Ep. 123: Everything Men Should Know But Don't Ask

[00:02] Episode Preview: Viagra vs. Cialis

Ep. 123: Everything Men Should Know But Don't Ask

Host: Dr. Kanwal Bawa | Guest: Dr. Bradley Garden | Runtime: 30:26 | Published: April 16, 2024

Dr. Garden: Viagra usually is absorbed more quickly than Cialis and can have what I call a quicker onset of action. But it does typically kind of leave your body more rapidly. So it may not last as long or for as many hours as Cialis might work. Cialis takes a little bit longer to kind of get absorbed well enough to have an effect, but can actually stay in your body for more than a 24-hour period. So you may still have some benefit from it in the next day. Cialis is also the only one that's at least approved by the FDA for a daily dose. So you take a lower dose every day that kind of builds up in your body. And theoretically, you should be ready to go at any point.

[01:12] Men's Sexual Health: Everything Men Should Know

Dr. Bawa: This podcast is a place where I help unravel the mysteries of human desire and sexual wellness. I am dedicated to guiding you on your quest for a fulfilling and vibrant sex life. And if you think that your best days are behind you, I am here to tell you why that does not need to be your reality. Today we are delving into the fascinating world of erectile dysfunction, premature ejaculation, testosterone, BawaBig® non-surgical enlargement, penis implants, and several other aspects of men's intimate and sexual health. From the iconic blue pill Viagra to its counterparts like Cialis, TriMix, and beyond, we will explore the science behind these medications, debunk common myths, and discuss why I'm not a fan. Joining us for this insightful conversation is urologist Dr. Bradley Garden. So if you have ever wondered about the secrets to achieving and maintaining a rock solid erection, you won't want to miss this episode. Get ready to expand your knowledge and reclaim your confidence in the bedroom, right here on Dr. Sex Fairy. Welcome, Dr. Garden. It's lovely to have you on the Dr. Sex Fairy podcast.

Dr. Garden: Thank you so much. I'm really happy to be here.

Dr. Bawa: You are a urologist and I practice sexual medicine myself. We do a lot that is similar and a lot that is different. And I'm very happy that you are here to clear up some of the questions our viewers may have about men's health issues.

Dr. Garden: Sure. I'm happy to, you know, compare our practices and our differing viewpoints and um you know continue to help patients together.

Dr. Bawa: Absolutely. That's the goal, helping people one way or another. And I refer patients to you as well. So there is definitely you know, a co-working uh relationship here.

Dr. Garden: Sure.

[03:02] What Is Erectile Dysfunction?

Dr. Bawa: So let's talk about the very basics. Now I'm going to ask you questions like our viewers would.

Dr. Garden: Okay.

Dr. Bawa: So the most basic questions. Please tell us what you define erectile dysfunction as.

Dr. Garden: So the way I think about it is erectile dysfunction is any time that you don't feel like you're performing the way that you should be, you know, sexually, with the strength of your erections, um how long you're lasting, the amount of time it takes you to reach orgasm and ejaculate, the quality of your orgasms, etc.

[03:33] How Common Is ED?

Dr. Bawa: Now let's talk about how common it really is.

Dr. Garden: So erect erectile dysfunction is actually very common. I have patients that come in in their teens all the way till 90 years old. Um it's you know more common as you get older for your erections to be not as strong or powerful as they used to be. Um I believe you know the quota rate is about 40% at 40 years old, 40 years of age, and it goes up from there. So it is a very common problem, and I see a lot of patients of all age and and backgrounds coming into my office.

[04:05] Common Causes of Erectile Dysfunction

Dr. Bawa: Now, I always talk about this to my patients and on this podcast that the most common cause of ED is actually blockages in blood vessels. What are some other common causes of it?

Dr. Garden: So, yeah, the I think The most common cause, like you said, is blockages in blood vessels or problems with blood flow to the penis. Um it's, you know, I say it's uh almost uh analogous to blockages in your heart and the arteries that feed your heart. some other causes are medication side effects, some beta blockers that patients use for their blood pressure, you know, lifestyle, you know, sedentary lifestyle, all these types of things can definitely influence the quality of their erections.

