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Erectile Dysfunction Radio Podcast
Dr. Ranjith Ramasamy, joins us to discuss what a typical visit to a urologist might look like for a patient facing erectile dysfunction (ED). Dr. Ramasamy is a urologist and serves as Director of Male Reproductive Medicine and Surgery, and Associate Professor in the Department of Urology at the Miller School of Medicine at the University of Miami Health System in Florida. In addition to ED, his area’s of expertise include:
- Vasectomy and Vasectomy Reversal
- Male Infertility
- Low Testosterone
- Peyronie’s disease
- Fertility Preservation
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 35 – Erectile Dysfunction and a Urology Visit | An Interview with Dr. Ranjith Ramasamy
Mark: Welcome to another episode. Today, we are joined by Dr. Ranjith Ramasamy, he is the Director of Male Reproductive Medicine and Surgery, and Assistant Professor in the Department of Urology at the University of Miami. Dr. Ramasamy is an expert in treating sexual dysfunction, including erectile dysfunction. He is a well-published author and a sought after speaker, and we are glad to have him join us. Thank you for being with us today.
Dr. Ramasamy: Thanks for having me, Mark, happy to be here.
Mark: So as part of our mission, we try to provide high quality information about the causes of and treatments for erectile dysfunction. Today, we want our listeners to understand more about the experience of working with the urologist to resolve erectile dysfunction. Can you tell us a bit about your practice and academic work?
Dr. Ramasamy: Sure. I am a reproductive urologist, trained in urology at Cornell, and then did a fellowship at Baylor in male sexual dysfunction and fertility, and I’ve been now at the University of Miami for about six years, and my practice primarily involves treating men with the issues such as testosterone deficiency, sexual dysfunction, both orgasm ejaculatory as well as ED, and men who have issues with fertility.
Mark: As a urologist, when someone who’s struggling with erectile dysfunction comes to you, what does that first visit typically look like?
Dr. Ramasamy: One of the first things that we want to evaluate when a man comes to us for ED is we want to understand if it is non-organic or psychogenic or organic and sometimes it can be a combination of both. With increasing exposure to television, internet, we feel like we’re seeing more and more men who come to our clinics with non-organic or psychogenic ED and usually, if we are able to get a good history, we are able to determine the distinction between the two.
For example, a guy walks into the office and tells us that his erectile dysfunction started on March 18, 2020, that is often a sign of non-organic or psychogenic ED. Any time that there is such a date, certain event, something bad must have happened. And ever since then, they are unable to have an erection or suffer from erectile dysfunction, that usually clues us into thinking this is non-organic or psychogenic ED.
However, on the other end of the spectrum, when men tell us, “it’s been getting worse over the last two or three years, in the beginning it was, okay, I was able to get an erection and then it didn’t last long, and then now I’m unable to get an erection, it’s just been progressively declining,” that mostly clues us into organic ED.
The reason this is important as a first step in a man with a history of erectile dysfunction is because a management for both these conditions aren’t entirely different, but very different in terms of the approach that we take and the number of tests that we do, the number of investigations that we do, and even the treatment options for erectile dysfunction.
The first thing that we do, anytime a man complains of ED is we want to determine whether it is non-organic or psychogenic ED, or if it’s truly because of an underlying organic case.
Mark: What I’m gathering is that first evaluation would involve a fair amount of discussion, history taking and exploration in terms of what the patient is reporting to try to determine if this is organically-based or psychogenic, and it’s something that I myself can appreciate because a lot of my initial evaluations, although they are for psychogenic, do involve a lot of information gathering to really determine even within a psychogenic setting, what are the particulars that are driving at that.
Dr. Ramasamy: I think the other important thing to establish as well is to understand what the expectations are from the patient. Different people have different expectations, what is it that they’re trying to achieve is also very important, and so I think during the history taking, it is important to understand what is frequency of sexual intercourse?
Some men may be just happy with once a month, some men may be happy with once a week, some men may not be happy with three times a day, so it is important to understand that, and then we want to understand what is erectile dysfunction in their mind.
