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Diane Newman: Welcome. I'm Diane Newman. I'm a nurse practitioner and the editor of the Bladder Health Center on UroToday. I'm also adjunct professor of urology and surgery at the University of Pennsylvania. Today we have a guest, Dr. Jeff Albaugh, who is a colleague of mine who specializes in erectile dysfunction and I've asked him to talk with me today about his practice and what can be done for men who suffer from Ed. Jeff, welcome.

Jeffrey Albaugh: Thank you Diane. I really appreciate this opportunity to share my expertise with your audience.

Diane Newman: Well thanks for coming, you know, and talking to us about this. And you know, Jeff, I want you to talk a little bit about yourself because you really have quite a background in erectile dysfunction and sexual dysfunction in men and women. And I want to tell our audience is that he's an author of a book that I have used in my practice repeatedly, that's very informative for men who have erectile dysfunction because it goes through the problem, as far as a lack of erections, libido issues, as well as all the treatments. So, but talk a little bit more about yourself and what you're doing in your practice.

Jeffrey Albaugh: Yes, well Diane, you know, I've been doing this for a very long time. I've been taking care of patients with sexual dysfunction for over 30 years. I work at the North Shore University health system in the private sector and I work at the Jesse Brown VA Medical Center in Chicago. Both of my practices center around treating men and women with sexual dysfunction, evaluating and treating those patients. The book was written as a labor of love really because as you know, both of us do quite a bit of speaking and when I was talking to men with prostate cancer in particular, they said, we don't have someone like you in Texas or we don't have someone like you in Oklahoma. What do we do and how do we know what to do about sexual dysfunction in particular erectile dysfunction and other issues that come up after prostate cancer treatment.

So I thought about it a lot and I thought, wow, I can speak to a large audience, but if I publish a book now, anyone can have access to that book. I was very blessed to have wonderful patients who supported my work. And so I'm able to offer the book when they go on the website www.drjeffalbaugh.com, they can download the book completely free. The book is an excellent guide to help them understand erectile dysfunction and other issues that arise when you have prostate cancer treatments, whether it be radiation or surgery. And it also has in depth information of the good, the bad, and the ugly about each of the treatment options. I try to tell them everything I could think of because if I don't, they'll come back and tell me something that I missed.

Diane Newman: The other thing about the book that Jeff, that I really like is the fact that you have some patient voice in here talking about their problem and then you know, what are solutions. So I really think it's really quite a formative, you know, as I said, I give it out to my practice all the time, and you were saying that you give it prior to actually some of the treatments, which is really a good idea. I tend to see them in after say the treatment, whether it be surgery, radiation therapy, and I see them for urinary dysfunction like incontinence, but they always do bring up their erectile dysfunction. Yes. And you really have to have that dialogue with them.

Jeffrey Albaugh: I think it's so important and I really, appreciate you reminding me of the importance of the, their voice of the patients in there. My research study really looked at men across the United States and talking about how do they feel about erectile dysfunction after prostate cancer treatment? How do they feel about each of the treatments? And I tried to put their voice throughout the book because I think that's really important for men and their partners both to know about how do patients feel about it? How do men who have prostate cancer feel and how do their partners feel about each and every one of these things? The book is based in research and so you'll see a lot of references and things like that. That's because I wanted it to be based in the science, but I wanted to give them all the information they need to empower them to figure out exactly what's the right thing. I try not to persuade or dissuade a man or their partner on what to do. I try to give them what they need to make their own informed decision.

Diane Newman: Well you brought up as far as the research in this area, and we do have several treatments now one of the first things that we would always go to is oral medication for erectile dysfunction. Correct. I mean they've really come a long way since the advent of Viagra. Talk a little bit about that for us, Jeff.

Jeffrey Albaugh: They have, but here's what's frustrating for men after prostate cancer treatment, especially after surgery in particular. Remember that when they take out the prostate, there's no way to get it out without pulling the nerves for erections off the back of the prostate. You can't get it out without, dissecting those off or removing them from the prostate. They were never meant to be touched. They become inflamed and the first response is usually a pretty, a pretty acute feeling of "I cannot get erections. It's like someone flipped off light switch." It doesn't even feel like it's connected anymore. Patients will say to me, did they do nerve sparing? Did they spare my nerves? It doesn't seem like that happened, because the initial response is a pretty distinct, very dramatic change in erections. So they're frustrated by that and the pills rely on the pathway between the brain and the penis and that communication, that nerve conduction is changed because of those, those nerves being inflamed and the problems that occur because of that.

