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Petar Bajic, MD, is a urologist in the Center for Men’s Health at the Cleveland Clinic's Glickman Urological and Kidney Institute, specializing in men's health and sexual medicine. He joins the Butts & Guts podcast as the special guest on this episode to discuss how certain diet and lifestyle changes can help men who experience Erectile Dysfunction (ED).

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Diet and Lifestyle Changes to Address Erectile Dysfunction

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast, exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi everybody and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at Cleveland Clinic in beautiful Cleveland, Ohio. And I'm so pleased today to have Dr. Peter Bajic, a urologist in Cleveland Clinic's Glickman Urological and Kidney Institute. And we're going to talk about something today that I have never talked about before and that's diet and lifestyle changes to address erectile dysfunction. Dr. Bajic, welcome to Butts & Guts.

Dr. Peter Bajic: Thanks so much for having me.

Dr. Scott Steele: So we don't have a ton of urologists on here. So we always like to start off with guests to tell us a little bit about where you're from, where'd you train and how did it come to the point that we're here at the Cleveland Clinic?

Dr. Peter Bajic: Yeah, so I actually grew up in Cleveland, spent the first 18 years of my life trying to get out of Cleveland, and then little did I know that I would be very happy to come back after completing all my urology training in Chicago. I did a residency at Loyola University Medical Center. I did a fellowship in basically men's health or Andrology and Male Genital Reconstruction at Rush University Medical Center in Chicago, and my practice primarily focuses on male sexual and urinary health. I see a lot of men for erectile dysfunction, prostate enlargement, low testosterone, things like that, and was drawn back to Cleveland Clinic because of the reputation and the great department we have here and also was very excited to actually come back home and start a family here. So, yeah, it's been great. I've been back for almost two years now and looking forward to our conversation today.

Dr. Scott Steele: Well, it's great to have you here and I really do appreciate you joining us on Butts & Guts, so let's delve right into it. So I would say probably prior to 10 years ago, or maybe even five years ago, talking about something like erectile dysfunction was just, man, that did not occur. And now we see the ads on TV, the different companies. I listen to a lot of sports radio and it seems like you can't go one commercial without somebody saying, you know, "You got low T? Why don't you come in and tell us." So just let's start really big and really broad. So what is erectile dysfunction, how common is it and what causes it?

Dr. Peter Bajic: So erectile dysfunction essentially refers to either inability to get a sufficient erection or inability to maintain a sufficient erection for sexual intercourse. We kind of loosely define that term because sexual activity is different for different people and some people engage in penetration, other people don't. So if you're basically bothered by a lack of sufficient rigidity, then you have erectile dysfunction. It's quite common, probably affecting about 50% of men by the end of their fifties at least to some degree. Now there are varying degrees. Some people just have it in certain situations, maybe related to performance anxiety, but the vast majority of erectile dysfunction is actually a blood flow problem related to cardiovascular disease. As we'll get into today, things like high blood pressure, high cholesterol, diabetes, tobacco use, all of those things that can lead to hardening and narrowing of the arteries can reduce blood flow to the penis and make it harder for it to fill up with blood.

Dr. Scott Steele: Yeah. So I was reading some interesting statistics and I just want to make sure we're talking about more of just that anatomical reasons right now, and we're not talking in some of the mental aspects that can be a large part of it. So you talked a little bit about which of the causes is most common, but the interesting thing you said to me is that diet and exercise, and that's what we're going to focus on today, can play a role in erectile dysfunction. So tell us a little bit more about that and how in the world would making a change here be the best way to prevent or help improve this condition?

Dr. Peter Bajic: So it goes back to those four most common causes that I just alluded to. So a lot of situations, your diet may contribute to whether or not you have high blood pressure, high cholesterol or diabetes. Exercise also is associated with these conditions. So when we talk about prevention, it's all about maintaining healthy body and, you know, the other thing that comes along with exercise, is also maintaining a healthy mind, stress relief. Those are all big things that play into your overall health, your cardiovascular health and that essential blood flow that's not only important for erections, but important for a lot of different things, basically everything.

