Alternative and Complementary Medicine to Treat Erectile Dysfunction

1) Definition and Importance of Erectile Dysfunction:

“Erectile dysfunction” (ED), sometimes called “male/sexual impotence” (or “impotence” only), corresponds to the inability to achieve or sustain an erection sufficient for satisfactory sexual intercourse (coitus/copulation). Erectile dysfunction is distinguishable from other conditions that impair normal sexual intercourse, such as lack of sexual desire (libido) and ejaculation/orgasm disorders. Nevertheless, multiple associated sexual disorders may occur, causing a significant suffering (morbidity) to patients.

ED, closely attached to cultural notions of potency, success and masculinity, can have devastating psychological consequences including feelings of shame, loss or inadequacy. ED can be a serious damaging to interpersonal relationships and self-esteem. It affects millions of men worldwide with implications that go far beyond sexual activity alone. By age 45, most men have underwent ED at least once in life. Many men also are unwilling to talk about erectile dysfunction with their wives and doctors, and thus the condition is underestimated.

Although ED can occur at any age, usually the older the man is, the higher his risk is.

– Core idea: ED is a frequent and important harmful condition in men’s life.

2) Anatomy and Physiology of Penile Erection:

The penis contains two chambers, called the “corpora cavernosa”, which run the length of the upper side of the penis. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa. Filling the corpora cavernosa is a spongy tissue consisting of smooth muscles, fibrous tissues, spaces, veins, and arteries. A membrane, called the “tunica albuginea”, surrounds the corpora cavernosa. Veins located in the tunica albuginea drain blood out of the penis.

Penile erection can be induced by two different mechanisms. The first one is the reflex erection, which is achieved by gently, directly and continuously touching and rubbing the penile shaft.

The second is the psychogenic erection, which is achieved by erotic fantasies, imagination or dreaming.

Thus, the sexual stimulation, which can be tactile (reflex) or psychogenic/psychologic, generates electrical impulses along the nerves going to the penis and causes the nerves to release nitric oxide (NO), which, in turn, increases the production of cyclic GMP (cGMP) in the smooth muscle cells of the corpora cavernosa. The cGMP causes the relaxation of smooth muscles of corpora cavernosa, allowing a rapid blood flowing into the penis (the blood fills the corpora cavernosa, making the penis bigger, harder and thicker). The consequential pressure compresses the veins in the tunica albuginea, helping to trap the blood in the corpora cavernosa, therefore maintaining erection. Erection is reversed when cGMP levels in the corpora cavernosa fall, allowing the smooth muscles of the corpora cavernosa to contract, ceasing the inflow of blood and opening veins that drain blood away from the penis. The levels of the cGMP in the corpora cavernosa fall because it is inactivated by an enzyme, named “phosphodiesterase type 5” (PDE5).

– Core ideas: Penis erection is triggered by sexual stimulation/arousal (physical and/or psychological), leading to swelling and enlargement of the penis due to local blood accumulation, conditioned by arterial dilatation. The so increased levels of nitric oxide (NO) will, in turn, increase cyclic GMP (cGMP) – this is the most important molecular vasodilator cascade promoting erection.

3) Causes (Etiopathogenesis) and Pathophsiology of ED:

There are many possible causes of ED, which typically can be grouped in 3 big classes: Organic/Somatic; Psychogenic/Psychological; Mixed/Miscellaneous. Each one of these classes may have subclasses, as an efficient way to organize, classify and study each case.

Organic/Somatic are those which origin is somewhere in the body, in an organ or tissue; not in mind nor thoughts/emotions. Hence, there is a lot of diseases able to cause ED – Endocrine (related to hormones and glands; for example: hypogonadism, hyperprolactinemia); Vascular (related to arteries and/or veins; such as: atherosclerosis, hypertension, dyslipidemia, diabetes, metabolic syndrome); Neurologic (related to Nervous System, the Central Nervous System (CNS) and/or the Peripheral Nervous System (PNS); for example: spinal cord injury, neuropathies, Parkinson’s disease, Alzheimer’s disease, multiple sclerosis, stroke); Drug-induced (many drugs can cause ED as side effect – some antihypertensives and antidepressants are very frequently associated with ED, but there are many more drugs with potential to cause ED).

