By Stephen T. Sinatra, M.D., F.A.C.C., F.A.C.N., C.N.S., C.B.T.
Myth: The only remedy for erectile dysfunction is a pharmaceutical pill.
Fact: As erectile dysfunction is often a symptom of underlying cardiovascular issues, adopting lifestyle habits that bolster cardiovascular health and improve blood flow can help alleviate ED as a symptom.
Recommendation: Using a pill here and there is okay, but with regular use comes side effects. A good primary approach to treating ED is to adopt healthy lifestyle practices that help improve blood flow to the penis: maintaining a healthy weight, ingesting lots of antioxidants and omega-3s through food and supplements, reducing sugar intake, and doing physical and penile-specific exercises. Pharmaceutical support, then, can become an if-needed and occasional, secondary approach.
Erectile dysfunction (ED) is the inability to get or keep an erection firm enough for sexual intercourse. That includes a total inability, an inconsistent ability to do so, or a tendency to sustain only brief erections.
If you have any such problem, you have a lot of company. The National Institutes of Health estimates that ED affects as many as 30 million men in the United States. Incidence increases with age: About 4 percent of men in their 50s and nearly 17 percent in their 60s experience a total inability to achieve an erection. The incidence jumps to 47 percent for men older than 75.
The impact of genuine ED on a man’s sex life is obvious, but what many men do not recognize is the fact that ED can also be a sign of cardiovascular disease, something not just related to the penis and performance.
Treating Erectile Dysfunction
The typical “treatment” for ED is a pharmaceutical pill. But a 2012 article in the International Journal of Impotence Research impressed me because it emphasized weight loss, antioxidants through diet and supplementation, reduced sugar, and physical and penile-specific exercises.
In most cases, I’m a big believer in lifestyle changes first and pharmaceutical solutions second, and this article provides solid ideas for taking that conservative approach.
According to David Meldrum, M.D., and colleagues from UCLA and the University of Naples, lifestyle changes should be integrated into any comprehensive approach to maximizing erectile function because they result in “greater overall success and patient satisfaction, as well as improved vascular health and longevity.”
Oxidative stress and inflammation are major causes of blood vessel damage and cardiovascular diseases, including ED. They disrupt production of nitric oxide (NO), an important chemical blood vessels need to stay healthy and dilate; they also contribute to insulin resistance. Men with ED have decreased levels of NO and increased levels of markers of oxidative stress and inflammation, factors that worsen with age.
Lifestyle can counteract this pattern in the following ways, the researchers said:
- Antioxidants increase NO and improve vascular and erectile function. They are particularly important in men with ED who smoke, are obese, or have diabetes. You can, of course, consume many antioxidants in a diet that includes fresh fruit and vegetables.
- Omega-3 fatty acids reduce inflammation and increase NO, and are particularly important for men with diabetes, hypertension, or coronary artery disease.
More on the Exercise Connection
In an interview on his research, Dr. Meldrum contended that exercise is the “single-most important modality to improve erectile function and cardiac health.” In my own practice, I repeatedly saw the benefits of exercise for aging men. Exercise is terrific for the heart, as most everybody knows, and it is also good for the pelvis as well, something that most men don’t know. I used to see so many men in their 40s, 50s, and 60s with big bellies, metabolic syndrome, insulin insensitivity, and hypertension. Their testosterone and libido were down in the dumps. The best thing for them was exercise.
I also remember one heart patient who came to see me and was doing really well. His testosterone had soared. I asked him if was taking any testosterone. “No,” he said, “I’m walking and skipping every morning.” He would walk along a golf course for maybe a tenth of a mile, and then skip for a 100 yards or so, and alternate like that. That’s right, skip like you did when you are were a kid. He was a smart guy, and knew that he was not only helping his heart but his sexuality as well.
Dr. Meldrum and his associates have created a fascinating educational website dedicated to erectile health (www.erectile-function.com), and features a potpourri of practical steps for reversing ED, including pelvic floor exercises. The exercises were originally designed by researchers in England to stop post-void dribbling among men and were found to also improve erectile function. According to the website, the British researchers found that the exercises work even for severe ED, and claimed similar effectiveness as Viagra. The website also offers a book entitled “Survival of the Firmest,” by Dr. Meldrum’s team, with an introduction by Louis Ignarro, Ph.D., professor of pharmacology at UCLA who was a co-recipient of the 1998 Nobel Prize in physiology for his research on nitric oxide.
Over the years I have recommended “the bridge,” a yoga pose that helps strengthen the back, gluteus muscles, the pelvic floor, and possibly even the prostate gland. It’s quite easy to do. You lie on your back, bend your knees, and plant both feet together and as close to your butt as possible. Arms are alongside your body, palms down. Press your feet, arms, and shoulders against the floor, and lift your hips upward. Squeeze your buttocks and try to hold for a few seconds. Slowly build up your holding time. Give it a try, but don’t do it if it is a strain.
