Erectile dysfunction can be a sign of heart disease.

Cordoba, Spain. (Dr. Noorali Bharwani)
Cordoba, Spain. (Dr. Noorali Bharwani)

From time to time most men will have problems with erection. That isn’t necessarily a cause for concern. But some men have erectile dysfunction (ED). This is when it is difficult to get or keep an erection that is firm enough for sexual intercourse.

If ED is an ongoing issue then it will cause stress, affect your self-confidence and contribute to relationship problems.

ED can also be a sign of an underlying health condition like heart disease that needs treatment.

Recently, I came across an article in Choosing Wisely (2018 article developed in cooperation with the American Urological Association) titled “Testosterone for Erection Problems When you need testosterone treatment – and when you don’t.” Here is some information from that article.

What is testosterone and does it help men with ED?

Testosterone is a male sex hormone. After age 50, men’s levels of testosterone slowly go down and ED becomes more common. But unless you have other symptoms of low testosterone, you should think twice about the treatment. Testosterone treatment usually isn’t helpful for ED irrespective of your testosterone level.

Male sexual arousal is a complex process that involves the brain, hormones, emotions, nerves, muscles and blood vessels. ED can result from a problem with any of these.

Choosing Wisely says ED is almost always caused by low blood flow to the penis. This is a result of other conditions, such as hardening of the arteries, high blood pressure, and high cholesterol level. These conditions narrow the blood vessels and reduce blood flow to the penis. Low testosterone may affect the desire for sex, but it rarely causes ED. Stress and mental health concerns can cause ED.

Testosterone replacement therapy has many risks. Do not use testosterone without medical advice.

Erectile dysfunction: A sign of heart disease?

It is important to remember that the same process that causes heart disease may also cause ED, only earlier. ED can be an early warning sign of current or future heart problems.

From a purely mechanical perspective, an erection is a hydraulic event – extra blood must be delivered to the penis, kept there for a while, then drained away. An erection may not happen if something interferes with blood flow to the penis.

ED does not always indicate an underlying heart problem. However, research suggests that men with ED who have no obvious cause, such as trauma, and who have no symptoms of heart problems should be screened for heart disease before starting any treatment. Getting the right treatment for your heart might help with ED.

Fortunately, there are several ways to combat erectile dysfunction. Simple lifestyle changes like losing weight, exercising more, or stopping smoking can help. Drink alcohol only in moderation or not at all.

Further tests or treatment might be needed if you have more-serious signs and symptoms of heart disease. If you take certain heart medications, especially nitrates, it is not safe to use many of the medications used to treat erectile dysfunction.

ED is a complex medical problem. Get appropriate medical advice before you try any medications.

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Male Menopause is Treatable

Yes, males do go through menopausal changes. As the joke goes, male menopause is a lot more fun than female menopause. With female menopause you gain weight and get hot flashes. With male menopause you get to buy a sports car, date young girls and drive motorcycles.

The correct name for male menopause is “andropause”. “Andro” stands for androgen – a male sex hormone, such as testosterone, that controls the development and maintenance of masculine characteristics. The onset of andropause is unpredictable. Its clinical manifestations are subtle and variable.

The symptoms of andropause include fatigue, depression, hot flushes, sweats, decreased libido, erectile dysfunction, changes in cognition (like poor concentration and memory) and mood. Since these symptoms are more subjective than objective, some experts have trouble accepting andropause as a clinical condition.

Physical examination of an aging male patient with andropause may be quite normal. There may be presence of gynaecomastia (enlargement of male breast) and/or soft small testicles. Low testosterone level does not produce any specific organ changes.

Diagnosis of andropause is made by symptoms, physical signs and early morning non-fasting specimen of blood for testosterone level. Testosterone level is highest in early morning and can decrease by 35 percent in the mid-afternoon and evening.

Early morning testosterone level less that 7 nmol/l indicates that a man has poor testicular function. Testosterone level found to be critical for sexual function in men is around 10.4 nmol/l. There can be some variation between individuals.

Normally men experience a continuous slow (an average of one to two percent a year) decline in serum testosterone level after about age 30 years. This is due to decrease in testosterone production. There are many other reasons why testicular function may fail – injury, infection, tumours, surgery and effect of other hormonal problems.

The goals of treatment for poor testicular function are to improve erectile function, restore libido, and improve psychological well-being and mood. It is important to remember that in men over 50, cause for erectile dysfunction may be other than low testosterone level. So testosterone replacement therapy will improve libido and psychological well-being in this age group but may occasionally improve erectile dysfunction. Testosterone replacement therapy improves bone mass, coronary artery disease, reduces total cholesterol and LDL (bad cholesterol) levels.

Testosterone should not be given to individuals with prostate or breast cancer. Sleep apnea has been shown to contribute to low serum testosterone levels and testosterone therapy has been reported to make sleep apnea worse. Testosterone therapy may make blood thick (polycythemia), promote benign and malignant changes in the prostate, and can cause tenderness and enlargement of breasts.

Testosterone is available for clinical use in many forms: injectable, oral pill, skin patch, gel and implantable formulations. Each one has advantages and disadvantages. Your physician will advice you the best formulation for you. The physician should monitor the treatment to check for any side-effects and for any long term complications like prostate cancer.

So there is hope for aging men. Besides sports cars and motor bikes, there is Viagra and testosterone. You will be laughing and driving your motor bike all the way to a nursing home when you are 90 or 100. But talk to your doctor first before you put your life’s savings in a sports car.

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Erectile Dysfunction May Be An Early Sign Of Heart Disease

Erectile dysfunction (impotence) may be an early sign of heart disease.

