Abstract
Erectile dysfunction (ED) is a multisystemic disorder most commonly caused by vascular insufficiency. Because the organic etiologies that cause ED often impact concurrently on other body systems, multiple comorbidities have been noted that occur more frequently among men with ED than among men without ED. This encourages us to consider the presence of ED as a signal of a variety of disorders that have similar etiologies, including psychosocial problems, endocrine imbalances, neurologic disorders, and, most notably, cardiovascular risk factors and/or disease. Evidence is accumulating that ED, especially vasculogenic ED, is a signal for endothelial dysfunction and resultant cardiovascular disease risk. ED may also be a "harbinger" of symptomatic cardiovascular or neurologic diseases. Knowing that a man has ED should encourage further evaluation for these comorbidities, because early detection may allow attenuation of disease risk or actual disease. The best way to perform this evaluation in men with ED needs further study. The role of the presence of ED as a “screening test” for increased cardiovascular disease risk also needs further exploration.
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References and Recommended Reading
Sadovsky R, Mulhall JP: The potential value of erectile dysfunction inquiry and management. Int J Clin Pract 2003, 57(7):601–608.
Lue T: Erectile dysfunction N Engl J Med 2000, 342:1802–1813.
Sullivan ME, Keoghane SR, Miller MA: Vascular risk factors and erectile dysfunction. BJU Int 2002, 87(9):838–845.
Meuleman EJ: Prevalence of erectile dysfunction: need for treatment? Int J Impot Res 2002, 14(Suppl):122–128.
Chew KK, Earle CM, Stuckey BG, et al.: Erectile dysfunction in general medicine practice: prevalence and clinical correlates. Int J Impot Res 2000, 12:41–45.
Rosen RC, Fisher WA, Eardley I, et al.: The multinational men’s attitudes to life events and sexuality (MALES) study, I: Prevalence of erectile dysfunction and related health concerns in the general population. Curr Med Res Opin 2004, 25:5:607–617.
Feldman HA, Johannes CB, Derby CA, et al.: Erectile dysfunction and coronary risk factors: prospective results from the Massachusetts Male Aging Study. Prev Med 2000, 30:328–338.
Walczak MK, Lokhandwala N, Hodge MB, Guay AT: Prevalence of cardiovascular risk factors in erectile dysfunction. J Gend Specif Med 2002, 5(6):19–24.This article is a good review of CVD risk factors in men with ED. ED reveals vascular disease in the helicine arteries in the same way that angina reveals vascular disease in the coronary arteries.
Billups K, Fiedrich S: Assessment of fasting lipid panels and Doppler ultrasound testing in men presenting with erectile dysfunction and other medical problems. J Urol 2000, 163(4):147.
Sullivan ME, Keoghane SR, Miller MA: Vascular risk factors and erectile dysfunction. Br Urol Int 2001, 87(9):838–845.
Burchardt M, Burchhardt T, Baer L, et al.: Hypertension is associated with severe erectile dysfunction. J Urol 2000, 164(4):1188–1191.
Derby CA, Mohr BA, Goldstein I, et al.: Modifiable risk factors and erectile dysfunction: Can lifestyle changes modify risk? Urology 2000, 56:302–306.
Chung WS, Sohn JH, Park YY: Is obesity an underlying factor in erectile dysfunction? Eur Urol 1999, 36:68–70.
Aruajo AB, Durnante R, Feldman HA, et al.: The relationship between depressive symptoms and male erectile dysfunction: cross sectional results from the Massachusetts Male Aging Study. Psychosom Med 1998, 60:458–465.
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(1):54–61.
Roumeguere T, Wespes E, Carpentier Y, et al.: Erectile dysfunction is associated with a high prevalence of hyperlipidemia and coronary heart disease risk. Eur Urol 2003, 44:355–359.
DeWire DM: Evaluation and treatment of ED. Am Fam Phys 1996, 53:2102–2107.
Curkendall SM, Jones JK, Glasser D, et al.: Incidence of medically detected erectile dysfunction and related diseases before and after Viagra (sildenafil citrate). Eur Urol 2000, 37(Suppl:2):81.
Heitzer T, Schlinzig T, Krohn K, et al.: Endothelial dysfunction, oxidative stress, and risk of cardiovascular events in patients with coronary artery disease. Circulation 2001, 104:2673–2678.
Halcox JP, Schenjke WH, Zalos G, et al.: Prognostic value of coronary vascular endothelial dysfunction. Circulation 2002, 106:653–658.
