男科学 NAN KE XUE - ANDROLOGY

Etymology: Gk, andros: man; logos: science: The study of the health of men.  Men do not always seek help for their health concerns. Most are aware of testicular cancer and erectile dysfunction, but not much else; and few recognize that what appears in their anatomy is the result of great and most important basic issues. Sympathetic nerve disorders, emotional and mental health, such as stress, depression, insomnia, eating disorders, etc., are increasingly being recognized as important topics for the health of men. At FullCircle Acupuncture HealthCentre we care for the health of men, and we address all issues that concerns the male patient. As an experienced practitioner of Chinese medicine Dr. Osorio knows what cases require biomedical care and quickly refers out, while continuing to care for the patient in all other areas.

SEXOLOGY IN CHINA
The best-known compendium on sexology in the West is perhaps the Kama Sutra from ancient Hindu practices dating back many centuries BC. It treats sexual practices as an esoteric art of sexual love between male and female. A less known in the West are the ancient Chinese sexology treatises dating back to 168 BC. The texts were only discovered in 1973 at the Ma Wang Tui Han tomb in Changsa, Hunan Province, China. They are composed of more than 20 ancient Chinese sex handbooks from the beginning of the Han Dynasty c.206 BC, to the end of the Tang Dynasty c.907 AD. In these ancient texts are found that Chinese medical sexology regards as the female giving Yin and receiving Yang; and the male giving Yang and receiving Yin. In principle, it is an equal and harmonious exchange of sexual energy, since both Yin and Yang Qi are present in all living things (Juan, FF, 1991).

The equal exchange of Yin and Yang between male and female in a physical, mental, and spiritual intercourse constitutes balance; and in Daoist terms it mirrors the harmony of nature and contributes to longevity. However, more is not better, because excessive sexual activity depletes Yin and Jing in males and Yang in females. The Chinese take a natural approach to human sexuality. In Chinese medical and erotic literature, sexology is called the “art of the bedchamber.” It outlines various techniques for men and women to satisfy one another in intensive, all-consuming love making and intimacy, and it emphasizes that strong sexual energy depends on one’s complete health. This perspective is logic in Chinese medical thought because according to Chinese medicine, the SP (spleen) makes the blood, the LV (liver) stores and moves it, the HT (heart) gives rise to desire, and the KD (kidney) provides the Will. If any of these aspects is malfunctioning, erectile dysfunction may ensue.

TCM PERSPECTIVE ON YANG WEI 杨伟 – IMPOTENCE or ERECTILE DYSFUNCTION

In Yang Wei, the Chinese expression for Erectile Dysfunction, Yang refers to the penis and Wei, to flaccidity. Yang Wei refers either to the inability of the penis to attain erection or the ability to attain only partial erection; both of these prohibit normal sexual activity. Clinically, impotence is often seen with seminal emission or premature ejaculation and, in most cases, is a functional disorder. 

ETIOLOGY AND PATHOGENESIS
Impotence is generally the result of overindulgent sexual activity, habitual masturbation, sympathetic nerve overload, or emotional disturbances such as stress, anxiety, worry, insomnia, fear or fright. These can cause weakening of the Life-Gate Fire and loss of sexual capacity. The downpour of Damp-Heat into the LowerJiao can also result in impotence, although such cases are relatively rare. The etiology of ED in Chinese medicine is comprised of all or some of the following: emotional, physical, or situational stress, overwork, excessive sexual and-or physical activity, old age, smoking, and irregular diet. It is important to differentiate between Full and Empty conditions, for these are the pathogenic factors involved. Full condition include Dampness, Phlegm, Blood Stasis, and Stasis of Jing; while empty condition is comprised of KD Yang Deficiency, HT Blood Deficiency, LV Blood Deficiency. HT/GB Qi Deficiency, KD Yin Deficiency.

KD Yang Deficiency may influence impotence because of deficiency of Minister Fire or Fire of Mingmen, and in terms of channels it implies pathology of the Du Mai which represents the Yang within the genital system. Besides, during erection the penis becomes hard which is Yang, and lifts up which is a Yang action, so erection is very much a Yang activity. Deficiency of KD Yang and of the Minister Fire is a common cause of ED in all young, middle age, and old men. This does not mean that all ED is due to KD Yang Deficiency. It does mean however that regardless of the cause of the dysfunction, in clinical treatment, a small amount of KD Yang herbal tonification is always pertinent, i.e. Du Zhong, Suo Yang, He Shou Wu.

