Erectile dysfunction: moving around, losing weight, giving up smoking, drinking less and relaxing can all work!

Cardiovascular disease and erectile dysfunction share the same risk factors (excess weight, sedentary lifestyle, smoking, stress, etc.) and the same pathophysiology. Erectile dysfunction is now recognised as a possible early sign of general vascular damage. In some cases, correction of cardiovascular risk factors can restore erectile capacity and prevent subsequent myocardial infarction or acute vascular accident.

Introduction

Worldwide, more than 100 million men suffer from erectile dysfunction. Cardiovascular disease and erectile dysfunction share identical aetiologies and pathophysiology (endothelial dysfunction). The severity of erectile dysfunction correlates with that of cardiovascular disease. A recent seven-year prospective study showed that the presence of erectile dysfunction is strongly associated with subsequent cardiovascular events.

The treatment of erectile dysfunction has been revolutionised by the advent of 5-alpha reductase inhibitors: sildenafil, vardenafil and tadalafil. The purpose of this article is not to denigrate the usefulness of these molecules, which are effective in over 80% of patients, but simply to remind us that correcting cardiovascular risk factors can have a positive effect on a previously defective erection, when undertaken in the middle years of life.

Relationship Between Erectile Dysfunction And Cardiovascular Disease

In so-called “civilized” societies, cardiovascular disease remains the leading cause of death, accounting for almost 40% of all deaths. The association between erectile dysfunction and cardiovascular disease was recognised several years ago. The risk factors for both conditions are identical: obesity, smoking, sedentary lifestyle, diabetes, hypertension and hyperlipidaemia.

In humans, 50% of deaths secondary to coronary heart disease occur in individuals who have not previously presented any cardiac symptoms. Identifying predictive symptoms is therefore of paramount importance if we are to intervene earlier. Erectile function is now considered to be a predictive symptom. 64% of men who suffer a myocardial infarction and 57% of men who undergo coronary bypass surgery suffer from previous erectile dysfunction. Why does erectile dysfunction precede cardiac symptoms? This may be explained by the difference in diameter of the arteries of the penis and the heart: 1 to 2 mm for the penis and 3 to 4 mm for the left anterior coronary artery. The study, which retrospectively reviewed the files of 12,825 patients suffering from erectile dysfunction and compared them with an equal number of patients with preserved erectile function, showed that men suffering from erectile dysfunction between the ages of 40 and 49 had a doubling of their risk of developing peripheral vascular disease, and that between the ages of 50 and 55, this risk tripled. Erectile dysfunction is therefore an early marker of generalised vascular disease.

Impact Of Changes In Cardiovascular Risk Factors On Erectile Function

Sedentary lifestyle

A sedentary lifestyle currently affects at least two-thirds of the Western population and an increasing proportion of those in developing countries. Everything is now done to prevent us from moving: the lack of safety in our cities gives us a good excuse to stop walking and use powerful 4 x 4s with padded seats, our office chairs are equipped with castors, our audiovisual equipment with remote controls, etc. In the United States, the proportion of young people who still make a significant effort at least once a week varies from 0 to 20%. In Australia, 27% of people can be considered to be physically active, 8.9% are regularly active, while 64.1% are not sufficiently active.

A sedentary lifestyle leads to a loss of endothelial function, which plays an important role in the development of arteriosclerosis. Regular physical activity reduces mortality by around 50% over a follow-up period of around twenty years. Individuals who engage in regular physical activity have blood pressure values 5 mmHg lower than sedentary subjects. Physical activity also has a positive effect on erectile function: the incidence of erectile dysfunction rises from 13.9% in physically active men to 31.8% in those who are sedentary. Vigorous physical exercise reduces the risk of erectile dysfunction by 30%. The beneficial effect of physical activity is greatest before the age of 60. Observation of two groups of patients over an eight-year period, the first initially comprising sedentary patients who subsequently resumed physical activity, and the second group who remained sedentary, showed that the lowest rate of erectile dysfunction was in the physically active group.6 A recent study showed that in a group of over 100 obese people (average BMI 36.5), weight loss combined with physical activity enabled one-third of them to regain normal erectile function! According to data collected by the Swiss Federal Institute of Sport in Macolin, 80% of Swiss people questioned about their degree of sedentary lifestyle would like their GP to advise them on this subject.

