What is Erectile Dysfunction

Symptoms of ED1

The DSM-5 has identified 3 symptoms for ED:1

• Marked difficulty in obtaining an erection during sexual activity
• Marked difficulty in maintaining an erection until completion of sexual activity
• Marked decrease in erectile rigidity or hardness
What might be causing ED?2
To establish what might be causing ED, a simple question to ask is: Is the ED
circumstantial or is it always a problem?2

    • If ED occurs all the time, the causes are likely to be physical2
    • If ED happens only now and again, psychological reasons may be the cause2

There are 4 main types of physical conditions that can result in ED:2

    • Vasculogenic conditions, for example, atherosclerosis, high BP, diabetes and high cholesterol
    • Neurogenic conditions, for example, multiple sclerosis, Parkinson’s disease or stroke
    • Hormonal conditions, for example, hypogonadism and hypo- or hyperthyroidism
    • Anatomical conditions, for example, Peyronie’s disease (a condition affecting the tissue of the penis), and hypospadias (abnormal development of the urethra)

The pathophysiology of ED may be drug-induced3

Some medications that can cause erection problems:3

    • Antihypertensives
      • Diuretics are the most common medication causing ED
    • Antidepressants
    • Hormone therapy for prostate

Recreational/illicit drugs can also cause erection problems.3

BP: blood pressure; DSM: Diagnostic and Statistical Manual of Mental Disorders; ED: erectile dysfunction; NCD: non-communicable disease.

Common risk factors of ED and CVD3,4

Common risk factors of ED and CVD

CV safety and medications for ED5

  • No evidence of increase in MI rates in men taking PDE-5 inhibitors to treat ED3
  • Nitrate preparations used to treat angina are contraindicated with PDE-5 inhibitors3
    • Can cause unpredictable falls in BP and symptoms of hypotension
  • Antihypertensive drugs may be co-administered with PDE-5 inhibitors3
    • May result in small additive decreases in BP
  • PDE-5 inhibitors can be given to men who are stable on alpha-blocker therapy3
    • Sildenafil should be used with caution in patients taking an alpha blocker (especially doxazosin)
    • Interaction under some conditions may cause orthostatic hypotension
    • Initiation of PDE-5 inhibitors at the lowest dose should be considered

The recognition of ED as a warning sign of silent vascular disease has led to the concept that a man with ED and no cardiac symptoms is a cardiac (or vascular) patient until proven otherwise 5,6

Screening in men with ED and known CVD6

Management of ED in all men with ED, especially those with known CVD, according to the Princeton III Consensus Recommendations.6

Common risk factors of ED and CVD

Adapted from Nehra A, et al, Mayo clin Proc. 2012.

When to treat or refer patients with ED6

When to treat or refer patients with ED

Adapted from Nehra A, et al, Mayo clin Proc. 2012.


  1. Mitchell KR, Jones KG, Wellings K, et al. Estimating the Prevalence of Sexual Function Problems: The Impact of Morbidity Criteria. J Sex Res. 2016;53(8):955-967.
  2. Nassar K. Are you prepared to talk about erectile dysfunction problems in your pharmacy? Pharm J. 2012. The Pharmaceutical Journal Web site. Available at https://www.pharmaceutical-journal.com/learning/learning-article/are-you-prepared-to-talk-about-erectile-dysfunction-problems-in-your-pharmacy/11105924.article . Accessed 25 Feb 2021.
  3. Hatzimouratidis K, Giuliano F, Moncada I, Muneer A, Salonia A, Verze P. European Association of Urology. Guidelines on erectile dysfunction, premature ejaculation, penile curvature and priapism. March 2016. Uroweb Web site. Available at https://uroweb.org/wp-content/uploads/EAU-Guidelines-Male-Sexual-Dysfunction-2016 .pdf. Accessed 25 Feb 2021.
  4. Solomon H, Man JW, Jackson G. Erectile dysfunction and the CV patient: endothelial dysfunction is the common denominator. Heart. 2003;89:251-254.
  5. Jackson G, Rosen RC, Kloner RA, Kostis JB. The second Princeton consensus on sexual dysfunction and cardiac risk: new guidelines for sexual medicine. J Sex Med. 2006;3(1):28-36.
  6. Nehra A, Jackson G, Miner M et al. The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc. 2012;87(8):766-778.


