Comparison of Canadian online pharmacies with conventional pharmacies for erectile dysfunction drugs. The Cost of Convenience and discretion

Comparison of Canadian online pharmacies with conventional pharmacies for erectile dysfunction drugs. 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The Cost of Convenience and discretion Michael Morra, Michael Morra, Harliv Dhillon, Harliv Dhillon, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4343298/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Erectile dysfunction (ED) is a common condition affecting about 50% of men over the age of 40. ED can be related to cardiovascular disease and diabetes requiring further evaluation and workup, unfortunately many men with ED commonly avoid seeking treatment for reasons such as embarrassment. In the past few years, multiple online pharmacies offering easy access to ED medications have emerged, advertising easy online forms, no conventional doctors visit and discreet delivery to their home. We sought to compare the prices of five popular online ED pharmacies with conventional pharmacies, hypothesizing that online pharmacies would come at increased cost to patients. Methods The five online pharmacies were found on the first result page of a google search for “ED drugs online Canada”. Consumer prices for Tadalafil and Sildenafil were acquired through available website information or by contacting customer service. The prices were expressed as price per pill and compared with four conventional pharmacies in Winnipeg, Manitoba. Pricing differences were expressed as a percentage. Results When comparing the price per pill of the smallest order of tabs that can be purchased, the price of ED medications from online pharmacies was on average 15% higher without including the dispensing fee of the conventional pharmacy comparators. Once taking dispensing fees into account, the cost ED medications from conventional pharmacies was about 3-4% higher compared to online conventional pharmacies. Dispensing fees ranged from $12.99 to $16.00 per order. Savings could be seen with conventional pharmacies when order quantities increased as the dispensing fee is fixed per order. Conclusions Online pharmacies in Canada that boast convenience and discretion to customers offer similar pricing to conventional pharmacies. Despite their competitive pricing, their focus on discretion further perpetuates common stereotypes of ED that may prevent men from seeking help from their care providers. Health sciences/Health care/Therapeutics/Drug therapy Health sciences/Health care/Therapeutics/Drug therapy Health sciences/Diseases/Reproductive disorders/Sexual dysfunction Health sciences/Diseases/Reproductive disorders/Sexual dysfunction Introduction Erectile dysfunction (ED) is a very common condition, affecting about 50% of men over the age of 40, with significant detrimental effects on quality of life. 1 It is also important for men to seek treatment for ED as it can be linked with cardiovascular disease, diabetes, and future coronary risk. 2 Despite its ubiquity in the male population, a large proportion of men avoid seeking treatment for various reasons. These include embarrassment, the belief that ED is a normal part of aging and is not a significant medical problem, or the belief that it will resolve on its own. 3 Treatment of ED ranges from lifestyle modifications, sexual counselling, pharmacological, vacuum device therapy and surgery in select cases. 1 Once reversible causes of ED are ruled out, pharmacological treatment of ED with oral phosphodiesterase type 5 (PDE-5) inhibitors is the first line treatment of ED. 1 Importantly, ED medications are not typically covered by insurance in Canada and patients usually have to pay out of pocket after receiving a prescription from their physician and filling the prescription at a conventional pharmacy. In the past few years, multiple online pharmacies offering easy access to ED medications have emerged, advertising easy online forms, no conventional doctors visit and discreet delivery to their home. To access these services, patients visit a specific online pharmacy website, create an account, and usually fill out a medical questionnaire that seeks to determine symptoms severity, past medical history, current medications etc. Patients then either select what erectile dysfunction medication (PDE-5 inhibitor) they would like to order including the dose and quantity or have one recommended based on questionnaire answers. Patient medical questionnaires are reviewed by healthcare professionals which may include a physician or nurse practitioner, with some pharmacies including virtual consultations and some including just a review of the completed questionnaire. Once cleared by the healthcare team, medication is delivered to the patients’ homes in discreet packaging. We seek to compare the costs of these online services to conventional pharmacies as well as describe the advertising methods used by these online pharmacies, with the goal of better informing consumers on these medications and how they are acquired. We hypothesized that online pharmacies would come at a higher cost due to the added convenience of these services, including online health questionnaires requiring review by health care practitioners, and costs of shipping. Methods Five online pharmacies were found on the first result page of a google search for “ED drugs online Canada”. The pharmacies chosen were deidentified and labelled as online pharmacy 1–5. Multiple