Erectile Dysfunction Therapies: Testosterone, PD-5 Inhibitors, & Beyond

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Can we do more than prescribe pills to address men’s sexual health complaints? In this episode of the BackTable Urology Podcast, men’s health expert Dr. Mohit Khera from Baylor College of Medicine joins guest host Dr. Amy Pearlman for a deep dive into testosterone management and the full spectrum of erectile dysfunction therapies.




SYNPOSIS

The conversation covers daily tadalafil use, lifestyle optimization, and the nuanced role of off-label medications. Dr. Khera also highlights emerging technologies like the Tech Ring and radiofrequency treatments, alongside practical insights into semen analysis and hormonal health markers. Throughout, he emphasizes a holistic, patient-centered approach to sexual health—blending medical therapy with meaningful lifestyle change. This is a must-listen for general urologists, men’s health specialists, and trainees looking to expand their toolkit in this evolving field.




TIMESTAMPS

00:00 - Introduction
02:13 - Erectile Dysfunction and Testosterone
08:05 - Young Men's Health and Early Detection
10:20 - Semen Analysis for Overall Health
12:50 - Daily Tadalafil and Its Benefits
16:40 - Proactive Sexual Health Management
21:28 - Female Sexual Health
25:16 - Treating Delayed Ejaculation
28:53 - Psychogenic Erectile Dysfunction
31:16 - Technology in Sexual Health
35:54 - Lifestyle Modifications for Better Sexual Health
41:55 - Resources and Referrals for Patients
44:30 - Final Thoughts

Detailed Briefing: Advancements in Erectile Dysfunction (ED) Therapies and Holistic Men's Health​

Source: Excerpts from "Erectile Dysfunction Therapies: Testosterone, PD-5 Inhibitors, & Beyond w/ Dr. Mohit Khera | Ep. 240" (Backtable Urology Podcast)

Key Presenters: Dr. Amy Pearlman (Board Certified Urologist, Host), Dr. Mohit Khera (Professor of Urology, Baylor College of Medicine; Director of the Laboratory for Andrology Research; Brantley Scott Chair in Urology)

Date of Discussion: Not specified, but references 2018 AUA guidelines.

I. Overarching Theme: ED as a "Ticket" for Broader Health Intervention

The central and most impactful theme is Dr. Khera's philosophy of using ED as a highly motivating "ticket" to engage men in comprehensive lifestyle and health improvements. He states, "I say you want to improve your erections you want to reverse ED you want to be able to have sex until the day you die your sex as long as your life you want that this is what you do today I have a much greater chance of him doing it than if I said 'Hey you know you got diabetes and I really it's a much greater chance of him listening and I will use that ticket over and over again to improve his quality of life moving forward.'"

This highlights a proactive, preventative approach to healthcare ("Medicine 2.0 and 3.0") rather than the traditional reactive model of waiting for severe conditions to manifest.

II. ED and Systemic Health: A Barometer for Overall Wellness

• ED as a Marker of Poor Health: ED is not merely a localized problem but a significant indicator of underlying systemic health issues. It's explicitly stated as a "marker of cardiovascular disease," "depression," and "diabetes."
• Low Testosterone (Low T) as a Health Barometer: Dr. Khera asserts that testosterone is "one of the best barometers of a man's overall health." Low T is linked to:
• Increased risk for cardiovascular events (as per AUA Testosterone Guidelines).
• Obesity and diabetes.
• Depression.
• Bone fractures.
• Association (not causation) with prostate cancer ("The lower t the more likely to have prostate cancer").
• Dr. Khera boldly claims, "You show me another blood test on the planet that's has more associates with more comorbid conditions. It's not your lipids. It's not your thyroid, you know low te."
• Recommendation for Testosterone Testing: Every man over 40 should have an annual testosterone level checked. The "delta" (change from baseline) and individual "set point" are crucial, as a "normal" level (e.g., 350 ng/dL) for one man might still be symptomatic if his personal optimal level is higher (e.g., 450-500 ng/dL).
• Semen Analysis as a Predictor of Future Health: A poor semen analysis is a strong predictor of future cardiovascular events, metabolic syndrome, and certain cancers (prostate, testicular). This underscores the interconnectedness of reproductive health and overall wellness.