[04:47] Premature Ejaculation and ED

Dr. Bawa: Let's talk about premature ejaculation next, or early ejaculation as some people like to call it now. A lot of people suffer from that. How is that similar to ED and how is it different from it?

Dr. Garden: So there's actually a lot of kind of interplay between premature ejaculation and erectile dysfunction. some patients who have uh premature ejaculation will actually have concerns about their ability to perform, and that gets into their head and can affect the quality of their erections, or they might lose the erections before they reach their climax, so as not to be embarrassed and things like that. Premature ejaculation is another common issue that I see in my office as well.

[05:28] Viagra and Cialis: Who Should Take Them?

Dr. Bawa: As far as treatment for erectile dysfunction is concerned, the first line treatment is usually a medication like Viagra or Cialis. In my office, it tends to be shockwave therapy or one of my other treatments. But let's talk about the conventional form of ED treatment and who is or isn't a good candidate for these medications.

Dr. Garden: Sure. So for Viagra and Cialis, the main risk factor, the main contraindication for treatment with those medications is someone that uses what we call a nitrate medication or nitroglycerin or some uh blood pressure medications that contain nitrates, because the risk or the concern is that the combination would make their blood pressure drop very low and actually could be uh life-threatening for them. some other contraindications or some patients that may not benefit or should not be started on these medications are those with um severe heart disease who may have shortness of breath or chest pain with even light physical activity, walking down the street, going up a flight of stairs. Those patients really need to be checked out by their primary care physician or a cardiologist before starting these medications.

[06:39] Viagra vs. Cialis

Dr. Bawa: How are these two medications similar and how are they different? Sure.

Dr. Garden: So Cialis and Viagra are the main, you know, two uh erectile dysfunction medications that are out there. They've been around the longest, and they're the most common that I use. you know, they both are part of a class of medications called phosphodiesterase-5 inhibitors. And basically their goal is to increase the blood flow to the penis and keep it around for longer. how they differ is the speed at which they're absorbed in the body, how quickly they take effect, and how long they last for. Viagra usually is absorbed more quickly than Cialis and can have a quicker on what I call quicker onset of action. but it does typically uh kind of leave your body more rapidly. so it may not last as long or for as many hours as the Cialis might uh work. Cialis takes a little bit longer to uh kind of get absorbed well enough to have an effect, but can actually stay in your body for more than a 24-hour period. So you may still have some benefit from it in the next day. Cialis is also the only one that's at least approved by the FDA for a daily dose. So you take a lower dose every day that kind of builds up in your body. and theoretically, you should be, you know, ready to go at any point.

[08:04] Managing Symptoms vs. Treating the Problem

Dr. Bawa: The reason I have a problem with these medications as a first-line treatment in my medical practice is that they're really not fixing the problem. It's more of a band-aid approach.

Dr. Garden: Correct. Yeah, it's um it is true that, you know, it's not doing anything to reverse the disease, it's really just to manage the symptoms you know, at the time that we need them.

Dr. Bawa: That's the reason why I don't really like them. You know, that whole concept of fixing the symptom, or I guess helping the symptom, but not really fixing the problem. And that's why I like to lead with more of the treatment approach rather than the medication approach. I just feel that in the long run, it seems to help people more.

Dr. Garden: Sure. I think you know uh it's great that that we have or that you have the uh options that can try to help patients, you know, achieve better erections without the medications or to try to reverse some of the disease process uh that they have. And I'm hoping that as you know more research is done, we have you know more high-quality options like that.

[09:06] TriMix, QuadMix, and the Risks

Dr. Bawa: Let's talk about TriMix. Men hate the thought of a needle in their penis, but when it comes down to it, some of them are injecting themselves with TriMix to get erections immediately so that they can have sex. It's a dangerous medication.

Dr. Garden: It is. So TriMix is a is a medication, it's or a medication, it's made of three different uh compounds that all work kind of synergistically to improve blood flow into the penis. And now there's actually something called QuadMix, which adds a fourth medication. they're definitely more potent uh than the uh the oral pills for erectile dysfunction, but you're right, they can be dangerous. There can be some side effects that that can cause some uh major issues.

