This presentation from urologist John Lindsey, MD, lays out the numerous contributing factors as well as treatments for erectile dysfunction, which affects about 30 million men in U.S. but isn’t always discussed during regular checkups. Lindsey offers help with navigating the sensitive topic, doing a complete diagnostic physical exam and running useful labs. He explains therapeutic options, including how to adjust oral meds for certain side effects, and describes investigational and experimental treatments.
All right. So, uh, good afternoon, everyone. Uh, as, as you mentioned, we're gonna talk about erectile dysfunction today. Uh, I'm John Lindsay. I'm in the department of urology at UCSF, uh, and I'll, I'll start with my first little soapbox here. Um, so, ED is tough to talk about, uh, it's tough to talk about for patients and, and also for providers. Um, I think ED as a label can, can sometimes negatively impact self-image. So it's kind of icebreakers instead of, you know, saying, you know, do you have ED or diagnosis of ED, I try to ask, how is your erectile function, how are your erections? Uh, a little bit about me, so, uh, you know, she mentioned most things in the bio there, but I did residency here at UCSF, uh, which I completed in June of, of last year. Uh, and then I just finished a fellowship in male reproductive health at Baylor, uh, in June of this year. Um, so there's kind of three, main aspects of that fellowship, uh, fertility, sexual medicine, and hypogonadism, and, uh, we'll touch on primarily sexual medicine with a little bit of the, the other two. Uh, and also I'm a new faculty with the department, just started on, on September 1st, so, uh, any questions after this talk, uh, please feel free to, to shoot me an email, um, and, I'm happy to discuss further. All right. So, uh, where are we headed today? I'm gonna talk about a couple of clinical questions, uh, a little bit about the physiology and pathophysiology, uh, evaluation, treatment, and a little bit of, uh, possible innovation, uh, in the field. Uh, so, you know, I asked my, my roommate from med school, uh, what are, he's, he's an internist. I asked him, what are three things you want to hear about, uh, in a talk on erectile dysfunction. So I'll use a couple of those things as, as an opener and to stimulate any questions that you, you might have, uh, after this talk. So, uh, the first thing he, he suggested is the differences between the first line agents, and that's a good place to start. So, um, as of 2018, our guidelines now. are operating under this kind of shared decision making framework so that there is no true first line. So if a patient presented with erectile dysfunction, any of the treatment options for erectile dysfunction, should be available to them. So whether that's oral medication or penile prosthesis, if, if you and the patient together decide on a prosthetic, for, for instance, then that's a reasonable first choice. But to that end, I will say that. Um, most patients that I've seen, um, start with an oral medication before moving to some of the other, um, uh, treatment options just cause it's, it's a pretty simple thing to try. Um, and then, you know, moving on with the differences between the first line agents, so here's a little schematic here and we'll talk a little bit more about it, but, um, you know, amongst the various agents, whether it's, you know, Cialis, Viagra, Levitra, um, or Avanafil, I forget the commercial name for that one. Um, they all work on, uh, if you can see my arrow, this PDE5 and, uh, um, enzyme, uh, to increase, um, the, um, cyclic GMP, this little molecule here, and ultimately that's gonna improve blood flow to the penis. So we'll talk a little bit more about that, but going back into the, the differences between the agents, so, um, oh, we're clicking too quickly here. Let's see. OK, so, um, You know, these 1st 3, so sildenafil, which is Viagra, Venafil, which is Levitra, and then tadalafil, which is Cialis, um, they're all equally efficacious. So, um, you know, choosing between efficacy is not a kind of decision point for you. They all, they all work well. Atlantaphil, it's just, it's, it's the newest one, and so there's just just less data on it. Uh, it's kind of claim to fame is that, you know, it can, you know, uh, be ready in, in about 15 minutes, a little bit faster onset there. Um, uh, one thing that, uh, is helpful for, for patients and, and getting optimal performance from their, uh, PDE5 inhibitors, Viagra