Disclaimer: This podcast is for informational purposes only and is not intended to be used as personalized medical advice. 

Joey Wahler (Host): They can negatively impact a man sexually and beyond. So, we're discussing erectile dysfunction known as ED and testosterone deficiency. Our guest, Dr. Curran Emeruwa. He's a urologist at Skagit Regional Health.

This is Be Well with Skagit Regional Health. Thanks for joining us. I'm Joey Wahler. Hi there, Dr. Emeruwa. Thanks for being with us.

Dr. Curran Emeruwa: Hi. Thanks so much for having me.

Joey Wahler (Host): Yeah, I really appreciate the time. So first, as you well know, some men can be embarrassed talking about men's health topics like those we're about to discuss. So, what do you say to reassure them that it's okay?

Dr. Curran Emeruwa: It's great always to talk about men's health. It's a huge deal, yet somehow it's one of those topics we tend to sweep under the rug. I think we guys, we often prioritize work, family, everything else over our own health and that often leads to neglecting some pretty important stuff. So, issues like testosterone deficiency and erectile dysfunction are just about the physical side of things. They hit your mental and emotional well-being as well, your relationships and your quality of life very hard. So, it's all about early detection and treatment. This can make a world of difference and prevent bigger problems down the road because it's not always just about sexual health and satisfaction. These issues are tied to a man's general health. And when we raise awareness about this topic and we encourage proactive health steps, we can help men to lead healthier, happier lives overall. So, it's great to be here today to talk openly about some of these issues.

Joey Wahler (Host): Absolutely. And that's why at the top I mentioned it can be impactful sexually and beyond. So, first, what exactly is erectile dysfunction? We've all heard of it, and talked about it. But for those that know exactly, medically speaking, exactly what's happening there, what is it and how common is it?

Dr. Curran Emeruwa: It's one of those things that can make you feel a bit uncomfortable but it's super important. Erectile dysfunction or ED. ED is when a guy has trouble getting or keeping an erection that's firm enough for sex, period. For some guys, that means a soft erection, unable to reach orgasm. Other guys, maybe they can't get it up at all. So, it's really a spectrum of symptoms, and it can wax and wane. Sometimes, you might have good weeks or bad weeks. The issues that cause ED are multifactorial: stress, anxiety, and cardiovascular disease, physical conditions, psychological issues. And so, we'll talk about a lot of these today. It's more common than you might think, and it can happen to men at any age, although it tends to be more frequent as we get older. 

So, as I mentioned, it can be physical, cardiovascular disease, or diabetes can play a role. It can be psychological. Stress and anxiety play important roles as well. Lifestyle choices make a huge difference as well when it comes to ED but it's important for men to understand that ED is a medical condition. It's not just a part of getting older. It's also a symptom of other more serious medical conditions. 

We call in Urology ED the harbinger, because it can be linked to issues like undiagnosed cardiovascular disease. So, ED can be an early sign that you have a clogged artery in your heart. And your heart's not pumping as well anymore, because it's just about blood flow, blood flow to the penis. And something that one of my attending surgeons that I trained with in residency, what he said was that what's a sign for your penis is a sign for your heart. And so, you can look at the two as interrelated in that way. But it's a serious topic. It affects a lot of men. To give you numbers, research shows that about 40% of men will experience some degree of ED by the age of 40. So, I mean, that's almost half, right? And then, that number rises to nearly 70% by the age of 70. And so, basically, any man you see walking down the street, chances are they've had ED in the past or will have it in the future. That's the way to look at just how common the issue is.

Joey Wahler (Host): Wow. Well, those are certainly some whopping numbers. And I would imagine, doc, that another one we could throw out is, I'm guessing, close to 0% of men admit to having ED, unless of course they're behind closed doors with a professional like you, right? 

Dr. Curran Emeruwa: Right. Exactly. But see, it's all about open communication because it's a tough issue to talk about and it can be pretty uncomfortable but open communication with your healthcare provider is absolutely essential. And that's why we're bringing it up today, because it doesn't have to be something that we feel embarrassed or reluctant to talk about, reluctant to bring up. I'm here to help. Doctors are here to help and not judge, okay? So, by sharing your symptoms, your medical history, and any concerns you have openly, then we can get to the bottom of what's really causing the issue and recommend the right treatment options. And so, this is all about improving your overall quality of life sexually, emotionally and mentally. But again, because it's a harbinger of other medical conditions, we can often catch other issues that could potentially shorten your life when we start to talk about issues like ED.

Joey Wahler (Host): Right. And I would certainly think that just hearing those numbers indicating how common this is would make men feel more comfortable in talking about it. You talk about lifestyle changes, diet and exercise. How do those impact ED?

