Kendal Williams, MD (Host): Welcome everyone to the Penn Primary Care podcast. I'm your host, Dr. Kendal Williams. If you're in primary care like me, one of the issues that comes up very often is men's sexual health. And if you were trained like me, you didn't get a lot of formal education on this topic in either medical school or residency.

But it comes up all the time. And you know, I know most of what I've had to learn, I've had to learn on my own to try and care for patients who come with various issues related to their sexual health. So, in order to address those issues, uh, I've invited on Dr. Kathleen Hwang. Dr. Hwang is a Professor of Surgery at Penn in the Division of Urology.

She is the Director of the Men Health Center at Penn, and an expert in men's sexual health. Kathleen, Kat, thanks for coming on.

Kathleen Y. Hwang, MD: Thanks for the invitation. I'm excited to be here.

Host: Yeah. So how did you get into this area? I assume you were trained as a urologist, but, tell me more about that.

Kathleen Y. Hwang, MD: Absolutely. So formal training, I am a urologist who finished residency and during residency I was actually fascinated with male reproductive and sexual health. Really just kind of just my mentors who sort of showed me the, the really fun surgeries we do in microsurgery, prosthetic surgery, but was actually pretty fascinated with the physiology behind it.

Then when I started learning a little bit more about how fulfilling it can be to kind of work with patients who are struggling with these really sensitive topics, it kind of became a passion for me.

Host: That's terrific. It is an area that is oft neglected, and I do, by the way, promise a podcast to the audience on women's issues regarding sexual health, but also around menopause, because that's become a big deal. And I don't know, Kathleen, if it's not you, maybe one of your colleagues we can have on to talk about the new developments in that area or sort of the old developments I suppose that have now become new.

Kathleen Y. Hwang, MD: Absolutey.

Host: Yeah. So, the only reason we're doing men's first is because I needed to study up on a lot of the, the women's issues before we did the podcast. So, Kathleen, let's just start with sort of the basics as you go through this with patients. I mean, and the things that I was going to talk about today were issues of erectile dysfunction, issues of ejaculation, issues of low libido, and then, you know, sort of anatomical structural abnormalities that, you know, Peyronie's disease and others that maybe you see, as well that need to be addressed. Does that sound like a good agenda?

Kathleen Y. Hwang, MD: Sounds good to me.

Host: So let's start with the basics and we often have patients that come in and, you know, they're often sort of shy to bring something up and then you realize quickly that, you know, they want to talk about sort of these more sensitive issues. They begin the discussion and then you begin to ask more questions. So, what is a good sexual history?

Kathleen Y. Hwang, MD: So most of the patients who show up have some inkling of what they want to talk about, and unfortunately, it isn't always as accurate as they think it is. So a lot of times people will label their sexual function concern as I have erectile dysfunction, and sometimes I do have to dig a little bit deeper because that's not properly what they actually are struggling with.

Maybe they're really struggling with premature ejaculation, but just label it as erectile dysfunction. So a lot of times we have to go really dial back and I have to ask some pretty detailed questions to understand really what is their chief complaint. Most of the time it starts off with how would you describe what your actual problem is?

Like, what are you most frustrated with? And a lot of times you get a laundry list of things and it's like five things listed down, and I always start with l et's talk about the top two and describe it for me, and if it's erectile dysfunction, tell me about your erection. Tell me about what the baseline function is, the rigidity, how easy it is to achieve it.

When it's with a partner or not. So there's so many different aspects about sexual function that aren't just about the erection itself, that you do have to ask a lot of broad questions to help them explain what they're concerned about.

Host: And, and I suppose oftentimes because it's the thing, it's ED, we see it on commercials, on TV. People are comfortable labeling that way, because it's a public label, but as you say, I mean, it may be issues of low libido to some degree. It may be issues of ejaculation, not able to achieve orgasm and so forth. Right.

Kathleen Y. Hwang, MD: Absolutely. And it's not uncommon for this cycle to start where you're struggling with your erection quality and because of how uncomfortable you are with intimacy at this point, because you're scared of this performance and anxiety kicks in, you naturally shy away from intimacy. So there you're, your sexual drive is now dropped because you just don't want to put yourself in that situation.

Then all of a sudden you can start having ejaculatory dysfunction because you're so fearful you're going to lose the erection, you're actually orgasming really fast, and that is the spiral of where all of the sexual dysfunction becomes kind of this one giant problem that started with just a partial erection that just wasn't up to your kind of satisfaction.

Host: Are there specific features of the history that you are kind of really looking for? Because I know in your mind you're, you have a differential diagnosis in your mind as you're approaching this issue. You're trying to figure out what the problem is, as we just discussed, right? What is the actual problem they're having, and then you're also starting to form a differential diagnosis for the possibilities. Are there features, not so much about medications and other things, but features of the experience themselves that can help you tease those out?

Kathleen Y. Hwang, MD: Absolutely. This is when we start asking about if there's a partner every time that they have a struggle, or is this similar when they're by themselves with masturbation? Is this a type of struggle that's across all types of stimulation. So we'll get as detailed as saying, do you struggle with this same problem when it's just by yourself and you're masturbating with manual stimulation?

Is it the same with manual with a partner, oral with a partner, or just with penetration? And some of that provides information about whether or not there's a lot of mental psychogenic emotional component to it. Like part of this puzzle is really just this anxiety, or is it really just across the board this is a true physiological problem?

