Erectile Dysfunction: What's Plan B?
Graham T. VerLee, MD
The year 2016 marks the 20th anniversary of the patent for Viagra, a pill which changed the world’s perspective of erectile dysfunction almost overnight and started a multi-billion-dollar subindustry.
Since that time, as our population ages, doctors have been encountering greater numbers of men with increasingly complicated medical problems who wish to maintain aspects of their sexuality.
And as many of these men are finding out, the more complicated one’s medical history, the less effective that oral medications like Viagra can be.
Hear from Dr. Graham VerLee, a urologist specializing in Men’s Health at Maine Medical Partners Urology, as he discusses the causes of ED, the reasons why prescription medications don’t always work in every patient, and the many options available for men beyond Viagra.
Dr. Graham Verlee (Guest): Well, thank you, Melanie. The major population risk factors that we see that might predispose a man to get erectile dysfunction haven't really changed. What has changed is the recognition of erectile dysfunction in the first place. What we now realize is, that up to 50% of men over the age of 40 will have admitted to some degree of difficulty in attaining or maintaining his erection. Now, obviously age is a risk factor, but we like to think it's more than just that. We think that, as men age, they become more prone to develop things like cholesterol problems, blood pressure problems, complications from major health problems like diabetes, cigarette smokers---you didn't really think about this when you were a teenager and you took it up, but now that it's 20 years later, maybe that type of behavior is starting to come to bite you. So, we do see this in a variety of men.
Melanie: So, when a man comes to you and, whether it's any one of those reasons, what's the first thing you do to test them for the cause?
Dr. Verlee: The first thing we do is to get a thorough history from the patient. We obtain knowledge about their lifestyle habits, their health habits. We want to make sure that erectile dysfunction isn't just a symptom of something else going on underneath. It's been called the "canary in a coal mine" as the metaphor of maybe it's a harbinger of something going on underneath that we need to be more concerned about--things like cholesterol and blood pressure. Beyond that, we ask some rather unique questions about particular types of erectile dysfunction. We say "Well, did this man incur some form of trauma at some point in his life? Is there a neurological condition that might predispose him to getting this problem?" And then, we talk about the physiology about how men get erections in the first place and we say, "Where could have this man fallen off the path? Where does there appear to be a weak link in the chain of the process?"
Melanie: Do some medications, if a man's on blood pressure medication, or if you've recognized they have low testosterone--any of these things--can they contribute to that?
Dr. Verlee: Most definitely. Speak about testosterone first, because it's certainly been in the media a lot lately, in the public eye. Testosterone itself isn't absolutely required to have an erection, contrary to popular belief. It's not as though just giving a man testosterone, if it's low, will necessarily combat that and make it bounce back. But, we do know that men with lower testosterone tend to have fewer erections and have greater difficulty in getting erections at all. So, if a man comes in and complains of a lack of libido, a lack of stimulus, a lack of vim and vigor, then I start thinking about, "Well, maybe it's wise to test this man's testosterone levels." Apart from that, we're talking more about how do we reverse the process of these different links in the chain falling down and corroding over time? How can you make the blood flow in a patient that perhaps they have reasons not to have the blood flow as well they once did? We talk about the disease processes that a man is already facing and how can we best optimize those risk factors so that they can get the most out of their sexual experience.
Melanie: So, as I mentioned at the beginning about Viagra, what is your first line of defense? Do you look towards, of course, all these causes we're discussing and possible other reasons and complications, and what do you do as a first line of defense to help somebody to get past this?
Dr. Verlee: The first thing you're looking for is a wrench in the gears. You're looking for something that is very clearly sticking out that says, "If we change this one thing, then all of a sudden the machine is going to work again as it once did." Sometimes, you find that. Sometimes, you don't. So, sometimes it's a very easy fix of "Oh, ever since I started this other medication for some other problem I have, I've been having difficulty having erections." "Oh, well, maybe there's an alternative that we can talk to your primary care doctor about that might be a little less harmful to your sex life." That kind of thing. When it comes down to it, Melanie, the drugs that are most commonly prescribed by both our practice and primary care practices across the state, our first line treatments are these so-called “phosphodiesterase inhibitors” of which Viagra is one. The other two trade names on the market are Cialis and Levitra. All three of them came out roughly within a few years of each other and, as you said in your introduction, it's been about 20 years since Viagra, the first of the three, was first patented. The truth is that all three of those medications work about equally well. They have to be taken roughly 30-60 minutes, on average, before sexual activity; they are relatively easy to take and they're relatively easy to keep and store. They're fairly safe for most men excepting those who have certain health conditions. On the other hand, they do cost a pretty penny and there has been quite a lot of resistance on the part of insurance companies in offering coverage for these medications for a multitude of reasons.
Melanie: So then, if medications and onward past that, what are some of the other modalities that you use to treat that, including lifestyle changes and possible surgical intervention?