and, and Levitra in particular, uh, those two can be absorbed by fatty foods. Uh, so I will often tell patients, um, taking this medication, it's Um, typically on a, on a PRN basis, so that, um, nothing to eat for 2 hours before you take that medication, cause it takes about 2 hours for the uh stomach to empty, um, and then you're gonna be taking that medication about 30 minutes to 1 hour before sexual activity, and that will give them the highest bioavailability of that medication, you know, you, you're not harming anything if you take that medication right after dinner, for instance, but you just may not be getting the full, um, full availability of the medication. Uh, so that's one difference, uh, between the two. tadalafil, uh, it's, its main difference is it's a very long half-life, so you can see, um, you know, it's about 18 hours for the half-life. Um, and, and that has, uh, implications for its, its administration. So instead of taking it an hour before, uh, which you can do, um, I will often prescribe, you know, a dose of about 5 mg. You take it daily, it doesn't matter what time of day, um, and then it's always there in the background, so your erections are more on demand. Uh, another kind of side effect that's, um, mostly, um, you know, uh, attributed to Viagra is this kind of blurry vision or blue vision, and that's because in addition to inhibiting that enzyme, that PDE5, there's cross reactivity with some of the other phosphodiesterases. I think it's number 6, but don't quote me on that. Um, and then, you know, to a lesser degree, uh, Vardenafil, Levitra, or tadalafil can also have that, but, uh, most often see that with, with Viagra. Um, Cialis, which, um, you know, maybe a higher dose is like the 20 mg, um, but even, even sometimes some patients with the 5 mg daily can have back pain, and so that may be a reason to, uh, to switch to the other ones. And I don't know that it's clear why the back pain occurs, but likely related to, to vasodilation. Um, and then, you know, speaking of the vasodilation, um, all of these medications, uh, can lead to headache, facial flushing, kind of a feeling of stuffy nose because it's dilating those blood vessels, uh, in the head and the blood vessels in the nose. Um, so, for instance, if someone's on 100 mg of, of Viagra, uh, and they're having, you know, uh, the headache and the facial flushing, maybe cutting that in half to 50. I might still give them, you know, um, uh, that response, uh, for, for an erection, but it might reduce those, those side effects, so things to consider. Uh, so another question my, my roommate from my school, uh, suggested was when to refer to urology. Uh, so I would say, you know, uh, of course, after failure of oral PD-5 inhibitors, uh, but again with that shared decision-making model, if they wanted to discuss, you know, all the available options before starting the oral, that would also be reasonable and reasonable to refer in that instance. Um, any younger patients with a history of pelvic or, or perineal trauma, uh, patients with significant penile deformity, so that could be, uh, an indication of Peyronie's disease, uh, and in those instances, we're looking for. Um, curvature that's, uh, preventing sexual activity or um looking for plaques that we can potentially intervene on. Uh, and then patients with hypogonadism. I know many primary care providers are, um, comfortable with testosterone therapy, but, uh, if not, um, you know, urology is, is a place where, um, they can potentially receive that testosterone therapy. All right, so moving on to anatomy and physiology, uh, the penis is comprised primarily of three cylindric structures, um, you know, kind of on the, the top side there, there's the two main chambers, uh, the corporal cavernosa, um, And then on the underside, uh, there's the corpus fungiosum, which surrounds the urethra, and all, all three of these chambers will engorge during an erection. Um, uh, another kind of thing that is useful for us when we're treating them is that these two top chambers, um, are connected, and so when you're doing therapy like penile injection therapy with, uh, trimix, which I'll talk a little bit more about, you only have to inject one side, uh, to get that effect. The main arterial supply to the penis is this internal pudendal artery. Um, and then, you know, a little bit more about the, you know, physiology. So, uh, you know, kind of, there are many things that are happening, but from a blood flow