In Heart Blood Deficiency, the penis needs the action of the heart for erection in two ways: HT Qi must descend to the penis to promote erection; and the HT governs Blood that the penis needs to fill the corpora cavernosa to achieve an erection. With Liver Blood Deficiency, the connective fibrous tissue and divergent channels of LV wrap around the penis; therefore, the LV channel plays a role in the pathology of erection, and it is most notable when it -the liver- suffers from Qi stagnation or dampness.

TCM PATTERNS
Debilitation of Life-Gate Fire
Downpour of Damp-Heat into the LowerJiao

Debilitation of Life-Gate Fire
Symptoms: Complete or partial impotence, frequent spontaneous seminal discharge, dizziness and vertigo, tinnitus, pale complexion, cold extremities, listlessness, weak aching lower back and legs, and frequent urination.

Tongue: Pale with white coating.
Pulse: Deep, thready.
Treatment Method: Supplement the kidney, invigorate Yang.

Downpour of Damp-Heat into the LowerJiao
Symptoms: Flaccidity of the penis with inability to achieve or sustain erection, accompanied by premature ejaculation in the majority of cases. Symptoms also include sweatiness of the scrotum, heavy aching lower limbs, thirst or bitter taste in the mouth, dark burning urine.

Tongue: Yellow slimy coating.
Pulse: Slippery, rapid.
Treatment Method: Clear heat, disinhibit dampness.

REMARKS
Besides acupuncture, herbal, and moxa therapy, stress management -including relaxation, meditation, hand and facial massage and reflexology, may reinforce therapeutic effectiveness. 

易静YI JING – SEMINAL EMISSION 

Seminal emission Yi Jing refers to patterns characterized by the spontaneous ejaculation of semen even when unrelated to sexual activity. Seminal emission is divided into two categories: nocturnal emission, and spontaneous seminal discharge. In nocturnal emission the patient’s condition is relatively mild and the emission generally occurs while dreaming, hence the Chinese name ‘dream-emission’ Meng Yi. Spontaneous seminal discharge, or ‘seminal efflux’ Hua Jing, does not coincide with dreaming, and in its more severe form, it occurs while patients are fully conscious. Spontaneous seminal discharge may well be a pathologic development of nocturnal emission, indicating progressive severity.

One or two instances of seminal emission per month is considered physiologically normal in adult males without a partner or adult males who do not engage in sexual activity. Seminal emission is considered pathological when it occurs more than twice per week or when spontaneous seminal discharge is accompanied by dizzy spells, listlessness, weak aching lower back and legs, palpitations, insomnia or forgetfulness. Seminal emission is often observed in biomedical disorders such as neurosis, prostatitis, spermatocystitis, and orchitis.

ETIOLOGY AND PATHOGENESIS
Failure of Kidney Qi to secure the essence is the constant factor in pathogenesis of seminal emission. Etiology, failure of Kidney Qi can be caused by a variety of factors that include emotional stress or disturbance, improper diet and eating habits, and overindulgent sexual activity. The pathological mechanism of seminal emission can be divided into four categories: Kidney Yin Deficiency leading to Exuberant Fire; Kidney Yang Deficiency resulting in Failure to Secure the Essence; Failure of Qi to Astringe the Essence; and Descent of Damp-Heat into the LowerJiao.

Patterns may be purely Excess or Deficiency, or complicated by both Excess and Deficiency. While Heart (HT), Liver (LV), Spleen (SP), or Kidney (KD) might be involved in the development of seminal emission, the pathogenesis is most intimately related to a disharmony between the HT and the KD.

TCM PATTERNS
Kidney Yin Deficiency with Exuberant Heart Fire
Kidney Yang Deficiency with Failure to Secure the Essence
Qi Deficiency with Failure to Astringe the Essence
Descent of Damp Heat into the LowerJiao

Kidney Yin Deficiency with Exuberant Heart Fire
Symptoms: Insomnia or frequent dreaming, palpitations, nocturnal emission, dry throat, dizziness and vertigo, vexation in the heart, weak aching lower back and legs, night sweating, tinnitus, forgetfulness, dark scanty urine.

Tongue: Red with little coating.
Pulse: Rapid, thready.
Treatment Method: Nourish Kidney Yin, clear Heart Fire, quiet the spirit, secure the essence.

