Lifestyle management in ED with concomitant risk factors

Lifestyle management in ED with concomitant risk factors

The basic work-up must identify reversible risk factors for ED. Lifestyle changes and risk factor modification
must precede or accompany ED treatment. These guidelines include lifestyle modification (e.g. weight loss,
exercise) for ED, but also address psychosocial issues, adverse side-effects of prescription or non-prescription
drugs and the presence of hypogonadism as a modifiable aetiology or comorbidity of ED. 
The potential benefits of lifestyle changes may be of special relevance in individuals with ED and
specific comorbid cardiovascular or metabolic diseases, such as diabetes or hypertension (9,29,30). For these
men, the positive consequences of aggressive lifestyle changes may be of special benefit not only for
improving erectile function, but also for improving overall cardiovascular and metabolic health. Recent studies
support the potential value of lifestyle intervention, for both ED and overall health benefits (10).
Clearly, further studies are needed to expand and clarify the role of lifestyle changes in the manage-
ment of ED and related cardiovascular disease (CVD). Lifestyle changes may be recommended independently
or in combination with PDE5 therapy. Some studies have suggested that the therapeutic effects of PDE5
inhibitors may be enhanced if other co-morbidities or risk factors are aggressively managed (31). Although
suggestive, these results have yet to be confirmed in well-controlled, long-term studies. Given the success of
pharmacological therapy for ED, clinicians in the future will need to provide specific evidence for the potential
benefits of lifestyle change. Hopefully, further evidence for these benefits will become available in the future.

Specialized diagnostic tests ED

Nocturnal penile tumescence and rigidity (NPTR)

The nocturnal penile tumescence and rigidity (NPTR) assessment should take place for at least two nights. 
The presence of an erectile event of at least 60% rigidity recorded on the tip of the penis, which lasts for 
10 minutes or more, should be considered as indicative of a functional erectile mechanism (24).

Intracavernous injection test

The intracavernous injection test offers limited information regarding vascular status. A positive test is defined
as a rigid erectile response (unable to bend the penis) that appears within 10 minutes after the intracavernous
injection and lasts for 30 minutes (25). Such a response may indicate a functional but not necessarily normal
erection, since an erection may coexist with arterial insufficiency or veno-occlusive dysfunction (26). Its clinical
implication is that the patients will respond to the intracavernous injection programme. In all other cases, the
test is inconclusive, and a duplex ultrasound of the penile arteries should be requested.

Duplex ultrasound of penile arteries

A peak systolic blood flow higher than 30 cm/sec and a resistance index higher than 0.8 are generally conside-
red to be normal (25). There is no need to continue vascular investigation when the duplex examination is normal.

Arteriography and dynamic infusion cavernosometry or cavernosography (DICC)

When it is abnormal, arteriography and dynamic infusion cavernosometry or cavernosography should be
performed only for patients who are considered potential candidates for vascular reconstructive surgery.

Psychiatric assessment

Patients with psychiatric disorders must be referred to a psychiatrist particularly interested in ED. For younger
patients (<40>

Penile abnormalities

Patients with ED due to penile abnormalities, such as hypospadias, congenital curvature, or Peyronie’s disease
with preserved rigidity, may require surgical correction with high success rates.

Pathophysiology of erectile dysfunction

Pathophysiology of erectile dysfunction

Vasculogenic
-
Cardiovascular disease
-
Hypertension
-
Diabetes mellitus
-
Hyperlipidaemia 
-
Smoking 
-
Major surgery or radiotherapy (pelvis or retroperitoneum)
•
Neurogenic
-
Central causes 
-
Multiple sclerosis
-
Multiple atrophy
-
Parkinson’s disease
-
Tumours
-
Stroke
-
Disk disease
-
Spinal cord disorders
-
Peripheral causes 
-
Diabetes mellitus
-
Alcoholism
-
Uraemia 
-
Polyneuropathy 
-
Surgery (pelvis or retroperitoneum)
•
Anatomical/structural
-
Peyronie’s disease
-
Penile fracture
-
Congenital curvature of the penis
-
Micropenis
-
Hypospadias, epispadias
•
Hormonal
-
Hypogonadism
-
Hyperprolactinemia
-
Hyper- and hypothyroidism
-
Cushing’s disease
•
Drug-induced
-
Antihypertensives (of all classes, most common by diuretics and beta-blockers)
-
Antidepressants 
-
Antipsychotics
-
Antiandrogens
-
Antihistamines
-
Recreational drugs (heroin, cocaine, methadone)
•
Psychogenic
-
Generalized type (e.g. lack of arousability and disorders of sexual intimacy)
-
Situational type (e.g. partner-related, performance-related issues or due to distress)

Sexual history
The sexual history may include information about previous and current sexual relationships, current emotional
status, onset and duration of the erectile problem, as well as possible previous consultations and treatments.
Detailed descriptions of the quality of both erotic and morning erections, in terms of rigidity and duration, as
well as arousal, ejaculation and orgasmic problems, should be discussed. The use of validated questionnaires,
such as the International Index for Erectile Function (IIEF), may be helpful in order to assess all sexual function
domains (erectile function, orgasmic function, sexual desire, ejaculation, intercourse and overall satisfaction),
but also the impact of a specific treatment modality .

