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Erectile Dysfunction (transcript)
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Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association; an Association of independent Blue Plans committed to better knowledge leading to better, more affordable health care for consumers.

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(Dr. Peter Salgo) 
Welcome to Second Opinion where each week our health care team solves a real medical mystery. When we close this file in a half an hour, you'll not only know the outcome of this week's case, you'll be better able to take charge of your own health care. I'm your host Dr. Peter Salgo and our story today concerns S tan. You've already met our special guests who are joining our cast of regulars; Primary Care Physician Dr. Lou Papa and health reporter Christine Rogers. No one on this team knows the case so let's get right to work shall we? Let me tell you a little bit about Stan. Stan is 72 years old, he's been married for 45 years and he comes to his Primary Care Physician's office for the best reason of all; the most common reason guys visit their doctors; his wife made him do it.

(Laughing)

(Peter) 
So here he is, he's in his Primary Care Physician's office and during the course of the exam and the discussion; his doctor asks him if anything is bothering him. Stan hems and he haws a little bit and he finally admits he's having problems with his sex life; precisely Stan is having problems maintaining an erection and that his interest in sex just isn't what it used to be. I'm just reading right here from the chart and that his wife isn't happy, hence her pushing him into the doctor's office. Lou, what does Stan expect? He is 72 years old.

(Dr. Lou Papa)  
Well I think you know it is paradigm shift in the way we look at sex in older folks, I mean there's, there are things we can do.

(Peter) 
Well let me just open this up to the panel. Should somebody who's 72 years old expect to have difficulty maintaining an erection and completing the sexual act, what to you think?

(Jean) 
Sex is often seen as a byproduct of aging, but that is changing as we define what age really means. We have people who are in their 80's who are sexually active, so should a 70 year old have a problem with sex? I think it should be investigated; it should be looked into.

(Peter) 
Is age relevant at all?

(Christine) 
Obviously I think it's important if the wife is sending him to the doctor that their intimacy is still important in this relationship.

(Pepper) 
They could be living together for the next 20 years, you know. Are you going to say I'm sorry 20 years and it's going to be over? Masters and Johnson found that basically the ability to have sex well into your 80's pretty much depended on not stopping so if you don't help him now; he's going to be in a lot worse trouble.

(Peter) 
Lou what do you want to ask him? What do you want to do if he's in your office?

(Lou)  
Well first of all, does he have any past medical history, because that's going to be relevant.

(Peter) 
Well not that he admits to, at least at this point. I mean, remember also that he's being forced into this entire encounter by his wife so he's not all that forthcoming I suspect.

(Lou)  
So he hasn't seen a doctor, he's not on any medications?

(Dr. Peter Salgo) 
Not that he indicates here. He says this; he's been having trouble for 2 years. He had not been able to sustain an erection reliably for 2 years; in fact he hasn't completed intercourse to the final point for 6 months. Now is this Erectile Dysfunction? How would you define that?

(Jean) 
He technically has Erectile Dysfunction, which is defined as a consistent inability to attain or maintain an erection to have satisfactory sexual performance. To go back to the last point as far as age, we have people of all ages with this type of problem. It's an issue to him and his wife therefore it should be investigated.

(Peter) 
Is it something that most men deal with, some men deal with?

(Mark)   
50% of men have Erectile Dysfunction at some point or other.  

(Peter) 
So it's fairly common?

(Mark)   
Yeah, very common.

(Pepper) 
I'd want to know, is he having ejaculations any other way, is he having any other kind of sexual life with his wife?

(Peter) 
Not that he indicates, but I think it is fair to say from the fact that they come in and specifically are starting to talk about this, that whatever used to be normal to them isn't happening.

(Lou)  
Right.

(Peter) 
Is that fair?

(Mark)   
Yeah it's fair and you know most people don't realize it's a normal part of life. In fact, having sex more often for men is associated with increased longevity.

(Peter) 
Let me go back to cause and effect then. Is it associated with longevity, are you implying that having sex keeps you alive or are you implying that those who can have sex are tending to live longer?

(Mark)   
Well that's a good question because I think what makes us sick also causes Erectile Dysfunction; Hypertension, Diabetes, Cardiovascular Disease.

(Pepper) 
Right.

(Dr. Mark Hyman)  
You know 60% of people with Erectile Dysfunction have high cholesterol, you know 20% have Diabetes and these are really common underlying lifestyle causes that we have the answer for.

