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Learning update: Men’s health and erection problems

Engaging with men about their health is a big challenge but should be viewed as an opportunity for increased pharmacy intervention. Many male customers may be suffering in silence with health issues such as erection problems, where embarrassment and lack of awareness of treatment options can prevent them from seeking help

Learning objectives

After reading this feature you should be able to:
•  Make your pharmacy a more ‘man friendly’ environment and improve engagement with male customers 
•  Recommend lifestyle changes and the OTC treatment options available for men with erection problems
•  Advise on the management of other common male health conditions including hair loss, sports injuries and fungal infections.


Health is often socially construed as a feminine concern and men’s levels of health literacy have been found to be significantly inferior to women’s,according to the Men’s Health Forum, a charity dedicated to improving the health of men and boys. As a result, general practice consultation rates in England are markedly lower for men than for women. This difference is particularly stark in the 20 to 40-year-old age group, where men attend general practice half as often as women.1 

Given the reticence of men to use general practice, the opportunity exists for pharmacy teams to improve engagement and promote positive behavioural change. One of the most effective ways to do this is by making simple changes to ensure a pharmacy is a ‘male friendly’ environment. This could include establishing a dedicated men’s health section containing, for example, grooming products, shaving accessories, condoms, nutritional supplements and vitamins and minerals targeted specifically at men. Pharmacy staff can then be alert for and proactive in approaching anyone browsing in this section who looks like they need help or advice, or who appears to be waiting for the pharmacist to be free.

Men’s health services can be actively promoted in pharmacy using tools such as in-store posters, window/counter displays, point-of-sale materials, information leaflets and via the pharmacy’s website or social media platforms. 

The National Pharmacy Association provides key resources that pharmacies can use to promote particular services they are offering in the local community, including those focused specifically on men’s health issues. Examples include posters, advertisements, templates and images for social media, as well as national and local health promotion resources. 

Global and national men’s health campaigns such as Men’s Health Week in June and Movember in November also provide an opportunity for pharmacy to raise its profile among male customers and increase engagement with this important group.

Key facts

•  Men continue to be reluctant to engage with primary healthcare services
 General practice consultation rates in England are markedly lower for men than for women
•  Assuming a bigger role in the management of erection problems represents a real opportunity for the pharmacy sector

Erection problems

Building on the momentum of the 2018 POM to P switch of Viagra Connect, pharmacy now has the chance to establish itself as the first port of call for men seeking help for erection problems – estimated to affect around 4.3 million men in the UK, with almost a fifth of sufferers under 45 years of age.2 Yet despite this high prevalence, new data from a national study of over 5,000 adults has shown that only around 4 per cent of men with erection problems have ever sought help from a pharmacist, with the vast majority of sufferers (76 per cent) feeling too embarrassed to discuss the issue at a pharmacy.2 

In order to encourage men with erection problems into a pharmacy setting, Viagra Connect recently launched an £8m nationwide campaign, including a new television commercial. The ad aims to raise awareness of modern-day lifestyle stresses that can contribute to erection problems and encourages men to take action by seeking advice from pharmacists. 

The campaign also includes an extensive set of pharmacy-focused education and training materials to help staff identify customers with erection problems, build trust with them and offer appropriate advice on lifestyle interventions and available treatment options. 

These new, data-backed resources comprise a CPD booklet to give pharmacy teams the tools to initiate conversations and manage in-pharmacy consultations, including key knowledge updates on erection problems and Viagra Connect; a pharmacy assistant workbook to build confidence in managing different patient scenarios, and a consumer leaflet with an overview on the lifestyle and physiological causes of erection problems and advice on whether Viagra Connect may be the right treatment option.

Despite the scale of the erection problem issue in the UK, data from the national survey indicate that men do not always understand the underlying causes of the condition, providing pharmacy teams with the perfect opportunity to educate customers on potential lifestyle contributors. 

Over 70 per cent of the men surveyed agreed there needs to be more visibility around the causes of erection problems, with a quarter unaware of lifestyle and physiological factors such as stress, alcohol, being overweight, blood flow issues and prostate problems.2 Less than half of men surveyed linked erection problems to stress (47 per cent) and excess alcohol consumption (46 per cent), with just 35 per cent knowing that being overweight can have an effect.2 

Raising awareness of the OTC availability of medication to treat erection problems is especially critical as evidence suggests men may already be looking for similar drugs online

The importance of lifestyle interventions to manage and mitigate the impact of erection problems has never been more pertinent, with pharmacies reporting surging demand for advice and treatment during the Covid-19 pandemic, fuelled by a rise in well-recognised risk factors such as stress, anxiety, tiredness and alcohol intake.3,4

“We know this issue can have a huge toll on men’s mental wellbeing, with almost a fifth of men with erection problems feeling depressed because of them,” says Rob Elliott, marketing director, Upjohn Ltd, manufacturer of Viagra Connect. “Worryingly, 5 per cent have even suffered panic attacks. It is so important pharmacists have the tools to initiate conversations with these men and advise them on the most appropriate treatment. 

