© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
Definition and prevalence
For years, the terms impotence and ED were used
interchangeably to denote the inability of a man to
achieve or maintain an erection sufficient to permit
satisfactory sexual intercourse.
4
Social scientists
objected to the impotence label, because of its pejorative
implications and lack of precision.
5
AnNIHConsensus
Development Conference suggested that ED be used
in place of the term impotence to signify “an inability
of the male to achieve an erect penis as part of the
overall multifaceted process of male sexual function.”
6
This de-emphasized intercourse as the sine qua non of
sexual life and gave equal importance to other aspects
of male sexual behavior. Sigal et al studied data onmen
20 years and older collected via The National Health
and Nutrition Examination Survey (NHANES) that
included medical histories in which specific queries
were made regarding sexual function.
7
ED was
reported by nearly 1 in 5 respondents.
7
Hispanic men
were more likely to report ED (odds ratio [OR], 1.89),
after controlling for other factors. The prevalence of
ED increased substantially with advanced age, and
77.5% of men ≥ 75 years were affected.
7
ED can be categorized as organic (vasculogenic) or
psychogenic or mixed, Table 1. In general, primary
vasculogenic ED is characterized by a gradual onset.
Erectile rigidity may be weakened, duration may
be shortened, or both. These changes occur slowly,
initially irregularly, and eventually are evident under
most or all circumstances, be it with the morning
erection, nocturnal erection, or sexually-stimulated
erection.
8
Situational ED, such as that occurring with a
partner but notwithmorning erections ormasturbatory
behavior, is usually considered psychogenic in origin.
8
Either Doppler duplex penile imaging or nocturnal
penile tumescence testing (Rigiscan) can validate
this, though is often not necessary in primary care
management.
Comorbidities and cardiometabolic risk
As mentioned, the cascade of metabolic parameters
associated with ED can lead to early endothelial
dysfunction and eventually, late CVS events. This
article will initially focus on the metabolic work
up of the ED patient and the evolving concept of
“cardiometabolic risk.”
Cardiometabolic risk entails the risk of developing
any of the following: type 2 diabetes (T2DM),
cardiovascular disease (CVD), or metabolic syndrome
(MetS). The assessment of cardiometabolic risk uses
traditional risk factors such as smoking, high LDL-C
cholesterol, hypertension, and elevated serumglucose
as well as emerging risk factors closely related to
abdominal obesity, especially intra-abdominal or
visceral obesity. The relationship between traditional
CVS risk factors (hypercholesterolemia, hypertension
and smoking) and the occurrence of CVS events is
well understood. Our increasing understanding of
the pathophysiology of CVD is now defining value of
a range of new CVS risk factors. Risk stratification for
future CVS events requires measurement tools of CVD
risk that must be valid in the general male population,
andmeasurement tests or biomarkers that help predict
cardiac risk.
9
Though not included in most CVS risk
engines such as Framingham, ED should become part
of this CVD risk assessment in the male.
Traditional models of CVS risk such as Framingham
Risk Score (FRS) are weighted toward age, and 80% of
TABLE 1.
Differential characteristics of psychogenic versus organic erectile dysfunction
8,13
Characteristic
Predominantly
Predominantly
psychogenic ED organic ED
Onset
Acute
Gradual
Circumstances
Situational
Global
Course
Intermittent
Constant
Noncoital erection
Rigid
Poor
Nocturnal/early morning erections
Normal
Inconsistent
Psychosexual problems
Long history
Secondary to ED
Partner problems
At onset
Secondary to ED
Anxiety/fear
Primary
Secondary to ED
ED = erectile dysfunction
26
Miner ET AL.
