Erectile dysfunction (ED) is a common disorder that affects the quality of sexual and relationship life in men. In France, epidemiological studies show that the prevalence of ED is estimated between 11% and 44% and prevalence surveys show a correlation between ED and age - between 40 and 70 years the relative risk of erectile dysfunction is multiplied by 2 at 4.Few patients consult their doctors, and only a small part of them benefit from a therapeutic treatment, and on the other hand, few doctors take the initiative and address the issue of the sexuality of their patients.
It is now necessary to understand erectile dysfunction and to raise awareness of the usefulness of screening or in any case to explore an erection disorder that may be the first symptom of pathology in erectile dysfunction. a Course such as cardiovascular disease, diabetes, depression, benign prostatic hypertrophy, prostatic cancer, androgen deficiency, or also the consequence of a drug iatrogenic. Evidence of erectile dysfunction is, therefore, an excellent opportunity to perform a health check, as more than a third of ED patients are unaware of their underlying health problem and thus take charge of it.
Preventive Medicine Approach
Erectile dysfunction (ED), or erectile dysfunction, is a common disorder that affects the quality of sexual and relationship life in men and is defined as the inability to obtain and/or maintain an erection sufficient for the achievement of sexual intercourse. It is now necessary to understand it well and to raise the awareness of the usefulness of detecting or in any case to explore an erection disorder which may be the first symptom of a current pathology such as cardiovascular disease (hypertension, silent coronary artery disease, dyslipidemia,), diabetes, depression, benign prostatic hypertrophy (BPH), prostatic cancer, androgen deficiency or also the consequence of iatrogenic medications.
In France, epidemiological studies show that the prevalence of ED is estimated to be between 11% and 44%, depending on whether we consider different age groups or erectile dysfunction levels of mild intensity, moderate or severe. All prevalence surveys also show a correlation between ED and age: between 40 and 70 years the relative risk of erectile dysfunction is multiplied by 2 to 4 and the age threshold seems to be between 50 and 60 years. The prevalence rate of 31.6% found in France is between higher rates reported in Finland (74%), in the United States (52%) and lower rates observed in Great Britain (26%). Germany (19%) or Spain (19%). A recent 2002 study conducted with
Several studies have confirmed that erectile insufficiency caused significant suffering in the individual with both erectile dysfunction and his partner and demonstrated the benefit of erectile dysfunction correction.
Few patients consult their doctor, and only a small part of them receives treatment. A survey of 12,671 men in Italy, who called a DE information hotline, showed that about 57% of the subjects had talked to their partner about their troubles, but were not more than 50.3% to have spoken to their doctor (general practitioner and urologist) and this after at least 3 years of evolution of their erectile disorders.
In addition, few physicians take the initiative and address the issue of the sexuality of their patients.
Contrary to what patients would like, it is rare that the general practitioner is spontaneously interested in the sexual health of his patients, even the elderly. Evidence of erectile dysfunction is, however, an excellent opportunity to perform a health check (with complete clinical examination of the patient and possible further investigations, if necessary) since the ED is often the first sign of attacks. Cardiovascular, diabetes, or depression. More than 30% of patients with an ED ignore their underlying health problem and take care of this is part of a real preventive medicine approach.
ED AND CARDIOVASCULAR PATHOLOGIES
Erectile dysfunction is associated with a high prevalence of the occult cardiovascular disease. Many patients may have ED as the first symptom of underlying cardiovascular disease, and this ED should be viewed as a warning signal of the potential existence of ischemic heart disease, yet to be diagnosed. The prevalence of erectile dysfunction is higher in particularly coronary heart disease and peripheral vascular disease. In the Chew survey, the prevalence of erectile dysfunction is 38.1% in coronary heart disease and 56.8% in peripheral vascular disease versus 18.6% in the general population. In the Parazzini survey, the prevalence of ED is 33.7% in cardiovascular disease compared to 12, 8% in the general population. Erectile dysfunction is, therefore, a cardiovascular marker and a warning signal.
The Montorsi study shows that 49% of patients with angiography-documented coronary artery disease have concomitant erectile dysfunction and that this condition subsequently leads to the appearance of anginal symptoms in more than 70% of cases. In a population of cardiology patients with erectile dysfunction, 40% of them have coronary artery disease. Another population of 174 patients with ED was followed by both urologists and cardiologists. Of these patients, 30% were identified as intermediate or high cardiovascular risk, and treatment for their ED was postponed pending a subsequent cardiac evaluation.
Furthermore, in 37% of cases, these patients had an abnormal lipid profile, in 24% of cases a high level of glycosylated hemoglobin, in 17% of cases uncontrolled hypertension (hypertension), and in 6% of cases, angina pectoris. Chest.
Hyperlipidemia is frequently found in patients with ED. It is essential to measure HDL-C and TC / HDL-C ratio in order to evaluate the risk of developing ischemic heart disease in these patients. The risk is higher in patients with HDL-C levels below 35 mg/ml and a high TC / HDL-C ratio.