Overweight and obesity

Before the age of 30, one man in six is overweight. The figure rises to one in three between the ages of 30 and 40, then one in two over the age of 40. In 2003, 41% of Australia men were overweight. That's 20 million people. In the years to come, the figures are set to rise still further, since 16% of Australian children are obese, and an adolescent who is overweight at puberty has an 80% chance of remaining so.

Being overweight is recognised as a risk factor for erectile dysfunction. A BMI > 28 is a predictive factor for the development of erectile dysfunction in the following eight years. There is a linear relationship between BMI and the incidence of erectile dysfunction: with a BMI of 25 to 30 the risk is 1.5 and 3 for a BMI > 30.8 The exact mechanism remains unknown.

In obese hypertensives treated with a low-calorie diet alone, a 4 to 8% reduction in initial weight results in a 3 mmHg reduction in systolic and diastolic blood pressure. Weight loss (diet and exercise) as mentioned in the previous paragraph is likely to improve erectile function.

Tobacco

There are still 1.7 million smokers in Australia, even though it is now common knowledge that tobacco kills around 8,000 people a year. Worldwide, cigarettes are expected to kill a billion people in the next 100 years!

Tobacco is recognised as a risk factor for cardiovascular disease, diabetes and stroke. Cigarettes are also known to have a deleterious effect on vascular endothelium and microcirculation.

It would therefore be logical to say that smoking makes you impotent. The link between smoking and erectile dysfunction was made several years ago, and the anti-smoking leagues have used this argument: in some countries, cigarette packets state that smoking makes you impotent. From a strictly scientific point of view, in this age of evidence-based medicine, there is a lack of data to support this claim. However, several recent epidemiological studies have demonstrated an association between smoking and erectile dysfunction. In a meta-analysis published in 2001, based on more than 1,000 articles published over twenty years, the authors concluded that 40% of men suffering from erectile dysfunction smoke, compared with 28% of the general population. They concluded that smoking is a risk factor for erectile dysfunction. Subsequently, several epidemiological studies were to sow confusion, some confirming an association between smoking and erectile dysfunction, others invalidating it.

What is the impact of passive smoking on erectile function? In animal models, it has been shown that prolonged exposure to passive smoking disrupts endothelial function, secondary to a reduction in penile oxide synthase. Studies of healthy non-smokers have shown no direct effect of passive smoking on endothelial function. Passive smoking is associated with a small but statistically insignificant increase in the risk of erectile dysfunction compared with smokers who consume ten to nineteen packs a year.

It is now known that smoking cessation leads to a progressive reduction in the risk of cardiovascular mortality: 50% during the first year and then more gradually to reach that of non-smokers after a period of five to ten years of abstinence. Unfortunately, the benefits of smoking cessation on erectile function are not as significant, especially in long-term smokers. It seems that stopping smoking between the ages of 40 and 50 is not enough to reverse or prevent the progression of erectile dysfunction: the deleterious effects of tobacco on the penile arteries and intracavernous musculature are irreversible!

Stress

People's personalities influence their state of health. The heart and circulatory system are the first of all the organs to translate emotions in a perceptible way: heart rate and blood pressure increase in the face of anxiety and anger.

Psychosocial stress factors could also play a role in the development of atherosclerosis. The cardiovascular system is sensitive to stress: people who are stressed, compared with those who are not, are twice as likely to develop heart disease, and people who are angry are 2.7 times more likely to have a heart attack or die suddenly.

