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Erectile dysfunction (ED) is common affecting over 50% of men aged 40–70 years.1 It increases with age so that men over 70 years (with a prevalence of 70%) have three times the incidence of men in their 40s. It is an important cause of relationships breaking down with the man losing self-esteem, feeling a failure, and the partner feeling rejected so that the man's problem becomes a couple's frustration and concern. With the development of the phosphodiesterase type 5 inhibitors has come a greater understanding of the mechanisms responsible and the important role of endothelial dysfunction, and hence vascular disease, as the major cause of ED.2 Though the commonest cause is now recognized to be organic, psychological consequences will result and both aspects need to be addressed.

With the recognition that endothelial dysfunction is the common denominator linking vascular disease to ED came the realization that ED may not just be a consequence of vascular disease, especially coronary disease, but a harbinger of silent coronary disease—‘a sentinel’.3 The smaller penile arteries (1–2 mm in diameter) potentially suffer from plaque burden and/or endothelial dysfunction symptomatically earlier than the larger coronary (3–4 mm), carotid (5–7 mm), and iliofemoral (6–8 mm) arteries and as a consequence, ED may act as a marker for silent CAD and therefore precede a coronary event.3,4 As acute coronary syndromes are invariably due to the rupture of a previous subclinical plaque (often in the presence of only single vessel disease) ED could be a predictor of an acute event as well as being a manifestation of more advanced chronic disease. This concept is reinforced by ED and vascular disease sharing the same risk factors—diabetes, smoking, hypertension hyperlipidaemia, obesity depression, and lack of physical activity.4

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