Men's Health: Tackling Erectile Dysfunction with Nurse Practitioner Luke Mitchell

MS Plus acknowledges the traditional custodians of the land this podcast is recorded on, the Wurundjeri people of the Kulin Nation. We pay our respects to their elders past and present.

This is the MS Boost. The stuff you need to know from the people who know it

Jess: Hi everyone, and welcome to the MS Boost. My name is Jess, and today with my co host Jodi and I, we are speaking with Luke Mitchell. Luke is a men's health nurse practitioner, and he has a fantastic background in sexual health and urology. And we're talking about something that isn't very well discussed at all, which is erectile dysfunction in men.

We know that that can be a common problem for men with MS, but even generally Luke, is that a problem that can affect men, in the general population?

Luke: Yeah, absolutely. Like, a lot of people will think that erectile dysfunction is something that only old people will experience, and it's something that's definitely just for the old blokes, and once you've got it, then that's it, hang up your hat.

But we definitely know there's a lot of emerging evidence coming out now that we're seeing more and more young people, even as young as their 20s, coming through and talking about erectile difficulties. And realistically, I think every guy at some point in their life is going to have some sort of issue with their sexual function.

You know, not necessarily erectile concerns, but ejaculatory or libido concerns as well. So, it is very, very common.

Jodi: Luke, why do you think that there's emerging incidents of it? Do you think people are bringing it up more or do you think there's actually increasing incidents of it?

Luke: Good question. I don't know. And the evidence that we see, they're still saying that we don't know why there's a lot more. Some people are theorizing that it's because, you know, maybe we're living a more sedentary lifestyle. We're not out working as much. Or it could be that people are a lot more comfortable talking about it and saying, you know, there's something wrong here and it's not, not something that they want to put up with.

Whereas traditionally in the past, it's something that has just gone unsaid and unresolved. There's also a question about the rise in mental health concerns and the pressure. how often we're treating mental health disorders now and whether or not that has a further impact on sexual function and erectile dysfunction as well.

Jodi: How much do those two go together? I know in the MS clinic there was often a perception that they were always to be together, and I wasn't quite sure that that was a right or wrong perception.

Luke: It's pretty, pretty accurate. So, mental health and erectile dysfunction are pretty common. So, I like to tell my bloke's that your brain is the second most important organ apart from your penis because it does control a lot of everything that you do. Like think of it as if you've got a bit of performance anxiety or a bit of stress and then that will then impact your ability to get an erection and then the next time you try to have sex or something, you have that perception in the back of your mind, like it's failed before, it's going to fail again, and then it sort of becomes a bit of a cycle of this isn't working well for me and it's not going to work for me.

Jess: Like a self-fulfilling prophecy.

Luke: Yeah, absolutely. And, you know, a lot of my younger patients, I definitely see that.

Jess: You talked a little bit before, there is often that misconception that erectile dysfunction is just an old person's problem, old man's problem. Are there other sort of misconceptions around erectile dysfunction, that you see or that sort of exist?

Luke: Yeah, I think that the biggest misconception is that erectile dysfunction is it's in itself a standalone thing and that you can just throw a band aid on it, take some tablets and fix the issue.

I think with sexual dysfunction, it's a very multifaceted issue and a lot of people tend to really downplay the impact that it can have on people and that they can really downplay how difficult at some times can be to treat as well.

So the big issue is that it's, really kind of laughed at a little bit for some people and some people find it really difficult to have that conversation because they feel like they're not going to be taken seriously.

And then the issue that that brings up is you see people who are quite vulnerable about their sexual function then going and speaking to someone, and if they're not taken seriously the first time, we know that they'll probably never bring it up to anyone ever again. So, it'll just become an unresolved issue.

Jodi: Yeah, we were talking earlier about that, that it's always going to be an awkward conversation and ways to overcome that. One of the things that you said at the time was that people sort of give it context. Tell me a little bit more about that.

Luke: When people come in to see me, I have a bit of a privileged position because people, when they're talking to me, know that they're coming in to speak to someone about their sexual function, so they're a little bit more comfortable.