(Dr. Peter Salgo) 
Since sexual function is dependent upon your health, and there are lots of causes as we've heard for Erectile Dysfunction, what would you be looking for as a Physician to rule in or rule out as a cause for Erectile Dysfunction?

(Lou)  
Like Hypertension, Hypercholesterolemia; does he smoke, does he drink, and does he use drugs?

(Peter) 
There is no smoking, no drinking, and no drug use in this chart. What else would you be looking for?

(Lou)  
There is Thyroid Disease; there is Gonadal Disease or hormonal problems.

(Jean) 
Also add lifestyle factors besides smoking; obesity.

(Mark)   
Stress.

(Peter)  
Obesity?

(Jean) 
And what's changed in his life?

(Mark)   
And stress. You know there is actually a study that men who were watching a football game and their team lost, their testosterone levels goes down; their team wins, it goes up so stress plays a huge role.

(Peter) 
Does that mean you should marry a man who has a winning football team?

(Mark)   
Absolutely.

(Laughing)

(Peter) 
Now Pepper, we've been talking about the guy, but what about the woman in this relationship? This is causing a lot of stress in his life. What's going on with her do you think?

(Pepper) 
Well she may feel rejected, she may wonder if it's about her and not just about him. Either there is a relationship issue, or it may be that because he feels he can't complete erection to ejaculation, he's pushed all of the affectionate behavior away.

(Peter) 
So it's not just the man's problem here? This is a couple's problem? Is that fair?

(Pepper Schwartz) 
Oh God no.

(Christine) 
The question I have though is how often is the sexual partner involved in the conversation with the doctor? And should they be? I mean, obviously they have a stake in all of this and I just wonder if that would be important information from a doctor's perspective.

(Mark)   
Absolutely.

(Dr. Lou Papa)  
It's funny because it depends. Many times when patients come in to talk to me about it, they are by themselves. That first encounter you want it to be as comfortable as possible to talk about it and to understand what's going on because you're going to be asking some very pointed questions.

(Dr. Peter Salgo) 
Now Jim you're here because you've had this interview. You've had this problem. What's that all like?

(Jim)     
Uncomfortable to start out with.

(Peter) 
Okay.

(Jim)     
Sex is talked about more today than it has been in the past, but that doesn't mean I talked about it a lot. So there was a little hold back on that. you know, I didn't want to answer some questions, didn't want to do certain things. But now the reason, I didn't, I don't have. The reason ...

(Peter) 
It's difficult for you even now isn't it?

(Jim)     
The reason I have ED is because I had a Prostatectomy.

(Peter) 
So you had surgery?

(Jim)     
Yes.

(Peter) 
This is a consequence of your surgery?

(Jim)     
Absolutely and I've been very happy about the fact that I have had no reoccurrence.

(Peter) 
That's because you had Prostate Cancer?

(Jim Gibney)    
Yeah.

(Dr. Peter Salgo) 
So the bigger issue for you was the cancer, but this is a common side effect of the surgery.

(Jim)     
Oh absolutely and I knew that going in; I did know that. But I would, you know it's a heck of a loss.

(Peter)  
I'd like to point out; correct me if I'm wrong, but even now here you are joining us, knowing what we're going to be talking about and this isn't the easiest thing to discuss for you right now.

(Jim)     
Well no.

(Jean) 
As an Urologist, when we see a patient with this problem, they often don't list what the problem is. I have a male problem. It's taboo to discuss it from some patient's perspective, even with their doctors. They have a hard time bringing it up, discussing it.

(Pepper) 
It's our culture too. I mean our culture makes it like a hard penis is what you are as a man, not your hands, not your mouth, not your charm, not your seductiveness, not your personality. So when a man doesn't have a hard penis, it's a whole identity issue. It's a huge issue to deal with.

(Jim)     
Absolutely, absolutely.

(Peter) 
Now you chose, I mean to put it in its basic most fundamental form, you chose life; you got the cancer out as opposed to a hard penis.

(Jim)     
Yeah. It all went overnight too.

(Peter) 
To quote Pepper, What I really want to tell you is what Stan tried because even before coming to the doctor, obviously Stan was concerned about this and he tried all kinds of therapies for himself. I'm going to look at you when I mention these. One of them was Shark Cartilage, Men's Health Vitamins, he tried penile rings and nothing helped him. Does that surprise you?

(Dr. Mark Hyman)  
From what he tried it doesn't surprises me.

(Peter) 
Why not? I thought you were the natural God.

(Mark)   
Those weren't the things I would pick.

