© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
inflammatory profile. Inflammatory markers, such as
IL-6,
93,94
TNF-apha,
93
or hsCRP,
94
are elevated and have
been associated with impaired endothelial function,
CVS events, and ED.
93,94
High-sensitivity C-reactive protein is a potential
marker of incident or future CVD that has not been
tested in ED-specific populations.
95
However, hsCRP
has been endorsed by the Centers for Disease Control
and Prevention and the AHA as an adjunct to global
risk prediction.
96
The ACCF/AHA guidelines
53
state
that measurement of hsCRP may be reasonable in
asymptomatic, intermediate risk men ≤ 50 years
of age. Results of the JUPITER study suggest that
measurement of hsCRP may useful in the selection of
patients for statin therapy.
97
Although data supporting the use of these emerging
markers to predict CVD outcomes in men with ED
are limited, evidence supporting the utility of these
markers in other populations is expected to extend to
ED populations.
53
From the above evidence and our experience, we
propose the following metabolic investigation of men
with ED, including anthropomorphic and vital sign
measurements:
• 2013 ASCVD Risk Estimator
• Waist circumference measured at the umbilicus
• Blood pressure/heart rate
• Fasting insulin and glucose levels
• Baseline renal function (BUN/creatinine)
• Fasting lipid profile
• Morning total testosterone level
• hs CRP
• Vitamin D325(OH)D
3
If any doubt with use of the 2013 ASCVD Risk
Estimator, then CT calcium scoring may clarify risk
and treatment options.
When we examine the use of biomarkers, we must
distinguish between screening to define a population
at risk that we are not currently treating, or reducing
surrogate endpoints (eg. MI, acute coronary syndrome,
stroke). These questions, together with the issue
posed by Thompson:
45
“Could erectile dysfunction
serve as a surrogate measure of treatment efficacy in
preventive interventions for cardiac disease?” can only
be answered by further studies of CVD prevention
strategies in men with largely vasculogenic ED. Men
with primary organic ED with or without CVS risk
factors, should be considered an ‘intermediate’ risk
group for future CVS events. It is this group of men,
particularly under the age of 60 years, whomay benefit
from utilization of some of these surrogate markers
of cardiometabolic risk in a cost-effective manner to
stratify them for subsequent aggressive treatment of
preventative CVS risk factors. These men, many of
whom may be missed by the traditional Framingham
risk criteria, may find this risk elaboratedwith prudent
use of these biomarkers or imaging studies. Only
further studies of men with vasculogenic ED and
preventative measures will provide evidence as to
which of the surrogate markers are impactful and
efficacious in the delineation of such risk.
Treatment of ED
Treatment plans need to be goal oriented, ideally
aimed at satisfying the needs of both the man and
his partner and maximizing the chance of achieving
patient satisfaction. Based on the desired outcome,
treatment can be simply pharmacologic, or may require
further comprehensive psychosocial and relationship
counseling. In many cases, the partner can be brought
in to participate in the discussion about the goal of
treatment improving the chance of success.
Educational and psychosocial interventions
In most cases, regardless of etiology, the treatment
options of the physiologic impairment of ED are the
same. Education is the first step in treatment and is
personalized to the needs of the specific patient. The
normal physiological changes associatedwith aging are
often misunderstood by patients and lead to problems.
Myths and misunderstandings about sexual activity
can directly cause sexual difficulties as well as generate
anxiety, guilt andworry that negatively impact on sexual
response and erectile ability.
98,99
Helping men to have
realistic expectations and to better understand healthy
function and honest, constructive communication
with partners can encourage more satisfactory sexual
interaction and a healthier sense of sexual function.
Research has demonstrated that the amount of sexual
intimacy correlates with relationship satisfaction.
100,101
The easily obtained erection begins to disappear in
older men, especially those with chronic illness, such
as diabetes, hypertension, or renal disease. Direct
tactile stimulation of the penis may be needed to
obtain and maintain an erection. The man becomes
increasingly anxious thereby causing further erectile
difficulties with the enhancement of “performance
anxiety”. Thus, information from the clinician about
these changes of aging can be extremely reassuring.
Partner issues vary widely. Issues around partner
choice, partner participation in sexual activity, and
partner physiology may influence erectile function.
When vaginal dryness, or vaginal atrophy leads to loss
of lubrication and pain, women often lose interest in
continued sexual activity.
32
Miner ET AL.
