1. Section I: Clinical and epidemiological correlates of erectile dysfunction and cardiovascular disease
Prevalence of sexual dysfunction in US adults
Content Points:
Sexual dysfunction is common in both sexes.1
43% of women report either low sexual desire, arousal problems, or sexual pain.
31% of men report premature ejaculation, erectile dysfunction (ED), or low sexual desire.
Experience of sexual dysfunction is more likely among women and men with poor physical and emotional health.

2. Epidemiology of erectile dysfunction
Content Points:
Data from the Massachusetts Male Aging Study (MMAS) show that 34.8% of men aged 40 to 70 years have moderate to complete ED that is strongly related to age, health status, and emotional function.1,2
Risk rises sharply with age, with a 3.6-fold greater prevalence in men aged 50 to 59 compared with men aged 18 to 29.1
Over 600,000 new cases occur annually in the United States in white males aged 40 to 69 years.3

3. Age-related comorbidities in males
Content Points:
Age-related comorbidity in males with ED include:
- Cardiovascular disease (CVD)
- Benign prostatic hyperplasia
- Depression

4. Classification of erectile dysfunction
Content Points:
Vasculogenic dysfunction may be arterial or cavernosal, and includes4:
- Arterial dysfunction-from focal stenosis of common penile artery or via arterial stenotic lesions
- Veno-occlusive dysfunction-from formation of large venous channels draining the corpora cavernosa, degenerative changes to tunica albuginea, traumatic injury, structural alterations of cavernous smooth muscle and endothelium, poor relaxation of trabecular smooth muscle, and shunts to correct priapism
Psychogenic dysfunction
Neurogenic dysfunction-from Parkinson's or Alzheimer's disease, stroke, cerebral trauma, or spinal cord injuries.4
Hormonal dysfunction caused by4:
- Androgen deficiency
- Hyperprolactinemia
Drugs inducing dysfunction include4:
- Antipsychotic, antidepressant, and centrally acting antihypertensive drugs
- ß-adrenergic-blocking drugs, which potentiate a1-adrenergic activity in the penis
- Thiazide diuretics
- Spironolactone
- Cigarette smoking induces vasoconstriction and penile venous leakage
- Alcohol in large amounts causes central sedation, decreased libido, and ED; chronic alcoholism can lead to hypogonadism and polyneuropathy
- Cimetidine, a histamine H2-receptor antagonist, acts as an antiandrogen and can lead to hyperprolactinemia
- Estrogens and drugs with antiandrogenic action, eg, ketoconazole and cyproterone acetate
Other systemic diseases or aging4:
- Aging men experience declining sexual function
- Chronic diabetes mellitus causes ED in about 50% of diabetic men
- Chronic renal failure-associated with diminished erectile function, impaired libido, and infertility
- Angina, myocardial infarction (MI), or heart failure (HF) may cause ED due to anxiety, depression, or penile arterial insufficiency

5. Risk factor conditions shared by both erectile dysfunction and cardiovascular disease
Content Points:
Endothelial dysfunction is common to both ED and atherosclerosis. Thus, cardiovascular (CV) risk factors are also risk factors for ED. Diabetes, hypertension, dyslipidemia, smoking, and aging are significantly linked to ED. These risk factors act synergistically and adversely affect endothelial function.5
ED is commonly associated with diabetes mellitus, and may affect more than half of diabetic men.6
A significant correlation of hypertension with ED is seen in epidemiological studies; evidence suggests that underlying vascular disease causing hypertension contributes more to ED than side effects from antihypertensive medication.
Men with hypercholesterolemia suffer impairment of endothelium-dependent relaxation in various vascular beds that may be reversible with lipid-lowering agents.
Chronic cigarette smoking is a major risk factor for ED because of the effects of cigarette smoke on the vascular endothelium and peripheral nerves. There is also evidence for a progressive additive effect of cigarette smoking on the development of atherosclerosis.
Healthy aging men experience a decline in sexual function, including ED; aging men are also at increased risk for CVD, which in turn can contribute to ED.

6. Association of erectile dysfunction and CV risk
Content Points:
Fifty 40- to 60-year-old males asymptomatic for CV but with ED of presumed vascular origin underwent CV stress testing, risk profile analysis, and angiography.7
Multiple CV risk factors were found in 80% of patients.
Exercise testing was abnormal in 46% of patients.
There was a high prevalence of angiographic coronary artery disease (CAD).
Thus, ED is a marker for silent CVD.

7. Erectile dysfunction in hypertensive men
Content Points:
ED is very common among hypertensive men.
Villa et al found an overall prevalence of 31%: 5% in men ages 40 to 49 years; 57% in men >70 years.8
Age-adjusted ED prevalence correlated with current systolic blood pressure (BP), but not with diastolic BP.
Multivariate analysis shows ED is positively associated with depression, prostate disease, diuretics, and diabetes. Men treated with two or more drugs have a significantly higher prevalence of ED than untreated men (odds ratio [OR] 3.8).

8. Degree of ED related to extent of CAD
Content Points:
The relation of ED to extent of CAD was studied in 40 patients (mean age 56.6 years; range years) with ischemic heart disease.9,10
As shown on the slide, ED correlates with severity of CAD. The authors recommend that urologists treating ED inform their patients of this correlation. Likewise, cardiologists should also recognize this correlation and query patients about ED, in order to recommend urologic follow-up when needed.