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Sex and the Heart
Erectile Dysfunction's Link to Cardiovascular Disease
By Christopher P. Steidle, Janet Casperson, Jack Kusler
Addicus Books, Inc.Copyright © 2008 Christopher P. Steidle, M.D. and Janet Casperson, M.S.M., ANP-C.
All rights reserved.
Erectile Dysfunction and the Heart
The heart is a powerful muscle. Each day, it beats approximately 100,000 times and pumps about two thousand gallons of blood through miles of vessels and arteries, delivering oxygen and nutrients to all our vital organs. Accordingly, our bodies are only as healthy as our arterial and vascular systems. If these systems are impaired, the health of all our organs, including the penis, is comprised. In a very real sense, a man's penis is a barometer of his overall health. There is truth in the adage, "If it's good for the heart, it's good for the penis."
In fact, medical studies have repeatedly demonstrated a correlation between cardiovascular disease (CVD) and sexual dysfunction, specifically erectile dysfunction (ED).
Defining Erectile Dysfunction
Erectile dysfunction is defined as the inability to achieve or maintain an erection satisfactory for penetration. If you are unable to maintain an erection until the completion of intercourse then you probably should be checked out. You may be asking yourself, "How do I know if I have erectile dysfunction?" Our response is, "You'll know it when you have it." This is a good way to judge: If you're not having as rigid an erection as you believe you should have, then you have erectile dysfunction.
Overcoming Erectile Dysfunction
Many men ask, "Will I ever be able to have a natural erection again?" The answer to this question is based on the degree of damage that has been done to the tissues of the penis. In men who have relatively new onset of organic erectile dysfunction and who are willing to modify the risk factors, the answer is absolutely yes. However, for men who haven't had a good erection for many years and who have not responded to any of the treatment options, the answer is probably not. However, these men also have viable treatment options, such as penile implants.
Anatomy of the Penis
The penis consists of three columns of tissues surrounded by a thick layer of fascia known as Buck's fascia, covered with subcutaneous tissue and loose skin. The main portion of the penis is made up of a pair of cylinders, known as the corpora cavernosa; these cylinders run the length of the penis and have a thick outer membrane called the tunica albuginea. Each of these cylinder bodies communicates with the other through a thin layer of tissues with tiny holes in it.
The erectile tissue itself is basically a bulk of smooth muscle, which is almost pure endothelial tissue. You'll see the term "endothelium" throughout this book. One of the most metabolically active organs in the body, the endothelium makes up the cells that line all the body's blood vessels, including arteries and veins as well as the innermost lining of the penis and other organs.
The urethra, through which we pass urine, is surrounded by a tissue called the corpus spongiosum; it expands at the head, also known as the glans penis. The entire penis has generous blood supply.
How the Penis Becomes Erect
An erection is a complex event. The process starts with sexually stimulating messages reaching the brain from any of the senses — vision, hearing, smell, taste, or touch. These messages activate nerve centers, which send messages to the erectile tissue in the two cylindrical tissues of the penis. This results in the dilatation of the endothelial tissue inside these cylinders, trapping the blood under pressure. Once this occurs, an erection develops.
The real secret to the erection is the relatively newly discovered neurotransmitter called nitric oxide, which is the specific neurotransmitter in the nerve cells that control erections. This discovery is actually what ultimately led to the development of the popular erectile dysfunction drugs. Nitric oxide plays a fundamental role in keeping an erection healthy. The reverse is also true and many men with erectile dysfunction have disorders that decrease the amount of nitric oxide available.
Defining Cardiovascular Disease
Cardiovascular disease is a form of heart disease that results from the narrowing of the coronary arteries that nourish the heart. When they are healthy, these arteries are flexible and have smooth walls; however, over the years these arteries can become damaged by such things as fats, cholesterol, calcium, cellular debris, and platelets, which are cells that help the blood to clot. When the artery walls are damaged, these substances, called plaque, can stick to them, causing them to gradually clog and become narrowed. The buildup of substances in the arteries is called atherosclerosis, or hardening of the arteries.
Atherosclerosis is the most common form of heart disease in the United States. When the arteries become totally clogged, the result can be a heart attack. Cardiovascular disease is the single largest killer of Americans, claiming a half million lives every year.
Link between Heart Health and Erectile Dysfunction
For the last twenty years, our sexual health clinical practice has focused on the treatment of erectile dysfunction. The connection between cardiovascular disease and erectile dysfunction has changed the way some clinicians view ED. We don't treat only the erectile dysfunction, rather we look for underlying causes of it, such as cardiovascular disease.
