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Erectile Dysfunction Radio Podcast

Dr. Melissa Mendez joins us to discuss how erectile dysfunction is commonly diagnosed. Dr. Mendez is a fellowship-trained urologist with Chesapeake Urology in Maryland. She was trained at one of the top programs in the United States in sexual dysfunction, genital reconstructive surgery, andrology and male infertility. Part of her clinical work includes treating men with erectile dysfunction.

The Erectile Dysfunction Radio Podcast is dedicated to educating and empowering men to address erectile dysfunction, improve confidence, and enhance the satisfaction in their relationships. This podcast is hosted by certified sex therapist, Mark Goldberg, LCMFT, CST.

Transcript of Episode 24 – How Erectile Dysfunction is Diagnosed with Dr. Melissa Mendez

Mark Goldberg: Welcome to another episode of the erectile dysfunction radio podcast. Today we are joined by Dr. Melissa Mendez. Dr. Mendez is a urologist with Chesapeake Urology, she has completed a fellowship in sexual dysfunction, among other things in the categories that are common in urology practice. We are really glad to have you join us.

Dr. Mendez: Thanks so much for the opportunity.

Mark Goldberg: Today we’re going to be discussing diagnostics when it comes to erectile dysfunction. I know a lot of men think that erectile dysfunction is a very binary process, either things are working or they’re not.

The truth is that in actuality, there’s really a lot of complexity that can be involved in the erection process . Can you give us an overview of the erection process and where problems can arise?

Dr. Mendez: Absolutely, so as you said, this is a complex process, but I’m going to try and break it down into three main thought categories. Erections themselves are based on the inflow coming from the arteries and then the prevention of the blood returning to the body from the penis, which would come back to the body through the veins.

So if you think of the erectile bodies, similar to a kitchen sponge, when you get the sponge wet, or in this case, fills with blood in the penis, it expands, it enlarges and engorges. This causes a compression of the veins which sit on the outside of these erectile bodies, which then get compressed and sealed off when the penis becomes firm, rigid and erect.

This process of sealing off the veins with the compression helps keep the blood in the penis because now it cannot flow back to the body through these means because they’re compressed.

Thus, the erection is maintained, so problems can arise in the erection process if there’s either an inflow problem or a problem with the arteries, a venous leak problem, or the blood returning too soon to the body through the veins, or something called Corporal fibrosis, which is essentially scar tissue formation.

So if we go back to our kitchen sponge analogy, think of a stiff sponge that does not expand.

Mark Goldberg: Generally speaking, there are three primary categories of components to the erection, and where things could be going wrong. Generally, what is the most common of those three that you see in your practice?

Dr. Mendez: So it’s really a mixed bag. Many men will have some components of both arterial flow being somewhat diminished, or venous leak, or that venous outflow being a little too fast for what we’d like.

Also, other things can affect the tissue quality, which can be things associated to diabetes, peripheral vascular disease, cardiac disease, which can affect the actual tissue of the penis.

Even erectile dysfunction itself, not getting those regular erectile cycles like morning erections and the penis not getting expanded as it usually would in times where the erections were strong in regular, that in itself can cause scar tissue.

Think of your other joints in your body or something else, where if you haven’t exercised it or used it lately, you feel stiff and it’s not quite as limber as it used to be. The same thing happens in the penal tissues.

Those are different things that can happen in the going-wrong process. Things that affect blood flow can arise from anything, like I briefly mentioned, cardiac disease, vascular disease, diabetes can affect flow, but another important category is the nervous system, so your nervous system controls your sympathetic system and your parasympathetic system. Those two can either dilate or increase blood flow or constrict and diminish your blood flow.

One of the important systems that we’ll talk a little bit about later is the sympathetic system, which is your stress system, think fight or flight, and that can constrict blood flow, so that can have an effect on blood flow as well, there can also be issues with preventing blood from returning to the body too soon, or failure to compress those veins that can result from either fibrosis or that scar tissue that we talked about, or other issues with the veins just remaining dilated, either they’re a little stiff or whatnot, so those are all things that can go wrong in the process.

