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Mild, moderate or severe erectile dysfunction affects more than 50% of American men between age 40 and 70. Although frequently associated with aging, the condition can also be caused by numerous diseases and conditions, as well as certain medications and surgeries. Lawrence Hakim, MD discusses symptoms and diagnosis of erectile dysfunction, as well as the range of medical and surgical treatments available for the condition.

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Managing Erectile Dysfunction with Lawrence Hakim, MD

Podcast Transcript

Speaker 1: There's so much health advice out there, lots of different voices and opinions, but who can you trust? Trust the experts, the world's brightest medical minds, our very own Cleveland Clinic experts. We ask them tough, intimate health question so you get the answers you need. This is The Health Essentials podcast brought to you by Cleveland Clinic and Cleveland Clinic Children's. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.

Annie Zaleski: Hello and thank you for joining us for this episode of The Health Essentials podcast. I'm your host, Annie Zaleski, and today we're talking with urology specialist Dr. Lawrence Hakim about medical and surgical management of erectile dysfunction. Mild, moderate, or severe erectile dysfunction, or ED, strikes more than 50% of American men between ages 40 and 70. Although frequently associated with aging, ED is more likely caused by numerous diseases and conditions, both medical and psychological, as well as certain medications and surgeries. ED understandably can be a sensitive or embarrassing condition although doctors do have a range of treatments available. Dr. Hakim is here to discuss symptoms and the diagnosis of erectile dysfunction well as medical and surgical treatments for the condition. Dr. Hakim, thank you so much for being here.

Dr. Lawrence Hakim: Oh, it's my pleasure. Thank you so much for inviting me.

Annie Zaleski: So first off, tell us a little bit about your work at Cleveland Clinic, what kind of research and clinical work do you do.

Dr. Lawrence Hakim: Yes. Well, I've been at the Cleveland Clinic now well over 20 years. I'm Chairman of Urology. My main area of specialty is in men's health. I'm actually an endowed chair in men's health here at the Cleveland Clinic. Our department is very multidisciplinary as far as every specialty within adult urology. My practice primarily focuses on, as I said, not just men's health, but andrology, sexual dysfunction, prosthetics, and we see quite a bit. Our research over the years has basically been in those areas of men's health, as far as various aspects of treatments and diagnostic testing for erectile function, looking at hormone therapy. So we've been involved in a number of projects over the last many years.

Annie Zaleski: Awesome. Wonderful. Well, this topic today we're talking about is erectile dysfunction. So first off define that. What is the medical definition of that?

Dr. Lawrence Hakim: Well, and I think it's important to differentiate the overall concept of sexual dysfunction, which incorporates many different types of issues such as erectile dysfunction, let's say premature ejaculation, issues with libido or desire, Peyronie's disease or curvature. There are many different types of sexual dysfunction.

Dr. Lawrence Hakim: Erectile dysfunction itself is really defined as the inability to attain or maintain an erection in a man that's adequate for sexual intercourse. That's kind of when you talk about purely erectile dysfunction, that's what they're talking about and that's what we refer to. And again, I think the important thing to understand, too, is it's not an all-or-none phenomenon. It's typically a spectrum. And we see many men that come in, they say, "Well, I don't have erectile dysfunction. I can still get some erections." But when you talk to them, their erections are very weak or they're very poorly maintained, et cetera. So there are varying degrees of erectile dysfunction and obviously all are treated differently depending on what the goals of the patient and their partner is. So again, erectile dysfunction really focuses on those issues.

Annie Zaleski: Well, that's interesting because when you talk about how common it is, I would guess that that's a little bit hard to determine because it is on such a continuum.

Dr. Lawrence Hakim: Oh well, it's true and that's why the evaluation is so critical. To your point about how common it is, I mean, it's been shown that over 50% of men above the age of 40 alone have some degree of erectile dysfunction. And certainly as men get older, it becomes a little more prevalent, but we see erectile dysfunction in teenagers and men of all ages. And we treat men from their teens well into their 90s. So I mean, this is a disease that can affect men at any age for various different reasons.

Annie Zaleski: So what are some of the common causes of erectile dysfunction?