perspective, um, you know, kind of three things are happening. So there's these sinusoids, these areas where blood can pool. So those are relaxed, um, you know, and, and Viagra and things like that promote that. Um, and then the, the arteries also relax and improve, uh, promote blood flow into the penis. Then as the, as the penis engorges, it compresses on the veins on the outside, uh, of these cavernosal bodies, and that compression of the veins prevents the outflow of blood. And so all those things in a concert, uh, lead to the erection. All right, and then, you know, nerves to, uh, to the penis. So, uh, there's both, um, kind of autonomic as well as somatic innervation, uh, to the penis, um, and uh you can see here these nerves are running behind this purple structure which is the prostate. Uh, these nerves are, you know, in, in a normally functioning person, um, providing, you know, input to the penis and, and promoting erection. Um, and kind of an aside here, so for patients who have their prostate removed and provided their cancer isn't, is, isn't very advanced, um, surgeons will try to preserve these, these nerves uh running behind the prostate, uh, to preserve erectile function. Uh, and, uh, sometimes the tissue that this is running in is referred to as the, the veil of Aphrodite. So, um, we, we work hard to try to preserve that. Uh, and then kind of coming back to the physiology, so, uh, again, uh, Viagra, Cialis, they're all working here on this enzyme PDE5, um, and that's increasing or, uh, maintaining the production of, um, this cyclic GMP ultimately, uh, to relax with muscles, so it's decreasing calcium, etc. Um, the other thing that you can kind of see here, so those nerves running in that, that vein of Aphrodite, uh, and someone who's who's functioning, um, normally, they release nitric oxide, uh, which stimulates this protein here, um, to, to do the same thing, to increase the quantity of this cyclic GMP. Uh, so that's, that's more than, than most want to know, but now you got some more sort of history there. All right, so moving on to the pathophysiology of erectile dysfunction, uh, but first we'll do a little bit of art. Uh, so my Nooky days are over, my pilot light is out. What used to be my sex appeal is now my water spout. Time was when, on its own accord, for my trousers it would spring, but now I've got a full-time job to find the gosh darn thing. It used to be embarrassing, the way it would behave, for every single morning, it would stand and watch me shave. Now, as old age approaches, it sure gives me the blues to see it hang its little head and watch me tie my shoes. All right, so back to work here. So, ED defined the inability to attain or maintain sufficient penile rigidity for sexual satisfaction. Um, it's estimated that as many as 30 million men in the US are affected by this, um, and, you know, there's some studies that can show that by By age 40, um, as much as 50% of men have some degree of erectile dysfunction, whether that's, uh, a reduction of rigidity, difficulty attaining, or difficulty maintaining that erection. So I try to use those numbers to, to reassure men, uh, so they feel, you know, kind of less, um, like it's, you know, something they've done wrong, some pathology on their end. Um, all right, on, and so many things can, can lead to ED, uh, probably most commonly vasculogenic, and we talked a little bit. We'll talk more about those things, neurogenic, so anything that's gonna take out those nerves, um, particularly, uh, those cavernosal nerves right behind the prostate, um, anatomic causes, so, uh, in diabetes, for instance, we see a lot of calcification, biommineralization of tissue, hardening of tissues, and so those smooth muscles that need to relax and pull blood into the penis can't relax as well, um, in some of those disease states. Then there are medications also that can contribute to this. And then psychogenic is a, is its own class of, of, of contributions. And so we'll talk about more, more about all those things. Um, so, you know, looking at kind of the anatomic and vasculogenic contributions, I, I tell patients that, um, diabetes, hypertension, you know, hyperlipidemia, smoking, all these things contribute to thickening and hardening of arteries, uh, which results in more narrow lumens and reduced blood flow to the penis. Um, that reduced blood flow is also Creates a more uh ischemic environment for the nerves um that, that need to release the nitric oxide to promote the erection. So