Defined as the persistent inability to achieve or maintain an erection needed for satisfactory sexual performance.
20-30 million men in the U.S.
Affects 100 million worldwide.
More than 600,000 men 40-69 years of age seek care for this process annually in the U.S.
The Massachusetts Male Aging Study (MMAS), a large community-based observational survey of men age 40-70 years estimated a 52% prevalence with 17.1% mild, 25.2% moderate and 9.6% severe.
Health Professionals Follow-up Study found moderate to severe disease reported by 12% of men younger than 59 years, 22% of men and a 60-69 years, and 30% of men older than 69 years.
Approximately 52% of men ages 40-70 years experience some degree of 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.
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.
About 70% of men with erectile dysfunction (ED) respond to the ED pills well enough to enable sexual intercourse.
A topical cream combining alprostadil with the permeation enhancer DDAIP has been approved in Canada.
Injected medication therapy with one of the following drugs is injected into the penis: papaverine, phentolamine, and prostaglandin E1.
A vacuum erection can be used to attain erection, with a separate compression ring fitted to the penis to maintain it.
Inflatable or rigid penile implants may be fitted surgically.
Often, as a last resort, the most common procedure is prosthetic implants which involves the insertion of artificial rods into the penis.
Trazodone may be beneficial