Talking about Erectile Dysfunction with a Urologist | Pelvis Party After Clinic Hours

We are so thrilled to have Dr. Alex Pinkhasov, urologist at Olmsted Medical Center back on this week’s episode of After Clinic Hours, our mini-series where we talk about pelvic health honestly and without shame with the clinicians who provide the care. 

Part two of Britt’s conversation with Dr. Pinkhasov focuses on common questions and concerns and treatment options for those experiencing erectile dysfunction. 

Make sure to check out part one of our After Clinic Hours episodes with Dr. Pinkhasov and stay tuned for more videos coming soon!

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See you next week! 💞

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Transcript

SPEAKER_01 0:00

Welcome back to Pelvis Party after clinic hours, where we talk about the things people are thinking about, but not always saying out loud. I'm really excited for this one because we're continuing our conversation with Dr. Alex, a urology expert. And today we're talking about erectile dysfunction. And just to say it right away, this is incredibly common, way more common than people think. But it's also one of those topics that carries a lot of pressure, a lot of assumptions, and honestly, a lot of misinformation. We're going to break it down in a way that actually makes sense, what's really going on, why it happens, and what's normal, what's not normal, and what your options look like if it's something you're dealing with. No awkwardness, no judgment, just real answers. Dr. Alex, welcome back. Today is a little bit of a spicy topic, but let's get into it. Welcome back, Dr. Alex. I'm so glad to have you on the show.

SPEAKER_00 1:01

I'm happy to be back. Excited to talk about erectile dysfunction today.

SPEAKER_01 1:05

Probably not something most people say.

SPEAKER_00 1:07

That's true. That's true. Actually, most guys will probably shy away, and you really have to tease it out of them before they bring it up, before they feel comfortable talking about it.

SPEAKER_01 1:15

I, you know, my husband and I have been married a couple years now, and we don't talk about erectile dysfunction like that, like come right out and say it. But we talk about sex life and other things, uh, and that's definitely a piece of it, right? So I want to hear from you, as someone who lives and breathes this work, uh, what it is exactly. Can we talk about plain language? What is erectile dysfunction?

SPEAKER_00 1:39

Yeah, absolutely. So uh in order for an erection to occur, uh it's basic plumbing, right? So you have arteries and veins. Those are the blood vessels that are in the penis. Uh arteries bring blood to the penis, uh, and then veins will draw blood away from the penis. So in order to get a great erection, what we want is we want to optimize the inflow and we want to reduce the outflow. In other words, we want to trap the blood in the penis, right, to make it nice and firm. And so erectile dysfunction occurs when one of those processes uh isn't working the right way. And so you can have some patients that may have issues with blood flow in, and then there's other patients who have normal blood flow in, but then they have a hard time with trapping that blood in the penis.

SPEAKER_01 2:23

And so when the blood is trapped, that is when you get an erection? Yes.

SPEAKER_00 2:27

So when the blood is trapped in the penis, that's what produces an erection. So when you have a firm erection, that's actually produced by blood that's trapped in the erectile bodies of the penis, which are basically two uh cylinders or two balloon-like structures uh that get engorged with blood.

SPEAKER_01 2:44

Age range, like when does that start typically?

SPEAKER_00 2:47

Yeah, so uh if you're ever changing a diaper uh on a kid, on a baby, you could sometimes see them uh having erections, but I'd say the frequency of erections tends to pick up around puberty. Uh erections are very closely related to testosterone levels, and so during puberty when testosterone levels start to increase, young men, young adults will start noticing that they're getting erections. Uh, so typically around teenage years.

SPEAKER_01 3:13

So that's usually probably a household joke for many people when your teenage son is taking longer showers or staying in their room longer, which is not unnatural these days because most teenagers do anyway.

SPEAKER_00 3:26

But yeah, and actually waking up in the morning with uh erections without realizing that they're having so spontaneous nocturnal uh erections.

SPEAKER_01 3:34

Okay, yeah, that makes a ton of sense. Let's talk a little bit about testosterone. I think it's probably a good time to do that. And um the not necessarily a roller coaster, but the time when you have more testosterone to when maybe it decreases, what influences that decrease? And does it go along a continuum of age?

SPEAKER_00 3:57

Yeah, so great question. Uh testosterone is a hormone that's produced by the body. Um, it you know that it serves a lot of purposes. Uh the way most people think about it, testosterone has to do with muscle mass, uh, it has to do with erections and erectile function, it has to do with libido, sex drive, uh, energy levels. It also uh helps with um, you know, mood, concentration, uh, those types of things. And so testosterone tends to peak again in mid to late teens, early 20s, uh, and then has a natural decline. So typically testosterone will decline by about 1% per year. So that's natural to occur uh over a person's life. On a given day, testosterone uh fluctuates pretty significantly. And so testosterone levels tend to peak uh in blood between 7 and 10 a.m., which you know kind of matches up with when most people wake up. Uh, and so it's closely associated with our circadian rhythm and then tends to kind of taper off during the day, so that at night when we're ready to go to bed, our testosterone levels are the lowest.

SPEAKER_01 5:05

I've heard some like friend groups will talk about it like when you're in your 30s, uh, and I don't it's probably different for men than it is women, but like when for women after we're done having babies, it's like maybe you don't want it want to have sexual intercourse as often, but then you have a surge later, and I think that's probably due to some kind of hormonal change. Is it like that for men as well?

SPEAKER_00 5:29

There's a lot of different factors that influence uh what your testosterone levels uh are like on a day-to-day basis or on a month-to-month basis. Things like sleep, diet, exercise, uh stress levels, they can all impact your testosterone levels. And so I feel like we go through uh periods of time in our life where stress levels naturally tend to be uh higher. And you know, those times are associated with lower testosterone levels, and then other periods of time in our life where stress levels may be lower, and then testosterone levels are uh higher. And then again, uh better testosterone levels are associated with better libido.