you kind of get this 12 punch when the vascular health is, is not good. Um, I try to use that to encourage patients to, to, uh, modify their lifestyle, whether that's exercise, um. Weight reduction, etc. uh, cessation of smoking. Um, I also, uh, always try to check a serum testosterone, and it's also recommended by guidelines, uh, on a new patient presenting with erectile dysfunction. Uh, so for many men, uh, correcting low testosterone can be adequate to restore erectile function. Uh, low libido is the most common sexual symptom of low T, uh, so asking about sexual desire during the history can clue you in to the likelihood of low testosterone. Um, also of note, uh, low testosterone can be associated with the development of other comorbidities, so insulin resistant, type 2 diabetes. Um, increased deposition of abdominal fat. So, um, a lot, a lot going into, to testosterone deficiency. Um, uh, another nice thing, so ED has been promoted by many experts as an early indicator of systemic endothelial dysfunction, uh, an indication for cardiac risk stratification, so. Um, you know, some studies show that, um, erectile dysfunction can kind of be the canary in the coal mine for the development of cardiovascular disease. Um, and then, you know, on the primary side as providers, you know, you can kind of use that as a motivating factor. So for, for patients who perhaps aren't, uh, taking the cardiovascular health seriously or, you know, the impact that it's having on other end organs, the kidneys, the eyes, um, sometimes, you know, letting them know the impact that this is having on erectile function can be, can be, uh, motivating enough for them, uh, to, to make those lifestyle modifications. Uh, so we talked about medications that can contribute, uh, you guys know most, uh, most of these classes, so. Diuretics and beta blockers are, are, are big ones, but other things to consider, you know, these, um, you know, opioids, uh, whether you're taking kind of uh perioperatively uh for surgery, can, even that acute period can be enough to suppress testosterone and cause transient erectile dysfunction. Certainly those on chronic opioids will have. uh, suppression of testosterone production, which can lead to erectile dysfunction. Uh, tobacco, just because of the effects of smoking on, uh, vasculature, um, alcohol, uh, it's kind of a mixed one. So a small, small dose of alcohol can sometimes be helpful just because it's reducing anxiety, but, uh, higher doses of alcohol, um, are, are, are definitely, um, Uh, not helpful for erectile function. And then marijuana as well, studies are showing that chronic use of marijuana, um, reduces testosterone production and that, you know, will contribute to erectile dysfunction. So all things to, uh, discuss with patients. Uh, so psychogenic ED, uh, there are many, many ways that psychosocial factors can contribute to erectile dysfunction. Um, placebo effects reliably in, in many trials, uh, of ED, um, uh, are, are seen. Uh, so that implies that even, even in cases where, you know, there's an organic cause or diabetes or, um, uh, neurogenic cause, uh, there's still unmet social needs, psychosocial needs. So, uh, we will, we try our best to refer these patients to. Uh, to sex therapists. I'll talk a little bit more about that. So, uh, moving on to diagnostic evaluation, uh, and fellowship, I started giving all men this form here. So this is the, uh, sexual health inventory for men, we call it the SHI. Uh, it's a nice icebreaker, uh, to discuss erectile function. Many men will not have even planned to discuss erectile dysfunction in their, their visit with urology, uh, but are happy for the, for the reminder. So, um, it also kind of provides me with this, uh, structured delineation of the, the degree of erectile dysfunction, uh, which is helpful in deciding the next steps. Um, and then, uh, in the sexual history, the goal there is just to assess psychogenic, um, you know, you know, for instance, uh, relationship stressors or organic causes. So, you know, those things that we mentioned, hypertension, hyperlipidemia, diabetes, or, or whether both are at play. Uh, in the medical history, you guys, you know, you kind of know the main ones that are contributory. And then again, you know, opioids, alcohol, and marijuana usage can also be, um, kind of ones that you don't think about immediately, uh, as contributors to erectile dysfunction, um, because they're going through the hormonal pathway and contributing to