Abstract - Dramatic advances in the management of erectile dysfunction have occurred over the past decade. Oral therapy with vasoactive agents has emerged as first-line treatment and has transformed both the manner in which the public views erectile dysfunction and the way health care providers deliver care.

Whereas an extensive investigation was previously common in the management of erectile dysfunction, recent treatment guidelines promote a more minimalist, goal-oriented approach. In this article, we review the physiology of erection, and the pathophysiology, diagnosis and clinical management of erectile dysfunction. We also present the existing evidence for the efficacy of 3 phosphodiesterase inhibitors, the most widely used class of agents for erectile dysfunction.

From the Division of Urology, Faculty of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada.

Erectile dysfunction can be defined as the inability to achieve or maintain a penile erection sufficient for satisfactory sexual performance. In the face of an aging population, decreasing social stigma associated with erectile dysfunction and an increasing availability of effective oral therapy for its treatment, the number of patients presenting with this complaint has increased dramatically.

Current estimates describe 2-3 million Canadian men as having significant recurring erectile difficulties. Recent reports identifying a dramatic increase in rates of diabetes, increased longevity and higher quality-of-life expectations by \"baby boomers\" are all believed to be factors in a projected continued expansion of the patient population requesting medical help with sexual issues in the near future.

Although historically erectile dysfunction was a problem identified and treated by urologists, today primary care physicians and other specialists write 80% of the prescriptions for sildenafil, the most popular drug used to treat the condition.

In this article, we review the epidemiology of erectile dysfunction, the current understanding of its pathophysiology and the evidence for the efficacy of oral therapy with phosphodiesterase type-5 inhibitors, which has become the first-line treatment of erectile dysfunction.

Epidemiology of erectile dysfunction

The Massachusetts Male Aging Study surveyed 1709 men aged 40-70 years in the greater Boston area between 1987 and 1989 and reported a prevalence of erectile dysfunction of 52%, with 9.6% of respondents reporting complete erectile dysfunction. In 2000 the overall prevalence of erectile dysfunction in this study population was re-estimated to be 44%. The Massachusetts study is important because it is the first cross-sectional, community-based, random-sample multidisciplinary survey on the topic and involved a significant cohort followed up for nearly a decade beyond the initial assessment. A survey of 3009 men aged 18-70 years from all regions of Canada revealed a similar prevalence of erectile dysfunction.

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