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Although doctors are well aware that erectile dysfunction doubles a man's risk of heart disease and can portend problems three years before he suffers a first heart attack, many are quietly ignoring the sign, mostly because they are uncomfortable asking patients about their erections.

That amounts to negligence, says Geoffrey Hackett, a urologist at the Good Hope Hospital in Birmingham who has written about the oversight this week in the British Medical Journal.

Dr. Hackett says many cardiologists see erectile dysfunction as a "lifestyle issue." They fail to treat it as a major risk factor that is equal to smoking and a family history of heart disease.

"It would almost be negligent for a physician assessing a man's risk of heart disease not to ask whether that man was a smoker. So here we have just as big a risk factor that they don't ask about, and the only reason can be a lack of comfort discussing the subject, which is not excusable in 2008," Dr. Hackett said.

He said that rather than asking a "simple question" that saves clinicians intricate blood and laboratory testing, some doctors would rather not open the "Pandora's box."

"If you know this is an additional risk, then you'll treat the person's cholesterol earlier, you'll treat their obesity earlier, you'll stop them smoking earlier, and you'll prevent the progression of the narrowing of the arteries."

Dr. Hackett said the omission is especially unfortunate because men are less likely to bring up sexual issues with their doctors than women are: "Women are much more open about talking about parts of their body. Men are much more reluctant, even with other men."

At the same time, he said, middle-aged men seek to be tested for sexual issues more often than they do for heart issues.

Urologist Gerald Brock runs an erectile-dysfunction clinic at St. Joseph's Hospital in London, Ont., and for five years has referred hundreds of young men with erectile problems - who show no other risk factors for cardiovascular disease - back to their family doctors with a consultation note about their potential for a heart attack or angina.

"It doesn't mean that all men with erectile dysfunction need to have a stress test. It means that a family doctor needs to have a light bulb go off in their head," Dr. Brock said.

He explained that erectile dysfunction can be the best predictor of cardiovascular risk because it is a "window into the man's circulation."

The penile arteries are narrower and get plugged up with cholesterol deposits faster than coronary arteries, he said.

"When the man has no erection, there's only a couple drops of blood going into the penis a minute. In order to get a normal erection, that has to increase a hundredfold for it to work properly. That's more than any vascular bed in the body. We think that that needed increase in blood flow from rest to fully normal activity gives a man a first clue that something isn't happening right with his blood supply."

And there is still another bonus to linking erections with heart disease: "When you treat the heart disease the erection improves, if you catch it early," Dr. Hackett says. "That's a win-win situation."