Scott Webb: Erectile dysfunction, or ED, affects roughly 30 million men in America, and though perhaps not always the easiest conversation to have with our providers, experts like my guests today, want all men and couples to know that confidential and compassionate help is available for ED. And I'm joined today by Drs. Blake Wynia and Will Flanagan. They're both Urologists with PRISMA Health.

 This is Flourish, the podcast brought to you by PRISMA Health. I'm Scott Webb.

Just want to thank you both for your time today. We're going to talk about erectile dysfunction, probably better known as ED, latest treatment options, and so on. Dr. Wynia, I'll start with you. What is ED? What is erectile dysfunction? And is it the same as impotence?

Dr. Blake Wynia: Well, the two terms have been used somewhat interchangeably, but, we sort of define erectile dysfunction as any sort of inability to either achieve or maintain an erection for sexual activity to a point that is satisfying for both the patient and his partner.

Host: All right, so there is a bit of a distinction that seems like for some, they're sort of interchangeable, but a little bit of a distinction. And Dr. Flanagan, is ED a normal part of getting older and understand this is a 55 year old man asking you, who's at risk for ED? What age is it common where guys start to experience ED?

Dr. Will Flanagan: In general, those of us in men's health, Dr. Wynia and myself feel that while you see more erectile dysfunction in older patients, it is not necessarily a normal process of aging, and you do not have to continue to deal with ED. We have a lot of great treatment options available. As far as the age range, I've seen everything from patients in their 20s to patients in their late 80s, early 90s that are interested in being sexually active and are not able to do so. As Dr. Wynia said, it is defined by the inability to achieve an erection sufficient to have intercourse.

Host: Yeah. And we're going to talk as we move on here a little bit later about sort of the mental side of this, not a non-physical part, but the mental health part of this. And as you're saying that age range of, you know, 20 to 90s. I'm sure there's big mental health component to this. And we'll get to that soon. Dr. Wynia, is there like a list of causes for ED? Can some medications lead to ED? In other words, how generally do men suffer from ED?

Dr. Blake Wynia: So there are some pretty well known etiologies of erectile dysfunction, and it's fairly common to not just have one of these reasons, but to have a number of different reasons that are all contributing to the problems with erections. About 40 percent of men will have what we call a vascular cause of erectile dysfunction. So that means essentially it boils down to poor blood flow in the vessels in the penis that cause an erection. And, a lot of other medical conditions can lead to this sort of poor blood flow. So that can include things like diabetes, patients with high cholesterol, high blood pressure, patients who have heart disease, which can lead to poor blood flow.

 All of these problems can definitely exacerbate an already existing issue. With regards to medications there definitely are medications that can also harm your erections. One of the most common types of medication is blood pressure medication. Now, not all blood pressure medications can lead to the same effect, but, the most common are patients who take either beta blockers or another class of blood pressure medication called thiazides. A variety of medications for psychiatric diseases can cause problems with erections. Medications that are intended for nerve related pain or other issues can also cause it. So, it's fairly common that we see men who don't just have one etiology but sort of have a combination of factors.

And, you also alluded to the mental health side of things. Certainly there is a strong psychological component to erections, and that can affect men who are young and men who are old. I think it's more often that in younger men who present to us with problems with erections, that we see more of a psychological cause, but, that doesn't necessarily have to be the case.

Host: So Dr. Flanagan then, if could be physical, could be mental, emotional, psychological, then I'm assuming maybe sometimes diagnosis can be a little tricky. Maybe not. That's why we have experts on. So I'm assuming that you take a patient history, find out what meds they're on, you know, figure out what their state of mind is, but take us through that. For erectile dysfunction, how do you diagnose and treat? And is there such a thing as a cure for ED or is it more sort of like managing it?

Dr. Will Flanagan: Obviously our goal is to partially determine the cause of the ED, mainly differentiating between physical causes and emotional causes, but within the realm of physical causes, there can be arterial, neurogenic, less often, but sometimes endocrine things such as profoundly low testosterone can contribute.

The treatment options tend to be relatively similar regardless of the diagnosis. So, I think the main thing that we want to do is differentiate between psychological issues and physical issues. Having said that, I would agree with Dr. Wynia that often the psychological issues may be a little more common in younger patients, but I've seen a number of patients that were younger that actually had what's called venous leak, where the arterial inflow to the penis is excellent, but the venous outflow is excessive so they couldn't maintain their erections.

And so one of the diagnostic tests that we can utilize is penile doppler blood flow, especially in cases where we're trying to ascertain is it arterial, is it venous, is it neurogenic or in the absence of that, is there some psychological component? And then we often check a testosterone level, in those patients we're highly suspicious that they could have a profoundly low testosterone.

