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Erectile Dysfunction
Erectile Physiology: Healthy and satisfactory erectile function involves:
a) Libido (an interest in intimacy), which requires testosterone and a
reasonably healthy mood.
b) Neural connections, intact and functional, between the brain, spinal
cord, and pelvic nerves.
c) An adequate blood supply to the pelvic organs (rarely a limiting
problem).
d) Intact endothelial function, the ability of the pelvic vasculature to
generate nitric oxide.
A cerebral interest in intimacy delivers a signal, via the pelvic nerves, to
the endothelial cells lining the pelvic vasculature, to generate nitric
oxide (NO). The NO generated produces arterial vasodilation, exposing the
penile vasculature to blood flow at systemic pressure. The penile
capillaries engorge, compressing the thin walled veins. Blood is thus
trapped within the penile circulation, generating an erection. If interest
is lost and/or if intimacy achieves its logical conclusion, then the
brain-pelvic nerves stop firing, NO production ceases, the penile arterioles
vasoconstrict, and the erection resolves.
Causes of ED and how we approach them:
a) Libido can be compromised by testosterone deficiency or a
depressed/stressed mood.
1. Testosterone falls with age, inflammation, lipid lowering therapy (20%
reduction), and in relation to environmental metal/hydrocarbon toxicity (the
mean American male testosterone level is lower now vs. 20 years ago,
and is inversely related to tissue pesticide content). Low free
testosterone and/or elevated estradiol is associated with an increased CV
risk, and is not infrequently present in our male patients, particularly
those < 60 years
of age
(please review our YouTube presentation on Testosterone and CV Disease,
which can be accessed through on heartfixer.com).
If ED is present and testosterone
is low, our first step will be to normalize testosterone
and estradiol levels (if prostate cancer is not present).
2. Stress and depression kill your libido; they lower testosterone and lead
to adrenal fatigue and impaired neurotransmitter generation. The Sanesco
panel measures salivary cortisol and urine neurotransmitter levels; we can
then restore your levels with nutritional interventions (nearly all of us
suffer from adrenal stress/fatigue and neurotransmitter imbalance).
b) Nervous system dysfunction:
1. Spinal trauma or damage to the pelvic nerves (competitive cyclists) are
rare causes of ED.
2. Neural dysfunction on the basis of prescription meds is a frequent cause
of ED. Anti-depressants, beta-blockers, statins, anti-seizure and anti-pain meds are
the leading culprits but any exogenous molecule can contribute.
Here we
try to substitute nutritional approaches (or weight loss) for the offending
meds.
c) Endothelial dysfunction:
In a testosterone dependent process, the enzyme Nitric Oxide Synthase (NOS)
converts the amino acid arginine into nitric oxide (NO). This is the same
molecule that maintains vascular health throughout your body. The causes
of ED, and the conditions associated with ED, are thus the same as those
associated with CV disease in general. Free radical stress, inflammation,
and Th1/Th17 immune dysregulation are the key culprits, which means that
overweight, HTN, DM, and atherosclerosis are the key associated conditions.
We can deal with pelvic endothelial dysfunction in a way that resolves ED
while exposing you to limited side-effects (Viagra-like drugs) or we
can deal with ED by using measures that improve your overall health (which
by definition is abnormal if you have ED).
NOS converts arginine into NO in a process that requires methyl-folate
(technically BH4 which is regenerated by methyl-folate), and which is
facilitated by bioflavonoids such as grape seed extract (best known as
Pycnogenol). When NOS is not functioning normally (due to free radical or
inflammatory stress or on a genetic basis) it will convert arginine into the
free radicals superoxide and peroxynitrite, which compromise NO activity.
Methyl-folate neutralizes peroxynitrite and Vitamin C handles superoxide.
Thus, a physiologic approach to pelvic endothelial dysfunction/ED that
concomitantly improves overall vascular health/endothelial function
involves:
1. Arginine 4,000 mg three times a day (or arginine containing NO
generating mixture – see below).
2. Methyl-folate as needed (800 mcg – 7.5 mg); in individuals who can
convert folate into methyl-folate, folic acid at 5 mg/day may get the job
done at a lower cost.
3. Pycnogenol (grape seed or pine bark extract) 100 mg/day and Vitamin C
500 mg twice a day.
4. This program will work best is you are also on a broad spectrum, 6/day
multi-nutritional and EFA program (to address the oxidative stress and
inflammation underlying your health problems).
5. Remember that pelvic endothelial function is testosterone dependent – we
need to address this.
Viagra (and the other drugs of its class – the phosphodiesterase inhibitors)
work not by generating nitric oxide, but rather by blocking its breakdown.
Technically speaking, it is not NO that generates arterial vasodilation, but
rather its second messenger, a molecule known as cyclic GMP (cGMP).
