127. Erectile dysfunction part 1: Medical considerations with urologist Dr. Chris Bitcon

In this episode, I discuss with Kelowna based urologist Dr. Chris Bitcon:

• What is erectile dysfunction (ED)? 
• At what point does it move from a temporary issue to a condition requiring a doctor's visit?
• Primary causes (prostate treatment, vascular, hormonal, neurological, psychological)
• What can you do before you go see a urologist?
• Treatment options

Dr Chris Bitcon is a practicing Urologist in Kelowna. Dr. Bitcon grew up in Kelowna and is the epitome of a BC boy: involved in every sport under the sun and loves being outdoors.  He completed medical school at UBC’s Island Medical Program in Victoria and urology residency at Dalhousie University in Halifax. He went on to complete a co-fellowship through the University of Toronto, specializing in both minimally invasive/robotic surgery as well as pediatric urology. Though he has two sub-specialties, he remains passionate about being a true general urologist and treats all urologic conditions.

EPISODE 128 will be PART 2 of this episode with Justin Paulsen (Psychotherapist/Couples Counsellor/Clinical Sexologist)

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Thanks for joining me!
Here is where you can find out how to work with me:  www.pelvicfloorprojectspace.com/

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Transcript

SPEAKER_01 0:00

Welcome to episode 127. This one is for the men, a two-part episode about erectile dysfunction or ED. There's a topic we don't hear people bring up at work, at the dinner table, out for a beer. Let's shed some light on it because that's what this podcast is all about. Helping you understand your body and knowing your options because knowledge is power. Erectile function is not determined by just a single factor, but by the interaction of multiple body systems, including, for example, the brain, nervous system, blood flow, hormones, and the pelvic floor. Understanding how all of these pieces work together is key to understanding why dysfunction happens in the first place. When someone's experiencing ED, we have to zoom out and ask, what factors are at play for this individual person? Joining me today is Dr. Chris BitCon, a Kelowna-based urologist, to discuss what factors can cause ED and what actions you can take before you see a urologist. Because let's face it, it takes a long time to get in to see a specialist. But you'll hear Chris talk about many treatment options that don't involve just medication. Then I'll follow up this episode with episode 128 with a sex therapist who will explain the psychosocial and emotional factors that play such a huge role in erectile dysfunction. Okay, let's get going first with Dr. Chris BitCon. I'll be right back. Listeners, have you ever heard of the benefits of using a high quality compression garment during pregnancy, after birth, or to address feelings of vulnerability, maybe in your tummy, or heaviness in your undercarriage? Did you know the evidence tells us that using these garments can decrease pain, ease apprehension, and increase the ability to move with comfort in your day if you have these unwanted symptoms? I'm grateful to have SRC Health as a podcast sponsor, and I want to take some time to tell you about their high quality products. Using a revolutionary fabric created by medical professionals, SRC has designed a line of compression shorts and leggings that are made to support your back, tummy, and pelvis in pregnancy or help you feel less pain and more confident with movements as you recover after pelvic surgery or birth. Their products have also helped many for symptoms like incontinence, diastasis, and prolapse. I also have to add that their customer service is like no other because they stand behind their products. To check out their full line, use the QR code provided in the show notes, which will automatically provide you with 10% off site-wide. Doesn't your mind and body deserve the support? All right, Dr. Chris BitCon, I'm so thankful that you're spending some time with me on the weekend talking about work. Um I have been meaning to cover the episode of erectile dysfunction for a while. I always I have this running list of ideas. I find that it becomes something that when enough people are coming in and I uh think, I don't have an episode on this. I just have a list, and when a guest comes up, I just try to roll with it. And before we get going, I think kind of as a pelvic health physio, I don't get many times that a man comes in to see me and says, I'm here for erectile dysfunction. I find that more often it's, you know, issues with urinary symptoms or maybe pain, what might be the primary reason they're coming in. But then when I ask questions and I show them, I use a lot of images to help people understand and show them, okay, here's your bladder, here's your pelvic floor. Um, your pelvic floor is also related to your bowel movements, your pelvic floor is related to your penis. Um, and that's when then I might say, Are you having any issues with your erectile function? Actually, and that's where this comes in. And so I thought it would be great to do a two-part episode where you and I first talk about some of the medical considerations that have to do with erectile dysfunction or ED, I'm gonna start saying eventually here. And then the episode after, I'm doing with um a therapist who works in with sex therapy and can talk more about the emotional or psychological aspects that are going to come alongside this most of the time. So I had been hearing, we have such a great group of urologists in Kelowna here, and I was hearing your name more and more of this new urologist that we have in town. Um that, and he was very kind. Everybody said he's so kind. And so I thought, well, then if he's kind, he'll probably say yes if I ask him. So he's a puffover. So, um, so I'm I've heard great things and and and really have appreciated get to know you in this short amount of time. And I'm gonna ask you before we get going here, Chris, would you take time to introduce yourself to our listeners?

SPEAKER_02 4:57

Yeah, so uh my name's Chris Bitcon, a new urologist uh here in Kelowna. I actually grew up in Kelowna, so it's uh amazing to be back home and um you know providing care to the community that gave a lot to me. Uh I did uh medical school in Victoria and then I went out to Halifax for my residency for five years, and then I stopped in Mississauga for uh fellowship in is actually an interesting fellowship. It's in uh it's a co-hybrid fellowship. So I I did uh robotics, uh minimally invasive surgery as well as pediatrics. So my patient population is very diverse. I accept basically anybody from the newborns to you know 90 plus year olds. And uh in a week it's it's nice because I'll, you know, maybe I'll be fixing up a two-year-old in the operating room, and my very next case will be, you know, potentially his grandfather who I'm helping with his enlarged prostate or something like that. So it's a very nice, uh, you know, diverse practice. And you know, I um yeah, so a little bit about me. Uh I have a wife here in Kelowna, and we have a young son, and uh, we're just looking forward to enjoying being back and and uh you know enjoying what the Okanagan has to offer.

SPEAKER_01 6:09

So well, we're lucky that you came back. Can you kiss so obviously to I I I like to think of a patient sitting in front of me or sitting in front of you and think of um what they're coming in for. Can you talk a little bit about, like you said, you kind of see a bit of a mixed bag, but can you talk a little bit about how erectile dysfunction comes up? Like what are some things that people will say to you that make you think that this is an erectile function issue?

SPEAKER_02 6:38

Yeah, I mean, being a a specialist, to be honest, we have kind of the luxury of the family doctors have already sorted out the main issue that somebody has, whether you know it's erectile dysfunction or like you mentioned earlier, some urinary issues. So by the time you know they've discussed their general health with the family doctor, um, they they usually get referred to us specifically for erectile dysfunction, right? Um so they they typically are coming in any and most of the time they're coming in to see us because they've already failed first-line treatments or lifestyle changes or those sort of things. Um so you know, yeah, to be frank, it's it's usually they come in and say, I'm having problems with my erections.

SPEAKER_01 7:24

Will you be a little bit more specific? Like, what would be some of the things that they might complain about? Like um, what specifically would someone notice?

SPEAKER_02 7:34

Yeah. So uh maybe I'll back up a little bit. So we define erectile dysfunction as the um the inability to either achieve or maintain an erection that's sufficient for sexual performance. Um, the other thing that I think, so that's kind of our standard urologic definition of erectile dysfunction, and you know, the amount of time an erection needs to be achieved or maintained, is different in every partnership, right? Um, and the other thing, even probably more important, is what does sexual performance mean to the individual and to the couple, right? Some men may not need an erection that lasts for all that long because them and him and his partner, whatever the relationship may be, maybe foreplay is actually what's more important to them, or the intimacy and the cuddling and and and so. But you know, in I think in general society, we think of erect erections or erectile function as the ability to achieve an erection that's rigid enough for penetrative intercourse, um, and um being able to maintain that to the point where both partners have achieved an orgasm is is you know um kind of what society has deemed a rectile function. Um but yeah, like I said, the so to answer your question, men will come in and they'll say, really, they're they're either one of those two issues. So either they can't achieve an erection at all, uh, or they can achieve an erection, um, but it doesn't, you know, it it isn't sustainable, they can't maintain it enough uh or long enough uh for penetrative intercourse.