Dr. Lawrence Hakim: Yeah, I would say the most common causes are anything that affect the normal erectile physiology. And what I mean by that basically is for a normal erection, you need to have adequate blood flow, you need to have good nerve function, et cetera. You need to have good hormones or at least in a normal range. So some of the more common problems that we see in men that present with erectile problems are for instance, men who have vascular problems like diabetes or hypertension or coronary artery disease, men who have had radical pelvic surgery, prostate surgery, bladder surgery, radiation therapy, men who have hormone issues. So again, any problems that affect any of the causes of normal erectile function can lead to erectile dysfunction.

Dr. Lawrence Hakim: And medications in some cases. In younger men, we see it very often affecting men who have had injuries, sports injuries in young men can have erectile problems. So again, there's many, many different physiologic or physical causes. In addition to sometimes there are other non-physical causes such as stress or other more psychological. Although for the most part, most of the men that we treat have an underlying physical cause.

Annie Zaleski: What about the role of either if someone is a smoker or if someone's not in an optimal weight? Can that have an impact?

Dr. Lawrence Hakim: Correct. No, I think exactly for the same reason. Certainly cigarette smoking affects blood flow, affects vascular function throughout the body, and ultimately is a major risk factor for men who develop erectile dysfunction. And it also leads to, as a result of poor blood flow, the tissues and the penis can scar and they can lose length in the penis as they can with any erectile function. And interestingly, we tell men to stop smoking for a number of different reasons. We tell them to stop smoking because they're going to get lung cancer or bladder cancer and stuff. But when you tell them they're going to have a shorter penis, they stop smoking. So it's important for them to understand that this is a risk factor as well.

Dr. Lawrence Hakim: I think another important thing to understand is erectile dysfunction, in and of itself, is also a marker. And where that becomes critical, I think, is for many men, it's often the first sign of their vascular disease. And most men don't ever go to doctors for anything. Men are usually pretty poor patients. And so they may not see early signs of problems like coronary artery problems or hypertension or cholesterol problems, but all of these things can lead to erectile problems, and due to the vascular nature of the penis and the impacts that those things have. So it's not uncommon.

Dr. Lawrence Hakim: And this also gets into the diagnostic evaluation. When we start working up these patients that come, we'll look and find some of those vascular issues. When we do look at blood flow in the erection, for instance, on a diagnostic test, and we might find for instance that there's arterial narrowing or poor blood flow leading to the erection problem. But they may not realize that this could be a marker for instance of heart disease and not infrequently we'll then send the patient to a cardiologist who will do a stress test and, low and behold, they have a positive stress test and end up needing stents or surgery. So again, erectile function, we're not just talking about quality of life issues. We're talking about overall health as well.

Annie Zaleski: And I think that's really important because obviously this is something a lot of people could be embarrassed by or they might be sensitive about it. But the fact that it's a marker for some other serious health issues makes it even more imperative that you get looked at.

Dr. Lawrence Hakim: Exactly. And as you said before, I think that's critical, too. Embarrassment is a main reason why most men don't come in very early. And I think unfortunately now we're in an era in an age where men can buy over-the-counter treatments or mail order medications which may be beneficial for some, but can be very dangerous on a number of levels. First of all, you don't always know what you're getting. And the other side of it is they're ignoring that exact point that this is not a problem in and of itself, but it might be a marker of other issues such as we said poor blood to leading to heart disease, et cetera. So they're not doing themselves as service by ignoring it or not going to a physician to be evaluated.

Annie Zaleski: Well, along the same lines and I think if you go online and start reading, there's often things that are attributed to causing erectile dysfunction that reality don't. What are some of the biggest myths in terms of causes that you come across?

Dr. Lawrence Hakim: Well, I think there's a number of different myths out there. I think the important thing is to recognize that the internet is probably a pretty poor resource when it comes to really understanding the underlying cause and the individual's cause and the risk factors, which is why it's so critical to be evaluated by someone who is trained or specializes in this area. There's also a lot of treatments out there that are not FDA approved, not well tested, and can in some cases even cause damaged potentially. So I think buyer beware, I think you have to be very careful when you try and (a) self-manage and (b), look at some miracle treatments that are being advertised whether it's on the internet or locally by certain centers. You have to be very careful about that.

Annie Zaleski: So overall then I guess, what are some of the most common symptoms that you see associated with erectile dysfunction?