Prevalence of ED

By 2025, the worldwide prevalence of ED is estimated to be approximately 320 million men*1

  • The combined prevalence of mild, moderate, moderate or severe and severe ED in men aged >30 years is 56.9%1
  • A majority were mild cases (32.7%), while the remainder were classified as moderate (18.0%), moderate or severe (4.3%) or severe (2.3%)1

ED is a globally prevalent sexual problem2

  • The prevalence of ED increases with age3
  • ED affects 20%-40% of men who are 60 and above, and 50%-75% of men older than 70 years3

Overall ED prevalence according to National Health and Wellness Surveys in 20164

  • Overall prevalence of ED was found to be 40.5% according to a large cross-sectional, internet-based National Health and Wellness Survey that represented adult populations in Brazil, China, France, Germany, Italy, Spain, UK and US4

ED prevalencae (weighted) by country among adult males age 18+

Increasing prevalence of ED with age5

In the European Male Ageing Study, it was reported that ED increases with age. Importantly, the prevalence of severe ED (defined as an IIEF score of 1-7) increases at a steeper rate than that of moderate ED (score of 8-11) in men over 60 years of age.4

Increasing prevalence of ED with age5

      Adapted from Yafi F. A, et al, Nat Rev Dis Primers. 2016.

ED: erectile dysfunction; IIEF: International index of erectile function; NCD: non-communicable disease; UK: United Kingdom; US: United States.


  1. Ahmed A, Alnaama A, Shams K, Salem M. Prevalence and risk factors of erectile dysfunction among patients attending primary health care centres in Qatar. East Mediterr Health J. .2011;17(7):587-592.
  2. Scaglione F, onde S, Hassan TA, Jannini EA. Phosphodiesterase type 5 inhibitors for the treatment of erectile dysfunction: pharmacology and clinical impact of the sildenafil citrate orodispersible tablet formulation. Clin Ther. 2017;39(2):370-377.
  3. Collica S, Pederzoli F, Bivalacqua T. The Epidemiology and Pathophysiology of Erectile Dysfunction and the Role of Environment-Current Updates. In Bioenvironmental Issues Affecting Men's Reproductive and Sexual Health. 2018:439-455.
  4. Goldstein I, Goren A, Li V, Tang WT, Hassan TA. Erectile dysfunction prevalence, patient characteristics, and health outcomes globally. J Sex Med. 2017;14(5):e298.
  5. Yafi FA, Jenkins L, Albersen M, et al. Erectile dysfunction. Nat Rev Dis Primers. 2016;2:16003.


ED and Comorbidities

In the “Multinational Men’s Attitudes to Life Events and Sexuality (MALES)” study:
Men with comorbid medical conditions and risk factors all reported higher prevalence of ED.1

Prevalence of comorbidities is higher in men with ED

ED, appearing in otherwise healthy men, may be an indicator of serious systemic conditions that have not yet manifested in other ways.5

Erection as the most efficient marker of the phenotypic condition of biological systems

 ED Figure

Management of NCD-generated ED

Medicines Figure


  • ED may be an early indicator for identifying men at higher risk of CVD,8 which has been demonstrated to occur on average 3 to 5 years prior to the CV event.9
  • Incidence of cardiac disease tends to be higher in those with ED.8 Studies have reported an increased prevalence of ED in patients with CAD compared with men without CAD as well as an increased risk of CVD in men with ED compared with men without ED.9
  • In a retrospective study of 62 men admitted to the hospital for first MI, 51.6% of patients were reported to have pre-existing ED.9
  • ED and CVD share many common risk factors, including age, hypertension, diabetes, insulin resistance, smoking, increased BMI, cholesterol and lower HDL.9
  • The artery size hypothesis stipulates that ED is an earlier symptom of systemic atherosclerosis.10

ED and CVD share many common risk factors

ED and CVD share many common risk factors

The artery size hypothesis. (A) Early stage of the atherosclerotic process. Significant vascular obstruction (>50% lumen artery narrowing) of penile circulation leading to ED symptoms is shown. (B) Late stage of the atherosclerotic process. Significant vascular obstruction of coronary circulation leading to angina pectoris is shown.10

The relationship between ED and CVD in various multivariate models.11

The relationship between ED and CVD in various multivariate models.11

*Hazard ratio compared with men with no ED.
†Wald Chi-square test.
‡The multivariate model includes BMI (continuous) and the variables that are part of the Framingham risk score: Age, HDL cholesterol and TC (all as continuous variables), as well as current smoking (yes/no), and hypertension categorised according to BP readings by JNC-V definition (optimal, normal, high normal, Stages I-IV).11

Why screening for ED matters for CVD8?