Burchardt M, Burchardt T, Anastasiadis AG, et al.: Erectile dysfunction is a marker for cardiovascular complications and psychological functioning in men with hypertension. Int J Impot Res 2001, 13:276–281.
Morley JE, Korenman SG, Kaiser FE, et al.: Relationship of penile brachial pressure index to myocardial infarction and cerebrovascular accidents in older men. Am J Med 1988, 84:445–448.
Kloner RA, Mullin SH, Shook T, et al.: Erectile dysfunction in the cardiac patient: how common and should we treat? J Urol 2003, 170(2 Pt 2):S46-S50.
Greenstein A, Chen J, Miller H, et al.: Does severity of ischemic coronary disease correlate with erectile function? Int J Impot Res 1997, 9:123–126.
Anderson M, Nicholson B, Louie E, et al.: An analysis of vasculogenic erectile dysfunction as a potential predictor of occult cardiovascular disease. J Urol 1998, 159(Suppl 5):118.
Zoler ML: Erectile dysfunction may presage vascular dysfunction. Fam Pract News 2004, 34(6):40.
Feldman HA, Johannes CB, Derby CA, et al.: Erectile dysfunction and coronary risk factors: prospective results from the Massachusetts male aging study. Prev Med 2000, 30:328–338. This article describes the relationship between baseline risk factors for coronary artery disease and subsequent ED. Because behaviorally modifiable risk factors for CVD such as smoking, obesity, and poor diet are also associated with ED, recognition of ED may stimulate positive behaviors. Data are also provided that point toward ED as a sentinel of subclinical coronary disease.
Montorsi F, Salonia A, Montorsi P, et al.: May erectile dysfunction predict heart disease? Int J Impot Res 2002, 14(Suppl 3):S51.
Anderson M, Nicholson B, Louise E, et al.: An analysis of vasculogenic erectile dysfunction as a potential predictor of occult cardiac disease. J Urol 1998, 159(Suppl):Abstract #118.
Pritzker M: The penile stress test: a window to the hearts of man? Circulation 1999, 100(Suppl 1):711.
Kaiser DR, Billups K, Mason C, et al.: Impaired brachial artery endothelium-dependent and-independent vasodilation in men with erectile dysfunction and no other clinical cardiovascular disease. J Am Coll Cardiol 2004, 43:179–184.
Khan A, Ledda A, Mikhalidis DP: Second consensus conference on cardiovascular risk factors and erectile dysfunction. Curr Med Res Opin 2002, 18(1):33–35.
Cheitlin MD: Erectile dysfunction the earliest sign of generalized vascular disease. J Am Coll Cardiol 2004, 43(2):185–186.
Lochmann A, Gallmetzer J: Erectile dysfunction of arterial origin as a possible manifestation of atherosclerosis. Minerva Cardioangiol 1996, 44:243–246.
Kirby M, Jackson G: Is erectile dysfunction a marker for cardiovascular disease? Int J Clin Pract 2001, 55:614–618.This article reviews ED as a symptom and marker of cardiovascular disease and as an indicator of disease progression.
Sullivan ME, Keoghane SR, Miller MA: Vascular risk factors and erectile dysfunction. BJU Int 2002, 87(9):838–845.
Jackson G, Betteridge J, Dean J, et al.: A systematic approach to erectile dysfunction in the cardiovascular patient: a consensus statement-update 2002. Int J Clin Pract 2002, 56(9):663–671.
Libby P, Ridker PM, Maseri A: Inflammation and atherosclerosis. Circulation 2002, 105:1135–1143.
Celermajer DS: Endothelial dysfunction: Does it matter? Is it reversible? J Am Coll Cardiol 1997, 30:325–333.
Quyyumi AA: Prognostic value of endothelial function. Am J Cardiol 2003, 91(Suppl):19H-24H.This article describes the prognostic value of endothelial dysfunction measurement for risk of coronary events. This predictive value of endothelial function appears most useful among high risk patients. It is less clear that improvement of endothelial dysfunction is a surrogate marker for risk reduction.
Gonzalez MA, Selwyn AP: Endothelial function, inflammation, and prognosis in cardiovascular disease. Am J Med 2003, 115(8A):99S-106S.
Edwards DG, Schofield RS, Lennon SL, et al.: Effect of exercise training on endothelial function in men with coronary artery disease. Am J Cardiol 2004, 93:617–620.
Richardson D, Vinik A: Etiology and treatment of erectile failure in diabetes mellitus. Curr Diab Rep 2002, 2:501–509.
Solomon H, Man JW, Jackson G: Erectile dysfunction and the cardiovascular patient: endothelial dysfunction is the common denominator. Heart 2003, 89:251–253.This article reviews endothelial dysfunction as the common link between CVD and ED. The impact of this link on the treatment choices for men with ED is discussed.
