Revive Your Mojo: Dr. Ryan Reveals Game-Changing ED Solutions to Reignite Your Bedroom Fire!"

0:01 hi there it's dr ryan and today we're 0:03 going to talk a little bit about 0:05 a 0:06 issue that arises with some of my 0:08 patients and that is erectile 0:10 dysfunction 0:11 and this is just a basic overview of my 0:13 thoughts on it we're going to kind of 0:15 talk about 0:16 the pathophysiology behind it some of 0:18 the treatment modalities you can utilize 0:20 for it 0:21 both conventional and integrative and 0:24 again this is really just a 0:27 another set of information that you can 0:29 utilize for if you are working with 0:31 another provider utilize this just to 0:34 add to your knowledge base 0:35 and then also to give you an idea of how 0:37 i 0:38 um evaluate individuals who have it in 0:41 the clinic 0:42 so let's go ahead and talk a little bit 0:44 about it 0:45 so i 0:46 open up this 0:48 powerpoint 0:50 okay 0:51 it's erectile this function 0:53 all right so 0:55 to start off uh just a little bit of 0:57 background about erectiles function so 1:00 what is it exactly it's the inability to 1:03 achieve or sustain 1:05 penile erection for satisfactory 1:08 sexual performance it affects a lot of 1:11 men across the u.s this statistic is 1:13 rather old 30 million american men 1:17 who are affected by erectile dysfunction 1:19 i suspect that's increased particularly 1:21 after coronavirus and with individuals 1:24 not following a healthy diet not 1:26 training maybe secondary to 1:29 isolation measures and closing to the 1:32 gym so i imagine this is probably a 1:33 little bit higher 1:35 not to mention some of the psychiatric 1:37 issues that have occurred owing to that 1:39 and then 1:42 one thing that's important to realize is 1:44 that many times 1:46 erectile dysfunction can be linked to 1:48 vascular health and thus cardiovascular 1:51 health so 1:52 if new onset erectile dysfunction can be 1:55 ominous and may be an indication for 1:58 certain providers 1:59 to 2:01 evaluate your heart function 2:05 so 2:06 let's go on uh let's talk a little bit 2:09 about how it actually occurs 2:11 so essentially what it is is just blood 2:14 flow and so blood flow occurs into the 2:18 corpora 2:19 corpora cavernosa which are these two 2:22 tubular structures that kind of flank 2:24 the penis on the dorsal surface and in 2:27 addition to something called the corpus 2:28 spongiosum which is a smaller tubular 2:30 structure both of these structures 2:33 engorge with blood during erection and 2:35 they are responsible primarily for the 2:37 rigidity 2:39 of found of the penis 2:42 and this diagram kind of describes what 2:44 is going on so during the process of 2:47 erection there are within the corporate 2:50 corporate cavernosa there are these uh 2:53 special there's this first 2:55 special type of arterial circuit with 2:57 trabecular arteries that engorges with 3:00 blood and uh swells and that 3:03 in addition to the um network found in 3:05 the corpus fungiosum contributes to the 3:08 rigidity 3:09 of um of the erection 3:15 okay 3:16 so physiology of the nervous system 3:19 so it's a fairly complicated system 3:22 involving 3:24 involving both the autonomic nervous 3:26 system the parasympathetic and the 3:28 sympathetic nervous system in addition 3:30 to the central nervous system and very 3:32 briefly you have afferents or basically 3:35 uh nerves that detect sensation that go 3:38 up to the central nervous system of 3:40 efferents they're involved in 3:42 smooth muscle relaxation and ejaculation 3:46 and the afferents are primarily via 3:49 the parasympathetic system 3:51 whereas the efferents are a combination 3:53 of both the parasympathetic and the 3:55 sympathetic system 3:57 and in addition there are 3:59 coordinating interneurons within the 4:01 central nervous system they're involved 4:04 both for facilitation of sensory input 4:07 but also 4:08 they can actually trigger erection on 4:10 