Erectile Dysfunction as a Warning Sign for Other Men’s Health Issues

[Dr. Amy Pearlman]:
Awesome. Let's begin. We know that PDE5 inhibitor medications are going to work in a large majority of patients, but they don't work in everyone, and they may not be as efficacious in men who have low testosterone. Now, looking back to my days when I was a student at Baylor, I remember very vividly you were giving grand rounds to the department, and you were talking about testosterone, transdermal formulations, and I was blown away. I was like, "This guy is a rock star."

I remember sitting in that room as a medical student. You are one of the most outspoken people when it comes to testosterone. How does testosterone play a role in the efficacy of PDE5 inhibitors?

[Dr. Mohit Khera]:
So much to talk about, Dr. Amy Pearlman. Let's talk about testosterone first. We know that testosterone has been used and first synthesized since 1935. It's been around for a long period of time. If you look, testosterone is so important for overall erectile function and preventing cavernosal atrophy, helping with improving the efficacy of PDE5 inhibitors. I was very fortunate. I was on the 2018 AUA guidelines for ED. It is true, we said that testosterone should not be used as monotherapy for erectile dysfunction. We still put it in the guidelines because it works phenomenally in combination therapy with PDE5 inhibitors.

I'll give you an example. A man walks into your office, he's hypergonadal. You start him on Viagra. It doesn't work. If you start him on testosterone supplementation, the literature would support that 30% to 50% of non-responders will become responders to PDE5 inhibitors by putting them on testosterone as well. That's in the guidelines. That's in the AUA guidelines. That's why we do it. Now, do I think that testosterone as monotherapy can be effective? I do in certain populations, certainly for patients who have very low starting T levels, like say, 200, 150, they'll see a dramatic increase as well.

Patients with mild to moderate ED, I do think it makes a significant difference. I do think that patients who don't have a significant number of comorbid conditions, that'll throw you off. There is some benefit, but yes, testosterone is very important for overall erectile function. Clearly, it's why we check it also, and then it's in the guidelines who present with ED.

[Dr. Amy Pearlman]:
Is any man presenting with ED, is he getting his testosterone level checked?

[Dr. Mohit Khera]:
No question. No question, are they getting their testosterone level checked. Now look, ED is a marker of poor health. Let's be honest. It's a marker of cardiovascular disease. It's a marker of depression. There's no question. Depression is also a marker of diabetes. By very nature, men who present with ED are more unhealthy. In the same token, testosterone is one of the best barometers of a man's overall health. For example, a man with low T, no question, increased risk for cardiovascular event. That's in the AUA testosterone guidelines.

Low T is a marker of increased risk of having a cardiovascular event. Low T is a marker of obesity and diabetes. Low T is a marker of depression. Low T is a risk factor for bone fractures. We know in the literature, low T is associated with, I'm not saying causing, is associated with prostate cancer. The lower the T, the more likely to have prostate cancer. You show me another blood test on the planet that has more associations with more comorbid conditions. It's not your lipids. It's not your thyroid. Low T. Every man, I believe, over the age of 40, every man, should have a testosterone level checked once a year. It is the best marker of overall health and your future overall health.

[Dr. Amy Pearlman]:
Mo, I was recently at the gym and I was listening to you on a podcast. That's my favorite thing to do as I'm at the gym. I'm either listening to you or Dr. Morgenthaler on a podcast on YouTube. You made that comment. If there's one test that you would want to get checked in a man, it would be his testosterone level. Is it ever too early to check a man's testosterone?

[Dr. Mohit Khera]:
Why not? We know that levels decline with age, and sometimes it's not the absolute, it's but the Delta. Men starting out at 800 level, and you drop them down to 350. Yes, he's still normal, but the delta can be an issue. Every man has his own set point. Maybe mine is 350, maybe someone else's is 450. That's why I found it ridiculous that we have this number of 300, and at 290 everyone must feel bad, at 310 everyone must feel good. That's not what happens. We all have our own number.

Sometimes I think that some patients have a higher number to be at where they tend to see symptomatic improvement. The big mistake is a man comes in at 250. I start him on testosterone supplementation, I take him to 400 and he says, "I still have symptoms." You have two options. You can say, "Well, you're normal, so something else is going on," or raise them even higher, still in the normal range, to see if there's some benefit. That makes more sense to me. Maybe his set point is 450 or 500. We need to raise him higher to a higher level.

I think that many men, at least 30% of men, if you just raise them to the upper quartile of normal, you can salvage someone who's not responding to T to have someone who is responding. Again, be sensitive about the fact that not everyone has the same number.

[Dr. Amy Pearlman]:
Are we failing young men as a healthcare institution, like the guys who are in their 20s and 30s? Are we failing them by not getting them into the office and checking these baseline levels?

