Subjective Sexual Function

The subjects provided sexual histories to a trained interviewer regarding the following: (1) frequency of sexual intercourse, (2) level of interest in sexual activity, (3) observation of spontaneous morning erections, and (4) quality of penile erections (duration and firmness). Changes in these parameters were recorded as percentage of the level of function at the time of the study vs the level of function just prior to the onset of severe exertional dyspnea (premoibid level). The observation of morning erections was recorded as same, decreased, or absent. The quality of penile erectile function was categorized as follows:

0. No change in firmness or duration of erection from die premorbid state.

1. Slight or moderate decrease in firmness or duration but no difficulty completing coitus.

2. Firm to semifirm erections capable of intromission but with as much as 75 percent reduction in duration. Subject is usually able to complete coitus.

3. Firm to semifirm erection that detumesces after intromission, frequently before climax.

4. Semifirm erection, much shortened in duration, usually not able to achieve intromission, occasional short-duration, firm erections.

5. Usually flaccid penis with occasional short-duration, semifirm erections or no erections at all.

Objective Erectile Function

Mercury-filled Silastic strain gauges placed at the tip and base of the penis and connected to a tumescence monitor (Event Systems) were used during three nights of polygraphic monitoring to evaluate erectile function objectively. Sleep stages were recorded by EEC and scored according to criteria of Rechtschaffen and Kales. Tumescence studies were scored according to criteria of Karacan et al and Fisher et al. Full erections required a circumferential change exceeding 16 mm or 80 percent of a maximal erection measured at the tip. The duration of full erections was reported as the time from initial deflection to the time of return to baseline (Fig 1). If the subject had no full nocturnal erections or an average of less than one full erection lasting at least five minutes per night of monitoring he was considered to have organogenic impotence.

Price et al. used a comprehensive group ED treatment with men without partners that included a ban on intercourse, education about sexual response, sensate focus techniques, and other strategies to enhance sexual arousal and communication. They found improvement in erectile response, as well as enhanced “sexual self-image.” Treatment gains were maintained at a 6-month follow-up. Another study by this group examined the effectiveness of a group treatment that included education, group discussions, and communication skills training for men without partners who presented with ED. They also found a statistically significant decrease in reported erectile difficulties.

In a study of men with ED and their partners Goldman and Carroll used a group format that focused on: education about normal sexual response, enhancing the couple’s comfort and communication about sex, and increased acceptance of the partner’s sexual difficulties. The couples in the treatment group showed greater increases in sexual satisfaction than the control group.

A review of psychological treatments for ED involved a reexamination and meta-analysis of controlled studies over the past 30 years. The review included eleven studies that met the criteria for empirically sound clinical trials. Melnik and colleagues drew several conclusions based on the results of the review. First, groups receiving sex therapyfocused treatment showed greater efficacy for the treatment of ED than did the control groups receiving no treatment. Second, there were no clear differences in the outcome based on age, relationship status, or severity. However, men with secondary ED, i.e., those who had developed ED after a period of normal erectile function, tended to respond better to treatment than did men with primary (i.e., lifelong) ED. Third, studies that compared psychological treatment with vacuum pump devices and intracavernosal injections did not show clear differences between the two treatments, though both the medical and psychosocial treatments were found to be effective.

Finally, the reviewers also examined several studies which compared psychological treatment in combination with sildenafil with medication alone. The meta-analysis showed that men with ED randomized to the combined treatment showed significantly greater improvement and lower dropout rates than men with the medication alone.

A small study by Melnik compared the standard sex therapy approach to the treatment with sildenafil alone. This study found a statistically significant greater improvement in erectile function in the sex therapy group, which continued at the 3-month follow-up. There was also a significantly lower dropout rate in the psychological treatment group.

A number of studies of the outcome of sex therapy have included bibliotherapy, i.e., books that provide education and self-treatment strategies. Results suggest that book-based, self-help forms of treatment are a beneficial adjunct to medical or psychological treatment. There are several recommended books that have been writ-ten by respected sex therapists. Most therapists have found that treatment outcome is enhanced if both members of the couple are involved, though treatments for single men have also been found to be effective.

