Let’s start by addressing the elephant in the room — erections — the thing no one likes to talk about. For some of you, the thought of talking to somebody about your erection not working is incredibly uncomfortable. You may even get sweaty palms just thinking about it. Don’t worry, this reaction is normal. First, problems with erections are incredibly common: 49 percent of men over the age of 40 have erectile dysfunction (ED) while 10 percent of men under age 40 are affected.1,2 ED is something your family physician is well versed in and you should feel at ease talking about your erections, as you will be given excellent management options. That said, let’s explore ED, its risk factors, treatment options and what you can do to alleviate this condition.
Erectile Function and Dysfunction
Getting an erection can be the product of either tactile stimulation (touch) or psychogenic (your mind’s processing of sexual stimulation: visual, auditory, imaginative). Both mechanisms converge on the cavernosal nerve supplying the erectile bodies of the penis. Here, things get interesting.
- The big picture – Tactile and psychogenic stimulation tells your penis “game on” and causes a series of molecules to be released causing more blood to flow into the penis and less blood to escape. The trapping of blood causes the pressure within the penis to increase. Eventually, this increased pressure results in the penis becoming erect, rigid and ready for prime time.
Five Reasons For Dysfunction
- Mental State – Your mental wellbeing can impact bodily functions, including erections. Added stress at work, relationship challenges, depression, performance anxiety and lack of sexual arousability are all factors that can impact erections.3 There are a few theories about how this works. The brain’s resting state is sending signals to your penis to remain relaxed while you carry out your daily activities and this inhibition can become exaggerated. Or, an increase in anti-erection nerve (sympathetic nerves) activity overshadows the pro-erection nerves (para-sympathetic nerves).4
- Vascular – The penile artery that carries blood into the penis can become diseased, thus reducing flow and function. Predisposing diseases include hypertension, hyperlipidemia, diabetes, smoking and pelvic trauma.3 Just like a leaky valve, the veins and smooth muscle within the penis can fail to trap blood, precluding production of the pressure needed for an erection. Predisposing conditions include diabetes, Peyronie’s disease (fibrosis of the penis often resulting in pain or curvature of the penis), traumatic injury or aging tissue.4 Vascular and psychological problems are the most common causes of ED.
- Neurogenic – Conditions such as brain injuries, strokes, dementia and Parkinson’s disease can cause ED. Injuries, strokes or tumours of the spinal cord are also factors. Finally, peripheral nerves can be damaged by trauma, pelvic surgery or diabetes.8
- Medications – Some psychiatric and blood pressure medications can negatively impact erections. Examples include certain antidepressants, antipsychotics, beta blockers and diuretics. In some circumstances, alternative medications may be available that allow more favourable erectile function. This should be discussed with your prescribing physician. Other drugs with potential negative impact include anti-testosterone medications and cimetidine. Moderate to high alcohol intake, smoking and marijuana may also contribute to ED.3
- Medical Conditions – Diabetes is a significant factor, with 50 percent of sufferers also experiencing ED.9 Other conditions contributing to ED are chronic kidney disease, heart disease, low testosterone and high prolactin levels.3
ED’s Dark Secret
Men with erectile dysfunction have nearly 2.5 times the risk of having undiagnosed diabetes compared to men with normal erectile function. This means that one in 10 men with ED has undiagnosed diabetes.10 We also know that, among men whose ED has vascular origins, they have a 65 percent greater risk of coronary artery disease or stroke after 10 years, with cardiac disease occurring within three years of ED onset. 11, 12 Experts believe ED precedes heart disease because both originate with blood vessel disease, often caused by smoking, hypertension, high cholesterol, diabetes, poor diet or lack of exercise. The vessels in the penis are smaller than those in the heart, therefore, symptoms show up earlier. Thus, ED is an important marker of your vascular health and should be checked out by your physician.
- Oral Medications – These pills are your first-line treatment options: Sildenafil (Viagra), Vardenafil (Levitra), Tadalifil (Cialis) and Avanafil (Stendra). They have been rigorously tested. A recent study summarizing 118 clinical trials with more than 31,000 patients found these medications result in significantly better erectile function.13 The results show that 28 percent more men have erections firm enough to penetrate their partner and an additional 36 percent of men maintain their erections to orgasm.13 Men with diagnosed heart disease must speak to their doctor before using these medications, which are dangerous when taken with nitroglycerin.
- Intraurethral or Injections – Other options include placing a small pellet of medication in the opening of the penis — called MUSE therapy. Seventy percent of men are able to achieve an erection with this treatment.14 Or, a small injection can be placed at the base of the penis, which may help up to 90 percent of men attain erections.15
- Vacuum – Other options include vacuum therapy, when a pump is placed over the penis, drawing blood into it. A band is then placed at the base of the penis to keep it erect.
- Surgery – For men with ED that hasn’t been alleviated by such treatments, a penile prosthesis can produce an erection with the touch of a pump hidden in the scrotum.
What can you Do?
- See your Doctor – There are excellent treatment options; you and your physician can find ones that work best for you. Your doctor will check for medical conditions associated with ED: diabetes, heart disease, high cholesterol and hormone imbalance. Catching such conditions early prevents your overall health from deteriorating.
