Episode 20: Sexual Health: Erectile and Ejaculation Problems


Episode Summary:

Erectile dysfunction (ED) can arise from several different causes, making the diagnosis a bit of a complex algorithm. The good news is that treatments are many and effective for these causes. All treatments (including Viagra), should be used with some medical supervision, due to interactions/side effects/contraindications with other aspects of an individual’s/couple’s health and life.

Episode Guest:

Hunter Wessells, M.D. Professor and Chair of the Department of Urology, University of Washington School of Medicine, member of Advisory Committee for Urology on the American College of Surgeons Legislative Task Force, and member of the Uro-Trauma Legislative Taskforce of the American Urologic.

During This Episode We Discuss:

  • Erections and ejaculation, normal and abnormal.
  • Mechanism of erections, nerves, arteries and veins all play a role.
  • Erection problems as they relate to another disease process of the body.
  • Loss of erections is an indicator of underlying health issues. Cardiovascular disease, hypertension, coronary disease, peripheral vascular disease, diabetes, smoking-related concerns.
  • Arginine pathways… The role of nitric oxide.
  • Strategies to manage Erectile Dysfunction (ED).
  • Psychological issues in ED.
  • Hormonal concerns in Erectile Dysfunction.
  • Evaluation of erectile dysfunction, treatment options.
  • Peyronie’s disease evaluation and treatment options both non-surgical and surgical.
  • Medications: Viagra, Levitra, Cialis safety and efficacy.
  • Surgical solutions.
  • Disorders of ejaculation: premature, delayed.
  • Shockwave and ultrasound treatment for ED.

Quotes (Tweetables):

“The conditions that occur with aging are what impact erections, cigarette smoking, diabetes, aging itself, high blood pressure, high cholesterol, those are the things that tend to be associated with erectile dysfunction.”

“A man could start a phosphodiesterase inhibitor, and then if he modifies his lifestyle, if he stops smoking, loses weight and gains better control of his diabetes, he may be able to come off those medicines.”

Hunter Wessells, M.D.

Recommended Resources:

Episode Transcript: 

Intro (00:07):

Baseball game, day in a park with friends and family, fishing in a remote stream, work, travels, providing for loved ones, or heading out for adventures, whatever you do, whatever you enjoy, you need your health. The Original Guide to Men’s Health, as presented by the Washington State Urology Society, to help take you through the steps necessary to get the most out of life. If you have invested in a retirement plan for your future, why not invest in your body, after all it makes better sense to retire healthy and enjoy your future. These podcasts are a guide for how to take care of yourself. If you take care of your car and maintain it, why not do the same for your personal machine, your body, if you know you should, but haven’t yet, the information in these podcasts contains some easy recommendations for where, when, and how to get started. Follow the podcast, as we explore men’s health with renowned experts and embark on a journey towards better health!

Dr. Pelman (01:24):

On today’s episode of “ The Original Guide to Men’s Health,” we review sexual health. Sexual health is complicated, and it is certainly of concern to men who have issues with ejaculation and/or erection problems. Today, we’re going to be with Dr. Hunter Wessells. Dr. Wessells is professor and chair of the Department of Urology at the University of Washington School of Medicine. He’s a member of the diabetic research team at UW medicine and has actually been investigating erectile mechanisms for a majority of his career. Welcome Dr. Wessels.

Dr Wessells (02:00):

It’s great to be with you Rich. 

Dr Pelman (2:03)

I like to call this sexual health rather than just erectile dysfunction, because there are many components. And you and I see patients who come in with issues that may not clearly be a organic problem but can be psychological. (This is to say it’s not a physical dysfunction, but one of the mind instead) And we might see somebody who comes in with good erections, but has trouble with ejaculation. We might see somebody who comes in with a concern that they’re going to be having trouble anticipating the potential. And they don’t even know if they’re going to have trouble with fertility or not. We’ve covered infertility with Dr. Walsh, but erection certainly play a part infertility. So as we know, sexual health is a broad category and encompasses more than just erectile dysfunction. We might be talking about ejaculation and other issues, but let’s start with erectile dysfunction. Since it’s a major concern with men who come in and who have a failure to achieve an erection or maintain an erection. Dr. Wessells, why don’t you go into little background about the mechanism of actually how erections occur.

