Tom (00:11.726)
Welcome back everyone. Today we're going to talk about erectile dysfunction. And this is when a man can't get up or keep an erection strong enough for sex. It's pretty common. It affects around 12 million men in the US and this increases with age. So if you're a man above 40, it has a chance of about 40 % affecting you. And I see this.
in my clinic, a lot of times the typical man that comes in, he's over 40 years old, he is a little bit overweight, and he will tell me that he's having problems in the bedroom. And we'll go through and try and elucidate or pick out the points that lead us to the cause of his erectile dysfunction. Now,
normal male sexual function requires certain things to happen. It requires an interaction between vascular, neurologic, hormonal, and psychological systems. All of these have to work in a beautiful concert to get an erection. And if there's a problem in one of these areas, it causes erectile dysfunction.
Now erections are caused by visual stimulation. So the visual cortex and the brain, they're also caused by tactile or touch stimulation. And this occurs through nerves that run through the back and come back to the penis. So it's called a reflex arc. And this can cause problems if you have say a back injury.
And it's also caused by nocturnal erections or erections that occur at night, which interestingly only occur during rapid eye movement. And then as men, of course, like I said, they get older, they can experience decreased sexual drive, a delay in erection, decreased intensity and duration of their orgasm and decreased
Tom (02:32.942)
force of ejaculation. So how do I narrow these problems down, right? If all of these things can go wrong, then how do I kind of start with narrowing things down? Well, I ask them questions about their history. I say, did it start suddenly or has it been getting worse over several years? You know, have you sustained any injury, things like this. I'll also give them a test called the
international index of erectile function. And this is a questionnaire that helps me figure out what is the root cause of ED. And you can actually go online and look it up. I think if you search IIEF PDF, you can take the questionnaire yourself. Now, what does it do? It kind of categorizes the erectile dysfunction.
into like four treatment paths. And these can occur at the same time. Like it's totally possible to have two things at once, but it kind of helps me narrow it down on what type of treatment pathway I should go down. So one of the first ones is, can this be helped by medications like Cialis, Viagra, or Sidenafil? Or is it...
primary orgasmic or ejaculatory dysfunction, meaning it's no longer like erectile dysfunction, it's they can get an erection, but they can't orgasm, or there's something going along that pathway. And usually those people, I will refer to urology. Or do they have, let's say, reduced sexual desire, and it's caused by low androgens or
prolactins and do I need to run the tests for that? Because it doesn't always mean that if you have erectile dysfunction that your testosterone is low, there's a whole host of other hormones that can affect that area. Or is it psychosocial, psychosexual problems between the man and his partner? And I should, I'm gonna add this in.
Tom (04:59.406)
We shouldn't be as a doctor, I shouldn't be judging people based on their sexual preferences, their sexual habits, things like this. I should just be looking at it in a kind of coaching way, asking them, how do you feel about this? What would you like to solve?
and laying no blame and no judgment because that will just shut the patient down and they will likely go and look somewhere else or not seek help at all. So it's very important to not pass judgment. Now, like I said, erectile dysfunction can happen because of problems with blood flow, nerves, feelings, or local penis factors that I'll discuss.
or certain lack of hormones as well. So what is a vascular problem? Well, this can include things like cardiovascular disease where the arteries of the penis have been damaged or maybe they've decreased. So there's not enough blood flow getting in there. There's also hypertension or high blood pressure. So I'll screen them for that. I'll take their blood pressure.
There's always diabetes. So that can lead to nerve damage as well as blood vessel damage. And so I have to screen them for that with certain lab work, high cholesterol will do it, smoking that affects the blood flow as well, because it causes damage and hardening of the arteries so they don't expand. Chronic kidney disease can affect
production of certain factors in the blood vessels. Obstructive sleep apnea is another major concern that can lead to hypertension as well as other things like major surgery or chemotherapy that can kind of destroy the blood vessels or the blood flow in that area. Now, what are some neurologic problems? Well, like I said, they can have spinal cord damage. So,
Tom (07:24.206)
the nerves at S2 to S4 in the back, if they get damaged, it can cause problems with that. Brain injuries, right? Obviously if you get hit in the head and you have to have brain surgery, cause you have a brain bleed, well, it looks like I just caused the fireworks to go off, which I didn't want to. So obviously that...
