Professor Mike Kirby
Editor, Trends in Urology and Men’s Health
Erectile dysfunction (ED) may be an early marker of cardiovascular disease (CVD), and its identification provides an opportunity for early intervention to reduce future risk.
Erectile dysfunction may reduce quality of life of sufferers and their partners.
Erectile dysfunction (ED) is the persistent inability to achieve and/or maintain an erection sufficient for satisfactory sexual performance. It is a common problem that affects men of all ages, although the incidence and prevalence increase with age.1,2
ED may compromise both physical and psychological health, and reduce quality of life of sufferers and their partners.3,4 It has also been proposed as an early marker of a more widespread systemic disorder that may eventually lead to cardiovascular disease (CVD).
ED and CVD share the same risk factors
ED and endothelial dysfunction are inextricably linked. Endothelial dysfunction is a condition in which the inner lining of the small arteries fail to function normally. ED and CVD share the same risk factors3,5,6, including:
- Sedentary lifestyle
- Obesity
- Dyslipidaemia
- Metabolic syndrome
- Diabetes
- Hypertension
- Smoking
ED is an important marker of future cardiovascular (CV) risk,7,8 and ED severity reflects coronary artery disease (CAD) severity.9
ED occurs before CAD in around two-thirds of cases. Time frames from ED to CAD symptoms, or a CV event, range from two to three years and three to five years, respectively.10 This may be partly due to endothelial dysfunction and plaque burden compromising blood flow in the smaller penile arteries first.10,11
A physical examination may highlight reversible causes of ED
The British Society for Sexual Medicine recommend taking a comprehensive medical, sexual and relationship history of the patient. A focused physical examination can identify potential reversible causes of ED. Prostate examination is recommended in the presence of genitourinary or persistent secondary ejaculatory symptoms.3
Routine laboratory testing should include:3
- Fasting glucose
- HbA1c
- Lipid profile
- Fasting testosterone (before 11am)
Thyroid function tests should also be considered.3
The Q-risk3 calculator can be used to calculate the risk of developing a myocardial infarction or stroke over the next decade, and this now includes ED as an additional risk factor (25% increase).
Managing ED to moderate your risk of a cardiovascular event
While men at low risk of future CV events can usually be managed in primary care, those at high risk should have their assessment and management supervised by a specialist team, which is likely to include a cardiologist.3
Following stabilisation of CV function and control of CV symptoms, ED management should include lifestyle advice and pharmacotherapy to aggressively control CV risk factors.3,12
Phosphodiesterase type 5 inhibitors (PDE5i) are the first-line treatment for ED, but they are contraindicated in patients taking nitrates and should be used with caution in those taking alpha-blockers.3
Patients who fail to respond to PDE5i may be rescued with testosterone replacement therapy if they are testosterone deficient. Additional ED treatments include vacuum devices, intraurethral alprostadil, intracorporeal alprostadil or Invicorp, and penile prosthesis as a last resort.
Patients should be reviewed regularly to assess CV status and response to therapies.
