It has become fairly easy to accept the preventive medicine benefits of stopping smoking. Urologists have felt free to advise, cajole and sometimes bully their patients into a healthier lifestyle where the problem has been bladder cancer. Sadly, the same cannot be said in the area of erectile dysfunction (ED). It is abundantly clear that ED and vascular disease in general share many critical causal characteristics and the need for diligent attention to very influential lifestyle factors. Yet the link between lifestyle and ED has not become widely used therapeutically. Indeed, the issues of vascular disease and ED seem mainly to have focused on drug safety, which although important has been shown to be scarcely an issue with the phosphodiesterase inhibitors in most patients. In limiting the focus to prescriptions and drug safety, urologists are missing a major opportunity for preventive medicine that may have a significant effect on several areas of health. Urologists have an opportunity in ED to make significant and beneficial lifestyle changes that arguably may have an even greater health benefit (in terms of life years) than the lifestyle issues in prostate cancer, bladder cancer or stone disease.
Many practitioners and the WHO now recognize the importance of ED as a widespread problem with significant effects on quality of life. However, it is still convenient to consign ED to a lifestyle (another use of the term) designation that effectively degrades its importance in terms of funding (grants, governments and drug plans). The success of oral therapy deceptively simplifies the medical intervention and the absence of a cogent reason for diagnostic effort further truncates the medical contact. Meanwhile, excellent evidence is accumulating that links ED with cardiac and vascular disease . The concept that ED may be a marker for occult vascular disease is becoming more widely accepted and has important ramifications . The critical opportunity from the new focus on the similarities between ED and cardiac and vascular disease is that the field of ED can adopt many of the hard-won advances in the vascular field almost without modification. This understanding is inexorably making changes in the way that ED is viewed. However, while the correlations between ED and risk of myocardial infarction require painstaking analysis and carefully considered interventional strategy, the benefits of adopting the lifestyle changes accepted in vascular patients may be profound, safe and worthwhile in the patient with ED. They may be adopted immediately, leaving proof for later. Proving a benefit for them will require careful study but clinical use does not need to wait for the evidence, because the benefits are already confirmed in vascular disease.
The most important lifestyle changes, apart from stopping smoking, are weight loss and exercise. Few urologists routinely note even the fundamental variables of heart rate, blood pressure, weight, height or waist circumference, based on informal surveys over the last 2 years. All of these contribute to an understanding of cardiac risk, vascular risk and the potential for disease modification. Few cardiologists would treat hypertension without significant attention to diet and exercise, as these are established; the health burden of a high body mass index, large waist circumference, intra-abdominal fat and low VO2 maximum are clear. The benefits of lifestyle modification in terms of blood pressure control, improvement in lipid profile, glucose tolerance and even mental state are well established.
There is clear evidence that exercise and weight loss together improve measures of vascular health beyond that which can be achieved by equivalent weight loss . There is also evidence that exercising one vascular bed (e.g. the leg) improves measures of vascular health in other vascular beds (e.g. the arm) [4,5]. The corollary of this is that exercise has a generalized vascular benefit that extends to the systemic circulation and presumably the penis. The mechanism for this is even thought to involve the neurotransmitter of sexual function, nitric oxide . The implication is that exercising almost certainly improves your sex life. How much exercise is required? The evidence suggests that the amount of exercise is relatively minor and aerobic exercise three times a week with a doubling of weekly exercise rate can produce significant changes .
The Process of Care Model  and other insightful commentators were right when they suggested that lifestyle factors should be addressed in parallel with offering drug therapy for ED. It is time to act on the simple and effective expedient of addressing lifestyle and particularly diet and exercise in all patients with ED.