← Rena Malik, MD Podcast
Rena Malik, MD Podcast
Erectile Dysfunction? Is It Blood Flow or Your Mind? Here’s How to Find Out!
00:20:31
Dr. Rena Malik, urologist and pelvic surgeon, discusses testosterone therapy and prostate cancer risk, urinary incontinence treatment, and penile Doppler ultrasounds for erectile dysfunction, sharing practical, evidence-based advice for sexual and urinary health.
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- [00:00]
A
Ever wonder if it's safe to take testosterone? Is it going to cause cancer? We're going to cover that and more on today's Ask Me Anything episode of the Rena Malik Maryland podcast. I'm your host, Dr. Reena Malik, urologist and pelvic surgeon. And welcome back to the Renamelic Maryland Podcast, your trusted guide for leveling up your health, sex life and relationships with evidence based tools. Today we are answering your questions and if you want to support us, consider joining our premium membership at renamelic.supercast.com, where you have access to early release of the podcast, access to transcripts of the podcast, as well as a place to ask me anything. And you get full length ask me anything episodes here you're only going to see the first half of the episode. If you want to see the full length episode, make sure to subscribe@renamelic supercast.com let's get into it.
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B
First question, I'm a male, 61 years old, I have low testosterone. But my doctor says getting TRT has a risk of getting cancer. Is it true?
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A
This concept of TRT causing cancer comes from some older data where they saw that men who took testosterone had a higher rate of getting prostate cancer. And for many, many years it was believed that giving testosterone would feed prostate cancer, cause prostate cancer growth and ultimately be very dangerous. And so some of those fears have been taken through many, many years and sort of become convoluted. Now. What the reality is is that we now have RA control trial data and a better understanding of what happens when you give someone testosterone and how that affects the prostate. So first and foremost, there is an abundance of observational data, epidemiological studies with large numbers of people that show that men who have low testosterone are actually at higher risk for prostate cancer. So that sort of is opposite of what you think. Also, if testosterone caused prostate cancer, you can imagine that testosterone is much higher in younger men. And we see obviously no prostate cancer in younger men. Third thing is now we have randomized controlled trials looking at how giving testosterone replacement and the instance of prostate cancer. It's called the Traverse trial. And so in this trial they took men and they randomized them to receive testosterone replacement versus not the replacement type was with a topical gel. And so the men who got testosterone versus those that didn't, they followed these guys for many years. They looked at if they had elevated psa, if they went on to get biopsies, if they were more likely to get cancer. Bottom line, they did not develop prostate cancer. And so what we understand now from this and many other sort of mechanistic studies is that when you look at the prostate, right, there are receptors in the prostate that attach testosterone. And so when I give a man who has low testosterone, testosterone, if that testosterone is very low, meaning all those prostate receptors are not sticking to testosterone. When I give him that, his PSA will go up a little bit, but that's because they're just starting to saturate those, those receptors. So even if a guy who has very low PSA and we give it to him, he may see a little bump in psa, but that does not mean that we're giving you prostate cancer. So basically what happens is that giving someone testosterone when they are low does not cause cells to transform and become cancerous. But if you develop prostate cancer while you're on testosterone, that can accelerate the growth of prostate cancer. And one in eight men will get prostate cancer. So there is that sor of concern. And that's why when men are on testosterone, they need to be screened with a PSA blood test called a psa. And you know, we even know that in some cases, if you have a really indolent cancer, like a very low grade cancer, it still might not be affected by testosterone. So we're still sort of figuring it out. But what we know now, and what is widely accepted in the urologic community, is that it does not cause cancer. You can absolutely give testosterone, no matter if you have a family history of prostate cancer. If you're concerned about prostate cancer, it's not an issue, but you do need to be followed. And if you get prostate cancer and it's treated, and it's been over a year since you've gotten prostate cancer, and you no longer have any concern for recurrence, at that point, you can start considering testosterone replacement if you qualify. And so many urologists are prescribing it again carefully, cautiously, and we're learning that it can be done. It doesn't cause prostate cancer recurrence. And so I think it's very safe. Of course, there are caveats. Testosterone therapy can has risks, right? It has risks of stroke, blood clot, it has risks of worsening sleep apnea potentially. And so there are lots of things you need to sort of look out for. When you're starting this medication, you need to be doing it under the guise of a physician who understands testosterone replacement and who follows you, and you need to follow up. So you need to make sure getting all your blood work regularly and you're monitoring your symptoms, making sure, you feel well and, and that you're doing well on the medication. But just like anything else, it needs careful monitoring and is very safe. It does not cause prostate cancer.
