Erections & Testosterone - Shocking Link to Muscle Mass & Men's Health | Dr Tobias S Kohler

Dr Tobias Kohler - Transcript

Men with more muscle mass have better erections. Men with less muscle mass have horrible erections, have low

0:05

libido, have lower testosterone. You just got the attention of every male listener on the planet.

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150 minutes of exercise per week, decrease the rate of erectile dysfunction by 20%, 300 minutes by

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essentially 40%. Erectile dysfunction is one of the earliest signs of heart disease. What do

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you mean by that? If the penis is failing, you should assume you're going to have problems with your heart soon

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until proven otherwise. Anything that is good for the ticker, the heart is good for the penis and vice versa. We know

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that men who don't get erections commonly get penal shortening. So, you lose length the penis.

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How rapid and how much? If you've got a consistent lack of erections for 3 months, you lose

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centimeters of length. That's a lot significant. The best overall marker for overall

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health in men is erectile function. Why? Because you have to have excellent vascular integrity, excellent overall

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health, and the penis requires normal mental health. There are many men who

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have never had a normal erection their entire life.

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Dr. Tobias Kohler, welcome to the show. It's a real honor to be here. You are a professor of urology at the

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Mayo Clinic in Rochester. You have treated patients with urological problems for over 20 years. A woman

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could go to a plastic surgeon. Say you live in Houston, you could go to Christy Hamilton and say, "I want a B-cup." Can

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a man go to a urologist and say, "I

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would like this penis size." Well, no, unfortunately. If uh if we

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could change penis size, I think I'd be busy operating currently. But what we can do with penal implants is guarantee

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an erection every time uh with no worries, no anxiety, no pills, shots or anything. It's a great surgical solution

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to a problem that's been around for a really long time. How long have penile implants been on

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the table for people? Yeah, most people are really surprised to know that it's 50 years, 50. We just had our 50th year anniversary last year.

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This treatment for erectile dysfunction actually preceded pills, shots,

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vacuuming devices, pretty much anything else. And that's one of the reasons actually why it's covered by insurance

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because it's the oldest. Wow. I'm fascinated. You have to break this down. Erectile dysfunction is a huge

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problem. Yes. Dr. Mo Cara, our very good friend, says 40% of men at the age or over the age of

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40, Yep. have it. 50% of men have it at 50 and so on. So erectile dysfunction is a major

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problem. Absolutely. Probably the first line solution isn't surgical. Is that

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of course uh the first line solution is to prevent it from happening in the first place and that of course is uh

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based on foundational pillars of health. Diet, exercise, sleep, stress

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mitigation. Uh those are the core tenants that are going to keep your penis healthy for a long time. But sometimes in life we get, I don't know,

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prostate cancer or whatever. We need a surgery and you get collateral damage. And so it's from that collateral damage

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that often men will develop problems with erections that no longer are response with the pills. And once that

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happens, uh, you can make the decision to fix it definitively with the surgery. Can you walk me through just on a very

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high level how how does that work? How is that surgical procedure implemented? Well, I guess uh the first thing to

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understand is that in order to get a good erection, you have to have blood flowing into the penis and that blood

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has to be trapped there, right? So when you look at why erections stop working,

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the most common cause is a vascular problem. So narrowing of the blood vessels going to the penis, so you have a blood flow in problem. Those can be

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often mitigated or addressed with pills or shots or even exercise, right? So if you exercise, you get better blood flow

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to the area. You can fix these problems. That's one set of uh reasons why the penis fails. The other one is the blood

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isn't trapped there appropriately. So you have to develop what these surgeries try to do is mimic mother nature and

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instead of blood flowing into the penis, we put a kind of a lining inside the penis, a prostthesis where men will pump

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normal saline or salt water into the device. And when they pump the device,

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the fluid is transferred from a a holding tank or reservoir which is typically hidden next to the bladder or

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somewhere in the abdomen. And so they'll pump the fluid into the penis and they'll keep the erection for as long as

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they leave the fluid in there, right? So, you know, uh you can have an erection for 4 hours or 15 minutes. It

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doesn't make a difference. And then when you're done, you hit it to flight button and that normal saline goes back to the holding tank. So, as a surgeon, when I

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do an implant, I put in 3 4 ounces of fluid, 100 milliliters or so of saline and that same saline powers the device

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for the next many, many years. the average device. Wait, the same saline the it's recycled.

