• Inability to attain or maintain an erection
Erectile dysfunction (ED) is the inability of a man to attain and maintain erection of the penis sufficient to permit satisfactory sexual intercourse. In the past, the term impotence was used, but that word may also imply loss of libido, premature ejaculation, or inability to achieve orgasm.1
An estimated 20 million to 30 million American men suffer from ED. This number is expected to increase dramatically as the median age of the population increases. Currently, the prevalence of ED is 12% in men younger than 59, 22% in those 60 to 69, and 30% in those older than 69.
Although the frequency of erectile dysfunction increases with age, it must be stressed that aging itself is not a cause of impotence. Although the amount and force of the ejaculate as well as the need to ejaculate decrease with age, the capacity for erection is retained. Men are capable of retaining their sexual virility well into their 80s. ED is now thought to be a major risk factor for cardiovascular disease.2
The Stages of the Sexual Act for Men
For men, the sexual act is initiated in most instances by an interplay of psychic and physical stimulation. Simply thinking sexual thoughts or dreaming that the act of sexual intercourse is taking place can lead to an erection and even ejaculation. Most men at some point in their sexual development (usually their teen years) experience nocturnal emissions (wet dreams at night).
Although psychological factors obviously contribute to the male sexual response, it is interesting to note that they are not absolutely necessary in the performance of the male sexual act. Appropriate genital stimulation can lead to an erection and ejaculation without psychic stimuli through an inherent reflex mechanism. For example, some individuals with spinal cord damage that prevents the transmission of nerve impulses from the brain are still capable of achieving an erection and ejaculation.
So either psychic or physical stimulation can initiate the sexual act. Physical stimulation of sensitive tissue, primarily the penis but also the entire pubic region, sends nerve impulses to the spinal cord, causing a reflex impulse to the penis that leads to dilation of the arteries and the filling up with blood of the erectile tissue. In addition, these same nerve impulses cause the glands in the urethra to secrete mucus that lubricates the urethra and also aids in the lubrication of intercourse.
The initial nerve stimulus from the spinal cord during the sexual act is controlled by the parasympathetic nervous system, which also controls bodily functions such as digestion, breathing, and heart rate during periods of rest, relaxation, visualization, meditation, and sleep. In contrast, the sympathetic nervous system is designed to protect us against immediate danger and is responsible for the so-called fight-or-flight reaction. While the parasympathetic nervous system is responsible for an erection and lubrication, the sympathetic nervous system controls emission and ejaculation.
Emission and ejaculation are the culmination of the male sexual act. When sexual stimulation becomes extremely intense, the reflex centers of the spinal cord begin to emit sympathetic nerve impulses to initiate emission, the forerunner of ejaculation.
Emission begins with contraction of the vas deferens, the tubule that transports the sperm from the epididymis to the prostate. This contraction leads to the expulsion of sperm into the ejaculatory duct and urethra. Then contractions of the prostate and seminal vesicles expel prostatic and seminal fluid into the ejaculatory duct, forcing the sperm into the urethra. All of these fluids mix in the internal urethra along with the secretions of the urethral glands to form semen. The process to this point is referred to as emission.
The filling of the urethra then elicits sensory nerve impulses that further excite the rhythmic contractions of the internal organs and also cause the rhythmic contraction of the erectile tissues. Together, these contractions lead to a tremendous increase in pressure that ejaculates the semen from the urethra. Simultaneously, the pelvic muscles and even muscles of the abdomen cause thrusting movements of the pelvis and penis, which also help propel the semen.
The entire process of emission and ejaculation is known as the male orgasm. After ejaculation, the male sexual excitement disappears almost entirely within one or two minutes, and erection disappears.
Causes
Erectile dysfunction may be due to organic or psychogenic factors. In the overwhelming majority of cases the cause is organic, that is, it is due to some physiological dysfunction. In fact, in men over the age of 50, organic causes are responsible for erectile dysfunction in more than 90% of cases.3 In the past, a man with ED who was able to have nighttime or early morning erections was thought to have psychogenic impotence. However, it is now recognized that this is not a reliable indicator. Common causes of ED are listed immediately below, and discussed in greater detail later in the chapter.