[09:51] Priapism: When an Erection Becomes an Emergency

Dr. Bawa: I have PTSD from the penises I've drained in the ER over the years.

Dr. Garden: Yes, so there's something called a priapism, which is a prolonged erection, a prolonged painful erection, typically one that lasts more than four to six hours. and what's actually happening uh on an anatomic level is that the penis is becoming starved of oxygen. The blood that's been trapped in the penis for the erection has stayed there for too long and it's used up all its oxygen. Um and if it's not reversed pretty rapidly, you can start having uh more permanent damage to the erectile tissues within the penis.

Dr. Bawa: I talked about how I've drained a few, but for our listeners, what are the different treatment options for priapism?

Dr. Garden: Sure. So if you've um if you're at home and you're experiencing an erection that's lasted, you know, four hours or more, one thing you can try is uh going to the pharmacy and picking up oral uh Sudafed and try taking uh 30 milligrams of oral Sudafed, see if that can help uh bring it down. Um sometimes for my patients who I prescribe TriMix to, um there's a medication called phenylephrine, which is also an injection medication into the penis that uh reverses the trimix. That if you're prone to them or you're really worried, you can have your doctor prescribe that for you as well and keep it at home in case you do uh run into an issue where your you know, your erection is lasting too long. but if you don't have those options or none of that is working, then the next step would be to you know get to the emergency room as quickly as you can because they can inject you with phenylephrine in the emergency room, or they might have to call in a specialist to come in and actually drain the old blood out of the penis and try to help establish good blood flow back into the penis to get the erection to go down. sometimes that itself isn't even enough, and you have to create new channels called shunting procedure, where new channels are created for the blood to kind of uh pass through the penis to keep that tissue uh nice and oxygenated.

Dr. Bawa: Unfortunately, many ERs don't have a urologist who will come in and time is penis.

Dr. Garden: Yes, exactly.

Dr. Bawa: So we poor ER doctors have to, you know, go ahead and do some of those procedures in an emergency situation. What to do?

Dr. Garden: Sure, sure, absolutely. Um it's uh yeah. I think uh most ER physicians hopefully should be trained on this, or at least uh to some extent if they don't have uh an urologist who's you know actively uh available to uh to come in and assist on those patients.

[12:26] When Medications Aren't the Right Fit

Dr. Bawa: I think so much of my approach towards sexual medicine was formulated based on all the things I saw going wrong with the conventional approach. Not to say that there isn't a time and place for Viagra, Cialis, and TriMix. It's just something that I felt wasn't ideal for my patient population. I think you know your vibe attracts your tribe. And I think a lot of the people who come to me don't want to be on medications or in some cases cannot be on medications, because like you said, these medications have side effects. And some people just aren't candidates for the medications, then what?

Dr. Garden: Right, exactly. And that's I think where your practice is definitely helping a lot of people who may not want the other options or um you know can't have the other options.

[13:14] Penile Implants: The Last Step

Dr. Bawa: And then TriMix, when it goes really, really wrong and priapism lasts too long, these men are in some extreme cases even requiring penis implants.

Dr. Garden: Correct. Um The last stage, at least in my algorithm for management of erectile dysfunction from any comer, whether it's you know uh prostate cancer, priapism, or just you know, their disease process for the erectile dysfunction is to the point where none of the other treatment options are available, there is a penile implant, which is a surgical procedure where you in uh you place a device inside the penis. there's a couple different models, but the most popular one is one that actually inflates with fluid. There's a little pump that we put in the scrotum and you pump it up to get an erection, and there's a button to release the fluid uh to drain, uh to drain the device and to you know make the uh penis appear more flaccid.

Dr. Bawa: And who should be getting it, who should not be getting it?

Dr. Garden: So um I think most people technically could be a candidate for this option. It is, um I do consult patients that this is basically the last step in the road. And once it's put in, it kind of makes all other treatment options moot, that you're basically destroying the tissues, the natural tissues that provide erections. Um but anyone that's healthy enough to undergo surgery and is you know has the desire to continue having sex despite you know, all the other treatment options out there not working, I think they would be a candidate.