Kendal Williams, MD (Host): I was always taught that asking about whether men are having erections at night or when they wake up was a helpful piece in sorting out is it psychogenic or is it sort of a neurovascular issue? Right.

Kathleen Y. Hwang, MD: Well, so morning erections, and a lot of patients will come and be like, listen, doc, I haven't had morning wood in a really, really long time. And then you start kind of explaining, you know, what is nocturnal erections? What really does that provide as far as information? And the way that I share with patients is those erections you get at night, they're, they're not sexual, they're real for your penile health.

It's getting that firm rigidity softening up and cycling overnight. It's protecting that penile flexibility of the tissue, providing healthy oxygenated blood throughout the entire shaft. And so what's left over is that morning erection. Maintaining that ability to keep those erections and those cycling of nocturnal erections at night sort of is a parallel and an indirect measure of just sort of like healthy blood flow, good nerve stimulation.

But the reality is as you age, that gets less and less just because you're aging. The blood vessels are aging. But doesn't always, parallel to function. So you have a lot of younger guys who will say, I do not have morning erections anymore. And I'm like, you're, you're 22. I'm surprised that you're sort of providing that information.

Because sometimes I'm shocked about that. And many a times they have just gotten to this place where like they missed them and they're still there and will do other ways to kind of do some testing to confirm that whether or not they truly are having them or not.

Host: So I want to dig down on this, because you mentioned that you were fascinated by the physiology and now you've piqued my interest in the physiology. Because you alluded to, there's a, there's a physiological purpose for nighttime nocturnal erections. Right. And, you mentioned it and, but is there any more detail to flesh out there in terms of, you know, why that happens?

Kathleen Y. Hwang, MD: What we figured out is when you start losing some of that nocturnal sort of cycling of erections and you are no longer having, you know, frequent enough voluntary erections for intimacy or sexual function, what'll happen is the penis contracts, your tissue contracts, it's this sort of dynamic organ that needs continued stretching to maintain that flexibility.

And when you lose it, it will contract. So a lot of guys will come in and say, my penis is doing the turtle. It's literally disappearing on me, and I know I haven't done anything to it. There's no trauma, but it's literally just because it has lost that natural sort of protective mechanism of these nocturnal erections to maintain that penile stretch, that penile flexibility of the tissue. And you'll see a lot of this in patients who are post-surgical.

Host: Because they have a period after surgery where they're not having natural erections, and then there's sort of a rehab process that needs to happen to get back on track. Right.

Kathleen Y. Hwang, MD: Exactly.

Host: Okay, I, now I'm curious about the physiology, because I want to go into this a little more detail. You know, we know that having an erection is a vascular phenomenon, right?

 I did not, read about this before the podcast, so I'm going back on basically, you know, but basically in some way, the floodgates get opened. The blood flow increases into the penis, it becomes erect. And then at some point that reduces. You know, that's all driven by nerves as well.

So, it's a neurovascular phenomenon. Right. Maybe we could just dig into, actually, you know, what causes that?

Kathleen Y. Hwang, MD: The way that I, I, like to describe it is basically your erections are dependent upon healthy blood vessels. Because the erection is a coordinated dance of arteries and veins, and the artery's job is to pump the blood into the shaft after sexual stimulation. The stimulation itself, whether it's this mental or emotional kind of sexual stimulation, triggers the nerves.

It sends a signal down to these blood vessels that says, let's get this blood going. This blood flow gets shunted into that penis, and that's what fills the shaft, creates the rigidity, but that's just the arterial aspect. Once the blood is there and the rigidity is created, the veins, the venous channels have to then snap shut to keep that rigidity there, and that's what maintains these erections.

And the coordination between the nerves, the arteries, and the veins is what creates healthy erections. Healthy erections that show up when you want them to, go away when you want them to, go away post orgasm. And so anything that interrupts either the nerve stimulation and or the arterial sort of response to the stimulation, how robust the response is and how well those veins close, is how well your erections are going to be achieved and maintained.

Host: And when it comes to the nerves, we're talking about almost exclusively autonomic nervous system. I mean, you can't necessarily will yourself to have an erection, although you probably have some conscious control over it, but it's mostly just autonomic, right?

Kathleen Y. Hwang, MD: Yes, yes, a hundred percent. There's rare instances where patients can genuinely just say, listen, I can do this on command, you know, in the midst of, you know, doing my taxes, I can get an erection, no problem, like, no sexual stimulation necessary. But the average person, it is a pure on autonomic response.

Host: Mm-hmm. So then I guess the problems that arise are, you know, impacting that system, the arteries, veins, or the nerves, or their coordination in some way. Right? And so let's just talk about the common causes of erectile dysfunction, meaning, I guess the whole category of things that somebody is not able to have an erection that is sufficient to complete sexual activity. Right?

Kathleen Y. Hwang, MD: Right, so, top winner in this is are going to be like vascular sort of etiology, right? And so the patient population who struggles with ED the most, are guys between the age of 40 and 70. You're going to see high blood pressure. Diabetes and lipid issues or cholesterol issues and those, that's how I describe like as the triple whammy.

If you've got the triple whammy, your blood vessels have aged faster than you have, and unfortunately they're going to misbehave earlier than you think should ever happen. So sometimes patients will come in and they're shocked that they have these struggles with ED, but they are a poorly controlled diabetic.

They're literally in the office and their blood pressure is wildly out of control. They're on, you know, all these medications, and yet they have very little insight into why they have ED. That's the first question that they have. They're like, doc, I have no idea. And I'm like, well, I do. Let's talk about what we think, what we need to do for you.

