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On a recent afternoon in the GP surgery, I had a student sitting in. Most of the time the students watch quietly but some of them ask difficult questions about things such as the molecular biology of immunity, so it’s always a good idea to deflect them by asking a question first.
“There’s a link between sex and heart disease, can you think what it is?” I said to Waleed. This blend of randomness and specificity is the hallmark of medical teaching: I used to find it confounding. Waleed was unfazed. “Sometimes a man has an affair, which is stressful, and he has a lot of sex, which is also stressful, and in the middle of the act he has a heart attack – maybe because of the stress together with the exercise? – and she can’t get free, she’s trapped! She has to cry for help! And no one can let on about what’s happened because he wasn’t meant to be there in the first place.”
People do occasionally have heart attacks during sex but I was fishing for a more common, if less exciting association. Erectile dysfunction – as the drug companies have rebranded impotence – can be an early marker for cardiac disease. Much of the time, “ED” (as the medical literature calls it) is psychological in origin but not always. Where there is a physical cause, it can tell you more than you might expect about the rest of the body.
To find out if your patient’s ED is physical, you first have to assess whether the mechanical side of things is functional or not. If he can achieve an erection on some occasions, there is more likely to be a psychological component. Morning erections are a useful indicator but unfortunately patients can’t always remember if these have taken place or not. I will never forget the lecture in which a professor of primary care described a crafty investigative tool for this situation. It involved wrapping the penis in a paper ring made from the trim from a sheet of stamps. If an erection took place, the power of “the arousal” – as the professor coyly described it – would tear the perforations and the patient would wake up to find a loose fragment of stamp paper in his bed. No erection and the ring would remain intact. “Awesome!” said the man sitting next to me.
If you can never achieve an erection, consciously or unconsciously – “I’m completely unmanned”, an elderly patient told me sadly – then your ED is likely to have a physical cause. ED can be a side effect of many drugs – including beta-blockers, antidepressants and many of the medications used to treat high blood pressure, such as bendroflumethiazide, enalapril and doxazosin.
Some medical and surgical treatments can damage erectile function, as can neurological diseases such as Parkinson’s and multiple sclerosis. Two common but less well-known physical causes are diabetes and high blood pressure. These cause harm by damaging the small blood vessels of the penis, so impeding its ability to fill with blood (diabetes can cause double destruction by also affecting the penis’s nerve endings).
This is what makes ED such a useful marker: the state of our smallest blood vessels – such as those supplying the penis and the kidneys – provides a valuable insight into what’s also going on inside the larger arteries that supply the heart and the brain. If you’re diagnosed with ED arising from vascular damage, your GP should calculate your cardiac risk for you and offer to check your renal function as well. It is embarrassing to take your penis to the doctor, but much better than ending up in any scenario devised by a medical student.
Sophie Harrison is a hospital doctor in South Yorkshire
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