Dr. Wessells (03:03):

Erection is a process that involves all the key structures in the genitalia, nerves, arteries, veins, the supporting surrounding structures, and all that happening in a normal hormonal environment. So anything that disrupts those can lead to erectile dysfunction, but basically the brain sends a signal down through the spinal cord, to the nerves, to the penis, to open blood vessels and start filling the penis with blood. At some point, the penis becomes distended or swollen enough to shut off the outflow mechanism, which are veins. And then you get full rigidity. So nerves, arteries, veins, all are playing a part in normal erection.

Dr. Pelman (03:47):

Now the arteries, uh, there’s one in each of the erection bodies and there’s two separate bodies. We call them the corpora cavernosa. They’re paired. They sit above the urethra, the urine pipe and the penis, the central arteries are smaller than coronaries. (Coronaries here are referring to the coronary arteries of the heart, these are a set of arteries that bring oxygen rich blood to feed the heart muscles. These are the arteries responsible for heart attacks and angina, which occurs when blood flow through them is blocked.)

Dr Wessells (03:59):

And so things that perturb the normal flow of blood in those arteries lead to erectile dysfunction in a 17 year old, it’s a pelvic fracture or some other injury, but for men over age 20, there’s a one in five chance of having erectile dysfunction, take all comers in that whole age group, but it goes up progressively with age. And so the conditions that occur with aging are what impact it. Cigarette smoking, diabetes, aging itself, high blood pressure, high cholesterol. Those are the things that tend to cause, or tend to be associated with erectile dysfunction.

Dr Pelman 2 (04:36):

So if somebody has underlying coronary disease, it’s a good bet that they’re not getting good blood flow through their erection

Dr Wessel’s (04:43):

That’s why the association between those conditions is so high. The same things that caused the blockage in the coronaries is probably causing blockage in the arteries of the penis or in the vascular tissue inside the penis, not just the arteries, the smooth muscle inside the Corpus cavernosum* relaxes to cause an erection. And if it can’t relax because of these conditions, then you get erectile dysfunction.

*the corpus cavernosum, or “cave like body” in Latin is, the word for a singular spongy mass of erectile tissue that fills with blood during an erection. The two corpus cavernosum of the penis form a pair called collectively the corpora cavernosa. The same tissue referred to earlier in the episode.

Dr Pelman (05:07):

And the little vascular spongy spaces are lying just like the inside of an artery. We call it endothelium.

Dr. Wessells (05:13):

That’s right. And diabetes, high blood pressure, and kidney disease can all cause endothelial dysfunction in the general vasculature and inside the penis.

Dr Pelman (05:21):

And smoking certainly accelerates those issues.

Dr Wessells (05:24):

As does diabetes. Diabetes has the unfortunate effect of also affecting the nerves. So you get sort of two hits there. 

Dr Pelman (05:32):

If we have a patient who has difficulty with erections, they usually present one of two ways. I’m not getting any stimulation, I Don’t feel things normally. Or I’m getting stimulation, I start to get an erection, but it’s not very strong and it’s not firm enough to penetrate. Or I can penetrate, but I don’t maintain it.

Dr Wessells (05:50):

And the definition of ED is the inability to obtain and/or maintain an erection sufficient for sexual activity. First of all, sexual activity is defined broadly. It doesn’t have to be sexual intercourse. It can be masturbation. It can be other forms of stimulation. And then to obtain or maintain can both be problems for them.

Dr Pelman (06:09):

Patient comes in and we do a history. We do a physical exam. If we have a undergraduate who comes in with failure and is otherwise totally healthy. According to our history and physical, what are some of the ways that we can diagnose that? This might be what we call performance anxiety… or they failed once and are worried about it? The more you think about it, the less it’s going to happen?

