Tip:
Highlight text to annotate it
X
Alright, well welcome. Thanks for um, ah being here, spending some time to come learn about
erectile dysfunction and about the different treatment options that are... that are available.
So, we'll kinda run through the slide deck, "What is ED?"
So ED, this is... this definition ah, was first came from the National Institutes of
Health and basically it's the inability to keep and maintain an *** that's normal
for *** intercourse. So for the patient to be satisfied having intercourse. Um, it's
something that is very, very common. It's estimated that about 30 million American men
have some type of ED. And it's a spectrum, it's not all or none. Meaning, you can have
mild, moderate to severe. And so it's a spectrum of a condition. Um, and I think that that's
important to understand.
When we look at reasons for problems with erectile dysfunction, there are lots of reasons
but the bottom line, sort of the take home message is that, typically there's a disease
state, or what we call organic, as opposed to, in the mind. A lot of guys wanna think
that, okay, gosh it's my mind, that is the problem, that I can't get erections. But generally
it's a reason. It's a physical cause. And so you can see on here, vascular... Um...
Getting an *** is normal blood flow, so anything that's going to cause vascular
disease, um heart disease, ah... high blood pressure, that kind of stuff, can affect it.
Ah diabetes... Diabetes is very common here in San Antonio. And diabetes is a disease
of both blood vessels and nerves. And so that can cause trouble.
And then medicines and obviously medicines can influence it a little bit. But I always
tell patients... You know a lot of patients are... they say, well, you know I was fine,
and then they put me on some medicine for my high blood pressure and then I started
to have trouble with erections. Ah, it's important to be treated for high blood pressure, 'cause
as I tell patients, I mean if you have a stroke, and it doesn't matter if you have an ***
or not. And so I think it's important to take the medicines that your, your regular doctor
has given you to treat the condition. And so that's important.
So we look at restoration or return of erectile function... Ah, there are a lot of different
options for patients that are out there.
And so I think everybody is familiar with the pills or oral therapy. *** came out
in 1998, and so it's amazing what it's done. And it's also amazing what their lawyers have
done because the patent is still protected, so there is no generic ***. None of these
medicines are generic, and so they're expensive.
I disagree with this slide a little bit. Ah, the oral medicines work in about 65% of patients
as opposed to what they say on here, 70, 80%. And really a lot of it just depends on how
bad the blood vessel disease is. So if somebody has diabetes and high blood pressure, heart
disease, treated for high cholesterol, the chances of the medicine, falls off. Maybe
it only works about 20 or 30%. If someone has been treated for prostate cancer, maybe
that... you know, again that number is less. And so it depends. There's not sort of one,
uniform percentage of patients that respond to the medicines. A lot of it just depends
on, on what medical condition that they have.
So the way that these medicines work, is that the patient takes them. There are some instructions
and also some precautions. Ah, the patient needs to have stimulation. So you can't take
it and then just sort of wait around and hope that an *** comes up. You actually have
to be stimulated. Ah you take it typically an hour or two before anticipated *** activity.
And then there's a window where the medicines work. So you have to plan. Ah Cialis, that
window is a little bit longer. Um, but in general, you have to plan when you want to
use it. Never take more than once a day. And again, some of the medicines can be affected
by, by food, and so, particularly *** and Levitra, food can affect it.
What are the side effects of the medicines? Well they're all fairly common, but they're
short-lived. And so you can have some headache, facial flushing, ah maybe a stuffy nose, a
little nasal congestion, that kind of stuff. The only contraindication, meaning, who can't
take this medicines? If the individual is on nitrates. And so nitrates is a heart medicine
and so... Really it's safe for any other medicine. Blood pressure medicines, beta blockers, diabetes
medicines, all that stuff and so the medicines... And it's been studied, because ***'s been
out since 1998, it's really been studied in every group and with all sorts of medicines.
Some precautions, alpha blockers, those are medicines used to help guys urinate a little
bit better. So patients want to be on stable prostate medicine. Um, and then again, if
there is some question about the heart condition of the patient and the patient needs to talks
to their... their cardiologist and just sort of see if they're okay to be sexually active.
