Evaluation of care given to patients suffering from erectile dysfunction by French urologists in 2018

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Progrèsenurologie(2020)30,318—321

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ORIGINAL ARTICLE

Evaluation of care given to patients suffering from erectile dysfunction by French urologists in 2018

Évaluation de la prise en charge de la dysfonction érectile par les urologues franc ¸ais en 2018

J. Gas

^a^,∗

, W. Sleiman

^b

, C. Borgogno

^b

, M. Elmokdad

^b

, M. Abdessater

^b

, A. Faix

^c

, P. Coloby

^b

, S. Bart

^b

aDepartementofurology,CHUToulouse,Toulouse,France

bDepartementofurology,centrehospitalierRené-Dubos,Pontoise,France

cDepartementofurology,cliniquePolygone,Montpellier,France

Received5February2020;accepted8April2020 Availableonline29April2020

KEYWORDS Erectiledysfunction;

Clinicalevaluation;

Cardiological evaluation;

Guidelines

Summary Erectiledysfunctionvariedbycountry,affectingbetween20to40%ofmenaged60 and69andmorethan50%ofmenagedover75.Ourobjectivewastoevaluatethehabitsofurol- ogistsin2018andalsoevaluatetheneedforadditional,objectivetoolstoaidphysicianswhen providingcare.AquestionnairewassentfromtheFrenchUrologyAssociationto1158physicians betweenNovemberandDecember2018.Inall,177urologists(15.28%)tookpartinthestudy.

Only22%ofurologistsregularlyusedaquestionnaire,suchastheIIEF-5.Whenfacedwitherec- tionproblems,56.5%ofthemdidnotcarryoutsystematiccardiologyevaluations.Morethan halfofurologistsrequestedfastingglucose,lipidandtotaltestosteronelevels.Twenty-seven percentdidnotcarryoutadditionaltests.Firstlinetreatmentincludedaphosphodiesterase 5inhibitorin81%ofcases.Twothirdsofurologists(78%)ratedthemselvesasbeingcorrectly trainedintheareaoferectiledysfunction. However,only49%systematicallyinquiredabout erectionproblemswhenfacedwithbenignprostatichyperplasiaand65%thoughtthaterectile dysfunctionwasnottreatedoptimally.Despiteexistingrecommendations,onlyhalfofurologists carryoutacardiacevaluationwhenaﬁnding oferectiledysfunctionismade. Onethirdof

∗Correspondingauthor.Departementofurology,andrologyandrenaltransplantation,CHURangueil,1,avenueduProfesseur-Jean-Poulhès, 31059Toulouse,France.

E-mailaddress:jeromegas@hotmail.fr(J.Gas).

https://doi.org/10.1016/j.purol.2020.04.008

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Evaluationofcaregiventopatientssufferingfromerectiledysfunctionin2018 319 urologistsdonotrequestadditionaltesting.Greatertraining,alongwiththeuseofanobjective diagnostictool couldhelpurologiststooptimisethecaretheyprovidefor patientssuffering fromerectiledysfunction,allowingthemtokeepworkingwithincurrentguidelines.Levelof evidence 3.

MOTSCLÉS

Dysfonctionérectile; Évaluationclinique; Évaluation

cardiologique; Recommandations

Résumé Laprévalencedeladysfonctionérectileestmajeureàtraverslesdifférentspays, touchantentre20et40%deshommesentre60et69ansetplusde50%au-delàde75ans.

Nousavonssouhaitéévaluerleshabitudesdesurologuesnonspéciﬁquementformésàlasex- ologieen2018.Unquestionnaireaétéadresséparlebiaisdel’Associationfranc¸aised’urologie à1158praticiensentrenovembre etdécembre2018. Autotal,177 urologues(15,28%)ont participé.Lesujetdeladysfonctionérectileétaitévoquédans80,23%descasspontanément parlepatient.Seulement22%desurologuesutilisaientrégulièrementunquestionnairetype IIEF-5,et56,50 %n’effectuait pasd’évaluationcardiologique systématiquedevantun trou- bledel’érection.Plusdelamoitiédesurologuesprescrivaientuneglycémieàjeun,unbilan lipidiqueetunetestostéronémietotale,27%neréalisaientaucunexamencomplémentaire.

