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Erectile dysfunction affects 50% of men aged 40 to 70 and sometimes, the cause can be deadly. Hear more from St. Joseph's urologist Dr. Jeffrey Campbell as he and host Ian Gillespie chat about the hidden health issues behind erectile dysfunction.
Welcome to the DocTalks Podcast, a conversation on what’s new and relevant in the world of Canadian medicine and hospital health care. Join us for each episode, as we interview physicians, patients and caregivers to dive deep into what it’s like to treat and live with some of today’s most common health challenges. Hosted by Ian Gillespie.
Note: The content of St. Joseph's DocTalks Podcasts is for informational purposes only. The material is not intended for and should not be used as a substitute for direct medical advice from a licensed health care practitioner.
The Doctalks Podcast - Erectile Dysfunction w/ Dr. Jeffrey Campbell
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[00:00:00] Ian Gillespie:
Hello. I'm Ian Gillespie. Welcome to The DocTalks Podcast brought to you by St. Joseph's Health Care London. Today's episode, I'm joined by Dr. Jeffrey Campbell, urologist at St. Joseph's hospital and an expert in the diagnosis and treatment of erectile dysfunction.
Dr. Campbell went to medical school at Dalhousie university in Halifax, Nova Scotia. He finished a urology residency at Western university here in London. He went on to complete fellowships in men's health and reconstructive residency - sorry, reconstructive, urology at John Hopkins university in Baltimore, Maryland, and in prosthetic surgery at Western. He also completed a master in public health through the Johns Hopkins university, Bloomberg school of public health.
His urology practice focuses on benign urology. BPH, which I looked up and I believe means benign prosthetic hyperplasia. Maybe I mispronounced that, but Dr. Campbell can correct me. Men's health, sexual dysfunction, and his clinical research focuses on minimally invasive treatments of BPH and new treatment options for erectile dysfunction and Peroni's disease.
I also hope I pronounce that one correctly. Anyway that was a bit of a, a mess, but Dr. Campbell, hello and welcome to the show.
[00:01:12] Dr. Jeffrey Campbell: Thanks so much for having me, Ian. Yes, your pronunciation was on par, so we're on track here.
[00:01:21] Ian Gillespie: So before we get into causes and treatments and, well, actually lemme start with one stat right off the bat that I find a little bit startling, roughly half of all men between the age of 40 and 70 are affected by erectile dysfunction. Is that correct, Dr. Campbell?
[00:01:43] Dr. Jeffrey Campbell: That's exactly correct. The range obviously worsens with a bit of time as you get a bit older, higher chance, but Yeah, about 50-50 chance.
[00:01:53] Ian Gillespie: Okay. So what I wanted to do though, before we get into the, the, the serious topics, I just wanted to get this out of the way. I, I don't know if there's a single topic, I've been thinking about this, that we've discussed on DocTalks or that we might discuss, that has made me more nervous and has rendered me more like my smirking, joking, fart and penis loving 10 year old self. I mean, I think about this, I wake up in the morning, I think erectile dysfunction, ooh, that show's gonna be hard, ba-da-dum, tshhhh. Can we address right at at the start, why, and maybe it's just me, but I don't think so, why is it so difficult for so many people, particularly men to discuss erectile dysfunction seriously?
[00:02:43] Dr. Jeffrey Campbell: It is a really uncomfortable topic for a lot of men to talk about. it's, you know, it's perceived as a very private area when you're talking about genitals in general but also, you know, opening up about difficulties men have had in the bedroom or erections or relationships is just not something that most men or even women are really used to talking about.
And I think being able to approach it from a both professional, but also, you know, kind of lighthearted standpoint so that men can feel more comfortable is the best thing that we can do for patients.
[00:03:18] Ian Gillespie: Do you think, is it a barrier at all, I mean, does it discourage men from seeking treatment and discussing it and learning more about it? Hmm.
[00:03:26] Dr. Jeffrey Campbell: For sure. It's multifactorial obviously. I think some men feel really uncomfortable talking to, you know, their primary care physician, which is usually the first point of contact. Sometimes it's a gender issue, sometimes it's just a rapport or an age difference, you know?
A 35 year old guy might not wanna talk to a 60 year old family doctor because they think, you know, I shouldn't be having this problem or vice versa. A 65 year old patient doesn't want to talk to their young, 35 year old family doctor. And so there's a lot of reasons that patients might not be upfront about it.
And also most people just don't ask. We're trying to normalizing, just asking men about their sexual function.
[00:04:05] Ian Gillespie: Yeah - Might it also be that a lot of me who are experiencing this won't or
can't admit it to themselves?