Causes of Erectile Dysfunction
Organic (90%)
• Vascular insufficiency
Atherosclerosis
Pelvic surgery
Pelvic trauma
• Drugs
Antihistamines
Antihypertensives
Anticholinergics
Antidepressants
Antipsychotics
Tranquilizers
Others
• Alcohol and tobacco use
• Endocrine disorders
Diabetes
Hypothyroidism
Decreased male sex hormones
Elevated prolactin levels
High serum estrogen levels
• Diseases of or trauma to the sexual organs
Diseases of the penis
Prostate disorders
• Neurological diseases
• Pelvic trauma
• Pelvic surgery
• Multiple sclerosis
Psychological (10%)
• Psychiatric illness
• Stress
• Performance anxiety
• Depression
Since correction of any underlying organic factor is the first step in restoring sexual function, it is critically important that a proper diagnosis be made. A thorough history and physical exam are most often all that is needed; however, there are special noninvasive tests that can be performed to diagnose the cause of erectile dysfunction. These tests are best performed or supervised by a urologist.
Procedures Used to Evaluate Erectile Dysfunction
• Medical history
• Physical examination
• Laboratory studies
Complete blood count and urinalysis
Biochemical profile
Glucose tolerance test
Serum hormone levels
• Psychological evaluation
• Nighttime penile monitoring
• Neurological examination
• Vascular examination
Atherosclerosis of the penile artery is the primary cause of impotence in nearly half the men over the age of 50 who have erectile dysfunction.1,2 Atherosclerosis refers to a process of hardening of the artery walls due to a buildup of plaque containing cholesterol, fatty material, and cellular debris. Atherosclerosis-related erectile dysfunction has been shown to be a risk factor for a heart attack or stroke.3 The process of atherosclerosis occurs systemically throughout the body, not just in the arteries supplying the heart or penis. Patients with diseased coronary arteries are much more likely to have erectile dysfunction than individuals without coronary disease. If erectile dysfunction is due to vascular insufficiency, especially important are measures to reduce cardiovascular risk factors such as elevated cholesterol and triglyceride levels, high blood pressure, obesity, lack of exercise, and smoking.
The diagnosis of erectile dysfunction due to atherosclerosis can be made with the aid of ultrasound techniques. It is also a good idea to have blood cholesterol and triglyceride levels checked. A total cholesterol level above 200 mg/dl is an indicator that atherosclerosis may be responsible for the decreased blood flow.
In many instances, physicians will inject papaverine or PGE1 into the penis during the clinical evaluation of erectile dysfunction when a vascular cause is suspected. These drugs cause the arteries to dilate, thus delivering more blood to erectile tissues. If the erectile dysfunction is due to arterial insufficiency, the penis will experience a sustained erection. But if the erection cannot be maintained it is a sign of venous leakage. This form of erectile dysfunction is much more difficult to treat and may require surgery.
A long list of prescription medications and drugs can interfere with sexual function, including medications such as blood pressure medications (especially beta-blockers), peptic ulcer medications, sleeping pills (sedative hypnotic drugs), antidepressants, and statins to lower cholesterol. If you are on a medication that may be linked to ED, work with your physician to get off the medication. For most common health conditions there are natural measures that will produce safer and better clinical results than these drugs.
Long-term alcohol consumption or tobacco use is often a big contributor to ED. In addition to increasing the risk for atherosclerosis, both of these agents negatively affect sexual function. Alcohol use can produce acute episodes of ED as well as more permanent ED due to testicular shrinkage. Smoking just two cigarettes has been shown to inhibit an erection.3
There are various endocrine and hormonal disorders that can lead to erectile dysfunction. The most common of these disorders is diabetes. Individuals with diabetes are at higher risk for atherosclerosis and nerve damage, both of which can cause ED. If you have diabetes, see the chapter “Diabetes.”
Other relatively common endocrine disorders associated with ED include low levels of testosterone and hypothyroidism (see the chapter “Hypothyroidism”). The diagnosis of low testosterone requires a blood test. Symptoms of low testosterone include decreased sexual desire and erectile dysfunction, changes in mood associated with fatigue, depression and anger, and decreases in memory and spatial orientation ability. It may also produce decreased lean body mass, reduced muscle volume and strength, and increases in abdominal obesity. Decreased or thinning facial and chest hair and skin alterations such as increases in facial wrinkling and pale-appearing skin suggestive of anemia are also common. Sometimes the testicles may have become smaller or softer.