SPEAKER_01 9:13

Um also sometimes accompanying pain. Like would you say how often do people come in and say that's their primary issue, is that there's pain with that?

SPEAKER_02 9:22

Uh not that common. Um usually if someone's coming in with pain with erections, they often are also being referred for something called pyrones, so curvature of the penis. Uh it's not, I I would say it's infrequent that they come in purely with pain with erections. Um, there are some times where we'll get referrals with pain with ejaculation, which is a little bit different, but pain purely in the, you know, in the shaft of the penis or the head of the penis, usually uh in the majority of patients is accompanied with new nuance at penile curvature in general. Yeah, not not always, but in general.

SPEAKER_01 10:00

What do you um I think is something you said I think is so uh uh interesting too, because I think this isn't something we usually talk about with friends, or I don't think men usually talk about with friends. And I think sometimes there's a kind of like a an expectation, like I should be able to have an erection this long, like you said. And I think we we don't we don't have a certain um like length that is like a gold standard of how long you can maintain an erection, but I think this is where a lot of people come in and they're just like, I just assumed it wasn't long enough. Um, but then when I think about it, it's long enough for like you said, my relationship. So I think there's sometimes a lot of this too of just I'm not sure what's normal.

SPEAKER_02 10:40

Yeah, yeah, or it comes up in and sometimes we're discussing with men and they say, Oh, yeah, I can achieve an erection. We have intercourse, we both orgasm, but when I was 30, I could go like three rounds and not lose my erection. Now I can only go one round and lose my erection. So, you know, there's some expectation setting uh, you know, in in the office. And uh again, it's okay, well, do you and your partner, you know, you guys are 77. Do you need to go three rounds, you know, or is one round enough? Are you both happy? And you say, Yeah, and I'm like, okay, well, you know, then you've already kind of answered your question. We probably don't need to do that much for it, right?

SPEAKER_01 11:18

What do you expect if someone, because obviously someone has to go through their family doctor before they come to see you, what do what kinds of things do you expect they're already kind of going through with their GP? Like when you say they've already kind of gone through that gatekeeper, um, yeah, what what would you assume has been done already?

SPEAKER_02 11:36

Yeah, so in you know, when whatever you read about erectile dysfunction, and you'll hear a lot that it's a marker for cardiovascular risk, cardiovascular disease. And so I think as well, our our first expectation is that they've kind of had a risk, uh cardiac risk assessment by their family doctor. Um they've had basic investigations done. They've had they've been checked for diabetes, and they've been checked for what we call dyslipidemia or abnormalities in their cholesterols that could be leading to you know, plugged arteries, uh, that sort of thing. Um, so we typically would expect a family doctor to evaluate them for the medical conditions that are potentially reversible or or manageable that may improve erectile function. Um we also assume that they've been canceled on diet, you know, um healthy diet, increased exercise, uh, you know, stopping smoking, reducing excess alcohol intake, reducing excess cannabis uh intake, and then once they've done done kind of the basic lifestyle and and dietary things, um, then typically most men will have been tried on um, you know, something like Viagra or Cialis or Levitra, what we call PD5 inhibitors. Um those are kind of the first-line medications that most people uh will have tried before before they come and see a urologist.

SPEAKER_01 13:01

Can you talk a little bit about those?

SPEAKER_02 13:04

Yeah, so maybe um and maybe we'll kind of back up because some I think understanding how erections even take place in the first part is important, and um, and I use a lot of analogies and usually they're off the cup. I kind of make them up as I go, and sometimes they land and other times they don't land. Sometimes they're really good, and other times you just like you throw it right past the patient and it hits the wall and they don't even budge. And you're like, okay, whoops. Um, but so uh I'm gonna back up. So the the kind of the sexual response cycle is is something that's important because it comes up a lot in our office around is what do we think is actually the cause of the erectile dysfunction in the first place. So um we talk about these four phases of the sexual response cycle, which is first desire, uh, which is in the brain. So if you're not interested in having sex, uh you're not, you know, hopefully you don't get an erection. Uh if you're out grocery shopping and you're not thinking about sex, there's no point in having an erection while you're you're doing you know in the grocery store. People will will, you know, uh you'll freak people out when that happens. So there has to be this desire and it has to be an appropriate setting to take place for you to have uh an erection. So the desire needs to be there. And the desire is what we talk about libido, right? The libido, are you interested in having sexual activity? Uh, then there's the arousal phase, uh, which is typically sexual stimulation, either self or with a partner. Uh, then there's the orgasm, and then there's the resolution, which is um, you know, typically we think of like the classic cuddling after you have sex sort of thing, right? Um, and then just calming down of all the functions and the physiologic changes that take place during um sex. So um so the very first thing is the neural input. So um the before you even get to blood vessels, everybody talks about the blood vessels and the cardiac risk factor, but there's nerve input that goes into achieving an erection. And there's two, technically three, but there's two major neural um pathways that are taking place during sexual activity and specifically with erection. So um there's this classic rest and digest nervous system, which is called the parasympathetic nervous system, uh, which needs to be active in order for somebody, uh in order for someone to be able to achieve an erection. Then there's the counteract to the parasympathetic nervous system, which we think of, or what we classically call the fight or flight nervous system. Um and so if you're if you're sympathetic, this fight or flight nervous system is too active, um, you're not going to be able to achieve an erection. And this is what I tell men that if you're in this fight or flight state, uh if you're running away from a tiger, right back evolutionarily, if you're running away from a tiger, you don't need to have an erection. That doesn't make sense for that to happen, right? Um, and so the so the parasympathetic nervous system, which is the rest digest, we're happy, we're relaxed, we can focus on on you know the finer things in life because we're not running away from a tiger. That needs to be present in order to even for any of these pathways to even start in the first place. Um like I said, there is a third, which is the uh pudendal nerve, which is you'd be able to talk to patients more about that. Um, but that helps with main maintenance of uh rigidity and then as well as uh ejaculation. But so the most important thing is the parasympathetic nervous system for even being able to achieve an erection in the first place. And the parasympathetic nervous system acts on the blood vessels, uh which allows for dilation of the arteries in the penis. The penis gets engorged, uh, and then you have this very neat evolution. I mean, the body is uh is an amazing thing, but you get this increased flow of blood into the penis, and then the veins, just by nature of the way that the penis is made up, uh, the veins actually get occluded and prevent the outflow of blood, uh which is allowing to maintain the rigidity of the erection. Um, there is some hormonal control that takes place. Everybody thinks if they have erectile dysfunction, they have testosterone deficiency, which is typically not the case. Um, testosterone is important for uh mainly for libido, to be honest with you, um, interest in sexual activity. Um, it does work a little bit on um some of the finer mechanisms that are taking place in the uh in the blood vessels, but it's it's typically not a big, uh not a big contributor. So, but anyway, so the the important thing is that to be able to have an erection, one, the the mindset needs to be appropriate, number one. So you have to have your parasympathetic nervous system active, and you need to have the sympathetic nervous system inactive. Um, you need to have the ability for your blood vessels to respond to that nervous input, and your blood vessels have to dilate appropriately, um, and uh and then you have to be able to occlude the outflow of blood. Um, and uh yeah, so that's that's kind of the basic um kind of physiology behind erection. So then where does to answer your question, where do you first of all I can cut you off and say beautifully explained?

SPEAKER_01 18:01

I think that that's I think that that is um such an important part of um like what we do for our patients. I think sometimes when you just explain that, they'll be able to tell you this is my problem, right? Don't you think? When you explain how the natural system works and and then they can um um, okay, I think maybe my messy divorce or something like that is affecting my um like at the level of the brain, right? And and I think this is where um I'm gonna let you kind of talk about the medications now because I think it's so common that like I just need a medication for it, and then people are frustrated when the medication doesn't work. But when you don't understand the cycle, the medication just might not be working at the like where you need the help in the cycle. So beautifully explained.