I’ve seen patients complain and say, “I used to be able to last for 10-30 minutes, now I’m lasting for 10 minutes, so I have ED.”
Some guys may say I cannot even last for a minute or two, so understanding expectations from people is also important, and I think that’s why a lot of patients get frustrated because they feel that their expectations are not being heard or not being understood completely by their treating physician.
Mark: So the expectations in goal setting are also part of that initial evaluation to make sure that the patient has realistic and obtainable goals, and that their expectations are not going to be beyond the scope or the reach of what is reasonably feasible. Is it common for somebody with erectile dysfunction to visit you once, or does it usually require multiple visits to be able to reach that goal that they’re trying to get to?
Dr. Ramasamy: I would say it’s probably very uncommon to just me once, usually, it requires a few visits to understand expectations and also try to determine whether the treatment or the management plan that we’ve come up with actually works in the patient or not, and sometimes based on treatments is when we determine whether something’s working or not.
I’d say having just one visit is very uncommon. Because we are so close to the University of Miami undergraduate campus, I see so many young adolescents and young men with erectile dysfunction, and more often than not, from the first visit once I sort of tell them that, that they need to get their confidence back and this is likely nothing wrong with them, and try to focus on the erection as opposed to thinking 10 other things as to what may happen if they are unable to get the erection and even to treat them with a trial of Cialis.
Those patients, I literally tell them that this may be the last time that they see me because if the pills work and they’re able to reset their brain and reset expectations and get back into things that they may never see me at the end. I’d be very happy for that. Other than that one sect of patients, the majority of patients that I see for ED are usually seeing me for more than once or twice.
Mark: Got it. So in cases with younger patients, I would assume that very often, that tends to be very clearly psychogenic. It’s a lot easier to determine that right off the bat, whereas as men age, there’s increased complexity and it takes a much deeper and clearer understanding of what the factors are that are driving or contributing to the erectile dysfunction.
We’re currently living in a telemedicine environment, which has advantages and disadvantages, what do you see as the benefits and limitations of this new form of medicine?
Dr. Ramasamy: Absolutely. It is an important concept and so applicable to men’s health and erectile dysfunction. So some of the advantages that I see are basically patients not needing to travel to go to a doctor’s office to sort of expose themselves in front of other people. That element of embarrassment and discussion of a very sensitive topic such as erectile dysfunction can possibly happen in the confines of their house and or the office.
Telemedicine for erectile dysfunction in that, that it helps maintain privacy, I think is hugely important and hugely beneficial. The other thing that telemedicine has done, is it has basically improved access to care, patients are now able to reach out to doctors from much farther away through a simple phone call and a video call and get care through telemedicine, as opposed to before they had to rely on the urologist or internist who necessarily did not specialize in ED and didn’t really know the in-depth treatment options for men.
Access to care has improved so much that I think we are able to reach out and obtain care from beyond their user confines of the geographic area. The disadvantage I see is I feel like that human connection and human touch, no matter how much we’re able to overcome with technology, is missing, especially with topics such as infertility and sexual dysfunction that I deal with.
I feel that human confidence and the doctor confidence providing the patient, saying that everything will be okay, can somehow not be given to no matter what technology you have with computers and phones and videos, and I think that element is missing.
Usually, I try and see as long as they are in the local area I ask patients to see me at least once, so we establish that human contact, and then I think establishing care after that through telemedicine is a great idea, but without that first initial contact, or a contact at any point in time during the care between a physician and the patient, I think is probably very important, not just in sexual dysfunction in men’s health, but certainly it feels like it is important even cancer, I think would be so important to establish that relationship, and have at least one visit with human contact.
Mark: One of the the things that comes to mind, and I’m wondering your opinion on this, is that sometimes, to my understanding, there are situations that a man either needs to be examined in person, or there are certain tests that would need to be carried out. Does telemedicine, present any barriers for men who maybe want to start the process, but then might be uncomfortable to come in afterwards?