iterations of this google search were completed and the five pharmacies were felt to be representative of the findings of most online consumers for these products, although multiple other online pharmacies serving Canada do exist. Consumer prices for generic tadalafil 5 mg, tadalafil 20 mg and sildenafil 100 mg were acquired through available website information or by contacting customer service for full pricing information. The prices were expressed as price per tab in Canadian dollars and compared with conventional pharmacies in Winnipeg, Manitoba Canada. The prices of the medications of interest were obtained from four conventional pharmacies by speaking to one of their pharmacists by phone. The conventional pharmacies represent physical pharmacies where patients fill prescriptions from their care providers. Pricing differences were expressed as a percentage. Information regarding the online pharmacy websites’ discreet delivery, online appointments, and advertisements were obtained from the website main page or advertisements through the authors social media accounts. Results Prices were compared using the lowest quantity order possible from online pharmacies and conventional pharmacies and are shown in Table 1 below. Only one online pharmacy offered significant savings with increasing order quantity (13–16% savings with 36 tabs vs 4 tabs for Tadalafil 20mg and Sildenafil 100mg). Tadalafil 5 mg daily treatment for ED was usually offered in quantities of 28 or 30 tabs and offered by four of the five online pharmacies. The price per tab was $ 4.60, $ 3.57, $ 4.25, and $ 4.81 for online pharmacies 1,2,4 and 5 respectively. The average comparator price per tab from conventional pharmacies was $ 3.88 for a 30-tab order not including a dispensing fee, representing an average premium of 7% for online pharmacies. Tadalafil 20mg as needed was typically offered as 4 tabs for the lowest possible quantity order and was available from all five online pharmacies. The price per tab was $ 15.58, $ 11.00, $ 17.00, $ 15.50, and $ 17.83 from online pharmacies 1–5 respectively. The comparator price per tab from conventional pharmacies was $ 13.25 for a 4-tab order not including a dispensing fee, representing an average premium of 14% for online pharmacies. Finally, sildenafil 100mg as needed treatment was also offered in 4-tab quantities and offered by all five online pharmacies. The price per tab was $ 11.59, $ 9.00, $ 13.50, $ 11.50, and $ 14.04 from online pharmacies 1–5 respectively. The comparator price per tab from conventional pharmacies was $ 9.85 for a 4-tab order, again representing an average premium of 17% for online pharmacies. One of the five online pharmacies offered lower prices for tadalafil 20mg and sildenafil 100mg than conventional pharmacy at this order quantity. Table 1 Comparison of per tab price between online and conventional pharmacies for lowest possible order quantity Online ED Pharmacy price per tab (CAD $ ) PDE-5 Inhibitor and Dose 1 2 3 4 5 Average Online Pharmacy Cost Average Conventional Pharmacy Cost (without dispensing fee) Average Conventional Pharmacy Cost (including dispensing fee) Tadalafil 5mg 4.60 3.57 - 4.25 4.81 4.31 3.88 4.35 Tadalafil 20 mg 15.58 11.00 17.00 15.50 17.83 15.38 13.25 16.05 Sildenafil 100 mg 11.59 9.00 13.50 11.50 14.04 11.93 9.85 12.65 All conventional pharmacies add on a dispensing fee for each prescription filled, and on average this fee was about $ 14.25 at the selected Winnipeg Pharmacies. At the order quantities included in our study, this added fee brings the cost of these medications to about 3–4% higher at conventional pharmacies than online pharmacies. Through browsing the websites of the five online pharmacies, all five pharmacies indicate that they offer “discreet delivery”. All five online pharmacies consist of a quick online questionnaire, with review by a health care professional to ensure treatment is appropriate. At least three of these online pharmacies include young men, presumably under 40 years of age in their advertisements for PDE-5 inhibitor medication. Most of the websites also provide information about the prevalence of ED in men based on age range, but there is minimal to no mention of the relationship of ED and cardiovascular disease. Discussion ED is a very prevalent condition in men, with increasing rates due to advancing age, cardiovascular disease, metabolic syndrome and diabetes. 4 Etiologies range from organic, psychogenic, or multifactorial, and some patients may require investigations to investigate vascular, endocrine, neurological and psychological factors. 1 Unfortunately, ED remains a taboo subject for many men due to embarrassment, misconceptions regarding the disease process and treatments, and even physician factors such as lack of comfort with discussing ED or time constraints in our health care system. 5 This disconnect has resulted in the emergence of numerous legitimate online pharmacies offering PDE-5 inhibitors direct to consumers in Canada, a trend also seen in the United States. 6 , 7 There are also many illegitimate online sellers that pose a risk to Canadian and global consumers. 