ERECTILE DYSFUNCTION AND

CARDIOVASCULAR DISEASES

Wimpie Pangkahila

Department of Andrology and Sexology

Post Graduate Program in Anti-Aging Medicine
Medical Faculty Udayana University
Indonesian Association of Andrologist (Persandi)
Indonesian Association of Sexology (ASI)
CLASSIFICATION OF MALE SEXUAL DYSFUNCTION

- Disorders of sexual desire:

• Hypoactive sexual desire disorder
• Sexual aversion disorder
- Disorders of erection:
• Erectile dysfunction
• Prolonged erection
- Disorders of ejaculation:
• Rapid ejaculation
• Retarded ejaculation
- Disorders of orgasm:
• Anorgasm
 We’re born
But remember! together, grew
This is not only up together,
about penis! but why you
There will be died earlier?
coming a deadly
threat!
 Why men get
Erectile Dysfunction?

Because they got the causes

What are the causes?

Doctors have to find the causes

to treat the patients properly
 Factors affecting sexual function

Physical factors:
• Hormonal factor
• Vasculogenic factor
• Neurogenic factor
• Iatrogenic factor
Psychogenic factors:
• Predisposing factor
• Precipitating factor
• Maintaining factor

Sexual
function
 Causes of sexual dysfunction

Physical factors:
• Hormonal factor Psychogenic factors:
Agingfactor
• Vasculogenic process, diseases,
• Predisposing factor
• Neurogenicunhealthy
factor life •style,
Precipitating factor
• Iatrogenicpsychological
factor • Maintaining factor
problems

Erectile
Dysfunction
 Indicator of
aging process
and life style
Indicator of
hypogonadism Related to
and other risk factors
hormonal Erectile and diseases
imbalance Dysfunction is
not Erectile
only about
sex organ and
dysfunction
activities
Predictor of Indicator of
CVD psychic problem
 Erection Hardness Score (EHS)
Severe ED Moderate ED Mild ED No ED
IIEF 5 - 10 IIEF 11 - 15 IIEF 16 - 20 IIEF 21 - 25

Penis is Penis is hard Penis is hard

larger but but not hard enough for
not hard enough for penetration Penis is
penetration but not completely
completely hard and
hard fully rigid
 Erection Hardness Score (EHS)
Severe ED Moderate ED Mild ED No ED
IIEF 6 - 10 IIEF 11 - 15 IIEF 16 - 20 IIEF 21 - 25
 Evolution of ED Treatments and Efficacy
Coming soon
•Sildenafil to Indonesia:
•Vardenafil Today
•Tadalafil avanafil
•Vardenafil (®Levitra)
•Tadalafil (®Cialis) 2000

•PDE-5i Sildenafil (®Viagra) 1990s

•PGE1
•Papaverine 1980s
•Pumps
•Yohimbine 1970s
•Surgery
 No life
without sex!

Is it right?
 Sexuality is a part of the whole life
No life without sexuality

Sexuality, in particular sexual

functions, depends on

• Limbic system
• Hypothalamus-hypophyse-gonad axis
• Sex steroid hormone
• Nerve system
• Other related hormones and neurotransmitter
Erection is about blood vessels in the corpus cavernosum
 ED as a Marker of CVD
Symptoms of vascular disease may appear earlier in penis
compared with other sites because luminal diameter is small
Artery Lumen Diameter
Penis 1–2 mm

Coronary 3–4 mm
Carotid 5–7 mm

Femoral 6–8 mm

1. Montorsi P et al. Eur Urol 2003;44:352-354

 ED prevalence and time of onset in 300
consecutive men with acute chest pain and CAD

• Mean age 62.5 years

• ED prevalence 49% (147/300)
• ED before CAD symptoms 99/147 (67%)
• The incidence of ED in men with CAD is
directly correlated to the number of
abnormal coronary arteries
• Mean time interval ED to CAD 38.8 months (1-168)

Montorsi F. et al. Eur Urol 2003;44:360-5

Bryan G. Schwartz. Circulation. Cardiovascular Implications of
Erectile Dysfunction, Volume: 123, Issue: 21, Pages: e609-e611, DOI:
© 2011 American Heart Association, Inc.
(10.1161/CIRCULATIONAHA.110.017681)
 Prevalence of ED in Indonesia, 2020

Birowo P, Deswanto IA, Rasyid N. Epidemiology of erectile dysfunction: a cross-sectional web-based survey conducted in an Indonesian national referral hospital. F1000Research. 2019;8(817):817.