I will emphasize that testosterone is rarely the cause of erectile dysfunction unless it's extremely low. Lower testosterone may lead to lower libido in some cases, which means interest in sex. But usually, in the vast majority of patients, their testosterone levels are sufficient to actually be able to achieve an erection.

Host: So just to staying with you, Dr. Flanagan, let's talk about the treatment options. You know, I was wondering, like, is this something that is cured? Here's a pill. Magically, you're all better. Or is it one of those things where it's more about sort of management, if you will, that there's no real cure per se, but getting guys back to where they want to be at least most of the time, maybe is the objective. From your perspective as an expert, what are the expectations when we think about cure versus manage and so on?

Dr. Will Flanagan: I think you're exactly right. The holy grail of men's health is to be able to cure it. There are some options that are sometimes discussed that are variable in their efficacy. One of the things that comes to mind is shockwave lithotripsy of the penis, but the studies are pretty iffy as to exactly how effective that treatment is. But that's alleged as a quote unquote cure for erectile dysfunction. And then there's platelet rich plasma, which even has less data to support it. So I mention those to say that those are touted as potential cures, but they are extremely variable in their ability to be effective. And for the most part, as you alluded to, I think it's mainly managing erectile dysfunction.

And those treatment options mainly fall under the category of oral medications such as Viagra, Levitra, Cialis, vacuum device, injection therapy, and penile implant surgery. And I wouldn't call them curative as much as methods to overcome the issue.

Host: Yeah, I see what you mean, and I'm sure most of us who watch television, we're familiar with those commercials, the little blue pill, and so forth. Dr. Wynia, I want to have you talk about diet and lifestyle. Is that any sort of factor here? If we make some changes, you know, so if a guy has ED, been diagnosed, if we make some changes to our diet and lifestyle, can that help?

Dr. Blake Wynia: It certainly can help. Again, I think it's pretty rare for lifestyle changes to be a cure for this issue, but in the sense that lifestyle changes can help some of the other chronic medical conditions that can lead to erectile dysfunction, it definitely can be helpful. So, for example, for patients who might be, you know, overweight, then weight loss can certainly help and eating a healthy diet.

Obviously being physically active can help in that area as well. For example, you know, with significant lifestyle changes, if you're able to have improvement in your diabetes and get your average blood sugar down significantly, then that's going to really help your erections as well. Dr. Flanagan had mentioned that low testosterone can also sometimes be a cause of ED, although I'll agree that the majority of the time, it's not the primary cause, unless the levels of testosterone are very low. But the lifestyle changes that you're describing also can help your testosterone level as well.

So in addition to the management of ED with medications, as we were just describing, we definitely recommend these lifestyle changes as well as an adjunct.

Host: Yeah, and as you say, it never hurts to be mentally and physically well, whether it's to deal with your ED or a multitude of other things. I want to stay with you, Dr. Wynia. You know, we were talking with Dr. Flanagan there about pills, and I know it's become very popular for folks to buy pills online. Right? Whether that's because of the cost or because it's more discreet perhaps than talking with a provider and then picking them up at your local pharmacy. What are your thoughts about that? The sexual enhancement pills that can be purchased online. Are you for or against the use of those?

Dr. Blake Wynia: Well, I think you do have to be very cautious because a lot of the things that are advertised online that you can get without a prescription, you know, most of these are things that not have not been rigorously studied, and so we don't have a great idea of potential side effects, and there are certainly not a lot of great evidence that those sorts of supplements will actually help.

And so, you're definitely putting yourself at risk for losing a substantial amount of money for potentially no benefit, and potentially putting yourself at risk. And so, our recommendation is typically to stick with the prescription medications that are available. And also another benefit to seeing us is that, you know, we can make sure that you're a good candidate for these medications and that they would be safe for you to take.

 There are a certain subset of people who might not be a good candidate for those pills because of various other health conditions that they have. In the past, price has been a fairly large barrier to some of the prescription medications that we have. But the good news is that nowadays, several of these medications are generic and so they can be obtained at a pretty cheap price. And so I, I don't think that price is a significant barrier any longer. That probably has been something that's driven people to look after those online supplements that are a little more discreet as opposed to having to get a prescription.

Host: Sure. Yeah, I'm not a fan of pills in general, so I like to have my provider prescribe them, I like to have experts prescribe them, I figure if they don't know, nobody would, so it just seems like a good practice to have our doctors, our providers be the ones to prescribe. As you say, the costs are coming down on generics, which is nice for all of us.

Dr. Flanagan, I want to talk about the mental health side of this, but we've identified that, there can be some psychological issues of factors or causes behind ED, but let's say someone's diagnosed with ED and it's purely physical. What impact can that have on that person's mental health?

