Sep 16, 2020

Interview Transcript

Interviewer: Erectile dysfunction can cause stress, self-confidence, and relationship problems, but making sure that you get the right treatment specific to your situation is important as well.

And that's why we've got Dr. John Smith, he's a urologist at University of Utah Health, on The Scope with us today. I wanted to talk to Dr. Smith about if a patient comes in with erectile dysfunction, what are some of the things that you do, what are some of the things you look at? But I think the first thing, Dr. Smith, that I do want to talk to you about is it seems like there's kind of this thought that maybe men are still embarrassed to go talk to their doctor about erectile dysfunction and any tips for overcoming that.

Dr. Smith: You know what, just it's okay. It happens. If you really look at it, I would say, in my practice doing men's health at the university, that's a majority of what I see. So you're in a majority, not a minority when you come to my clinic.

Interviewer: Yeah. I think another thing to keep in mind too is it's a lot of things that could cause erectile dysfunction, I mean, from physical to mental. So it's not necessarily like any sort of personal thing. It's not about you. It's a system. It's a complicated system, and that's one of the things that I want to get to today. So what are some of the causes?

Dr. Smith: So there's quite a few things. Some medical conditions can cause it. Diabetes is one that's well known. Gentlemen who've had prostate cancer and had treatment for that is another common one. Another probably less commonly known one is, you know, having stress in your life, whether it be at work, at home, relationship issues. The complexity of life can kind of get at you sometimes and wreak havoc on your body's libido and erections.

And sometimes its underlying medical conditions we don't know about. So we mentioned diabetes and prostate cancer that's been treated, but some folks with underlying, you know, cardiovascular problems that they don't know that they're there may also have a sudden onset of erectile dysfunction that could be kind of a harbinger of other things.

Interviewer: Yeah, that's interesting. So erectile dysfunction could be a symptom of, like you said, a lot of other just physical conditions we've all heard about before. So if somebody is experiencing erectile dysfunction and they come into your clinic, what does that visit look like? How do you try to figure out the best treatment for that individual?

Dr. Smith: So I bring folks in and we sit down and we start to have a conversation. I like to get a nice history of, you know, what's gone on, if they have past medical problems, and kind of also get kind of their social situation, what's going on relationship-wise and other things in their life, you know, work-wise, see and look at the whole individual and see, you know, kind of what could be causing this issue. And if we can put our finger on something specific, like they've been a diabetic for quite some time and this has been a long time coming, you know, that's one thing, or if they come in and it's just kind of a sudden onset thing, where stress, you know, went up in their life and they just noticed kind of a more sudden onset and kind of get a real feel for what brings them in and what kind of things we can do to help them. I like to get a testosterone on folks that come in to make sure that there isn't some kind of an endocrine issue going on as well as make sure, with my history and physical exam, that there may not be some other underlying condition that may be, you know, more problematic.

Interviewer: What's the next step in treatment? Obviously, if there's an underlying condition, the first goal would be to treat those underlying conditions. I'd imagine you want to make sure that those are taken care of. But what's the next step at that point?

Dr. Smith: For a lot of folks, you know, exercise can increase erections. You know, diet and exercise can be a great improvement for some folks who may have a few extra pounds and who may not be as active as they once were. That can help boost testosterone levels and also just kind of help them in general. If that's something that, you know, they're not really keen on or they're already doing and they're still having erectile dysfunction, you know, sometimes we'll trial medication to see how that can help them to have maybe a little bit more confidence or help their erections to be of a higher caliber or quality.

Interviewer: What types of medications are available? I mean, we've all heard of the one, right? Are there other types that do something different?

Dr. Smith: So in the class of drugs like the little blue pill that we've heard of so much, many of them have gone generic now. So the Viagra now is generic as sildenafil and Cialis is now generic as tadalafil. There's also Levitra, which was hot on the market for some time. That's also known as vardenafil. Those have all gone generic and have become quite inexpensive as treatment options. And there is some differences between those medications that we kind of go over with patients to make sure that we're getting them the right medication if that's the course that we go to.