Dr Wessells (06:32):

Well, you’re highlighting a point that’s erections aren’t just a physical event. There’s a whole psychological and behavioral sequence of events around it. And it’s always an interplay between the two. It starts off as a physical problem that can get psychological overtones and vice versa. And so we really try and do the assessment based on the expected risk factors. So the undergraduate who comes in and has not had a pelvic fracture, doesn’t have diabetes, is totally healthy, and had normal erections during adolescence. We’re going to pursue a different workup than the 50 year old man with high blood pressure, diabetes, and cigarette smoking. And who’s also overweight. You know, that patient is going to have much more likely a physical cause than they have psychological.

Dr Pelman (07:21):

You specialize in this. What are some of the things somebody might expect? Who’s in that latter category, somebody with underlying disease.

Dr Wessells (07:27):

What you’d expect is that there’s probably a slow deterioration in function and that can lead to changes in their level of sexual desire, the intimacy they have with their partner. And oftentimes, there is a period where men won’t talk about this and that can even lead to some thoughts of depression and the like, hopefully they know more now to come in because there are lots of things we can do to make them better. 

Dr Pelman (07:54):

You do any specialized investigations or laboratory tests or just the history and physical?

Dr Wessells (08:00):

The guidelines from our professional association, the American Urological Association , don’t recommend a lot of sophisticated testing for the typical patient. The 50 year old man with several risk factors, because it’s not going to change our management that much. So we would want to know about their testosterone level because that’s now something our guidelines suggest we look at because they may or may not respond as well to some of our treatments, if they have low testosterone at the same time. So we’ll usually talk to them about the options and see what they want to pursue and start them on therapy. What are some of the options? If someone has new onset erectile dysfunction, we always want to think about their overall cardiovascular health and whether it’s safe for them to be sexually active and safe for them to take these medicines. So that’s something. That’s one reason why a health care provider should be evaluating and assessing a patient with ED because there are potentially serious health risks with the condition and its treatment.

Dr Pelman (08:57):

Going back to the arteries, being smaller than coronaries. If a man comes in, he hasn’t been seen by a primary*, doesn’t know whether he has diabetes, coronary disease, or other issues. If we just have him resume intercourse, he may end up having a corner at some point down the road.

*primary care physician, or PCP, your “family doctor” who you might see once a year or more for health check ups.

Dr Wessells(09:13):

I mean, those risks are very low. And typically if someone can exercise and then walk up and down a couple flights of stairs, it’s going to be safe for them to be sexually active. But in patients who have angina/chest pain or some problem like that, they shouldn’t just initiate sexual activity.

Dr Pelman

 If they’ve been inactive, even if they can go upstairs and be active, if they’re having erectile dysfunction that isn’t psychological, they should get evaluated by a practitioner, primary care doc or cardiologist, to make certain they don’t have underlying coronary disease.

Dr Wessells (09:46):

Well, they should be assessed for the risks that they have, because you could have ED with no other risk factors, you know, or you just have some mild hypertension. And that patient doesn’t necessarily need cardiac workup and a stress test, not everyone who has ED needs to get on the treadmill. Okay.

*treadmills are often used in medicine to perform stress testing for the heart. As you can imagine, someone with poor heart/cardiovascular health is going to acquire a elevated heart rate much more quickly than a endurance athlete with perfect heart health for instance.

Dr Pelman (10:02):

So, uh, cardiovascular risk factors, which we talk about in our cardiovascular episode, there are some online tools that somebody could look at and can help guide them. Most people who are seeking care are going to be seeing a physician and can be helped guided towards that.

Dr Wessells (10:18):

Yeah. We work in collaboration with, uh, primary care and with mental health professionals, because one of the issues is that we’re going to talk about treatment and that’s going to be medications and shots and other things, but you can also go down the path of investigating the psychological and behavioral aspects of the erectile dysfunction. They may be primary. They may be secondary, but it’s, it’s worth part of the conversation.

Dr Pelman (10:43):

Bombarded by advertising on radio and TV for supplements and other things that help erections. What are some of the traditional therapies that a patient coming in, who is having difficulties can now have?

Dr Wessells (10:53):

Well, the first one is the use of medications. Typically the phosphodiesterase inhibitors*, Viagra was the first, as sildenafil. Then there are several others on the market and they all have the same mechanism of action, which is to enhance that relaxation of smooth muscle in the erectile bodies to keep it relaxed longer, so that more blood can flow in and store in there. And that’s generally what we think of as first first-line therapy, but there’s some people who can’t tolerate it for whatever reason, because of side effects, or it just doesn’t work, or they just don’t want to try it. So it’s also okay to move on to other therapies. They’re vacuum erection devices that can draw blood into the penis. And then it gets trapped there with a ring around the base. That’s a vacuum device. We can deliver medicine into the penis, either through a little shot directly into the side of the penis, called an intracavernosal injection, or a urethral pellet. And those are effective in a large number of men. And lastly, we have very effective implant devices that can be surgically implanted to restore erection, even when all else fails and nothing else will work.

*an enzyme responsible for breaking down nitric oxide in the blood, nitric oxide causes the blood vessels to dilate, or allow more blood to flow through. By inhibiting this enzyme it promotes the bodies ability to attain or maintain an erection.

Dr Pelman (12:00):

We have number of supplements* that again, people hear about they read about, is there anything that you have found research that would actually be useful?

*commonly purported supplements for erectile quality include, but are not limited to: l arginine, horny goat weed, tongkat ali, tribulis, agmatine sulfate, and many more.

Dr Wessells (12:09):

None of these treatments have really stood the rigorous tests of scientific randomized trials against a placebo. But some of the things that make sense are the L arginine pathway, because that is the building block for nitric oxide, which is the molecule that leads to smooth muscle relaxation. And probably there’s some natural compounds that have property similar to phosphodiesterase inhibitors.* The problem is you may be paying just as much for those as for something that’s FDA approved and known to be safe. So I typically steer my patients towards the phosphodiesterase inhibitors.

*Horny Goatweed is one such supplement, however it doesn’t compare to FDA approved pharmaceuticals.

Dr Pelman (12:45):

Some people take citrulline because it’s in that Arginine pathway. safe?

Dr Wessells (12:50):

Well likely, but I’m not sure what the safety data and depth of information is on these supplements.

Dr Pelman (12:56):

Then that’s the issue with the supplements. They’re not FDA approved. There hasn’t been any usual studies. Um, we don’t really know what the threshold

Dr Wessells (13:05):

It’s interesting because in Europe they’re regulated more significantly. So the savvy person who’s interested in these complimentary and alternative medicines may want to actually see if any of these products have been approved for use in Europe, because the bar is a little bit higher towards safety and efficacy. 

Dr Pelman (13:22):

A Patient comes in and says, “well, I’m concerned about taking those pills*. Um, I’m worried.” We know they’re generally safe. They’ve been used for a long time. We don’t want patients who have had recent heart attack or stroke within three months.

*referring to pharmaceuticals 

Dr Wessells (13:36):

They’re very safe. I think one of the biggest fears is that they’ll somehow make you dependent on the medication so that you can’t then get better and come off of them. And that’s not true. There are some medicines, different classes of medicines that work that way. The nice thing is, let’s say we take our man. Who’s 50, he’s overweight, he’s smoking and his diabetes isn’t in good control. He could start a phosphodiesterase inhibitor. And then if he modifies his lifestyle, if he stops smoking loses, weight gets better control of his diabetes. You know, he may be able to come off those medicines. There’s evidence that some of those strategies will reduce the risk of ED.

Dr Pelman (14:14):

We always want to make certain patients using these oral medicines are not on nitroglycerin*. That’s the big contraindication. The good thing is they’ve all mostly come down in price now. So they are available. They’re prescribed and they’re safe. We would recommend you and I being urologists that they’d be prescribed under the care of a physician. The patient actually sees, although there are now the ability to, uh, for patients or the public to go online and acquire these answering questions to a physician.