Rakhit RD, Marber MS: Nitric oxide: an emerging role in cardioprotection? Heart 2001, 86:368–372.
Screening for Coronary Heart Disease. Recommendation Statement. US Preventive Services Task Force. Ann Intern Med 2004, 140:569–572.
Barrett-Connor E: Cardiovascular risk stratification and cardiovascular risk factors associated with erectile dysfunction. Clin Cardiol 2004, 274 (Suppl):I8-I13.This article is a good review of CVD risk factors and their presence in men with ED.
Jackson G: Sex, The Heart and Erectile Dysfunction. London: Taylor & Francis; 2004:18.
Wilson PW, D’Agostino RB, Levy D, et al.: Prediction of coronary heart disease using risk factor categories. Circulation 1998, 97:1837–1847.
Lloyd-Jones DM, Wilson PW, Larson MG, et al.: Framingham risk score and prediction of lifetime risk for coronary heart disease. Am J Cardiol 2004, 94(1):20–24.
Hambrecht R, Wolf A, Gielen S, et al.: Effect of exercise on coronary endothelial function in patients with coronary artery disease. N Engl J Med 2000, 342:454–460.
Gokce N, Vita JA, Bader DS, et al.: Effect of exercise on upper and lower extremity endothelial function in patients with coronary artery disease. Am J Cardiol 2002, 90:124–132.
Edwards DG, Schofield RS, Lennon SL, et al.: Effect of exercise training on endothelial function in men with coronary artery disease. Am J Cardiol 2004, 93:617–620.
Watts K, Beye P, Siafarkas A, et al.: Effects of exercise training on vascular function in obese children. J Pediatr 2004, 144:620–625.
Rose G, Barker DJP: Epidemiology for the Uninitiated, edn 2. London: British Medical Journal; 1986:42–46.
Dzau VJ, Gibbons GH, Mann M, Braun-Dullaeus R: Future horizons in cardiovascular molecular therapeutics. Am J Cardiol 1997, 80:33I-39I.
Gazzaruso B, Giordanetti S, De Amici E, et al.: Relationship between erectile dysfunction and silent myocardial ischemia in apparently uncomplicated type 2 diabetic patients. Circulation 2004, 110:22–26.
Hackam DG, Anand SS: Emerging risk factors for atherosclerotic vascular disease. JAMA 2003, 290(7):932–940.
Ridker PM, Rifai N, Rose L, et al.: Comparison of C-reactive protein and low density lipoprotein cholesterol levels in the prediction of first cardiovascular events. N Engl J Med 2002, 347:1557–1565.
Greenland P, LaBree L, Azen SP, et al.: Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals. JAMA 2004, 291:210–215.
Kim SW, Paick JS, Park W, et al.: Potential predictors of asymptomatic ischemic heart disease in patients with vasculogenic erectile dysfunction. Urology 2001, 58:441–445.
O’Kane P, Jackson G: Erectile dysfunction: Is there silent obstructive coronary artery disease? Int J Clin Pract 2001, 55(3):219–220.
Goldstein I, Siroky MB, Sax DS, Krane RJ: Neurologic abnormalities in multiple sclerosis. J Urol 1982, 128(3):541–545.
Fujisawa H, Igarashi S, Koyama T: Acute caudal equina syndrome secondary to lumbar disc herniation mimicking pure conus medullaris syndrome. Neurol Medico-Chirurg 1998, 38(7):429–431.
Zonszein J: Diagnosis and management of endocrine disorders of erectile dysfunction. Urol Clin North Am 1995, 22(4):789–802.
Whitehead ED, Klyde BJ: Diabetes-related impotence in the elderly. Clin Geriatr Med 1990, 6:771–795.
DeBerardis G, Franciosi M, Belfiglio M, et al.: Erectile dysfunction and quality of life in type 2 diabetic patients: a serious problem too often overlooked. Diabetes Care 2002, 25:284–291.
Gaspar S, Maytom M, Okamoto L: Comorbid conditions in patients with erectile dysfunction in a community setting. Managed Care Interface 2001, 14(12):36–42.This article reviews all medical comorbidities of ED and recommends using the presence of ED as a signal that further patient evaluation is indicated to look for these comorbidities.
Romero JH, Seftel AD, Madhun ZT, et al.: Sexual function in men with type 2 diabetes: association with glycemic control. J Urol 2000, 163:788–791.
Klein R, Klein BE, Lee KE, et al.: Prevalence of self-reported erectile dysfunction in people with long-term IDDM. Diabetes Care 1996, 19:135–141.
