, Volume 17, Issue 1, pp 77–107 | Cite as

Economic Cost of Male Erectile Dysfunction Using a Decision Analytic Model

For a Hypothetical Managed-Care Plan of 100 000 Members
Original Research Article


Objective: This paper examined the economic cost of male erectile dysfunction (ED) for a hypothetical managed-care (MC) model.

Design and Setting: A prevalence-based cost-of-illness approach was used to estimate the direct medical cost for ED treatment. A treatment plan algorithm was developed from a MC perspective to model the initial treatment selection of various patient groups [vacuum erection device, intracavernosal injection (ICI) therapy, transurethral alprostadil suppository, sildenafil, testosterone replacement therapy, penile prosthesis] and their therapy outcomes during a 3-year period. Overall cost was based on 1998 US dollars. Total direct medical cost of ED considered in this model included the cost of initial physician consultation and evaluation, the cost incurred by patients from various treatment groups (pharmacological and surgical options), as well as the cost related to patients’ follow-up for treatment within the 3-year period. Consideration for therapy switches made by patients who failed initial therapy was included as part of the clinical assumptions for this model. Treatment response and expected outcomes (dropouts) were considered for the various treatment options.

Participants: A total of 100 000 enrolled members were included in the study.

Main outcome measures and results: The total cost of ED was $US3 204 792 for the 3-year period in the hypothetical MC plan. The treatment portion accounted for approximately 80% of the total cost while the cost of medical services and diagnostic tests were minimal in comparison. The 3 year total cost of nonsurgical treatment was $US2 473 045. Costs associated with each treatment alternative were $US81 866 (testosterone transdermal patch), $US51 930 (vacuum erection device), $US384 624 (ICI therapy), $US226 483 (transurethral alprostadil suppository) and $US1 728 142 (sildenafil citrate). Results from the model showed a noticeable trend of decreasing cost patterns over time and reflected the attrition observed for many of the standard medical therapies for ED.

Conclusions: Sildenafil and the vacuum erection device should be considered as first-line management strategies for ED whereas ICI therapy, transurethral alprostadil suppository and penile prosthesis implant should be reserved for second- or third-line therapy. Because costs associated with switches related to successive treatment failures can be high, treatment considerations should, therefore, focus on achieving long term patient satisfaction. The patient’s preferred treatment choice, using goal-directed therapy during the initial consultation and evaluation visit, should be used.


Erectile Dysfunction Alprostadil Penile Prosthesis Total Direct Medical Cost Consultation Visit 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    National Institute of Health. Impotence. Natl Inst Health Consens Dev Conf Consens Statement 1992; 10 (4): 1–33Google Scholar
  2. 2.
    Benet AE, Melman A. The epidemiology of erectile dysfunction. Urol Clin North Am 1995; 22 (4): 699–709PubMedGoogle Scholar
  3. 3.
    Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States. JAMA 1999; 281: 537–44PubMedCrossRefGoogle Scholar
  4. 4.
    National Center for Health Statistics. In: Nelson C, McLemore T, editors. The National Ambulatory Medical Care Survey: United States 1975–81 and 1985 trends. Vital and Health Statistics: series 13, no.93. Washington, DC.: Government Printing Office, 1988. DHHS publication no.: (PHS) 88–1754Google Scholar
  5. 5.
    National Center for Health Statistics. National Hospital Discharge Survey, 1985. Bethesda (MD): Department of Health and Human Services, 1989. DHHS Publication no.: 87–1751Google Scholar
  6. 6.
    Donatucci CF, Lue TF. Erectile dysfunction in men under 40: etiology and treatment choice. Int J Impot Res 1993; 5: 97–103PubMedGoogle Scholar
  7. 7.
    Krane RJ, Goldstein I, Saenz De Tejada I. Impotence. N Engl J Med 1989; 321 (24): 1648–59PubMedCrossRefGoogle Scholar
  8. 8.
    Zonszein J. Diagnosis and management of endocrine disorders of erectile dysfunction. Urol Clin North Am 1995; 22 (4): 789–802PubMedGoogle Scholar
  9. 9.
    Wein AJ, Van Arsdalen KN. Drug-induced male sexual dysfunction. Urol Clin North Am 1988; 15 (1): 23–31PubMedGoogle Scholar
  10. 10.
    Smith AD. Psychologic factors in the multidisciplinary evaluation and treatment of erectile dysfunction. Urol Clin North Am 1988; 15 (1): 41–51PubMedGoogle Scholar
  11. 11.
    Kuritzky L. Management of impotence in primary care. Compr Ther 1998; 24 (3): 137–46PubMedGoogle Scholar
  12. 12.
    Mobley DF, Baum N. When patients request the impotence pill. Tips for office evaluation and treatment. Postgrad Med 1998; 104 (2): 55–66PubMedCrossRefGoogle Scholar
  13. 13.
    Tiefer L, Schuetz-Mueller D. Psychological issues in diagnosis and treatment of erectile disorders. Urol Clin North Am 1995; 22 (4): 767–73PubMedGoogle Scholar
  14. 14.
    Jackson SE, Lue TF. Erectile dysfunction: therapy health outcomes. Urology 1998; 51 (6): 874–82PubMedCrossRefGoogle Scholar
  15. 15.
    Montague DK, Barada JH, Belker AM, et al. Clinical guidelines panel on erectile dysfunction: summary report on the treatment of organic erectile dysfunction. J Urol 1996; 156: 2007–11PubMedCrossRefGoogle Scholar
  16. 16.
    Turner LA, Althof SE, Levine SB, et al. Treating erectile dysfunction with external vacuum devices: impact upon sexual, psychological and marital functioning. J Urol 1990; 144: 79–82PubMedGoogle Scholar
  17. 17.
    Vrijhof HJEJ, Delaere KPJ. Vacuum constriction devices in erectile dysfunction: acceptance and effectiveness in patients with impotence of organic ormixed aetiology. Br J Urol 1994; 74: 102–5PubMedCrossRefGoogle Scholar
  18. 18.
    Willke RJ, Glick HA, McCarron TJ, et al. Quality of life effects of alprostadil therapy for erectile dysfunction. J Urol 1997; 157: 2124–8PubMedCrossRefGoogle Scholar
  19. 19.
    Armstrong DKB, Convery AG, Dinsmore WW. Reasons for patient drop-out from an intracavernous auto-injection programme for erectile dysfunction. Br J Urol 1994; 74: 99–101PubMedCrossRefGoogle Scholar
  20. 20.
    Whale RK, Merrill DC. Patient satisfaction with Mentor inflatable penile prosthesis. Urology 1991; 37 (6): 531–9CrossRefGoogle Scholar
  21. 21.