So initially, especially in the first month or two after surgery, the pills may not be working right then and that may cause a man to think the pills aren't gonna work. But the nerves do recover over time. Recuperate recover, they do get better. They don't always get back where they were before. And most men will say they're not exactly back where they were before, but they do recover over time. But that can take an average of two years. So the pills are a great thing to go to. We use them sometimes we start men on them before surgery if they want to just to get things going in the right direction, make sure everything's headed in the direction of really good erections. And then we stop for about a week while the catheter's in with surgery and different things and we start again after the catheter comes out again with regular use of them.

I tell men, do not stop using them regularly because they're not working initially because how they work three months later or six months later or 12 months later may be totally different than how they work right after surgery with radiation. It's a slow insidious, a slow change. You don't see the problems right away. They start happening towards the end of radiation or the first couple months afterwards and they get worse over time. It's the opposite with the surgery. It's an immediate erectile response because of those nerves being inflamed and then it gets better over time. So the pills are a good choice, but you have to know how they're gonna work and those particular men and often they're not. So we have to turn to other things as well. And I think that's really important that they work with someone who can help guide them to understand all those other options and what do they want to do?

What, there's only two opinions that matter in the room. What does the man want to do? And if they have a partner, how does their partner feel about it and what do they want to do then when the pills aren't doing everything they want, for example. Or if they are, hey, everybody's happy if things are working well, but if they're not we can intervene with some of the local therapies that work directly on the penis like the vacuum device or the shots or something that works right on the penis that don't require that communication between brain and penis or nerve conduction.

Diane Newman: Yeah, I'm glad that you brought that up about the fact of it does, it may take time and, and I think afterwards men are really like so anxious they think that's what's gonna, you know, they're not gonna ever get an erection back, but over time those nerves do go back to normal or at least as far as functioning better. But you brought up a really important point, the other options, and you brought up the vacuum erection device. I used to tell my patients and I still do, hey, that's like taking your penis out to the gym, can you kind of demonstrate and show us a little bit about that device, because I know you brought it here today show.

Jeffrey Albaugh: And I really like what you say and I say to men, I say you're actually doing physical therapy on your penis somewhat with it, especially after prostate cancer treatment. So I agree with you, it is like a gym visit, but they can do it right at home. So I think, I think probably the most important thing I want to say today is when men walk in my office and in your office what they want, we can't give them because they want back exactly what they used to have. That's what they really want. And the sad truth is they want to think it and it happens and it takes nothing more than that and that's really what they're looking for. But all of these things require some adjustment in that thinking because now we have to integrate things like a vacuum device into their love play with their partner.

And that's why I really like patients to bring their partner or partners or whoever's involved in sex with them to that clinic visit so that we can sit down and together explore and look at these things and think about them. But you think about now how do I integrate that into my love play? But believe me, I've taught thousands of men to do this and I know you have as well. And so these things are not perfect. Perfect is you think it, it happens and man, if I could give that to the men, I would be the most popular guy on the face of the earth and I would be thrilled. What I can give them are some things that help them and can move them along with things. And one of the things is this vacuum pump. The vacuum pump is a pretty simple system.

And so basically when we think about rehab, we think if the patient is getting any erectile function when they're walking in there, if they get erections after their surgery, they get and men think of I'm hard, I'm not hard. We think of a continuum from zero, you have absolutely nothing to four, you couldn't possibly be any harder. And in between one it fills out like it wants to do something but it doesn't get hard. Two, it gets slightly hard but not nearly hard enough for sex. Three, it gets hard enough for penetration but not any harder. Four, it can't get any harder if you're getting a 0.5 or a one or one and a half, build off of that. Get started with that with sexual thoughts and stimulation with your partner on your own to get it started and then now lubricate the penis.

