Erectile Dysfunction and Subclinical Cardiovascular Disease.

BACKGROUND: An association between erectile dysfunction (ED) and cardiovascular (CV) disease (CVD) has long been recognized, and studies suggest that ED is an independent marker of CVD risk. More significantly, ED is a marker for both obstructive and non-obstructive coronary artery disease (CAD) and may reveal the presence of subclinical CAD in otherwise asymptomatic men. AIM: To discuss the role of ED as an early marker of subclinical CVD; describe an approach to quantifying that burden; and propose an algorithm for the evaluation and management of CV risk in men 40-60 years of age with vasculogenic ED, those presumed to have the highest risk for a CV event. METHODS: A comprehensive review of original literature and expert consensus documents was conducted and incorporated into clinical recommendations for ED management in the context of CV risk. OUTCOMES: Assessment and management of ED may help identify and reduce the risk of future CV events. Initial evaluation should distinguish between vasculogenic ED and ED of other etiologies. RESULTS: For men with predominantly vasculogenic ED, we recommend that initial CV risk stratification be based on the 2013 American College of Cardiology/American Heart Association atherosclerotic CV disease risk score. Management of men with ED who are at low risk for CVD should focus on risk factor control; men at high risk, including those with CV symptoms, should be referred to a cardiologist. Intermediate-risk men should undergo non-invasive evaluation for subclinical atherosclerosis. Evidence supports use of a prognostic markers, particularly coronary calcium score, to further understand CV risk in men with ED. CONCLUSIONS: Clinicians must assess the presence or absence of ED in every man >40 years of age, especially those men who are asymptomatic for signs and symptoms of CAD. We support CV risk stratification and CVD risk factor reduction in all men with vasculogenic ED. Miner M, Parish SJ, Billups KL, et al. Erectile Dysfunction and Subclinical Cardiovascular Disease. Sex Med Rev 2018;7:455-463.

The utility and feasibility of assessing sleep disruption in a men's health clinic using a mobile health platform device: A pilot study.

INTRODUCTION: Evidence linking sleep disruption and sexual dysfunction in men is mounting; yet the characterisation of sleep patterns and complaints utilising a clinically feasible method within this patient population remain largely under-reported. AIM: A pilot study aiming to demonstrate a clinically feasible method to characterise the sleep patterns and complaints in a representative sample of patients treated in a men's health clinic. METHODS: Male patients (n = 48) completed a battery of validated sleep questionnaires using an mHealth mobile platform, MySleepScript, at the Johns Hopkins Men's Health and Vitality Center. Metrics related to clinical feasibility such as completion time, ease of use, preference of electronic format, and patient satisfaction were also collected. MAIN OUTCOME MEASURES: Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Berlin Questionnaire, Patient Health Questionnaire (PHQ-9), and Primary Care PTSD Screen (PC-PTSD). RESULTS: Primary urological chief symptoms for this sample patient population were erectile dysfunction (ED; 80%), hypogonadism (40%), benign prostatic hyperplasia/lower urinary tract symptoms (BPH/LUTS; 40%) and Peyronie's disease (10%). Mean PSQI score was 7.8 [SD 4.2], with 67% of all patients falling within the "poor sleeper" range. At least mild symptoms of depression were noted in 40% and 43% were at risk for obstructive sleep apnea (OSA) on the Berlin Questionnaire. CONCLUSIONS: This pilot study demonstrated the feasibility and potential utility of an mHealth platform to assist clinicians, within a men's health clinic, in detecting sleep disturbances. Disrupted sleep was revealed in well over half of this sample of patients. As a result of the growing evidence linking poor sleep and sleep disorders (eg, OSA) to the conditions relevant to men's health (eg, erectile dysfunction, hypogonadism and BPH), further efforts beyond this pilot study are necessary to identify the aetiological processes underlying the association between specific disrupted sleep disorders and urological conditions.

Prognostic value of exercise capacity among men undergoing pharmacologic treatment for erectile dysfunction: The FIT Project.