Tom (07:52.91)
Hmm, that was kind of odd. So I just had an interruption in the video, but like I said, brain injuries, Parkinson's disease, Alzheimer's, multiple sclerosis, stroke, as well as an interesting one, bicycling due to damage to the pudendal nerve. So it's important that your bicycle has a good seat.
as well as you're wearing good bicycling shorts to protect that area.
Local problems like at the penis itself, you can have what's called Pirione's disease, which is an abnormal curvature of the penis. So this can cause all sorts of psychological problems where they may look at, like let's say pornography, right? And they will see that, oh, this guy or this actor, person,
has this shape of penis, which is what mine should look like, or they may be in gym and they see other guys with a certain shape of penis, but theirs is not like that. And so that can cause significant problems as well as with penetration problems, things like this. They can also get what's called cavernous fibrosis. So within the penis itself, they can get kind of a scar that causes the penis to curve.
and this can interrupt blood flow, things like this. They can get a penile fracture, which can also interrupt blood flow and nerve transmission as well. Now, hormonal problems are not just the testes or production of testosterone. It can also include the thalamus, the pituitary, the thyroid,
Tom (09:55.118)
So there's a certain axis where all of these hormones work together and they're giving signals kind of to each other. So that's the way your glands work. So they give signals to each other to say, okay, I don't have enough testosterone. So, hey, I need you to send out that signal more to make more testosterone.
sometimes that what we call access doesn't work. So that needs to be investigated with certain labs and kind of going down that path. It may even require going to endocrinology to get looked at. Now, one of the ones that people will come to me with, they'll say, doc, as soon as I started taking this medication, I got erectile dysfunction. And so these medications include things like,
Antihypertension is like chlorothalidone can cause it or beta blockers or antidepressants. So like your Prozac, right? This can cause erectile dysfunction to occur as well as certain anti -androgens like doxazosin and other drugs like alcohol. So alcohol can cause it through multiple, there's multiple pathways, vascular,
nerve as well as psychogenic. So a long psychogenic, let's say maybe one time, you didn't perform well. So now you have anxiety and that could have resulted because drank too much alcohol, didn't perform well, partner got angry. And so now this caused anxiety to occur.
And also traumatic past experiences, right? Maybe they were shunned in the past by their parents for having sex and maybe before marriage. And so now they don't want to have sex, because that's always kind of in the back of their mind. Then we have relationship problems, anxiety, depression, or just like stressful times can significantly affect it.
Tom (12:22.446)
And I see this, the stressful times a lot. So they'll say, doc, you know, I'm really stressed at work. But also now I can't seem to perform well in the bedroom. And so I'll talk to them about how that's kind of related because once again, you have to have this kind of concert of everything working together, like blood vessels, nerves, hormones.
So all of these have to work together so that you actually get an erection. There is also, I've seen a few cases in my office where one partner was viewing too much pornography and now they have to see a certain thing happen or have to view it in a certain way. So instead of seeing it in real life, they only get aroused by seeing it on a screen.
Right? So they may be seeing too much pornography and they're not communicating enough. Maybe they're embarrassed to tell their partner what they want. So they're, they get kind of stopped right there. And so I'll say, okay, let's bring your partner in and let's go over the certain things that, that, you know, you want to happen. So it's important to talk through that and really understand what's going on with that dynamic.
Pornography can also cause, I've seen it cause premature ejaculation. So people will watch it and they only see, you know, maybe two to three minutes of the parts that really stimulate them instead of the entire, you know, video or whatever. So what then happens is in real life, they will go and try to have sex, but they ejaculate.
ejaculate prematurely because that's how they prime their mind to be. So then we start to talk about, okay, how do we back down off the pornography? How do we practice certain sexual habits that are effective for premature ejaculation? So I've seen that just happen in my clinic and I had to walk them through those things. Now I wanna share some interesting facts.