erectile dysfunction. And then COVID, uh, you know, it's kind of a question mark. So, uh, during my fellowship, Uh, we saw cases of men who, um, had a reduction in spermatogenous, reduction reduct, um, sorry, reduction in sperm production, uh, reduction in, uh, testosterone and, and erectile dysfunction, dysfunction, kind of lining up with, uh, an acute COVID infection, and, you know, it's transient, uh, but, uh, something that we'll have to, to study more, uh, to understand the impact that COVID's had on these things. Um, and then going, you know, kind of back to the psychosocial history, um, we're looking for, uh, things like a diagnosis of a mood disorder, uh, being managed with SSRIs, paroxetine is kind of one of the nefarious ones for erectile, uh, dysfunction, anxiolytics, looking for new emotional stressors, whether that's with work or in a relationship, um. And uh you know, kind of moving on to the physical exam, uh, so things that we're looking at, so the body habitus, so fat cells will convert testosterone into estrogen naturally, and so for people with increased adipocity, they're having increased production of estradiol which feeds back. Uh, to the brain and inhibits production of testosterone. So, uh, weight loss can, can be helpful in that end. Your cardiovascular, you're looking for hypertension, other things that contribute to poor, poor vasculature. Uh, neurologic, again, um, you know, sometimes we see patients with paresthesias, uh, high A1C, uh, type 2 diabetes. And, um, that kind of clues you into, to what's contributing to the erectile dysfunction there. And then on the genital exam, um, you know, uh, you're looking for, um, penile plaques or curvature uh that may uh suggest Peyronie's disease. In that case, you want to refer to urology if the patient is interested in further evaluation. Um, atrophic testicles, so decrease in testicular size, uh, could suggest hypogonadism, uh, and, and prompt measuring of. Uh, the serum testosterone. So, um, you know, typical labs to get in evaluating, uh, erectile dysfunction, just a BMP, CBC, A1C, lipid profile, um, and also an AM testosterone. So, um, testosterone peaks, uh, in the morning, and so that's what, that's what we use as our, our barometer, that a.m. testosterone to determine, uh, the normal level, which, you know, can be anywhere between 300 and 1000 nanograms per deciliter. Um All right. What we have here. OK, and then, you know, on our end, an additional diagnostic evaluation that we would do, uh, perhaps in someone who's, uh, failed oral therapy or, uh, given that younger patient who may have, have had, uh, pelvic or perineal trauma. Um, as a penile Doppler, uh, to assess that, that inflow, uh, as well as the outflow. So, you know, to form an erection, you gotta have good inflow of blood and you can't have too much of the blood leaving. So that's what we look for. Uh, we do an injection before the start of the procedure to generate an erection. And in addition to looking at the dynamics of the blood flow, we're looking for a penile plaque, looking for curvature, um, uh, that might suggest Peyronie's disease. All right. Um, and then, you know, some sort of, uh, treatment, um, I can hear many of my attendings saying anything that's good for the heart is good for the penis. Um, it's an easy way for patients to think about preserving erectile function through diet, exercise, and, uh, modification of recreational activities, uh, tobacco, marijuana. Um, additionally, uh, I'm a cyclist, and the Bay Area has many cyclists, so if, if you have any of these patients, I recommend that they use a saddle with, uh, depression in the middle of the seat, uh, to reduce pressure on, uh, the erectile tissue and the perineum. Uh, but, you know, it's a small side. Uh, so for psychosexual, psychosexual therapy or possible, uh, modified thiazides, um, beta blockers, and SSRIs. Uh, for men being treated for ED, um, American Urological Association recommends that we refer to a mental health professional, uh, to improve communication between partners, um, to improve treatment adherence, reduce anxiety, uh, and arrive at treatments that work for both partners. All right. Uh, and then testosterone therapy, so, uh, there are many, many forms of testosterone therapy, um, and, and this alone can be enough to resolve erectile dysfunction in some men. Um. and you know, in fellowship, I'd say, you know, the most common one that, that I saw was kind of intramuscular, but, um, implanted pellets