Dr. Lawrence Hakim: Well, I think the major presentation for many men with erectile problems are they're going to tell you that they've noticed over some period of time, and often it's many months or years, that their ability to get an erection or the ability to maintain the erection has diminished. They'll tell you that, "I used to be able to get a hundred percent erection. Now my erection's only 50% or 90% or 20% of what it used to be as far as hardness." They may tell you that it takes a lot longer for them to be able to get erect. They might tell you that they can get a partial or full erection, but they can't maintain that erection. So, I think all of those play into it. They might tell you they're having issues as a result of their poor erections, maybe with premature ejaculation.

Dr. Lawrence Hakim: So oftentimes different central functions can go hand in hand. They might tell you that they're noticing problems with penile curvature at the time of erection, which makes you start thinking about other issues such as Peyronie's disease. So those are some of the more common ways that these men present. They might tell you that they're feeling tired. They're not feeling energetic. They're not feeling interested in sexual activity. And that might lead to you thinking about some type of hormonal problem or a hypogonadism or something.

Dr. Lawrence Hakim: So I think there are many different ways that these men present. And unfortunately it's not very often that they come in immediately, and sometimes these problems have been there for quite a while. And that can have negative impacts on underlying health, but also on relationship issues, because this problem may have been going on in a marriage or some relationship for many years and causing some of these stressful issues that are associated with that as well.

Dr. Lawrence Hakim: So I think that's one of the reasons why it's so important to address this. And I think on another side, we have to think in terms of this is not just affecting the man in this case that we're talking about with erectile problems, but it's also potentially affecting their partner. And I always say that erectile dysfunction or sexual dysfunction's a couple's disease. It's not just affecting the individual. And that could be on many levels. It could be the problem that man is having, in some situations their partner, man or woman, might also be having sexual problems and that can lead to further stress and further issues. So we don't just look at the individual unlike in other diseases where let's say heart disease or other things, you're just focusing on the individual. When you're talking about erectile problems or sexual dysfunction in general, you kind of want to look at the couple as well or their partner as well.

Annie Zaleski: In light of that then, when someone comes in to get a diagnosis then, what kind of goes into that and what kind of doctor do you see? Obviously maybe a urologist, but can a psychologist potentially come into this? Walk us through that a little bit.

Dr. Lawrence Hakim: Yeah. I would say the primary person most men should be seeing for erectile dysfunction is a urologist, 100 percent. And we work very closely with other physicians, especially here at the Cleveland Clinic for instance, and for a number of reasons. First of all as I said, this can be associated with other problems, both urologic and non-urologic. The urologist is going to not only do a good history, do a good physical exam, but is also then going to look at what are the appropriate lab evaluations to do. Let's look at cholesterol. Let's look at PSA. Let's look at testosterone. Let's look at other things that may be part of the picture.

Dr. Lawrence Hakim: There's relatively specialized testing that are done primarily by trained urologists that can actually help make a better diagnosis and understanding what is the underlying cause. We can look at blood flow and do let's say a Doppler or a penile ultrasound, and sometimes using certain medications to really understand what is the blood flow situation? Is this a problem with poor filling or poor blood flow coming into the erection? Is this a problem where poor sustaining or not storing the blood well? Is there an anatomic deformity like we mentioned before, Peyronie's, which is a very common problem typically due to injuries during sexual activities, et cetera, that we see more and more especially now that there are some FDA approved treatments for it. So men are becoming more aware of it due to advertising.

Dr. Lawrence Hakim: So again, a urologist is really primarily positioned to be the initial evaluation for these. Now as I mentioned, when we see problems with let's say lipid problems, or cholesterol problems, or poor blood flow, we're going to refer that patient for a cardiologic evaluation, the stress test, et cetera. When we see problems that might be non-physical, maybe it's relationship stress, or other issues, or psychological issues, we're going to refer them to that psychologist, psychiatrist, or a sex therapist.

Dr. Lawrence Hakim: And again, if it's an etiological problem, sometime the urologist will manage the hormone side or sometimes they'll work closely with an endocrinologist. So again, it's a multifactorial approach, but the urologist typically is most well positioned to be the go-to person, especially if they're trained in that area.

Dr. Lawrence Hakim: And beyond that, the main reason is now when we start talking down the road about treatment options, who is going to be able to offer the most effective treatments, well, certainly a urologist is best positioned for that. Because while anybody can write a prescription for an oral medication, there are a lot of situations where medications are not either effective or appropriate for many reasons.