Dr. Curran Emeruwa: Yeah. So, we'll talk about lifestyle choices. Smoking is a major no-no when it comes to ED, okay? So, everyone knows about smoking causing lung damage. But really, what the toxins in the cigarettes and cigars, different forms of nicotine use, do is they damage the blood vessels. And remember what I said earlier, what's bad for your heart is bad for your penis and vice versa. It's all about blood flow. Erectile dysfunction is just an issue with blood flow to the penis. And so, anything that reduces blood flow to the penis is going to cause ED. And smoking, we know, causes vasoconstriction. It damages the blood vessels and it will reduce blood flow to the penis. And so, smoking is a big no-no in terms of lifestyle choices.

Excessive alcohol consumption as well messes with the nervous system. It impairs the body's ability to respond to sexual stimulation. And so, for men that are taking excessive alcohol on either a daily or even a weekly basis, that's going to impair the body's ability to achieve and maintain erection. If you're not getting enough exercise, your cardiovascular health takes a hit. And remember what I already said, bad for your heart, bad for your penis. And so, exercise improves your cardiovascular health, which then improves your blood flow and overall erectile function. 

And so, making positive lifestyle changes like quitting smoking, cutting back on alcohol, getting regular exercise, that alone can dramatically improve not only your overall health, but reduce the risk of ED and also be an effective treatment for ED. So, it's often small changes, but they can lead to really big improvements.

Joey Wahler (Host): Gotcha. Now, you touched on mental health. What role does mental health, stress, for instance play in erectile dysfunction? And then, how can being affected by this, having ED, affect something like self-confidence?

Dr. Curran Emeruwa: Right. So, let's get into the head game a bit. So ED, it's not just about physical issues. There's just so many factors that are involved in achieving an erection and getting to orgasm. You know, it's almost like the stars have to align. But psychological factors play a big part of this overall picture. Stress, we see, is the most common culprit these days in terms of having a direct impact on erectile dysfunction. When you're stressed, your body's going to have a harder time getting and keeping an erection, and that's due to the increased cortisol levels in the bloodstream, which basically counteract testosterone's action on the penis. And during the erectile and the sex function and process that you go through.

Anxiety as well, especially performance anxiety. So, we can have generalized anxiety, anxiety related to worried about the kids, worried about work, worried about money. But then, also performance anxiety, taking a new partner out for a date, thinking about later, "Am I going to perform the way I want to?" But this anxiety can create a vicious cycle where worrying about ED actually causes the ED to happen. 

Depression as well. Not only depression itself, but the medications we prescribe for depression. These can zap sexual desire, energy levels, and make it more difficult to perform. And relationship issues, we know as well, like poor communication with a partner, unresolved conflicts, emotional disconnection, all these things can also lead to ED. And so, what we know is that when we tackle some of these psychological factors involved, and that's, again, the role of the urologist in this process as well. It's not just about the physical factors. It's about talking about these psychological issues and talking in an open way with you, that's not only going to treat ED, but that's going to give you confidence and help you address some of those other issues as well in your life, like stress, anxiety, relationship issues. And that's going to be a huge boost to your confidence levels overall. You'll be healthier, happier, more satisfied in the bedroom and outside.

Joey Wahler (Host): Now, there is, of course, tons of information out there about treatment options for ED. So, what's most effective and who are they best suited for here?

Dr. Curran Emeruwa: I kind of would break them into different sections maybe, or different groups. And so, number one is lifestyle changes, which we've already talked about. So, we've already hit the nail on the head there. The little things, exercise, quitting smoking, eating healthy, all those things are going to play a role. 

But often, that's not going to cut it, because often when it's age-related decline, you can be as healthy as you want and still have issues. And so, that's where medical therapy comes into play. And there's even surgical options and there's even psychological support. So, a lot to talk about in terms of treatment options, but I would say the easiest and lowest hanging fruit when it comes to treatment options are going to be your run-of-the-mill oral medications. And so, these are very common, but the number one thing I want to mention regarding oral medications, Viagra, Cialis, is that a lot of men were worried about these being price-prohibitive, these medications are now generic. And so, Viagra is sildenafil, Cialis is Tadalafil. These medications are extremely inexpensive. You can get large portions of them. If they're not covered by insurance, they're typically very cheap now. And so, they can be prescribed without them hurting the bank account. 

The other common worry with these medications is that, "Okay, it's going to cause me to get a heart attack," or "It's going to cause me to have a stroke or some other issue." These medications are extremely safe. In fact, they were initially developed for men who were having pulmonary hypertension. And then, they realized that on these clinical trials that these men were having improved erectile function, and the drug companies pivoted to market them as penile medications, but they're extremely safe. We've been using them for decades. What they do is they enhance the blood flow to the penis to help achieve and maintain that erection. There's different dosages, and we tailor it to you. 