III. Advancements in ED Therapies: Beyond the "Little Blue Pill"

• PD5 Inhibitors (e.g., Viagra, Cialis) - Not a Cure, but a Tool:They are effective for many but not all, especially those with low testosterone.
• They are described as "Vicodin" for ED – masking the problem, not curing it.
• Daily Tadalafil (Cialis) - A "No-Brainer": Dr. Khera is a strong advocate for daily low-dose tadalafil, deeming it "far more important to me than that 20 seals on demand." Its benefits extend beyond ED:
• Causes hypertrophy (muscle growth) of cavernosal smooth muscle in the penis, promoting penile health.
• FDA approved for Benign Prostatic Hyperplasia (BPH).
• FDA approved for Pulmonary Hypertension.
• Preserves endothelial lining (systemic effect, cardioprotective).
• Studies show a "13% reduction in MI" and "25% reduction in mortality" with daily tadalafil.
• Now generic and affordable, making it a highly recommended preventative measure.
• Testosterone Supplementation:Not recommended as monotherapy for ED (per 2018 AUA guidelines).
• "Works phenomenally in combination therapy with PD5 inhibitors." 30-50% of non-responders to PD5 inhibitors become responders when testosterone is added.
• Can be effective as monotherapy in certain populations (very low baseline T, mild to moderate ED, few comorbidities).
• Emerging Therapies & Technologies:FirmTech "Tech Ring": A device that monitors nocturnal erections (rigidity, duration, frequency) via Bluetooth.
• Valuable research tool for assessing treatment efficacy.
• Crucially, it prevents venous leak: By decreasing outflow, it addresses a common cause of ED (unlike most other treatments that focus on increasing inflow). It's "not a drug," and cost-effective long-term.
• Part of a "triple cocktail" for young men's "erectile fitness" (along with testosterone testing and semen analysis).
• Radiofrequency (RF) Therapy (Vertica device): A novel approach currently in clinical trials (Dr. Khera is involved in one of three sites nationally).
• Aims to tighten Type 1 and 3 collagen in the tunica albuginea (penile sheath).
• Theoretically addresses venous leak by making the "drum" (tunica) tauter.
• Preliminary non-placebo studies out of Israel showed significant improvements as early as four weeks.
• Addyi (Flibanserin) & PT-141 (Bremelanotide): Primarily for libido issues, increasing dopamine and norepinephrine (excitatory neurotransmitters). Can also help with orgasmic dysfunction (e.g., in cases of anorgasmia).
• Future Desired Technology: Real-time hormone level tracking.

IV. Lifestyle Modification: The "Cure" for ED and Overall Health

• Dr. Khera emphasizes that lifestyle changes are the true "cure" for ED, unlike pills that only mask symptoms. This is his "most excitement."

1. Four Pillars of Lifestyle Modificationiet: Mediterranean diet (low sugar, more antioxidants), significantly improves IIEF scores.
2. Exercise: 40 minutes, 4 times/week of moderate exercise significantly improves IIEF scores, especially for severe ED.
3. Sleep: 7-8 hours of sleep per night improves erectile function. Less than 6 hours increases ED risk and hypogonadism (due to hypoxia affecting LH secretion). More than 9 hours shows no additional benefit.
4. Stress Reduction: Stress significantly impacts sexual function and hormone levels (e.g., "operator syndrome" in military personnel). Acknowledging and addressing stress is crucial.

• Patient Motivation: Men are highly motivated to make lifestyle changes when framed around improving their erections and sexual function. This is the "ticket" for broader health impact.
• Role of Urologists: Urologists, as "experts in sexual dysfunction," have an obligation to educate patients on the natural history of ED and the benefits of lifestyle changes. This can be achieved through handouts, videos, social media, and crucially, by referring to other specialists (nutritionists, exercise counselors, sleep labs).

V. Psychogenic ED and the Vicious Cycle:

• Situational ED: When erections are normal with masturbation but not with a partner, it indicates a psychogenic component.
• Vicious Cycle: Initial ED incidents lead to anxiety and self-monitoring during sex ("I hope I don't get ED again"), which in turn causes ED, perpetuating the cycle.
• Breaking the Cycleaily PD5 Inhibitors: Can build confidence by ensuring consistent erections, allowing men to relax during sex.
• Penile Ultrasound: A "therapeutic" tool to reassure patients that their "penis looks fantastic" and there's no underlying physical problem.
• Sex Therapy: Recommended for psychogenic issues, now more accessible via Zoom.

VI. The Importance of Treating the Couple (Female Sexual Dysfunction)

• A significant disservice is done if male ED is treated in isolation, without considering the partner's sexual health.
• Urologists should expand their expertise to include female sexual medicine.
• Many medications used off-label in men (e.g., Addyi, PT-141, testosterone) are approved for use in women (e.g., for HSDD/low libido, arousal disorder).
• Treating both partners leads to "far greater" satisfaction and positive impact.

VII. Proactive Healthcare and Preventing Frailty:

• The discussion advocates for a proactive approach to sexual health, preventing ED rather than just treating it reactively.
• Testosterone in older men, combined with protein intake and weightlifting, is crucial for preventing sarcopenia (muscle loss) and bone fractures, combating frailty. It also helps with cognition and depression.

VIII. Resources and Future Outlook:

• Dr. Khera's website: drkhera.com
• Sexual Medicine Society of North America (SMSNA) website: SMSNA.org
• Recommended podcasts: Peter Attia's The Drive, Gabrielle Lyon, Luis Nome, Dhru Purohit, Andrew Huberman's Huberman Lab.
• Dr. Khera is currently writing a book on "Sexspan," due 2026.