But when I've spoken to some of my other colleagues who aren't so overtly open about sexual function, they say that patients will come in and they'll tend to beat around the bush a little bit, or they'll not openly say that they're having an issue, and they're sort of hoping that the clinician will sort of pick up what they're putting down.

And, you know, sometimes as the doctor or the nurse sitting in front of the patient, you sort of happen to really read between the lines about what the patient's trying to say. For all clinicians, I always stand up and say, you know, if you are working in a space where blokes are vulnerable to sexual dysfunction, you have a responsibility to be very open about asking the questions because patients often won't.

But also, if a patient is bringing something up to you that you think, oh, could this be something related to sexual function, ask.

Jodi: Do you think that a lot of men don't talk about it because they don't feel like anything can be done about it anyway?

Luke: Yeah, absolutely. They'll often turn around and say, oh, well, it is what it is.

You know, older patients in particular, they'll turn around and say, oh, I've got old man's disease. That's about it. And I've had a good life, and that's all I need now. But they just think there's nothing that can be done. But there is, there's a lot that we can do for it. It's not necessarily the something that looks the same to everyone, you know.

Everyone's sex life is different. Everyone's goals for sex is different. So, everyone's treatment should look a little bit different as well. So no, it's not necessarily a matter of just throwing a tablet at something. It's a matter of talking to patients about it and finding out what they want to achieve, what kind of sex they want to have, what their partners want, and make it work from there. There's lots of different things that we can do.

Jodi: I think in MS that's a really big problem that the concept of it's just all part of the disease of what I've got and therefore I just accept it as part of the MS and there's nothing I can do about MS and there's nothing I can do about this symptom as well too.

And as you were talking, I was thinking about how, it's so common in MS that for men out there who might be listening to this podcast, you can say, I know it's common in MS to have erectile dysfunction and I've got that too. It's kind of a good segue to you know, sometimes it's nice to give people the words and then people can go from having a conversation.

Another thing that you alluded to, I think, was about a sense of safety. Like, they know that they're going to talk to you because that's your title and that's your role, and safety and trust are so important in that discussion.

How would you guide someone who just didn't have that sense of open trusting safety with a neurologist or a GP? Where could they go to? Like where would be the next thing to help, to open the discussion about it?

Luke: I always think the GP is the first person they should be speaking to. And if they're not comfortable talking to their regular GP, there are definitely GPs out there that do specialize in sexual function. So sometimes reaching out and, just having a separate GP apart from your regular GP is a really great space.

And that, I mean, they will communicate with each other, so it's not going to be that you're dealing with each issue in silo, but sometimes it's just nicer to have someone who's separate in a way.

Obviously people can access myself, nurse practitioners as well, we're starting to pop up more and more frequently.

And we can provide services like that, where we can do education support know, as a nurse practitioner, I can prescribe medications as well, if that's necessary, and we also communicate with your treating teams.

And sometimes even online supports, you know, there are some, my soapbox is trying to get away from the online health platforms, but online support forums and all that sort of jazz where people can talk to other people with MS or with similar conditions to see what they have to say, what have you done? What's worked for you?

There's also the option of a sex therapist or a sexologist. And I think they're really important because they can help come to the root of any psychological causes and they can also help people find different ways to have sex and have pleasure, even if you're not able to get an erection.

And what I often tell my patients is that sex isn't about penetration. Sex is about finding a way to connect with your partner, enjoying that fun time together. Penetration is sort of the cherry on top, that a lot of people were sort of conditioned and were never taught how to have sex.

So, we're sort of conditioned to jump straight from nothing into penetration and think if you don't have that penetrative sex, then that's all there is. But maybe taking some time with someone like a sex therapist who can teach you ways that you can have sex, removing such the penetrative focus can be really beneficial for a lot of blokes.

And then, you know, we can work on getting the erectile function working as well, but the erection should sort of be the cherry on top. It shouldn't necessarily be everything that we're working on.

Jess: And I'm just thinking back Luke, obviously, MS and neurological causes can be a factor in erectile dysfunction, but what are some of the other things that, for men who maybe don't have MS, can play a role in developing ED?

