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Erectile Dysfunction

GMJ News knowledge hub · last reviewed August 2026 · Georgian Medical Journal

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Erectile dysfunction (ED) — the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual activity — affects an estimated 150 million men globally (with projections to 322 million by 2025) and is now recognised as far more than a quality-of-life issue: ED is a cardiovascular sentinel event, typically preceding symptomatic cardiovascular disease by 3-5 years and serving as an independent marker of endothelial dysfunction and atherosclerotic vascular disease that should trigger full cardiovascular risk assessment (WHO). Phosphodiesterase-5 inhibitors — sildenafil (Viagra, 1998), tadalafil (Cialis), vardenafil and avanafil — are the first-line pharmacological treatment, but the most important therapeutic principle is addressing the underlying cause: vascular risk factors (hypertension, diabetes, dyslipidaemia), hormonal imbalances (testosterone deficiency) and psychogenic factors.

Key messages

150M men affected — cardiovascular sentinel event
Erectile dysfunction affects approximately 150 million men globally (projected 322 million by 2025). ED is now recognised as a cardiovascular sentinel event — typically preceding symptomatic CAD by 3-5 years and representing an independent marker of endothelial dysfunction (WHO/EAU).
PDE5 inhibitors — first-line treatment
Phosphodiesterase-5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) are first-line pharmacological treatment for ED — enhancing cyclic GMP-mediated smooth muscle relaxation to augment erection in response to sexual stimulation. Contraindicated with any nitrate-based medication (life-threatening hypotension).
Organic vs psychogenic ED
Organic ED (gradual onset, consistent, absent morning erections, older men with vascular risk factors — the most common type) vs psychogenic ED (sudden onset, situational, normal morning erections, younger men — anxiety-driven). Both can coexist. Psychogenic ED is increasingly common in young men, often related to internet pornography-associated ED (IPED).
Address underlying cause — not just the symptom
ED treatment should target the underlying aetiology: cardiovascular risk factor modification (control hypertension, diabetes, dyslipidaemia, smoking cessation); testosterone replacement if hypogonadal; stop offending medications (antihypertensives: thiazides, beta-blockers — not ACE-I/ARB; SSRIs; antipsychotics; 5-alpha reductase inhibitors); psychosexual therapy for psychogenic ED.
Penile rehabilitation after prostate surgery
Radical prostatectomy causes cavernous nerve injury in most men → postoperative ED in 50-80%. Early and regular use of PDE5 inhibitors (penile rehabilitation) and vacuum erection devices preserves erectile tissue oxygenation and improves recovery of natural erections after nerve-sparing prostatectomy.
Penile prosthesis — last resort
For ED refractory to all pharmacological and vacuum device therapy: inflatable penile prosthesis (IPP) implantation — the most effective treatment for severe refractory ED, achieving highest patient and partner satisfaction of any ED treatment. Not reversible.

Key statistics

150M
men globally affected by ED (WHO/EAU estimate)
WHO/EAU
322M
projected ED cases by 2025 (projection from 1999 data)
WHO 1999 projection
3-5yr
ED typically precedes symptomatic CAD by 3-5 years
JACC/EAU
50-80%
of men have ED after radical prostatectomy
EAU/Urology
Nitrate
contraindication with all PDE5 inhibitors — life-threatening hypotension
FDA/EMA
Increasing
ED in young men <40 years — rising prevalence linked to psychological and lifestyle factors
EAU 2024

Erectile dysfunction aetiology — relative proportions (EAU/WHO)

Source: EAU. Vascular/organic causes dominate in older men; psychogenic increasingly prevalent in younger men.

Glossary of key terms

Phosphodiesterase-5 (PDE5) inhibitors
WHO/FDADrugs that inhibit PDE5 — the enzyme that breaks down cyclic GMP (cGMP) in penile smooth muscle. During sexual stimulation, nitric oxide (NO) is released → activates guanylate cyclase → raises cGMP → smooth muscle relaxation → arterial dilation → erection. PDE5i prolong cGMP elevation. The four approved agents: sildenafil (Viagra, 50mg; take 30-60 min before; duration 4h); tadalafil (Cialis, 10-20mg daily or 5mg daily for daily use; duration 36h); vardenafil (10mg; similar to sildenafil); avanafil (100-200mg; fastest onset, 15-30 min).
Endothelial dysfunction and ED
JACC/EAUErectile function depends on intact endothelial function — penile arteries are among the smallest arteries in the body (diameter 1-2mm) and are exquisitely sensitive to early endothelial dysfunction and atherosclerosis. ED from vascular causes therefore represents the first clinical manifestation of systemic atherosclerotic vascular disease — typically appearing 3-5 years before angina or MI (because the smaller penile arteries are affected first). This makes ED a cardiovascular screening opportunity.
Testosterone deficiency and ED
EAU/EndocrinologyMale hypogonadism (testosterone <10-12 nmol/L by most guidelines, with symptoms) causes reduced libido and can contribute to ED by reducing the sensitivity of penile smooth muscle to NO and reducing the central drive for sexual activity. Testosterone replacement restores libido and may improve PDE5i response. All men with ED should have morning testosterone measured. Treat hypogonadism before concluding ED is purely vascular.
Drug-induced ED
BNF/EAUCommon drug causes of ED: antihypertensives (thiazide diuretics — most implicated; beta-blockers; spironolactone; NOT ACE inhibitors or ARBs); antidepressants (SSRIs — probably the most common drug cause in younger men; tricyclics; SNRIs); antipsychotics (risperidone — hyperprolactinaemia; olanzapine); 5-alpha reductase inhibitors (finasteride — persistent sexual dysfunction possible even after stopping); opioids; antiandrogens (for prostate cancer); recreational drugs (alcohol in excess; cannabis; cocaine).
Vacuum erection device (VED)
EAUA non-pharmacological treatment: a plastic cylinder placed over the penis + a pump creates negative pressure drawing blood into the corpora cavernosa → erection → constriction ring placed at the base to maintain erection for up to 30 minutes. Effective; no systemic side effects. Useful for: post-prostatectomy rehabilitation; men who cannot take PDE5i (cardiac contraindications); preference for drug-free option.
Peyronie's disease
EAUFibrotic plaques developing in the tunica albuginea of the penis — causing penile curvature, pain (acute phase) and ED. Prevalence: approximately 3-9% of adult men. Collagenase Clostridium histolyticum (CCH, Xiaflex) — the only approved pharmacological treatment for Peyronie's disease — breaks down collagen in the plaque. Surgical correction (plication or graft procedures) for stable disease with significant curvature.

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Related health topics

Men's healthCVD (ED as sentinel)Diabetes (vascular ED)Hypertension (drug-induced ED)Post-prostatectomy EDPsychogenic ED

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