SPEAKER_01 6:05

So testosterone hormones, that sounds like one aspect of this, but are there other things that affect erectile dysfunction?

SPEAKER_00 6:13

Yeah, absolutely. And so it's a multifactorial uh process, meaning there's a lot that goes into it, right? So broadly speaking, uh you want to you need to make sure that your vascular health is good. You need to make sure that your neurological health is good. Like you alluded to, you want to make sure that your hormonal health is good. Uh psychologically, you want to make sure that you're healthy. Uh sometimes erectile dysfunction be can be caused as a side effect of certain medications that you're on. Uh and so there it it there's could be a lot uh of different explanations for why somebody's having erectile dysfunction.

SPEAKER_01 6:44

From what I understand, erectile dysfunction could be symptomatic of something larger going on in the body.

SPEAKER_00 6:51

Oh, absolutely. Yeah. And so uh there are studies that show uh that erectile dysfunction is kind of like the canary in the coal mine. Uh and so erectile dysfunction can sometimes serve as an indicator of cardiovascular disease and can uh precede a heart attack by up to two years. Okay. Wow. Yeah. And so if we see a young patient with erectile dysfunction, we always want to make sure that they will see our preventative cardiology uh colleagues to make sure they don't have something else going on. It makes sense, right, from a uh from an anatomic standpoint. The the size of the blood vessels that are in the penis are very, very small. The size of the blood vessels that are in the heart are slightly larger, and then the s the ones that are in the brain are slightly larger. And so naturally, if you're having a disease process that's affecting the small blood vessels in the penis, the next thing that's coming is the slightly larger blood vessels. Well, those are in your heart. And so that's why you can sometimes uh you know come on two years prior to having something like a heart attack.

SPEAKER_01 7:58

And in your career so far, have you had that encounter with a patient?

SPEAKER_00 8:02

Uh a lot of times, unfortunately, we see it in the back end. So we'll see guys that have cardiovascular disease, they have had a heart attack, uh, and now are coming in to see us with erectile dysfunction. And when talking to them, I'm like, oh yeah, this has been going on for years. So don't ignore the warning signs.

SPEAKER_01 8:19

Yeah. Yeah. Well, it sounds like it's complicated, just like a lot of other healthcare needs that we need to get in to be seen for. And that's what where your job is so important to investigate and try to figure out with the patient what's going on.

SPEAKER_00 8:33

Yeah. And so I look at my job, my job as twofold. One is I'm an investigator. Uh, I try to kind of, you know, unbury uh things that uh might be going on in the patient. But my second job is to educate patients. And so I spend a lot of time uh telling patients things that, you know, maybe they're not bothered by now, uh, you know, things that pertain to their prostate, things that pertain to their erections, because I want them to uh keep a lookout for these things before they become a problem, right? Your body will tell you when there's an issue happening. Like, for example, if you're noticing that you're waking up in the middle of the night several times now, you're noticing that the strength of your urinary stream is weaker, you're going much more frequently, that's your body talking to you, telling you that, hey, your prostate is growing, it's acting up. Uh, please look into this. And the same thing goes with your erections. You know, guys, uh, they don't want to ever admit that they're having issues with erection. It's a very sensitive topic, right? It's it's their manhood, it's you know, the thing that defines them. And so men uh are um always very reluctant, very hesitant to bring up erectile dysfunction. And so it's important to set the stage to make them comfortable and also to normalize it. You know, I I love telling this statistic to patients, but 30% of men in their 30s have some degree of erectile dysfunction. And I've probably alluded to it before, uh, you know, erectile dysfunction is not a binary thing. It's not, yes, I have it, no, I don't have it. Erectile dysfunction is more of a spectrum. So, you know, if you compare to when you were 20 years old, rate your erection from zero to 10. And then that's when guys start realizing that, oh yeah, you know, maybe I'm sitting at uh a seven or an eight. Or actually, what I love to do is I'll ask them that question and then I'll turn to their partner and I'll ask them that question. And a lot of times it's two different answers. And it's good because it gets the conversation going, you know. Uh sometimes, you know, it doesn't have to be all the time, but sometimes directions are uh uh it takes two to tango, basically. And so it's something that affects both the patient and their partner. Uh and so both are invested in addressing it.

SPEAKER_01 10:44

Yeah, and I wonder how many times um men or partners just think, oh, it's just this is how it is. It comes with aging. I can't do anything about it, just not as um hard of an erection as I used to have. And what would you say to that?

SPEAKER_00 10:59

I hate that. Yeah, I hate it uh for several reasons, right? So one is again, that's your body telling you that there might be something going on. Number two is we also live in like one of the best eras of medicine, right? So when Viagra and Cialis first came out, they actually came out as heart medications. Viagra and Cialis were medications for the heart. And then the investigators saw that one of the side effects were all these guys are walking around with erections and they're like, wait, hang on a second. We can't sell $50 a pill to save somebody's heart. Nobody's gonna do that. But what somebody will pay $50 for is to get an erection, and so they pivoted, they rebranded, they named their medication Viagra or Via Gra, right? Uh, and they started selling those pills at a very expensive price. Money's uh deterrent for a lot of patients, right? But whereas pills used to cost $50 per pill, you know, 10 years ago, now they cost less than 50 cents per pill. Okay. And so it's very accessible, it's very safe. So the the answer is you don't have to live like that. You don't have to come to terms with, oh, I'm just aging or this is normal, or like everyone that I know that you know, this is just like it's not important to us anymore. Or we, you know, we've come to terms with it. I hate hearing those things. Yeah.

SPEAKER_01 12:16

It's no different than the weight loss industry as it is right now. Everybody will spend money to imagine what it would be like to have the body that they want. So, like GLP wants, originally used for diabetes management. Yep. Um, and now it's become the most popular weight loss drug on the market.