Host: When we talk about blood vessel abnormalities on, in my world, in my internal medicine, particularly when it relates to diabetes, we talk about microvascular changes, right? The things that we also see manifested in the retina with retinopathy, nephropathy and so forth. And then we talk about macrovascular, where people are, you know, clogging with plaque.

We see coronary artery disease and so forth. And I, I imagine that problems with blood flow come in both forms, and could contribute to erectile dysfunction. Diabetics have both, but I, I don't know. Is it, it's, these aren't that small of blood vessels. I imagine this is mostly a macrovascular phenomenon.

Kathleen Y. Hwang, MD: Mostly, so mostly a macrovascular kind of phenomena where the blood flow that is supposed to be shunted down into the penile corpra, which are the cylinders in the shaft that are supposed to be where the erectile tissues are kind of waiting for all this blood flow to get there, are just not receiving that level of blood. Right?

Now, a lot of folks will talk about, Hey, we have all these like new vessels that we're regenerating with all these new technologies in the penis itself. That that's why these things don't work that well yet because they're, they're targeting kind of like the microvascular kind of things, which really aren't going to shift big, big, major, moderate to severe ED.

Host: Yeah, and, and I guess the other problem that diabetics have is the neuropathy, which can involve autonomic systems and, and therefore may contribute to ED as well. And I would imagine other folks with neuropathy, I know you know folks who are alcoholic. My understanding is they also can have problems with ED that may be part of a neuropathy.

Maybe other issues, it may be the direct effect of alcohol on the overall system. I'm not sure. Then, you know, years ago, I remember it is probably the 1990s or even before that, watching a 60 minutes and they were doing this whole sort of expose on how smoking had caused ED and how that the public was not aware that this was actually a, a problem with smoking.

But of course it makes perfect sense because smoking is a major contributor to macrovascular problems. Okay. So, I want to talk about some of the common things that we do that impact this physiologic system. And then I want to, I want to get into the hormonal aspects, but before we leave the, the sort of the neurovascular phenomenon itself; I mean, we give a lot of drugs that can potentially cause this. You know, I remember reading in my youth, if you will, that any hyper anti-hypertensive can, can have an effect on erectile function. And so some patients it, you know, some more than others, but any specific one, is that generally true or are there ones that you look out for when you're taking a history that you think could be playing a role more than others?

Kathleen Y. Hwang, MD: So, I mean, usually when I'm looking over the, the med list, right? So like anything that alters blood flow, anything that changes, that in its sense has a role to it, whether it's the big piece of the puzzle or a small piece of the puzzle, it's still part of it. The classical ones where we're always like, Ooh, red flag are like the beta blockers, right?

So patients who are on very high metoprolol doses, I'm like, listen, this is not helping for sure. Now, obviously your priority is like your heart health. We're not here to piss off your heart. We're here to work with you. But this is a medication that is certainly not making erections easy to get.

Host: The other category we deal with a lot related to sexual function, not necessarily to ED, although I, I don't really know, is SSRIs, the antidepressant class, the Zoloft, the Prozacs, the Lexapros and others of the world. Although I think Lexapro has a little bit less of a side effect of that.

It's often why we think about drugs like Wellbutrin. Or others because patients come in and say, you know, they're really having issues with the sexual function. Any thoughts on that category and what you see?

Kathleen Y. Hwang, MD: Well, I mean it's sort of this strange kind of situation where you have patients coming in asking for SSRIs because of premature ejaculation, right? The off-label usage of them to help you know, last longer to increase their latency timeframe after penetration. But the strange kind of reality is that a well-known side effect is it could drop your libido by changing your sexual drive.

It could make it more challenging to get erections that are quality and, and the ability to maintain them. And so you always have this sort of like balance of being like, okay, well we can certainly explore SSRIs to treat your sexual function complaint of premature ejaculation, but let's just be clear, it might cause other ones that you currently don't have.

Then there's the separate patient population where they're on SSRIs for mental health issues. Right. And they're doing great on it, but they're like, I'm really struggling with these sexual function complaints and it's really changing the quality of my life in a different way that I just was not hoping for.

And so oftentimes you are like, okay, is this the only medication class of drugs that works for you or can we talk about alternatives with your provider? Is there something else out there that can be equally as effective for your depression, but maybe less sexual side effects? Sometimes it is a discussion with patients that we have to caution that it isn't as easy with some of the patients who are on SSRIs to just wash out of these drugs that easily. Sometimes these side effects linger and well beyond what you would expect the average, you know, person stopping SSRIs. And so we, we always pre-warn folks, right? Like, these are things that are well established. We have to be, make you aware before you start taking this, you know, on demand or even daily for premature ejaculation.

Host: Interesting. So I want to get into very commonly the psychogenic causes, but I want to go back to the physiology a little bit. Because there's issues of erectile dysfunction, but there's also issues of libido. And I wanted to ask, what role testosterone plays in this whole cycle. I had always thought of testosterone oh, somebody has ED.

Well let's check their testosterone levels. But, you know, doing some more reading about this a couple years ago, the sources I was reading were educating that, you know, testosterone actually contributes more to libido than it does to the erectile function that the neurovascular phenomenon we just described itself. But educate us about testosterone in this whole paradigm.

Kathleen Y. Hwang, MD: Testosterone is so popular, so very popular at this moment. It's highly successfully marketed. And so we get lots of questions about low testosterone, lots of questions about testosterone replacement therapy. But testosterone levels are very closely linked to your sexual drive.