Dr. Ramasamy: I think the issue there is sort of setting expectations and telling patients what the tests that you’re planning to do are going to be useful for. A perfect example is something called a penile doppler, which we do in our offices, it’s not done at a radiologist’s office. We have to actually give an injection to obtain an erection to evaluate blood flow, and as soon as you mentioned the word injection and the penis, most patients get frightened and they’re like, “I don’t want to come in for this test.”
But if you explain the utility and that it’ll help us determine issues with underlying vasculature issues, whether an injection would even work as a potential treatment option for ED, it will give us confidence and give the patient confidence that they’re able to get an erection without any issues with a simple low-dose injection.
I think as long as you can set the expectations to the goals and tell the patient how the management would potentially change based on what tests you’re planning to do, I think that would sort of increase the compliance from the patient standpoint.
Mark: Can you explain to our listeners why erectile dysfunction may in certain circumstances be a canary in the coal mine or a warning sign when it comes to men’s health?
Dr. Ramasamy: The biggest concern, erectile dysfunction is just a small signal in terms of vasculature. The penis is supplied by the same blood supply, by the same blood that goes to the heart, goes to the brain, goes to the other parts of the body, and if erectile dysfunction happens in young men and it’s truly organic in their late 30s or 40s.
There are very robust population-based studies saying that it could be a silent predictor of a heart attack, a silent predictor of a stroke. Men with erectile dysfunction have three times a higher risk of developing a heart attack over their lifetime than men without erectile dysfunction.
ED often in internist offices and primary care offices gets a prescription for PDE5 inhibitors such as Viagra and gets dismissed. I think it’s very important if it persists in a young man, and it doesn’t get better with PDE5 inhibitors and it’s really organic, we spoke a lot about organic vs psychogenic, if it’s organic ED in a young man between his 40s and 50s, I think other causes of underlying erectile dysfunctions such as dyslipidemia, hypertension, diabetes should all be investigated, and if there are modifiable risk factors that can be identified, they should be fixed.
And the nice thing is, this is very well-known, but often not discussed, is men hate showing up to doctor’s offices. Women go to doctor’s offices all the time, get their health check-ups routinely, but men hate going to doctors, but the one thing that will absolutely drive them to seek medical care is ED.
They may have uncontrolled diabetes, they may have uncontrolled hypertension, they may have terrible lipids, they’re not going to see the doctor, but if they have ED, they’re going to see the doctor and that may be the one chance for that doctor to pick up on all the other modifiable risk factors and potentially even treat those as a way to improve ED.
Mark: Got it. So there’s a potential silver lining in a man experiencing ED, certainly, if generally he’s reluctant to go to a routine check-up or to deal with other medical issues, this oftentimes is something that does drive men back into the doctor’s office to get resolved that it may reveal in certain circumstances. or in certain cases, some other underlying issues that can be medically managed or treated?
Dr. Ramasamy: Correct.
Mark: Now, one of the focuses of this podcast and Erection IQ, is the role of the brain in the erection process and in ED, as a urologist, what do you see as the role of the mind in this process, how common is it that erection issues are caused by or worsen by mental aspects like performance anxiety and relationship issues?
Dr. Ramasamy: We’ve actually seen it way more commonly now, especially post-covid pandemic than we’ve ever seen it before. Relationship struggles, partners and men and women being in the same household for extended periods of time has actually impacted sex life more than it has increased, and we are seeing several relationship struggles, divorce rates go up post-pandemic, and I think it is extremely important that we consider all of those things in the treatment and evaluation of ED.
Like we talked about earlier in the podcast, psychogenic ED was a slam dunk diagnosis in the young adolescent male from college or medical school, whereas now we’re seeing a lot of psychogenic ED happening because of depression, anxiety, and other mental health disorders that have happened now during the lockdown and covid pandemic era, that we are seeing men with psychogenic and non-organic ED in their 40s and 50s that we did not see previously.