*a medication used to treat exacerbation of angina and coronary artery occlusion.

Dr Wessells (14:44):

And those strategies probably are going to be safe for the majority of patients, but they won’t get the full range of potential issues. And I don’t think they take into account the psychological issues that are always running along with ED and they won’t also address the issues related to hormone. ED can lead to premature ejaculation because the dysfunction sort of sets up a scenario where early ejaculations may occur. And so some men with ED need treatment for their premature ejaculation as well. And of course, then there are situations where there might be other medications like depression, medicines, blood pressure medicines, other things that that could contribute to the ED that need to be coordinated with the whole healthcare team.

Dr Pelman (15:32):

And that wouldn’t be necessarily achieved by an online prescription.

Dr Wessells (15:36):

I don’t think that’s going to have a significant enough algorithm to figure out these subtleties.

Dr Pelman (15:44):

The patient who comes back and says, I tried the medicine. I went to the higher dose. We try a different medicine. The patients always ask me, which one’s better. And I go, you’ll tell me because there is some individual metabolism. So it is worth trying various oral medicines. Not just one.

Dr Wessells (15:59):

Yeah. If you try, if you’ve had a good try of something like Viagra and it doesn’t work, then a second agent is worth investigating. That’s where it might also be important to make sure that the testosterone levels are normal because there’s some evidence that if you supplement low testosterone, that could improve the effectiveness of the phosphodiesterase inhibitor. And then there are simple things like making sure you don’t take some of them with meals and the delivery of the medication matters for each individual one. 

Dr Pelman (16:28):

And Just before we leave the oral medicines, the tadalafil or Cialis in the traditional 10 and 20 milligrams, the molecule stays in the body longer. So it’s available. It doesn’t give an erection for 24 hours, but it’s available to help for a longer period than the other medicines, which usually have a four to six hours.

Dr Wessells (16:46):

So I think some of the differences between the drugs are preference issues and a skilled provider can sort of walk through the patient. What’s going to meet their needs best.

Dr Pelman (16:56):

The patient comes back and says, “I tried those. I tried the other it’s not working.” So then what do we do?

Dr Wessells (17:01):

I think then it’s again, going over the list of the other options, which it might be that they want to try, and injection system to deliver the medicine directly into the penis. Some men may absolutely refuse that they just don’t want to go down that route and they may be moving more towards an implant directly. So again, it’s counseling, but most of these treatments are quite effective. 

Dr Pelman (17:23):

There are a lot of actual videos on YouTube on penile injection. I know patients are hesitant. Guys go: “I got to put a needle where?”  On the shaft, not on the glans*. And most people come back and go: “you’re right. It didn’t hurt.” And it creates an opportunity for interaction where the oral medicines may fail. 

*Technical term for the head of the penis.

Dr Wessells (17:42):

Before we had the, uh, the phosphodiesterase inhibitors. This was the mainstay of treatment and we treated thousands and thousands of men with it. So it’s still very effective and quite reliable. So if you give yourself an injection, it’s likely that the next time you give it, you’ll also get the same response so that you can develop some confidence. The last point I’d make though, is that the first dose is generally recommended to be given in the office. And so that’s to make sure that it doesn’t last too long, and then we get the right dose and that there’s proper technique. It doesn’t have to be with a physician. It can be with another member of the physician’s team. 

Dr Pelman (18:15):

The medicine is prescribed. It’s in a vial. It’s kept in refrigerator. Patients draw up what they need. Usually there’s needles and syringes to dispense, where patients get comfortable and are able to give themselves an erection when they need it.

Dr Wessells (18:27):

There’s also the opportunity to use some kits that are pre-packaged, that are dry. You know, it’s a powder form so that if you’re traveling and you can’t refrigerate your medication. There are ways to be flexible about this, so you can take it with you. So there’s a whole range of ways to deliver the medication, but the principles the same.