And it's just like, you know, are they okay to exercise? So it's the same type of question.
And so these are the things, and that's why it's important that the individual, um, ah,
ah see their physician, um to get prescribed the medicine so they can be counseled on how
to take it correctly. And then also given the proper instructions, and so that's important.
So, what else is out there? Um, and then let me say, the pills average $20, $25 for one
pill. Um, and so, just as your baseline.
So what else is out there? Well the other some other options are the vacuum ***
device. Ah, one of my patients, his wife refers to this as the mood killer. It's a very cumbersome,
bulky, ah, device. And you can see on here, um, there's a vacuum, it's a cylinder that
goes over the ***. And then the vacuum draws blood into the ***, and then when the ***
is full, there's a little constrictive band that's placed around the ***. And so, um,
it does take some time to kinda set up and you... you can see the side effects listed
here. It can cause some bruising, maybe some discomfort. Um, the *** also isn't warm.
And so some of the women don't like that and so... Ah, but nonetheless, it's out there
and...
You know I put all these things on here, not to tell you which one is better. But just
so you know there are choices. So, for some people, the vacuum *** device is... they
like it. Well that's great. I mean it doesn't matter to me. And some people the pills work
and they like it. Well that's great too. But I think it's important to know what's out
there. And um, just so you're educated.
Another, ah, um treatment option is a, is a, a suppository. And basically what that
is, it's a little pellet, it's about the size of a grain of rice that goes inside the urine
channel. And MUSE stands for um, this Medicated Urethral Suppository for ***. But another
patient... You know I learn all these things from patients. MUSE doesn't work that well
and he says that MUSE stands for, "Maybe we'll see an ***." Um, it only works in about
40% of patients. And it's expensive, it's about $30 for one little pellet, one treatment.
So no needles are needed. You get an *** in 10-15 minutes. You got to refrigerate it.
But again, um, it's expensive and doesn't have a great efficacy rate, um, only in about
30 or 40% of patients.
These are some of the side effects. But really the big one is probably urethral burning and
irritation. So just like if you've gotten soap inside your urethra, the urine channel,
that's maybe that's what it feels like. Ah and so ah... Nonetheless, so for some people,
MUSE is what they prefer. Ah, we don't write a lot of prescriptions for MUSE, to be quite
honest. There are some patients that have tried it and like it. And so I'll refill it.
But as far as you know, starting out with therapy, um, it's really not a great option
for patients.
Also we have here, injection therapy, and... and um, so Caverject as listed on here is
a widely used agent. There's other types of injection therapy that we use, ah there's
stuff that we get from a compounding pharmacy that we teach patients. And so, you know,
when you see some of the advertisements in the newspaper, the Men's Solution and that
kind of stuff, they guarantee an ***, they pretty much put everybody on injection
therapy. So they're not going to try different treatment options. They're not going to try...
okay, let's try the pills. And if that doesn't work, then, you know, we can try injections.
And if that doesn't work, then we can try something else. There there's just basically
one answer. And so... because they can sell that stuff to you. And so they actually...
I've heard that it's actually pretty expensive for a vial.
The injection therapy has been out... the concept has been out since 1982 or so. And
we have lots of patients on injection therapy. And there are patients that fail oral medicine,
and we'll go ahead and put them on injection therapy. And so, we do the teaching in our
office. It's actually very cost effective. Now we get our injection medicine made generally
at one of the local compounding pharmacies, so it's really only about 2-$3 per ***.
So it's just getting over the hurdle of putting a needle into the ***. Guys have to get
over.
But um, the efficacy, effectiveness of injection, may be about 80%. Remember where I said pills
were about 65%. MUSE is about 40%. So that kind of gives you an idea of... of... of where
everything kinda fits in. But you can see on here I mean you got to put a needle in.
You've got to inject it right into the erectile tissue. You get an ***. It's about 10
minutes to get an ***.