Now, the testosterone normal reference range in a lab is wide, right? If you go from 300 all the way through like a thousand, and it's all encompassing for all ages of adults. All adult males. So sometimes it's a little challenging to say to someone, Hey, your T level of 500 is really normal. When they're like, I'm symptomatic with my, you know, this or that.

But what you'll find most commonly is when I'm asking patients about low T or I am concerned, I have low T, I'm like, well, tell me about your sexual drive. And if they're like, oh doc, my sexual drive is awesome. I've got a sexual drive, like a 18-year-old I am every day, all day. And then I'm like, I don't think there's a problem with your testosterone then. Because it is that directly linked, that you will really see this association of folks who are very symptomatic, truly can describe the situation of really low libido. Their T levels are often going to be quite low, or definitely on the lower end of normal. Whereas in contrast with erectile dysfunction, while testosterone certainly is that male hormone, it is a good piece of the puzzle for just in general sexual function.

It rarely is going to correct erectile dysfunction alone. Right? Somebody who has a low testosterone but they have ED, you can give them replacement to make them more uvenatal. But the reality is their ED is not most often not going to be corrected. Their treatments that they take may work more effectively.

They may need less Viagra, maybe 50 milligrams instead of the a hundred or 25 milligrams instead of the a hundred. Or you can downgrade them off of an injection down to an oral, but they're still going to need some additional help with the erections because correcting the hormone isn't going to be enough.

Host: What is your, by the way, just because there does seem to be some fudging of what is a low testosterone, what is your low number?

Kathleen Y. Hwang, MD: So that is a very good question because it is so lab dependent. It depends on who you're asking, whether you're asking an endocrinologist, a urologist, a primary care physician. We all have our own like cutoffs, our own little, you know, warm spot where we're like, okay, this is low. I'm not comfortable with this.

Just based on just sort of the past clinical trials I've worked on and all these different things, my cutoff is in our lab, 300 nanograms per deciliter. Okay. And so typically we're like, okay, this, it has to be below 300, and part of that discussion is also, it needs to fall within these ranges in order to convince your insurance that you truly have low T and that they're going to cover your medical replacement therapy.

Host: Can we talk about testosterone levels through the decades of life? So it does naturally decline in men just as estrogen declines, precipitously at menopause. But men have a slower decline with testosterone over time. So do you interpret a little differently for a 75-year-old than a, I'm sure you do for a 35-year-old, right?

Kathleen Y. Hwang, MD: So this is the hardest part about managing hypogonadism or testosterone deficiency, is that checking a blood level is just a number. And so a number, so somebody who has a total testosterone of 350 nanograms per deciliter may be completely happy in life and have no symptoms at all, and are presenting to see something else, and someone just happens to check and they're like, oh, but I'm fine.

I don't have any complaints at all. And you can see the same number in somebody who is miserable with complaints of fatigue and sexual dysfunction, and they're the same age. And you can see these symptoms in multiple different people across different age groups. But these numbers are all over the place.

So when we counsel patients, we're like this, and I know your T level that you had checked is this. You don't have symptoms that support whatever is going on here. Because hypogonadism is a combination of symptoms and blood supporting levels. It's not just your symptoms and it's not just a blood test.

 We have sometimes have to get into the weeds about like what the different types of testosterones are out there, right? A total versus a free versus a bioavailable. And why is checking protein levels important with your sex hormone binding globulin, or your albumin levels? These are all parts of understanding, you know, what your T level means to you as a person and how that influences your symptoms.

Host: Can we go through that real quick? Just a brief primer on total versus free in particular, I suppose those two.

Kathleen Y. Hwang, MD: Sure. So I mean, total testosterone is like in general what's floating through your system, but what's available to your receptors is very different because some of your testosterone molecules can be bound by some of these hearty proteins like SHBG, your sex hormone binding globulin. Any testosterone molecule that's bound to SHBG basically is rendered not available to your receptors.

So weakly bound things bound to like albumin are freely available. And still functionally, you know, part of the system that's supporting you. So there are times when you can have an individual who has a very robust total testosterone, but they're so symptomatic and you are at this moment just being like, maybe I'm being tricked by this total testosterone.

Let's check an SHBG. Now if his SHBG is really high, like surprisingly high, his free testosterone or even his bioavailable testosterone will be much lower than where it should be. So his symptoms are now making more sense. And now beyond just testosterone, different flavors, we actually are encouraging patients to consider, you know, checking estradiol levels as well.

If you have really pretty normal testosterone levels for the range that we think you know is normal in this reference range, but your estradiol levels are sky high, triple digits, you're likely going to be symptomatic as well. That testosterone to estradiol ratio, which is going to support your, your testicular function, needs to be in a reasonable, you know, hopefully 10 to one kind of thing.

Host: Do you ever check prolactin levels just to rule out a prolactinoma?

Kathleen Y. Hwang, MD: Yeah, so prolactin's a great way to kind of monitor the central concerns, right, about where that's stimulating your pituitary and how these different things are going to influence your downstream testicular function. And the way that I describe it to patients, I'm like, your testicle like literally only has two jobs.

It's to make testosterone and it makes sperm. But the funny thing is it sits there and it does nothing. It will do nothing until your brain tells it to. And so that stimulation is very important in that circuit of how that access and feedback creates a balance of function. And so when you have something in the brain that's being pumped out like a prolactin level, right from your pituitary, that's too high, it actually suppresses the rest of that stimulation in your HPG access.

