An erect penis has long been seen as a symbol of a man’s masculinity, virility, and sexual prowess. However, more than 150 million men around the world are unable to persistently attain and maintain an erection sufficient to permit satisfactory sexual performance – defined as erectile dysfunction (ED). 

About 40% of men in their 40s will have some form of erectile dysfunction and this prevalence will increase about 10% per decade.

SIGN OF SERIOUS UNDERLYING MEDICAL CONDITION 

Not only does ED negatively impact the psychological well-being and quality of life (QoL) of those affected, but doctors caution that it may be a warning sign of a serious underlying medical condition including atherosclerosis, cardiovascular (CV) risk, and subclinical systemic vascular disease.  

Sometimes described as a barometer of male health, ED in younger, even more than in older men, can be considered a harbinger of CVD and offers a unique opportunity to unearth the presence of CV risk factors, thus allowing effective and high-quality preventive interventions.  

There are also strong correlations between ED and: 

  • Hypertension – 40% of men with ED have hypertension, while 35% of hypertensive men will also have ED 
  • Hyperlipidaemia – 42% 
  • Diabetes – undiagnosed diabetes is up to three times as likely in men with ED (28%) compared to non-diabetic men with normal erections (10%). Among men over 50, diabetics are roughly twice as likely to have ED (46%) compared to non-diabetics (24%) 
  • Hypogonadism – 35% of all men with ED will also have hypogonadism and about 6% will have abnormal thyroid function 
  • Benign prostatic hyperplasia (BPH) with lower urinary symptoms (LUTS) – 72% of men with symptomatic BPH have ED 

Recent studies have also linked ED to other diseases such as psoriasis, gouty arthritis, ankylosing spondylitis, non-alcoholic fatty liver, other chronic liver disorders, chronic periodontitis, open-angle glaucoma, and inflammatory bowel disease.  

ED shares unmodifiable and modifiable common risk factors with CVD (e.g. obesity, diabetes, dyslipidaemia, metabolic syndrome, lack of exercise, and smoking). The association between ED status and age, diabetes duration, poor glycaemic control, body mass index, obstructive sleep apnoea, hyperhomocysteinaemia, and chronic liver failure associated with hepatitis B, has been confirmed. In addition, an association between ED status and vitamin D deficiency has also been reported.  

PSYCHOLOGICAL IMPACT OF ED 

Most studies agree that ED not only affects the patient’s QoL but also that of his partner. Studies show that ED often leads to frustration, depression and anxiety in couples, and can even result in separation and/or divorce.  

Men with ED are at high risk of depression and anxiety, which often exacerbates ED and vice versa. A recent study found that men with ED have a 1.39 odd ratio of suffering from depression, and 37% suffer from anxiety.  

In men, the inability to sustain an erection can trigger a loss of sexual confidence leading to the avoidance of sexual situations. ED has also been associated with partner sexual dysfunction.  

In the Female Experience of Men’s Attitudes to Life Events and Sexuality (FEMALES) survey, assessing the quality of their sexual experience, female partners of men (>20 years) complaining of ED, reported a significant deterioration of sexual satisfaction after the onset of ED in their partners.  

A 2018 British survey of 2 000 men (aged 18-60) revealed that 31% felt a strain on their relationship as a result of ED, 31% even broken up with a partner due to the issue, 25% said they had lost confidence when dating, and 21% indicated that they developed mental health issues as a result.  

TREATMENT 

Current treatment options include pharmacotherapy, surgical treatments (penile prosthesis), topical therapy, hormonal treatment, psychosocial interventions (behavioural interventions, cognitive behavioural therapy, hypnosis, and mindfulness-based interventions), and complementary and alternative medicine treatments.  

According to the latest European ED guideline ED can be treated successfully, but it cannot be cured. The only exceptions are psychogenic ED, post-traumatic arteriogenic ED in young patients, and hormonal causes (e.g. hypogonadism and hyperprolactinaemia), which can potentially be cured with specific treatment.  

The guideline recommends lifestyle modification (weight reduction, limiting alcohol consumption, smoking cessation, etc.) and pharmacotherapy using phosphodiesterase type 5 inhibitors (PDE5is), as first-line treatment modalities. In the FEMALES study, respondents reported improved satisfaction, sexual desire, arousal, and orgasm when their partners started using PDE5is.  

Inhibition of PDE5 results in smooth muscle relaxation with increased arterial blood flow, leading to compression of the subtunical venous plexus followed by penile erection. In SA, three potent selective PDE5Is have been approved for the treatment of ED, namely Tadalafil, Sildenafil, and Vardenafil.  

  • SILDENAFIL: The first PDE5I available on the market (1998). Effective 30-60 minutes after administration, however, efficacy is reduced after a heavy, fatty meal due to delayed absorption. Efficacy may be maintained for up to twelve hours. Improved erections were reported by 56%, 77%, and 84% of a general ED population taking 25mg, 50mg, and 100mg respectively, compared to 25% of men taking placebo. The efficacy of sildenafil in almost every subgroup of patients with ED has been successfully established. 
  • VARDENAFIL: Became commercially available in March 2003. Effective from 30 minutes after administration, with up to one out of three patients achieving satisfactory erections within 15 minutes. Its effect is reduced by a heavy, fatty meal (>57% fat). Doses of 5mg, 10mg, and 20mg have been approved for on-demand treatment of ED. After twelve weeks in a dose-response study, improved erections were reported by 66%, 76%, and 80% of a general ED population taking 5mg, 10mg, and 20mg, respectively, compared with 30% of men taking placebo. Efficacy has been confirmed in almost every subgroup of patients with ED, including difficult-to-treat subgroups. 
  • TADALAFIL: Licensed for treatment of ED in February 2003. Effective from 30 minutes after administration, with peak efficacy after about two hours. Efficacy is maintained for up to 36 hours and is not affected by food. It is administered in on-demand doses of 20mg or a daily dose of 5mg. After twelve weeks of treatment in a dose-response study, improved erections were reported by 81% of a general ED population taking 20mg tadalafil, respectively, compared to 35% of men in the control placebo group. Tadalafil significantly improves patient satisfaction. Efficacy in almost every subgroup of patients with ED has been confirmed, including difficult-to-treat subgroups (e.g. diabetes).