SPEAKER_00 12:34

Hopefully it doesn't take too long for us to get to some generic versions of those medications or make it more affordable for patients. So obesity can contribute to erectile dysfunction, also related to testosterone, right? So I like to explain this to patients. When the larger you are, the more fat tissue you have. Well, uh fat tissue has an enzyme that converts testosterone into estrogen. And so the more fat tissue you have, the more testosterone you're converting to estrogen. And so, you know, testosterone is the you know man's hormone and estrogen is the lady's hormone, even though we both have both uh just at different levels. But if you have more fat tissue and you're converting more of that testosterone to estrogen, you have lower serum testosterone levels, and that can impact the quality of your erections. Absolutely. And so a lot of times when I'm seeing uh guys who uh are interested in improving their testosterone or come in because of erectile dysfunction but have obesity, I'll counsel them on ways to improve their overall health, try to, you know, lose weight with the goal of raising their testosterone with the ultimate goal of improving their erectile dysfunction.

SPEAKER_01 13:45

Obesity uh being overweight in itself can cause psychological effects on your sexual health life. Yes. But then you have maybe the one bad experience where it didn't work as well for you, or maybe you had a couple of them. Psychologically, what does that do for someone? And what have you seen in the office from patients? How long does it take them to get to see you after they've had these misfires?

SPEAKER_00 14:10

Yeah, yeah. That that's a great question. And we see them quite frequently. So what happens there is you have a stressful situation. Uh, you know, performance anxiety, for example. And that is associated with you releasing stress hormones, right? Or the the fight or flight hormones. And so the last thing your body's thinking about when it's in fight or flight mode is about having an erection or doing something leisurely like having intercourse, right? And so you then start associating any sexual encounter with that flight or fight uh response. And so that's where performance anxiety kicks in. Um, I think guys, when they're younger, if they're, you know, in an uncomfortable situation, that's something that they can carry forward with them. And so it, you know, this is where two providers can come together. So speaking with a sexual therapist uh helps a lot. Or sometimes I do offer those patients uh things like Fiagorcialis, not so much because I think they have a uh anatomic cause for their issue, but because this medication will help and it will help them gain their confidence back or put them back on the horse, as we say.

SPEAKER_01 15:21

So you talked a little bit earlier about having a patient in the room and their partner present as well. I've heard you say in the past, you're very encouraging of that. Can you talk a little bit more about that and why it's important?

SPEAKER_00 15:34

Yes, yes. This is like a good public service announcement. If you're ever coming to see me, bring your partner. If you're ever coming to see me with your partner, don't leave them in the waiting room. Uh I love it when I talk to a guy and then I tell them, you know, like, oh, you should bring your partner next time. And they're like, oh, she's actually in the waiting room. Well, you know, why don't you bring them in? Yeah. Um, you know, there's this funny statistic that I heard uh that I actually believe 80% of healthcare decisions uh in the United States are made by ladies. And so I think I don't know, I I I like having partners around. One is they help with the history, they also uh help with an honest history. They'll you know, they'll be uh more truthful. Uh, and also they can help with the encouragement process. And so I think it's always good to have a support system in the room.

SPEAKER_01 16:19

Yeah, that's really vulnerable though. I mean, on both sides, right? The partner has to be honest, and so does the male too, right? But you're kind of putting that all out there and in front of someone else.

SPEAKER_00 16:32

Yeah, yeah, yeah. That's actually so the reason why I chose to become a urologist is for this reason. These are some of the most intimate issues that you can deal with, right? Like again, a lot of men identify erections with their manhood. If they have erectile dysfunction, it some somehow makes them feel, you know, inadequate, inferior, you know, whatever other negative term you could think of that goes with that. And it's very hard for them to be vulnerable with you, right? Especially with me, with another man, or if you even if you're seeing a female provider to see to have that discussion with them, like anybody. Uh, that's why you know I enjoy my work, is because we usually we don't just dive into it, we'll segue into it. Uh, I like you know, kind of setting down a foundation, making them comfortable with me, and then having them open up to me about it. Again, I do the a portion of my job is to educate patients. And I feel like when you educate patients, uh you tend you you can normalize it, they'll realize that they're not the only ones that are struggling with it, and they don't have to struggle with it. And there are you know a buffet of options of things that we can do to get you better. And so it a lot of times, whereas they come in initially feeling uh defeated, uh, when they leave, they feel very empowered.

SPEAKER_01 17:45

Yeah, and what what I hear you saying, and I appreciate about your style is that one, it's very normal, it's common, yes, and there are solutions. And two, it's about relationship building. You're not just gonna jump in, what's the problem? How are we gonna fix it? You wanna build those relationships first.

SPEAKER_00 18:03

Yeah, absolutely. And so I spend a lot of time, again, the investigator hat, I spend a lot of time trying to understand why they have this. I think I would be doing a disservice if I saw somebody, if they told me I have problems with my erections, and I simply told them, here's a medication, it will cure it, have a good day. If I don't investigate, you know, how long has this been going on, assess them from a cardiovascular standpoint, try to get a better understanding of their risk factors, I am doing them a disservice by treating the symptoms. Sometimes erectile dysfunction is just a symptom of a bigger issue. And so I feel like I like to take my time, you know, see what else is going on. I may not have all the answers for you as it pertains to those other issues, but I can at least point you in the right direction or coordinate your care with your primary care doctor, with other specialists, cardiologists, endocrinologists to get you in a better spot.

SPEAKER_01 18:54

So when a patient makes the decision to finally come see you, imagining that there's probably a lot of anxiety going into the first appointment, what does that look like? What does a first appointment with you look like?