BACKGROUND: Vascular erectile dysfunction (ED) has been identified as a potentially useful risk factor for predicting future cardiovascular events, particularly in younger men. Because these men typically score more favorably on traditional cardiovascular disease risk assessment tools, there exists a gap in knowledge for how to most appropriately identify those men who would benefit from more aggressive treatments. To date, no studies have examined the impact of fitness on cardiovascular outcomes in men with ED. This study sought to examine the prognostic impact of maximal exercise capacity on cardiovascular-related outcomes in men ages 40 to 60 years being treated for ED. HYPOTHESIS: We hypothesized that there would be an independent association between higher baseline fitness level and lower cardiovascular events. METHODS: We analyzed 1152 men with pharmacy claims file-confirmed active pharmacologic treatment for ED from the Henry Ford Exercise Testing (FIT) Project (1991-2009). All patients were free of coronary heart disease and heart failure, and underwent clinician-referred exercise stress testing, with fitness measured in metabolic equivalents of task (METs). Multivariable Cox proportional hazard models adjusted for traditional cardiovascular risk factors were used to study the association between fitness and all-cause mortality, major adverse cardiovascular events (MACE) (defined as myocardial infarction or revascularization), and incident type 2 diabetes mellitus. RESULTS: The mean age of the population was 53 years, with 39% African Americans. In multivariable analysis, each 1 MET of fitness was associated with a 16% lower risk of death (hazard ratio [HR]: 0.84, 95% confidence interval [CI]: 0.76-0.94, P = 0.002), and a nonsignificant reduction in MACE (HR: 0.89, 95% CI: 0.79-1.003, P = 0.048), and incident diabetes (HR: 0.92, 95% CI: 0.85-1.01, P = 0.129). CONCLUSIONS: Higher baseline fitness is associated with improved cardiovascular prognosis in a population of middle-aged men treated for ED.

Serum vitamin D and sex hormones levels in men and women: The Multi-Ethnic Study of Atherosclerosis (MESA).

INTRODUCTION: 25-hydroxyvitamin D [25(OH)D] deficiency has been associated with low testosterone levels in men, but there are conflicting reports of its associations with sex hormones in women. Less is known about whether these associations are independent of adiposity and lifestyle factors, and whether they differ by race/ethnicity. AIM: To examine associations of 25(OH)D concentrations with sex hormone levels. METHODS: Cross-sectional analysis of 3017 men and 2929 women in a multi-ethnic cohort. MAIN OUTCOME MEASURES: Testosterone, estradiol, dehydroepiandrosterone (DHEA), sex hormone binding globulin (SHBG), and free testosterone. RESULTS: The mean (SD) levels of 25(OH)D in men and women were 25.7(10.4) and 26.1(12.0)ng/ml, respectively. In men, after adjusting for demographic and lifestyle variables, a 10ng/ml [25nmol/L] decrease in 25(OH)D was associated with an average difference of -0.70nmol/L (95%CI -1.36, -0.05) in SHBG and 0.02 percent (0.01, 0.04) in free testosterone, but was not associated with low total testosterone level (<10.41nmol/L). In women, a 10ng/ml decrease in 25(OH)D levels was associated with an average difference of -0.01nmol/L (-0.01, -0.00) for estradiol, -8.29nmol/L (-10.13, -6.45) for SHBG, 0.06 percent (0.04, 0.07) for free testosterone, and 0.40nmol/L (0.19, 0.62) for DHEA. There was no significant interaction by race/ethnicity. CONCLUSIONS: Lower 25(OH)D concentrations were associated with lower SHBG levels and higher free testosterone levels in both men and women, and lower estradiol and higher DHEA levels in women, independent of adiposity and lifestyle. We observed no significant association of 25(OH)D with total testosterone in men. Future studies are needed to determine whether vitamin D supplementation influences sex hormone levels.

Vascular Erectile Dysfunction and Subclinical Cardiovascular Disease.

PURPOSE OF REVIEW: We review the recent literature on the hypothesized temporal relationship between subclinical cardiovascular disease (CVD), vascular erectile dysfunction (ED), and clinical CVD. In addition, we combine emerging research with expert consensus guidelines such as The Princeton Consensus III to provide a preventive cardiologist's perspective toward an ideal approach to evaluating and managing CVD and ED risk in patients. RECENT FINDINGS: Development of ED was found to occur during the progression from subclinical CVD to clinical CVD. A strong association was observed between subclinical CVD as assessed by coronary artery calcium (CAC) and carotid plaque and subsequent ED, providing evidence for the role of subclinical CVD in predicting ED. ED is also identified as a substantial independent risk factor for overt clinical CVD, and ED symptoms may precede CVD symptoms by 2-3 years. SUMMARY: Given the body of evidence on the relationship between subclinical CVD, ED, and clinical CVD we recommend that all men with vascular ED should undergo cardiovascular risk assessment. We further recommend using CAC scores for advanced risk assessment in patients at low-intermediate to intermediate risk (5-20% CVD risk), with risk driving subsequent lifestyle and pharmacologic treatment decisions.