SPEAKER_02 18:49

Yeah, well, I think you bring up an important, you know, yeah, we go into the, you know, we can go into the medications and the treatments, but the you know, the big thing with erectile dysfunction is the history, right? Um, you know, we can go into there's a whole bunch of different what's the etiology or what's the cause of this erectile dysfunction. Um, and you know, sometimes when I'm in the office with patients, I'll you know, we'll do the history, we'll talk about the options, and they say, Oh, you know, don't you want to do any of those fancy tests? And we can, you know, there's these things like nocturnal um tumescence thing, is basically like you put the a blood pressure cuff on the penis overnight, and it can help you determine what the cause is. You can do these fancy Doppler ultrasounds of the penis. Um, but if you do a proper history, uh, number one, we don't do pretty much anywhere unless you're at an academic center, you're not gonna get these fancy tests down or unless you're down in the States. Uh, but then number two, really it's only gonna answer questions that you could have just asked the patient themselves, you know, do you wake up with morning erections? Yes or no? You know, um are do you have are you able to masturbate when you're alone? Can you masturbate? Can you get an erection? And can you, you know, do you have an orgasm when you're alone? Yes, okay. Then you do have normal erections, right? And it's more of a situational problem. Um, I always ask about life stressors. Has it have you recently uh had a divorce or change in partnership, new child, um, change in work, uh, a big health diagnosis? Have you or anyone in your family been diagnosed with any new health conditions? And oh yes, you know, my mom actually got a very, you know, she now has Alzheimer's and it's really we don't know how we're gonna get her into a home and she's really declining, and you know, and it's like, okay, then this is probably more psychogenic, and I, you know, probably don't need to give you a pill, you probably counseling is probably what's gonna help you out the most, right? So um, yeah, so before we even get into the medications, you know, I think that's I think that's the benefit of obviously coming and seeing a specialist is that we have a very we've been trained um to ask very specific questions. And some patients, you know, maybe say, oh, they don't, you know, maybe you guys don't take enough time with us, and and uh, you know, it's like, well, we're just we're trained to see so many people, we have so many, you know, patients waiting to see specialists that we really just hone into, okay, can we get down to the root of the problem, um, figure out exactly what's going on, uh, and then you know, do treatment that we think is gonna help you out the most, right?

SPEAKER_01 21:12

I think that's where that's what I was gonna say. And one of the reasons why I love to do these episodes because I know your time is limited in your appointments, and I think people go in with an expectation that I think that you're gonna give them a pill, I think a lot of times or a test because they're gonna you're gonna be able to diagnose the problem and give them the the option. And I think that um when if someone comes in and could what can you give me an idea of like a typical appointment time? Like what what you have a uh what time do you have to explain all this to someone?

SPEAKER_02 21:46

Uh first visits, new consultations. Most urologists have a 15 minute consultation.

SPEAKER_01 21:52

If they come in with a preconceived notion that you're gonna do a test and give a pill because they have a diagnosed of a diagnosable problem. And then you have to somehow flip gears and talk to them about the sexual response cycle can be kind of hard, right? And so I think sometimes if um, like let's say, because a lot of times I will see someone that maybe is waiting to see you. They've been referred, and someone tells them, like, there's a lot going on on Google now. People say go see a pelvic floor physio, or their friend tells them. So they come in, they're still waiting to see you. Um, I might ask something where they feel comfortable telling me that yes, I have erectile dysfunction. And now, how helpful is it if I can give them this and they can go into your office if they still plan to go to their your appointment, kind of being like, okay, I kind of have an idea of what he might talk about. And I've thought about this before I go talk to him or something like that. Yeah, because I think that I find a lot of times if they come in and say, I'm having this symptom, and I start asking questions around their, you know, their stress or um their nervous system and talk about their nervous system, I think sometimes I find that I'm uh they're on the defense there, kind of like, you don't know, I haven't seen the urologist yet, or do you know what I mean? Totally. Yeah.

SPEAKER_02 23:09

So very helpful. For sure. And I you know, I think I don't think there's any, I don't I wouldn't think that you were overstepping your boundaries by any means asking those questions to patients. You know, and the other thing is that like you mentioned already, is that um in someone like your profession, erectile dysfunction often can come up as a secondary thing. You know, if someone has chronic prostatitis, chronic pelvic pain, uh, chronic testicular pain, we've seen a lot of patients that have intermittent or chronic or calgia, chronic testicular pain, to see a pelvic fluorophysiotherapist, that's like step one in our guidelines is pelvic fluorophysiotherapy. Um, and those those conditions, um, you know, if you have stuff, if you have issues that are going on with the remainder of your urinary tract, again, it like we said, with that desire cycle, it can be very hard to be interested in having sex if you have pain down in your pelvis, because probably having intercourse is going to precipitate the other issues that you're already dealing with. So I think, you know, I I I think there's no problem with you either offering some, you know, basic advice on erectile dysfunction management or you know, you're you're a healthcare professional, right?

SPEAKER_01 24:16

Yes. So and and and at the end of the day, like I have uh we all are different in how we set up our times, but I have 45 minutes to um explain this um to people and you know get them get them thinking about things. And and I think it's hard for them not to think there's something wrong with me, but then when you explain the cycle and explain the anatomy, it's like there's nothing not necessarily something wrong with you, but maybe more like the stress that you're experiencing, like you said, your your nervous system's responding appropriately to stress is just not conducive for a good erection, perhaps. Totally.

SPEAKER_02 24:53

Um and the other thing in the sorry, and the one the one thing that I forgot to maybe clarify is that the the so the parasympathetic nervous system, like I mentioned, is uh uh what helps stimulate the erection, but the s parasympathetic nervous system kicks in or the sorry, the the sympathetic nervous system, the function of the sympathetic nervous system with respect to the whole cycle, um the uh the sexual cycle is uh ejaculation and then detumescence, so losing your erection. So the sympathetic, that's what once you have a uh ejaculated and sex is quote unquote over, uh you don't need to be walking around with an erection. Again, you're going to the grocery store after having sex. You don't need you shouldn't have an erection anymore. Um and so we we know the sympathetic nervous system, uh, its purpose is to get rid of your erection. And again, if that's too high, it's per it it's in that state of no, we're not getting an erection, right? Um yeah, so that that's anyways, I forgot to mention that.

SPEAKER_01 25:55

Yeah, and I think that it's um I actually think I might just kind of talk about physiotherapy just a little bit more for a second, because then I want to go back to some of the options that you'll provide. I think because a lot of people hear pelvic floor muscle training. Like go see the physiotherapist for pelvic floor muscle training, and sometimes that term is just not doing it justice because I think most people assume we just teach Kegels. We we teach Kegels, we're gonna teach them to tighten. And um that is muscle training, I think, of so many different things. Sometimes it's coordination, sometimes it's learning to let go, sometimes it's learning how to um how your pelvic floor is related to your breathing and your posture and the way you exercise and and and things like that. It's so much more than than just kegels. Um, because I do find a lot of people will describe that they're trying to make their erection, like they're trying to get more power in their muscles to make an erection and sometimes just the explanation and you have to allow an erection. That's that kind of change, like, oh my gosh, I think I was trying to make it, like I was I was trying to make it come instead of let it come. And then again, the next episode that follows this, we go into so much more detail around just the psychosocial aspects and and the the lack of learning we get around a lot of this. I mean, most of our learning is from TV, which is just not an an accurate depiction of how this the cycle works, and and obviously the porn ruins it for a lot of men. Yeah, and just honestly, just the differences in partners, you know, what worked for your last partner doesn't work for this partner, or or you know, there's just so many things at play there that allow us to feel desire, allow us to feel arousal. Yeah. Yeah. That a pill can change.