Dr Pelman (18:44):

And the vacuum devices are external prosthetic. They’re available online. They’re the law of physics.

Dr Wessels (18:50):

So it’s drawing blood into the Corpus cavernosum, those erectile bodies. The two of them that you described earlier through basically suction, you should get a device that has the safety mechanism to prevent excess negative pressure on the penis. And these used to be regulated by the FDA. Although now you can get them over the counter. This is probably a “you get what you pay for.” And probably if you’re buying one for a really low cost, 25 or 50 dollars, it’s not going to be particularly good. But the nice thing is they allow people to engage in sexual activity and they are low cost over the long haul. Some men who are in stable relationships with a supportive partner can use these effectively. The bottom line is though that over time, I think a lot of patients become frustrated with this technique because it’s not that spontaneous. And you have to have a ring around the base of the penis to hold the blood in. And that can be uncomfortable for either the patient or the partner.

Dr Pelman (19:43):

It was only from the body wall out where a normal erection actually is anchor deep in the pelvis because the erectile bodies go deep in the pelvis. And that the penis is a little cold because the blood is not it’s trapped and coolest down

Dr Wessells (19:55):

In contrast to the erection within injection, which is actually filling the penis with the natural mechanism of an erection. 

Dr Pelman (20:02):

Right. Now, the patient comes back and said, “the erections really didn’t work for me, or they did, but I want to be more spontaneous.” And you had mentioned a prosthetic and prosthetics initially were just rods, rigid rods. It could be bent into position of function and non-function, but they have certainly evolved over time.

Dr Wessells (20:17):

These devices all are based on putting them inside the natural erectile body that we were describing. Normally it fills with blood, but we can put an implant inside it. So it’s safely inside the body and the original bendable rods or malleable devices they work, but they don’t allow as much concealability and they probably don’t give as good girth and sort of stretching out of the penis to its full extent. So they’ve been largely overtaken by inflatable devices. They’re self-contained hydraulic devices. There’s a pump in the scrotum, inflating and deflating the device and the cylinders inside the penis are what make it rigid. Then there’s a reservoir with the extra fluid that’s hidden where no one sees it. So these are very safe operations that can be performed in the outpatient setting and have a high success rate, about 90% of patients. And nearly a similar percent of their partners are very satisfied with the devices. The risk of infection has become very low in the range of 1% to 2%, but it’s a surgery. It requires recovery, a hospitalization or outpatient stay, and there’s costs associated with it. 

Dr Pelman (21:21):

You recommend when you get to these later stages that men bring their sexual partner with them to discuss these.

Dr Wessells (21:26):

I’m always happy, at any phase, when the patient comes in with their partner, because it’s a patient and partner condition that affects both members of the partnership and of the couple. And we always get better outcomes when the partners present.

Dr Pelman (21:41):

So guys who are embarrassed and do go to see a provider about the issue may not want to really mention the issue, but it’d be good for them to bring their sexual partner.

Dr Wessells (21:51):

It would be good from the get-go. And then particularly when you’re thinking about an irreversible surgical procedure, you know, I’m always worried when a patient is trying to make an implant, a surprise or keep it from their partner that doesn’t always end up well, because there are complications that occur and it’s surgery. So you wouldn’t want that to be a surprise,

Dr Pelman (22:14):

You know, for some of the patients who are older, whose wives may be post-menopausal*, I always want them to make certain, their wife is aware and have their wife perhaps see her caregiver because the rigidity of the erection with the prosthetics could be uncomfortable for a woman who doesn’t have estrogen or a supplement.

*Vaginal Dryness and mild loss of ruggedness can occur in women who have gone through menopause owing to the lack of hormones that normally stimulate the “upkeep” of vaginal suitedness for sexual function. 

Dr Wessels (22:31):

I think that’s true for all men with erectile dysfunction, keeping them aware of what the consequences are for the partners is a good idea. 

Dr Pelman (22:40):

If the body senses the erection is going to fail, it wants to ejaculate. So if we can give a more dependable erection, we may be able to help with premature ejaculation. What are some of the other techniques that we can help with premature ejaculation.

