Why More Health Systems Should Adopt a Multidisciplinary ED Approach
Erectile dysfunction (ED) is incredibly common, affecting about 30 million men in the United States. Of course, that number includes all forms of ED and both short-term and long-term cases: the inability to get an erection anytime, getting one only on occasion or simply not being able to maintain one long enough for enjoyable sex.
Regardless, every form of ED shares one trait: It sucks.
For many men, it's embarrassing. For others, it can negatively impact the overall quality of life. ED can ruin intimacy in relationships and lead to a host of other issues, such as anxiety, depression and low self-esteem.
The bright side is ED is usually treatable, assuming men are willing to talk about it with their healthcare providers and follow through on treatment. Given that many men don't go to their doctor for checkups, it's not surprising they have a difficult time opening up about an issue many of them consider shameful. On the flip side of this communication issue, as more men open up and discuss ED, they all aim to benefit from two major advantages: the lessening of the embarrassing stigma around ED and learning more about treating the condition.
The many factors that contribute to ED
"There are a lot of factors that play into erectile dysfunction, and sometimes it's difficult to tease out just one or two," said Mehdi Shishehbor, D.O., M.P.H., the president of the Harrington Heart & Vascular Institute at University Hospitals Cleveland.
Recently, Shishehbor helped one of his patients overcome a 30-year struggle with ED. Tony is a Floridian in his 60s who sought and failed, for decades, to find successful treatment elsewhere. The issue? Tony had a blockage in his veins that prevented blood flow to his penis; several other doctors told him ED was "all in his head."
"In his case, he had atherosclerotic disease that had caused blockages in the arteries that supply blood to the penis," Shishehbor said. "But you know, if you have that, then you lose your confidence, then you have psychological issues, then it's just a vicious cycle that keeps adding upon itself."
Nannan Thirumavalavan, M.D., University Hospitals' chief of male reproductive and sexual health, said the classic textbook teaching indicates if a man's morning erections are fine or he's still able to get an erection on occasion, then the cause of his ED must be psychological.
"But as we're learning, that's not really true," he said.
"That's what I want to emphasize," Shishehbor added. "Erectile dysfunction is very complex. There are multiple causes, and many times they overlap with each other. The same guy who has blockages might also have depression, lack of confidence. Many have hormonal issues, to be honest. So it's multifactorial, and you need a team of experts—endocrinologists, urologists and vascular specialists—taking care of these patients."
Looking at a patient's ED isn't just important for accurately diagnosing the cause of the ED itself, but it might also be helpful in identifying whether their ED is actually a symptom of another condition.
"We will often refer a patient to a cardiologist for a cardiometabolic evaluation," said Kathleen Hwang, M.D., a urologist with the University of Pittsburgh Medical Center (UPMC). "This is often the case when we have new-onset erectile dysfunction and have concerns that the ED may be the first symptom in someone where their cardiovascular health is at risk. The most prominent causes of ED include diseases that influence the health of your blood vessels, including diabetes, high blood pressure, high cholesterol and heart disease."
The penis relies almost solely on blood flow for getting and maintaining erections. A decrease in blood flow could point to potential cardiovascular issues. Human bodies are very much like trees or roadways; the body systems are interconnected and reliant on each individual component.
Patients should seek teams of experts to help with issues
Most people don't often think about it, but a strange feeling in their foot or wrist might be linked to an issue with their lungs, for example, or perhaps with their kidneys. The body's processes don't exist in separate vacuums.
"Forget about sex for a moment," Shishehbor said. "Erectile dysfunction by itself is a risk factor for heart disease. That doesn't mean it causes heart disease, but it's predictive. It means there's something in your body that's happening and has caused erectile dysfunction. That same thing could be affecting your heart. In this way, erectile dysfunction can be fascinating, really."
Of course, psychological factors may play into ED, creating a "vicious cycle," as Shishehbor said. But it's important for healthcare professionals and patients to consider other components that could be contributing to the development of ED, not ruling them out or dismissing them solely as psychological.
'What's important is for patients to be able to ask for second and third opinions, [and] look for teams to take care of your condition.'
For Tony, this was his biggest issue. He knew there was a blockage in his veins, but for years, the specialists he spoke to either dismissed this as the cause of his ED or admitted there was nothing they could do about it. While he learned to manage his sex life despite his issue, it was incredibly frustrating to have limited function due to a known cause that seemingly nobody could fix.
"I think patients now, as consumers, are very smart," Shishehbor said. "There are multiple modalities and tools for them to search and identify the right care. Either through the internet, social media, whatever it is, there are a lot of opportunities out there for folks to learn and to be able to get second and third opinions. And I think what's important is for patients to be able to ask for second and third opinions, [and] look for teams to take care of your condition."
Shishehbor's recommendation for patients is to look for organizations and programs that are system-based and multidisciplinary to ensure they're getting the proper treatment. For example, you might exclusively see a urologist who recommends a penile implant when, in fact, the best option for your condition might be a stent, a wearable device or a testosterone injection. Perhaps the issue is psychological and requires the assistance of a sex therapist.
"Multidisciplinary teams of experts bring different value to the table," Shishehbor said. "It's a patient-centric, therapeutic kind of algorithm that is specialty-driven. We need to break those barriers and identify the best approach for each patient."