Luke: Yeah, good question. I really simplify it with my blokes. I say that to get an erection, you need three major things. You need a good blood supply to your penis. You need a good nerve supply. And you need the desire to have sex.

So, the blood supply is very obvious. Your penis is an organ that fills up with blood as an erection. So, if you have some heart diseases, so for example peripheral vascular disease that comes often with diabetes or smoking, if you have high blood pressure, anything like that, then that can impact your erections.

And in fact, there's really strong evidence linking erectile dysfunction in men to heart disease. And they say that erectile dysfunction is sort of like a red flag for anyone saying, if you're getting erectile dysfunction, you don't have any heart disease, go to your doctor and check it out, because there may be something there.

You need a good nerve supply. So that's the message from the brain to the penis saying, all right, hey, let's go. So, if there's anything that's interrupting the signal from the brain to the penis you're not going to be able to get an erection. And that's very common in obviously MS and any other spinal disorders. Also, diabetes as well can sometimes disrupt the nervous messaging. Prostate cancer people who've had surgery or radiation can interrupt the messaging getting through.

The more common one the big one, is the desire to have sex. That's your libido. That's your mental health. You know, that's your testosterone levels. Do you want this to happen? How's your relationship? You know, how do you feel about yourself, your body? All that comes into play. So, there's quite a lot that goes into erectile dysfunction.

You know, a lot of blokes will think, they take their erections for granted. I see someone walking past, I think, “hey, that's a bit of all right, good to go”. But there's quite a lot going on behind it.

Jess: It's really interesting when you said erectile dysfunction can be like a red flag for heart health and things like that, and it's interesting. So, I wonder if men think sexual health isn't as important or isn't really part of healthcare, but when you frame it like that, that's a pretty significant link and connection to overall wellbeing.

Luke: I tell my blokes that the penis is sort of like the closest that the body gets to a check engine light.

You know, there's so much that you've got going on that you need to get an erection. All these micro systems need to be working properly. So, if you're suddenly not able to get an erection, that's the check engine light. That's time to go and get a service done. Get your heart checked, get your lungs checked, get your sugars checked,check your testosterone. And if you were to speak to a doctor and say, I've got erectile dysfunction and this is suddenly something new for me, those are the things that they should be checking.

Jodi: What about medication side effects? How common is erectile dysfunction to medication side effects?

Luke: Pretty common, depending on the medication that you're taking. So, some drugs for mental health, so antidepressants, they won't necessarily cause erectile dysfunction, but they can cause what they call anorgasmia which is the inability to orgasm, or they can really delay an orgasm.

Some drugs that we use to help control hormones, such as if you've got urinary issues, we'll put you on a drug like Duodart and that can cause erectile dysfunction as well.

So, all sorts of different things. Some blood pressure drugs can also impact your erectile function. So, it's worth having a chat to your doctor when they are starting you on a drug and saying, what are the side effects? Every person who's taking any medication should always know what impacts the medication they're taking has, sexual function or otherwise.

Jodi: So, what can you do about it? Straight to the practical, you know, obviously take a holistic approach to it. I can hear the importance of that when you talk about the three main reasons, but there's so much going on there that it is a whole engine. So, the importance of holistic approach, but where do you start when a guy comes to you and talks about it, where do you, start in terms of helping with a management plan?

Luke: It's a million-dollar question. So, the first thing I would do is I would sit down with them and find out, what's been happening? I would take a bit of a history from them. What's been happening? What sort of function they have at the moment? You know, has there anything that's predated this erectile function issues? I talk to them about what their ideal goals are and what their partner's goals are.

Oftentimes as best I can, I will try to involve their partners in these conversations.

If a bloke is single, then, would you like to be partnered? What does that look like? But the goal setting is really important. And what you sort of need to do is to, depending on the cause of the erectile function, set some realistic goals.

It sounds awful, but sometimes you will have to sit down and say to a bloke, you've had your prostate removed, you've had all sorts of different cancer treatments, I'm never going to be able to get you a full erection unaided for 80 minutes so you can have a full lovemaking session. So, you do have to sort of sometimes be a bit more realistic with them.