Physical examination
A focused physical examination must be performed on every patient, with particular emphasis on the
genitourinary, endocrine, vascular and neurological systems (16). The physical examination may reveal
unsuspected findings, such as Peyronie’s disease, prostatic enlargement or cancer, as well as the signs and
symptoms indicative of hypogonadism (small testes, alterations in secondary sexual characteristics, diminished
sexual desire, and changes in mood) (17). A rectal examination should be performed in every patient older than
50 years. Blood pressure and heart rate should be measured if they have not been assessed in the previous 
3-6 months. Particular attention must be given to patients with cardiovascular disease.
Laboratory testing
Laboratory testing must be tailored to the patient complaints and risk factors. All patients must undergo a
fasting glucose and lipid profile if not assessed in the previous 12 months. Hormonal tests must include a

Managing ED: implications for the every-day clinical practice

Managing ED: implications for the every-day clinical practice

The advances in basic and clinical research in ED made during the last 15 years has led to the development of
several new treatment options for ED, including new pharmacological agents for intracavernous, intraurethral,
and, more recently, oral use (11-13). Reconstructive vascular surgery is associated with poor outcomes in long-
term follow-up (14,15). As a result, treatment strategies have been significantly modified.
The current availability of effective and safe oral drugs for ED, together with the tremendous media
interest in this condition, has resulted in an increasing number of men seeking help for ED. Many physicians
without background knowledge and clinical experience of the diagnosis and treatment of ED are involved in
decision-making concerning the evaluation and treatment of these men. Therefore, some men with ED may
undergo little or no evaluation before treatment is initiated, or men without ED may seek treatment in order to
enhance their sexual performance. In such circumstances, the underlying disease causing the symptom (ED)
may remain untreated. Such observations have made the development of guidelines for the diagnosis and
treatment of ED, a necessity.

Epidemiology and risk factors. Male erectile dysfunction

Male erectile dysfunction has been defined as the persistent inability to attain and maintain an erection

sufficient to permit satisfactory sexual performance. Although erectile dysfunctionis a benign disorder, it is related to physical
and psychosocial health, and has a significant impact on the quality of life of both sufferers and their partners
and families.
Recent epidemiological data have shown a high prevalence and incidence of erectile dysfunctionworldwide. The first
large-scale, community-based study, Massachusetts Male Aging Study (MMAS), reported a combined
prevalence of 52% erectile dysfunction in non-institutionalized 40 to 70-year-old men in the Boston area (2). In this study, the
individual prevalences were 17.2, 25.2 and 9.6 for minimal, moderate and complete erectile dysfunction, respectively. In the
Cologne study (men 30-80 year-old), the prevalence of ED was 19.2%, with a steep age-related increase 
(2.3-53.4%) (3), while the prevalence of sexual dysfunctions (not specific ED) in the National Health and Social
Life Survey was 31% (4). Analysis of the longitudinal results from the MMAS study estimated that the incidence
of ED was 26 new cases per 1000 men annually (5), while the incidence rates (new cases per 1000 men annually)
of ED in a Brazilian (6) and in a Dutch (7) study were estimated at 65.6 (mean follow-up 2 years) and 19.2 (mean
follow-up 4.2 years), respectively. Differences in these studies can be explained by the methodology design of
the different surveys, the age and the socio-economic status of the populations studied.
Erection is a neurovascular phenomenon under hormonal control. It includes arterial dilatation,
trabecular smooth muscle relaxation and activation of the corporeal veno-occlusive mechanism (8). Several risk
factors have been identified based on the knowledge of physiology or erection. Actually, it became clear that
ED shares common risk factors with cardiovascular disease as the lack of exercise, obesity, smoking,
hypercholesterolaemia and the metabolic syndrome. Several life-style risk factors can be modified. In the
MMAS, men who initiated physical activity in midlife had a 70% reduced risk for ED relative to those who
remained sedentary, while in its longitudinal results, regular exercising showed a significantly lower incidence of
ED over an 8-year follow up period (9). A multicentre, randomized, open-label study compared 2 years of
intensive exercise and weight loss with an educational control in obese men with moderate ED (10). 
Significant improvements in body mass index (BMI) and physical activity scores, as well as in erectile function
were observed in the lifestyle intervention group, while those changes were highly correlated with both weight
loss and activity levels. However, it should be emphasized that controlled prospective studies are necessary to
determine the effects of exercise or other lifestyle changes in prevention or treatment of ED.