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“Sometimes a cigar is just a cigar, but sometimes a cigar is more than a cigar.”
Technically the penis belongs to the genital-urinary system. However, it also belongs to the cardiovascular system and is an extension of the main artery of the body –the aorta — hence the term “dangling aorta.” The take home message of this entry is that if the penis does little more than dangle and does not effectively rise to the occasion, it may indicate a problem not just with the penis, but with the cardiovascular system at large. Erectile dysfunction may be a symptom of a potentially life-threatening cardiovascular issue that should be addressed by a cardiologist in addition to the urologist. In other words, erectile dysfunction may be just the tip of the cardiovascular iceberg.
Men typically have a special bond with their most curious appendage, arguably their most precious accessory. It is truly a remarkably organ in terms of its versatility — sexual, reproductive, and urinary functions — and dimensional changes in its various states. Most of the time it is flaccid, concealed, and low-profile. However, given the right circumstances, our hopefully cooperative friend will readily rise to the occasion and assume the gravity-defying role of “proud soldier,” a term commonly used during my urological residency when I rotated through Children’s Hospital of Philadelphia.
The only other body parts that demonstrate such versatility in terms of physical changes between “inactive” and “active” states are the pupils, nipples, clitoris, and vagina, but the penile changes are most dramatic. Aside from sexual function, the penis provides reproductive capacity via the ability to place genetic material in the optimal locale for egg fertilization. Finally, the penis endows men with the means of emptying their bladders and the luxury of being able to do so in the standing position with laser-like precision (some of us!. It is fair to state that most females are highly envious of this unique male ability.
The penis transitions from dangling to erect by virtue of functioning nerves, arteries, erectile vascular smooth muscle, pelvic floor skeletal muscles, and veins that need to constrict to trap blood. Of these five key components to the erectile process, three involve the vascular (blood vessel) system. If any one or more of these components are not functioning properly, the penis may not be able to do anything more than dangle, although still functioning as a means for urinating in the upright position. For more information on the components necessary to achieve erectile rigidity, see: An Erection is a Symphony.
Sexual function is a good indicator of cardiovascular health since a healthy sexual response is impossible without intact blood flow to the genital and pelvic area. The penis is a marvel of engineering, uniquely capable of increasing its blood flow by a factor of 40-50 times over baseline, this surge happening within seconds and responsible for the remarkable physical transition from flaccid to erect. This surge is accomplished by a dramatic relaxation of the smooth muscle within the penile arteries and erectile tissues. Pelvic muscle engagement and contraction help prevent the exit of blood from the penis, enhancing penile rigidity and creating penile blood pressures that far exceed normal arterial blood pressure. The penis is the only organ in the body where blood pressure needs to be in the hypertensive range for adequate function. For good reason, Gray’s Anatomy textbook over 100 years ago referred to the ischiocavernosus muscle (one of the pelvic floor muscles) as the “erector penis.”
On a simplistic basis, erectile dysfunction can be categorized into defective inflow of blood to the penis and defective trapping of blood. Defective inflow is commonly caused by atherosclerotic fatty plaque narrowing the diameter of penile and other blood vessels. It can also be caused by defective nerve function that does not relay the message to the arteries to dilate, commonly seen after radical pelvic surgery. Analogous to essential hypertension that occurs because of arterial smooth muscle stiffening with aging, spongy vascular erectile smooth muscle also stiffens with aging, inhibiting the smooth muscle relaxation necessary to fill the erectile chambers with blood and compromising the occlusion of veins, leading to venous leakage. The vascular compromise of men suffering with erectile dysfunction is often due to a combination of both arterial inflow and venous outflow issues. The defective inflow of blood can be thought of as insufficient pump pressure to inflate a car tire; venous leak can be thought of as a puncture in the tire that does not allow filling.
Bottom Line: If you are having issues with erectile function– decreased erectile rigidity and/or diminished erectile durability (premature loss of erections) — in addition to having a local urological problem, think about the bigger cardiovascular picture. Erectile dysfunction is a clearcut reason for seeing a cardiologist to potentially diagnose and treat more serious and life-threatening cardiovascular problems that may be initially manifested by altered penile function.
