Updated: May 14, 2021
Sexual satisfaction is an important part of a thriving life. However, clients aren’t likely to discuss their sexual concerns with their practitioner and clinicians aren’t likely to ask about it even though dysfunction is an important indicator of declining health.
One in ten men have had some sort of sexual dysfunction in the last year and nearly seven in ten experience infrequent or mild sexual difficulties at least occasionally. The most common concerns were low sexual interest, premature ejaculation and performance anxiety (Vik & Brekke, 2017). The large majority of clients have made clear they would have liked their primary care provider to have initiated a conversation about sexual dysfunction, as they felt this would have been less embarrassing than raising the topic themselves (Bladwin, Ginsberg, & Harkaway, 2003; Fisher, Dervaitis, Bryan, Silcox, & Kohn, 2000; Fisher, Meryn, & Sand, 2005; Pascoal, Slater, & Guiang, 2017).
Sexual dysfunction may be from an organic or psychological cause and may be related to chronic disease or medication. The primary care provider is the perfect provider to evaluate and manage sexual dysfunction because these disease states and medications are within their specialty. Embarrassment by both parties must first be overcome, and the misbelief that their problem is an inevitable part of the aging process. Primary care providers often lack the time or knowledge of treatment regimens to engage in sexual dysfunction discussion which is why this aspect of wellness has become a passion of mine (Pascoal, Slater, & Guiang, 2017; & Vik & Brekke, 2017).
The aging population in particular are overlooked as sexually active beings, but the data suggests men and women remain sexual their entire lives. Sexual satisfaction has been found to have an important association with their physical and mental health, and their self-rated quality of life, suggesting that sexuality is a key element in vitality in the later years (Pascoal, Slater, & Guiang, 2017). An older study found 70% of Americans, aged 57 to 64 years, 50% of those aged 65 to 74 years, and 30% of those 75 to 85 years of age remain sexually active (Lindau, Schumm, Laumann, Levinson, & O’Muircheartaigh et al., 2007). Half report a history of one or more bothersome sexual problems after turning 50 years old (Lindau et al., 2007).
Common complaints among elderly men include premature ejaculation and erectile difficulties, but also they have more injury and chronic illness which lead to more frequent sexual problems and decreased sexual satisfaction. Rates of sexually transmitted infections are also becoming more prevalent among the aging. In Canada for example, the rates of Chlamydia doubled between the years 2003 and 2012 for men older than 60 years, and tripled for women in the same age group (Public Health Agency of Canada, 2015). HIV rates are also increasing, yet the 40 to 69 year age group have little concern and are less likely to utilize condoms as those younger have demonstrated (Pascoal, Slater, & Guiang, 2017).
The inability to attain or maintain a penile erection sufficient for a satisfactory sexual experience is the definition of erectile dysfunction (ED). It is a common disorder that significantly impacts the quality of life for men and their partners. More than 90% of men who suffer with ED have an organic cause, with vascular disease being the most common etiology. Aging does impact ED but this is because chronic disease is also a natural consequence of aging. The severity of ED is related to the severity of vascular disease, such as blood pressure, atherosclerosis, coronary artery disease, smoking, dyslipidemia, and diabetes mellitus, all of which are associated with endothelial dysfunction (Cayan et al., 2017).
One study argued that “the penis has been recently considered as the barometer of the body’s endothelial function” (Cayan et al., 2017, p 123); therefore, it seems reasonable for clinicians to consider ED the early warning sign of other comorbidities as the vascular endothelium plays a pivotal role in the health of the corpora cavernosa. Prostatic diseases, kidney failure, chronic obstructive pulmonary disease, and vascular risk factors including atherosclerosis, high blood pressure, dyslipidemia, coronary artery disease, heart disorders, and diabetes are all risk factors associated with erectile dysfunction; however, neurological disorders, spinal cord injuries, epilepsy, prior pelvic surgery or trauma were not associated in a recent study (Cayan et al., 2017, p 126). Diabetes mellitus was the strongest independent predictor for moderate-severe ED in men older than forty with a 5-fold increased risk of ED. The risk is four-fold with hypertension, three-fold with atherosclerosis, two-fold for coronary artery disease, and two-fold for elevated lipids. Prostate disorders are also an independent risk factor for occurrence for moderate to severe ED (Cayan et al., 2017, p 126). Erectile dysfunction is an early symptom of artery disease and studies show it presents as an early warning sign two or three years before a heart attack or stroke (Jackson, 2008).
Nitric oxide relaxes blood vessels and enables efficient blood flow, which is vital for vascular health and male sexual function (Schoones, Visser, & Musekiwa, 2012; Wu & Meininger, 2009; Stanislavov, Nikolova, Rohdewald, & 2008). A study published in Andrology found a significant number of men with erectile dysfunction also have low levels of L-arginine, an amino acid and precursor for nitric oxide (Barassi, Corsi, & Pezzilli, 2017). Another recent study shows that supplementing with L-arginine and pine-bark extract significantly boosts erectile function (Kobori, Suzuki, & Iwahata, 2015). These nutriceuticals not only improve erectile dysfunction, but also the root cause within the cardiovascular system (Stanislavov, Nikolova, & Rohdewald, 2008; Kobori, Suzuki, & Iwahata, 2015; Stanislavov & Nikolova, 2003).