Commonly, Organic/Somatic are associated with a worse prognosis; being atherosclerosis, now, recognized as a “sentinel event” in cardiovascular disease, metabolic syndrome and diabetes mellitus.

Psychogenic/Psychological causes of ED are, overall, the most frequent; and young men can be affected – the sexually inexperienced young man, without any disease, may have ED during the first sexual activities with his partner, because he may get “fear to fail/disappoint his partner”. The conviction that an erection will not develop when required, therefore, becomes a self-fulfilling prophesy.

And, on the other hand, for any age, men who live under psychological stress (excessive work; lack of sleep; personal conflicts) can get depressed, anxious, impotent and feel lack of libido (sexual desire). Then, ED may emerge and aggravate the existent anxiety, and so a “vicious cycle” could be established and become very difficult to deal with.

Increased sympathetic vasoconstrictor tone, with raised blood circulating norepinephrine/epinephrine levels, seems to play a key role in psychogenic ED. The sympathetic branch of the autonomic nervous system is typically activated under stress situations, preparing the body for a “fight or flight” reaction, by releasing 2 main catecholamines (norepinephrine = noradrenalin is directly released by sympathetic nerves; and epinephrine = adrenalin is released from adrenal = supra-renal glands, after stimulation by sympathetic nerves). This catecholamines induce vasoconstriction (constriction of arteries), what makes erection more difficult to occur.

Although not frequently, ED can be associated with a more serious psychiatric disorder, such as major depression, schizophrenia, substance abuse, panic disorder, generalized anxiety disorder, personality disorders.

There are some other possible causes of ED (Mixed/Miscellaneous), but they are relatively infrequent – Penile disorders associated with ED (other primary diseases of penis, such as: Peyronie’s disease; Epispadias; Post-priapism); Hematologic diseases (blood-related diseases; for example: Sickle cell anemia; Leukemias); Liver cirrhosis; Hemochromatosis; Scleroderma…

All causes of ED will converge to a common effect – the dilatation of penile arteries fails and consequently no local blood trapping occurs.

Diagnosis of ED usually begins by patient report, and next, the study of nocturnal penile tumescence (NPT) is the subsequent requested diagnostic test to confirm the suspected diagnosis. NPT corresponds to the spontaneous penile erections during sleep. All men without ED go through this phenomenon, typically many times while sleeping. Therefore, the NPT test is crucial to establish the ED diagnosis, since it can indicate a psychological cause (most common), or an organic cause – patients with psychogenic ED have nocturnal erections, what means that there is no organic/somatic basis for their ED.

– Core ideas: Although ED can be caused by a lot of serious diseases/disorders; many times it occurs in men who were otherwise healthy, and are temporarily under heavy psychological stress, resulting in a bad lifestyle, characterized by anxiety, bad quality of sleep and bad nutrition; which leads to ED and to a general bad feeling and weakness .

The causes of ED meet an overlapping consequence – there is no dilatation of penile arteries; therefore no local blood retention occur.

The diagnosis of ED is confirmed by the NPT test.

4) Natural Alternatives for Treatment of ED do Worthwhile!

Everybody is familiar with the names “Viagra”, “Levitra”, and “Cialis”.

Viagra (Sildenafil), Levitra (Vardenafil), and Cialis (Tadalafil) are drugs acting as PDE5 inhibitors, and are widely prescribed for the treatment of ED. Few drugs have received as many attentions and approvals as Viagra/Levitra/Cialis, partly attributable to heavy and pricey marketing efforts by the pharmaceutical companies.

