Vascular aging-driven erectile dysfunction: pathophysiological mechanisms and emerging therapies-a narrative review.

Background and Objective: Age-related erectile dysfunction (ED) is a significant health concern linked to vascular aging, characterized by endothelial dysfunction and vascular smooth muscle alterations. This study aimed to explores the pathophysiological mechanisms of age-related ED in elderly men, providing new directions for diagnosis and the development of novel targeted therapies. Methods: This review focused on literature from 2000 to 2025 concerning vascular aging and ED. We searched PubMed, Web of Science, and Embase using keywords like "erectile dysfunction", "aging", "vascular endothelium", and "vascular smooth muscle". The selection process prioritized high-quality clinical and innovative preclinical studies in humans or animal models that explored pathophysiology or novel treatments. Exclusion criteria included duplicates, non-peer-reviewed articles, and off-topic studies. Key Content and Findings: Key contributors to age-related ED include reduced nitric oxide (NO) bioavailability due to endothelial oxidative stress and inflammation, diminished cavernosal smooth muscle content leading to impaired veno-occlusion, and increased arterial stiffness compounded by metabolic disorders. Chronic inflammation, oxidative stress, hormonal imbalances (particularly testosterone deficiency), and metabolic disruption accelerate these vascular aging processes, making ED an early indicator of systemic vascular pathology. Current treatment strategies mainly include phosphodiesterase-5 inhibitors (PDE5i) and testosterone, both of which are suitable for immediate symptom relief in most ED, although there are serious limitations. Emerging interventions are currently experimental and their evidence is mainly derived from preclinical studies. These include interventions to preserve endothelial NO synthase (eNOS) function, stem-cell regenerative therapies targeting tissue repair, nanotechnology to enhance the efficiency of drug delivery, and modulation of mitochondrial integrity and inflammation. Conclusions: Age-related ED is a manifestation of systemic vascular pathology. A deeper understanding of its mechanisms underscores its role as an "early warning signal" for overall vascular health. While current treatments like PDE5i and testosterone offer symptomatic relief, they have limitations. Promising future directions lie in novel targeted therapies, such as enhancing eNOS function, stem-cell therapy, and nanotechnology, which are currently in the experimental stage and require further clinical validation.