BERKELEY, CA (UroToday.com) - Erectile dysfunction (ED) has a high prevalence that seems to be increasing in developing countries where people are getting older.
Growing number of evidences reinforces ED as an early marker of cardiovascular risk especially in men under 60 years-old.1 Phosphodiesterase-5 (PDE5) inhibitors became first line therapy and changed primary ED management from specialist to clinicians and cardiologists. But when PDE5 inhibitors do not work, usually patients are referred to urologists that should improve the knowledge about possible reasons for lack of efficacy and alternative therapies in such cases.
In this article, we studied hypertensive men with different stages of atherosclerosis and among those without clinical development of major cardiovascular disease, vasculogenic ED severity correlated with carotid intima-media thickness (IMT). Moreover, clinical response to PDE5 inhibitor was worst when peripheral flow mediated dilation was lower. Interestingly, only carotid IMT and ED severity correlated with clinical response among diabetics. These results could suggest that erectile function in hypertensive subjects without clinical atherosclerosis follow structural changes in the arterial tree and PDE5 inhibitors efficacy depends on endothelial nitric oxide availability. Therefore, lack of PDE5 inhibitor efficacy could point out the need of strategies to improve endothelial function rather than auto-injection and prosthesis. This seems to be more logical in terms of ED as part of a systemic vascular disease and could help to avoid other end-organ damages. Several authors are looking for ways to rescue non-responders to PDE5 inhibitors and postpone auto-injection and prosthesis.2 Small trials with long-term use of statins,3 anti-oxidants,4 angiotensin receptor antagonists5 and PDE5 inhibitors6 have shown that erectile function could be improved with oral therapy.
Concerning all these aspects, it is important not only to consider ED as an early marker of cardiovascular risk and part of a systemic vasculopathy, but also to evaluate and treat patients in the same terms. As cardiologists are used to, urologists should implement all therapeutic options to improve endothelial function in order to avoid atherosclerosis progression and end-organ lesions. Urologists should help to stimulate traditional risk factors control and life styles changes linking these attitudes with erectile function preservation, prevention of ED, better clinical response to on demand oral therapy and even penile rehabilitation alternatives.
- Jackson G, Montorsi P, Adams MA, et al. Cardiovascular aspects of sexual medicine. J Sex Med. 2010;7(4 Pt 2):1608-1626.
- Aversa A, Bruzziches R, Francomano D, et al. Endothelial dysfunction and erectile dysfunction in the aging man. Int J Urol. 2010;17(1):38-47.
- Dadkhah F, Safarinejad MR, Asgari MA, et al. Atorvastatin improves the response to sildenafil in hypercholesterolemic men with erectile dysfunction not initially responsive to sildenafil. Int J Impot Res. 2010;22(1):51-60.
- Morano S, Mandosi E, Fallarino M, et al. Antioxidant treatment associated with sildenafil reduces monocyte activation and markers of endothelial damage in patients with diabetic erectile dysfunction: a double-blind, placebo-controlled study. Eur Urol. 2007;52(6):1768-1774.
- Baumhakel M, Schlimmer N, Bohm M. Effect of irbesartan on erectile function in patients with hypertension and metabolic syndrome. Int J Impot Res. 2008;20(5):493-500.
- Shindel AW. 2009 update on phosphodiesterase type 5 inhibitor therapy part 1: Recent studies on routine dosing for penile rehabilitation, lower urinary tract symptoms, and other indications (CME). J Sex Med. 2009;6(7):1794-1808; quiz 1793, 1809-1710.
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