their own and hence the 4:13 situation where there is no stimulation 4:15 of the penis but you develop an erection 4:19 and again a very complicated system but 4:22 basically there are 4:24 dorsal nerves of the penis which 4:27 uh connect to these potential nerve 4:29 afferents which go via the 4:31 parasympathetic system and travel the 4:33 spinal cord to this uh central nerve to 4:35 the cerebral cortex and 4:37 then uh go via efference to control 4:41 erection 4:42 and which is primarily due to 4:45 vasodilation of those arteries in the 4:48 corpus cavernosum 4:50 and then 4:51 towards the very end 4:53 particularly in terms of 4:55 ejaculation 4:57 the parasympathetic system and the 5:00 sympathetic system coordinate together 5:02 to promote that 5:07 so what exactly is occurring at a 5:11 in terms of biochemical status well 5:15 acetylcholine is released on 5:17 postsynaptic receptors on arterial 5:19 endothelial cells and i'll have a 5:21 diagram that kind of demonstrates this a 5:23 little bit better 5:24 this in turn 5:26 leads to nitric oxide secretion by the 5:29 endothelial cells 5:31 which leads to dilation of blood vessels 5:34 okay 5:35 and how does it do it well the nitric 5:37 oxide 5:39 basically potentiates guanolyl cyclase 5:43 and 5:44 this in turn increases cyclic gmp 5:47 which then in turn 5:49 decreases intracellular calcium which 5:51 then finally causes vasodilation of 5:54 penile blood vessels and this is 5:56 important to realize because it's 5:58 part of this is how phosphodiesterase 6:01 5 inhibitors work 6:03 and so finally 6:05 as these arteries are vasodilated 6:08 the corpus cavernosum the corpora 6:10 cavernosum along with the corpus fungi 6:13 ocean 6:14 fill with blood 6:15 and uh in addition so they fill with 6:17 blood but they also compress sub-tunical 6:20 venules which are precursors to veins 6:23 and 6:24 this restricts blood flow out of the 6:26 penis 6:27 okay 6:28 and so just to kind of talk about that 6:30 nerves 6:32 enervate the endothelium which is the 6:34 inner line 6:35 of arteries which are primarily 6:37 perfusing 6:38 the penis and 6:41 what happens is acetylcholine 6:44 releases nitric oxide within the 6:47 endothelium that's inner layer which 6:49 then acts upon vascular smug smooth 6:53 muscle 6:54 and what occurs primarily is the nitric 6:56 oxide potentiates guanolate cyclase 7:00 which converts 7:02 gtp guanosine triphosphate to cyclic gmp 7:06 and cyclic gmp the increase in that 7:10 seems to decrease intracellular calcium 7:12 stores and cause smooth muscle 7:14 relaxation this is important because 7:18 the phosphodiesterase 5 inhibitors such 7:20 as 7:21 cialis and viagra to 7:29 work download block 7:31 the breakdown of cyclic gmp 7:34 to 7:36 guanosine monophosphate right and this 7:39 is potentiated by this enzyme 7:41 phosphodiesterase 7:43 and that is blocked by 7:46 sildenafil and to dialyphil 7:49 okay and so that way if you have more 7:51 cyclic gmp 7:52 you have 7:54 more of a decrease in intracellular 7:56 calcium which causes more smooth muscle 7:58 relaxation and facilitates penile 8:00 erection 8:03 and again this is just another 8:06 diagram that kind of describes what's 8:07 occurring remember so through nerve 8:09 stimulation and through that process we 8:12 described you get vasodilation of the 8:15 arteries and there is this interesting 8:18 trabecular network within the corpora 8:20 cavernosum which is just 8:22 interconnections of many different 8:24 arteries 8:25 and so 8:26 what occurs is that 8:28 as the vasodilation occurs the smooth 8:32 muscle relax relaxation occurs these 8:35 spongy neck of arteries fills with blood 8:38 right and you can kind of see it in the 8:40 flaccid view where it's not filled with 8:42 blood and the erect view or it's filled 8:43 with blood and during that entire period 8:47 both the 8:48 corpus cambrinosum is 8:50 filled with blood and it gorges so you 8:52 get an erection but at the same time the 