Kidney Yang Deficiency with Failure to Secure the Essence
Symptoms: Persistent seminal emission and spontaneous seminal discharge accompanied by cold extremities, physical cold, impotence, premature ejaculation, and pale complexion.

Tongue: Delicate, pale, with tooth marks; white glossy coating.
Pulse: Deep, thready.
Treatment Method: Supplement Kidney Yang, secure essence.

Qi Deficiency with Failure to Astringe the Essence
Symptoms: Palpitations, insomnia, forgetfulness, sallow complexion, loss of appetite, loose stools, seminal emission following overwork.

Tongue: Pale with white coating.
Pulse: Weak.
Treatment Method: Rectify and supplement the Heart and Spleen, boost Qi, secure essence.

Descent of Damp-Heat into the LowerJiao
Symptoms: Frequent seminal emissions, escape of a small amount of semen during urination, dark burning cloudy urine or difficult urination, thirst, bitter taste in the mouth, irritability, insomnia, loose foul-smelling stools, tenesmus, fullness and discomfort of the epigastrium and abdomen, nausea.

Tongue: Yellow slimy coating.
Pulse: Soft, rapid.
Treatment Method: Clear heat, disinhibit dampness, secure essence.

REMARKS
To achieve maximum therapeutic results treating seminal emission, patients should foster a healthy mental attitude towards sex by engaging moderately in sexual activity, refraining from masturbation and abstaining from white carbohydrates such as corn and its products, rice of all kinds, wheat and its products, extra rich foods, alcohol -apart from the occasional glass of red wine with food. It is also advisable to engage in suitable physical exercise, such as soccer and football, Qigong, yoga, walks, wood-chopping, farm heavy work, moderate weight lifting (heavy weight lifting is discouraged), and strengthening the core.

DISEASE MECHANISM
KD Disorders, LV Imbalance, SP Deficiency, HT Deficiency, Injury of CHONG, REN, DU, and DAI mai; Qi and Blood Imbalances; and of course, the consequences of their respective Fu dysfunctions all play a part in the mechanism of the imbalance. The LV primary channel encircles the genitalia; the luo connecting channel ascends to the genitals; the LV divergent channel ascends to the pubic region, and the LV sinew channel binds with all other sinew channels at the genitals. The penis is called “Zong Jin” which means meeting of the ancestral or 100 sinews. The HT and KD work in conjunction to keep a healthy penile function; thus, the HT above and the KD below have to be tonified to this end if there is dysfunction. If the HT is deficient, no amount of KD tonifying will rectify the depressed penis. The HT is linked to the LowerJiao by the CHONG mai and the Bao Mai, known in gynecology as “the uterus vessel” and it is via these vessels that HT Fire and HT Blood descend to the genitals and promote erection. Note that the “uterus vessel” is not exclusive to women, but it is part of the human body, male and female.

In Chinese medicine Erectile Dysfunction or Impotence is called Yang Wei. Yang refers to Yang or penis, and Wei means listless, flaccidity or withering. It is therefore listlessness of Yang. Yang Wei is the inability to achieve an erection, or to maintain one for unencumbered intercourse. Conversely, the ancient term for impotence was Yin Wei in which the term Yin was used comparatively to Yin as in flesh, or tangible matter. This difference in terminology is probably due to the fact that Yin and Yin Wei refers to the penis and is called Yin Jing in Chinese, which literally means Yin Stem. Moreover, in ancient times impotence was sometimes called Jin Wei which means listlessness of the sinews. Apart from all medical connection or significance, the word flesh in the Chinese language is said Yin.

This name could be related to the term Zong Jin or ancestral muscle or sinew, which was another term for the penis. Chapter 70 of the Su Wen Simple Questions mentions impotence calling it ‘Yin Wei’: ‘When the energy of TaiYin predominates, there is impotence. In man, the diseases of unquietness of the chest, impotence, extreme debility of Yang energy, fails to erect and inability of conducting sexual action will occur.’ In chapter 44 of the Su Wen Simple Questions it says: ‘When one is affected by desire without satisfaction and pursues outside excessive goals, or when one engages in excessive sexual activity, the penis, Zong Jin or Ancestral Muscle, will become slack causing impotence ‘Jin Wei’ and seminal emissions.