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Exactly. So it's essentially when the fluid's in the reservoir and not in the penis, the penis looks normal. Flaccid,

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nobody can tell you have. No one can tell. What about the the pump? It's like a third testicle but hidden.

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Wow. So most men who are single who uh have an implant, their partner has no idea.

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Holy cow. Yep. Yep. So it's completely hidden. It's completely locker room proof. The joke is of course if you leave it inflated all the time it's not so it's

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not so uh you know not so um hidden but uh you can you can decide when and when

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and where it's going to happen and so it takes away all the anxiety and problems that people have when they're thinking

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about having problems with sex. So and on average these devices last half of them last 20 years right? So they tend

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to outlive most other prosthetics. They outlive breast implants pacemakers hip implants these kind of things. is

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amazing because they have functional parts but at 5 years 5% break at 10 years about 10 to 15% will have broken.

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15 years 30% break. So they have a really long longevity and most guys uh who get an implant will die with it

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working. The average age of implantation is around 70 years of of age or so. But

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wait what's the average years uh the average age of implantation? Average age of implantations is about 68

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around 70. But would uh if someone came in who was younger Yeah. Would there be any issue

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of let's say someone has major performance anxiety and they're 50?

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Yeah. The strength of the implant is that it works really well every time. One of the weaknesses is that if other

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stuff still works then you know you don't want to do an implant because that other stuff won't work anymore.

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I see. So it's a surgical decision and once pills fail that's the decision point. Do

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I want to try shots or do I want to do surgery? It's very reasonable to get the surgery if you don't like needles. It's covered, like I said, covered by

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insurance. Completely invisible, very spontaneous. And the other thing which people always ask me is like, well, does

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it feel the same? The answer is yes. For both parties. Yes. Yes. Again, the partner doesn't

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know you have a prostthesis. Uh, unless they're like in the medical profession or very very observant. For the the man

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who gets the implant, a sensation is essentially unchanged. Does it change the size of the penis?

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Great question. And like everybody always asks, you know, can you add an inch or two dock, right? And again, like

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the answer is no. Essentially, uh, mother nature gives you certain length

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and then, uh, you're kind of stuck with that. Now, there is debate as to whether or not when you get the implant whether

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or not you lose a little bit of length. When we actually do good studies, the answer is no. Uh, but patients do have

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this perception because they tend to remember the majesty of their erection when they were 18 compared to now when

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they haven't had sex for 10 years. Some men have um you know this perception

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that the mean is so much shorter. So you have really have to counsel about that right. So as a surgeon it's all about

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risk benefits ratios. And if a patient comes to me and says doc I want to have a consistent erection without having to

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use pills or shots without fear of it not working they're going to be happy. Right? right? If they just want to have

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penetrative intercourse with with their partner, if they come in with the expectation that they're going to be enhanced somehow in terms of lengthwise,

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they're going to be disappointed. So, you really have to do a good job as a surgeon to make sure that the patients understand that. And anybody, you know,

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considering this type of surgery, really, you need to educate yourself as to the risks and benefits of any procedure. And then you'll end up uh

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happy. I love it when people are happy. Both parties, mental health and erections

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definitely seem to be tied. You say, and you've said this before, that erectile

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dysfunction is one of the earliest signs of heart disease. What do you mean by that?

