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Melanie Cole (Host): Erectile dysfunction is the most common sex problem that men report to their doctor. It may be a result of a medication they are on or treatment for cancer or another reason; but they may be hesitant to tell anyone about their symptoms. My guest today is Dr. Uwais Zaid. He’s a urologist with the Carle Foundation Hospital. Dr. Zaid, tell us about the current state of ED today. What’s the prevalence and certainly, what’s the societal impact of this?

Uwais Zaid, MD (Guest): Well thank you for having me. I really appreciate the opportunity to discuss this very common and major issue that a lot of men suffer with and a lot of them suffer with it quietly because they are embarrassed to talk about it. But it’s very common. When you look at the data, upwards of 35-40% of men starting as early as their 30s, start noticing some issues with erectile dysfunction. As you get older, the prevalence increases as well. Men up to about 44% of men ages 60-69 have issues with maintaining adequate erections for intercourse and upwards of 70% of men 70 and older have issue with erectile dysfunction as well. When we look at our diabetic patients, it’s very common. Up to half of them are going to have issue with erectile dysfunction. As men as living longer and more active; this is going to become a more and more prevalent issue that’s going to be causing more and more issues and interpersonal relationship problems as well.

The other issue which you alluded to earlier was erectile dysfunction could be a harbinger of other medical issues as well. So, there are a lot of different causes and a lot of different treatment options we have to offer patients for erectile dysfunction as well.

Host: So, as I said in the intro, it could be a result of medication or treatment for cancer. Tell us a little bit about the etiology and some of the common conditions and factors that can lead to this, that you would look to when a patient first comes to you with this issue.

Dr. Zaid: Of course. You are 100% correct. There is a lot of different sources and etiologies for erectile dysfunction. In fact, upwards of 80% of cases of ED have some sort of organic or medical cause behind them. So, common causes could be medications. These are very common medications we use regularly like blood pressure medicine, such as the beta blockers or hydrochlorothiazide. A lot of the antidepressants that are very commonly used can also cause erectile dysfunction as well. You have vascular causes, you have cardiovascular issues, diabetes can cause it.

Prior surgeries can cause it as well. So, if somebody has had prostate cancer surgery or colorectal surgery, vascular surgery; these can all negatively impact the ability for a man to have an adequate erection. And of course, there are a lot of hormonal causes, testosterone issues, and different issues with being overweight and obesity can wreak havoc with the erectile functions as well. And then of course, in a small subset of population, you do get worried about psychological component as well. More overview wise though, this can still affect men’s overall wellbeing, their happiness and their self-image if they can’t have an adequate erection as well.

Host: One of the interesting things I found in my research Dr. Zaid was that this is now possibly being considered a marker for cardiovascular disease. How do you address the risk factors and medical comorbidities that could be associated with this complaint?

Dr. Zaid: Of course. Yeah, and that’s exactly correct. Because the same – in order to get an erection, one needs to get blood into the penis so if there is anything that compromises that ability, which you often see in cardiovascular diseases; that could be an early sign of cardiovascular disease as well. So, things that we want to address with our patients are while sometimes they may have undiagnosed diabetes, so we do some labwork to see such as a hemoglobin A1c to see if they have any concerns for diabetes. If they smoke, that’s a huge risk factor that we work on smoking cessation as well. We look on our examination, we check for any signs of peripheral vasculopathies such as pulses, and the lower extremity appearance and things of that nature as well. And then of course, you want to make sure somebody doesn’t have any cardiac risk factors that could make sexual activity unhealthy for them, but more importantly, that could be a sign that they need an evaluation by our cardiology doctors as well. So, you ask about their general activity levels, their health status as well too.

Host: What are some current issues in medical or surgical management? Assess for us doctor, specific treatments you would look to, first line of defense once you detect the cause and what’s going on whether it’s psychological or anxiety and you would have to look to lifestyle changes or medicational intervention. Tell us how you go on down the line to look for first defense.

Dr. Zaid: Of course, and I think you hit it right on the head. The first thing we want to work on is looking at any modifiable risk factors that could lead to erectile dysfunction. So, you always want to assess somebody’s interpersonal relationship status, that a really critical, important part of this. You want to make sure they are in a safe relationship as well that they feel comfortable having sexual intercourse. You want to assess their genital overall health status, their libido, their sexual desire as well. You want to look for any offending medications such as the blood pressure medicines or the antidepressants and that’s where we work really closely with our colleagues in primary care to see if there is any alternatives. So, for instance, instead of a beta blocker or a hydrochlorothiazide, can we switch to a calcium channel blocker or an ACE inhibitor or something because those are less negative on the erections as well.