“We know that two-thirds of men with erection problems feel too embarrassed to even discuss the issue with their partner and friends, so that having a conversation with a pharmacist could be the first time they’ve opened up with anyone.”2

Raising awareness of the OTC availability of medication to treat erection problems is especially critical as evidence suggests men may already be looking for similar drugs online. Results from a study of 935 men aged over 35 years carried out across major UK cities found one in 10 had purchased a prescription-only medication without a prescription, with half of these purchases taking place via the internet. 

When looking at purchases of erection problem treatments specifically, the number of men buying POMs online rose to 67 per cent.1,5 Estimates from Europe indicate that up to 2.5 million men have self-treated with illicit sildenafil. If correct, that could mean there are now more illegal users of sildenafil than there are legal ones.

Counterfeit phosphodiesterase-5 (PDE5) inhibitors already account for the bulk of illicit pharmaceutical seizures, with millions of counterfeit doses confiscated each year.5 In Europe, the Experts on the Operation of European Conventions in the Penal Field estimate that 44 per cent of sildenafil sold over the internet is counterfeit.5 

As well as raising awareness of the availability of OTC sildenafil, it is therefore also important to caution men about the dangers of buying PDE5 inhibitors online. Informing patients that their medication may be counterfeit is a proven strategy that can help dissuade them from a potential purchase.5 

Analysis of the contents of counterfeit PDE5 inhibitors has revealed inconsistent doses of active pharmaceutical ingredients, potentially harmful contaminants, such as commercial paint and printer ink, as well as other potentially hazardous ingredients. In one analysis, only one in 10 of the samples tested were within 10 per cent of the labelled tablet strength, making it highly unlikely that the medication would even work as intended.5

Over 70 per cent of men surveyed agreed there needs to be more visibility around the lifestyle causes of erection problems

Common conditions that affect men

As part of the overall effort to improve men’s health and wellbeing, community pharmacy teams are perfectly positioned to advise on the management of a host of everyday ailments that can affect men, such as hair loss, fungal nail and foot infections, and sports injuries. 

Hair loss

The main OTC treatment for male hair loss is minoxidil, a topical agent that works by expanding blood vessels in the scalp to increase blood flow to the hair follicles. 

Minoxidil is maximally effective when used early in the natural history of hair loss and results can take four to six months to become noticeable.6 

It is important to counsel customers that hair loss treatments don’t work for everyone and effects only persist for as long as the product is used, which can prove expensive over the long-term. 

Finasteride, the other approved pharmacological treatment for hair loss, is only available via private prescription in the UK.6 It is an oral drug that works by inhibiting the enzyme 5-alpha reductase to stop conversion of testosterone into dihydrotestosterone, which causes hair follicles to shrink. 

A number of caffeine-based shampoos and scalp lotions are also available to buy in pharmacy that claim to reduce hair loss, although the evidence for their efficacy is less robust. Hair loss can sometimes be linked to nutritional deficiencies, so it is important to remind male customers of the key principles of a healthy, balanced diet and recommend targeted vitamin and mineral supplements where appropriate. 

Fungal nail and foot infections

Men aged over 55 years and regular swimmers/gym users are particularly prone to fungal nail infections, most commonly affecting the toenails. The mainstay of treatment is an OTC topical antifungal such as amorolfine or tioconazole applied as a lacquer, solution or cream direct to the nail. These products are most effective if used early and if abnormal nail material is removed regularly during treatment with clippers or files. 

Meticulous hygiene of affected feet during treatment is also important. Customers should be made aware that the cure rate with topical products alone is low, approximately 15-30 per cent, and prolonged treatment for up to 12 months may be required.7 

In order to prevent the recurrence of future fungal nail infections, key self-care measures should be recommended to customers. These include keeping nails short and clean, washing and drying feet daily (using a separate towel from the rest of the body), wearing clean socks daily  (cotton is best) and well-fitting, breathable shoes, using flip flops in communal showers and expeditiously treating any cases of athlete’s foot before they can spread to the nails. 