Birowo P, Deswanto IA, Rasyid N. Epidemiology of erectile dysfunction: a cross-sectional web-based survey conducted in an Indonesian national referral hospital. F1000Research. 2019;8(817):817.
 Global prevalence of
Cardiovascular Disease (CVD) and ED

ED, erectile dysfunction

• World Health Organization. Global Atlas on cardiovascular disease prevention and 4. Park K, et al. Asian J Androl. 2011;13:543-549.
control. 2011. Geneva, Switzerland. Last accessed 25 Aug 2015. Available from: 5. Pushkar D, et al. Urologiia. 2012:5-9.
http://www.who.int/cardiovascular_diseases/publications/global_brief_hypertens 6. Feldman HA, et al. J Urol. 1994;151:54-61.
ion.pdf 7. Shaeer O, Shaeer K. J Sex Med. 2012;9:3018-3027.
• Selvin E, et al. Am J Med. 2007;120:151-157. 8. Shaeer O. Shaeer K. J Sex Med. 2011;8:2152-2160.
Image source: © Paul Stringer/Shutterstock.com
 ED and CVD both increase with age

* United States, United Kingdom, Germany, France, Italy, Spain, Mexico, and Brazil CVD, cardiovascular disease; ED, erectile dysfunction; NHANES, National Health and Nutrition
Examination Survey Mozaffarian D, et al. Circulation. 2015;131:e29-322. Rosen RC, et al. Curr Med Res Opin. 2004;20:607-617.
 Causes of CVD

CVD, cardiovascular disease; ED, erectile dysfunction Chrysant SG, et al. Curr Clin Pharmacol. 2010;5:89-85.
• Matsui H, et al. Curr Drug Targets. 2015;16:411-419.
 Causes of ED

• Matsui H, et al. Curr Drug Targets. 2015;16:411-419. = Overlapping factors related to cardiovascular disease
 Common Risk Factor Proposition

Modifiable risk factors

for CVD that are shared with ED

Hypertension-hyperlipidemia
Diabetes Mellitus-obesity
Smoking-poor diet
Lack of exercise
Excessive alcohol
Psychogenic stress, depression
*Hypertension, hyperlipidemia, diabetes mellitus and/or depression
• Seftel AD, et al. J Urol. 2004;171:2341-2345. Feldman HA, et al. J Urol. 1994;151:54-61. Jackson G. Arab J Urol. 2013;11:212-216.
 Common Risk Factor Proposition

*Hypertension, hyperlipidemia, diabetes mellitus and/or depression

• Seftel AD, et al. J Urol. 2004;171:2341-2345. Feldman HA, et al. J Urol. 1994;151:54-61. Jackson G. Arab J Urol. 2013;11:212-216.
 Relationship between endothelial dysfunction, low-grade chronic
inflammation and atherosclerosis in the pathogenesis of ED and CVD1

Cardiovascular
Inflammation
risk factors

Atherosclerosis

Low
Endothelial Erectile Dysfunction
testosterone
dysfunction Coronary Artery
level
Disease
CVD, cardiovascular disease; ED, erectile dysfunction. Gandaglia G, et al. Euro Urol. 2014;65:968-978.
 Therefore Erectile
Dysfunction is not only
about the failure of
sexual function, but
also about the hidden
threat
Change of the etiology factors of sexual dysfunction based on
the development of science and technology

In the past: psychogenic factors

were considered as the most
etiology of sexual dysfunction

Now it is clear that

Results in
sexual dysfunction
psychic
mostly caused by
complaints
physical factor
 Physical and
Decreased
psychic
hormone or
complaints
imbalance
or problems
A man, 58 y o, Jakarta
Obese (WC122),
erectile dysfunction,
sleepy, gynaecomastia

Glucose 250 mg/dl

Total Cholesterol 255;
LDL 150;HDL 37;
TG 215 Patient of Dr Pangkahila
Grasia Clinic
T 158, IGF1 105
LH 6.06 (1.5-9.3)
FSH 7.79 (1.4-18.1)
ED prevalence by decade of age

1 Saigal CS. Arch Intern Med 2006;166:207-212 (Based on U.S. NHANES 2002 data)
2 Feldman HA, et al. J Urol 1994;151:54-61 (Massachusetts Male Aging Study)
 Endothelial dysfunction:
Final common pathway in CV diseases

