Erectile Problems Getting Worse? Urologist Explains How Men Can Fix It | AMA - Rena Malik, MD Podcast

Episode Overview

Theme:
In this AMA (Ask Me Anything) episode, board-certified urologist and pelvic surgeon Dr. Rena Malik answers real questions from listeners—particularly focusing on erectile dysfunction (ED), why treatments sometimes fail, and what realistic options remain for men when standard therapies aren't working. Dr. Malik also addresses a question about blood tests to diagnose menopause. The advice is clear, practical, and science-driven, aiming to arm listeners with evidence-based solutions and what to discuss with their own doctors.

Key Discussion Points & Insights

1. Chronic & Refractory Erectile Dysfunction in Older Men

Case Study:
A 70-year-old man with moderate to severe ED has unsuccessfully tried Viagra, pumps, shockwave therapy, and constriction rings (00:35).
Underlying Causes:
- Most common in older men due to diminished blood flow (01:02).
- Dr. Malik stresses the importance of addressing general health determinants: "Things that are good for your heart are good for your erection." (01:18)
Lifestyle Optimization:
- Check and optimize cholesterol, diabetes status, blood pressure (01:07).
- Exercise recommendation: “150 minutes of aerobic exercise every week, all those things are going to improve blood flow.” (01:19)
Medications Recap:
- Viagra, Cialis (Tadalafil), Sildenafil work well for many, especially with correct use and expectations (01:31).
- Vacuum erection devices (VEDs) require patience and correct ring sizing for greatest success. Dr. Malik notes, “Go slow, try to cycle it up slow…there is a learning curve, but they can work pretty well.” (01:45)
Shockwave Therapy:
- Effective mainly in mild to moderate ED, but less so in severe cases:
  “At some point, it’s not going to be as effective because the vessels have become so unhealthy.” (02:30)
- Not beneficial if ED is not blood-flow related (e.g. neurological or hormonal causes).
Hormonal & Medication Review:
- Always check testosterone and current medications to rule out other contributing factors (03:10).

2. Advanced Medical Options

Intracavernosal Injections:
- Next step after failed oral meds/other therapies: “Medications that you inject into the erectile tissue with a really, really tiny needle. It sounds super scary, but it is really not very painful.” (03:25)
- In-office dose-finding; risk of priapism (prolonged erection):
  “Everyone jokes that would be great. That’s actually not great, because after that point, you’re not having any blood flow move in or out of the penis…you can have irreversible damage.” (04:37)
- Many formulations and dose titration possible (05:20).
Regenerative & Experimental Therapies:
- PRP and stem cells: Insufficient evidence, not presently recommended (05:35).
- Botox Injections:
  - Dr. Malik offers this selectively: “We actually inject Botox into the erectile tissue…it causes the smooth muscle to relax. So when you have an erection, the first step is a smooth muscle needs to relax for blood to flow in.” (05:47)
  - Data:
    - 30% improvement in severe, 50% in moderate, 90% in mild ED in small studies (06:31)
  - “Because it’s very safe… and because of that data, I’ve offered it and I’ve seen my patients really do see a benefit.” (06:46)
Penile Implants:
- Ultimate option if all else fails:
  “If none of those things work, then you can talk about penile implants. We’ve talked about penile implants on the podcast before…” (07:10)

3. Diagnosing Menopause & Perimenopause

Listener Question: “Is there a blood test for menopause?” (07:28)
Clinical Diagnosis:
- Menopause = 12 months without a period.
- “People will say, obviously, ‘Oh, you should get a blood test to diagnose you.’ We know that once you stop menstruating, your estrogen and progesterone are going to plummet.” (07:34)
Why Blood Tests Are Misleading:
- Hormone levels in perimenopause “are basically a roller coaster”—results vary widely day-to-day and are not reliable for diagnosis (07:52).
- Both menopause and perimenopause are ultimately clinical diagnoses based on symptoms and history.
Blood Tests in Hormone Therapy:
- Might be used after starting hormone replacement therapy to monitor absorption, especially with patches or gels (08:45).

