Treatment of Erectile Dysfunction
A variety of medical and nonmedical options can be used to treat vascular ED. Lifestyle changes, such as weight loss, exercise, dietary changes, cessation of smoking, and reduced alcohol consumption, help treat ED and prevent the development of CVD. These modifiable behaviors should be the first interventions addressed with patients to improve their ED and their cardiovascular health.23
A longitudinal study found that men who initiated physical activity for the first time in midlife had a reduced risk for ED compared with those who remained sedentary (odds ratio, 0.3; 95% CI, 0.1-0.6). One-third of men with ED at baseline were able to improve sexual function through lifestyle changes alone.24
Younger men with vascular ED, in particular, should be counseled on their increased risk for atherosclerosis and educated about lifestyle changes that can lower the risk for CVD and mortality and improve quality of life. For example, the risk for death from CVD declines by half after 5 years of stopping smoking. Thus, smoking cessation should be encouraged in the younger population.25
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Phosphodiesterase type 5 (PDE5) inhibitors have been proven to be effective in improving ED in patients with cardiovascular risk factors or CVD. These medications allow for corporeal vascular relaxation and penile erection during sexual stimulation.26 This class of medications also has been shown to improve cardiovascular functioning by increasing the ischemic threshold.27 Three PDE5 inhibitors have been approved by the US Food and Drug Administration: sildenafil, tadalafil, and vardenafil. The drugs are the mainstay of the pharmacologic treatment for ED and have been shown to improve hypertension and endothelial changes in patients with CVD.19 These drugs do not increase the risk for cardiovascular events, such as ischemia, myocardial infarction, and myocardial hypertrophy, and can be safely coadministered with anti-hypertensive medications, statins, and most other medications. However, patients should avoid taking nitrates while taking PDE5 inhibitors because a severe drop in blood pressure may occur if these agents are used together.28
Aspirin, a medication known for its antiplatelet activity, also has been studied in patients with ED. In a study comparing aspirin and tadalafil, both medications were proven effective in the treatment of vascular ED; however, a combination of tadalafil and aspirin showed greater efficacy compared with aspirin or tadalafil alone.29 In addition, the analgesic and anti-inflammatory effects of aspirin decrease side effects of tadalafil, such as headache, back pain, extremity pain, flushing, and myalgia. Aspirin also may delay the onset of penile atherosclerosis by inhibiting platelet activity, reducing proinflammatory mediators, and decreasing vascular smooth muscle cell proliferation.29
Low intensity shock-wave therapy (LISWT) is a more invasive treatment option for men with vascular ED. While the mechanism of action of LISWT is unclear, it is believed that the compression and negative pressures created by this therapy lead to shear stress on cell membranes, causing an increased expression of vascular endothelial growth factor and resulting in neovascularization of penile arteries.30
For patients taking β-blockers for heart failure or hypertension who experience ED, practitioners should consider nebivolol, a β-blocker that is less likely to cause difficulty with obtaining and maintain an erection.19
Conclusion
Healthcare providers should discuss cardiovascular risk factors in all patients with ED. Men with any sexual dysfunction should be screened for CVD and educated promptly about lifestyle management. Early detection and comanagement of CVD risk factors in men with ED is beneficial to promote sexual well-being and prevent CVD.5
Melissa Long, PA-C, is a recently graduated physician assistant currently working at Doctors Urology and Pelvic Health Specialists in Augusta, Georgia. E. Rachel Fink, MPA, PA-C, is a physician assistant at Augusta Urology Associates and an assistant professor in the Physician Assistant Program at Augusta University.
References
1. Jackson G, Boon N, Eardley I, et al. Erectile dysfunction and coronary artery disease prediction: evidence-based guidance and consensus. Int J Clin Pract. 2010;64(7):848-857. doi:10.1111/j.1742-1241.2010.02410.x
2. Selvin E, Burnett AL, Platz EA. Prevalence and risk factors for erectile dysfunction in the US. Am J Med. 2007;120(2):151-157. doi:10.1016/j.amjmed.2006.06.010.
3. Nguyen HMT, Gabrielson AT, Hellstrom WJG. Erectile dysfunction in young men—a review of the prevalence and risk factors. Sex Med Rev. 2017;5(4):508-520. doi:10.1016/j.sxmr.2017.05.004
4. Pastuszak AW. Current diagnosis and management of erectile dysfunction. Curr Sex Health Rep. 2014;6:164-176. doi.10.1007/s11930-014-0023-9
5. Walczak MK, Lokhandwala N, Hodge MB, Guay AT. Prevalence of cardiovascular risk factors in erectile dysfunction. J Gend Specif Med. 2002;5(6):19-24.
6. Inman BA, Sauver JL, Jacobson DJ, et al. A population-based, longitudinal study of erectile dysfunction and future coronary artery disease. Mayo Clin Proc. 2009;84(2):108-113. doi:10.4065/84.2.108
7. Dzenkeviciute V, Petrulioniene Z, Rinkuniene E, Sapoka V, Petrylaite M, Badariene J. Cardiorenal determinants of erectile dysfunction in primary prevention: a cross-sectional study. Med Princ Pract. 2018;27(1):73-79. doi:10.1159/000484949
8. Shah NP, Cainzos-Achirica M, Feldman DI, et al. Cardiovascular disease prevention in men with vascular erectile dysfunction: the view of the preventive cardiologist. Am J Med. 2016;129(3):251-259 doi:10.1016/j.amjmed.2015.08.038
9. Banks E, Joshy G, Abhayaratna WP, et al. Erectile dysfunction severity as a risk marker for cardiovascular disease hospitalisation and all-cause mortality : a prospective cohort study. PLoS Med. 2013;10(1): e1001372. doi:10.1371/journal.pmed.1001372
10. Deveci S, O’Brien K, Ahmed A, Parker M, Guhring P, Mulhall JP. Can the International Index of Erectile Function distinguish between organic and psychogenic erectile function? BJU Int. 2008;102(3):354-356. doi:10.1111/j.1464-410X.2008.07610.x
11. Same RV, Miner MM, Blaha MJ, Feldman DI, Billups KL. Erectile dysfunction: an early sign of cardiovascular disease. Curr Cardiovasc Risk Rep. 2015;9(49). doi.10.1007/s12170-015-0477-y.