Dr. Bawa: So if somebody is to get a penis implant just because they want to do it for size, they need to understand that once that implant comes out, they're not going to have normal erectile function again.

Dr. Garden: Correct. Yes. It's uh yeah, definitely not something that I would recommend a patient just for you know penile enhancement. It's really um the last step in a long line of treatment options to try to enhance their erections.

[15:15] Prostate Cancer and Erectile Dysfunction

Dr. Bawa: You talked about men who have had cancer-related ED. Let's talk about that. Prostate cancer is a major, major patient population where these men are not able to have proper sex, normal erections after treatment. So, what are the treatments that are causing this and what can they do about it?

Dr. Garden: So, for prostate cancer is very common uh affliction for men, especially as they get into their 60s, 70s, and 80s. and the two main treatments for prostate cancer, which is uh surgery to remove the prostate and radiation therapy, both can cause significant erectile dysfunction. With the surgery, it usually happens right after the surgery, right as you wake up from the anesthesia. With radiation treatment, uh with radiation treatments, it can be uh several months or even years before the um the detrimental effects of the radiation um are seen with your erections. Um the treatment options for patients who have been uh treated for prostate cancer is similar to the run-of-the-mill erectile dysfunction. We start with the oral medications, we can move to the injection treatments, or uh and lastly with a penile implant. for patients who have had prostatectomy or surgery to remove their prostate because of prostate cancer, sometimes we'll even include a vacuum erection device to help kind of sustain their penile length and elasticity while they're recovering from their surgery and while we're trying to get them back on the road to recovering their erectile function.

[16:56] Why Ejaculation Changes After Prostate Cancer

Dr. Bawa: After prostate cancer, men are unable to ejaculate. Let's talk about why that happens and if that can be reversed.

Dr. Garden: Sure. So with treatments for prostate cancer, particularly the surgical treatments where we remove the entire prostate, all men will not ejaculate after that procedure. And that's because um the majority of the fluid that comes out when you ejaculate, the seminal fluid, comes from the prostate and the seminal vesicles. And both of those structures are removed during surgery. While even if you have a what we call a nerve-sparing surgery, where we're trying to preserve the nerves that go to the penis to preserve erectile function, the uh the fluid um will no longer come out, but patients still can still reach orgasm and still can have enjoyable sexual activity despite them not being able to ejaculate.

[17:55] Lower Ejaculate Volume With Age

Dr. Bawa: Men who have not had prostate cancer as they age, they too are having difficulty ejaculating as much. And they want to ejaculate more. They want to have that you know gush that they used to have with semen in the younger days. So is that something that can be fixed?

Dr. Garden: So it really depends on what's behind that you know decrease in fluid, whether it's or whether it's uh a medication side effect or um uh a complication of a surgery that they've had. Um there are some treatment options for that, especially if it's something we call retrograde ejaculation, which is where the seminal fluid is going backwards into the bladder as opposed to uh being uh propelled out the penis. Um that can be helped with either changing of medications or adding an additional medication. But there are a number of kind of ailments that can't be reversed, unfortunately.

[18:50] Testosterone and Male Sexual Function

Dr. Bawa: Testosterone is another factor that plays a very important role in male erectile function. So when testosterone levels are low, really nothing is working very well. Muscle mass, erections, even their mood is suffering. So could you tell our viewers more about how testosterone plays a role in ED and what we can do to replace it?

Dr. Garden: Sure. So yeah, testosterone is um a hormone that is essential to both men and women. but in men, it plays a variety of roles in their bone health, their muscle health, their heart health, as well as their erectile function, as well as their desire for sexual activity and their libido. Um usually, you know, as men age, their testosterone levels fall. but men of all age can have low testosterone levels, and even though their levels might even be borderline, they can still have symptoms of low testosterone. there are a variety of treatment options for low testosterone, low testosterone, some of which include trying to trick the body into producing more testosterone using a medication called Clomid or clomiphene. there's also a variety of forms of testosterone, whether it's a nasal spray, oral medications, uh injections, topical creams, um pellets that we insert under the skin. So there are a variety of treatment options for patients who may have symptoms of low testosterone but might be concerned about uh starting it.

