Between 38% to 42% of men with ED have hypertension and approximately 35% of men with hypertension have some degree of ED, according to the American Urology Association (AUA).

Impotence is derived from the Latin word impotencia, which literally translated means lack of power.

ED is defined as the ‘inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance’. It is commonly known as impotence. Although the oldest reference to impotence was made in the Samhita of Sushruta, around the 18th BC in India, the first ED treatment guideline was published by the Americans in 1996, followed by the European guideline in 2000.

More than just sexual health affected

Up to 42.4% of men with ED also have hyperlipidaemia and men with poor to very poor erectile function had twice the odds of an elevated total cholesterol/high-density lipoprotein cholesterol ratio compared with men with good and very good erectile function.

ED is also one of the most common complications of diabetes.

Depending on the severity and duration of diabetes, the prevalence of ED ranges from 20% to 85% and about 20% of men with ED also had diabetes. Studies also show that the prevalence of ED is higher in men with diabetes who are older than 50 years, nearly double that in age-matched men without diabetes (45.8% versus 24.1%).

In addition, an increase in the relative risk of ED was associated with increased duration of diabetes. ED is known to occur at an earlier age in men with diabetes than in those without it. In some cases, ED may be a manifestation of previously undiagnosed diabetes, which highlights the importance of screening men with ED for diabetes-related risk factors, writes the authors of the new AUA ED guideline.

A 2019 study by Uddin et al looked at ED as an independent predictor of future coronary heart disease (CHD). They used data from the Multi-Ethnic Study of Atherosclerosis to examine the value of self-reported ED for predicting incident CHD and CVD in those free of these CVD events at baseline.

A total of 51 757 participants were followed for 3.8 years and outcomes of hard CHD and CVD events were assessed. Hard CVD events included all hard CHD events (myocardial infarction, resuscitated cardiac arrest, and CHD death), plus stroke and stroke death.

To further assess the potential bidirectional relationship of prior CVD with ED, an additional shifted-time cross-sectional analysis was conducted to see if an interim CVD event before MESA visit five was associated with self-reported ED at visit five. For this analysis, all 1 914 participants with an ED assessment were included in a multivariable-adjusted logistic regression adjusting for the above-mentioned covariates.

They found that participants with ED were more likely to have diabetes and a family history of CHD. They were also more likely to use β-blocker, antihypertensive, lipid-lowering, and antidepressant medications.

Over the follow-up, there were a total of 40 CHD and 75 CVD hard events. A significantly greater proportion of participants with ED experienced hard events than those without ED (CHD hard events: 3.4% versus 1.4%, CVD hard events: 6.3% versus 2.6%).

In the unadjusted Cox models, ED was a significant predictor of both hard CHD and CVD events. In the fully adjusted models, ED remained a significant predictor of hard CVD events, whereas hard CHD events became nonsignificant, albeit with a similar point estimate of risk.

In the shifted-time cross-sectional analysis, a significant association was also seen between prior CVD event and ED at visit five, which remained significant but was attenuated by medication use and depression in the fully adjusted models.

The authors concluded that their study provides some of the strongest evidence to date for the independent predictive value of ED in a modern, multi-ethnic and well-phenotyped cohort. 

Evaluation and diagnosis

The 2018 AUA guideline recommends that men presenting with symptoms of ED should:

  • Undergo a thorough medical, sexual, and psychosocial history, a physical examination and selective laboratory testing
  • Complete a validated questionnaire to assess the severity of ED, measure treatment effectiveness, and to guide future management
  • Be counselled that ED is a risk marker for underlying CVD and other health conditions that may warrant evaluation and treatment
  • Undergo testing to measure morning serum total testosterone levels
  • If deemed necessary, undergo specialised testing and evaluation may be to guide treatment.

Treatment recommendations

The AUA recommends the following:

  • Refer patient to a mental healthcare professional to promote treatment adherence, reduce performance anxiety, and integrate treatments into a sexual relationship
  • Discuss lifestyle modifications, including changes in diet and increased physical activity, with patients who have comorbidities that negatively affect erectile function but may improve erectile function
  • Discuss the risk/benefits of approved oral phosphodiesterase type 5 inhibitors (PDE5i) with patients in whom treatment is indicated
  • Provide detailed instructions on how to maximise the use of oral PDE5i benefit/efficacy and manage expectations
  • Titrate PDE5i dose for optimal efficacy
  • Inform patients who desire preservation of erectile function after treatment for prostate cancer by radical prostatectomy or radiotherapy that early use of PDE5i post-treatment may not improve spontaneous, unassisted erectile function
  • Inform patients with testosterone deficiency who are considering ED treatment with a PDE5i that the drug may be more effective if combined with testosterone therapy
  • Inform patients about the possibility of vacuum erection device treatment, including discussion of benefits and risks
  • Inform patients about the possibility of intraurethral (IU) alprostadil treatment, including discussion of benefits and risks. Perform an in-office test in patients who are considering the use of IU alprostadil
  • Inform the patient about the possibility of treatment with intracavernosal injections (ICI), including discussion of benefits and risks and perform an in-office injection test
  • Inform the patient about the possibility of penile prosthesis implantation, including discussion of benefits and risks and discuss post-operative expectations
  • Do not perform penile prosthetic surgery in the presence of systemic, cutaneous, or urinary tract infection
  • Consider penile arterial reconstruction in young patients without focal pelvic/penile arterial occlusion, documented generalised vascular disease or veno-occlusive dysfunction
  • Penile venous surgery is not recommended
  • Low-intensity extracorporeal shock wave and intracavernosal stem cell therapies are still being investigated
  • Platelet-rich plasma therapy should be considered experimental.

Can physical activity really make a difference?

Physical activity (PA) can potentially decrease ED, and PA has been identified as the lifestyle factor most strongly correlated with erectile function and the most important promoter of vascular health. Thus, moderate- and vigorous-intensity PA is associated with normal erectile function and lower risk of ED, according to Gerbild et al.

The problem, however, write the authors, is that the quality and quantity of PA needed (eg modalities, duration, intensity and frequency) have not been sufficiently described but is essential for clinical guidance of patients with ED.

To provide effective recommendations for PA-induced improvement of erectile function in men characterised by physical inactivity, obesity, hypertension, metabolic syndrome, and/or manifest CVD, the authors conducted a systematic review of clinical intervention studies.

They found the following:

  • Continuous and interval-based aerobic training improve erectile function for men with arterial ED
  • PA with moderate intensity and intervals of vigorous intensity seems to be one of the key elements in determining the efficiency of the applied PA. Resistance training can complement aerobic exercises
  • Regarding the weekly dose of aerobic PA required to treat ED successfully, a volume of four sessions of moderate- to high-intensity training lasting 40 minutes per session, corresponding to a weekly dose of 160 minutes is recommended.

Other important non-pharmacologic interventions such as diet, weight loss, pelvic floor muscle training, and smoking cessation also improve erectile function for men with arterial ED, recommend Gerbild and team.