© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
treatment can be planned by the PCP who has good
communication skills about sexual activity and who is
knowledgeable about first-line treatments. Common
indications for referral to an appropriate specialist
include 1) significant penile anatomic disease, 2) a
younger patient with a history of pelvic or perineal
trauma, 3) cases requiring vascular or neurosurgical
intervention, 4) complicated endocrinopathies, 5)
complicated psychiatric or psychosocial problems, or
6) patient or physician desire for further evaluation.
Urologists can be helpful in difficult or complex
ED situations or when the patient presents with an
anatomical problem such as Peyronie’s disease. An
endocrinologist or andrologist may be consulted
to assist in managing men with difficult to control
diabetes, hypogonadism, or evidence of pituitary
dysfunction.
Sex therapists are practitioners in the medical or
mental health field who, in addition to their basic
clinical education, have had additional training in sex
therapy including evaluation and treatment options.
Sex therapists havemore time to talkwith the patient, to
workwith couples suggesting enhancement techniques,
and to educate couples that there are many ways of
having pleasurable sexual relations without a firm
erection. These could be physicians, ministers, and
mental health professionals. TheAmericanAssociation
of SexTherapists andCounselors canprovide adirectory
for your state of trained, certified sex therapists. (www.
aasect.org/Home/).Mostmajor teaching hospitals have
such a trained individual on their staffs.
Conclusion
The metabolic investigation of ED involves primarily
the investigation of metabolic sequellae of visceral
adiposity leading to type 2 DM or CVD. This is
known as cardiometabolic risk. Older models of
cardiovascular risk assessment (FRS) have generally
underestimated risk in younger and middle-aged
populations. The authors of the new risk models
make adjustments for this and introduce the idea
of balancing 10 year risk with lifetime risk to aid in
decision-making in younger and middle-aged adults.
Whether it’s lifetime risk or ED that is used to enhance
10 year risk assessment, the concept is the same: to
discern those who have started down the path of
inflammation, endothelial dysfunction and vulnerable
plaque formation, and thereby intervene somewhere
upstream from the first ASCVD event. Lifetime risk
may be something abstract to most patients, and
current evidence does not support its use to guide
pharmacotherapy. The value is tomotivate therapeutic
lifestyle changes. ED is something tangible. It affects
mental health and quality-of-life. Young and middle-
agedmale patients with ED are likely to make changes
that will have an immediate impact on both their CVS
risk and overall sexual function.
Disclosure
Dr. Martin Miner has been a consultant for Abbvie
and Endo. He has also done research for Forest.
Dr Matt T. Rosenberg has been a speaker and
consultant forAstellas, Easai, Ferring, Forest, Horizon,
Ortho-McNeil, Lilly, Pfizer and Bayer. Dr. Jack Barkin
has been a clinical investigator, speaker and medical
advisory board member and consultant for Abbott,
Lilly, Bayer, Paladin, Actavis, AstraZeneca, Astellas,
Pfizer and Triton.
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Erectile dysfunction in primary care: a focus on cardiometabolic risk evaluation and stratification for future
cardiovascular events