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Problems with erections is like the check engine light uh sign going off where if the penis is failing, you

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should assume you're going to have problems with your heart soon until proven otherwise. Let me explain that. So, we talked about earlier how blood

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flowing to the penis is essential to get a good erection. The blood vessels going to the penis are 1 to 2 millimeters the

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main ones and the blood vessels in the heart are 3 to four millimeters. The blood vessels in the corateeds 7 to 8 millimeters. So as a scerosis happens

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this kind of endothelial plaque the the crud that grows inside the vessels as we age and if we don't take care of

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ourselves especially uh you get narrowing of those vessels and as those uh vessels narrow the smaller vessels

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will have danger signs first right. So if you have ascoratic disease uh

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according to many many studies has been repeated several times first problems with erections happen and then if you

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don't do anything and the disease progresses the first heart attack typically occurs three to five years

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later and then the first stroke a couple years after that and then finally people have pain with walking or something

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called claudication because you start to get narrowing of the femoral vessels which are gigantic but even those can

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manifest with pain and problems of blood flow as they narrow down. So because

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this narrowing typically follows this pathway, if you have problems with erections, it can predict heart heart

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attacks very reliably. And so the number one kind of risk factor in young men and

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even older men to predict heart disease that don't doesn't have any other warning signs is the penis. And the

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beauty of this is that anything that is good for the ticker, the heart is good for the penis and vice versa. Right? So

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if you want to have better erections, exercise, lose weight, eat right, get good sleep, mitigate

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stress. That will have positive effects on the erections as powerfully as many pills do, if not better. And at the same

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time, you're going to be on the right side of the grass longer because you're much less likely to heart attack. It makes me think as physicians

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screening, early detection screening. I wanted to take a moment to let you know about something new we've created. It's

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Let's keep getting stronger together. How would someone know that they qualify

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for having erectile dysfunction? Yeah. So, the definition is a persistent problem with getting and maintaining

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erections adequate for intercourse for greater than 3 months. So, let me be clear. Many young men will have a bad

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night, okay? Maybe there's some some alcohol involved or some other chemicals. Maybe you're nervous because

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you're with a new partner for the first time. Most men in their lifetime will have a couple episodes of performance

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anxiety. And so, if it goes back to normal after

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you kind of get your confidence back, and often we have to give pills to make that happen to get confidence back, then

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it's not a true warning sign for cardiac disease. But if it's a persistent problem, then indeed you should be at

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least screened for cardiac disease. And so recently um there was a panel that I

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was involved with called the P4 consensus panel. And we basically wrote in this document that if men have

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problems with erections, uh you do an assessment of cardiac risk and if they

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qualify, which is most men, you should get a coronary calcium score. It's a CT scan of the heart which looks for for

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calcifications. And that's a really good also predictor of future heart events. In this recent guideline, we know the

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evidence is so strong that the penis is predictive of of cardiac problems that

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we've also instituted this additional testing based on the diagnosis. It makes me also think about um when you go to

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your physician for a regular annual physical, they might do an EKG,

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obviously blood pressure, you know, in office glucose stick, maybe a handful of things. Listen to your heart, listen to

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your lungs. Do you think that if blood flow to the penis is an indicator of

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health? Would it make sense that we do a normal Doppler screening just like

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someone does, I don't know, an echo cardiogram? Getting a penal Doppler is a very smart thing to do if you're worried,

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but frankly, the easiest thing to do for the physician is to ask, do you have problems with sex? That's the screen.

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And if the answer is yes, then that leads to more questions. And then let's turn around from a patient perspective.

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As a patient, you have to take responsibility for your own health. And if you go to the doctor without a plan,

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a lot of things that you want to get addressed won't get addressed. If you have problems with sexual function as a

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man or woman, there are many, many good treatments available. But you have to ask, right? You have to be bold. You

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have to be courageous. You have to say, "Hey, I've been struggling with this. What do you think this means?" And if you do that, you know, there's many

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benefits that will will come from uh that question. And as physicians, we need to do a much better job of asking

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routinely about this. The first time I ask a patient, they may be embarrassed, they may be shy, but then the second

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time they ask them or the third time, now it becomes normalized and now maybe they'll reveal this part of their life where they're hesitant to talk about.

