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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
If you would like to receive the latest
Journal abstracts on this ED Risk Factor, please click on the email icon.
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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