September 08, 2016 9 min read

By Mary Bradley Weak erections or premature ejaculation, while a “downer” literally, can also be a sign of serious underlying health issues. If you’re going more than a month with no mojo, you should check it out with a doctor. [av_three_fourth first av_uid='av-3w040l'] Guys are often accused by women of obsessing about sex, including the hardness and staying power of their erections, not to mention how often they get it up and, for that matter, get it on.  The thing is men may be onto something with their focus on their member, …  if for the wrong reasons. Like the canary in the coal mine, not being able to get it up, keep it up, or shooting too quickly or not quickly enough may be a sign, sometimes the first, of underlying health problems, including cardiovascular disease, hormonal imbalances and neurological problems among others. Dr. Prithy Ramlachan, co-author of a study on male sexual dysfunction published 2014 in South African Medical Journal  explains that for healthy erections a lot must be working right, including a healthy vascular system, good blood supply, balanced and adequate hormones including testosterone and thyroid hormones, and a satisfying psycho-social world.   According to Ramlachan, a fraught relationship with one’s sexual partner; negative cultural or religious attitudes about sex; depression and anxiety; as well as self-esteem issues including job loss and financial stress can affect a man’s erections for the worse. The last are significant issues for many South African men with the country’s high unemployment rate and economic uncertainty. When any of the above factors are out of whack or not up to snuff, the result can be problems in the bedroom including weak erections, ejaculation difficulties, low libido and, possibly, serious underlying health problems. Tellingly, many of the risk factors for male sexual dysfunction are the same for cardiovascular disease (CVD) and include high blood pressure, overweight especially the roll around the belly, high LDL cholesterol, raised blood sugar including diabetes and insulin resistance, smoking, and poor diet, advancing age and stress and depression. You’ve heard ‘em before, when it comes to your heart, but these risks also affect your penis. Talk about cutting close to the bone! Experts estimate 40% of men will suffer erectile dysfunction (ED) at some point in their lives.  While rates are much higher among older men (52% of men aged 40-70, cited in a 2013 article in The Journal of Royal College of Physicians), 14% to 20% between ages 18 and 40 experience sexual problems, according to a 2011 study of European males.  Dr. Ramlachan, conducting an exploratory study at a primary healthcare clinic in KZN, found a prevalence of 64.9% in a sample of more than 500 men aged 18 and over.  That’s both guys on either side of you at the rugby game suffering ED, excluding yourself of course! Why the connection between CVD and a happy penis? The answer is a matter of good plumbing. Erections require good blood flow and pressure, and top-notch piping, aka, vascular system. Weak erections can be a first sign of otherwise silent CVD. Why would CVD show up first in the penis? Penile blood vessels are much narrower at 1-2 mm diameter than vessels elsewhere, including the coronary (3-4 mm) and carotid (5-7 mm) arteries; it follows, the penile artery will exhibit effects of arthrosclerosis – cholesterol-laden fat deposits combined with inflammation - and high blood pressure – sooner than larger blood vessels.  Anything that inhibits healthy blood flow will inhibit erections. Not surprisingly, ED is an independent risk factor for heart disease, and here’s the kicker; it’s especially indicative of CVD in younger men. A study published in 2009 Mayo Clinic Proceedings found that men aged 40-49 with erectile dysfunction were twice as likely to develop heart disease as men without ED.  Indeed, ED sufferers have an 80% higher risk of heart disease than dudes who don’t have erection problems. Experts have concluded that a guy with organic, as opposed to psychological, ED is at risk of experiencing a major cardiovascular event within 3-5 years of the onset of ED symptoms. ….so that’s the bad news. The good news is that, you’ve got a 3-year window, after first experiencing bad sex, to take preventative action, through lifestyle changes and medical treatment. If the side-effects of turning your health around, include avoiding a major CV event and improving your sex life; that’s terrific news! The bottom line is that the younger you are and experience ED, the more important to take action now, get screened and lower your risk of CVD. Occasional softness or inability to get it up or keep it up once in a while is generally not a concern. That’s part of life in the 21st century fast-lane.  