(Peter) 
What would you pick?

(Mark)   
I'd look at his lifestyle. I mean the biggest reason for causing Erectile Dysfunction is sugar in the diet because it causes your insulin levels to go up and what that does is that drives your testosterone down and I check that all the times in my patients and I say very low testosterone levels. So your sex life is really determined in large part by what you eat, how much stress you're under, how much exercise you do, and those are the things that are most important. Yes there are, quote natural things you can do in addition to taking care of your blood vessels through diet and lifestyle. You can take Fish Oil which helps your blood vessels, you can use Ginkgo which may help increase circulation, you can use R-Gening which is the amino acid that can help increase circulation that's the same as Viagra does, but it's through a different natural mechanism, so there are a lot of things that can be very helpful. But unless you address if someone is drinking and taking medications and eating a terrible dieting and not exercising, there're not going to overcome this. You can't just take a pill and fix a bad lifestyle.

(Lou)  
There are 2 things that I get out of that. One is the fact that he's trying all that tells me that he has some sex drive. The second part of it is I want to know what his lifestyle is, but I also want to take the opportunity to evaluate for some things. I do want to do a physical examination and make sure I don't find abnormalities; are his testicles normal size, you know does he have normal hair patterns; that gives me an idea if his testosterone is normal. Does he have an enlarged thyroid, is his blood pressure elevated, does he have a body mass index that could suggest that he's at risk for Diabetes.

(Mark)   
Does he have a big stomach you mean?

(Laughing)

(Lou)  
Right, yeah, I mean there are several things that I can get from looking at him that says, okay we, you know there are things that we can do that may not involve medicine at all.

(Dr. Peter Salgo) 
Alright well let me pause for just a moment over here and sum up where we are. Erectile Dysfunction is the inability to maintain an erection to completion of intercourse. Erectile Dysfunction is not a normal part of aging. It may in fact mean that there is something else going on with your health which you need to pay attention to. Well Stan, in the doctor's office, he said I did hear about testosterone. Why do people come in and ask for testosterone? Why?

(Lou)  
Well I think that it's part of it, I guess it's what Pepper's getting at, it's like, and you know testosterone equals maleness which equals a good hard penis. I think there's an ideal that that will help. In some respects, he's really jumping the gun here and that's not to be taken lightly. Testosterone is not a benign situation to enter in to.

(Dr. Jean Joseph) 
It's our job also to see if he has signs of Hypogonadism.

(Peter) 
Hypogonadism, meaning what?

(Mark)   
Small testicles.

(Peter) 
Small testicles.

(Jean) 
Or if he is not producing adequate testosterone; does he have fatigue, lethargy or a good sex drive. Those are some questions to be answered and while we don't want to put people on hormone, but some people need to be on such.

(Peter) 
We've been talking about all of these, which can lead to Erectile Dysfunction. Here Stan comes in and he wants this global hammer, this testosterone.

(Lou)  
Right.

(Peter) 
But I think we really ought to just establish what needs to happen in the body physiologically to have an erection, going on to the conclusion of intercourse. How does that work? What's the sequence?

(Jean) 
Well besides the stimulation that one should get, it is a combination of what comes down from the brain to stimulate the penis to react in certain ways to have the blood flow to allow a firm erection. So once, if anywhere in the sequence is interrupted, that may be the result of an Erectile Dysfunction.

(Peter) 
So it's a psychological stimulus to start with?

(Jean) 
Absolutely.

(Dr. Peter Salgo) 
Followed by a neurological part?

(Jean) 
Neurological part.

(Peter) 
Followed by a physiological part; the blood flow has to change.

(Dr. Jean Joseph) 
All this has to work.

(Dr. Mark Hyman)  
You have to actually be relaxed too.

(Peter) 
You've got to be relaxed?

(Mark)   
Yeah because your Parasympathetic Nervous System, which is your relaxation nervous system, helps you have an erection.

(Peter) 
Okay so it's very complicated.

(Jean) 
The process itself is a vassal dilation that takes place; the blood vessels dilate in such strength that it gets engorged, it doesn't drain fast enough so an engorgement takes place so hormones have to be working properly, the blood vessels have to be working properly, and again as you mentioned, the psychological aspect has to work.

(Peter) 
And the nerves have to work properly as well.

(Mark)   
Yeah and people don't realize it's often the first sign that people come to the doctor with that tells them they have heart disease.

(Peter) 
I'll tell you what Stan's doctor did. He actually looked at him and examined him, did some laboratory work. You want to know some of the results? What would you like know?