SPEAKER_02 27:46

Yeah, and I think that for a lot of conditions, the pill thing, um, you know, I I we all everybody goes in to be a doctor to help, you know, to help patients. That's why we do what we do. Um, and I think there is an expectation that everything's treated with a pill. Um, I, you know, if I if I'm seeing a patient who you could offer a pill, or we could instill long-term self-regulated or managed um treatment options out there, that's way better for patients, right? You have side effects of medications. You go on a medication, you have side effects, then you need another pill to manage that side effect. Okay, then that pill that you're managing a side effect of another medication also has a side effect, and then before you know it, it's like this cascade of three, four, five different pills. And it's like, well, you could have just gone and done, you know, lifestyle changes and some physiotherapy, um, and we probably could have avoided a lot of this stuff, right? Polypharmacy comes up a huge, you know, all the time in medicine, right?

SPEAKER_01 28:47

So let's say that um, best case scenario, someone gets the information, like you said, lifestyle changes. Um, maybe they talk to a physio, they talk to a counselor and they start kind of figuring this this out, the cycle and how it works between them and or them and their partner, um, but they're still having issues. And I can think of some different situations like um people that have had back injuries, for example, where the the nerves are affected, um, lots of times after prostate cancer treatments, where like we do have to consider things like medications um or things like that. So can we talk a little bit about now? Um, because we I think we're saying like first line, you can do a lot of things without medication, but can we go into a little bit more some of those options now that that are out there in the event that that's not enough?

SPEAKER_02 29:40

Yeah. So the and and maybe I'd say the reason why uh we would I don't know, not necessarily expect, but the our first line lifestyle changes is the reason we we assume that that's been talked about and that's kind of first-line stuff, uh, is because uh the most common cause of erectile dysfunction is vasculogenic or vascular issues, uh, which is typically precipitated by obesity, um, diabetes, smoking, um, you know, those sort of uh hypertension, um, so those sort of things. And so that's you know, diet, increased physical activity, aerobic activity, uh important for blood vessels, uh, and cardiovascular health, uh, stopping your smoking, um, minimizing alcohol consumption, uh, lowering cannabis use, um, that sort of thing. And that's that's the reason why, is because of vasculogenic is is the most common cause that we see in uh you know as the culprits. So whenever I'm uh talking about uh the treatment options with patients, again, I always talk about the dietary, the lifestyle things as as important and uh something that they should do for their overall health. Again, because erectile dysfunction is usually uh a marker of cardiovascular disease. If they can make those changes, not only will it potentially be beneficial for their reactions, but probably best for their overall health, right? Um, so when I'm doing a counseling session on the various options uh for treatments, I go uh I kind of set the stage. Okay, I'm gonna talk about all of your options. You tell me which is gonna be most conducive to your life, right? Um and everybody's situation is a little bit different with respect to how much time do they have available to set the stage for sexual activity to take place. Because some of the options that we have take a little bit more time before either the medication or the treatment becomes active or the penis is ready for sexual activity. So uh yeah, I say we go, here's your options. We're gonna go least invasive to most invasive. You tell me which one sounds best for you. We can try that for a little while. We'll re-convene and see if we need to change up what we're doing. So um, least invasive but super effective is something called a vacuum-assisted erection device. Uh, a lot of the, again, because it's older men who we're typically seeing, not always, but most of them know Austin Powers do is they they put the penis, uh, make sure that they have a good seal up against the pubic bone, and uh you activate the device. Now, the devices, there's different models. Uh, there's the manual inflating or manual inflation, uh, where you would manually uh use a pump basically, and and what the pump is doing is providing negative pressure to suck blood into the penis and engorge the penis. Uh there are other models that have a little compressor built in that you can just press on and it'll automatically provide the suction to inflate the uh or engorge the penis. Once the penis is engorged, the patient would then put a what's called a penile constriction band on at the base of the penis, which helps simply just hold the blood in the penis, right? Um we say that you shouldn't leave the constriction band on for more than 30 minutes to provide uh to avoid uh any we call ischemic or lack of new blood flow damage to the penis. Um, but they're very effective. 90% of patients who use it, regardless of what the cause of the erectile dysfunction is, will have an erection that's rigid enough for intercourse. Uh not great for spontaneity because you're you know getting hot and heavy, and it's like, oh hold on, I gotta go, you know, put this thing on, and then you hear penis inflates, but um, but they're very effective, um, like I said. Um cost effective, you know, if you look at long-term use, they're they are relatively cost effective. It's a one-time upfront purchase. The purchase costs vary depending on the model, anywhere from 250 to$500. Uh, you can get them cheaper on Amazon or other online um retailers. I usually recommend if you're gonna buy something that you are planning on using for a while, comes with warranty, all this sort of stuff, why not buy from a reputable medical device company and I'll provide patients with a uh brand or a brand or two that they can use. So one-time cost, it's reusable, um, and again, relatively effective. Um, and so the other thing is that some men who get um you know a reasonable, they they let's say they get uh a half erection, they just need a little bit of a boost. Uh that's a reasonable option for them as well, just to kind of help engorge the penis a little bit more. And again, they don't have to take any medications with it.

SPEAKER_01 34:23

Listeners, I know many of you are physios that are perhaps new to the area of pelvic health and feeling like you could benefit from some guidance as the complexity of your caseload goes up. I offer mentorship and I'm here to help. Let's figure out a structure that works best for you. My contact details are in the show notes, so please do reach out. How often do you because you know, after something like prostatectomy or different prostate cancer treatments, men might expect to have erectile dysfunction? You know, maybe that might say that's one of the risk factors of this treatment. Are you often kind of like preemptively getting them to work on this? Or do you find that it's more kind of like when the dust settles and they're coming to me with erectile dysfunction, then I will bring it up. Like can you talk a little bit about like let's say someone, let's say we're talking to someone that knows they're gonna have prostate treatment. Um, what what are your recommendations?

SPEAKER_02 35:16

Uh yeah, so there's this whole, I mean, we can do a whole podcast on P Nob rehabilitation after radical prostatectomy. Um, but all men who have eradical prostatectomy, whether it's open or robotic or however the prostate came out, they will all be aware that they're going to have erectile dysfunction. Um that's the, you know, we we talk about, of course, all the risks of surgery that could happen and all these scary things. Uh patients want to know what's what are the quality of life implicators, uh, erectile dysfunction and incontinence. Every single urologist that does a prostatectomy has hammered that uh into their patients' head, this will happen afterwards. Um now, so it that's a hard question to answer. First is because they don't, after a prostatectomy, they wouldn't usually be coming back to us to talk about that. They're already seeing us, and that's something that we're always talking about, erectile function and their incontinence every time we see them. Um so there are some, there has there's been a lot of things that have been done in the uh in the space of radical prostatectomies and erectile dysfunction, as far as what could we do to um either earlier return of erections or better long-term outcomes with respect to erectile dysfunction? Um, and a lot of has been tried. Various different pills, um, various different, there's injectable options, um, all trying to, okay, if we increase the blood flow to the penis artificially, will that uh naturally or physiologically then just happen on its own sooner? Uh the reality is nothing has panned out in trials as far as earlier return of erectile um function um after prostatectomy. Um people could you, you know, we could argue this until the cows come home, uh, but you know, overall uh data is is not very favorable. Um now there are some things that patients can do. Um, you know, with the vacuum-assisted erection device comes in, so not necessarily for return of erectile function after a prostatectomy, but what we do know, uh, and this is kind of borrowing more from the andrology uh in the men's health literature, but the longer uh a man has erectile dysfunction or doesn't engorge the penis, uh they will eventually lead to penile shortening. And so we know about a year of not uh achieving erections, you'll lose somewhere between five to ten millimeters of length uh with each subsequent year. You know, at some point the penis doesn't obviously just shrivel away into nothing. If you haven't used it for 10 years, it's gonna disappear. No, but um, we know that uh the penis does get shorter the longer it's not being used. And so um, you know, if if there are men who are interested in preserving length after prostatectomy, uh, or some of them will ask just to put like kind of penile health and and uh blood flow to that area, using a vacuum assessed erection device for maintenance uh would be a very reasonable thing for them to try. Um but we do talk, I I don't push the penile rehabilitation on on patients because it is quite expensive. Um the government doesn't cover uh the um you know the erectile dysfunction medications. Uh so if someone is going on a pill that they're taking every day, you know, it can be in the neighborhood of how of about$120 a month uh with no real statistical evidence that it's gonna improve things. Um our counseling is that by a year after a prostatectomy, that's probably where your new baseline of erectile function is gonna be.