Everyone recognizes, yes, Viagra/Levitra/Cialis do work… But at what cost to the health?! Like with all chemical drugs, there are risks and side effects in Viagra/Levitra/Cialis. These drugs have potential side effects, and so, all men ought to be informed about them, while considering using these drugs. Viagra/Levitra/Cialis side effects, usually range from mild to moderate (although not very frequently, sometimes side effects can be severe or even life-threating). They generally last from a couple of minutes to a few hours after dosage. The most common side effects are: nasal congestion (stuffy nose); headaches; flushing (facial warmth or redness); dyspepsia (upset stomach). The most serious potential side effects are: sudden vision or hearing loss; angina pectoris (chest pain or heavy feeling); cardiac arrhythmia (irregular heartbeat); dyspnea (shortness of breath); edema (swelling); priapism (painful condition in which the erect penis does not return to its flaccid state, notwithstanding the absence of both physical and psychological stimulus; lasting at least four hours). On the other hand, there is the possibility that users may become psychologically dependent on it, incapable to reach erections without taking Viagra/Levitra/Cialis. Not surprisingly, many men seek alternatives; less hazardous natural products which work fine and have no side effects. These Viagra/Levitra/Cialis alternatives are not chemical drugs, and they provide a more natural and gentle approach in the direction of a better sexual and general health and wellbeing. Unlike Viagra/Levitra/Cialis, natural alternatives are accessible without prescription, hence they are promptly usable – men need not to lose time and money only to get the prescription sheet, and avoid shaming and embarrassing interviews . Furthermore, natural Viagra/Levitra/Cialis alternatives are cheaper, and have additional advantageous actions. They increase blood flow, not only to the genital organs, but to all organs of the body, including the brain. They also supply the body with several nutritive compounds, such as amino acids, vitamins and minerals, important for a healthy life. Thus, natural alternatives are worthwhile, since they work well, are safe and inexpensive.

5) Best Natural Products for Treatment of ED:

Many natural products can help men with ED; mainly organized as:

=> Dietary (Nutritional) supplements:

– L-Arginine (Amino Acid)

– Minerals: Zinc; Selenium; Magnesium

– DHEA (De-Hydro-Epi-Androsterone)

=> Herbs/Plants/Vegetals and related natural products (Phytotherapy):

– Yohimbine;

– Panax (Asian) ginseng;

– Tribulus terrestris;

– Ginkgo biloba;

– Muira Puama(Ptychopetalum unicatum/Ptychopetalum olacoides);

– Maca (Lepidium meyenii);

– Damiana (Turnera diffusa/Turnera aphrodisiaca);

– Forskolin (Coleus forskohlii);

– Pycnogenol

=> Other Natural Products:

– Velvet Deer Antler

L-Arginine is an amino acid.

L-arginine is the precursor for the synthesis of Nitric Oxide (NO) (production of cyclic GMP is subsequently increased), and also it is necessary for the synthesis of creatine; thereby its oral ingestion is beneficial not only in men with ED; it has a lot of important benefits for the health in general:

#] Increases blood circulation throughout arteries in whole body (not only, but also, in genital organs);

#] Counteracts male subfertility/infertility, by improving sperm production and motility;

#] Reduces blood pressure (excellent for hypertensive people);

#] Reduces body fat (excellent for overweight/obese people);

#]Improves insulin sensitivity (excellent for diabetic people);

#] Decreases risk of severe heart disease (such as heart attack);

#] Increases muscle mass (athletes do like it!);

#] Stimulates the release of the most important anti-aging hormone in the body (GH = Growth Hormone);

#] Improves immune function;

#] Decreases healing time of injuries.

Zinc, like Selenium and Magnesium, is an indispensable element (mineral), required for sustaining the life. Numerous proteins in the human body incorporate zinc prosthetic groups, one type of which is the so-called “zinc finger”. It is a cofactor in many biological processes including DNA, RNA, and protein synthesis. Approximately 30% of cellular zinc is located inside the nucleus. A great amount of proteins that play a role in the regulation of gene expression are believed to incorporate zinc.

In men, the testes and prostate have especially high concentrations of zinc. The sites where male hormones bind to cells (androgen receptors) need zinc in order to work adequately.

Zinc deficiency considerably diminishes testosterone levels, sperm production, and can reduce the lifetime of ejaculated sperm, as well. Male fertility seems to be influenced by zinc. Infertile males have lower seminal plasma zinc, with normal or decreased blood zinc. Short-term dietary zinc depletion leads to a decrease in serum testosterone concentrations, seminal volume, and total seminal zinc loss per ejaculate. Supplementation with zinc ameliorates sperm parameters in men with diminished sperm mobility. Zinc levels seem to fall in the prostate tissue and prostatic fluid in men with prostatic carcinoma.

