Southern Illinois University School of Medicine

SIU School of Medicine Office of Public Affairs - Aspects Volume 37 No. 1

Men's Health

In the early 1900s, miners carried canaries in small cages down into the mines to stand sentinel. As dangerous gases leaked into the mine shafts, the canaries died, and their singing stopped, alerting the men to exit the tunnels immediately. Similar warnings exist within the human body, says Tobias Köhler, MD. Dr. Köhler is an associate professor of urology in SIU’s Department of Surgery, director of SIU’s sexual dysfunction clinic, onco-fertility program and co-director of SIU’s andrology fellowship. "The penis is like the canary," he says. "Once the canary stops singing, look out, because trouble is imminent."


Men very often tie their identities to their sexuality, so for a man who might be experiencing issues with sexual health, it’s a very serious, frightening topic. A man may not seek treatment for problems with an erection due to embarrassment, but studies also show that most believe that the issue is a normal consequence of aging. Dr. Köhler disagrees: "It’s not normal, and it is a problem if a man can’t get an erection, because death may be coming soon in the form of a heart attack," Dr. Köhler says. “ matter how good your testosterone is, if there isn’t air flowing into the tire, you’ve still got a flat tire.” - Dr. Köhler

Cardiac disease is the number one killer of American men. Educating men that ED is a precursor to cardiac events could decrease that number significantly. Men over age 40 who have problems with erections are 52 times more likely get heart disease, according to Dr. Köhler. "ED predates a man’s first heart attack by about 3-5 years," Dr. Köhler says. "If you ask men who have had heart attacks when they first started having problems with erections, it’s remarkable how many will admit that it was several years earlier."

An erection is a neurovascular event. That plaque build-up will eventually occur in the vessels supporting the heart. "If I run tests and find very low blood flow, I immediately send him to the cardiologist," Dr. Köhler says. "I know that if he has low blood flow to the penis, he’s at a greater risk for cardiac event."

Low T

For the younger crowd experiencing a lack of libido, low testosterone (low T) could be the culprit. Symptoms range from fatigue and low sex drive to hair loss and decreased bone mass.

Like ED, men may think low T is inevitable with the passing years. Recent marketing efforts have made the public more aware of the symptoms of low T, but according to the SIU urologists, it’s not all a good thing. "Symptoms overlap with other health issues, and it can often be confused with signs of natural aging," Dr. Köhler says. "For example, a man who has trouble getting erections might be less interested in sex and more depressed than usual. Depression, anemia, sleep issues and other things could also be causing the symptoms." The overall message: not every man with a symptom of low T needs to have testosterone supplement.

If low T truly is the culprit, boosting the hormone doesn’t necessarily mean that erections will return. "One misconception is that fixing testosterone will always make ED better," Dr. Köhler says. "But no matter how good your testosterone is, if there isn’t air flowing into the tire, you’ve still got a flat tire."

"The main point of increasing testosterone is to give a man more energy and increase sex drive so he can go exercise and take better care of himself," Dr. Köhler says. Testosterone changes the body from a catabolic state to an anabolic state so that it burns fat instead of storing it, thus aiding weight loss. When testosterone is depleted, the rate of diabetes and heart disease significantly escalate. Too much testosterone, however, causes the testicles to stop their own natural production of testosterone and sperm.

Patient Buy-in

Dr. Köhler emphasizes that patients must be active participants in curing low T. This includes the usual advice: exercise, eating healthy and no smoking. "Lifestyle changes are better than any pill I can prescribe or any surgery I can do," Dr. Köhler says.

Smoking is one of the most common causes of ED, though the correlation is widely unrecognized. Obesity is another instigator. Strong data show that a heart-healthy diet is also a penis-healthy diet. "Weight gain can become a vicious cycle for men," says Dr. Köhler. The more flab a man has, the more he converts testosterone to estrogen. "Once you get obese, your testosterone gets low and estrogen gets high, causing decreased motivation. Then you exercise less, get more obese and the cycle continues."

Spouses can be key to the recovery. "I think that sexual health is a great motivator to get men to change their lifestyle and their behavior," Dr. Köhler says. "If we got the word out more about ED being an indicator of cardiovascular issues, then I think we’d see a much greater response from the wives. I encourage all my ED and low T appointments to bring their spouses along. If they have buy-in, they’re more apt for making changes together."

