Erectile dysfunction ‘can be a warning of a cardiovascular problem’

The writer Stefan Zweig said in his biography of Marie Antoinette that the sexual dysfunction of her husband, King Louis XVI, not only profoundly affected their marriage but probably also the king’s reign and the path of French history. “Rien (Nothing),” the monarch wrote in his diary a day after the wedding. And so on for years. The king reportedly suffered from phimosis and the couple did not consummate their relationship until seven years after they married. His inability to achieve satisfactory sexual relations led to him being ridiculed at court and may even have fueled the Revolutionary movement.

But the French monarch’s erectile dysfunction was nothing extraordinary. In hindsight and with the benefit of scientific research, it has become clear that the case of Louis XVI is common enough. A study published in the Journal of Urology analyzed his condition and concluded that, probably, the origin of his condition was multi-causal: on the one hand, there is evidence that the king suffered from rigid and painful phimosis, “which may have inhibited erection and ejaculation.” Other historians postulate that the monarch also suffered from hypogonadism — whereby the testes produce insufficient sex hormones — hence his lack of libido.

The study also points out that social factors could have contributed to the king’s erectile dysfunction, since he was a lonely, shy young man without a sex education. All these variables, along with others, are usually behind erectile dysfunction which can affect any post-puberty male but is more common in later life, with about half of men between 40 and 70 suffering from it.

To understand the world of erectile dysfunction, experts begin by clarifying that erection, ejaculation and orgasm are different processes. They occur in parallel, but they are not the same, says Venancio Chantada, head of Urology at the University Hospital Complex of A Coruña (CHUAC) in northwestern Spain: “In the male sexual sphere, the most frequent pathologies are erectile dysfunction, premature ejaculation and lack of desire. People often confuse all three, but shouldn’t. It is not essential that there be a complete erection to ejaculate or have an orgasm. They are different phenomena.”

According to experts, erectile dysfunction is the inability to have a sufficient erection to maintain a satisfactory sexual relationship, either due to rigidity or duration. “Most erection disorders have a physical explanation, especially vascular problems,” says Chantada. “This can be compounded by other factors, such as fear of performance: the man flees from contact with his partner and psychological problems pile up.” The most common profile of the patient who comes to the clinic with erectile dysfunction is that of a man, between 55 and 65 years old, who has been experiencing problems having satisfactory sexual relations for some time.

Josep Torramadé, national coordinator of Andrology of the Spanish Association of Urology, adds that young men with erectile dysfunction linked to psychological problems are another common visitor to the clinic. “In these cases, the origin of erectile dysfunction is more associated with anticipatory anxiety. It is not because of an organic problem, they are young men with no cardiovascular history,” he says.

An erection is, in essence, a reflex that occurs in response to an erotic stimulus. But behind that there is an intricate neurovascular process where mechanisms of the nervous and circulatory system, endocrine variables and psychological aspects intervene: on the one hand, the penis needs blood flow to achieve and maintain an erection; but the nervous system (brain, spinal cord and nerves) also works to send electrical impulses that help the body, including the penis, to move. Regarding the endocrine factor, there are hormones, such as testosterone, that help dilate blood vessels and facilitate blood flow to the penis. The psychological variable influences this entire process directly or indirectly: there are diseases (depression, anxiety...), stress or frustrated expectations that can affect sexual performance.

Vascular problems

The sphere of erectile dysfunction is complex and the reasons for it are diverse. As Chantada points out, among the organic causes, vascular problems are the most frequent. In fact, erectile dysfunction can appear as a consequence of several cardiovascular symptoms, but it can also “be a warning of a cardiovascular problem,” adds the urologist, who is also a member of the board of directors of the Spanish Association of Andrology.

Torremadé also stresses this bidirectional relationship: “Cardiovascular risk factors, such as diabetes, hypertension, a sedentary lifestyle or smoking, are the same as those for erectile dysfunction, because [this condition] is also a vascular interaction.” He adds that medicine is increasingly looking at erectile dysfunction as another cardiovascular risk factor: “It is a symptom that warns us that the body is not well: the arteries of the penis are already starting to cause problems; those of the heart will follow... It is a sentinel symptom, the tip of the iceberg, an early manifestation of something that is not going well at the cardiovascular level.”