And then as far as treating erectile dysfunction, this is a condition that affects a lot of men. There's a lot of different degrees of severity and things like that. But for men that have kind of early erectile dysfunction, there is some evidence that regular cardiovascular exercise, 45 minutes, three times a week of exercise where you're getting out of breath, you know, jogging, biking, running, things like that, can actually to some degree reverse some of that restricted blood flow, improve the erections, if done consistently for a period of several months.

So there are actually ways that changing your behaviors, starting to exercise, can actually reverse some of this.

Dr. Scott Steele: So truth or myth. Bike riding, specifically sitting on a seat, can be associated with ED.

Dr. Peter Bajic: I would say for the most part, myth. I mean, we talk about bike seats a lot as it relates to scrotal pain in men, pelvic floor, muscle dysfunction. And in some men maybe less commonly, maybe more commonly than we think, some of that pelvic floor muscle dysfunction can also contribute to ED. So there may be some mechanisms that we don't fully understand where, you know, prolonged biking and bike seats and things like that can negatively impact erections. But in general, like I said, vast majority of men, this is a blood flow issue and simply put, those types of blood flow issues don't come from what you're sitting on.

Dr. Scott Steele: So are there any foods that we should add to our diet? Or the opposite end, are there any foods that we should avoid as it pertains to erectile dysfunction?

Dr. Peter Bajic: Yeah. I would say there is increasing evidence, not just in urology, but to support plant-based diets. And I think that a lot of that comes down to the benefits that plant-based diets have on lipids and cholesterol, blood pressure and things like that. So specifically for ED, I think that anything that is going to keep your cholesterol and blood pressure down is going to be beneficial to preventing ED. You know, when we talk about blood pressure, we're commonly talking about things like sodium. As a urologist I am by no means the nutrition expert for preventing cardiovascular disease, but generally speaking, Mediterranean diet, these things that we hear about, commonly are important for prevention. There's not a particular food necessarily that has been associated with improved erections. There's been a lot of things that have been suggested depending on how deep you dive in the internet. But like many things relating to men's health and specifically male sexuality, there's not really robust evidence to support any individual theory.

Dr. Scott Steele: So you mentioned a little bit before about the bike seat that can cause other things apart from ED, but any particular exercises that maybe are good for erectile function?

Dr. Peter Bajic: I think number one is the cardio. So I'm a big Peloton guy. I encourage my patients that are looking for some sort of motivating thing to consider something like that, where maybe they need a little encouragement and somebody barking at them to get their heart rate up to, you know, get moving. Because it's really getting that heart rate up, probably at least 75% of your max based on your age and things like that is probably the most likely to make a change if done consistently over, you know, periods of months. This is not something that can necessarily change overnight.

I also want to emphasize that a lot of the guys that I see, they have a history of heart attack, poorly controlled diabetes, and things like that. These are generally not the guys who I'm telling, "If you start exercising this much, your problem is going to be cured." Right, there's different ranges of the spectrum here. And I think the guys who the exercise and diet change that are going to make the most of a difference for are the guys that are thinking about prevention, maybe have some early signs of it.

There's some pretty solid evidence that suggests that erectile dysfunction can proceed a heart attack by about five years. And the thought there is essentially that the penis relies on two arteries that are less than one millimeter in diameter for its blood flow. So typically the smallest arteries in the body are affected first by cardiovascular disease. So by the time the coronaries are affected, which are 10 times the size of those penile arteries, the ED likely has happened several years prior. So when guys come to see me with new onset ED, I always have that discussion. If they don't have a primary care doctor, we get their lipids ordered. We get them plugged into somebody that can do a thorough screening and discussion about how to optimize their overall health.

Dr. Scott Steele: Does nocturnal erections have anything to do with having the ability, if you have erectile dysfunction during the sexual intercourse or anything sexually, are those two related in any capacity? Does that guide kind of how you work these patients up or treat them in a specific way whether or not they can still have that function?

