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Rena Malik, MD Podcast
Erectile Problems Getting Worse? Urologist Explains How Men Can Fix It | AMA
00:11:17
In this episode of the Rena Malik MD Podcast, Dr. Malik answers real questions from her community — from what to do when nothing works for erectile dysfunction to whether a blood test can truly diagnose menopause. Discover the latest evidence-based treatments, why lifestyle still matters most, and what options remain when everything else fails. Watch now for clear, practical answers to your sexual health questions.
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- [00:00]
A
Welcome back to The Rename Malik, M.D. podcast, your source for evidence based information about your sexual health and more. I'm your host, Dr. Rena Malik, urologist and pelvic surgeon. And today we are going to be doing our Ask Me Anything segment. This is a segment where we get questions from you guys, our members, and we answer them once a month. And we share the first half of this podcast on the platform. If you want to get the full length, make sure to sign up for the membership@renamelic.supercast.com there we give you an opportunity to ask questions to get early access to all our podcasts as well as transcripts for those podcasts. Without further ado, let's get right into it.
- [00:36]
B
All right, first question. It's quite long. It's from one of our members as well. He's a 70 year old gentleman, intermediate to high ed. I'm not sure what that is, but.
- [00:46]
A
So let's say moderate to severe ed.
- [00:48]
B
Moderate to severe, okay. Has tried Viagra, has tried pumps, has tried shockwave, has tried rings. You know, he sounds like he's tried basically everything, everything under the sun. So he's elderly gentleman, 70s. What's left for him?
- [01:03]
A
Yeah, well, so let's just talk about ED in general. We talked about it briefly earlier in the podcast, but erectile dysfunction can happen for a variety of reasons. Most often, especially in older guys, is due to blood flow issues. So when I see a guy in my clinic with erectile dysfunction, we make sure that we're assessing their cholesterol, we're making sure they're not diabetic or we're managing, we're seeing what their sugars are, we're assessing their blood pressure, so we're making sure those things are optimized. One, I would say to this, this gentleman, you know, make sure you're fixing those issues. So things that are good for your heart are good for your erection. So make sure you're optimizing your diet, you're optimizing your exercise, 150 minutes of aerobic exercise every week, all those things are going to improve blood flow. Now, in terms of treatment options for ed, what can you do? So you can start by, you know, the things he's tried. Medications like Viagra, Cialis or Tadalafil, Sildenafil are the most commonly prescribed medications. They can work very, very, very well. I've talked about them ad nauseam on this channel and on this podcast and so you can certainly learn more about them. But they do work quite well. There's Also vacuum erection devices, which he alluded to, which I've also made a video on my YouTube channel about. But essentially these are devices that create a vacuum and force an erection. And then you use a constriction band at the base of the penis to maintain an erection. Now, most times these don't work when you can't find the right size ring or the ring is uncomfortable, it has to be so tight that it's uncomfort. And so usually they will work. If you could figure out the size of the ring you need. But I tell people go slow, try to cycle it up slow. 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. Now, Shockwave is an option that he mentioned he's tried. Shockwave is really good for mild to moderate ed. He sounds like he has moderate to severe ed, in which case Shockwave may or may not be helpful. What Shockwave does is it applies sound waves to the penis and which then creates new blood vessels, essentially microtraumas. Then your body sends growth factors into the penis to create new blood vessels. And so that sounds great. We're regenerating or calling regenerative therapy for the penis. We're trying to create more blood vessels so there's more blood flow. But again, I think at some point it's not going to be as effective because the vessels have become so poorly, so, so unhealthy. And also if you don't have a vascular etiology, meaning it's not because of blood flow, but maybe it's because of hormonal issues or, or nerve issues, it's not going to be helpful. Those are the things that he's tried. Now I would also obviously check your hormones, check your testosterone. I would also check your medications to make sure that there is no other issues going on, to make sure we can optimize those as well. Now, what else is there is really the question here, what else can you do if you've tried all those things and nothing's working? The next thing that you can try pharmacologically is to do intracaver nosal injections. Now these are medications that you inject into the erectile tiss. It's with a really, really tiny little. It sounds super scary, but it is really not very painful. I've had patients actually get injections. We do them in the office. So they get a test before they do it at home and they look up and say, oh, that's it. Like it's so small that they really. It's not a huge issue. So it's more of getting over that fear. We're injecting medications that increase blood flow into the penis, right locally into the tissues. Now, these are very effective.