Mark: So it seems to you that certainly over the past year, that seems to be a growing phenomenon of men who are experiencing Ed, that seems to have a stronger psychogenic component. Is that correct?
Dr. Ramasamy: Yes.
Mark: Can you tell us the different treatment options or the next steps that an ED patient might have after going through that evaluation process, what are some of the different pathways that men can go down in terms of treating and addressing erectile dysfunction?
Dr. Ramasamy: Let’s take non-organic and psychogenic ED, I often tell them that it is sort of a vicious cycle. Men keep thinking that they’re not going to have an erection, so they don’t get an erection, and it’s sort of a vicious cycle that they get trapped in, that it’s very hard for them to come out of, even though they have a normal functioning penis and a perfectly normal brain to direct it.
The usual strategy that I do is to refer the man to a sex therapist, and at the same time prescribe them a trial of Cialis just to sort of in-combination break the cycle, and if they’re able to break the cycle, I tell them they don’t need to see me again.
But if they are unable to, and the combination of sex therapy and the Cialis is not working, I do want to see them in three months because maybe there is some sort of underlying vascular dysfunction that we are not picking up and that needs to get investigated with other evaluations and men with organic ED, the American Urological Association actually has very good guidelines on treatment of erectile dysfunction with a shared decision-making approach.
This is new since 2018, because prior to that, there was advocacy for stepwise therapy for men with ED, and usually the first line is lifestyle and behavioral modifications with modifiable risk factors with changing anti-hypertensives, anti-depressants, controlling blood sugar, controlling lipids and so on, and in addition to that was if you fail that, then you were going to go on to try PDE5 inhibitors such as Cialis or Viagra.
Then if you failed that, the third line treatments were intracavernosal injections, intraurethral suppositories and vacuum erection devices. Then if you fail that, you could discuss a penile prothesis which is a surgery for treatment of erectile dysfunction with urologists.
Now the AUA has modified this into a shared decision-making approach where doctors and patients can talk about all these treatment options at the same time, as long as this is men with organic ED. If you determine that this is organic, I think it’s any reasonable to discuss all of the treatment options at the same time. Men are no longer forced to try and fail one therapy at a time, and before they move on to the next one
So a young man who’s 40, who has had profound diabetes all his life, has pretty severe ED, I am not hesitant to discussing a penile prothesis, because I know he’s young, and he’s going to need a sex life for 30 plus years, and so discussing a penile prosthesis with him is not a bad option. We don’t need to start with PDE5 inhibitors and sort of use that step-wise approach.
Mark: Got it. There clearly are a number of treatments available, and what I’m gathering is that previous guidance around treatment was to go through a progression, and as men progressed, if the treatments were not effective, they could kind of advance to the next stage of treatment all the way up to and including a prosthetic implant.
Now, what I’m gathering from you is there is more flexibility for organic patients to be able to have some input and choice as to what the best treatment might be given their circumstances. Is that correct?
Dr. Ramasamy: That’s correct, yes.
Mark: I’m wondering, from your perspective, what does success or a best case outcome look like when an ED patient visits you?
Dr. Ramasamy: Best case is, “Doc, you’ve changed my whole life around.” But more often than not I actually unfortunately don’t see those patients back, if I have fixed their ED problem, more often than not, they have disappeared from my radar, they’re happy somewhere and I’m just happy.
If it continues to be a problem and persist, then I still keep seeing them, but if I don’t see them, then I’m sort of confident that their problems have been fixed. The patients that I do truly see back and give me feedback are the patients who we have done surgery on for penile prothesis, so obviously I see them and follow up and make sure that everything is healing okay, and the implant is functioning well, and those patients come back and give me very good feedback that life has changed and their partners and them are extremely happy with the surgical outcome.