    Pedersen B, Tiefer L, Ruiz M, et al. Evaluation of patients and partners 1 to 4 years after penile prosthesis surgery. J Urol 1988; 139: 956–8PubMedGoogle Scholar
  22. 22.
    Lewis RW. Long term results of penile prosthetic implants. Urol Clin North Am 1995; 22 (4): 847–56PubMedGoogle Scholar
  23. 23.
    Fishman IJ. Complicated implantation of inflatable penile prosthesis. Urol Clin North Am 1987; 14 (1): 217–39PubMedGoogle Scholar
  24. 24.
    Kabalin JN, Kessler R. Infectious complications of penile prosthesis surgery. J Urol 1988; 139: 953–5PubMedGoogle Scholar
  25. 25.
    Thomalla JV, Thompson ST, Rowland RG, et al. Infectious complications of penile prosthetic implants. J Urol 1987; 138: 65–7PubMedGoogle Scholar
  26. 26.
    Sharaby JS, Benet AE, Melman A. Penile revascularization. Urol Clin North Am 1995; 22 (4): 821–32PubMedGoogle Scholar
  27. 27.
    Wespes E, Schulman C. Venous impotence: pathophysiology, diagnosis and treatment. J Urol 1993; 149: 1238–45PubMedGoogle Scholar
  28. 28.
    Bennett AH. Venous arterialization for erectile impotence. Urol Clin North Am 1988; 15 (1): 111–3PubMedGoogle Scholar
  29. 29.
    Lewis RW. Venous surgery for impotence. Urol Clin North Am 1988; 15 (1): 115–21PubMedGoogle Scholar
  30. 30.
    Jarow JP, DeFranzo AJ. Long term results of arterial bypass surgery for impotence secondary to segmental vascular disease. J Urol 1996; 156: 982–5PubMedCrossRefGoogle Scholar
  31. 31.
    Freedman AL, Neto FC, Mehringer CM, et al. Long-term results of penile vein ligation for impotence from venous leakage. J Urol 1993; 149: 1301–3PubMedGoogle Scholar
  32. 32.
    IMS America. Viagra challenges drug coverage policy [online]. Available from: URL: [Accessed 1998 Nov 23]
  33. 33.
    Drummond M. Cost-of-illness studies: a major headache? Pharmacoeconomics 1992; 2 (1): 1–4PubMedCrossRefGoogle Scholar
  34. 34.
    Johannesson M. Economic evaluation of drugs and its potential uses in policy making. Pharmacoeconomics 1995; 8 (3): 190–8PubMedCrossRefGoogle Scholar
  35. 35.
    Hodgson TA. Costs-of-illness in cost-effectiveness analysis: a review of the methodology. Pharmacoeconomics 1994; 6 (6): 536–52PubMedCrossRefGoogle Scholar
  36. 36.
    Scitovsky, AA. Estimating the direct costs of illness. Milbank Mem Fund Q 1982; 60 (3): 463–91CrossRefGoogle Scholar
  37. 37.
    Feldman HA, Goldstein I, Hatzichristou DG, et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts male aging study. J Urol 1994; 151: 54–61PubMedGoogle Scholar
  38. 38.
    Kinsey AC, Pomeroy W, Martin CE. Sexual behavior in the human male. Philadelphia (PA): W.B. Saunders, 1948: 218–62Google Scholar
  39. 39.
    Day JC. Population projections of the United States by age, sex, race, and hispanic origin: 1995 to 2050. U. S. Bureau of the Census: Current Population Reports, P25–1130, U.S. Washington, DC: Government Printing Office, 1996Google Scholar
  40. 40.
    Managed care. In: Cherner LL, editor. A complete guide for the healthcare professional-facts, figures, analysis. The universal healthcare almanac 1998. Pheonix (AR): R-C Publications; 1999: 98–3Google Scholar
  41. 41.
    Lue TF. Impotence: a patient’s goal-directed approach to treatment. World J Urol 1990; 8: 67–74CrossRefGoogle Scholar
  42. 42.
    Lue TF. Erectile dysfunction: problems and challenges [editorial]. J Urol 1993; 149: 1256–7PubMedGoogle Scholar
  43. 43.
    Long Jr RL, Sherman LS, Lombardi TJ. A goal-oriented, cost-effective approach to the diagnosis and treatment of male erectile dysfunction. Kentucky Med Assoc J 1995; 93: 500–8Google Scholar
  44. 44.