Vitamin D deficiency is independently associated with greater prevalence of erectile dysfunction: The National Health and Nutrition Examination Survey (NHANES) 2001-2004.

BACKGROUND AND AIMS: Erectile dysfunction (ED) and atherosclerotic cardiovascular disease (ASCVD) share many common risk factors, and vascular ED is a marker for increased ASCVD risk. Low 25-hydroxyvitamin D [25(OH)D] concentrations have been associated with increased ASCVD risk, but less is known regarding the relationship of low 25(OH)D with ED. We determined whether 25(OH)D deficiency is associated with ED independent of ASCVD risk factors. METHODS: We performed cross-sectional analyses of 3390 men aged ≥20 years free of ASCVD who participated in NHANES 2001-2004. Serum 25(OH)D was measured by the DiaSorin radioimmunoassay; deficiency was defined as levels <20 ng/ml (<50 nmol/L). Self-reported ED, assessed by a single validated question, was defined as men who reported being "never" or "sometimes able" to maintain an erection. We assessed the relationship between 25(OH)D deficiency and ED prevalence using adjusted Poisson regression methods. RESULTS: After accounting for NHANES sampling, the weighted prevalence of 25(OH)D deficiency and of ED were 30% and 15.2%, respectively. 25(OH)D levels were lower in men with vs. those without ED (mean 22.8 vs 24.3 ng/mL, respectively; p = 0.0005). After adjusting for lifestyle variables, comorbidities, and medication use, men with 25(OH)D deficiency had a higher prevalence of ED compared to those with levels ≥30 ng/ml (Prevalence Ratio 1.30, 95% CI 1.08-1.57). CONCLUSION: In this cross-sectional analysis of a representative sample of U.S. men, vitamin D deficiency was associated with an increased prevalence of ED independent of ASCVD risk factors. Additional research is needed to evaluate whether treating vitamin D deficiency improves erectile function.

Subclinical Vascular Disease and Subsequent Erectile Dysfunction: The Multiethnic Study of Atherosclerosis (MESA).

BACKGROUND: The association between subclinical cardiovascular disease and subsequent development of erectile dysfunction (ED) remains poorly described. HYPOTHESIS: Among multiple subclinical atherosclerosis and vascular dysfunction measurements, coronary artery calcium (CAC) score best predicts ED. METHODS: After excluding participants taking ED medications at baseline, we studied 1862 men age 45 to 84 years free of known cardiovascular disease from the Multi-Ethnic Study of Atherosclerosis (MESA) with comprehensive baseline subclinical vascular disease phenotyping and ED status assessed at MESA visit 5 (9.4 ± 0.5 years after baseline) using a standardized question on ED symptoms. Multivariable logistic regression was used to assess the associations between baseline measures of vascular disease (atherosclerosis domain: CAC, carotid intima-media thickness, carotid plaque, ankle-brachial index; vascular stiffness/function domain: aortic stiffness, carotid stiffness, brachial flow-mediated dilation) and ED symptoms at follow-up. RESULTS: Mean baseline age was 59.5 ± 9 years, and 839 participants (45%) reported ED symptoms at follow-up. Compared with symptom-free individuals, participants with ED had higher baseline prevalence of CAC score >100 (36.4% vs 17.2%), carotid intima-media thickness Z score >75th percentile (35.3% vs 16.6%), carotid plaque score ≥2 (39% vs 21.1%), carotid distensibility <25th percentile (34.6% vs 17.1%), aortic distensibility <25th percentile (34.2% vs 18.7%), and brachial flow-mediated dilation <25th percentile (28.4% vs 21.3%); all P < 0.01. Only CAC >100 (odds ratio: 1.43, 95% confidence interval: 1.09-1.88) and carotid plaque score ≥2 (odds ratio: 1.33, 95% confidence interval: 1.02-1.73) were significantly associated with ED. CONCLUSIONS: Subclinical vascular disease is common in men who later self-report ED. Early detection of subclinical atherosclerosis, particularly advanced CAC and carotid plaque, may provide opportunities for predicting the onset of subsequent vascular ED.

Cardiovascular Disease Prevention in Men with Vascular Erectile Dysfunction: The View of the Preventive Cardiologist.