Low testosterone levels are most often treated with prescription testosterone preparations. The most popular choices are transdermal gels, injectables, and transdermal patches. The adrenal hormone DHEA may be helpful (see the chapter “Longevity and Life Extension”) but for best results should be used under a physician’s guidance for proper monitoring.
Diseases of or trauma to the male sexual organs can cause erectile dysfunction. Diseases of the penis, such as Peyronie’s disease, and an enlarged prostate (see the chapter “Prostate Enlargement [BPH]”) are among the most common findings in this particular category. Peyronie’s disease (PD) is a disorder of the penis in which part of the sheath of fibrous connective tissue within the penis thickens, causing the penis to bend at an angle during an erection. Intercourse is often difficult and quite painful. The underlying cause of PD is not well understood, but it is thought to be caused by minor trauma or injury to the penis. PD may also be caused by the use of high blood pressure medications including beta-blockers and calcium channel blockers.
Although PD will sometimes improve without any treatment, coenzyme Q10, the enzyme bromelain, and a concentrated extract of gotu kola (Centella asiatica) may be helpful. CoQ10 exerts antioxidant effects that are thought to play a role in arresting and possibly reversing PD. In the development of PD an initial inflammatory reaction is followed by fibrous inelastic scar formation. It is thought that CoQ10 prevents or reduces the action of a specific mediator of the fibrous scar, a compound known as TGF-b1. In a double-blind clinical trial of 186 patients with chronic early PD, patients were randomly assigned to take either 300 mg CoQ10 per day or a placebo for 24 weeks. Erectile function, pain during erection, plaque volume, penile curvature, and satisfaction with treatment were assessed at baseline and every four weeks during the study period. After 24 weeks, significant improvements were noted in all these variables. Average plaque size and penile curvature degree were decreased in the CoQ10 group (average reduction approximately 40%), whereas an increase (average 35%) was noted in the placebo group. Only 11 patients in the CoQ10 group (13.6%) had disease progression. In contrast, 46 patients (56.1%) in the placebo group experienced disease progression. This study provides compelling evidence that CoQ10 at the very least can impair disease progression and in many cases may lead to significant improvements in plaque size, penile curvature, and erectile function.4
Bromelain prevents the deposition of fibrin, which is thought to be responsible for the thickening of the fibrous connective tissue in the penis. For PD, take 750 mg bromelain three times per day on an empty stomach (20 minutes before meals is good). The dosage of gotu kola is based upon the concentration of active compounds (triterpenic acids). An effective dosage is 60 mg triterpenic acids twice per day.
Therapeutic Considerations
Although erectile function is largely dependent upon adequate male sex hormones, adequate sensory stimulation, and adequate blood supply to the erectile tissues, a strong case could be made that all of these factors are dependent upon adequate nutrition. Therefore, it can be concluded that nutrition plays a major role in determining virility. Exercise is also critical. The health benefits of regular exercise cannot be overstated. The immediate effect of exercise is stress on the body; however, with a regular exercise program the body adapts. The body’s response to this regular stress is that it becomes stronger, functions more efficiently, and has greater endurance. Exercise is a vital component of health, especially sexual health.
Regular exercise improves a man’s sexual performance. In one study the effects of nine months of regular exercise on aerobic work capacity (physical fitness), coronary heart disease risk factors, and sexuality were studied in 78 sedentary but healthy men (average age 48 years).5 The men exercised in supervised groups 60 minutes per day, 3.5 days per week on average. Peak sustained exercise intensity was targeted at 75 to 80% of maximum heart rate (see the chapter “The Healing Power Within”). A control group of 17 men (mean age 44 years) participated in organized walking at a moderate pace 60 minutes per day, 4.1 days per week on average. Each subject maintained a daily diary of exercise, diet, smoking, and sexuality during the first and last months of the program. Like many other studies, this one showed the beneficial effects of regular exercise on fitness and coronary heart disease risk factors. Analysis of diary entries revealed significantly greater sexuality enhancements in the exercise group (frequency of various intimate activities, reliability of adequate functioning during sex, percentage of satisfying orgasms, etc.). Moreover, the degree of sexuality enhancement among exercisers was correlated with the degree of their individual improvement in fitness. In other words, the better physical fitness the men were able to attain, the better their sexuality.