Hypertension DM Dyslipidemia Cigarette

Oxidative Stress

Endothelial Injury
Erectile Dysfunction
Myocardial No vaginal lubrication
Infarction
Stroke Renal disease
Changes in diabetic corpus cavernosum

o Fraying and fibrosis in smooth muscles

o Increased trabecular collagen fibers
o Reduction of elastic fibers

Erectile
Dysfunction
 Diseases and risk factors causing ED

Coronary heart disease,

60%

Smoking, 50%

Hypertension, 52%

 Chew KK, et al. Erectile dysfunction in general medical practice : prevalence and clinical correlates. Int J Impot Res 1997; (suppl
1): Abstract.
 Jackson G, et al. A systematic approach to erectile dysfunction in the cardiovascular patient: A consensus statement. Int J Clin
Pract 1999; 53: 445-451
Diseases and risk factors causing ED

Peripheral blood vessel diseases,

80% Diabetes

Hypercholesterolemia, 40%

Depression, 90%
 Prevalence of Common Comorbidities
Without and With ED

Without ED With ED

Hypertension 19% 36%

Heart disease 7% 17%

Hyperlipidemia 16% 29%

Diabetes 4% 14%
P<.0001 for all

Data from the Men’s Attitudes to Life Events and Sexuality (MALES) study
Rosen RC, et al. Curr Med Res Opin. 2004;25:607-617.
N = 27,839 men aged 20-75 years
 ED and common co-morbid diseases

1 Saigal CS. Arch Intern Med 2006;166:207-212 (Based on U.S. NHANES 2002 data)
2 Feldman HA, et al. J Urol 1994;151:54-61 (Massachusetts Male Aging Study)
 Screening in men with ED
but No known CVD

The Princeton III Consensus Guidelines for

the Management of ED and CVD
recommends sexual inquiry of all men1

All men with ED aged >30 years old are

considered to be at increased CVD risk

BMI, body mass index; BP, blood pressure; CVD, cardiovascular disease; ED, erectile dysfunction; HDL, high-density lipoprotein;
LDL, low-density lipoprotein Nehra A, et al. Mayo Clin Proc. 2012;87:766-778.
BMI, body mass index; BP, blood pressure; CVD, cardiovascular disease; ED, erectile dysfunction; HDL, high-density lipoprotein;
LDL, low-density lipoprotein Nehra A, et al. Mayo Clin Proc. 2012;87:766-778.
 Management of ED in all men with ED, especially those with known CVD,
according to the Princeton III Consensus Recommendations1
Sexual enquiry (all men)

Confirmed ED High risk

Low risk With cardiac condition
Sexual activity does not severe or unstable to
Review exercise
present significant pose significant risk with
tolerance
cardiac risk sexual activity
Indeterminate risk Sexual activity
Sexual activity Elective risk
can be initiated assessment
should be
Conduct Fail deferred until
or resumed;
Low stress test High cardiac condition
Begin ED
treatment risk Pass risk stabilized-
*Sexual
Cardiologist
activity is equivalent to walking 1 mile on the flat in 20 minutes or briskly climbing two flights of stairs in 10 seconds **Sexual activity is
equivalent to 4 minutes of the Bruce treadmill protocol CVD, cardiovascular disease; ED, erectile dysfunction Nehra A, et al. Mayo Clin Proc. 2012;87:766-778.
High risk group Low risk group
• High risk arrhythmia Intermediate risk
• Asymptomatic 3
• Unstable or refractory group
CAD risk factors
angina • 3 risk factors
• Mild, stable angina
• Recent MI < 2 weeks for CAD
• Uncomplicated
• LVD/CHF NYHA class • Moderate, stable
previous MI
III/IV angina
• LVD/CHF NYHA
• Obstructive • LVD/CHF NYHA
class I
hypertrophy class I
• Post successful
cardiomyopathy • Non cardiac-
coronary artery
• Uncontrolled atherosclerotic
revascularization
hypertension diseases (eg.
• Controlled
• Moderate to severe Cerebrovascular
hypertension
valve diseases disease
*
Sexual activity is equivalent to walking 1 mile on the flat in 20 minutes or briskly climbing two flights of stairs in 10 seconds
**Sexual
• Mild valve disase
activity is equivalent to 4 minutes of the Bruce treadmill protocol
CVD, cardiovascular disease; ED, erectile dysfunction
41
1. Nehra A, et al. Mayo Clin Proc. 2012;87:766-778.
 ED treatment in patients with CVD

