05).
Is sexual activity an important part of your overall wellbeing?
In group A, 166 men chose “yes” to this question, with 8 “no” answers, and 2 patients who were undecided. In group B, 198 men chose “yes,” 16 chose “no,” and 30 were undecided. In group C, 48 men chose “yes,” 9 chose “no,” and 9 were undecided. The answers to question 1 are shown in Fig. 2.
The analysis of the answers to question 1 showed a statistically significant difference between groups A and C (p = 0.005). This means that sexual activity seemed less important to the men with serious chronic illnesses and those with malignancies. This is probably because they were preoccupied with their general health issues.
If you had erectile dysfunction, would you be willing to treat it?
In group A, 155 participants chose “yes” to this question, 14 chose “no,” and 7 were undecided. In group B, 218 participants chose “yes,” 12 chose “no,” and 14 were undecided. In group C, 46 participants chose “yes,” 8 chose “no,” and 12 were undecided. The answers to question 2 are shown in Fig. 3.
The analysis of the answers to question 2 showed statistically significant differences between the answers in groups A and C (p = 0.03) and between groups B and C (p = 0.01). However, the difference between groups A and B was not statistically significant (p = 0.22). This shows that the men with no underlying diseases and those with mild chronic illnesses were more likely to seek help for erectile dysfunction when compared to the men with more serious chronic or malignant diseases.
Sexual activity is an important factor for assessing the quality of life . Erectile dysfunction can prevent a man (and a couple) from having a satisfying sexual life, which can lead to a significant decline in his (their) overall life quality . Erectile problems are not rare, and they affect a large number of otherwise active men. Even though erectile dysfunction can be treated effectively, only a small proportion of the affected men actually seek help and receive the proper treatment . However, the reasons for this are relatively unknown and largely speculative.
Few papers have been published that describe the reasons why men do not seek help for their erectile problems. Shabsigh et al. published a paper in 2004 that compared men from 6 different countries regarding their desire to treat erection problems. Those researchers concluded that the treatment desire was dependent on the sexual activity desire of either the affected man or his partner. The explanations for the small proportion of men who sought treatment included the belief of the younger group of men (20–39 years old) that the problem would resolve by itself, while the older group of men (40–75 years old) generally thought that erectile dysfunction was normal as one gets older .
The article by Shabsigh and Stone from 2006 claimed that an individual approach was needed to improve the health care of men with erectile dysfunction, in which the specific needs and expectations of the patient should be accounted for. Those authors also stated that there were many barriers preventing a larger number of men from being treated, but they did not specifically name any of these barriers .
Similar findings were published by Berner et al. in 2007. They stated that there were large differences between men regarding their attitudes toward sexual activity. Based on these differences and the different opinions regarding the desire for and objections to active erectile dysfunction treatment, they divided the men into five different types: sensation seeker, sensuous, anxious, confident, and abstinent. The article barely touched on the men’s attitudes toward oral therapy for erectile dysfunction, concluding that the expectations regarding the efficacy and fear of possible adverse effects were potential barriers .
The article by Hosny et al. from 2014 also described men’s barriers to oral erectile dysfunction treatment using sildenafil. The late onset of action and possible adverse effects were blamed for the lack of interest in this treatment. It was the authors’ opinion that a new orodispersible form of sildenafil could improve the use of this medication based on faster action, less adverse effects, and greater biological availability .
In 2013, Nelson et al. described the difficulties of men using intracavernosal injections. They concluded that a fear of needles was present in a large proportion of the men, especially at the beginning of the treatment. For example, 65% of the men reported significant fear (greater than 5 on a scale from 0 to 10) during the first administration, while 42% of the men still reported significant fear after 4 weeks of treatment. Psychological counselling and reassurance were proposed for the men using intracavernosal injections in order to achieve better compliance with and tolerance of this therapy .