So the classical patient we teach, med students and residents about are like the 18-year-old who comes in is like, I've never had an erection. I have zero sexual drive. I'm curious as to why this is. I find it so strange that I've never had this. And you're like, well, that's not normal. That's a big red flag.

And you'll check a prolactin level and it's 3000, right? Like that individual needs MRI of his brain, he probably has a functional tumor that we need to address. And so those are the classical patients that you're like, yes, please don't forget this.

Host: I want to go back to the sex hormone binding globulin because you mentioned a scenario where the free will be low because their total's fine, but the sex, what causes sex hormone binding globulin to go up, or do we know?

Kathleen Y. Hwang, MD: So there are a couple different scenarios, right? So like chronic diseases can do it. So one really classical one is like, you know, COPD. Chronic liver diseases can do it. And sometimes we find them incredibly high and we have no idea why. And then I'm like, well, maybe you haven't been diagnosed with the things that we know about, but we'll ask.

Right. And obviously, like I'm not the medicine person, but I'm always like, okay, there's a list that I'm supposed to ask you about because your SHBG is triple digits and I don't like it. And so we do, we engage with our PCP, you know, counterparts to be like, Hey, I'm really worried about this because it doesn't make sense to me.

Host: That's interesting. So, okay. I actually, I'm thinking of questions as we've gone through this. They're not on our outline, but, we all have to do Medicare wellness exams on our patients. These folks are on Medicare, so they're generally 65 or older. And, as part of that, there's a list of questions, that we're have to ask them every year, and one of them is about sexual health.

And so that probably has led in the last couple years more PCPs to talk to their 65 plus year olds, men about sexual health than before because we're sort of mandated to ask it. But what I don't have in my head is kind of what's normal for a man in their, say, 65 and older seventies, eighties in terms of all these issues, libido, erectile function and so forth. Are men supposed to have normal erectile function into their eighties, or is it all related to testosterone? Let's assume they don't have diabetes and all these other problems. They're just a healthy, 80 some year old man. What's normal for that age group is my question?

Kathleen Y. Hwang, MD: So excluding all these other comorbidities, right? In your seventies and eighties, you still should be able to get erections. We have so many of these patients who are, you know, in their eighties coming in to see me and be like, listen, doc, it's six months. I've had this issue with ED, and I'm like, I'm so proud of you.

This is great. I'm, I'm so happy for you. Let's get you functional again. Now whether or not the individual's like really active and like, you know, meeting new people or interested, that's a totally different story. But without any other comorbidities you still should be able to generate healthy erections for intimacy.

Host: Yeah. Good. And there's a separate discussion about when to replace testosterone generally, you know, for overall bone health in men and other issues, and that's changed. I know this, it's a separate part of this discussion, but I know it's part of your field, of, replacing testosterone in generally in older folks, in older men, for all of those issues. And I know that recently we've come to the conclusion it's largely safe to do right.

Kathleen Y. Hwang, MD: Yes, so testosterone replacement therapy is safe to do if you monitor correctly. And you're identifying the right patients. It's a wonderful thing and can really change people's quality of lives in, in very meaningful ways. But you just want to be very thoughtful about informing these patients about what they're getting into and recognizing what the best approach to replace the testosterone is.

Because there are actually quite a few options at this point, but also doing the proper monitoring.

Host: That's great. Just to make sure it doesn't go too high, right?

Kathleen Y. Hwang, MD: Yeah. So we have a target we're always aiming for. We talk about, you know, what's an appropriate range for whoever we're working with. We talk about, you know, what the different approaches are and what fits into their lifestyle, whether it's a daily, whether it's a weekly, a biweekly, a monthly right, or even the depo injections or the pellets that go into like every four to six months.

There's quite a variety of different options in how to fit them into their lifestyle. Each of these options will have different strengths on how you can quickly get the uvinatal or sometimes have the potential to overshoot. Depending upon the approach, like for example, a testosterone pellet has a pretty high rate of generating erythrocytosis, right?

So 25, 30% of all patients who have testosterone pellets are really going to have to pay attention to their H and H, to ensure that they don't develop, really, really sort of high levels where we're going to have to start having them be phlebotomised. This is a much slower, lower rate of developing erythrocytosis in topicals. And are sometimes more preferable depending upon the age group.

Host: What's the high testosterone you've mentioned 300 to 900; is over 900 sort of raise concern. You need to drop the dose?

Kathleen Y. Hwang, MD: So there are some patients who really love being above that level, and I'm always like, listen, this is super physiologic. Like your body is not naturally made to generate these kind of numbers. And so I know you might feel like this is normal for you, but this is neither necessary nor where I want you to be.

And so I often warn patients like, if we're going to do this TRT journey together, I'm really aiming for like, you know, five to 700.

Host: So I want to skip back, and talk about the psychogenic aspects. And then I want to go forward into treatment and, and then I really want to make sure we have time to talk about the folks who have had a prostatectomy and what they can expect. Because I have a lot of folks who in that category, but, we have psychogenic as a cause of low libido of ED. And a very common cause. Right. Literature I was reading did talk about penile tumescence testing that can be done to potential sort out whether people are actually having nighttime erections. I don't know how often you end up having to order that, but I'm curious about that testing.

Kathleen Y. Hwang, MD: So, nocturnal penile tumescence testing used to be a very commonly ordered thing. They actually had this machine that's called a RigiScan that we would have one or two units in the office and we would just rent them out for patients to take home at night. And essentially what it was, is this band of a cuff that went around the penis at night and had a couple wires that, you know, followed out.

