The virtual direct-to-consumer (DTC) model of health care delivery has grown rapidly to become a major player in men’s health, especially in the treatment of erectile dysfunction (ED). Easy access, up-front pricing, and clearly defined treatment protocols—with minimal delay in initiating therapy—all contribute to the success of this model. While it lowers barriers to care for those who can afford it, DTC ED care has exceptional markups on drug costs, fails to address important comorbidities, and may deviate from accepted guidelines.

Virtual treatment for ED is hugely popular: there were 11 million visits in the fourth quarter of 2019, a 1500% increase from the same period in 2017.¹ A 2023 study identified 15 DTC solely virtual sites that treated ED in the US, the majority of which offered free initial consultations or bundled the consultation fee with the cost of the first month of treatment.² Men who choose virtual care are younger than those who seek office-based care and cite convenience (48%), shame (23%), and privacy (13%) in their choice to seek online care. A German study found that about half of these men accessed this care outside of normal business hours, with the majority in rural areas (69%) and first-time phosphodiesterase 5 inhibitor users (63.5%).³ These clinics are staffed by a variety of providers: a 2023 study of 223 virtual men’s health clinics found that providers from 20 specialties were represented, most commonly internal medicine (17.4%) and family medicine (11.1%).⁴ For their primary provider, the majority listed a physician; 4.5% listed an advanced practice provider, and 20% did not list their provider.

The ease of initial access to DTC care will be outweighed for many by the cost of subsequent treatment. Many DTC sites sell medications directly to patients through specialty pharmacies, driving the sites’ revenue. The price of phosphodiesterase 5 inhibitor therapy sold by virtual clinics varies widely: tadalafil ranges from $0.50 to $9.80 per pill (mean, $4.70/pill) and sildenafil from $0.50 to $35 per pill (mean, $5.16/pill).² Prices at traditional pharmacies are usually far lower, especially with the use of online coupons.⁵ The convenience of a questionnaire-based virtual clinic can also lead to overlooking important comorbidities. A 2020 study of 388 young men presenting with ED to an academic andrology clinic led to the new diagnoses of hypogonadism (20%), dyslipidemia (54%), diabetes or prediabetes (20%), and obesity (15%).⁶ Additional findings of varicocele (35%) and abnormal semen analysis (40%) were noted.

DTC care is clearly a popular initial point of access to ED care, and will continue to provide the on-demand, convenient, and discreet care that patients desire. It also acts as a conduit to traditional brick-and-mortar care, both urologic and otherwise, as patients present when the oral medications become ineffective, the costs become too great, or they seek more holistic care. The recently published ASMH/SMSNA Men’s Health Checklist gives clear guidance to providers as to which screenings should be offered to men at every decade of life, putting preventative care squarely in the realm of the urologist.⁷ As a urologic community, we must strive to promote the myriad ways to support men’s health and view this DTC model as a first step for many in a conversation about ED that we can develop into urologic health throughout their lives.

Since 2002, the AUA Residents and Fellows Committee has represented the voice of trainee members. The Committee’s mission is to address the educational and professional needs of urology residents and fellows and promote engagement with the AUA. The Committee welcomes your input and feedback! To contact us, or inquire about ways to be involved, please email rescommittee@AUAnet.org.