A 51 year old patient with Erectile Dysfunction

I thought it would be helpful to go through a case study of a typical male patient with erectile dysfunction/low testosterone, describe his concerns, how I treated him and the results he achieved after only a few weeks time.  I chose him because he is fairly typical of the male patients I see at my clinic  and his treatment course illustrates what can realistically be achieved with our treatment plans.  I’ll change his initials for this post.  For more information on our ED treatment options, please check out these 3 links:  ED Shockwave Treatment, P-Shot and Bocox  for ED and Testosterone Therapy for ED.

JJ is 51, works in a construction trade, married and is starting to feel his age.  He is concerned about fatigue, decreased libido, decreased sexual stamina, some degree of erectile dysfunction in that its harder to get hard and often difficult to maintain his erection during sex.  He reports a lower libido, loss of muscle on his body despite doing a physical job, gaining of belly fat and had been told in the past he had sleep apnea.  He had been diagnosed with low testosterone at an out of state clinic, and had used testosterone injections for 2 months and felt better energy but still had ED symptoms; at the same clinic, he was also treated with Ozempic for obesity but not given any real nutritional plan or support but nevertheless lost 30 pounds of weight, which he thinks helped his snoring and sleep apnea.  He had also been prescribed the drug anastrozole as a pill to control his estrogen levels, but he hadn’t been taking it regularly.  More on this later.  He hadn’t tried any ED drugs such as Viagra yet.

Sleep apnea is a very serious condition, often under-diagnosed and often left untreated.  It occurs when the airway is blocked by the tongue when asleep and the person literally suffocates until they abruptly awaken and take a breath.  This can happen over and over, sometimes hundreds of times per night.  If left untreated, it causes fatigue during the day, dozing off while driving or car accidents due to poor attention, and can lead to heart attacks, high blood pressure, low testosterone levels, diabetes, and obesity.  Doctors who treat patients with low testosterone should always check for this condition.

JJ’s history was also significant for prostatitis and he had been told he was prediabetic before the weight loss.  This is important, because many men who have ED actually are prediabetic and this is contributing to their ED symptoms.  Prediabetes, also known as metabolic syndrome or insulin resistance, directly impairs the artery function of the penis and all over the body leading to ED, high blood pressure, and even promoting plaque in the arteries of the heart and elsewhere.  It is very important for a doctor who treats men with ED to be aware of prediabetes/metabolic syndrome and know how to reverse it and not just prescribe ED treatments.  By getting to the root of the problem (prediabetes) and fixing it, we can truly help the patient-not just treat his symptoms with drugs.

When I examined JJ, he was a healthy-appearing middle aged man, always very busy on his cell phone, obviously under stress running his business.  Stress raises a hormone called CRH and cortisol, which lowers the pituitary hormone LH, which then leads to low testosterone production-another potential root cause for his problems. Did he really have low testosterone due to testicular failure or was the brain system that controls testosterone at fault due to stress of life or perhaps the stress from sleep apnea?  Unfortunately, the prior clinic did not do the proper labs before starting him on testosterone, and now that he was on it, it was impossible to to know for sure without stopping testosterone completely for several months and retesting as LH is always somewhat  or completely suppressed by testosterone injections.  Since he felt better on test and his stress wasn’t going away anytime soon, we decided to continue the testosterone on his current prescription and dose  but check some labs to see where his levels were.  He was injecting 100mg of testosterone cypionate weekly, a fairly typical dose.

JJ was overweight by 30 pounds of fat based on body-composition testing.  He was 27% fat by weight; ideal is 10-15%.  He did have plenty of muscle, with no need to increase muscle mass based on this testing.  His visceral fat (internal abdominal fat around his organs) was elevated (12); normal is less than 10; optimal is as close to zero as possible.  Visceral fat is very dangerous as it is causes inflammation in the body and is a sign that the patient is over consuming calories, particularly sugar, carbohydrates, and alcohol, is likely experiencing high cortisol levels from stress, and is at increased risk for heart disease, diabetes, high blood pressure, as well as ED.  His blood pressure was somewhat elevated, but not high enough to start him on medication immediately.  I thought a better diet and further weight reduction might be enough to get his blood pressure into the normal range.  Incidentally, most blood pressure drugs worsen ED, so from his standpoint of wanting better erections, starting him on medication to control blood pressure right away would have been counterproductive.  We decided to check some labs to see where he was hormonally on his current dosing of testosterone and also check other important tests relevant to his health, and I gave him diet instructions and referred him to my in-office nutritionist to start a weight loss diet to reverse his obesity and pre-diabetes.  As most patients eating a typical diet are nutritionally depleted, I recommended supplements containing omega-3 oil, a quality multivitamin, and extra vitamin K2 and D3.  There are many other supplements that could benefit him, but I wanted to check his labs first.

