The current study using data from the NHWS considered multiple aspects of ED and included a subgroup of men aged 18–39 years, an age group so far not included in similar studies. Based on population projections, 21.7 million men in France, Germany, Italy, Spain, and the UK may experience ED. In addition to well-established underlying conditions, such as diabetes and hypertension, ED was associated with neurological and psychiatric comorbidities, decreased HRQoL, and impaired work productivity and activity. Half of all men with self-reported ED had not discussed their condition with their physician. Among those who had spoken to a physician, two thirds were not currently using PDE5 inhibitor therapy. In this survey of adult men across 5EU, 17% of respondents self-reported experiencing ED in the past 6 months. Published estimates of ED prevalence in Europe range from 8% to 48% [2,3,5,17,19,34,35]. Differences in survey approach and sample population account for some of the variations in estimated prevalence [3,35,36]; nevertheless, the rate in this survey falls well within the expected range, with the prevalence and severity of ED positively associated with age [2–5,17,35–37]. Interestingly, this study showed that 5% of men aged between 18 and 39 years (an age group that is seldom included in ED studies) had experienced ED in the past 6 months and therefore these findings confirm that a significant proportion of young men suffer from ED. Across all ages, men with ED reported a less healthy lifestyle and a higher comorbidity burden than men without ED. The associations of ED with cardiovascular disease, depression, diabetes, obesity, physical inactivity, and smoking are well documented [2,10,12,14,16,17,37,38]. In these subjects, neurological and psychiatric disorders were also prevalent among men with ED. As highlighted by Corona et al. [39,40], not only psychiatric disorders are associated with relational problems, but also free-floating anxiety symptoms are more pronounced in patients affirming to have difficulties in maintaining erection [39,40].
One of the most interesting findings drawn from this survey is that despite advances in ED treatment and widespread awareness of this condition, ED is still underdiagnosed and undertreated. In addition, a critical point remains the difficulty to individualize subjects not satisfying criteria for the diagnosis of ED , who may be diagnosed as affected by subclinical erectile dysfunction (SED).
In this study, more than half of the respondents have not discussed the condition with their physician, although men who were older or had more severe ED were more likely to consult their physician for advice [1,2,19,21–24,26–28,42]. Rates of help-seeking behavior appear to have changed little, despite greater public and physician awareness, perhaps in part due to the poor physician–patient relationship reported by the respondents in this survey. Even when men discussed their ED with a physician, the physician seldom recommended a therapy and treatment rates were low. These data are not surprising as the MALES study found similar results . Mental and physical domains of HRQoL were both impaired in men with ED. Compared with those without ED, men with ED were frequently absent from work, and their general activity and work productivity were more affected by health problems [17,43,44]. These data have important implications as we found that men with ED also reported impaired HRQoL and work productivity. On the contrary, as shown in the current survey, men with severe ED who currently use PDE5 inhibitors have improved health and report lower impairment in HRQoL. Therefore, to provide the best care for their patients, physicians should proactively initiate discussions about sexual health when a man presents in the office for any reason, and discuss the range of treatment options. However, this survey also clearly demonstrates that there is the need to improve the degree of satisfaction regarding ED treatments. Although men taking a PDE5 inhibitor for their ED reported a certain degree of satisfaction with treatment (35%, 47%, and 44% of users were extremely or very satisfied with sildenafil, tadalafil, or vardenafil, respectively), about one half of patients show some levels of treatment dissatisfaction as already documented in other studies [27,28,45,46]. Interestingly, the average use of PDE5 inhibitors was lower than once per week. This supports the evidence that, in real life, despite questionable patients' preference, on-demand use may better fit both men's and couples' needs compared with chronic use. Furthermore, although our survey was not specifically aimed at investigating the patient's preference with respect to orodispersible tablet (ODT) formulation, literature suggests that difficulty in swallowing tablets and capsules may configure a negative factor in medication compliance [47,48]. Thus, the development of alternative drug delivery strategies such as ODTs has been promoted. In this regard, the use of this specific formulation is associated with improved medication compliance compared with traditional tablet formulations , and in some measure vardenafil ODT may present a potential opportunity for physicians to open up dialogue and maintaining therapeutic relationship as an essential foundation for ensuring patient compliance. This study has several potential limitations. The main limit is that this survey was not a longitudinal study, and no conclusions can be drawn about the relationship between any identified associations. Although distinguished literature indicates that single-question self-report accurately identifies subjects with clinically diagnosed ED when compared with International Index of Erectile Function , the ascertaining of ED without this tool is a significant limitation. However, the peculiarity of our survey was not to conduct a study on the prevalence of ED but to investigate the unmet needs of men with ED from the participants' point of view. Other aspects such as information regarding patients' hormonal data were not reported, making it impossible to evaluate any correlation with important clinical characteristics. In addition, the respondents were not asked whether they were concerned by ED, which may influence their help-seeking behavior including the presence of a stable relationship. However, previous studies have successfully used similar single-question approaches, and this may be preferable to longer questionnaires that have lower response rates . While prevalence rates may vary according to the questionnaire used, health-related associations appear to be consistent [35,36]. Finally, the dropout/exclusion rate we reported could be interpreted as hugely large and could configure itself as a main limitation. However, we believe that the dropout/exclusion rate that we report is the result of a conservative approach in the selection of participants and the potential resulting bias has been largely overcome by the huge number of subjects studied.