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The other thing that often happens in modern day medicine is patients will come and they won't ask the question

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till the last 30 seconds. the hand proverbial hand on the doororknob question, right? So, you have a set amount of time with your physician in

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modern day medicine and as the doctor's leaving say, "Oh, by the way, there's this as well." Don't do that because you

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short change the ability to ask further questions to get good treatment. Ask the important stuff first. That makes a ton of sense. And people

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come to you as a urologist at Mayo Clinic who is an expert in sexual

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health. They are coming to you. They might come and talk about their dog and all these other things but at the end of the day they are probably there and very

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motivated. Are you seeing erectile dysfunction increase in our youth

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in general as our society gets less healthy? Clearly erectile dysfunction

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rates will go up. All right. Again if you look at metabolic disease disorders,

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diabetes, obesity, cardiac disease, these are all increasing with our society. And as these go up, problems

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with erections will occur as well. I mean, if you think about it, the body has a primary job of protecting the

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brain and everything that supports the brain function. And as we become unhealthy, it makes intuitive sense that

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the body is willing to sacrifice a few of the organ systems here or there, whether it's fertility or erections,

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which aren't essential to keep you alive in that moment, right? And so as an example, if a patient has cancer,

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they'll often they'll have a low sperm count, right? Because the body is diverting resources to take care of the

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primary problems. It doesn't have time to nurture the penis and keep that part healthy. So it makes intuitive sense

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that as we become an unhealthier problems with erections also occur. The other thing is, you know, psychoggenic

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ED. So psychoggenic means like performance anxiety. Now 50 years ago when masters and Johnson started doing

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grobranging research on on sex they said 90% of problems with erections is in the

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man's head. Okay and 10% is organic. We know that to be completely opposite

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wrong. So 90% of erections are vascular or of you know true organic origin and

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only 10% are purely psychoggenic or from anxiety or depression. And so what does

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that mean? And it means that you know we need to screen for it and if it is truly psychoggenic often we can support

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patients by increasing confidence. Uh but again as we get unhealthier problems

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with erections will get higher and higher. What role does alcohol and or cannabis

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use play in erectile dysfunction at while trying to have sex? Alcohol and

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cannabis can have this kind of um strange role. Sometimes it can make uh

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erections more difficult to achieve because again their body's busy metabolizing alcohol. Erectile

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performance is often impaired. That is the most common scenario where somebody drinks too much and then tries to have

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sex and it doesn't work. And then the next time they try to have sex, they think about the last time it didn't work. And so this is literally the

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thought going through their head. It's not gonna work. It's not gonna work. It's not going to work. So the, you know, it's very interesting

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why that makes the penis fail. So if you're running from a bear as a man,

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right, it clearly does not make sense to have a strong erection, right? You want to divest resources away from the penis.

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The blood flow goes to your brain so you can think clearly run and then like make a good decision as to which direction to

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run. You want to shunt blood towards the muscles so you can escape and run faster. But obviously the penis is, you

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know, not a good thing to put energy into at that time. And so that's why when you're worried about erections, when you're trying to have sex, it never

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works cuz your adrenal glands kick in. You make a little adrenaline. Adrenaline is the most powerful anti-rective

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chemical that we have. Say that again. Yeah. So adrenaline, the most powerful

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anti-erectile chemical we have. If somebody has pribism, what's pribism? When you have an unwanted erection

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greater than a few hours where your penis really starts to hurt, it isn't subtle. You have to go to the nursery room because it hurts so bad. uh you

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know, we inject adrenaline directly into the penis and the erection goes away within seconds. The joke is you show the

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patient the needle and you use a giant needle just like I'm going about to stick this in there and then all of a

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sudden erection goes away to trigger this natural um adrenaline rush which you know is what we use to make it go

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away. I did not know that. I to be fair I've never had to treat priism.

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Is that common? Pripism is most commonly occurs after uh men get a prescription

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for penal injections, a medicine that we give to create erections. And then

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occasionally we'll have patients that don't need these type of drugs use them because they think it's going to be awesome.

19:15

Okay. What kind of medications are we talking? Yeah. So these are every Matt over there is my producer wants to take notes.

19:20

Yeah. So penal injections uh are various chemicals which essentially their main job is to vasoddilate the blood vessels

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in the penis so that blood flows in right and so they're they go under um like the branded drugs are like edicts.

