COMMENTARY

The Penis as Canary in a Coal Mine: Erectile Dysfunction in Primary Care

Matthew F. Watto, MD; Paul N. Williams, MD

Disclosures

May 31, 2022

This transcript has been edited for clarity.

Matthew F. Watto, MD: Welcome back to The Curbsiders. I'm Dr Matthew Watto, here with my good friend, Dr Paul Nelson Williams. Paul, how are you doing tonight? I think I might have downgraded you on this video.

Paul N. Williams, MD: I think you did in terms of level of friendship. But I like the energy — it was pitched at the right level. So I think we're doing great, buddy.

Watto: This is a video recap of our podcast on erectile dysfunction (ED). We're going to be telling you about some of our favorite pearls from a discussion we had with the great Dr Ashley Winter, who is a urologist and very famous on social media for her commentary, which is always hilarious, but she's also a great doctor and gave us some really great information.

The first tip that she gave us was to normalize the conversation. She mentioned that as a female urologist, a lot of her patients remark to her that they "thought the conversation was going to be awkward, but you made it so easy." It's because she does it all the time; she just makes it normal. That's a great pearl that we can all use when talking to patients about ED.

One of the first things she asks patients as far as history, to figure out the type of ED, is whether it occurs with partnered or unpartnered sexual activity. If it's only occurring during partnered sexual activity, then it may be more of a performance anxiety situation, and that is a main differentiator.

I don't know about you, Paul, but in my practice, with most of the patients I see, I'm suspecting a vascular cause. These are middle-aged patients with penises who have vascular risk factors. Is this pretty much what you're seeing as well?

Paul N. Williams, MD: Yes, that is largely my experience in the clinical setting. Tell me your thoughts in terms of how ED correlates with other systemic disease. We had a really useful conversation with Dr Winter about that.

Watto: This was on my radar, of course. I knew that patients with microvascular disease might have ED, but I didn't realize that this can actually be a major cardiac risk factor, and that ED can be a sign in younger patients that something is wrong and they're at increased cardiovascular risk. So you might actually have time to intervene with primary prevention measures. Do you feel comfortable with that as a primary care doctor?

Williams: I was thrilled with this discussion because it's all the stuff that we should be doing anyway, and that we do well — things like tobacco cessation, glycemic control, lipid control, weight loss. I liked the pathophysiology pearl that because adipose tissue contains aromatase, which converts testosterone to estrogen, that weight loss can actually help mitigate hypogonadism. So there is a lot of primary care counseling that we can do around this. It might be the carrot to get patients motivated to make some lifestyle changes because it can all be helpful with ED. I thought it was a great way to frame the conversation. I should also throw in management of obstructive sleep apnea, which is really important in this patient population.

Watto: It's a good motivator for patients to tighten up their lifestyle and start to work on their overall health, and that will improve erectile function.

Back to the history. One thing she mentioned is that she asks patients, "Why are you worried about this? What are your goals?" She said not every patient with a penis is looking to have penetrative intercourse and they can still have an orgasm, even if they're not having high-quality erections. Some patients are just worried about what ED means for their health. Why is this happening? Is it a testosterone thing? Is it a cardiovascular thing? That was a really cool way to frame it. In the modern world where we're practicing, you're going to see a lot of different reasons for ED.

Williams: And I think it goes back, to some extent, to normalizing the conversation. Some people worry that the ED suggests that there is something else going on. Speaking about it openly and frankly, and saying this is a common condition that we have solutions for, can be very helpful.

Watto: Most of our internist and family medicine colleagues are comfortable prescribing the PDE5 inhibitors such as sildenafil. Dr Winter was saying that the public has a perception of these drugs that you take a pill and you immediately get an erection. And that is just not the case.

Williams: We've all seen the movies.

Watto: It allows you to get a strong erection, but you still need to have some arousal for that to happen. Additionally, Paul, she said these do not cause priapism. That's something that's mostly seen with some of the other therapies. So you can feel pretty safe as an internist prescribing the PDE5 inhibitors. Make sure patients are not taking long-acting nitrates with them. There was a recent observational study saying that maybe it's not as dangerous as we thought, but I am still not going to be doing that. She mentioned not going above the maximum recommended dose because you're more likely to get side effects, and it's not going to help the erections to just take extra pills if you're outside the dose range.

Williams: There are injectable medications that can mitigate some of the systemic side effects of the PDE5 inhibitors, medications that can be injected by the patient. Dr Winter talked about counseling the patient's partner to help with the injections as part of foreplay. Our colleagues in urology may also recommend the vacuum pumps, but Dr Winter was largely unimpressed by their efficacy. So at least according to one expert's opinion, it may not be a first-line choice.

There are also surgeries that can be done with implantable devices that are either malleable or inflatable. And then lastly, you mentioned earlier that ED can be partnered or unpartnered. If it's more of a partner thing, don't forget things like psychotherapy, or even couples counseling may be particularly helpful for ED. It doesn't have to be a surgical or medication intervention; there are other things that we might be able to offer if there's a psychological component to a patient's ED.

Watto: In the full podcast, we talked about a lot more than just what we've told you here. There were a lot of pearls and some great scripts for patient counseling, which I'm always looking for in primary care. Click on Erectile Dysfunction if you want to hear more from this podcast.

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