Cardiac rehabilitation programs typically neglect the role of sexual function. Health professionals approach management of these disorders from a disease-centered perspective, which often fails to integrate the patient’s needs and perspectives (Hatzichristou and Tsimtsiou 2005). The trajectory, however, of a cardiovascular event and the comorbid ED may demand continuous adjustment from both patients and their partners as they adapt to the chronicity of heart disease. In turn, patients frequently complain about lack of sensitivity or awareness on the part of their physicians. Recently, a joint position statement from the American Heart Association and the European Society of Cardiology Council on Cardiovascular Nursing and Allied Professions has been published (Steinke et al. 2013), in order to address the barriers for successful sexual counselling interventions in CV patients and emphasize the significant value of including sexual counselling content in healthcare providers’ educational programs. The document includes recommendations for sexual activity in patients with congenital heart disease, coronary artery disease, angina and MI, coronary artery bypass surgery, cardiac transplantation and left ventricular assist device, heart failure, implantation of cardioverter-defibrillator, and stroke (Steinke et al. 2013).

BPH-associated lower urinary tract symptoms (LUTS) are the most common non-vascular risk factor for ED. Community-based and clinical studies demonstrate a strong and consistent association between LUTS and ED, suggesting that elderly men with LUTS should be evaluated for ED and vice versa (Gacci et al. 2011).

ED is a common side effect of medication and should be interpreted with caution. Several drug categories have been associated with ED, including beta-adrenoreceptor antagonists, digoxin, thiazide diuretic, older antipsychotics and risperidone, selective serotonin reuptake inhibitors (SSRIs) and venlafaxine, lithium, gabapentin, carbamazepine, as well as antiandrogens (U 2010). However, two drug categories are the most widely used and associated with ED: antihypertensives and antidepressants. Although ED treatments are efficacious in such patients, strategies to prevent ED are absent. Regarding antihypertensives, sexually related side effects may not only compromise the patient’s and partner’s quality of life, but may also lead to withdrawal or poor compliance with severe consequences: abnormal blood pressure and associated life-threatening morbidity. Unfortunately, only a minority of the existing clinical practice guidelines (CPGs) for the treatment of hypertension consider ED or other sexual issues to be either an adverse outcome or a factor to consider in treatment (Karavitakis et al. 2011). This is partly due to the lack of randomized trials assessing the effects of switching to currently available antidepressant agents with lower rates of adverse sexual effects, the role of psychological or mechanical interventions or of techniques such as “drug holidays” (Taylor et al. 2013). From a clinical practice point of view, the only way to identify the effect of a drug is to order a drug holiday, if indicated: in other words, if erectile function is restored when the prescribed medication is interrupted for some period of time, this easily leads to the conclusion that ED was drug induced. In such case, a change of the prescribed drug to one with similar action without sexual side effects may be worthy. In cases that this is not feasible, the following aspects should be discussed with the physician who prescribed the drug:

From a urologist’s perspective, ED associated with other urological diseases or treatments is of major interest, particularly post-radical prostatectomy ED, as well as penile surgery-associated ED.

The goal of any diagnostic approach is to: (a) increase certainty about presence/absence of a disease, (b) define severity of the disease, (c) monitor clinical course, (d) assess prognosis/risks, and (e) plan treatment. Given that ED is essentially a self-reported condition, diagnostic tests or procedures should not be recommended without controlled clinical data or research evidence supporting their use. A broad array of specialized diagnostic tests has been developed, but their clinical utility is limited only to a small minority of men (Meuleman et al. 2010).

Typically, ED is curable in most psychogenic cases; in organic ED, cure is possible in cases of endocrinological etiology and in mild cases through lifestyle modifications and better management of comorbidities. Lastly, urologists pay high attention to a novel treatment the shockwave therapy for vasculogenic ED. Finally, in rare cases of trauma-associated ED, vascular surgery may offer cure potential. The treatment options that offer not symptom relief, but cure, are briefly discussed.

Despite the fact that VED is considered a first-line therapy option for ED of any etiology, erections with these devices are not normal because they provide passive engorgement of the corpora cavernosa. A constrictor ring is placed at the base of the penis to retain blood within the corpora, which has to be removed within 30 min in order to avoid skin necrosis. Also, VEDs are contraindicated in patients with bleeding disorders or on anticoagulant therapy.

Satisfaction rates range between 27 and 94 % (Levine and Dimitriou 2001). Older men with a motivated, interested, and understanding partner report the high satisfaction rates. Most men who discontinue use of VEDs do so within 3 months. The commonest adverse events include pain, inability to ejaculate, petechiae, bruising, and numbness, which occur in <30 % of patients (Lewis and Witherington 1997). VEDs may be the treatment of choice for well-informed older patients who are in long-term partnerships with occasional intercourse attempts or in patients where comorbidity requires noninvasive, drug-free management of ED.

Phosphodiesterase 5 (PDE 5) inhibitors are selective inhibitors of the enzyme PDE-5, which catalyze the hydrolysis of cyclic guanosine monophosphate (cGMP), a potent vasodilator and nitric oxide (NO) donor, into its corresponding metabolites (monophosphates) (Andersson 2011). PDE5-Is exert their beneficial effect by producing vasodilation and increased blood flow to the corpora cavernosa of the penis, which facilitate penile erection.

Currently, three PDE5-Is are in clinical use worldwide for on-demand use with indication for ED: sildenafil (25, 50, 100 mg), vardenafil (5, 10, 20 mg), and tadalafil (10, 20 mg). Vardenafil 10 mg is available also in the form of orodispersible tablet (ODT) in a discreet packaging; it is applied on the tongue without the need of water or any other fluid and provides a rapid disintegration within the mouth before swallowing. Tadalafil has been approved for daily application (OAD) in doses of 2.5 and 5 mg as an alternative treatment regimen to on-demand dosing. Recently, this form of treatment has been approved also for the treatment of BPH-associated lower urinary tract symptoms. Two of the PDE5-Is (sildenafil and tadalafil) are also approved with indication pulmonary arterial hypertension.

Four new PDE5 inhibitors (avanafil, udenafil, lodenafil, and mirodenafil) have been investigated in randomized controlled trials (RCTs) and have shown similar efficacy and safety profiles to sildenafil, tadalafil, and vardenafil. Two of them are marketed in European countries; avanafil has been recently approved in the EU (and the USA), and udenafil is marketed in Russia (and Korea); lodenafil is approved only in Brazil and mirodenafil in South Korea.