However, don’t write-off repeated soft erections or bad sex as merely a result of overwork or not enough sleep.  Dr. Elna Rudolph, medical doctor and sexologist at My Sexual Health Clinic, advises that, if symptoms persist a month, get screened by a doctor for underlying health problems. Dr. Ramlachan says that too often men discount symptoms as a result of overwork, stress or aging and delay or avoid seeing a doctor, because they don’t think it’s serious. Sex problems may not suggest only CVD. They can be a sign of blood sugar imbalances including insulin resistance, which can put you at risk for diabetes. According to a 2007 study in The American Journal of Medicine, diabetic men had more than 2.5 times the rate of ED than non-diabetics.  High blood sugar and insulin levels can damage blood vessels and result in poor penile blood flow, as well as damage nerve function needed for A-1 erections.  Not surprisingly, CVD can be a knock-on effect of untreated insulin resistance, especially when it comes in the form of metabolic syndrome. Men with metabolic syndrome have a higher incidence of ED. Metabolic syndrome is that constellation of symptoms that include high blood pressure, abdominal obesity, cholesterol abnormalities and insulin resistance.  So, if you’re suffering ED, be on the lookout … Metabolic Syndrome increases your chances of heart disease and diabetes. As well, diabetes and insulin resistance are linked to lower testosterone in men.   While testosterone levels gradually decrease with age, eating too many refined and sugary foods or being sedentary or over-weight can affect testosterone levels for the worse.  Sometimes it’s not a problem of too little testosterone but too much estrogen, caused by excess body fat, among other factors. Excess estrogen can overwhelm the testosterone you’ve got, leading to signs of low testosterone like weakness, fatigue, low libido and ED.   Dr. Justin Howlett, urologist at UCT Private Academic Hospital, routinely tests testosterone levels in patients with ED. ED, ejaculation problems and low libido can be a sign of poor thyroid function. The thyroid gland and its hormones   govern metabolism and energy levels. They affect pretty much every system in your body including production of sex, stress and blood pressure hormones. When the thyroid is out of whack, you can suffer a cluster of symptoms including fatigue, weakness, hair loss, ED and, in the case of too much thyroid hormone, anxiety and premature ejaculation. Depression can also lead to sexual dysfunction and vice versa.   Another side-effect of low testosterone, along with sexual dysfunction, is depression.   The chicken and egg relationship of mood and sexual performance continues; SSRIs, commonly prescribed drugs to combat depression, include ED as a side-effect. SSRI’s are not the only drugs that may affect a guy’s mojo. Beta-blockers can do the same.  Cape Town cardiologist J.P. Smedema explains that a side-effect of many drugs, including over-the-counter meds, can include sexual dysfunction. The important thing, Smedema says, is to let your doc know immediately of any changes in your sex drive or erections after starting a new medication. Often alternate meds won’t cause symptoms. Similarly, stress and anxiety can contribute to ED, ejaculation problems and lack of desire. Conditions like Parkinson’s, kidney disease, brain and spinal cord injury can impact sexual performance including stroke, dementia and prostate and rectal surgery.  A study reported at the 2008 Clinical Congress of the American College of Surgeons found rates of sexual dysfunction among patients under 50 who’d suffered traumatic injury of any kind in the past year was triple the normal population! Excess porn viewing has been linked to erectile dysfunction. Rudolph suggests that it is not porn itself but the intimacy problems watching too much can reinforce. She notes that porn addiction and resulting sexual dysfunction are some of the toughest problems to treat and can wreak havoc on a man’s sexual relationships. So, what to do, if you’re unhappy with your sexual performance? Lots! Dr. Rudolph says that, in this day and age with the pharmaceutical advances and expanded knowledge of the effects of lifestyle on sexual health, there is seldom reason for a man to suffer bad erections. The first step, if you’re noticing poor performance, is to visit your doctor and be screened for health issues that could cause or contribute to the problem. She’ll ask you what’s up or, as the case may be, what’s not up and want details about the nature of the problem and how and when it began. ED with gradual, as opposed to sudden, onset may suggest different causes.   