[00:04:13] Dr. Jeffrey Campbell: For sure. So a lot of men don't want to believe anything is wrong and, you know, as soon as they discuss it or bring it up openly they either feel like they're a failure because they have all of these kind of built up myths in their head about how they're supposed to perform and how they're supposed to quote, be a man.
And so they feel like this is a failure which it's not, it's a normal, natural, physiological process in most people. And you know, as soon as they start treatment, they think, this isn't how things are supposed to be, and they're very embarrassed, which they really don't need to be.
[00:04:42] Ian Gillespie: Okay. Well, we got that outta the way. That's great. That's a relief. I've got a list here of some of the causes of erectile dysfunction. I've got a list of more than a dozen items, which seems to point to the complexity of what can cause this condition. Amongst them I'm seeing past trauma to the penis, poor blood supply, low testosterone, I guess it's Peroni's disease, diabetes, and so on and so forth.
Can, can we talk about first of all then what, what are some of the causes of erectile dysfunction?
[00:05:12] Dr. Jeffrey Campbell: Yeah. So, I mean, I'd like to start by saying erectile function is almost always multifactorial. So it's rarely that you have one thing that's caused a problem. Yes, sure. If you've had some sort of trauma, that's like, cut your penis off, Right, that's probably the isolated event.
But otherwise everything else kind of builds on each other.
One of the most underappreciated causes of erectile dysfunction, which you didn't mention is psychologic. So a lot of guys, again, have these myths and beliefs of how things are supposed to perform, and they get things like performance, anxiety, or kind of, concerns about their own sexual function, which basically debilitates their abilities to have good and normal erections, usually with their partner. And that can come into play with things like you mentioned, diabetes poor blood supply, vascular disease. And although, you know, it all kind of goes together. So diabetes and vascular disease go together. Hypertension and diabetes go together. Obesity and low testosterone kind of go together, poor exercise tolerance.
So all of these things all go together. Another important thing to note is a lot of medications have a side effect of causing issues with erectile function. A lot of men who are on antidepressant medication for mood, the side effect not only might improve your mood, but it affects your erections, which then subsequently can affect your mood.
So again, kind of showing that it's very multifactorial. Some blood pressure medications can affect the erections as well. Obviously, chemotherapy radiation. Anybody who's had pelvic surgery either for prostate cancer or colorectal cancer, bladder cancer bowel disease, Crohn's all of these things can affect erectile function as well.
So there's very few things that actually don't cause it, really.
[00:06:52] Ian Gillespie: Wow. Well that yikes.
[00:06:53] Dr. Jeffrey Campbell: And I, guess the other, the thing that you alluded to earlier is age, age is also just a normal factor. So if you live to be 90, the chance of you having a erectile dysfunction at the age of 90 is almost a hundred percent. Most men over 50 have about 50% chance, and again goes back to most men don't talk about it. You're not gonna be in the change room after hockey or in the, the golf, you know, 19th hole talking about your problems with erections, but you might be talking about, you know, your new diabetes medication.
[00:07:22] Ian Gillespie: Wow. So if, if I approach my family doctor it, it would just be a sort of, almost an interview process, would it be that where she tries to pinpoint what the cause is? I, it just seems so, so complex. I don't know how you would navigate it.
[00:07:36] Dr. Jeffrey Campbell: It. is very complex. And I think, I mean the first step, if there is a problem, definitely talking to your primary care physician. Depending on your age, there are definitely some things that should be ruled out that could be dangerous. So cardiovascular disease. in a lot of men erectile dysfunction actually precipitates cardiovascular disease or heart attack by about two or three years.
So if you're kind of a, a 40, 45 or 50 55, kind of that earlier age range, and you start having progressive changes with the erectile function, could mean that the blood vessels are being affected by vascular disease, which subsequently will then effect your heart. And because the blood vessels in your penis are smaller than the blood vessels in your heart, and if they get affected first, it could be an early sign.
So, from a primary care standpoint, that should be something that's just investigated. We usually do a bit of blood work to make sure, you know, cholesterol levels are okay. Some guys I've sent for a stress test if they're at risk for cardiovascular disease as well.
[00:08:34] Ian Gillespie: Wow. Okay. So, well, my next question was gonna be about treatment, but obviously the treatment depends on the specific cause that's pinpointed, right?
[00:08:46] Dr. Jeffrey Campbell: Yeah, so treatment is, again, I kind of approach it in a very multifactorial approach. I talk to all men about working with either a psychotherapist or a sex counselor especially as kind of earlier on in the stages, just so they understand their disease process and that will help improve the recovery.