SPEAKER_03 38:58

Okay.

SPEAKER_02 38:59

Right. So like you said, we kind of let the dust settle, uh, and then we reconvene and and uh you know see what we need to do for them.

SPEAKER_01 39:07

Who after you after you see them though, after your after their surgery or their treatment, who's counseling that? Who might be, you know, who's bringing that up in discharge planning, or are they stumbling on it more online?

SPEAKER_02 39:24

Um the which part, the erectile function part? Yeah. Uh that's in uh our pre-op counseling, I would say.

SPEAKER_03 39:32

Okay.

SPEAKER_02 39:33

Um just that this is going to happen. We give them the statistics uh regarding how, you know, what what's kind of the likelihood of them developing erectile dysfunction after prostatectomy. Um men uh who have good, we say you know, good erections, but who have the ability to achieve an erection, maintain for sexual activity, um, those guys that are in the neighborhood of 30 to 40 percent uh one year after prostatectomy will need some assistance with erections. Men who already have poor erectile function before the operation, uh their erections, I'm definitely not gonna make the erections any better by taking the prostate out. Uh, so the majority of them uh will need assistance with erections. You know, if they already need assistance with erections before the prostatectomy, they're for sure gonna need assistance with erections after the prostatectomy, right?

SPEAKER_01 40:21

Okay.

SPEAKER_02 40:22

Yeah.

SPEAKER_01 40:23

So sorry.

SPEAKER_02 40:23

Yeah, we basically every both before before we take the prostate out, we talk to them about that. Um, and then every time we see them for follow-up uh or call them to review the PSA, say, hey, how many pads are you wearing a day? How's the incontinence? Are you doing your pelvic floor exercises? And then how are your erections? Any spontaneous erections, partial erections? Is this something you and your partner want to work on right now? Because you just see subman, you know, you take out subman's prostates, and in the consultation, we say, hey, you know, the erectile dysfunction uh is a big thing afterwards, and they say, you know what? My wife and I we had that discussion, and um and that's not a problem for us. We're happy with the intimacy. We like cuddling, uh, we have our glass of wine in the evening, we are close, we talk, we cuddle, and you know, we haven't often they'll kind of joke about it, they're like, we're not in our 30s anymore, you know, we don't have sex every night. Um they say, yeah, maybe once a month on a special occasion, but if that's something that we don't have anymore, we still have that cloteness, closeness and intimacy, and that's more important for us, anyways, right? And so in those patients, again, but we still always ask them about it and say, hey, is it bothersome enough or impactful to quality of life? That's what you know. I think the the punchline is with anything in urology, is does it affect your quality of life? And if it does, then hey, let's do something about it because I'm happy to help you, right?

SPEAKER_01 41:45

Okay. So I kind of got you off on a tangent there, but that was kind of like the the pump was one of the vacuum-assisted device was one of the kind of like least invasive.

SPEAKER_02 41:56

Yeah. So vacuum-assisted erection device. So then the next option is the class of what we call PDE5 inhibitors. Um, so basically they work by inhibiting an enzyme that degrades uh some of the chemicals that are allowing for erections. We don't need to go into the physiology behind it, but um so uh but so the thing with the PD5 inhibitors, there's three of them. Uh the I don't know if I'm allowed to say trade names, but uh there's uh Cialis, uh, Viagra, La vitra, syldenophyll tidalophil, bardenophyll. Um, and uh so but the things with PD5 inhibitors, and this this is an analogy, and sometimes it lands, sometimes it doesn't with the patients. But PD5 inhibitors, if you take them, they won't just give you an erection. Like if you pop Viagra and you just sit there uh in a dark room, uh you with no stimulation, you will not get an erection. That's not the way that they work, they don't just induce an erection. Um, but they add fuel to the fire. So the analogy that I use with them is that uh, you know, you're out camping and you're making a fire, the you know, you gotta you still have to uh the the PD5 inhibitor or Viagra is gonna build your TP or the the cabin and it's gonna put the newspaper in there, but you personally you still have to have the desire and there still has to be sexual input. You have to strike your match and come and light the fire, right? Um you're not it's not just someone walking in with a flamethrower and just here's your erection, right? They there still has to be, you still have to uh you know have the interest and there still has to be the sexual stimulation for those medications um to work. Now, within that class of uh medications, so between the Viagra, the Cialis, and the uh Levitra that's out there, uh there's they're they are different, and uh and some of them you can do dose escalation with them. Um some people will say I didn't have any response whatsoever to ABC, whatever medication that they use. And then that brings up okay, well, what for First of all, what was the medication? What was the dosing? And then let's so let's say it was Viagra. They said, I got nothing with Viagra. Or it didn't work until like three or four hours later. Okay, well, when did you take it and what did you eat with in and around the time that you took the medication? Because uh the Viagra and uh La Vitra uh are food sensitive, um, so they will delay the onset of the action of that medication. Uh whereas Cialis, uh, it doesn't matter what you've had to eat. Um, and so you know, I think right now there's probably I probably would prescribe Cialis more than Viagra for a few different uh reasons. Uh mainly I I obviously I present all of the options to the patients and say, hey, here's the pros and cons of all of them. Um but Cialis has a few benefits. Uh it's longer, much longer acting than Viagra or Levitrain. So some of us kind of refer to it as the weekend pill. If you take it Friday, you know, after you're you finished work, you just pop your pill and it's active in your system, you know, not actually for the entire weekend, but theoretically it's there for you know a day or two. Uh the half-life, you know, if we're gonna get into the nitty-gritty, it's not a full 24 hours, but you need a couple half-lifes for that medication to fully clear your system. So um, but so that you can do this on-demand thing with Cialis. Um, there are options for people to take a lower dose of a daily um a daily PD5 inhibitor, a daily Cialis, so then it's always in their system. Um, the benefit to that is some men we see have both urinary symptoms from their enlarged prostate plus they have erectile dysfunction. We could actually manage both of those conditions with uh low dose daily cialis uh as well. So um so that's the uh kind of the next step in the latter. Of course, we talk about the potential side effects of them, of the medications being the most common that men um bring up is uh the headaches and the flushing of the skin that can happen. They're vasodilators, they're helping dilate blood vessels. Um so you could get uh you know, some men get really severe headaches uh with them, not in general, but some people uh do. Cialis has uh um uh muscle aches. Most men complain of low backaches if they're gonna experience side effects on the Cialis and the low backache. Usually, if they if you cut down their dose, typically symptoms will not be as intense, but um, but yeah, so anyways, we talk about of course the side effects of that. Uh you gotta be careful with taking those medications. Uh so anybody, and again, erectile dysfunction, cardiac, cardiovascular risk factor, a lot of men who we see with erectile dysfunction also have other medical comorbidities, which may be cardiovascular disease. Uh, so you don't uh we don't prescribe those medications to men who are taking nitrates or have uh on-demand nitroglycerin spray is one that you got to tell them that if you know if you have a uh a patient who's very reliable in front of you and you say, Hey, if you take this pill and you have chest pain, you cannot take your nitro spray. You've got to go to the hospital and they gotta give you something else because it can really tank their blood pressure and it can be exceedingly challenging to bring that blood pressure back up. Uh so I I'm very hesitant if someone is has nitrates or has on-demand nitrates um or nitro spray, uh, unless they're like, hey, I promise, and even then when they say I promise, you're like, uh maybe let's try something else. I want something bad to go wrong. But yeah, so anyway, so that's the next uh the next option that they have.

SPEAKER_01 47:36

Um okay, and how often go in my ladder. Would how often would their GP um try that first? Would that happen quite often?