The L-arginine Connection
As I mentioned a moment ago, nitric oxide is an important compound produced in the walls of blood vessels, including those in your penis. This compound keeps the vessels dilated and relaxed to facilitate blood flow. As we age, we make less nitric oxide. Deficiency contributes to constriction and lost flexibility, vessel stiffness, inflammation and plaque buildup, and hypertension. Moreover, a vicious cycle develops: increased blood pressure and inflammation impair the ability of the blood vessel wall cells to make nitric oxide.
Above and beyond these central effects, nitric oxide’s biggest claim to fame is its link to Viagra®, the popular ED drug. Viagra promotes the action of nitric oxide to help relax blood vessels and vascular smooth muscle tissue in the penis. The result: increased blood flow and a harder erection. It is interesting to note that Viagra was developed originally for cardiovascular disease. It didn’t work for that purpose because it increases the nitric oxide effect only in the penis and eye, and possibly in the pulmonary artery in kids with congenital heart disease.
To make nitric oxide, the body needs L-arginine, an amino acid found in many foods. The biggest concentration is found in nuts and seeds. Meat, poultry, fish, dairy, and chocolate are also good sources. If you take in a lot of L-arginine, you make more nitric oxide, and obtain greater protection against the damaging effects of diabetes, smoking, high blood pressure, free radical stress, and many of the problems related to cardiovascular disease.
L-arginine can also be taken as a supplement. Years ago, I used to recommend high doses (8 grams) of L-arginine as a way to lower cholesterol. I would then hear from excited male patients telling me that they were waking up with firm erections. Very high dosages will do that. Lower dosages will not. L-arginine has value for the whole gamut of atherosclerosis − from early signs such as high blood pressure and ED, to advanced cardiac events. It offers promise for plaque stabilization and reversal. It’s inexpensive and non-toxic. My suggested dosage was 2-3 grams 3 times daily, and to specifically affect penis potency, a single 8 gram dose at bedtime.
A few words of caution about L-arginine, however. If you have recently had a heart attack, it may be prudent to hold off taking L-arginine during the sensitive year-long recuperation period and when patients are under close medical supervision. Don’t use L-arginine if you have a herpes infection. It might stimulate an outbreak, in which case you could take lysine, an antagonistic amino acid. L-arginine might also make migraine worse because of the arterial dilation effect.
ED and Stress
One frequent factor behind ED is psychological stress. In such cases, the ED may be temporary, and when the cause of stress ebbs in one’s life, the symptoms of ED will ease and disappear. However, when stress persists it can make ED even worse. Studies have pointed to the involvement of depression, loss of self-esteem, and other psychosocial stresses. Stress management techniques and psychotherapy can be helpful in such cases.
The Big Picture
ED often may represent a real problem extending beyond your penis and performance.
In 2010, an international group of researchers did a great service to all men − and their doctors − by demonstrating that the combination of erectile dysfunction (ED) and arterial disease (CVD) is potentially lethal. In short, the presence of both puts you at higher risk for death and heart attack, stroke and heart failure.
The study (Böhm, et.al), involving more than 1,500 men in 13 countries, was the first to show that ED is a substantial predictor of death and cardiovascular trouble. The researchers found that those individuals with CVD and ED (compared to those without ED) were twice as likely to suffer death from all causes and 1.6 times more likely to suffer the composite of cardiovascular death, heart attack, stroke and heart failure hospitalization.
The study’s lead author, Michael Böhm, M.D., head of the internal medicine department at Germany’s University of Saarland, had this to say: “Men are being treated for the ED, but not the underlying cardiovascular disease. A whole segment of men is being placed at risk. If a man has erectile dysfunction, then he needs to ask his physician to check for other risk factors of cardiovascular disease.”
In my cardiology practice, I often heard complaints from men about ED and that’s because the nature of vascular disease is diffuse. It is not just limited to the coronary arteries. Typically it is also present in the legs, the brain, and even the penis. ED is closely associated with the same kind of damage and dysfunction to the delicate lining of blood vessels that occurs in atherosclerosis and the build-up of plaque that precedes heart attack and stroke.
The take-away message is this: If you are a younger man, say in your thirties or forties, and you develop erectile dysfunction (ED), that could be a sign of arterial blockage to the penis − and possible heart trouble in the not too distant future. There is a strong link between the two as long as the erectile problem isn’t related to a psychological issue.
You shouldn’t have erectile dysfunction below age fifty. If you do, you are at increased risk of developing premature coronary artery disease. ED is angina of the reproductive organs. Interestingly, Viagra was developed to treat angina. That was the original goal.
So if you go to a general practitioner or an urologist for ED be sure to get a cardiovascular workup as well.
- Meldrum DR, Gambone JC, et al. Lifestyle and metabolic approaches to maximizing erectile and vascular health. Int J Impot Res, 2012;24(2):61-8.
- Rosen RC. Psychogenic erectile dysfunction. Classification and management. Urol Clin North Am, 2001;28(2):269-78.
- Böhm M, et al. Erectile Dysfunction Predicts Cardiovascular Events in High-Risk Patients Receiving Telmisartan, Ramipril, or Both. Circulation, 2010; 121(12): 1439-1446.
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