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Life sciences · Journal article
Sexual Medicine · September 14, 2026
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Introduction. Erectile dysfunction (ED) in men under 40 is frequently attributed to psychogenic causes, yet the contribution of objectively measured vascular disease in this age group is poorly characterized. We asked: in men under 40 undergoing penile duplex ultrasound (PDU) for ED, are obesity and obstructive sleep apnea (OSA) associated with arterial insufficiency (AI) independently of psychological factors, and do routine laboratory markers identify men with AI?Methods. Single-center retrospective cohort of men under 40 undergoing PDU between January 2010 and January 2025 (IRB H-51556, consent waived). Of 139 men, 33 were excluded for non-ED indications or neurogenic/anatomic confounders, leaving 106. Intracavernosal Trimix (papaverine 30 mg/phentolamine 1 mg/alprostadil 10 mcg per mL) was administered by the attending urologist; a single redose was permitted for absent response (n = 4, 3.8%), of whom only 1 subsequently reached an adequate response. Peak systolic velocity (PSV) and end-diastolic velocity (EDV) were recorded bilaterally at 5 and 15 minutes. Erectile response was recorded on a patient-reported 0-10 hardness scale; the validated four-point Erection Hardness Score was not administered. AI was classified side-specifically (PSV <30 cm/s). Venous leak (VL) was defined as EDV >5 cm/s at the timepoint of best PSV and analyzed as a binary variable, restricted to men with a final hardness score ≥ 5/10 (n = 79). OSA was ascertained by polysomnography (n = 5), home sleep testing (n = 2), or documented clinical diagnosis (n = 6); smoking, hypertension, diabetes, dyslipidemia, active stress, and psychiatric history were abstracted from the record.Results. Median age was 30.8 years; median BMI 25.7 kg/m2 (16.0% obese). AI was present in 18 (17.0%): 13 unilateral, 5 bilateral. VL was present in 31 of 79 (39.2%). AI was associated with BMI category (P =.016) and OSA (38.5% vs 14.0%, P =.036); OSA was associated with obesity (P =.001). In multivariable regression, OSA was associated with AI independently of BMI (OR 6.39, 95% CI 1.19-34.50, P =.031), although this interval is wide and rests on 13 OSA-positive men; BMI was not associated (P =.957). Neither active stress (P =.701) nor psychiatric history (P =.179) was associated with AI. Cholesterol, LDL, HbA1c, and testosterone were all non-discriminatory. VL was unrelated to BMI or OSA.Conclusions. Objectively measured arterial insufficiency affects a clinically meaningful minority of men under 40 with ED, is associated with OSA independently of BMI, and is not identified by routine laboratory testing or explained by psychological factors.