Question:
Could anybody give me any advices of doctors about Erectile Dysfunction?
Answer:
In the TV commercials, the patients are the portrait of health: broad-
shouldered, slim, just slightly preoccupied.
They return from the doctor's office looking relieved: Their problem is
erectile dysfunction and they've got the solution - a prescription.
Real life is more complicated.
In the past few years, there has been a sea change in the understanding
of erectile dysfunction. Once seen almost entirely from a psychological
it's-all- in-your-head prism, erectile dysfunction is now acknowledged
to be a disease with a substantial physiological component. A growing
body of evidence indicates that erectile dysfunction may be a symptom or
early warning sign of several underlying systemic diseases that
potentially can be life- threatening, from diabetes, hypertension and
lipid abnormalities to cardiovascular disease. All of these conditions
affect the health of the blood vessels, contributing to erectile
dysfunction.
Doctors say that some patients come in asking for Viagra, only to find
out they have diabetes or hypertension.
"One of the things we're figuring out is that erectile dysfunction is
often an early sign a man is predisposed to getting heart attacks and
strokes," said Dr. Abraham Morgentaler, associate professor of urology
at Harvard Medical School and author of "The Viagra Myth: The Surprising
Impact on Love and Relationships" (Jossey-Bass, 2003).
There are several underlying reasons for this. "The first one is that
atherosclerotic disease that affects the coronary arteries can also
affect the arteries that supply blood to the erectile organs," said Dr.
Valentin Fuster, head of cardiology at Mount Sinai Medical Center in
Manhattan and past president of the American Heart Association.
"It is a big paradigm shift," said Dr. Allen Seftel, a urologist and
researcher at Case Western Reserve University. "The data is still
evolving, but there appears to be an epidemiological and statistical
association between erectile dysfunction and cardiovascular disease.
"So if you have erectile dysfunction, you have many many reasons to come
in and be checked," Seftel said. Blood pressure, blood glucose and
testosterone levels should all be checked at the initial doctor visit,
he said.
The cardiac correlation
Some specific causes of erectile dysfunction include structural
abnormalities such as Peyronie's disease, or curvature of the penis, and
priapism, which causes persistent and painful erections. Other
conditions that may contribute to dysfunction include the use of some
high blood pressure medications, hypogonadism (low testosterone),
neurological illnesses, pelvic surgery or trauma, radiation treatment
for cancer in the pelvic region, alcoholism or drug abuse, and heavy
smoking.
But new studies are finding a correlation between erectile dysfunction
and diseases of the heart and blood vessels. Two published studies
examining records of 12,825 patients with erectile dysfunction found
they were at twice the risk for heart attack and 1.7 times the risk for
vascular disease - the narrowing of blood vessels outside the heart and
brain - even after adjusting for differences in age, smoking, obesity
and medication use. Men ages 40-44 with the condition were at 3.8 times
the risk for heart attack, and men in their early 50s, four times the
risk.
The risk for vascular disease increased with age, so by the time men
were 50 to 55, they were at three times the risk for vascular disease if
they had erectile dysfunction.
The studies were published in the International Journal of Impotence
Research and Aging Male in recent months.
And in the June issue of the Journal of Urology, Seftel and his
colleagues report that hypertension, diabetes, depression and a
condition called hyperlipidemia (the presence of elevated blood lipids,
including cholesterol and triglycerides, which increase the risk of
stroke and heart attack) are prevalent in patients with erectile
dysfunction, based on a study of 272,325 patients with erectile
dysfunction. Only a third did not have any of the four conditions. The
study suggested erectile dysfunction may be a marker for all four,
potentially a signal for earlier detection and treatment.
"It's more than just an annoying problem," said Dr. Ira Sharlip,
spokesman for the American Urological Association.
How many are affected?
Clearly, there is a psychological component as well. Erectile
dysfunction - the politically correct term that encompasses a broad
spectrum, from mild to moderate to complete impotence - is closely
associated with depression. Doctors say the experience exacts a
psychological toll and can lead to reactive depression.
"Once you fail once, you develop performance anxiety and it just gets
worse," Sharlip said. Nevertheless, "The underlying problem in 90
percent of men over age 40 is physical."