It was with the advent of the popular drugs Viagra, Levitra, and Cialis that our basic understanding of erectile dysfunction began to change dramatically. This realization came about, in part, when Viagra failed in some patients; it led us to focus more on finding other, underlying causes of erectile dysfunction.
In the context of our discussion of sex and heart disease, the abbreviation "ED," can also stand for several key topics, related to erectile dysfunction: early diagnosis, endothelial dysfunction, exercise and diet, effective drugs, and early death.
When a man mentions to his physician that he has erectile dysfunction, he may be saving his own life. Testing for ED may lead to the early diagnosis of cardiovascular disease (CVD). More than 2 million people have coronary disease and have no symptoms; one out of four men with no risk factors will die suddenly of a cardiovascular event. It is estimated that over 50 percent of men with known CVD who underwent vascular surgery had erectile dysfunction. Accordingly, we now view erectile dysfunction as a risk factor and an early indicator of cardiovascular disease.
In a study, published in Circulation in 2005, Shlomo Stern, M.D., demonstrated that erectile dysfunction, along with fatigue, shortness of breath, feeling of rapid heartbeat, and genetics, all may be potential markers for silent CVD. This is a significant finding.
Endothelial dysfunction is the basis of erectile dysfunction. When the endothelium, tissues which line the penis, is damaged by such things as diet, tobacco use, and certain lifestyle habits, its performance is affected. Endothelial dysfunction affects the vascular smooth muscle cells, which produce relaxation or contraction, thus affecting the dilation or constriction of blood vessels. When this dysfunction occurs, the arteries, the heart, and other endothelial-lined organs can become hard and stiff. This leads to both coronary artery disease and erectile dysfunction, specifically the inability to maintain an erection adequate for sexual intercourse. The symptom of erectile dysfunction may precede coronary artery disease by as much as four years.
Exercise and Diet
Exercise and diet are one way to insure endothelial health as well as overall health. Exercise and diet are also one of the best treatments for erectile dysfunction, although, unfortunately, it's typically the treatment least used by most men. Still, studies have shown that exercising and losing weight not only can prevent erectile dysfunction but also can actually reverse it.
Not since the approval of birth control pills, which sparked the first sexual revolution of the 1960s, has a single pill — Viagra — made such an impact on society.
With the 1998 release of Viagra, soon followed by Levitra and Cialis, we entered into a second sexual revolution. Never before have we had as many effective drugs available for the treatment of mild to moderate erectile dysfunction. Medically, these drugs are known as PDE-5 inhibitors, which stands for phosphodiesterase type 5 inhibitors. (Throughout this book we will often refer to these three drugs — Viagra, Levitra, Cialis — collectively as PDE-5 inhibitors.)
However, as effective as these drugs are, it is no longer appropriate for us, as clinicians, to prescribe these ED drugs without first questioning a patient about cardiovascular risk factors. When appropriate, we perform a cardiovascular evaluation and often other tests to measure for abnormalities in cholesterol levels, blood glucose, and blood pressure; these conditions can affect erectile function on a long-term basis.
Unfortunately, early death could result from ignoring endothelial dysfunction and coronary artery disease. American men have a nearly 50 percent chance of dying of cardiovascular disease, and half of these men will die suddenly without any prior warning. Fortunately, we can detect silent heart disease with thorough medical exams; we also now know that men who cannot maintain an erection sufficient for penetration may have significant underlying cardiovascular disease.CHAPTER 2
Overview: Risk Factors for Heart Disease and Erectile Dysfunction
The concept of addressing cardiovascular risk factors in the field of urology and erectile dysfunction is relatively new and extremely important. It's clear now that the risk factors for cardiovascular disease are similar to the risk factors for erectile dysfunction. Any man who is showing signs of erectile dysfunction should be evaluated for underlying cardiovascular disease.
Aging is the most significant risk factor shared by patients with sexual dysfunction and cardiovascular disease. As men age, the blood flow to the tissues such as the penis decreases. This decreased blood flow can lead to a man's inability to achieve and/or maintain an erection.
The concept of aging and risks factors for heart disease is well documented in the Massachusetts Male Aging Study, conducted from 1987 through 1989 among 1,200 randomly selected Boston men, ages forty to seventy. The study examined many facets of the men's health, including their cholesterol levels, blood pressure, lifestyle habits, medications, the presence of heart disease, whether or not they smoked, testosterone levels, and erectile function.
The Massachusetts study found that more than 50 percent of men ages forty to seventy had minimal, moderate, or severe degrees of erectile dysfunction. Age was the factor most strongly associated with erectile dysfunction. The older the man, the more likely he was to have some degree of erectile dysfunction.
The study findings also showed a direct correlation between erectile dysfunction and heart disease, hypertension, diabetes, certain medications, depression, cholesterol levels, smoking, testosterone levels, and personality characteristics.
