In the course of treatment for erectile dysfunction, some men may be treated with penile injections. This method involves men injecting medications directly into the penis,instead of taking a pill like Viagra. This is the most direct route, and a very effective treatment for ED. In general, obtaining medication to do this type of injection is different than obtaining other prescriptions.  

Penile injections for ED
Commercially available injectables include Edex and Caverject, and some insurances may cover them. However, most plans do not cover them, and they can be very expensive, from $50-$100 per dose! Obtaining the same medications from a compound pharmacy reduces the cost significantly, bringing it to $8-$20 per dose, depending on the type of medication, dose used, and compound pharmacy.

Compound pharmacies
When I mention ‘compound pharmacy’ most men have never heard of it. Typical pharmacies sell only medications that are ‘pre-packaged’ and sold ‘as-is.’ Compound pharmacies are different. From the FDA website, “a licensed pharmacist, combines, mixes, or alters ingredients of a drug to create a medication tailored to the needs of an individual patient.” This allows us to tailor the strength and even combine 2, 3 or 4 medications, increasing the efficacy or potency of the compound solution.

In the Seattle area, a online search for compound pharmacy yields a few different results. We have worked with most of the pharmacies listed, and all of them have at least a couple of commonly used compounds readily available. Prescribing injections that are not part of that pharmacies ‘usual compounding’ results in a higher price, because each unique solution requires quality testing. Each pharmacy will also have a different price often for similar compounds. It pays to do some research, and some men find using an online compounder is the most convenient.  

It is important to note that the medications that go ‘into’ a compound are FDA approved, but once compounded into a solution, it is NOT FDA approved. This type of prescribing is called ‘off-label’ and in general is safe, however quality can vary. I encourage everyone to read this information from the FDA about compound pharmacies.

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Testicular self-examination is a quick and easy way for men to catch issues quickly if/when they arise. Typically recommended for men over 18 years of age, self-examination takes just a few minutes and can be performed in the comfort of your own home. The process can help men identify lumps on the testes.  Personally, I found a lump of my own, which turned out to be cancerous.  Fortunately, it was small, and I received the treatment I needed at the earliest possible stage.

How to perform a self-exam

• Perform a self-examination once a month after a warm shower, when the scrotum is relaxed and changes can be more readily identified.
• Grasp the testicle with your thumb on top, and pointer and middle finger on the bottom and roll gently, yet firmly.
• Feel for swelling, hardness, lumps, or changes to the texture of the scrotum.
• Familiarize yourself with the epididymis, the tube at the back of your testicles that stores and carries sperm to the vas deferens. This tube can often be mistaken for a lump. Its equally important to become familiar with how it normally feels.  If it is sore to touch, this could be a sign of a common infection called epididymitis.

Causes of testicular lumps
Testicular lumps are not always a cause for alarm. While they can indicate cancer, there are many other benign conditions that can present themselves as lumps. Varicoceles can cause swelling due to enlarged veins in the cord above the testicle, while hydroceles causes swelling as a result of fluid build-up around the testicle. Epididymal cysts may cause one testicle to feel heavier than the other, are generally painless and will usually feel like they are above or behind the testicle. Swelling caused by infection may often be painful and accompanied by fever or unusual testicular placement or redness and thickening of the skin.

If you’re experiencing pain, collection of fluid in your scrotum, an ache in your groin or abdomen, or swelling in your chest, it’s important to schedule a doctor’s appointment as soon as possible.

When to contact your doctor
If you found a lump, you might panic or be scared, but don’t minimize or think it ‘will go away’.  Contact your doctor any time you detect a change in your testicles. Identifying the cause of a lump in its early stages is critical for treatment–whether it’s cancerous, or caused by other medical conditions. Your doctor will use a variety of methods and tests to determine the cause of any testicular abnormalities, and work with you to find the best treatment solution. Often a simple examination in the office is all that is needed to rule out serious causes.  When indicated, an ultrasound is a very good test to evaluate the testicles.

