A recent article in Nature Reviews Cardiology1 provides a valuable update on what’s known about the relationship between erectile dysfunction, and cardiovascular disease and its treatment.
If you ask Australian men, just over 2% aged 45 to 54 will say they have erectile dysfunction, with the self-reported incidence increasing with age to around 7% aged 55 to 64, 20% aged 65 to 74, 50% aged 75 to 84 and 75% aged 85 years or older but not everyone will answer the question2. In practice, only about half of patients with sexual difficulties seek help from a health professional, and far fewer are asked about sexual difficulties by their doctor3.
Failure to diagnose erectile dysfunction, regardless of the reason, is a missed opportunity to improve the quality of life for men and their sexual partners4. It’s also a missed opportunity to save men’s lives.
Erectile dysfunction is an independent risk factor for cardiovascular disease (it does not depend on the presence of age, body mass index, blood pressure, diabetes and high cholesterol5), increasing a man’s risk of cardiovascular disease to the same extent as smoking or having a family history of heart attack1, 3. This means the inclusion of erectile dysfunction in cardiovascular risk prediction models can improve the ability to identify men at risk of adverse cardiovascular events, like heart attack, stroke and death1.
In fact, erectile dysfunction often precedes cardiac symptoms of cardiovascular disease by around three years1. Several studies using computed tomography angiography show a remarkably high prevalence of clinically silent coronary artery atherosclerotic plaques among men with erectile dysfunction, suggesting a potential mechanism for the temporal relationship between erectile dysfunction and adverse cardiovascular events.
Early detection of erectile dysfunction, therefore, provides an opportunity to initiate treatment that may circumvent an impending adverse event. Unfortunately, there’s not a lot of evidence to guide medical treatment of erectile dysfunction to avoid adverse cardiovascular events, and the effects on sexual function of drugs used to treat cardiovascular disease are not entirely understood1.
The use of phosphodiesterase type-5 inhibitors to treat erectile dysfunction is generally safe in men with cardiovascular disease (but PDE5 inhibitors are strictly contraindicated in men using nitrates), and the drugs may have some beneficial effect on their cardiovascular health1. Lifestyle modifications that reduce the risk of cardiovascular disease are associated with substantial improvements in erectile function along with their overall benefit for health and wellbeing1.
Of course, not all cases of erectile dysfunction are caused by cardiovascular disease; psychological causes are common6. Men with erectile dysfunction but a low baseline risk of cardiovascular disease may be more likely to have psychogenic erectile dysfunction1. Accurate identification of the underlying cause of erectile dysfunction is therefore important for guiding its treatment and counselling men about their risk of cardiovascular disease.
Communication between men and their healthcare providers is critical for timely diagnosis of erectile dysfunction6. Men with erectile dysfunction want to discuss their problem with their doctors and evidence-based guidance for health professionals, a patient questionnaire can be useful for initiating communication6. The International Index of Erectile Dysfunction (IIEF) can be completed by the patient independently and aids diagnosis in general practice1. A list of questions that can be used for taking a sexual history is available7.
Erectile dysfunction is far more than a source of embarrassment and inconvenience. Erectile dysfunction can cloud men’s mental health and their relationships, but diagnosis is straightforward and there are effective treatments. The silver lining is that erectile function can be used to identify men at risk of potentially fatal cardiovascular events years before they would occur, providing time for effective treatment.
 Terentes-Printzios et al., 2021. Interactions between erectile dysfunction, cardiovascular disease and cardiovascular drugs. Nature Reviews Cardiology
 Banks et al., 2013. Erectile Dysfunction Severity as a Risk Marker for Cardiovascular Disease Hospitalisation and All-Cause Mortality: A Prospective Cohort Study. PLOS Medicine
 Moreira et al., 2008. Sexual difficulties and help-seeking among mature adults in Australia: results from the Global Study of Sexual Attitudes and Behaviours. Sexual Health
 Yafi et al., 2016. Erectile dysfunction. Nature Reviews Disease Primers
 Dong et al., 2011. Erectile Dysfunction and Risk of Cardiovascular Disease. Journal of the American College of Cardiology
 Hartmann & Burkart, 2007. Erectile Dysfunctions in Patient–Physician Communication: Optimized Strategies for Addressing Sexual Issues and the Benefit of Using a Patient Questionnaire. The Journal of Sexual Medicine
 Sooriyamoorthy, 2011. Erectile dysfunction. StatPearls https://www.statpearls.com/ArticleLibrary/viewarticle/91330