key: cord-0049159-15t42hz1
authors: Ibrahim, Ahmed; Carrier, Serge
title: EDITORIAL COMMENT
date: 2020-08-28
journal: Urology
DOI: 10.1016/j.urology.2020.03.070
sha: cec9f83d1b6b2650ce82fe43c78bf8d8dbbcb461
doc_id: 49159
cord_uid: 15t42hz1

nan

This is a retrospective analysis of the comorbidities potentially present in young men with erectile dysfunction (ED) who are targeted by direct-to-consumer (DTC) internet platforms that sell PDEi-5 without comprehensive clinical evaluation. In this study, the authors analyzed 388 patients ≤40 years at an andrology clinic over a period of 3 years. As expected, they detected a significant number of comorbidities that would be missed by DTC platforms, which rely only on questionnaires for health screening. In their cohort, they found 15% rate of obesity, 20% prediabetes or diabetes, 54% dyslipidemia, and 20% hypogonadism. Additionally, a varicocele was found in 35% during the physical exam. The authors recommended that urologists may play an important role in incorporating telemedicine to enfranchise young men with evidence-based evaluation to ensure adequate medical assessment and reduce mismanagement.

In an era where everything is fast, DTC telemedicine companies offer a convenience within a health care system that many patients find complex and difficult to access. It is uncertain, however, if the care provided is equivalent to a traditional inperson visit. DTC telemedicine visits may have several potential advantages − information gathering through a questionnaire before the patient is encountered; questionnaires may be consistent and comprehensive; increase efficiency when the patient is encountered.

This study is one of the rare studies evaluating the potential impact of DTC internet platforms on young men diagnosed with ED which sell PDEi-5 without comprehensive clinical evaluation. We agree with the authors that DTC internet platforms are still lacking formal guidelines in the context of online media. Therefore, we strongly believe that urologists should be a crucial element in incorporating telemedicine to enfranchise young men with evidence-based evaluation to ensure adequate medical assessment and reduce mismanagement or overtreatment. Although DTC platforms are becoming a prominent part of the health care landscape of the United States, they are still not approved in many countries. Therefore, evaluating the impact of these new platforms on our patients should be better studied.

As the authors acknowledge, the limitations and inconstancy of certain DTC platforms screening questionnaires without office visits could explain for ED mismanagement in the study cohort. Prospective studies would help us to identify the actual pitfalls of DTC platforms and provide corrective measures for better practice as well as help us to recommend its proper use for better clinical practice. Since the pandemic with COVID-19, we had the opportunity to use telemedicine. As a follow-up for known patients, it is a useful tool. However, in assessing a new patient, it lacks the direct interaction that enables us to have a better judgment of the patient's psychological distress that a questionnaire may not give. It would be sad and dangerous if physician judgment is replaced by a questionnaire. The lack of a physical exam will miss some comorbidities. However, if done properly, telemedicine could attract individuals that would not consult a physician usually, but allow further follow-up in person. It could be a useful tool for men's health if used properly to bring men into our offices. Time will tell us but useful guideline for telemedicine is needed as well as research. 1 

We appreciate the supportive editorial comment on our study. The controversy surrounding direct-to-consumer (DTC) internet prescription platforms comes at a time when the COVID-19 pandemic has shifted the paradigm of how patients receive care. In the months preceding the pandemic, DTC internet companies were achieving billion-dollar valuations, in large part due to their collective focus on catering to a younger generation portrayed as unwilling to engage with an increasingly byzantine health care system in an era of smartphone conveniences. Since the pandemic, however, it is clear that telemedicine has become an essential component of health care delivery and is here to stay. 1 In this paradigm, the value-added is therefore the physician, not the platform. It is incumbent on urologists and their primary care referral base to recognize that young men with erectile dysfunction (ED) may have comorbid conditions worth addressing, either with further evaluation or targeted counseling − elements that are absent from DTC internet prescribing platforms, which rely solely on yes/no questionnaires. The American Urological Association Guideline on ED 2 serves an important foundation for providing comprehensive, evidence-based care and can be adapted for telemedicine by individual practices. Though the nature of the "office" visit may change, the doctoring does not.

Sriram V. Eleswarapu, Robert H. Shahinyan, Division of Andrology, Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA

Prescriptions on demand: the growth of direct-to-consumer telemedicine companies

Direct-to-consumer advertising of prescription drugs and the References

Implementing telemedicine in response to the COVID-19 pandemic

Erectile dysfunction: AUA guideline