These are some of the side effects, you can get some scar tissue, ah, it can be painful.
If guys have been treated for prostate cancer, they always complain of some discomfort when
they use injection therapy. So ah, so there are some issues with it. But all treatments
are going to have some side effects. I mean that's just the way it is.
So now *** implants. So, what are *** implants? And um, I have a great slide that's
kind of pokes fun at it, but we're not allowed to use it anymore. So anyway, *** implants
have actually been out for a long time, so since 1972. And ah, it was actually invented
at Baylor, one of my professors, Brantley Scott, was the guy that came up with this.
Which is really pretty amazing. He also came up with the artificial sphincter, um. And
he was originally from San Antonio, I mean there's a lot of Texas roots to this. So,
so the device has been out for over 40 years, which is amazing. And ah and um, so this slide
needs to updated.
Um, it is an operation, ah, but it's... the surgery has evolved. So when I was a resident
and learned how to do the surgery, it was a 2-3 hour operation. You know for a first
time patient, patients were in the hospital for 4, 5 days. And it was a big deal. Complications
were greater. Now, it's an outpatient operation. So today I did one artificial urinary sphincter
and then three *** implants and so... On the *** patients, meaning, who have not
had surgery before, it's 30 minutes, they go home the same day. And so big difference
from... from years ago.
Excellent patient, partner satisfaction... Lots of studies we've done, a bunch of studies
ourselves, and um, it does demonstrate, ah, that.
These are ah, when you look at ah, patient satisfaction ah, now this is actually a two-piece
device, but again, at the end of the day, it's the same concept. Patients and partners
are happy with this and you know, there's a lot of positives to it. Mr. King will get
up here and kind of give you his feeling about it but, you know the spontaneity of it. Um,
and again, they're fairly durable devices.
Now some people think that there's something hanging out the body. That people can tell
you have an implant inside you. That's quite the contrary. I mean nobody knows, um, you
can't tell. I mean, even looking at somebody, even when it's deflated, with the type of
device I tend to put in. If the individual has good use of their hands, called the inflatable
device. And so that's a device where there's a pump in the ***.
And on here, you know, just kind of backing up, let me just go over the diagram. There's
a little reservoir here that holds sterile saline. Um, inside the ***, the ***
chamber, or the cylinder, and then down in the ***, between the testicles is the
pump. So everything is underneath the skin. There's a little incision, maybe about an
inch or so, and everything is put in through that.
So the device is, think of hydraulics, it's filled with water and that's essentially how
it works, ah with the device. And so as long as the individual has good use of their hands,
they're able to get the inflatable device. And when they want to use it, they inflate
it, it provides good rigidity. They can leave it up as long as they want. When they're done
they let it down. You can use it, you know, five times a day. And there's no limit, once
the patient has healed up for this. And then again, as I said, when it's deflated, the
cylinders are soft, it looks soft and you can hardly tell that anybody has anything
inside of them.
And there's different types of cylinders, and everyone asks, well, you know, how do
you measure? And this and that... Well everyone has a different sized *** of course, and
so we measure and put in what's appropriate for the individual. And um, so that's how
that... that works. We keep all this stuff in the hospital so we have plenty of, ah,
choices for patients.
So this is a long-term solution. So these devices, as I tell patients, they're meant
to last 15-20 years, when we put them in. Um, ah the companies that make them they do
provide the patient with a warranty, generally for the lifetime of the patient. And I always
joke that it's just for parts, it's not for labor, so... Um, but you can use it anytime
you want. Spontaneous, ah, again... Um, and good patient satisfaction. It doesn't affect
*** or ***, really has no... no role with that. That's separate.
So risks. Again, everything has risks. Just like the shots have risks, the pills have
risks, everything has risks. Um, so it's important thing to understand. Probably the biggest
thing that people are afraid of, infection. And so you know, I think now days, some of
the enhancements with the device they're coated with antibiotics. I think that was probably
the best thing. That's been, I guess about 10 years. And that's really deceased the infection
rate. So in a non-diabetic, the infection rate is less than 1%, which is I think, amazing.
