Peter Pommerville, BA, MD, FRCS(C), Director of Research, Can-Med Clinical Research, Inc.; Clinical Instructor, University of British Columbia; Clinical Instructor, University of Victoria; Consulting Urologist, Vancouver Island Health Authority, Vancouver, BC.

It is estimated that 50% of men between 40 and 70 have erectile dysfunction (ED). The number of men with ED rises to 65% or greater over age 70. Despite the fact that men in this age range have significant medical comorbidities causing their ED, they have often cared for a spouse with a terminal illness. In search of companionship, they become acquainted with a woman who has just been through a similar circumstance. Therefore, it’s usual for men to have performance anxiety contributing to their ED. Proper diagnosis and assessment to determine the etiology of ED is usually done by the primary care physician, with possible follow-up by an urologist or psychiatrist if the main cause is deemed to be organic or psychological, respectively. In some cases, there is overlap as medications such as antidepressants may interfere with sexual function.
Primary care physicians, geriatricians, and allied health care professionals charged with the management of these older men should be empathetic towards their sexual health. Safe and effective treatments for ED are available to permit these couples to enjoy a healthy sexual experience in their elder years.
Key words: erectile dysfunction, diabetes, vardenafil, sildenafil, tadalafil.

Kevin L. Billups, MD, Urologist & Medical Director, The EpiCenter for Sexual Health & Medicine, Edina; Adjunct Assistant Professor, Laboratory Medicine & Pathology, University of Minnesota, Minneapolis, MN, USA.

Erectile dysfunction (ED) is a prevalent vascular disorder that, like cardiovascular disease, is now believed to cause endothelial dysfunction. In fact, a growing body of literature now suggests that ED may be an early marker for atherosclerosis, increased cardiovascular risk, and subclinical vascular disease. The emerging awareness of ED as a barometer of overall cardiovascular health represents a unique opportunity for primary prevention of vascular disease in all men. Although the implications of this relationship for primary and secondary prevention of cardiovascular disease are not yet fully appreciated, the available literature makes a strong argument for the role of erectile dysfunction as an early marker for the development of significant cardiovascular risk factors and cardiovascular disease. Early detection of erectile dysfunction could play a major role in improving male cardiovascular health.
Key words: erectile dysfunction, cardiovascular disease, atherosclerosis, endothelium, prevention.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Peter Pommerville, BA, MD, FRCS(C), Director of Research, Can-med Clinical Research, Inc.; Consulting Urologist, Vancouver Island Health Authority,
Vancouver, BC.

Abstract:Sildenafil was introduced in Canada in 1998 as the first effective oral therapy for erectile dysfunction (ED). Since its release, sidenafil has been proven to be an effective and safe treatment for ED in older patients with multiple medical problems. In the last year, two new PDE5 inhibitors have been approved for ED treatment: vardenafil and tadalafil. There are subtle differences between the three phosphodiesterase type 5 (PDE5) inhibitors with respect to efficacy, dosing instructions, and adverse event profiles. All three PDE5 inhibitors have exhibited efficacy and safety in the cardiac patient as long as he is not reliant upon the regular use of nitroglycerine. This article reviews the similarities and differences between the three PDE5 inhibitors, and refers to patient attitudes in Canada towards sexual activity and its treatment with these agents, as discussed in the Canadian Sexual Satisfaction Survey (CSSS).

Key words: Erectile dysfunction, phosphodiesterase inhibitor, sildenafil, vardenafil, tadalafil

Introduction
Physicians in Canada are treating an increasingly aging population, and coupled with this is an increase in the incidence of specific diseases that may arise as a result of the breakdown of biological mechanisms (e.

Muammer Kendirci, MD, Tulane University, School of Medicine, Department of Urology, Section of Andrology and Male Infertility, New Orleans, LA, USA.
Wayne J. G. Hellstrom, MD, FACS, Tulane University, School of Medicine, Department of Urology, Section of Andrology and Male Infertility, New Orleans, LA, USA.