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B
And you said randomized control trials. Just as a reminder, those are like the gold standard.
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A
Absolutely. So randomized controlled trials are essentially where you take a group of men and you randomize them. So they're either going to get the treatment or they're going to get a fake treatment. So in this case, they would get a gel with testosterone and the placebo would get a gel that doesn't have testosterone in it. So neither they would know nor the person giving the treatment would know if you got the treatment or not. So there's no bias from the people, people who are, you know, following the patients. And so these types of trials allow you to eliminate a lot of biases. They allow you to compare apples to apples because you have this, you know, you sort of add a certain number, you have the same type of person in each group, and they're not what healthier people are not getting testosterone, or, or there's no sort of variation. You can control for a lot of different things. We do randomized control trials. So that is considered the gold standard test in any research to really identify if there are truly, you know, factors that play into, for example, prostate cancer and testosterone therapy.
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B
All right, next question. So it's a 44 year old female. It's kind of a long question. She was on a date recently. She went to a comedy show, she had never gone to one before and she had a couple of drinks of wine. She says she laughed harder than she's ever laughed before. Problem is that every time she laughed really hard, she leaked a little bit of urine. It got to the point at the end of the show, she went to the bathroom, she realized that she needed a full change of clothes, so she cut the date short. This has never happened to her. So she's basically trying to figure out, like, do I need to get worked up for this?
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A
Yeah, so this is very, very common. Urinary incontinence, or leakage of urine occurs in one in three women. So very, very common. And there's different types of leakage. So there's leakage that occurs when you cough, sneeze, lift, everything, laugh. Like in this woman's situation, that's called stress urinary incontinence. And then there's other types of leakage that can happen when you gotta go, gotta go, can't make it. So you feel the urge to go and you're like, oh, I gotta go real bad. And then it leaks out. And so those two can occur independently, they can occur together. So you can have a little bit of both. And then rarely, sometimes you'll see people who are not emptying their bladder well, and they have what's called overflow incontinence. So the bladder gets so full and they start leaking because of that. So focusing on what she's talking about, she's having stress incontinence. So stress incontinence basically is leakage that happens anytime you increase the abdominal pressure. So you increase the pressure in your belly because you bend over, because you cough, because you sneeze, because you walk. When you're younger, you have really strong pelvic floor muscles that help prevent that leakage from occurring. As you get older, if you've had babies, either vaginal or even C section deliveries, if you've had a job where you're standing a lot, if you do a lot of high intensity exercise, if you have neurologic conditions like multiple sclerosis or other issues, if you have collagen disorders where your tissues are just not as strong, these things put you at higher risk for weakening of the pelvic floor muscles. And think of the pelvic floor muscles like a hammock that holds some resistance underneath your urethra. When you normally have an increased pressure, your urethra stays closed because of that hammock helping support it and so that it doesn't leak out. But as that hammock gets looser and looser, the urethra has a harder time staying closed. And when there's higher pressure, it opens and the urine leaks out. So we want to essentially support that hammock. And so the best way to do that is by increasing the strength of those pelvic floor muscles. The typical treatment for this sort of thing that a lot of people know about, have heard about, are Kegel exercises. And they're essentially exercises that strengthen the pelvic floor for women will often describe them as the sort of visualizing like there's a blueberry outside your vagina and you're sucking it up with the vagina, or you're pulling up and in and you squeeze up and in, and then you relax. And so you do those exercises without sort of clenching your abdominal muscles, without clenching your bottom, and really just focusing on trying to localize those pelvic floor muscles. And so I tell people when they're doing these exercises to start by lying down. And then once you get strong