8 We sought to compare drug prices through these online pharmacies with conventional pharmacies that would usually entail obtaining a prescription from a patient’s family doctor or urologist. We also seek to discuss the implications of these online pharmacies on patient care for ED. Five online pharmacies were selected for analysis, and when all included costs are accounted for, these services were priced comparably with conventional pharmacies. One online pharmacy was able to offer a significantly lower price for all three medications than conventional pharmacies and the other online pharmacies. Online pharmacy services offered very modest savings with increasing order quantity, if offered at all. When a conventional pharmacies’ dispensing fee was taken into account, the difference in cost per tab between online and conventional pharmacy disappeared at a low order quantity. Therefore, more significant savings can be acquired through higher order quantities at conventional pharmacies because a dispensing fee is a fixed cost, per prescription. Dispensing fees also differ between Canadian provinces, for example dispensing fees are maxed out at $ 13.25 in Ontario, and $ 10.00 in British Columbia. 9 All five of the online pharmacies advertise ease of use of their online platform, no need for a physical doctor’s visit, and discreet delivery. They are providing these additional services and benefits to the consumer, and we hypothesized that this would come at an increased cost to the consumer, which we now know is incorrect. This study also aims to provide the Canadian consumer with the necessary information to make an informed decision about how and where they seek healthcare for ED, and from our findings of competitive pricing, it is reasonable to assume that many Canadian men will utilize these services, especially as these companies directly advertise ED medications through online ads and social media campaigns. From the perspective of the healthcare provider and Urologist, the focus on “discreet delivery” as well as “no conventional doctors visit” further perpetuates the stigma surrounding ED. Although these websites do put some effort into normalizing this diagnosis by providing information on ED prevalence, there is minimal information regarding the relationship of ED with cardiovascular disease and diabetes. Thus, these advertising methods and services raise questions regarding the quality-of-care patients are receiving through online means and the potential for inadequately investigating underlying etiologies of ED. In addition, the advertisements of PDE-5 medications for ED by some online pharmacies include young men, presumably under 40 years of age based on appearance. Organic causes of erectile dysfunction do exist in this population, but the vast majority is of a psychogenic nature. 10 Although PDE-5 inhibitors may be indicated in this population, lifestyle factors and conservative measures are important factors to consider before moving to medical therapy. Furthermore, it is conceivable that these additional factors will be less adequately addressed by health questionnaires and quick online virtual visits by a healthcare provider not known to the patient. This is a possible area of future research to ensure patients are not receiving suboptimal care due to use of online healthcare platforms. The increasing prevalence of these online pharmacies serves as a reminder to the healthcare community and urologists specifically that the state of ED care in Canada remains suboptimal, with significant barriers. Whether attributed to the patient factors described above such as embarrassment, physician discomfort with speaking about the diagnosis or long wait times and specialist referral times 11 , Urologists, as the specialists of ED, may need to be more involved in helping to remove these barriers. This study does have limitations. We did not make any orders from these online pharmacies; therefore, it is unclear if there are additional discounts with multiple orders or if there are hidden costs not seen when setting up an order. We did not actually observe an online medical visit or questionnaire review to comment on the quality of this medical review. We also only used comparator pharmacies in our local area which may not be representative of pharmacies across the country. Conclusions Online pharmacies offering direct to consumer PDE-5 inhibitors are becoming more prevalent and advertise ease of use, discretion, and overall convenience to the consumer at comparable prices. Concerns remain regarding the quality-of-care Canadian men are receiving from direct-to-consumer online pharmacies. It is important for consumers to understand the significance of underlying etiologies to ED and feel comfortable speaking with their care providers regarding the diagnosis. Declarations Funding disclosures: none Conflicts of Interest disclosures: no conflicts of interest to disclose Ethical Approval of studies : This project did not require IRB approval as all information is available to the public and obtained through publicly available websites. There were no human participants in the study. Acknowledgements: N/A Author Contributions: All authors listed have contributed to this work. Michael Morra: Design and concept, data and pricing acquisition, Data analysis/interpretation, Manuscript drafting and primary author Harliv Dhillon: Responsible for data and pricing acquisition, manuscript editor Premal Patel: Supervisor of work, Design and concept, manuscript editor References Bella AJ, Lee JC, Carrier S, Bénard F, Brock GB. 2015 CUA Practice guidelines for erectile dysfunction. Can Urol Assoc J. 2015;9(1-2):23-29. doi:10.5489/cuaj.2699 Grover SA, Lowensteyn I, Kaouache M, et al. The prevalence of erectile dysfunction in the primary care setting: importance of risk factors for diabetes and vascular disease. Arch Intern Med. 2006;166(2):213-219. doi:10.1001/archinte.166.2.213 Shabsigh R, Perelman MA, Laumann EO, Lockhart DC. Drivers and barriers to seeking treatment for erectile dysfunction: a comparison of six countries. BJU Int. 2004;94(7):1055-1065. doi:10.1111/j.1464-410X.2004.05104.x Johannes CB, Araujo AB, Feldman HA, Derby CA, Kleinman KP, McKinlay JB. Incidence of erectile dysfunction in men 40 to 69 years old: longitudinal results from the Massachusetts male aging study. J Urol. 2000;163(2):460-463. Al-Shaiji TF. Breaking the Ice of Erectile Dysfunction Taboo: A Focus on Clinician-Patient Communication. J Patient Exp. 2022;9:23743735221077512. Published 2022 Jan 31. doi:10.1177/23743735221077512 Brink SM, Iarajuli T, Shin D. Characteristics of direct-to-consumer platforms offering erectile dysfunction treatment. Sex Med . 