Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring that you stay at the forefront of your field. I'm Melanie Cole. And today, our discussion focuses on erectile dysfunction, a comprehensive approach.

Joining me is Dr. Kiran Sury. He's a urologist specializing in reconstructive urology with the Allegheny Health Network. Dr. Sury, thank you so much for joining us today. I'd like you to start by telling us about ED, the prevalence, the scope of the issue that we're discussing here today.

Dr. Kiran Sury: Thanks a lot for having me, Melanie. ED, erectile dysfunction, just in case you're not familiar with the acronym is incredibly prevalent. Millions of men have it. Now, there's a big range in ED, right? You drink too much, you can't get it up one night, that's not something you really need treatment for. But it's really that persistent inability to either get a full erection or maintain an erection that is a hallmark of erectile dysfunction.

They have done some studies sort of on national data sets, such as Medicare, looking at millions of patients across the country, and they've found prevalences of anywhere from 25% in men under 40 to it gets 50% once you're in your 60s and even higher. And I think the true number is probably almost every man has had at least a fleeting moment of ED in his life.

And so, I think it's something that physicians probably see regularly. Now, whether the patient is willing to talk about it or whether the provider is comfortable bringing it up is a different story. And so, that's kind of what I'm hoping to get across today: ways to bring it up in conversations and easy ways to think about ED causes and treatments.

Melanie Cole, MS: Well, I'm so glad you said that because certain things like ED, incontinence, men specifically are not always comfortable going to a urologist to discuss these things. But because it's a chronic condition that can really affect quality of life, I'd like you to speak about some of the causes, the etiology, and pathophysiology that we do know because there are both physical and psychological factors, yes?

Dr. Kiran Sury: Absolutely. So, psychogenic ED is probably one of the biggest categories, which is where all the plumbing is working. These men will often wake up with good, strong erections. But then when it comes time to perform, they cannot. And for those patients, sometimes talking to a therapist or a psychologist or a psychiatrist can help. It often coincides with depression. And an interesting thing is sort of a chicken or the egg thing: is the ED coming from depression or is the depression coming from ED? And in fact, there have been studies that show that treating ED can have significant psychological impact for men and improve their depressive scores.

So, I'm a big fan of it just from that perspective. But the other thing is, I'm a urologist. I see a patient referred for ED, and I'm thinking about how to fix that. But I still screen for the things that could be causing it. For example, cardiovascular disease. One of the things that causes ED is the tiny blood vessels that feed the penis. If they're not working as well, whether it's through years of smoking or hard living, it's hard for the penis to maintain blood flow and get an erection. But what we always say is the other small blood vessels in the body that are similar to the blood vessels to the penis are the ones around the heart. And so, ED is often the earliest marker of significant cardiac disease. And I think it's really important that any patient be screened if they have a family history, that they go and either see their primary care or cardiologist to talk about that. And frankly, a lot of my referrals come from cardiologists who are seeing men as part of a cardiac workup, and they note ED and they know that these patients can be served by seeing me as well.

Also, another big one is diabetes. The mechanism for why diabetes affects ED is the same way that it affects everything else, all that sugar in the body, the glycosylation, it damages the nerves that cause erectile dysfunction. And just like you can get diabetic retinopathy, you can get diabetic neuropathy on the fingers and toes. You essentially get a diabetic neuropathy of the penis so that nervous system doesn't work either.

Melanie Cole, MS: That's so interesting, Dr. Sury. And as you were talking about being a marker for cardiovascular disease and how addressing the risk factors, the comorbidities, sometimes you don't find out that they have cardiovascular disease until you found out about the ED. So, the two can be incidentally linked in the actual diagnoses. Is that criteria for diagnosis more than a few occurrences? What do you determine before you will start treatment, is that criteria?

Dr. Kiran Sury: Yeah. So when to treat ED, it's not a simple question. I get men in their 20s and 30s, they're college age or university or that kind of thing. They are active, they play sports. They're very fit. They don't have diabetes, they don't have heart disease, and they have that psychogenic ED where they get it up overnight. But then once it comes nighttime and they're out with someone, they can't perform.

I am a big fan of treating upfront. I always tell these men it's going to be a combination of things. And I really, really encourage therapy, whether that's sex therapy, behavioral therapy, even just talking to their friends and loved ones.