In sum, psychological treatments for ED have been demonstrated to be effective in group, couple, and individual treatment formats. Most of the studies have used an integrated sex therapy model that combines education, anxiety reduction, a temporary ban on sexual intercourse, enhanced communication and graduated steps of sexual activity. Heiman and Meston’s review of empirically validated treatment for sexual dysfunction offers support for some of the long-standing approaches to these disorders. Using the criteria of the American Psychological Association Task Force on empirically validated treatments, they found that psychological treatments were “well established” for erectile disorder in men. It remains unclear, which of these components of treatment is most effective, though most components have been shown to be effective by themselves. More research is needed to identify the most effective and efficient psychological approaches to the treatment of ED.

Erectile dysfunction is now a recognized marker for cardiovascular disease as a result of several studies. The artery size hypothesis has been used to explain how ED acts as a silent marker of vascular disease elsewhere in the body, and more significantly as a marker of CAD.

Artery size varies considerably according to location within the vascular system.

For example, the lumen of the penile arteries is considerably smaller (1–2 mm) compared with that of the coronary (3–4 mm), carotid (5–6 mm), and femoral (6–8 mm) arteries. Because of their smaller size, the same level of plaque burden and/or endothelial dysfunction has a greater effect on blood flow through the penile arteries than through the coronary, carotid, and femoral arteries. Therefore the clinical manifestations of penile endothelial dysfunction (ED) may become evident before the consequences of coronary or peripheral vascular disease. By the time the lumen of the larger arteries become significantly obstructed (>50%), the penile blood flow may have already decreased considerably, which explains why so many men with CAD have ED.

Thus on the basis of artery size hypothesis and the fact that the endothelium is the same throughout the arterial tree, a malfunction in the penile arteries causing ED may be a predictor of silent subclinical cardiovascular disease (CVD). Furthermore, because an acute coronary syndrome often arises as the result of the rupture of a subclinical plaque, the presence of ED may also be an early warning sign of an acute event as well as being a manifestation of advanced obstructive CAD.

In 1999, Pritzker presented a preliminary report entitled “The penile stress test: A window to the hearts of man”. He reviewed the results of exercise stress testing, risk factor profiles, and, in selected cases, angiography in 50 men with ED, who had no cardiac symptoms or past history. Multiple cardiovascular risk factors were present in 80%. Exercise tests positive for ischemia were found in 28 of the 50 men. Coronary angiography was performed in 20 men and revealed left main stem or severe three-vessel disease in 6 men, moderate two-vessel disease in 7 men, and significant single-vessel disease in 7 men. This study identi-fied the significant incidence of occult coronary disease in cardiologically asymptomatic men presenting with ED to a urological service. Others have reported similar findings and noted the occurrence of ED before cardiac symptoms developed. In a study comparing the velocity of cavernosal artery blood flow with the presence of ischemic heart disease in men with ED, a low peak systolic velocity (PSV) predicted the presence of CAD. A PSV below 35 cm/s was associated with CAD in 41.9% of men and above 35 cm/s in only 3.7% of men.

In support of this concept, a series of 300 patients with acute chest pain and angiographically proven CAD were evaluated with a semi-structured interview to assess their medical and sexual histories prior to presentation. The prevalence of ED among these patients was 49% (n = 147). In these 147 men with both ED and CAD, ED was experienced before CAD symptoms in 99 patients (67%). The mean time interval between the occurrence of ED and the occurrence of CAD was 38.8 months (range: 1–168 months). Interestingly, all men with ED and type 1 diabetes developed sexual dysfunction before the onset of CAD symptoms. The authors do point out the absence of a control group with CAD and normal erections, but their findings clearly identify the need to assess cardiovascular risk in all males presenting with ED without obvious psychosexual etiology, especially in patients with diabetes.