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Erectile dysfunction (ED) is often the chief complaint that leads to adiagnosis of hypogonadism. About half of men 40–70 years of age reportsymptoms of ED, and the incidence of ED is much higher among men withdiabetes, affecting up to 85%.
Bombarded by advertisements for phosphodiesterase-5 (PDE-5) inhibitors suchas sildenafil (Viagra, Pfizer), tadalafil (Cialis, Lilly), and vardenafil(Levitra, Bayer/Glaxo-SmithKline), many men think a pill is the answer totheir erectile problems. But in clinical practice, resolution is not thatsimple.
In men with diabetes, the severity of ED increases as glycemic controlworsens, according to recentresearch.1 Heartdisease and hypertension are important risk factors for ED. It also can be aside effect of antihypertensive drugs, statins, antidepressants, and numerousother drugs.
"[ED] can be a heralding sign for cardiovascular disease anddiabetes," says urologist Jennifer Berman, MD, of University ofCalifornia Los Angeles Medical Center. "There's data showing that if [apatient] presents with ED, he's at increased risk for vascular disease andthus at increased risk for heart attacks."
A provider might not ask about ED if a patient has hypertension, but if apatient complains of ED, it should be a clue to investigate cardiovasculardisease as a cause. Peripheral or autonomic neuropathy, peripheral vasculardisease, and gynecomastia also should be investigated as potentialcontributors to sexual dysfunction, experts say.
In addition, a lab evaluation of the patient's glycemic control, serumcreatinine, cholesterol, testosterone, prolactin, thyrotropin, and urinaryprotein excretions also must be considered to understand the root causes ofhis ED and diagnose related problems.
According to Cully C. Carson, MD, chair of urology at University of NorthCarolina at Chapel Hill School of Medicine, PDE-5 drugs tend to be lesseffective in people with diabetes. About 75% of nondiabetic men are satisfiedwith PDE-5 therapy, compared with 60% of those with diabetes, he says.
Fortunately, weight loss and other lifestyle changes improve erectilefunction in many men. One report suggests that a lifestyle interventiondesigned to reduce 
10% of body weight by reducing caloric intake andincreasing physical activity improves sexual function in about one-third ofobese men withED.2
If ED is a side effect of drug therapy, lowering dosages or switchingmedication often helps.
Carson does prescribe a PDE-5 drug to many men with ED in hispractice—when it's not contraindicated—but he does so along withlifestyle intervention and treatment of underlying risks.
HEALTH RISKS
Bradley Anawalt, MD, associate professor at University of Washington inSeattle and associate chief of medicine at the Veterans Affairs Puget SoundHealth Care System, says PDE-5s are being prescribed frequently to older menbecause the prevalence of ED increases with aging.
"The big no-no's for prescribing these drugs are if [patients] haveheart disease that is severe enough that they can't tolerate significantexercise and if they are taking any medication with nitrate, such asnitroglycerine and amyl nitrate; a relative contraindication is taking alphablockers to treat prostate disease," Anawalt says.
"If you can't walk a mile in 20 minutes or can't walk up two flightsof stairs in 10 seconds, you probably don't have the cardiovascular ability tohave sex safely," he explains. "We shouldn't be giving thosepatients these medications. That's giving them powerful incentive to doexercise they're not ready for."
PDE-5 drugs recently have been linked to nonarteric anterior ischemic opticneuropathy (NAION). The Food and Drug Administration (FDA) has received 43reports of NAION among PDE-5 drug users and is looking further into the issue.Other common side effects include headache, skin flushing, indigestion, andpersistent erection.
Improper use of PDE-5 drugs also poses risk to the adventurous male public,but a review of sources at the FDA and the Centers for Disease Control, aswell as a search of the medical literature, suggests that PDE-5 abuse is not asignificant public health problem.
However, the FDA and other regulatory agencies warn consumers about buyingPDE-5 drugs—or any prescription drug—on the Internet. According tofederal officials, about 75% of ED "drugs" sold online arecounterfeit. 
References
2. Esposito K, Giugliano F, Di Palo C, et al.: Effect of lifestylechanges on erectile dysfunction in obese men: A randomized controlled trial.JAMA 291:2978–2984, 2004.
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