Vascular erectile dysfunction is a powerful marker of increased cardiovascular risk. However, current guidelines lack specific recommendations on the role that the evaluation of vascular erectile dysfunction should play in cardiovascular risk assessment, as well on the risk stratification strategy that men with vascular erectile dysfunction should undergo. In the last 3 years, erectile dysfunction experts have made a call for more specific guidance and have proposed the selective use of several prognostic tests for further cardiovascular risk assessment in these patients. Among them, stress testing has been prioritized, whereas other tests are considered second-line tools. In this review, we provide additional perspective from the viewpoint of the preventive cardiologist. We discuss the limitations of current risk scores and the potential interplay between erectile dysfunction assessment and the use of personalized prognostic tools, such as the coronary artery calcium score, in the cardiovascular risk stratification and management of men with vascular erectile dysfunction. Finally, we present an algorithm for primary care physicians, urologists, and cardiologists to aid clinical decision-making.

Testosterone and prostate cancer: an evidence-based review of pathogenesis and oncologic risk.

Testosterone plays a central role in male development and health. Likewise, androgen deficiency, or hypogonadism, is associated with a variety of symptoms including decreased energy, diminished libido and erectile dysfunction, among others. Male androgen levels steadily decline with age, and, in a subset of symptomatic older men, can result in late-onset hypogonadism (LOH). Over the last decade, increased awareness of hypogonadism among patients and providers has led to a significant rise in the use of testosterone replacement therapy (TRT) for hypogonadism, and especially in LOH. Accompanying the rise in TRT are concerns of potential adverse effects, including cardiovascular risks and the promotion of prostate cancer. The 'androgen hypothesis' asserts that prostate cancer development and progression is driven by androgens, and thus TRT has the theoretical potential to drive prostate cancer development and progression. In this review, we examine existing data surrounding testosterone and prostate cancer. There is significant evidence that androgens promote prostate cancer in experimental systems. However, there is no clear evidence that elevations in endogenous testosterone levels promote the development of prostate cancer in humans. As a result of experimental and historical data on the progression of prostate cancer following TRT, there has been widespread belief that TRT will promote disease progression in prostate cancer patients. Despite these fears, there are a growing number of studies demonstrating no increase in prostate cancer incidence among men on TRT. Furthermore, in studies involving a small number of patients, there has been no discernable increase in disease progression in prostate cancer patients on TRT. While data from large, prospective, randomized, controlled trials are absent, TRT in select prostate cancer patients is likely safe. In the end, the use of TRT in prostate cancer patients is still considered experimental and should only be offered after well-informed shared decision making and with close monitoring.

Diagnosis and treatment of erectile dysfunction for reduction of cardiovascular risk.

PURPOSE: We established erectile dysfunction as an often neglected but valuable marker of cardiovascular risk, particularly in younger men and men with diabetes. We also reviewed evidence that lifestyle change, combined with informed prescribing of pharmacotherapies used to mitigate cardiovascular risk, can improve overall vascular health and sexual functioning in men with erectile dysfunction. MATERIALS AND METHODS: We performed a PubMed® search for articles and guidelines pertinent to relationships between erectile dysfunction and cardiovascular disease, cardiovascular and all cause mortality, and pharmacotherapies for dyslipidemia and hypertension. The clinical guidance presented incorporates the current literature and the expertise of the multispecialty investigator group. RESULTS: Numerous cardiovascular risk assessment tools exist but risk stratification remains challenging, particularly in patients at low or intermediate short-term risk. Erectile dysfunction has a predictive value for cardiovascular events that is comparable to or better than that of traditional risk factors. Interventional studies support lifestyle changes as a means of improving overall vascular health as well as sexual functioning. Statins, diuretics, ß-blockers and renin-angiotensin system modifiers may positively or negatively affect erectile function. Furthermore, the phosphodiesterase type 5 inhibitors used to treat erectile dysfunction may have systemic vascular benefits. CONCLUSIONS: Erectile dysfunction treatment should be considered secondary to decreasing cardiovascular risk. However, informed prescribing may prevent worsening sexual function in men receiving pharmacotherapy for dyslipidemia and hypertension. As the first point of medical contact for men with erectile dysfunction symptoms, the primary care physician or urologist has a unique opportunity to identify those who require early intervention to prevent cardiovascular disease.

The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease.