I talk to patients about their relationships as a starting point and I get them to make sure that they're starting to have some sort of sex, even if they're not able to get penetrative sex, but you know, massage, intimacy, cuddling, all that sort of jazz as a starting point because, yes, I can fix an erection, but an erection is not going to fix a relationship.

So, a lot of patients when they do have erectile issues will tend to pull away from their partners. And then they'll come to you three years down the track and say, I want to have sex again, but they don't have that relationship anymore with their partner. So, we really need to make sure that the partner's on board and they want to start having sex. So, working quite closely on that, get that started.

Once you've got some sort of sex, or some sort of intimacy happening within the relationship again we can start talking about what sort of sex they'd like to have. Sex for everyone looks very different. It's not necessarily, like I said, it's not necessarily just penetrative sex.

It looks very different between couples, it looks very different between, individual people, there's cultural aspects, there's sexuality aspects, so finding out what sort of sex they want to have helps me guide. what sort of treatment they have.

From a treatment perspective, we, we've got all sorts of different medications. And that's oftentimes the starting point. A lot of blokes will have heard about things like Viagra and Cialis. And they're great. They do definitely have their place.

There's different ways that you can take the tablets. I generally say if you're just taking the tablet and that's the only thing you're doing, then you're sort of just putting a band aid on a wound. A tablet is a tool to help you. It's not necessarily going to be the only thing you're going to need to use.

So, you know, tablets definitely have their place. There's also a lot of tools that we can use, penis pumps, vibrators penis enlargers, cages, etc., that can be really effective for people who don't really want to use medications. And they can be really good as well because they can be a little bit more spontaneous as opposed to waiting for the medication to kick in.

There's also the option for people who aren't very good at taking tablets or who the tablets don't necessarily work well for them because the tablets do need a really intact neural pathway. There's the option of injections which is a drug that you put in directly into your penis that gives you an erection that sort of does look and feel like a normal erection, but the main draw is that it's not relying on your body's normal systems. You're not getting the message from your brain to your penis saying, “hey, it's go time” and then orgasm and having a switch off again. You know, you've got an erection that is there while the drug is in place and then as the drug wears off, the erection dies off. And that can be really effective because it takes about 15 minutes to kick in. You've got foreplay time there. You have a decent length and strength erection and then it dies off over time.

There's obviously a little bit of playing and forward and back with yourself and your clinician to find the right dose or medication that works for you. But for patients that it works well for, it's a really great option.

End of the line, there's the option of a penile implant, which is a device that a surgeon will place inside the penis. It's sort of like two balloons that run down the length of the penis and then has a little bit of a like a reservoir of water that sits up sort of in your tummy somewhere and then you've got a little pump in your scrotum so when you want to have sex you can pump it up and have sex with it and then when you're done you can switch it off again.

All sorts of different things. But like I said, sex looks different for everyone. So everyone's treatment options and everyone's treatment plan will look a little bit different depending on what they want to achieve.

Jodi: Well, there's lots of different options to consider. It's really great to think about that it's unlikely to just be a medication and say here you are and go away and I guess we see that a fair bit of time with in MS people just come to, get the Viagra from the GP and away they go.

Do you have concerns about that approach? Like do you think lots of men don't understand how to use the medications properly?

Luke: Yeah. Oftentimes they'll just go in, get their script from the GP and walk out and be like, great, I've got this and that's all I need. But then they take the tablet one time and they're like, oh, it didn't work for me. They have this sort of impression that Viagra works like it does in the movies where you take the tablet and your hard is a rock, but that's not how medicine works.

Viagra works it's what's called a PDE5 inhibitor. It blocks off the body's mechanism that switches off the erectile process.

So, you still need to be able to get a normal erection. You still need the message from your brain to your penis saying, hey, let's go. That triggers the start of the erectile process. And then the Viagra is sort of blocking, the mechanism that's turning it off, so it's sort of elongating and strengthening the erection, but it's not going to help give you an erection if you can't get one naturally.

