Sexual medicine in the year 2006 is receiving the attention of the medical community, not because we have been convinced that there are 150 million men worldwide with erectile dysfunction (ED), and not because we are concerned that ED has enormous implications for quality of life, but rather because of the new overwhelming evidence that ED is comorbid with cardiovascular disease (CVD), hypertension, diabetes, and the metabolic syndrome, and that there is strong data that ED may precede the

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... cal manifestations of CVD. In other words, ED may be a sentinel marker that cannot be ignored. Currently, 70-90% of men with ED are not treated or properly diagnosed. They are not being evaluated for their comorbid conditions and this has led to potentially devastating consequences. In the US, according to recent census data, 28% of male deaths are attributed to CVD with an additional 5% attributable to cerebral vascular disease, and at least 3% to diabetes. The opportunity to reduce the 350,000 deaths among men by monitoring erectile performance as early warning sensors for future vasculopathy raises the discussion of ED to a status it deserves.Thompson et al. presented elegant data on more than 9,000 men followed over a nine-year period in a recent article in the Journal of the American Medical Association. In those men who had ED at the onset, or developed ED during the study, the risk of developing CVD was 1.45, comparable with the risks associated with smoking or a family history of myocardial infarction (MI). In studies appearing in the Archives of Internal Medicine, further linkage with CVD was noted. In one study by Grover, 49% of the men had ED, and the presence of CVD or diabetes raised the risk of ED by 1.45 and three, respectively. Grover's studies were conducted in Canada. In a second study, men who were referred for nuclear stress testing at the University of Chicago were studied by Ward et al., who noted that 55% had ED and it was associated with more severe coronary heart disease (CHD), shorter exercise testing, and left ventricular (LV) dysfunction. The results suggest that sexual function was a useful tool in stratifying risk in individuals with CHD. The burden shifts to the medical profession to overcome whatever barriers exist in not initiating discussions of ED with their patients. The following excuses are no longer acceptable: • embarrassment; • inadequate knowledge or skills of physicians; • lack of awareness of comorbidity; • belief that improving the quality of life is not a high priority in medical practice; and • evaluation of ED is time-consuming and comes with poor reimbursement. The consequences of not initiating or pursuing ED can have serious CV consequences for the patient. The fact that patients actually believe that 70% of physicians would dismiss sexual concerns as being unimportant, or that 68% fear that the clinician might be embarrassed, is a problem and a significant barrier that makes it difficult for patients to initiate the important dialogue. The patient's own partner's lack of interest or a fear of treatment side effects are additional barriers. Raising awareness of the CV linkage is likely to facilitate dialogue between partners and between patients. The common pathologic pathways for ED and CVD include oxidative stress (OS) disorders, interference with nitrous oxide pathways, and increased adhesiveness of platelets and neutrophils. The link between the vasculopathy and ED provides the physician with a powerful new argument for their male patients to stop smoking, achieve normal lipid status, start engaging in regular physical activity, and start to follow a healthy nutrition program. Metabolic syndrome, a linked but separate entity, provides further establishment of comorbidity with ED. Obesity, hyperlapidarian, low high-density lipoprotein (HDL) levels, hypertension, and blood glucose abnormalities are all, separately and in combination, related to ED. The fact that metabolic syndrome may also be linked to hypogonadism is particularly interesting, but is not the subject of this paper.