Limited cardiac workup is vital in men with erectile dysfunction, according to urologists

April 1, 2010

We asked several urologists around the country if they conducted workups on their patients with ED to determine whether there was coexisting cardiovascular disease, or if they referred patients to cardiologists for an assessment before starting ED treatment.

Over the past few years, a number of studies have linked erectile dysfunction with cardiovascular disease and peripheral artery disease. Researchers have suggested that ED may be a marker for undiagnosed heart disease. More recently, data from a large population-based study have shown that frequency of sexual activity may be a potential red flag for future cardiac disease (see, "ED, frequency of sexual activity linked to CVD,").

Urology Times wanted to know whether and how practicing urologists applied these findings to their daily practice. We asked several urologists around the country if they conducted workups on their patients with ED to determine whether there was coexisting cardiovascular disease, or if they referred patients to cardiologists for an assessment before starting ED treatment. We also asked how they approach the treatment of ED if cardiovascular disease was involved.

Danny Keiller, MD, an associate clinical professor of urology at the University of California, San Diego, says most of his ED patients have primary care physicians who have already assessed them for cardiovascular symptoms.

"The other reason to do that assessment is that if we manage to make a man sexually capable again and he has a cardiac condition, he can damage his heart from overexertion while performing sex."

Dr. Keiller says that if there's any question about exercise tolerance of chest pain or if a patient has edema or any hint of congestive heart failure, he is sent to an internist or cardiologist for further examination.

"I'm a urologist, so I don't do EKGs and angiograms. What I do is part of an overall assessment-looking for diabetes, vascular problems, cardiac problems, hormonal problems, along with everything else," Dr. Keiller said.

First visit may be to a urologist

In San Antonio, LeRoy Jones, MD, says he does see younger men in the 35- to 45-year-old range who have never seen a physician before.

"We give seminars and we talk on television about ED, so sometimes younger men who are having trouble with erections will come in. My job is to educate them about the causes of erectile dysfunction," he said. "The perception among a lot of young patients is that it's in their mind-that for some reason their mind is not allowing them to get an erection. They don't really make the link between vascular health and erectile dysfunction.

"I try to impress upon them the importance of that link. I diagnose probably 15 patients a year with diabetes who present with erectile dysfunction. That's not a small number.

"Trying to get them to understand that they may have some diabetes or blood pressure issues and certainly some underlying heart disease issues isn't always easy. I've actually aligned myself with a couple of internal medicine doctors who will work patients up further and educate them and be aggressive in treating the patient," he added.

"In other words, I want to send these patients to the kind of doctor who will put them on a cholesterol medication, as opposed to someone who just recommends diet and exercise and sees them back in 6 months. If they already have symptoms for erectile dysfunction, that means they have some sort of vascular compromise. So I've linked myself with doctors who will be more aggressive in treatment."

Work closely with family docs

Neil Dunn, MD, who practices in Panama City, FL, stresses the importance of working with family physicians in his community when it comes to patients with ED.

"We correspond and work with those physicians very closely so we're not isolated," he said. "At least 90% of the men who come in will have a note that goes back to their primary care doctor every time they sees us. We'll say, 'the patient has erectile dysfunction and we think he has a lipid problem. We're sending him back to you for management of that.' Then, we will manage the erectile dysfunction more or less separately.

"A lot of our patients are referred by their family physician because they have a problem. But we do seminars for the public to talk about ED, so yes, some men come to us directly. We always try to assign a weighted score to the causes of erectile dysfunction. Is it hormonal? Is it lipids? Is it vascular disease? Did they have a radical prostatectomy? All of those are good reasons and we try to score every person as to the cause of their ED," Dr. Dunn explained.

"Whether or not cardiovascular issues are a major cause of the problem, it is usually indicated by obvious risk factors such as smoking or hypertension or weight."

An opportunity to diagnose early

Neil Baum, MD, a clinical associate professor of urology at Tulane University in New Orleans, says erectile dysfunction should be considered an indicator of cardiovascular disease, even if the man has no other apparent symptoms.

"We call ED a 'dangling stress test.' We know full-well that ED can predate a cardiovascular event such as a myocardial infarction by as much as 2 years," Dr. Baum said. "So as urologists, we have an opportunity to diagnose cardiovascular disease when it's in the subclinical state.

"Consequently, it's a good idea to at least do a lipid profile, take the patient's blood pressure, check for diabetes, and see if there are any risk factors such as family history, lymphedema, or hypertension. The men should be referred to their primary doctor or to a cardiologist for stress testing. Often it's possible to pick up clinical artery disease and peripheral vascular disease with ED as the presenting symptom. So it's good medicine to make sure these men understand that," he said.

Jack Baker, DO, in Canton, OH, says he used to do more cardiovascular workups in the past than he does now.

"I used to do more of a workup when we did more surgeries that were consistently helpful in treating ED. But with the advent of the various pills for erectile dysfunction, I simply use those," Dr. Baker said.

"I always try to do a basic physical vascular exam, take a history, and see if they have any past history of vascular or cardio problems, or angina," he added. "Usually, I just let patients know that ED can be a symptom of cardiovascular disease, so they should have that checked out too."

All of the urologists who were interviewed start treating a patient's erectile dysfunction, even if the patient is referred for follow-up cardiac care with an internist or cardiologist. Providing the patient is not taking nitrates, which the urologists say they see less frequently now, most patients respond well to oral phosphodiesterase type-5 inhibitors, they report.

Karen Nash is a medical reporter and media consultant based in Sioux Falls, SD.