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Uh but most men will use compounded agents something called tryix where it has a series of different chemicals all

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playing different roles to help improve blood flow but it's safe in men who have

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problems with erections but it can be a little sketchy if you don't have problems. So, don't go for

19:53

a good time. Yeah, it's not a not a good idea. And I guess the public service announcement

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part of this is like if you have an ever have an erection that doesn't go away. First of all, it's not subtle. If you

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have to ask me if you think you have priism, you don't have privism. It's like literally getting a a lightning

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bolt to the penis. The the penis is becoming eskeemic. There's no blood flow cuz essentially blood flows in but can't flow out. So, then you have oxygen

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deprivation. So it starts to hurt and it starts to hurt more and more and this is like 11 out of 10 erection. And if that

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happens, if you go to the emergency room and we take care of it right away, no problem. Then you learn your lesson.

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Never do that thing again that you just did. However, if you wait because you're embarrassed and after 24, after 36 hours

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of privacy, gosh, it's broken forever. And what happen? What happens if Well, you get es schemic. So all the

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smooth muscle in the penis dies. So it's like a heart attack of the penis. And that's one reason why men sometimes need

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penal implants because once you have this devastating loss of penal function,

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nothing except surgery would potentially fix it. Don't wait. Don't delay care. How big of an impact, you know, from a a family

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practice or geriatric perspective. We use tradone for sleep at times, not

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at high doses. There is a little blackbox warning that says this could cause privism. I've never seen it. I

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don't know any physician that has seen it or any of the physicians in our practice. Is that something common or is

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that just a another blackbox warning that just has not died yet? Well, I think you're going to do great

21:27

on the test because they always ask that question. Uh but no, I have seen it before. And so, a lot of the

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psychotropic medications that can be used that have central effects actually can cause priism. There's a really long

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drug list. Uh cannabis is another really big one that's pipistic meaning it can cause pribism. So we're seeing

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increasing rates of pribism in our emergency rooms now because because of the legalization and you know social

21:50

acceptance of cannabis. So just another public service announcement. I think it's a great public service announcement because people believe many

21:59

people believe that these drugs are benign including cannabis. I personally don't think so. I think

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that the data would also suggest otherwise in various domains of health and wellness.

22:11

Yeah, I think both alcohol and cannabis uh really disturb REM sleep. REM sleep

22:16

is critical for kind of the brain self-healing uh for psychiatric wellness

22:21

and for the production of hormones. So, the vast majority of sex hormones are produced during REM sleep. So, if you want to sabotage that, sleep lousy and

22:29

you'll do a good job and you'll feel lousy as well. I'd like to acknowledge one of the sponsors of the show and that is Pury.

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and use the code Dr. Lion at checkout. You mentioned exercise, penile vascular

23:33

health. Mhm. This is the first time I've probably ever said those words together.

23:38

I'll just say them again. Penile vascular health. Exercise increases blood flow. Absolutely.

23:44

Are there things like I saw Austin Powers and he has the penis

23:50

pump. It would also make sense if we exercise our muscle that perhaps something like

23:57

that would also work. You know, the guys may take advantage of this statement, but the penis is a lose it or use it or

24:03

lose it organ. Okay, so when the penis goes in the garage for an extended amount of time, meaning no erections,

24:09

like no sex, no physiological erections that normally occur in the middle of night. Now, why would that happen? You just had a prostate surgery, uh, and you

24:17

stun the nerves, you have significant diabetes, you've basically just gotten to the point where the erections aren't

24:22

happening very often. We know that men who don't get erections commonly get penal shortening, right? So, you lose

24:29

length of the penis. Everybody wants to know how rapid and how much. Yeah. So, on average, if you've got a

24:35

consistent lack of erections for 3 months, you lose 1 to 2 centimeters of length, which is a/ inch to an inch in

24:42

length. And every millimeter guys fight for, right? That's a lot. Significant. Yeah, it's significant.

24:48

Actually earlier in my career as as I was a urologist at the VA and we were

24:53

doing prostctomy surgeons, the patients would say after the prostate surgery say, "Doc, I think my penis is shorter."