The development of an erection requires complete relaxation of the intracavernous smooth fibre, vasodilatation of the cavernous arteries and blockage of the venous emptying system of the corpora cavernosa. The deleterious effect of stress on the quality of the erection is a notion that has been well known for as long as erectile dysfunction has been investigated. Intracavernous injection of prostaglandin E1 in men suffering from erectile dysfunction of psychogenic origin should normally result in a complete erection. However, if the patient is particularly stressed, it has no effect. A new attempt, in the same relaxed patient, results in a complete and lasting erection.

Couples are also sensitive to stress. The number of divorces is rising all the time. A longitudinal study conducted at the University of Fribourg showed that couples under daily stress fare significantly worse than couples under little stress over a five-year period. Stress is a causal factor in the deterioration of relationship quality. Based on the level of stress and the way in which it is managed, the authors were able to predict divorce with a certainty of 73%. Two types of stress are fatal for couples: everyday worries and free-time stress. Free-time stress is 'fatal' to a couple's life because it prevents them from being able to recharge their batteries. Good stress management increases the likelihood of a happy, stable relationship. The principle of relaxation is to intervene in the state of muscular tension in order to achieve psychological relaxation. By reducing muscular tension, relaxation helps to combat anxiety, apprehension, anguish and certain forms of overly violent emotion. Physiological relaxations such as biofeedback, Jacobson's progressive relaxation, Schultz's autogenic training, transcendental meditation, relaxing gymnastics, yoga and sophrology are the most widely used and are practised individually or in groups. They do not involve talking, unlike psychotherapeutic relaxation practised alone by a psychiatrist or psychologist.

Alcohol

Alcohol is not strictly speaking a cardiovascular risk factor. It does, however, have a deleterious effect on sexuality. In Switzerland, alcohol consumption is responsible for 4,000 deaths every year. While in small doses alcohol lifts inhibitions, exacerbates desire and sometimes allows shy people to act on their desires, in larger doses and on a chronic basis, as well as triggering aggression, it is a powerful inhibitor of sexuality and a destroyer of social relationships. What's more, by lifting certain inhibitions, it sometimes facilitates transgressions such as rape and incest!

The harmful effect of alcohol on sexuality has been known for a long time, and several studies carried out in the 1980s were already highlighting it: compared with a control group in which the incidence of sexual dysfunction is around 10% (lack of desire and erectile dysfunction), it is 63% in alcoholic patients. 71% of chronic alcoholics have sexual problems (lack of desire 56%, erectile dysfunction 16%, anejaculation 22% and premature ejaculation 4%). Consumption of more than 600 ml of alcohol per week increases the incidence of erectile dysfunction from 17% to 29%. Chronic consumption of alcoholic beverages also leads to a deterioration in the couple's atmosphere, with an increase in conflicts. In addition, women living with alcoholic men have a lower libido and suffer more frequently from orgasmic problems.

Excessive and repeated alcohol consumption leads to central and peripheral neuropathy and multi-organ damage, including testicular atrophy. Cirrhotics also often develop gynaecomastia. From a hormonal point of view, testosterone decreases, oestrogen increases and the androgen/oestrogen ratio changes.

A relatively old study shows that 25% of impotent chronic alcoholics who choose to abstain regain satisfactory erectile function. The absence of testicular atrophy and a normal response to the LHRH test are prognostic factors for recovery. However, the severity of liver damage (biochemical or histological) is not correlated with recovery of erectile function.

Conclusion

We know what happened to the famous Titanic when the first icebergs were reported to its captain and he did not see fit to reduce the speed of his ship.

Erectile dysfunction in a 40-year-old man may be an early sign of generalised arteriopathy and an opportunity to look for cardiovascular risk factors and try to correct them. When it comes to erectile function, forty is a key turning point, because it's the last time you'll be able to turn things around: after this point, lifestyle changes, with the exception of resuming regular physical activity, unfortunately have little beneficial effect on erectile function.