In this episode, Dr. Rena Malik, MD invites Dr. John Mulhall, to explore the complexities of erectile dysfunction (ED) and penile ...

why-every-man-should-take-sildenafil-amp-tadalafil-even-with-good-erections

Why Every Man Should Take Sildenafil &amp; Tadalafil (even with good erections)

do you think that there's benefit for the young healthy man to start a deli daily or seld daily that's an interesting I asked that question of uh we had a cardiologist talked about this yesterday at one of our conferences I asked him that question he was not it he he wasn't able to give me an age at which we should start I would say if you're a healthy 40y old you should consider start doing things to protect your long-term erecti function okay if you're a sexual human being not everyone is but if you're sexual human being and your uh intercourse based relations is important to you then I think you need to start thinking about your penal Health okay we talked about the lifestyle things um but I think that if you were 40 years of age and you were interested in protecting your penis and you said I'm going to take regular pd5 I would have no problem with that I think if you said to me the 25-year-old comes in who's perfectly healthy my concern about that population is not so much that they're looking to protect their penis but they're looking for an ex boost and while there's no physical dependency on PD fius there's most certainly the potential for psychological dependency right this concept of you know I'm great when I use vit guy with perfectly normal duplex Opals on his vascular is perfectly normal and he's on pd5 Inhibitors and he is only able to have penetration hardness when he's on the pill not because his Machinery is not good at it but because his confidence level is so low without the pill so I think that's something that I'm just a little bit concerned about in the younger population sometimes I find that um the opposite is sometimes true it allows them to get their confidence back if they have a lot of anxiety around sex that it becomes a little easier to have an erection and then we try to Wing them off and that is sort of a challenge so we published a paper Al shenkin was the first author in this paper um he was one of my fellows he's now to Lan and we published this a couple of years ago and we show that if you are a men with psychogenic needed day so normal hormones normal vasculature and your the strategy you talked about confidence restoration through pd5 use um 90% of those men who are in a relationship are off pills in the long term that you can restore their confidence now I say in a relationship because if you happen to be single and every two months you're starting a new dating or a new situationship right I think that that's a new stressor to you every new partner is a new adrenaline generator right so I think that in the in the confines of a sustained loving comfortable relationship then people's confidence comes back yeah in time I love it know the word situationship sexual medicine do yeah um I want to briefly touch on intracavernosal injections which are therapies I think are very undern underutilized and under known for many erectile disfunction so let's talk about how they work yeah and um how many today yeah so that's that's a bit of a lesson in history right so uh credit once still alive I think uh or Ron vag was a vas is a vascular s in parison during an operation on the lower limb they were injecting medicine uh to vasod cause vasodilation of the of the arteries in the leg and the injection went into the wrong artery and the patient got an erection and that was an injection with a drug called pavine and then around the same time chap Jes Brindley from um the UK was doing this with a drug called phoxy Benz and that was 1982 and then by 1985 injection therapy became a big deal in the United States it's never been uh well they're FDA approved and non FDA approved drugs so it is basically the use of vasodilator drugs that are injected directly into the shaft of the penis into the me of the penis using a diabetic needle middle of the shaft nowhere near the head mosquito bite Mr Jones okay and uh depending on the population that you're looking at but has an incredibly High success rate I mean you know if you come in to see us and your post prostect and your star injections within 6 months 92% of then get penetration hardest erections you know I said that you'll get an erection will be proud of okay and they're incredibly incredibly po right from uh a safety standpoint of course the only concern would be priorism really okay so the induction of an erection that a man cannot get rid of those four hours call your doctor erections that you see on TV um and the chances of that happening in a well organized well monitored program is very low in our program is 0.2% uh of men who get a a prism and it's probably um maybe five times out getting a prolonged Direction two hours but not getting to four hours um but incredibly incredibly effective the problem is that there's a 50% drop at rate over five years right and this is not even in the rehab population this is in the general population people just get hired of the whole injection concept it's not very spontaneous hold on honey let me inject okay and so I I talk with all of my patients I know traines about the concept of integratability now if you're on a drug treatment on a treatment for ED whether it's a drug a vacuum device even a mental health strategy or an implant if it's not integratable into your love making you're never going to stick with it right and so the problem for injection therapy as effective as it is it just as difficult to integrate into love making so take for example the 45-year-old recently divorced male post prostectomy out once to start dating again he's single now he's got to bring his injection medicine on a date with him right so it's hard to integrate that into look making we understand that but I think for temporary confidence restoration for um showing men that their Machinery is functional again I think injection