Regarding his testosterone prescription,  after we checked his initial labs, I prescribed a new type of injected testosterone that contains anastrozole mixed into it and the oil is MCT oil, not a potentially toxic oil such as cottonseed or sesame oil as is typical of most testosterones.  Now he could stop taking the anastrozole pills since his testosterone would self-regulate his estradiol levels.  Estradiol is important because too high a level inhibits release of LH, leading to low testosterone and it inhibits libido.  Estradiol also causes growth of hip and belly fat and gynecomastia also known as “man-boobs”  Estradiol is typically high in overweight men as it is produced from testosterone in the fat cells.  It’s a vicious cycle:  obesity leads to high estradiol and lower T, which leads to fatigue and depression, which leads to less exercise and more overeating, which leads to worse obesity, higher estradiol, lower T, and so on.  This is very common and we address this immediately by putting the patient on a strict fat-loss diet and using cobination anastrozole+Testosterone, not just plain testosterone or anastrozole pills.

In the meantime, JJ decided to have a P-Shot done and also a series of shockwave treatment to treat his ED symptoms.  Both the P-Shot and shockwave are excellent ways to improve erections and they enhance each others effects.  Most men do a combination as JJ did; we can also add Botox injections, we call this “Bocox”, a fairly new but very effective treatment for ED that lasts about 3 months, for even more benefit, but he decided to wait and see how the first two treatments worked.

We rate ED symptoms with 2 scales and we have the patient rate themselves by answering a series of questions at each visit.  The two scales are the EHS (Erection Hardness Scale, rated 1-4) and the SHIM (rated 5-25).  The higher the score, the better.  ASJ scored 2-3 on the EHS, meaning his penis could get hard but but not always hard enough to penetrate his partner and never fully hard.  On the SHIM, he rated a 14, which is consistent with “mild-moderate ED”.  He was scheduled for a total of 6 shockwave sessions of 20 minutes each and I did his P-Shot on his first shockwave visit.

Shockwave works by activating the stem cells in the penis blood vessels with sound waves; the P-Shot involves drawing blood from the patient and extracting a component of the blood called platelet-rich plasma, which contains the growth peptides to heal wounds.  We then inject that plasma into 5 locations on the penis to trigger repair of damaged blood vessel and nerves and other cells.  Both work well on their own, but when we look at the results, based on the scores, we can clearly see that men who do both treatments together get the best results.  For a video of the shockwave treatment click here.  To see me do a P-Shot, click here.  A nice benefit of the P-Shot is that it commonly causes growth of the penis in girth and in length, typically about a 10% increase, which is long-lasting or permanent.

I reviewed JJ’s labs, done on his old testosterone prescription, and discovered the following:  On his previous dose of testosterone, his total testosterone was 487/free 65.  This is adequate but not optimal for men with ED.  I like to see the free T at about 100.  Next, his estradiol was high at 32; it should be 10-20.  His LH was 2.8, not zero, indicating he really was not taking enough testosterone to even suppress his LH levels.  His insulin and fasting glucose levels and HbA1c were higher than optimal and he had elevated PLA2, ApoB, high triglycerides and low HDL; this is all consistent with prediabetes/metabolic syndrome and arterial plaque development.  Furthermore his PSA was elevated at 4.0, previously 2.36 1 year previous.  He told me he had been treated for prostatitis with antibiotics recently by his primary doctor, so that was the likely reason.  PSA is very important to follow; normal is less than 4, but most men are about 1.5.  A higher than normal PSA can indicate prostatitis or even prostate cancer, so we routinely monitor this every 6 months to 1 year and refer for a urology workup if I suspect a serious issue.  Given his cardiac risk and labs, I decided to treat him with a cholesterol lowering drug, rosuvastatin, which would also improve his arterial health.  I also started him on a compounded combination of tadalafil and apomorphine in the form of a chewable lozenge.  The purpose is to improve blood flow to his penis to enhance the benefit from the P-Shot and Shockwave treatments.  I also prescribed him sildenafil chewable lozenges to use before sex.

