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Trouble with sex? It could be all in your heart.

No man wants to be diagnosed with erectile dysfunction (ED), but believe it or not, it could save your life. In many cases, ED is a precursor to cardiovascular disease and when diagnosed properly could reduce the chance of having a heart attack or stroke.

ED is the inability to get or sustain an erection. It is extremely common, affecting more than half of men over 60. When a man comes to my office with symptoms of ED, I ask about his lifestyle, assess his blood pressure and measure his BMI/waist circumference. Given our rising rates of obesity and sedentary lifestyles, there is a good chance that performance in the bedroom is not about emotional issues or the male anatomy itself. It may sound strange but the penis is the barometer of a man's overall health.

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You can imagine how a heart artery gets clogged in a person with high blood pressure, high cholesterol or diabetes. When that coronary artery, which measures around 3-4 millimetres, gets so blocked that little to no blood flows through it, that person is going to experience chest pain (angina) or a heart attack. The same holds true for the carotid arteries, which measure 5-7 mm and take blood up to the brain. When they get blocked, that person will experience symptoms of a stroke. Now imagine the tiny penile artery, measuring only 1-2 mm. Its smaller diameter makes it ultra-sensitive to blockages, resulting in …you guessed it, erectile dysfunction.

What I've just described is the Artery Size Hypothesis. Our entire vascular system is connected and the same things that harm our big blood vessels will affect our smallest ones as well. The common cause of all this is what's called endothelial dysfunction, which is a problem with the inner lining of our blood vessels resulting in changes to blood flow, clot and plaque formation, and atherosclerosis. As the same systemic process takes place throughout our vascular system, it's these small arteries in the penis that will feel the effects earlier and manifest the outcome (ED) before other organs start to suffer.

Now, you may say to yourself, "I feel fine and healthy. I'm not that much overweight. My erections just aren't as good as they were when I was younger." But this is exactly when the alarm should sound for men, their partners and their doctors. It's important to realize that ED and cardiovascular disease have the same risk factors. These include high blood pressure, diabetes, high cholesterol, smoking and excess weight. Realize, too, that all these risk factors are modifiable, meaning you can actually improve them to reverse or halt the damage that is being done.

The Framingham Heart Study, which has followed three generations of the residents of Framingham, Mass., has taught us many things about heart-disease risk. One important lesson is that the probability of ED rises over each decade of life starting at age 40. Also, those with the risk factors I mentioned above have significantly higher probabilities of having ED. The opposite is true as well. Those with more severe ED have higher cardiovascular disease risk. But what about younger men or men with only "mild" ED? Should we wait until their symptoms are more pronounced?

The conclusion of the Second Princeton Consensus Conference on sexual dysfunction and cardiac risk put it this way, "The recognition of ED as a warning sign of silent vascular disease has led to the concept that a man with ED and no cardiac symptoms is a cardiac (or vascular) patient until proven otherwise." Studies show that men presenting with only mild ED have a significant amount of undiagnosed high blood pressure, high blood sugar and high cholesterol, among other things. This is why men with mild ED, particularly if they are younger than 50, need to be screened for cardiovascular risk factors and have those risks treated aggressively.

We've come a long way since the days when ED was something men kept to themselves, too embarrassed to discuss with their buddies or doctor. The introduction of pills to treat ED over 15 years ago opened the door for conversations about the condition. Newer technologies, such as low-intensity shock-wave therapy, improve the volume of blood flow into the penis by stimulating growth of new, healthy blood vessels in the penile tissue. At the end of the day though, it's lifestyle changes to modify risk factors that will provide the greatest benefit to a man's entire body, not just his penis.

Erectile dysfunction is the early warning system for serious cardiovascular disease. ED may precede cardiovascular disease by two to five years (on average three years) so time is of the essence when it comes to diagnosis and treatment. Urologists, family doctors and partners should all be the watchmen for men's health. We should be asking men about their sexual function during every routine visit.

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Health Advisor contributors share their knowledge in fields ranging from fitness to psychology, pediatrics to aging.

Dr. Dean Elterman is a urologic surgeon at the Toronto Western Hospital/University Health Network with a special interest in men's health. He is the Medical Director of the Prostate Cancer Rehabilitation Clinic at Princess Margaret Hospital Cancer Centre. Dr. Elterman specializes in voiding dysfunction, sexual dysfunction and pelvic reconstruction in both men and women.

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