The Princeton Consensus (Expert Panel) Conference is a multispecialty collaborative tradition dedicated to optimizing sexual function and preserving cardiovascular health. The third Princeton Consensus met November 8 to 10, 2010, and had 2 primary objectives. The first objective focused on the evaluation and management of cardiovascular risk in men with erectile dysfunction (ED) and no known cardiovascular disease (CVD), with particular emphasis on identification of men with ED who may require additional cardiologic work-up. The second objective focused on reevaluation and modification of previous recommendations for evaluation of cardiac risk associated with sexual activity in men with known CVD. The Panel's recommendations build on those developed during the first and second Princeton Consensus Conferences, first emphasizing the use of exercise ability and stress testing to ensure that each man's cardiovascular health is consistent with the physical demands of sexual activity before prescribing treatment for ED, and second highlighting the link between ED and CVD, which may be asymptomatic and may benefit from cardiovascular risk reduction.

Erectile dysfunction and dyslipidemia: relevance and role of phosphodiesterase type-5 inhibitors and statins.

INTRODUCTION: There is a close link between hyperlipidemia/dyslipidemia and erectile dysfunction (ED), with endothelial dysfunction as a common mechanism. Both ED and hyperlipidemia/dyslipidemia are rising in prevalence with mounting evidence that these conditions are harbingers of cardiovascular disease. AIM: This review was conducted to provide an update on the epidemiology and oral therapy of both dyslipidemia and ED, the connection between these two conditions, and clinical outcomes relating to the use of statins and phosphodiesterase type-5 (PDE5) inhibitors in men with ED who have associated dyslipidemia. METHODS: A systematic search was performed of MEDLINE and EMBASE research databases to obtain articles pertaining to the epidemiology, mechanism, and clinical outcomes of statins and PDE5 inhibitors in men with ED and associated dyslipidemia. MAIN OUTCOME MEASURES: The clinical and preclinical studies related to ED and dyslipidemia are analyzed and their findings are assessed and summarized. Results. Hyperlipidemia/Dyslipidemia constitute a vascular risk factor having a considerable impact on erectile function. Furthermore, the role of endothelial dysfunction in the pathophysiology of both ED and dyslipidemia is paramount suggesting the importance of comanaging these conditions. Therefore, hyperlipidemia/dyslipidemia when present in patients with ED should prompt management with diet/exercise as well as appropriate pharmacotherapy. With ED being often associated with comorbidities, the use of concomitant pharmacotherapies enhances opportunities for managing the overall global cardiometabolic risk. Newer studies assessing the effect of PDE5 inhibitors in men with dyslipidemia will shed more light on the clinical profile of these agents when used in this patient population. CONCLUSIONS: While dyslipidemia and ED are important concerns for clinicians, there exists a gap that needs to be closed between the number of individuals who have either or both conditions and those who are receiving appropriate therapy based on evidence and patient-driven goals regarding clinical outcomes.

The effects of quinapril and atorvastatin on the responsiveness to sildenafil in men with erectile dysfunction.

Phosphodiesterase-5 (PDE-5) inhibitors are an effective therapy for the majority of men with erectile dysfunction (ED). However, many men with ED still report a suboptimal or partial response even after an adequate trial of oral PDE-5 therapy. Since ED is associated with impaired vascular function and both atorvastatin and quinapril have been previously shown to improve vascular function, we examined the effects of adjunctive treatment with these medications in men with vasculogenic ED who were suboptimal responders to 100 mg of sildenafil. Men with ED and suboptimal response to sildenafil were randomly assigned to 3 months of treatment with atorvastatin 40 mg (n = 12), quinapril 10 mg (n = 10), or placebo (n = 13), along with continued adjunctive sildenafil use. Measured variables included: International Index of Erectile Function (IIEF) questionnaire, brachial artery flow-mediated dilation (FMD), endothelium-independent dilation (EID) via nitroglycerin, penile Doppler blood flow, blood pressure (BP), lipids, and C-reactive protein (CRP). Compared to placebo, quinapril (p < 0.01) significantly improved symptoms of ED as measured by the IIEF-5 questionnaire. There was a trend toward a significant improvement in IIEF-5 with atorvastatin. Similarly, quinapril significantly improved the IIEF ED Domain (p < 0.05). Other peripheral and penile vascular parameters were unchanged with drug therapy as compared to placebo. In conclusion, treatment with quinapril, in combination with sildenafil, improved ED in men with suboptimal response to sildenafil alone. Atorvastatin demonstrated a trend toward improved ED in this group.

