Pathak: So if we are really thinking that there's a chronic condition like diabetes or high cholesterol or high blood pressure that needs to be managed, that clearly, fundamentally needs to be managed as the foundation of the treatment. Then also lifestyle factors. So really addressing smoking, addressing things like sleep and stress. Is there a role for nutrition, for physical activity in, in that baseline prescription as well that you're thinking about?

Winter: That's a great question. I mean, everything that improves your cardiovascular fitness is potentially going to improve the erections, right? If you have very profound scarring of the penile tissue, then maybe it's not gonna help. But people always ask, like, can I reverse my erectile dysfunction?

And on some level, there is data that if you're taking, let's say, a low dose of continual tadalafil, right, then that's a PD5 inhibitor. So people think of like the most common erectile dysfunction drugs. If you're taking a low dose of that continuously, it may actually help maintain penile health by improving blood flow. But that said, when people are like, “Hey Doc, can I reverse this?” I'm like, everything you can do to make your blood vessels healthier is going to set you up the best to potentially have a healthier penis that's working better on its own. And most of the drugs we're giving you are not. They're a temporary fix. They're gonna help you get that erection, perform, but they're not restoring your penis back to the penis you had when you were 21, which is what you want. We all know that's what you want, and because of that, yes, absolutely. If you can drink less alcohol, stop smoking, exercise, particularly cardiovascular exercise, all of these things are good for your penis.

Pathak: So then let's spend a little time talking about some of the symptomatic treatments that patients often ask for, whether that's pills, injections, devices, even surgery. Can you talk to us a little bit about what's in your toolbox there?

Winter: Absolutely. The mainstay of therapy that has level one evidence, that's the best study, are the PD5 inhibitors, and I love using them. They used to be extremely expensive. Now they are very inexpensive, even if your insurance doesn't cover it. You can get it, you know, with GoodRx. You can get it with the Mark Cuban pharmacy. They're generic. You can get, you know, half a year of them for like $10 basically. And, and they're great.

And you know, I, I was actually presenting at this internal medicine conference this last week and one of the things I highlighted in talking about sex-friendly general urology was just that there's observational studies, not clinical trials. So it, it doesn't improve causation, but there's observational studies showing that these categories of drugs, PD5 inhibitors, reduce something called MACE, which is like major adverse cardiovascular events, right? So, so on an observational level, those, those drugs for some reason seem to actually have beneficial cardiovascular health outcomes. So I'm just a huge fan of the, I'm a huge fan of these medications.

And oftentimes the patients have actually already tried it, but if they haven't, obviously we're gonna think about giving them that. A really easy one is just doing a low dose of tadalafil every day. That's very long-acting. They don't have to worry about like taking it before sex or have it interfering with their spontaneity. And because this often happens in men who are getting older, that is also an FDA-approved treatment for BPH symptoms. So, you know, difficulty like emptying the bladder. So it's kind of like a, you know, double whammy. And they're very happy to take it. So that is my go-to starting place.

There's also devices, you know, that pump the blood into the penis. I find patients may have a little less comfort with those, but you certainly, there are tons of options on the market. Just maybe ask your urologist which companies they recommend because there are products out there that are really high quality and products that are not. So, talk to somebody you trust. There are online stores run even by board-certified urologists where they sell penile erection devices or constriction rings. So that's another area.

I would also, as a side, and I didn't talk about this, when we think of these PD5 inhibitors, again, tadalafil, sildenafil, you're thinking the little blue pill, people often fear those because they think it's going to give them a spontaneous erection. That is not true. What those medications do, they amplify the signal that the brain is sending to the penis. Meaning if you are not sending the sexy signals from the brain to the penis, stimulating the penis, if you're not interested in sex, it's not going to generate an erection. It is amplifying that nitric oxide that we talked about before. It's amplifying that. If that signal is not coming to the penis in the first place, it's not doing anything. I always tell people, you're not gonna be doing your income taxes with an erection if you take it.

So, I think people have fear of that and it's not how it works. So that's number one. And number two, there's actually no real data that they cause something called priapism, which people are very scared of. So priapism is a painful erection that doesn't go down, right? And unfortunately, it has to say on the warning label that if they have an erection that lasts longer than four hours, talk to your doctor.

So one of the other main things I do is prescribe injectable medicines for erectile dysfunction. That you're probably really gonna be going to a men's health specialist or a urologist to do that. It's probably less so going to happen in the primary care setting. Those medications are medications that can cause priapism, so the erection that won't go down. And they are going to work regardless of interest in sex. So those are the medications where I say, if you inject this and start working on your income taxes, you are still going to have an erection.

So you wanna use them judiciously, but they can be extraordinarily effective when the pills are not working. So I am a big fan of them, and they can be used extremely safely. You just need to have them prescribed by somebody who knows what they're doing. So that's that.

And then there's a lot of other options, right? So there's surgery, there's penile prosthesis. So that's basically like an inner tube for the erection. That is FDA-approved. It's actually one of the first treatments for erectile dysfunction. You can find a urologist who does it, I'm sure, and it is covered by a number of insurance plans.