Zinc also plays a role in immune function, wound healing; behaviour and learning; taste and smell; blood coagulation; thyroid hormone function, and insulin action. Additionally, zinc is necessary to the hepatic synthesis of “retinol binding protein” (RBP), the transport protein of vitamin A. Without enough zinc, symptoms of vitamin A deficiency can appear, notwithstanding extensive vitamin A supplementation.

Magnesium, like Zinc and Selenium, is one of the highest importance minerals, acting as an enzymatic cofactor in many biochemical reactions inside human body. It plays a key role in the production and transfer of biologic energy (ATP = Adenosine Tri-Phosphate), in muscle contraction and relaxation, in nerve conduction, in protein synthesis…

In what more closely respects to ED, it is pertinent to emphasize that magnesium promotes the synthesis of Nitric Oxide (NO), what will promptly lead to the amplification of cGMP cellular signalling, resulting in arterial dilation – as already discussed, this is the physiologic basis of penile erection.

Beyond ED, magnesium is very important to other medical/health conditions; hence magnesium intake always should be encouraged. The same ideas are valid for Selenium…

Selenium is a key component of the glutathione peroxidase system, acting as an antioxidant. It works in coordination with vitamins A, C, E to prevent oxidative damage to cells (“oxidative stress”). Reactive oxygen species (ROS) are free radicals that come from the metabolism of oxygen. The production of ROS, such as superoxide (O2-), hydrogen peroxide (H2O2), and the hydroxyl radical (OH-), unremarkably occurs in cells. ROS play an important role in many cellular physiologic processes. “Oxidative stress” is a condition that happens when high concentrations of ROS subsist defeating the antioxidant defences against oxidative damage. This is the pathophysiologic basis of most serious diseases. All body organs need to have strong enough antioxidant defences. Selenium supplementation is beneficial not only for genital organs; all organs become healthier with it!

Pycnogenol also acts as antioxidant. It is an extract from the bark of the French maritime pine tree. Pycnogenol contains several active constituents including flavonoid monomers such as catechin, epicatechin, and taxifolin. It also contains condensed procyanidins (also known as flavonoids or proanthocyanidins) such as procyanidin B1, B3, B6, and B7 which are dimers, oligomers, and polymers of catechin and epicatechin. Pycnogenol also contains phenolic acids including gallic, ferulic, caffeic, vanillic, p-coumaric, protocatechuic, and p-hydroxybenzoic acids, and their glucosides and glucose esters.

Ginkgo biloba stands for a singular Chinese specie of tree with no near living congeners. The useful parts of ginkgo are the leaf and the seed. Ginkgo leaf is the most commonly used form of ginkgo, usually as an extract. Ginkgo leaf and its extracts contain many active constituents including flavonoids, terpenoids, and organic acids. Many ginkgo leaf extracts are standardized to contain 24% to 25% flavonoid glycosides and 6% terpenoids. The major flavonoids are primarily derived from the flavonol rutin and include isorhamnetin, quercetin, kaempferol, and proanthocyanidins. The primary terpenoids are ginkgolides A, B, C, M, and J, and bilobalide. Although many of ginkgo’s constituents have intrinsic pharmacological effects individually, there is evidence that the constituents work synergistically to produce more potent pharmacological effects than any individual constituent. Ginkgo leaf products have a potent antioxidant action; inhibit the platelets aggregation (blockade of blood clotting; blood-thinning effect), and also relax smooth muscle of arterial wall, therefore enhancing blood flow. These are the reasons why Ginkgo leaf products are so important for people with ED and/or many other conditions.

Forskolin is a labdane diterpene produced by the Indian Coleus plant (Coleus forskohlii). Forskolin stimulates and activates the enzyme adenylate cyclase in the heart and smooth muscle. This drives an inflated production of cyclic AMP (cAMP), which causes calcium channels to open and intracellular calcium concentrations to increase, resulting in increased contractility of heart muscle and relaxation of smooth muscle (therefore it acts as vasodilator).