Dr Wessels (22:51):

Premature ejaculation may be lifelong or acquired, and oftentimes it’s some sort of excessive sensitivity. So the strategies that can be used are through the use of condoms, use of numbing agents that are put on the head of the penis, or through medications to sort of reduce the sensitivity and the signals from the penis to. So we use topical numbing agents. We can have the patient use a prophylactic condom, but most often we try and prescribe actually, is an antidepressant*. And there are a number of antidepressants that we’re using for their side effect, namely, that they delay ejaculation. And that goes to the other side of. There are men who cannot use either because of loss of nerve sensation from diabetes, or potentially as a side effect of treatment for depression with antidepressants*.

You can learn more about sex related side effects caused by SSRI’s (the most commonly prescribed antidepressant class) here for free: Sexual dysfunction in selective serotonin reuptake inhibitors (SSRIs) and potential solutions: A narrative literature review (nih.gov)

0912CP_Article1.pdf (mdedge.com)

Dr Pelman (23:46):

The, uh, side effect of certain antidepressants is to delay ejaculations.  Where men come in and go: “I just don’t achieve orgasm anymore.” And it is a direct drug effect. When they stop the drug does it return generally? Yes. There are also behavioral methods that people can use to improve threshold. I like to send patients to the Sexual Medicine Society in North America website and embedded in that, on the homepage, is sex health matters, which is the patient portal. And they can look up erectile dysfunction, ejaculatory dysfunction. There’s a lot of good information there.

Dr Wessells (24:18):

And there is a lot of information out there! So when we can refer people to a professional society with a highly curated information, it’s going to give them the best data. 

Dr Pelman (24:28):

You have done research on erectile dysfunction, including some genetic research. What’s exciting out there?

Dr Wessells (24:34):

 Well, there are a couple of things that are exciting. One is the, we always knew that there were a lot of men who develop ED with no other known risk factors. And maybe that’s part of the population that we’re capturing with our genetic research. We always said, “well, why is it just aging itself? Or maybe it’s something else.” The other group that we want to look at is… there seems to be a group of younger men developing erectile dysfunction, and that’s particularly burdensome because it affects them for a long period of time. And so that’s areas where genetic research may help us identify high risk individuals and figure out what’s going on there. The other thing I’m excited about is the idea of intervention studies to reduce the onset or to reverse erectile dysfunction. As I mentioned, that 50 year old person with some mild to moderate ed who may have several risk factors, maybe we can turn it around for them, get them to do the things they need to do to regain their full health, lose weight, exercise, more, get their blood pressure under control, and maybe we can make it so they don’t need medications.

Dr Pelman (25:35):

Those are the kinds of studies that I think we need too. And then, uh, we’ll touch briefly on Peyronie’s disease. A patient comes in, says, “I have a curvature of the penis that just developed. There’s a lump.”

Dr Wessells (25:46):

Peyronies disease is relatively prevalent, depending on how you define it. There’s several percent up to six or 8% of the male population in their middle age who may have this condition. And the curvature is the signature aspect of it. The penis can curve up, down, left, or right, and it can be painful. And often the first sign is painful erection. Fortunately, there’s now both surgical and non-surgical treatments. Uh, and FDA approved medication can be injected into the scar tissue to try and break it down and straighten things out. So that’s an exciting new development in Peyronie’s disease. It’s a condition like ED that has been largely ignored and many physicians and providers still don’t know what to do about it. So we have work to do on that front,

Dr Pelman (26:33):

That it is something that would be worth having a man evaluated for men should not ignore it. They develop a curvature, a painful lump, and this is a new issue they should come in because there are things that we can now do and offer them.

Dr Wessells (26:46):

 And oftentimes there’s a lot of bother and distress related to Peyronie’s disease because it tends to interfere with a couple’s intimacy and their ability to, uh, maintain the kind of relationship that they’ve had potentially for many years. 