And then beyond that, like I said, lifestyle modifications. Weight loss is critical, smoking cessation is critical as well, just generally being active and healthy is quite important and it has been shown to be beneficial for erectile dysfunction. Then once we address those reversible or those modifiable factors; then we have a whole host of different treatment options to help men with erections. Our first line stuff usually tends to be oral medications. These are like Viagra, Levitra, Cialis and the benefit is some of these medications have been around so long, they are no longer on patents so we can get medications a lot cheaper. One of the biggest barriers used to be the cost of medications, but Viagra in particular, you can get through a compounding pharmacy and it’s very affordable and we have many great compounding pharmacies we work with to get people affordable medications.

There are a lot of little nuances as to how to use the medications as well that we can talk about if you would like. Beyond that, there is a little bit more invasive options, but what I call the advanced therapies for men who have ongoing erectile dysfunction that doesn’t respond to medications or if they can’t take medications. Some men take concomitant nitrites for chest pain and things of that nature and they cannot have the sildenafil inhibitors. So, then we have options like intracavernosal injection therapy which has a 92% success rate. We have alprostadil urethral suppositories which work reasonably well. We have a vacuum erectile device which is an external penis pump and then we have surgical options such as penile prosthesis that come in different forms and varieties and they work really well for the right patient with very high patient and patient partner satisfaction rates as well.

So, there is a lot of different treatment options for men with erectile dysfunction that go beyond risk factor modification and assessment.

Host: Do you have some predictors of treatment response based on what you determine the cause of it is and depending on whether you try blood vessel surgery or one of the vacuum devices or… what have you seen as far as outcomes for men?

Dr. Zaid: Sure, I think certain men you can predict are going to do better with less invasive therapies. So, for instance, in our younger patients who have less severe vascular disease or who have had diabetes that is controlled or not as longstanding; they generally tend to have a better response to our oral medications as well. In younger men who have psychological issues in relationships I think counseling is so important and that by itself is more than adequate for a lot of men as well. Now certain men who have had very significant vascular disease, longstanding history of smoking or longstanding diabetes; then you get more – you get less – you think that the oral therapies will be a little less successful. It doesn’t mean you shouldn’t try them. You can always offer them to patients, but then you are more likely to proceed with the advanced therapies like penile injection therapy or penile prosthesis surgery for these men, depending upon what they want to do next basically as well.

And you alluded to this a little earlier, erectile dysfunction is basically an overall marker of somebody’s overall health status and if they have significant comorbidities, then the same effects on their lower extremities or on their heart will be seen to the blood vessels and the nerves that go to the penis as well.

Host: As we wrap up, doctor, aside from telling other providers how you want them to assess their patients and discuss this sensitive topic with their patients; what type of other providers are also involved? Because we have mentioned a few different treatment options and so tell us about a team that might be able to help somebody with these issues and how do you want providers to work with their patients?

Dr. Zaid: Of course, that’s actually a key question. I think this is a team effort and there are a lot of providers that help these patients because a lot of these patients have concomitant medical issues that will negatively – that they are also working on that adversely affect erections. So, other doctors that are – or other providers that are involved in the care of these patients include endocrinologists. A lot of our endocrinologists help with diabetes management, our vascular surgeons, colorectal doctors and providers are really critical as well. So, all of these different providers can also help assess this important topic and kind of help guide the patient in the right direction to discuss at least, treatment options which we are happy to help with here as well.

And then beyond that, we have a whole host of other folks that help out. For example, dieticians and nutritionists and people who counsel patients on dietary modifications, people who counsel patients about smoking cessation can all assess patients for erectile dysfunction. And then lastly, anybody who is involved in cancer survivorship issues because a lot of our cancer survivor patients because of radical pelvic surgeries whether it’s prostate surgery, colorectal surgery or anything like that; may have the same issue as well as the consequence of their surgery. So, anybody who helps cancer survivors would be a great resource for patients as well to help guide them in the right direction for treatment as well.

So, there is a lot of people who can be involved in the care of these patients and kind of guide them in the right direction.

Host: It’s great information Dr. Zaid, thank you so much for helping us today and for sharing your expertise and discussing this very sensitive topic that many men are very hesitant to discuss with their providers. Thank you again for coming on with us. You’re listening to Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities please visit www.carleconnect.com, that’s www.carleconnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole.