Nowadays, erection problem (erectile dysfunction, ED, erectile dysfunction) is one of the most common problems. ED is the inability to achieve or maintain an erection sufficient for a normal sexual intercourse. It occurs in varying degrees. There are many causes of erectile dysfunction. One of these is excess weight, that is, obesity. In this article, I will give general information about obesity-related erection problems, their causes and treatment, in the light of our own experiences and current literature.

What is obesity?

Obesity (overweight) is an important health problem in developed countries today. Obesity is a condition in which the ratio of the amount of fat in the body to the fat-free portion increases significantly and the body weight is above normal values ​​​​compared to the height. In other words, the ratio of height to body weight in kilograms, that is, body mass index, is over 30. This condition generally occurs as excessive fat accumulation in the internal organs and around the abdomen.

How is overweight diagnosed?

Body mass index is a frequently used method in practice to diagnose obesity. Body mass index (BMI) is calculated by dividing the body weight in kilograms by the square of the person’s height in meters.

BMI is calculated according to the following formula: BMI= Body weight (kg)/Height in m².

BMI calculated according to this formula is evaluated in 6 classes:

• 18.5 and below Weak
• 18.5-24.9 Normal weight
• 25.0-29.9 Overweight
• 30.0-34.9 Obese (Obese 1)
• 35.0-39.9 Morbidly obese (Obese 2)
• 40 and above Super morbid obesity (Obese 3)

Research on the excess weight problem in our country

Today, obesity is a serious health problem in our country, as it is all over the world. Negative research on obesity and erection has also been conducted in Turkey. The summary of two different studies on this subject is as follows:

• Endocrinology and Metabolism Association Obesity and Lipid Hypertension Group: In this study, more than 10 thousand participants were examined. The results of the three-year study showed that 40 out of 100 women and 20 out of 100 men aged 20 and over had obesity problems.
• Turkish Andrology Association: In this study conducted on 2,760 men over the age of 40, it was concluded that 49% of men were overweight and 19% were obese. In other words, the research of the Turkish Andrology Association showed that 2 out of every 3 men have overweight or obesity problems.

These two studies show that obesity is a serious health problem in our country, as in developed western countries. The replacement of the traditional diet with ready-made, processed and high-calorie foods and a sedentary lifestyle play an important role in this.

What are the causes of overweight?

There are many reasons for extreme obesity, which is a serious health problem in the world and tends to increase in our country. We can summarize these as follows:

• Nutrition with high-calorie foods
• Irregular and wrong nutrition
• A sedentary, sedentary lifestyle
• Metabolic and hormonal reasons
• Psychological problems
• Genetic (familial) factors
• Excessive smoking and alcohol use
• Medication habits
• Wrong eating habits during childhood
• Being overweight in childhood
• Inadequate breastfeeding during childhood
• Age and gender
• Socio-economic reasons
• The risk is high in women with parity and frequent births.

What are the symptoms of excess weight?

Apart from physical appearance, obesity also causes some health problems and complaints in patients. We can list the common complaints about obesity as follows:

• Excessive fat around the waist
• Sleep disorders (sleep apnea)
• Difficulty and difficulty in breathing
• Difficulty during exercise
• The person feels weak and tired
• Pain in joints, back and legs
• Psychological problems, feeling unwell, social isolation
• Heat intolerance
• Complaints due to underlying endocrine cause
• Complaints about sexual life

What diseases can excess weight cause?

Excess weight increases the risk of some diseases. These are important health problems that cause serious health problems and negatively affect the quality of life. We can list these diseases as follows:

• Diabetes (Type 2 diabetes mellitus)
• Hypertension
• Hypercholesterolemia
• Excessive fat in the liver
• Cardiovascular diseases
• Joint disorders
• Sleep apnea syndrome
• Ovarian cysts and menstrual irregularities in women
• Depression
• Some types of cancer
• Penile recession and hormonal irregularities in men
• Sexual dysfunctions in men
• Irregularities in hair distribution

What are the ways to prevent excess weight?

Lifestyle changes are important in patients with erection problems due to excess weight. These people should pay attention to the following points against excessive weight gain:

• Staying away from high-calorie ready-made foods
• Excessive glucose and salt should not be consumed
• Balanced and regular nutrition
• Reducing consumption of carbonated and sugary drinks
• Alcohol and cigarettes should not be used
• Regular sports program
• Consumption of vegetables and fruits should be emphasized.

What tests are requested in patients who are overweight   and have erection problems?

Obesity is a serious health problem that affects all systems. In these patients, we request the tests we use to diagnose erection problems, including endocrinological tests. Generally, we request the following tests for our patients with obesity and erection problems;

• Fasting blood glucose (FBG): Some of these patients have diabetes or latent diabetes. When these patients come with complaints of ED, we definitely request a fasting blood sugar (FBG) test. If diabetes is present, patients must follow a regular diet and take their medications regularly. Diabetics should definitely be seen by an Endocrinologist.
• Cholesterol: Obese patients generally have high cholesterol levels. We request a routine cholesterol profile from these patients. If cholesterol levels are very high, cholesterol-lowering medications are started by the relevant specialist, if necessary. Patients with high cholesterol need to follow a regular diet and exercise program.
• Hormone test: The hormonal system is negatively affected in obese patients. There may be irregularities in hormone balance. In these patients, thyroid tests should be requested as well as FSH, LH, Testosterone and prolactin hormones. For this purpose, TSH, T3, T4 hormones are required.
• Vitamin D3 and B12: Vitamins D3 and B12 play an important role in the erection mechanism. In patients with erection problems, these hormones need to be measured and treated if they are low.
• Penile color Doppler USG: In men with erection problems, there may be narrowing of the penile arteries and insufficiency in the veins. Since the vascular system will be negatively affected due to obesity, penile color Doppler ultrasonography should be performed in these patients. If there is a problem in the veins in these patients, it is shown by penile color Doppler USG.