Dr. Lawrence Hakim: For instance, we see men all the time who go online or get the PDE5 drugs sildenafil (Viagra®) or tadalafil (Cialis®) and get them on their own. And you talk to them and yet they have medical issues like heart problems, and they're on nitroglycerin or nitrates, which are contraindications of these medications and extent.

Dr. Lawrence Hakim: So someone who's really experienced in treating this is going to really understand that. There are other types of treatment options we can get into, other medications, injection therapies, that a lot of non-urologic specialists are not going to be as comfortable and or experienced using.

Dr. Lawrence Hakim: And then we get into a whole area of surgical treatments which makes up a very large part of the treatment possibilities for many men. And certainly that's where a urologist is most well trained to do that. So again, a urologist, I think is someone who specializes especially in men's health and sexual dysfunction and prosthetics, is going to be able to offer all of those treatments as well as refer when appropriate for the different, as I said before, multidisciplinary specialties to address their individual problem.

Annie Zaleski: Well, if you do receive a diagnosis then what are some helpful questions that someone can ask their doctor information they can share? I think what you mentioned about making sure you say, "I'm taking these medications," is really important, but what other information is really important to share?

Dr. Lawrence Hakim: Yeah, and that's where the critical part of that initial history is so important. How long has this been going on? What other medical problems do they have? Do they have a history of heart disease? Do they have a history of lipid problems? Are they a smoker? What we're doing is looking at risk factors. Do they have some underlying neurologic problems? Have they had hormonal issues? What kind of surgical history have they had? Have they had any other major surgeries that can have an impact? Especially in some of the population we deal with, we look at PSA and look at prostate health? And we see many men who have had prostate cancer, who after a radiation therapy or medical therapy or surgical therapy, develop problems with sexual function.

Dr. Lawrence Hakim: So I think these are the things that the doctor's going to be looking for during that history as well. And again, a person I think needs to be honest about what types of sexual problems they're having and how long this has been going on, how what's the real impact, is there an impact? Sometimes we see minor or less severe forms of sexual dysfunction, which really aren't having a negative impact on the couple and that's important to understand as well.

Annie Zaleski: I mean, you mentioned all the different treatments then, so let's talk about some of them then. And I would imagine that not everyone is a good candidate for all the treatments. Some are more effective than others. Some you want to try before you go into something more involved. So let's talk a little bit, I guess, about some of those then. Talk first about lifestyle changes, obviously quitting smoking, but exercise, dietary changes, weight loss, things like that.

Dr. Lawrence Hakim: Yeah. And I think, well, and I think you kind of hit on the most fundamental point is that there's no one treatment that's right for every person or every couple. Every situation is a little different. We certainly want to offer the least invasive type of treatment that's effective for that individual, although for some men that might not be appropriate. The simplest things, as you alluded to, such as lifestyle changes, are always a positive. Although in every situation they may not necessarily reverse the erectile problem, in some cases, it may slow down the progression. It might make them healthier for other reasons. I mean, certainly cholesterol issues, smoking. We talked about weight control, diabetic control, all those issues. I mean, those are not only going to improve potentially some sexual health, but their general health and prevent strokes and heart attacks and other issues. So a lot of those lifestyle changes are not only beneficial potentially for sexual health, but for general health as well.

Annie Zaleski: Talk a little bit about medications then. Who's a good candidate for medications?

Dr. Lawrence Hakim: For many men, I would say the majority of men, medications typically make up a reasonable first line therapy. For like the last 25, 30 years, we've had effective oral medications for some men such as Sildenafil, Tadalafil. There's a number of PDE5 inhibitor drugs that are very commonly known, for instance, a trade name such as Viagra® or Cialis®. And for some men, especially with less severe forms of erectile function, they could be very, very excellent options in certain cases. They do have some potential side effects men need to be aware of. And as we talked about briefly before, they're not indicated for everybody. There are certain men who have certain types of heart issues or other underlying health issues where those may not be appropriate or may actually be contraindicated such as men who take any type of nitrate medication for let's say coronary artery disease or angina, et cetera.