Notable Quotes & Memorable Moments

Dr. Malik on Lifestyle & ED:

“Things that are good for your heart are good for your erection.” (01:18)
On Vacuum Devices:

“People try to, you know, go really fast and it can be uncomfortable. And really there is a learning curve, but they can work pretty well.” (01:54)
On the Fear of Injections:

“It sounds super scary, but it is really not very painful. I’ve had patients actually get injections… they look up and say, ‘Oh, that’s it?’” (03:27)
On Priapism and Injection Risks:

“Everyone jokes that would be great. That’s actually not great, because after that point, you’re not having any blood flow move in or out of the penis…you can have irreversible damage.” (04:37)
On Experimental Therapies:

“I generally don’t find things like PRP or stem cells has robust data… still experimental, still not considered to be that useful in my mind.” (05:35)
Botox for ED:

“The reason I started offering it, even though there’s not a ton of evidence behind it, is, one, because it’s very safe… and two, because [the study] saw 30% improvement in severe… 50% in moderate, and 90% in mild ED.” (06:21)
On Menopause Diagnosis:

“The bottom line is, no, there is no blood test needed to diagnose menopause or perimenopause.” (08:10)

Timestamps for Important Segments

00:35: Listener question on refractory ED and previous failed therapies
01:02: Why ED happens in older men and foundational health checks
01:18: Heart health = erection health
03:25: Introduction to intracavernosal injections
04:37: Risks of priapism and safe dosing
05:35: PRP, stem cell, and Botox therapy for ED
06:31: Botox study data
07:10: When to consider penile implants
07:28: Is there a blood test for menopause?
08:10: The take-home on diagnosing menopause or perimenopause

Takeaways

If you have persistent ED despite “trying everything,” comprehensive health optimization and advanced therapies still exist—work with your specialist.
Injections and even Botox have a role for carefully selected men.
Penile implants are a definitive, last-resort option.
Menopause and perimenopause are diagnosed by symptoms, not blood tests. Hormone testing only plays a small role after starting therapy.

Dr. Rena Malik delivers compassionate, honest, evidence-based answers—reminding listeners: self-care is worth it.

Episode Overview

Key Discussion Points & Insights

1. Chronic & Refractory Erectile Dysfunction in Older Men

Case Study:
A 70-year-old man with moderate to severe ED has unsuccessfully tried Viagra, pumps, shockwave therapy, and constriction rings (00:35).
Underlying Causes:
- Most common in older men due to diminished blood flow (01:02).
- Dr. Malik stresses the importance of addressing general health determinants: "Things that are good for your heart are good for your erection." (01:18)
Lifestyle Optimization:
- Check and optimize cholesterol, diabetes status, blood pressure (01:07).
- Exercise recommendation: “150 minutes of aerobic exercise every week, all those things are going to improve blood flow.” (01:19)
Medications Recap:
- Viagra, Cialis (Tadalafil), Sildenafil work well for many, especially with correct use and expectations (01:31).
- Vacuum erection devices (VEDs) require patience and correct ring sizing for greatest success. Dr. Malik notes, “Go slow, try to cycle it up slow…there is a learning curve, but they can work pretty well.” (01:45)
Shockwave Therapy:
- Effective mainly in mild to moderate ED, but less so in severe cases:
  “At some point, it’s not going to be as effective because the vessels have become so unhealthy.” (02:30)
- Not beneficial if ED is not blood-flow related (e.g. neurological or hormonal causes).
Hormonal & Medication Review:
- Always check testosterone and current medications to rule out other contributing factors (03:10).

2. Advanced Medical Options

Intracavernosal Injections:
- Next step after failed oral meds/other therapies: “Medications that you inject into the erectile tissue with a really, really tiny needle. It sounds super scary, but it is really not very painful.” (03:25)
- In-office dose-finding; risk of priapism (prolonged erection):
  “Everyone jokes that would be great. That’s actually not great, because after that point, you’re not having any blood flow move in or out of the penis…you can have irreversible damage.” (04:37)
- Many formulations and dose titration possible (05:20).
Regenerative & Experimental Therapies:
- PRP and stem cells: Insufficient evidence, not presently recommended (05:35).
- Botox Injections:
  - Dr. Malik offers this selectively: “We actually inject Botox into the erectile tissue…it causes the smooth muscle to relax. So when you have an erection, the first step is a smooth muscle needs to relax for blood to flow in.” (05:47)
  - Data:
    - 30% improvement in severe, 50% in moderate, 90% in mild ED in small studies (06:31)
  - “Because it’s very safe… and because of that data, I’ve offered it and I’ve seen my patients really do see a benefit.” (06:46)
Penile Implants:
- Ultimate option if all else fails:
  “If none of those things work, then you can talk about penile implants. We’ve talked about penile implants on the podcast before…” (07:10)