Dr Pelman (27:01):

Lastly, there’s a lot of advertising now about shockwave or ultrasound treatment for erectile dysfunction. I know it was controversial. I was at the, uh, Sexual Medicine Society update and we heard a pro and con on it, your thoughts?

Dr Wessells (27:14):

It’s one of several exciting possibilities where we’d really like to see better data. The shock wave intervention for erectile dysfunction is thought to activate stem cells and improve the vascular function of the penis, but not all shock wave systems are created equal and the delivery parameters and the timing and frequency all matter. And so right now it’s largely unregulated. It is approved. It costs a few thousand dollars for the treatment. And I would like to have more information on the cost, benefit, and cons.

Dr Pelman (27:47):

Not all delivery devices are the same, you know, and I know that was, uh, a major point that was made in the controversy.

Dr Wessells (27:54):

Potentially valuable and could be an adjunct to some of the other things we’re talking about here. But as a standalone treatment, I don’t think it will make most men regain full function. And lastly, I just mentioned there’s these stem cell and other treatments where people’s own blood is used to concentrate certain factors that are then injected back into the penis. This is very unregulated and it’s hard for the FDA to regulate it because it’s your own cells, but this is one where I think the evidence is really weak to support it. And again, we need better regulation and better trials. 

Dr Pelman (28:28):

While we’re more enlightened as healthcare practitioners, I would urge listeners that if it’s not covered in their physicals, to bring up sexual health with their practitioner, they can always be referred to a urologist, but their practitioner may be perfectly comfortable in helping them.

Dr Wessells (28:41):

And we’ve actually come a long way in the last 20 years since sildenafil was approved by the FDA in 1998. At that point, there was very little discussion about sexual function and ED, and we’ve been able to allow people to have conversations about it and receive treatment. And there’s always something that can be done to treat the ED and improve quality of life for patients and their partners at whatever stage of the disease.

Dr Pelman (29:06):

And as we wrap up, I mentioned this Sexual Medicine Society of North America, any other websites that patients can go to that you like for information?

SMSNA – For Patients

Dr Wessells (29:14):

If they are looking into sex therapy and those sorts of issues, the American Association of Sexual Educators, Counselors and Therapists, AASECT is a good resource to get information about that part of the equation.


Dr Pelman (29:29):

And then AUA net.org, which is the American Urological Association website. If you go to education and then go to guidelines and policies, you can actually see the guidelines on erectile dysfunction, somewhat technical for some people,* but it’s a good read.

*The Guidelines at the AUA are intended for use by healthcare providers, however the information is free for use by the public. Terminology may be a little clinical however, for those interested its a great resource. Sexual and Reproductive Health – American Urological Association (auanet.org)

Dr Wessells (29:44):

Yeah. And it can sort of give you a sense that there are a lot of options and there’s no wrong choice about what you,and what the patient wants to do, for their ED. It’s really a choice driven decision at this point, which is exciting. I think the future,  we touched on it a little bit. There’s a lot of ways that we can maybe identify people earlier and find ways to treat them. And hopefully the intervention and prevention piece will come on board so that in the future, we don’t let people get as far along before we intervene and try and turn the tide. 

Dr Pelman (30:17):

Well, it’s been wonderful. I appreciate your time, Dr. Wessells.

Dr Wessells (30:20):

Thank you, always a pleasure. Thank you.

Dr Pelman (30:23):

This completes another podcast chapter of the Washington State Urology Societies: “The Original Guide to Men’s Health.” This is Dr. Richard Pelman reminding you to take care of yourself. The Washington State Urology Society wishes to thank all contributors, who volunteered their time and knowledge. The information presented is the opinion of the speakers. The Society also wishes to thank Sean Fox for his invaluable technical assistance, music theme “San Juan bells” written and performed by Dr. Dave Whiting, the podcast is the property of the Washington State Urology Society.  Reproduction and use without the express consent of the Society is strictly prohibited. For more information about men’s health visit wsus.org or visit your physician or care provider.

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