Dr. Lawrence Hakim: But for men in whom they're safe alternatives, in whom they're effective, there's certainly a very reasonable treatment option to consider. In the evaluation, like I mentioned, we also look at lab evaluations and hormones. And one of the things that's so important, I think, for men to realize is that as they get older, certainly testosterone levels can diminish, and a normal or relatively normal testosterone level is important for the normal erectile function to be there. So when testosterone levels drop precipitously as men get older, or in certain cases even in younger men, you need to address that as well. So you need to be closely monitored for that and there are many different treatment options that can help to improve testosterone levels if they're low.

Dr. Lawrence Hakim: I think the important thing to realize is if they're normal, taking more testosterone makes no sense. In fact, you're telling your body to stop making it. And trying to be superman or super physiologic with testosterone can be dangerous. I mean, we see men sometimes whether it's from body building or weightlifting, or just some of these other centers that pop up, where they get very high doses testosterone, their levels can be so high as to be dangerous to lead to things like strokes. So men need to be very careful with that. No. 2, testosterone can lead to prostate growth which can affect PSA. So although testosterone replacement does not cause prostate cancer, and I repeat does not cause prostate cancer and is very safe for these men, it can have an impact on their labs and those need to be monitored closely for changes, et cetera. So that's an important factor.

Dr. Lawrence Hakim: And if testosterone levels are very low and are untreated, certainly certain simple medications like we talked about, Sildenafil, may be less effective. So it's important to try and normalize those levels as part of the treatment plan and lifestyle change, et cetera. There are different types of oral meds that we mentioned. Some are taken on demand right before sexual activity. There are some medications that are taken on a daily basis. And the advantage for some men is number one, not only can they help with their sexual function, they can help with urinary function, which can be important as men get older. And they can also give men a degree of spontaneity that is lacking with any type of on-demand treatment especially for sexual health. So there are certain advantages for certain medications that we look at in the individual. Yeah?

Annie Zaleski: Well, and you're right that it all depends on the person, their situation and I think there's just so many different situations and everyone's at a different kind of place, and so it really all depends and I think you really explain that well.

Dr. Lawrence Hakim: Right. And again, I think it's important to involve the partner and we certainly try and do that whenever possible because again, the treatment, the problem affects both of them. And we want to find a treatment option that's appropriate not just for the patient that's affected, but that is something that they can use together and the partner has buy into. And in men that don't respond to oral medications, there are other types of medications such as injectable medications that were actually used as a gold standard before the pills were produced and before they were approved. And for some men that becomes an option, too. That's something they use on demand where they give themselves a little injection with a tiny insulin needle which is pretty painless. And for some men it can give them adequate rigidity in erection that that can be an effective treatment option for their erectile problem.

Dr. Lawrence Hakim: There are potential downsides with that as well. So it needs to be monitored closely. It needs to be used when appropriately and so again, it's something that needs to be treated by urologist, by someone who can manage not only the underlying problem, but potential complications associated with the treatment option.

Annie Zaleski: Well, speaking of different options too, I know low intensity shockwave therapy is something that's come up. Talk a little bit about that and how is that effective and who's a good candidate for that.

Dr. Lawrence Hakim: I mean, at this point, it's still considered experimental, and the major organizations, the Sexual Medicine Society of North America put out position statements telling men that these are not FDA-approved treatment options, that they are considered experimental. And that really if they're going to be used, should be done in a more academic setting and in a place where that can be done appropriately.

Dr. Lawrence Hakim: There are no good long term studies that show that the shockwave lithotripsy low intensity can be an effective treatment for everybody. And there might be a role for it and it's certainly being looked at very closely, but at this point it's not something we recommend certainly as a first line therapy for someone who's looking for something that's an FDA approved effective treatment option. But there are studies going on in many centers around the country and it's certainly something that people are looking at more closely.

Dr. Lawrence Hakim: I think the other thing is there are many different forms of technologies being utilized that give those shockwaves and some may or may not be more effective than others. So again, it's not really there yet as a treatment that we recommend, as again, it's not an FDA-approved therapy for erectile problems.

Annie Zaleski: Talk a little bit about implants, too. I know that that's come up and that's something that people might have read about as well.

Dr. Lawrence Hakim: Yeah. And I think for many men, especially men who have a more significant or severe form of erectile problems, penile implants are really the only treatment that fix their problem. And the advantages of implants are that it gives men with a more significant or severe form of erectile problems, and those typically are men who have tried pills or they've tried injections or external devices, which is a vacuum erection device which has been around for many years, which tends to be a little more cumbersome, not as natural. But it gives these men the ability to get and maintain a rigid erection anytime they want on demand for as long as they want. So it gives them really an excellent opportunity to restore their sexual function. And the satisfaction level among penile implant patients and their partners is incredible because it does fix the problem for them.