How does obesity cause erectile dysfunction?

Excess weight causes serious health problems in men. One of these is erectile dysfunction (ED). There are approximately 8 million patients in the USA with erection problems due to diabetes and obesity. The incidence of obesity and diabetes is increasing in our country, and accordingly, an increase in the number of ED patients is observed. Excess weight is a serious risk factor for ED. This situation increases in direct proportion to BMI. Waist circumference is also one of the parameters used in obesity evaluation. Many studies have reported that waist circumference negatively affects erection.

In studies, compared to men with normal BMI, the risk of ED in men with BMI between 25-30 is 1.5 times; This risk was found to be 3 times higher in men over 30.

Obesity-related ED occurs due to the following reasons:

• Hormonal irregularities
• Endothelial dysfunction (cardiovascular diseases, high blood pressure)
• Insulin resistance
• Leptin resistance
• Psychological factors
• Sexual performance anxiety
• Inactivity
• Increased oxidative stress
• Increased chronic inflammation
• High cholesterol
• Diabetes

How to treat erection problems due to excess weight?

Treatment of obesity-related ED requires a multidisciplinary approach. These patients should be investigated for underlying endocrine and metabolic diseases. The patient should definitely be evaluated by an Endocrinology and Metabolic Diseases specialist. Additionally, if there are cardiovascular problems, patients should be evaluated by a cardiologist. Lifestyle changes are very important in these patients. Losing weight is essential to get the desired effect from available treatments. In general, we can list the ED treatment principles in these patients as follows:

• Diet: Our first and most important recommendation to our patients who apply to us with obesity-related ED complaints is to follow a healthy and balanced diet program. For this, it is important to get the recommendations of a dietitian and Endocrinologist.
• Exercise: One of the causes of excess weight is a sedentary life. These patients must start an active lifestyle. After the necessary health tests are performed, exercise programs suitable for the person are applied. It is useful to get professional support for this purpose.
• Quitting alcohol and smoking: Excessive alcohol and cigarette use causes serious health problems. The most important of these is the negative impact on sexual functions. If patients with overweight problems also use excessive alcohol and cigarettes, they should quit these habits. If necessary, it would be beneficial for these people to get support in quitting their alcohol and smoking habits.
• Drug treatment: PDEi5 group drugs used in the treatment of ED are widely consumed. We also recommend these treatments to our patients who are overweight and complain of ED. However, this group of drugs does not show the desired effects in patients with excess weight problems. Studies have shown that these drugs are more effective in patients who lose weight and exercise regularly. Our observations are also in line with this. For this reason, we recommend these patients to lose weight and exercise regularly in order for oral medications used in the treatment of ED to be more effective.
• ESWT treatment: ESWT (LiESWT, shock wave therapy to the penis) treatment is a treatment method that has been used in the treatment of erectile dysfunction since 2010. It is a painless treatment that does not require anesthesia and has no side effects. Its effectiveness is greater in patients with mild and moderate ED complaints. It is also applied and effective in obese patients. Studies have shown that its effectiveness is lower in obese patients than in normal weight people. Therefore, we recommend our patients to lose weight to get better results with ESWT.
• PRP treatment: PRP (platelet-rich plasma) is prepared from the patient’s own blood and administered to the penis. It is thought that PRP causes renewal in the structures responsible for erection in the penis. It is a treatment method in the experimental phase.
• Stem cell therapy: Stem cell therapy is a trial phase used in the treatment of erection problems and many diseases. There is data in studies that this treatment is effective. It can be tried on suitable patients.
• Psychological treatment: These patients also have psychological problems. It is important for patients to be evaluated by a psychiatrist and given appropriate treatment. It can be given to overweight patients, but we do not expect it to be very effective. To achieve the desired effect, patients need to lose weight.
• Food supplements: Food supplements are widely used today. Properly and healthily prepared food supplements can be effective when used in the treatment of ED, but they must be seen by a Urologist. This group of products are not medicines, they are used as food supplements.
• Treatment of co-existing diseases: Problems such as diabetes, high cholesterol and hypertension may occur due to excessive weight gain. These disorders also need to be treated. Treatments that address only the patient’s ED complaint will not be very successful otherwise.
• Obesity surgery: Surgical treatments can be applied to extremely obese patients if the relevant specialist deems it necessary. Studies have reported that erection problems improved in patients who lost weight after such surgeries.
• Penile prosthesis: The last option in the treatment of ED is penile prosthesis surgery. The last procedure to be performed in patients who do not respond to current treatments is prosthesis surgery. The doctor chooses the prosthesis suitable for the patient’s condition.

Conclusion

As a result, obesity is a health problem that seriously negatively affects erectile functions. A multidisciplinary approach is required in treatment. It is very important for patients to lose weight for current treatments to be effective. Erectile dysfunction can return to normal in patients who reach their ideal weight with a regular diet and exercise program. After losing weight, the effectiveness of the drugs used in the treatment of erection becomes greater. In severe cases, obesity surgery (bariatric surgery) may be required. Improvements have been reported in patients after this surgery. The age of the patient and other co-existing conditions (such as high blood pressure, diabetes) are also important in achieving the desired result. Treatments for these diseases also need to be provided.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY