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Isn't it Time You Talked to Your Doctor About Erectile Dysfunction?

NEW YORK (Feb 1, 2012)

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Some health problems can be uncomfortable to bring up – even with your family doctor – and for many men erectile and sexual dysfunction are probably close to the top of the list. But because there are now many treatments for erectile dysfunction (E.D.), and because E.D. may be a sign of a serious underlying problem, men who have concerns about their sexual function should discuss them with their primary care physician.

Primary care doctors such as internist Barron H. Lerner, M.D., Ph.D. at NewYork-Presbyterian/Columbia University Medical Center make sure to provide a forum during visits where patients can easily discuss sexual problems. "I try to normalize the situation by including questions about E.D. whenever I see a new patient," he said. "Or at the end of a visit with a longstanding patient I'll say something like, 'We have a little extra time today and something we haven't spoken about in a while is your sex life or your ability to get an erection. Are there any problems in that area you want to talk about?'"

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If your doctor is not as forthcoming as Dr. Lerner, you should be bold enough to express your concern about E.D. when your doctor asks how you are doing, he advises. "It's something doctors expect to hear now," he said. "Patients can mention at the beginning of the appointment that there is a new problem they want to discuss in order to lay the groundwork for the discussion," he said. Most doctors and patients have become more comfortable discussing E.D. because of the highly visible advertising campaigns for Viagra, Cialis, and Levitra. "As with anything that is getting more attention, E.D. is now less stigmatized and easier to talk about," Dr. Lerner added.

One of the biggest barriers to talking about E.D. is time, Dr. Lerner said. "If I have 15 minutes with a patient who has 25 serious medical problems, things like chest pain and high cholesterol, and I can barely get through that list, their sexual problems may go on the back burner." All the more reason for the patient to bring up the issue, he said.

Barron H. Lerner, M.D., Ph.D.
Barron H. Lerner, M.D.,

If there is no reason to suspect that a patient's E.D. is linked to a serious issue, Dr. Lerner will prescribe one of the oral medications now available for E.D. "I talk to patients about the differences between the pills, that some are short-acting and others long-acting, and the potential side effects, including flushing and headaches. I also warn them to stop the pill immediately if they get chest pain. The next time I see them I follow up to see how it's going." If the medication didn't help out, he might increase the dose or prescribe a different medication. Some patients want to see an expert at that point, Dr. Lerner said, and he refers them to a sexual medicine specialist.

Darius Paduch, M.D., Ph.D., a urologist and sexual medicine specialist at NewYork-Presbyterian/Weill Cornell Medical Center, says that the general outlook on E.D. has changed in his field. "Nowadays, we take a much more holistic approach to sexual dysfunction. We are concerned not only about whether the patient can get an erection but also about his sex drive and what happens during sexual activity. Is the patient able to ejaculate? Does he have problems with orgasm?"

Darius Paduch, M.D., Ph.D.
Darius Paduch, M.D., Ph.D.

Among men in their mid-60s and older E.D. is not uncommon and is related to normal aging processes, and is often treated by a patient's primary care doctor. "But when younger men develop E.D. – guys in their 20s to 50s – we strongly recommend that they are evaluated by a specialist," Dr. Paduch said, because E.D. in this age group can indicate low testosterone, early diabetes, accelerated atherosclerosis, or even a pituitary tumor or multiple sclerosis.

One of the most common risk factors for E.D. among men of all ages is diabetes, said Dr. Paduch, and "in men with longstanding diabetes the incidence of E.D. is 47 to 50 percent." Elevated cholesterol and atherosclerosis (hardening of the arteries) also cause problems with blood flow through the arteries, and can result in a form of erectile dysfunction called vascular E.D.

Some simple lifestyle changes that will improve patients' overall health can also have a big effect on sexual function, Dr. Paduch said. "If patients smoke they should stop smoking and if they have high cholesterol they should lower their cholesterol with exercise. Those are things that are known to improve sexual function."

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Oral medications for E.D. do not work for every patient, and Dr. Paduch said a vacuum constriction device might be helpful for those who do not respond to the pills. These devices work by creating negative pressure around the penis and pulling blood into it, creating an erection. Another approach is injection therapy, in which patients inject a medication that dilates the arteries directly into the penis. Over time injection therapy can increase blood flow through the penis and improve the quality of erection so patients can go back to oral medications, Dr. Paduch said. Men whose E.D. does not respond to these treatments may have surgery to insert a penile prosthesis, a special pump that inflates the shaft of the penis.

Sexual medicine specialists have gotten much better at diagnosing sexual dysfunction and E.D., Dr. Paduch said, and have more specific forms of therapy. "There are many treatment options right now. No patient should ever be ashamed to discuss E.D. with his doctor and ask for help."

Contributing faculty for this article:

Darius Paduch, M.D., Ph.D., is an Assistant Attending Urologist at NewYork-Presbyterian/Weill Cornell Medical Center and an Assistant Professor of Urology and Reproductive Medicine at Weill Cornell Medical College.

Barron H. Lerner, M.D., Ph.D., is an Associate Attending Physician at NewYork-Presbyterian/Columbia University Medical Center and the Angelica Berrie-Gold Foundation Associate Professor of Medicine and Public Health at Columbia University College of Physicians and Surgeons.

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