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Erectile dysfunction rarely happens on its own. More often, it is the result of an underlying medical issue, from heart disease to mental health problems. One of the leading causes of ED is diabetes–and it can begin unexpectedly years after your diagnosis. According to research from Boston University, “Of those diabetic men who will develop impotence, 50% will do so within 5-10 years of the diagnosis of their diabetes.” Diabetes directly causes erectile dysfunction when unmanaged blood-sugar levels damage nerves and blood vessels, or when diabetes contributes to co-occurring conditions, like coronary artery disease or high blood pressure.

When you have ED caused by diabetes, it can often feel like you’re fighting two separate battles. The fortunate reality of the situation is that with proper diabetes management, you can “kill two birds with one stone”–by reducing the impact of your diabetes, you can minimize its tendency to prevent erections and interfere with intimacy.

Addressing diabetes
Proper daily glycemic control is a critical step in minimizing ED. Not only will your chances of getting an erection be improved, but your response to ED medications, like Viagra, will be more successful when your day-to-day blood sugar levels are stabilized. Following your diabetes care plan will not only improve your quality of life, but can improve your sexual health as well.

Just as important as your daily diabetes management is your long-term glycemic control. Your primary care provider, along with your urologist, can help improve your outcomes by looking at the bigger picture of your health care and figuring out how you’ll manage your diabetes moving forward. In conjunction with medications, lifestyle changes like losing weight, exercising more often, and quitting smoking can contribute to regulating your blood sugar over the long-term.

Urology solutions
If you find that you’re still experiencing ED even with proper diabetes treatment, consider consulting a urologist to learn more about other options that are available to you. Whether you’ve been diagnosed with ED or not, it’s important to be screened for the condition as it can lead to early detection of more serious diabetic complications, like heart disease.

Your urologist can offer a number of different solutions to eliminate your erectile dysfunction, from prescribing medication and injections to recommending a penile pump or implant. Certain penile implants, like the AMS line, are prefered for diabetics, as they are antibiotic-coated to prevent infection. If you chose to receive a penile implant, managing your blood sugar level will be even more important to ensure that you don’t contract an infection during or after your surgery.

Relief from diabetes-related erectile dysfunction is possible, whether you’ve just been diagnosed or have been struggling for a while. By involving your PCP and consulting a urologist, you can address both your physical and sexual health for the best outcome and a future free from ED.

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A good night’s rest is essential in maintaining peak performance–physically, mentally and emotionally. It’s also an important part of maintaining healthy testosterone levels. Recent research suggests that interrupted or short sleep can have a negative impact on your sexual function, contributing to low levels of testosterone and erectile dysfunction.

The sleep apnea connection
One of the leading causes of interrupted sleep in adult males is sleep apnea. The condition is caused by a blockage of your airways while you sleep, causing you to wake frequently (even if you’re not noticing it). This can be a result of obesity, age, physical factors (large tongue, tonsils or small jaw), or nasal obstruction as a result of allergies or other sinus issues.  Left untreated, it can increase a man’s risk of heart disease, hypertension and stroke. Many men seeking treatment for erectile dysfunction also fit this profile of a sleep apnea patient.

Taking a holistic approach to your sexual health can improve your overall quality of life. Experiencing symptoms associated with low testosterone, like sexual dysfunction or muscle loss, while also experiencing daytime fatigue can be an indication that sleep apnea is causing your hormones to go haywire. Low testosterone can also be an indication of other physical issues, like injury or illness.

According to a CNN article from sleep specialist Dr. Lisa Shives, “testosterone is produced during the night; the levels climb steadily throughout the night and peak in the morning. There are studies showing not only that a decrease in the total amount of sleep can lower a man’s testosterone, but also that REM sleep is important to the production and release of testosterone. We know that REM sleep is often decreased or absent in patients with sleep apnea. Therefore, it seems that both the quantity and quality of sleep are important for testosterone production.”

