Impotence: Why it's time to tell your doctor

A leading American urologist believes doctors should routinely ask their male patients if they have erection problems. Peter Baker reports.

How would you feel if your doctor asked if you have erection problems even though you made the appointment to discuss your bad back or night-time indigestion? You might well feel embarrassed, or perhaps even a little angry, but it is a question that could potentially save your life.

Very few doctors do routinely ask their male patients about erection problems, of course, although many more might if they heed the advice of Dr Lawrence Levine, a urologist at Rush-Presbyterian-St. Luke's Medical Center in Chicago.

In an editorial in this month's issue of The American Journal of Cardiology, Dr Levine argues that doctors should ask because erectile dysfunction (more commonly known as impotence) is not only a problem in itself but can also be a symptom of a serious but as yet undiagnosed medical condition.

ED can be an important early-warning sign of heart disease, according to research by Dr Marc Pritzker, director of heart failure and transplantation at the Minneapolis Heart Foundation. He examined 50 men with ED who had sought prescriptions for Viagra. Although none of them had any symptoms of heart disease, six had blockages in all three major heart arteries, seven had two arteries that showed narrowing and one artery was blocked in another seven. Overall, 40 per cent of the men were at significant risk of angina or a heart attack.

'We now understand that atherosclerosis [the thickening and narrowing of blood vessels, mainly due to fatty deposits] detected in one set of blood vessels markedly increases the chances of having this form of blood vessel disease in other areas of the body,' says Dr Pritzker. 'Because the blood vessels that supply the penis are narrower than arteries in other areas of the body, atherosclerosis may manifest itself as erectile dysfunction before the disease becomes apparent in other arteries.'

Some doctors use an 'exercise stress test' - an electrocardiogram (ECG) conducted while the patient is physically active - to detect cardiovascular anomalies. Dr Pritzker believes 'erectile dysfunction could be called a "penile stress test" and may be another way of detecting diseased blood vessels.' 

Dr Pritzker is quick to point out that 'we don't want every male who's running around with erectile dysfunction to think he's at risk of dropping dead with a heart attack.' He freely admits that the 50 men he examined were already considered to be candidates for a cardiovascular disorder because there were no other obvious explanations for their erection problems and most of them had at least one other risk factor for heart disease including smoking, high cholesterol levels and high blood pressure.

But Dr Pritzker warns that 'if you've been used to regular sexual activity and then things don't work as well, it's a sign that something could be wrong. One needs to pay attention to that.' Heart disease is not the only serious problem for which ED can be an early symptom. Diabetes can damage the nerves that cause the blood vessels of the penis to expand and also lead to a hardening and narrowing of the blood vessels supplying the penis.

Up to 25 per cent of all diabetic men aged 30-34 experience erection problems; by the age of 60-64, 75 per cent of diabetic men are affected. Untreated, diabetes can become a very serious disease, affecting the eyes, kidneys and heart.

The links between ED and potentially life-threatening health problems makes it essential that men seek medical help as soon as possible. Unfortunately, feelings of embarrassment or shame mean that men often wait a long time before seeing their GP. An Impotence Association survey of over 430 British men with erection problems found that 41 per cent tried self-help - such as mechanical devices, videos, books or creams - before visiting a doctor. 

A study presented to this year's American Urological Association meeting came to a similar conclusion. In a survey of 500 men who were seeing urologists for reasons other than ED, 44 per cent of them had experienced ED but had not told their doctor about the problem. The reason cited by 74 per cent of these men was embarrassment. Some men are known to have waited up to 40 years before seeking the medical help they need. Alan Riley, professor of sexual medicine at the Lancashire Postgraduate School of Medicine and Health says: 'We know that 10 per cent of men have problems but this number aren't actually seeking help. The patients seen by doctors are only the tip of the iceberg.'

The Government's guidelines on the treatment of ED, introduced because of fears that the demand for Viagra would create an astronomic increase in NHS spending, have also confused patients and deterred many men from coming forward for treatment, argues Dr Ian Banks, a GP and chairman of The Men's Health Forum.

Since July 1999, GPs have only been able to prescribe drug treatments on the NHS to men whose ED is caused by a limited range of specific conditions. These include diabetes, spinal cord injury and treatment for prostate cancer but not cardiovascular disease. The Impotence Association believes that only half of patients seeing their GP are now able to receive treatment on the NHS.More worryingly still, GPs' responses to men with ED can be woefully inadequate. 'It's still common for some GPs to treat impotence as a joke and I don't think many are good at looking for underlying diseases,' says Ann Tailor, director of the Impotence Association.

She believes too many men are leaving doctors' surgeries clutching a prescription for Viagra or Caverject, a drug that can be injected directly into the penis, but without having undergone the full range of necessary tests. Men who are concerned about their GP's approach should not hesitate to ask for a referral to a specialist.From a cardiologist's perspective, Dr Pritzker has few doubts about what should happen when a man tells his doctor he has ED. 'We have an opportunity to look for heart disease, make a diagnosis and offer appropriate prevention.' That could mean a healthier diet, more exercise and quitting smoking. This may not want to be the message many men will wish to receive, but it could turn out to be a real life-saver.

Peter Baker is CEO of the Men's Health Forum