2023;11(4):1-4. doi:10.1093/sexmed/qfad038 Vercnocke J, Zhong A, Liaw A, Ginsburg K, The High Price of Anonymity: Comparison of Cost of Direct-to-Consumer Mail Order Pharmacies Compared with an Online Wholesale Pharmacy, The Journal of Urology® (2023), doi: 10.1097/JU.0000000000003720. Government of Canada. Buying drugs over the Internet. Accessed Feb 3, 2024. https://www.canada.ca/en/health-canada/services/buying-drugs-over-internet.html Government of Canada. Dispensing Fee Policies in Public Drug Plans, 2021/22. Accessed April 7, 2024. https://www.canada.ca/en/patented-medicine-prices-review/services/npduis/analytical-studies/supporting-information/dispensing-fee-policies.html Karadeniz T, Topsakal M, Aydogmus A, Basak D. Erectile dysfunction under age 40: etiology and role of contributing factors. ScientificWorldJournal. 2004;4 Suppl 1:171-174. Published 2004 Jun 7. doi:10.1100/tsw.2004.64 Liddy C, Moroz I, Affleck E, et al. How long are Canadians waiting to access specialty care? Retrospective study from a primary care perspective. Can Fam Physician. 2020;66(6):434-444. Additional Declarations There is NO conflict of interest to disclose. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4343298","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":298911950,"identity":"c05851d9-8fcb-4822-8b41-b90adacc53b9","order_by":0,"name":"Michael Morra","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYPACGyhtAEZEgTSYFgOitRyGMYjQotve++zDz5zz0QY3shM/FxT8kTNnP8D44QceLWZnjhvP7N12O3fDjdzN0jMMDIwtexKYJXvwabmRxszAC9GyQZrHwCBxw4EENgYeAloY/247B7blN1jL+QdsjH8IaGHm3XYApGUbxJYbCWzMeG05c4yZWXZbcu7MM2+3WfMYGBtbznjYLC2DT8vxNmbGt9vscvuO526+zfNHTs6cP/ngxzd4tMCBwgE4k7GBGA0MDPJEqhsFo2AUjIIRCAAoElB0H1NiQwAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-8051-2262","institution":"University of Manitoba","correspondingAuthor":true,"prefix":"","firstName":"Michael","middleName":"","lastName":"Morra","suffix":""},{"id":298911951,"identity":"ac666322-30c9-402e-8518-f36268a00eb7","order_by":1,"name":"Michael Morra","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYPACGyhtAEZEgTSYFgOitRyGMYjQotve++zDz5zz0QY3shM/FxT8kTNnP8D44QceLWZnjhvP7N12O3fDjdzN0jMMDIwtexKYJXvwabmRxszAC9GyQZrHwCBxw4EENgYeAloY/247B7blN1jL+QdsjH8IaGHm3XYApGUbxJYbCWzMeG05c4yZWXZbcu7MM2+3WfMYGBtbznjYLC2DT8vxNmbGt9vscvuO526+zfNHTs6cP/ngxzd4tMCBwgE4k7GBGA0MDPJEqhsFo2AUjIIRCAAoElB0H1NiQwAAAABJRU5ErkJggg==","orcid":"","institution":"University of Manitoba","correspondingAuthor":true,"prefix":"","firstName":"Michael","middleName":"","lastName":"Morra","suffix":""},{"id":298911952,"identity":"2a187402-dc4e-4d5c-940e-028cd3eb50d3","order_by":2,"name":"Harliv Dhillon","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Harliv","middleName":"","lastName":"Dhillon","suffix":""},{"id":298911953,"identity":"644acc49-c3bb-41f4-8615-9589f24862ca","order_by":3,"name":"Harliv Dhillon","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Harliv","middleName":"","lastName":"Dhillon","suffix":""},{"id":298911954,"identity":"e66f3b00-b32a-442f-9b03-ad3d103a8180","order_by":4,"name":"Premal Patel","email":"","orcid":"https://orcid.org/0000-0002-2748-6720","institution":"University of Manitoba","correspondingAuthor":false,"prefix":"","firstName":"Premal","middleName":"","lastName":"Patel","suffix":""},{"id":298911955,"identity":"259433d2-c9c7-4a64-9991-9920e68d6408","order_by":5,"name":"Premal Patel","email":"","orcid":"","institution":"University of Manitoba","correspondingAuthor":false,"prefix":"","firstName":"Premal","middleName":"","lastName":"Patel","suffix":""}],"badges":[],"createdAt":"2024-04-29 13:47:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4343298/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4343298/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57690723,"identity":"cb6af482-08d4-4822-ba0c-3ff289acde91","added_by":"auto","created_at":"2024-06-04 11:13:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":290716,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4343298/v1/e3150a26-4aa7-4af1-8e4c-4f7f02acd256.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"Comparison of Canadian online pharmacies with conventional pharmacies for erectile dysfunction drugs. The Cost of Convenience and discretion","fulltext":[{"header":"Introduction","content":"\u003cp\u003eErectile dysfunction (ED) is a very common condition, affecting about 50% of men over the age of 40, with significant detrimental effects on quality of life.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e It is also important for men to seek treatment for ED as it can be linked with cardiovascular disease, diabetes, and future coronary risk.