Interviewer: Other than pills, are there things that you do for treatment options before you think surgery?

Dr. Smith: Of course, of course. There's multiple of different things we can do up until surgery. There's constrictive devices. The layman's term would be a cock ring. That can help people who are able to get an erection, but have difficulty maintaining it because that's part of the erectile pathway as well. If they have what we call venous leak, where their penis is letting out more blood than is coming in, you can lose that erection. And so sometimes those constrictive rings can really help during sexual intercourse. You can't leave that on for an elongated period of time. You use it during your sexual encounter, and then it's got to come off so it doesn't damage the tissue surrounding it because of the pressure. But that's one thing that we can do if we suspect a venous leak. That's why a thorough history and physical and understanding what's going on with a patient's erections, when they come in, can kind of lead us down a path to treat them with that rather than medicine.

Interviewer: What if the problem that is causing the erectile dysfunction is more of a mental issue? First of all, what types of mental issues kind of get in the way of that? And then what would you do to help somebody with that?

Dr. Smith: So one of the things is we call it psychogenic erectile dysfunction, where physiologically there's absolutely nothing wrong with the patient, but they're having difficulty with an erection. And I've seen this quite a bit with a few different types of patients. Someone who's been in a new relationship or had something like that, where they've had difficulty with their performance say, that can kind of ruin their psyche and kind of gets you down and then they have problems continuing. Another one that's fairly common is once people have started to try to conceive children, when sex kind of becomes a job at that point, sometimes I've seen men who kind of have difficulty with an erection because now it's not a spontaneous thing or it wasn't as fun as it used to be. Then I'll see them come in and say, "You know, I've had some trouble. We've been trying to have a kid for six months. It's been difficult, and I'm just, you know, a little short on the confidence thing, where this has kind of become more of a job than anything else."

Interviewer: And then ultimately, when a patient leaves, will they be coming back at some point then?

Dr. Smith: I generally say, "Here's the medication. We'll start with a dose." And I usually let them titrate the dose up or down depending on if they need additional medication within safe limits. And then I bring them back within, you know, a few months to make sure that that medication is effective, because if it's a not, I want them to know that we can look at other avenues and options to make sure that we can take care of their erectile dysfunction.

Interviewer: So the ultimate message is that if somebody is experiencing ED, that there is a solution for it. You can help in most cases.

Dr. Smith: Seven out of ten men will do well with just pills alone and, you know, beyond that, we can help them with other avenues as need be. So there is hope we can definitely help folks to get to their goals.

Interviewer: Are there times that you decide with a patient not to treat it because it just ultimately doesn't matter? Like they come there because they think that it is a problem, but ultimately, they're just kind of like, "Well, I really don't care."

Dr. Smith: Yeah. I've seen that, not too often. I mean, it's mostly older patients who may be like post-prostatectomy, who come in and they're not partnered anymore. They're, you know, either a widower or they're divorced. They don't have a partner. And it's like, "Why am I going to give you pills that may give you a headache or flushing, or, you know, those types of things when I don't really need an erection at this point?"

Interviewer: Yeah. Got you.

Dr. Smith: So those aren't as common. But I think some guys, when they come in, the younger guys as well, but they usually want a pill as kind of the ace in the hole to have in their back pocket so that it gives them a little confidence, to be honest.

Interviewer: Well, yeah. I mean, there's something to be said for that, right? They might not even never need to take it.

Dr. Smith: Oh, I've had tons of guys come in that are psychogenic erectile dysfunction, who come in, you know, in their 20s and 30s, who there's not a darn thing physiologically wrong with them. They have no underlying medical conditions. They go to the gym all the time. They're otherwise healthy. It's just they had that one sexual encounter and it didn't work, and now it's never going to work again.

Interviewer: But then you've got that pill. At least, you know that if worse comes to worse and that pill and you might not even need it.

Dr. Smith: Yeah. Well, and that pill potentiates things. I mean, once you get an erection, that pill will help you keep it. And that's the whole point of the pill. And so those guys totally, you know, it's total placebo, but not at the same time, if that makes sense.

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