Men: Don't be surprised if a discussion with your doctor about erection problems veers into a talk about your heart, or vice versa. Problems getting or keeping an erection may be a red flag for heart trouble down the road, and many men with heart disease have sexual concerns they aren't talking about.
The connection between heart disease and erection problems (doctors call it erectile dysfunction) isn't far-fetched at all. Both follow the same age-related trajectory and become increasingly common from age 45 onward. They even share common causes.
A study of middle-aged California men begun in 1972 shows that smoking, overweight, and high cholesterol or high triglycerides — all risk factors for heart disease — were also linked with erection problems 25 years later. The report appeared in the April 21, 2004, Journal of the American College of Cardiology.
From a purely mechanical point of view, an erection is a hydraulic event. It's a matter of getting extra blood into the penis, keeping it there, then eventually letting it drain away.
When a touch, a look, even a thought nudges the brain to send signals of arousal down the spinal cord and into nerves in the penis, a key chemical messenger is nitric oxide. This tiny molecule is made by both nerves and the inner lining of arteries. It relaxes smooth muscle tissue inside the penis and inside arteries. This relaxation is crucial to creating and keeping an erection.
As arteries in the penis relax, they widen and carry more blood. This extra blood flows into two parallel shafts of smooth muscle that run the length of the penis. Relaxation of this spongy muscle lets blood trickle into its tiny crevices. This makes the muscle more rigid and compresses small veins that drain blood away from the penis.
Many things can derail this process. Atherosclerosis — the same disease that causes heart attacks and strokes — is one of them. The accumulation of fatty plaque inside blood vessels throughout the body injures artery walls and interferes with nitric oxide production. Not enough nitric oxide in arteries leading to or inside the penis can weaken or prevent an erection.
This knowledge isn't terribly new. So why did it take so long for doctors to make the connection between erectile dysfunction and heart disease? Thank the Viagra Revolution. Before the introduction of the little blue pill, most men were too embarrassed to mention erection problems. And doctors didn't ask because there wasn't much they could do to help.
Viagra helped transform erectile dysfunction from a deep, dark secret into grist for television talk shows and fair game for questions in the doctor's office. The ensuing openness made it possible to better gauge the extent of erection problems (they affect somewhere between 15 million and 30 million American men). This, in turn, has allowed researchers and clinicians to see links between erectile dysfunction and other conditions.
Better understanding of the two-way connection between erection problems and cardiovascular disease has implications for both.
Erection problems warrant a thorough checkup for signs of heart disease. This includes testing for high cholesterol, high blood pressure, and diabetes; a discussion about smoking and other risk factors; and a conversation about symptoms that might suggest atherosclerosis elsewhere in the body, such as chest pressure, episodes of weakness or numbness, or pain in the calf muscles while walking.Heart disease should, at some point, prompt a man-to-doctor conversation about sexual function. Heart trouble shouldn't stand in the way of a satisfying sex life or the use of Viagra or one of the other drugs for erection problems. If your doctor brushes off your questions about sex or seems uncomfortable answering them, ask for a referral to a clinician with a special interest in sexual function.
September 2004 Update