If you want to see major improvement in quality and duration of erections, treatment of ED needs a much broader and more integrative approach\u2014including medication, diet, proper supplements to increase Nitric Oxide production and decrease inflammation\/microvascular damage, the right type of exercise to reduce excess body fat, attention to sleep hygiene, cognitive therapy, and even innovative therapies such as GainsWAVE low-intensity shockwave therapy that uses sound waves to stimulate blood flow and promote healing.\u00a0 That\u2019s why it\u2019s so important to start with an extremely thorough comprehensive medical-endocrine-metabolic-vascular-psychological evaluation to get the most effective help for ED, not just a piece meal approach with either Viagra\/Cialis or Testosterone alone although either or both will often be part of an integrated treatment plan.<\/p>\n
In today\u2019s Health Tip, I want to focus primarily on Nitric Oxide\u2014the tiny molecule that helps coordinate all these pathways regulating the erectile process, because it is one that is often overlooked in medical evaluations. It is beyond the scope and space for this short article to go into detail on all of the physiological pathways and how they work together, and all of the diagnostic testing I use to assess patients in my practice, but you can check out my other articles and seminars in these links for more information, particularly my entire series on testosterone replacement therapy (TRT) in our Faith Over Fear archives at these links:<\/p>\n
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- The Hidden Health Costs of Low T in Men<\/strong><\/a><\/li>\n
- The Hidden Health Costs of Low T in Men: PART II: Health Benefits of Testosterone, studies on Testosterone therapy after successfully treated prostate cancer<\/strong><\/a><\/li>\n
- The Hidden Health Costs of Low T in Men: PART III: Androgen Deprivation Therapy \u2013 Risks and Benefits<\/strong><\/a><\/li>\n
- The Hidden Health Costs of Low T in Men: PART IV<\/strong><\/a><\/li>\n<\/ul>\n
Today I want to explore with our readers what action steps you can take on your own to improve the quality of erections, and what questions and options to discuss with your own physicians.<\/p>\n
Healthy Erections: More Complex Than You Realize!<\/strong><\/p>\n
The human penile erection is a complex process involving the coordinated interaction of vascular, hormonal, neurological, and psychological organ systems. Failure of erectile function can occur from dysfunction in ANY of these areas, and most commonly involves several pathways at the same time. The goal of a comprehensive evaluation is to establish the degree to which physiological factors AND psychological contribute to erectile dysfunction for each patient.\u00a0 There is no \u201cone-size-fits-all\u201d approach, nor is there a single treatment options (medication OR supplement) that addresses all these complex factors in achieving health erections.<\/p>\n
Erections begin with sexual stimulation, but achieving an optimal erection depends on far more than just sexual desire.\u00a0 There are many more interacting factors that must work together in a coordinated way to achieve the neurovascular event of a healthy firm erection. One small molecule helps coordinate this response: nitric oxide<\/strong>, commonly abbreviated NO, that signal the nerves, blood vessels, hormones, and smooth muscle to work together for the erection to occur.<\/p>\n
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If nitric oxide is deficient, hormone replacement therapy AND Viagra\/Cialis may fail to work. This is the \u201cblunting\u201d effect of low nitric oxide. Nitric oxide is necessary for proper signaling in the brain for the nervous system to fully interpret sexual hormone signals. Nitric oxide tells blood vessels and erectile tissue to relax, allowing blood to enter the penis. When the body produces too little NO\u2014or destroys it before it can act\u2014erections become less firm or harder to maintain. Supporting this pathway through exercise, healthy eating and supplementation can help protect and improve healthy erections.<\/p>\n
Nitric Oxide: The Tiny Molecule Master Signal for Erections<\/strong><\/p>\n
During sexual stimulation, nerve endings release nitric oxide into penile tissue. Cells lining the blood vessels, called endothelial cells, also produce nitric oxide and help sustain the response.\u00a0 Nitric oxide activates an enzyme that increases cyclic guanosine monophosphate, or cGMP. This intracellular messenger lowers calcium signaling and relaxes smooth muscle in the penile arteries and the corpora cavernosa\u2014the two principal chambers of erectile tissue. Blood flows into these chambers, which expand and compress the veins that normally drain the penis. This combination of increased inflow and reduced outflow creates firmness.<\/p>\n