Now, actually at the University of Miami we are doing a clinical trial with both two regenerative forms of therapies for erectile dysfunction. One is a shock wave therapy, which is high energy ultrasound delivered to the penis, and the other is using PRP or platelet-rich plasma as two injections from the patient’s own blood, the growth factors are spun down and injected inside the penis for the series of two injections, so because these are clinical trials, we see these patients in follow-up, and obviously if it works, they come back with lots of enthusiasm and joy, and are very happy and very appreciative that they were able to get these treatments that could potentially reverse the underlying erectile dysfunction that they have, and they don’t need to depend on pills or injections to achieve an erection.
Mark: So what I’m hearing from you is that satisfied patients, when you get that feedback, you’re saying that is the best case outcome for you as a provider in many instances though, if the treatments do not require a follow-up, if they’re not part of a study or if they’re don’t need follow-up after a prosthetic implant, you may never hear from them again because they’ve solved it and they’re off living their life.
I also really appreciate you mentioning these two forms of treatment that I don’t know if they are FDA-approved, I don’t know if they’re widely available, if they’re under some kind of study, but I think it’s important for our listeners to understand that treatments for erectile dysfunction are continually being researched and developed, and there is reason to be hopeful and optimistic that even if some of the treatments have not been successful, there are many good people working on developing more and more ways to be able to help men resolve erectile dysfunction.
Dr. Ramasamy: Yeah, absolutely. All of the treatments that we talked about for erectile dysfunction are sort of a patch, they don’t really cure, they don’t reverse the underlying pathophysiology of erectile dysfunction, and so therefore, the regenerative therapies offer a lot of hope.
It is important to note that none of the regenerative therapies are FDA-approved, it is widely available, however, on an off-label basis from physicians, sometimes non-urologists, sometimes non-doctors, and so patients truly should investigate what they’re getting and what they’re going to be paying for, because unfortunately, men with the ED is a vulnerable population that can be used upon… if I might say.
Therefore, it’s important for patients to understand what they’re signing up for, what they’re getting, and not to be offered a promise of voodoo medicine with these regionalized therapies. But at the University of Miami, we have two IRB-approved role calls, it’s a clinical trial. If patients do qualify for the trial after the initiative valuation, we do not charge them, and so it is important for patients to really seek out clinical trials in their area to try and get these therapies, because these are truly on the horizon.
It is going to be a while before they get FDA authorization, but at least it offers the promise of a cure, if not permanent, at least even a temporary cure for the underlying cause of erectile dysfunction.
Mark: I appreciate you sharing that with our listeners, and I hope to be able to cover these topics in future podcasts to really, again, deliver more specific information to men about what these treatments are all about.
What have you learned from the many men that have come to you who are dealing with erectile dysfunction?
Dr. Ramasamy: Every man is different, every penis different, every expectation is different. To try and use this one treatment approach for every guy with erectile dysfunction, often doesn’t work, and I think physicians should be aware of the treatment options that are available to men with erectile dysfunction and to move towards a personalized medicine approach, individualized treatment care planning as opposed to just giving out pills and PDE5 inhibitors to all men with ED.
Some patients like it, some patients don’t, and different people respond to different therapies differently based on their expectations and their underlying medical conditions. So if I’ve learned one thing over all these years in treating men with ED, I think it is important to understand clearly what the expectations are from the patient and offer personalized treatment approaches based on the underlying problem, what the underlying cause and etiology of the ED is, and what their ultimate expectations are of them and their partner.
Mark: Any final thoughts that you would want to share with our listeners?
Dr. Ramasamy: I think it’s important for men with ED to understand that there is hope, but in terms of treatment, fixing their underlying problem and resolving the condition. It is important for men to seek out proper medical care and not go after radio and TV ads that may sometimes be legit, but sometimes may just be taking advantage of their underlying condition and their vulnerability.
If I’m going to leave the listeners with some sort of parting message, ED is a medical condition just like hypertension, diabetes and high cholesterol, so seek out medical care and like yourself, don’t be afraid to speak with the sex therapist, because so much of erectile dysfunction is not just in the penis, the brain has to control the penis and how it works.
I think that’s probably the most important message that I’d like to convey.
Mark: Thank you for that, and thank you so much for joining us today on the podcast.
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