Erectile Dysfunction

Affects approximately 40% of males age 40-49 years and 70% of males and 70-79 years.

Initial evaluation should distinguish between vasculogenic erectile dysfunction and erectile dysfunction of other etiologies.

Many patients with erectile dysfunction have increased risk for coronary artery disease, hypertension, hyperlipidemia, depression, diabetes and increased body mass index.

ED symptoms often coexist with subclinical, otherwise silent cardiovascular disease and usually antecedent cardiovascular symptoms.

Endothelial dysfunction from disturbances of smooth muscle contraction may explain the association between hypertension and male ED.

Endothelial dysfunction causes insufficient relaxation of the penile arteries.

Most cases thought to be multifactorial.

Psychogenic causes can be present but most cases are organic in nature.

Coronary calcium analysis is good for evaluating cardiovascular risk in patients with ED

Organic causes: hypertension, diabetes, dyslipidemia, chronic renal insufficiency, smoking, alcoholism, chronic marijuana use, chronic narcotic use, Peyronie’s disease, trauma, advanced age, spinal cord injury, chronic neurological disease, multiple endocrine disorders, vascular insufficiency, hormonal derangement, hemodialysis, more than 300 medications.

ED in men with diabetes reported to be present in as many as 71% of patients and commonly presents within 10 years of diabetes diagnosis.

Men with diabetes have a significant greater prevalence of ED, and the onset generally occurs an early age compared with men in the general population.

Erectile dysfunction is positively correlated with greater duration and severity of diabetes and poor diabetic control.

Important associations with depression and benign prostatic hypertrophy.

In a study of 132 men undergoing coronary angiograms 45% had a history of erectile dysfunction preceding the diagnosis of coronary artery disease in 58% of the men.

The risk of myocardial infarction in 13,000 men with erectile dysfunction was double that of a similar sized group without erectile dysfunction at one year follow-up.

A screening study revealed undiagnosed hypertension and diabetes in a third of 125 affected men.

Its presence in otherwise asymptomatic men should prompt the investigation for the presence of coronary artery disease.

An independent marker of cardiovascular disease risk.

The prognostic value of ED for CV events is greater in younger men.

Frequently precedes coronary artery disease, peripheral artery disease, and stroke, and symptoms appear 2-5 years before the onset of cardiovascular symptoms.

The more the severity of ED the greater the likelihood of atherosclerotic burden, extensive coronary artery disease, peripheral arterial disease and major cardiovascular events

In men with vascular induced erectile dysfunction, cardiovascular risk stratification should utilize the Framingham Risk Score:patients with low risk should be managed with risk factor control, men with intermediate risk should undergo noninvasive evaluation for atherosclerosis, and men with high risk could be referred for cardiac evaluation (MinorM et al).

The degree of erectile dysfunction correlates with the severity of cardiovascular disease and may be a sentinel symptom of occult cardiovascular disease.

Incidence of atrial fibrillation is higher in patients with erectile dysfunction.

Endothelial dysfunction is part of the pathogenesis of erectile dysfunction.

Common pathophysiologic abnormalities for erectile dysfunction and cardiovascular disease include endothelial dysfunction, inflammation, and low testosterone levels

Exercise and weight loss in obese but otherwise healthy patients may reverse erectile dysfunction.

Psychological problems include impaired affect, loneliness, marital discord and depression.

Impairs one’s sense of identity and how he relates to his significant other.

Shares similar modifiable with coronary artery disease, and meta-analysis of studies have shown improvements in sexual function with lifestyle modification and pharmocotherapy targeting cardiovascular risk factors (Gupta BP et al).

Treatment depends on the cause of ED.

Management of erectile dysfunction (ED) involves a multifaceted approach that includes lifestyle modifications, addressing underlying comorbidities, and integrating psycho-sexological therapies with medical treatments.

Lifestyle modifications include changes in diet and increased physical activity to improve overall health and erectile function, particularly in patients with ED having comorbidities known to negatively affect erectile function.

Physical activity has been shown to benefit erectile function, comparable with established treatment options such as testosterone therapy and phosphodiesterase type 5 inhibitors.

Physical activityassociated with psychological and metabolic adaptations that are compatible with the adaptations required for the treatment of ED.

Lifestyle change, combined with informed prescribing of pharmacotherapies used to mitigate cardiovascular risk, can improve overall vascular health and sexual functioning in men with ED.

Psycho-sexological therapies should be integrated with lifestyle changes and medical, physical, and surgical

Exercise, particularly aerobic exercise during midlife is effective for preventing ED.

For tobacco users, cessation of smoking results in a significant improvement.

Oral pharmacotherapy and vacuum erection devices are first-line treatments,followed by injections of drugs into the penis, and penile implants.

Phosphodiesterase type 5 inhibitors sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) are prescription drugs which are taken orally.

Regular use of phosphodiesterase type 5 inhibitors for erectile dysfunction is associated with increased risk of serious retinal detachment, retinal vascular occlusion, and ischemic optic neuropathy, among older US men in observation studies.