Panax ginseng is used as “adaptogen”, for increasing resistance to environmental stress and as a general tonic for improving well-being. The useful part of Panax ginseng is the root. It contains several active constituents. The most important constituents are the triterpenoid saponins referred to collectively as ginsenosides or panaxosides. Other constituents include pectin, B vitamins, and various flavonoids.

Panax ginseng has vasodilator and antioxidant actions, and also enhances the libido.

Maca (Lepidium meyenii); is a robust and long plant cultivated high in the Andes Mountains. The relevant part of maca is the root. Dried maca root has 59% carbohydrates; 10.2% protein; 8.5% fiber; and 2.2% lipids including linolenic, palmitic, and oleic acids. It also contains sterols such as campesterol, stigmasterol, and beta-sitosterol; and substantial amounts of minerals including iron, calcium, and copper. Two polyunsaturated fatty acids, macaene and macamide, are used as marker compounds for maca. Lipid extracts of macaene and macamide increase sexual activity and improve ED. This stimulating plant is also cited as Peruvian ginseng (although maca does not belong to the same family of ginseng); because, similarly to ginseng, maca increases strength, energy, stamina, libido and sexual function.

Yohimbe corresponds to a tall evergreen tree proceeding from western Africa, known as Pausinystalia yohimbe or Corynanthe yohimbe. The relevant part of yohimbe is the bark. The constituent amenable for yohimbe’s effects is the alkaloid yohimbine. Yohimbe bark has around 6% yohimbine. Aphrodisiac actions of yohimbe are due to genital blood vessel dilation, nerve impulse transmission to genital tissue, and increased reflex excitability in the sacral region of the spinal cord. The yohimbine constituent promptly enters the central nervous system (CNS) and acts chiefly through alpha 2-adrenergic receptor blockade. It also has monoamine oxidase (MOA) inhibiting, calcium channel blocking, and peripheral serotonin receptor blocking effects. Yohimbine’s consequences on impotence are mediated through both increased penile blood flow and increased central sympathetic excitatory impulses to the genital tissue.

Muira Puama (Ptychopetalum unicatum/Ptychopetalum olacoides); is a little tree that grows to 5 m high and is indigene in the Brazilian Amazon and other regions of the Amazon rainforest. The Ptychopetalum genus is a short one – only two species of small trees grow in tropical South America, and five in tropical Africa. The two South American varieties, P. olacoides (observed in Brazil, French Guiana, Guyana, and Suriname) and P. uncinatum (encountered only in Brazil), are used interchangeably in South American herbal medication schemes. The olacoides type is usually chose, since it has a higher content of lupeol (one of the plant’s active phytochemicals). An entirely distinguishable species of Brazilian tree, Liriosma ovata, also passes by the vulgar name of muira puama (and is frequently distributed in commerce as such); nonetheless, it is a totally distinct tree with a different phytochemical constitution.

Historically, whole components of muira puama have been employed medicinally, but the bark and roots are the most utilized parts of the plant. The root and bark are rich in fatty acids and fatty acid esters (the primary one being behenic acid), essential oils (including beta-caryophyllene and alpha-humulene), plant sterols, triterpenes (including lupeol), and an alkaloid called muirapuamine. The active components also included free long-chain fatty acids, sesquiterpenes, monoterpenes, and novel alkaloids.

Reviewing, the main plant chemicals found in muira puama include: alpha-copaene, alpha-elemene, alpha-guaiene, alpha-humulene, alpha-muurolene, alpha-pinene, alpha-resinic acid, alpha-terpinene, arachidic acid, allo-aromadendren, behenic acid, beta-bisabolene, beta-caryophyllene, beta-pinene, beta-resinic acid, beta-sitosterol, beta-transfarnesene, borneol, campesterols, camphene, camphor, car-3-ene, caryophyllene, cerotic acid, chromium, coumarin, cubebene, delta-cadinene, dotriacontanoic acid, elixene, ergosterols, eugenol, essential oils, gamma-muurolene, hentriacontanoic acid, heptacosanoic acid, lignoceric acid, limonene, linalool, lupeol, melissic acid, montanic acid, muirapuamine, myrcene, nonacosanoic acid, para-cymene, pentacosanoic acid, phlobaphene, stigmasterols, trichosanic acid, and uncosanic acid.