The Complete Book of Jing Yue -Jing Yue Quan Shu, 1624- relates the etiology of impotence to emotional stress: “Worry and pensiveness deplete Qi, excessive worry leads to impotence.” The Secret Formula of the Border Official Wai Tai Mi Yao, 752 AD, clearly relates impotence to the KD: “The KD controls the lower orifices; overexertion injures the KD, and the deficient KD cannot control the lower orifices and impotence results.” The Discussion of the Origin of Symptoms in Diseases -Zhu Bing Yuan Hou Lun AD 610- relates impotence to the KD: “The genitals are an orifice of the KD, when these are injured by overwork, the deficient KD cannot nourish the genitals and impotence results.”

Anatomically, the corpora cavernosa, Huang Membranes in Chinese medicine are controlled by the CHONG mai and runs the length of the shaft of the penis. In Chinese medicine an erection is related to the Shen and the Heart. HT Qi and HT Blood need to descend to the penis to promote an erection, and it requires a precise sequence of events: nerve impulses in the brain, spinal column, and the area around the penis, response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa; which from the Chinese medical perspective are essentially the LV and CHONG mai.

The Chong Mai influences erection in seven ways:

It is the Sea of Blood

It is connected to the Post-Natal Qi

It is connected to the Pre-Natal Qi

It controls the membranes –Huang

It controls the Ancestral Muscle -Zong Jin

It controls the Luo Mai in the penis

It allows communication between HT and KD

CHONG mai as the Sea of Blood provides blood to the penis -in this sense this function occurs in synergy with that of the HT. It is the Sea of Channels and is intricately connected to Post-Natal Qi of the ST through QICHONG ST30. Therefore, the CHONG mai also provides the Qi necessary for erection to occur. It is also connected to the Pre-Natal Qi of the KD. For erection to occur, both Post-Natal Qi and Pre-Natal Qi are needed. It controls the membranes (Huang), and most of the penis tissue is part of the membranes. It influences the Zong Jin which is the penis. It controls the Luo mai in the penis which allows it to be filled with blood to erect. It assists the communication between HT and KD and therefore the descending of HT-Blood to the penis. It is therefore that CHONG mai is an important vessel to treat for ED.

Acupuncture Points to Treat Chong Mai

1) (L) GONGSUN SP4 and (R) NEIGUAN PC6 Chong Mai master/couple
2) DAHE KD12 (B), GUANYUAN REN4, QIHAI CV6, HUANGSHU KD16 (B), JIUWEI REN15.

HUANGSHU KD16 has the function of promoting communication between HT and KD, and the combination of REN4 and REN15 have the same function. The above points stimulate the descending of HT Qi to the penis and promote the communication between HT and KD.

Topical Formulas

The following are topical treatments for impotence from a modern Chinese book. The treatment is based on ointments to be rubbed onto the shaft of the penis once a day. There are several methods of making the unguent, and here we will uncover one easy form. The ingredients however can only be acquired by a licensed acupuncturist. While this website is accessible to the general public, most of the information in it is for the consumption of students, teachers, or practitioners of Chinese medicine.

Thus, acquire these in powder form and mix them up. To prepare, boil rice wine or vodka, at first boil retire from the burner and use it a little at a time to mix the herbs. When the mixture is pasty and can no longer be mixed, add olive oil, or sunflower oil or any other oil, except lavender, and mix the paste with the oil a little at a time until smooth as a cream. Transfer to a glass container and dispense, or use it.

(1)
WU WEI ZI 6g
HUANG QI 6g
LIU HUANG 3g
CHUAN SHAN JIA 2g
FU ZI 3g
SHE XIANG 3g

(2)
FU ZI 45g
CHUAN SHAN JIA 3g
LIU HUANG 6g
E JIAO 1.5g
SHE XIANG 3g

Chinese Folk Remedy

In cases of impotence debilitation of Life-Gate Fire, the following prescription can be used:

Take  two  sheep’s testicles  and  add a small amount of old wine. Steam and consume each
morning  for  one  month,  continuing  for  a  second month if necessary. During treatment,
patients should abstain from sexual activity.

Traditional Chinese Medicine (TCM) is a holistic modality deriving from ancient Eastern philosophy, whose concept believes that the human body has a set of inner homeostatic system maintained by Yin-Yang balance. Yin & Yang are two opposite yet complementary forces, which could be understood as anabolic and catabolic processes from a Western perspective. According to TCM philosophical theories, disease results from the imbalance between the two forces over time. Thereby, the goal of treatment is to restore the balance between Yin &Yang.