therapy is a fantastic strategy are there errors that men make when starting therapy yeah I mean the the classic errors would be you know and errors in quotations would be um just bad injection technique even though we train them how to do it in the office we use two injection visits um many of all just use one we use two uh they they nervous at home home and they just don't inject at the right angle the wrong depth we have men who are you know it's uh needle in plunger down needle out pressure between two fingers Mr Jones for three minutes right but they're as they're as they're um the plunger is going down they're pulling the needle out position got to get the needle out as quickly as possible the major concerns we have were men who change the dose themselves right okay so we send patients home after the second injection visit we say you're on X number of units of triix or bimix or pavine we don't use a lot of edex or cabaj which are the two FDA proof drugs and they just I'm not getting direction I'm happy with and they self adjust their dose and they'll come into me all the time and they'll say well I just went from four to five units I'll say Well Mr Jones that was 25% increase in your dose you know so if we look at our patients who don't do what they're told to do they have a tenfold increase in their cism with yeah okay so that's a that's an issue then we men who want to inject twice within the same day or twice within eight hours of each other which is Young speaking no no um but if you're well trained and well monitored it's really easy to do it's actually quite difficult not to do it properly yeah I think the other thing about the medications is some of the medications require refrigeration yeah and that can be a real challenge yeah you so medications that contain prag one because it is inherently unstable and loses its potency it's its kind of activity over a four plus month period that needs to be refrigerated for sure now that's over time so if you got a bottle of tryig you want to you want to refrigerate that you don't want to be carrying your bottle around wherever you're going but if you're going away for a romantic weekend and you're on injection therapy just pre-fill two injection syringes and you don't have to be crazy about refrigerating them your PR it down doesn't deactivate over the weekend it's the accumulated exposure over time weeks or months to room temperature that causes a problem but for those Pati who struggle with refrigeration then we just use BX to have an infant without Pros great so I know you have a lot of expertise from working at Memorial s cing on particularly taking care of men after prostate cancer who have erectile dysfunction so what is the true rate in modern day of erectile dysfunction after arrival Pro yeah so I think that's that that's a excellent question and it's difficult answer with a number because as you know very well there are many confounders right so patient age is a factor the younger the age the better men preserve their function there is based on erectile function okay sometimes ages are so good for that but sometimes your younger men have got bad erees due to diabetes for example so the better your erectile function going into surgery going into radiation the better your recovery or preservation at the time of surgery there is nerve sparing and that's very very important so for somebody who comes in to see me preop I always say when you speak to your surgeon in the morning of surgery in the preop area don't say Dr East chair of Urology at at C Center Dr East don't forget do your best with my nerves the better the nerve spare the better the recovery um and then from a radiation standpoint the higher the radiation dose the greater the problem and then probably the most penous threatening thing that can you can do to a human being will be take their testosterone away from them and as important as Androgen deprivation therapy ADT those drugs that cause testosterone to go to zero as important as they are in the radiation patient and in the advanced prostate cancer or metastatic prostate cancer patient they are really really bad for rectal tissue so if you think of your penis like your biceps Mr Jones you put your hand around your penis most of us inside your hand is a muscle if you put your plastic has for a year that's really what lupon is going to do those drugs lupon apparat Etc that's what those drugs do to your PE you need some testosterone for erectile tissue Health it's actually probably not a huge amount of testosterone but you need some when you have none reflexly in time that muscle under go collagen deposition now that's not in three or four month but those patients who are on hormone therapy for a year a year and a half two years which is increasing now because of the stage migration of prate cancer um those patients have really huge problems so if you take men in our practice who are have been on long-term hormone therapy almost none of them will ever be pd5 andh responders they will need at least injection so getting back to your question um after prostectomy I think it will be very fair to say to a patient in general terms you will have a 50 to 60% chance of getting back function with or without a pd5 inhibitor two years after your cross the and I think those figures are approximately the same for patients who have radiation therapy okay now if you radiation therapy with long-term ADT if youve non- nurse pring surgery and these figures change dramatically but I think to the average patient 50 to 60% pd5 andh response rate 2 years is a very honest and reasonable estimate pre-operative it's equival pretty much equivalent between surgery and yeah I get these patients all the time what should I do and I always say I'm not a cancer doctor I'm not going to tell you what to do um what I say to them is as follows three years after each intervention the Ed rates are approximately the same provided you good nurse fairing surgery and youve radiation therapy as monotherapy when you start doing non- nurse fairing surgery when you start doing