Erectile Dysfunction - A Naturopathic Approach

Among all sexual dysfunctions, erectile dysfunction (ED) is the most common ^[1]. Approximately 1 in 10 men worldwide have ED, the prevalence ranging from 10-71% for men older than 70 years old ^[2]. This range is so wide and there are no reliable figures available for the incidence and prevalence of ED because most men do not seek treatment.

Social stigma is all too familiar and continues to be a reality for men suffering with erectile dysfunction (ED), this being the biggest barrier to them seeking treatment. Even more worrisome, due to the fact that ED can be linked to early signs of cardiovascular disease, is that 25% of all men diagnosed with ED are young (under 40 years of age) ^[3]. There are a several approaches available to treat ED: drug therapy, psychotherapy, self-injection therapy, and penile prosthesis implantation. However, the treatment options that are available come with many problems. For instance, drug therapy comes with side effects, which include flushing, headaches, dyspepsia, transient visual changes, priapism, and risk of death if taken with nitric oxide ^[4]. The side effects of self-injection therapy include pain, fibrosis at injection site, hypotension, and priapism. Penile prosthesis implantation is used for men who do not respond to the other therapies and this type of treatment is expensive and is complicated by mechanical failure, infection, and granuloma formation in the penis ^[5]. For these reasons, many choose to resort to alternative medicines or decide to remain untreated to avoid negative side effects and dependency of pharmacotherapy.

Risk factors that can contribute to ED include: smoking, obesity, diabetes, and cardiovascular disease.

There are three types of ED: organic, psychogenic, and a mixture of both. The organic causes include vascular, neurogenic, hormonal, anatomic, traumatic, and drug-induced ^[1]. Psychogenic causes include depression, anxiety, and other mental-emotional disorders. Most organic cases of ED are due to a reduction in nitric oxide which causes an insufficient relaxation of the corpus cavernosum, leading to decreased blood flow to that area ^[6].

Physiology of an erection

Erections are a complex process involving neurophysiology (somatic and autonomic – sympathetic, parasympathetic), psychological, vascular, and hormonal factors. These systems must all work together to fill the erectile tissue with blood and cause an erection. Penile erectile tissue, known as the cavernous tissue (which consists of sinusoids, and trabeculae), as well as the arteries, all play a key role in erections. Sexual stimulation releases neurotransmitters that lead to the dilation of the arteries, trapping of the blood inside the sinusoids, compresses and reduces venous outflow, all leading to an erect penis. Understandably, there is a lot more at play when it comes to achieving an erection, however, only the information mentioned is required to understand how some of the following natural approaches are effective.

Naturopathic Approaches Nutraceuticals

The amino acid L-arginine is often used due to its ability to make nitric oxide, the principal mediator of penile erection. Nitric oxide relaxes the corpus cavernosal tissue, allowing blood to flow into the area, which leads to an erection. Oral administration of the nitric oxide donor L-arginine at a high dose of 5g/day has been shown to only improve sexual function in men with organic causes of ED ^[7]. Some adverse events may include digestive complaints such as nausea, vomiting, diarrhea, as well as headaches, flushing, hypotension ^[7].

Zinc is often thought of as a natural remedy for ED.

However, studies show that it is only efficient in men that have both a kidney disease and experience ED secondary to a zinc deficiency. It is unclear whether or not men with normal renal function and a zinc deficiency would benefit from zinc supplementation ^[8]. Long-term supplementation of zinc can deplete copper stores; therefore copper should be supplemented as well.

Botanical Medicine

Like L-arginine, pycnogenol (derived from the plant Pinus pinaster) works by increasing the amounts of nitric oxide ^[9]. A study has shown that 92.5% of men were able to achieve erection after taking 120 mg of pycnogenol in divided doses in combination with L-arginine for a period of 3 months ^[9]. A second study has also demonstrated promising results of increased hardness of erection and satisfaction of intercourse ^[10]. Both studies reported that no adverse reactions were observed during the study period.