The common side effects can be mild headache, some mild body aches, but they're typically short. And as you take the medication more often, they tend to go away. So, they're often extremely well-tolerated. if oral medications don't work, and sometimes they don't, there's many other options available as well. There's pellets we can place into the urethra. There's injections we can do into the penis. Everyone's worried about the injections, but we're talking about a tiny insulin needle. You know, people that inject themselves with insulin three to five times a day, we use these tiny needles to inject the medication directly into the penis, and that can be very potent for a lot of gentlemen. There's gadgets we can use, like vacuum devices and rings. And there's even a solution called a penile implant, where if all else has failed, we can actually implant a device into the penis that you control with a pump, and it gives you an artificial erection for you to reach orgasm. 

And so, all this to say that there are so many treatment options available, and a lot of gentlemen don't even know about the first ones that are available to them. You don't have to give up sex. I'd say the vast majority, 95 plus percent of patients that come in the door for erectile dysfunction leave with a treatment option that's effective for them so they don't actually have to give up sex at any point. And we'll see men through their 80s and 90s that we're keeping on the horse with the treatment options that we have available today.

Joey Wahler (Host): Got to try and stay on that horse, right? It's part of life.

Dr. Curran Emeruwa: That's right, exactly. It's part of life. It doesn't have to be given up.

Joey Wahler (Host): All right, doc, let's switch gears. It's a hot topic these days, of course, regarding testosterone deficiency. So, remind us, what exactly is testosterone in terms of what it is and how it affects a man's health?

Dr. Curran Emeruwa: So, let's get into it. So, testosterone deficiency or hypogonadism if you want to get technical, this is when the body is not producing enough testosterone. And so, the way to think about testosterone is the king of male hormones. It wears the crown. It's crucial for developing male reproductive organs. So, we're bathed in testosterone from the time that we're in utero, in your mother's womb. There's testosterone being poured into your body as a fetus, and it's helping to develop the male reproductive organs like the penis and the testicles. But, as we get into our teenage years, we go through puberty, we become men, it plays a vital role in turning you into a man and keeping you a man. And so, it's going to maintain your muscle mass, it's going to increase your bone density. And most importantly, it's going to keep your energy levels up. And so, when you're low on testosterone, the symptoms of that we notice is that we might start feeling a bit off in various ways. And sometimes this can be due to aging, some certain medical conditions can impact testosterone, lifestyle factors, again. But the key here is recognizing and addressing it early, just like ED, to keep yourself feeling and performing at your best.

Joey Wahler (Host): So, what are some of the symptoms of that low testosterone to look for?

Dr. Curran Emeruwa: Right. So, how do we know when testosterone might be taking a nosedive is another way to put it. And there's a few red flags to keep an eye out for. The first is going to be that low energy. So, it's like if you're finding that it's hard to get through the day without feeling wiped out, this could be a sign. 

And so, another way to think about that too, is when you're in your early 20s and you just work for 12 hours and then you meet your boys out at the bar. And you're at the bar until 1:00 a.m. and then, you meet your girlfriend back home, and then you work the next day at 6:00 a.m. and you're fine, that's testosterone that's driving you. And so, when you start to find that it's difficult to get through your day without feeling low energy, again, this is a sign that it could be low T or low testosterone. 

Another big symptom is decreased libido. So, it's just the interest for sex has taken a hit. Like maybe you still get erections, but you just don't feel the drive to have sex. That's something to note. Mood changes are very common as well. You might feel more irritable. Irritability is extremely common with low T. Anxious or unexplained depression is oftentimes tied to low testosterone.

Physically, we might notice reduced muscle mass and strength. So if you go to the gym, some of those gym sessions might feel less effective. But your body itself, you might feel more doughy, like you're losing muscle mass or having difficulty maintaining muscle mass. Other symptoms might include trouble concentrating. So, brain fog is often how patients might describe it, gaining body fat, as I mentioned, feeling doughy. And some men even lose bone density, which can increase the risk for fractures, which is extremely important as we get into our 60s, 70s, and 80s. And so, spotting these symptoms early can help to manage them effectively but then keep a man's overall health on track.

Joey Wahler (Host):  And so, having said that, what should a man do if he suspects low testosterone and how do you diagnose it?

Dr. Curran Emeruwa: If you're having any of those symptoms, even one, just unexplained fatigue, understand that this could be an age-related decline in testosterone levels, which happens to basically all men as we age. It'll kick off at the age of 30 and then keeps going as we get older. So, by the time you're hitting your 40s and 50s you might notice symptoms like fatigue, lower libido or mood swings. But medical conditions like obesity, diabetes and chronic illness, all these things can have a factor on reducing testosterone levels in the bloodstream. And then, lifestyle factors, as we mentioned before, smoking, stress, poor diet, lack of exercise, these can also cause testosterone levels to drop.