8:56 venous system the venules 8:58 which 8:59 lead to the deep dorsal vein up here 9:02 is compressed so you have decreased 9:04 blood flow out of the penis which allows 9:06 you to have a sustained erection 9:11 okay so we kind of talked about how an 9:13 erection occurs let's talk about a 9:15 little bit about why it doesn't occur so 9:17 some of the causes of erectile function 9:20 dysfunction the most common 9:22 are related to the cardiovascular system 9:24 or atherosclerosis as you can imagine 9:27 there's a lot of blood flow blood flow 9:30 is very very important to erection right 9:33 and so if you have any sort of scarring 9:35 of the arteries that's likely to 9:38 decrease the probability of occurring 9:41 and you can see this the core erectile 9:42 dysfunction oftentimes is correlated 9:45 with high blood pressure endothelial 9:47 dysfunction 9:49 and as i mentioned 9:51 new onset erectile dysfunction 9:54 is an ominous harbinger of 9:56 heart disease potentially and so some 9:58 primary care practitioners 10:00 if it's new and you have potentially of 10:03 other risk factors 10:04 may 10:05 move you towards a cardiac workup 10:07 um 10:08 because the nervous system involved in 10:11 erection is quite complicated anything 10:14 that disrupts it is obviously going to 10:17 be linked to erectile dysfunction and 10:19 diabetes is one of those by virtue of 10:21 the fact that you'll have increased 10:23 blood glucose concentrations which can 10:27 dramatically affect neurotransmitter 10:29 output this can lead to neuropathy and 10:33 there as i mentioned it's a very 10:35 complicated 10:37 um 10:38 innervation in regards to how 10:41 sensory nerves and 10:43 both efferents and afferents 10:46 work to create an erection so anything 10:48 that disrupts that could could certainly 10:50 impede it so making sure that your 10:52 hemoglobin a1c 10:54 is uh 10:55 you know under 5.7 ideally under 5 10:58 making sure that you're eating a diet 11:00 which in which you control your 11:02 carbohydrates you stay away from 11:04 simple sugars and try to utilize complex 11:07 carbohydrates and maintain insulin 11:09 sensitivity is key 11:11 to 11:12 reduce your risk of erectile dysfunction 11:14 then of course as we age we're going to 11:16 get declines 11:18 a decline in hormone levels particularly 11:20 testosterone and dhea both of which are 11:23 linked to erectile function 11:26 another age-related decline that's not 11:28 necessarily to hormone levels but just 11:30 to age is a decrease in the penile 11:32 elastic fibers so there are these fibers 11:35 that are within the corpora cavernosa of 11:38 the penis within these trabeculae and if 11:41 they become too rigid it's difficult for 11:44 blood to flow in and engorge right and 11:48 so with decreased elasticity which can 11:50 occur with age of course 11:53 you may have some difficulty with 11:57 having an erection 11:58 and then of course there are psychogenic 12:00 causes depression anxiety or stress and 12:03 this appears to be more common younger 12:05 individuals but can of course occur in 12:07 any segment of the population 12:11 okay 12:12 now um hormonal levels let's talk a 12:15 little bit about this so testosterone is 12:17 clearly linked to 12:19 erectile dysfunction 12:20 and it we believe it's because it's 12:22 secondary to nitric oxide release it 12:25 seems to improve nitric oxide release 12:27 which as you know is correlated with uh 12:30 vascular smooth muscle relaxation 12:33 it also is improved it also seems to 12:35 improve libido too 12:38 so 12:39 and again if you increase nitric oxide 12:42 release you're likely to 12:44 have decreased breakdown of cyclic gmp 12:47 as well 12:49 there is 12:50 this a low testosterone level seems to 12:53 be one of the main reasons that you'll 12:55 have failure of the phosphate esteres 12:57 vibe inhibitors to work so if you might 12:59 utilize this a 13:00 physician might initiate this therapy 13:02 but