Sexual dysfunction in the older man is common and has a significant impact on quality of life. In the aging man, erectile dysfunction (ED) has been encountered frequently due not only to associated comorbidities such as heart disease, hypertension, medications, diabetes, smoking, and depression, but also as a result of the aging process itself. Aging may impair molecular and structural components of erectile function. The introduction of effective oral erectogenic drugs has led to increased awareness of sexual issues and advancement in the methods used by clinicians to diagnose ED. Over the last twenty years, the approach for identification and evaluation of ED has transformed from invasive techniques to patient self-reporting and minimally invasive office procedures.

Key words: erectile dysfunction, aging, diagnosis, evaluation.

Peter J. Pommerville, BA, MD, FRCS(C), Consultant Urologist, Vancouver Island Health Authority, Victoria, BC; Principal Investigator, Can-Med Clinical Research Inc., Victoria, BC.

Introduction
Erectile Dysfunction is a significant and common medical problem. The National Institutes of Health has defined erectile dysfunction as "the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance."¹ The nature of sexual dysfunction is more precisely defined by the term erectile dysfunction (ED) than by the term impotence.¹

ED is a clearly defined problem that the medical practitioner must differentiate from premature ejaculation, orgasmic dysfunction and Peyronie's disease.

Prevalence of Erectile Dysfunction
According to the NIH Consensus Development Panel, ED may affect as many as 30 million males in the U.S.¹ Data collected by Statistics Canada indicate that as many as three million Canadian men may suffer from ED. However, it is estimated that fewer than 20% seek treatment.²

Epidemiological studies conducted in the U.S. provide the most extensive information on the prevalence of ED. One such study that is often referred to is the Massachusetts Male Aging Study (MMAS).³ This study demonstrated a combined prevalence of minimal, moderate and severe ED in 52% of non-institutionalized men aged 40 to 70 (Figure 1). Of these, 10% reported complete ED, 25% reported moderate ED and 17% minimal ED.

Options Range From Pills to Hand- and Battery-Operated Pumps

Joyce So, BSc
Co-author:
Sidney Radomski, MD, FRCSC
Urology, Toronto Western Hospital

Erectile dysfunction (ED), the persistent inability to attain or maintain a sufficient penile erection for sexual intercourse in at least 50% of attempts, afflicts more men and with greater severity as they age. A quarter of men who are 65 years of age struggle with erectile dysfunction, while more than half of 75-year-olds and 65% of 80-year-olds, experience difficulties with sexual function. Although age is the greatest risk factor associated with ED, it is not considered to be a part of the normal aging process. Physicians should encourage patients and their partners to discuss this problem so that appropriate treatment can be initiated.

Because ED often comprises both organic and psychogenic components, manage- ment of this problem can address both medical and psychological causes. The management of medical causes of ED includes oral therapy, intracavernosal injection therapy, intraurethral therapy, vacuum constriction devices, surgical options including penile prostheses, and various preparations of testosterone for men with diagnosed testosterone deficiency.

In March 1998, the Food and Drug Administration (FDA) approved sildenafil (Viagra), in the United States as the first oral medication available for the treatment of erectile dysfunction in men. Soon after, it was also approved for use in Canada.

Joyce So, BSc
Co-author:
Dr. Sidney Radomski,
Urology, Toronto Western Hospital

In 1992, the National Institutes of Health Consensus Development Conference¹ suggested the use of the term "erectile dysfunction" instead of "impotence" to describe one of the most common chronic medical problems affecting men over the age of 40. Erectile dysfunction is defined as the persistent inability to attain or maintain a sufficient penile erection for sexual intercourse in at least 50% of attempts. The prevalence and degree of erectile dysfunction increases with age, with men in their fifties being three times more likely to have this condition compared to men in their twenties.² By the age of 65, 25% of men are afflicted with erectile dysfunction, a number which increases to 55% among 75-year-olds and 65% among 80-year-olds.² However, erectile dysfunction should not be considered part of the normal aging process.

The multi-disciplinary, community-based Massachusetts Male Aging Study (MMAS)³ of men aged 40 to 70, conducted between 1987 and 1989, showed that 35% of the men reported moderate to complete erectile dysfunction, with 52% reporting at least some degree of dysfunction. They also reported a decrease in libido and the number of sexual thoughts, fewer nocturnal or morning erections, and less frequent intercourse with age.