Mark Goldberg: Veins control the outflow. So, if I’m understanding you correctly, a big part of the erection process is the dilation or compression of the arteries, which is bringing the blood flow in, and the veins, which is taking the blood back out.

Dr. Mendez: Exactly. So sometimes I use a bucket analogy. So filling the bucket, trying to get the bucket full is the job of the arteries, the in-flow we want to be the dilated, and then the bottom of the bucket, if it has a hole in it, think of that is our veins returning the blood to the body too soon. If you have a big return of blood through those veins, it’s very hard to keep that bucket full.

Mark Goldberg: When it comes to making those diagnostics… I know at the time of this recording, we are really on the one hand, hopefully on the precipice of coming to some better place with this pandemic, but we’re also in a really tough time, and telehealth has never been more common than it is today, so when would someone need to come into the office if they’re experiencing a erectile dysfunction versus being able to handle this over a telehealth appointment?

Dr. Mendez: That’s an excellent question. So telehealth has really opened up the avenue to a new way of taking even better care of patients, in my opinion. So I often will see men for a telehealth appointment first, even before we’ve met in person, so we’ll kind of discuss what’s been going on with them, what their experiences have been, what they’ve tried, what’s worked, what’s not worked, what are their goals?

All of those things are excellent to do over Telehealth. So it’s a good introduction in terms of establishing that relationship. I always recommend for gentlemen to come into the office if they haven’t had a physical exam of the penis, testicles and the prostate, especially if it’s been more than a year.

If they’re having any complaints of penile curvature, or any lumps, bumps or hard areas in the penis that they feel is new or different, I definitely want to see them in the office for an exam or if we’re talking about their erectile dysfunction, things that they’ve tried, things that haven’t worked, things that maybe need a little bit more investigation and they may benefit from diagnostic diagnostic testing, then we bring them into the office as well.

Mark Goldberg: And how does that diagnostic testing work for ED?

Dr. Mendez: Diagnostic testing in erectile dysfunction is predominantly utilized with what’s called a penile doppler ultrasound, so the penile doppler ultrasound is a ultrasound test, so if you’ve had an ultrasound on other parts of the body, it’s just a probe with some jelly, there’s no radiation, it’s not painful.

It allows me to look at the tissues on the inside of the body in real time. If you think about a pregnant woman and they put the ultrasound probe on the belly to look at the baby, it’s the same type of technology, except for this time we’re looking at the penis.

It’s really helpful for a man to understand why is he having difficulties with his erection because this ultrasound test can look at the blood flow in the penis, it’s sensitive enough where I can see the arterial flow and measure how strong that is… And also look at the venous return or the venous blood flow, returning the blood to the body and see how fast that’s happening.

It also allows me to look at the quality of the tissues in the actual erectile part of the penis, or what we call the erectile bodies, to see if there’s any development of that tightened tissue or that scar tissue, otherwise known as fibrosis.

So from that information, the arterial inflow, the venous outflow in the quality of the tissue and the penis, I can tell a man where his erectile dysfunction may be stemming from just based on the investigation of those things.

So that is not only helpful for the patient to understand what’s going on with why he is having trouble, but it’s really important for me because it allows me to tailor his treatment options to the root cause of his erectile dysfunction in this results in a much more effective outcome in terms of getting them back to the erections that he’s looking for.

The test itself takes about 15 to 20 minutes. During that test, you’re giving an injection with a medication that helps bring on the erection, and universally, all men are very nervous about having an injection into the penis, but it’s done with the very smallest needle that’s available.

And most men honestly ask me if I’ve done it and I’ve already done the injection, so they didn’t even feel it. I would say the worst part about the test is worrying about the injection and then realizing that it was no big deal.

Mark Goldberg: And the injection, the intention is to facilitate an erection, I’m assuming, in order to be able to see the blood flow process. Is that correct?