Dr. Will Flanagan: I and Dr. Wynia both see patients all the time and part of the reason that we went into men's health and have such a passion for it is because the inability to achieve an erection doesn't just affect their ability to have sex and the ability to have an erection; it affects the mental state profoundly. Men that cannot perform sexually have a much higher incidence of depression and it spills over into all aspects of their life. So I think that even though most men don't have a pure psychological cause of their erectile dysfunction, when you start having trouble with erections, you start to have performance anxiety, which makes the erectile dysfunction issue even worse.

And then also it in uh, many cases spills over in depression and just affects their entire life and affects the quality of their relationship with their spouse. And so I think it's incredibly important, not just from the mechanical aspects of being able to achieve an erection and have sex, but your overall sense of wellbeing and how you feel about your life is amazingly affected by this. And I think it's a privilege to be able to try to help people to work through that and figure out a treatment option that is good for them.

Host: I'm sure. I'm sure, Dr. Flanagan, let's take COVID out of this and just to say in general, that a lot of people suffer from a lot of things and they don't go and see their providers, they don't get diagnosed or they don't follow through with the treatment plans and things like that. What would be your words of wisdom or encouragement? Because this is one of those things I used the word discreet earlier, and I'm certain that, you know, two experts like yourselves are discreet, but in general, getting men or couples to come in and talk about ED, you know, how do we do that? How do we encourage them?

Dr. Will Flanagan: Well, I think there's a couple of things that I would say, A this used to be a much bigger problem before. I mean, the pills don't work for everybody, but the commercials encourage people to realize that so many men have this. And I think that as we present this to people, there's 30 million men in this country that have erectile dysfunction. I think people are starting to become more aware of that and they are more willing to talk about it. And, I do think that sometimes it's difficult to get men to come in and do this. But what we've done, is we've done seminars. The reason we're doing this podcast also is to try to help people in a confidential environment realize that we're here for them.

And, we both have done a number of online series of podcasts or video conferences. And it's amazing how many people are signing into this. To your point, the more that we can offer kind of a confidential environment for them to at least begin investigating this, I think that that's really helpful.

Host: Yeah, every little bit helps, uh, the education, and as you say, being as confidential as possible, and I'm sure you're right. I'm sure our exposure to all these commercials has helped to sort of reduce the stigma that there used to be about ED, so it's all good stuff. I want to finish up with you, Dr. Wynia, today. I want to have you talk about supporting a partner with ED, how you do that, and what would be your advice? And then just final thoughts about erectile dysfunction.

Dr. Blake Wynia: We often find that with this mental toll that erectile dysfunction can have on men, it's extremely important that they have a supportive partner who's understanding, because no matter what treatment we offer, how effective it might be, if they don't have a supportive partner, it's still not going to be a satisfying part of their life. And again, that can spill out into their mental health and other aspects of their life as well. So encouraging patients to have, you know, a very open conversation with their partners is helpful. I know a lot of partners worry that if their husband or boyfriend or whoever is having problems with erections, that that means that they're not attracted to them anymore, or that there's a problem with the relationship and that's why they're having issues.

And I think it's important for the couple to have a very frank and honest discussion that, you know, the majority of the time it's not due to a lack of interest or not due to a lack of attraction, but it's a physiological problem, and they just need the correct support for that. And in a similar way, it's very, very helpful also to have partners come to their appointments with us as well. I find that patients who have an engaged and active partner who's there at the appointment and taking part in the conversation and offering, you know, bits of the story and the history, I think those are the patients that often have the most success in terms of their treatment, no matter what the form of treatment ends up being.

 In terms of overall thoughts, I would say that it's important to remember that this is a very, very prevalent issue. It's nothing to be embarrassed about. There are lots and lots of different causes and having an open discussion with both your partner and with your physician is the first step to overcoming this and greatly improving your quality of life.

Host: Yeah, that's perfect. I love when I get experts on, I learn from them. I hear their compassion. Clearly you both went in, as you say, to men's health for a reason, to help men, to help couples. So if the men are getting support at home and they have experts at the office at PRISMA Health, like the two of you; it would seem like they're in good hands and whether it's a cure or more of management, either way, sort of getting things sorted out, seems like the odds are in their favor. So just want to thank you both and you both stay well.

Dr. Blake Wynia: Thank you so much, Scott.

Dr. Will Flanagan: Thank you.

Host: For more information and other podcasts just like this one, head on over to prismahealth.org/flourish. This has been Flourish, a podcast brought to you by PRISMA Health. I'm Scott Webb. Stay well.