Good lubricate the vacuum device and put your penis inside that device as hard as you can get it or as full as you can get it or whatever will happen. And if it won't do anything, put it in there that way. But if you have anything to start with, that's a big deal because that's like a jumpstart. There's already blood that's moved across your penis all the way down to the head and it's ready for more. There's always blood in there, but the more there is in there, the easier this process will be and if there's nothing in there we can work with that too. So they put their penis, they get it lubricated hard as they can, they lubricate this and they put it inside. Once they put it in there, they're gonna put this against their body with their penis inside there and they're gonna start pumping with it against their body, which will create a suction inside.

And there's lots of different vacuum devices out there. They vary in prices. So you need to look around and find a good medical grade vacuum device and then that suction is gonna simply force more blood in the penis and make it fuller or harder and you're gonna slowly, gently work with it. Men, when we think of physical therapy, sometimes we think of pain but this is not a circumstance where there should be pain. Every single time there's pain you're gonna release by pushing the release button and pulling your penis loose and readjusting. So you're gonna release and every single time it hurts no pain for gain. And so after you release and readjust each time, your goal is to get a painless every time it hurts, release and readjust even. And this is tricky, the more you start with the easier it is. But even across it not fat back at the base and then blood not down in the head of the penis even and lift it off.

So those are the three things. Painless even and lifted off erection. Once you get that painless, even lifted off erection, now you let it sit in there for a couple minutes full of blood. You're not overstretching it but just bringing it up to painless even and lift it off. Let it sit in there for one or two minutes according to the research and then release it completely, take it all the way out. It won't even go all the way down, put it right back in and work it up again. Once you get another painless, even lift it off erection, let it sit in there a minute or two, take it out, put it back in again. Do about five to 10 of those what we call penis pushups, holding them each a minute or two and that's how we do some stretching and kind of get the penis used to more blood in there. All of this can be used as part of a penile rehab strategy.

Diane Newman: Yeah. You know and you're bringing that, it's interesting you bring up some, I mean the belief now right? Is that we start this right away actually, you know, to just like you're saying rehab the penis. Do you ever give it to anybody pretreatment?

Jeffrey Albaugh: Some patients do get the vacuum pump pre treatment. A lot of our patients because our surgeon, that's his choice that he likes to start people on 30 days before the pills. So they start with sildenafil or tadalafil, one of the medications they'll start with for 30 days straight, taking a low dose of that or as needed but every day and then they'll stop it with surgery and restart it after the catheter's removed. The vacuum pump typically would be started one month after surgery. That's when it should be started. You don't want to delay it because those are the people in the studies we used as the control group because they didn't get as good of responses. So you want to start it within that first month or two but don't start it before one month because let the healing occur but at one month they can begin and then they can start doing those daily penis pushups.

Those stretches five to 10 penis pushups, hold them each a minute or two and that should do it. The tricky part is learning to get those painless even lifted off erections and the more they start with when they put it in there, the easier those are, the more they start with nothing, the more releases they'll have to do back and forth. It is not unusual when you start with a flacid penis to need to do 20, 30 or 40 releases before you get that painless even lift off erection. The number one thing when people come back in my office with their vacuum pump they're doing wrong is they didn't do enough release and readjust to get that painless even lifted off erection. But if you start with a fair amount, like if you start with a two out of four where you have some hardness and um, just not enough hardness, it could take a couple pumps and you could already be there.

That's the difference with, so the more you start with, the better. If you start with something, if not a little more work, a little more things, but then can you use it for sex too? So that's the rehab part and that's the stretching part. But if you wanted to use it for sex, you can't have sex with this on obviously. You're right. And the only thing maintaining your erection is that suction. So what do you do? You can't get your penis out of there and keep it hard. That's where the rings come in and you can um, lubricate underneath because you want to lubricate the tip and then you stretch the ring across the tip and now what you're all you're gonna do is same process you did with the rehab, you're working towards those excellent, painless, even lifted off erections that you've learned to get.

Right. And once you get that now, instead of just letting it sit in there for one or two minutes, you're gonna take your other fingers, one on each side or your finger thumb and you're gonna transfer the ring off the end to the base of your penis and now you can get your penis. There'll be lubricant so it won't snap like that. You can get your penis outta the device and into the vagina because you've got a ring holding it there. So this ring's gonna be on your penis, holding it while you're having sex. The vacuum brings more blood in to um, make you harder. The ring traps it.

