Erectile Dysfunction: A Urologic 'Canary in a Coal Mine'

Ingrid Hein

July 21, 2020

Erectile dysfunction might well be the "canary in a coal mine" of men's health, indicating that men need to "metaphorically evacuate" before they develop life-threatening disorders, said Arie Parnham, MD, from the Christie NHS Foundation Trust in Manchester, United Kingdom.

More than half of all men 40 to 70 years of age have experienced erectile dysfunction — defined in EAU guidelines as "an inability to attain or maintain an erection sufficient for sexual performance" — according to the Massachusetts Male Aging Study.

Many of these men have multiple comorbidities, the most prevalent of which is coronary artery disease, Parnham explained during his presentation at the European Association of Urology 2020 Congress.

The link between erectile dysfunction and coronary artery disease was first made by Italian researchers in a 2003 study of 300 men with acute chest pain and angiographically documented coronary artery disease. The prevalence of erectile dysfunction in the study cohort was 49%, and in 70% of those men, the onset occurred in the 40 months preceding their diagnosis of coronary artery disease.

Then, a 44% increase in the risk for cardiovascular events, a 62% increase in the risk for myocardial infraction, and a 25% increase in the risk for all-cause mortality were seen in a 2013 systemic review of 14 studies — a pool of 92,757 men with erectile dysfunction — with a mean follow-up of 6.1 years.

"Younger people were at higher risk" the systemic review showed, said Parnham, which "highlights the importance of screening in this group."

An association between mortality risk and erectile dysfunction (hazard ratio [HR], 1.40; P = .001) and poor morning erections (HR, 1.30; P = .012) was shown in an analysis of data from the European Male Ageing Study, recently presented at ENDO 2020, as reported by Medscape Medical News. Penile arteries are smaller than coronary arteries, which might be why they provide warning signs of coronary disease, the researchers hypothesized.

In fact, the "artery size hypothesis" was put forward by the team that identified the link in 2003, Parnham said. "At the point the penile vessels are 50% depleted, the larger [coronary] vessels aren't." But 2 to 3 years later, penile artery stenosis has progressed, and by then, stenosis in the coronary arteries is in the 50% range.

Many of the men with atherosclerosis and subsequent stenosis have a combination of "poor diet, diabetes or glucose intolerance, and smoke, are obese, and live sedentary lifestyles," he said. Three or more of these attributes is recognized as metabolic syndrome, which causes a proinflammatory prothrombolic state and "leads to endothelial dysfunction."

"We should try to administer a score, such as the QRISK2," to stratify patients in terms of risk, he suggested. Patients with erectile dysfunction should also be assessed for risk of continuing sexual intercourse, using the Princeton II criteria, and "those at high risk should get stress testing."

And smoking history, blood pressure, body mass index, A1c, and fasting glucose should be documented. "We should also encourage increased exercise, Mediterranean diet, stopping smoking, and reducing weight," said Parnham.

In addition, the treatment of obstructive sleep apnea and vitamin D deficiency, which have also been associated with erectile dysfunction, can lead to improvement, he said.

Porn Might Also Cause Erectile Dysfunction

Erectile dysfunction can also be an indication that a patient has an addiction to pornography, said Tim Jacobs, MD, from the University of Antwerp in Belgium, during his presentation.

Jacobs and his colleagues looked at the association between erectile dysfunction and porn in a 5-month study of 3267 men from Belgium and Denmark. All men were 45 years and younger, and 50% were younger than 35 years. All participants completed a 118-question survey on their sexual health.

The researchers found "a clear negative relationship between the number of minutes of pornography watched and the degree of erectile dysfunction," Jacobs reported.

What's more, "we know watching more porn is also related to porn addiction. Higher scores on the porn-addiction questionnaire were associated with worse erectile function," he explained. But other factors need to be closely examined, and "more analysis is necessary to find out which porn watchers are at risk."

Parnham has received travel grants from Coloplast and a speaker fee from Boston Scientific. Jacobs has disclosed no relevant financial relationships.

European Association of Urology (EAU) 2020 Congress. Presented July 17, 2020.

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