Integrative Therapies for Erectile Dysfunction
By Luke Fortney, MD. Dr. Fortney is Assistant Professor, University of Wisconsin-Madison, Department of Family Medicine; he reports no financial relationship to this field of study.
Erectile dysfunction (ED) is the most common sexual problem in men, affecting up to one-third at some point in their lives. It is defined as the inability to achieve or maintain a sufficient erection for satisfactory sex. The prevalence of ED increases with age1 and is associated with poor cardiovascular health, psychosocial factors, hormonal disorders, recreational drug abuse, and adverse effects from prescribed medications. Anatomic, traumatic, or infectious causes are less commonly involved.2
Normally, an erection is stimulated by a combination of neurovascular, hormonal, psychological, and situational factors beginning with sexual interest and desire. Through parasympathetic activation, endothelial cells are directly activated to produce nitric oxide (NO), which relaxes endothelial smooth muscle and engorges the corpus cavernosum with arterial blood while venous return is simultaneously restricted.3
An integrative approach views the presentation of ED as an opportunity to improve health and reverse the progression of cardiovascular disease, which is the main risk factor for ED. As such, the evaluation and treatment of ED should be sensible, safe, and start with lifestyle. The World Health Organization and American Urological Association recommend using the five-item International Index of Erectile Function Questionnaire (IIEF-5) to assess the patient's concerns and symptoms, and as a precursor to determining treatment options and expectations.4 An integrative approach should begin by identifying those contributing factors that interfere with the body's optimal functioning and natural healing processes. Several classes of medications and substance abuse particularly alcohol, tobacco, and marijuana are common culprits.5 Blood pressure, BMI, and weight/abdominal girth measurements are quick but sensitive tools that assess and monitor cardiovascular health.
There is a strong association between chronic diseases of lifestyle and ED, and it is essential that treatment emphasize weight loss, healthy nutrition, and regular exercise.2,5 Research shows that men with ED are at significant risk for cardiovascular disease.6-11 One study found that ED symptoms present on average 3 years earlier than symptoms of coronary artery disease.10 Conversely, adequate blood pressure control is associated with a lower prevalence of ED, particularly in older patients.11 Similarly, metabolic syndrome seems to play an important role in the etiopathogenesis of ED.6 For men diagnosed with diabetes mellitus, ED prevalence is as high as 89%.12,13 Further, both obesity and smoking nearly double the risk of ED,1,12,14 and alcoholism is a well-known contributor to ED symptoms.15 Identifying ED presents the opportunity to use an integrative medicine approach that strongly emphasizes healthy lifestyle and mind-body modifications.12,16 One study found that men who seek treatment for ED may prefer alternatives such as lifestyle changes to pharmaceutical intervention.17 Even though there is no validated exercise or nutrition regimen that specifically treats ED, exercise and nutrition should be tailored to each patient's specific needs without being extreme, heavily restrictive, or overwhelming. Other lifestyle recommendations include regular dental care, such as flossing, which may be beneficial for prevention of cardiovascular disease and ED.18 In addition, prolonged (more than 3 hours weekly) or frequent bike riding may inhibit neurovascular flow to the perineum, thereby negatively influencing ED. In these patients, a trial of rest, change in exercise routine, or cycling adaptations such as a split seat or recumbent posture can be tried.
For those men lacking organic etiology of ED as determined through medical evaluation, psycho-social-spiritual interventions should be pursued skillfully. It is important to recognize that sexual desire, arousal, and climax are mediated through complex psychoneurological mechanisms. Triggers and causes of ED symptoms can include anxiety, depression, PTSD, excessive worry and guilt, sex abuse history, relationship strain, performance anxiety, postsurgical adjustment disorder, and many other general stresses.19-23 Although psychological interventions are recognized as a SORT (Strength of Recommendation Taxonomy) category B for ED, there is insufficient evidence to specifically recommend art therapy, hypnosis, aromatherapy, meditation, or guided imagery.19 However, appropriate methods that enhance the relaxation response and encourage self-reflection should be adapted individually and encouraged as needed.16,22
Targeted pharmaceutical options begin with phosphodiesterase (PDE5) inhibitors such as sildenafil, vardenafil, and tadalafil, which are widely recognized as SORT category A first-line treatment options for ED.24 Even though PDE5 inhibitors are generally safe, effective, and well tolerated,25 approximately one-third of men do not respond to them. Prescriptions should include warnings about prolonged and painful erections, worsening or development of Peyronie's symptoms, and other drug interaction precautions. It also must be clarified that these agents are not considered effective for improving libido.26 However, PDE5 activity is testosterone dependent research data show that testosterone supplementation in hypogonadism (prevalence 5%-15%) is superior to placebo in improving erections, sexual function, and libido.27-29 Testosterone supplementation with either compounded bioidentical testosterone or pharmaceutical brands should be used cautiously and monitored regularly by a physician. Further escalation of treatment for unique or refractory cases may rely on the self-administered prostaglandin E1 agent alprostadil.
