Choi was deeply distressed. His performance in bed was not what it used to be, and his wife was worried, too. When, after a few agonising months, the 54-year-old professional finally decided to see a doctor, he was in for a surprise. Rather than just prescribing a 'magic pill', the doctor ordered a series of tests. The results came a few days later: Choi not only had erectile dysfunction (ED), but also high blood pressure and mild diabetes. Although Choi isn't the patient's real name, there's nothing phoney about his problem which is all too common. 'ED, or sexual impotence, is not just about sex,' says Choi's physician, Andrew Yip Wai-chun, a specialist in urology. 'It is often a harbinger of serious underlying conditions, such as diabetes, hypertension and high cholesterol.' These related conditions, when coupled with abdominal obesity, are often referred to as metabolic syndrome - a cluster of risk factors predisposing people to cardiovascular disease. An estimated 20-25 per cent of the world's adult population have metabolic syndrome, making them three times as likely to have a heart attack or stroke as people without it. ED affects an estimated 152 million men worldwide, or 16 per cent of all men aged 20-75, and Yip says about one-third of Hong Kong's adult males may have the problem. Yip, who runs the Men's Clinic at Kwong Wah Hospital, says 50 per cent of his ED patients - most of them in their 50s and 60s - have diabetes, and many are treated for hypertension. Many ED patients also share risk factors with testosterone-deficient patients. 'Testosterone - the principal male hormone - plays a key role not only in sexual desire and function but also in body shape, muscle mass and strength, self-confidence, mood and general well-being. A man without testosterone is not a man. Testosterone deficiency, or male hypogonadism, also has been linked to symptoms of metabolic syndrome,' says Ronald Tan, a specialist in internal medicine and healthy ageing. 'ED is a barometer of men's health since it usually appears before symptoms of any underlying conditions. In about 30 per cent of men with ED, it is the first hint of heart disease,' says John Dean, a British sexual physician and secretary general of the European Society for Sexual Medicine. 'Recognising this link means that ... we have an opportunity to identify and treat this triad of ED, metabolic syndrome and hypogonadism, and improve their overall health. If testosterone replacement is indicated, it will result in significant improvement in erection, libido and sexual quality of life.' Testosterone is available in oral, injectable, gel and skin-patch preparations. According to Tan, most men prefer a long-acting injectable, which - although not cheap (more than HK$1,000 per shot) - is effective for two to three months. All men taking supplemental testosterone should have periodic prostate examinations and prostate-specific antigen testing as elevating serum levels may stimulate prostate growth and increase the risk of activating latent prostate cancer. In about 70 per cent of cases, ED has a physical cause, such as metabolic syndrome, spinal injury, prostate surgery or vascular or neurological conditions. ED may also be caused by stress, relationship problems, anxiety and depression. Studies suggest one-quarter of men with ED also suffer depression and anxiety. And a similar proportion of men with depression and anxiety report ED. 'ED results in loss of self-esteem, poor self-image and disruption of personal relationships,' says Dean. 'When a man with ED presents to the doctor, it is important for their well-being that ED is treated immediately.' Yet, despite its wide prevalence and the numerous treatments available, data suggest that only 15-20 per cent of ED sufferers are treated. 'Some perceive ED as a natural part of ageing, while others think their problem is temporary or are too embarrassed to speak to the doctor. We really need to increase awareness of therapies and have an open dialogue between patient and doctor,' says Dean. Although treatments such as vacuum erection devices, vascular surgery, penile prostheses and injections, psychotherapy and alternative medications have been available for decades, people rarely spoke openly about ED. All that changed in 1998 when Viagra hit the market, bringing the problem out of the bedroom and into the doctor's office. The 'little blue pill' revolutionised the way we think about and treat ED, mainly because it's so easy to use and effective. Viagra was followed in 2003 by two closely related drugs - Levitra and Cialis. All three products belong to a class of drugs called phosphodiesterase type 5 (PDE-5) inhibitors, which block the activity of PDE-5, an enzyme in the blood vessels of the penis associated with erections. This promotes increased blood flow in the penis, enhancing or prolonging the erectile response. The differences between the three drugs are mainly to do with timing. Levitra is the fastest working (15-30 minutes); Cialis stays longer in the body, extending the window of opportunity to 24-36 hours, which is why it is sometimes called 'the weekend drug'; Viagra has been associated with greater erection hardness, but its action may be delayed or impaired when taken with food. 'It's up to the patient's personal preference, depending on his needs,' says Yip. 'ED drugs are not reimbursed by public health services. Patients have to pay about HK$80 for a pill, so they are free to choose. We just explain the differences briefly, but basically the effectiveness and side effects are similar. 'We also stress that these drugs are not aphrodisiacs, and sexual stimulation is required for the medication to work. Switching to another drug if one of them doesn't work for you, or has intolerable side effects, is the obvious step,' Yip says. The most common side effects of PDE-5 inhibitors are headaches, flushing and an upset stomach. They are relatively mild, and disappear within a few hours. Some men may experience temporary sensitivity to light and blurred vision. People taking nitrate medications for heart disease should avoid taking PDE-5 inhibitors as the combination can cause life-threatening falls in blood pressure. 'In general, the PDE-5 inhibitors are very effective. They have improved the quality of life for millions of men and their partners,' says Yip. 'With a response rate of 80-90 per cent, we see a lot of happy faces at follow-up visits.' For ED treatment to work best, he also suggests involving the patient's partner. 'ED is a couple's problem,' says Yip. 'The woman has a major role in boosting her partner's morale and supporting his treatment, so it's best if we can discuss it with the couple. Unfortunately, fewer than 5 per cent of men with ED in our clinic come with their wives, but we always suggest they talk to their partner about the treatment.' Tan says diet and lifestyle are key, as is testosterone supplementation as required. 'Testosterone levels decline from around age 40, so returning to youthful levels makes perfect sense. Nowadays, ED is coming earlier and earlier because men are stressed to the limit, and stress reduces the release of adrenal hormones. In addition, many Hong Kong people don't get enough regular sleep, which is necessary to restore normal hormone levels.' Often just correcting the hormone imbalance may restore normal erectile function. 'Last year, I had a 43-year-old business executive who [had] ED,' says Tan. 'He also had signs of hypogonadism - abdominal fat deposit, shrunken testes and reduced body hair. Plus, he had hypertension and his liver enzymes were elevated. After prescribing Viagra and drugs to lower blood-pressure, I gave him lifestyle advice, including a high-protein, low-sugar diet, no alcohol, limited caffeine and regular sleep. I also gave him a testosterone injection and DHEA, another hormone that was low. 'Two months later, his testosterone levels were nearly normal, and after two more injections he didn't need Viagra any more. ED is a sign of vascular and hormonal dysfunction. To manage it, we must treat the whole man, not just his sexual problem.'