Dr. Peter Bajic: One of the common misconceptions that guys have is that low testosterone is the most common cause of ED. It really is not. Declining testosterone which in some men can happen with age can sometimes contribute, but it's not one of those most common causes. Now the reason testosterone is important is that it does fluctuate throughout the day. The testosterone levels are highest in the early morning between 3:00 and 6:00 AM and that's the main reason why a lot of men have morning and nocturnal erections. It's related to their kind of natural testosterone up and down. Now if I see a guy who maybe doesn't have that history of the diabetes and other medical conditions, but has this new ED and he tells me, "Oh, I'm getting excellent morning erections, but when I'm with a partner, things just seem to not function properly or, you know, it's causing me a lot of distress," and things like that, that might be somebody that I might think it's more anxiety or situational and not necessarily based on, you know, a complete blood flow issue that might be affecting other areas of his body.

So it is an important piece of information. And some men who develop low testosterone later in life, that maybe one of the things that they first notice is, "Hey, I'm not getting those morning erections anymore." Or, "Hey, when I'm with my partner, they're not as full as they used to." And particularly if they're having other symptoms like low libido, low energy, then we might be more inclined to, you know, evaluate the testosterone level. In general, we have a low threshold to check that, but it might be higher on the differential or more likely if those other issues are present.

Dr. Scott Steele: Okay. So I always hear on these ads on the radio to say, you know, "Come online. So, you know, you don't have to sit in a waiting room," and this and that and the other. So tell our listeners, hey, what can they expect if they want to come in and see you or a member of your team so they kind of know ahead of time like what they're going towards. What does a typical visit involve?

Dr. Peter Bajic: I think one of the really unfortunate things, not just in this day and age, this has been going on for a long time, but there's a lot of misleading marketing and a lot of predatory behaviors in the whole marketplace surrounding men's health. I mean, as you alluded to, you listen to the radio, you just drive on the highway, you see all these billboards everywhere for these men's health centers and things like that. And these are, I mean, places that are advertising in a direct consumer fashion. They're for profit. They're, you know, not exactly focusing on the most evidence-based treatments and things like that.

I generally encourage men to start the conversation with either their primary care doctor or a urologist. Okay. I mean, these are things that both primary care and urology deals with on a daily basis. If you're having an issue, if you notice something new, bring it to the attention to your doctor and let them help you figure out the best place to go.

When a guy comes to see me for erectile dysfunction, we start with just having him fill out some questionnaires. You know, we, just like any other doctor's visit, start with a history, get an idea of when's it happening, how long ago did it start, any other medical issues? Looking for some of those red flag things that may suggest something more serious going on. And I think that's really the value of seeing somebody who has experience in this condition and also in general and overall health to try to identify, could there be some cardiovascular disease? Could there be some diabetes that maybe you don't even know about?

You know, we do a physical exam, which for me is generally just focused on examining the testicles, the penis, to make sure there's not any lumps or bumps or, you know, abnormalities that may explain, let's say a low testosterone or something like that. We'll a lot of times check a testosterone level, which is just a blood test. And at that initial visit, we'll send you out with some sort of treatment plan whether that's medications and non-medication type treatments that are available.

So it's really an individualized approach, a case-by-case basis. We don't just use one blanket treatment for everybody, which I think is definitely a mistake where in some places that that happens. And the nice thing is that going this route. I mean, it should be covered by your insurance. Nearly all insurance plans cover the diagnosis, and a lot of times, usually treatment of this condition. So you don't have to go to these, you know, men's health centers that are charging thousands and thousands of dollars cash for stuff that you could be getting through your primary care doctor.

Dr. Scott Steele: And you mentioned it briefly about other lifestyle changes or even obesity, healthy weights. Any information about either one of those two things especially as it relates to this topic?