In the case of peripheral vascular disorders due to arteriosclerosis, patients will initially present an ED because of the higher sensitivity of the penile vasculature to any hemodynamic changes, even minor. When the arteriosclerotic process develops, resulting in a decrease in the coronary artery lumen greater than 50%, typical clinical signs appear, such as angina. We now know that from the moment when the clinical symptomatology of ischemic heart disease appears, the patient had presented symptoms of a DE for at least three years. At the time of onset of angina, the prevalence of ED varies between 44% and 65%. It, therefore, seems evident that ED represents one of the first visible clinical signs of the existence of an underlying vascular pathology much more diffuse. The DE is what we could call "the tip of the iceberg."
These findings allow some to suggest that cardiologists are directly involved in the management of patients with cardiovascular risk factors and complaining of erectile dysfunction in order to assess the risk of underlying cardiovascular disease.
ED AND DIABETES
Type II diabetes is a generally silent disease, often diagnosed 9 to 12 years after its onset, which will soon rival cancer and cardiovascular disease in terms of cost and suffering. Diabetes-related complications can occur early in the illness but remain silent for many years.
Despite highly codified therapeutic management and the numerous diabetes treatments available, it is essential to emphasize in these patients early detection of their disease, prevention (control of blood glucose), and the correction of associated risk factors, because often the complications of diabetes, installed at the time of diagnosis, will remain irreversible. Hence the need to stay vigilant and seek the existence of type II diabetes in any man who may have a sign of appeal. In about 10% of cases, erectile insufficiency reveals diabetes. The search for hyperglycemia will thus make it possible to diagnose diabetes and to make it likely to start its assumption of responsibility immediately.
It will also be useful to treat ED, because diabetic patients, and especially those who suffer from erectile dysfunction, are convinced that ED has a significant impact on their quality of life and that it is as important to treat as other complications associated with diabetes, such as retinopathy, plantar ulcers, hypertension, hypercholesterolemia, migraine, and digestive and sleep disorders. The development of erectile dysfunction in diabetic patients is often the consequence of several mechanisms interacting with each other, such as vascular disorders, endothelial dysfunctions, neuropathies, hormonal imbalances, and the taking of certain drugs.
Note that in diabetic patients with androgen deficiency and also suffering from ED, testosterone THS makes it possible both to correct symptoms related to androgen deficiency (including erectile dysfunction), to reduce weight (especially body fat), and to control carbohydrate parameters (serum glucose level and glycosylated hemoglobin).
ED AND BENIGN PROSTATIC HYPERTROPHY
The adenoma of the prostate or benign prostatic hyperplasia (BPH) is a benign tumor whose histological prevalence is exceptionally high. All men with histological BPH do not suffer. The prevalence of urinary disorders related to the presence of secondary cervical-urethral obstruction, or symptomatic BPH, varies in France from 8% between 50 to 59 years, up to 27% between 70 and 79 years. BPH is often found in elderly patients who complain of erectile dysfunction. In the same way as other non-tumoral disorders such as cardiovascular diseases and depression, BPH and ED are among the pathologies that have a very negative impact on the quality of life of the subjects.
The presence of BPH also decreases the quality of life of the partners of patients with BPH. A study conducted by Sells showed, through the development of a specific variety of life scale, that BPH had a significant impact on the quality of life of the partners of patients with this disease, including the appearance of sleep disorders, the fear that their companion has cancer, the fear of surgery and severe alteration of their sex life.
HBP and DE appear strongly linked. In a survey of 4883 men aged 30 to 80 in Germany, the prevalence of ED was 19.2%, increasing rapidly with age (2.3% between 30 and 39 years, 53.4%). % between 70 and 80 years). Subjects with DE had more symptoms of the lower urinary tract, mainly related to BPH, with a prevalence of 72.2% compared to 37.7% in men without ED.
A clear relationship between BPH, the severity of micturition disorders, and sexual dysfunction are now admitted. A survey of 3500 men aged 50 to 80 in France found an alteration of sexual desire, sexual function, and sexual satisfaction in more than 30% of subjects complaining of lower urinary tract disorders. The sexuality disorders are, in this survey, closely correlated with the severity of the urinary symptoms, regardless of the age of the subjects. These data have just been confirmed by an international study of nearly 14,000 men over the age of 50. The presence and severity of micturition disorders associated with BPH are indeed independent risk factors for developing erectile dysfunction as well as diseases of the body. Ejaculation. The prevalence of sexual disorders increases in parallel with that of speech disorders.
There is no relationship between sexual dysfunctions and the presence or absence of other comorbidities such as diabetes, high blood pressure, cardiovascular disease, and hypercholesterolemia. These results emphasize the importance of assessing micturition disorders in patients with ED and the need to reconsider sexuality in the management of patients with benign prostatic hypertrophy. Other comorbidity factors, such as diabetes, high blood pressure, cardiovascular disease, and high cholesterol. These results emphasize the importance of assessing micturition disorders in patients with ED and the need to reconsider sexuality in the management of patients with benign prostatic hypertrophy. Other comorbidity factors, such as diabetes, high blood pressure, cardiovascular disease, and high cholesterol. These results emphasize the importance of assessing micturition disorders in patients with ED and the need to reconsider sexuality in the management of patients with benign prostatic hypertrophy.
ED AND PROSTATE CANCER
AFU recommends screening for prostate cancer in men over 50 years of age with PSA, and digital rectal examination routinely performed every year. An ED can be an opportunity to question and explore (PSA) a man still young without micturition disorders and thus promote early diagnosis.
ED, ANXIETY, AND DEPRESSION
Depression and erectile dysfunction often coincide. However, it is difficult to determine the causal relationship. Indeed, ED may be one of the symptoms of depression, but the anxiety and anxiety associated with ED can precipitate the onset of depression.
Anxiety plays a significant role in the development of ED problems. Psychological or behavioral reactions to ED can lead to the creation of a vicious circle of conflict and dissatisfaction. This will decrease the number of sexual acts, limit the time shared by the couple, and cause a lack of communication between the partners during a relationship. To improve this state of sexual anxiety, several solutions are possible: psychosexual counseling including a detailed explanation of the mechanisms of ED, a reassurance of the patient, and a proposal for management, both psychological and pharmacological, within the framework of a multidisciplinary approach.
The prevalence of sexual disorders is essential in patients with major depression. These sexual dysfunctions are rarely handled optimally. Antidepressants often increase these conditions, as some therapeutic classes are better tolerated than others. Serotonin reuptake inhibitors (SSRIs) are frequently incriminated. EDs associated with taking antidepressant medications can be effectively treated with oral intake of IPDE5.
Conversely, depression often has a sexual cause, even if it is not always put forward. Patients with ED are more likely to be depressed. Anxiety and psychological distress related to erectile dysfunction can lead to the appearance of real depression. A study conducted in the USA found the presence of ED with depression with a prevalence of 5.1% in a population of men aged 40 to 70 years and followed in medical consultations general. Research is currently underway to identify the links between erectile dysfunction, andropause, and depression to explore new opportunities to address the different age-related comorbidity factors.
The association between depression, ischemic heart disease, and cardiovascular mortality is now well documented. Patients with coronary heart disease who are depressed are more likely to have erectile dysfunction. For them, an attempt at intercourse is often more fruitless, and given the increase in cardiac mortality associated with depression, this attempt may be the cause of a significant heart attack.
ED ANDROGEN DEFICIENCY
ED may be the inaugural symptom of an androgen deficiency that has been evolving for some time. The study of the treated patients shows that androgenic treatment can restore the libido and a satisfactory sexual activity. Improvement of sexuality is likely to be mediated by an intervention on desire, as no direct link has been found between testosterone levels and erection quality. There is also an improvement in the quality of sleep, a reduction in both physical and mental fatigue, an increase in mood, behavior, and feelings of well-being. Spatial and verbal memory improves.
The restoration of a physiological rate of androgens increases the lean mass and more specifically, the muscular mass reduces the fat mass and increases the muscular strength both at the level of the upper and lower limbs. It has also long been known that hypogonadism is a possible etiology of osteoporosis in humans. Testosterone will boost bone formation. Thus, tests involving prolonged administration of testosterone, at sufficient doses, show an increase in bone density at the level of the lumbar spine.
Androgen therapy improves several cardiovascular risk factors: decreased total cholesterol and LDL fraction (although this could be counterbalanced by the decrease in the HDL fraction), decreased fat mass, and improved insulin resistance.
In terms of safety, the androgen therapy of the elderly man raised many questions, mainly related to the androgen-dependent nature of prostate cancer. In fact, the latter formally contra-indicates the initiation or continuation of androgen therapy In practice, a prostate evaluation (digital rectal exam, PSA, but no ultrasound) is necessary before prescribing testosterone. Thus cancer can be detected early, although it is not possible to formally eliminate subclinical disease (especially in case of high normal PSA). The discovery of prostate cancer at the beginning stage may be particularly beneficial in patients with hypotestosteronemia.
On the other hand, there is no argument to say that hormone therapy promotes the creation of new cancers. In most (but not all) epidemiological studies, plasma testosterone levels are not correlated with the risk of prostate cancer.
ED AND MEDICINES
The Thoms study shows that the effect of beta-blockers and diuretics is not so different from that of placebo. The decrease of libido is equivalent under beta-blockers and placebo (11%), but higher under diuretics and IEC (15-16%) compared to placebo. The effects on the frequency of sexual intercourse were more top with beta-blockers (18%) compared to placebo (13%) as well as diuretics and ACE inhibitors (20-22%) compared with placebo (13%).
In a meta-analysis of six studies that evaluated 14,897 hypertensive patients, 21.6% of patients treated with beta-blockers experienced sexual dysfunction versus 17.4% of patients treated with a placebo. Other studies confirm the deleterious role of beta-blockers, stopping treatment with beta-blockers because of sexual dysfunction was estimated at 1 out of 438 patients treated per year.
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CONCLUSION
All physicians, whether general practitioners or specialists, need to recognize the importance of diagnosing and managing ED. On the one hand, because proper care will improve the psychological state of his patient (and his partner). But also because, on the other hand, these disorders are frequently linked to other pathologies that will have to be identified but that it will then be possible to treat, thus increasing the quality of the practitioner's work and his own satisfaction.
