Treating erectile dysfunction | Mayo Clinic Q&A
We know that men are less likely to seek routine medical care than women are, but while men have a terrible habit of avoiding the doctor, some problems will prompt them to take action, like a common complaint – erectile dysfunction.
In this article, we will discuss men’s sexual health and treatments of erectile dysfunction and infertility with Dr. Sevann Helo, a urologist from Mayo Clinic.
Can you explain to our readers what the definition of erectile dysfunction is?
The simplest way to define it is the inability to get or keep an erection firm enough for sex.
Does the loss of erectile function is a normal process of aging?
I always tell patients that it doesn’t have to be. It certainly is more common as men get older, but it doesn’t necessarily have to be something that happens to every man.
How common is it?
It’s estimated that 40% of men by the age of 40 will have some degree of erectile dysfunction, and by the time they get to age 70, that number goes up to 70. So it’s certainly more common than you would think.
Is there anything that can be done to prevent sexual dysfunction?
Fortunately, many of the things that men can do to lower their risk of erectile dysfunction will also reduce their risk of diabetes, high blood pressure, or heart disease.
The three most common things that I tell men that they can do to prevent erectile dysfunction are to exercise regularly, maintain a healthy diet, and refrain from smoking.
I imagine there are treatments for erectile dysfunction. We know of some of them because we see them advertised on television but what are the common treatments, and how successful are they?
We have many treatment options for men. The options range from pills to vacuum erection device injections and even a surgery a penile implant.
I always tell my patients that I guarantee there’s something I can do to help them, but it’s a matter of how invasive that treatment is going to be.
I know you’ve mentioned that there are different ways that sexual dysfunction can occur. Is there a difference between when it occurs just from a disease state versus surgically, such as after prostatectomy, and are the treatments different?
Certainly are special situations, and men who have undergone previous surgery in the pelvis like prostatectomy for prostate cancer or various kind of surgeries for the colon can undoubtedly affect the nerve function for erections.
The vast majority of cases that we see really are a blood flow problem or a vascular problem, and so generally, most of the treatments aim to correct that. Although the penile implant will solve the problem regardless of what the cause is.
Is there a connection between erectile dysfunction and heart disease?
Absolutely, because the vessels that carry blood flow to the penis are about an eighth the diameter of the vessels that carry blood flow to your heart, so you can imagine that these vessels are very sensitive to changes in blood flow, and that can be caused by a buildup of cholesterol and plaque inside the vessels, just like causes for heart disease.
Sometimes erectile dysfunction is actually the first sign of a heart problem, and it can develop even 10 years earlier than a man may ultimately have heart issues like a heart attack.
That’s a great perspective to put it in, and what should the first step be that a man takes if he notices this is starting to occur?
The first thing is to talk to your doctor about treatment options like we talked about. When we see patients in our clinic generally, they’ve already tried the pills, and the pills either work for a period of time, or maybe it didn’t work from the get-go. In those cases, if they don’t have a strong history of something such as high blood pressure, heart disease, or previous history of heart attack or surgery on their heart, then sometimes there’s some additional testing that we’ll do in the office to make sure that there are no major issues with blood flow.
If we find that the blood flow they’re getting to the penis is a lot lower than we would expect for their health and or age, then sometimes we’ll refer them to a cardiologist to make sure they’ve had a thorough workup so that we’re not missing the bigger picture.
It sounds to me like when a man presents with concerns for erectile dysfunction that that’s a great time for him to get some of his routine screening for other potential disease states done as well?
For me, that’s the most gratifying kind of visit when a guy comes in saying, I just want to make sure that we’re not missing something else because that’s the guy who is willing to make some lifestyle changes if there are things we can do to improve his overall health. So, that’s really an excellent opportunity for intervening early.
Let’s switch tracks just a little bit because I know that another area of expertise for you is male infertility. What percentage of couples are infertile, and can you tell us what that means exactly?
10 to 15% of all couples who are trying to conceive will ultimately struggle with infertility, and it’s defined as an ability to conceive after a year of trying with unprotected intercourse. Unfortunately, it’s more common than you would imagine.
I feel like we hear so much about female infertility and the measures that are taken to help correct that. How common is it that the male may have fertility issues in the relationship?
First off, the way I approach it is I tell couples that it’s no one feels like they’re at fault, and honestly, that being said, ultimately a third of the time, a male factor is identified along with a female factor. So it’s very common that it’s a little bit of both partners are having an issue conceiving, and 15% of the time, it’s a male-only factor.
What are the most common reasons that couples may experience infertility?
The most common reason would be a hormone imbalance on the male’s part with his testosterone. It’s a male hormone that is important for building muscles but also for making sperm.