Doctors’ attitudes toward treatment can also influence the rate at which men are treated for erectile dysfunction. Lowe et al. conducted a survey among 28 general practitioners in 2004, and they published interesting data. The prevailing opinion of the doctors was that erectile dysfunction did not represent a serious health problem. The barriers to prescribing treatment for this condition were the physician’s age (younger doctors were less likely to discuss sexual health with their patients), gender (female doctors were less likely to prescribe medication for erectile dysfunction), lack of time, and lack of experience with the treatment of sexual problems. Moreover, the doctors were less likely to offer erectile dysfunction treatment to patients with concomitant diseases, older patients, and patients with lower economic statuses because they assumed that the patients could not afford the treatment .
Another article by De Berardis et al. from 2009 showed similar barriers in addressing sexual issues among general practitioners and they concluded that further training is needed for a more proactive approach to erectile dysfunction screening and management .
Even the newest published data show that the situation has not changed much over the years. The article by Almigbal et al. from 2018 concluded that most patients are not asked about erectile dysfunction and are also less willing to discuss these problems with their doctor if they were older or suffering more severe erectile dysfunction . It is true, though, that the study was conducted on a specific group of men with type 2 diabetes.
It is well-known that erectile dysfunction appears more often in men with different chronic diseases . An underlying medical condition could also be one of the reasons why men are reluctant to seek help and obtain treatment for erection problems. It is easy to speculate that one’s concern about the basic disease is greater than one’s desire for sexual activity. This may be especially true if the basic disease causes physical disability or is potentially life threatening. Unfortunately, there is almost no data on this subject in the literature. The article by Ball et al. from 2013 described the problems men experience after they have been treated for colorectal malignancies. The two most frequently mentioned complaints were difficulty passing stools (100%) and erectile dysfunction (92%). The desire to treat erectile dysfunction was practically nonexistent immediately after the surgical treatment, but after some time, the sexual desire reappeared. At this point, the men expressed the desire for psychological counselling that would help them understand the reasons for their erectile problems and make it easier to choose a possible treatment .
In 2014, Hartman et al. studied how men dealt with erectile dysfunction after a radical prostatectomy. The patients in that study also expressed the need for more detailed counselling regarding possible sexual rehabilitation after the surgery. However, the study was limited to three homosexual couples, and the only conclusion made was that the sexual problems after radical prostatectomies were similar between homosexual and heterosexual couples .
Several other articles also dealt with erectile dysfunction after a radical prostatectomy, and all of the patients expressed a need for better postoperative counselling; however, the sexual desire itself was not studied. Therefore, there is actually no data in the literature describing how an underlying medical condition affects a man’s willingness to treat erectile problems [19,20,21].
In this study, we proved that there was a direct relationship between the basic disease severity and the readiness of men to treat concomitant erectile dysfunction. The results of our study showed that men with serious chronic illnesses and malignancies were less likely to seek help and obtain treatment for erection problems. The difference was statistically significant when compared to the results of those men with no underlying medical conditions, as well as those men with milder chronic diseases. The difference between groups A and B could, in part, be due to the difference in mean age of the participants (there was some statistically significant difference in average age between groups A and B). However, the difference in mean age was very small between groups B and C (the difference was not statistically significant) so we don’t think that the age is the main factor in decision about being treated for erectile dysfunction. The same was proven regarding the importance of sexual activity, which was statistically significantly lower in the men with serious chronic illnesses and malignancies when compared to those with no underlying diseases. The same difference was also observed in the comparison with the men with milder chronic conditions, but it was not statistically significant.
The proper education and reassurance of patients with severe chronic illnesses and malignancies could help raise the proportion of men who remain interested in sexual activity and the proportion who are prepared for erectile dysfunction treatment. This could improve the quality of life of these men as well as their partners. Further and more detailed studies could provide us with even more information about the various fears and concerns of men with chronic diseases. Broader public campaigns are needed to make the most of this knowledge and optimize the treatment of sexual dysfunction in most sensitive patient groups.
There are of course some limitations of our study. The questionnaire that we have used hasn’t been validated and there could be other possible reasons for men not to be willing to seek treatment for erectile dysfunction as we didn’t gather the information about the status of their relationship, their sexual preferences or the concomitant medications. However, since the question about the erectile dysfunction was hypothetical, we think that these other circumstances didn’t influence the answers. Larger studies are needed to confirm the results of our findings.
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