I see that a lot with a lot of guys who have diabetes, who aren't able to get that message through and they try to take the Viagra and it hasn't worked. It's like, well, that's because you're not able to get the message through to begin with.

People will also take the medication and they'll start by taking too much, and then they'll start to get side effects, you know, things like flushing of the face they'll start to feel really congested, really nasty headaches, sometimes they can feel a bit crappy and woozy because they've taken too much. So, you know, you really do need someone to teach you how to use these medications properly.

Jess: And do you find, Luke, like if men maybe do go and have that conversation with the GP, they take the medication, and it doesn't work. Do you find that a lot don't go back or don't sort of follow it up again?

Luke: Yeah. So, I mean, we do know that because sexual health is really, it's quite personal and because it is so personal, people will put a lot of faith in the first thing working.

And then if the first thing doesn't work, then that's when they start to feel a little bit dejected, for lack of a better word. And so, a lot of my job does involve counselling, saying, you know, what, this might not work, but, you know, we've got other options and making sure that if the first thing doesn't work, that's fine.

We'll find something that works for you, but it does take a bit of patience, a bit of time. And that's why I get them to start with all these other sorts of things first. You know, the massage and building up that intimacy within their relationship first. That way they've got something they can latch on to, you know, they've got a win there.

And then we can work on the erectile function in the background. You know, you're not waiting for your erection to suddenly go through and start fixing everything else.

Jodi: I guess when you make yourself that vulnerable the first time, and it doesn't work, it's so hard to be vulnerable again. It is an area which just requires a huge amount of bravery because of the vulnerability around that.

But it's great, I think, for men to know that there are services outside their usual way of thinking about how to tackle a health issue. You know, it's so often we think about how to just go, GPs or neurologists, but they're not always the right people to see. And yes, online can be dangerous, but obviously the increasing number of nurse practitioners is just fantastic.

People feel safe speaking to nurses, so it's really great to see people stepping into that area. It acknowledges the importance of it as a health issue. I think it reduces the vulnerability, I suppose, when it's in a health issue environment as well too.

Luke: Yeah, and as nurse practitioners, like, we've lived it. We've gone through and we've walked the walk for years and years. We've got the piece of paper beside us saying, yeah we've studied a lot. But we've also sat down with, some of us, thousands and thousands of patients over 10, 15 years, learning these people and learning the issues that they're facing and then being able to apply that experience to what we do.

That's why I love being a nurse is because you know, I've got 15 years now of looking at patients and listening to what they've had.

Jess: It sounds so incredibly valuable for men to have a space where, maybe the GP doesn't have time, but to actually go through that comprehensive, looking at everything, point of view just sounds like it would be so valuable for people to be able to access and feel really safe to go back and know, right, this one didn't work the first time, but I have a supportive healthcare practitioner or health professional who is going to help me with this journey and knowing that erectile dysfunction is a journey. It's not just, you know, an on and off health condition.

Luke: Yeah, there's no magic pill that will fix it, you know. There's a magic pill sometimes, yeah, but it's not going to be the one and only thing you have to do. And if you put all your faith in just one thing, then you're setting yourself up for disappointment.

Jess: That's been really good to hear and some really good strategies and just normalizing, talking about it. And that, as we just said, it sort of is a bit of trial and error almost to sort of see what works or what's going on and investigating, but yet really tying it back to that, sexual dysfunction is a health issue but obviously has so many different facets to it, including, mental health So it's very important for men to feel empowered to actually go and see what's going on.

Luke: Yeah. And it is something that you deserve to have as a person. It's a human right, you know, it's important for everyone. So you deserve to have it treated appropriately.

Jess: Absolutely. I mean if you have a problem with any other organ, if your eyes suddenly aren't working, you'd go and get an eye test. So, I think it should be sort of viewed a bit the same way. So, thank you so much for speaking with us today, Luke. It's been great.

Jodi: Thanks Luke.

Luke: No worries. Thanks for having me.

Thanks for listening to the MS Boost. Check out the show notes for more details and you can catch up with a new episode of the M Boost next fortnight.