(Lou)  
I'd like to see what his fasting blood glucose and his lipid level.

(Dr. Peter Salgo) 
I've got that for you. His Fasting Blood Glucose was normal, but his 2 hour, after a Glucose load; Blood Sugar was slightly elevated. In addition his blood pressure was 130 over 86, his physical exam of his abdomen was normal, his testicular size was normal. I can tell you also, because you mentioned it and I see a note here; Stan does not have hair below his knees and he's complaining always of cold feet. Now does that ring any bells for you guys?

(Mark)   
The blood vessels aren't healthy. If you don't get blood to your legs, you don't have hair on your legs.

(Dr. Lou Papa)  
The answer to what Mark was talking about is that's sometimes the first sign of vascular disease and that suggests that. he's a non smoker you said?

(Peter) 
He's a non smoker.

(Mark)   
You know what's interesting though is that if his blood sugar is up, his testosterone goes down and his estrogen goes up. When estrogen goes up for a guy, you lose hair.

(Peter) 
Okay so what now are you thinking?

(Lou)  
Well the concern is what is the pulse like in his legs? I mean that was part ...

(Peter) 
He's got pulses; Distal Pulses, at least according to the chart. But his doctor goes on and does something else. He does this; he takes this tiny little thread, this little wire.

(Lou)  
Monofilament.

(Peter) 
A monofilament and rubs it on Stan's lower legs. Stan doesn't feel it so now what's wrong?

(Lou)  
It raises the question that there is Vascular Disease because he has the decreased hair pattern along with the fact that his blood pressure is a little bit up, his blood sugar's up raises concern that there's, you know metabolic problem. Now you have this sensory aspect, which suggests that there's, a neuropathy, that there may be a problem with the loss of sensation, which is another issue that gets back to Erectile Dysfunction.

(Peter) 
Let's stop for a second and sum it up for us right here. Erectile Dysfunction can be a symptom of an underlying problem in the physiologic chain. It can be your blood vessels, it can be your nerves, and it could be something in your mind as well. With your doctor you've got to figure out where the problem is occurring because unless you find the cause, it's going to be far, far more difficult to deal with the affects and to get a real handle on it. Is that fair?

(Dr. Mark Hyman)  
That's so key; I mean doctors are so willing to give a pill; take Viagra without thinking about dealing with the real issues that are causing the problem.

(Lou)   
Absolutely. And it's an opportunity. I mean this is a guy who hasn't been to the doctor and ironically this issue that he's talking about is addressing his whole health.

(Dr. Peter Salgo) 
When you first see a male patient, do you always ask?

(Lou)  
Not first, no. I mean, that's one of those things, you know I want to get to know the patient and it doesn't always come up. It's kind of an uncomfortable thing when you first meet the guy; hi I'm Dr. Papa, how are your erections?

(Laughing)

(Dr. Lou Papa)  
You can't really, you know it's kind of something you have to kind of warm up to and there are many instances I'll be asking a patient in review systems and they say yeah well it's okay. I actually ask it at the physical because that gives me an opportunity, I'm saying I'm doing this overview of your body and it gives me a freer reign to ask very pointed questions. I'll ask him, do you get erections and are they good enough for, you know penetration in sex?

(Peter) 
Well let me tell you a little bit more about Stan. Would you like to know what his doctor did? First of all his doctor took note of the blood sugar, took note of his blood pressure and he decided to begin Stan on therapy for all of this; he put him Metformin which is a drug for his blood sugar, he put him on an Ace inhibitor for his blood pressure and put him on a statin because he assumed that his blood lipids were going to be a little bit disordered.

(Mark)   
Did he tell him to eat better and exercise?

(Lou)  
He assumed?

(Peter) 
No not according to the chart.

(Laughing) 

(Lou)  
Yeah I agree with Mark. I mean one of the things that concern him, Mark's exactly right. This is an opportunity to get a change in lifestyle and before I feel 3 drugs at this man who has kind of borderline abnormalities, you know things we do can affect erectile function as well so you could be compounding the problem.

(Peter) 
Now before we even take note of the unique moment in American history where the 2 of these 2 agreed...

(Laughing)

(Lou)  
We always agree.

(Laughing)

(Peter) 
I'm going to move over here and get away from you because I'm going to tell you what else his doctor did. He did not give him testosterone he did give him Viagra. Good idea, bad idea, what?

(Christine) 
If he does have any heart, potentially heart problems would the Viagra aggravate that? I mean if we don't know that ...

