As a board-certified urologist who specializes in male sexual dysfunction and men’s health, I often find that people can be pretty dismissive of treatment for erectile dysfunction (ED), as though it’s entirely a recreational problem rather than a medical one. Ask people what society should care more about, erectile dysfunction or heart disease, and it’s not hard to guess what their answer will be.
But mocking or ignoring ED presents a major missed opportunity for men and for stewards of public health. ED is an early marker and predictor of cardiovascular disease, the leading cause of mortality in the world. Investigating and addressing this crucial connection could be the key to saving millions of men’s lives by intervening before cardiovascular disease develops or progresses. But there continues to be significant challenges in treating ED as something more than a problem of aging men or a quality of life issue. It’s past time to view this disease from a different lens.
ED is the most common sexual dysfunction in the world, affecting about 52% of men between 40 and 70. In 2000, the Massachusetts Male Aging Study became one of the earliest landmark studies to look at the prevalence of erectile dysfunction in a large cohort of randomized men. It found significantly elevated relative risks for diabetes, heart disease, and hypertension in men with ED.
On average, cardiovascular disease develops about two to five years after the onset of ED, creating a critical window for intervention. Of note, ED is also quite prevalent in men under 40 — up to 30%, according to one study. This has important implications from a public health perspective, as we anticipate a much larger burden of cardiovascular disease in the future, due in part to the rising incidence of diabetes, obesity, metabolic syndrome, and hyperlipidemia. If all the men currently presenting with ED are not treated with the degree of urgency this early cardiovascular disease marker warrants, the consequences for the U.S. health care system could be devastating.
Another interesting link with ED is dementia and neurodegeneration. ED is highly prevalent in men with Alzheimer’s disease and related dementias, often preceding it by several years. In fact, the two are biologically linked, with overlapping pathologies in endothelial function, and signaling in testosterone and nitric oxide. With an increasingly aging population, this is an exciting frontier of research.
But men face perhaps surprising challenges in access to true ED care.
Sure, there are discount prescription drug programs and new online clinics offering an array of treatment options. But these access points are akin to putting a bandage on a gushing wound.
ED care is also a billion-dollar industry and a major driver for men into health systems. A patient who comes to an in-person urologist for an erectile dysfunction drug can also be screened for other critical health problems — at least when the system works.
But there is a major paucity of urologists in the United States, with about four urologists for every 100,000 Americans, according to the American Urological Association’s 2024 census. An even smaller subset of specialized urologists focus on ED treatments and sexual dysfunction, making it difficult for men to get the appropriate attention and workup this disease warrants.
Furthermore, there are no state mandates addressing access to ED care, further widening the gap of exclusionary practices by insurance companies. Oral medications for ED, which have some favorable evidence in regards to improving vascular health and dementia symptoms, are often not covered through insurance, making way for predatory clinics and practices to provide alternatives to men. This funneling of men outside of the traditional health system circumvents the important step of appropriate medical workups. If men are not being diagnosed and treated for ED, this makes it difficult to address the underlying cardiovascular problems early enough to hinder progression.
Unfortunately, most current patient resources from public health agencies, like the Centers for Disease Control and Prevention and the National Institutes of Health, do not include information about ED when discussing cardiovascular health. This represents a missed opportunity to help men understand the connection and adopt some lifestyle changes before cardiovascular problems rear their ugly head.
But there are some positive changes on the horizon. The recently proposed, bipartisan State of Men’s Health Act would establish an Office of Men’s Health within the Department of Health and Human Services. The ultimate goal of this center would be to centralize preventive and research efforts for men’s health and reduce disparate health outcomes.
Although not typically seen as public health stewards, urologists are in unique positions to influence the landscape of how we address men’s health by leveraging visits for ED. Many men may not fully appreciate the implications of ED on cardiovascular disease and dementia. However, they do care now about their erections and would be open to learning about ways to address this and prevent other chronic killers — it’s a win-win.
Unfortunately, this silent gateway to CVD and possibly dementia continues to be ignored by many in our society and not seen outside of the lens of quality of life. However, addressing ED later in life is simply too late.
Denise Asafu-Adjei, M.D., M.P.H., is a board-certified urologist and is fellowship-trained in male sexual dysfunction and infertility.
STAT’s coverage of health challenges facing men and boys is supported by Rise Together, a donor advised fund sponsored and administered by National Philanthropic Trust and established by Richard Reeves, founding president of the American Institute for Boys and Men; and by the Boston Foundation. Our financial supporters are not involved in any decisions about our journalism.
