Not Just a Bedroom Problem: What Erectile Dysfunction May Reveal About Your Health

INTRODUCTION

Erectile dysfunction (ED) is defined as the persistent inability to achieve and maintain an erection sufficient for sexual intercourse [1]. It is not a disease itself, but rather a symptom reflecting underlying physical health disorders and often causing psychological distress for both the patient and their partner. It is also well established that ED may serve as an early marker of cardiovascular disease, thereby enabling earlier diagnosis and prevention of more serious conditions [2, 3].

The exact global prevalence of ED is difficult to determine, but epidemiological studies indicate that it is highly common. According to the Massachusetts Male Aging Study, up to 52% of men aged 40–70 experience some degree of ED, while the Cologne study reported an overall prevalence of 19.2% among men aged 30–80, with frequency increasing significantly with age [4, 5].

ETIOPATHOGENESIS

Erectile dysfunction can arise from multiple causes, including vascular, neurogenic, endocrine, psychogenic, medication-related, or mixed origins. Because of this, the range of risk factors is broad.

One of the primary mechanisms underlying ED is endothelial dysfunction. Therefore, many risk factors overlap with those for cardiovascular disease, including obesity, diabetes mellitus, dyslipidemia, metabolic syndrome, physical inactivity, and smoking.

Neurological causes may result from pelvic surgeries or radiation therapy (most commonly for prostate or rectal malignancies), pelvic trauma, spinal cord injury, multiple sclerosis, or Parkinson’s disease.

Endocrine factors include hypogonadism, hyperprolactinemia, thyroid dysfunction (both hyperthyroidism and hypothyroidism), and disorders of cortisol metabolism, such as Cushing’s syndrome.

Recent epidemiological studies have also demonstrated a strong association between lower urinary tract symptoms and ED, independent of age or comorbid conditions. In the Multinational Survey on the Aging Male study involving more than 12,000 men aged 50–80, ED was diagnosed in 49% of participants, and 90% reported lower urinary tract symptoms [6].

DIAGNOSIS

A thorough medical and sexual history is one of the most important steps in diagnosing ED. Particular attention should be given to penile rigidity, duration of erections (including nocturnal and morning erections), sexual desire, ejaculation, and orgasm.

Standardized questionnaires, such as the International Index of Erectile Function (IIEF), are widely used to facilitate structured and comprehensive assessment [7].

It is also essential to evaluate symptoms of depression, hypogonadism (such as fatigue, decreased libido, and low energy), and lower urinary tract symptoms.

During physical examination, the following systems should be assessed:

• Urogenital system (e.g., Peyronie’s disease, penile tumors, prostate enlargement)
• Endocrine system (e.g., testicular size and development)
• Cardiovascular system
• Neurological system

Laboratory investigations should be tailored to the patient’s condition and may include:

• Morning total testosterone levels
• Prostate-specific antigen (PSA)
• Prolactin and luteinizing hormone
• Lipid profile
• Glucose and glycated hemoglobin

In selected cases, additional diagnostic methods such as penile Duplex ultrasound, angiography, specialized neurological or endocrine testing, and psychiatric evaluation may be required.

Failure to perform adequate diagnostics may result in inappropriate or ineffective treatment.

TREATMENT

Before initiating specific ED treatment, it is strongly recommended to correct modifiable risk factors, such as increasing physical activity, reducing excess weight, quitting smoking, and managing blood pressure. These measures alone can significantly improve treatment outcomes.

In cases where risk factors cannot be corrected (e.g., endocrine disorders), strict disease control is essential.

In most cases, ED treatment is symptomatic. Treatment is considered successful when penile rigidity is sufficient for sexual intercourse. Etiological treatment and complete recovery are possible only in selected cases, particularly when ED is caused by psychogenic, vascular, or endocrine disorders.

PHARMACOLOGICAL TREATMENT

Phosphodiesterase type 5 inhibitors (PDE-5 inhibitors) are the first-line treatment. These medications enhance smooth muscle relaxation in penile tissue, increasing arterial blood flow and enabling erection. Importantly, they do not induce erection without sexual stimulation.

Clinical studies show that effective erections are achieved in more than 80% of patients. However, 60–70% of patients discontinue treatment within 2–3 years, often due to side effects [13].

Currently, four PDE-5 inhibitors are widely used:

• Sildenafil
• Tadalafil
• Vardenafil
• Avanafil

Sildenafil is the first approved PDE-5 inhibitor, typically used in doses of 25–100 mg. The recommended starting dose is 50 mg. Its effectiveness may decrease after fatty meals due to delayed absorption.

Tadalafil is used in doses of 10–20 mg as needed or 5 mg daily. It is not significantly affected by food or alcohol.

Vardenafil is taken in doses of 5–20 mg. Its absorption may also be reduced by fatty meals.

Avanafil is a newer, second-generation PDE-5 inhibitor with rapid onset and high selectivity, resulting in fewer side effects. It is used in doses of 50–200 mg, with 100 mg as the standard starting dose. In severe cases, 200 mg may be used. It can be taken once daily, and dose adjustment is usually not required in elderly patients or those with mild hepatic or renal impairment.

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SAFETY AND CONTRAINDICATIONS

PDE-5 inhibitors do not increase the risk of myocardial infarction but are contraindicated in:

• Recent myocardial infarction or stroke
• Severe arrhythmias
• Hypotension (<90/50 mm Hg)
• Severe hypertension (>170/100 mm Hg)
• Unstable angina
• Severe heart failure (NYHA class IV)

They must not be used with nitrates due to the risk of life-threatening hypotension.

If chest pain occurs after taking these drugs:

• Nitroglycerin should be delayed for 24 hours (sildenafil, vardenafil)
• 48 hours (tadalafil)
• 12 hours (avanafil)

COMMON REASONS FOR TREATMENT FAILURE

Treatment may be ineffective due to:

• Incorrect drug use
• Lack of sexual stimulation
• Inadequate dosage
• Insufficient time before intercourse
• Delayed intercourse after drug intake

OTHER TREATMENT OPTIONS

If PDE-5 inhibitors are ineffective:

Vacuum devices (pumps) can be used, especially in older patients. Constriction should not exceed 30 minutes to avoid complications.

Intracavernosal injections (e.g., alprostadil) are highly effective (up to 85%). The erection occurs within 5–15 minutes without stimulation. Possible side effects include pain, prolonged erection, and priapism.

Intraurethral therapy is less effective (30–65%).

Surgical treatment (penile prosthesis implantation) is considered third-line therapy. It provides high satisfaction rates (over 90%), but carries risks such as mechanical failure.

SUMMARY

Erectile dysfunction is a multifactorial clinical symptom rather than a standalone disease. Accurate diagnosis based on medical history, physical examination, and targeted investigations is essential for selecting appropriate treatment.

Correction of risk factors and patient education are crucial first steps. PDE-5 inhibitors remain the primary treatment option, with other methods reserved for resistant cases.

Proper management can significantly improve both physical and psychological well-being and overall quality of life.

Dr. Arnas Bakavičius
Vilnius University Hospital Santaros Clinics
Urology Center

Source: “Internistas” Journal, Urology Supplement No. 1 (9), 2016