TCM, including acupuncture and Chinese herbs, is used as an alternative therapy to increase the curative effect for erectile dysfunction. Several studies have been conducted to investigate the effect and mechanism of TCM for treating ED. Some Chinese herbs might improve erectile function by activating nitric oxide synthase (NOS)-cyclic guanosine monophosphate (cGMP) pathway, increasing cyclic adenosine monophosphate (cAMP) expression, elevating testosterone levels, reducing intracellular Ca2+ concentration, inhibiting PDE5, down-regulating transforming growth factor β1 (TGFβ1)/Smad2 signaling pathway, or ameliorating the oxidative stress.

In TCM, Heart, Kidney and Liver are the three primary organs related to ED. Heart ignites desire, Kidney stores the essence, and Liver stores blood. Essence can be recognized as a power that is responsible for growth, development, and reproduction. Kidney essence enhances immunity. In addition to storing blood, liver can modulate blood volume and maintain the flow of blood. Sexual and reproductive functions are also under the control of liver. Thereby, kidney and liver are two important organs with a wide range of functions in TCM. Both essence and blood are Yin in nature, hence the kidney and liver are thought to be of the same source. The weakness of one organ usually leads to the imbalance of the other. The diagnosis of disease in TCM lies in identifying patterns of disharmony, which is called syndrome differentiation. ED commonly involves the heart, kidney or liver patterns of disharmony, such as Heart Qi Deficiency, Kidney Yin Deficiency, Kidney Yang Deficiency, and Liver Qi Stagnation. Recognizing the relationship among the organs involved in ED is critical for making an effective therapy plan.

There is sufficient evidence to support that acupuncture can regulate the function of endocrine, circulatory, and nervous systems. Acupuncture was confirmed as a promising therapy for a wide range of diseases by the National Institutes of Health (NIH) and the World Health Organization (WHO). It is now believed that the neurophysiological effects of acupuncture result from the central nervous system activation as well as neurotransmitters modulation. Acupuncture might modulate the release of nitric oxide (NO) and some neuropeptides involved in the process of erection.

Functions of Chinese Herbs for Treating ED

Folium Ginkgo Bilobae BAI GUO: Increases NOS expression, increases dopaminergic activity
Tribulus terrestris BAI JI LI: Increases testosterone levels
Morinda Officinalis BA JI TIAN: Increases testosterone levels
Ligusticum CHUANXIONG: Increases cAMP and cGMP content
Angelica sinensis DANG GUI: Enhances NOS (Nitrous Oxide Systems) activity
Tetrandrine FANG JI: Reduces intracellular Ca2+ concentration in corpus cavernosum
Lycium Barbarum L GOU QI ZI: Reduces oxidative stress
Berberin HUANG LIAN: Increases eNOS expression; reduces oxidative stress
Neferine LIAN ZI XIN: Reduces intracellular Ca2+ concentration in corpus cavernosum, increasing cAMP content
Ginseng REN SHEN: Reduces oxidative stress
Herba Cistanche ROU CONG RONG: Increases testosterone levels
Panax Notoginseng SAN QI/TIAN QI: Reduces oxidative stress; increases eNOS expression
Kaempferia parviflora SHA JIANG: Reduces intracellular Ca2+ concentration in corpus cavernosum, inhibits PDE5
Common Cnidium Fruit SHE CHUANG ZI: Increases NO release, inhibiting phosphodiesterase
Semen Cuscutae TU SI ZI: Increases testosterone levels, promotes fertility
Herba Epimedii YIN YANG HUO: Inhibits PDE5; increases NOS expression; down-regulates TGFβ1/Smad2 pathway; increases testosterone levels.

Mini Glossary: ED, erectile dysfunction; NOS, nitric oxide synthase; eNOS, endothelial nitric oxide synthase; cAMP, cyclic adenosine monophosphate; cGMP, cyclic guanosine monophosphate; NO, nitric oxide; PDE5, phosphodiesterase type 5; TGFβ1, transforming growth factor β1.