Estimates of the prevalence vary. But most doctors refer to a study of
aging done in Massachusetts that found 52 percent of men between the
ages of 40 and 70 reported some degree of erectile dysfunction. Moderate
erectile dysfunction increased from 17 percent in the men in their 40s
to 34 percent by age 70, with complete dysfunction increasing from 5
percent in the younger men to 50 percent by age 70. That translates into
30 million men nationwide who experience mild erectile dysfunction.
And it explains why sales of Viagra and two newer drugs, Cialis and
Levitra, have soared and why the market is expected to continue growing.
(Doctors emphasize that the drugs do not enhance or prolong an erection
in a man who is otherwise able to achieve one, and that the drugs cannot
be taken if patients are taking nitrates, certain other heart
medications, or illicit drugs called "poppers," amyl nitrate and butyl
nitrate.)
Normal process is complex
Though erections may appear effortless for most men, they're a result of
adequate levels of hormones, functioning nerves, healthy veins and
arteries, all working in concert. It's an intricate process that starts
with sensory or mental stimulation.
Ultimately, however, the blood vessels must be healthy, which is why
impaired ability to achieve erection is a significant indicator for
vascular disease.
"Erection is a vascular event," said Dr. Robert Kloner, a cardiologist
and director of research at The Heart Institute at Good Samaritan
Hospital in Los Angeles, and a professor of medicine at Keck School of
Medicine at the University of Southern California. "The blood vessels
need to be intact. All of the risk factors for erectile dysfunction -
high blood pressure, diabetes, lipid abnormalities, smoking - can damage
the blood vessels."
Dysfunction as an indicator
The earliest stages of atherosclerosis involve abnormalities in the
endothelial inner layer of blood vessels, he said - a group of cells
that regulates the ability of the vessels to respond to changes and
dilate when necessary.
Though the changes may occur throughout the body, he said, erectile
dysfunction may be one of the first noticed symptoms. In a study
published last year, Kloner and colleagues reported that 75 percent of
their own patients with chronic coronary artery disease had some degree
of erectile dysfunction. (Many were taking medications that could
contribute to the problem.) The mean age of the group of 76 patients was
64 years; most had never discussed erectile dysfunction with their
cardiologist.
Diabetes can also cause blockages in the small arteries that lead to
various organs as well as neuropathy, or damage to the nervous system.
Studies have found that drugs for erectile dysfunction are slightly less
effective in patients with diabetes.
Fuster cited the potential impact of medications that treat heart
disease. "In my experience, all of them can in certain circumstances
affect the function," he said. "In one out of four patients in my
experience, the patient can tell you there may be a relationship to
medication."
He said he takes a detailed medical history of a patient and may
substitute a medication for one that seems problematic. Often a patient
can figure out, based on the timing, which medication is the culprit.
"This is a huge issue, and it's an important issue that cannot be
disregarded," he said. "There has to be a lot of sensitivity by the
doctor in how you approach the patient."
The patient's role
Many men are still reluctant to raise the subject with their doctors.
Questionnaires that can be filled out at home or in the waiting room can
be a helpful screening tool.
"When Dole was on TV, they'd say, 'I've got that Bob Dole problem,' and
that helped," said Dr. David B. Inger, a family practitioner outside
Portland, Maine, who said he makes sure to always ask the question. If
the answer is affirmative, he runs several tests, including checking for
testicular cancer.
"Sometimes someone will say, 'My wife made me tell you.' No one wants to
talk about it." And he added, "I rarely get a guy complaining of E.D.
who doesn't have some other disease. Sometimes they don't know it."
It is not clear whether lifestyle changes - controlling blood pressure
and cholesterol or quitting smoking - can reverse erectile dysfunction,
experts say.
But Kloner, the cardiologist, says all the brouhaha around the new
medications may wind up with a positive result: getting more people to
visit the doctor's office.
"If a person comes in complaining about erectile dysfunction because he
saw a commercial on TV, it's a great opportunity for the health care
provider to say, 'Aha, does he have other risk factors for heart
disease?'" Kloner said. "It's an opportunity to work the patient up, get
the person's blood pressure under control, get their cholesterol down,
get them to stop smoking - and frankly, that could help save their
life."
knowledge is power - growing old is mandatory - growing wise is optional
"Many more men die with prostate cancer than of it. Growing old is
invariably fatal. Prostate cancer is only sometimes so."