- Diet – If food is healthy for your heart, it’s also healthy for your penis. There is evidence that the Mediterranean diet — rich in fresh vegetables, healthy oils, and fish — supports cardiovascular health.16 It is reasonable that such a diet also helps prevent ED and it is my opinion that natural, whole foods — eaten in in moderation — is a good lifestyle strategy. If you are overweight, however, various diets that help you lose the pounds will improve erectile function.17
- Weight Control – Men who are overweight have higher rates of ED and men who lose weight have improved erectile function.17,18
- Exercise – Men who exercise at least moderately have a 40-60 percent risk reduction in ED.19 Strive to exercise more than 2.5 hours every week.23 Men aged 45-60 with severe ED had an 83 percent reduction in symptoms when they starting exercising five to six hours a week.20 This may be even more important if you have other health conditions such as diabetes or hypertension.21,22 Talk to your physician before embarking on an ambitious exercise regime.
ED is common among men but is commonly not spoken about. Addressing this problem with your doctor early on can get you back in the game and potentially identify undiagnosed medical conditions. Maintaining a healthy diet and weight and exercising will not only help strengthen your erections but make you feel better overall.
- Grover SA, Lowensteyn I, Kaouache M, et al. The prevalence of erectile dysfunction in the primary care setting: importance of risk factors for diabetes and vascular disease. Arch Intern Med. 2006;166(2):213-219.
- Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281(6):537-544.
- Lue TF. Erectile dysfunction. N Engl J Med. 2000;342(24):1802-1813.
- Steers WD. Neural pathways and central sites involved in penile erection: neuroanatomy and clinical implications. Neurosci Biobehav Rev. 2000;24(5):507-516.
- Biering-Sorensen F, Sonksen J. Sexual function in spinal cord lesioned men. Spinal Cord. 2001;39(9):455-470.
- Wang G, Wang Z, Jiang Z, Liu J, Zhao J, Li J. Male urinary and sexual function after robotic pelvic autonomic nerve-preserving surgery for rectal cancer. Int J Med Robot. 2016.
- Weyne E, Castiglione F, Van der Aa F, Bivalacqua TJ, Albersen M. Landmarks in erectile function recovery after radical prostatectomy. Nat Rev Urol. 2015;12(5):289-297.
- Saenz de Tejada I, Goldstein I. Diabetic penile neuropathy. Urol Clin North Am. 1988;15(1):17-22.
- Saenz de Tejada I, Goldstein I, Azadzoi K, Krane RJ, Cohen RA. Impaired neurogenic and endothelium-mediated relaxation of penile smooth muscle from diabetic men with impotence. N Engl J Med. 1989;320(16):1025-1030.
- Skeldon SC, Detsky AS, Goldenberg SL, Law MR. Erectile Dysfunction and Undiagnosed Diabetes, Hypertension, and Hypercholesterolemia. Ann Fam Med. 2015;13(4):331-335.
- Ponholzer A, Temml C, Obermayr R, Wehrberger C, Madersbacher S. Is erectile dysfunction an indicator for increased risk of coronary heart disease and stroke? Eur Urol. 2005;48(3):512-518; discussion 517-518.
- Montorsi F, Briganti A, Salonia A, et al. Erectile dysfunction prevalence, time of onset and association with risk factors in 300 consecutive patients with acute chest pain and angiographically documented coronary artery disease. Eur Urol. 2003;44(3):360-364; discussion 364-365.
- Yuan J, Zhang R, Yang Z, et al. Comparative effectiveness and safety of oral phosphodiesterase type 5 inhibitors for erectile dysfunction: a systematic review and network meta-analysis. Eur Urol. 2013;63(5):902-912.
- Padma-Nathan H, Hellstrom WJ, Kaiser FE, et al. Treatment of men with erectile dysfunction with transurethral alprostadil. Medicated Urethral System for Erection (MUSE) Study Group. N Engl J Med. 1997;336(1):1-7.
- Linet OI, Ogrinc FG. Efficacy and safety of intracavernosal alprostadil in men with erectile dysfunction. The Alprostadil Study Group. N Engl J Med. 1996;334(14):873-877.
- Liyanage T, Ninomiya T, Wang A, et al. Effects of the Mediterranean Diet on Cardiovascular Outcomes-A Systematic Review and Meta-Analysis. PLoS One. 2016;11(8):e0159252.
- Khoo J, Piantadosi C, Duncan R, et al. Comparing effects of a low-energy diet and a high-protein low-fat diet on sexual and endothelial function, urinary tract symptoms, and inflammation in obese diabetic men. J Sex Med. 2011;8(10):2868-2875.
- Khoo J, Piantadosi C, Worthley S, Wittert GA. Effects of a low-energy diet on sexual function and lower urinary tract symptoms in obese men. Int J Obes (Lond). 2010;34(9):1396-1403.
- Cheng JY, Ng EM, Ko JS, Chen RY. Physical activity and erectile dysfunction: meta-analysis of population-based studies. Int J Impot Res. 2007;19(3):245-252.
- Kratzik CW, Lackner JE, Mark I, et al. How much physical activity is needed to maintain erectile function? Results of the Androx Vienna Municipality Study. Eur Urol. 2009;55(2):509-516.
- Rosen RC, Wing RR, Schneider S, et al. Erectile dysfunction in type 2 diabetic men: relationship to exercise fitness and cardiovascular risk factors in the Look AHEAD trial. J Sex Med. 2009;6(5):1414-1422.
- Lamina S, Okoye CG, Dagogo TT. Therapeutic effect of an interval exercise training program in the management of erectile dysfunction in hypertensive patients. J Clin Hypertens (Greenwich). 2009;11(3):125-129.
- Janiszewski PM, Janssen I, Ross R. Abdominal obesity and physical inactivity are associated with erectile dysfunction independent of body mass index. J Sex Med. 2009;6(7):1990-1998.