Most men get in a cycle where you know, they have difficulty getting an erection and then every time they try to have an interaction, they're thinking about their penis and then that by default means they're not gonna get one. Um, And even if that's related to diabetes, it doesn't matter how much medication we give you.
If we haven't kind of helped the underlying anxiety might have around it, you're never going to get better. And then a lot of lifestyle changes are usually my first approach, but they also often will come with medication. So things like exercise. I know every doctor tells you to exercise for everything.
But 30 minutes a day, five days a week has been clinically proven to improve erectile function. Quitting smoking, if you smoke. Improving your diabetes control, if you're diabetic, as well as your blood pressure controlled. All of these things have been shown to actually improve or maintain the erectile function.
And I warn my patients, you know, you decide is this worth, you know, losing your erections for, and a lot of those lifestyle things can be changed. And then as you mentioned, looking at, is there certain medication we can change safely to give you less of that side effect? Or is there ways that we can kind of wean off of things?
[00:10:16] Ian Gillespie: Right. So sorry, if I approach though, my family physician, might I be referred to someone like yourself?
I'd wanna talk to you!
[00:10:23] Dr. Jeffrey Campbell: It really depends on your primary care physician. Most family doctors are fairly comfortable starting treatment workup for erectile dysfunction. It would fall under the primary care umbrella. But some family doctors are not comfortable with it, which is fine, and I see those patients, but things that I've mentioned that I've everything I've spoken about right already is something that most family doctors can and will do. They can do a basic workup in some patients who have other symptoms of low testosterone, like fatigue, change in their weight or their muscle mass low libido or sex drive.
They can work that up as well. And usually by the time patients are seeing me, they've tried things that are not working. And most people have heard about Viagra and Cialis, which are two of the main, or I guess sildenafil and tadalafil, and vardenafil are three medications that you can use to try to help improve erections.
They work great in men who get maybe a partial erection or they can't maintain it very long. And most family doctors would be comfortable prescribing those in patients without contraindications.
[00:11:23] Ian Gillespie: Right. Okay. So again, there's a whole array of it would, there might be blood tests, there would be an interview process, right. You'd be looking into, as you said, psychological issues Wow. It just seems a little overwhelming, how to pinpoint what's going on.
So, let's talk about, you mentioned how it is sometimes a, a warning sign of vascular disease. Correct? How, how common is that or how, I mean, that seems like a dangerous situation, obviously, a condition.
[00:11:53] Dr. Jeffrey Campbell: Yeah, so it's definitely it's it's so people who are at risk for erectile dysfunction, for most of the things we've talked about, you know, being overweight, poor diabetes control, high blood pressure, smoking, are all at risk for heart disease. Those are all the same risk factors. So those are the patients that you kind of have to be a little bit more concerned about and appropriate workup is often beneficial for those patients.
The chance of you actually finding early cardiac disease is probably relatively small, but in the patients that. you do find it and I've definitely picked it up. It can save a life.
[00:12:26] Ian Gillespie: I'm just looking here at a stat that one study apparently showed that men with a new onset of erectile dysfunction are at increased risk of heart attack or stroke within five years of their first erectile dysfunction episode. So that's, that's true, eh?
[00:12:42] Dr. Jeffrey Campbell: Yep. Yep. And I usually tell patients two or three years is you know, it's kind of, precipitates it because like I said, blood vessels are smaller. So if your blood vessels are being affected, usually the first ones to go are the ones in your penis.
[00:12:54] Ian Gillespie: And what about just physically, what's happening? We've talked about some of the psychological, medical causes, pharmaceutical causes what, what actually happens in the body to, to, to cause this.
[00:13:04] Dr. Jeffrey Campbell: Again, so it would, it would depend on the underlying cause, but if we're thinking it's kind of more natural aging or um, vascular disease, which is probably the most common you get so the way an erection works is with stimulation, you get a bunch of neurotransmitters and proteins that are released in order to allow the blood vessels to dilate.
And then as the blood vessels to dilate, the bigger blood vessels are the obviously fill up with blood. And then when you have an erection, it actually blocks off the, the veins from emptying. So that's why you can maintain an erection for a period of time. In, in men with uh, vascular disease, either their arteries can't dilate because they have calcifications in their arteries.
So they can't dilate. They don't have that elasticity that we would want. Or they might have calcifications in their veins so the veins can't be occluded when they have an erection and then, they might fill but it, they can't hold it in. So it's just draining back out. So that's the kind of the mechanism.