Herbal and Dietary Supplements
In general, supplements are less effective for treating ED when compared to pharmaceutical options.30 Further, in 2007, the FDA issued a statement warning consumers to avoid use of impotence supplements.31 Health care providers should counsel patients to avoid e-mail promotions and Internet advertisements for these and other products that falsely claim to enhance male libido and sexual function. Many of these products are contaminated or adulterated and are not considered reliable or safe for use.32,33 Other products may be safe but ineffective.19,30 However, there is some evidence for the judicious use of high-quality dietary supplements that may be considered in appropriate situations.
Yohimbine is likely the most effective supplement for treating ED; however it has significant interactions with medications. There also are safety concerns in patients with cardiovascular disease, mood disorders, and renal/hepatic disease among others. Yohimbine, although effective, should be avoided for most patients.30,34-37 L-arginine in combination with pycnogenol has demonstrated additive effectiveness in treating ED when taken in respective doses of 1000 mg and 40 mg three times a day. Response to this treatment may take up to 12 weeks of consistent daily use, and the combination should be used with caution in patients with gout, asthma, vertigo, and concomitant warfarin use.38-40 Panax ginseng (Asian or Korean) 1000 mg three times a day may be helpful, and there are topical creams available that may also help with premature ejaculation.30,41-43 For men with documented low dehydroepiandrosterone (DHEA) or testosterone levels, DHEA supplementation at 50 mg daily may be helpful in improving ED symptoms. However, treatment response may take up to 24 weeks. Caution should be used in patients with sleep disturbance, bipolar disorder, acne, and gynecomastia. DHEA treatment seems to be more helpful in men who are also diagnosed with hypertension, but less effective in men with diabetes.44,45 Ginkgo biloba has mixed evidence, but 60-120 mg twice a day may be helpful in treating ED due to antidepressant side effects. Ginkgo should be used cautiously with aspirin or warfarin due to potentiating drug interactions.46,47 Propionyl-L-carnitine also has mixed evidence, but may be most helpful in improving sildenafil effectiveness in men who have undergone prostate surgery when taken at 1000 mg twice a day. It also may be an adjunctive option to support sildenafil response in men with diabetes.48,49 Other agents, such as epimedium (horny goat weed), saffron, and pomegranate, are considered safe but evidence is lacking for efficacy in ED treatment.50-54
Other treatment and adjunctive integrative approaches include vacuum erection/constriction devices (VED/VCDs). For those men who are comfortable, motivated, and open-minded to this approach, VED/VCDs have shown promise in postsurgical, structural (Peyronie's), and prostate cancer radiation rehabilitation.55,56 Satisfaction rates for VED/VCD use are higher than 80% when used appropriately, but the device should be avoided in men with severe Peyronie's, sickle cell disease, or other bleeding disorders.57 Patients who elect this treatment option should be counseled by a trained health care worker experienced with VED/VCDs.
Acupuncture and Traditional Chinese Medicine
Evidence is generally lacking for acupuncture to treat ED.58 Further, evidence also is lacking for massage, osteopathic and chiropractic manipulation, yoga, energy medicine, physical therapy, and Alexander technique for the specific treatment of ED.19 However, these and other methods should be adapted individually and encouraged as part of a larger individualized health plan when appropriate.16 Comprehensive treatment plans that encourage greater overall health and self awareness can be facilitated through Ayurveda, traditional Chinese medicine, and naturopathy. However, there is insufficient evidence to recommend specific treatments within these disciplines for ED, and caution should be used to avoid complex, overstated, and costly treatments. Various detoxification programs also should be approached skeptically.
Although ED is not a life-threatening disease, it does portend underlying health risk and should be approached skillfully. An integrative approach sees the patient as an active contributor to the treatment process, and strongly emphasizes both mind and body interventions that take the whole person, including beliefs and preferences, into consideration. Treatment of ED starts with the therapeutic relationship and emphasizes lifestyle changes that more appropriately address the root of the problem in which ED symptoms are only a part. Although pharmaceutical agents are effective, other options should also be considered when appropriate. Caution should be used regarding supplements, particularly those brands that are not verified or third-party tested for quality. Safety and multimedia marketing scams for sex enhancement products continue to be problematic and should be avoided. Finally, maintaining communication with timely follow-up is important to ensure that each patient's concerns are being addressed adequately, noting that ED is a sensitive and often missed diagnosis.
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