Dr. Mendez: That’s absolutely correct. So it helps dilate those arteries to allow the blood flow into the penis, so I can do some measurements of how well do the arteries respond to the medicine, and how well does the penis become erect with the administration of this medicine, and it’s a stronger medicine than what gentleman take by mouth?

Mark Goldberg: A question off of that, I’ll hear this from patients that I see, and I have no doubt that you see something similar, where a man will complain that primarily, he’s experiencing erectile dysfunction at maybe a minute, three minute, five minute six into his erection process, is that part of why this test takes some time, because it might take some time to identify a leak or the veins will dilate earlier on than the man wants, and that just takes time to see on the test?

Dr. Mendez: Yes, right on the money. So at the beginning of the test, we take some measurements without the medication, so then I can compare them to the results with the medication, so I can see the degree of response based on the flow in the inflow and outflow. And then, as you said, there’s different time points within the erection, so there’s the initial phase of the erection where you may have a nice strong, firm, rigid erection, but you might start to lose that after a certain number of minutes.

It’s very important to capture that, with doing the scan at that initial point, and then a little bit later on in the erection process to see are we losing more blood flow through the veins, or is the arterial flow initially strong and then diminished. So there’s lots of information that I can get from that.

Mark Goldberg: Would you say diagnostics are needed for every patient, or there’s a particular type of presentation or situation that more warrants a Doppler?

Dr. Mendez: So for men that are achieving their goals and consistently having good function with either pills by mouth like Viagra, Cialis, things of that nature, those men probably don’t need an ultrasound right off the bat, because if they’re achieving their goals and they’re having good results with the oral medications, then we typically leave things there unless something changes.

But for the men that are not meeting their goals, either with pills or other therapies, or maybe they’re having intermittent results where sometimes it’s working, sometimes it’s not, maybe they’ve noticed a change in their penis, either the shape or the size, maybe there’s a bend, maybe there’s a new lump or bump, the ultrasound test becomes very important for those men because it not only lets me kind of help tailor their treatment options moving forward, but it also lets me diagnose them with other things that it can affect the penis, such as Peyronie’s disease or scar tissue, or things of the like.

Mark Goldberg: What does this test not tell you?

Dr. Mendez: The test itself, like I said, it measures the inflow, the outflow, and it looks at the tissue in the penis to look for any problems with the tissue of the penis, but it does not tell me what caused these issues.

So part of my specialty and what my job is it to figure out, now that I see these things, with the blood flow or the tissues, what may be the cause of them, so the test itself just gives me numbers and then my job is to interpret those numbers and let the patient know what’s going on, and then you have a source of ideology or where did these problems come from, looking at his overall picture of health.

So not only do I talk to men about their erections, but I’m going to ask them, are they having any other health issues, hypertension, diabetes, heart issues, family heart issues.

I can’t tell you how many men that I’ve personally diagnosed with diabetes that had no idea, or with heart issues, which can be life-saving for men that otherwise didn’t know that they were having problems with their vessel, so my job in a sense is to take the numbers and give them meaning.

Mark Goldberg: Okay, so what I’m gathering is the test can indicate where things may not be working properly or as efficiently in the blood flow process within the penis, but in terms of what might be causing that in other areas in the body or other underlying conditions that requires further medical examination, potentially further testing and what not, and clinical and diagnostic judgment by somebody like yourself?

Dr. Mendez: Absolutely, yep, exactly.

Mark Goldberg: What would you say are some of the psychogenic implications of these test results in particular, can these different manifestations of erection problems or blood flow problems, is that something that can be resolved by addressing the mind?

Dr. Mendez: Yeah. It’s incredibly important to address the man is a whole in regard to the brain, body communication. So in erectile dysfunction, men may find it very comforting to know the why, why are they having troubles, what’s causing the troubles, it may be a relief to know that the blood flow in isn’t as strong as it may have been in their younger years.