And so, how do we diagnose it? First is going to be recognizing the signs, which I've already mentioned. Early detection is key and often it's the symptoms that are driving men to the office, either with their primary care or to the urologist or even an endocrinologist can test for it as well. But ultimately, what it's going to entail is going to be a blood test, very simple morning blood test. Testosterone levels can fluctuate throughout the day, and so we want to test it in the morning. But it's a simple blood test, and this will give us a comprehensive understanding of the hormone status in the body. And so, we typically do it twice. And so, we might do it once in the morning, and then a week later do it again. Again, this is because testosterone levels fluctuate. But this will give us an average or an idea of where your testosterone levels are. 

And another part to understand is that testosterone is a bell curve. And so, for some men, 700 is a good testosterone level for them. And so, for 450 for them, that might be a deficiency for them but other men might be doing okay at 500. They're putting on muscle, they feel good at 500. And deficiency for them might mean 250. And so, for the physician, it's going to be understanding where their normal baseline level is and if they're falling into that deficient range. And again, just a simple blood test to figure that out.

Joey Wahler (Host): And what treatment options are available here?

Dr. Curran Emeruwa: Treatment options, again, for testosterone deficiency are going to be multifactorial. But just like ED, we're going to focus on lifestyle changes, so diet, exercise and stress management. Once we're managing those things, because we can often reverse testosterone deficiency with just those alone. We could talk about medical treatments.

And so, TRT, which is basically testosterone replacement therapy, this can be in various forms: injections, gels, patches, pellets. It's going to be what works for you. Some men are okay with needles, maybe the injection works well for them. Some men want to come in less often, maybe pellets work for them because they only have to get it once every three to four months or, later. Some gentlemen like patches, some like gels, to rub in their skin every day just because it's easy. 

When you come in and if you're diagnosed with testosterone deficiency, we find a solution that works for you. There's pros and cons to every single treatment option when it comes to medical therapy. But the most important thing when it comes to medical therapy is going to be tracking it and making sure that you have a professional, whether it's your primary care or urologist or some type of specialist monitoring your levels, making sure you're taking it appropriately, monitoring for side effects, not getting it off the street, not ordering it online because the potential side effects, if it's not managed appropriately, can be severe.

Joey Wahler (Host): And then, finally, in summary here, doctor, if someone is experiencing some of the symptoms you've covered for either of these conditions, ED or reduced testosterone, let's say they feel a little something but they think it's nothing, or they're not sure if it's something. Where's the line? How do you know when it's time to at least find out whether everything is okay or not?

Dr. Curran Emeruwa: It's always difficult to broach these topics but discussing with your primary care physician is going to be step one. I worry about some of the information that's online there sometimes, because men are often targeted for these issues and so they end up being pulled into other directions. So, you know, "Buy this supplement" or "Do that." And so, we want to provide the resources here, like today's podcast, to give you this accessible and reliable information. And so, listening to these podcasts, understanding it, reaching out to our clinic, we can provide brochures and educational materials without even an appointment if you're not sure, you know, "Do I really belong here? Is this what's going on?" Even if it's not that, right? Maybe you have a few of the symptoms, or you don't have all the symptoms, still coming into the urologist, look at the urologist as your men's health expert, not just prostate issues or kidney stones. The urologist is really a doctor for men. And so, if you have questions about these things, even if the urologist doesn't end up being the appropriate provider for you, they can get you to the right place. And so, making an appointment, calling, making an appointment online, speaking to your primary care, any of these options work great.

Joey Wahler (Host): Well, folks, we trust you are now more familiar with ED and testosterone deficiency. Dr. Curran Emeruwa, valuable information for men Indeed. Thanks so much again.

Dr. Curran Emeruwa: Thank you so much for having me.

Joey Wahler (Host): And for more information, please visit skagitregionalhealth.org. Again, that's skagitregionalhealth.org. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler, and thanks again for listening to Be Well with Skagit Regional Health. 

Sources: 

https://www.auanet.org/guidelines-and-quality/guidelines/erectile-dysfunction-(ed)-guideline

McKinlay JB: The worldwide prevalence and epidemiology of erectile dysfunction. Int J Impot Res 2000; 12 Suppl 4: S6.  

Ayta IA, McKinlay JB and Krane RJ: The likely worldwide increase in erectile dysfunction between 1995 and 2025 and some possible policy consequences. BJU Int 1999; 84: 50.