[20:24] How to Preserve Erectile Function

Dr. Bawa: What are the top five or six things that you think men should be doing to preserve their erectile function?

Dr. Garden: So, as I mentioned, I think you know the penis and the heart are actually very similar organs. we want to try to preserve the blood flow to them as much as possible. So if you think about things that are good for your heart, they're probably also good for your penis. whether that's you know, maintaining a healthy diet, getting good exercise, a combination of um kind of resistance, weightlifting, as well as uh cardio, you know, running, jogging, biking, etc., getting your heart rate up, you know, talking to your doctor or your provider about getting your hormone levels checked, making sure your um testosterone and and your other kind of supplemental hormones are in the ranges that they should be. and also, you know, using the penis. You know, it's a it's a it has some muscle in it just like any other part of your body. And um if you're not using it sufficiently, it may not function as well as it should. Use it or lose it. Exactly.

[21:25] ED Can Be an Early Sign of Heart Disease

Dr. Bawa: I actually did an episode about it. Use it or lose it. And I even did an episode about the connection between ED and heart disease. I had Dr. Mohanty on, who is a local cardiologist, and we had a wonderful conversation about how ED and heart disease are connected, and I'm so happy that you're mentioning that as well, because it's important to men uh if their penis doesn't work. But they don't always pay attention if maybe they have a little shortness of breath or a little swelling in their extremities. They don't notice that as much, they don't care as much. So sometimes ED can be the very first sign that there's something wrong with the heart.

Dr. Garden: Exactly. Um The blood vessels that go to the penis are actually smaller than the blood vessels that that supply blood to the heart. So you can imagine that if you have at the same rate, you know, plaque or or cholesterol that's building up in the walls of these arteries, it's more likely that The arteries to the penis will start to malfunction earlier than the uh those in the heart will.

[22:21] The Aging Prostate

Dr. Bawa: As men are aging, their prostate is getting bigger as well. And that has its own cascade effect of problems.

Dr. Garden: Yeah, absolutely. As uh one of my mentors always used to say, that the two parts of your body that grow throughout your life are your nose and your prostate. And as men age, that their prostates will continue to grow, especially if their testosterone is in the normal range, because testosterone is a hormone that influences the growth of the prostate. Um but as your prostate grows, you may notice increasing difficulty with urination. It could just start off as being you feel like your stream is slowing down, or you feel like you're maybe not emptying to completion. You're having to run back to the bathroom after five or ten minutes after you finished urinating. Um you may have some dribbling after the end of urination. No matter how many times you shake, there are always a few extra drips that come out that you notice uh in your underwear. and those can be relatively easily managed with medications or a procedure to try to reduce the obstruction from your prostate on your bladder and and can actually significantly improve your life.

Dr. Bawa: Some of these medications, like the one you mentioned, Propecia in particular, that people are using for their prostate can also cause some erectile issues.

Dr. Garden: So you're you're right. It's it is really just a very small percentage of patients that have these side effects, and even a smaller uh percentage that have you know irreversibility of those side effects. Um but I definitely, whenever I start a patient on this medication, we'll counsel them on this risk. Um and we'll typically only reserve it for patients who are older, who can't tolerate other treatment options or other procedures, or just won't be bothered by the side effects.

Dr. Bawa: So they should definitely treat their prostate.

Dr. Garden: Yes.

[24:13] Testosterone and Prostate Cancer

Dr. Bawa: They shouldn't let that hold them back. Exactly. We talked about testosterone and we talked about prostate cancer. We should probably talk about the link between the two.

Dr. Garden: Correct. So, like I had mentioned previously, testosterone is a hormone that causes the prostate to grow. And all the more so when you have prostate cancer, it can cause the cancer cells to grow more rapidly and become more aggressive. Actually, one of the ways that we treat prostate cancer is by shutting down a patient's testosterone production and basically bringing their testosterone levels down to as close to zero as possible. if you've been diagnosed or recently treated for prostate cancer and you are on testosterone replacement therapy, it's probably uh we should definitely check with your cancer specialists or your urologist about whether it makes sense to continue with your testosterone treatment or potentially stop it for a period of time until uh you can be sure that you're you're clear of your cancer has been cured.