12. Yildirim D, Bozkurt IH, Gurses B, Cirakoglu A. A new parameter in the diagnosis of vascular erectile dysfunction with penile Doppler ultrasound : cavernous artery ondulation index. Eur Rev Med Pharmacol Sci. 2013;17(10):1382-1388.
13. Ponholzer A, Temml C, Rauchenwald M, Madersbacher S. Vascular risk factors and erectile dysfunction in healthy men. Int J Impot Res. 2006;18(5):489-493. doi:10.1038/sj.ijir.3901468
14. Solomon H, Man JW, Jackson G. Erectile dysfunction and the cardiovascular patient: endothelial dysfunction is the common denominator. Heart. 2003;89(3):251-253. doi:10.1136/heart.89.3.251
15. Pohjantähti-Maaroos H, Palomäki A. Comparison of metabolic syndrome subjects with and without erectile dysfunction – levels of circulating oxidised LDL and arterial elasticity. Int J Clin Pract. 2011;65(3):274-280. doi:10.1111/j.1742-1241.2010.02595.x
16. Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623-2629. doi:10.1001/jama.294.20.2623
17. Irwin GM. Erectile dysfunction. Prim Care. 2019;46(2):249-255. doi:10.1016/j.pop.2019.02.006
18. Schwartz BG, Kloner RA. How to save a life during a clinic visit for erectile dysfunction by modifying cardiovascular risk factors. Int J Impot Res. 2009;21(6):327-335. doi:10.1038/ijir.2009.38
19. Nehra A, Jackson G, Miner M,,et al. The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc. 2012;87(8):766-778. doi:10.1016/j.mayocp.2012.06.015
20. Schroeder S, Enderle MD, Ossen R, et al. Noninvasive determination of endothelium-mediated vasodilation as a screening test for coronary artery disease: pilot study to assess the predictive value in comparison with angina pectoris, exercise electrocardiography, and myocardial perfusion imaging. Am Heart J. 1999;138(4 Pt 1):731-739. doi:10.1016/s0002-8703(99)70189-4
21. Tang Z, Li D, Zhang X, et al. Comparison of the simplified International Index of Erectile Function (IIEF-5) in patients of erectile dysfunction with different pathophysiologies. BMC Urol. 2014;14:52. doi:10.1186/1471-2490-14-52
22. Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Peñ BM. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 1999;11(6):319-326. doi:10.1038/sj.ijir.3900472
23. Esposito K, Giugliano F, Maiorino MI, Giugliano D. Dietary factors, Mediterranean diet and erectile dysfunction. J Sex Med. 2010;7(7):2338-2345. doi:10.1111/j.1743-6109.2010.01842.x
24. Derby CA, Mohr BA, Goldstein I, Feldman HA, Johannes CB, McKinlay JB. Modifiable risk factors and erectile dysfunction: can lifestyle changes modify risk? Urology. 2000;56(2):302-306. doi:10.1016/s0090-4295(00)00614-2
25. Prabhat J. The hazards of smoking and the benefits of cessation: a critical summation of the epidemiological evidence in high-income countries. eLife. 2020;9:e49979. doi:10.7554/eLife.49979
26. Gazzaruso C, Solerte SB, Pujia A, et al. Erectile dysfunction as a predictor of cardiovascular events and death in diabetic patients with angiographically proven asymptomatic coronary artery disease: a potential protective role for statins and 5-phosphodiesterase inhibitors. J Am Coll Cardiol. 2008;51(21):2040-2044. doi:10.1016/j.jacc.2007.10.069
27. Thadani U, Smith W, Nash S, et al. The effect of vardenafil, a potent and highly selective phosphodiesterase-5 inhibitor for the treatment of erectile dysfunction, on the cardiovascular response to exercise in patients with coronary artery disease. J Am Coll Cardiol. 2002;40(11):2006-2012. doi:10.1016/s0735-1097(02)02563-9
29. Vlachopoulos C, Ioakeimidis N, Rokkas K, Stefanadis C. Cardiovascular effects of phosphodiesterase type 5 inhibitors. J Sex Med. 2009;6(3):658-674. doi: 10.1111/j.1743-6109.2008.01107.x
29. Bayraktar Z, Albayrak S. Efficacy and safety of combination of tadalafil and aspirin versus tadalafil or aspirin alone in patients with vascular erectile dysfunction: a comparative randomized prospective study. Int Urol Nephrol. 2019;51(9):1491-1499. doi:10.1007/s11255-019-02211-4
30. Brunckhorst O, Wells L, Teeling F, Muir G, Muneer A, Ahmed K. A systematic review of the long-term efficacy of low-intensity shockwave therapy for vasculogenic erectile dysfunction. Int Urol Nephrol [Internet]. 2019;51(5):773-781. doi:10.1007/s11255-019-02127-z