SPEAKER_02 47:46

Uh yeah, yeah, I would say the major I I mean, I would say probably 70%, 75% of the time at least, I would say that they've been at least tried on that. Now, some you know, some men want to talk to a urologist um rather than their having their GP prescribe the medication only because they want to know what are all of their options, and then they want to kind of pick of it. And I don't expect um you know uh a GP to know every single option for managing erectile dysfunction. And so I think it's a reasonable, they're like, you know, the pill, maybe I maybe I don't really want to take pills. What other options are out there? And they say, okay, well, why don't you just go and see the urologist and they can talk to you about all the different options, right? But the majority of the time I would say that they have tried it. Now, not always do they then go on to a different option. Sometimes I will redo the oral options uh with a little bit of counseling around how are they taking it, or we've switched to a different type or whatever the situation may be, right?

SPEAKER_00 48:45

What about injections?

SPEAKER_02 48:47

Yeah, so then the next, and then so this is kind of the next thing on the ladder, uh, is injections. So we typically, there's a whole bunch of injections out there. Um we typically will prescribe something called trimix, uh, which is a mixture of three different medications. Uh there is biMix and then there's a single uh agent that you can inject. Um we do trimix mainly, well, one, because it's effective, but uh the other ingredients that are in Tri-Mix as a mixture uh make the injections less painful, which is why we give that medication. Uh you can do it with something called L-prostadil as a single injection, but L-prostadil is quite painful as a single injection. So uh we find men tolerate this uh mixture um better. So um, yeah, Triomix is super effective. Uh what they so if men are interested in trying it, um you we do a little counseling session in the office, you put the penis on stretch, uh, you inject an insulin needle, so it's a very small, very fine needle into either the three or the nine o'clock position on the penis. And I tell all men it's exceedingly important that you never inject at the six o'clock position on the penis, because that's your urethra. Number one, the medication is not going to work if you inject it in your urethra. Number two, you're gonna end up getting scar tissue there, which is gonna then bring up a problem with urinary function. So it's super important, either the three or the nine o'clock position. And I usually recommend that they switch sides. Um so uh every the next dose that they do, if they can remember, switch it to the opposite sides. So alternate which side you get the you put the injections in.

SPEAKER_01 50:23

Into the base? Into the base?

SPEAKER_02 50:25

In at the yeah, at the base of the penis. Okay. Yeah, so pull the penis on stretch, and then at the base of the penis at either the three or the nine o'clock position, uh, directly like horizontal. Um they you put the needle all the way into the hub uh and you give the injection and then you pull the needle out. Uh a little there's a you know mild pain uh with the injection, you may get some bruising at the injection site, um, low risk of infection, uh, but it works exceedingly effective within about 15 to 20 minutes. Uh, they will, whether they're interested in sexual activity or not, you inject this stuff and you will have an erection. So this is where um you know, some men who do shift work uh or who spend a lot of time doing international travel and they're just they're circadian rhythms and whatever, they've got a lot of life stuff going on, and the uh the um the PDE5 inhibitors just aren't working well for them, uh often giving them a low dose because they have you know normal erectile function, probably, or or reasonable erectile um function, but they're being in they're inhibited um because of life stressors or other things going on. Uh, these guys respond exceedingly well to trimix. Uh most men uh respond quite well to trimix irrespective of it, but some men who just need like a little bit of a boost. Um, the partner really is interested in sexual activity. A lot of them find this very useful because it can kind of just get them into the saddle, ready to go.

SPEAKER_01 51:50

So so obviously you have to get over the thought of injecting yourself, but is there less side effects?

SPEAKER_02 51:58

Yeah, less systemic, um less systemic. Like you're not the men typically don't complain of a raging headache and flushing of the skin and and those sort of side effects.

unknown 52:07

Yeah.

SPEAKER_02 52:08

You gotta be careful. Um I mean, there's a few with any again, with any sort of treatment we offer with people, there's potential uh you know contraindications. So I wouldn't give it to somebody who has poor manual dexterity that I'm concerned that they're gonna inject it into, you know, not even to their penis, they're gonna miss and inject it somewhere else, or or they're not cognitively uh you know intact enough um to avoid injecting it at the six o'clock position and just kind of jam it in wherever. Uh now, if you have a partner who's willing to do the injections and someone who's confused but they still want to have um sex as a couple, then you know theoretically you could have the partner uh be in charge of doing the injections. Um we don't want to give to anybody who has severe uncontrolled hypertension because it can worsen that. And then there's some medications that uh men, or not men, but just anybody can take, um, something called monoamine um uh uh oxidase inhibitors. Uh, you want to avoid those as well. Yeah, and then there's and we're kind of getting into the nitty-gritty, but hematologic or blood um cancers um which are a predisposition for um for having an erection that lasts longer than four hours, you want to avoid it in those uh patients. And then someone with severe curvature of the penis with scar tissue, you may also not want to give it to them because there's a risk of worsening that condition as well.

unknown 53:34

Yeah.

SPEAKER_01 53:35

Is there any other major treatments that I haven't asked you about? Like I also want to just touch on, I just want to make sure that I haven't forgotten anything, but I also want to touch on like um this day and age, you can find so many things online, and it can be confusing to wade through the the marketing, like what's evidence-based and what's marketing, with things like some of the things offered out there, right? Because people will hear about all sorts of things like laser, um, shockwave, the kegel chair, uh, the like the throne or whatever. Like, there's a lot of things out there. And so I kind of just want you to touch on what you say to people when they ask you about those things or some different things they hear about. And then anything else treatment-wise that I haven't asked you about.

SPEAKER_02 54:22

Yeah, the last major treatment one would be penile prosthetics. Um, so either an inflatable penile prosthesis or a uh, so that's where you'd have a device that's implanted in the penis. Uh, we have a pump in the scrotum and uh what we call a reservoir that gets implanted in the abdomen. Uh, come time for sexual activity, men will um use the pump in the scrotum to inflate their penis. It holds the uh the fluid in the cylinders. Uh they have sexual intercourse, and then when they're done, they can release the uh tension and the device will automatically deflate for them. Uh, and then there's malleable ones where the penis is always semi-rigid. It's um somewhat bendable, uh, I guess if you'll say so. When it's not in use, you kind of bend it off and move it over to the side, or the classic flip and tuck, you flip it up uh and tuck it away. Um, very high satisfaction rates for men who have you know not been tolerable or um didn't get any use from the other options, all of a sudden you inflate these devices or you put these devices in, and um, you know, as long as they don't obviously have a complication from it or a surgical issue, um, very high satisfaction rates with them. The one downside with the putting in a penile prosthetic and kind of all of these other treatment options that we've talked about already, patients, and I'll tell them this, is that they can hop between these ones. You know, you could try the vacuum device, okay. You didn't like it because it wasn't as uh conducive to spontaneity. Then they went to some ejections for a while, they found them painful. Okay, then we tried the uh oral options again, and then maybe they did a combination of them. Once you get to a penile prosthetic, it's irreversible. The the inflatable tissue within the penis that allows for erections uh gets destroyed during the uh during the surgery itself. So they can't have a penile prosthetic, decide that they don't want it, take it out, and then go back to injectables, it's it's unlikely that that's going to work for them. Um so that's the other the other major one that we talk about. Um there are some other things out there that comes up, and and men may definitely ask you about this, but hormonal therapy, so doing testosterone treatments. Um, you know, in our guidelines, if if and this is where the important where the history is important, is that are you not interested in sexual activity at all? I have no libido. Okay, then maybe checking your testosterone and doing testosterone supplementation, potentially increasing your libido, if that is a truly a problem with low testosterone, maybe you may get your erections back, maybe your erectile function will improve. Um, but that's only if they're truly hypogonadal or have truly have low testosterone and they have no libido. If someone has normal libido uh and they're interested in sexual activity, putting them on testosterone is not going to be the silver bullet that gets them erections back. It's just not, right? Um, there are some men who will do testosterone supplementation and a PDE5 inhibitor. You give them back their normal libido, they're interested in sexual activity, and then you give them a boost, uh uh, give the erections a boost with Cialis or Viagra or Libitra. Um, but a lot of men ask about testosterone. Uh, in the studies that are out there, simply just putting men on testosterone therapy is unlikely to cure their erectile dysfunction, uh, unless, again, like I said, it's a more of the psychogenic cause that's the main driver here. Um, and then there's some other, there's something that we there used to be on the market, uh, is still on the market, but it's not commonly used, something called um intraurrethral alprostadil, which is a tablet that you put into the urethra. Uh one of the medications that's in trimix is this alprostadil. Uh, so men could put a tablet of L-prostadil in the urethra, help with erections. The reason it's not very commonly used uh is it's exceedingly painful that men say they're like peeing razor blades after. So uh not a desirable uh yeah, it got them to erections, but then they peed hot sauce for a couple days afterwards was so uh not too much excitement around using that. Um and then you brought up, yeah, a whole bunch of other stuff that's out there. Um the low-intensity shockwave therapy uh is is you know kind of bounced around. You know, the thing stuff that's not covered by the stuff that's covered by the government as far as options that are out there have gone through rigorous trials and have showed improvement uh at managing managing the conditions. So things that aren't approved is typically because uh the experts in that field uh have not deemed it uh beneficial enough for the healthcare system to cover it. Now, that being said, um are if people can afford some of these alternative options that may help them, and this is how I approach supplementation as well. Other supplements that you know, I say there's not, I can't tell you that this is going to improve things, and it's not something that I'm actually recommending to you. However, if you are interested in it and you can afford it and it's not unsafe to try, then you know, it's up to you if you want to try it. Um, so yeah, like I said, the shockwave uh therapy uh uh you know probably not great for somebody who has zero erectile function at all. Um someone with maybe mild to moderate, you know, theoretically, the the theory behind this low-intensity shockwave therapy is kind of promoting angiogenesis or promoting new blood vessels forming to the penis by giving them these low continuous shocks to the penis. You know, those would be if someone's interested in something other than pills, or I could say you could look up online, find a practitioner that offers uh low-intensity shockwave therapy. Uh, there's other things like platelet-rich uh plasma injections, um, really all of this other stuff hasn't really panned out yet uh for a urologist to recommend in a in a social, you know, a socially funded system as far as you know improved or or robust evidence um for managing erectile dysfunction. So really the options that we've kind of outlined, including the penile prosthetic, which is covered by the government, um, those are kind of our our main treatment options that we offer to patients.