In other words, healthy erections require effective relaxation, not simply stronger muscles and that is where nitric oxide plays a critical role.<\/strong><\/div>\nNitric oxide is also the mechanism of action for the popular prescription medications – Sildenafil (Viagra), and tadalafil (Cialis). Each medicine slows down the breakdown of cGMP, allowing the nitric oxide-initiated signal to last longer. These medicines do not primarily manufacture nitric oxide, just makes it last longer. Nitric oxide is the key factor.\u00a0 If you aren\u2019t making enough NO, or don\u2019t have the dietary precursor building blocks to make it, then the medicines alone can\u2019t be as effective as they should be.<\/p>\n
When Nitric Oxide signaling falters<\/strong><\/p>\n
A \u201clack of nitric oxide\u201d usually means reduced availability where it matters, rather than a clearly measurable, whole-body deficiency. The body may produce less nitric oxide, its enzymes may function poorly, or oxidative stress may destroy nitric oxide before it reaches nearby smooth-muscle cells.<\/p>\n
Common causes of endothelial damage and reduced production of NO include the COVID shots, Diabetes, hypertension, smoking, abnormal cholesterol, certain medications, and vascular aging. Diabetes, anticonvulsant\/mood stabilizer medicines plus pelvic nerve injury can also interfere with the nerve signals that initiate an erection.<\/p>\n
ED does not automatically indicate JUST a nitric oxide problem.\u00a0 <\/em>\u00a0As I discussed in our seminars on Testosterone therapy, there are many other contributing causes: medication effects, low testosterone, medical conditions listed above, anxiety, depression, structural changes in the penis and impaired blood retention, to name a few of the common ones.\u00a0 In my medical experience working with men over 40 years of practice, I have found that over 95% of my patients have had more than one cause\u2014many have multiple causes from the list I gave you above.\u00a0 Persistent ED is itself a marker for both early Diabetes and early cardiovascular disease, even before these diseases may have been officially diagnosed.\u00a0 Again, that is why it is so important to have a thorough evaluation before starting any therapy or medication.<\/p>\n
Nitric Oxide Production: Two pathways, different nutritional tools<\/strong><\/p>\n
The body produces nitric oxide (NO) through two complementary routes. Understanding them helps explain why arginine, citrulline, and beet juice are not interchangeable but complement the actions of each other.
Healthy Erections: What arginine research shows<\/strong><\/p>\n
L-arginine supplies the raw material that nitric-oxide-synthase enzymes use to produce nitric oxide. For men with ED, the evidence is encouraging. A 2019 systematic review and meta-analysis included 10 randomized trials involving 540 men found that arginine-containing interventions, using doses ranging from 1.5\u20135 grams daily, improved mild-to-moderate ED compared with placebo or no treatment.<\/p>\n
L-arginine supplements have additional benefits beyond increasing nitric oxide: protein synthesis, ammonia detoxification, hormone secretion, and immune function. Athletes often use L-arginine to increase \u201cmuscle pump\u201d during a workout and for several hours afterward, and to increase in overall workout capacity (muscular endurance) and an increase in post-exercise recovery.<\/p>\n
Healthy Erections: Where citrulline fits<\/strong><\/p>\n
L-citrulline helps replenish arginine. It largely avoids the intestinal and liver metabolism that limits oral arginine availability, and the body subsequently converts it to arginine.\u00a0\u00a0 Arginine is a more direct route and currently has a larger direct ED trial literature than citrulline and is why I chose to use L-arginine in a sustained release form for the Truth for Health store\u2019s TruNitric Oxide SR\u2122<\/a>.<\/strong>.<\/p>\n
Featuring TruNitric Oxide SR\u2122.<\/strong><\/p>\n
TruNitric Oxide SR\u2122<\/a> <\/strong>offers a sustained-release arginine alpha-ketoglutarate formulation that supports circulatory and cardiovascular health, as well as muscle function and adaptation to exercise. Its defining feature is the sustained-release delivery design. Rather than presenting arginine only as an immediate-release ingredient, this formulation releases it over time. This provides a different delivery approach\u2014to prolong bioavailability of L-arginine to make nitric oxide.<\/p>\n
TruNitricOxide SR\u2122<\/a> also contains ACTINOS2<\/strong>, a mixture of both high- and low-molecular weight fractions of proteins and peptides that activate nitric oxide synthase (NOS) activity which boosts nitric oxide production, enhances transcription of the NOS gene and supports its role in reducing the negative feedback mechanism for nitric oxide production.
