Erectile Dysfunction: New Therapeutic Recommendations

Erectile dysfunction: what is it?

Erectile dysfunction, formerly known as male impotence, is defined as the inability to obtain or maintain an erection that is sufficiently rigid to allow satisfactory sexual intercourse, despite adequate desire and stimulation. This condition is truly considered pathological when it recurs and persists over time; some specialists define this as a minimum duration of six months (1).

This condition, the prevalence of which increases with age, is thought to affect up to 1 in 3 men over the age of 40 (2). Still taboo, it remains largely under-diagnosed and under-treated: it is estimated that only 10% of sufferers receive appropriate treatment. Yet its psychological impact is very real, with significant repercussions on self-esteem and relationships (3). There is therefore no reason to be ashamed of consulting a healthcare professional if you are affected, not to mention the fact that erectile dysfunction sometimes conceals other underlying pathologies, particularly cardiovascular (4).

Standard treatments for erectile dysfunction

Medical management of erectile dysfunction typically begins with an assessment of cardiovascular risk, with a view to proposing a treatment that is compatible with the patient's state of health. It has now been established that coronary artery disease, hypertension and hyperlipidaemia, as well as diabetes and obesity, are major contributors to the onset of erectile dysfunction (5).

Unless there are proven contraindications, oral treatment with phosphodiesterase 5 inhibitors (or IPDE-5s) is usually prescribed as first-line therapy (6). The aim of these drugs is to maintain the erectile process by prolonging the effects of cGMP, a molecule that relaxes the smooth muscles of the cavernous body of the penis. If this is not possible or fails, the main alternatives are local treatments: intracavernous injections of prostaglandin E1 or the use of a vacuum (a vacuum pump that produces a mechanical erection). A penile prosthesis is generally used as a last resort.

It should be noted that some erectile dysfunctions have a psychogenic origin, especially in young men (performance anxiety, stress, depression, relationship tensions within the couple, negative sexual experiences in the past, etc.), which merit additional psychological support (7).

Male impotence: new medical recommendations

Healthcare professionals are placing greater emphasis on providing patients with sexual information to reassure them, relieve their guilt and help them play the situation down. Explanations of the physiology of erection, the psychological component of the mechanism and the importance of foreplay are sometimes enough to solve the problem.

Hygienic and dietary measures also play a central role, and are now part of first-line treatment: a balanced Mediterranean-style diet, stopping the use of toxic substances (tobacco, alcohol, etc.), getting enough sleep, regular physical exercise (ideally combining 2 endurance sessions with 2 muscle-strengthening sessions and 1 team sport session) and weight loss if necessary (8-10).

Treatment, which used to be standard, is now individualised to suit the expectations, lifestyle and frequency of sexual relations of the patient, who plays a more active role in therapeutic decisions. The dosage and frequency of use of IPDE-5s (continuous or on demand) are now adjusted, revised and optimised. Certain dual therapies—for example, IPDE-5 + prostaglandin, IPDE-5 + vacuum, or even two IPDE-5s in cases of severe dysfunction—are also being validated earlier in the course of treatment. It should be noted that all comorbidities (sleep apnoea, hypogonadism, obesity, addictions, etc.) are now systematically screened.

In terms of therapeutic advances, we are seeing the arrival of new forms of fast-acting IPDE-5, to be taken sublingually. Extracorporeal low-intensity shockwave therapy, which is still little-known, is emerging as a new option, but its benefits have yet to be proven (11). Finally, emphasis is being placed on the biopsychosocial dimension, which has long been sidelined, with the development of counselling (psychological and sexological support) and sex therapy; these also include the partner in the treatment protocol (12).

Natural compounds to improve erectile function?

Certain natural substances act more or less directly on the erectile process by harmonising the hormonal sphere, boosting libido, reducing stress or improving blood circulation.

Hormonal mediators

As the guarantor of male sexual vitality, testosterone has an indirect impact on the quality of erections. A marked deficiency, for example in cases of hypogonadism, results in reduced physical stamina, reduced sexual desire and pleasure, and reduced sensitivity of the erectile tissue in the cavernous body of the penis (13).

Thanks to its saponins (including protodioscin), which are thought to support the production of androgenic hormones, including testosterone, Tribulus terrestris contributes to the proper activity of the sexual organs (14). Part of the Ayurvedic pharmacopoeia, this plant was widely used in India as a natural remedy for erectile dysfunction.

You'll find it in Tribulus Terrestris, standardised to 40% saponins.

In terms of vitamins and minerals, it's important to ensure that you get enough zinc, which helps maintain normal levels of testosterone in the blood, and magnesium, which helps maintain normal muscle function and reduce fatigue (15-16). It should be noted that vitamin D receptors are implanted in the testicular Leydig cells which synthesise testosterone, suggesting that it could modulate this production (17-18).

Natural TestoFormula combines the best natural 'testosterone boosters', including Tribulus terrestris and zinc.

The Prosexual Formula Man synergy covers all aspects of male sexual health, combining Tribulus terrestris with magnesium and various renowned extracts: catuaba, banded wood, etc.

Aphrodisiacs and adaptogens

Native to the Peruvian Andes, Maca (Lepidium meyenii) is a plant in the cruciferous family which has long been used by Indigenous peoples to increase fertility and invigorate the body. Its macamides and macaenes support sexual function by combating the physical and mental fatigue that hinders sexual motivation and appetite (19).

Discover Super Maca, maca extract containing 0.6% macamides and macaenes.

Ginseng is a favourite in Chinese medicine. This adaptogenic rhizome, rich in ginsenosides, helps maintain good sexual well-being, most likely by improving general tone, resistance to stress and blood flow to the genital area (20).

Super Ginseng is titrated to 30% ginsenosides for maximum effectiveness on sexual vigour.

Circulatory action

Nitric oxide (NO) is a messenger gas released during sexual stimulation. It relaxes the smooth muscles of the cavernous bodies of the penis and dilates the penile arterioles, which are responsible for erectile rigidity. As amino acids that are precursors of nitric oxide, L-arginine and citrulline indirectly promote the vasodilation required for erection (21).

The supplement Arginine Alpha Ketoglutarate is based on a more effective form than conventional L-arginine for this indication.

Supplementation with L-Citrulline effectively increases levels of citrulline, which is poorly represented in the diet.

Innovative supplements also make use of plant polyphenols, which have been extensively studied for their role in protecting nitric oxide (22).

Nitric Oxide Formula combines arginine and citrulline with a patented extract of apple and grape polyphenols (Vinitrox™).

Prosextim, meanwhile, relies on a patented ingredient called EnoSTIM™, formulated from grape pomace, apple and saffron stigma extracts.