SPEAKER_01 1:00:25

How I'm curious to know how often um I mean it's all it's always relevant for people to come see you, but how how often would you say that people come to you and and you think um uh that something like this or seeing someone like a counselor could help them before? I don't know if I'm asking my question.

SPEAKER_02 1:00:49

Yeah, yeah, I mean, kind of what you're uh you know inherently touching on is uh psychogenic erectile dysfunction. Yeah. Uh which psychogenic erectile dysfunction is very common, and uh, you know, especially in the younger, uh in the younger patients that we see, whether it's because of, you know, they're embarrassed, they had a uh one night they were drinking too much, they couldn't get it up with their partner, and now they're in their head that they're you know concerned every time they're gonna have sex that they're not gonna perform. So that performance anxiety, again, that's part of the history stuff that we ask about, uh recent uh divorce uh or separation or illness or whatever. So the psychogenic one um comes up actually quite a bit. Now, sometimes with usually what I rec if I think there's a psychogenic component to it, which again is usually pretty obvious on history, not always, but uh if I think there's a psychogenic component, I always recommend that they go and see uh a sexual counselor. Uh now sometimes uh and this also comes up with uh there's some there's a condition called uh congenital penile curvature where uh not, and again, this is I mentioned that porn's kind of ruined it for everybody. Oh, everybody assumes that the erection uh that penises are perfectly arrow straight and they're 12 inches long and all this sort of stuff. That's not what I can tell you as a urologist. I see a lot of penises, uh, they're not like that. Uh and so a lot of people, a lot of men, um will uh are there you know they usually have a little bit of curve to one side or the other, and some but some uh you know men are born with um with penises that have more curve than the other. And so you also see some young guys who it turns out someone made fun of their penis because it was curved when it was erect, and it's like, oh man, that just destroys your self-confidence. Uh, you know, you're not gonna want to show your penis to anybody in the future, which sucks. So that's you know, those those men really, really derive benefit from sexual counseling. Um, so I think it's a huge part of erectile function. And you know, on the flip side of the spectrum as well, is it's okay, well, look, we can be as aggressive as you want with uh with erectile function. We can do the injectable, we can do the prosthetics, but you know, maybe if you had some sexual counseling and it turns out that you and your partner, the intimacy and just uh you know uh foreplay, not necessarily penetrative intercourse, but maybe that's uh you know, maybe that would be sufficient for the relationship. You know, someone who has bad heart problems that I really don't want to, you know, I mean you're kind of concerned about them having sex, you know, if they have a heart attack or something to germinate. Um that maybe seeing someone to have some counseling in and determining that that's actually just as important as penetrative intercourse, which is that intimacy and closeness is enough for them to be satisfied. Uh, you know, I think there's a role for the sexual counseling, regardless of where you are on that spectrum of what the culprit is, right? Um now, so the kind of little caveat to that is that some younger guys uh won't be so fired up with me saying, okay, you need well, you just need to go to counseling. And they're like, uh what? You know, I came to see a specialist, and that's what you're gonna tell me is that I need to go talk to somebody about it. Uh yeah, actually, because I think that's gonna solve your problem, number one. But if there's a wait list for that to take place, or you're gonna have to have, you know, you're gonna undergo multiple sessions and it's gonna take, you know, self-work, regardless of what it is, is gonna take some time. There are situations where I will um, you know, either prescribe Cialis or talk about injectables as a means to reinstill confidence in themselves, you know, especially if it's they lost their erections after a night of drinking or for whatever reason they got in their heads and now they have a bunch of performance anxiety for maintenance that they're concerned. I say, hey, you know, why don't we just give you a little bit of a boost? Let's reinstill your confidence. I think your erectile function is fine, but you just need that, you know, you just kind of need your buddy to help you out a little bit. Um, you know, and then once they've once I've you know reinstilled their confidence, and it's like, hey, that divorce was the reason why you were in your head. Look, here, you know, inject this medication into your penis or take this pill, show, prove to yourself that that you do have good erectile function, and then you know I've seen some guys that see me follow-up, they're like, hey doc, I use the pill a couple times, you're totally right, I feel good again, I've stopped all medications, and my erections are totally fine, right? They probably could have cured themselves with counseling, uh you know, but they were more interested in just doing the again the medical coming out with a pill, right?

SPEAKER_00 1:05:15

Which is where they're at.

SPEAKER_02 1:05:20

That's where you say patient, you know, decision making, it's a shared decision-making model. I say, hey, this is what I think is gonna help you. Some people don't like that idea. Okay, well, we you know, there's a little bit of negotiation, I guess we'll say.

SPEAKER_01 1:05:32

Totally. At the end of the day, I think we do better in healthcare lately at presenting a menu of options, and and people choose different menu, like options on the menu. So if I kind of go full circle to where we started and I picture that someone's listening to this that probably clicked on it and listened to it for a reason, they're experiencing some erectile dysfunction, um, and they may or may not have talked to their Family doctor yet? Let's say, let's say they have and they're waiting to see you, or another urologist, or maybe they haven't even booked an appointment with their family doctor yet. Anything that we haven't covered that you because I uh the reason I'm asking, like people wait a long time to see someone like you right now. That's the the reality is they're not getting in to see you next week. So they might wait a long time. And I think what we're trying to get at is that you might not have to wait to start a lot of this stuff. So anything that you kind of want to say uh um to those people listening, whether they're waiting for you or not, um, that kind of just to summarize our conversation.