Diane Newman: So it traps, it basically traps the blood in the penis. So it keeps it as erect as it can be. You know, I have many, many, many patients who use this that are really very pleased with it. And you're right, that concept of rehabbing is, you know, the penis getting it back over time is in try and try is really what needs to be done. Okay. Now there's other options also. Right?

Jeffrey Albaugh: The truth is Diane, some people hate it. Each of these treatments, they can have high dropout rates because it's not, what they really want is spontaneity. They want it, they think that it happens and we get that if they're willing to practice and be patient and I mean work with this every day till they kind of get it. Once you get it, it, you're gonna work with it for rehab each day. But you're fine. Once you've mastered it and we rehab period is over, which could be a year or two years depending on how you feel about it and how you're progressing, then you could put it aside and just use it for sex when you want to use it for sex or you can continue to use it for stretching. But not everyone, every treatment has good and bad. And so, but I think people are willing to do it because it's non-invasive and it's simple physics, it works in about 80 to 90% of patients and that's why we've both had success, but I was kind of not big on it until a colleague told me, are you working directly with patients with this to see what it really can do in their lives?

And that's when I, like you said, this can be a big deal for men, right? It's cumbersome, it's awkward, it is not perfect, but it can be a very helpful tool and it's non-invasive and it works. So yes, there's other options.

Diane Newman: Okay, so there are other, so you know, we talked about medications, we talked about the vacuum correction device, but there's also injections, correct? That men can give, let's talk a little bit about that because for years, I taught men how to do penile injections. Me too. And almost everybody who comes in was just so fearful, but actually whenever they did it, it wasn't as bad as they thought. Right? They're like quote unquote fear of the unknown. So talk a little bit about the injections.

Jeffrey Albaugh: I think that's probably the most important point you could bring up is it's interesting how they walked in your office fearful, really nervous about it. Oh why would I ever want to do this? And how they walk out going, okay, I did it. I feel comfortable with it, it's doable. Is it perfect? No, again, perfect is I think it happens, but it's something else that offers them an opportunity. And so why would you do it? Why would anybody take a needle and put it in their penis? First off, it's a very fine needle. I did one, the first, one of the first studies ever and one of three studies now to show that men don't find it painful because men kept telling me after they did it with this very fine, it's hard to even see that needle.

Diane Newman: It's an insulin needle, right? People use it all the time for insulin injections.

Jeffrey Albaugh: Yeah, it's so small. And so they're fearful of it. But then after they do it, we would ask them this, all the study did was look at, tell me how much that needle hurt the minute they took it out. We'd say, what was the pain? Zero to 10, 10 being the worst pain you could have in your life. Zero being nothing. 40% of our patients said zero. Literally I felt it go in, but it didn't even hurt. And then of the patients who reported any pain, the average pain rating was about one to two out of 10. So most people did not find it especially painful. Having said that, a needle is not for anybody. I'm not gonna talk you into doing a needle. There's no way. My job is not to persuade you or dissuade you, it's to help you know what the good and bad are. But I do think it is a doable process for some men, not for everyone. The vacuum pump is not for everybody. Neither is the needle. You have to decide for yourself.

Diane Newman: We're talking about they do the injections on the side of the urethra, right? Wait a minute that's wrong. When we talk about doing the injections, we're talking about doing on the side of the shaft of the penis. Right? The urethra is underneath. The penis, you know, on the bottom side. But where you want to get is into the blood vessels though they're on, on either side of the penis. So they really, that's how they inject, correct?

Jeffrey Albaugh: Yes. So what they're shooting for on the top, there's two big cylinders in there. They're called the corpus cavernosum. And they're shooting right into those cylinders. When you see blood vessels, the, you will see some of those there superficially, you're avoiding those, you're shooting right into the corpora because you're trying to, those cylinders are full of blood vessels and those cylinders, the, as the smooth muscle relaxes, the blood vessels fill with blood, you become engorged. And that's what an erection involved is in an erection. So, so we don't want to go near the head of the penis, right? That would really be painful. And of course we never do shots in the head of the penis. We do shots along the shaft on either side. So if they were looking at this here would be midnight right here would be now, now this would be 10 o'clock area and this would be two o'clock area.