OTC treatments for athlete’s foot come in a range of formulations including creams, gels, sprays, solutions and powders. Terbinafine is the only active fungicidal ingredient that directly kills the tinea pedis fungus that causes athlete’s foot and is usually applied once or twice a day for a week, although single application products are also available. 

Miconazole, clotrimazole and tolnaftate are all fungi- statics, so require a longer period of application, usually several weeks. Continuing treatment for the recommended course is essential to stop the infection from recurring. It is also important to choose the product that best suits each individual customer’s needs (e.g. caution is required when using miconazole in patients on oral anticoagulants) and to advise them to follow usage instructions carefully. 

A few different treatments may need to be tried to find the one that works best. Self-care advice for preventing/managing athlete’s foot is the same as that for fungal nail infections. 

Sports injuries

Men who play sports regularly may be particularly prone to injuries affecting the ankles, knees and legs – most commonly sprains and strains. The cornerstone of sprain/strain management is rest, ice (applied to the injured area for approximately 20 minutes every two to three hours), compression (with a tubular support bandage) and elevation (RICE). 

Standard OTC pain relievers can also be recommended, although ibuprofen should be avoided for the first 48 hours as it can impede the healing process. Topical NSAID analgesics are proven to be very effective in treating acute musculoskeletal pain and can be a good choice for men who wish to avoid oral medication or where potential side-effects are an issue. 

Rubefacients, heat therapy and cooling sprays can also be recommended for sports injuries and are suitable for use alongside oral pain relief.  

Breaking down barriers

Starting a conversation with male customers is the first step for pharmacists when addressing any men’s health issue. The Men’s Health Forum notes that, “fear surrounding the potential loss of masculinity may result in a façade of control and stoicism, instead of honesty about reporting symptoms and accepting interventions, or openness about feelings and insecurities associated with particular illnesses”.1 This applies particularly in the area of erection problems.

Around 20 per cent of men will experience erection problems every time they try to initiate sexual relations and, as a direct consequence, over a quarter of men are unable to be physically intimate with their partners.2 This can have a significant impact on men’s confidence, with many feeling that the inability to get/maintain an erection is a direct reflection of their masculinity. Men may feel frustrated, depressed or begin to lose self esteem and confidence. 

With this context in mind, accessibility and discretion are key for men when seeking treatment in the pharmacy setting. It is vital to have a consultation room or other discrete space available where private conversations and one-on-one consultations with male customers can be carried out. 

Pharmacy staff need to put patients at ease from the outset and provide reassurance that all conversations are completely confidential. Consultations must be conducted with sensitivity and empathy, taking care to maintain the customer’s dignity throughout. The language used to talk about erection problems is also important. Pharmacy teams need to be comfortable using words such as penis and erection but should also try to reflect and mirror back the type of language used by the customer when describing his problem. 

Allow time, particularly for the initial consultation, to ensure men don’t feel rushed and can raise any concerns and ask all the questions they may have. Displaying leaflets or tokens on the counter that a customer can pick up and hand to the team to reduce the need to ask out loud about erection problems is also a useful tip. 

Any pharmacy-based interaction with a male customer can also provide a chance to ask about their wider health. This could include routine prescription dispensing and discussions about medicines (especially for drugs such as antidepressants, beta blockers, ACE inhibitors and antiepileptics, which can be linked to erection problems), men accessing sexual health or smoking cessation services, or even straightforward OTC medication recommendations. 

As well as providing therapy for erection problems where appropriate, pharmacists can also use these consultations to advise on underlying health issues such as diabetes, hypertension and dyslipid- aemia – often associated with erectile issues. Self-care measures that can help ameliorate the effects of erection problems, as well as having a positive impact on overall health and wellbeing, include losing weight, taking steps to reduce stress, stopping smoking, reducing alcohol intake and/or recreational drug use and exercising regularly. 

References

1. Men’s Health Forum. Key data: understanding of health and access to services
2. Upjohn Ltd. Ground-breaking £8 million campaign launches, enabling pharmacists to assist the millions of men struggling in silence with erection problems. Press release. July 2020 
3. Carter R. Expanded erectile dysfunction service at Superdrug as demand surges. 25 June 2020
4. Metcalf S. Nottingham online pharmacy firm reports rise in Viagra sales. 26 March 2020
5. Jackson G et al. Counterfeit phosphodiesterase type 5 inhibitors pose significant safety risks. Int J Clin Pract 2010; 64(4): 497-504
6. Clinical Knowledge Summaries (CKS). Alopecia, androgenic – male. Last revised July 2018 
7.  British Association of Dermatologists (BAD). Fungal infectios of the nails.

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