then wonder well hey how come it's 13:04 not working well oftentimes a low 13:06 testosterone level may be one of the 13:08 reasons and by improving this you can 13:11 you can um 13:12 get appropriate change and so i ideally 13:15 i like to improve levels to 13:19 a free of 20 to 30 nanograms per 13:21 deciliter and a total of 900 to 1000 13:23 nanograms per deciliter 13:25 and i use lab core primarily 13:28 other lab systems may have different 13:31 concentrations for what's considered 13:32 normal but this is where i like to keep 13:34 my patients 13:36 what about dhea well dha is a precursor 13:38 to testosterone it is it's important in 13:41 production but also it appears to be a 13:44 pretty interesting neurosteroid that is 13:46 improved that is important in dopamine 13:49 and 13:50 norepinephrine release in the brain 13:53 and low dhe levels are linked to 13:55 erectile dysfunction also it appears to 13:57 be linked to low libido and i like to 13:59 keep patients levels between 200 to 350 14:03 micrograms per deciliter 14:05 what about estradiol 14:07 so in certain individuals you may have 14:09 excessive conversion of testosterone to 14:11 estrogen and then of course you have 14:13 decreased testosterone levels right and 14:15 as we know decreased testosterone levels 14:17 is not good for erectile's function 14:20 there has been evidence suggesting both 14:22 low and high levels of estradiol are 14:25 associated with an increased risk of 14:26 heart failure and i usually like to keep 14:29 my patients between 20 to 40 picograms 14:32 per milliliter right and of course this 14:34 is using lab coarse ranges 14:36 now 14:37 um sometimes i have to utilize 14:39 anastrozole to 14:42 decrease aromatize 14:44 activity which is how testosterones 14:46 convert estradiol but sometimes they 14:48 don't and one thing to realize is if you 14:51 have a 14:52 fairly high amount of body fat of 14:54 adipose tissue you're likely going to 14:56 have a significant conversion of 14:59 testosterone to estrogen as you get 15:01 leaner this will 15:03 decrease 15:05 okay 15:06 what about some conventional therapy 15:08 well 15:10 there are several different modalities 15:12 one of the most common are the phosphide 15:14 diasterase five inhibitors two the more 15:16 common medications we utilize are 15:18 sildenafil and stellophile 15:21 and what is and again how do these 15:23 actually work so as i mentioned and 15:25 that's kind of complicated regime the 15:28 acetylcholine 15:29 acts on the endothelial cells to release 15:32 nitric oxide which then goes to 15:34 guanolate cyclase which then converts 15:37 gtp to cyclic gmp which then decreases 15:41 intracellular calcium in the smooth 15:43 muscles and causes muscle relaxation 15:45 which then increases blood flow right 15:48 and 15:49 during this process cyclic gmp is very 15:51 important but it's broken down to cyclic 15:53 gmp which is inactive in this process uh 15:57 by phosphodiesterase five inhibitor and 15:59 so our 16:00 phosphoriesterase five that enzyme so an 16:03 inhibitor 16:04 of this enzyme 16:06 can drastically improve cyclic gmp and 16:09 thus improve smooth muscle relaxation 16:12 and that's exactly what these 16:14 medications are 16:16 and um 16:18 so 16:19 again since they are 16:21 since they do cause vehicle dilation 16:23 they work quite well but there are some 16:25 side effects associated with them um 16:27 headache nasal congestion flushing 16:30 prolonged direction although this may be 16:32 overstated in individuals that stay 16:34 within the um dosing ranges both for 16:38 cialis and 16:39 for for today and cedenophil 16:42 and then of course there is a concern 16:44 when you combine this medication with 16:46 other medications for cardiovascular 16:48 disease in particular the nitrates and 16:50 that's because 16:51 you may have pretty profound 16:53 vasodilation when you have 16:55 a 16:56 blood pressure nitric blood pressure 16:58 medication 