And that's exactly where they're gonna inject on the upper side at 10 or two. So they inject right there at 10 or right there at two on either side and they rotate the sites so that they're not doing the same spot all the time. So we teach them how to do that injection. They actually do the first injection in our office after we teach them. And so they can know I did it. If their partner wants to be involved, however they want to do that injection, that's how they should do it in our clinic. Just like they'll do it at home. So they have the knowledge and the comfort of knowing I did it, I know how to do it. And that training is really key to it because we understand when you walk in you're fearful, but once they get past the injection, putting that needle in and giving themselves a shot, I think a lot of the fears dissipated. But there are side effects, there are things to think about. All of them I list in the book, because there's good and bad with every treatment, it may or may not be the right treatment for you, but I would say like you don't let the fear of the needle be the one thing that stops, you know, about the side effects, know about the good and bad of it and is it right for you.

Diane Newman: And usually they get a response within about 20 minutes. Correct. And then you know you, and that's why you say we do it in the office. The other thing I think too that's important is that a prolonged direction, you can have a prolonged direction with the injections, and you know, that can be a concern, especially after a certain period of time. And that is one the complications that can occur. And I always tell my men, Hey, you need to come back to the ER, you know, and really have, because we really need to get, get rid of the erection. Yes. I also tell them sometimes they put ice on their penis, right. That'll also help decrease the erection, correct?

Jeffrey Albaugh: So it's not one of the more common side effects, but it's more serious side effects. So that's why we all spend time teaching them and give them some written information on what to do if it happens, because it only happens in up to about 10 to 15%, but it can become a medical emergency because when blood can't move back and forth, some men say, wow, to have an erection that won't go away. Seems like a good thing, but it's not because after a couple hours when the blood can't move back and forth, neither can the oxygen and the nutrients. And so the penis was not meant to be hard for hours. And so, we need it to go up and down and, and not to remain that hard. So we teach them exactly what to do. And that is one of the more serious side effects that we give them very, explicit instructions for the other more serious side effects.

Sometimes men will get scarring from it, but again, it's not common. It's, it's up to 10 to 15%. The most common complaints we hear, if anything, the medication itself can cause a throbby headachey pain in the penis in a third of men. We can eliminate that medication in some of the compounded off label medications if that's a problem. So we can change things around to fix that. But pain can be one of the things that can occur in about a third of patients, especially with the FDA-approved product. And so it feels like a throbby headache in the penis. That's number one. Number two is bleeding and bruising. You are putting a needle in a vascular area and you have to press over that site for five full minutes afterwards and you press over the site to not only prevent bleeding and bruising, but to trap the medicine right there so it doesn't dissipate and it stays there and does the job right there in the penis of causing the smooth muscle to relax and the blood vessels to fill. So the main side effects are those, but, so there's things to consider and it's not for everyone. And if you were scared to death of a needle, this might not be the thing for you.

Diane Newman: Right. But you know, I, I don't, I'm sure you, you've seen this too, I have patients who have used this for years. Yeah. And I've been very pleased with it. It's more spontaneous than that. So they really like that kind of option.

Jeffrey Albaugh: Although we didn't have time to talk about each of the treatments because there are five FDA-approved treatments, the pills, the vacuum pump, there's a pellet that goes down the wet urethra after urinating the shot and the penile implant surgery. All of those are talked about in great detail in the book and they can get that for free off the website. So of course we didn't have time to cover all that today, but I would encourage them to go to the website and download the free information on the good, bad and the ugly of the five approved things. One last thing I'd like to say, Diane, is there's a lot of people out there who want your money, and know men are very desperate about erectile dysfunction. The herbal industry is unregulated. And so there's all kinds of things that can make you harder, fuller, longer.

Some of them don't work at all, some of them are unsafe. So you want to be very careful with that. There are those five FDA approved things. There's also some cosmetic people and other medical people out there who are doing things that are not yet FDA approved. And so men come in all the time asking for them and talking about them. We provide that information about the safety and efficacy. Some of them are being researched, but I think it's very important to know, go to urology, certified people to find the right treatments that are safe and effective.

Diane Newman: Well, listen, Jeff, this has been really a wonderful review of erectile dysfunction, sexual dysfunction in men, especially post-prostatectomy or post-prostate cancer treatments. And I really appreciate because you really are an expert in this area. So thank you.

Jeffrey Albaugh: Oh, you're welcome.