- Introduction to erectile dysfunction and systemic health
- Conditions associated with erectile dysfunction
- Conditions not associated with erectile dysfunction
- Erectile dysfunction as an indicator of health
- Assessing and managing lifestyle risk factors
Erectile dysfunction is a condition in which a man cannot achieve or maintain an erection rigid enough to allow sexual intercourse. Erectile dysfunction is associated with increasing age – the chances of a man experiencing erectile dysfunction doubles (and may even triple) between 40 and 70 years of age. However, erectile dysfunction can affect men of all ages. In one Australian study, almost 10% of men aged 20–39 reported experiencing erectile dysfunction.
Erectile dysfunction is not a life-threatening condition, but it can have a serious impact on a man’s sense of wellbeing, relationships, and quality of life. Sexual dysfunction (including erectile dysfunction) is a major cause of relationship breakdown and stress, and can negatively affect a man’s self-esteem. In addition, a man’s erectile function adversely affects his partner’s sexual function.
Erectile dysfunction is also associated with many systemic health conditions (health conditions which affect the whole body or other body systems). Systemic health conditions affect a man’s physical health, can impact negatively on the treatment of erectile dysfunction and, in some cases, are life-threatening.
It is increasingly understood that erectile dysfunction is underpinned by disorders of the blood vessels. These diseases affect the way blood is transported through the body (including through the penis), and include hypertension (high blood pressure) and ischaemic heart disease (insufficient blood flow into the heart); both of which are often associated with the development of type 2 diabetes mellitus. These diseases, similar to erectile dysfunction, are all caused by dysfunction of the endothelium, which controls the opening and closing of blood vessels and therefore regulates blood flow through the body.
Erectile function is regulated by both arterial and venous penile blood flow (i.e. blood flow into and out of the penis). As the arteries of the penis are much smaller than other arteries in the body, they may be amongst the first to be affected by endothelial dysfunction. Erectile dysfunction may therefore occur before other symptoms of vascular disease become apparent. Vascular disease is the most common cause of erectile dysfunction, and the two conditions often occur together.
Erectile dysfunction is also a risk factor for cardiovascular disease. Men with erectile dysfunction are about one and a half times more likely to develop cardiovascular (heart) disease in the future than those who are able to achieve erections. Having erectile dysfunction increases the risk of cardiovascular disease to a similar degree as smoking or a family history of heart attack or dyslipidaemia (abnormalities of blood lipids such as cholesterol), which are considered major risk factors for cardiovascular disorders.
Erectile dysfunction and diabetes mellitus are often comorbid (the conditions often occur at the same time), and erectile dysfunction is the first symptom of diabetes in some 20% of men who develop the condition. Between 20% and 85% of diabetic men experience erectile dysfunction, and the prevalence increases depending on the severity of their diabetes and their age.
Erectile dysfunction is the most frequent complaint amongst diabetic men and is also common amongst men with metabolic syndrome (a condition that often leads to type 2 diabetes mellitus, in which there are several co-occuring metabolic and vascular abnormalities, such as high blood glucose levels and high blood pressure) or symptoms of the disorder. An American study found that high proportions of men with erectile dysfunction exhibited at least one metabolic abnormality characteristic of metabolic syndrome (e.g. 31% had high blood pressure). An Italian study reported that a significantly higher proportion of men with metabolic syndrome also experienced erectile dysfunction, compared to healthy men.
Dyslipidaemia (abnormal blood lipid concentrations) is also associated with erectile dysfunction. Moderate cases of dyslipidaemia, which might not typically warrant treatment, may be the primary cause of erectile dysfunction in some men. Treating moderate dyslipidaemia can improve erectile function in these cases. The two conditions commonly co-exist. Different studies have reported that 40–70% of men with erectile dysfunction also experience dyslipidaemia, and men with dyslipidemia have an increased risk of developing erectile dysfunction.
Hypertension and erectile dysfunction are commonly comorbid. Some 40% of men with erectile dysfunction are hypertensive, while 35% of hypertensive men experience erectile dysfunction.
Endocrine disorders (i.e. disorders of the body’s hormone-production system), including hyper- and hypothyroidism (over- and under-production of thyroid-secreted hormones), hyperprolactinaemia (excessive prolactin concentrations in blood) and hypogonadism (testosterone deficiency), may result in or worsen erectile dysfunction.