This actually gives autonomy or ability for the man to take a little bit more control over his care moving forward, and that is important also for the man that we do this test, and we look, and he has normal blood flow, because there are many men that we do the tests that are having troubles with their erections, and we see they’ve got great blood flow in, they’re not leaking blood through the veins back to the body and their tissues look nice and healthy.

For these men, their source of dysfunction is most likely coming from the nervous system, which I briefly mentioned before, and the nervous system is incredibly important in the regulation of blood flow. And the nervous system is controlled by the mind, so we talked very briefly about the sympathetic system, which is our stress system, so our stress system is going to be that little voice in the head that may be saying, “Well, it’s time for an erection, is it going to be strong enough? Am I going to last long enough? Is what is my partner going to think…”

So all of those thought processes activate the sympathetic system or the anxiety system, and that from an anatomy standpoint, constricts those blood vessels, and it is darn near impossible to have a strong, good erection if you’re constricting the blood flow to the penis, because the erection is completely dependent on blood flow.

So for men that have normal results, the test is just as important because now they have a window to look at another system that can be treated, which is the mind, and learning how to quiet the sympathetic system and activate the parasympathetic system, which is the state of relaxation.

Mark Goldberg: You mentioned this in terms of constructing blood flow, which I think is the traditional way of looking at the psychogenic role. A question that I’m curious about is, if a man were to come and he shared with you that on his own or something that you can see through one of these diagnostic tests, he’s able to gain and maintain an erection for an adequate period of time, when it comes to being with a partner, he is able to gain an erection, but he tends to lose it, let’s say a couple of minutes into sexual activity beyond just the constriction of blood flow in… Do you think it’s possible that the psychogenic factors or the role of the brain also impact the blood flow out or if the veins are dilating or constricting?

Dr. Mendez: So, absolutely, so I think what you’re alluding to is right on the money, so the process of preventing the outflow of the veins is the compression by the erectile bodies, so if we’re having activation of that stress system and we’re having a little bit of constriction and that flow in isn’t as strong, were likely also not getting that compression of the veins, and so the veins remain dilated, returning that blood to the body.

You can have situations where you’re increasing that return and so from a pathophysiological standpoint, when we’re looking at blood flow in the penis and the man that has a great erection in individual or independent sexual experiences, but then when it comes to partnered situations, has difficulty maintaining it is, I believe, a largely effect when the nervous system starts influencing those pathways in and out, so not just the construction, but also as you mentioned, the return of blood through the venous system to the body.

Mark Goldberg: Okay, I really appreciate that because when I work with men who really come in with all types of different situations and different walks of life, it does become intricate in terms of what men might be thinking or what types of anxieties come up leading up to sexual activity going to engage with a partner, or sometimes men will be looking at their partner’s reactions and that can have a certain impact later on in the process, and knowing that the mind can play a role at various stages, I think it’s just very important for our listeners to keep in mind as well.

You shared that there are three different categories, and I’m going to put these into layman’s terms, both for myself and for our listeners, and these are three different categories of where things could be going wrong are: blood flow in, retention or like the blood flow going out, and scaring.

How do these differences impact treatment and in particular, will oral medications work in all three of these instances?

Dr. Mendez: Excellent question. So I’ll start with the blood flow in, so if we see what we call medically is arterial insufficiency or we’re not getting enough blood flow into the penis to cause the firmness of the erection, the treatment options include increasing the flow, which can be done through medications, such as Cialis, Viagra, one of the more traditional forms that you might think of for treatments of the erections, it helps dilate those blood vessels.

L-Arginine are amino acids, which are known to help increase blood flow to the periphery, used by a lot of high performance athletes, but also can help with blood flow to the penis. There are other technologies that are new to the field such as gains waiver e-wave, which can cause angiogenesis, which is development of blood vessels, which can increase blood flow to the penis. And then as we mentioned just a moment ago, increasing that parasympathetic system or that state of relaxation can increase the blood flow to the penis.

