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Treatments for Erectile Dysfunction
Krishnan Venkatesan, MD, discusses the common causes of erectile dysfunction (ED), including high blood pressure, high cholesterol, diabetes, side effects from certain medications, prior surgeries, trauma to the pelvic and/or genital region, and mental/emotional hindarances. Dr. Venkatesan also explains the various ways to address ED, such as medication, vacuum devices, injections and penile prostheses.
Featured Speaker:
Learn more about Krishnan Venkatesan, MD
Krishnan Venkatesan, MD
Krishnan Venkatesan, MD, is the Director of Urologic Reconstruction at Medstar Washington Hospital Center.Learn more about Krishnan Venkatesan, MD
Transcription:
Treatments for Erectile Dysfunction
Melanie Cole (Host): Erectile dysfunction is a common problem affecting many men of all ages. Currently in the US, up to thirty three million men are affected by ED. My guest today is Dr. Krishnan Venkatesan. He’s the Director of Urologic Reconstruction at MedStar Washington Hospital Center. Welcome to the show, doctor. So, what are the most common causes of erectile dysfunction?
Dr. Krishnan Venkatesan (Guest): Hi, Melanie, thanks for having me. Erectile dysfunction is something that’s hard to pin down on one cause often. Usually, it’s a combination of things and very much so will depend on each particular patient. Often it’s a combination of other medical conditions like high blood pressure, diabetes, high cholesterol--all those conditions that are known to also cause atherosclerosis in the heart and other blood vessels anywhere else in the body. It could also be a result of other medications. Sometimes it could be a result of specific surgery or other trauma that’s happened in the pelvis or that’s happened externally to the genitalia. There’s also a strong component of mental health or emotional well-being to sexual health that can also manifest as trouble with erection.
Melanie: So, are there certain risk factors? Are there men that are more at risk for this than others?
Dr. Venkatesan: Yes, generally, erectile dysfunction is something that gets progressively more common with age. So, age itself may be a risk factor although somebody who’s older and who’s perfectly healthy shouldn’t have any increased chance of erectile dysfunction compared to somebody who’s half their age who has a lot of medical problems. But, generally speaking, as you age you also accumulate all these other medical issues so all those risk factors I mentioned in your first question like high blood pressure, high cholesterol, diabetes, especially if those things are not well controlled or if they have some peripheral artery disease or, like I said, any history of trauma to the pelvis or genitals or external genitalia or any previous surgeries like surgery for colon cancer, surgery for prostate or bladder cancer--all of those things can be risk factors that can make men more prone to erectile dysfunction.
Melanie: Dr. Venkatesan, I think before men can get treatment for this, they first have to come to see you and women, they’re the ones getting their men in to see a urologist in the first place. What do you want women to know and men about coming in for something like this and why they should not be embarrassed because it is a medical condition?
Dr. Venkatesan: Yes. That’s absolutely a good question and I agree that we do rely on women or partners of either gender to get their loved ones in to get this issue addressed. What I’d like them to know is that this is important for multiple reasons. Number one, because quality of life is a major issue and if this is weighing in on you, you know weighing on somebody very heavily, it can cause relationship stress. It can cause depression. All those things can cause other medical problems or difficulty in functioning on a day-to-day basis. The other issue is erectile dysfunction may be a sentinel sign of other issues going on in the body. Often it can be the first presenting sign for peripheral arterial disease or atherosclerotic disease or some other cardiovascular disease elsewhere in the body. Like you mentioned, men are not very prone to going in to the doctor for regular healthcare visits and for checkups. So, they many not believe that they have any health problems or any conditions that need to be addressed until they realize that they’re having trouble with erection. As it turns out, this may be actually reflecting some other underlying medical problem that also needs to be investigated and addressed.
Melanie: What’s the first line of defense? Of course, in the media and all the commercials, doctors talk about Levitra, Viagra, and Cialis, and you see very famous men coming on to these commercials to promote these medications. What are the medications really intended to do? Explain to the patients what you want them to know about seeing all these ads.