BICYCLE SEATS AND ERECTILE DYSFUNCTION
While exercise is good for sexual function, riding a bike can be very detrimental to erectile function. The problem is not in the activity but in the design of the seat. Several studies have shown that cyclists experience more erectile dysfunction, groin and penile numbness, and problems urinating than noncyclists. Riding on a hard bicycle seat too long can compress the vital arteries and nerves necessary for normal sexual functioning. Studies done with bicycle seats designed to shift the rider’s weight off the vital blood vessels and nerves show a dramatic reduction in complaints.6
If you are an enthusiastic cyclist, we recommend utilizing one of the newly designed seats that solve the problem. There are several on the market. One that we like is the RideOut (see www.rideout.com for more information).
Optimal sexual function requires optimal nutrition. The diet and nutritional supplementation program in the chapters “A Health-Promoting Diet” and “Supplementary Measures,” respectively, provide the factors men need to function at their best. A diet rich in whole foods, particularly vegetables, fruits, whole grains, and legumes, is extremely important. Adequate protein is also a must; it is better to get high-quality protein from fish, chicken, turkey, and lean cuts of beef (preferably hormone free) than from fat-filled sources such as hamburgers, roasts, and pork.
Special foods often recommended to enhance virility include liver, oysters, and various types of nuts, seeds, and legumes. All of these foods are good sources of zinc, which is perhaps the most important nutrient for sexual function. Zinc is concentrated in semen, and frequent ejaculation can greatly diminish body zinc stores. If a zinc deficiency exists, the body appears to respond by reducing sexual drive as a mechanism by which to hold on to this important trace mineral.
Other key nutrients for sexual function include essential fatty acids, vitamin A, vitamin B6, and vitamin E. A high-potency multiple vitamin and mineral formula ensures adequate intake of these nutrients as well as others important for health and sexual function.
Since atherosclerosis and diabetes are primary causes of erectile dysfunction, it is especially important to address these underlying issues if they are present. For atherosclerosis, follow the dietary recommendations in the chapter “A Health-Promoting Diet” along with the additional recommendations given in the chapter “Heart and Cardiovascular Health”; for help in lowering cholesterol levels, see the chapter “High Cholesterol and/or Triglycerides.” These recommendations will prevent as well as possibly reverse atherosclerosis. For information on diabetes, see the chapter “Diabetes.”
Arginine increases the formation of nitric oxide within blood vessels, and higher levels of nitric oxide may improve blood flow to erectile tissue—the same net effect as that of drugs such as Viagra and Cialis. In one double-blind study, 31% of patients taking L-arginine reported a significant improvement in sexual function compared with only 11% of the control subjects.7 Even more effective is combining arginine with procyanidolic oligomers from either grape seed or pine bark extract. Three double-blind studies have shown that a combination of pine bark extract (Pycnogenol) and arginine dramatically increases the benefits of arginine, presumably by enhancing the production of nitric oxide within erectile tissues even more than with arginine alone.8–10 In a more recent study, Japanese patients with mild to moderate erectile dysfunction were instructed to take a supplement (Pycnogenol 60 mg per day, L-arginine 690 mg per day, and aspartic acid 552 mg per day) or a placebo for eight weeks.10 Results were assessed using the five-item erectile domain of the International Index of Erectile Function (IIEF-5). Eight weeks of supplement intake improved the total score on the IIEF-5. In particular, a marked improvement was observed in hardness of erection and satisfaction with sexual intercourse. A decrease in blood pressure and a slight increase in salivary testosterone were observed in the supplement group.
In another double-blind study, involving 124 patients age 30 to 50 with moderate ED, the effects of the Pycnogenol-arginine combination were significant compared with the placebo. In addition, total plasma testosterone levels increased significantly, from 15.9 to 18.9 nmol/l, after six months of treatment with the combination.10
Recently, L-citrulline has been proposed as an alternative to arginine. The rationale is that it is efficiently converted to arginine where needed. In one study, 50% of men with mild ED taking 1.5 g L-citrulline per day for one month had an improvement in the erection hardness score, while that improvement was noted in only 8.3% of the men taking a placebo.11
Improving sexual desire and function is possible with the use of herbs that (1) improve the activity of the male glandular system, (2) improve the blood supply to erectile tissue, and (3) enhance the transmission or stimulation of the nerve signal.