                                          FOODS FOR PROMOTING NITRIC OXIDE (NO)

Beets
Black tea
Cayenne pepper
Chocolate pure or semi-pure 70% to 90%
Cooked Spinach
Cranberries
Garlic
Garlic chives and regular chives
Kale
Liver (beef, chicken, duck, lamb)
Onions
Oranges
Pistachio
Pomegranate
Raw Honey
Salmon
Sardines
Shrimp
Walnuts
Watermelon


                          BIOMEDICAL PERSPECTIVE ON ERECTILE DYSFUNCTION

ANDROPAUSE
Mosby’s Medical Dictionary defines Andropause as ‘A change of life in males that may be expressed in terms of a career change, divorce, or reordering of life. It is associated with a decline in androgen levels that occurs in men during their late 40s or early 50s,’ while Webster’s defines it as ‘A gradual and highly variable decline in the production of androgenic hormones, especially testosterone in the human male together with its associated effects that is held to occur during and after middle age, also called climacteric, and male menopause.’

The word andropause is not recognized, as of yet, by the WHO and its ICD-9 medical coding; the word hypogonadism which is a deficiency state in which testosterone falls below the normal range, is used instead.

Andropause describes an emotional and physical change that men experience as they age. The symptoms are generally related to aging and associated with significant hormonal alterations. Andropause is widely understood in the medical community and can be defined as a natural subtle decline in hormones that occurs in men as they age; beginning at age 35-40 onward. In the West, the fact that the production of androgens by the testes decrease as men age has been known for the ages, but only recently interest developed in terms of its clinical implications. The Chinese have known this for just as long or more, and as we read above, have done something about it. 

This state in the normal passage of time for some men has been referred to as ‘male menopause,’ ‘male climacteric,’ “’late onset hypogonadism,’ ‘androgen decline in the aging male (ADAM)’ or ‘viropause’ (from virility). The term ‘andropause’ can be considered inappropriate because the process is not universal and occurs subtly over time. In women, menopause occurs universally and usually happens dramatically. The incidence of andropause from ages 40-49 is estimated between 2-5%. From ages 50-59, between 6-40%, from 60-69, between 20-45%, and from ages 70-79, between 34-70%.

Symptoms
Andropause is characterized by a subtle and gradual onset and slow progression of symptoms. Mistakenly, often these changes are attributed to the unavoidable consequences of aging, but not all men show symptoms of andropause as they age, and not all who show symptoms have andropause; moreover, not all men show a significant decrease in androgens either. The syndrome is characterized by diminished sexual desire and erectile quality, and a good sign of decreased androgens is the absence of nocturnal erections, decreased intellectual acuteness, mood changes, fatigue, depression, anger, impatience, and poor spatial orientation; decreased lean body mass, along with muscle mass and strength; decreased body hair and bone density resulting in osteoporosis, which can lead to increased incidence of bone fractures and breaks; increased fat surrounding the internal organs and the mid-section. Other symptoms include low sex drive, low energy, depression, sleep difficulties and insomnia, and the most insidious and pernicious, slow and protracted decline of self-esteem.

Diagnosis
To diagnose andropause not all these symptoms need to be present, and not all appear to the same degree in all men. Some may suffer from some of these symptoms and from others just mildly or not at all. A blood test is necessary to diagnose andropause, and it is therefore that it’s necessary that you encourage your patient to have a Western PCP.

Treatment
The goal of treatment is to restore sexual function, increase of sexual energy and a sense of general well-being; prevent osteoporosis by optimizing bone density; restore muscle strength and improve mental function. Hormone replacement is often effective, but it is not a stand-alone miracle treatment; it should be accompanied by proper muscle building moderate fatty-diet and exercise. Hormone replacement should aim not only to reach normal levels of serum testosterone, but to normalize levels of secondary hormones dependent on testosterone; these include dihydrotestosterone and estradiol among others.

ERECTILE DYSFUNCTION

Impotence is one of the major hazards of cigarette smoking.
                                                                        ─Loni Anderson

There is no evolutionary reason for the female orgasm, because women can get pregnant without one; not men however, for whom it is imperative to achieve orgasm to perpetuate the species (Symons D, 1979). Erectile dysfunction (ED) is the medical term for impotence, and according to the National Institute of Health (NIH), it is defined as the inability to achieve and sustain an erection for successful sexual performance (NIH Consensus Statement of Impotence 1993). This ailment is serious, and it is linked to complex feelings of inadequacy and shaken confidence, which over time tend to interfere with other aspects of life due to its psychological consequences.