24:59

I'm like, "No, no, you're just a little bit fatter. You know, it's hidden more." You know, and then they kept saying it. And that was like one of the first

25:05

studies I ever did and we actually measured and it's true. Guys lost penile length. The good news is is that if you

25:12

exercise the penis with a vacuum device, you can regain that length back. So it's not about like physically shortening the

25:18

penis. It's about having scar tissue in the penis. And uh if you have a uniform

25:24

scar with erection the penis looks shorter. If you have a non-uniform scar you get this curvature, right? And

25:30

that's disease. Peron disease is loss of elasticity on one side or one part of the penis.

25:36

And like a balloon, if you put a piece of tape on a balloon, you inflate it, the balloon's going to curve where that piece of tape is. That's what perinous

25:42

disease is. And again, that's uh something that's very common in men, about 10% of men above age 50.

25:47

10% of men above age 50. You do support the use of what do you call it? A penile

25:54

enhancement device. What are they? Yes, a vacuum erection device. Vacuum erection device. An adjunctive tool to help men kind of

26:01

rehab the penis. We we often have men use it prior to surgery to optimize length to to facilitate an easier

26:06

surgery. There's data to support that. Um again, it's a use or lose organ. So, as a long-term treatment for significant

26:14

problems with rectums, the vacuum correction device is not awesome. Right? You can imagine you're with a partner and you're like carrying this thing

26:19

around like going through TSA precheck or going without TSA pre-check. Yeah.

26:24

Right. U but you know we do have better treatments that are more subtle, more hidable, uh less embarrassing. Uh

26:30

surgery being one of them, pills being another. Uh but yeah, I I think back devices play an important role. The

26:35

other thing about vacuuming devices that men should know is that there's you can get blood to flow into the penis with

26:41

this with this negative pressure, right? But then you take the cylinder off and the erection goes away within 10

26:48

seconds, right? So you have to somehow trap the blood and trapping the blood we talked about in the beginning is in is

26:54

essential for keeping erections. So as the veins uh become

26:59

uh malf as they malfunction as we age or if there's more scar tissue around the veins after fibrosis from surgery for

27:05

example those veins no longer could be compressed adequately. So what happens is blood flows in but the veins don't

27:12

get compressed like they should. So blood flows out at the same rate very similar to like a uh tire with a bunch of holes in it. Okay? So you can hook up

27:19

an air compressor to the tire. It'll look like it'll get hard, but then as soon as you start to drive on, it goes

27:25

flat. That happens with in men, too. And so, if men describe to me, hey, I can get erection, but then I lose it when I

27:31

when I start to try to have sex or when I, you know, uh, with intermission,

27:37

then I'll know that's probably a Venus leak. And that Venus leak can be treated best with surgery. But the other you can

27:42

try are these constriction bands where you're essentially trying to crush the vessels from the outside. Never use a

27:49

metal band on the penis. That also sounds really painful. Yeah. Yeah. No. As as urologists, you know, we've I've had cases where I had

27:54

to call in use like a neurosurgical drill. We have the fire department, you know, try to cut off these metal rings.

28:00

I had one gentleman use a titanium ring. That is not a good plan cuz it gets stuck. So, if you're going to use a ring

28:05

or a band to support erections, which is a reasonable thing to try, use something that is uh, you know,

28:10

elastic. Yeah. There you go. That would make much more sense than something that doesn't expand. Thank you

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29:31

about drugs. And I have and when I say drugs, I'm talking about PD E5

29:38

inhibitors, Viagra, Seialis. There was a massive review. It was 1.26

29:44

million people found that regular Seialis use reduced major cardiac events

29:50

by 22%. And lowered all cause mortality by 30%.

29:56

Do you think there is a place for people that are healthy to be on these types of medications like

30:03

Seialis? Yeah, if you ask me if there's data to support that for all patients, not yet.

