Can combining erectile dysfunction (ED) medications enhance their effectiveness, or does it pose serious risks? In this video, Dr.

scientifically-proven-ways-to-make-sildenafil-and-tadalafil-work-again-according-to-a-urologist

Scientifically Proven Ways to Make Sildenafil and Tadalafil Work Again, according to a Urologist

what do you do when your meds for erectile dysfunction are not working I'm Dr Reena Malik urologist and pelvic surgeon and today we're going to talk about what's the next step if your medications that you're trying to take for erectile dysfunction are not working now in a previous video we talked about how to make sure you're optimizing taking those Ed meds and not making the most common mistakes that people make when they take those medications now if you're still having issues what can you do today we're going to cover exactly that what can you add to your Ed meds to get a stronger harder firmer erection now erectile dysfunction is very very common it's expected to affect 300 million men worldwide by 2025 and basically how do you define Ed it's the persistent inability to attain and maintain an erection that's sufficient for sexual penetration now very often when you're struggling with erections you'll be prescribed a medication and these medications are pde5 Inhibitors they're like seleny tadalfil or venil also known as viagracialis or Levitra and they help you on demand meaning you take it before you have sex however these sometimes don't work and I've talked about this in the past in that video about how sometimes it takes you six to eight tries before you see full efficacy of those medications but even then it's only about 70 to 80% effective meaning that 20 to 30% of guys who use it it's not going to work so to review these medications work by inhibiting the breakdown of an enzyme called cyclic guanosine monop phosphate or cgmp now this is a key molecule that's involved in the process of the erection and it's great for helping maintain erections and get erections but it's not actually reversing the problem and so first and foremost before I give you any other things that you can add to your regimen to help you get erections you got to figure out what is causing the erectile dysfunction and how to fix it so what causes Ed most often it's vascular or blood flow issues which means that you need to work on improving your blood pressure your lipid panel so your cholesterol and your diabetes and you can learn about Ed and all the causes in a variety of videos and podcasts I've made in the past so make sure you check those out because again treating the underlying issue is the most important part of this process now what typically happens most often if you fail these medications you'll be offered something called an inav noal injection now this is a medication that's injected into the penis directly to increase blood flow now these are very effective medications but it requires injections and for obvious reasons it's scary to a lot of men and that's something that they really would like to avoid so to help you out I looked at some research on combining other treatments with pde5 Inhibitors to help you get again better stronger firmer erections number one adding a daily tadalfil with the on demand medication now this is by far my favorite combination treatment because you are essentially continuously increasing blood flow to the genitals it's not just on demand so if you think about it like this at Baseline the penis has a low oxygenated State and so when you get an erection that's the only time you get increased blood flow to the penis now normally your body takes care of getting blood flow and oxygen to those tissues regularly because you're having nighttime erections three to five nighttime erections every single night however when you have erectile dysfunction those nocturnal erections go away so now you're not actually increasing blood flow throughout the day only when you try to have sex with these medications so taking daily medication allows you to increase blood flow to the penis throughout the day particularly when you have those nighttime erection spontaneously which then prevents tissue damage from lack of oxygenation when you're in this constant low oxygen State the tissues are changing all the time and they're getting a little bit less flexible less elastic maybe even developing some scar tissue or we call fibrosis now as I mentioned guys with normal erections don't need this because they're getting good nighttime erections and good blood flow to the genitals on their own now how well does this work so one stud he looked at a total of 180 patients who had erectile dysfunction and they were randomly assigned to either Take 5 milligram of tadalfil daily with a 50 migr selenop on demand meaning when you wanted to have sex compared to just 5 milligrams of zalil daily for 12 weeks now the results showed that both groups had pretty similar improvements in terms of erectile function based on these validated questionnaires that we use however combination therapy was actually better for those men who had severe erectile dysfunction and so this is an important fact right if you have severe Ed you're more likely to fail those medications on demand and this is a great option before having to do more invasive treatment options now another study looked at men who didn't respond to those on demand medications so this is a specific subset of men and treated them with on demand tadalfil in addition to a daily dose of tadalfil and they did that for 5 milligrams daily and they could then take either 10 milligrams or 20 milligrams with that 5 Mig on demand for 12 weeks and what they found was that daily tadalfil in addition to that on demand to delil increased erectile function significantly compared to just taking to delil as needed and lastly in a study of men again who didn't respond to On Demand medications they were then offered to take 20 milligrams of dalil every other day or venail 20 Mig every day for 2 weeks so they didn't take a 5 milligram dose but they took a larger dose every other day or every day and what they found was that 11% of those patients in the tadal group and 18% of the patients in the venail group now were able to get erections