 Although ED does not affect life expectancy, in most of the male population it has a negative effect on wellbeing and quality of life. Some men conceal their difficulties from their spouses which in turn makes the problem worse by its misinterpretation as unfaithfulness and conflict that exacerbate the dysfunction. Once the problem is in the open however, medical support can help resolve it. Several advances in diagnosing and treating specific causes of ED have restored sexual function, but curiously enough, many patients and their general practitioners are still unaware of this.

The National Institute of Health estimates that ED affects as many as 30 million men in the United States. Incidence increases with age: About 4 percent of men in their 50s, and nearly 17 percent of men in their 60s experience a total inability to achieve an erection. The incidence jumps to 47 percent for men older than 75. But ED is not an inevitable part of aging.

In allopathic medicine, drugs like Viagra®, Cialis®, and Levitra® are now available to men suffering from ED who would have otherwise resorted to questionable and unpleasant alternatives like penile implants, pumps, or painful injections and urethral suppositories. But these drugs can have a significant and life threatening side effects which include, but are not limited to difficulty breathing, tightness in the chest, chest pain, fast or irregular heartbeat, fainting, memory loss, numbness of an arm or leg, one-sided weakness, painful and/or prolonged erection, seizures, severe or persistent vision changes, blindness, sudden decrease or loss of hearing, rash, hives, itching, swelling of the mouth, face, lips, or tongue; diarrhea, flushing, headache, heartburn, stuffy nose, upset stomach, indigestion, and death. (Akash R et al, 2005).

It is practical for the patient to get a baseline blood levels of testosterone and estradiol before beginning therapy for ED, because as men age, they often suffer from a deficiency of testosterone and elevation of estrogen. Mood, musculature, sexual desire, strong erections, and performance are affected by these hormones. There are safe ways of naturally increasing testosterone levels and reducing excess estrogen.

From an etiological perspective, there is a distinction between organic and psychogenic form of ED. The organic form is sub-classified in terms of physical injury, neurological, vascular, surgery or radiation, anatomical and endocrinological causes. With the psychogenic form, the subdivision includes situation-dependent ED, and intrinsic psychological disorder (Lizza and Rosen 1999).

There is also a frequent combination of both organic and psychogenic forms of ED; as well as a purely occasional form triggered by beta blockers, SSRI’s, diuretics, and the use of certain illegal drugs (Gresser U et al, 2002).

 ANATOMY OF THE PENIS
The penis is composed of the paired corpora cavernosa, a spongy tissue running the length of the penis that is surrounded by a membrane called the tunica albuginea. The tissue of the corpora cavernosa contains bundles of smooth muscle fibers intertwined in a collagenous extracellular matrix, and distributed within this parenchyma is a complex network of endothelial cell-lined sinuses, fibrous tissues, spaces or lacunae, veins, helicine arteries, and nerve endings. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa and is surrounded by the corpus spongiosum; and a static structure in the form of a conical expansion of the corpus spongiosum that forms the head of the penis (Lue TF, 2000).

MECHANISM OF AN ERECTION
The penis is under the control of the central and peripheral nervous systems, and it is thus that an erection begins with sensory or mental stimulation, or both. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in through the arteries and fill the spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The tunica albuginea helps trap the blood in the corpora cavernosa, thereby sustaining the erection. The penis is innervated by somatic and autonomic nerve fibers.

The somatic innervation supplies the penis with sensory fibers and provides the perineal skeletal muscles with motor fibers. Contraction of the perineal skeletal muscles during erection leads to a temporary increase in corporeal body pressure to a level above the mean systolic pressure, and thus helps to increase penile firmness (Goldstein I, 1988).

Sexual stimulation triggers the brain to release the neurotransmitter nitric oxide (NO) by parasympathetic neurons that innervate the corpora cavernosa of the penis. As NO diffuses into the smooth-muscle cells lining the arteries of the corpora cavernosa and corpus spongiosum, it activates the soluble enzyme guanylate cyclase which produces cyclic guanosine monophosphate (cGMP), which in turn induces the activation of a biochemical cascade of protein kinases to  reduce the intracellular calcium concentration in the serum prompting the relaxation of the smooth muscles of the penis; and simultaneously restricting the blood return via penile veins, trapping blood in the organ, resulting in engorgement and erection (Moreland et al, 2001).