SPEAKER_00 19:05

Absolutely. So yeah, I see we see that a lot. I mean, patients are very timid at first. My style, which is not everyone's style, and I tell them like, I'm from New York, you know, I'm gonna tell you like it is. I'm gonna be very honest with you. I don't use fancy words, I'm just gonna tell you how it is, uh, in very simple terms. And if you like it, great. And if not, you know, you tell me what you like. Uh tell me how you want me to set the stage for you. But uh I I like to just kind of be on the same level as the patient. I, you know, I'm very comfortable with patients calling me Dr. Pinkazov. I'm very comfortable with patients calling me Alex, you know, people used to call me Pinkie Pie, whatever you want. Whatever Pinkie Pie, yeah. Whatever you want to set the stage uh to make you feel more comfortable, right? Like I am here for you. And so you tell me what you need, we'll make that happen.

SPEAKER_01 19:55

The first appointment, is it an hour, 30 minutes? Is someone getting undressed in that first appointment with you?

SPEAKER_00 20:02

Typically, I like to reserve at least half an hour. Most urologists, you know, will see you for under 10 minutes. If you're lucky, you'll see them for 15 minutes. I like to reserve half an hour to see my patients. And that's most patients, regardless of if they are coming to see me and for the first time or the tenth time, I like to see my patients for half an hour because I never want to feel rushed, I never want them to feel rushed, right? It's all about setting a comfortable environment. And so typically on the first time, unless there is something that's concerning for them from like a physical exam standpoint, if they tell me, like, oh, I have a lump or I have a bump or I need you to take a look at this, I don't need to have them get undressed. If they have any concerns, then yeah, we, you know, we could do a physical exam. But uh most of the time we're just having a discussion, you know, similar to how we're doing now.

SPEAKER_01 20:47

Okay. That's good to know. I think, you know, even as a female going into some of my appointments, not knowing what to expect is most of the fear about sharing what's going on with me. Um, so I think listeners might be curious to know what that was.

SPEAKER_00 21:02

Yeah, absolutely. So it it I'm very flexible. Okay. If you want me to examine something, we can examine it. If you don't, and most of the time we don't, then you know, we're just having a discussion, we're just talking.

SPEAKER_01 21:14

Treatment options. There are a lot of them, uh, and they're probably specific to each patient, but let's break it down for the audience.

SPEAKER_00 21:23

Okay, great. So, broadly speaking, there's pills, there's injections, there's uh vacuum erection devices, and there's penile implants. Those are the four broad categories of uh treatment options that have evidence behind them. And I'm very specific when I say that because there are other treatment options, things like you know, you'll hear people advertise oh, shockwave therapy to the penis will help you with your erectile dysfunction, or platelet rich plasma injections will help you with your erectile dysfunction. Uh those things do not have enough evidence behind them to. Say that yes, this helps you uh beyond what a placebo would do. And so the people, the testimonials that you see that like, oh yeah, this helped me, that could just be anecdote uh and not necessarily like true evidence beyond what a placebo would do for you.

SPEAKER_01 22:15

Pills, you can just get them off the internet.

SPEAKER_00 22:17

Uh there are a lot of companies that sell pills uh online. Uh again, those those companies are brilliant in terms of from a business standpoint what they're doing. They're making it very accessible. But where those companies come up short is they do not take the time to understand why patients uh are presenting with this symptom. Remember, erectile dysfunction could be uh a symptom of a larger disease process. And so that's where we take the time to sit, talk, understand what's going on. Yes, we'll treat the erectile dysfunction, but we'll also make sure we're not missing uh one of the other things. And so, yeah, there are companies, they sell it, they mark up on it like crazy. Uh whereas, you know, you can get a prescription for Viagra for, you know, 10 bucks, they'll sell it to you for a hundred bucks. You know, $100 for a one-month supply doesn't seem too bad, but you know, they're marking up 10 times on it.

SPEAKER_01 23:06

Yeah, and if you're embarrassed to go in, then maybe you're gonna try that before you go in. Not what we would encourage here. Dosage amounts, is that something that you monitor? Is that even a thing with um erectile dysfunction medication?

SPEAKER_00 23:21

Yeah, absolutely. And so uh Cialis, for example, right? Or Tadalophil is the generic for that. Uh, there are two different indications for it. So there's what I call the baby dose. Uh, that that dose has been approved for management of BPH, or in other words, an enlarged prostate. And then the larger dose is approved for management of erectile dysfunction. So if I'm talking to a patient with both erectile dysfunction and an enlarged prostate, we may be talking about them taking the baby dose on a daily basis to help address their urinary symptoms. And then they'll take that booster dose on the days that they want an erection.

SPEAKER_01 24:00

So if you can take it daily, that means that you're not having a prolonged erection. I think that's probably a myth.

SPEAKER_00 24:07

Yes. Well, uh, yes and no. In theory, in theory, uh, these medications can cause a prolonged erection. Uh, but one of the other things that patients don't realize, or sometimes you know, our providers fail to mention this, is that even if you're taking medications like Viagra and Cialis, you still need stimulation, whether that's uh auditory, visual, tactile stimulation, need something to stimulate. So basically, if you're taking uh a baby dose of Cialis every single day, you're not walking around with an erection all day, every day.

SPEAKER_01 24:37

You know, so you can't we're talking about actual stimulation, it's not like the rub on your pants, or maybe it could be.

SPEAKER_00 24:43

I mean, it depends on how sensitive you are, I guess. In theory, for some patients, that's all they need. Yeah. Um, but some patients need actual, you know, tactile hands-on simulation.

SPEAKER_01 24:54

And then dosage, um is it range from like the baby dose and just a secondary dose, or is there more than that?