Why screening for ED matters for CVD

A systematic literature review was conducted to analyse the relationship between ED and CVD, including pathological links between these conditions. A systematic literature review searching Medline, Embase and Web of Science databases was performed. The search strategy included the terms erectile dysfunction, cardiovascular disease, coronary artery disease, risk factors, pathophysiology, atherosclerosis, low androgen levels, inflammation, screening and phosphodiesterase type 5 inhibitors alone or in combination. ED and CVD should be regarded as 2 different manifestations of the same systemic disorder. ED usually precedes CVD onset, and it might be considered an early marker of symptomatic CVD.8
A systematic review discusses the role of cardiologists and urologists in the characterisation of risk and management of CVD in the setting of ED, as well as contrasting the current evaluation of CVD and ED from the standpoint of published consensus statements.9
A pathophysiologic mechanism was proposed to explain the link between ED and CAD called the artery size hypothesis. Given the systemic nature of atherosclerosis, all major vascular beds should be affected to the same extent. However, symptoms rarely become evident at the same time. This difference in rate of occurrence of different symptoms is proposed to be caused by the different size of the arteries supplying different vascular beds that allow a larger vessel to better tolerate the same amount of plaque compared with a smaller one.10
A prospective, population-based study of 1709 men (of 3258 eligible) aged 40-70 years was conducted. ED was measured by self-report. Subjects were followed for CVD for an average follow-up of 11.7 years. The association between ED and CVD was examined using the Cox proportional hazards regression model. The discriminatory capability of ED was examined using c-statistics. The reclassification of CVD risk associated with ED was assessed using a method that quantifies net reclassification improvement.11

BMI: body mass index; BP: blood pressure; CAD: coronary artery disease, CI: confidence interval; CV: cardiovascular; CVD: cardiovascular disease, ED: erectile dysfunction, HDL: high-density lipoprotein, JNC: Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure; MI: myocardial infarction, NCD: non-communicable disease; TC: total cholesterol; TIA: transient ischaemic attack.


  1. Rosen RC, Fisher WA, Eardley I, Niederberger C, Nadel A, Sand M. The multinational Men’s Attitudes to Life Events and Sexuality (MALES) study: I. Prevalence of erectile dysfunction and related health concerns in the general population. Curr Med Res Opin. 2004;20(5):607-617.
  2. Awad H, Salem A, Gadalla A, El Wafa NA, Mohamed OA. Erectile function in men with diabetes type 2: correlation with glycemic control. Int J lmpot Res. 2010;22(1):36-39.
  3. Esposito K, Giugliano F, Di Palo C, et al. Effect of lifestyle changes on erectile dysfunction in obese men: a randomized controlled trial. JAMA. 2004;291(24):2978-2984.
  4. Feldman HA, Johannes CB, Derby CA, et al. Erectile dysfunction and coronary risk factors: prospective results from the Massachusetts male aging study. Prev Med. 2000;30(4):328-338.
  5. La Rochelle JC, Levine LA. Evaluation of the patient with erectile dysfunction. In: Male Sexual Function. Current Clinical Urology. Humana Press. 2006:253-270.
  6. Cellerino A, Jannini EA. Male reproductive physiology as a sexually selected handicap? Erectile dysfunction is correlated with general health and health prognosis and may have evolved as a marker of poor phenotypic quality. Med Hypotheses. 2005;65(1):179-184.
  7. Scranton RE, Goldstein I, Stecher VJ. Erectile dysfunction diagnosis and treatment as a means to improve medication adherence and optimize comorbidity management. J Sex Med. 2013;10(2):551-561.
  8. Gandaglia G, Briganti A, Jackson G, et al. Systematic review of the association between erectile dysfunction and cardiovascular disease. Eur Urol. 2014;65(5):868-968.
  9. Raheem OA, Su JJ, Wilson JR, Hsieh TC. The association of erectile dysfunction and cardiovascular disease: a systematic critical review. Am J Mens Health. 2017;11(3):552-563.
  10. Montorsi P, Ravagnani PM, Galli S, et al. The artery size hypothesis: a macrovascular link between erectile dysfunction and coronary artery disease. Am J Cardiol. 2005;96(12B):19M-23M.
  11. Araujo AB, Hall SA, Ganz P, et al. Does erectile dysfunction contribute to cardiovascular disease risk prediction beyond the Framingham risk score? J Am Coll Cardiol. 2010;55(4):350-356.