But would trace how many erections, rigidities, the stretching, basically, it would track and trace the stretching overnight, and then you'd like look at the tracing. It was like an EKG for your penis. But we would look at them and say, okay, oh, you had three or four cycles. This is pretty solid that you've got great, great cycling at night.

I'm feeling really positive about your function. But the reality is it's kind of fallen out of favor just because the machine itself is really expensive. It would break and it's hard to get now. Now a lot of folks have made parallels where they're like, we'll just put postage stamps, like old school postage stamp the ring around the penis, and if it breaks, that feels good, right?

That means, okay, I got an erection at night and I didn't even know it. So there are simple ways to look at that, like home kits that we have sent people home with. What we are doing now sort of in place of that is not replacing the nighttime kind of monitoring, but we do penile doppler ultrasounds now. This is where we're generating erections and mid development of this erection, we're monitoring the arterial flow, we're monitoring the venous flow. And for somebody who is concerned about ED, but as like rock solid, normal waves of peak systolic waves and like end diastolic waves, you can reassure them like your vessels are beautiful, they're doing amazing things.

And a lot of times they're like, oh, really? And you're like, yeah, yeah. There's no evidence that your vessels are not happy.

Host: You know, it's funny because uh, there are certain tests in medicine like, tilt tests, for instance, that have no diagnostic value, but they have therapeutic value. Once you give somebody a diagnosis, they get a lot better, even if the test was a sham. Right. So, not that your tests are a sham, but I I, I'm curious as to whether, as, whether or not folks get, if you tell them they're fine and all of a sudden their problem goes away. So this is a phenomenon in medicine, but I want to talk about Viagra, not just Viagra, but PD5 inhibitors generally, which I guess I was probably in residency when these came out to much fanfare. And you know, listen, Viagra was one of those true, developments and advancements in medicine.

It solved a major problem, very successfully, right, sildenafil. And now, you know, the other one, I'm most familiar with is tadalafil. And I'd be curious to see what you think of others in addition to that. And you know, of course Viagra, sildenafil comes as 50 or a hundred milligram pills, as far as I know.

Comes in eight pills a month as a standard prescription. Tadalafil comes as 20 milligram pills, which is tadalafil is longer acting right in the sense that it will last longer in your system, allow you to have erections over maybe a two to three day period as opposed to a one day period. Comes as 20 milligrams.

But it also is FDA approved for urinary flow, at a five milligram dose. Right? So I wanted to get all that intro out of the way so you didn't have to say it, but are there any pearls within those two drugs and how you use them?

Kathleen Y. Hwang, MD: Sure. So Viagra's old and tried and true. It's been around forever. Sildenafil is generic and relatively cheap, right? So great for starter, but it's short acting. The other trick is Viagra has to be taken on an empty stomach. If it's got food in the stomach, it doesn't get absorbed. The response is blunted.

People get really frustrated when there's inconsistencies. And so when we first start prescribing Viagra, I'm like, take this on an empty stomach. If you're not taking it on an empty stomach, you're going to be really sad when it doesn't work as well. And so anytime I start anybody on an oral PD5 inhibitor, I tell them like, listen, the first six to eight doses, this is by yourself, Sir. You're not allowed to involve a partner yet. We need to prove to you and to build confidence that when you take this medication on an empty stomach, when we start changing the scenarios, we're going to take this three hours after dinner, we're going to create all these different trials so that you understand in this scenario, I've already done this.

I know what my body does, I know what kind of erection I'm going to generate. Only then can you feel confident enough to be with a partner and not worry what is my penis going to do? Right? So Viagra's great. For short acting, for on an empty stomach, and it's the cheapest out there. Now for younger individuals, they don't love this massive on demand planning.

It's really hard on their psyche. It's really hard on the stress and the strain of the anxiety of like, oh my gosh, I gotta plan and take this ahead. Cialis doesn't care if you have food or not in your stomach. You can take it with a full dinner and it still does just what it would if you took it on an empty stomach.

Cialis, as you mentioned, they call it the weekend pill. Take it Friday. It's good through Sunday. It's amazing. The best part about Cialis is the five milligram low dose daily. Double FDA approved erections and voiding function, just because it's really improving the blood flow to the pelvis. The way that I frame this to patients and I'm like, you're going to be taking this every day.

You cannot think that every time I take this pill, I'm going to get an erection. Right. This is a vitamin for your penis. You're taking it every day. It's there for you to boost your natural sexual erection when you want, so you don't have to stress about planning. You can rely on the fact that it'll be there for you.

It is typically not covered by insurance, but we use GoodRx coupons and get it very affordably at just about any pharmacy. So, great Levitra, not a huge fan, right? Older as well. Very similar to Viagra, but just does, does not have the same efficacy. Stendra, the newest kid on the block. It's not that new anymore.

It's still like 10 plus years old. The claim to fame is that it had the quickest onset of action. Once you took it, dissolved fast, absorbed fastest, it's not that much faster and it's just a whole lot more expensive. So we, we really are still sticking to Viagra, Cialis now.

Host: How long does it take for Viagra to kick in?

Kathleen Y. Hwang, MD: So on average, we tell folks everybody should be taking it at least one hour before you want that erection to kick in. For some individuals, they can clock it and they're like, you know, it took me about 35 minutes. Fantastic. Right? We tell them, do your own little mini trials at home. Figure out how long it can take to actually absorb for you to start getting these erections.