It also revolves around the smooth muscles. So there are muscles in your penis that allow penis to grow and expand with the erection and those can get affected. They can become fibrotic or not very elastic, and therefore, again, can't accommodate the change in bloodflow There can also be a lot of neurological reasons.
And so if you have a nerve injury, either from surgery, radiation, diabetes, et cetera then if you don't have a nerve input, the nerve can't signal the blood vessels to dilate, and then you never actually get that signal to initiate things as well.
[00:14:30] Ian Gillespie: It just occurs to me how , what's the sort of history of diagnosis and treatment of erectile dysfunction. I mean, was this, is this a fairly new like, were people looking into this 50, 60, 70 years ago or is this a more recent sort of specialty?
[00:14:47] Dr. Jeffrey Campbell: Well, it is definitely not recent. So sildenafil, or Viagra has been around for over 30 years since the nineties. So, I mean, people have been looking at it. Um, We can do surgery and, you know, surgery dates back to 200 years ago, obviously doing much different technologies than we're using now, but this has been I mean, a known issue for many, many years.
Again, it's kind of gets underappreciated for the severity of it and how it can impact quality of life and mental health. And that's probably why up until more recently when people are being a bit more advocates for their own health or for sexuality, we're finally talking about it as opposed to just, you know, it's this dirty little secret that people would carry with them.
[00:15:27] Ian Gillespie: Right. Okay. Actually the, when you say 30 years ago, for guys my age, that, that sounds recent, but anyway, so, wow. So treatments, is there any sort of new and exciting research or developments in the field about treatments or diagnosis that's on the horizon?
[00:15:43] Dr. Jeffrey Campbell: So there's a lot of treatment options. And I think that again, it's probably a common misconception, so there's a lot of things that can be done beyond just pills. And a lot of men will try a pill once, given to them by their family doctor and it doesn't work and they just give up and think, well, there's my sex life, we're done.
And that's not the case. So pills, most people do know about. But there are lots of other treatment options. Things that are well established at this point are intra urethral suppository. So it's actually a little pill that men can put into their urethra and it dissolves and kind of gets absorbed into the bloodstream or the erectile tissue.
And it can help with erections. There are injections, so men can actually self administer a needle into their penis that will give them a medication to dilate the blood vessels. That's something we very commonly have men doing. We teach them how to do it. Not something a family doctor would prescribe, usually a urologist and a specialist.
But very common for a lot of. There is surgery, so we can do things we put in prosthetic devices. So an inflatable or malleable penile prosthesis, which is basically a well engineered device that replaces the erectile tissue. And then actually have a pump that sits inside their scrotum between their testicles, that they can inflate and deflate the device. So it is a, a prosthetic. We do that very commonly here in London. We have the highest volume in the country and it's very common practice. Again, that's been established for 30 years as well. It's been around for a very long time, so not a new thing. But obviously the technology continues to change and then some men will do vacuum erection devices.
So these are devices that men will put on their penis. They kind of inflate it like a blood pressure cuff. It draws the blood into their penis, engorges it, and then they can put a constriction band at the base of the penis to help hold the blood in. These are kind of all of the known, approved techniques currently.
Again, like I mentioned working with a psychotherapist or a sexual counselor, is great as well. And so kind of adding that into the mix.
We've actually recently run a virtual mindfulness based program. So men kind of working through kind of being in the moment and enjoying sex, and that's been shown to also help improve erectile and sexual function.
It was a four week course. And patients would log in for two hours once a week and given homework in between. And they kind of had some didactic education about sexual health and sexual health myths as well as you know, how erections work, the erection cycle. And then trained on how to do mindfulness and we just presented that data.
It has shown that it does at the three month mark, has been shown to stabilize and improve erectile function, as well as overall quality of life, relationship function, or relationship status for those who are in a relationship and help improve confidence. And like I said, most men kind of get in their own head.
They all have a specific day they remember they lost their erections and then they get into this kind of negative cycle. And every time they try to have sex or have an erection afterwards they can't perform and then extends into this, you know, this whole cycle and what the mindfulness program is really doing is teaching them to just be in the moment and not think about the next . Stage in in sex.
Thinking about the end result and thinking about climax and just enjoying what's happening. And we've had a, a great turnout for that program. Everybody who's done it enjoyed it. We're making a few modifications and then hopefully be able to just offer it to patients through our facilitators, because it is definitely innovative. And I think A lot of medicine is really leaning towards more conservative things instead of just treating with pills. Getting to the underlying nature and treating the actual process. So those are kind of the two, the main things we've been doing for erectile dysfunction research.