SPEAKER_00 25:03

Yeah, so great question. Uh, so you know, it comes the uh CLS comes in different strengths, okay. And so there's, for example, you know, the five milligram tablets, and then there's the 20 milligram tablets. Five milligrams is what's approved for uh BPH or an enlarged prostate. The 20 milligram dose is the dose that patients take for erections. So when uh speaking to patients, uh again, I'm kind of trying to gauge what the degree of their erectile dysfunction is. Sometimes if they're taking that five milligrams every single day, that might be all they need. Uh, and so the booster dose is up to the maximum dose, which is that 20 milligrams. Uh, so they can take, you know, one pill every day. They can, when they need the booster dose, they can take one additional, two additional, or up to three total uh additional pills. Again, and that's a nuance that we discuss in clinic and that you know we kind of uh tailor specifically to that patient. It's not like a blanket statement. So I don't want patients to hear this and be like, oh yeah, like I'm gonna do this without actually talking to a healthcare provider.

SPEAKER_01 26:04

Yeah. When you're taking a pill for ED, what is it doing to your body? Like, is it increasing the hormone that increases your sexual drive, or is it just the physiological response to an erect like stimulation for an erection?

SPEAKER_00 26:19

So that's a good question. Uh it uh increases something called nitric oxide. Uh so it's basically increasing a molecule that causes the blood vessels in the penis to get more dilated. Okay, so it doesn't really impact your hormones per se. Uh like it doesn't impact testosterone levels, for example. It increases the molecules that help uh open up the blood vessels to the penis.

SPEAKER_01 26:46

Other treatment options. Yes. Mention them at a high level, but let's uh dive a little deeper into injections.

SPEAKER_00 26:52

Yes. Okay. So injections are the strongest non-surgical option that we have for uh treatment of erectile dysfunction. The reason that is because you're delivering the medication directly into the penis. And so the Which sounds painful, is it? Yes, that's exactly the response that I usually get. I, you know, usually they get this look on their face when you tell them they have to inject a needle, uh, a needle into their penis. But when you show them the needle, they're they you know that that goes away very, very quickly. It's the needles, you know, I related to it like a mosquito bite. It's a tiny, tiny little uh needle. If a patient is a diabetic and they're injecting insulin, that's the needle. Okay, so it's not any different uh than uh that. And so the medication is delivered directly into the penis, and so and it's a very concentrated, strong medication. Uh, and with that medication, actually, a lot of times you don't need the you know tactile stimulation, you don't need the visual stimulation, although those things still impact the quality of your erection, but the medication is strong enough that it will work on its own. Um and with that medication, that's where you know I'm telling patients that you you want to make sure you don't have an erection for more than four hours.

SPEAKER_01 28:04

So you inject in the office and they immediately get an erection?

SPEAKER_00 28:08

Uh we can inject in the office uh and they can.

SPEAKER_01 28:11

Oh, it's something that they do before they want to have intercourse.

SPEAKER_00 28:15

Yes, exactly. Okay. Yeah, yeah, yeah, yeah. So uh no, but you know what you're saying is valid. So the first time I prescribe this medication to a patient, I actually have a teaching visit with them. They'll come in, they'll bring in their prescription, I will show show them how to draw up the medication, I'll instruct them on the dose, I'll show them how to go up or go down on that dose. Um, and then I demonstrate to them how to inject themselves. And so after that teaching visit, they go home and then you know they they do it uh whenever they want.

SPEAKER_01 28:42

Yeah, just like any other prescribed medication that you would take home with you.

SPEAKER_00 28:46

Yeah, yeah. A few nuances though with the injections is that it's a compounded medication, uh, meaning that you know you have to go to a specialty pharmacy that can mix those ingredients together. Uh, and so there's a couple here locally uh that do it. And because it's a compounded medication, sometimes it's not uh covered by insurance. Uh it's still pretty affordable. Uh I, you know, generally ballpark costs about $100 per vial. How long a vial lasts depends on the patient's dose. And so I tell them that you'll typically get at least a couple of doses uh out there. One of the kind of negatives about it is that it has to be stored in the refrigerator, makes it a little bit of a hassle. Like if you're trying to travel or you know, go on vacation, you want to have an erection there, makes it a little bit of a hassle because you have to take an ice pack in the I'm wondering.

SPEAKER_01 29:32

So you touched on the insurance concept. Is this considered medically necessary? Where some insurance, or is it that's probably a rabbit hole?

SPEAKER_00 29:41

But so good question. Uh, in general, I'd say most of the treatment options are covered or either covered or are affordable enough that it's not a barrier to patients. So what I tell patients is, and this is all part of our visit, this is why I like my visits to be 30 minutes, because I'll actually go on websites that I know, like legitimate online pharmacy, uh like costplusdrugs.com, right? Uh, we'll go on these websites, I'll show them this is how much this medication should cost you. I'm gonna send it to whatever pharmacy you want it. But if they're charging you more than this price or something reasonable within that range, you let me know and I'll send it there uh because I want to make sure that I'm addressing their problem and also addressing the barrier that's gonna prevent them from trying that solution, right? Uh and so the, for example, the uh injections, uh, you know, if they're not covered by the insurance, they'll typically run a patient about uh $100 per vial. Other options like vacuum erection devices, if they're not covered by insurance, they're usually covered by HSAs. So that's been uh really nice for patients to use that route. Uh or things like penile implants typically uh are covered by insurance.

SPEAKER_01 30:53

So let's talk more about the other two options, which would be how did you call it a vacuum erection. Vacuum, okay, I was gonna call it a pump, but is that the technical term?

SPEAKER_00 31:02

Uh you can call it a penis pump. Uh it gets a little patients get a little bit confused sometimes because we have the penile implant. And so the penile implant has a pump in it or can have a pump in it, and so they get confused a little bit sometimes. So I like to call you know one of them the vacuum erection device and the second one the penile implant. Two different things. Okay. Very, very different.

SPEAKER_01 31:22

How does a vacuum work?