and comfortable, Doing them lying down. You can start doing them sitting up and eventually standing as I start with like 10 or 15 in the morning, 10 or 15 at night, and start doing them regularly. It's very important that when you're doing these exercises, you also allow time for relaxation. So you squeeze, but you also relax. Just like you're going to the gym, you're not going to just like hold isometrics for the whole time. You're going to relax and you're going to do sets and you're going to take breaks in between. So the same thing. The pelvic floor muscles need to go through their full range of motion. Rarely. Sometimes we'll see that people develop tension in those muscles. And so when they need them to work, like when you cough or sneeze or laugh, they don't because they're in a state of tension. And so that often happens in people who maybe have a lot of stress or anxiety or they have sort of dysfunctional constipation, other things that have happened, trauma. And so their muscles learn to tense up and don't relax. And so in those cases, you have to learn how to relax the muscles to first before you can strengthen them. And. And in both cases, I recommend seeing a pelvic floor physical therapist. I often say it's like going to the gym with a trainer rather than going to the gym by yourself. You're going to get better results, you're going to do things better, and you're going to have more success. Because honestly, no one really understands how to do Kegel exercises until they've had a little bit of training. And the therapists have a lot of tools in their back pocket. Like they can use biofeedback and other things to help you see, see when you're doing the exercise correctly and also see the relaxation. And so they can essentially coach you in how to do the exercises. There's also now, like some insurances have at home, pelvic floor physical therapy available through the insurance. And there's a variety of different ways to get access. There's tons of videos on YouTube, but generally recommend, like, learning from a guide and really trying to make sure that you're doing them correctly. Is this dangerous? Then there's other treatment options, too. There's no medications that work, but there's also surgeries. I've talked about that on my channel before, so you can check, check those videos out. But getting back to, you know, this particular patient, she was worried, is this normal? Is this dangerous? And I think that the most important Thing to realize is this is a quality of life issue and so it's not dangerous, you're not harming yourself. However, if you are feeling, you know, bad about the leakage, it's completely reasonable to go talk to your doctor about treatment options because we do have a lot of options. We have minimally invasive procedures, surgeries. We have lots of things available that can help you. We even have pessaries, sort of like almost like diaphragms, dishes with little support that you can put in the vagina that can hold things up. You can even buy sort of these specialized tampon looking things that are, that can hold the urethra up. One brand is called Poise Impressa that I know of. And so there are things that you can do that can help. And I think really the biggest thing I will say for taking care of women for decades is that women tend to take care of everyone else first. They take care of their children, they take care of their spouse, their partner, their parents. And then eventually like 10, 20 years, are they like, oh, I finally should take care of myself? And I would say you will be happier and more confident and feeling better when you feel good in your body. And so if this is bothering you, I please encourage you, go see a doctor, get help, because it will help and make your life better. And then, you know, if you want to learn more about urgency incontinence, check out my videos on overactive bladder, because that's typically related to that. And there's lots of treatment options for that. And I would say the other things, like lifestyle things, is avoid constipation. That can make any type of leakage worse. So make sure you're not getting constipated. Make sure you're not holding your urine for too long. Some people will leak because they've just been holding their urine for hours. So that when they cough or sneeze, then they leak. But if they didn't hold their urine, they wouldn't. So these are sort of simple things that can help. And yeah, I think men can also get stress incontinence, but it's less common. It's usually after a prostate surgery or some sort of surgical intervention. Kegel exercises can help them as well, but they also have different surgical options available to them. So I hope I answered that question.
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B
Very comprehensive answer. Next question. Penile dopplers. Google says it's an ultrasound, but like, what does it tell us? What can we do with this test?