[Dr. Mohit Khera]:
Yes. I love this question and Dr. Amy Pearlman, this is something I'm very passionate about. I think we're failing them in a different way and let me explain why. When I was 30, if you asked me to go in and get my blood pressure checked, there's no way I'd do that. Just annually. If you asked me to go get my hemoglobin A1c checked, there's no way I'd go in for an annual checkup. If a man gets erectile dysfunction today, a young man, he is at my door first thing tomorrow morning. He's ready to talk about it. It's like, "What is going on? This is horrible." They come in.

There've been numerous, very impressive studies looking at young men. One of them came out of St. Louis, ages 18 to 40, finding that when the men came in for ED, 30% on the spot were diagnosed with diabetes or prediabetes. That's pretty impressive. 30%. There's this concept called area under the curve, which means if I catch your diabetes at 30 or I catch it at 40, the 10 years I would've waited to catch it at 40 is 10 years of damage that occurs to the vessels and to the body. 10 years. That's a lot of damage.

If I catch it at 30 and intervene, the trajectory of your life, health span will change. The trajectory. Catching it early. What is the biggest mistake that urologists or a lot of my colleagues make, and I'm just as guilty when I started my practice. The biggest mistake is to hand them the Viagra and say goodbye. That is the mistake. That's what 99% of us do. Like, "Okay, here's your Viagra, erections are going to be fine. Let's go," and not looking for cardiovascular disease, diabetes, or even intervening on lifestyle modification.

If I say, "Mr. Schmidt, you're 28 years old, you got ED, but let me tell you something. If you improve your diet, exercise, sleep, and stress reduction, you will significantly improve your erectile function," he's going to listen. He's going to listen to me. I'm secretly improving his health span and his lifespan as well. The mistake again is, I hand him Viagra and say, "Hey, we're all good." He says, "Yes, we're all good," and he leaves. That's a problem.

[Dr. Amy Pearlman]:
A little bit off topic, but certainly related to your field with you directing the andrology lab, should we also be offering semen analyses for these young men for baseline information?

[Dr. Mohit Khera]:
Yes. You're hitting another important topic. As I mentioned to you, I think that testosterone is one of the best barometers of a man's overall health. I can tell you so much about a man's health with the testosterone. The same goes with a semen analysis. You look at our colleague, Mike Eisenberg, a beautiful paper showing that semen analysis-- if a man has a poor semen analysis today, it's a predictor of future cardiovascular events, comorbid conditions. That's a predictor, and it was very strong.

If you have a poor semen analysis today, I can tell you in the future that you may have an increased risk for diabetes, metabolic syndrome, and having a heart attack. Another one of our colleagues, Tom Walsh, showed a great paper showing that if you have poor semen analysis today, it's a predictor of cancer, prostate cancer in the future, testicular cancer has been shown as well. It's well known, the nature of the land is fertility is a marker of overall health. The more healthy you are, the more fertile you are. The more unhealthy you are, the less fertile you are. That is how it works. It's a predictor of future health.

I think that getting a semen analysis is an excellent way of predicting future health. Now, it's a lot easier to get a T level than just to take semen analyses of men, but I agree with you. It's a wonderful window into a man's overall health is a semen analysis.

[Dr. Amy Pearlman]:
Yes. I think one of the things that we as urologists need to learn too, in order to make this more accessible, is which are the therapies that maybe patients could do at home to make it a little bit more cost effective, especially for the young man who may not have an issue, but wants to at least do some sort of screening test or baseline. Do you use any at home technologies for semen analysis testing?

[Dr. Mohit Khera]:
Yes. A Fellow is fantastic. You've seen that also. They're a great company.

[Dr. Amy Pearlman]:
I use them as well.

[Dr. Mohit Khera]:
Yes. They ship the kits. You can ship it back. It's a lot easier. Some men are very uncomfortable leaving a semen analysis in the office, so it's a little more difficult. They can do this at home.

[Dr. Amy Pearlman]:
Can you believe that we still have people do that?

[Dr. Mohit Khera]:
We still have people who do that. Sometimes, particularly when you're in the office for a visit, and if you have your semen analysis connected to your office, then it's very easy. They can do it right there. You usually get the answer within 30 minutes. It's fast. You're right. Fellow does help with making it discreet. It's more comfortable. You can do it at home. It's a nice window into your fertility, but also, I believe, your overall health. Getting a testosterone level check. These two tests are not expensive. They do help predict overall health.

[Dr. Amy Pearlman]:
Mo, you're doing some really interesting research using the Tech Ring by Firm Tech at Baylor, and you're using it in men who are on testosterone therapy. Can you talk a little bit about the role of this device in testosterone patients?

