Implications of Our New Tools to Treat
Erectile Dysfunction

Irl B. Hirsch, MD, Editor

The 79-year-old widower greeted me enthusiastically as I entered the room. This man with type 2 diabetes, proliferative retinopathy, nephropathy, advanced vascular disease, and a history of diabetic amyotrophy seemed in better spirits than usual.

With his ever-present tremor, he handed me a piece of paper. "I want this," he exclaimed. The paper bore one word: "VIAGRA."

Puzzled, I commented, "I didn’t know you had a girlfriend." "I don’t," he replied, "but it doesn’t matter." Now I was even more confused. "Don’t worry about me," he assured me. "I can take care of myself."

"Do you know how much these pills cost?" I asked him. Looking me straight in the eye, he said without hesitation, "They are cheaper than a girlfriend."

As I write this, I note that every local and national newscast within the previous 3 weeks has had some story about sildenafil (Viagra). Record sales have impressed Wall Street analysts. One could argue that this is the most successful drug launch in the history of the American pharmaceutical industry. U.S. pharmacists are filling more than 100,000 prescriptions each week.¹

What percentage of Americans knew what Viagra was 6 months ago? Who doesn’t know what it is today? Indeed, based on earlier surveys, I suspect that more men with diabetes know what Viagra is than know what their HbA_1c is.² This is arguably the most important product promoting sexual behavior since the introduction of the birth control pill more than three decades ago.

Why all the attention? This is really not a complicated question.

The treatment of erectile dysfunction (ED) has been one of our most frustrating problems. Not too long ago, our treatments were limited to psychological counseling, avoidance of certain drugs, and penile prostheses. The latter were frequently associated with infectious complications and mechanical failures, and the surgery was expensive. Eventually, vacuum devices and penile injections became available. More recently, transurethral alprostadil was introduced. Except for the occasional patient with diabetes who is hypogonadal and can be treated with testosterone replacement therapy, none of the available options was ideal.

As Dr. Vinik and Dr. Richardson point out in their outstanding review on p. 108, perhaps just as important is the fact that ED in men "equates with a limp ego and a loss of gender identity." Understanding this and the complicated medical regimens that most of our patients require for their diabetes and its associated problems, ingesting a pill before sexual activity seems almost too good to be true.

The introduction of sildenafil has other implications. Until now, health care providers often neglected to take a sexual history. There are numerous barriers to this type of discussion, on the part of both physicians³ and patients. Time constraints on office visits compound the problem. Spending adequate time on what might be considered more "serious" problems means having little time in which to discuss ED. The advent of sildenafil, besides providing us with such an effective and easy treatment for ED, has introduced the topic into our media like never before. As a result, both men and women may feel less embarrassed and awkward in discussing this very common problem.

There is another important implication. Whereas previous treatments of ED usually required specialist care by urologists, ED has suddenly become a disease to be treated by primary care providers, or any other physicians willing to take pen to prescription pad. A former roommate of mine is now prescribing sildenafil. He is an otolaryngologist in North Miami. There are also stories of pediatricians, ophthalmologists, and emergency room physicians prescribing the drug. The obvious question is, how is this going to change referral patterns to our urology colleagues?

The cost of treatment for ED is a related topic. At approximately $10 per pill, and with no referral necessary, the overall costs per patient should be less. Of course, after hearing some of the economic predictions for sildenafil, one could argue that more men will seek treatment than before, so the absolute cost may be greater.

Another concern is that the treatment of ED will become so convenient that health care providers will miss other important medical problems. Ethanol abusers and heavy marijuana smokers often present with ED. Is it possible that a diagnosis of substance abuse will be missed because it is easier to write a prescription than to investigate? What about someone presenting with gonadal failure from a large pituitary tumor? Hypogonadism occurs frequently enough and with potentially serious but treatable etiologies that I believe that measuring a serum testosterone before initiating any treatment⁴ should still be part of the assessment for any man with ED.

Lost in the media frenzy about sildenafil is an equally important problem: sexual dysfunction in women and, in particular, in women with diabetes. Women with type 1 and type 2 diabetes report fatigue, vaginitis, decreased sexual desire, decreased vaginal lubrication, and an increased time to reach orgasm.⁵ Clearly more research on and effective treatments for sexual dysfunction in women are needed.

For now, we need to make sure our patients do not misuse this new drug. While we all strive to improve the lives of our patients, we need to make sure we don’t abuse sildenafil by prescribing it inappropriately. This would include prescribing it for patients who don’t have ED but are not satisfied with their erections. Whereas some are concerned this will become the recreational drug of the ’90s, it is also likely that inappropriate use (in conjunction with nitrates) or overuse (multiple times in one day) will eventually result in adverse effects.

In 1923, Elliot Joslin noted: "Insulin is a remedy primarily for the wise and not for the foolish, be they patients or doctors." The same can be said for sildenafil.

References

¹Insurers’ refusal to pay Rx costs exposes coverage flaws. USA Today, May 1, 1998, p. 12A.

²Marrero DG: Current effectiveness of diabetes health care in the U.S.: how far from the ideal? Diabetes Revs 2:292-309, 1994.

³Temple-Smith M, Hammond J, Pyett P, Presswell N: Barriers to sexual history in general practice. Aust Fam Phys 25 (Suppl. 2):S71-74, 1996.

⁴Carrier S, Zvara P, Lue TF: Erectile dysfunction. Endocrinol Metab Clin North Am 23:773-82, 1994.