Erectile Dysfunction (ED): Natural Ways to Address Its Complexities

Did you know that erectile dysfunction (ED) is very common among American men of all ages and that the risk of its development increases with age? Understanding its causes and adopting natural ways to address its complexities can help tackle its power to undermine self-confidence, quality of life, and intimate relationships.

Erection Physiology
A penile erection is essentially a spinal reflex that is generated through the complex interplay of the sympathetic and parasympathetic nervous systems (reflex aspect), combined with local genital stimulation and/or stimulation from erotic or emotional stimuli that involves the limbic system of the brain (psychological aspect). Various neurotransmitters released from the endothelial cells and excitatory nerves in the penis:

• facilitate erectile function, including nitric oxide (NO), dopamine, glutamate, ATP, acetylcholine, oxytocin, ACTH (stimulates cortisol production), and MSH;
• inhibit erectile function (noradrenaline, enkephalins, GABA, and endocannabinoids);
• both facilitate and inhibit erectile function (serotonin). The balance among these molecules controls the degree of contraction of the smooth muscle of the corpora cavernosa (CC)—the two columns of spongy tissue that run through the penile shaft—and in turn controls overall penis function.

By initiating production of another chemical messenger called cGMP (cyclic guanosine monophosphate), NO triggers a biochemical cascade leading to vasodilatation (relaxation and expansion) of penile blood vessels, This allows for increased blood flow into the CC, which then stretches, compressing the primary site where blood exits the penis (the subtunical venules) and causing the resistance to blood flow out of the penis, thereby producing and maintaining an erection.

What Is ED?
ED is the inability to achieve or sustain a penile erection for satisfactory sexual performance. According to the Cleveland Clinic, the failure to get an erection less than 20% of the time is not abnormal and generally does not require treatment. However, such failure more than 50% of the time is generally diagnosed as ED and can be a symptom of a more serious underlying problem, including:

1. vascular disease, including cardiovascular disease (CVD) and blocked blood flow from various factors such as atherosclerosis (note also that hypertension, a risk factor for CVD, may damage blood vessels and disrupt blood flow to the penis);
2. neurological disorders resulting from multiple chronic conditions, including diabetes, MS, lupus, Parkinson’s disease, and the aftermath of stroke;
3. psychological problems such as severe stress/PTSD, depression,low libido, relationship problems, and performance anxiety;
4. male hormone deficiencies (testosterone, DHEA);
5. physical injury to the penis, including that causing Peyronie’s disease, or prostate, bladder, or colon conditions and surgeries;
6. obesity and metabolic syndrome.

Many common medications can also cause ED, including those prescribed for cholesterol (statins); pain/inflammation (NSAIDs); blood pressure (including diuretics); acid-related conditions (Zantac, Tagamet, Pepcid); allergies; depression; irregular heart function (antiarrhythmics); anxiety (tranquilizers, opiates); muscle tension (muscle relaxants); hormonal imbalance; cancer (chemotherapy prescriptions); seizures; and recreational drugs (alcohol, nicotine, illicit drugs such as marijuana and cocaine).

Conventional Treatment
PDE5 inhibitors (PDE5Is—Viagra, Levitra, Cialis) are the primary allopathic treatment for ED. These medications inhibit the phosphodiesterase-5 enzyme, which otherwise naturally destroys cGMP, the above-mentioned critical mediator of vasodilatation, penile blood flow, and resulting erection. Like all prescriptions, PDE5Is have potential side effects, including headache, indigestion, priapism (painful, prolonged erection lasting more than six hours), and vision problems, including blindness. While they are appropriate for men with vascular ED, they do not work for 30–40% of men suffering from ED who also have neurological disorders or low testosterone. PDE5Is are also inappropriate for men with CVD and can interact with other medications, including nitrates (nitroglycerin), alpha blockers (Flomax), and drugs that inhibit the detoxifying cytochrome CYP3A4 pathway [certain antibiotics, antifungals (Ketoconazole), Cimetidine, Ritonavir)], which consequently decrease the metabolism, increase the plasma concentrations of PDE5Is, and can thus exacerbate the severity of ED drug side effects.