[Dr. Mohit Khera]:
Yes, this is a great invention. Remember that historically, we used to use MPT testing, and that is very archaic in how we would measure a man's erections and how long they would last. Now we have the Firm Tech, which Bluetooth's automatically to a man's phone and you can get incredible real-time data, how long the erections are, how rigid the erections are, how often they get the erection. What's amazing is that you can do any intervention you want. You can give drug X, you can give drug Y, you can give testosterone, and look at the before and after on the Firm Tech, and it gives you wonderful data on how well that therapy is improving.

Remember, men get anywhere from three to five erections every night, then you want to then see if they're getting these nocturnal erections and how rigid they are. Great piece of information, but flip it, not only is it a great research tool, it's great to prevent venous leak. It's the same instrument, the same band that we've been using for decades to help, because again, remember, most of ED is venous leak. How do we as urologists treat venous leak? We try to overcome it by increasing the inflow.

That's what we've always done. I tell the patient, "Hey, your inflow is 10, your outflow is 15. Why don't we increase your inflow to 20?" That'll work, or use a Firm Tech and decrease the outflow. That's a very effective treatment. What's nice about Firm Tech, a lot of patients like it because it's not a drug, it's not a pill. It doesn't cost every time you use it. You've already bought it. There's a benefit in cost and in terms of safety, I think.

[Dr. Amy Pearlman]:
If we go back to our earlier discussion, what are the things that a young man should know about his body? We spoke about testosterone, we spoke about a semen analysis, and now we're talking about erectile fitness. Maybe this is like the triple cocktail for young men to get them engaged in their bodies in the healthcare system. Perhaps what you so eloquently talk about all the time, the four things that are responsible for lifestyle modification to improve overall health. How do we get people to change behavior? We give them data, and we track it before and after.

[Dr. Mohit Khera]:
Yes. I think you said something very important. Look, and I follow Peter Attia. He had a great book that came out, Outlive, and he talked about medicine 2.0 and 3.0. The reality is that what we do today in medicine is reactive. "I'm going to wait for that heart attack, and I'm going to put you on a cardiac diet and have you exercise. I'm going to wait for that diabetes, I'm going to put you on metformin, and I'm going to try to decrease your diabetes." That's a mistake. That means our healthcare system waits for the problem and then tries to treat it.

That's what we do for sexual medicine. We wait for the ED, and then we treat it. Then the ED gets worse because our treatment is just a band-aid on a problem. Then we go to the injection and the implant. Wouldn't it be great if you met the patient 20 years earlier somehow, before they had the ED, and we started something that would prevent the ED from happening in the first place? That would be ideal. It's idealistic. Maybe that can't happen. I do look at the patient presenting with mild ED who asked for Viagra as exactly the patient who presents, who gets a hemoglobin A1c, and it's 5.9. He's pre-diabetic. He's sitting there. You have a couple of options.

Now, you can start with lifestyle modification of that pre-diabetic and get that hemoglobin A1c below 5.7, and the same goes for that guy you're giving Viagra to. You can either help him now and help him reduce the ED with lifestyle modification, which does work, or you just let the ED and the diabetes get worse, and you treat it when it goes on. That's what we do right now. We just give them the Viagra and say, "Call me when it stops working." You start the injections, "Call me when it stops working. Okay, let's go to the implant." That's our model. That's the model we do today. It's very archaic.

We know that lifestyle modification can work. We knew that some of the regenerative therapies have a tremendous amount of promise as well. I do feel like it's important to be proactive about your sexual health as opposed to just being reactive and waiting till the problems get worse.

[Dr. Amy Pearlman]:
Whose job is that to have these conversations?

[Dr. Mohit Khera]:
Our job as urologists, I think, is to educate the patients on this natural history that's going to occur. I think we are the leaders in the field. We are what we call the experts in sexual dysfunction. I think that we have an obligation to educate. I know we are all under time constraints. I get it. It's tight. With modern technology, there's ways to make handouts, videos, social media. There's ways to educate besides face-to-face now. You know that, and you know that better than anyone. I think that's very important. I still think that the system is designed to say, "You got ED, here's your pill. I'll see you later." That's how the system works right now.

One more thing, Amy, women. We are the experts in male sexual dysfunction, but we have an ability to actually be experts in female sexual dysfunction as well. I know you have a good interest in this as well. It is very important. Remember, it is not about that patient, that male patient sitting across from you in the exam room. It's also about his female partner sitting at home, and it is a disservice to skyrocket his libido and skyrocket his erections, and he has no one to have sex with except some woman at home that's, "We're going to be miserable and fighting with him every day now because things were great before he met me." You’ve got to be very sensitive to what you are really trying to accomplish.