Finding a solution for better sleep & sex
The quickest way to overcome sleep apnea is with a CPAP machine. The CPAP (continuous positive air pressure) device keeps your airways open while you sleep by increasing the air pressure in your throat. There are many different models that you can choose from to ensure the best fit for a comfortable night’s sleep. The best part? Studies suggest that typically after just two weeks, your sleep quality will return to normal.

While some newly diagnosed people with sleep apnea may be initially put off by the machine, there are a whole host of reasons to give it a shot. While you may find the machine cumbersome at first, or feel embarrassed about wearing it around your partner, you can rest easy knowing that you’re doing both of you a favor! You’re not the only person suffering from your untreated sleep apnea–many partners report loss of sleep or being awoken by the gasping or snorting sounds associated with the condition. By wearing the mask, you’ll also be preventing some of the other common issues associated with sleep apnea: weight gain, stress, hypertension, GERD, and frequent nighttime urination.

A CPAP machine isn’t the only way to solve sleep apnea and related sexual health complications. While addressing the issue immediately is helpful, eliminating the causes of the condition will not only improve your sleep, but your sexual health as well. Obesity is a significant contributor to both sleep apnea and low testosterone, so a proper diet and exercise routine can work wonders in both arenas. Untreated sleep apnea can also contribute to diabetes, which in turn contributes to erectile dysfunction. Stopping sleep apnea in its tracks can prevent sexual health complications down the road.

As a urologist, I do not personally diagnose or treat sleep apnea, but I will recommend obtaining a sleep study if low testosterone is an issue for a patient.

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Meeting the treatment expectations of men who have been left impotent and incontinent after prostate removal for cancer requires a careful understanding of their priorities. Understanding patients allows us to embark on a step-by-step approach to address each problem.  I was taught by one of my mentors (and my experience has confirmed) that it is often difficult to treat a man’s impotence if he is still leaking urine, especially when this occurs during arousal and sexual activity.  We call this climacturia, and most men are never told that it will happen after their prostate is removed.

Nearly all men after prostate surgery have experienced some leakage during arousal. Fortunately for most men, as they regain control of urination, fewer men continue to have leakage during sex. For obvious reasons, many couples are bothered by actual urine leakage, but climacturia is also associated with shame and embarrassment. This can lead to men and couples avoiding being intimate, prevention of good erections, and frustration in a relationship.  

Being aware of a few simple practices has the potential to reduce how much this type of incontinence can affect intimacy:

1. Keep an open mind and be creative
2. Remember to do your Kegel exercises
3. Empty your bladder before engaging in sexual activity
4. Have hand/paper towels nearby
5. Consider using a condom to catch drips
6. Experiment with different positions

Where do we go when this doesn’t solve or settle the issue?

1. Have a discussion with a urologist
2. Ask about seeing a physical therapist specialized in male incontinence/pelvic muscle rehabilitation
3. In select cases, we might consider minimally invasive surgical procedures, such as a urethral sling designed specifically for men

In the past, we would consider doing surgery at the same time as a penile implant if this was required, but currently I think it is in a man’s best interest to approach each problem (even though connected) one at a time. This doesn’t mean men cannot use medications like Viagra, penile injections or vacuum erection pumps in the meantime. One of the other reasons to delay surgery, gets back to my initial statement that impotence often doesn’t improve until we have adequately controlled urine leakage.  Occasionally, men are surprised that when they are finally dry during sex, they feel more ‘in the mood’, are more likely to pursue intimacy and  have better erections or respond better to the therapies– and that, of course, is a great thing!

Keeping an open mind, knowing your options, and speaking with a trusted urologist can make all the difference for men and couples experiencing climacturia.

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When it comes to being a urologist, some would say that sexual dysfunction isn’t sexy. Historically urologic surgeons chased the big cases like kidney, bladder and prostate removal. While there is tremendous need for these important operations (and I respect the skills and care of the urologists performing those surgeries) I eventually discovered that it wasn’t for me.  What I learned over time was that quality of life after cancer surgeries was just as important to a man’s survivorship.