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Despite its ubiquity in the male population, a large proportion of men avoid seeking treatment for various reasons. These include embarrassment, the belief that ED is a normal part of aging and is not a significant medical problem, or the belief that it will resolve on its own.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Treatment of ED ranges from lifestyle modifications, sexual counselling, pharmacological, vacuum device therapy and surgery in select cases.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Once reversible causes of ED are ruled out, pharmacological treatment of ED with oral phosphodiesterase type 5 (PDE-5) inhibitors is the first line treatment of ED.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Importantly, ED medications are not typically covered by insurance in Canada and patients usually have to pay out of pocket after receiving a prescription from their physician and filling the prescription at a conventional pharmacy.\u003c/p\u003e \u003cp\u003eIn the past few years, multiple online pharmacies offering easy access to ED medications have emerged, advertising easy online forms, no conventional doctors visit and discreet delivery to their home. To access these services, patients visit a specific online pharmacy website, create an account, and usually fill out a medical questionnaire that seeks to determine symptoms severity, past medical history, current medications etc. Patients then either select what erectile dysfunction medication (PDE-5 inhibitor) they would like to order including the dose and quantity or have one recommended based on questionnaire answers. Patient medical questionnaires are reviewed by healthcare professionals which may include a physician or nurse practitioner, with some pharmacies including virtual consultations and some including just a review of the completed questionnaire. Once cleared by the healthcare team, medication is delivered to the patients\u0026rsquo; homes in discreet packaging.\u003c/p\u003e \u003cp\u003eWe seek to compare the costs of these online services to conventional pharmacies as well as describe the advertising methods used by these online pharmacies, with the goal of better informing consumers on these medications and how they are acquired. We hypothesized that online pharmacies would come at a higher cost due to the added convenience of these services, including online health questionnaires requiring review by health care practitioners, and costs of shipping.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eFive online pharmacies were found on the first result page of a google search for \u0026ldquo;ED drugs online Canada\u0026rdquo;. The pharmacies chosen were deidentified and labelled as online pharmacy 1\u0026ndash;5. Multiple iterations of this google search were completed and the five pharmacies were felt to be representative of the findings of most online consumers for these products, although multiple other online pharmacies serving Canada do exist. Consumer prices for generic tadalafil 5 mg, tadalafil 20 mg and sildenafil 100 mg were acquired through available website information or by contacting customer service for full pricing information. The prices were expressed as price per tab in Canadian dollars and compared with conventional pharmacies in Winnipeg, Manitoba Canada. The prices of the medications of interest were obtained from four conventional pharmacies by speaking to one of their pharmacists by phone. The conventional pharmacies represent physical pharmacies where patients fill prescriptions from their care providers. Pricing differences were expressed as a percentage. Information regarding the online pharmacy websites\u0026rsquo; discreet delivery, online appointments, and advertisements were obtained from the website main page or advertisements through the authors social media accounts.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003ePrices were compared using the lowest quantity order possible from online pharmacies and conventional pharmacies and are shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e below. Only one online pharmacy offered significant savings with increasing order quantity (13\u0026ndash;16% savings with 36 tabs vs 4 tabs for Tadalafil 20mg and Sildenafil 100mg). Tadalafil 5 mg daily treatment for ED was usually offered in quantities of 28 or 30 tabs and offered by four of the five online pharmacies. The price per tab was \u003cspan\u003e$\u003c/span\u003e4.60, \u003cspan\u003e$\u003c/span\u003e3.57, \u003cspan\u003e$\u003c/span\u003e4.25, and \u003cspan\u003e$\u003c/span\u003e4.81 for online pharmacies 1,2,4 and 5 respectively. The average comparator price per tab from conventional pharmacies was \u003cspan\u003e$\u003c/span\u003e3.88 for a 30-tab order not including a dispensing fee, representing an average premium of 7% for online pharmacies. Tadalafil 20mg as needed was typically offered as 4 tabs for the lowest possible quantity order and was available from all five online pharmacies. The price per tab was \u003cspan\u003e$\u003c/span\u003e15.58, \u003cspan\u003e$\u003c/span\u003e11.00, \u003cspan\u003e$\u003c/span\u003e17.00, \u003cspan\u003e$\u003c/span\u003e15.50, and \u003cspan\u003e$\u003c/span\u003e17.83 from online pharmacies 1\u0026ndash;5 respectively. The comparator price per tab from conventional pharmacies was \u003cspan\u003e$\u003c/span\u003e13.25 for a 4-tab order not including a dispensing fee, representing an average premium of 14% for online pharmacies. Finally, sildenafil 100mg as needed treatment was also offered in 4-tab quantities and offered by all five online pharmacies. The price per tab was \u003cspan\u003e$\u003c/span\u003e11.59, \u003cspan\u003e$\u003c/span\u003e9.00, \u003cspan\u003e$\u003c/span\u003e13.50, \u003cspan\u003e$\u003c/span\u003e11.50, and \u003cspan\u003e$\u003c/span\u003e14.04 from online pharmacies 1\u0026ndash;5 respectively. The comparator price per tab from conventional pharmacies was \u003cspan\u003e$\u003c/span\u003e9.85 for a 4-tab order, again representing an average premium of 17% for online pharmacies. One of the five online pharmacies offered lower prices for tadalafil 20mg and sildenafil 100mg than conventional pharmacy at this order quantity.