Varicocele is also a common cause of infertility. It’s essentially like dilated veins that go to the testicles, warm up the environment of the testicle and make it hard harder to produce sperm.
You can also have a blockage of the vas deferens. That is a tube that carries sperm from the testicle out through the ejaculate, and that can be caused either by genetic factors or by previous surgery that you may have had.
And then lastly, there are some more rare genetic causes that typically will run in families but also can appear over time.
It sounds like there are multiple causes for male infertility, just as there can be for erectile dysfunction. Are these causes fixable? What can be done to aid male infertility?
The answer is yes and no. Some of the causes are hormone imbalances, potentially infections, or surgeries that may have caused a blockage of that tube carrying the sperm. Some of those can be corrected either with medication or surgery.
That being said, average sperm counts in the last 40 years have dropped by about 60%, and we don’t completely understand why that is. Some of the reasons that may account for that may be environmental exposures such as increased radiation around us, higher rates of obesity, and increased use of prescription medications.
Again, some of those things may be treatable or reversible, but a lot of the time, even after we’ve taken a very thorough history that we may not find, so to speak, that smoking gun that may be fixable and it’s likely a number of factors that we can potentially modify.
I know that many couples are waiting until later in life when they’re more established to attempt to have children now, which can certainly affect female infertility. Do sperm counts drop with aging? Could that affect it in any way?
We get that question all the time. Certainly, female fertility age is a major factor there, but that being said, if you look around you – celebrities seem like they have children a lot later in life, and for some people, it normalizes that men in their 60s have children, but realistically sperm counts do drop over time, and the quality of the sperm tends to diminish.
You can also have increased DNA fragmentation, which is essentially like the quality of the DNA inside of the sperm itself also diminishes with time.
While I certainly understand people putting that off later in life, you don’t want to put it off too late in life because there is a point where it can certainly be more difficult.
I’ve had multiple couples that I know who struggled with infertility. I think everybody has it’s so common inevitably it seems to reach a point where people are anxious to start investigating, women understand their biological clock is ticking, etc. When a couple begins to investigate infertility, what should the man expect when he comes to see you in the office?
The most important test that we’ll do for men is is a semen analysis. That will give you a total idea of the number of sperm that are in your ejaculate. It will give you an idea of the volume of the ejaculate and how well the sperm move.
Using those numbers, we calculate a total modal sperm count, which is the number that’s most predictive of being able to conceive naturally.
That’s probably the most crucial test that we’ll do. Then aside from that, we’ll also typically look at the hormones, including the testosterone level, which more often men who even aren’t having symptoms will find that their testosterone is low and that’s potentially treatable and will not just help their sperm counts but potentially also improve other aspects of their life that maybe they didn’t realize.
When there are concerns for male fertility, how successful are the treatments and management options?
That really depends on what the cause is. For men who have some sort of blockage, surgery to bypass that blockage is generally very effective. We talked about a varicocele, those dilated veins to the testicle surgery for that also is typically effective in improving their sperm counts. Often, men also have pain related to the varicocele, which is also very effective at treating that.
Then, men with low testosterone who we can treat with medication generally will improve their testosterone levels pretty dramatically and will have some modest improvements in their sperm count.
We focused on two pretty narrow topics today, which is a big part of your practice, but in broader terms, could you tell us how urologists help assist with men’s health and what some of your other rules are?
The most common men’s health conditions that I treat are intimately associated with a man’s overall health and well-being. So it’s really a great opportunity for us as providers to discuss with our patients’ ways that they can improve their life on multiple levels.
One of the most gratifying things is hearing couples talk about how this treatment or intervention has improved their relationship with their partner. But also just to be overall aware of their health because your erectile function and your fertility – those are really manifestations of your overall well-being.
For us again, it’s a great opportunity just to highlight some things that men may not be thinking about or sometimes may be scared to talk about, and I think approaching that in a cautious way that feels like it’s a safe space and really knows that we are here to help.
One of the most important things today that you’ve shared with us is just empowering men to seek answers to concerns that they might be having. We often think of women as more likely to pursue that type of care from a physician or another provider, but men understanding that there can be improvements made if they’re desired, and they can get their questions answered is really important.
I can’t tell you how many guys will say I wish I’d come in sooner, or I’ve been so anxious to talk to someone about this or scared to bring it up but know that this is what we talk about all day long. There is nothing to be embarrassed about. There’s almost nothing we haven’t heard.
So come in with your questions. We’re really excited when patients come in with questions because that means that they’re engaged in their overall health, and I know there’s something that we can do to help.
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