Dr. Venkatesan: Sure. The medications are not intended to be an on-and-off switch. They’re basically meant to act like a signal amplifier. The signal still needs to be traveling from the brain to the penis to be able to elicit an erection. The signal in the brain starts with the appropriate mood, the stimulation, all of the external factors that help to bring on an erection naturally. Now, what the medications do is basically amplify that signal from the brain so that the penis can get harder. You can get more blood flowing into the penis and the erection can last a little bit longer. Those are usually two out of the three complaints that men have is that they have trouble achieving an erection or it’s taking longer to get or it doesn’t last as long or it’s not as hard as it used to be. Now, as far as what to know about those commercials, obviously, everybody’s got some skin in the game as far as these pharmaceutical companies. All of the medications work generally in a similar fashion. They all work in the same mechanism. Each one may have a slightly different chemical compounding so that one has a longer half-life than the other. Because of this, also, I found that some patients respond better to one medication preferably over another.
Melanie: If the medication, as you say, this is not an on-again-off-again switch, you have to commit to these medications, correct?
Dr. Venkatesan: Right.
Melanie: So, if somebody is finding that the medications do not work for them, first of all, are there lifestyle behaviors, things, alcohol, smoking that will make it so these medications don’t work the way that they should?
Dr. Venkatesan: Yes, absolutely. So, all of those underlying conditions that we talked about earlier, if those are not addressed and well controlled, then the medications may have little to no effect. The primary step is really to get the underlying problem addressed and either well-controlled or if possible, even reversed. Once you do that, it may not reverse all the damage that’s been done over time but it can certainly prevent further progression of the damage that’s causing the erectile dysfunction. Then, if the medications still don’t work, generally, we have a broad algorithm, at least here in my practice, where I tell patients that they should get up to the maximum dose of one medication and if that hasn’t worked, then they should try another medication in the same class. If the maximum dose of that also doesn’t work, then it’s probably not a reflection of the medication being ineffective themselves but of the reflection of the severity of their erectile dysfunction and a sign that we may need to move on to the next step on that ladder.
Melanie: So, let’s talk about the next step on that ladder, some procedural interventions, external devices, vacuum devices. What would be the next line?
Dr. Venkatesan: Good question. Our treatments basically travel the spectrum going from least invasive to most invasive. So, the first step, like we said, was pills like all the different brand names you mentioned. If the pills don’t work, then the next step is actually considered or the next least invasive step is considered the vacuum erectile device. This is basically a plastic cylinder that’s placed on the outside of the penis and with a pump that’s either battery operated or manually operated, this pumps all the air other of the cylinder which creates a negative pressure that basically pulls blood into the penis. Once the penis has enough blood in it to give an erection that’s efficient for penetration, then the patient has to slide on a rubber band or a ring of sorts to help keep the blood in the penis. If that doesn’t work or if it doesn’t work well for a specific patient because of their anatomy or the nature of the device, then the next step would be injections directly into the penis. This is something where we initially have to do the first injection in the office so we can show the patient how to assemble it, where to inject, and to figure out what the right dose is for them. Then, whenever the patient wants to have an erection, they can inject this medication directly into the side of the penis and this should give a fairly predictable response within five to ten minutes where it gives them an erection that should last about 30-45 minutes. This same medication that we inject also comes in a small tablet form that’s called a “suppository” that can actually be inserted into the tip of the penis, into the urethra that men urinate through. So, that’s one alternate option that’s in the same class.
Melanie: And, Dr. V, how do you get men here to either of these, whether you’re using the injection or the suppository type treatment? Men’s eyes must roll back when you discuss this type of treatment.