But in the meantime, I'm a big fan of starting a medication. We have lots of pills. They work really well. The side effects are pretty well tolerated. And so, I will generally start these men on a pill while also encouraging them to seek some of that psychological treatment. And what I find is while they don't really need the pill, it gives them the reliable erection that they don't need to worry about that anymore. And that confidence boost can be enough to start almost a virtuous cycle of having more normal, regular erections. And down the line, they can stop the pill.

Melanie Cole, MS: What a great approach. Now, what are some of the other treatment options that are available? Tell us about this multifaceted approach. You've mentioned the pill, but what else do you do for men?

Dr. Kiran Sury: Yeah. So, I mentioned the pill only because it works so well. Everybody's heard about Viagra. Everybody's heard about the little blue pill. Well, the nice thing is they used to be hundreds of dollars for these prescriptions, but now they're all generics. And so, we have generic sildenafil. We have tadalafil. We have Avanafil. And I think patients can cycle through them and try everything they want, and I genuinely encourage primary care providers to let their patients kind of try these because it's never going to be a one-size-fits-all approach.

But sometimes either in replace of the pills or, in conjunction with them, we do have other medical and mechanical options starting with vacuum erection devices. You can do penile injection therapy. And ultimately, what I offer, the penile prosthesis, which is a surgical solution for ED. 

Melanie Cole, MS: Tell us a little bit more about that. When is that indicated?

Dr. Kiran Sury: Technically, anytime you want. If I have a patient come into my clinic with ED, I can offer them surgery, go straight to it. There is no stepwise treatment. There is no right or wrong. That said, I would never do that. The surgery is a great option. It is a guaranteed direction that you get when you want, it lasts as long as you want, and then it goes away. And I love that and my patients love it too. But frankly, if you can get a more natural erection with one of the other less invasive methods, you should do that. And I always counsel my patients towards that.

Melanie Cole, MS: It's my understanding that a lot of these treatment approaches are really along the lines of shared decision-making based on individualized perceptions, things that people want, individualized, personalized medicine, yes?

Dr. Kiran Sury: Absolutely correct. And that's why this is one of the things where it's really nice for these patients to actually come in and see a physician or an APP because there are online clinics. There are specialty men's clinics and those kinds of things where you can throw money at the internet and buy whatever you want. But I think it's really seeing someone with the medical knowledge to discuss these options and talk through them that patients are going to get the best results.

Melanie Cole, MS: Anything exciting on the horizon, Dr. Sury?

Dr. Kiran Sury: The way an erection is the penis fills up with blood. It's two natural cylinders. The blood stays in, the blood goes away. And when that mechanism is disrupted, the surgery is basically putting in two almost cylinders or water balloons inside that mimic that natural filling and emptying. And you control that through a pump I hide in your scrotum. Obviously, not all men can pump so well, and it can sometimes affect the mood if you have to wait to use that or even if you're doing any of the other treatments, the injections you have to stick a needle in or the vacuum pump.

They're actually working on a fully electronic penile prosthesis, which would have essentially some sort of Bluetooth or WiFi component and a battery and you could just press a button or say, "Hey Siri, give me an erection," something like that. And it would give you an erection on command. I think we're probably at least five years out from that being implanted in people regularly, but it's certainly something I'm looking forward to. 

Melanie Cole, MS: That is so interesting and such an exciting time in your field. Dr. Sury, as we get ready to wrap up, I'd like you to offer providers your best advice in counseling their patients, when to see a urologist and managing patient expectations when they do come to see you and they want to know what's going on, what you tell them about how well all of these different options work and what you'd like other providers to take away from this episode.

Dr. Kiran Sury: I guess what I would want them to take away is that there is no one-size-fits-all approach. And if you are willing to work through the various options with these patients, they will be incredibly grateful. And I would love it if all of my referring physicians, the primary care as the endocrinologist, the cardiologist would have all of these conversations.

But the truth is all of my colleagues are incredibly busy. They don't have time to go through all of that. They're not just dealing with the ED, which I'm laser focused on, they're dealing with all the other medical issues, these patients come in with. So, what I would say is, by all means, get them started on a pill or not whatever you want. But if the patient is bothered enough to come talk to you about their ED, I think the most important thing is letting them know they have a lot of options and that we have experts who will work through those options with them to get them what they want. And I think your local urologist is exactly positioned to be that expert. 

Melanie Cole, MS: Great advice and such an informative episode. Dr. Sury, thank you so much for joining us today. And to learn more or to refer a patient to Dr. Sury, please call 844-MD-REFER, or you can visit ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole.