Modifiable Factors

Obesity is associated with decreased levels of testosterone and free testosterone and increased peripheral conversion of testosterone and other androgens to oestrogen. Weight loss may therefore influence testosterone levels.

A randomised single-blind trial of 110 obese men aged between 35 and 55 years without diabetes, hypertension or hyperlipidemia and who had ED with an IIEF score of 21 or less were assigned to either advice to achieve a loss of 10% or more of their total body weight by reducing calorie intake and increasing physical activity or a control group who were given general information about healthy food choice and exercise.
Lifestyle changes were associated with improvement in around one third of obese men with ED at baseline.

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– High body mass index may be related with sleep apnoea which is itself associated with ED. Treatment with continued positive airway pressure to the nasal passages improves erectile function.
A recent comprehensive evaluation identified via a Medline search until July 2007 supports the association between metabolic syndrome, ED and low-grade inflammatory state. The increased circulating levels of inflammatory and endothelial-prothrombotic compounds are related to the presence and severity of ED. Specific inflammatory biomarkers and their combination appear to have the potential to aid the diagnosis or exclusion of ED. It is concluded that ED and coronary artery disease may confer a similar unfavourable impact on the inflammatory and prothrombotic state and that ED adds an incremental activation in addition to coronary artery disease. Lifestyle and risk factor modification as well as pharmacological therapy are associated with anti-inflammatory effects.

– A Mediterranean style diet has been shown to lead to an improvement of erectile function score (IIEF-5) after 2 years with around one third of men regaining normal erectile function with a significant improvement in endothelial function score and inflammatory markers (hsCRP). As noted, Esposito reported that the loss of total body weight by greater than 10% and the increase in physical activity led to an improvement in the IIEF-5 score and reduction in serum concentrations of IL-6 and hsCRP after 2 years. The potential role of phosphodiesterase type 5 (PDE5) inhibitors, statins and ACE inhibitors are considered further by Vlachopoulos et al.

– Smoking cigarettes increases the risk of cardiovascular disease which in turn is associated with ED. A recent article supports the association between ED and smoking cigarettes. The controversies regarding the association between smoking and ED are considered further in this article. Nicotine is also a potent vasoconstrictor and for those people with compromised arterial function the immediate effect of smoking a cigarette persists for at least 2 h.

– The role of illicit substance abuse is a further factor where lifestyle change can have a marked impact on ED. Lifetime use of ED medications was reported as used in a quarter of men surveyed in a substance abuse treatment outpatient clinic.

Psychological and Psychosexual Couple Interventions

The role of psychological treatments in conjunction with physical treatments remains an area of controversy and debate. For many men, there is an inevitable psychological cognitive or emotional response to a failure to achieve or maintain a rigid erection which he considers essential to have satisfactory sexual intercourse either alone or with his partner.

For some men there may be a wholly psychological contribution towards the ED. In either case, there is often a rejection of the suggestion that engagement in psychological or talking therapies will bring benefit to the man and his partner. For some patients, it is helpful to demonstrate the presence of an adequate erection. This has included the use of a pharmacological induced erection within the clinic (for example using intra-cavernosal alprostadil) or by using other evidence to demonstrate erectile capacity. Use of partner recall can be helpful but in other circumstances objective measurement such as nocturnal RigiScan or ultrasonography demonstrating excellent function is required before the patient agrees to engage in a talking therapy Australian Viagra Sales.

The literature is sparse for randomised control trials as the primary or secondary treatment for ED. With this in mind the interested reader is referred to a recent article which reviewed the various psychological and theoretical frameworks and review of literature for the use of talking therapies for ED. A recent Cochrane review of psychosocial interventions for ED found evidence that group therapy improves ED in selected patients who received group therapy, and sildenafil showed significant improvement of ED. Men were less likely than those receiving only sildenafil to drop out.