Dr. Venkatesan: Yes, obviously, some of these options are cringe inducing initially when you hear about them but a lot of it just takes reassurance. I have to tell men that I have plenty of patients who use these regularly and that they, too, had the same reaction when they first heard about it but they get over that initial mental block or that anxiety about having to do it. Once they do, they’ve been able to get predictable results. Basically, if the man is motivated enough to come see us about erectile dysfunction, then it’s likely that they’ll be motivated enough to try the different options available to them to restore that quality of life.
Melanie: So, then, go to one last bit of procedure and what you would go to next. And, then, I’d like you to really give your best advice for men about what they can do about their situation.
Dr. Venkatesan: Yes, sure. So, the end of the spectrum, as far as treatment options go, is what we call a penile prosthesis. This is also often called the pump so sometimes men may confuse it with the vacuum device. But, this is a silicone device that’s surgically implanted into the penis. There are essentially two cylinders that go inside the penis and there are a few different models. Sometimes they’re just cylinders that the men can bend upwards or downwards depending on what position they want the penis to be in. There are a little bit more sophisticated models as well that also are attached to a reservoir and a pump, all of which will be internal. The pump sits in the scrotum and when the men want to have an erection, they pump up the pump. It gives them an instantaneous erection and there’s no lag time which is one advantage. The other nice thing is they can use it as frequently as they want and they can use it for any given time. They can keep the erection for as long as they want. There’s no limits on that. It also maintains the same sensation; ejaculation and orgasm are also maintained without any dampening. So, despite it being a surgery and being considered one of the later options, it’s certainly not a last resort because it’s the least effective. It probably has the highest patient satisfaction rates and the highest patient partner satisfaction rate of all the treatment options other than the pills.
Melanie: So, then, wrap it up for us and what do you tell men and their loved ones about the importance of seeking treatment for erectile dysfunction and the reasons, really, to go see somebody about it.
Dr. Venkatesan: Well, good question. Just like I said before, I think this is something that’s worth addressing because it can really put a strain on a relationship. It can have a personal strain that can cause depression and inability to function normally throughout the day and it can have effects even though this is something that obviously comes up mainly in the bedroom; it can have effects outside the bedroom and that quality of life is certainly something worth addressing and worth restoring. Additionally, like I said before, this erectile dysfunction may be a sentinel sign or a signal that there’s other problems going on that may not be evident themselves or may not have been diagnosed before and it’s important to get those addressed and investigated accordingly.
Melanie: Thank you so much for being with us today. It’s really great information. You're listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie Cole. Thanks so much for listening.
Treatments for Erectile Dysfunction
Melanie Cole (Host): Erectile dysfunction is a common problem affecting many men of all ages. Currently in the US, up to thirty three million men are affected by ED. My guest today is Dr. Krishnan Venkatesan. He’s the Director of Urologic Reconstruction at MedStar Washington Hospital Center. Welcome to the show, doctor. So, what are the most common causes of erectile dysfunction?
Dr. Krishnan Venkatesan (Guest): Hi, Melanie, thanks for having me. Erectile dysfunction is something that’s hard to pin down on one cause often. Usually, it’s a combination of things and very much so will depend on each particular patient. Often it’s a combination of other medical conditions like high blood pressure, diabetes, high cholesterol--all those conditions that are known to also cause atherosclerosis in the heart and other blood vessels anywhere else in the body. It could also be a result of other medications. Sometimes it could be a result of specific surgery or other trauma that’s happened in the pelvis or that’s happened externally to the genitalia. There’s also a strong component of mental health or emotional well-being to sexual health that can also manifest as trouble with erection.
Melanie: So, are there certain risk factors? Are there men that are more at risk for this than others?
Dr. Venkatesan: Yes, generally, erectile dysfunction is something that gets progressively more common with age. So, age itself may be a risk factor although somebody who’s older and who’s perfectly healthy shouldn’t have any increased chance of erectile dysfunction compared to somebody who’s half their age who has a lot of medical problems. But, generally speaking, as you age you also accumulate all these other medical issues so all those risk factors I mentioned in your first question like high blood pressure, high cholesterol, diabetes, especially if those things are not well controlled or if they have some peripheral artery disease or, like I said, any history of trauma to the pelvis or genitals or external genitalia or any previous surgeries like surgery for colon cancer, surgery for prostate or bladder cancer--all of those things can be risk factors that can make men more prone to erectile dysfunction.
Melanie: Dr. Venkatesan, I think before men can get treatment for this, they first have to come to see you and women, they’re the ones getting their men in to see a urologist in the first place. What do you want women to know and men about coming in for something like this and why they should not be embarrassed because it is a medical condition?
Dr. Venkatesan: Yes. That’s absolutely a good question and I agree that we do rely on women or partners of either gender to get their loved ones in to get this issue addressed. What I’d like them to know is that this is important for multiple reasons. Number one, because quality of life is a major issue and if this is weighing in on you, you know weighing on somebody very heavily, it can cause relationship stress. It can cause depression. All those things can cause other medical problems or difficulty in functioning on a day-to-day basis. The other issue is erectile dysfunction may be a sentinel sign of other issues going on in the body. Often it can be the first presenting sign for peripheral arterial disease or atherosclerotic disease or some other cardiovascular disease elsewhere in the body. Like you mentioned, men are not very prone to going in to the doctor for regular healthcare visits and for checkups. So, they many not believe that they have any health problems or any conditions that need to be addressed until they realize that they’re having trouble with erection. As it turns out, this may be actually reflecting some other underlying medical problem that also needs to be investigated and addressed.
Melanie: What’s the first line of defense? Of course, in the media and all the commercials, doctors talk about Levitra, Viagra, and Cialis, and you see very famous men coming on to these commercials to promote these medications. What are the medications really intended to do? Explain to the patients what you want them to know about seeing all these ads.
Dr. Venkatesan: Sure. The medications are not intended to be an on-and-off switch. They’re basically meant to act like a signal amplifier. The signal still needs to be traveling from the brain to the penis to be able to elicit an erection. The signal in the brain starts with the appropriate mood, the stimulation, all of the external factors that help to bring on an erection naturally. Now, what the medications do is basically amplify that signal from the brain so that the penis can get harder. You can get more blood flowing into the penis and the erection can last a little bit longer. Those are usually two out of the three complaints that men have is that they have trouble achieving an erection or it’s taking longer to get or it doesn’t last as long or it’s not as hard as it used to be. Now, as far as what to know about those commercials, obviously, everybody’s got some skin in the game as far as these pharmaceutical companies. All of the medications work generally in a similar fashion. They all work in the same mechanism. Each one may have a slightly different chemical compounding so that one has a longer half-life than the other. Because of this, also, I found that some patients respond better to one medication preferably over another.
Melanie: If the medication, as you say, this is not an on-again-off-again switch, you have to commit to these medications, correct?
Dr. Venkatesan: Right.
Melanie: So, if somebody is finding that the medications do not work for them, first of all, are there lifestyle behaviors, things, alcohol, smoking that will make it so these medications don’t work the way that they should?
Dr. Venkatesan: Yes, absolutely. So, all of those underlying conditions that we talked about earlier, if those are not addressed and well controlled, then the medications may have little to no effect. The primary step is really to get the underlying problem addressed and either well-controlled or if possible, even reversed. Once you do that, it may not reverse all the damage that’s been done over time but it can certainly prevent further progression of the damage that’s causing the erectile dysfunction. Then, if the medications still don’t work, generally, we have a broad algorithm, at least here in my practice, where I tell patients that they should get up to the maximum dose of one medication and if that hasn’t worked, then they should try another medication in the same class. If the maximum dose of that also doesn’t work, then it’s probably not a reflection of the medication being ineffective themselves but of the reflection of the severity of their erectile dysfunction and a sign that we may need to move on to the next step on that ladder.
Melanie: So, let’s talk about the next step on that ladder, some procedural interventions, external devices, vacuum devices. What would be the next line?
Dr. Venkatesan: Good question. Our treatments basically travel the spectrum going from least invasive to most invasive. So, the first step, like we said, was pills like all the different brand names you mentioned. If the pills don’t work, then the next step is actually considered or the next least invasive step is considered the vacuum erectile device. This is basically a plastic cylinder that’s placed on the outside of the penis and with a pump that’s either battery operated or manually operated, this pumps all the air other of the cylinder which creates a negative pressure that basically pulls blood into the penis. Once the penis has enough blood in it to give an erection that’s efficient for penetration, then the patient has to slide on a rubber band or a ring of sorts to help keep the blood in the penis. If that doesn’t work or if it doesn’t work well for a specific patient because of their anatomy or the nature of the device, then the next step would be injections directly into the penis. This is something where we initially have to do the first injection in the office so we can show the patient how to assemble it, where to inject, and to figure out what the right dose is for them. Then, whenever the patient wants to have an erection, they can inject this medication directly into the side of the penis and this should give a fairly predictable response within five to ten minutes where it gives them an erection that should last about 30-45 minutes. This same medication that we inject also comes in a small tablet form that’s called a “suppository” that can actually be inserted into the tip of the penis, into the urethra that men urinate through. So, that’s one alternate option that’s in the same class.
Melanie: And, Dr. V, how do you get men here to either of these, whether you’re using the injection or the suppository type treatment? Men’s eyes must roll back when you discuss this type of treatment.
Dr. Venkatesan: Yes, obviously, some of these options are cringe inducing initially when you hear about them but a lot of it just takes reassurance. I have to tell men that I have plenty of patients who use these regularly and that they, too, had the same reaction when they first heard about it but they get over that initial mental block or that anxiety about having to do it. Once they do, they’ve been able to get predictable results. Basically, if the man is motivated enough to come see us about erectile dysfunction, then it’s likely that they’ll be motivated enough to try the different options available to them to restore that quality of life.
Melanie: So, then, go to one last bit of procedure and what you would go to next. And, then, I’d like you to really give your best advice for men about what they can do about their situation.
Dr. Venkatesan: Yes, sure. So, the end of the spectrum, as far as treatment options go, is what we call a penile prosthesis. This is also often called the pump so sometimes men may confuse it with the vacuum device. But, this is a silicone device that’s surgically implanted into the penis. There are essentially two cylinders that go inside the penis and there are a few different models. Sometimes they’re just cylinders that the men can bend upwards or downwards depending on what position they want the penis to be in. There are a little bit more sophisticated models as well that also are attached to a reservoir and a pump, all of which will be internal. The pump sits in the scrotum and when the men want to have an erection, they pump up the pump. It gives them an instantaneous erection and there’s no lag time which is one advantage. The other nice thing is they can use it as frequently as they want and they can use it for any given time. They can keep the erection for as long as they want. There’s no limits on that. It also maintains the same sensation; ejaculation and orgasm are also maintained without any dampening. So, despite it being a surgery and being considered one of the later options, it’s certainly not a last resort because it’s the least effective. It probably has the highest patient satisfaction rates and the highest patient partner satisfaction rate of all the treatment options other than the pills.
Melanie: So, then, wrap it up for us and what do you tell men and their loved ones about the importance of seeking treatment for erectile dysfunction and the reasons, really, to go see somebody about it.
Dr. Venkatesan: Well, good question. Just like I said before, I think this is something that’s worth addressing because it can really put a strain on a relationship. It can have a personal strain that can cause depression and inability to function normally throughout the day and it can have effects even though this is something that obviously comes up mainly in the bedroom; it can have effects outside the bedroom and that quality of life is certainly something worth addressing and worth restoring. Additionally, like I said before, this erectile dysfunction may be a sentinel sign or a signal that there’s other problems going on that may not be evident themselves or may not have been diagnosed before and it’s important to get those addressed and investigated accordingly.
Melanie: Thank you so much for being with us today. It’s really great information. You're listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie Cole. Thanks so much for listening.