\nStudies found ACTINOS2 increases nitric oxide production in human endothelial cells in vitro from 9.5 to 12.7 times compared to a control<\/em><\/strong>.<\/p>\nI also selected our TruNitricOxide SR\u2122<\/a> product because it is manufactured in the United States using the highest purity (>98.0%) of commercially available L-arginine alpha ketoglutarate.\u00a0 This formulation is designed to deliver L-arginine alpha ketoglutarate in a controlled manner over a period of approximately 4-6 hours.<\/p>\n
Healthy Erections: Food and Lifestyle Foundations<\/strong><\/p>\n
The strongest nutritional strategy is not a single \u201cerection food.\u201d It is a dietary pattern that supports the cardiovascular and metabolic systems on which erections depend.<\/p>\n
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- Mediterranean-style Meal Plans: The Foundation<\/em><\/strong><\/li>\n<\/ul>\n
A Mediterranean-style pattern emphasizes vegetables, fruit, legumes, whole grains, nuts, fish, and olive oil while limiting frequent processed meats and heavily refined foods. Research links this pattern with lower ED risk, and selected intervention studies suggest improvements in erectile function.
\nA 2020 cohort study followed 21,469 men<\/strong>. Among men younger than 60, those with the highest Mediterranean-diet scores had a 22% lower relative risk of developing ED than those with the lowest scores. Another study, a two-year randomized trial involving men with metabolic syndrome and ED also found improvements with a Mediterranean dietary intervention.<\/p>\n- \n
- Mediterranean Foods that Support Healthier Erections <\/strong>
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\n Note: The evidence is strongest for combining these foods consistently.<\/p>\n - \n
- What about beets, cacao, and watermelon promoted as \u201cnature\u2019s Viagra\u201d<\/em><\/strong><\/li>\n<\/ul>\n
Beet juice<\/strong> can increase nitrate and nitrite availability and modestly reduce blood pressure in some people. However, a standardized nitrate product provides a more predictable exposure than random servings of juice which can depend on many other factors including brand quality, other added fruit juices and sugars, etc.<\/p>\n
Raw or natural cacao<\/strong> provides flavanols that can support endothelial NO signaling. Processing matters: alkalization, also called Dutch processing, substantially reduces flavanol content.<\/p>\n
Watermelon<\/strong> contains citrulline, but ordinary servings are not equivalent to the measured supplement used in a clinical trial. Calling watermelon \u201cnatural Viagra\u201d overstates the evidence.<\/p>\n
These are certainly healthy foods, and the beet juice supplies the clearest NO-related mechanism but may not be an effective ED treatment alone.<\/p>\n
The Many Benefits of Exercise on Healthier Erections:<\/strong> it matters more than you think!<\/strong><\/p>\n
Aerobic exercise has direct evidence for improving erectile function. Trials commonly use 30\u201360-minute sessions, three to five times weekly. A practical goal is approximately 150\u2013160 minutes each week, built up gradually. Brisk walking, swimming, and other comfortable aerobic activities are a good way to start.\u00a0 Consistency is the most important part of any exercise routine. Resistance training can complement the routine, but aerobic exercise has clearer direct evidence for ED
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\nBut there are many other frequently overlooked benefits of resistance (weight training) with aerobic exercise to help improve erectile function via other pathways.\u00a0 Here are just a few:<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n
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\n Dr. Vliet\u2019s Guide to Additional Exercise Benefits for Healthy Erections<\/strong><\/p>\n - \n
- Exercise increases loss of body fat that decreases testosterone action due to the estrone in body fat that increases sex hormone binding globulin and lowers free testosterone.\u00a0 <\/strong><\/li>\n
- Exercise increases muscle mass that adds another dimension to healthy testosterone production<\/strong><\/li>\n
- Exercise lowers inflammation and improves blood flow and nitric oxide production \u2013 benefitting penile blood flow to sustain erections.<\/strong><\/li>\n