By mouth, muira puama is often used for preventing sexual disorders, and as an aphrodisiac. It raises libido and ameliorates the ability to maintain penile erections; and in addition acts as adaptogen, anti-fatigue, anti-stress agent. It can be employed alone or in combination with other herbs. It is also used (orally) as a nerve stimulant, for dyspepsia, menstrual irregularities, rheumatism, paralysis caused by poliomyelitis, a general tonic, and as an appetite stimulant.

Damiana (Turnera diffusa/Turnera aphrodisiaca); is a bush native to Central America, Mexico, South America, and the Caribbean. The medicinal part of the plant is its leaves, which are reaped during the flowering season. Damiana is found throughout Mexico, Central America, and the West Indies, as well as in parts of South America. Turnera diffusa and T. aphrodisiaca are commonly reputed the same plant in herbal commerce. A closely-related species, T. ulmifolia, is similar in the visual aspect, but it has different conventional medicinal uses. The botanical Latin name of the plant, Turnera aphrodisiaca, reports its ancient use as an aphrodisiac. With such an ancient history of traditional uses worldwide, it is not strange that the plant appears in many books on herbal remedies released worldwide. Damiana is also widely acquirable on health food and natural product shops in a diversity of forms – from tea blends, capsules and tablets to liquid tinctures and extracts. Most herb doctors choose to apply damiana in combination with additional medicinal plants; consequently, it can be encountered in quite a few herbal combination formulas for sexual potency, weight loss, depression, hormonal balancing, and overall tonics.

Damiana components include as many as 35 compounds including flavonoids, terpenoids, saccharides, and cyanogenic glycosides. Some of these include triacontane, beta-sitosterol, hexacosanol, 5-hydroxy-7,3,4-trimethoxyflavone, arbutin, tannins, resins, hydroquinone glycosides, luteolin 8-C-E-propenoic acid, and others.

DHEA (De-Hydro-Epi-Androsterone/dehydroepiandrosterone); is a natural steroid pro-hormone made from cholesterol by the suprarenal glands, the sex glands, fatty tissue, brain and in the skin (by an autocrine mechanism). DHEA is the precursor of androstenedione, which can go through further conversion to produce the androgen testosterone and the estrogens estrone and estradiol. DHEA is a potent sigma-1 agonist as well. Orally, DHEA is used for retarding or reversing aging, weight loss, metabolic syndrome, and increasing immune and cognitive function. It is also used for increasing strength, energy, and muscle mass. Taking DHEA orally for 24 weeks improves ED, orgasmic function, libido, and general sexual gratification in men with ED.

The active parts of Tribulus terrestris are the leaf, fruit, and root. Tribulus terrestris contains saponins such as diosgenin and protodioscin, flavonoids, and alkaloids.Tribulus terrestris increases the levels of testosterone, luteinizing hormone (LH), DHEA, and di-hydro-testosterone. LH is the pituitary hormone that signals natural testosterone production. Thus, libido; and sperm production and motility will be improved. Tribulus terrestris lowers blood pressure by inhibiting angiotensin-converting enzyme (ACE) and stimulating the release of NO. This also explains why blood flow into the corpus cavernosa increases, thereby favouring penile erection. Extracts from the fruit and leaves additionally have a diuretic effect, which can explain the traditional use of Tribulus terrestris for kidney stones and other urinary problems. Tribulus terrestris has anti-inflammatory activity since it acts as a cyclo-oxygenase (COX)-2 inhibitor. Tribulus terrestris helps diabetic patients because it lowers blood glucose. Some constituents of Tribulus terrestris also have anti-helmintic activity.

Velvet Deer Antler is a pillar of Traditional Chinese Medicine, probably second only to ginseng in importance. Velvet antler does not relate to the velvety “skin” on growing antlers, but instead the whole cartilaginous antler in a pre-calcified stage. Typically, the antler is cut out near the base after it is approximately two-thirds of its potential full size, and before any substantial calcification takes place.

The antler is dehydrated and is used powdered or in tea form for a wide variety of health curatives. Velvet antler is efficient as an anti-inflammatory, anti-cancer, immune stimulant, and pro-growth agent.

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