A systematic review of the association between erectile dysfunction and cardiovascular disease

Eur Urol. 2014 May;65(5):968-78. doi: 10.1016/j.eururo.2013.08.023. Epub 2013 Aug 23.


Context: Erectile dysfunction (ED) is considered a vascular impairment that shares many risk factors with cardiovascular disease (CVD). A correlation between ED and CVD has been hypothesized, and ED has been proposed as an early marker of symptomatic CVD.

Objective: To analyze the relationship between ED and CVD, evaluating the pathophysiologic links between these conditions, and to identify which patients would benefit from cardiologic assessment when presenting with ED.

Evidence acquisition: A systematic literature review searching Medline, Embase, and Web of Science databases was performed. The search strategy included the terms erectile dysfunction, cardiovascular disease, coronary artery disease, risk factors, pathophysiology, atherosclerosis, low androgen levels, inflammation, screening, and phosphodiesterase type 5 inhibitors alone or in combination. We limited our search to studies published between January 2005 and May 2013.

Evidence synthesis: Several studies reported an association between ED and CVD. The link between these conditions might reside in the interaction between androgens, chronic inflammation, and cardiovascular risk factors that determines endothelial dysfunction and atherosclerosis, resulting in disorders of penile and coronary circulation. Because penile artery size is smaller compared with coronary arteries, the same level of endothelial dysfunction causes a more significant reduction of blood flow in erectile tissues compared with that in coronary circulation. Thus ED could be an indicator of systemic endothelial dysfunction. From a clinical standpoint, because ED may precede CVD, it can be used as an early marker to identify men at higher risk of CVD events. ED patients at high risk of CVD should undergo detailed cardiologic assessment and receive intensive treatment of risk factors.

Conclusions: ED and CVD should be regarded as two different manifestations of the same systemic disorder. ED usually precedes CVD onset, and it might be considered an early marker of symptomatic CVD.

Keywords: Artery-size hypothesis; Cardiovascular diseases; Coronary artery disease; Erectile dysfunction; Phosphodiesterase type 5 inhibitors; Screening.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Arteries / physiopathology
  • Atherosclerosis / complications*
  • Biomarkers
  • Cardiovascular Diseases / diagnosis
  • Cardiovascular Diseases / etiology
  • Cardiovascular Diseases / physiopathology*
  • Coronary Artery Disease / drug therapy
  • Coronary Artery Disease / etiology
  • Coronary Artery Disease / physiopathology
  • Endothelium / physiopathology*
  • Erectile Dysfunction / drug therapy
  • Erectile Dysfunction / etiology
  • Erectile Dysfunction / physiopathology*
  • Humans
  • Inflammation / complications*
  • Male
  • Nitric Oxide / metabolism
  • Phosphodiesterase 5 Inhibitors / therapeutic use
  • Testosterone / blood
  • Testosterone / therapeutic use


  • Biomarkers
  • Phosphodiesterase 5 Inhibitors
  • Nitric Oxide
  • Testosterone