Because then it makes it easier for you to plan and meet pa you know, people, partners, and so you're less self-conscious about it.

Host: So these drugs, are like a rising tide that floats all boats. I mean, it almost, in a sense, it doesn't matter so much what the cause of your ED is, they can at least probably help. So is that right, in general?

Kathleen Y. Hwang, MD: Unfortunately I share with him, I'm like, it really? This whole cachet of treatments that I have for your erections. They, we don't care why you have ED. We're going to share the same cachet regardless of why you have erectile dysfunction. And then we cater to how your response is, which seems a little kind of like, you know, sledgehammer approach, but that's kind of where it is.

Host: So you have patients then that fail, Viagra or Cialis?

Kathleen Y. Hwang, MD: Many.

Host: Yes. Right. So it's not uncommon to fail. Is there data on that? How many fail, by the way? I guess it depends. I mean, you get your post prostatectomy folks and others, right so.

Kathleen Y. Hwang, MD: What we tell folks, PD5 inhibitors are really going to be effective for mild ED. Anything more than mild ED, it's not really going to be your one solution.

Host: Yeah. So then what are the options? This is a point at which I send them to you, by the way, because I, I've run out of my options, so now I'm sending them to you.

Kathleen Y. Hwang, MD: So, so there are some folks who are like, listen, I don't want to have to deal with medications. I don't want any of this. We have penis pumps. Vacuum erection devices. These are external mechanical devices that create a negative pressure within a cylinder that goes over the shaft, generates blood flow, pulls the blood into the shaft, and creates fantastic rigidity, but that's only getting the erection.

Then you have to create a penile constriction ring. Put it at the base and then that maintains the erection. So this is really popular against folks who have bad hearts, can't take any other kind of medication. Travel's easy, you get this little kit. It's fantastic little little box where it goes in. It's like a little piece of luggage.

But it takes a little bit of practice up front to get really coordinated with the device itself. But once people sync in, pretty popular. And the reason being, it works in everyone because it's mechanical. There's, there's no reliance on how your body responds to it. It's just mechanical. So there's a lot of tips and tricks, but everybody can respond to it.

 The most popular option are these penile self injections. It sounds absolutely terrifying. Nobody ever wants to hear about sticking a needle anywhere near their penis, but the reality is we can blend these medications that are these vasodilators. They're mostly based out of either prostaglandin E1, papavrine, phentolamine, blended to some degree in different formulation, and if you introduce it directly into the corpora, a nd there's little bridges that go to one side to the next. They're very, very powerful. So these can really help patients get really functional erections consistently in the very most severe patients. The one challenge is this is the one approach that has the highest risk for priapsim, right? So you have to be very thoughtful about the education.

Host: Yeah, I would think so. Because you're, you're opening up the floodgates, but it's not clear what's going to reopen the vein gates. Right? So once you've, uh, opened up the arterial gates.

Kathleen Y. Hwang, MD: Right.

Host: Uh,

Kathleen Y. Hwang, MD: The last option is surgery.

Host: Yeah. So tell us about surgery.

Kathleen Y. Hwang, MD: Surgery comes with penile implant prosthetics. They come in two different flavors. One is a semi-rigid rod, so these two rods are implanted into the shaft and they're malleable. So you live in the state of about 80% rigidity. Fantastic for people who have, you know, dexterity issues, um, but is able and firm enough to penetrate and be intimate at any reason, any cause with any partner.

And the sensation's the same. So your ability to reach orgasm is preserved. All of that's there. The most popular prosthetic is the inflatable. The inflatable prosthesis allows the patient to live in a state that's natural and flacid for 99% of the time. But then there's a pump device that's in, uh, inserted into the scrotal sac where they're able to pump it up like personally, pump it up and there's an inflation mechanism and then you penetrate, you reach orgasm, you go back down and you deflate. And so it's very, almost natural in the sense that you have these different phases and they last a decade plus. And so patients are really happy with them.

Host: It sounds now that you're reviewing these options, and I've only known them in a cursory way in the past, but it sounds like any man could probably get back to sexual function, given these options. Right? For the most part?

Kathleen Y. Hwang, MD: Yeah. Yeah. I am always a little disheartened when they're like, I just didn't know that there were all these choices. And so I'm like, we, we've got choices. Now, I describe it as a ladder. The higher you climb on this ladder, the more aggressive the treatment is, but the more powerful it is, so the worse your ED is, we have to just climb together. We'll get there.

Host: So let's talk about the post prostatectomy folks. Because those are the folks that are in our offices. So I'll just to give you two scenarios that we're, dealing with, I think, uh, one is, a patient who has been diagnosed with prostate cancer and is now, making a decision about whether to get a prostatectomy or radiation therapy and balancing the risk and benefits of both.

 So what do you tell patients before the prostatectomy?

Kathleen Y. Hwang, MD: The post prostatectomy individual, right, we are actually encouraging patients to come meet with us preoperatively just so that they have an understanding of what to expect. Because it is, it's like a different world. It's a an alien planet for them. They have no idea what to expect and it's always overwhelming.

So when we sit down with patients preoperatively, we tell them like, you know, my role here is to be your coach in helping to get your quality of life issues back on track. We're actually going to push you, pretty early, right? So we have them come back to see us postoperatively at six weeks, really early.

Now part of it is, I describe there is this concept called this penile rehab program. And that's generally what we're trying to do, is we're trying to rehabilitate the penile tissue in sort of restoring penile health, which hopefully will translate into restoration of better sexual function earlier. I describe that the program lasts for about a year. During this year, they will meet with us on a certain frequency, usually every three months after that first six week visit, and it involves different approaches. One of the first things that we talk about is, you know, warning them about that loss of penile length.