Le traitementde 1^re intentionétait uninhibiteurde la phosphodiestérase5 dans81 %des cas.Les deux-tiersdesurologues(78%) s’estimaientcorrectementformésdans ledomaine deladysfonctionérectile,maisseulement49%cherchaientsystématiquementuntroublede l’érectionlorsd’unbiland’hyperplasiebénignedeprostateet65%estimaientquelestroubles del’érection n’étaientpasprisencharge defac¸on optimale.Malgrélesrecommandations, seulementlamoitiédesurologueseffectueuneévaluationcardiologiquelorsdeladécouverte d’unedysfonctionérectileavecuntiersquineprescritaucunexamencomplémentaire,une meilleure formationassociéeàun outild’aide diagnostique objectifpourrait aiderles uro- loguesàoptimiserleurpriseenchargedestroublesérectilesetainsiêtreplusenphaseavec lesrecommandationsactuelles.

Niveaudepreuve.— 3.

Introduction

Erectile dysfunction is deﬁned as ‘‘the inability to get and/orkeepanerectionﬁrmenoughtopermitsatisfactory sexualactivity’’.Theprevalenceoferectiledysfunctionvar- iedbycountry,affectingbetween20and40%ofmenaged between60and69years,andover50%ofthoseagedover 75,150millionmenworldwideareestimatedtobeaffected by erectiledysfunction [1—3]. A majorlinkhas alsobeen shownbetweenerectiledysfunctionandsubsequentcardiac events[4].

Thelastobservationofclinicalpracticestudywascarried outin2004inFrance[5].Wewishedtoevaluatethehabits ofurologistswhohave notbeentrainedspeciﬁcallyin the ﬁeldofsexology,in 2018.Wealsowantedtoevaluatethe needforadditional,objectivetoolstoaidphysicianswhen providingcare.

Methods

A questionnaire designed by the authors was sent from theFrenchUrologyAssociationto1158physiciansbetween NovemberandDecember2018.

Thequestionnairewasdividedinto2parts,theﬁrstwith clinicalpractice,andthesecondwithfutureprospectsand theirfeelingsaboutthemanagementoferectiledysfunction (Appendix1).Thequestionnaire wasﬁlledinanonymously andparticipantcouldanswerjustonce.

Results

Out of a total of 1158 questionnaires sent, 177 (15.28%) were ﬁlled in completely by the urologists. Each urologist attended a median of 70 (5;150) patients per week, out of which a median of 5 (0;30) attended speciﬁcally forerectionproblems.Erectiledysfunctionwasbroughtup spontaneouslyby the urologist in 20%of cases. The aver- ageconsultationtimededicatedtoerectionswas17minutes (estimatedtimebyparticipant).Only22%ofurologistsregularlyusedaquestionnaire,suchastheIIEF-5.Whenfaced witherection problems,56.50% ofthem didnotcarryout systematiccardiologyevaluations.Morethanhalfofurolo- gistsrequestedfastingglucose,lipidandtotaltestosterone levels.Twenty-seven percent did not carry out any addi- tionaltests(Table1).

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320 J.Gasetal.

Table1 Laboratorytestsuggestbyurologisttoexplore erectiledysfunction(n=177).

Type n %

None 49 28

Fastingglucose 104 59

HbA1c 42 24

Lipids 89 51

Totaltestosterone 89 51

Bio-avalaibletestosterone 53 30

Penileecho-doppler 20 11

Penilerigiditytesting 0 0

Table2 Treatment suggest inﬁrstand secondline by urologisttomanageerectiledysfunction.

n %

Firstlinetreatment(n=177) Phosphodiesterase5 inhibitors(P5I)

144 81

Behaviouraltherapy+P5I 27 15

Localtherapy

alprostadil/intracorporal injection

2 1

Vacuum 0 0

Other 4 3

Secondlinetreatment (n=177)

Phosphodiesterase5 inhibitors(P5I)

34 19

Localtherapy

alprostadil/intracorporal injection

130 73

Vacuum 6 3

Penileprosthesis 0 0

Other 7 4

First line treatment included phosphodiesterase 5 inhibitorsin81%ofcases.Behaviouraltherapywasaddedin 15%ofcases.Secondlinetreatmentincludedlocaltherapy eitherthroughtheuseofintraurethralagents,orintracav- ernosalinjections (Table2).Two thirdsofurologists(78%) rated themselves as being correctly trained in the area of erectile dysfunction.However, only 49% systematically inquiredabouterection problemswhen facedwithbenign prostatichyperplasiaand65%thoughtthaterectiledysfunc- tionwasnottreatedoptimally.Morethan76%ofurologists statedthaterectionswereamajorsubjectinurologyandfor meninthe21stcentury.Forty-eightpercentwouldbewill- ingtouseanobjectivetoolfortheevaluationoferections (similartoaﬂowmeterforlowerurinarytractsymptoms).