Blood flow through the arteries and endothelial function are essential to sexual arousal, which is why #erectile dysfunction should trigger the clinician to investigate the underlying cause. This concern is not just an inconvenience to the couple, but an early indication of cardiovascular disease. Unfortunately, the reality is that even if a client speaks with his provider about erectile dysfunction, at best, he would receive a pharmaceutical without regard to the cause. Consumers have been educated by pharmaceutical companies that sexual symptoms are corrected with drugs and this same propaganda has led physicians to not think any further than the primary complaint, simply offering Viagra, Cialis, or Levitra. These pharmaceuticals only work in half of all men for which they are prescribed and cause significant side effects in others. Permanent hearing loss and blindness have resulted for some men, even neurologic disorders and heart attacks (Lim, Moorthy, & Benton, 2002; Blonde, 2006; Laties, 2009; Santaella, & Fraunfelder, 2007; Mukherjee, & Shivakumar, 2007; Choi, Ahn, & Kim, 2003; & Kruuse, Thomsen, & Birk, 2003).
Pine Bark Extract
Adding pine bark (80 mg) to L-arginine aspartate increased the number of men who could achieve errections by 75% over L-arginine alone. Increasing the dose of pine-bark to 120mg increased response another 12.5% so that 92.5% of men could achieve and maintain an erection (Stanislavov & Nikolova, 2003). In a second double-blind, placebo-controlled, crossover design pine bark extract and L-arginine restored erectile function to normal and doubled intercourse frequency within one month. Nitric oxide synthase and blood testosterone levels were also significantly increased. Blood cholesterol and blood pressure were also increased (Stanislavov, Nikolova, & Rohdewald, 2008). Yet another double-blind study, patients with mild-to-moderate erectile dysfunction were treated with either placebo or a daily dose of pine bark extract (60 mg), L-arginine (690 mg), and aspartic acid (552 mg) and after eight weeks, there was remarkable improvement in erectile dysfunction, including improved hardness and satisfaction with sexual intercourse. There was also significant decrease in blood pressure and a slight boost in salivary testosterone, with no adverse reactions (Aoki, Nagao, & Ueda, 2012).
A fourth clinical trial in 2015, found men with erectile dysfunction and a low sperm count receiving pine-bark extract (60 mg), L-arginine (690 mg), and aspartic acid (552 mg) and significantly improved sexual function four months later and their sperm concentration was notably increased. No adverse reactions were reported (Kobori, Suzuki, & Iwahata, 2015). All of these findings are significant on their own but when viewed in light of the realization that a 2017 study found a significant portion of men with ED have low levels of L-arginine and that this combination can not only address that complaint in more than nine of ten men, without adverse reactions, and while addressing the underlying cause, arterial disease, then why offer conventional treatments ever again? Because the sales representative is handsome or offers Starbucks the third Friday of every month?
One more compound for this blend: icarrin, a Chinese flavonoid extracted from the plants in the Epimedium genus. Icariin produces aphrodisiac effects and restores erectile function in a variety of ways. Similar to Viagra and the other pharmaceuticals for ED, icarrin blocks the action of the enzyme that causes erections to subside (Ning, Zin, & Lin, 2006; Jiang, Hu, & Wang, 2006; in, Kim, & Lin, 2003, Dell’ Agli, Galli, & Dal Cero, 2008). However, it also enhances the production of nitric oxide in both human endothelial cells and animal models (even diabetic rats) (Xu & Huang, 2007; Tian, Xin, & Liu, 2004; Li, Xin, & Xin, 2005; Zhang, Li, & Liu, 2013). Icarrin behaves similar to testosterone and so adding this compound to the above mentioned nutriceuticals optimizes sexual outcomes for men otherwise suffering from ED.
Primary care providers fear they may offend clients or fear conversations about sex may jeopardize their professional relationship. Others have personal cultural or religious beliefs that prohibit these discussions and still others make the assumption that their clients are not sexually active so they avoid the topic entirely (Gott, Galena, Hinchliff & Elford, 2004; Gott, Hinchliff, & Galena, 2004; & Wei & Mayouf, 2009). The literature has clearly indicated that physicians are poorly prepared to discuss human sexuality with their clients (Dogan, Demir, Eker, & Karim, 2008; Gott, Hinchliff, & Galena, 2004; Bouman & Arcelus, 2001), but it has also demonstrated they are interested in learning more (Hughes & Wittmann, 2015). Sadly research has found they aren’t even capable of discussing condom use, sexual coercion or intimate partner violence (Garcia & Fisher, 2008).
If the discussion does occur, physicians are most likely to simply prescribe a medication that is only effective for half and offers a plethora of side effects, and does nothing to address the underlying cause - chronic endothelial dysfunction. Healthy endothelial cells release nitric oxide synthase, but if the artery walls are calcified from the build up of plaque they can no longer produce sufficient levels required to achieve an erection. The clinician’s goal should be to address the complaint and correct or treat the root cause in effort to optimize health. Research has demonstrated L-arginine and pine bark extract as addressing both male sexual dysfunction and overall vascular health. Icarrin, a Chinese herbal medicine, offers further support by blocking phosphodiesterase-5 (Ning, Zin, & Lin, 2006).
Humans were created for relationships, including sexual intimacy. Not being able to achieve this is pathologic and cause for concern. Offering a band-aid only masks the underlying condition. The clinician has opportunity to affect both the primary concern while also addressing the root cause. This is not typical of the conventional medicine model, but foundation for those in functional medicine.
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