Prescription medications are also available for those men who need a little more help filling the flat tire. "A huge part of the population hasn’t tried the medications that could help them," Dr. Köhler says. These drugs boost nitric oxide, sending more blood to the penis; however, each medication behaves a little differently. Some last 24-48 hours, while the effects last only a few hours with others, and they all take some time to kick in. "These drugs work in about two-thirds of men with ED," says Dr. Köhler.

Penile Stents & Prosthesis

When the more conservative methods aren’t working, physicians can employ surgical options to treat ED. One option is placing penile experimental stents in the arteries of the penis, similar to stents inserted in the heart, to help blood flow.

Another option is a penile implant. With a 95 percent satisfaction rate, the highest of all options available to men with ED, the surgery is giving men — and women — new hope.

The 90-minute procedure can upgrade a man’s sexual machinery if other treatments have failed. Expandable chambers implanted in the penis enlarge with a few squeezes of a small saline pump placed in the scrotum. Components are invisible and can be used at any time. "Devices are more reliable in recent years," says Dr. Köhler. "Most men are happy with the implants, and insurance often covers the procedure." For men faced with perpetual ED, Dr. Köhler considers the surgery a win-win.

“text quoate"Some of the most grateful patients I’ve had are couples that have been together a very long time, but they can’t have sex anymore," he says. But the implant can fix that. "I’ve had several wives thank me after the surgery because it’s changed the relationship, and the man feels whole and normal again. Guys just want to be able to do the things guys are supposed to be able to do."

One of Dr. Köhler’s patients who is a patient advocate/educator had the implant surgery. Now a retiree in southern Illinois, he was first troubled by ED in his 40s. He was married, didn’t smoke and felt healthy and turned to medication as a temporary solution to his ED. In 2007 he saw blood in his urine, and a few weeks later was diagnosed with bladder cancer. The disease had metastasized, forcing the removal of his bladder, lymph nodes and prostate. Surgeons fashioned a new bladder for him from a portion of his large intestine. He recovered, but the surgery left him impotent.

He went to Dr. Köhler in 2009. When pharmaceutical therapies didn’t offer any solutions, he weighed his options and decided, after much discussion with his wife, to have an implant.

The surgery was done as an outpatient procedure and recovery time was brief. Approximately six weeks later, he had resumed physical activity and tested the prosthesis. His sex life was back on track. The couple has subsequently become patient advocate/educators for the implant surgery and counsel other men facing the same challenges. He says that if he had to do it over again, he would have had the surgery sooner.

It pleases Dr. Köhler to lead men down the road to recovery. "I have a lot of happy patients," he says. "As a men’s health specialist, I think that sexual health is just as important as mental health, joint health, etc. We all have a right to be sexually healthy and there shouldn’t be anything embarrassing about it."

SIU offers men group medical appointments

One of the best messages a man can hear about his health issues is that he’s not alone. Tobias Köhler, MD, has taken this concept into motion by introducing group shared medical appointments for men. Dr. Köhler specializes in men’s health and fertility.

These appointments are becoming more prevalent across the country, especially in the area of men’s health. Dr. Köhler began the group shared medical appointments five years ago for those who were interested in getting vasectomies. "We’re going to continue to use this model for other types of appointments such as low testosterone, erectile dysfunction and urinary problems," Dr. Köhler says.

The 60-minute appointments are in the evening, after work hours. The men watch a video, listen to Dr. Köhler and ask questions. "A lot of times the guys forget the questions they want to ask, but since there’s ten of them, they’re more likely to get all their questions answered because someone else will ask." After the discussion, the men are examined privately, just as they would be at a regular medical appointment.

"If the patient has a private question, he can ask me in the exam room," Dr. Köhler says. If the men choose to have a vasectomy, they can make their appointment that night. "Group shared medical appointments are very efficient and a great way to make men more comfortable addressing their health."


Read more about the penile stent in aspects 34-3.

The mission of SIU School of Medicine is to assist the citizens of central and southern Illinois in meeting their health-care needs through education, patient care, research and service to the community.


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