• Exercise tolerance should be established before the

initiation of ED therapy in all men regardless of CV risk
• ED treatment should be considered secondary to
decreasing CV risk
• The PDE5 inhibitors (sildenafil, tadalafil, vardenafil)
are recommended as first-line agents and are widely
used to treat ED
CAD, coronary artery disease; CV, cardiovascular; ED, erectile dysfunction; MI, myocardial infarction; PDE5, phosphodiesterase type 5
• Nehra A, et al. Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. Updated March 2013. Available
from: http://uroweb.org/guideline/male-sexual-dysfunction/. Last accessed, June 2015.
• Kostis JB, et al. Am J Cardiol. 2005;96:313-321.
 ED treatment in patients with CVD

Princeton II guidelines reviewed the safety of PDE5

inhibitors in men with CVD and found:

•No increase in MI or death rates compared with

expected rates
•No worsening of ischemia, coronary vasoconstriction, or
hemodynamics on exercise testing or cardiac
catheterization
CAD, coronary in men
artery disease; CV, cardiovascular; with
ED, erectile known
dysfunction; CAD
MI, myocardial or PDE5,
infarction; heart failuretype 5
phosphodiesterase
• Nehra A, et al. Mayo Clin Proc. 2012;87:766-778.
• Hatzimouratidis K, et al. Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. Updated March 2013.
Available from: http://uroweb.org/guideline/male-sexual-dysfunction/. Last accessed, June 2015.
• Kostis JB, et al. Am J Cardiol. 2005;96:313-321.
 Recommendations for Treatment of ED

• AUA: American Urological Association; ED: Erectile Dysfunction; PDE5i: phosphodiesterase type 5 inhibitors; Burnett AL,
 Summary: When to treat or refer patients with ED

• Nehra A, et al. Mayo Clin Proc. 2012;87:766-778.

 Viagra® may help more men achieve rigid erections
(EHS grade 4)

3 of 5 men with ED achieve completely hard and fully rigid

erections with Viagra®1
94% of EHS EHS,
*P<0.0001 4 erections resulted in successful sexual intercourse 2
erection hardness sore
1) Kadioglu A, et al. J Sex Med. 2008;5:726-734; 2) Mulhall JP, et al. J Sex Med. 2007;4:1626-1634.
Image source: © Picturestudio/Shutterstock.com
Viagra® may help more men achieve rigid erections (EHS grade 4)

*P<0.0001 EHS, erection hardness sore

1) Kadioglu A, et al. J Sex Med. 2008;5:726-734; 2) Mulhall JP, et al. J Sex Med. 2007;4:1626-1634.
Image source: © Picturestudio/Shutterstock.com
Sildenafil Citrate is Effective in ED Patients with Comorbid Conditions

Adapted from Carson CC, et al. The efficacy of sildenafil citrate (Viagra®) in clinical populations: an update. Urology. 2002;60(2):12-27.
 There are a lot of scientific and clinical data
demonstrated the evidenced-base and safety of
sildenafil citrate in the treatment of ED

The failure of
sildenafil treatment
is caused by some
factors
 Causes of treatment failure

▪misdiagnosis of ED
▪unrecognized hypogonadism
▪untreated comorbid disease
▪severe penile vascular disease
▪inadequate dose
▪incorrect administration
▪lack of sexual stimulation
▪psychosocial and female partner factors
▪radical prostatectomy: almost universal
 Finally, this is an
attention!
It is very risky to give
PDE5-inhibitor without
information about the CV
and other risk factors
condition

Beware with the products

advertised for ED
 Fraud and fake advertisement

Kopi Kuat
Peningkat
Vitalitas Pria
 Fraud and fake advertisement

Kopi Kejantanan
Pria Dewasa.
Untuk Stamina &
Vitalitas
 Banyak ramuan herbal dalam kapsul
diiklankan untuk disfungsi ereksi
Padahal dicampur PDE5 inhibitor,
khususnya sildenafil

Banyak dokter yang tertipu dan

menggunakan untuk pasiennya
Setiap tahun BPOM menarik banyak produk
herbal abal-abal dari peredaran
 Penerbit
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