Sexual habits of men with Erectile dysfunction

According to a Global Sexual Habits survey,* a majority of men with ED plan for sexual intercourse.†2

Sexual habits of men with ED

In 9/10 men, the 2 most important attributes of ED medications were:

  • Providing a rigid erection (93%)2
  • Low level of side effects (90%)2

83% of men taking medication for sexual intercourse always or sometimes plan a specific time for intercourse.2

Median frequency of sexual intercourse:1

6 times a month

Calendar Figure

Median frequency of ED medication use:1

5 times a month

Importance of product attributes3

The highest rated attribute in terms of importance when purchasing an ED medication is efficacy – provides rigid erection (93%) and low levels of side effects (90%).3

Importance of product attributes

Base: all respondents (see brackets)

Q6b. To what extent do you consider the following attributes to be important when thinking about purchasing an erectile dysfunction medication?

*Brazil, China, Italy, Japan, Russia, Taiwan and Turkey.

In total, 1458 men were screened in this survey.

ED: erectile dysfunction; NCD: non-communicable disease.


  1. Mulhall JP, Hassan TA, Rienow J. Sexual habits of men with ED who take phosphodiesterase 5 inhibitors: a survey conducted in 7 countries. Int J Clin Pract. 2018;e13074.
  2. Mulhall JP, Hassan TA, Rienow J. PI-LBAOS; Understanding the sexual habits of men taking medication for erectile dysfunction (ED), survey results from 7 countries. J Urol. 2016;195(4S),e951.
  3. Understanding the Sexual Habits of Men Taking Medication for Erectile Dysfunction (ED): Survey Results From 7 Countries. Poster presented at 20th World Meeting on Sexual Medicine & Global Chinese Andrology and Sexual Medicine Congress. 2016.



Evaluating hardness with EHS1

Penile rigidity is the most important determinant of the quality of an erection.1

The EHS is a validated instrument.1

Adapted from Mulhall J. P, et al, J Sex Med. 2007.

  • Completely hard erections should be considered a treatment goal in most men2
  • Erection hardness affects self-esteem, overall relationship satisfaction, confidence and sexual satisfaction3

In men with ED, VIAGRA® delivered an increase in Grade 4 erections versus placebo4

Men with ED were able to attain Grade 4 erection hardness with increasing dose of VIAGRA®.4

Men with ED were able to attain Grade 4 erection hardness with increasing dose of VIAGRA

Adapted from Goldstein I, et al, N Engl J Med. 1998.

*P<0.001 for the comparison with placebo of Grade 4 and of Grade 3 plus Grade 4.4

In a 24-week, dose-response study, 532 men were treated with oral sildenafil (25 mg, 50 mg or 100 mg) or placebo. In a 12-week, flexible dose-escalation study, 329 different men were treated with sildenafil or placebo, with dose escalation to 100 mg based on efficacy and tolerance. After this dose-escalation study, 225 of the 329 men entered a 32-week, open-label extension study. We assessed efficacy according to the IIEF, a patient log and a global-efficacy question.4

ED: erectile dysfunction; EHS: erectile hardness score; IIEF: International Index of Erectile Function; NCD: non-communicable disease.


  1. Mulhall JP, Goldstein I, Bushmakin AG, Cappelleri JC, Hvidsten K. Validation of the erection hardness score. J Sex Med. 2007;4:1626-1634.
  2. Kadioglu A, Grohmann W, Depko A, Levinson IP, Sun F, Collins S. Quality of erections in men treated with flexible-dose sildenafil for erectile dysfunction: multicenter trial with a double-blind, randomized, placebo-controlled phase and an open-label phase. J Sex Med. 2008;5:726-734.
  3. Althof S, O'Leary M, Cappelleri J et al. Sildenafil Citrate Improves Self‐Esteem, Confidence, and Relationships in Men with Erectile Dysfunction: Results from an International, Multi‐Center, Double‐Blind, Placebo‐Controlled Trial. J Sex Med. 2006;3(3):521-529.
  4. Goldstein I, Lue TF, Padma-Nathan H, Rosen RC, Steers WD, Wicker PA. Oral sildenafil in the treatment of erectile dysfunction. Sildenafil Study Group. N Engl J Med. 1998;338(20):1397-1404.



Viagra® Efficacy in treatment of Erectile dysfunction

Viagra® Efficacy in treatment of Erectile dysfunction

Quick onset of action with VIAGRA® film-coated tablets

Viagra® quick onset of action

Viagra® quick onset of action

Dosing and Administration

Viagra® Dosing and Administration

Viagra® Dosing and Administration

Advantages of ODT

Viagra® Advantages of ODT

Viagra® Advantages of ODT