Dr Oladimeji Adebayo, a consultant cardiologist at the University College Hospital, Ibadan, and research fellow at the Institute of Cardiovascular Diseases, College of Medicine, University of Ibadan, in this interview with SADE OGUNTOLA, speaks to why poor libido in men with heart conditions shouldn’t be overlooked because it is more common than many people can imagine. Excerpts :
H OW strong is the connection between erectile dysfunction and heart problems generally?
There is a strong connection between erectile dysfunction, heart disease and cardiovascular disease, including the risk factors associated with heart diseases like hypertension, smoking, obesity and diabetes mellitus. They are interwoven in the sense that these risk factors can both cause erectile dysfunction and heart disease. In an average cardiac clinic, cardiologists find a lot of males coming with erectile dysfunction, which is simply the inability to maintain or achieve an erection long enough for satisfactory sexual intercourse. Quite a few men, when screened, would be found with risk factors for heart disease; these are similar to those for erectile dysfunction.
Why is it that men with erectile dysfunction should be carefully assessed?
The fact that erectile dysfunction has a very strong effect on quality of life, influences harmony in relations, leads to relational problems, and might just be the warning sign for a heart disease or other cardiovascular risk factor that might not be very obvious makes it very important that such men be carefully assessed.
As a cardiologist, for these men, it will be important to also consider screening them for risk factors for heart disease and other cardiovascular risk factors. There is strong evidence of an increase in the burden of cardiovascular diseases and, also, cardiovascular risk factors like hypertension.
Cardiovascular diseases and cardiovascular risk factors – what do you mean?
If you talk about cardiovascular diseases, these include things like heart failure and coronary artery disease. But when you talk about cardiovascular risk factors, you talk about things like hypertension and diabetes that are ingredients that predispose to an end point of a cardiovascular disease. Since cardiovascular disease cases are rising, we can assume that erectile dysfunction cases will also rise.
In our recent study in a big tertiary hospital in Ibadan, we found that four out of every five heart failure patients have some level of erectile dysfunction. In other diseases, too, there are varying percentages of people with erectile dysfunction associated with cardiovascular disease.
Well, most of them were interestingly mild cases of ED, and patients might even want to trivialise it. But quite a significant proportion in the studied group had severe ED. But it might not be a problem to propel them to want to seek care without somebody probing or somebody thinking that this is a problem.
Well, is erectile dysfunction a problem?
Erectile dysfunction is absolutely a problem, but men don’t talk about it. No doubt, it is a problem that needs to be attended to because it affects quality of life and leads to relational problems and the family, which is the key fabric of society. Harmony at home is very important. Having a cardiovascular disease in any household member has some effect on that household. So, if you now have another issue, the silent factor that nobody is talking about or finding a solution to, this could further compound issues in such a household. So, if there is an opportunity to sort out the cardiovascular disease or the cardiovascular risk factors, you can also solve the silent one that could be a problem in the background.
Is it only heart disease that is associated with erectile dysfunction in men?
The common factors that are associated with erectile dysfunction in men overlap; there are many others that colleagues in the urology speciality may also be interested in. However, the ones that overlap with heart conditions and erectile dysfunction are things like hypertension, diabetes, smoking as a lifestyle, chronic stress and lipid problems, dyslipidaemia and being overweight. They can, in both ways, contribute to or predispose that person to such problems. Even things like depression, sleep apnoea and other things can be contributory factors to erectile dysfunction in men with heart problems.
Under what condition or under what situation would you say erectile dysfunction is a pointer to a heart problem in a man?
Well, if a patient comes, he has hypertension, and you took a detailed history, and you ask the person, ‘Do you have erectile dysfunction?’ But if a patient has erectile dysfunction, he is likely going to say he’s having difficulty achieving or maintaining a penile erection sufficient for satisfactory sexual intercourse. Of course, there are sensitive tools which may be questionnaire-based for screening for erectile dysfunction and to tell objectively if the case is mild, moderate or severe.
Can you say erectile dysfunction is a problem since men don’t talk about it?
Well, men do talk about it. Many studies have evidence to prove that if you are a doctor and you talk about it, men are glad to respond, and they want to talk about it. However, due to stigma and probably our busy clinics, men shy away from talking about it or possibly initiating discussion about it. They perceive that the doctor is too busy to have time to listen to them, thinking it’s a shameful thing to mention, particularly because they had come with family members to the clinic. They probably will not want to talk about erectile dysfunction in the presence of their family member.
The other issue is the fact that a patient who comes with maybe heart failure will probably deem the heart failure to be a more serious problem, and it is an issue that you, as a cardiologist, are not interested in listening to. This is not correct because you treat a whole man as a doctor, and you want to completely solve the patient’s medical problem. Because what you think is trivial might be the major concern of the patient.
Are there effective corrective methods for ED in men, particularly those with heart conditions?
There are very corrective ways of solving the ED; it’s multi-pronged. As a cardiologist, you want to take care of the core heart-related issue in the patient as well as counsel the patient. You also want to ensure there’s lifestyle modification: smoking cessation, regular exercise, weight reduction if obese or overweight and stress management. Usually, it is a multidisciplinary management. Some drugs are the culprit. So, it is important to change the patient’s drug or alter the patient’s drug regimen if it is the drug that is the predisposing factor to erectile dysfunction. Quite a few patients are smart enough to know the particular drug contributing to their poor libido. That might be their major concern for deciding to stop taking their medication. But peradventure the patient arbitrarily stops without informing or taking the doctor for guidance, he can develop serious complications, including stroke, heart failure and chronic kidney disease. This is aside from erectile dysfunction, which is his concern. So, a man with heart disease always requires holistic care. There are medications specifically provided for such patients with erectile dysfunction. And in extreme cases, they are referred to the urologist for definitive care. Urologists have several surgical procedures that help people with erectile dysfunction, with varying levels of success among those patients. Some may need behavioural therapy too.