Dr. Lawrence Hakim: And many of our implant patients (and we do implants every week) regret that they waited so long to have an implant done. So I think for many men it's an excellent treatment option and it goes back to what we talked about before. There's no one treatment that's right for everybody. For some couples having to take a pill every time they want to have sex or have to give themselves an injection, even if they're effective, is not something they want to do. They want something that's going to be more spontaneous, that's going to give them the ability to have sex when they want, whenever they want, wherever they are, for as long as they want. And that's where penile implants really shine in that they give men that ability.

Dr. Lawrence Hakim: It's a 30- to 40-minute procedure, typically done as an outpatient, and again, it's completely concealed. No one knows it's there except the man or the couple that are using it, and it has no effect on their urinary function or sensitivity. It's just there to give them the quality of erection. And again, for the men and couples and whom other treatment options are not ideal or are ineffective or contraindicated, it fixes the problem and that's one of the reasons that penile implant surgery has become so popular.

Annie Zaleski: So are there any other treatments we haven't talked about that you want to point out or mention, or that are popular or things that you recommend?

Dr. Lawrence Hakim: Yeah, certainly. Well, I think we mentioned briefly the use of a vacuum erection device. It's basically a simple cylinder, some used often with a little constricting ring, very commonly used in what we would consider like penile rehabilitation, or someone, for instance, a man who's had prostate surgery and has initial loss of erectile function, to help not only maintain some of the length, but also to maybe improve blood flow and potentially help restore their function sooner.

Dr. Lawrence Hakim: I think another area of sexual problems and erectile that are often associated with erectile problems are in the area of Peyronie's disease. And we see this much more, not that it's more common now, but men I think are more willing to come in and talk about it more. And in part, because like I said, there are now FDA approved treatment options. So men are more aware that they're not alone and that there are opportunities for them to be treated. And we see many men each day with Peyronie's.

Dr. Lawrence Hakim: And so there are specific medications in addition to some of the treatments we talked about that can be effective for those men as well. There's what we call intralesional therapies, which are medications that are actually injected into scar tissue or the plaque of the Peyronie's to help improve penile curvature or straightening. There are external devices, stretching devices, that could be used in conjunction with that help improve loss of penile length and also enhance straightening. There are many very effective surgical treatment options for men that don't respond to the simple treatments to help them restore a more normal sexual function, more normal erectile function. And even penile prosthetics can be very effective for men who have combination of severe erectile problems as well as Peyronie's.

Dr. Lawrence Hakim: So I think the take home message is that the problem can always be fixed. And I think that's really something that very few areas of medicine can tell patients. That's I think one of the most amazing parts of our field within men's health of sexual health is that almost regardless of the problem, it could certainly be improved and often always be fixed. There are many different treatment options out there. There's not one that's right for everybody, but depending on what the underlying problem is, that can often be addressed or the end result can lead to much more normal erectile function, whether it's with medication or surgery, et cetera.

Dr. Lawrence Hakim: Again, the first step is men need to make that first step and see someone who's really trained to deal with this and not rely on the internet or going to someone who doesn't really focus on this area because your options at that point are going to be much more limited. And again, the negative we talked about before is you might be missing a severe underlying problem that needs to be addressed as well. So again, this is a multifocal multidisciplinary approach but the beauty is that it could always be fixed. And I think that's one of the important take home messages that men and couples and their partners need to understand.

Annie Zaleski: So when people do get treatment, then how quickly can people see results then?

Dr. Lawrence Hakim: Well, depending on the treatment option, they could often see results immediately, sometimes even in the office. I mean, depending on the type of injection therapies used, some of the responses are immediate. But many of the men, especially with more minimal to moderate erectile problems can see improvement in their function almost immediately with medications. And like I said, depending on the underlying degree of the problem will depend on the type of therapy and ultimately the type of response that they get. But, you know, it's something can always be improved.

Annie Zaleski: So you mentioned that understandably people might be reluctant to go to the doctor or reluctant to talk about this then. Do you have any tips for people on either how to make this easier or ways they can talk about this?

