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Erectile Dysfunction: A Warning Sign?   arrow

When a man has erection issues, these may be a warning sign of additional problems – that may surprisingly include the heart.

Background: Erectile dysfunction (ED) is defined as consistent inability to maintain or achieve an erection suitable for satisfactory sexual intercourse. Erection is a carefully conducted “orchestra” based on vasculature (artery and vein blood flow), hormones, nerves, and a man’s psychologic state.  Normal erection increases arterial blood flow and penile engorgement. Cells do not function well in patients with arterial plaque (atherosclerosis) or other abnormalities.

Erectile dysfunction risk factors:

Age (associated heart risk factors)
High Blood Pressure
High Cholesterol (the only risk factor in up to 40% of patients)
Diabetes mellitus Type 2
Overweight/sedentary lifestyle
Medications (i.e. thiazide diuretics), Depression, Alcohol)
Associated conditions including:  metabolic Syndrome (abdominal obesity, high blood pressure, high cholesterol, high blood sugar), chronic Inflammation, obstructive sleep apnea


The issue: ED is an independent risk factor for heart (cardiovascular) disease which may predict future cardiovascular problems as accurately as traditional risks of smoking, high cholesterol, and family history of heart attack (myocardial infarction).

heart_diagram_colourIdentification of ED in men under 60 years of age and those with diabetes is a critical initial task in detecting heart risk (2-3 times increased risk for heart and vascular disease).  There is a 50 fold higher rate of new coronary (heart) artery disease in men 40-49 years of age with ED than those without ED.  Also ED is powerful predictor of cardiovascular disease in diabetic men.

Diagnosis: Princeton III Consensus Recommendations (a standard of medical management) describes that a man with ED should be considered at increased risk for coronary disease until recommended checks suggest otherwise.  Increased coronary risk exists with or without heart disease symptoms or history.  For all men with ED, a specific regimen of history and physical including labs determined by your doctor are recommended.  Your urologist can determine whether a penile doppler ultrasound may be helpful in diagnosis.

Treatment: Medications including phosphodiesterase inhibitors (oral pills known as PDE5 inhibitors which have many advertisements on TV) such as sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis), and avanafil (Stendra) are common treatment options.  Other options for erectile dysfunction depending on the cause include medications directly injected into the side of the penis including prostaglandin E1 injections, and other multi-agent mixtures (i.e. trimixture of phentolamine, papaverine, and prostaglandin E1) for injection.  Such prostaglandin-based mixtures have been useful for some men with significant comorbidities (including cardiovascular disease)  An alternative to injections is intraurethral pellet of prostaglandin E1 (called Muse), but this has been found to be less effective than injections.  If medical therapy is not helpful or desired, penile vacuum erectile devices (VED) alone or in combination with medication may be useful.  Finally, penile prosthesis insertion may be an excellent option for select patients.  Penile prosthesis is also useful in some men immediately following some cases of priapism (sustained erection with damaging fibrosis of the erectile tissue).  Finally, in men with penile curvature (Peyronie’s disease) and ED not responsive to medication, penile prosthesis insertion may be needed.

For more information about erectile dysfunction initial evaluation and treatment options, please visit the Center for Male Health and Reproduction site.  You may also contact us with any additional questions and our physician team will respond.

Matthew Wosnitzer, M.D. June 1, 2014