Ginseng (Panax ginseng) is commonly used in the treatment of ED due to its action on the cardiovascular system. It increases the production and promotes the release of nitric oxide in penile tissue through catalyzing the conversion of arginine to citrulline by the enzyme NOS which in turn releases NO ^[11]. These mechanisms of actions all lead to the relaxation of the corpus cavernosum and vasodilation of penile arteries causing increased blood flow to the penis. In addition, ginsenosides also have an effect on the nervous system through inhibiting the reuptake of GABA, glutamate, dopamine, noradrenalin, and serotonin ^[12]. Although it is not well understood, this suggests that it may act on the central nervous system in the process of erection ^[12]. Studies found that at a dosage of 600-1000mg taken 3 times per day for 4-12 weeks, ginseng not only improved erection, but also sexual desire and satisfaction. Overall, there were very little adverse effects reported in the human studies.

Yohimbe has long been known to have an affinity for males, often used as an aphrodisiac to increase libido. It is an α2-adrenergic receptor blocker that acts on the central nervous system to increase norepinephrine and it also has a direct action on penile tissue and arteries ^[13]. A study has shown that 30mg per day for 8 weeks of yohimbe extract was significantly more effective than placebo at improving sexual desire, satisfaction, and penile rigidity ^[13]. However, a second study concluded that yohimbine alone is not effective at treating ED, but in combination with L-arginine, it can be a great treatment option ^[14]. Seeing as yohimbe works on the CNS, it has a smaller therapeutic index and comes with side effects. In the above study, 30.2% of participants reported adverse effects but the details were not released ^[13].

Traditional Chinese Medicine and Acupuncture

Erectile dysfunction can be either a full condition caused by dampness, blood stasis, and phlegm, or an empty condition caused by heart-blood deficiency, heart and gall-bladder Qi deficiency, kidney-yin deficiency, liver-blood deficiency or kidney-yang deficiencies. Acupuncture points may be chosen based on the TCM diagnosis as treatment. A prospective study of acupuncture in men with psychogenic ED demonstrated that acupuncture lead to sexual satisfaction in 68.4% and erections improved in 21% of men ^[15].

Lifestyle counseling

Seeing as obesity, diabetes, heart disease, dyslipidemia, depression, anxiety, and hypertension are all risk factors for ED, lifestyle counseling and modifications can improve erectile function. According to the evidence available, weight loss and exercise should be the main focus for men with ED, as it can significantly improve erectile function ^[16]. A 2 year long RCT of regular exercise and diet change (Mediterranean diet) significantly improved erectile function ^[16]. Though it might take more time to see results from lifestyle changes, it is the most beneficial treatment especially in men diagnosed with ED secondary to a chronic condition, diabetes, heart disease, or obesity. Let’s not forget that ED not only affects men physically but emotionally as well. Often, little importance is given to the impact of ED on quality of life of affected men. Men with ED have been shown to have an increased incidence of depression, anxiety (both general and performance), and low self-confidence. ED also has an impact on sexual partners and relationships. Partners of men with ED have a reduction in libido and report feelings of rejection and guilt. It is suggested that ED has a tremendous impact on a man’s life and marriage, and accounts for 1 in 5 failed marriages ^[17]. Providing counseling for both the man and his partner could provide the couple with tools to deal with the emotional aspect of ED and find ways to be sexual without an erection.

Conclusion

Erectile dysfunction is becoming more and more common, not only seen in middle-aged and elderly men, but also in younger men. Because ED can be a sign of an underlying health problem, it is important that men discuss this with their primary healthcare practitioner for further assessment. Natural therapies for the treatment of ED are available and not only do they tend to have fewer side effects, they also increase overall health through other actions. For instance, ginseng is traditionally used as an adaptogen to enhance well-being and increase energy, L-arginine can reduce blood pressure through its vasodilation action, and lifestyle counseling, often used as first line therapy, is health promoting and reduces many of the risk factors associated with ED. Overall, there are a number of different naturopathic therapies that can be considered and have shown to be effective in the treatment of erectile dysfunction but as always, it is best to speak with your naturopathic doctor or healthcare provider about the options and proper dosing.