Dr. Peter Bajic: Yeah. We had this conversation very commonly among men who are diabetic. I mean, weight loss can be, you know, a way to significantly improve and sometimes even cure that condition. It all goes back to as well, things that are associated with gaining weight, which can be cholesterol, other medical issues that can reduce blood flow. So eating a healthy diet, keeping your blood pressure and cholesterol down, keeping your weight down, cardiovascular exercise, all these things that make your body healthy are going to improve and maintain your sexual function.

Dr. Scott Steele: Okay. So for all of our listeners, we'd like to get to know our guests a little bit better. So first of all, what's your favorite food?

Dr. Peter Bajic: Pizza, hands down.

Dr. Scott Steele: Any particular type of pizza or just pizza?

Dr. Peter Bajic: I'm a big fan of like Neapolitan style pizza, you know, wood fire oven. Having lived in Chicago for seven years, I'm not exactly like a cheesy deep dish guy, but I really like a good pan pizza as well, but that's kind of my weakness.

Dr. Scott Steele: What's your favorite sport?

Dr. Peter Bajic: I got to say basketball.

Dr. Scott Steele: Is that to play or to watch or both?

Dr. Peter Bajic: It's been a little while since I've played regularly, but both. For sure.

Dr. Scott Steele: Fantastic. And then maybe one of your favorite places that you've been to.

Dr. Peter Bajic: Oh, so traveling's always been a big thing that we've enjoyed doing. I would say it's a toss up between Italy Amalfi Coast and Paris.

Dr. Scott Steele: Fantastic. And since you're a Cleveland boy as you said, west side or east side, and what is it that you like here about living in northeast Ohio?

Dr. Peter Bajic: So west side, I grew up in North Royalton and I'm not going to say the weather, particularly not after it's snowed yesterday, but I got to say just the people. I mean, I think that after seeing a lot of the rest of the country and even the world, I think the people in northeast Ohio are just wonderful. I think that for a mid-sized town, the food scene here is actually excellent and there's never anywhere quite like home so it'll always be home for me.

Dr. Scott Steele: So what's a final take home message for our listeners regarding this topic?

Dr. Peter Bajic: If you are experiencing any degree of erectile dysfunction or any new issue like this that you're concerned about, or that you feel like is a change, go and see your doctor whether it's your primary doc, a urologist. Get that comprehensive holistic evaluation that's going to not just think about this one problem, but how the rest of your health and your body may be impacting what's going on and try to get to the bottom of it as early as you can. That's going to give you the best chance of reversing it, correcting it, and maybe identifying some issue. It may be totally outside of your control. I mean, there may be a genetic reason, but it's going to really set you up for success for the rest of your life. It's going to set you up for, you know, satisfaction with your sex life, with your relationship if you're in one, or with future relationships. So I think it's really important for men to recognize that link because I think that a lot of guys don't really realize that.

Dr. Scott Steele: Well, that's great words of wisdom. And it is really no secret that men are statistically much less likely than women to seek medical care. So it is important for men to consult with their physician, as he said, your primary care doc, your urologist. Bring these things up especially if they feel or suspect that something's not quite right.

Our experts also recommend seeing a urologist regularly beginning at age 40. So learn more by visiting Clevelandclinic.org/menshealth. That's Clevelandclinic.org/menshealth, M-E-N-S-H-E-A-L-T-H. You can also call the Glickman Urological and Kidney Institute at 216-444-5600. That's 216-444-5600. And again, you've heard me say this many, many times. Remember it's important for you and your family to continue to receive medical care, regular checkups and screenings, and rest assured here at The Clinic, we're doing everything possible to take all the necessary precautions to sterilize our facilities and protect our patients and caregivers.

Peter, thanks for joining us on Butts & Guts.

Dr. Peter Bajic: Thanks so much for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.

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A Cleveland Clinic podcast exploring your digestive and surgical health from end to end. You’ll learn how to have the best digestive health possible from your gall bladder to your liver and more from our host, Colorectal Surgery Chairman Scott Steele, MD.
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