Beneficial Lifestyle Changes
As with every health condition, the first and foremost line of defense against ED is making improved lifestyle changes. Research has shown that the most valuable modifications include exercising on a regular basis; following a healthy diet, especially to manage cardiovascular conditions and weight (obesity nearly doubles the risk of ED); eliminating smoking and recreational drug use; minimizing alcohol intake; reducing prescription medications when possible and advised by a physician; psychological therapy/consciousness management; and increasing open communication and emotional connection with one’s sexual partner.

Evidence-Based Nutritional Therapies
Both the reflex and psychological aspects of ED can be addressed with natural therapies, as can its underlying health issues. Space limitation allows only brief discussion here of some remedies that can address the physical elements of ED.

• Natural Vasodilators: The conditionally essential amino acid L-arginine is a highly effective nitric oxide (NO) precursor. L-citrulline, a nonessential amino acid that the kidneys convert to L-arginine, can also enhance vasodilation. Prelox, a combination of L-arginine and Pycnogenol, from French maritime pine bark, has been proven in five independent clinical studies to combat ED. In this writer’s clinical practice, L-arginine combined with beet root, another NO precursor, has proven highly effective against ED in several men. In one 1998 study, 120–240 mg of Ginkgo biloba extract was associated with a 76% improvement in antidepressant-induced ED. According to the researchers, ginkgo enhanced all four phases of the sexual response cycle: desire, excitement (erection and lubrication), orgasm, and resolution (afterglow).
• Natural PDE5 Inhibitors: One natural alternative to prescription PDE5 inhibitors is epimedium (horny goat weed), used for centuries in traditional Chinese medicine as an aphrodisiac and for ED treatment. Icariin, one of its key bioactive components, not only inhibits PDE5 but also has testosterone-like properties and is associated with increased NO. Other PDE5Is include pomegranate (supported by limited research) and Thai ginseng (kaempferia parviflora root/black ginger), shown to enhance erectile function and response time, penile size, intercourse satisfaction, and sexual desire.
• Natural Testosterone Boosters: Ample research has shown tongkat ali (longjack), a centuries-old remedy used in traditional Southeast Asian medicine, to be an effective testosterone booster. In a 2012 one-month study of 76 men, researchers found that 200 mg of this herb significantly improved serum testosterone in most of the subjects. While there is some evidence that panax ginseng may increase testosterone, it has principally proven otherwise able to improve penile rigidity, libido, and satisfaction in men with ED. The nonessential amino acid L-carnitine may have testosterone-like effects and has been associated with enhanced erection quality and function, orgasm, and overall sexual well-being.
• Other Natural Remedies:
  Additional evidence-based remedies that can improve ED and related health issues include:
  • Maca (preliminary research indicates it increases libido).
  • Yohimbe/yohimbine (alone or with L-arginine).
  • Vitamin D (deficiency can be a risk factor as it contributes to vascular dysfunction/arterial stiffness).
  • Vitamin E (increases CC pressure, improves NO-mediated relaxation, enhances endothelial cell function, scavenges free radicals, improves NO-mediated relaxation, preserves nerve function).
  • B vitamins including folate, B6, B12 (may reduce ED by keeping homocysteine levels in a healthy range).

All of the remedies discussed here should be used with caution and, ideally, with the guidance and approval of a healthcare practitioner, especially in the presence of various chronic health conditions, including neurological, cardiovascular, and psychological disorders.

The statements in this article have not been evaluated by the Food and Drug Administration, are for educational purposes only and are not intended to take the place of a physician’s advice.

Submitted by Erika Dworkin, Board Certified in Holistic Nutrition®, former owner of the Manchester Parkade Health Shoppe in Manchester, CT (www.cthealthshop.com), which operated for 65 years.

Erika is available for nutrition consultations and to speak to groups, including via video communication platforms. She welcomes inquiries at Vitathena Wellness (successor to Parkade Health) by phone at 860.646.8178, or by email at: edworkin@vitathena.com.

All statements in this article are practice- or scientific evidence-based and references are available upon request.