(Peter) 
Look at this face.

(Lou)  
I mean that's a good, that's exactly right. Here you have some concerning issues that this individual has Vascular Disease and one of the things before you start them on Viagra is that you did ask if they were having chest pain. You know when you see this question of Vascular Disease, that maybe, you know, you want to get more information about any exertion related symptoms. You may even want to do a Stress Test if they have multiple risk factors.

(Mark)   
Maybe having sex is going to be more exercise than he's had in a year, so you know he might have a heart attack.

(Lou)  
Exactly.

(Pepper) 
Right.

(Dr. Peter Salgo) 
Let me ask the bottom line question on Viagra. Given this history; given the history of some vascular and neurological involvement, is Viagra going to work for him? What do you think?

(Jean) 
It may.

(Peter) 
You think?

(Jean) 
It may work for him, but before that you need to optimize his health because these medications, these, this whole class of medications; Viagra Levitra, Cialis, they may work better if the person's weight comes down, they quit smoking or their blood pressure is better controlled. It may work for them, but you have to address these other issues also.

(Peter) 
Well Jim did you try Viagra?

(Jim)     
And Cialis, yes.

(Peter) 
Did they work for you?

(Jim Gibney)    
Not at all.

(Mark)   
But he had a different reason for having the problem.

(Jim)     
By listening to this group, there's a whole bunch of things that I've done wrong like the weight, you know, I like sugar, I drink, I don't smoke, but you know after hearing this and I've never heard this before.

(Pepper Schwartz) 
Your doctors never brought that up?

(Jim)     
No.

(Peter) 
Well you want me to tell you what happened with Stan?

(Jim)     
Please.

(Peter) 
Six months went by. He actually adhered to the regimen his doctor prescribed, he took all those drugs and he also tried Viagra and he comes back to see his Primary Care Physician because guess what? Viagra didn't work. It simply didn't work so now what?

(Mark)   
The doctor started at the end instead of at the beginning.

(Dr. Peter Salgo) 
What does that mean?

(Dr. Mark Hyman)  
It means he didn't deal with the underlying causes. If you're eating a lot of sugar, if you're having lots of trans fats in your diet, if you're eating a diet of processed food and junk food and drinking sodas and alcohol and not exercising, you can't expect your erections to happen.

(Peter) 
But didn't his doctor actually address some of these things; I mean he started feeling better.

(Mark)   
No, but the medications can't fix a lifestyle. You can't take Viagra and Lipitor and an Ace inhibitor and a sugar pill like Metformin and expect it to correct a lifestyle issue.

(Dr. Lou Papa)  
There are studies to show that individuals who are overweight, they lose weight and the Erectile Dysfunction improves.

(Peter) 
Well Stan...

(Pepper) 
I'm sort of worried about this guy's relationship with his wife in the meantime and if anybody's counseling them about how to relate to each other physically and sexually and affectionately. I mean, is this it? Is it zero sum? Is that the only thing that anybody is offering him?

(Peter) 
Well nothing in the chart here indicates they are giving him anything else. Does that bother you?

(Pepper) 
Well I'd like him to have some counseling and some support and their relationship to have some support.

(Peter) 
Is it possible that as he feels better, if his lipids come down, his sugar is improved, maybe he exercises, that with or without Viagra his sex life is going to improve? Specifically, sexual intercourse?

(Pepper) 
Well sexual intercourse, I think, you know, these guys are more expert on the hydraulics than I am.

(Laughing)

(Pepper Schwartz) 
So I'm worried more about the interpersonal aspects and what else they could do to turn each other on.

(Peter) 
I mean are we all focused on the hydraulics here?

(Pepper) 
Seems to be.

(Lou)  
Yeah, absolutely.

(Dr. Peter Salgo) 
Are we not focusing on Stan as a person; just relaxing as you put it, taking a deep breath and going forward again? How important is that?

(Lou)  
It's vitally important. A lot of patients seem to think you pop this pill and boing it happens. You still have to have some intimacy because what it will do is keep the blood there; you've got to get it there in the first place.

(Peter) 
Well I'll tell you Stan was then offered because the Viagra wasn't working; right away they said why don't you try inter-penile injections?

(Lou)  
My God.

(Peter) 
Lou, he was offered injections. You don't seem as shocked as Lou is. What are these things?

(Jean) 
No, it's not a first line therapy for this. Viagra or these other drugs may help after an improvement in his overall health, but if we correct everything, they are always optimizing the hydraulics that you call it.