SPEAKER_00 31:23

So a vacuum is basically you're putting on what looks like a long cup uh onto your penis, and then there's, you know, you're using a pump to mechanically pull the blood into the penis. Uh they have you know pumps that you're pumping by hand. They, you know, some of the fancier gadgets have an automatic one, but basically drawing the blood into the penis, the um cylinder itself has like a little uh rubber band on it, uh, or confidence band or contriction band, whatever you want to call it. Uh, and then they once the blood gets into the penis, they slip that on the base of the penis, uh, and then that helps trap the blood in the penis. Okay. So you're again the the two things, right? The bringing the blood to the penis and then trapping it in the penis. When your body can't do it on its own, this thing uh does it for you, the vacuum erection device.

SPEAKER_01 32:11

Okay. So would you be recommending these as like the first thing we try is the pills? If that's working, great. Second thing is injections, or maybe those are, you know, you could do one or either. And then this next option?

SPEAKER_00 32:27

No. Uh I tell patients that this is the this is a buffet, you know, the this is everything we have on the menu today. Uh, you tell me what uh, you know, what interests you and I'll serve you that thing, right? So, you know, historically it used to be yes, you try pills first, you have to fail this many times, then you try the next thing, the injections, the vacuum erection devices, uh, and then you work your way up to a surgery. Now uh I present patients with you know all the options right away, uh, and then they tell me, you know, like I want to learn more about this. So then we spend more time talking about that. You know, if they uh have a friend who has had the surgery before and loves it and has been raving about it, and that's the thing that he wants, well, why would I have him try three other things before we uh go to the implant here?

SPEAKER_01 33:20

Is there a difference between the pill and injection? How long the erection lasts or how hard?

SPEAKER_00 33:26

Uh so yes, the the the medications, the active ingredients in the medications are actually different and their mechanism of action is different. Uh and so I tell patients that the injections uh produce uh there it's it's a stronger medication, and so it's intended to produce a harder erection. But again, you know, sometimes you may not necessarily need to do an injection to get a 10 out of 10 erection. It depends on where you're starting out from. Uh, and so sometimes taking, you know, just five milligrams of Cialis is enough for you to go from a you know six out of ten to a ten out of ten. And so generally when we do the injections because it's such a potent medication, we start with literally like a teeny teeny dose, and then we have patients work their way up because what we don't want to do is give them a big dose right away and then cause them to have an erection that lasts for more than four hours because then they need an antidote and like all those things.

SPEAKER_01 34:21

Do you have antidotes readily available?

SPEAKER_00 34:23

In the emergency room. In the emergency room.

SPEAKER_01 34:25

Okay. But you said that's like what percentage of patients?

SPEAKER_00 34:28

It's very low. Yeah. It's very, very low. I uh if you if you do it the way it's prescribed. Okay.

SPEAKER_01 34:34

So yeah, because I could that could be more embarrassing than coming in to see you in the first place. Yeah. Right?

SPEAKER_00 34:41

Yeah, but again, I I think when you counsel patients the right way, you spend time teaching them, you spend time uh, you know, kind of explaining how the dosing works, uh, giving them good instruction, uh, you you're normalizing the entire process. And so it no longer becomes uh as embarrassing for them.

unknown 34:59

Okay.

SPEAKER_00 35:00

Yeah, they feel supported, you know, they have somebody that understands that's working with them uh on addressing this thing. And then, you know, they have their partner there with them. Some this is actually uh a good point, is for these visits, I like to I especially like to have the patient's partner there because sometimes this is part of their foreplay, you know, sometimes this is the thing that gets them going. You know, you know, your partner will poke you with uh anneal and that helps turn them on some, you know. And so uh for some patients that's a part of their routine. But when when they feel that the process is normalized, if they have an erection that lasts longer than four hours and they need an antidote, I I don't think they'd shy away from uh going to the emergency room or or calling your clinic during uh office hours.

SPEAKER_01 35:41

Yeah, I can appreciate that, like normalizing it, you know, it becomes part of well, it's gonna be part of the routine if that's what you choose to do um to enhance your sexual health. Um, so yeah, that's I like that take on it for sure. The last item on the buffet uh would be a surgical option.

SPEAKER_00 36:00

Yes, yeah. So the surgical option is a penile implant. Essentially the penile implant replaces the erectile bodies or takes the place of the erectile bodies. So you're no longer depending on blood flow in, on trapping the blood flow there. You have an erection that's on demand. It's anytime, every time, as long as you want. Uh, you know, I joke with patients, but if they want it three times a day, they get it three times a day. You know, God bless their partners. Uh, but if they want it once a month, then they get it once a month. You know, it's really it is the most reliable on-demand way to get an erection. That's the penile implant. But it is a little bit of an investment, you know, there's the uh the surgery, and so surgery is typically an outpatient surgery, meaning that they get surgery, they can go home the same day. Sometimes patients will choose to stay uh a night over stay overnight for one night, uh, but they get the implant, then there's the recovery, you know, you're recovering for a couple of weeks where your penis, you know, is bruised, swollen. That typically takes a couple of weeks. Uh, but after that, you know, the studies show that satisfaction rate with penile implants can be as high as 95%, both for patients and partners. And so the way the penile implant works is we implant these two cylinders that go inside the penis. They have a reservoir that's tucked into their lower belly where it holds fluid, and then they have a pump that's in their scrotum. Yeah. So anytime, uh, anytime they want, every time they want, they take this pump, they pump it up, it pulls the fluid from the reservoir into those cylinders, and then they have uh an on-demand direction. So, and again, one of those scenarios where uh when they come in to learn how to use their device, I like having the patient's partner there because that can be a part of their foreplay.

SPEAKER_01 37:40

And their understanding, that's I mean, amazing. Like you said earlier, we're in this era of medicine that almost anything is possible.

SPEAKER_00 37:49

Yeah. Actually, interesting fun fact uh penile implants have been around longer than pills. So Viagra Cialis, you know, have been around for the past 20 to 30 years, penile implants have been around for the past 50 years. Wow. Yeah. And so we we do have some like, you know, next generation penile implants that use, you know, very durable materials to build them. And so they've definitely evolved over the past years, but yeah, certainly have been around longer.

