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Understanding Erectile Dysfunction

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Understanding Erectile Dysfunction

Mar 20, 2024

Erectile dysfunction (ED) impacts an estimated 18 million men in the U.S. alone, yet it is rarely discussed openly. John Smith, DO, a urologist at University of Utah Health, addresses the barriers to honest conversation about ED, its various causes, and the array of treatment options available. From vascular issues to psychological factors, understand the complexity of ED and how it can serve as an early warning sign for other serious health conditions.

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    All thoughts and opinions expressed by hosts and guests are their own and do not necessarily reflect the views held by the institutions with which they are affiliated.


    Interviewer: Erectile dysfunction is one of those topics that are not really talked about openly among men. Yet it really does affect quite a few men and their partners. In fact, according to a Reuters study recently, as about as many as 18.4% of men in the U.S. have experienced erectile dysfunction at some time or another in their lives. That's 18 million men in this country. 

    So today we're going to be breaking down some of those barriers about talking openly about ED, or erectile dysfunction, and discuss what causes it and some of the ways that it can be treated. 

    We're joined by Dr. John Smith. He is a non-surgical urologist with University of Utah Health. 

    Erectile Dysfunction Stigma and Prevalence

    Now, Dr. Smith, if this issue is so commonplace, what is preventing them from talking about it, learning more about it, etc.?

    Dr. Smith: I think the stigma is going away, but I think there's been a stigma over the years. I think oftentimes, too, no one wants to be vulnerable, and that's something . . . Especially genitalia, sexual health, those types of things, being vulnerable and having the opportunity to really talk about those things, people can feel that that's a very daunting task. So I think that's one of the reasons people don't.

    I'm surprised that number is not higher. I think the number is probably higher than 18%, if I were to be honest about it.

    Erectile Dysfunction Symptoms

    Interviewer: Wow. So why don't we start at just the basics then? What is the definition of erectile dysfunction, and what are some of the symptoms that men might experience?

    Dr. Smith: So the definition of erectile dysfunction is the inability to obtain or maintain an erection adequate for sexual function. And so that's the textbook definition. And erectile dysfunction has many . . . I call them different flavors. You can have chocolate, strawberry, and Neapolitan, because sometimes it's a mix of multiple things. 

    Commonly, it can be due to vascular problems, or neurologic issues. You can have it be due to medications, whether it be prescription medications, or even substances that we use that are not prescription, trauma-associated erectile issues, as well as psychogenic erectile dysfunction. 

    So there's a myriad of different reasons why you might have erectile dysfunction. And so having a conversation with a specialist sometimes is important to really kind of dig down and look into things.

    Long-Term Consequences of Erectile Dysfunction

    Interviewer: What are some of the kinds of long-term consequences that can affect a man who is experiencing one of these many different types of erectile dysfunction?

    Impact on Sexual Function and Satisfaction

    Dr. Smith: Yeah. So long term, obviously, you're going to have a decreased quality of erection. You're going to have a decreased satisfaction with sexual function. Long term, those are the things that you're going to see most commonly with erectile dysfunction.

    Diabetes, Heart Disease, and Hormonal Imbalances

    Interviewer: What are the big marquee items of things that . . . maybe diabetes or heart disease. What are the big things that can contribute to ED?

    Dr. Smith: So diabetes is a big one. Diabetic men tend to have erectile dysfunction at an earlier onset and on a more frequent basis than men who don't have diabetes. 

    Men with cardiac disease or vascular disease tend to have erectile dysfunction more commonly as well because the vessels in the penile arteries are 1 to 2 millimeters in size. 

    Interviewer: Wow.

    Dr. Smith: And the coronary arteries that you think of that would cause a heart attack are 5 to 6 millimeters in size. You need about a 50% decrease in the flow in order to have a dysfunction, and so if you think about a penile artery that's 1 to 2 millimeters, really, you only need 0.5 millimeters to 1 millimeter of a plaque buildup to cause dysfunction. In the heart, you'd need 2 to 3 millimeters in order to cause dysfunction or decreased flow that would cause chest pain. 

    And so there are people that we look at who has early-onset erectile dysfunction where we will send them to the cardiologist and say, "Hey, you should probably have this looked at," because it can be like the canary in the coal mine of things where you start to have erectile dysfunction earlier and there are some cardiac issues there.

    Interviewer: And what about, say, hormonal imbalances? It seems like all the ads I see online talk about, "ED, treat it with testosterone."

    Dr. Smith: Yeah, and that's another one . . . I don't know if I mentioned that one specifically, but yeah, hormones can play a big role. 

    Testosterone does have more control over the libido than it does the erection. Studies show that there's not a huge improvement in erectile function with testosterone use, although some men do find improvement with it, it's not known to bring back the erection necessarily as much as it does increase the libido or sex drive. 

    Interviewer: Gotcha. So it's not necessarily a cure-all for sexual dysfunction?