Thyroid disorders create imbalances in sex hormone binding globulin (SHBG) levels, which in turn affect the amount of bioavailable testosterone in the body. This affects erectile function. As such, treating these conditions may improve erectile function in the absence of other treatments.
High levels of prolactin, characterised by hyperprolactinaemia, may reduce the production of testosterone, as it suppresses the secretion of luteinising hormone (LH), which is needed to trigger testosterone production. As testosterone deficiency and erectile dysfunction are associated, conditions which affect testosterone production may also affect erectile function.
Hypogonadism is characterised by testosterone deficiency, causing reduced libido. It is associated with many of the same risk factors as erectile dysfunction, including obesity, diabetes, metabolic syndrome and depression. By definition, men with low libido often do not feel like having sex; therefore, they do not need to achieve an erection, and thus many testosterone-deficient men do not experience erectile dysfunction. However, in some cases of hypogonadism, men with reduced libido may still want to have sex on some occasions; in these cases, testosterone deficiency may negatively influence erectile function and its response to treatment with PDE-5 inhibitors. There is evidence that for some men, combined testosterone and PDE-5 inhibitor therapy is more effective than either treatment alone.
Other health conditions associated with erectile dysfunction include:
- Depression: Some studies have shown strong associations between current erectile dysfunction and depression. However, a large study from the United States reported that being depressed did not increase the risk of experiencing erectile dysfunction. This may mean that the association between erectile dysfunction and depression found in other studies arises because erectile dysfunction causes depression, rather than vice versa.
- Premature ejaculation: Up to one third of men with erectile dysfunction also experience premature ejaculation. Having both conditions has a greater negative impact on quality of life and sexual enjoyment than experiencing either condition alone;
- Lower urinary tract disorders: Men with lower urinary tract disorders are significantly more likely to experience erectile dysfunction than those without. Studies have reported a 2–9 times increased likelihood of erectile dysfunction in men with lower urinary tract disorders, depending on the characteristics of the man (e.g. their age). Studies have also reported that the risk of erectile dysfunction increases with the severity of lower urinary tract symptoms;
- Benign prostatic hyperplasia: There is little evidence to show a direct association between erectile dysfunction and benign prostatic hyperplasia, although the risk of erectile dysfunction may increase, either because of lower urinary tract symptoms related to benign prostatic hyperplasia, or as a result of surgical treatment for benign prostatic hyperplasia. While evidence suggests that erectile dysfunction improves for more men following benign prostatic hyperplasia surgery, a significant proportion of men (~20%) experience more severe erectile dysfunction following surgery. A study of erectile dysfunction in Nigerian men with benign prostatic hyperplasia-related lower urinary tract disorders reported that more severe prostate symptoms of the lower urinary tract were associated with an increased likelihood of erectile dysfunction.
Alcohol abuse has been reported to impair erectile function, and moderate alcohol consumption is recommended because of its broad health effects. However, current evidence does not suggest that alcohol consumption impairs erectile function.
Erectile dysfunction is an increasingly common complaint for men. The widespread approval of PDE-5 inhibitors for the treatment of erectile dysfunction has changed management of the condition considerably. Marketing of PDE-5 inhibitor-containing drugs directly to the public (as opposed to marketing to health professionals) has increased the demand for this form of treatment and resulted in more men seeking medical advice about erectile dysfunction.
As many men do not seek medical advice regularly, doctors may use the opportunity that a visit for erectile dysfunction offers to assess and, if necessary, treat comorbid health conditions associated with erectile dysfunction. The detection and treatment of these conditions can help improve a man’s erectile function and response to its treatments, and may also considerably improve a man’s overall health and wellbeing.
PDE-5 inhibitors have a reputation for being “magic bullet” solutions to erectile dysfunction, which can be offered in the absence of other treatments and lifestyle modifications. Because of this, many men are unaware of the associations between erectile dysfunction and other chronic health conditions, or that the existence of such conditions can considerably reduce the effectiveness of PDE-5 inhibitor treatment, and may not mention other health problems to their doctor. Doctors may therefore need to investigate the possibility of comorbid chronic conditions in men complaining of erectile dysfunction.
As erectile dysfunction is associated with (and may be a symptom of) many systemic health conditions, men who go to a doctor with erectile dysfunction of unexplained origin (e.g. not resulting from relationship problems) are evaluated for systemic health conditions. Screening for comorbid conditions can enhance the early detection and treatment of these conditions, and improve their treatment outcomes.