About that contracture, about that turtling because that's always very startling and very bothersome for patients and if they don't know to anticipate it, it's can be really panicking for them. The other aspect is we talk about that you should expect that you will not have any erections for the first six to eight weeks.

Do not expect erections because you'll be disappointed. Your nerves are in shock. Your pelvis is in shock. Everything is in in this in state of inflammation. Nothing is ready for your body to put any energy into fixing any of this stuff yet. We talk about the different approaches with utilizing the PD5 inhibitors, utilizing the vacuum pump, utilizing injections.

So basically every tool that we have, we're going to implement at some point during this year to get the stimulation going.

Host: What numbers do you quote now to folks what they can expect after? Well, I mean, you basically said that a hundred percent of people can eventually, depending on what, what tool they end up using, that a hundred percent of people can basically get back erectile function, but you know what percentage naturally will lose it?

And then how through a through a rehab program that you outlined, how much better you can, you get those numbers?

Kathleen Y. Hwang, MD: So these are one of the first questions that people ask. They're like, am I going to be myself afterwards? That's the biggest question. So it depends, right? So it depends on did you have erectile dysfunction before surgery? Right. So if you had ED before surgery, then we're working harder in an uphill battle.

If you had completely normal function prior to surgery, the likelihood of restoring all of your normal function, it's not a slam dunk, right? So we tell them it's probably about, you know, 30 to 40% that are going to have zero change to their sexual function right. Now a lot of folks define success differently.

Success to them can be, I'm functional. I just need to be able to generate an erection, to be able to be intimate with a partner and penetrate when I want. Okay? We can get there. It just depends on how comfortable you are in all those different treatment options that I just described. Most patients want natural.

Most patients want. Give me back what I had, and it's a little hard to hear that, that only truly really happens in about 30% of patients. Okay. And that is not even going into the intricacies of like what your cancer surgery was like. Did we have to take a nerve? Did we have to take both nerves? Because the approach to doing a prostatectomy is oftentimes dependent upon the severity of the prostate cancer.

For more severe, higher grade, nastier cancers, they have to go wider, which means you're losing your nerves, they're cutting them out to do the right cancer surgery. Those are patients who are not going to get their function back. We just took your nerves out. It's in pathology, right? So it depends.

And, and some patients are frustrated that I can't give them a rule that everybody follows. But I tell them, your body's different than everybody else's. Your cancer is going to be different than everybody else's, and your baseline function is different. And so there's, there's so many moving parts.

All I can tell you is we will start from the starting line after your surgery, and then we'll get you moving as soon as you can. What Penile Rehab program wise does is, is it doesn't miraculously make your erections better. What it a hundred percent does is it makes patients feel supported. It makes them feel heard and seen and not lost.

And so they can navigate the first year after having surgery, easier. And they have an advocate to kind of talk to about these really sensitive issues of like, listen, every time I cough, I pee myself. Right? Or I can't even think about sexual function because I'm leaking all over the place. So just having an advocate to kind of talk them through those things.

Will we engage them in saying like, your homework is, I need you to use this vacuum device and stretch your penis every night, right? That's what's going to restore some of this penile length, this flexibility that you're going to lose unless you do it. This is where you it or lose it actually makes sense.

Host: This is very informative. I have patients come in to all the time, sometimes they're 20 years out from their prostatectomy. I had a gentleman who is actually relatively young and had a, they had to go back in after his original prostatectomy and he really ended up with no function.

And he said, I don't even see a urologist anymore. He's in his early sixties, mid, I guess maybe now, mid to later sixties, but it'd been five or six years and, he just not seen anyone. and was assuming that he was not going to have any possibility. So I sent him to one of your colleagues and he was actually very pleased.

Came outta that more optimistic, but is it now standard as part of the prostatectomy process at Penn to meet with you or your colleagues? Or do we as primary care physicians need to advocate for it?

Kathleen Y. Hwang, MD: I wish I could tell you yes. So we are in the process of building a formal program to become a uniform everybody who has invasive pelvic surgery, whether from colorectal, urology, for bladder cancer, prostate cancer, they're going to be told about our program and given the opportunity to make these appointments earlier. So we're giving them the choice.

Host: Kat, that's great. And this is going to be very helpful to me because it comes up a lot. I mean, I think probably. I don't know. It's a handful of prostate cancer diagnoses every year or two. I mean, I, I, it's not uncommon at all, and, patients come into their primary care physicians to ask these things, so knowing we have these resources available is very helpful. Maybe we should end the podcast there and just ask you, how do we get patients to you?

Kathleen Y. Hwang, MD: The same way anybody else, you look me up, you gimme a call. So I exclusively really only see men's health patients, and so it's either male reproductive or male sexual health. And if you have any questions of any kind regarding either of those topics, come on in.

Host: So we didn't talk about the reproductive piece. This has to do with male infertility, right?

Kathleen Y. Hwang, MD: Correct.

Host: And maybe we can have you on to talk about that at a later date.

Kathleen Y. Hwang, MD: Sounds good.

Host: Yeah, thanks Kat. This is really informative. You know, I, this is, something we all deal with all the time, but, this is the most informative discussion I have ever been in about it, and maybe even ever heard. So it's really valuable. I hope the audience enjoyed it as well. Please join us again next time for the Penn Primary Care podcast.