Erectile dysfunction as a marker for vascular disease.

A body of evidence from basic science and clinical research is emerging to provide a compelling argument for endothelial dysfunction as a central etiologic factor in the development of atherosclerosis and systemic vascular diseases (hypertension, dyslipidemia, diabetes, ischemic heart disease, stroke, or claudication). Erectile dysfunction (ED) is another prevalent vascular disorder that, like cardiovascular disease, is now thought to be caused by endothelial dysfunction. In fact, a burgeoning literature is now available that suggests that ED may be an early marker for atherosclerosis, cardiovascular risk, and subclinical systemic vascular disease. The emerging awareness of ED as a barometer for vascular health and occult cardiovascular disease represents a unique opportunity for primary prevention of vascular disease in all men. Although the implications of this relationship for primary and secondary prevention of cardiovascular disease are not fully appreciated, the available literature makes a strong argument for the role of ED as an early marker for the development of significant cardiovascular risk factors and cardiovascular disease.

Sexual dysfunction and cardiovascular disease: integrative concepts and strategies.

The relation between erectile dysfunction (ED) and cardiovascular disease (CVD) is relevant and important to all fields of medicine. ED is often not considered in the same context as traditional cardiovascular conditions, such as hypertension, dyslipidemia, ischemic heart disease, diabetes mellitus, or the insulin resistance/metabolic syndrome complex. Specific guidelines for treating men with ED and known CVD have been established and recently updated. This article focuses on ED as an early symptom of systemic CVD as well as insulin resistance and the metabolic syndrome. The diagnosis of ED and the subsequent evaluation of underlying cardiovascular risk factors could become a powerful clinical tool to help with early detection of atherosclerotic disease and enhance overall preventive vascular health in men.

Erectile dysfunction is a marker for cardiovascular disease: results of the minority health institute expert advisory panel.

INTRODUCTION: Cardiovascular disease and its related comorbidities are associated with significant morbidity and mortality and affect a disproportionately large number of African Americans and Hispanics. The prevalence of cardiovascular disease is increasing worldwide, which underscores the urgency to improve methods of prevention and early detection. AIM: To develop a risk assessment and management algorithm for primary care patients with erectile dysfunction (ED) that facilitates diagnosis, early intervention, and prevention of cardiovascular disease. METHODS: The Minority Health Institute (MHI) convened an Expert Advisory Panel of cardiologists and urologists to design a new practice model algorithm that uses ED as a clinical tool for early identification of men with systemic vascular disease. A draft of the algorithm was presented at a national symposium and comments from symposium participants were considered in the development of the final algorithm. MAIN OUTCOME MEASURES AND RESULTS: Erectile dysfunction is common and has long been considered a secondary complication of cardiovascular disease, diabetes, hypertension, and dyslipidemia. However, a growing body of evidence challenges this view, suggesting instead that ED is an early manifestation of atherosclerosis and a precursor to systemic vascular disease. Endothelial dysfunction is the etiologic factor linking ED and cardiovascular disease. CONCLUSIONS: The recognition of ED as an early sign of systemic cardiovascular disease offers an opportunity for prevention, particularly in high-risk and underserved minority populations. The MHI algorithm stipulates that all men 25 years old and older regardless of sexual dysfunction complaints should be asked about ED. The presence of ED should prompt an aggressive assessment for cardiovascular risk and occult systemic vascular disease.

The role of mechanical devices in treating female sexual dysfunction and enhancing the female sexual response.

Female sexual dysfunction (FSD) is a common medical problem estimated to affect about 40 million American women. In 1998, the American Foundation of Urologic Disease (AFUD) Consensus Panel classified FSD into four different categories: sexual desire disorder, sexual arousal disorder, orgasmic disorder, and sexual pain disorder. This article will focus on the role of mechanical devices to treat sexual arousal and orgasm disorders and to enhance the female sexual response. Mechanical devices may work through vibratory stimulation or by causing clitoral vascular engorgement using a vacuum system. While a number of vibratory stimulating devices are available, only one U.S. Food and Drug Administration cleared-to-market device is available by prescription to treat FSD, the Eros Therapy device (UroMetrics, Inc., St. Paul, Minn., USA). The Eros Therapy is a small, battery-powered device used to gently apply direct vacuum over the clitoris causing the clitoral erectile chambers and labia to fill with blood. This article will review the rationale and benefits of using mechanical devices to treat FSD.