16:59 and so you have to be really careful 17:03 if you do have heart disease 17:04 and you're taking those medications 17:07 one thing to note is that they seem to 17:09 improve erectile function primarily and 17:11 not libido 17:12 and also if there's failure to double 17:15 check and see where your testosterone 17:16 levels are 17:18 and 17:19 uh the two main ones it's adenophile and 17:22 dalapho 17:23 the main 17:24 difference is primarily through their 17:26 uh effective time tidal phil is has a 17:29 much longer duration of action 36 hours 17:32 versus the xylophone which is 8 to 12 17:34 hours 17:35 and that is why i typically will use 17:38 this 17:39 in my patients 17:40 and it's been shown low doses two and a 17:43 half to five milligrams as opposed to 20 17:46 milligrams that's typically 17:48 dose can work quite well and at low 17:50 dosages there is some 17:52 [Music] 17:54 well it's already indicated for 17:56 treatment of benign prostatic 17:57 hyperplasia and there is some research 17:59 suggesting that it can help reduce 18:01 cardiovascular outcomes by virtue of the 18:03 fact that it decreases blood pressure so 18:07 it's a it's a great drug all around and 18:09 that seems to be the 18:11 uh the medication i 18:13 suggest to patients um who have this 18:15 issue 18:18 okay 18:19 there are other medications that you can 18:21 inject directly 18:23 into the 18:24 corporate cavernosum 18:26 these are called intracavernosa 18:28 medications and 18:30 i do not utilize these in my clinic 18:32 although they are pretty popular many 18:34 urologists will utilize them with their 18:36 patients 18:37 and again it does require uh some 18:40 specific training um to ensure that 18:42 you're injecting these medications in 18:44 the correct area basically what you're 18:46 doing is you're taking one of these 18:47 medications and you're injecting it into 18:49 the corpus cavernosum 18:51 uh again those blood filled channels 18:54 within the penis but remember you have 18:56 to be really careful because 18:58 uh there are there you have to inject in 19:01 the right position because there are 19:02 certain anatomical structures 19:05 that you could damage 19:07 the dorsal penile artery which is at the 19:09 very top of the penis and of course 19:12 you never want to inject anywhere near 19:14 uh the base of the penis right with the 19:16 um 19:17 or the ventral surface where 19:19 the urethra is 19:21 uh 19:22 even though the corpus spongiosum is 19:24 here and you could 19:26 get some benefit in terms of injecting 19:29 in that area because you'll get some 19:30 vasodilation it is really close to your 19:32 urethra and it's definitely not 19:34 something that's recommended 19:36 so what are the three medications uh 19:38 that are utilized alprostadil papaverin 19:41 and phentolamine a procedural is a 19:43 prostaglandin it has vasodilating 19:46 properties on its own the pavarin 19:48 appears to 19:49 inhibit phosphodiesterase 19:52 enzymes which as we mentioned 19:54 uh actually there should be decreases 19:57 intracellular calcium release and 19:59 however there is some concern with 20:00 hepatotoxicity if you use it continually 20:03 and then photonamine blocks alpha-1 20:05 alpha-2 20:06 adreneric receptors which causes 20:09 vasodilation 20:11 and 20:14 and this is primarily smooth muscle 20:15 constriction so all of these seem to 20:18 improve blood flow but as i mentioned 20:20 because of the fact that 20:22 they require specialized training 20:24 and there is a potential for 20:27 some damages certain structures i try to 20:29 stay away from these if if at all 20:31 possible 20:33 there are also vacuum erection devices 20:36 or veds and these artificially increase 20:39 blood flow by 20:40 uh just primarily 20:43 encouraging blood flow into corpus 20:45 cavernosum 20:46 and um there these have been around for 20:49 a while 20:51 one of which is one particular um 20:55 pump that's very popular is