We continued his shockwave treatments, and retested his labs on the new testosterone prescription.  On the new testosterone formula, which contained anastrozole, his total T was 823/free T 155 at the same dosage as the previous prescription.  The reason his testosterone was higher is because the anastrozole prevented the testosterone from turning into estradiol.  His estradiol level was now 20, which was optimal and down from 32.  His  PSA had also dropped to 3.1.

JJ reported that his erections had started to improve significantly by the third shockwave treatment (3 weeks into the shockwave sessions).  His EHS now rated 4/4 or fully hard with sex, and his SHIM score was 21/25.  By his fourth session, his EHS was 4/4 and his SHIM score was 24/25.  By his 5th and 6th treatments, his SHIM score was 25/25 and he was thrilled with his results.  He plans on continuing to get periodic shockwave sessions, perhaps one treatment per quarter as aintenance and will repeat the P-Shot if needed. 

What can JJ expect going forward?

Typically, I find that, if a patient is willing to do the hard work of really losing that extra fat, commit to a healthy diet long-term, reduce or as nearly as possible eliminate alcohol, optimize hormonal levels, engage in high-intensity exercise on a regular basis, work on reducing stress and getting restful sleep, then they may do just fine and may not even need medication to have good sex after treatments such as the P-Shot and Shockwave.

In my view, the best diet is higher lean protein, low carb, low to moderate fat with a Paleo/Mediterranean focus.which will also reduce the risk for heart disease and diabetes, cancer, dementia and other degenerative diseases.

If, like most guys, a patient can make some improvements to diet and lifestyle, but are not 100%, then some combination of medicines for ED as well as periodic maintenance shockwaves and P-Shots can keep sexual function at an optimal level.

If the issue is losing the extra weight, we have an outstanding weight loss program.  Click here to learn more about our medical weight loss program.  We prescribe the medications semaglutide and tirzepatide and my nutritionist coaches our clients weekly to  help them stay on a very strict fat loss diet that delivers fast results and maintains muscle mass.  We make it as easy as possible to get back into metabolic health, which helps ED symptoms as well as everything else..

If you have made it this far, thanks for reading and feel free to call the office.  I’m always willing to talk to a prospective patient ahead of their initial visit to better understand their concerns and see if we can offer help to them.

Important Points to Know from this Case:

  1.  ED symptoms may be related to low testosterone, but they are also likely due to aged and damaged blood vessels.  Testosterone therapy alone will not necessarily get you the optimal results for erections and libido.
  2. Sleep apnea, prediabetes, obesity, excessive stress, lack of sleep, and lack of exercise all contribute to ED symptoms; It is important to address these “root causes” as well as optimize testosterone for good results.
  3. Treatments such as ED Shockwave and the P-Shot can actually repair the damaged blood vessels in the penis, improving erections.
  4. Special compounded medications, such as testosterone+anastrozole, Tadalafil+Apomorphine or Oxytocin in lozenge form may work better than conventional Cialis or Viagra and can be part of the plan for managing ED.
  5. New treatments such as “Bocox“, Botox injected into the penis have shown great success in treating ED in men who can’t tolerate the usual ED medicines or in addition to them and other therapies.
  6. Losing fat and reversing the prediabetic state is very important for overall health, including erection hardness.  We can help with our medical weight loss program and nutritional coaching and diet plans.
  7. For all these reasons, you are much better off seeing an experienced physician for problems such as ED and not just self-diagnosing and ordering testosterone for yourself or using some online service.  There are many factors involved in ED and a qualified physician should know how to check for underlying causes and fix them.



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