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of per tab price between online and conventional pharmacies for lowest possible order quantity\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eOnline ED Pharmacy price per tab (CAD\u003cspan\u003e$\u003c/span\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePDE-5 Inhibitor and Dose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAverage Online Pharmacy Cost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAverage Conventional Pharmacy Cost (without dispensing fee)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAverage Conventional Pharmacy Cost (including dispensing fee)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTadalafil 5mg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e4.31\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e4.35\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTadalafil 20 mg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e15.38\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e16.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSildenafil 100 mg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e11.93\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e12.65\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAll conventional pharmacies add on a dispensing fee for each prescription filled, and on average this fee was about \u003cspan\u003e$\u003c/span\u003e14.25 at the selected Winnipeg Pharmacies. At the order quantities included in our study, this added fee brings the cost of these medications to about 3\u0026ndash;4% higher at conventional pharmacies than online pharmacies.\u003c/p\u003e \u003cp\u003eThrough browsing the websites of the five online pharmacies, all five pharmacies indicate that they offer \u0026ldquo;discreet delivery\u0026rdquo;. All five online pharmacies consist of a quick online questionnaire, with review by a health care professional to ensure treatment is appropriate. At least three of these online pharmacies include young men, presumably under 40 years of age in their advertisements for PDE-5 inhibitor medication. Most of the websites also provide information about the prevalence of ED in men based on age range, but there is minimal to no mention of the relationship of ED and cardiovascular disease.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eED is a very prevalent condition in men, with increasing rates due to advancing age, cardiovascular disease, metabolic syndrome and diabetes.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Etiologies range from organic, psychogenic, or multifactorial, and some patients may require investigations to investigate vascular, endocrine, neurological and psychological factors.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Unfortunately, ED remains a taboo subject for many men due to embarrassment, misconceptions regarding the disease process and treatments, and even physician factors such as lack of comfort with discussing ED or time constraints in our health care system.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e This disconnect has resulted in the emergence of numerous legitimate online pharmacies offering PDE-5 inhibitors direct to consumers in Canada, a trend also seen in the United States.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e There are also many illegitimate online sellers that pose a risk to Canadian and global consumers.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e We sought to compare drug prices through these online pharmacies with conventional pharmacies that would usually entail obtaining a prescription from a patient\u0026rsquo;s family doctor or urologist. We also seek to discuss the implications of these online pharmacies on patient care for ED.\u003c/p\u003e \u003cp\u003eFive online pharmacies were selected for analysis, and when all included costs are accounted for, these services were priced comparably with conventional pharmacies. One online pharmacy was able to offer a significantly lower price for all three medications than conventional pharmacies and the other online pharmacies. Online pharmacy services offered very modest savings with increasing order quantity, if offered at all. When a conventional pharmacies\u0026rsquo; dispensing fee was taken into account, the difference in cost per tab between online and conventional pharmacy disappeared at a low order quantity. Therefore, more significant savings can be acquired through higher order quantities at conventional pharmacies because a dispensing fee is a fixed cost, per prescription. Dispensing fees also differ between Canadian provinces, for example dispensing fees are maxed out at \u003cspan\u003e$\u003c/span\u003e13.25 in Ontario, and \u003cspan\u003e$\u003c/span\u003e10.00 in British Columbia.