Urology Case Challenge: A Sexually Active Construction Worker Has Erection Concerns

Edward D. Kim, MD


January 30, 2023

ED and cardiovascular disease share similar underlying risk factors, including endothelial dysfunction, blood vessel size, and androgen levels. Abnormalities of endothelial function are closely linked with the metabolic syndrome, diabetes, hypertension, and dyslipidemia.

Thompson and colleagues' landmark study from the Prostate Cancer Prevention Trial determined that ED can be an indicator of future morbidity and mortality, with the incident development of ED being associated with a hazard ratio of 1.25 for future cardiovascular events.[3]

In a separate study, Inman and colleagues followed men with ED and identified an 80% increased risk of developing coronary artery disease after 10 years.[4] In younger men, ED was associated with an increased risk for future cardiac events, while having little prognostic significance in older men.

The Princeton Consensus Guidelines Panel recommended that men with ED undergo a full medical assessment, with stratification of cardiovascular risk as high, medium, or low.[5] High-risk men are those with unstable or refractory angina, a recent history of myocardial infarction, certain arrhythmias, or uncontrolled hypertension. Figure 3 shows the risk factors for patients with and without established cardiovascular disease.

Sexual activity with any particular ED therapy should be deferred until the cardiac condition is stabilized for high-risk men, who should undergo cardiologic referral for cardiovascular stress testing and subsequent risk reduction therapy. The patient in this case is classified as having medium risk factors -- obesity, dyslipidemia, hypertension, and a family history of cardiac disease -- and would benefit from cardiac stress testing.

Penile duplex ultrasonography, nocturnal penile tumescence tests, and penile angiography are considered specialized tests for ED. They are not recommended for routine use, but are best reserved for complicated or unusual cases in which they may affect selection of treatment.

The IIEF is a validated questionnaire that is widely used to characterize ED. The severity of ED is classified into 5 diagnostic categories, as follows:

  • No ED: IIEF score = 26-30

  • Mild ED: IIEF score = 22-25

  • Mild to moderate ED: IIEF score = 17-21

  • Moderate ED: IIEF score = 11-16

  • Severe ED: IIEF score = 6-10

The association of modifiable behavioral factors with ED, primarily among men free of comorbidities, underlies the rationale for intervention. These strategies have been proposed to prevent and potentially improve erectile function. Because nitric oxide is the key factor in vascular health, ED, and cardiovascular disease, the focus has been on measures to increase vascular nitric oxide production.


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