Discussion

Ourstudyfoundthat7%ofconsultationsareexclusivelydue toerectiledysfunctionasintheENJEUstudy(5.4%)[6].In guidelines,urologist shouldresearch sexual trouble in all patients consulting for lower urinary tractsymptoms [7],

butonly49%ofthem,inourstudy,exploreitsystematically versus 16%for Droupyetal.[6].In ourstudy80% ofurol- ogiststoldthatpatientspokeoftheirerectiledysfunction spontaneously,whereasin2004morethanhalfofpatients fail todiscussthis subjectwiththeir doctor [5]. Maybe a changeofcustomshasappearedovertheyears.

Eighty-eightpercentofurologistssurveyeddonotuseany oftheIIEF(InternationalIndexofErectileFunction)questionnaire.IneuropeanGuidelinesasinglequestionmaybe sufﬁcient to clarify erectile dysfuncion and questionnaire areonlyoptionalwhereasquestionnairearerecommended toassessexualfunctioninBritishGuidelines[8,9].Neijen- huijsetalquestionthevalidityofthosequestionnaires[10].

It has been noted by the scientiﬁc community that erectiledysfunctionisanearlypredictorofcardiovascular events (myocardial infarction, stroke) in the 3 to5 years after its appearance and that, in the presence of three cardiovascularriskfactors,patientssufferingfromerectile dysfunctionshouldundergoacomplete cardiacevaluation [3,8,11,12].Ataminimum,fastingglucose,lipidandtestos- teronelevelsshouldberequested[3,8].Thisiscarriedout byonlyhalfoftheurologistswhotookpartinourstudy.The PISTES study,carriedoutin 2004found that90%of urolo- gistsrequestedhormoneleveltests,andthat73%requested ametabolicpanel[5].

Intheparaclinicalsetting,testssuchasnocturnalpenile rigiditytestingorpenileecho-dopplertestswereonlyused inveryspeciﬁccases.Nocturnalpenilerigiditytestingpre- viously allowedthe userstoobtain objectivemeasures of erectile dysfunction. It is not in use anymore due to its price and lack of simplicity [13]. We found that 48% of urologists believe that a tool which would allow them to obtain objectivemeasures of erectiledysfunction,similar to theﬂow-meters currently used tomeasure micturition problems,couldhelpthem.

When atreatment wasrequired, mosturologists use a phosphodiesterase5inhibitor,suchasthosediscussedinthe guidelinesandintheliterature[8].Localtreatmentwasonly usedasasecondlinetreatment.ThePISTESstudyfoundthat behaviouraltherapywasmoreimportantonceadistinction hasbeenmadebetweenpsychogenicandorganicimpotence [5].

Themajority ofurologiststhinkofthemselvesasbeing adequatelytrained.However,Themajorityofthemdidnot followguidelines(cardiologicalevaluation,mesureofserum totaltestosterone...)wedon’texplainthisinconsistency.

Thisstudywassubjecttoanumberof biases.The ﬁrst onewastheweakphysicianparticipation,probablydueto thefactthatstudiesinvolvingquestionnairesarequitecom- mon,withparticipantsregularlybeingcontactedandasked totake part in them. We sent questionnaire toall urologist withoutdistinction,perhaps thosemostinterested by erectiledysfunctionansweredmoretothesurvey.Wehave also reduced the number of questions asked in order to encourageparticipation.This limitstheanalysiswhichcan becarriedout(population,age,privateor publicpractice etc.).

Despite this, this is one of the most recent studies to be undertaken on the subject. It has highlighted the absence of adherence to the guidelines in the diagnosis of erectiledysfunction,especiallythesystematic carrying outofcardiovascularchecks,despitethefactthatthelink

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Evaluationofcaregiventopatientssufferingfromerectiledysfunctionin2018 321 betweenerectiledysfunctionandvascular pathologieshas

beenclearlyshowntoexist.Thestudyalsohighlightedthat questionnairesarenotbeingusedandthatthereisadesire foranadditionalusefulclinicaltool,inordertoobjectively classifyerectionproblems,andthusbeabletoprovidecare whichisbetteradaptedtothepatient.

Conclusion

Despite theguidelines, only half of urologistscarry out a cardiacevaluationwhenaﬁndingoferectiledysfunctionis made.Lessthanathirduseevaluationquestionnairesanda thirddonotrequestanyadditionaltesting.

Anobjectivediagnostictoolcouldhelpurologiststoopti- misethediagnosis, careandfollowupofthepatientwith erectionproblems,andthus makeearlyﬁndingsofcardio- vascularpathologies.

Appendix A. Supplementary data

Supplementary data associated with this article can be found, in the online version, at https://doi.org/

10.1016/j.purol.2020.04.008.

Disclosure of interest

Theauthorsdeclarethattheyhavenocompetinginterest.

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