- Exercise increases physiological relaxation that helps improve sexual arousal and helps reduce performance anxiety<\/strong><\/li>\n
- Exercise helps improve self-image with improved body composition and fitness, which in turn helps improve self confidence that can improve performance.<\/strong><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n
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\n Lifestyle strategies to Improve Erectile Quality<\/strong><\/p>\n Steps YOU control and can take now include these lifestyle strategies:<\/p>\n
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- Stop smoking (both tobacco and marijuana impair erections via different pathways and mechanisms)<\/li>\n
- Reduce heavy alcohol use (or cut it out completely for six months and observe the benefits!)<\/li>\n
- Set up a regular exercise program<\/li>\n
- Lose excess body fat<\/li>\n
- Monitor blood pressure and blood glucose levels<\/li>\n
- Improve sleep hygiene, and establish a regular sleep-wake cycle<\/li>\n
- Evaluate suspected sleep apnea, especially when loud snoring, witnessed breathing pauses, or marked daytime sleepiness occur. Sleep-apnea treatment can improve erectile function in some men.<\/li>\n
- Nasal breathing and humming are other interesting lifestyle strategies that have become popular lifestyle \u201chacks\u201d but do have some credibility. Both nasal (and not mouth) breathing and humming increasing locally produced sinus nitric oxide that reaches the lungs. That is a real physiological process, but unfortunately it does not establish that nasal breathing or humming treats ED or substantially increases penile nitric oxide availability.<\/li>\n
- Meditation, prayer, and relaxation training all help reduce lifestyle situational stress that can impair erections<\/li>\n
- Relationship enhancement: take time for \u201cdate nights,\u201d set aside time for focused foreplay to enhance sexual arousal and relaxation.\u00a0 Work with a couples\u2019 therapist if significant marital conflicts are affecting performance for both partners.<\/li>\n<\/ul>\n
Lifestyle benefits usually unfold over months to years. Exercise trials have typically assessed outcomes over several months, with a median intervention duration of six months. So don\u2019t give up if these strategies don’t show immediate improvement! \u00a0This is a marathon, not a sprint, and the changes you make now will have lasting benefits over many years!<\/p>\n
Correct deficiencies, don\u2019t just take supplements randomly<\/strong><\/p>\n
I know friends suggest new supplements, and guys at the gym are also talking about the latest gimmick to \u201cbuild muscle\u201d or \u201cboost\u201d sexual function. But you have to remember that nutrients help maintain normal hormone and metabolic balance and function, but supplements works most effectively when correcting a genuine deficiency. Adequate sleep, exercise, healthy meal plans (making sure you get the precursors needed for the body to make critical components like Nitric Oxide and your own testosterone!), weight management and stress management are the crucial foundations for your overall health, as well as healthy erections.<\/p>\n
Clinical studies have found that nutraceutical effects to increase production of testosterone are generally modest and do not consistently translate into meaningful clinical benefits unless treating a documented deficiency demonstrated on reliable blood tests.
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- Exercise increases muscle mass that adds another dimension to healthy testosterone production<\/strong><\/li>\n
- Exercise increases loss of body fat that decreases testosterone action due to the estrone in body fat that increases sex hormone binding globulin and lowers free testosterone.\u00a0 <\/strong><\/li>\n
- What about beets, cacao, and watermelon promoted as \u201cnature\u2019s Viagra\u201d<\/em><\/strong><\/li>\n<\/ul>\n
- Mediterranean Foods that Support Healthier Erections <\/strong>
- The Hidden Health Costs of Low T in Men: PART II: Health Benefits of Testosterone, studies on Testosterone therapy after successfully treated prostate cancer<\/strong><\/a><\/li>\n