    Dr. Smith: Exactly. It's not the cure-all, but it definitely can help. Obviously, if you have abnormal testosterone and then you bring that into the normal level, you're going to allow your body to be able to have a more natural sexual function and function more normally in a range that's normal for testosterone.

    Depression, Anxiety, and Mental Health Conditions

    Interviewer: You mentioned briefly this idea of psychogenic erectile dysfunction, this idea that it's partially psychological factors that are leading to it. And I just was kind of wondering what are some of the big items when it comes to mental health that can lead to erectile dysfunction?

    Dr. Smith: Yeah, erections are not just a thing where it's like, "Oh, I get an erection. I don't get an erection." Some of it can be due to psychogenic causes. Sometimes I'll deem this life erectile dysfunction. When you have things that come along, disagreements with your partner, a family member is sick, the dog passed away, grandma is in the hospital and she may pass, those types of things and your mood can really affect erectile function. 

    People who suffer from mental health conditions like depression and anxiety, sometimes it's very overwhelming for them, and they have a decreased libido, and decreased ability to have really enjoyable sexual function. 

    And then you flip to the other side, some of the medications that we take to treat those things can also decrease libido and decrease erectile quality. 

    And so it's best if those things are occurring to really have a conversation with your doctor, if it's your primary doctor or a specialist, to really kind of dig down deep. And there are also sexual therapists that can be brought into the mix when needed to really bring things together.

    Treatment Options for Erectile Dysfunction

    Interviewer: What are some of the ways that we can treat erectile dysfunction?

    Dr. Smith: So for the different types of erectile dysfunction, you've got different treatments. If you've got cardiovascular disease, there's no really good way to revascularize the penis like there is the heart where you can go in and have open-heart surgery and have them revascularize the heart. So a lot of times we rely on medications to help increase the blood flow, like Viagra, Cialis, Levitra, or other medications that are utilized in the penis as well. 

    That's utilized specifically for the vascular disease, of people with diabetes. And most of the time, those drugs are effective for a high percentage of the population that uses them. 

    People who have other things, like if you take medications that are decreasing your libido, decreasing your erectile quality, sometimes you can switch to a different medication that's not as detrimental to erectile function.

    Some blood pressure medications, some medications that are used for mental health can really affect erectile function. And so sometimes switching to a different drug that's not known to cause as many problems is also a good one. 

    If you do have hormonal issues, replacing testosterone or even weight loss and exercise to help your body be more healthy and be able to have a more normal testosterone level can also be appropriate. 

    So those are the big things that you can do. The reason you have erectile dysfunction, there are always ways to kind of look at specific treatment options.

    Considerations and Caution of Online ED Treatment Services

    Interviewer: I also see that there are a lot of these online ED treatment sites where guys can log in, maybe they have a chat with a doctor virtually, etc., and they can get their hands on, say, ED medications, etc. Are these trustworthy? Are these places that people should be going to, or really is this best for in-person in a traditional medical setting?

    Dr. Smith: I think it kind of depends on the patient. Some people really appreciate a face-to-face conversation. Other people, it may be they need a little bit more anonymity. 

    If you're going to look for those places, look for one where you do get to speak with a licensed physician or a licensed healthcare provider, like a physician's assistant or nurse practitioner. Those things are going to be important because not everyone needs to be prescribed medication, and oftentimes it's very easy to get medication prescribed to you. However, understanding the side effects and other things associated with these medications is very important. 

    I don't necessarily think that they're a bad option, but I think looking to utilize them, I would advise caution just to make sure that you're talking to licensed folks who can take care of you. 

    And the other thing I would say is a majority of those places that you'll go to online, you'll pay more for the drugs there for the anonymity than you would if you came into the office. There are very inexpensive ways to obtain those medications if they're warranted.

    When to Seek Treatment for Erectile Dysfunction

    Interviewer: Now, if there is a listener that is one of these 18 million or more men who are experiencing erectile dysfunction, are there any signs or how long they're experiencing symptoms, etc., for when they should go find treatment?

    Dr. Smith: There's no time frame where, "You should wait three months to see if your erection comes back," or anything like that. I would say when you feel like it's affecting you sexually, affecting you personally, where you're concerned about it would be the time to come in and have that conversation. 

    Sometimes for folks who may not have a traditional erectile dysfunction, who may have psychogenic erectile dysfunction, having a conversation with a physician and being asked some pointed questions may really help to bring some peace of mind and help them with their issue or difficulty with erections.

    Interviewer: Now, imagine there's a listener right now, and maybe it's a guy who is really nervous about going and talking to someone like you. Do you have any words of advice or anything, or a pep talk that you would give to them to get them to go get this treated?

    Dr. Smith: Well, I can tell them they're not alone. There are plenty of folks who come into the office. I can't tell you that anybody comes in just ready to talk about it. You've got to realize that this is what we do every day and we talk to so many people about this. So don't be one of the 18 million that doesn't come and talk to a doctor.  

    But know that we'll treat it with the respect and dignity it deserves, and get you back to your full sexual potential rather than having you sit on the sidelines.