Phosphodiesterase enzymes break down cGMP. If we block phosphodiesterase
with Viagra, then the NO/cGMP that you can still make (not enough for
normal erectile function) will work longer (enough for satisfactory
function). The Viagra drugs are designed to block phosphodiesterase in the
pelvic vasculature and not elsewhere, but they are not 100% specific. Thus
if you
are taking a pharmacologic NO donor (NTG or a long-acting nitrate) you
cannot take Viagra concomitantly. Viagra would block the
breakdown of this exogenous NO and your BP would fall to the floor. This
does not occur when NO is generated physiologically (endogenously or in
response to the above program), but any NO so generated should enhance the
efficacy of Viagra.
Blunting inflammation is critical in restoring erectile function and your
overall health. Visceral fat is an inflammation generator, and it
elaborates aromatase, an enzyme that converts testosterone into estradiol
(estradiol
antagonizes testosterone and leads to CV disease in men). Resolution of
visceral fat excess makes sense, with a diet appropriate to your metabolic
status. We can also use pentoxifylline (PTX) to blunt inflammation. PTX is
helpful in nearly all CV conditions (see Part III of Immune Mechanisms of
Atherosclerosis on heartfixer.com) and it has been shown to be helpful in
ED. Viagra is more effective with PTX on board. Similarly, testosterone
replacement enhances the efficacy of Viagra. Amongst men with Viagra
non-response ED, testosterone supplementation resolved ED in 1/3rd
and rendered Viagra effective in another 1/3rd; in only 1/3rd
of the men did ED persist.
Regenerative Medicine seeks to “turn back the clock” by directing autologous stem cells (we use VSELs) or exogenous growth factors (we use exosomes derived from newborn umbilical material), to regions of interest. Both methods have been used in the amelioration of ED These approaches are discussed elsewhere on heartfixer.com or in our office information brochures.
Plan of Action:
1. Lifestyle Modification – Exercise, lose weight, and improve your diet.
2. Drug Modification – Can we eliminate (or substitute for) a likely
offending drug?
3. Androgen Status – Measure and address any abnormalities in testosterone
and/or estradiol.
4. Mood and Stress – If these are concerns carry out the Sanesco salivary
cortisol/DHEA and urine neurotransmitter analysis (covered by Medicare and
commercial insurers), and then utilize nutritional approaches to address
any abnormalities present (why take drugs instead of nutritional
precursors)?
5. Nitric Oxide – Begin an Arginine-based NO generating program as
described below.
6. Anti-Inflammatory Support – Pentoxifylline 400 mg three times a day can
be utilized.
7. Pharmacologic Support – The Viagra class drugs can be used alone or
within the above program.
8. Injection Therapy – Vasodilator substances and be injected directly into
the penile tissue.
9. Vacuum Pump – This is used to engorge the penile vasculature to allow an
erection to develop.
10. Penile Implants – A prosthetic material is implanted within the penile
tissue to help maintain and erection (options 8-10 are prescribed by
specialists in Urology).
11. Exosome or VSEL autologous stem cell activation.
12. Nutraceutical interventions (to normalize your biology – the preferred
approach):
1.
Arginine
can be taken as a maintenance therapy or on an as needed basis - take a dose
concomitant with a Viagra (Arginine to generate NO and Viagra to block its
breakdown) – Options:
A. Arginine powder 4,000 mg (1 & 1/3 teaspoons) three times a day, best
between meals (low cost).
B. NOx Synergy (DfH) 1 to 2 tsps. twice a day. One tsp. provides
750 mg arginine, 750 mg citrulline, 500 mg taurine, 80 mcg methyl-folate, 60
mg magnesium and 125 mg bioflavonoids.
C. ArginCor (Metagenics), 1-2 scoops twice a day. Two scoops provide 3000
mg arginine, 680 mcg methyl-folate, and 2 gm. Of beet root powder.
D. Hybrid therapy – ½ dose Arginine (lowest cost) mixed with ½ dose NOx
Synergy or ArginCor (higher cost) to mask the taste of pure Arginine powder.
E. Nitroxx (Gematria) 2 three times a day (best away from meals) contains
arginine activated with the SONG Laser (that we use in VSEL Activation).
2. Methyl-folate (if not taking an arginine prep that contains this agent) 800-5000 mcg/day.
3.
Pycnogenol 100 mg/day (pine bark or grape seed extract).
4.
Vitamin C 500-1000 mg twice a day.
5.
Pentoxifylline 400 mg 2-3 times a day.
6.
Six
tablet/day multivitamin, 2 tablets 3 times a day or 3 tablets twice a day
(e.g. Basic Preventive V).
7.
Fish
Oil 1000 mg/day.
Please note that arginine below 4,000 mg/day will have little biological
effect. Arginine is best taken on an empty stomach or between meals.
Arginine can be mixed with orange juice (unsweetened), apple sauce, or taken
with warm water. You can have a carbohydrate with the powder to help with
the taste. Concomitant protein intake (other amino acids will compete for
absorption) will blunt arginine absorption. A capsule maker can
be
obtained from a Health Food
Store or on-line.
Endothelial dysfunction per se is discussed in another section of the heartfixer.com website.
Links to the Designs for Health (DfH) and Metagenics (M) websites are available - click on Supplement Ordering Page
James Roberts MD FACC FAARFM 12/23/23