Yohimbe
The first FDA-approved medicine for ED was yohimbine, an alkaloid isolated from the bark of the yohimbe tree (Pausinystalia johimbe), native to tropical West Africa. Yohimbine hydrochloride increases libido, but its primary action is to increase blood flow to erectile tissue. Contrary to popular belief, yohimbine has no effect on testosterone levels. The use of yohimbine as a prescription for ED has been supplanted by newer medications.
When used alone, yohimbine is successful in 34 to 43% of cases.12 If combined with strychnine and testosterone it is much more effective. However, side effects often make yohimbine very difficult to utilize. Yohimbine can induce anxiety, panic attacks, and hallucinations in some individuals. Other side effects include elevations in blood pressure and heart rate, dizziness, headache, and skin flushing. Yohimbine should not be used by individuals with kidney disease, women, or individuals with psychological disturbances.
Because of the yohimbine content of yohimbe bark, the FDA classifies yohimbe as an unsafe herb. We think there is some validity to this classification. Nonetheless, it is available without a prescription. It is our opinion that yohimbe and yohimbine are best used under the supervision of a physician. In addition to the problem of side effects with the use of commercial yohimbe preparations, consumers should be very suspicious of the quality of yohimbe products that are sold in health food stores. A 1995 analysis showed that while crude yohimbe bark typically contains 6% total alkaloids, most commercial products contained virtually no yohimbine.13 Compared with authentic yohimbine bark, which contained yohimbine in concentrations of 7,089 parts per million (ppm), concentrations in the commercial products ranged from less than 0.1 to 489 ppm. Of the 26 samples, 9 were found to contain absolutely zero yohimbine and 7 contained only trace amounts (0.1 to 1 ppm). The remaining 10 products contained negligible amounts of yohimbine. In other words, none of the products tested was of acceptable quality. If you elect to use yohimbine, choose products marketed by reputable companies that clearly state the level of yohimbine per dose. If the content of yohimbine is unknown, it is virtually impossible to prescribe an effective and consistent dosage or attain any consistent benefit.
Potency Wood or Muira Puama
Muira puama (Ptychopetalum olacoides) is a shrub native to Brazil that has long been used as an aphrodisiac in South American folk medicine. At the Institute of Sexology in Paris, France, under the supervision of one of the world’s foremost authorities on sexual function, Dr. Jacques Waynberg, a clinical study with 262 patients complaining of lack of sexual desire and the inability to attain or maintain an erection demonstrated muira puama extract to be effective in many cases. Within two weeks, at a dose of 1 to 1.5 g per day, 62% of patients with loss of libido claimed that the treatment had a dynamic effect, while 51% of patients with erection failure felt that muira puama was of benefit.14
At present, the mechanism of action of muira puama is unknown. From preliminary information, it appears that it enhances both psychological and physical aspects of sexual function.
Ginseng
In animal studies, ginseng (Panax ginseng) has been shown to promote the growth of the testes, increase sperm formation and testosterone levels, and increase sexual activity and mating behavior. These results seem to support ginseng’s use as a fertility and virility aid, but human studies have been somewhat inconsistent. In regard to ED, a meta-analysis of existing studies concluded that there is suggestive evidence to indicate benefit with Panax ginseng, but more research is needed.15 In the study with the highest-quality research methods, 45 men diagnosed with ED were randomized and received either 900 mg Panax ginseng or a placebo three times per day for eight weeks.16 Results showed significant improvements in indexes of erectile function, but there were no changes in serum testosterone.
Longjack
In Southeast Asia, longjack (Eurycoma longifolia Jack) is a traditional remedy for preventing or treating ED. Several experimental studies of rodents were performed, showing the ability of longjack to improve sexual behavior, and including impressive results with sluggish and impotent rats—regarded as the most meaningful animal model of human ED.17,18 The only human study was a small pilot study of 14 men randomly selected to consume either 100 mg per day longjack extract or a placebo.19 The results indicated that water-soluble extract of Eurycoma longifolia Jack increased lean body mass, reduced body fat, and increased muscle strength and size.
Tribulus
Tribulus (Tribulus terrestris) has been used traditionally to energize, vitalize, and improve sexual function and physical performance in men. Based upon animal studies, it is believed that tribulus affects testosterone levels.20 However, studies of humans have not found any consistent effect on levels of testosterone or testosterone precursor.21 Nonetheless, it has demonstrated sexual enhancement in primates.