\u003csup\u003e \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e \u003c/sup\u003e \u003c/p\u003e \u003cp\u003eAll five of the online pharmacies advertise ease of use of their online platform, no need for a physical doctor\u0026rsquo;s visit, and discreet delivery. They are providing these additional services and benefits to the consumer, and we hypothesized that this would come at an increased cost to the consumer, which we now know is incorrect. This study also aims to provide the Canadian consumer with the necessary information to make an informed decision about how and where they seek healthcare for ED, and from our findings of competitive pricing, it is reasonable to assume that many Canadian men will utilize these services, especially as these companies directly advertise ED medications through online ads and social media campaigns. From the perspective of the healthcare provider and Urologist, the focus on \u0026ldquo;discreet delivery\u0026rdquo; as well as \u0026ldquo;no conventional doctors visit\u0026rdquo; further perpetuates the stigma surrounding ED. Although these websites do put some effort into normalizing this diagnosis by providing information on ED prevalence, there is minimal information regarding the relationship of ED with cardiovascular disease and diabetes. Thus, these advertising methods and services raise questions regarding the quality-of-care patients are receiving through online means and the potential for inadequately investigating underlying etiologies of ED. In addition, the advertisements of PDE-5 medications for ED by some online pharmacies include young men, presumably under 40 years of age based on appearance. Organic causes of erectile dysfunction do exist in this population, but the vast majority is of a psychogenic nature.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Although PDE-5 inhibitors may be indicated in this population, lifestyle factors and conservative measures are important factors to consider before moving to medical therapy. Furthermore, it is conceivable that these additional factors will be less adequately addressed by health questionnaires and quick online virtual visits by a healthcare provider not known to the patient. This is a possible area of future research to ensure patients are not receiving suboptimal care due to use of online healthcare platforms.\u003c/p\u003e \u003cp\u003eThe increasing prevalence of these online pharmacies serves as a reminder to the healthcare community and urologists specifically that the state of ED care in Canada remains suboptimal, with significant barriers. Whether attributed to the patient factors described above such as embarrassment, physician discomfort with speaking about the diagnosis or long wait times and specialist referral times\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, Urologists, as the specialists of ED, may need to be more involved in helping to remove these barriers.\u003c/p\u003e \u003cp\u003eThis study does have limitations. We did not make any orders from these online pharmacies; therefore, it is unclear if there are additional discounts with multiple orders or if there are hidden costs not seen when setting up an order. We did not actually observe an online medical visit or questionnaire review to comment on the quality of this medical review. We also only used comparator pharmacies in our local area which may not be representative of pharmacies across the country.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOnline pharmacies offering direct to consumer PDE-5 inhibitors are becoming more prevalent and advertise ease of use, discretion, and overall convenience to the consumer at comparable prices. Concerns remain regarding the quality-of-care Canadian men are receiving from direct-to-consumer online pharmacies. It is important for consumers to understand the significance of underlying etiologies to ED and feel comfortable speaking with their care providers regarding the diagnosis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding disclosures:\u003c/strong\u003e none\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest disclosures:\u003c/strong\u003e no conflicts of interest to disclose\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval of studies\u003c/strong\u003e:\u0026nbsp;This project did not require IRB approval as all information is available to the public and obtained through publicly available websites. There were no human participants in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e N/A\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e All authors listed have contributed to this work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMichael Morra: Design and concept, data and pricing acquisition, Data analysis/interpretation, Manuscript drafting and primary author\u003c/p\u003e\n\u003cp\u003eHarliv Dhillon: Responsible for data and pricing acquisition, manuscript editor\u003c/p\u003e\n\u003cp\u003ePremal Patel: Supervisor of work, Design and concept, manuscript editor\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBella AJ, Lee JC, Carrier S, B\u0026eacute;nard F, Brock GB. 2015 CUA Practice guidelines for erectile dysfunction. Can Urol Assoc J. 2015;9(1-2):23-29. doi:10.5489/cuaj.2699\u003c/li\u003e\n \u003cli\u003eGrover SA, Lowensteyn I, Kaouache M, et al. The prevalence of erectile dysfunction in the primary care setting: importance of risk factors for diabetes and vascular disease. Arch Intern Med. 2006;166(2):213-219. doi:10.1001/archinte.166.2.213\u003c/li\u003e\n \u003cli\u003eShabsigh R, Perelman MA, Laumann EO, Lockhart DC. Drivers and barriers to seeking treatment for erectile dysfunction: a comparison of six countries. BJU Int. 2004;94(7):1055-1065. doi:10.1111/j.1464-410X.2004.05104.x\u003c/li\u003e\n \u003cli\u003eJohannes CB, Araujo AB, Feldman HA, Derby CA, Kleinman KP, McKinlay JB. Incidence of erectile dysfunction in men 40 to 69 years old: longitudinal results from the Massachusetts male aging study. J Urol. 2000;163(2):460-463.