Erectile dysfunction (ED) is defined as the inability to attain or maintain penile erection sufficient for satisfactory sexual performance [1]. According to prevalence data, ED is known to occur in 16.0% to 34.8% of the world's male population, and as age increases, its incidence rises [2,3,4,5,6]. Additionally, prior research has established that patients suffering from ED are more prone to stress or psychiatric problems, such as depression [7,8].

Although phosphodiesterase type 5 inhibitors (PDE5Is) have shown positive results in treating ED, patients in South Korea's health care system have complained of the inconvenience of receiving prescriptions for PDE5Is in hospitals and then obtaining their medication at pharmacies. As pharmacies are open, public places where a number of people or customers may be present at any given time, the privacy that ED patients seek with respect to their condition may be compromised.

In this study, we attempted to investigate the discomfort experienced by patients taking PDE5Is in clinical practice.

Between September 2011 and March 2012, we surveyed patients who had been prescribed PDE5Is for ED at the Korea University Guro Hospital. Approval for this study was obtained from the Institutional Review Board of the hospital, and informed consent was obtained from each patient.

A structured, self-administered questionnaire was developed to examine the medication counseling that the patients had received and the inconveniences that they had experienced in hospitals and at pharmacies.

The questionnaire contained items on patients' 1) age, 2) underlying disease, and 3) other medications for co-morbidities, as well as 4) any inconvenience felt during the process of being prescribed PDE5Is at the hospital, 5) any inconvenience felt during the process of dispensing PDE5Is at a pharmacy, 6) medication counseling received in the hospital, 7) medication counseling received at the pharmacy, 8) satisfaction with the therapeutic effects of PDE5Is, and 9) the separation of the prescribing and the dispensing (SPD) of PDE5Is (Supplement).

For items 1 to 3, the investigating physicians retrospectively ascertained the presence of concurrent illnesses through the survey data and the patients' medical records. Patients who indicated having felt inconvenienced in response to items 4 and 5 were instructed to describe their answers in further detail. As for information regarding medication counseling obtained via items 6-1 and 7-1, the following factors were examined: A) the appropriate time to take the medicine before intercourse, B) the adjusted/modified time at which the medicine is to be taken after consuming fatty foods, C) the daily dosage limit or frequency of medicine intake, D) the patient's behavior or conditions necessary for the medication to be effective, E) the duration for which effects are expected to be sustained after taking the medicine, and F) explanations regarding the accompanying side effects. Additionally, patients' satisfaction with medication counseling received in hospitals and pharmacies were ascertained from their responses to items 6-2 and 7-2, while item 8 evaluated the satisfaction with the therapeutic effects of PDE5Is. Finally, item 9 assessed patient' preferences for the prescribing and the dispensing of PDE5Is; namely, if the patients preferred to obtain their medication from a pharmacy after receiving their prescriptions (as present), or from respective hospitals along with the prescriptions.

Since sildenafil was first released in 1998, the introduction of PDE5Is in recent years has increased the therapeutic options for male sexual disorders and led to a change in the numbers of patients seeking medical help [2]. PDE5Is have become the primary form of therapy and preferred treatment for ED. In the Cologne Male Survey [2], 73.8% of the respondents indicated that they preferred oral treatments or medications for ED.

Before they can begin taking PDE5Is, ED patients in Korea are required to see two health care providers: one of them, a physician (e.g., a urologist), and the other, a pharmacist. In 2000, the Korean government instituted the SPD of medications to provide greater differentiation between the roles of physicians and pharmacists [9,10,11,12]. Since the introduction of SPD, patients first consult with their physicians, obtain their prescriptions in the hospital, and then go to the local pharmacy where they receive the medications.

In the pharmaceutical affairs law, there are some exceptions to SPD, one of which pertains to psychiatric drugs. Due to the nature of psychiatric diseases, patients do not want their medical histories or medications to become known to other people. As most pharmacies do not have a private space in which psychiatric patients can be assured of their privacy, a majority of these patients are allowed to obtain their medication in the physicians' offices instead.

We suggest that the same exception be applied to ED patients, due to the nature of ED, wherein patients are frequently self-conscious of having to take medication for their condition. Over the treatment period, physicians are able to build a rapport with patients, which is fundamental to ED patients and their urologists. Appropriate patient counseling and follow-up is necessary to overcome psychological and partner issues [13].

Several sociocultural and economic factors appear to prevent individuals from seeking medical help for ED in Asian as compared to Western countries [14,15,16]. Research by Nicolosi et al [14] revealed that East Asians (people from China, Hong Kong, Taiwan, South Korea, and Japan) were less likely to act on ED than Southeast Asians. Predominant cultural and religious influences, such as those of Confucianism in East Asia, may contribute to sexual attitudes and preferences with respect to the treatment of ED [14]. Additionally, patients suffering from ED are more prone to stress or psychiatric problems, such as depression [7,8].

Unlike physicians' offices where ED patients are able to meet in private with their physicians to discuss their condition and treatment options, pharmacies are open, public spaces where patients are required to meet relatively unfamiliar pharmacists who may be female or someone whom they have not met before. This could cause significant stress in ED patients, who sometimes lack the ability to cope with stress, which could disrupt the continuity or effectiveness of treatment.

In this study, we aimed to identify inconveniences that the patients experienced in the process of acquiring prescriptions and medications. We found that 57.8% of the respondents reported inconveniences in obtaining the prescribed PDE5Is from pharmacists. The most common concern of patients receiving medication at the pharmacy was a feeling of a lack of privacy and embarrassment. On the other hand, 26.0% of the respondents reported inconveniences in the hospitals. The most common discomfort in the hospitals was the inconvenience related to the assistant staff, including nurses. At both pharmacies and hospitals, the main concern of ED patients was 'self-consciousness' that might be influenced by predominant cultural and religious influences. Sociocultural factors (e.g., lack of sexual education and cultural taboos about sex) appear to prevent patients from seeking a solution for sexual problems. For the ED patients, special attention should be taken to build rapport in the comfortable environment [17,18].

Another complaint of patients receiving medication at the pharmacy was insufficient medication counseling. Although the patients with ED received medication counseling from their physician, they wanted additional medication counseling from the pharmacist. However, most pharmacies have a privacy problem, and the pharmacist was hardly able to provide medication counseling to patients. While most patients were satisfied with the level of medication counseling in the hospitals, fewer patients were satisfied with the medication counseling from the pharmacy.

A limitation of the present study was its relatively small respondent population. However, to the best of our knowledge, few studies have been conducted on the discomfort or the inconveniences that patients experience in the prescribing and the dispensing of medication for ED. Therefore, our findings are meaningful as they reflect the important yet rarely examined needs of patients suffering from ED from this aspect of the treatment. However, a larger multicenter study is needed to confirm these results.

The treatment of ED is a highly private matter for many individuals. According to the survey, ED patients more often felt that obtaining medication from pharmacies was inconvenient. Respondents also felt that they received more detailed medication counseling from their physicians in hospitals. Due to the sociocultural aspects of ED, exceptions to SPD should be applied to ED patients.