The Massachusetts study was the first to document the prevalence of erectile dysfunction in America. The study determined that more than 35 million men in America had some level of erectile dysfunction. It was this finding that identified the large market for the PDE-5 inhibitors to treat erectile dysfunction.
The study has been the catalyst for numerous subsequent studies on the aging process in men, and clinicians have gained a great deal of information about this process and how it relates to erectile dysfunction. However, older men can be treated successfully for ED. It's not uncommon in our practice to see many men well into their eighties who have very active sex lives and the desire to keep it that way.
Obesity is now the most preventable cause of disease in America. It is a significant risk factor for cardiovascular disease and erectile dysfunction. Obesity is defined as being at a weight greater than 20 percent above the recommended weight for height and age. As a culture, we Americans have progressively gained weight over the last few decades. In 1962, the nation's obesity rate was 13 percent. Now, the Center for Disease Control reports that 63 percent of Americans are either overweight or obese. Obesity is the cause of nearly 300,000 deaths annually.
Humans weren't always overweight. Many hundreds of years ago, when we were "hunters and gatherers," we didn't eat every day. We lived on very low-calorie diets; our bodies adapted to long periods of fasting when food was not available. But modern times and technology have given Western nations an abundance of foods available at all times. We eat every day and often excessively. This behavior has contributed to an obesity epidemic. An Italian study documented that even modest weight loss can restore erectile function; we have seen this fact proven in our clinical practice over and over again.
Metabolic syndrome, closely related to obesity, is a relatively new condition that we are just beginning to understand. This syndrome is not a single disease, but rather a cluster of metabolic disorders, which include obesity, insulin resistance, abnormal cholesterol levels, and high blood pressure. According to the National Cholesterol Education Program of the National Heart, Lung, and Blood Institute, you have metabolic syndrome if you three of more of the criteria listed below.
Metabolic syndrome is made even more complex by the fact that the disorders are interrelated. For example, insulin resistance can cause abnormal blood fats (cholesterol), high blood pressure, and high blood sugar. Similarly, high blood sugar levels can cause abnormal cholesterol levels.
There is newer research that shows when one has metabolic syndrome, belly fat, also called visceral fat, is especially harmful. This fat actually acts almost as a separate organ system and contains cells known as adipocytes that release fatty acids and other hormones into the blood, increasing insulin resistance. When we are insulin resistant, our bodies don't recognize our insulin and produces more. When more insulin is released, appetite is increased, we eat more, and gain more weight. It becomes a vicious cycle. The fat cells in the abdomen also release toxic chemicals, cytokines, which disrupt the production of insulin and may promote inflammation of the tissues lining the blood vessels.
Individuals with metabolic syndrome are 3.5 times more likely to die of a heart- related problem and 5 times more likely to develop Type II Diabetes. Men with metabolic syndrome are at much greater risk for erectile dysfunction.
Estimates suggest that approximately 25 percent of the adult population in the United States has metabolic syndrome — that's nearly 55 million people, and many people who are affected don't even know it. Metabolic syndrome is also known by other names such as syndrome X, insulin resistance syndrome, and insulin resistance syndrome.
Inactivity is a leading contributor to cardiovascular disease, a disease that claims more lives than any other in the United States. Moderate physical activity can significantly lower one's risk for heart disease, Type II Diabetes, and certain cancers, including colon cancer. Exercise also reduces blood pressure and cholesterol levels and helps with weight management. All of these factors affect erectile dysfunction.
Unfortunately, only about 30 percent of Americans exercise regularly. (Adequate exercise is considered to be at least thirty minutes of physical activity three to five times a week.)
Excerpted from Sex and the Heart by Christopher P. Steidle, Janet Casperson, Jack Kusler. Copyright © 2008 Christopher P. Steidle, M.D. and Janet Casperson, M.S.M., ANP-C.. Excerpted by permission of Addicus Books, Inc..
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents
PART I Erectile Dysfunction and Cardiovascular Disease,
1 Erectile Dysfunction and the Heart,
2 Overview: Risk Factors for Heart Disease and ErectileDysfunction,
PART II Conditions Related to Heart Disease and Erectile Dysfunction.,
6 Low Testosterone and Sexual Dysfunction,
PART III Diagnosis and Treatment for ED,
7 How Erectile Dysfunction Is Diagnosed,
8 Treatment for Erectile Dysfunction,
9 Penile Implant Surgery,
10 Safe Sex: It's Not Only Avoiding STDs,
11 Repair, Restore, and Rejuvenate Your Sex Life,
Part IV Women and Sexual Dysfunction,
12 Female Sexual Dysfunction,
About the Authors,