\u003c/li\u003e\n \u003cli\u003eAl-Shaiji TF. Breaking the Ice of Erectile Dysfunction Taboo: A Focus on Clinician-Patient Communication. J Patient Exp. 2022;9:23743735221077512. Published 2022 Jan 31. doi:10.1177/23743735221077512\u003c/li\u003e\n \u003cli\u003eBrink SM, Iarajuli T, Shin D. Characteristics of direct-to-consumer platforms offering erectile dysfunction treatment. \u003cem\u003eSex Med\u003c/em\u003e. 2023;11(4):1-4. doi:10.1093/sexmed/qfad038\u003c/li\u003e\n \u003cli\u003eVercnocke J, Zhong A, Liaw A, Ginsburg K, The High Price of Anonymity: Comparison of Cost of Direct-to-Consumer Mail Order Pharmacies Compared with an Online Wholesale Pharmacy, The Journal of Urology\u0026reg; (2023), doi: 10.1097/JU.0000000000003720.\u003c/li\u003e\n \u003cli\u003eGovernment of Canada. Buying drugs over the Internet. Accessed Feb 3, 2024. https://www.canada.ca/en/health-canada/services/buying-drugs-over-internet.html\u003c/li\u003e\n \u003cli\u003eGovernment of Canada. Dispensing Fee Policies in Public Drug Plans, 2021/22. Accessed April 7, 2024. https://www.canada.ca/en/patented-medicine-prices-review/services/npduis/analytical-studies/supporting-information/dispensing-fee-policies.html\u003c/li\u003e\n \u003cli\u003eKaradeniz T, Topsakal M, Aydogmus A, Basak D. Erectile dysfunction under age 40: etiology and role of contributing factors. ScientificWorldJournal. 2004;4 Suppl 1:171-174. Published 2004 Jun 7. doi:10.1100/tsw.2004.64\u003c/li\u003e\n \u003cli\u003eLiddy C, Moroz I, Affleck E, et al. How long are Canadians waiting to access specialty care? Retrospective study from a primary care perspective. Can Fam Physician. 2020;66(6):434-444.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4343298/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4343298/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eErectile dysfunction (ED) is a common condition affecting about 50% of men over the age of 40. ED can be related to cardiovascular disease and diabetes requiring further evaluation and workup, unfortunately many men with ED commonly avoid seeking treatment for reasons such as embarrassment. In the past few years, multiple online pharmacies offering easy access to ED medications have emerged, advertising easy online forms, no conventional doctors visit and discreet delivery to their home. We sought to compare the prices of five popular online ED pharmacies with conventional pharmacies, hypothesizing that online pharmacies would come at increased cost to patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe five online pharmacies were found on the first result page of a google search for “ED drugs online Canada”. Consumer prices for Tadalafil and Sildenafil were acquired through available website information or by contacting customer service. The prices were expressed as price per pill and compared with four conventional pharmacies in Winnipeg, Manitoba. Pricing differences were expressed as a percentage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen comparing the price per pill of the smallest order of tabs that can be purchased, the price of ED medications from online pharmacies was on average 15% higher without including the dispensing fee of the conventional pharmacy comparators. Once taking dispensing fees into account, the cost ED medications from conventional pharmacies was about 3-4% higher compared to online conventional pharmacies. Dispensing fees ranged from $12.99 to $16.00 per order. Savings could be seen with conventional pharmacies when order quantities increased as the dispensing fee is fixed per order.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnline pharmacies in Canada that boast convenience and discretion to customers offer similar pricing to conventional pharmacies. Despite their competitive pricing, their focus on discretion further perpetuates common stereotypes of ED that may prevent men from seeking help from their care providers.\u003c/p\u003e","manuscriptTitle":"Comparison of Canadian online pharmacies with conventional pharmacies for erectile dysfunction drugs. The Cost of Convenience and discretion","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-13 15:55:25","doi":"10.21203/rs.3.rs-4343298/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"35a54060-a506-4528-bfbc-f122c8c3ce99","owner":[],"postedDate":"May 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":31534667,"name":"Health sciences/Health care/Therapeutics/Drug therapy"},{"id":31534668,"name":"Health sciences/Health care/Therapeutics/Drug therapy"},{"id":31534669,"name":"Health sciences/Diseases/Reproductive disorders/Sexual dysfunction"},{"id":31534670,"name":"Health sciences/Diseases/Reproductive disorders/Sexual dysfunction"}],"tags":[],"updatedAt":"2024-06-04T11:05:43+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-13 15:55:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4343298","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4343298","identity":"rs-4343298","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}