Erectile dysfunction (ED): Definition and Forms of Treatment
Guest: Dr. Ross Rames – Urology Services, MUSC
Host: Dr. Linda Austin – Psychiatry, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin, talking, today, with Dr. Ross Rames, Associate Professor of Urology at MUSC. Dr. Rames, with the advent of Viagra, a whole new diagnosis, erectile dysfunction, or ED, became a household term. How do you, as a urologist, determine what ED is?
Dr. Ross Rames: Well, ED varies according to the patient. Essentially, it’s not being able to obtain and maintain an erection at the level that the patient would like. That can be anywhere from something that’s fairly mild, or it occurs on occasion, to men that can’t get an erection at all.
Dr. Linda Austin: Since the advent of medications like Viagra and Cialis, Levitra, have men begun to self-diagnose ED in ways that, perhaps, they wouldn’t have even thought about before?
Dr. Ross Rames: Well, I think that’s true. They have. And, in part, that’s due to having a treatment that’s acceptable to patients. At one point, we had very few effective treatments that patients would like to use. They could use a vacuum erection device. They didn’t like it. It’s cumbersome. There’s a lot of equipment. They could use an injection, where they had to inject a medication into their penis, and they didn’t like that for obvious reasons. Or, they could have surgery. And, many of them, at that point, decided that they didn’t want to have an operation. When Viagra came along; and, of course, Viagra was the first of these medicines, and they’re called PDE-5 inhibitors (phospho- diesterase-5 inhibitors), we finally had an effective medication with few side effects, and it really worked.
Dr. Linda Austin: What causes ED?
Dr. Ross Rames: ED is usually caused by a diminished blood flow into the penis. And that can occur for the same reasons that you may have diminished blood flow anywhere else. For instance, one of the things we’re aware of if a man has ED, we look at his cardiac risk factors. We’ll talk to them about chest pain and whether they’re having any other symptoms of low blood flow in any other parts of their body. It an also be caused by psychological factors; stress. It can be caused by low testosterone levels. And it can be caused by neurologic disease, for instance, multiple sclerosis, or other things that may impact the nerves that supply the penis.
Dr. Linda Austin: So, it’s really a common end point for a lot of different organ systems that are not functioning quite up to par? Is that right?
Dr. Ross Rames: That’s right.
Dr. Linda Austin: Statistics about how common ED is through the life cycle, do you have any easy-to-understand statistics on that?
Dr. Ross Rames: It really depends on how you define ED. But, I would say that by the time a man is 65 years old, it’s a pretty safe bet that he has about a 30 percent chance of having significant erectile dysfunction.
Dr. Linda Austin: If a man does have ED and just wants to go to his family doctor, let’s say, and get one of those medications, in your view, is that okay, or do you think it’s important to look for the underlying cause?
Dr. Ross Rames: Well, family doctors are often monitoring these patients for some of the underlying causes: diabetes, elevated cholesterol, hypertension, so they’re already looking at the patient as whole patient, if they’re a primary care physician. In general, these medications are very safe to use. They only have a couple of contraindications with their use. So, patients are usually safely treated by their primary care physicians.
Dr. Linda Austin: And, what are those contraindications?
Dr. Ross Rames: Well, the main one is that you really shouldn’t use it along with nitroglycerine, if you’re using that for chest pain.
Dr. Linda Austin: Do you ever see cases of people overdoing it with the use of these medications? Is that possible?
Dr. Ross Rames: Yeah. That’s an interesting question, because you will see patients that don’t fit the classic definition of erectile dysfunction for using these medications; kids in high school, college-age kids using this as a party-type drug, and often combining it with other drugs or medications in an inappropriate way. And that can have some bad side effects.
Dr. Linda Austin: How effective are these medications?
Dr. Ross Rames: Fortunately, for most patients, they’re very effective. And I would say around 85 percent of patients will respond well to the medications, depending on what’s caused the erectile dysfunction.
Dr. Linda Austin: How do you decide on the dose?
Dr. Ross Rames: What we normally do is start the patient on a lower dose, or perhaps somewhere in the middle. And, all these medications are available with a couple of different dosage levels. So, we may start off, for instance, with Viagra at 25 or 50 milligrams. And some patients will need to go ahead and go up to 100 milligrams, or the maximum dose. We do the same type of titration, or adjustment, of the doses for all the other drugs as well, and we want to find the lowest possible dose that gives the patient the desired effect.
Dr. Linda Austin: Is any one of these three drugs, in your view, any better or worse than any of the others?
Dr. Ross Rames: Well, they’re different. And the main difference is that Cialis has what’s called a longer half life; it lasts longer, which could be a good thing, but it could also be a bad thing. For instance, you have a longer window with which you could have intercourse, or expect that you’d have a good effect from the medication. On the other hand, if you were having a side effect from the medication, that would also last longer. What generally happens is patients will try the different medications and they’ll find the one that works best for them and has the fewest side effects. And it varies a lot between individuals.
Dr. Linda Austin: Are there any forms of ED for which these medications are ineffective?
Dr. Ross Rames: If you have a patient that has very severe ED; and you may see this in someone who has very bad vascular disease, or perhaps they have erectile dysfunction that occurs after a major pelvic surgery, like prostatectomy, those patients may not respond as well to this class of medications.
Dr. Linda Austin: But then it sounds like, for any cause of ED, it’s at least worth a try. Is that correct?
Dr. Ross Rames: That’s correct; absolutely.
Dr. Linda Austin: Dr. Rames, thanks so much for talking with us today.
Dr. Ross Rames: Thank you.
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