the bathmate 20:57 and 20:58 although there isn't a lot of there 21:00 aren't a lot of research studies 21:01 indicating its effectiveness there are 21:03 many anecdotal reports of it providing 21:06 some benefit to patients 21:08 surprisingly it seems to 21:10 help 21:11 but it may potentially help in terms of 21:14 improving girth and length although this 21:16 is not potentially by research but there 21:18 are many angdoma reports of 21:20 patients who are very happy with this 21:22 device so this is another 21:25 device that may be of utility 21:29 and then there is ultrasound so 21:32 low intensity ultrasound shockwave 21:34 therapy or the gains wave 21:36 this is basically where uh you have low 21:38 intensity ultrasound about like 150 21:42 waves per minute or so which are 21:44 directed at certain areas of the penis 21:46 primarily 21:47 where there are where the corpus 21:50 cavernosum is and potentially the corpus 21:52 spongiosum just to break up 21:54 um 21:56 break up and uh or 21:58 to increase blood flow within those 22:00 channels and 22:02 we're not entirely sure what the 22:03 mechanism of action is but seems to 22:05 increase vascular endothelial growth 22:07 factor and it causes these uh very um 22:12 very minut 22:13 tears within the 22:16 vasculature which in ten overturn over 22:19 time seems to improve blood flow 22:22 and so by just a couple of sessions of 22:25 over a period of 12 to 15 weeks there 22:27 have been certain individuals that have 22:28 seen pretty significant improvement in 22:31 terms of erectile function as it appears 22:34 to increase vascular flow 22:37 okay and then finally 22:39 to end off this presentation we'll talk 22:41 a little bit about the integrative 22:43 interventions that i utilized so again 22:46 number one um as i mentioned 22:49 erectiles function for many many 22:51 individuals in fact the majority is 22:53 really a vascular issue so any 22:54 supplements that you can do to improve 22:56 your 22:57 vascular health things like coenzyme q10 22:59 fish oil and krill oil magnesium 23:01 carnitine and b vitamins to reduce 23:04 homocysteine 23:05 is really really important anything to 23:07 improve your lipid panel anything to 23:09 improve 23:10 or decrease your risk of developing 23:12 diabetes anything that is going to 23:13 reduce risk of long-term chronic 23:15 illnesses that will 23:18 affect the arteries is going to help 23:19 with erectile 23:20 function in addition there are other 23:23 supplements that can improve 23:25 vasodilation arginine appears to improve 23:28 vasodilation it's an essential amino 23:30 acid and taking five to ten milligrams 23:32 has helped some daily has helped some of 23:34 my patients 23:35 if your dhea levels are low remember you 23:38 want them between 200 and 350. let me go 23:42 get that right here 23:44 see 200 to 350 micrograms per deciliter 23:49 it may be a good idea to consider 23:51 utilizing dhea 25 to 75 milligrams it 23:55 seems to do the trick and of course i 23:57 would 23:58 make sure that you check labs 24:00 to 24:01 to get within that range and then you 24:04 have yohimbine 24:06 which seems to block alpha two 24:08 adrenergic receptors and cause smooth 24:10 muscle this should be relaxation 24:12 and at five to ten milligrams daily 24:14 that's the dose that typically is one 24:16 thing to remember though is some 24:18 individuals may develop anxiety with 24:20 yohimbine 24:22 at higher doses i i rarely see it at the 24:25 5 to 10 milligram dose but just be aware 24:27 of it and try not to go much higher than 24:30 20. 24:32 okay 24:34 well hopefully uh this has been helpful 24:36 and 24:37 has given you some information about 24:39 erectile dysfunction 24:40 and maybe uh giving you some more 24:43 talking points with your pcp or 24:46 your provider that's 24:48 involved in treating this 24:50 and it also gives you an idea of how i 24:52 look at erectiles function for patients 24:54 coming to the clinic