Dr. Verlee: Sure. So, it's important to know that these pills, as good as they are and as popular as they have become, don't work in all men. There are about 30% of healthy men with erectile dysfunction who won't respond to oral medications, no matter how high the dose goes. It turns out that diabetic men actually fare worse and only about 50% of those men might respond to oral medication. So, we start talking about not only mitigating the risk factors, optimizing control of conditions like diabetes, we talk about eliminating causative factors like cigarette smoking, and we talk about maintaining a healthy lifestyle. But, we also talk about the next step--Plan "B" if you will. How do you help these men who fall short of responding as they should, or expected to, from the oral pills? Well, it gets a little bit more invasive and I'm very upfront with our patients about saying it's a little bit "no pain, no gain" in this scenario. There's a category of drug that actually predates the oral pills by a few years that's been in use with hundreds of thousands of men since. There are preparations that can actually be delivered by injection. It's no use sugarcoating it. This is an injection where the sun doesn't shine and it's an injection that the man must learn to give himself, but that said, I do tell men that, believe it or not, it's a fairly small needle injection and most men actually get used to it very easily. These injectable medications act by causing the blood vessels to directly relax, engorge, carry more traffic into the erection. They, therefore, often work where the oral pills fail. The problem of that type of medication, of course, is that not everybody is too excited about putting a needle into the sex organ. So, whereas they do often succeed in maintaining an erection, the experience itself may be slightly less satisfactory. That's when we talk about additional types of interventions including surgeries.
Melanie: Do you often see men whose wives or spouses have shoved them into see you, or do men typically come in to see you on their own because this is something that is bothering them?
Dr. Verlee: That's a great question and I think it used to be more the former that patient's spouse or partner would be dragging them to the urologist. What I think we're finding now, at least in our demographic, in our population, is that it's quite the opposite in that a lot of men have dwelled on the sexuality aspect of their relationships as a pillar and if they have progressed to a state of health in which that's no longer a given, they somehow feel less masculine. On the one hand, you want to try to encourage them and say, "Don't worry, it's just a natural part of things," but on the other hand, you can certainly relate to that and say "I recognize that this is a part of many couples' relationships that's important to them and important to them to the core and that they have a certain quality of life adjustment when they lose that." So, we start talking as men go through this process about options such as a surgical solution and it turns out that far before Viagra, far before these injectable medications, men were undergoing surgery to implant devices into the penis in an effort to replicate the natural erection. That type of device is something that's undergone a number of refinements in recent years and it's one that we implant not uncommonly. Typically, most men, you can understand, might opt for medical therapy first over surgical therapy, but for the man who is otherwise not content with relying on pills, relying on injections, and doesn't much relish the lack of spontaneity that those medications afford, there are surgical options to implant something into the male genitalia that, more or less, replicates that erection. Truth be told, a vast majority of the men who undergo such a surgery end up very satisfied with the result.
Melanie: In just the last few minutes, what great information--and you are so well-spoken. I can see why you're such an amazing doctor. Give the listeners your best advice about the men who suffer from ED and their spouses that love them and what you tell them every single day when they come in to see you.
Dr. Verlee: One thing that's really interesting about our patient population, Melanie, here in Maine, is that I feel like there are some Puritan roots that sort of pre-dates modern society. It's almost as though men assume that erectile dysfunction has to be a part of who they become. That really doesn't need to be the case. What we've found over decades of doing this, and in dozens of other treatment areas across the country is that overwhelmingly, men have a positive outlook after treatment of their erectile dysfunction. I can't promise that it's going to fix every marriage and every relationship, of course, but to see the confidence that a man has in acquiring and maintaining his erection and the ability to share that with his spouse is just a positive way that I've seen patients show appreciation for this. So, I can't stress enough that it's really worthwhile asking your physician about the options that are available for treating erectile dysfunction and give us a call. Reach out to us on either the internet or by telephone for a consultation and we'd be happy to see you and happy to talk to you.
Melanie: And just tell us about your team at Maine Medical Center.
Dr. Verlee: Sure. Right now, we have 8 urologists on our staff. I joined not quite 5 years ago, now. We are soon acquiring two more physicians in the coming months who carry their own share of expertise. It used to be that, when we were a private practice group back ten years ago, or so, it was a whole bunch of private practice individual urologists--Jacks of all trades--but what we've done now, over the last several years, is to more or less divide up the specialty of urology among the eight physicians currently on practice here. That means that we each see specific diagnoses and specific patient populations. In doing that, we're delivering a higher quality of expert level care and because we're bolstering our own experience in doing so. We have, among our group, some of the best trained and most experienced urologists available in the state for treatment of various ailments including malignancies and cancers of the urinary tract. Both prostate, bladder, testicular cancer, kidney cancer, and so on, as well as benign diseases: kidney stones, benign enlargement of the prostate, which many men come to find is also something that catches up with them as the time goes by. We've also got the only three specialty-trained pediatric urologists in the state. So, many of our pediatric patients come from all over the state to see our specialists. We also have some of the best-trained mid-level physician assistants and nurse practitioners that you'll find in any urologist's practice in the state that help to support the care that we give to our patients. I'm a real proud member of our staff here at Maine Medical Partners Urology.
Melanie: Thank you so much. What great information. You're listening to MMC Radio and for more information, you can go to mmc.org. That's mmc.org. This is Melanie Cole. Thanks so much for listening.