Fenugreek
Fenugreek (Trigonella foenigracum) contains a number of active plant steroids, most notably fenuside and protodioscin. A proprietary fenugreek extract, Testofen, has shown promising results in improving libido and testosterone levels in human clinical studies. In a recent double-blind study, the group taking 600 mg Testofen per day reported improved libido (81.5%), shortened recovery time (66.7%), and improved quality of sexual performance (63%).22
Ginkgo biloba
The idea that ginkgo biloba extract (GBE) may benefit ED started with the observation that male geriatric patients taking GBE for memory enhancement reported improved erections. This observation led to several studies in men with ED due to insufficient penile blood flow. In the first study, 60 patients with proven erectile dysfunction were treated with GBE at a dose of 60 mg per day for 12 to 18 months.23 Penile blood flow was reevaluated by ultrasound every four weeks. The first signs of improved blood supply were seen after six to eight weeks; after six months of therapy 50% of the patients had fully regained potency. In a follow-up study, 50 patients with erectile dysfunction due to arterial insufficiency were divided into two groups: the first group (20 subjects) responded to injection of a drug that improves blood flow to erectile tissue prior to taking the ginkgo, and the second group did not respond to injection therapy.24 After six months of treatment, all 20 patients in the first group regained the ability to attain and maintain a rigid erection. In the second group, 19 out of 30 responded positively to ginkgo in that they were able to attain and maintain an erection with the help of a drug injected into the erectile tissue.
Initial research also suggested that GBE can offset sexual dysfunction caused by antidepressant drugs. An open trial of GBE to alleviate antidepressant-induced sexual dysfunction found it to be 76% effective in alleviating symptoms related to all phases of the sexual response cycle in men, including erectile function.25 Subsequent trials, including a double-blind study, have not shown much benefit with GBE in this application.26
Psychotherapy
Psychological therapies for ED are useful in some cases, but it must be kept in mind that in men over the age of 50, psychological factors are rarely the cause of erectile dysfunction. Nonetheless, ED itself can lead to psychological disturbances. Even in men with clear-cut organic erectile dysfunction, repeated inability to attain or sustain an erection leads to frustration, anxiety, and anticipation of failure. Learning stress reduction techniques such as relaxation exercises, biofeedback, and deep-breathing exercises may help when anxiety is present. Also, for ED in men with depression, psychological treatment may be especially beneficial.
Drugs for Erectile Dysfunction
Viagra, Cialis, Levitra, and Staxyn are popular drug treatments for ED that work by inhibiting an enzyme called phosphodiesterase. The end result is increased production of nitric oxide and hence increased blood supply to the erectile tissue of the penis. Interestingly, men who do not respond to phosphodiesterase inhibitors are apparently the ones who are most likely to benefit from citrulline—a precursor to arginine, which in turn is the precursor to nitric oxide.
There are certain situations in which these drugs may not be safe to take. If you have suffered a heart attack, stroke, or life-threatening arrhythmia (irregular heartbeat) or are currently taking medications for angina, then these drugs are not for you. These drugs also have significant side effects. Common side effects include headache, painful or prolonged erection (longer than four hours), upset stomach or heartburn, flushing (feeling warm), nasal congestion, changes in vision (color, glare), rash, itching or burning during urination, and back pain. Occasionally men experience even more serious side effects, including hearing loss, fainting, chest pain, and heart attacks.
Penile Prosthesis
One medical treatment of erectile dysfunction is the surgical insertion of a penile prosthesis. Three forms are available: semirigid, malleable, and inflatable. Effectiveness, complications, and acceptability vary among the three types. The main problems are mechanical failure, infection, erosions, and irreversible damage to erectile tissue.
Obviously, insertion of a penile prosthesis should be viewed not as a first step in the treatment of erectile dysfunction but rather as the very last step, after all other attempts have proved futile.
QUICK REVIEW
• An estimated 10 million to 20 million American men suffer from impotence.
• Men are capable of retaining their sexual virility well into their 80s.
• Atherosclerosis of the penile artery is the primary cause of impotence in nearly half the men over the age of 50 who have erectile dysfunction.
• Alcohol or tobacco use decreases sexual function.
• Nutrition plays a major role in determining virility.
• Low levels of testosterone and hypothyroidism can lead to erectile dysfunction.
• Regular exercise improves a man’s sexual performance.
• A combination of pine bark extract (Pycnogenol) and arginine dramatically increases the benefits of arginine.
