Current diagnosis and management of erectile dysfunction

To the Editor: We thoroughly enjoyed the insightful review on erectile dysfunction by McMahon.1 We offer some observations, as most of the abnormalities described in erectile dysfunction are also associated with obstructive sleep apnoea (OSA).

Fortunately, OSA can be reliably diagnosed in 80% of cases by bilateral, simultaneous, lateral, passive, anterosuperior, paramarginal distraction of a patient's upper eyelids.2 Finding lax (floppy) lids clearly has a positive association with OSA. Clinical examination of patients with lax eyelids — and in their extreme manifestation, floppy eyelid syndrome — can elucidate a patient's preferred sleeping laterality. Moreover, the presence of OSA can be imputed if the lid laxity is moderate to severe.2

We were concerned that there was no mention of the pathogenetic association of OSA with erectile dysfunction; it may be prudent to exclude OSA in patients diagnosed with erectile dysfunction.

As management of floppy eyelid syndrome includes weight loss, it was gratifying to see McMahon emphasising lifestyle modification to reduce the impact of vascular risk factors. Similarly, upper eyelid laxity can also be improved with weight loss.3 This also benefits the OSA‐related complications of hypertension, diabetes, myocardial infarction, stroke and depression, and the ophthalmological complications of floppy eyelid syndrome.

It was pleasing to note that McMahon referred to non‐arteritic ischaemic optic neuropathy. However, this condition occurs not only in the context of utilisation of phosphodiesterase type 5 inhibitors but also as a consequence of OSA.4

We suggest that clinicians carry out lid distraction to screen for OSA and assist in the diagnosis and management of erectile dysfunction.