Dr. Lawrence Hakim: Yeah, sure. I mean, first of all, you want to have an honest conversation with your partner ideally, and that's sometimes the hardest thing for many, especially if they've been in a long term relationship. We see that as a problem. And the problem is when they don't talk about it, the sexual function or the sexual side of their relationship can go away and that can lead to other stressors and other problems and lack of communication. And men, by definition, are horrible communicators. It's true. I mean, so I think that's important for men to try and communicate this problem with their partner.

Dr. Lawrence Hakim: The next important thing is, as I mentioned earlier, you need to seek out somebody who's really specialized in the area. If you had a brain tumor, you're not going to go to an internist or you're not going to go to someone who doesn't specialize in that treatment. You need to go to someone who's going to do the right workup, who's going to give you reasonable options, who's going to understand what the underlying problem is and really address the whole picture. And I think that's really the take home message is that you need to make that first step. You need to seek out somebody who has that expertise.

Dr. Lawrence Hakim: And most major cities, there are people at the Cleveland Clinic. You have amazing people at all the clinic centers that really focus on men's health and in their practice. And as importantly is, at a place like the Cleveland Clinic, you have that multidisciplinary approach. You're not just looking at it from the urologic side, but you're looking at it from is there a cardiology problem? Is there an antigen problem that you have to see an endocrinologist? Is there some other problem? Is there a lipid problem you're going to see your internist for? And the team works together to try and not only improve sexual function, but to improve health in general. And anything that you can do to improve health can potentially help improve sexual health as well.

Annie Zaleski: For partners then who might be dealing with a partner who is having issues and might be obviously distressed about it, what sort of advice do you have for them?

Dr. Lawrence Hakim: Well, it depends. I mean, no. 1 is the partner distressed because of the male's erectile function? And if that's the issue, again, it goes back to communication and trying to get to the right person for them to be evaluated. If it's a female partner, sometimes we see that sexual dysfunction in women is as common as it is in men. And there's certainly many different reasons for that. And they need to also be evaluated. And very often we'll see a couple who's been married for many years. The woman might be postmenopausal or have had some other procedures that have led to problems with her sexual function. And we can't just treat the male side and it get better without addressing that as well. Because that's not going to fix the problem, because she might be having issues with pain issues or other types of arousal issues and orgasm issues.

Dr. Lawrence Hakim: And those need to be addressed or you're not going to improve their quality of their sexual relationship if you missing half of the equation. So I think that's why I said before that erectile problems and sexual dysfunction is a couple's disease. It's something you really need to look at as well. And while the urologist may or may not be the expert let's say in a female sexual dysfunction side, there are many doctors out there who do specialize in that that can address. Maybe it's a hormonal problem. Maybe it's some other issue that needs to be addressed. And again, maybe there's stress issues that need to be evaluated with a psychologist, et cetera. So again, it's multifactorial multidisciplinary, and it involves both the patient and their partner.

Annie Zaleski: How often then is something like maybe couples therapy part of treatment then as someone who's going along?

Dr. Lawrence Hakim: Yeah, it depends. I mean, it's not uncommon — couples therapy as far as psychology or sex therapy. Oftentimes if there are physical issues that can be addressed, maybe a little less necessary because you address those physical issues and if there are no underlying psychological stressors, then that kind of can fix the problem. But when appropriate, I think it's an excellent option to offer couples and anything again that can help bring their communication better, that can lead to improved health, can improve their relationship as well.

Annie Zaleski: Well, this has been a great, comprehensive conversation today. Is there anything else you want to add?

Dr. Lawrence Hakim: No, I think we've kind of hit most of the topics. I mean, again, the take home message for men and for women, you're not alone. This is a problem that affects more than half of men over 40. And again, it can occur at any age and there are experts out there that can help you, and there are excellent treatment options out there. And it could always be fixed and always be improved. But you need to make the first step. And once you do that, hopefully the problem can be addressed.

Annie Zaleski: Excellent. Dr. Hakim, thank you some much for being here today.

Dr. Lawrence Hakim: No, thank you so much. It's a pleasure. Thank you.

Annie Zaleski: If you're experiencing erectile dysfunction, a urologist can help you figure out the best treatment so you can resume living your life. Visit www.clevelandclinic.org/urology, or call 216-444-5600 for Cleveland appointments or 954-659-5188 for appointments in Florida.

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