- [04:25]
B
So intracavernosal means in the. In the penis, not like a shot in the arm.
- [04:29]
A
In the erectile tissue.
- [04:30]
B
In the erectile tissue.
- [04:32]
A
Okay? Yeah. And so we're. So we're injecting right in there. And these work pretty quickly, so within about 10 minutes, you see an erection. The beauty of these medications are that once you find the dose that works for you, it works very well. The issue is getting to that point. So we don't want to overshoot. Like, we don't want to give you the highest dose of this medication, because then you can get what's called a priapism or an erection that lasts longer than four hours. Now, 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. And that can then over time, after about four to six hours, cause scarring of the penile tissue, because now there's no blood flow. And then you can have irreversible damage. And so if that happens to you, come to the emergency room immediately so we can get that old blood removed from the penis. So we usually start with low doses. We say start with one dose, and if that doesn't work, you can go up the next time. Not the same day, but the next time you try, you can go up to a higher dose until we find your dose. And the beauty of these medications is we have so many different formulations, and we have. Have lower doses and we have higher doses. So you can really experiment to find the right dose for you. Now, in terms of other options, there are some other things that have been studied for, like regenerative options for. As well as sort of experimental things. I generally don't find things like PRP or stem cells has robust data yet to show that it benefits men with erectile dysfunction. So I would say at this point, still experimental, still not considered to be that useful in my mind. There's one other experimental that I do offer, and that's called Botox injection. So we actually inject Botox into the erectile tissue, so again, into the penis. And the way this works is causing the smooth muscle of the penis to relax. So when you have an erection, the first step is a smooth muscle needs to relax for blood to flow in. And so it makes that process easier. And the reason I started offering it, even though there's not a ton of evidence behind it, is, one, because it's very safe, there's really very low risk with this, and two, because they did this study, they did the studies for this on guys who had really severe erectile dysfunction, meaning that they were about to have surgery, like an implant for their erectile dysfunction, and they did the Botox, and 30% of them had an improvement. Now, usually you'll see, like, no improvement in these guys with severe ED because they're at the point where nothing is going to help. And then they saw 50% improvement in moderate and 90% improvement in mild ED. So ultimately, I thought, because of that data, I've offered it and I've seen my patients really do some see a benefit with it. And so, yeah, I think those are the big things that I would say are, you know, have some evidence behind them, are helpful, and can really be helpful. If none of those things work, then you can talk about penile implants. We've talked about penile implants on the podcast before. We've also made videos on our YouTube channel. So check those out if you want to learn more about that.
- [07:29]
B
Is there a blood test for menopause?
- [07:32]
A
Yeah. So, great question. So what happens during menopause? Right. So during menopause, it's actually a clinical diagnosis. Menopause is the absence of having a period for 12 months. So if you haven't had a period for 12 months, you are officially in menopause. 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. You are going to have significantly lower numbers of estrogen, progesterone. Now, during perimenopause, there's a whole industry behind getting your blood tested. But ultimately, if I test your blood today and I test it three days later, the numbers are going to be dramatically different because perimenopause is basically what we call a roller coaster. And so your blood levels, one day your estrogen will be high, your progesterone will be low. Another day your estrogen will be low, your progesterone will be stable. It's never really sort of predictive. Now, you can check it on the third day of your cycle, which might give you some information. But ultimately, I tell people perimenopause is also a clinical diagnosis. We talk to you about your symptoms, we discuss what is going on with you. So we can sort of address those and decide if hormone replacement therapy is a good option for you. Even if you are in perimenopause, you can be considered for hormone replacement therapy and the same thing obviously, during menopause. Now there's a whole host of risks and benefits to discuss, and we need to take your individual medical history into context. And there's several different options for hormone replacement. So ultimately deciding between those is a longer discussion that you should have with your doctor. But the bottom line is no there is no blood test needed to diagnose menopause or perimenopause. Now, in some cases, you can check levels after starting hormone replacement just to see if you are absorbing the medications appropriately, because some of the transdermal pre operations, meaning the patches and the gels, don't get absorbed as well from some people because their skin just doesn't absorb as well as others. Thank you guys so much for joining us for this episode of the Ask Me Anything podcast. If you guys like this and want to check out the rest of the episode, make sure to sign up for our membership@supercast renamelic.com where you get access to new podcasts early each and every week, as well as transcripts. The ability to ask me anything and to be part of our community. And as always, I'm gonna take care of yourself because you're worth it.