Can they take a drug like Viagra? We have on sale a lot of medications said to boost sexual power.
Well, they may prescribe sildenafil or other drugs in its class for a man with ED. However, a man with any cardiovascular disease needs proper assessment by his primary physician before he can take such medications and should avoid certain classes of drugs. Several factors have to be taken into consideration in the context of the patient’s clinical status. Drugs that boost sexual power can interact with antihypertensive medications.
How about the use of local or herbal aphrodisiac products by a heart patient? What would be your advice?
It is very important that we need to clarify this. We are shying away from drugs or substances that are unsubstantiated, properly scientifically assessed for their efficacy and certified safe for a particular condition. So we must discourage people from buying just an aphrodisiac. It is best avoided by all men, particularly men who have other medical conditions like heart disease. We shouldn’t forget the possibility of having a drug-herb or drug-drug interaction. Rather than resort to the use of an herbal aphrodisiac or off-the-shelf prescription, they should speak with their doctor for guidance on what to do.
Can a man that recovered from a heart attack have sex?
Well, ultimately, a man that recovered from a heart attack should be able to have sex, depending on the effort tolerance and clinical status. Usually, there are guidelines and a minimum duration. Usually, most times, you want to assess and be sure of the risk level of that patient before you tell them to go back to sexual intercourse. While the man abstains from sexual intercourse, other non-intercourse sexual expressions may be advised in the interim. Then, subsequently, he can go back in a graded manner to a regular, almost normal lifestyle. That is where counselling comes in. Even after a heart attack, some guidelines must be followed; you don’t drive immediately and also may not have sexual intercourse.
One of the procedures they used for treatment is a pacemaker; can a person with a pacemaker have sex?
A pacemaker is safe for patients, and once the wound site has healed and there are no major health concerns, there is no reason why someone with a pacemaker cannot enjoy an active sexual life. It is important to avoid direct pressure on the pacemaker site, particularly during the first few weeks after implantation. During sexual activity, patients should choose positions that minimise pressure on the chest or arm where the pacemaker is located.
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A standard pacemaker does not deliver shocks, so there is no risk of receiving a shock during sex. Overall, a pacemaker is considered very safe during sexual intercourse, and there is no harm directly caused by the device. There is also no risk from the device to the partner.
Is the incidence of erectile dysfunction higher in men with cardiovascular risk factors or in those with heart disease, diabetes or kidney disease?
There are many studies regarding erectile dysfunction in different disease conditions. But I’ll narrow myself down to those that are cardiovascular-related. In a study in Ibadan, we found that almost four out of five patients with heart failure had erectile dysfunction of different degrees. Also, another study in coronary artery disease patients puts the incidence of erectile dysfunction at about 50 to 70%. Also, about half of patients with hypertension and diabetes have a varying degree of erectile dysfunction. That’s all the more reason why there is a need to be conscious of it in an average cardiovascular medicine practice.
We have been talking about erectile dysfunction as an issue with the hearts of men. Does it affect the hearts of women with heart conditions?
Well, we cannot say that women have erectile dysfunction. However, women with heart disease can also have sexual issues. This may include decreased libido, difficulty in achieving orgasm, and painful sex. Also, these diverse sexual problems can come from the cardiovascular drugs being used. That is why patients should always express their concerns about their drugs to their physician. And this is very important.
Are there practices that patients with heart conditions can get involved with that may be inimical to their health?
Yes, there are a number of them. Use of recreational drugs, smoking, not exercising, excessive alcohol intake and poor diet all can impair their health. These are things that generally should be avoided to have fewer issues with erectile dysfunction. For example, smoking causes the hardening of the inner walls of the blood vessels, including the ones that supply blood to the penile organ to ensure erection. This overtime impairs the functioning of the blood vessel and ultimately predisposes men who smoke to having erectile dysfunction.
Are there cultural practices that negatively impact the health of persons with heart conditions?
Obesity and being overweight are risk factors for erectile dysfunction. So, cultural practices that encourage a sedentary lifestyle and being obese or overweight should be discouraged. Smoking for men is a cultural practice in some climes, and the behaviour or lifestyle must also be discouraged.
Why does erectile dysfunction occur more in the elderly?
Yes, age itself is a risk factor for having erectile dysfunction. So, the probability of erectile dysfunction is higher in the elderly population. Also, it is likely to be more common among the elderly with heart disease than among those without heart disease. Similarly, other cardiovascular risk factors that also work synergistically can make the elderly population more predisposed to erectile dysfunction.
What roles can partners and society play regarding erectile dysfunction?
Partners and society can play a supportive role to encourage open communication about erectile dysfunction, particularly sexual health literacy. They can ensure that discussions happen in the clinic between doctors and their patients, promote healthy lifestyle choices, exercise, cessation of smoking, and weight loss to improve erectile function, particularly in patients with cardiovascular disease and the general public.
It is important to reduce stigma regarding erectile dysfunction because many people are suffering in silence. They will then be able to talk openly about it as they provide emotional support and understanding. Certainly, increased talk about erectile dysfunction in the media will go a long way in destigmatising the condition. Arguably, people don’t want to talk about sex; they are not talking about it in an open context because there’s a lot of stigma around sex. This has also been transferred to sexual disorders like erectile dysfunction.
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