And then there's what we call more of the regenerative therapies. So the idea of like, how can we improve the tissue health directly? So there's some data that in men with moderate erectile dysfunction, using a low-intensity shockwave device can improve erections. So that's where you're going into an office for like a series of six sessions and they're putting this shockwave, it's non-invasive, and it can cause tissue regeneration. Less excellent data, but there is some data showing improvements if you use something called platelet-rich plasma. Again, that's not necessarily prime time. And then more experimental things are treatments like stem cell therapies, but those in the U.S. should be in the context of a clinical trial.

Pathak: I imagine that for a partner who is experiencing this along with the man who may have erectile dysfunction, this can also be, in a lot of ways, psychologically concerning for them as well. And so I'm curious about what that looks like in practice for you. Are you seeing couples coming in together? How do you counsel someone to talk to their partner about their erectile dysfunction, especially if it is impacting the relationship, impacting the self-esteem of their partner?

Winter: I love it when couples come to the office together because then they learn about all of this together, and I think it takes a tremendous load off relationships. There are very few other areas of health where a relationship partner can take the outcome so personally, right? If your husband broke his leg and wasn't able to walk without crutches, you wouldn't take it personally.

I can say an extreme example. I've seen situations where somebody comes with their partner into my office for erectile dysfunction that happened at the time of prostate cancer surgery. So we know this is a very, very physical thing, right? It is very common that somebody can have injury to the nerves that go to the penis at the time of their prostate cancer surgery. There are many people who have prostate cancer surgery where that doesn't happen, but it can happen.

So if somebody goes and has prostate cancer surgery and they have a sudden onset of erectile dysfunction after that, and they come in with their spouse or their partner, and the partner breaks down in tears in my office and says they don't love me anymore, they won't have sex with me, and I'm like, again, this is, this is why the education and the discussions are so important, and this is why this is a domain of healthcare. Because when I sit down and explain to them, this is the anatomy, this is the nerves that may have been affected by the surgery, it has absolutely nothing to do with you. And I know he looks at you and tells you that, but you still have the spirit. You need to hear it from somebody else, right? You need to hear it from somebody else.

And I'm so glad you came along to this appointment, and I'm so glad you were vulnerable and you expressed the way you felt about this, because I have a tremendous role that I can do in helping them with their relationship, right? And I'm not a therapist, I'm not a relationship counselor, but me providing that medical information can take a tremendous burden off of people navigating these concerns.

Pathak: I'd love to, in our last few minutes together, just hand it over to you for any final messages you have for anyone listening who's struggling or is part of a couple, a relationship where the partner is struggling with erectile dysfunction. What would be your advice for navigating this experience together?

Winter: I think number one, be open about it. If you say, “Hey, I've noticed that I'm having trouble with my erections and it's not you,” right? Like, mention that. Be open about it. Please seek out a trusted healthcare provider. That would be amazing, and involve your spouse in it, right? These are all important tools.

I'd say also, and one of the core themes that come up in my care of patients, is people wanting so desperately to have a good erection because they have not learned or they've lost the ability to see other ways of intimacy. And keeping that in mind is also important. And what do I mean by that, right? I always say to patients, like when you were a teenager before you ever had sex for the first time, you caressed each other and you hugged each other and you kissed for a long time, and you were excited about that.

And while you go through this process, keeping in mind what the true definition of intimacy is, using that to, to reinvigorate your intimacy with your partner is important. Like I, of course, I wanna help you get your erection. That said, I have had patients that chose to not pursue any treatment and they're having the best sex life of their entire life because they were able to focus on their partner's pleasure. They were able to do more erotic touch. They were able to do mutual masturbation, right? And so they've reframed that. And I think providing that reframing of what this means, like the loss of the erection is not the loss of intimacy, can really be fundamental.

Pathak: Beautifully said, and I wanna thank you so much for your time. This has been such important information and you really helped to lay it out step by step for us. So really, really appreciate the conversation.

Winter: Thank you so much for having me.

Pathak: I'd like to share my three key takeaways from our discussion. First, erectile dysfunction is not just a sexual health issue. It's often your body's first warning sign of potential cardiovascular disease, diabetes, or high blood pressure. That's why it's so important to bring this topic up with your healthcare provider. It's not only a quality of life issue, it's also an indicator of overall health.

Second, there are treatment options available, probably many more than you realize. Don't let fear, stigma, or misinformation prevent you from discussing these options with your healthcare provider.

And finally, erectile dysfunction does not have to mean a loss of intimacy. It is important to bring your partner into the conversation. Explore what intimacy means beyond penetration and work with a trusted clinician. A certified sex therapist can also help open doors that may feel completely closed right now.

Erectile dysfunction does not have to mean the end of a fulfilling, connected sex life. You're not alone in this, and help is available.

To find out more information about Dr. Winter, how to address erectile dysfunction, and other information about sexual health, please make sure to check out our show notes. Thank you so much for listening. Please take a moment to follow, rate, and review this podcast on your favorite listening platform.

If you'd like to send me an email about topics you are interested in or questions for future guests, please send me a note at [email protected]. This is Dr. Neha Pathak for the WebMD Health Discover Podcast.