I mean that's less than hips and knees that the orthopedic physicians put in. So I think
that right there, is fairly amazing.
Um, it does, as it says on here, will make natural and spontaneous erections impossible.
But you know patients always they always question, well if it doesn't work, can I go back to
what I had? And I tell them, I mean what did you have before? I mean the guys that are
getting implants have ED. Alright, so we're not putting implants in patients that, you
know they take *** and it works great or they're happy on shots. I mean, they have
erectile dysfunction, and generally they don't respond to any other treatment. So they're
looking to be treated. And so that's why we put it in.
Um, you can get some shortening with the device. A lot of it just depends on... again everyone's
*** is different. How elastic or stretchable the *** is. Ah some patients will complain
of some loss of length, some don't. And all that stuff is determined by physical exam.
And there are things that we do before surgery, to help stretch up the ***, um, if that's
a big concern of patients. And again, this is where seeing somebody with some experience
in this um, ah process can help you to get good satisfaction, um.
Mechanical failures we talked about, and then pain. But again this goes back to... um, and
the risks have to be put on here. I think it's important.
If you look at patient satisfaction, in excess of 90, 95% and that's been over the years.
And so that's not anything that's new that just kind of popped up. And that's... various
studies all over the U.S. and outside of the country, um, that patients like it. So certainly
if something had all these horrible risks, we wouldn't still be putting in the implants.
And so ah, that's a possible thing, ah.
Is it covered by insurance or Medicare? It actually is. Medicare covers it. At least
for now, I joke. And ah, it is covered by Medicare, TriCare, really most insurances
cover it. It's rare that insurances don't. Um, for those that are self-pay, it's expensive
so, you know, fifteen, eighteen thousand dollars. And I do have some patients that... pay. Um,
but in general, most of the patients, the majority, the overwhelming majority of patients,
um their insurance covers it. Their Medicare and what have you, cover it. So it is covered
by insurance, and if here is a problem with the device, um, again, um, insurance will
cover for it to be fixed, and corrected, and this and that.
Ah, obviously the company doesn't guarantee insurance coverage and that's something that
the practice does. We have people, that's all they do, they figure out authorization
and everything else and, counsel the patient on what their piece, if they decide to get
an implant, is gonna be. You know, what their component is.
So not every urologist is a prosthetic urologist. Um, ah, and you know, as we said, I mean,
you know I've been doing prosthetic urology, really since I got out of training so, now
we're coming up on 20 years, which is sort of a scary number. But, ah, I've been fortunate
enough to do it. I really like it. And because I really like it and I've done a lot, I've
gotten pretty accomplished at it and so... And I think it's important to get good outcomes,
to see somebody that's experienced in it. Because, you know, there are little nuances,
just with any surgery. Um, I don't do cancer robotic surgery. We have people here that
do that stuff and... and ah. Or we have people that take out kidneys. I mean again, fortunately
in our group we have all these specialists that can concentrate and focus. And so today,
like I said, I mean I did four prosthetic cases. That' a lot of cases, when you ask
the AMS people... I mean that's, and that happens every week. Um, Tuesday is my day.
And so we stay fairly busy. And so it's important to seek somebody with some experience in this
and ah, um to get a good result, I think that that's key.
So again, erectile dysfunction is very common. A lot of great treatment options. *** implant
is a solution and especially if you're nonresponsive to the other therapies. But get the partner
involved, no question about it. And, and feel free... We just opened up our men's health
and wellness clinic. It's just at the end of the parking lot, so I'm very excited about
that. So, it's an environment for men, um... Obviously the wives can come with their husband.
But ah... But you know the way that the décor is set up and once the patients get in the
back, there are just guys taking care of them, so... it's a sensitive subject, no question
about it, and so we try and make the environment, um geared towards guys where they can feel
comfortable talking to us. The people I work with, my team, um, they've been with me...
Chris now, a number of years and so ah... does a great job and so, I think that that's
really part of it as well. I mean the feedback we get from patients.