I always recommend for men, no matter what their testing shows, but particularly for men that have issues with blood flow in, to make sure that they’re doing all of the heart healthy care for their general health, so regular physical activity, getting the heart rate up, getting a light sweat a couple of times per week, taking care of their diet, making sure that they’re avoiding salt and sugar to keep high blood pressure and either diabetes or potential future diabetes under control, and avoiding body toxins, which would include alcohol or cigarette smoking.

Just a side note, cigarette smoking a single cigarette is going to cause constriction of your blood vessels for seven hours after each cigarette, so maybe motivation to quit if you’re a current smoker, so that’s kind of grouping everything for arterial flow or blood flow in.

When we start looking at the venous return to the body, or the retention of blood in the penis, this is a much more challenging area to address. The medications oftentimes don’t work as effectively in this category for men, if men have a good robust response with blood flow in, because of the medications, they may be able to compress the venous return a little bit more effectively, allowing them for more maintenance of their erection.

But on a direct interaction, the medicines don’t work directly on the veins, so they don’t help compress the veins, they just help dilate the arteries to, in that regard, help compress the veins, so venous leak or early return of blood to the body is more challenging to treat.

The mainstays of treatment here for many men are going to be what’s called either a constriction band or a cockring to go at the base of the penis to give a mechanical blockage to the return of blood to the body, or for severe cases for men that are not having good erectile function with any of the other treatment modalities, we often consider the surgery, the penile implant surgery for men that are not responding well to there other treatment modalities.

And that goes for any of these categories in terms of the penile implant. The last category in terms of the scar tissue, for men that are not having their regular erection cycle or morning erections or have evidence of fibrosis or scar tissue in the tissues, I typically recommend something called vacuum or erectile device therapy.

If you think Austin Powers back in the day, put the penis in the tube and you pump, and  that is what it’s doing is it’s putting a gentle stretch on the tissues, never to the point of pain, but it kind of gives blood flow to the penis that it may not have seen in a while and helps gently stretch those tissues.

Think of it is warming up for the race in a sense, and I typically have men do this on a daily basis for about 5 to 10 minutes to help increase the health of the tissues, I have a little sheet that says, yoga for the penis to give it a little framework.

Mark Goldberg: And I think our listeners are going to appreciate that Austin Powers reference, it’s something that definitely brings up a little nostalgia for myself.

What struck me about that is if a man is struggling with erectile dysfunction, has tried oral medication, what I’m really hearing from you is that there could be other things going on that really could warrant a bit of a different treatment approach that might not exclude the usage of oral medication, but certainly if there is leakage, or if there’s scar tissue, there are other ways to go about approaching this that can really make a significant difference between having a robust erection and not being able to gain or maintain one.

Dr. Mendez: Absolutely, and there are so many different things; there’s an entire menu of options of how to optimize a man’s erections, and knowing how the blood flow looks, how the tissues look, how they feel about their erection goals, if their blood flow is normal and their tissues are normal, helping them understand that there’s other things in their bodies that they can learn about in terms of their thought process, their mindset on their erections that can significantly improve their erections…

I have many men that are not getting a good response from the pills by mouth, they have normal blood flow on their study, and then they learn some of the pathways that you specialize in in terms of increasing the parasympathetic, decreasing the sympathetic and learning how to address the mind, in terms of the erections, and that in itself can give a better result then even the pills.

Mark Goldberg: Well, that is very helpful to hear, and I hope that that message comes across in a really strong way that there are multiple approaches, and if medication has not worked for you or it’s not as reliable or effective, there are other ways and other interventions and other treatments out there, and I don’t know if you agree with me, but I would encourage men to utilize anything and everything that is out there that is medically safe and sound, to be able to really address some of these challenges and get closer to a satisfactory sex life that I think everybody deserves.

Dr. Mendez: Absolutely, I couldn’t have said it better. We can always get a man back to erections, it’s just finding the pathway that’s right for him.

Learn more about Dr. Mendez and her practice by visiting the Chesapeake Urology website.

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