Erectile Dysfunction is, for the most part, going untreated!
A recent evaluation done by NorthShore University Health System Evanston, Illinois based insurance claims has uncovered a starling fact – 75% of men diagnosed with erectile dysfunction do not get treated.
To be classified as “treated” in this study a patient needed to have filled a prescription for:
1) a phosphodiestarase type-5 inhibitor or PDE-5 (the now too-familiar Viagra, Cialis or Levitra of TV ads)
2) treatments with injections or urethral pellets that involve prostaglandins
3) androgen replacement therapy (testosterone)
Of the 25% minority of the 6.23 million patients involved in the study, 75% got PDE-5 inhibitors. Since other research on these medicines has shown them to be effective for about 60% of those who try them, our calculations indicate that for all the diagnoses of ED in America about 25% x 75% x 60% or ~11% of patients are being effectively treated with PDE-5 inhibitors.
The next most common “treatment for ED (at 31%) was testosterone replacement therapy (31% and 75% add up to more than 100% it is clear that many men used both modalities). We put treatment in quotes here because testosterone may be a fine medicine for men with documented “low-T” levels, but it is not a major factor in treating ED unless the patient experiences loss of libido due to low hormone levels. Other research has shown that well under 10% of men can expect improvement in their ED via hormone replacement.
The math here is grim. 25% x 31% x ~10% equals under 1% of ED patients who are being helped by the use of hormones.
This leaves prostaglandins, described as “fewer than 2%” of patients in the study. We note that only a tiny minority of patients of patients use the “muse” system of urethral pellets. Their efficacy is spotty, probably less than half of patients see a benefit.
This type of therapy involves either a prostaglandin alone (Caverject or Edex) or far more commonly “tri-mix”. These are any of various combinations of alprostadil (the prostglandin) plus vasodilators phentolamine and papaverine. Tri-mix has proven effective for over 80% of patients.
If the Evanston study is to be believed of the 6+ million patients diagnosed with ED just 25% x ~2% x ~80% of patients have been helped by the use of injections. This works out to under 0.4% of sufferers.
The absolute numbers are staggering. Of 6.23 million men diagnosed with ED only about 1.6 million get any treatment! We estimate that PDE-5 inhibitors help 75% x 60% or about 700,000 of these men.
Testosterone replacement, though considered a treatment for ED in the study can be expected to improve the lot of just 31% x ~10% of these 1.6 million. About 50,000 men.
Bringing up the rear is prostaglandin treatment. Since no more than 2% of ED patients use it is it not having a major impact despite it being effective 80+% of the time. We estimate, using this information, that only about 25,000 men have benefited from its use.
Clearly, a lot of work needs to be done to get men with erectile dysfunction the help they need. This study sheds little light on why so few men are getting medications appropriate to their diagnosis, but there is a major problem here.
We think of PDE-5 inhibitor pills (viagra etc) as the logical first step for patients with ED. They are helpful for a majority of patients who take them. Many, many more American men deserve a trial prescription of one or more of these pills.
We do not understand why testosterone replacement is considered a major player in ED treatment. It should not be since only a tiny minority of patients have “low-T” playing any role in their problem, and testosterone does not affect the normal physiology of erections in any major way.
Finally, for patients who have used PDE-5 inhibitors and failed there is clearly a role to by played by injection therapies. Of the 4.6 million men who have tried no treatments at all the vast majority will be eligible to try PDE-5 inhibitors. But since about 40% of these men will fail this treatment for one reason or another it seems clear that something like two million ED patients need to be considered for injection therapy as a logical next step.
ED has proven to be a tough enough topic for doctor and patient to discuss when needles are not a part of the conversation, so this is going to be a tough row to how, but the potential to help people is vast and we will have more to say about this in future posts.