ad of different durations then those it just becomes impossible to estimate for those patients yes so I say the patients speak to your surgeon about nerve sparing you know based on your PSA your MRI Etc what are the chance of good nerve sparing and I say to the patients speaked to your radiation oncologist and ask about the role of ADT and especially about the duration of ADT and I always say the same thing the patients ask your Raton your radiation oncologist about the survival benefit of two versus one year versus 6 months and you decide that is that survival benefit important to you if it's six months or six years you make that decision I don't think I I have a phrase that I use now in my lectures of obsessive obsessive enco centricity that cancer doctors are like you know PSA PSA for prostate cancer or ca for colon cancer Etc and really we need to empower patients to make better decisions for themselves right so on a big patient advocacy P this is classic sh decision the patient should be the one who's making those decisions we give them the information and then they decide quality elment yes we are survivorship Physicians right what about more focused therapies like there are now emerging Focus therapies timey frequency ultrasound also called Kyu cryotherapy those sorts of things have you um what have you seen in this station yeah so there really are no long-term studies to look at cryotherapy uh hu uh and some of the more modern things like irreversible uh electr coration and things like that that have had a as a focus sex order okay I think that if you look at Mark Amberton data from the UK that uni lober treatment so Hemi gland ablation will be called so half of of those patients are most probably going to do better from an erectile function stpoint than classic radical prostectomy or radiation patients I think however when you get to whole gland ablation then you start getting into into uh rates of Ed that are approximately similar okay um to prosate we have a lot of patients of Memorial who want kind of ejaculation sparing prostate cancer treatments and so they go for things like H Fu or they go for things like I okay um they have to be made aware of this NE if they're listening to this you must must understand that those treatments are administered very closely to the ejaculatory ducts and the ejaculatory ducts are millimeters apart from each other right and so well I'm only having Hemy ground ablation but if they're treating around the area the white ejaculatory duct there's a chance you're left ejaculatory duct is going to get injured so it's not uncommon for those men to come in and at least temporarily for them to have an inability to have ejaculation after those minimally invasive procedures um that leads me to the idea of ejaculatory distress which is a really interesting concept about men who are distressed post prostectomy for example at their inability to uh ejaculate um about a third of our straight men are very bothered now that's 80 plus% of game yeah right but about a third of our straight man are bothered by the fact that post prostectomy I'll never EAC it again and that's not something that's well appreciated by by surgeons yes and and it's very it's not discussed to a great extent prior to any procedure when surgery radiation yeah yeah and by the way after radiation if you look at our data it's the data that we published uh 50% of men at 3 years and 90% of at 5 years no longer ejaculate just the radiation damage to the cross the the occlusion of eory ducks they just stop ejaculting so in time they also stop ecting now I want to clarify ejaculation versus orgasm yeah because what happens to orgasmic function after we yes so after proc first of all let's get radiation out of the way because there's really not much literature up there okay so my anecdotal experience at a radiation patients they send to have better preservation of orgasm uh than the prostectomy population if you look at prostatectomy patients while they don't eject nearly all of them are going to be orgasmic and this is a you know a classic thing in our practice as you know where men just don't understand that's is a difference between ejaculation and orgasm ejaculation is the exort of semen and orgasm is the pleasure the pleasure that's derived from that yes our blood pressure goes up yes or pulse goes up yes there pelvic muscle Flor contractions during orgasm but the pleasure is a cerebral phenomenon okay so men orgasmic after prostate everyone says the same thing it feels different right and even in the long term I think you would have to we talk about the new sex after radical crossectomy part of that new sex is you have to accept that your orgasm is going to be different in some way however if you look at orgasmic intensity at two years about 50% of men will say their orgasmic intensity is less but 40% will say it's about the same and 10% will say consistent it's more intense post plastic and we have no idea why that is right you mean it's the public floor it has to be something to do with the public floor I mean you think it's like in those 10% their public floor SLE exercises to prevent leakage and that's never been L there that's that's an interesting we've been very interested in doing urethal pressure profiles and Ur this urami barometer uh in these patients um I don't know the answer to that but it is it is not a flute it is Con I've been in practice 28 years and over my 28 years thousands of post it is 10% of men who have increased orgasmic intensity there was a lot of concern you know the seamen bolus going through the uro is important for orgasm intensity but the 10% having higher intensity says that can't be the case well I think it's also a mental there right because it's it's so ingrained in that component of pleasure reaching that climax that feeling that and when it's reduced or gone it can be it can feel like L yeah and and I think that Links of the whole you know ejaculatory orgasmic distress that occurs after after radical prostit

Dr.

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