Dr. Bawa: On an average, if there is such a thing, how many years after prostate cancer do you see men going back on testosterone therapy?

Dr. Garden: It's definitely variable. Um I would say that it depends a little bit on uh this grade and stage of their cancer uh after it was treated and um whether or not it's been fully cured. Um I would say I probably myself wouldn't feel overly comfortable treating someone unless they've been uh cured for at least five years.

[25:49] Adult Circumcision

Dr. Bawa: An interesting reason why I send you patients is circumcision, even as adults, because I do BawaBig® non-surgical penis enlargement, and my results are significantly better and smoother when men have been circumcised. So I'm not saying that all my treatments are uncircumcised men, but some of my uncircumcised patients like to, for best results, uh get circumcised as adults. Now that's not something that's very common, but in my practice it happens a lot.

Dr. Garden: Sure, yeah. you know, the common reasons why I see adult or older patients for circumcision is something called phimosis. Um basically The foreskin gets too tight and they have difficulty retracting their foreskin for hygiene or they start getting infections of the head of the penis. you know, The procedure itself is relatively straightforward. you know, in patients' minds, they think that it's you know, you know, terribly painful and and and you know they'll be in bed for for weeks at a time while they're recovering. But you know, overall I've found for my patients that it's not terribly painful. Um within a day or two, they're back up and moving around. Um the only kind of restriction I have is no sexual activity after circumcision for four to six weeks, just to let everything heal up appropriately.

[27:13] Can a Vasectomy Cause ED?

Dr. Bawa: So let me ask you a question once and for all. Can a vasectomy cause erectile problems?

Dr. Garden: Not that I've seen. I don't think there's any studies that will show a vasectomy causing erectile dysfunction. Um The or you know, while they kind of share the same space, you know, The testicles and the penis are are definitely separate. you know, aside from some sort of complication affecting your testicles and affecting your testosterone levels, I don't think there's any um any real explanation or any real reason why a vasectomy would cause uh erectile dysfunction.

[27:52] How to Find Dr. Garden

Dr. Bawa: Well, thank you for clearing that up because I have gone blue in the face telling men that their vasectomy did not cause their ED, but they that's their story and they're sticking to it. So, Dr. Garden, if somebody has questions or wants to see you as a patient, how can they find you?

Dr. Garden: Sure. so I work at a group called Z Urology. Um you can visit our website, zurology.com. You can give us a phone, a call, 954-718-8200, to schedule an appointment. I'd be happy to see you in my office.

Dr. Bawa: Well, thank you so much. You cleared a lot of issues for our viewers, and uh I'm glad we had this very important and very needed discussion.

Dr. Garden: Uh thank you so much for having me. I had a great time.

[28:33] Recorded Outro

Dr. Bawa: And with that, we bring another enlightening episode of Dr. Sex Fairy to a close. I want to extend my heartfelt thanks to each and every one of you for tuning in and joining me on this journey towards sexual empowerment and wellness. Remember, your sexual health is a vital aspect of your overall well-being, and there is no shame in seeking guidance or treatment when needed. Whether you are grappling with ED, premature ejaculation, or some other concerns, know that you are not alone and that help is available. I encourage you to continue exploring and learning about your own sexual journey. You can always give my office a call at 1-877-DR-SEX-FAIRY or fill out the contact form on my website, drsexfairy.com, to schedule an in-office or virtual consultation with me. People travel to my Boca Raton, Florida, practice Bawa Medical from all over the world, and I am able to connect with you in person or over a video consultation or a phone call, no matter where you are. There are several links to help you in the podcast description below, including a link for Dr. Sex Fairy supplements. Please subscribe to the Dr. Sex Fairy Podcast on platforms like Apple Podcasts and Spotify, and don't forget to leave us a five-star review. Your subscriptions and reviews will help me spread my message of wellness, performance, and pleasure. For those of you on YouTube, like this video, share it with your partner and friends, and subscribe to the Dr. Sex Fairy channel for more great content. And remember, your best days are not behind you. They are right here, waiting to be embraced. Until next time.