Erectile dysfunction (ED) is a common medical condition that affects approximately 100 million men worldwide and is currently recognized as a major public health problem. It is estimated that nearly one half of men older than 40 years have some degree of ED. It is projected that by 2025, more than 320 million patients will be afflicted with the largest projected increases in the developing world. Both ED and coronary artery disease (CAD) commonly coexist and share risk factors such as obesity, metabolic diabetes, smoking, hypertension, and metabolic syndrome. There is evidence that rather than being a disease of the penile vasculature, ED may be a manifestation of a systemic vascular disease. Since symptoms of ED often appear before that of CAD due to the smaller size of the penile vasculature, it can serve as a potential CAD risk equivalent.
The overall prevalence of ED has been reported to be 16-25 per cent in the general population depending on the cohort of study and the definition of ED being applied. Age is a strong determinant of occurrence of ED, and epidemiological studies indicate a strong relationship between ED and advancing age. While men aged 50-59 years have a 3.6 times higher risk of developing ED as compared to those aged 18-29 years, the risk is even higher (6-7 times) among males older than 70 years. Age-related hormonal, metabolic and inflammatory as well as increased prevalence of other risk factors for ED in the older population may be responsible for this association. When ED occurs in younger males, it is associated with a greater increase in the risk of future cardiac events as compared to its first detection in older males. Therefore, younger men with early-onset ED may be the ideal candidates for intensive cardiovascular risk factor screening and medical interventions.
Should patients with ED be routinely screened for CAD
Men with ED have been reported to have a two-fold higher risk for acute myocardial infarction (MI) after adjusting for covariates such as age, smoking, obesity and use of cardiac medications. Although ED is an early manifestation of atherosclerosis, an exhaustive cardiologic screening for all such patients might not prove cost-effective. Detailed cardiac screening would be more beneficial for patients suffering from ED who are at high risk for Cardiovascular assessment (eg, with multiple CV risk factors and those with ED onset at a younger age). Patients with ED must undergo a detailed medical assessment along with measurement of BP, fasting lipid profile and glucose levels 24-26. Patients are categorized into low, intermediate, and high risk based on the long-term CV risk and the ability to sustain sexual activity based on their physiological reserve. High-risk patients need evaluation by specialized tests including echocardiography and exercise or nuclear stress testing to detect inducible myocardial ischaemia. Other tests which assess alternate measures of atherosclerosis may also be used, for example, brachial artery flow-mediated vasodilatation, peripheral arterial tonometry, carotid artery intimal medical thickness and ankle-brachial index.Treatment of patients with ED
It is often challenging because of possible adverse effects of CV medications used to treat ED. It is important to stabilize CV status before initiating treatment for ED. Regular exercise should be practiced by patients suffering from ED so that there is minimum risk of getting a cardiac arrest during or after the exercise. Low-risk patients can engage in sexual activity and participate safely in an exercise program; they need regular follow up and drugs for ED may be prescribed without additional cardiac testing. For intermediate- to high-risk patients, CVD management should be prioritised, and they should avoid sexual activity till the cardiac condition is evaluated by detailed cardiac assessment, managed, and stabilized. Risk factor management for all patients with ED is essential and includes maintenance of optimal body weight, adequate physical activity, smoking cessation, and management of associated risk factors. Lifestyle interventions, although unlikely to reverse ED, are usually recommended for the overall health benefits.
Alternatively, there are other ways the andrologist may help to treat it and these may include complementary or alternative therapies such as couple counseling or psychosexual counseling. However, ensure that an andrologist must be consulted before availing any of these options for the correct guidance and treatment.
The author is a consultant andrologist at NU Hospitals and NU Fertility, Bangalore.
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