SPEAKER_02 1:06:42

Um I mean, I would say first off, you're you know, you're not a lone erectile dysfunction, super common um statistically, which this is surprising, but 40 the statistics is like 40% of men at the age of 40 will have some erectile dysfunction, which I thought was mind-boggling, but uh, you know, being in practice, we actually see a lot of men, and then it just goes up by 10% with each decade of life. And so um, you know, so first off, you're it's very common, you're not alone. There's a lot of different treatment options out there, and there's things that you can do to help yourself before you even come and see a urologist. That's you know, that like we said, the the diet, the lifestyle, um, cutting out the you know, potentially precipitating factors, and then and the other thing is just having a you know having a conversation with your partner about is this is this something that we need in our relationship? Um, you know, and you'll be surprised how many men that I actually see that do end up, they've waited for the consultation, I seem they see us in the office, and then I present all these options and say, you know what, actually, yeah, I I think I don't need to, I don't really need to have you know, I don't think I need to have sex. You're like, what? You know, that okay, I mean I we're happy to have that conversation, of course, but you know, potentially if if you have that, you know, very open and you know uh it can be embarrassing number one to bring up to anybody your erectile dysfunction, um, you know, your friends, family, your partner, um, but you know, bringing it up with the person that's closest to you in your life and who you're planning on, you know, having sex with, bringing that up with them and having a you know a conversation about that is is this important to our relationship? I think probably would bring you guys closer as a couple as well, right? Um if you know if it is important, urologists and and other physicians are here to help you out. If it's if it's not really that important and the intimacy and closeness in what you have as a couple is just satisfactory for you know for what you need at your time in life, then you know maybe you don't need to come and see us. But uh I think having resources like this out here, uh and kudos to you for doing this podcast, because we didn't really talk about public floor physiotherapy at all, yet you're a public floor physiotherapist who's taken interest in this in this topic, which I think is very commendable, um, you know, having resources like this available for patients to have a uh listen to or read through the the show notes or whatever the situation may be, is okay. Here is, you know, quote unquote expert in this field. These are the options. Actually, none of them sound really that great. I don't I probably don't really actually need a referral to a urologist, or oh, I didn't even know that that, you know, the flip side, I didn't even know that that was an option. That sounds great. That's something I think that would work very well for my life. I would love to go and see a urologist and talk about that um further. So I think having resources like this is is super valuable for patients who are, like you said, they've got a lot of time um in general to to do some reading online and uh find some information before they come and see us because our wait lists are long. Um so I think this is a great resource for patients, right?

SPEAKER_01 1:09:48

Well, and I think like I think of I think of um look of landed myself in this area of pelvic health, but I I use a lot of analogies too, and I think about parallels to say the orthopedic world, which feels a bit more understandable to people where if you have knee pain, that's just the symptom, but you know you're gonna get different things from your family doctor versus a physio versus a surgeon, right? And in in the orthopedic world, you don't have knee pain and go straight to a surgeon. Like this, that's just we don't do that. Um like people start with things like massage therapy, physiotherapy, exercise, because um quite often that will address your knee pain. And if you have knee pain, I there's no way that I can say everybody with knee pain needs this one exercise. Like I have to look at your knee. Um, and and but there there'll be lots of different things that are contributing. And same thing with, for example, erectile dysfunction, very rarely will it exist in isolation when someone's coming to see me for it. There'll be other symptoms, but I'm gonna think of it like knee pain. I'm gonna ask you questions kind of like, when did it start? What does it feel like? Um, what do you think's going on? And and then I find just like I would if you're with your knee, I might bring out some images and show you the muscles that attach to the knee, um, check the movement of your knee. Um, how do you walk? How do you stand? What sports do you do? What do you do for work? And the same thing in this area. I'm gonna ask things like, what do you do for sports? What do you do for work? Um, sh I find this area a little a little bit more mysterious and involves more creativity around analogies or pictures or models in the clinic to show people what the muscles look like, how the bowels relate to the pelvic floor, how the bladder, everything, just so that people can look at it and explain. For example, with um erectile dysfunction, I would explain the the sexual response cycle like you do, and then usually get people to be like, okay, this is why I ask these questions about pooping and peeing, and um be so do you see how kind of the system works and kind of explain this a pretty smart system, actually, and we can sometimes get in the way of it, right? And so so then kind of like what do you think? I usually kind of explain it first, and then I because I always say I don't know you as well as you know yourself. So tell me kind of what of these things that I said, and let's say I might like let's say you like you said, you can quite often read from them, you know, um, is this a stress thing? Is it a lifestyle? Like you can kind of quite often read the person. And I might not say, Are you stressed? Like I probably wouldn't say that. I would give examples of other people that I've seen before and I'll see what lands with them. Because quite often, if I accuse them of being stressed or if I say their nervous system's upregulated, that's kind of puts them on the defense. Whereas if I explain, like, these are some other people I've seen that similar symptoms to you. Does any of this land with you? Quite often, like, that's me. So then, okay, you've given me something. Now I'm gonna send you home with, you know, and I think this is so much more than just Kegels. Like, it's like the person with knee pain. There's no way I'm only gonna give you knee tightening, right? I'm gonna look at so many other things. And I have 45 minutes to explain all of this stuff to you. And quite often my first treatment is go home and just notice things. Like now that you understand the system more, go home and just notice things. Um, and then come back and tell me more. And they usually tell you the answer, right? Yeah, yeah.

SPEAKER_02 1:13:23

Totally.

SPEAKER_01 1:13:23

Yeah, yeah.

SPEAKER_02 1:13:24

That's why we, you know, that's why we have follow-up visits. We say, hey, you know, we discussed these options, we do your history. I mean, we didn't even necessarily even talk about the specific history things for erectile dysfunction. Um uh we've talked about some of that, but but yeah, but so you know, we we do our our consultation and then we have a follow-up visit. And I think, you know, probably some people also get a little bit nervous that okay, you're gonna see a specialist once, and then that's it. It's like, no, no, no, we you know, this is an ongoing care plan. You see us, we come up with a plan. Just like yourself, you know, we you go home, you do some things, come back and you see us again for follow-up, we readjust, how is the treatment's going, you know, yada yada yada, right?

SPEAKER_01 1:14:04

Yeah. And and just like in the orthopedic world, we even if you saw a surgeon, we would probably be in involved in your care just because we're doing different things. And and we know as physios in the orthopedic world, like if we test something or or their weight bearing's not getting better, oh, you should go for a scan. Like, this is kind of outside of my wheelhouse. And so I know what's outside of my scope of practice in the orthopedic world or when someone's not getting better, right? And know to refer on. And the same thing in this world is I can tell which things are like I can start with the education and and things like muscle coordination and movement patterns, and maybe your pelvis is your muscles in your pelvis or your hips or something like that is not happy. I know I know what's outside of my scope of practice and when it might be like go go to your family doctor and tell them these things are happening because you should ask for a urology referral or what have you, right?

SPEAKER_02 1:15:00

Yeah, totally. Yeah, I mean, I think anytime something's out of someone's uh scope of practice where you don't know, I mean send a referral to uh you know to urologists to, you know, this is what we talk about all day, every day, right?

SPEAKER_01 1:15:13

Yeah, exactly. Anyways, I really appreciate um I appreciate your openness, I appreciate your explanations and obviously your time. Um and that's it. I I I feel like I asked you everything that I wanted to ask you, unless there's anything you feel like I didn't ask you.

SPEAKER_02 1:15:32

No, like I said, I just kudos to you for taking you know your own time and to to do what you do for patients and for and for other healthcare professionals. I mean, uh, if uh anyone listening to this podcast go to your channel and see the the various different specialists that you have and the the variety of topics that you cover for you know providing resources to patients, I think it's huge. Uh and uh yeah, anytime there's a topic you want to talk about, I'm happy to talk about it.

SPEAKER_01 1:16:00

Awesome. And that's a wrap. If you enjoyed the show, can I ask you a big favor? Would you do one of three things for me? Number one, leave a review because we could all use a little positive feedback sometimes. Number two, download the episodes because it helps me see what people are interested in. Or number three, share it with somebody else because sharing is caring. Catch you next time.