    Burnett AL. Erectile dysfunction: a practical approach for primary care. Geriatrics 1998; 53 (2): 34–48PubMedGoogle Scholar
  45. 45.
    Knispel HH, Huland H. Influence of cause on choice of therapy in 174 patients with erectile dysfunction. J Urol 1992; 147: 1274–6PubMedGoogle Scholar
  46. 46.
    Hanash KA. Comparative results of goal oriented therapy for erectile dysfunction. J Urol 1997; 157: 2135–8PubMedCrossRefGoogle Scholar
  47. 47.
    Jarow JP, Nana-Sinkam P, Sabbagh M, et al. Outcome analysis of goal-directed therapy for impotence. J Urol 1996; 155: 1609–12PubMedCrossRefGoogle Scholar
  48. 48.
    Baum N, Rhodes D. A practical approach to the evaluation and treatment of erectile dysfunction: a private practitioner’s viewpoint. Urol Clin North Am 1995; 22 (4): 865–77PubMedGoogle Scholar
  49. 49.
    Buvat J, Lemaire A. Endocrine screening in 1,022 men with erectile dysfunction: clinical significance and cost-effective strategy. J Urol 1997; 158: 1764–7PubMedCrossRefGoogle Scholar
  50. 50.
    Levine LA, Lenting EL. Use of nocturnal penile tumescence and rigidity in the evaluation of male erectile dysfunction. Urol Clin North Am 1995; 22 (4): 775–88PubMedGoogle Scholar
  51. 51.
    Lottman PEM, Hendriks JCM, Vruggink PA, et al. The impact of marital satisfaction and pyschological counseling on the outcome of ICI-treatment in men with ED. Int J Impotence Res 1998; 10: 83–7CrossRefGoogle Scholar
  52. 52.
    Morales A, Johnston B, Heaton JPW, et al. Testosterone supplementation for hypogondal impotence: assessment of biochemical measures and therapeutic outcomes. J Urol 1997; 157: 849–54PubMedCrossRefGoogle Scholar
  53. 53.
    Govier FE, McClure RD, Kramer-Levien D. Endocrine screening for sexual dysfunction using free testosterone determinations. J Urol 1996; 156: 405–8PubMedCrossRefGoogle Scholar
  54. 54.
    Jr Jordan WP, Atkinson LE, Lai C. Comparison of the skin irritation potential of two testosterone transdermal systems: an investigational system and a marketed product. Clin Ther 1998; 20 (1): 80–7PubMedCrossRefGoogle Scholar
  55. 55.
    McClellan KJ, Goa KL. Transdermal testosterone. Drugs 1998; 55 (2): 253–8PubMedCrossRefGoogle Scholar
  56. 56.
    Arver S, Dobs AS, Meikle AW, et al. Improvement of sexual function in testosterone deficient men treated for 1 year with a permeation enhanced testosterone transdermal system. J Urol 1996; 15 (5): 1604–8Google Scholar
  57. 57.
    Arver S, Dobs AS, Meikle AW, et al. Long-term efficacy and safety of a permeation-enhanced testosterone transdermal system in hypogonadal men. Clin Endocrinol 1997; 47 (6): 727–37CrossRefGoogle Scholar
  58. 58.
    Mentor urology products surgical price list. Santa Barbara (CA): Mentor Corporation, 1998Google Scholar
  59. 59.
    Fallon B, Intracavernous injection therapy formale erectile dysfunction. Urol Clin North Am 1995; 22 (4): 833–45PubMedGoogle Scholar
  60. 59.
    Fallon B, Intracavernous injection therapy formale erectile dysfunction. Urol Clin North Am 1995; 22 (4): 833–45PubMedGoogle Scholar
  61. 61.
    Engel JD, McVary KT. Transurethral alprostadil as therapy for patients who withdrew from or failed prior intracavernous injection therapy. Urology 1998; 51: 687–92PubMedCrossRefGoogle Scholar
  62. 62.
    Padma-Nathan H, Hellstrom WJG, Kaiser FE, et al. Treatment of men with erectile dysfunction with transurethral alprostadil. N Engl J Med 1997; 336: 1–7PubMedCrossRefGoogle Scholar
  63. 63.
    Goldstein I, Lue TF, Padma-Nathan H, et al. Oral sildenafil in the treatment of erectile dysfunction. N Engl J Med 1998; 338: 1397–404PubMedCrossRefGoogle Scholar
  64. 64.
