This paper describes several aspects of erectile dysfunction (ED). The ED incidence increases with age and the number of older men is on the rise due to the increasing life expectancy. Therefore, the number of men with ED increases and ED became a problem of public health. Vasculogenic ED is particularly important. Symptomatic cardiovascular diseases (CVD), such as ischemic heart disease or hypertension, are often associated with ED. It is partly related to cardiovascular risk factors (smoking, sedentary lifestyle, obesity, diabetes, dyslipidaemia) and to medications (thiazides, b-blockers, quinidine, amiodrone). In men aged <60 without known CVD, ED may be a marker of cardiovascular status. A man in his forties who reports an onset of ED should be considered a “cardiac patient” until proven otherwise.
The most important part of the diagnosis of ED is history taking. In case of psychogenic ED it helps to establish predisposing, precipitating and maintaining factors. In some cases, it may reveal severe psychosocial disorders necessitating psychiatric therapy. It also helps to identify the presence of factors increasing the risk of ED (lifestyle, concomitant diseases, drugs). The assessment of the patient’s opinions on his sexual performance, masculinity, penile length and on his attitude to sex should be a part of history taking. Interviewing the patient’s partner is also advisable. Local physical examination permits to assess organic congenital and acquired diseases. Laboratory investigations should comprise fasting blood sugar, lipid profile and testosterone. The patient’s cardiovascular risk should be also assessed.
The therapeutic choice should be based on the specific problems of the patient. Psychosexual therapy (of the patient or of the couple) is recommended in the psychogenic ED. However, the efficacy of this treatment has not been appropriately investigated. Smoking cessation, weight loss and physical exercise improve erectile function and augment the efficacy of other types of therapy. Selective phosphodiesterase type 5 inhibitors (PDE5-Is) are the mainstay of the treatment of ED. However, their efficacy is 65% and they are contraindicated in men with severe CVD or taking some types of drugs. The failure of PDE5-Is may be related to the underlying diseases (e.g. diabetes, severe CVD, hypogonadism). Thus, its management should include the treatment of the underlying disease. Decision on other options (intracavernosal injection, vacuum constrictive device, penile prosthesis) depends on the health status of the patient, his preferences and on the failure or side effects of other therapeutic methods.
This paper presents useful hints for the management of ED. It will probably elicit a discussion of experts in the field which may be interesting for physicians in charge of patients with ED.