It's such a, I mean, It's such a novel program and it's it's been, it was really great. The, I mean, the patients obviously self select themselves if they're gonna do it because you know, a lot of patients don't, don't like to believe there's any psychological component and they don't want, like, they don't wanna cuz they,
they think that's a negative, but it's, I mean, it's natural that everybody, you know, has that going on and what the program kind of teaches them is that, you know, let all these preconceived notions, all these men have like, you know, their penis on a pedestal. They think that they have to have this erection that lasts for an hour and everybody orgasms 10 times.
And you know, all these like crazy myths of how sex goes and especially young men. And what happens in, you know, if they're watching pornography and this is kind of how they think sex is and kind of debunking some of those myths and then just teaching them how to kind of enjoy the act and the relationship and their partner.
And then i guess new on the horizon is there's a lot of new regenerative therapy. So, there's been a lot of research looking at ways to help regain normal erectile function. Instead of just taking a pill or using a needle, something that actually helps improve the physiological function in the penis.
Men have been using or studies have been using stem cells. So injections that stem cells into the penis. Platelet rich plasma, which the evidence for that is kind of debatable. That is basically you take your own blood, you spin it down, you collect the platelets and it's injected, and it's supposed to kind of stimulate new growth.
Shockwave therapy. That would be a treatment that men can have in specialized clinics. It's not currently approved by any of the urology guidelines and kind of meant to be experimental. But is starting to make headway. And I'm sure you've seen, there's lots of clinics that are popping up that are marketing themselves as men health clinics.
But I would caution that most of those things that I just mentioned are actually don't have great evidence behind them yet. And from the, you know, sexual medicine society there's been a physician statement that really, those should only be done under clinical trials that some men are forking out you know, three to $5,000 to get these treatments that aren't yet proven.
But eventually I think there will be those options.
[00:21:57] Ian Gillespie: Wow. Again, this might be difficult to answer given the vast array of causes and treatments that you've discussed, but what, what generally is the, is there, can you gimme a number like the success rate of treatment? I mean, is the problem solved most of the time?
[00:22:14] Dr. Jeffrey Campbell: So I can tell you, I can solve your problem almost every time, but that really depends on how aggressive or invasive you want to be. So, you know, If we did surgery on everyone that has about a 95% success rate, but most people are not maybe good surgical candidates or do not want an invasive surgery.
Some men don't like needles and aren't going to do injections. And so everyone's very variable on how far they want to go to try to make things better. And what they're willing to do to kind of regain their erectile function. So success rate totally varies. If you were willing to do everything I told you to do, almost everyone could get improvement, but obviously we have to take every individual patient into account and what they're willing to do and how they want to improve things.
[00:23:01] Ian Gillespie: Wow. Okay. Well, I, I think we, I don't know, we might be drawing to our close. Is there anything Dr. Campbell that we haven't touched on that we, we
[00:23:08] Dr. Jeffrey Campbell: No, I think uh, we've we've I really think we've got to the main treatments and the importance of why we should talk about this and why it is important. There's a, a huge correlation between erectile or sexual dysfunction and mental health. A high rate of depression and anxiety in men with sexual dysfunction.
It's hard to know which came first, the chicken or the egg. Did the erectile and sexual dysfunction lead to depression and anxiety, probably in a lot of cases, but also depression and anxiety can lead to erectile dysfunction either directly or indirectly through medication. And I think that is all the more reason to talk about it.
Because there is such a close link. I also really stress the point that it's always multifactorial. It's never one cause and it's really important to work with patients and providers to kind of understand how we can best treat people. I gave you a whole list of options and I'd say almost all my patients are doing more than one.
Because they're doing, you know, they're doing an exercise regimen and they're actively quitting smoking, but they're also on medication and we're working with a counselor and there's a lot of different things that can be done in order to optimize things. And I think it's really important that patients bring it up to their primary care physicians.
I think family doctors should really be asking at their yearly visit just to make sure, you know, every diabetic you should be asking about erectile function when you're there doing their diabetes check. And sometimes it's very overlooked because people are uncomfortable talking about it. I've really tried to normalize men's health and sexual function in general.
In our clinic, obviously we're very open. We see it all the time, have to make a very comfortable setting for patients to be able to open up and talk to us so that we can really help them. And I think it just, the more men talk about it, the more likely they are going to get better.
[00:24:58] Ian Gillespie: Wow. Well, thank you for talking about it. It's been fascinating. Frankly. I, I had no idea. Dr. Campbell, thank you for joining us today on the DocTalks Podcast. And I hope that some of our listeners have learned as much as I have. Thank you, sir.
[00:25:13] Dr. Jeffrey Campbell: Thanks for having me, it was great.