SPEAKER_01 38:17

Would not have guessed that. So with a penile implant, you're literally putting something into your body, uh, probably like a breast augmentation uh for enhancement. Do patients feel like it's part of them? What are you hearing?

SPEAKER_00 38:33

Yeah, so that's a great question. Uh and so, yes, you know, it's similar to uh breast implants, but also similar to, you know, knees, ankles, hips. And so what I tell patients is, you know, if you've ever had a you know hip replacement or a knee replacement or ankle replacement, you know that initial period that you just you you you know that it's new, uh, but then over the coming weeks and months, it just becomes a part of you. Same thing with the penile implant, like you're gonna know you have an implant there initially after surgery, but then it becomes a part of you. It's locker room safe. So aside from you, your partner, or anybody that comes in contact with it, or unless you tell somebody, nobody really knows you have it. If you're in a locker room, nobody can ever tell. There's nothing external on it. And so I think there is a little period of time where you're getting used to it, but then it's just a part of who you are.

SPEAKER_01 39:21

I guess maybe the breast implants aren't a good example then because you physically see that, but with penile implants, there's nothing that changes on the outside.

SPEAKER_00 39:30

Nothing that changes on the outside. And I think if you have a good surgeon doing your breast implants, sometimes you don't even know that you have those.

SPEAKER_01 39:36

True. Very they can be very natural looking. So you mentioned that a reservoir fills up. What is it filling up with?

SPEAKER_00 39:44

It's just saline. So saline, it's a fluid that has the same uh composition as our, you know, the fluid in our body. And so it's you know safe to be inside the body. Uh, it's not something that we ever have to worry about rejection uh or anything like that.

SPEAKER_01 39:58

But you have to fill it up?

SPEAKER_00 39:59

We do fill it up, yeah. Okay. And you have to come back to the office for that. Nope, it's filled up at the time of surgery, after your surgery, if everything goes well, you never have to, you know, you don't have to do anything else for it. There's no maintenance that goes in into it. Uh, but you know, I tell patients the device, uh, it's a mechanical device and so it has a shelf life. Uh the shelf life's pretty good. It's about, you know, 85% of guys have a functional device at 10 years. Uh, and so, you know, at 10 years, about 15% of guys will need to have their device either uh entirely replaced or touched up. Uh, but if you're coming to see me 10 years later and you want your device replaced, uh, I'd say it's a good problem to have. That that makes me feel good because I know that's still that you've enjoyed this one uh and that it's a priority for you to keep that going. So good problem to have 10 years from now.

SPEAKER_01 40:49

And there's enough saline to keep it going for 10 years?

SPEAKER_00 40:53

Yeah, yeah. This it's a it's a closed system. And so there's no fluid ever being added, and as long as it's functioning properly, there's no fluid ever being lost. So in in that 10-year span, sometimes you can have, you know, tubing fracture or something like that, very, very rarely. Um, but if that happens in theory, you can lose fluid, but uh in the absence of that, it the fluid stays in there the entire time.

SPEAKER_01 41:18

Oh, gotcha. So it's like recycling it through Exactly. Okay, understood.

SPEAKER_00 41:21

So two balloon-like cylinders that go into the penis, a pump that's in the scrotum, and the reservoir that basically holds this fluid. When you press the pump, it pulls the fluid from the reservoir into these cylinders. And then when you're done, there's another button on that pump that releases the fluid from those cylinders back into the reservoir.

SPEAKER_01 41:40

And you're the person is controlling this with a handheld device?

SPEAKER_00 41:45

They're controlling it with their hands and they have a pump that's in their scrotum that's implanted also at the time of surgery. Nothing on the outside.

SPEAKER_01 41:53

Okay. Yeah. Wow. Yeah.

SPEAKER_00 41:55

That's we and I do have I, you know, whenever I have patients asking about this device, I have a few models uh that I bring into the office. Uh, and I have them tried. I have them, you know, practice on the model to see what that would be like. Um, sometimes I have patients with, you know, you know, they don't have good dexterity uh in their hands. Um and so there is an option also for patients that don't want to have an inflatable device. They can have a device that always stays, you know, partially erect, something called a malleable uh implant or a semi-rigid implant. That device goes in, it seems, you know, it it deflects upward and downward. And so you, you know, when you're not using it uh for sexual intercourse or erectile function, you have it pointed down. Uh whenever you're ready to use it, you point it up, but it's always in this like semi-erect state. But it it it it requires a lot less dexterity.

SPEAKER_01 42:46

Okay. And sometimes I think surgery is always a last option, but in this case, you could skip everything and go right to penile implants.

SPEAKER_00 42:58

Yeah, absolutely. Absolutely. And so again, this is why that first visit's very important. Uh, it's important to uh establish what the patient's goals are, right? And so when I have patients come in, for example, let's say I have a you know 50, 60 year old guy who travels a lot for work, or they, you know, they're they're retired and they go on vacation every month and you know they've tried pills, but uh they, you know, the the injections like wouldn't work for them because they'd have to have, you know, an ice pack and pack the needles and pack the the vials. And so you you have to gauge what their goals are. Uh I'd say for most patients, the number one priority is spontaneity, right? Uh and reliability. And so they want to make sure that they don't have to pre plan three days ahead of time that they want to have an erection on Sunday night, right? And the second thing is that when they're ready to have that erection, they actually get it. And so uh penile implant is a very good option uh for those types of patients, right? Patients who want spontaneity, who want reliability. I tell patients it's anytime, every time, and as long as you want.

SPEAKER_01 44:06

So I don't know for listeners out there, sometimes spontaneity isn't even a real thing. Let's be honest, in like regular day-to-day, sometimes you gotta schedule that in, baby.