Greek researchers evaluated the incidence of asymptomatic coronary artery disease in 26 men with erectile dysfunction and found 23 per cent had coronary artery disease confirmed by angiography (x-rays of the coronary vessels).

Italian researchers studied 162 patients and found the prevalence of erectile dysfunction was high (66 per cent) among those with chronic angina and multivessel disease and low (18 per cent) among those who had had an acute myocardial infarction with only one vessel affected.

Patients with erectile dysfunction, with no obvious cardiac problems, are at a risk of a heart attack within two to three years. In these kinds of patients, erectile dysfunction is considered to be a warning sign of heart attack to come. For this reason, it is being suggested that patients with erectile dysfunction, with no obvious cardiac symptoms, should be evaluated for cardiovascular disease.

There are several reasons why patients with heart disease will have erectile dysfunction. Atherosclerosis (clogging and hardening of the blood vessels) narrows the blood vessels and reduces blood flow to your heart, brain, extremities and the penis. Reduced blood supply to the penis causes erectile dysfunction.

Certain medications taken for heart disease can cause erectile dysfunction (high blood pressure pills and diuretics). It is also important to remember medications taken for impotence may not be safe when combined with certain heart medications (for example nitrates). There is a connection between depression, heart disease and erectile dysfunction. Feeling anxious can also lead to erectile dysfunction. Fear of having a heart attack while having sex can lead to impotence.

Usually, this is an unfounded fear. After a heart attack, you can resume your sexual activity as soon as your doctor says ok. Sexual intercourse seldom causes heart attacks. Having sex with your usual partner in a familiar setting doesn’t lead to a particularly high blood pressure level or heart rate. Even if you’re at high risk of having a heart attack, weekly sexual activity only slightly raises the risk. In fact, regular sexual activity leads to a happy and satisfactory relationship and is good for your heart.

There are a number of risk factors that can contribute to both heart disease and erectile dysfunction. These factors are well known: diabetes, obesity, high cholesterol level, smoking and high blood pressure fall into this category. So, erectile dysfunction may have multifactorial cause and will require investigations and long term planning to get the situation under control.

Let us go back to the real life scenario – you have erectile dysfunction but have no other obvious health problem. What should you do?

First, you have to look at your personal scenario. Is your relationship with your partner stressful or unpleasant? Are you living or working in an environment which is depressing? Such factors will affect your performance in bed.

Your next step is to talk to your doctor. After evaluating your history and physical examination, your doctor will decide on what kind of investigations to undertake. Your doctor may decide to refer you to a urologist, a cardiologist or to a psychiatrist.

So, don’t be shy. If you are having problems maintaining an erection during sexual intercourse then see your doctor. It may save your life and your sex life.

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Impotence (Erectile Dysfunction)

Dear Dr. B: I have erectile dysfunction (impotence) and have been on Viagra (sildenafil) for sometime. Can you tell me more about this drug and is it safe to take Viagra if a person has heart disease? Yours Anxious.

Dear Mr. Anxious: About 100 million people worldwide are estimated to be affected by erectile dysfunction. Since the introduction of Viagra (sildenafil), the treatment of erectile dysfunction has significantly improved. It is a medication easy to take by mouth and is effective in 84 percent of the people with erectile dysfunction. Viagra (sildenafil) is quite specific in improving penile circulation and thus effective in producing penile erection.

A recent review article in the Canadian Medical Association Journal (CMAJ) says that there are several risk factors common to both, erectile dysfunction and cardiovascular diseases. These are: age, high blood pressure, hardening of the arteries, smoking, and diabetes. Therefore, cardiovascular disease and erectile dysfunction frequently occur together.

Sildenafil was first tested on patients with angina to relax coronary arteries to improve blood supply to the heart. One of the side effects was penile erection. This is how the researchers discovered that sildenafil might be beneficial to patients with erectile dysfunction. But the erection occurs only after sexual stimulation. Sildenafil does not cause spontaneous erection.

Sildenafil dosage can be anywhere from 25mg to 100mg. The drug is metabolized in the liver and excreted in the feces and urine. So sildenafil should be used with caution in patients with liver failure and kidney failure. Under normal conditions, the drug disappears from the body within four hours.

The most common side effects are from the drug’s property to relax the blood vessels – this leads to headache, flushing and runny nose. Some people get heartburn due to relaxation of the muscle at the junction of oesophagus and stomach. In about three percent of sildenafil users, there is visual abnormality related to blue-green colour vision.

Sildenafil’s effect on blood pressure is small and lasts for approximately four hours. Heart rate is not significantly affected. The article says, “The increase in sexual activity that can be expected after a patient receives a prescription for sildenafil should not be of concern for men with stable coronary artery disease (and negative results on exercise stress testing).”

But the situation is different for patients who are taking nitrates in any form (pill under the tongue, spray, patch) for the treatment of angina. There is a potential for the interaction between sildenafil and nitrates resulting in significant prolonged drop in blood pressure and heart attack. This may lead to death. Sildenafil is absolutely contraindicated in patients who take nitrate in any form.

Sildenafil should be used with caution in patients who have recent positive result on cardiac stress test, who have congestive heart failure, who are on multidrug therapy for high blood pressure and patients who are on any drug that could prolong the disappearance of sildenafil from the body.

The article says that overall, sildenafil does not appear to increase the incidence of heart attack or death in men with erectile dysfunction. So, if you are on sildenafil and have heart problems then you must discuss this with your family doctor. Although your heart may not be your most favourite organ, it is necessary to have good heart to enjoy the good effects of sildenafil!

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!