Cardiovascular disease and erectile dysfunction commonly co-exist. Where no other causes can be identified, a doctor will consider the possibility of this condition in men with erectile dysfunction, even in the absence of cardiovascular disease symptoms. Health conditions such as diabetes mellitus and hypertension may also be suspected in cases of unexplained erectile dysfunction, as they have common causes and men with these conditions often visit a doctor because of erectile dysfunction. A significant proportion (30%) may be unaware they have hypertension, and thus screening men with erectile dysfunction for this condition may help detect unidentified cases of hypertension. Similarly, erectile dysfunction may be a presenting complaint in cases of undiagnosed diabetes or dyslipidaemia. As such, men with erectile dysfunction that has no identifiable cause will probably have their blood lipid concentrations, fasting blood glucose levels, blood pressure and other cardiovascular parameters assessed by the doctor. Men with reduced libido or other symptoms of testosterone deficiency will likely have their blood testosterone levels assessed to screen for hypogonadism.
Men who have previously experienced cardiovascular disease may be monitored by their doctor for erectile dysfunction, as it may indicate a recurrence. Men with previously diagnosed hypertension or dyslipidaemia may also be monitored for the development of erectile dysfunction.
Men with newly diagnosed hypertension may also be screened for erectile dysfunction, as its presence or absence will influence the choice of medication. Angiotensin II receptor blockers have been shown to improve erectile function in hypertensive patients and may therefore be an appropriate choice for men with both conditions. On the other hand, thiazides and non-selective beta blockers are associated with erectile dysfunction and may be inappropriate for men who have difficulty achieving erections. Your doctor will be able to advise which medication is best for you.
Many modifiable lifestyle factors affect erectile function and the effectiveness of its treatments, or are associated with conditions that cause erectile function. For example, diet and smoking are associated with cardiovascular disease, of which erectile dysfunction can be a symptom. Thus doctors are likely to assess the lifestyle of men with erectile dysfunction, with the aim of identifying and modifying lifestyle factors which may be exacerbating the condition.
Poor nutrition, being overweight or obese, and inadequate exercise are associated with most of the conditions that increase the risk of erectile dysfunction. Thus, good nutrition and physical activity should reduce the risk of these conditions and improve erectile function. Men with erectile dysfunction should therefore attempt to:
- Maintain a healthy BMI (body mass index): Obesity is associated with an increased risk of erectile dysfunction. One study reported that obese men (BMI > 30) were almost twice as likely to experience erectile dysfunction compared to non-obese men. Another study reported that men who were obese earlier in life had a higher risk of experiencing erectile dysfunction than those who were not, even if they lost weight later in life;
- Consume a healthy balanced diet and particularly a diet low in fat and cholesterol: Reducing cholesterol intake has been shown to improve erectile function in as little as three months, and is also thought to improve the effectiveness of PDE-5 inhibitor therapy. High-fat foods may interact with PDE-5 inhibitors and limit their effectiveness, so eating a low-fat diet during PDE-5 inhibitor therapy is also important for optimising treatment response. Low-fat and Mediterranean-style diets have proven effective in reducing the risk of erectile dysfunction in men with metabolic syndrome and obesity.
- Be physically active: Physical activity protects against erectile dysfunction, even in men who start in mid-life. One study reported a 30% reduced risk of erectile dysfunction amongst men with high levels of physical activity compared to men with low levels. Exercise programs have also been demonstrated effective in improving sexual response in men with erectile dysfunction. However, take note that cycling for more than 3 hours per week is a risk factor for erectile dysfunction, and cycling may therefore not be an appropriate form of exercise for men who are unable to achieve erections. Cycling should be considered a potential contributor to erectile dysfunction by men who undertake this form of exercise.
- Drink alcohol in moderation (if they choose to drink).
- Quit smoking: There is evidence that smoking increases the risk of erectile dysfunction. One study reported a 50% increased risk of erectile dysfunction amongst men who smoked compared to those who did not. Another reported that men in their 40s who smoked were almost three times more likely to experience erectile dysfunction compared to former and never smokers;
- Avoid using recreational drugs.
|For more information on erectile dysfunction, types, causes and treatments of erectile dysfunction, and tips for dealing with it, see Erectile Dysfunction.|
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