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A
Yeah, so a penile Doppler ultrasound is a diagnostic test for erectile Dysfunction. Now, you may have heard me before talk about erectile dysfunction. Essentially, it's defined as the inability to sustain or maintain an erection. And the most common cause is vascular. So blood flow issues. And so, you know, this test can help us identify clearly if there is a blood flow issue and if it's a problem with an artery or the inflow, arterial flow, or venous outflow. Now, it's not always something that we do for every single person, because ultimately, if we suspect that the problem is blood flow, which is the most common problem, the treatment options are generally the same. We're going to go through the same treatment plan with you, regardless of what the artery problem is or the vein problem is. What is benefit? So, one, it benefits guys where we're not sure if there's a blood flow problem. So if you've got a lot of stress, anxiety, other causes, depression, anxiety, that might be contributing to erectile dysfunction. Because I tell all my patients, right, like, if you have a problem with your erections, part of it is bothering you in your head, right? You are stressed about it, you're anxious about it, you're thinking about it, and it makes it worse. It becomes a vicious cycle. And so if we want to parse out how much of this is in your head versus how much of this is vascular, that's a good indication to do the procedure. It also can be helpful if we want to identify other issues, like if you have a curvature of the penis and we want to identify plaques on the penis, we can use the ultrasound for that as well. And also it can be useful if you have really severe erectile dysfunction. Sometimes we could identify venous leak. Now, venous leak, essentially when you think about what happens during an erection, first step is you have nitric oxide, which is released from nerves and vessels. When you see something, hear something, feel something, that's erotic, that turns you on, your body releases nitric oxide, the muscles relax and the vessels relax and blood flows into the penis. That's what makes it rigid. And when it feels fills, it compresses veins around the erectile tissue. Normally, what happens is they compress. Blood stays there until you're done having intercourse. And then, you know, it goes back into the body through those veins. Now, if you have venous leak, it's not a problem with that. There's not enough blood coming in. It's that it's leaking out through those veins. Those veins aren't compressing well enough. And sometimes you can overcome that by increasing the blood flow in with medications or injections. Or things like that. However, sometimes it's, it's, it's just doesn't work very well because the veins are damaged, unhealthy, whatever the reason is. So some people argue that we can find out that you have venous leak and then we can go straight to surgery because we know these other things aren't going to work. Now, for some people, I think that's very reasonable. However, I think most patients want to try other things before they have surgery. So I don't ascribe to that thought process. However, I think it, it could be beneficial for some people where they're like, I just don't want to waste my time. Most important thing is realizing that your anxiety for this test can actually affect the test results. So you want to be, come in trying to be as relaxed as possible. Don't come rushing, don't be stressed to get there. You come in, you get undressed from the waist down. We do an ultrasound, you know, just to get a sense of what blood flow and is before you start the procedure. We'll also look for any other structural abnormalities. Then we'll come in and we'll inject a medication to get you an erection. And this is the scariest part, right, because we have to put a little needle in the penis to do that. But it is really not that scary. Once it's done, it's very small, it's very tiny. People do fine with it. But we want you to get the most rigid erection that you can get. So what we'll do is we'll inject, start a small dose, and we'll wait and see if you get an erection. If you don't, then we'll add more until we get to a point where you get a, an erection that you would get at your maximal rigidity. Because that's going to give us the best idea of what's happening during an erection when, when you have blood flow going in or out. It's important because sometimes people will have the, and they don't have a very rigid erection. And then it's not really a great study if you're very anxious. Sometimes we can't override that with medication. And so that's where it plays a role. Like we want to try to be as calm as possible. This is something that we do as urologists all the time. And you shouldn't feel nervous. You know, where this is like something we're specialized in, we're experts in. And then afterwards we want you to wait and see that the erection goes down because Sometimes we don't. What can happen with injectable medications is the erection can take longer to go away. And if an erection lasts longer than four hours, we start getting worried and that's an emergency. So we want to make sure your erection goes down. If it doesn't, we usually have medication on available to us to reverse the medication to help the erection come down. That's the whole procedure. It takes about 30 minutes or so. And then you have to wait afterwards for your erection to go down. And then we have information. We get information on how quickly blood flows in, how quickly it leaves, and we have benchmarks on what's normal and what's not to compare it to. So we get a lot of information and it can be useful and it can be helpful for some patients. Patients as I mentioned earlier. All right, thank you guys so much for joining us on today's episode of Ask Me Anything on The Rena Malik, M.D. podcast. Listen. If you guys made it this far, I want you to do me a solid favor. Follow the podcast on your favorite podcast platform. This tells people that, hey, this podcast is worth listening to and other people should listen to it too. And so I really appreciate when you guys do that. It helps me out so much. It takes just a couple seconds. If you guys want to listen to the rest of the Ask Me Anything, make sure to check out the full episode on ritamallock.super cast.com you can sign up there and as always, want to take care of yourself because you're worth it.
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C
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