3. Diagnosing Menopause & Perimenopause

Listener Question: “Is there a blood test for menopause?” (07:28)
Clinical Diagnosis:
- Menopause = 12 months without a period.
- “People will say, obviously, ‘Oh, you should get a blood test to diagnose you.’ We know that once you stop menstruating, your estrogen and progesterone are going to plummet.” (07:34)
Why Blood Tests Are Misleading:
- Hormone levels in perimenopause “are basically a roller coaster”—results vary widely day-to-day and are not reliable for diagnosis (07:52).
- Both menopause and perimenopause are ultimately clinical diagnoses based on symptoms and history.
Blood Tests in Hormone Therapy:
- Might be used after starting hormone replacement therapy to monitor absorption, especially with patches or gels (08:45).

Notable Quotes & Memorable Moments

Dr. Malik on Lifestyle & ED:

“Things that are good for your heart are good for your erection.” (01:18)
On Vacuum Devices:

“People try to, you know, go really fast and it can be uncomfortable. And really there is a learning curve, but they can work pretty well.” (01:54)
On the Fear of Injections:

“It sounds super scary, but it is really not very painful. I’ve had patients actually get injections… they look up and say, ‘Oh, that’s it?’” (03:27)
On Priapism and Injection Risks:

“Everyone jokes that would be great. That’s actually not great, because after that point, you’re not having any blood flow move in or out of the penis…you can have irreversible damage.” (04:37)
On Experimental Therapies:

“I generally don’t find things like PRP or stem cells has robust data… still experimental, still not considered to be that useful in my mind.” (05:35)
Botox for ED:

“The reason I started offering it, even though there’s not a ton of evidence behind it, is, one, because it’s very safe… and two, because [the study] saw 30% improvement in severe… 50% in moderate, and 90% in mild ED.” (06:21)
On Menopause Diagnosis:

“The bottom line is, no, there is no blood test needed to diagnose menopause or perimenopause.” (08:10)

Timestamps for Important Segments

00:35: Listener question on refractory ED and previous failed therapies
01:02: Why ED happens in older men and foundational health checks
01:18: Heart health = erection health
03:25: Introduction to intracavernosal injections
04:37: Risks of priapism and safe dosing
05:35: PRP, stem cell, and Botox therapy for ED
06:31: Botox study data
07:10: When to consider penile implants
07:28: Is there a blood test for menopause?
08:10: The take-home on diagnosing menopause or perimenopause

Takeaways

If you have persistent ED despite “trying everything,” comprehensive health optimization and advanced therapies still exist—work with your specialist.
Injections and even Botox have a role for carefully selected men.
Penile implants are a definitive, last-resort option.
Menopause and perimenopause are diagnosed by symptoms, not blood tests. Hormone testing only plays a small role after starting therapy.

Dr. Rena Malik delivers compassionate, honest, evidence-based answers—reminding listeners: self-care is worth it.

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Erectile Problems Getting Worse? Urologist Explains How Men Can Fix It | AMA

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Summary

Episode Overview

Key Discussion Points & Insights

1. Chronic & Refractory Erectile Dysfunction in Older Men

2. Advanced Medical Options

3. Diagnosing Menopause & Perimenopause

Notable Quotes & Memorable Moments

Timestamps for Important Segments

Takeaways

Summary

Episode Overview

Key Discussion Points & Insights

1. Chronic & Refractory Erectile Dysfunction in Older Men

2. Advanced Medical Options

3. Diagnosing Menopause & Perimenopause

Notable Quotes & Memorable Moments

Timestamps for Important Segments

Takeaways