also work well for patients and they're also topical and oral formulations. Uh, important considerations before starting, uh, fertility, uh, before starting testosterone therapy, and fertility planning. So if anyone, uh, is planning fertility, you would not want to start them on testosterone therapy cause that's gonna reduce your ability to make sperm. Um, anyone with significant cardiovascular disease, uh, want to have a discussion more with their, um, cardiologist. There's no strong evidence in either direction whether it's helpful or harmful, testosterone therapy, but, um, for someone with complex cardiovascular history, you want to have a discussion with the patient and the cardiologist before starting therapy, uh, making sure that you're assessing the liver function, um, you know, warning patients about uh potential testicular atrophy. Uh, so how many patients, um, you know, plugged in with, um, testosterone clinics, um, Uh, can have, uh, testicular atrophy if, if they're solely on testosterone. Um, and then, you know, frequently checking hematocrits, uh, so, you know, roughly every, every 6 months, you want to make sure that, um, hematocrit is not above 54%, uh, per, per guidelines. All right. And so this, this area you guys are, uh, I assume you're very familiar with, um, you know, one regimen that, um, I, I liked and that I saw in fellowship was starting patients on, um, you know, roughly 5 mg of Cialis daily. Uh, and again, you know, kind of going back to the earlier discussion, Cialis, it doesn't matter what time of day you're taking it, um, And uh you know, it's, it's just kind of there in the background. So for a new start for that patient, I, you know, I let them know that it can take about, because the half-life's 18 hours, you know, technically it takes 3 to 4 days for it to build up, but I just tell them, you know, give it a week before you decide how well that's working for you. Um, and then depending on the response that they're getting with that, that 5 daily, you can on top of that still add, um, Viagra, sildenafil, so 100 mg as needed. And again, uh, it has to be on an empty stomach, so 2 hours after eating, 30 to 60 minutes before sexual activity. Um, so you can do these things in combination or you can do either or, uh, but those are my kind of go-tos. Um, you know, important things to ask about the cardiovascular history, uh, so anyone, you know, on sublingual nitrogen, for instance, uh, is absolute contraindication. Um. And then also, if I have a patient who's, for instance, on Flomax, I'm just separating the timing of the two. So if they're taking Flomax at night, uh, start a new start for tadalafil, you'd have to take it in the a.m. just so you don't have the uh potential uh hypotension from the two. and then another important thing to, to remind patients, uh, if they have an erection lasting 4 hours, that's an emergency, they should come to. Uh, the emergency department for, uh, further evaluation. Um, I will say that it's, um, it's rare for, for just an oral, um, PDE-5 to, um, have this, uh, priapism, but, um, it's something that all patients should be, be aware of. Uh, another option for treatment of ED, um, in the primary care setting, uh, is a vacuum erection device, so. Um, it's relatively low cost. It's a conservative option. Um, the important thing to know that the devices should have a vacuum limiter, uh, to reduce penile injury, and patients should also be counseled not to wear, uh, the constriction. So you, you know, you use the, the pump to pull blood into the penis to generate erection, and then these rings that you can see here, you put on, uh, get to the base of the penis and, uh, hold that blood in place, uh, for sexual activity, but they shouldn't keep that on for more than 30 minutes. All right. Uh, other treatment options, um, uh, kind of on the urology side, so we talked about this intracavernosal injection. So, uh, we take a tiny, you know, when patients hear about this, uh, and, and they have not heard about it before, they're normally very alarmed, uh, uh, but we typically use a very tiny needle, you know, something on the, on the order of 28 gauge, 29 gauge, um, and, uh, this picture is not quite accurate. You want to go at like the 3 o'clock or 9 o'clock position. Uh, but, uh, the most common formulation is Trimix, so three medications that are all promoting vasodilation, phentolamine, pepparin, and alprazoil, um, and, you know, the, another formulation of just Byix, so just two