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Image of StentThe penile stent aims to improve erectile function in men.

Research

The Urology-Cardiology Connection
Sexual troubles can be a warning sign of bigger health issues

Dr. KohlerDr. Kohler Specializes in andrology, which includes the treatment of male infertility and erectile and sexual dysfunction. He also heads the onco-fertility program at the Simmons Cancer Institute at SIU, which addresses fertility preservation and sexual health issues before patients undergo cancer treatments. He is part of the fertility center at SIU.

It’s a subject no man wants to discuss: erectile dysfunction. But researchers say it affects 52 percent of men ages 40-70. SIU Assistant Professor of Surgery Tobias Köhler, M.D., explains that erectile dysfunction may not just be a natural part of aging; it actually may be an indicator of heart disease. Even though men may have no cardiac symptoms, about 80 percent of erectile dysfunction can be traced to vascular causes. Dr. Köhler specializes in andrology, which includes the treatment of male infertility and erectile and sexual dysfunction.

“Research shows a definite link between erectile dysfunction and heart disease,” Dr. Köhler says. “Blood vessels in the penis are one-third the size of the heart. So it’s sort of like the canary in the coal mine. Men are embarrassed to talk about this problem, but heart disease is the number one killer of men, so it’s important to publicize the correlation between erectile dysfunction and heart disease.” When a penile doppler ultrasound indicates blood flow problems, Dr. Köhler refers his patients to cardiologists. “Often, patients come back to me a few weeks later with a heart stent,” Dr. Köhler says.

Despite the link, Dr. Köhler says it’s not typical of urologists to refer patients to cardiologists. Establishing the collaboration between cardiologists and urology has been Dr. Köhler’s mission since he joined SIU School of Medicine in 2009.

Two years later, he has forged a strong collaboration with cardiologists at the Prairie Heart Institute in Springfield, who include Krishna Rocha Singh, M.D., Nilesh J. Goswami, M.D., Jeffrey A. Goldstein, M.D., and Gregory J. Mishkel, M.D. “They’ve changed the way they talk with patients. They now ask them about any sexual problems and have changed their new patient forms to include questions related to sexual function.”

“Erectile dysfunction may predate the clinical onset of coronary disease or symptomatic peripheral arterial disease by three years,” Dr. Rocha Singh told Endovascular Today in March 2011.

A multitude of treatments for erectile dysfunction make it a very treatable disorder, from lifestyle modification to medicine and surgery. In a unique collaboration, SIU School of Medicine and Prairie Heart Institute have become leaders in innovative, national clinical research trials to add another option: penile stents.

MedTronic’s ZEN Trial (ZOTAROLIMUS ELUTING STENT) aims to improve erectile function in men with erectile dysfunction by putting stents in the arteries of the penis, similar to stents inserted in the heart to help blood flow.
The ZEN trial began in 2009. Thanks to the SIU-Prairie partnership, Springfield was the second highest-enrolling site in the country (after a California site). The team placed 10 stents in patients. Results will be published this year, but Dr. Köhler admits the results were mixed. Dr. Rocha-Singh noted in Endovascular Today, “The ZEN trial has shown that the drug-eluting stent in internal pudendal arteries (IPAs) can be safe.”

Dr. Köhler cautions that men achieving success with a penile stent still have to change their lifestyles to prevent heart problems. His direct approach motivates men to change their behaviors. “I tell them, ‘Your penis won’t work if you don’t quit smoking.’ I write as many or more quit smoking prescriptions as do many primary care doctors.”

The collaboration continues with a related clinical study authored by Dr. Köhler, Dr. Rocha-Singh, and Dr Nilesh Goswami that takes a closer look at the ED population. The IMPASSE Trial (Incidence of Male Pudendal Artery Stenosis Suboptimal Erections) began in April. SIU School of Medicine is the only Midwestern site participating in this million-dollar, five-center trial involving men who are seeking elective angiography for suspected or known coronary artery disease. If they choose to participate, physicians will x-ray the pelvis to see if there are any indicators of problems, such as atherosclerotic lesions. The investigators will evaluate these lesions over time to assess predictive patterns in penile arteries related to erectile dysfunction. “We will learn the natural history of the disease, which will aid in clinical research and treatments,” Dr. Köhler says.

A third study, the CUPID study (Cardio Urologic Pathology Interplay Determination), authored by Dr. Köhler and urology residents Aaron Benson, M.D., and Joel Koenig, M.D., funded by Abbott Laboratories and the American Medical System, attempts to evaluate patients in the cardiology clinics for urologic problems typically linked to aging that could instead lead to more serious health issues. “We are asking, ‘What is the true prevalence of erection problems for cardiology patients?’ Sexual problems can indicate major health problems in both men and women, from heart disease to diabetes and depression.”

Continuing the collaboration, Dr. Köhler and the cardiologists are keeping a watchful eye on the connection between sexual problems and more serious health issues. “I’m trying to build the case for cardiologists and primary care physicians to check these things. It’s all about getting the message out there that good treatments are available,” Dr. Köhler says. “Stents may prove useful for some patients, but other good treatments, such as implants, are sound options for others.”

Dr. Köhler, who previously worked at two other institutions in Chicago and Minneapolis, says Springfieldians are very receptive to clinical trials. “I’m very impressed of the willingness of people in Springfield to do research and to try new things.”

For more information about these clinical trials, contact Dr. Kohler at 217-545-2598.