Patients
with certain medical conditions, lifestyle choices or those taking
certain medication are more prone to suffering from ED. This section
takes you through the common ED risk factors like diabetes, smoking
and cardiovascular disease.
Ageing
Ageing, which has the strongest association with ED, probably exerts
its effects mainly through impaired vasodilatory and veno-occlusive
mechanisms. Atheroma of the internal iliac arteries and their pudendal
branches and age-related degeneration of intracorporeal smooth muscle
resulting in venous leakage are important factors related to age.
In the MMAS (Massachusetts Male Ageing Study) sample, the probability
of complete impotence tripled from 5 to 15% between subject ages of
40 and 70 years.
There is no doubt that ED is associated with age, but it must be remembered
that a wide range of medical problems and their treatment, which could
possibly impair erectile function, are inevitably present or are increasingly
being used with advancing age. The current cadre of men aged 60 years
and beyond is more accepting of the idea that impotence is a natural
consequence of the ageing process. Clearly such attitudes will change.
Baby boomers, the people who have lived through the so-called sexual
revolution, will probably be more demanding of treatment than were
the generations that preceded them
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Diabetes Mellitus
ED is one of the most common complications of diabetes, its prevalence
ranging from 35% to 75% of diabetic men. Damage to small blood vessels
is the main etiology and, therefore, ED often occurs in association
with diabetic retinopathy. Diabetic peripheral autonomic neuropathy
is a further contributory factor. ED may develop as a result of the
progressive loss of small unmyelinated so-called C fibres secondary
to diabetes. Saenz de Tejada et al has reported that diabetes is associated
with loss of nitric oxide synthatase(NOS) from NANC nerve endings
and endothelial cells in the corpora. This may explain the common
association of ED with diabetes.
In a study
of the clinical features of diabetic patients both with and without
ED, the duration of diabetes mellitus was found to be significantly
longer in those with ED. In addition, the proportion of patients receiving
insulin treatment was considerably higher in the group with ED (61%
versus 9%) proving that the overall probability of impotence is higher
in treated diabetics. The prevalence of ED amongst diabetic patients
is also age related. Changes in the cavernous artery and cavernous
erectile tissue have been reported in patients with diabetes. Diabetic
men and older men were found to have a high incidence of fibrotic
lesions in the cavernous artery, with intimal proliferation, calcification,
and luminal stenosis.
Cardiovascular Disease
Heart disease and its associated risk factors, hypertension and low
serum high-density lipoprotein, had significant correlation with impotence
in the MMAS (Massachusetts Male Ageing Study) samples. In the MMAS
sample, though minimal impotence was unchanged, two different patterns
were noticed in moderate and complete impotence with respect to cigarette
smoking. In the non-smoking group, both moderate and complete impotence
doubled, whereas in the smoking group, moderate impotence decreased
slightly and complete impotence increased six times. This data may
imply that patients with heart disease and moderate impotence could
have complete impotence if they were smokers.
Treated heart disease is associated with 78% overall impotence in
non-smokers and 94.3% in smokers, thereby making heart disease an
important risk factor for erectile dysfunction. Impairments in the
hemodynamics of erection have been demonstrated in patients with myocardial
infarction, coronary bypass surgery, cerebrovascular accidents and
peripheral vascular disease. This can be correlated with the study
by Oaks and Moyer, who reported that 8 to 10% of all untreated hypertensive
patients were impotent at diagnosis of hypertension. Greenstein et
al report a significant correlation between the number of coronary
vessels occluded on angiography and erectile dysfunction Assessment
of plasma fibrinogen concentrations revealed higher levels of this
coagulation factor in men with ED.
Approximately
one-third of men beyond middle age have a diastolic blood pressure
(DBP) > 90 mmHg. Hypertension causes damage to small blood vessels
and this may adversely affect intracorporeal vasodilatory mechanisms.
Moreover, many of the agents used to control hypertension, especially
-blockers and diuretics, are associated with the development of ED.
It has been postulated that, because high intracorporeal pressures
are required to produce penile rigidity, the reduction of blood pressure
by any agent is likely to increase the incidence of ED. However, -blockers,
perhaps through the induction of intracorporeal vasodilation, appear
to enhance erection, while still lowering both systolic blood pressure
(SBP) and diastolic blood pressure (DBP). Billups and Friedrich, suggest
that erectile dysfunction may be one of the earliest indications of
vascular disease.
The logical
conclusion from their work is that a vascular screening evaluation
should become a part of the diagnostic evaluation for all men presenting
with erectile dysfunction. Most erectile dysfunction experts suggest
that the screening vascular evaluation should include a fasting lipid
panel, a hemoglobin level and an electrocardiogram.
Smoking
Cigarette smoking has been shown to be an independent risk factor
for vasculogenic impotence. This is because of its deleterious effects
on blood vessels and its action leading to an increase of platelet
stickiness. The MMAS (Massachusetts Male Ageing Study) demonstrated
the contribution of smoking to the probability of ED development.
The association of ED with certain risk factors, such as heart disease
and hypertension, was amplified in current cigarette smokers. In subjects
with treated heart disease, the age-adjusted probability of complete
ED was 56% for current smokers compared with 21% for current non-smokers.
Chronic Renal Failure
Impaired erectile function is frequent in men with chronic renal failure,
and the prevalence of ED has been reported to be as high as 45% in
this setting. The pathophysiology of ED in patients with renal failure
is not clear. Hypogonadism due to dysfunctioning Leydig cells, hyperprolactinemia,
hyperpara-thyroidism, anemia, protein malnutrition, zinc deficiency,
hypertension and use of antihypertensive drugs have all been implicated.
Drug Therapy
The role of some drug classes such as estrogens (used in the treatment
of prostatic cancer), antihypertensives, and cardiac-active drugs
in causation of ED is well documented. Newer classes of antihypertensive
agents are less frequently associated with sexual dysfunction than
diuretics or -blockers. However, nearly every first-line antihypertensive
drug has been reported to cause some degree of erectile dysfunction.
ED has been reported in patients with most psychotherapeutic drugs
that produce central nervous system sedation or depression, and the
mechanism has been attributed to an elevation of serum prolactin concentrations,
sedative effects, an anticholinergic effect, decreased dopaminergic
activity, or central effects on the limbic system.
Alcohol
Available data reveals that a high proportion of alcoholics showed
signs of sexual deviation. Alcohol increases libido, inhibits sexual
physiological responses and adversely affects reproductive processes
in both men and women.
Depression
Reactive or endogenous depression is strongly associated with ED:
nearly 90% of severely depressed men report complete impotence. Treatment
with antidepressants may sometimes improve the situation, although
both monoamine oxidase inhibitors and tricyclic antidepressants may
in themselves cause ED. Selective serotonin reuptake inhibitors, such
as fluoxetine may not only cause ED, but may also retard ejaculation.
Psychological explanations for impotence, which are common in popular
conceptions and in case histories, have a specific physiological basis.
While psychogenic stimuli normally facilitate erection, cerebral signals
can produce impotence equally well by inhibiting reflex activation
of the parasympathetic dilator nerves that enhance inflow of blood
to the penis. In MMAS (Massachusetts Male Ageing Study) the psychological
factors strongly associated with impotence included depression, low
levels of dominance and anger.
Previous Surgery
Pelvic surgery, particularly radical prostatectomy, cystoprostatectomy
and abdomino perineal resection (APR) are all strongly associated
with subsequent ED.
Reference
Physicians' Desk Reference 2000, 54th Ed.: 2381-2386.
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