Tom (14:50.318)
Erectile dysfunction, remember it's linked to other things. So it has a positive predictive value for coronary artery disease equal to that of smoking. So if you have ED, then it's comparable to predicting coronary artery disease as if you were smoking. So it's important to understand it's not just an isolated problem down there.
it can be more indicative of a larger cardiovascular problem. And it can start about two to five years before coronary artery disease in the heart occurs. So you wanna get ahead of this and start looking at, are there certain things I need to change in my life? And so if you have erectile dysfunction, you're three to five times more likely,
Sorry, let me reverse that. If you have diabetes, you're three to five more times likely to develop ED. And what this means is your doc may be talking about diabetes and you're like, well, I don't really feel anything right now. They may say you just are at the beginning of diabetes. Well, you really wanna get that handled before it progresses to other diseases or what we call end organ damage. So not only will it affect
getting an erection, but you may have a stroke, you may have a heart attack, and this can cause significant problems in your life. And then the reverse, if you have ED, then one in 10 men will also have diabetes. So if you have ED, you wanna look for diabetes as well as cardiovascular disease, two major, major problems.
in healthcare today. So what does treatment look like? Well, one, lifestyle modifications. Very interestingly, it usually involves the other partner, like either cooking differently or supporting the man through this kind of journey. It's extremely important. So one, like weight loss through healthy eating, like the Mediterranean diet, which I say everybody go to Amazon,
Tom (17:17.998)
Look Up Mediterranean Diet, download you a good book with recipes to cook up. And you'll find that it's almost a completely opposite of the SAD diet. And the SAD diet is the standard American diet. So I highly recommend doing that, which can also improve diabetes. And a good source or a good program to look at is,
the Mayo Clinic diet. So I think it's like 200 a year and you can also get, you got all these recipes tailored to what you like. If you like vegan, if you like keto, if you like meat, you get that. Plus you get access to a counselor for like 200 bucks a year. It's pretty insane. And then next your exercise, right? How is your...
Is your exercise, what is your relationship like? What was it like when you were a kid? How did you exercise? Are there things that you want to do again, right? When you're older now that remind you of playing when you were a kid. So that gives you that drive to get back in there and exercise. Now I usually recommend kind of a graduated CrossFit like program that includes things like HIIT or high intensity training.
as well as resistance training with adequate warmup. So I like to do a little bit of both and I personally use what's called the Mayhem CrossFit plan in my life. And this has both components on their everyday hero kind of plan that they have. Now, another thing is mindfulness -based stress reduction programs like the ones that I have where...
It teaches you to be more resilient in stressful situations. So this program involves looking at your reactions to stressors that arise and the solutions your mind provides for it. So if the stressor comes up, is the solution to go and eat, right? It's a solution to get angry at people, which will then cause you more stress.
Tom (19:35.982)
So instead of doing that, you can focus on the better habits. One of them is meditation that will decrease your stress and allow you to see that stress arising and how it actually affects you in life. Another option is medications, right? I don't always like to throw medications at things, but they can be extremely, extremely useful. So it's the Alice, Tidalafil, Viagra.
they can all help and if those aren't working, let's say you take them, if they're not working, then the next step is I usually refer to urology or another specialist. And it's important to note that, interesting, there's an uncommon side effect. About 3 % of men will get blue vision. So their vision, and it won't be like stark blue, it will be tinted blue just a little bit. And they'll come in and tell me about it. And usually I'll try and...
I'll switch them to a different one. Now warning here, if the erection lasts longer than four hours, you should go to the emergency room. This is called priapism. And unfortunately, the treatment can be sticking a needle in there and drawing out the blood. Another concerning problem is that these medications will lower your blood pressure. So dizziness, fatigue can all occur.