these are not huge numbers but again if you're struggling with erections and you're not getting the effect you want this is a great option number two adding testosterone replacement therapy now the rationale behind this approach is that if you have low testosterone or what we call Androgen deficiency that can contribute to erectile dysfunction and potentially the combination of these medications and testosterone may have what we call a synergistic effect however three randomized control trials looking at this found no significant benefit in adding testosterone replacement to medications for Ed compared to men who were just getting medications for Ed for erectile function now these studies included men who had normal testosterone and they were not very large studies so I suspect that if you have truly low testosterone and you have symptoms of low testosterone one of which is erectile dysfunction you will see a benefit particularly in nighttime erections which will allow you then to maintain oxygenation to the tissues at nighttime but sometimes people do have low testosterone but they also have other issues causing their Ed which is very very common only about 3 to 6% of men is low testosterone the sole cause of erectile dysfunction bottom line if you're struggling with erectile dysfunction it is beneficial to at least get tested for your testosterone level and determine if adding testosterone replacement therapy may be a good option for you next up number three adding antioxidants now I've talked about some antioxidants before on this channel specifically L Arginine so you can watch videos about that but L Arginine as well as another antioxidant propinal lcarnitine has shown some benefit in treating men with Ed now briefly to review L arginine is a precursor to nitric oxide and nitric oxide is the ignition for erections now propinal l carnitine is an antioxidant and what antioxidants do is they prevent the formation of reactive oxygen species and these r or reactive oxygen species work to deactivate nitric oxide so they're then preventing that ignition from sticking around long enough to get erections now a systematic review looked at nine total studies including over 300 patients and they were getting L Arginine somewhere between 2.5 to 5 G per day or propanol lcarnitine 2 gam per day in addition to a 50 or milligram seleny on demand and mostly these studies saw significant improvements in erectile function now some of these studies did have really short followup for only 8 to 12 weeks and they had really again small numbers so we still need larger studies with longterm followup to see if this is something that will help everybody but certainly a great option if you are struggling to add L Arginine or El citrine which is a precursor to L Arginine which I've also talked about on the channel before or pinol L carnitine what about other combination therapy so in that same systematic review that reviewed the antioxidants they also looked at other combinations so they looked at pd5 Inhibitors with things like metformin folic acid five Alpha reductase Inhibitors like finasteride and Angiotensin type 1 receptor antagonist which are often used for high blood pressure now some of these combinations showed some promising results but they were still really really small studies and I wouldn't necessarily take this data and recommend this widely I have talked about folic acid before on this channel so you can check out the video about that but the data from that is really on small numbers of patients but there was one interesting tidbit I found from this review which was that the people who benefit from taking folic acid was even more impressive in men who had Baseline low levels of folic acid or evidence of a condition called hyper homos symia now you can test for these things by getting a blood test to measure folic acid or testing for the presence of something called an mtfr genotype now usually if you do have MTHFR genotype or hyper homos symia you're going to have other symptoms things like weakness dizziness sores on the mouth or tongue but ultimately it's a reasonable thing to check your folic acid and see if you may benefit number five is adding shock wave therapy now I have made several videos on what Shockwave therapy is as well as how effective it is but essentially it works by sending sound waves to the erectile tissue resulting in microscopic trauma which then leads to your body sending a whole host of growth factors that causes new blood vessel formation but does it improve erectile function in addition to medications like pd5 Inhibitors now full transparency I currently offer shock wve therapy in my practice and I do see significant benefits in men who are not responding perfectly to pd5 Inhibitors however you don't have to just take my word for it there's also some evidence to support this a randomized control trial in 2020 looked at 922 men who were about 65 years of age on average who had Ed specifically after prostatectomy for prostate cancer now these men had daily tadalfil plus eight sessions of Shockwave therapy once per week and they did see a significant Improvement in erectile function now this is not a perfect study it doesn't include all different types of men there still needs to be more research done in the space to understand better if this is really a Wonder ful option for all men but I think ultimately this is promising and there are options available to try before having to do something more invasive like an injection or a vacuum erection device now before you go I want to let you know about my newsletter called eurology with Dr Malik and each and every week we send you a newsletter that covers one new research article that I haven't covered on my YouTube channel as well as I answer a newsletter subscriber question in addition I'll let you know what's going on with me and updates from the podcast as well as the YouTube channel so in case you didn't get a chance to watch the video or listen to the podcast you get to see a little bit about what's covered in there and decide if you have the time to add that to your playlist and of course as always take care of yourself because you're worth it

Dr.

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