A scientific review explains that the smaller diameter of the cavernous arteries of the penis means that erectile dysfunction due to vascular causes usually precedes coronary heart disease, heart attacks and strokes by up to five years. “Boys who have unexplained erectile dysfunction appear to have up to a 50-fold increase in cardiovascular risk in adulthood,” the researchers note. Other research indicates that erectile dysfunction increases cardiovascular risk as much as smoking or having a family history of heart attack.

However, there are more organic causes that can explain erectile dysfunction. For example, oncological surgeries on the prostate, bladder or rectum. “Luckily, in 90% of cases, we can treat these tumors curatively, but these treatments generate erectile dysfunction as a secondary effect,” says Torremadé. Of prostate cancer patients who undergo total organ removal, for example, 85% can expect postoperative erectile dysfunction, while among those who received radiotherapy, only about 25% suffer from this condition.

The risks of cycling

Other explanations include neurological problems (e.g., spinal cord injuries) or endocrine problems, such as hypogonadism. And also trauma. There are even studies on the link between cycling and erectile dysfunction, although the conclusions are “controversial,” according to the review. “The saddles of traditional racing bikes exert considerable pressure directly on the perineal nerves, as well as on the arteries [of the penis], suggesting they could be a potential problem for cyclists,” the researchers point out.

A 2020 meta-analysis comparing more than 3,000 cyclists with 1,500 non-cyclists concluded that there was a significantly higher risk of erectile dysfunction among the former. However, other research on amateur cyclists found that amateur cycling has no effect on erectile function. Scientist Irwin Goldstein, who researched the subject, concluded in an article for Boston University: “Most men can take advantage of the numerous benefits of moderate cycling without worrying that it will lead to erectile dysfunction. Before they begin to ride, however, they should be aware of the need for a properly fitting bicycle and comfortable saddle as well as the potential risks to sexual health presented by long-distance cycling.”

Erectile dysfunction can also be collateral damage from the intake of some medications (antihypertensives, chemotherapy, antidepressants) and behaviors, such as the consumption of toxic substances, says Chantada: “Tobacco is very harmful for the arteries and those of the penis are very small and can become clogged more easily. Alcohol, meanwhile, reduces inhibitions when it comes to sexual relations, but then does not help with the erection. It’s bad for erections.”

Alcohol is a bad for erections

Venancio Chantada, head of Urology at the University Hospital Complex of A Coruña

On the upside, there are solutions to erectile dysfunction, which can be adapted to the origin of the problem. Apart from the universal recommendation of improving lifestyle habits, which is always valid, regarding a psychological origin, treatment is based, above all, on therapy with a sexologist. If there is an organic cause, other options are available, such as Viagra, shockwaves and prostheses. The best-known therapeutic approach is that of vasodilator drugs, such as Viagra pills or other analogues. “What these drugs do is inhibit the degradation of the erection. And they are usually very effective, though within a sexual context. That is, if there is a sexual context, the drug will prove effective. If you start reading the newspaper, for example, the penis will hardly respond,” Torremadé explains. In other words, there has to be an erotic stimulus.

There are also vasoactive drugs that are injected directly into the urethra and generate an erection. “In this case, these treatments stimulate the system that generates the erection and there is no need for sexual stimulation,” says Torremadé. Another strategy is shock waves, which try to increase blood flow to recover lost erectile function. However, one of the booming therapeutic strategies is the penile prosthesis, which consists of implanting a hydraulic system inside the sexual organ to create an erection artificially when the person wants it. Doctors say that the device is imperceptible to the eye and, in addition to being a safe and effective surgery, patient satisfaction is very high.

Chantada warns, however, that this option is usually a last resort because “there is no going back. It has many advantages and the prosthesis has an average life of 10 or 15 years, but it’s always a last resort because when you do that surgery, you destroy the veins inside and that means they will no longer respond to other treatment.” Unlike what happens with female sexuality, which is historically less studied and addressed, research to address erectile dysfunction continues to move forward. And there are studies underway to optimize treatments, experts explain – for example, through regenerative medicine strategies or with technological improvements in prostheses.

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