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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

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Erectile Dysfunction: The Bad News and the Bad News

October 01, 2014

By Thomas H. Lee M.D.

Harvard Medical School

More bad news about erectile dysfunction? Men must be wondering, "How much worse can it get?" Sexual performance issues aside, it is slowly dawning on doctors — and some of their patients — that there are other long-term issues for the otherwise healthy man who has trouble getting erections. That is, erectile dysfunction is often an early warning sign of atherosclerosis, which increases one's risk of a heart attack or stroke.

Physicians have known all along that an erection is a complex process that depends upon having healthy blood vessels that can carry blood into the penis. Put simply, here is what happens with a normal erection:

  • Psychological arousal leads to signals from the brain that release the chemical nitric oxide from the blood vessels supplying and lying within the man's genitalia.
  • The nitric oxide triggers a series of chemical reactions that cause the arteries supplying the penis to open up, increasing the amount of blood that can flow in.
  • The veins within the penis get compressed by the blood within the penis, so that blood cannot get out.

Erections do not happen — or are weakened — if the lining of your arteries is damaged and cannot manufacture nitric oxide, or dilate in response to the usual chemical signals. Atherosclerosis, the same disease that causes heart attacks and most strokes, is the culprit most likely to cause this problem. Drugs like sildenafil (Viagra) work by prolonging the effects of the chemicals that dilate the arteries. When these chemicals are broken down by the body's natural processes, the arteries squeeze down, blood flow decreases, and the erection ends.

Connecting erectile dysfunction and atherosclerosis is in no way out in left field. For one, erectile dysfunction is about 3.6 times more common among men in their 50s than men in their 20s. It is also common among people with coronary disease and other conditions linked to atherosclerosis. In fact, the risk factors for atherosclerosis, which include high blood pressure, smoking, diabetes and high cholesterol, are also risk factors for erectile dysfunction.

None of this knowledge is that new, but the implications have been sinking in only slowly in recent years. (The comment "Duhhh" does not seem out of place here.) The fact that we are thinking more clearly about erectile dysfunction is one of the most positive effects of the Viagra revolution — the cultural change that occurred with the introduction of this drug, which made conversations about erectile dysfunction common in the doctor's office, and even at the family dinner table. In the past, doctors didn't ask about erectile dysfunction very often because there wasn't much that could be done, and patients didn't raise the concern because they were pained and embarrassed.

Now patients and doctors can take action to address the problem and related health risks:

    • Men with erectile dysfunction should be screened for risk factors for heart disease (smoking, high blood pressure, diabetes, high cholesterol), and do everything they can to control these risk factors.
    • Doctors also should ask men who have erectile dysfunction about symptoms that might suggest heart disease or atherosclerosis elsewhere in their bodies, such as chest pressure, episodes of weakness or numbness, or pain in their calf muscles while walking.
    • Doctors also should ask men who do have heart disease or risk factors for atherosclerosis about their sexual function, because many who have the condition will not bring it up on their own.

Just as men are becoming more comfortable dealing with erectile dysfunction, they now have to consider their risk of atherosclerosis, which ultimately could lead to a heart attack or stroke. There are other causes for erectile dysfunction besides atherosclerosis, but you and your doctor should discuss this issue in detail to be sure that you are doing everything you can to reduce your long-term risk of cardiovascular disease.

Thomas H. Lee, M.D., is the chief executive officer for Partners Community HealthCare Inc. He is a professor of medicine at Harvard Medical School. He is an internist and cardiologist at Brigham and Women's Hospital. Dr. Lee is the chairman of the Cardiovascular Measurement Assessment Panel of the National Committee for Quality Assurance.

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