I counsel men weekly about treatment options for a new diagnosis of prostate cancer.  Most of these men are in good general health, active, working, in relationships and enjoy being sexually active. Whether they choose surgery or radiation to treat their cancer, I acknowledge that what I am asking them to consider is like asking them, “If I were going to push you in front of a bus, which bus do you prefer [surgery or radiation]?” Even though most men do very well after prostate cancer treatment, a man’s quality of life can suffer. Until we address the treatment-related side effects, such as erectile dysfunction (ED), we fail our patients.  I explain that the reason you go through treatment is so you will be “around for years to come,” and hopefully with a quality of life not at all different from what they enjoy before treatment. I invite all of my patients to return anytime after their treatment to discuss their sexual and/or urinary dysfunction if their needs are not being met.

Addressing underlying conditions
This type of encounter, year after year, made me understand that the care that happens ‘after the cancer is cured’ is just as important– and even becomes the priority– yet historically we have not be great at carrying this torch. I quickly appreciated that the impact of successful treatment for ED was significant and life-changing for both men and their partners.  Furthermore, I learned that this benefit is experienced by all men who develop sexual dysfunction, whatever the underlying cause: diabetes, heart disease, hypertension, high cholesterol, low testosterone, trauma/injury, Peyronie’s disease.  

I’ve had to respond to comments like, “That’s great, but you’re not really treating disease.”  I explain that after thorough evaluation for underlying causes, I diagnose men with diabetes, hypothyroidism, and vascular disease. In doing so, I am able to help men begin to receive the care they need for these problems. Erectile dysfunction (ED) is a precursor for serious conditions like stroke, angina, and heart attack, often preceding those events by only a few years. People are surprised to learn that working up a ‘trivial’ sexual complaint can essentially save a life.

More than a ‘shot clinic’
In recent years, there has been a surge in the number of what we call “shot clinics.”  Anyone who listens to talk radio has probably heard an ad for a men’s health clinic, with an offer of a ‘free consult’ and ‘guaranteed success on the first visit.’  Men are taught to do penile injections and/or given testosterone, with little evaluation or discussion of all their options. Men are then asked to purchase large quantities of medications, and many clinics have a ‘subscription service for the meds: as long as you’re buying, they’re interested. I have seen countless men who went to one of these clinics, feeling frustrated with unsatisfactory results, seeking answers to their unanswered questions. To me it’s obvious that offering only one treatment for sexual dysfunction is not enough, and the information and treatment gap is huge.  In fact, it is out of this need that this specific business model for ED prospered.  

Good information, thorough evaluation, and comprehensive care options are needed to fill the void. Sadly, there is often no time at the end of a visit with your PCP or urologist to fully address sexual dysfunction. It’s easy to prescribe a ‘blue pill’ as the appointment wraps up, but what if that doesn’t work, or didn’t work the last time you tried it?  This is can add insult to injury for men already frustrated with poor performance.  As urologists, we are uniquely qualified to care for these problems with training in both the medicine and surgery for the genitourinary system (penis, testicles, prostate)– if we take the time to ask the questions.

Communication is key
Meeting with men and their partners has become a very rewarding part of my practice. Sexual dysfunction encompasses a lot of conditions, not just erectile dysfunction.  It’s rare that men tell me anything that I haven’t heard before, whether it is about problems with orgasm, ejaculation, pain, injury, deformity, sex drive, desire or identity. As a trainee, I approached these visits with dread, then early in my practice I accepted my own challenge: making men feel comfortable talking about intimate personal details within seconds of meeting me had to be the goal. Unless I was able to understand the whole picture and the impact the problem was having, (not just the mechanics) I wasn’t offering much more than the docs who don’t like treating sexual dysfunction. Quickly, I discovered that I was able to do this with a surprising amount of ease. Giving men a place to speak discreetly and honestly allows me to better treat them successfully, helping them restore healthy sexual functioning. How great is that?

In closing, I guess you could say that I stumbled into sexual medicine as a specialty, and I am glad I did. The feedback that I receive from my patients confirms that I am helping men/couples find solutions to important problems and improving quality of life.I can live with that.

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