The autonomic innervation of the penis is both parasympathetic and sympathetic. The sacral parasympathetic neurons are chiefly responsible for the erectile function and are influenced by a cortical-sacral efferent pathway. Maintenance of erection for an extended period without significant changes in corporeal body blood can be achieved with repetitive stimulation for 40–50 sec, with a minimum latency period of 50 sec between each stimulus. The sympathetic innervation of the penis mediates the detumescence after the orgasmic relief by activating phosphodiesterase type 5 enzymes to catalyze the break down cGMP and cAMP and maintain thus the penis in the flaccid state (Goldstein I, 1988).

The chain of events leading to erection and detumescence of the penis presents opportunities for the treatment of ED, in the form of increasing the availability of NO and decreasing the activity of PDE5. Viagra®, Cialis®, and Levitra®, are selective inhibitors of PDE5 by inhibiting the degradation of cGMP and cAMP, but have tremendous side effects and significant risks. cGMP appears to be the direct intracellular mediator of the NO pathway, and therefore men taking organic nitrates for cardiovascular conditions must not take the drugs in this class, because the mixing may result in life-threatening low blood pressure. Moreover, any of these drugs, as a side effect, may induce sustained erection that does not subside for more than four hours, which is a damaging condition known as priapism. (Akash R et al, 2005).

CAUSES OF ERECTILE DYSFUNCTION
ED usually has a physical cause, such as disease, injury, or side effects of drugs. Any disorder that causes injury to the nerves or impairs blood flow to the penis has the potential to cause ED. Since an erection requires a precise sequence of events, ED can occur when any of the events is disrupted. The sequence includes nerve impulses in the brain, spinal column, and area around the penis, and response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa. Damage to nerves, arteries, smooth muscles, and fibrous tissues, often as a result of disease, is the most common cause of ED. Diseases—such as stress, diabetes, high blood pressure, nerve disease or nerve damage, multiple sclerosis, atherosclerosis, and heart disease—account for the majority of ED cases. Patients should be thoroughly evaluated for these conditions before they begin any form of treatment for ED.

Lifestyle choices that contribute to heart disease and vascular problems also raise the risk of ED. Smoking, drinking alcohol excessively, being overweight, and not exercising are possible causes of ED. Surgery—especially radical prostate and bladder surgery for cancer—can also injure nerves and arteries near the penis, causing ED. Injury to the penis, spinal cord, prostate, bladder, and pelvis can lead to ED by harming nerves, smooth muscles, arteries, and the fibrous tissues of the corpora cavernosa. In addition, ED can be a side effect of many common medicines such as blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine, an ulcer drug.

Psychological factors such as stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure can also cause ED. Even when ED has a physical cause, psychological factors may make the condition worse. Hormonal abnormalities, such as low levels of testosterone, are a less frequent cause of ED. Causes of ED could be said to be classified as a)Disorders of desire leading to ED b) Disorder of ejaculation, c) Orgasmic dysfunction, and d) Failure of detumescence.

CONCLUSION
For reasons unbeknown to me, some western doctors contest the relevance of recent advances in the treatment of impotence. The condition can greatly affect quality of life for all concerned. More education is required to counter the considerable misinformation concerning impotence not only among the general public but among doctors, who are often reluctant to discuss sexual matters with the patients. Additionally, more studies are needed to evaluate the clinical value of the biomedical diagnostic tests available and to establish the long-term outcome of medical and surgical interventions. Some doctors dismiss the complaint, and more often than not blame it to old age, but that’s not accurate. If the body is maintained in optimal condition, old age is just a passage of years. It’s like a car, if something malfunction or breaks, what we do is fix it, and little by little we tweek whatever appears and thus keep healthy. Some causes of the dysfunction can be reversed through TCM because Chinese medicine treats the root of the imbalances that present. Most men want a sympathetic interview with a clear explanation of the problem and informed advice about self-administered treatments and all other possibilities. Erectile dysfunction is as old as the ages and the Chinese have explored for millennia how to resolve the issue. Chinese medicine has proven to be an effective resource for the treatment of the causes of the condition. In clinical practice at FullCircle Acupuncture HealthCentre, individual cases usually resolve approximately over the same period of endurance of the ailment since its onset, provided the patient follows the careful and personalized prescriptions of Dr. Osorio.

 

TREATMENTS OFFERED

 

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-Above Article Written by Dr. Osorio, Gloria DAOM, L.Ac. 2011.
-Above Article Revised and Updated by Dr. Osorio, Gloria DAOM, L.Ac. 2021.