So you have to be extremely careful if you already have cardiovascular disease or hypertension and you're already on this other blood pressure medication. So you don't wanna take these two things at the same time. And the ED medications are usually for a shorter time period than the cardiovascular medications. And it's important to have your doctor, your doctor should review your medications, make sure you're not on these.
Other ones that can cause additional drops in your blood pressure, which can cause you to fall and hit your head or break a bone or get, you know, just injured in general. It's not good. And there's also hormone replacement. So that can involve testosterone. And one of the warnings there that I have that I've seen come in the ED or the emergency department, not erectile dysfunction, emergency department.
Tom (22:02.766)
is that certain men will take over the counter unregulated medications. And the problem, like I'll say this all the time, with medications that are not regulated is you do not know the percentage in there. And as a previous chemical engineer, the percentage and the regulation of that percentage is difficult. So it's difficult to actually produce a certain percentage of testosterone in,
a drug and that's why you get a degree in doing these things. And if somebody just says, hey, I just wanna produce this on the cheap, well, they're not gonna do certain checks along the production line that look at what percentage of testosterone is in there. The problem is you come in with a super high testosterone, now your blood levels, your blood is thick like motor oil and then this can cause all
sorts of awful, awful problems like end organ damage, where your kidneys die, liver dies, you have a stroke, a heart attack, all these other things. So I highly recommend do not take over the counter testosterone. Now there are devices like a vacuum pumps, which can usually only be applied for about 30 minutes, which can help achieve erection. Now it may not help it.
last for a long time, but it can help you achieve erection. Other things include like prostate devices, revascularization procedures, like low energy shock waves. So this means you get several thousand low intensity shocks at the penis over several weeks. And what this does is actually cause new blood vessels to grow in. And then you can respond to...
the pills like Viagra and Cialis. Now I've never seen a patient that underwent this. So I don't know if it actually is painful or not. In my head it seems like it would be, but I don't know. Another option is platelet rich plasma. This is where the doctor will take out your own blood, spin it down and get this amount.
Tom (24:27.726)
which is full of platelets and it's called in the plasma part of the blood. Re -inject it into that area to help regrow nerves and blood vessels. And I've seen this done for knees, like for knee pain or knees that have degenerated and as well as back problems. Now, I personally don't know about the effectiveness and I don't think there's much.
data on it, I couldn't find it myself, but it's always worth maybe looking into. Hyperbaric oxygen therapy where you get in the chamber and they lower or they increase the oxygen for you, that's shown some potential a little bit. Now, another effective one is psychotherapy, which can be helpful for things like performance anxiety, as well as couples counseling and...
You should note that when men go to this, men are not usually the more talkative ones, usually. And so it can be very difficult in the beginning for the man to go to this and talk about problems. So what I suggest is sometimes why don't you write it down first and then go to counseling, right? So you write down what you want done as a man.
and let's say a journal or something like that, which is another part of mindfulness, but you write it down in the journal and then you take that to counseling and then you walk through them with that. And it can be difficult, very difficult to go through counseling, right? But it's an important step. And honestly, I think everybody should have a counselor just because it's fantastic to shoot ideas off of someone that...
that you can't do with yourself. Now it's very important that this counselor should not be passing judgment as well. They should be giving you options to try. And so another thing with couples that I do is I ask them to both go to the gym and work out because after you go to the gym and work out, you get a higher level of endorphins as well as
Tom (26:56.014)
brain activity as well as the feeling of accomplishing something for both of the people. And so once that happens, they may get a renewal in their sexual energy and they can initiate sex better than before because it also produces things like dopamine, serotonin, as well as epinephrine. And so all of these,
are contributing and helping to their overall sexual life. So I hope you enjoyed that episode. There's a, you know, erectile dysfunction is a large topic. Your doctor should be discussing some of it with you, at least asking a few questions about it, especially if you have cardiovascular disease or diabetes or obstructive sleep apnea. So those should all be combined together and asked about,
But I hope this was informative. And as always, let me know if you have any questions and looking forward to talking next time.