(Laughing)

(Peter) 
Well Jim they offered you injections.

(Jim)     
Yes and I took them.

(Peter) 
Well what was your first response to them?

(Jim)     
In the beginning when they told me what I had to do, I was going to try anything, you know. I would have tapped danced on a wire over Niagara Falls if I could have.

(Peter) 
Okay.

(Jim Gibney)    
If that would have helped.

[laughed]

(Dr. Peter Salgo) 
What about spontaneity? Jim was that a problem for you?

(Jim)     
Absolutely.

(Peter)  
Tell me about that.

(Jim)     
Well it, you have to make an appointment with your wife? I'm not...about 2 hours from now, I haven't had anything to eat, I think I'm good, be in the bed.

(Laughing)

(Peter) 
All right why don't we stop for a second and sort of sum up what's gone on so far? If you are suffering from Erectile Dysfunction there is help available. There are good treatments, but you've got to make sure that the treatment is appropriate to the problem; whether it's your nerves, whether it's your blood vessels, whether it's your blood sugar, whether one of these new drugs like Viagra or Cialis works or one of the alternative therapies. There are mechanical therapies too like penile rings, which we really haven't mentioned yet, but they're out there and all of these things seem to, and for some people at least, provide some benefit. Is that fair? Is that fair? Well I can tell you a little bit more. Stan started using the injections and his sex life is better and his therapy for his Diabetes and his Hypertension, such as it was, and control of his blood lipids also seem to be helping him because over time he comes back and tells his doctor he's regained; not complete sexual function, but better sexual function. Jim how are you doing these days?

(Jim)     
Lousy.

(Peter) 
Lousy? Are you considering any other options; another surgery out there? Have they talked to you about this?

(Jim)     
No, there's very little I know. I'm learning more here than I've had, you know, all along. This is good, this is, and I hope other people out there are hearing this.

(Christine Rogers) 
Did the doctors really say you would have to accept it; this is as good as it's going to get?

(Peter) 
Well we've got to hear elective surgery.

(Jim)     
Yeah.

(Peter) 
Help Jim. You're a Urology Surgeon, what are his surgical options at this point or are there any?

(Dr. Jean Joseph) 
Well if the injections don't work, we can talk about penile prosthesis.

(Dr. Peter Salgo) 
What is that?

(Jean) 
We often do not want to talk about that because it's an irreversible way to go. There are men who were impotent 10 years ago who are now using those medications successfully so if new medications become available that would help them, penile prosthetics, are pretty much, they take out any medical form of treatment that may come down the road so it's irreversible.

(Peter) 
So this is in effect you place a stiff object or one that you can inflate in the penis so cause you to become rigid?

(Jean) 
There are different types. Some are rigid, some are malleable and some are inflatable. There is a pump that is placed in the scrotum that is pumped and then slowly the penis firms up. So it's an actual procedure that you have to go through and the devices are inserted in the penis and also in the scrotum to allow a man to have an erection.

(Christine) 
I have a question because we're talking about all these options, but isn't it true, you're going to have a sizeable portion of people who are going to be so uncomfortable to bring this topic up, or any of these options?

(Mark)   
You know who is often uncomfortable is the doctor is uncomfortable and if the doctor is comfortable; the patient's going to be comfortable.

(Christine) 
How do you reach them?

(Peter) 
All right with that I think that we're going to have to leave. It's been an amazing, amazing discussion. Jim, thank you so much for sharing what could not have been an easy discussion.

(Jim Gibney)    
You're welcome, thank you. Everyone, thank you very much.

(Peter) 
We appreciate your being here.

(Jim)     
I've heard a lot of stuff.

(Peter) 
Before we go let me sort of sum up what we discussed today. We covered a lot of ground so just the key things to remember. Erectile Dysfunction is the inability to maintain an erection to completion of intercourse. Erectile Dysfunction is not a normal part of aging. It may in fact mean that there is something else going on with your health, which needs to be addressed. Erectile Dysfunction can be a symptom of an underlying problem in the physiologic chain. With your doctor, you've got to find out where the problem is occurring and then you can do something about it. If you're suffering from Erectile Dysfunction there is help available; there are good treatments but you've got to make sure that the treatment is appropriate for the problem from which you're suffering so diagnosis is important. And of course our final message is this; taking charge of your health means being informed and having quality communication with your doctor. I'm Dr. Peter Salgo and I'll see you next time for another Second Opinion.

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