SPEAKER_00 44:17

Yeah. Well, listen, I'll I'll tell you, it depends on where you are uh in life. Um, you know, you have patients that are in their, you know, 50s, 60s that have better sex lives than patients that are in their 20s and 30s. And so it really depends on where you are in your life, what obligations you have. You know, if you have retired folks who, you know, they're all about enjoying life. And so unfortunately, you know, at the age when you are retired is a lot of times when we'll see signs of erectile dysfunction. Uh, and the thing that I hate the most is when patients say, Oh, you know, it's something that I've just come to terms with, you know, it's something that we've we learned to live with, uh, or that's no longer we we find other ways to satisfy each other. Yeah, we would do it if we could, but we found other ways to satisfy each other. Unfortunately, you know, it happens right around that time when you have all this free time. You know, you could do anything, go anywhere. You know, I like being a part of the process that can help restore that for them.

SPEAKER_01 45:12

Something that we say often on the pelvis party is never settle because we see patients doing that all the time, not advocating for themselves or not seeking care in a timely manner when something's bothering them. And as a spouse, I know myself, I've had to encourage my husband over and over to get something checked out, whether it's a lower back issue or something that's bothering him, or remind him constantly to go schedule your colonoscopy. If you're listening, you still need to do that.

SPEAKER_00 45:40

Yes, yes, I love that. Uh, I think it's very important. You know, spouses play a critical role in encouraging my patients or men to come and see me. I think that a lot of guys initially are reluctant, but then after our first time, most guys warm up and we're really having these like heart-to-heart uh conversations. What I will tell you is this if it's important to you, or even if it strikes your curiosity, come in and let's talk about it. I'm sure we can find something for you. And honestly, if we can't, then at least in the back of your mind, you know that you've done everything uh that you can, or that you've gotten all the information, all the research, uh, before you come to that conclusion and say, like, oh, this is something that we've come to terms uh to live with. But before you do that, you know, come and see a specialist, come and see me, uh, we'll talk about it. Uh, you know, we'll see if there's something that we could do for you.

SPEAKER_01 46:30

Beautifully said. And you are so approachable, Dr. Alex. And I've met a lot of physicians um who are brilliant, but don't always come with that level of comfort that you provide. And I've gotten to know you in these past few weeks and can definitely attest to that.

SPEAKER_00 46:48

I I really do appreciate that. Uh that's what I that's that's my style. Yes, I went to school for a very long time. I wasn't training for a very long time. I did subspecialty, but at the end of the day, I want you to think of me as your doctor and as somebody that you go and grab a beer with.

SPEAKER_01 47:03

And you got into this because you want to help people.

SPEAKER_00 47:05

Yeah, absolutely. And games, and we can.

SPEAKER_01 47:08

We've covered a lot today from what erectile dysfunction actually is, symptoms, treatment options, how your spouse can be supportive. So what's next?

SPEAKER_00 47:18

I hope that we were able to pique the interest of uh at least a couple of listeners. Uh the next step is I'd encourage patients to come see me. You know, uh there that's that's the first step. You gotta come in, and usually when patients are in my clinic, they've taken that first step. They're ready to embark on their journey, uh, they're ready to get help. And so, you know, we'll sit down, we'll identify specific risk factors in you, try to see, you know, if there's anything else that could be contributing to this, anything that's modifiable. And then again, you know, we'll we'll dive deeper into these treatment options that we've briefly discussed here, uh, see where you have questions, you know, anything that I can elaborate on and see which treatment option is right for you. Uh, or if nothing else, then you just walk away with more information and give you some time to think about it, and then you get back to me and tell me, you know, what uh what you want to do.

SPEAKER_01 48:10

I love that response. Um, I think it meets people where they're at. You can be on any continuum of experiencing different kinds of symptoms and know that when you're ready, you, Dr. Alex, are also ready to have that conversation.

SPEAKER_00 48:26

Yeah, I I very rarely tell my patients what to do. I tell my patients what to do when it's a life-threatening condition. In the absence of any threat uh or harm to your life or well-being, I generally lay all the options out in front of you and then we engage in chair decision making. So sometimes patients want me to tell them, like, tell me what to do. Uh, I can guide you. My my job is, you know, you bring the horse to the water, but then the patient is the one making that decision. Uh, I don't ever have to force my patients to make decisions, feel obligated, nothing like that.

SPEAKER_01 48:59

So, Dr. Alex, if someone's listening to this right now and they've been dealing with something maybe quietly, oftentimes silently, and unsure if it's even serious enough to come in and see you to talk about, what do you want them to know?

SPEAKER_00 49:12

The impression I'd like to leave on our listeners today is don't ignore changes to your body. If you are unsure if certain changes are normal or expected or a part of something bigger, uh reach out to somebody and ask. You know, that could be your primary care doctor. You're more than welcome to reach out to me, but don't ignore, you know, when your body is trying to tell you something. And in my line of work, erectile dysfunction is one of those things. If you have it, come in, talk about it. Sometimes we can help prevent something else from uh something worse, something more serious from occurring. Uh, or sometimes, you know, you need something as simple as a single dose of Cialis.

SPEAKER_01 49:53

I think the biggest takeaway for me today is again, this is a common, common problem. There are answers and you don't just have to deal with it. You don't have to settle, you don't have to live with it. And honestly, even just having the conversation is a step in the right direction. Dr. Alex, thank you again for coming on the show and making this feel a lot more approachable than people expect.

SPEAKER_00 50:17

My pleasure. Happy to be here.

SPEAKER_01 50:18

For those of you listening, we have more episodes coming up with Dr. Alex. So tune in wherever you get your podcast, like and follow. That helps us keep running, uh, the pelvis party. And as always, if this is something you have had questions about or maybe didn't know how to ask your provider or talk with your spouse about, this is exactly why we have these conversations. We'll see you next time on Pelvis Party after clinic hours.