    Porst H. The rationale for prostaglandin E1 in erectile failure: a survey of worldwide experience. J Urol 1996; 155: 802–15PubMedCrossRefGoogle Scholar
  65. 65.
    Medical Economics. 1998 Physician’s Desk Reference: product information for testoderm TTS. Oradell (NJ): Medical Economics, 1998Google Scholar
  66. 66.
    Wilson DE, Kaidbey K, Boike SC, et al. Use of topical corticosteroid pretreatment to reduce the incidence and severity of skin reactions associated with testosterone transdermal therapy. Clin Ther 1998; 20 (2): 299–306PubMedCrossRefGoogle Scholar
  67. 67.
    Cookson MS, Nadig PW. Long-term results with the vacuum constriction device. J Urol 1993; 149: 290–4PubMedGoogle Scholar
  68. 68.
    Lundberg L, Olsson J, Kihl B. Long term experience of self-injection therapy with prostaglandin E1 for erectile dysfunction. Scand J Urol Nephrol 1996; 30: 395–7PubMedCrossRefGoogle Scholar
  69. 69.
    Virag R, Shoukry K, Floresco J, et al. Intracavernous self-injection of vasoactive drugs in the treatment of impotence: 8 years experience with 615 cases. J Urol 1991; 145: 287–93PubMedGoogle Scholar
  70. 70.
    Sundaram CP, Thomas W, Pryor LE, et al. Long term follow-up of patients receiving injection therapy for erectile dysfunction. Urology 1997; 49: 932–5PubMedCrossRefGoogle Scholar
  71. 71.
    Williams G, Abbou CC, Amar ET, et al. Efficacy and safety of transurethral alprostadil therapy in men with erectile dysfunction. Br J Urol 1998; 81 (6): 889–94PubMedCrossRefGoogle Scholar
  72. 72.
    Goldstein I, Newman L, Baum N, et al. Safety and efficacy outcome of Mentor Alpha-1 inflatable penile prosthesis implantation for impotence treatment. J Urol 1997; 157: 833–9PubMedCrossRefGoogle Scholar
  73. 73.
    Weinstein MC. Challenges for cost-effectiveness research. Med Decis Making 1986; 6 (4): 194–8PubMedCrossRefGoogle Scholar
  74. 74.
    Derry FA, Dinsmore WW, Fraser M, et al. Efficacy and safety of oral sildenafil (Viagra) in men with erectile dysfunction caused by spinal cord injury. Neurology 1998; 51 (6): 1629–33PubMedCrossRefGoogle Scholar
  75. 75.
    Zippe CD, Kedia AW, Kedia K, et al. Treatment of erectile dysfunction after radical prostatectomy with sildenafil citrate (Viagra). Urology 1998; 52 (6): 963–6PubMedCrossRefGoogle Scholar
  76. 76.
    Price DE, Gingell JC, Gepi-Attee S, et al. Sildenafil: study of a novel oral treatment for erectile dysfunction in diabetic men. Diabet Med 1998; 15 (10): 821–5PubMedCrossRefGoogle Scholar
  77. 77.
    Rendell MS, Rajfer J, Wicker PA, et al. Sildenafil for treatment of erectile dysfunction in men with diabetes: a randomized controlled trial [abstract]. JAMA 1999; 281: 421–6PubMedCrossRefGoogle Scholar
  78. 78.
    Competition mounts but ’Viagra’ stays on top. Inpharma 1998; 1149: 11–2Google Scholar
  79. 79.
    Pfizer. Product package insert for sildenafil citrate (Viagra). New York: Pfizer, 1998Google Scholar
  80. 80.
    FDA. Postmarketing safety of sildenafil citrate (Viagra). Available from: URL: [Accessed 1999 Feb 22]
  81. 81.
    IMS America. IMS Health forecasts Viagra sales to reach $1 billion in first year. Available from: URL: [Accessed 1998 Nov 22]
  82. 82.
    Levy RA. Prescription cost sharing: economic and health impacts, and implications for health policy. Pharmacoeconomics 1992; 2 (3): 219–37PubMedCrossRefGoogle Scholar
  83. 83.
    Burstall ML. Copayments for medicines: how much should patients pay? [editorial]. Pharmacoeconomics 1994; 6 (3): 187–92PubMedCrossRefGoogle Scholar

Copyright information

© Adis International Limited 2000

Authors and Affiliations

  1. 1.Health Outcomes Research Design Consultants LLCDoverUSA

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