• A meta-analysis of existing studies concluded that there is sufficient evidence to indicate that Panax ginseng has benefit in ED.
• Ginkgo biloba extract can be helpful in cases that are due to a lack of blood flow.
• In men over the age of 50, psychological factors are rarely the cause of erectile dysfunction.
• Another treatment for erectile dysfunction is the surgical insertion of a penile prosthesis.
Vacuum-constrictive devices are used to literally pump blood into the erectile tissue. Most of these devices consist of a vacuum chamber, a pump, connector tubing, and penile constrictor bands. The vacuum chamber is large enough to fit over the erect penis. A connector tube runs to the pump from a small opening at the closed end of the container. An elastic constrictor band is placed around the base of the chamber. Water-soluble lubricant is applied to the open end of the cylinder and to the entire penis. The chamber is placed over the flaccid penis, and an airtight seal is obtained.
Vacuum is applied with the pump (some pumps are battery operated) to create negative pressure within the chamber. The suction produced draws blood into the penis to produce an erection-like state. The constrictor band is then guided from the vacuum chamber onto the base of the penis. An erection is maintained because the blood is essentially trapped in the penis.
Although manufacturers and many physicians have stated that vacuum devices have revolutionized the management of erectile dysfunction, patient acceptance does not match this enthusiasm. Vacuum constrictive devices are generally effective and are extremely safe, but for some reason they have a significant rate of patient dropout. The reason may be that they are somewhat uncomfortable, cumbersome, and difficult to use; it takes patience and persistence to master the process. Most vacuum devices require both hands or the assistance of the sexual partner. Other patients quit using these devices because they may impair ejaculation and thus lead to some discomfort; some patients and partners complain about the lack of spontaneity. Despite these shortcomings, vacuum constrictive devices have been used successfully by many men with erectile dysfunction.
TREATMENT SUMMARY
It is normal for a man to retain sexual function well into his 80s. However, erectile dysfunction is an extremely common condition. Restoring potency requires addressing the underlying cause. In the majority of cases, organic factors are the cause. The chief cause is decreased blood flow (vascular insufficiency) due to atherosclerosis.
There are a variety of medical treatments for erectile dysfunction, but each treatment has its drawbacks. The natural approach to ED involves the use of diet, exercise, nutritional supplements, and botanical measures designed to address underlying issues. This combined approach is designed to restore potency by restoring normal physiology.
Follow the recommendations given in the chapter “A Health-Promoting Diet.” Maintaining ideal body weight and blood sugar control is an important consideration for long-term male sexual vitality. A diet rich in whole foods, particularly vegetables, fruits, whole grains, and legumes, is also extremely important. Adequate protein is a must, and it is better to get high-quality protein from fish, chicken, turkey, and lean cuts of beef (preferably hormone free) than from fat-filled sources such as hamburgers, roasts, and pork.
Special foods often recommended to enhance virility include liver, oysters, nuts, seeds, and legumes. All of these foods are good sources of zinc.
Avoid health-destroying practices such as smoking or excessive consumption of alcohol. Develop a regular exercise program according to the guidelines in the chapter “A Health-Promoting Lifestyle.”
• A high-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”
• Fish oils: 1,000 to 3,000 mg EPA + DHA per day
• L-arginine or L-citrulline: 1,600 to 3,200 mg per day
• Grape seed extract or pine bark extract (>95% procyanidolic oligomers): 150 to 300 mg per day
• One or more of the following:
Panax ginseng: Dose depends on ginsenoside content, with a goal of 5 mg ginsenosides with a 2:1 ratio of Rb1 to Rg1, one to three times a day; for example, for a high-quality ginseng root powder or extract containing 5% ginsenosides, the dose would be 100 mg.
Muira puama (Ptychopetalum olacoides) extract (6:1): 250 mg three times per day
Longjack (Eurycoma longifolia Jack): 100 mg water-soluble extract per day
Tribulus (Tribulus terrestris): 85 to 250 mg three times per day
Fenugreek (Trigonella foenigracum): equivalent of 600 mg Testofen per day
• For arterial insufficiency, ginkgo biloba extract (24% ginkgo flavonglycosides): 240 to 320 mg per day
• For supportive therapy, the herbs described in the chapter “Prostate Enlargement (BPH),” especially Pygeum africanum, may be helpful.