Whether you experience spontaneous nighttime erections is clue to the cause and resolution of sexual dysfunction. Howlett explains the initial blood tests for ED include blood sugar, cholesterol and testosterone. Depending on levels, he will check prostate specific antigen (PSA), thyroid hormones, as well as inflammatory markers and kidney and liver function. He routinely checks blood pressure.  If he discovers markers for heart disease, he’ll refer to a cardiologist for treatment and, depending on the severity, begin treating the sexual dysfunction with lifestyle changes and meds, as appropriate. After addressing lifestyle issues, he explains, the first line of treatment for ED is usually a PDE-5 inhibitor, the most familiar being sildenfal, aka Viagra. If these fail, penile injections are the next treatment of choice and have a high success rate. Nevertheless, their use must be monitored for side-effects like prolonged erections (Priapism) that can cause permanent damage. The next treatment in South Africa is likely vacuum pumps. These devices draw blood into the penis creating an erection. Should they not work, according to Howlett, penile prostheses are an option. Interestingly, the greatest need for penile implants in his practice stems from patients who’ve bought penile injections on-line and not been adequately supervised by a physician. Howlett strongly urges men avoid herbal or “natural” remedies to resolve sexual problems. Unlike pharmaceuticals, supplements are unregulated. Some have been found to contain ingredients not on the label, including PDE-5 inhibitors.  “If you are treated with nitrates for chest pain and don’t know you’re on PDE-5 inhibitors, the result could be fatal,” he explains. Dr. Rudolph’s practice includes clinical psychologists on-site who treat psychological issues that may cause or exacerbate a man’s sexual dysfunction.  Howlett, Rudolph and Ramlachan see psychological factors as key when treating the patient with performance issues and may, or may not, use depression or anxiety meds as part of that. Bottom line, there is a lot you can do to prevent and resolve penis-performance problems that don’t involve medical treatment or drugs.

  • Healthy Diet. - Make sure you eat heart-healthy food– The Mediterranean Diet is what the 2012 Princeton III Consensus Recommendations for Management of ED and CVD specifically recommends. That diet emphasizes fruits and vegetables, beans and legumes, whole grains, fish, lean meat, poultry and dairy and polyunsaturated oils. Avoid trans and excessive saturated fats and sugary and refined foods.
  • Regular Exercise - Studies have shown improved erectile function for men who are physically active compared to coach potatoes. In one 2012 Journal of Sexual Medicine study of men between 18 and 40, those who were physically active had not only improved erectile function but better orgasms and overall sexual satisfaction.
  • Butt out – Smokers have 1.5 to 2 times greater risk than non-smokers of ED. Smoking damages blood vessels and cigarettes are not the only problem. Howlett has seen recreational drugs, including cannabis, negatively affect patients’ erections.
  • Keep Trim - Being overweight, especially abdominal obesity, is linked to worsening ED. Obese men were found to have ED twice as often as normal weight guys.
  • Manage Stress – Stress and anxiety can lower testosterone as well as your libido and sexual performance. Anxiety can cause PE and ED.
  • Watch the biking – Studies have found that excessive bicycling can cause erection problems, due to chronic friction and pressure in the penile region. Interestingly, studies indicate that horseback riding is not a problem. Go figure!
  • Limit Porn – While studies conflict, there appears a link between excessive porn viewing and sexual problems, especially among younger men, some of whom watch in excess of several hours a day of the hot and horny stuff on-line. A review published in the 2016 issue of Behavioral Sciences observes how men exposed to excess porn may exhibit signs of ED, delayed ejaculation and decreased libido and sexual satisfaction.  The authors speculate that the limitless novelty and extreme nature of some porn eventually desensitize men to sex with real partners and hamper arousal.[/av_three_fourth]
[av_one_fourth av_uid='av-302uk5'] Improve your Sex Life
  • Stop Smoking,
  • Do regular vigorous exercise
  • Maintain a normal weight
  • Eat a healthy diet
  • Maintain a healthy LDL/HDL cholesterol ratio
Common Risks for ED
  • High Blood Pressure
  • Cardiovascular Disease
  • Medications including SSRI’s, Beta blockers and many other meds
  • Smoking
  • Overweight especially abdominal obesity
  • Low testosterone (hypogonadism)
  • Blood sugar problems including insulin resistance and diabetes
  • Psycho-social factors including self-esteem issues, depression and anxiety
  • Increasing age[/av_one_fourth]
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