of these, these medications, but it works very well. So, uh, for patients who are, um, you know, starting to fail PDE5 inhibitors or, you know, recently just kind of failing PDE5 inhibitors, this is, this is a great next step for them, and have a, a pretty good response. Um, the tricky thing with, uh, starting that is just making sure you're not, uh, overshooting, uh, the appropriate, uh, dose for them, uh, cause that can certainly lead to preapism more so than the oral medications and, um, So finding out that balance uh can, can be kind of challenging. And then a, a much frequently used um alternative to the, the injection is um Muse, so you're um doing an entry urethral suppository of, of, I think it's just alprazoil, but don't quote me on that. Um, but, uh, it's, it burns for most patients, uh, it's, it creates this burning sensation in the urethra, so, um, I, I think maybe in my training, I saw one patient, uh, uh, that was using this, um, and, and, and happy with it. Uh, all right, so other treatment options, um, is the, uh, penile prosthesis, um, and, uh, it's obviously, you know, something that, that reconstructive urologists do as well as, um, you know, urologists who are trained in my especially male reproductive health. Um. So the, the main components of this, you know, we have a reservoir, um, which I'll, I'll show you kind of the layout of the body, the pump, uh, and the cylinders. Uh, so the, uh, the pump, you know, sits here in the scrotum. Uh, patients kind of squeeze on this end of it to inflate the penis, so water will move from uh the reservoir into the cylinders to generate an erection. And there's a little button that's not, not well visualized in this image that they press to, um, uh, to, you know, promote detscence, you know, uh, in quotations, um, to promote the water going back. Into the reservoir. So, um, you know, patients who are at the stage where oral medications aren't working anymore or ICI is either something that they don't want to try or no longer works, uh, this is a great option for them, um, and both, both the patients and their partners are, are very happy with it. Sensation in the penis, uh, remains intact. Patients remain the retain the ability to, to orgasm. Uh, so it's something they're very happy with. You know, there are some limitations. The Uh, it's a mechanical device, so, you know, the, the general life for it is, you know, in the order of 8 to 10 years. Uh, so things that could fail or, you know, there could be a leak somewhere or, um, you know, some, you know, some of the tubing kind of falls apart from the leaking, so, uh, they, they do have to be, um, they're, they're not a one and done. And then, you know, other risks, you know, sometimes, um, infection can develop and we take a lot of measures to prevent infection, but it is a foreign, foreign body and, and implanted, so, uh, infection risk is non-zero. Uh, so that could be another reason for explant, but overall, patients are, are very happy with these. Um, kind of, uh, upcoming treatments. I don't know if that's the right word, but, uh, shock wave therapy is something that, um, uh, we did in my fellowship and it's still kind of investigational status, but Um, our, our protocol is twice weekly, you know, for, um, you know, roughly 5 to 10 minutes. Uh, we administer these low intensity shock waves, and the, and the thought behind that is, uh, it's creating a, you know, kind of a micro level of injury that's uh stimulating, uh, vasculogenesis, um, and, and perhaps nerves as well, um, and restoring some erectile function. And so the ideal patients for, for this are, are men who Um, are on oral PD-5 inhibitors or maybe just starting to kind of fail on oral PD-5 inhibitors, and this can give them a boost. And, uh, I think, you know, what I've seen in clinic, you know, somewhere between maybe 40 and 60% of men do notice an improvement in erectile function after this therapy. Uh, another one that's kind of, uh, popping up everywhere is, um, a PRP platelet rich plasma, uh, and even, you know, kind of a, a lesser grade right now. It's in the experimental stage, so no clear evidence that it's helpful, um, in improving erectile function, but, uh, there are many, many clinics, um, not necessarily urology clinics, but just kind of Um, you know, general clinics who are doing PRP for, for many indications, um, are, are trying to solve erectile function, so, um, just need more data to, to know how well, um, that, that will work for patients.