Reiter WJ, Pycha A, Schatzl G, et al.: Serum dehydroepiandrosterone sulfate concentrations in men with erectile dysfunction. Urology 2000, 55(5):755–758.
Fine SR: Erectile dysfunction and comorbid diseases, androgen deficiency, and diminished libido in men. J Am Osteopath Assoc 2004, 104 1 Suppl 1:S9-S15.
Richardson D, Vinik A: Etiology and treatment of erectile failure in diabetes mellitus. Curr Diab Rep 2002, 2:501–509.
Rosen R, Altwein J, Boyle P, et al.: Lower urinary tract symptoms and male sexual dysfunction. The Multinational Survey of the Aging Male (MSAM-7). Eur Urol 2003, 44:637–649.
Boyle P, Robertson C, Mazzetta C, et al.: The association between lower urinary tract symptoms and erectile dysfunction in four centers. The UrPik study. Br J Urol Int 2003, 92:719–725.
Hellstrom WJ: Benign prostatic hyperplasia, sexual function, and overall evaluation of the male patient. J Am Osteopath Assoc 2004, 104 2 Suppl 2):S5–10.
Mulhall JP, Creech SD, Boorjian SA: Subjective and objective analysis of the prevalence of Peyronie’s disease in a population of men presenting for prostate cancer screening. J Urol 2004, 171(6 Pt 1):2350–2353.
Kadioglu A, Oktar T, Kandirali E: Incidentally diagnosed Peyronie’s disease in men presenting with erectile dysfunction. Int J Impot Res 2004 [epub ahead of print].
Aruajo AB, Durnante R, Feldman HA, et al.: The relationship between depressive symptoms and male erectile dysfunction: cross sectional results from the Massachusetts Male Aging Study. Psychosom Med 1998, 60:458–465.
Roose SP: Depression: links with ischemic heart disease and erectile dysfunction. J Clin Psychiatry 2003, 64(Suppl 10):26–30.
Seidman SN, Roose SP: The relationship between depression and erectile dysfunction. Curr Psychiatry Rep 2000, 2:201–205.
Shabsigh R, Klein LT, Seidman S, et al.: Increased incidence of depressive symptoms in men with erectile dysfunction. Urology 1998, 52:848–852.
Mathew RJ, Weinman MI: Sexual dysfunctions in depression. Arch Sex Behav 1982, 11:323–328.
Kennedy SH, Dickens SE, Eisfeld BS, et al.: Sexual dysfunction before antidepressant therapy in major depression. J Affect Disord 1999, 56:201–208.
Todaro JF, Shen BJ, Niauru R, et al.: Effect of negative emotions on frequency of coronary heart disease (The Normative Aging Study). Am J Cardiol 2003, 92:901–906.
Hemingway H, Shipley M, Mullen MJ, et al.: Social and psychosocial influences on inflammatory markers and vascular function in civil servants (The Whitehall II Study). Am J Cardiol 2003, 92:984–987.
Bokhourn BG, Clark JA, Inui TS, et al.: Sexuality after treatment for early prostate cancer: exploring the meanings of "erectile dysfunction". J Gen Intern Med 2001, 16(10):649–655.
Kaiser FE: Erectile dysfunction in the aging man. Med Clin North Am 1999, 83:1267–1287.
Sadovsky R: Asking the questions and offering solutions: the ongoing dialogue between the primary care physicians and the patient with erectile dysfunction. Rev Urol 2003, 5(Suppl 7):S35-S48.
Berkman LF: The role of social relations in health promotion. Psychosom Med 1995, 57:245–254.
Friedman E, Thomas AA: Pet ownership, social support, and one year survival after acute myocardial infarction in the Cardiac Arrhythmia Suppression Trial (CAST). Am J Cardiol 1995, 76(17):1213–1217.
Maurice WL: Sexual Medicine in Primary Care. New York: Mosby; 1999:95.
Dunn KM, Croft PR, Hackett GI: Association of sexual problems with social, psychological, and physical problems in men and women: a cross-sectional population survey. J Epidemiol Community Health 1999, 53:144–148.
Berkman LF: Emotional support and survival after myocardial infarction: a prospective, population-based study of the elderly. Ann Intern Med 1992, 117(12):1003–1009.
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Sadovsky, R. Erectile dysfunction is a signal of risk for significant medical comorbidities: A primary care view. Curr sex health rep 1, 129–136 (2004). https://doi.org/10.1007/s11930-004-0031-2
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DOI: https://doi.org/10.1007/s11930-004-0031-2