Expert highlights research on sexual dysfunction, telehealth

In this interview, Taher Naeem, a fourth-year medical student at Baylor College of Medicine in Houston, Texas, highlights 3 abstracts that he presented during the 24th Annual Fall Scientific Meeting of the Sexual Medicine Society of North America in San Diego, California.

"A lot of work in telehealth has been done showing that physicians and patients and sometimes even health systems are for it. They recognize the value of it in reducing disparities and increasing access to care in a lot of patient populations," says Taher Naeem.

Could you highlight the background and key findings from the study, “Changing Landscape of Erectile Dysfunction: Shift in Risk Factors and Presentation Patterns”?

Recent trends and data have shown that men are presenting earlier and at younger ages with erectile dysfunction. In one study, 52% of men in their 40s presented with erectile dysfunction. So, the purpose of this study was to see if we can identify any risk factors or anything like that would explain those [trends].

The main thing that we noted in this study was that the men that presented to our clinic have lower rates of the most common comorbidities like hypertension, hyperlipidemia, [and] diabetes than previously reported in the literature. What that means is that people presenting with erectile dysfunction are healthier now than in the past. Additionally, they also presented at a median of 2 years after developing symptoms, which was 2 years earlier than previously reported. So, they're healthier and presenting earlier. Another notable finding is that almost half of the patients had already tried PDE-5 inhibitors like Viagra [sildenafil citrate] or Cialis [tadalafil] before they ever came to us. This begs the question, why are younger, healthier people coming with erectile dysfunction sooner? It's hard to know what percent of these people have erectile dysfunction caused by some medical problem or whether it's psychogenic. This was a retrospective study, so we didn't have ultrasound data on all of them to know for sure.

What might be some reasons for these findings?

A guess is with the recent efforts to destigmatize sexual and pelvic health, it's possible that a lot of people are coming in as soon as they realize they're having issues. As for why so many more people are presenting with already being on PDE-5 inhibitors, it's hard to know whether that's truly because they're presenting with more advanced disease, which is unlikely given that they're younger and healthier. A more likely explanation could be the proliferation of direct-to-consumer marketing with things like Hims, making it a lot easier for men to get access to these drugs without ever actually seeing a doctor.

What are some of the implications of these findings for urology?

I think it's important for a urologist to keep this in mind when seeing younger patients with erectile dysfunction, especially if they're already presenting on PDE-5 inhibitors. [They need to be] getting a better sexual history, understanding why they're already on PDE-5 inhibitors, understanding their new relationship or things like that, the typical things that could cause psychogenic erectile dysfunction. Also, keeping in mind that they may not actually have more advanced disease.

You also presented the study, “The Emerging Role of Telehealth in Sexual Medicine: A Survey of Patient Attitudes.” Could you highlight the background and key findings from this work?

The impetus for this study was the impetus for a lot of telehealth studies over the past few years. We had a lot of patients who we had seen in the clinic during the COVID-19 era who had been seen by telehealth. We wanted to understand what these patients felt about the telehealth visit and whether that's something we should continue to offer and to what extent in our clinic. What we found in this study was what we expected; a majority of patients preferred telehealth. Somewhat surprisingly, this was pretty consistent across all indications. We expected that maybe patients with Peyronie's disease, for example, might prefer to see a provider in person for a physical examination or something of the sort. But aside from an initial visit for a physical exam, most of them prefer to have all the follow-up and things like that done via telehealth.

We further analyzed the data, looking at their distance from our clinic, as well as socioeconomic status and other factors. We found through that analysis that as their distance from our clinic increased, they did prefer telehealth more. But interestingly enough, socioeconomic status was not a statistically significant consideration as to whether a patient would prefer telehealth or not. Additionally, age was not a significant factor. We thought that perhaps older patients might not prefer telehealth compared with younger patients, but that was not something that we saw in our data.

What does the future hold for telehealth in urology?

A lot of work in telehealth has been done showing that physicians and patients and sometimes even health systems are for it. They recognize the value of it in reducing disparities and increasing access to care in a lot of patient populations. The struggle with it seems to be a regulatory one. During COVID-19, when reimbursements had gone up to the same level as in-person visits, we saw a huge uptick in telehealth, but of course, it's hard to know whether that was because people wanted to social distance or if they truly preferred telehealth. As technology continues to get better and people get more comfortable with it, maybe one day we'll be having virtual visits in a fully VR environment or things like that. It definitely has a place, and I think it's only going to continue to expand.

And finally, could you touch on the background and key findings from the work, “Shining a Light on Women's Sexual Health: Insights from Patients Presenting with Sexual Dysfunction”?

Our practice, like a lot of other sexual medicine practices, is largely men. As you might be aware, there's been a recent emphasis on female sexual dysfunction. Even just at this meeting, we had a female sexual medicine course, in collaboration with [the International Society for the Study of Women's Sexual Health]. We have people like Dr. Rachel Rubin who are taking the charge on this. [In this study,] we wanted to better understand our female patients so we could provide them with better care and could understand any risk factors that were causing them to present with sexual dysfunction.

I would say the most important thing we found was that 58% of women in the study reported mild to moderate depressive symptoms on the PHQ-9 questionnaire. Out of those patients, only 2 of them actually had a formal diagnosis of depression, which means that we're missing a lot in this population. Additionally, a multivariate logistic regression showed a strong positive correlation between depressive symptoms and increased pain during intercourse and decreased sexual satisfaction. Because it's a correlation, it's hard to know which came first, so more robust studies are definitely needed in that area.

The high incidence of depression in this population highlights the need for more comprehensive sexual health assessments along with the mental health screening, and that's something that urologists can really help out with especially when seeing these patients [in clinic]. To further explore and understand this patient population's presentation, we need larger studies to look into this phenomenon.

Could you expand on the importance of comprehensive sexual health assessments based on findings from this work?

Historically, we haven't done a great job screening for female sexual dysfunction. For cultural and social reasons, it's always fallen by the wayside. Especially with the increased effort on trying to address this issue in this population, and the association that we've seen with depression and mental health, I think it's very important in this population to make sure that we're not missing anything. As urologists seeing these patients in your clinic, it can do a lot of good to screen these patients for depression and anxiety and other mental health concerns as well.

What does future work look like?

We're still following these patients. We've had 3-month, 6-month, and 1 year follow-up. We don't have the data yet analyzed for that, but we should have that hopefully by [the American Urological Association Annual Meeting] and be able to see what ended up happening [with] these women: if any of them had gotten a formal diagnosis of depression after this point, or if they were able to get therapy for that, if their symptoms improved, or if they had [improved] sexual function. We're hopeful that these findings will empower people to screen women for sexual and mental health. Hopefully our data will show that it can make a positive difference in their lives.