30:09

From a personal standpoint, I believe so. Like my read on the data is these are preventative drugs that can prevent

30:16

significant disease. Do you know the story of Viagra? It's an interesting one. So, Viagra was initially a drug

30:23

developed um and they were tested in England and so it was initially a drug

30:29

jo uh designed to treat anggina chest pain. So you get all these men who have a history of chest pain. You give them

30:35

Viagra. Say, "Okay, when you get the chest pain, take the drug. See what happens." Turns out lousy drug for chest

30:41

pain. Like doesn't work. And so that's what nitroglycerin does, right? It reduces reduces pain with um you lack of

30:48

blood flow to the heart. And then the people who doing the study are like uh back to the drawing board. And they're like, "Send us the drugs back." And like

30:55

they weren't getting them back. Like what is happening? Patients never keep these drugs. And so of course the

31:00

patients noted that their penis was working better on these drugs and that's how Viagra was born. It was initially a

31:06

heart drug for anga but then we developed into a penis drug and seialis

31:11

had a similar history. And so it's not that surprising as we look back at the data which has been in front of us now

31:17

for 20 to 25 years that men who take these drugs consistently seem to have a much lower risk of heart disease. The

31:25

mechanism is unclear. It probably has to do with endothelial health, the inner lining of the blood vessels being

31:31

healthy. Has to do with maybe uh decreasing clotting in the major blood vessels. You get drugs like Viagra and

31:37

Seialis. Um Selenapil, Tedalophil are the you know the names. And if you take

31:44

them, not only do they help erections, we also discover that Tedalopil, which is a drug that stays in your bloodstream

31:50

for 24 hours, used to be called the weekender, actually helps with urinary symptoms as well. And then now

31:56

helps how it helps with these urgency frequency get up in the getting up in the middle of type middle of the night type

32:02

symptoms. So Dalopil has an FDA indication for urinary symptoms or a lots lower urinary tract symptoms. And

32:08

so I write for these drugs a lot uh because I find every excuse I can to

32:14

give them to men whether they have problems with erections or they have problems with urin urination or and then

32:19

they get this likely benefit of cardiac protection. So, it's like this triple threat drug, which by the way is like 25

32:26

cents a pill. You can get a prescription um you know through Mark Cubans Pharmacy

32:31

or goodex.com. Literally three months for 30 bucks. So, even if insurance doesn't pay for it, it's worth it. And

32:37

so, we routinely uh use these drugs and they're massively effective. Restore

32:42

confidence, probably good for you overall, help with urination. I mean, it's great. There are downsides any

32:48

pill, but you know, they're relatively low with this class of drugs. One in 33 men will stop because of side effects.

32:54

One in 33. That can include headache, facial flushing, maybe worsen reflux disease, but 32 out of 33 men are like,

33:01

"I'm good. I'll take the reflex. Give me extra flushing."

33:06

And this is Seialis. Yep. Five mill. Is it Do you prescribe 5 milligrams of Seialis daily?

33:12

We do too in clinic. It's going to be the most effective because it's in your bloodstream constantly. So if you if you believe the

33:18

data that it's cardioprotective, it makes sense you need to have it in in your bloodstream the whole day as

33:23

opposed to like a window which Viagra Sedenul would gives you a 4-hour window of efficacy whereas Seattle 24 hours.

33:29

You only see men to be fair, right? For the most part. Yeah. Especially where I am now. My job at primarily

33:36

men's health used to see a lot of women uh for stones when I was in Springfield, Illinois. Stones are very very common

33:42

for aologist. Yes. Did you at that time use Seialis in

33:47

women? This is a study that clearly needs to be done for a variety of reasons. Number one, you know, overactive bladder. This

33:54

is symptoms where people have to pee so often that it negatively affects their life. And like 40% of all humans above

34:02

age 50 have overactive bladder. And this really 40%.

34:07

It's super super common. You know, my dad's always saying I have BPH. I'm peeing 100 times a night. lets

34:14

me meditate. I'd love to dive into that because there's a lot of misconceptions about the prostate being at fault for everything.

34:19

But when we get older, we get physiologic changes in the bladder. So like the bladder capacity goes down

34:25

and our sense of urgency and the sense of stretch is increased. So we end up

34:31

peeing more often at lower volumes. Just like many things, as we get older, things tend to get worse. As you're when

34:38

you're a baby, when you're born, the bladder just squeezes when when it wants to. And then age four or five, the

34:44

bladder takes commands from the brain, says, "No, no, no. You can't squeeze now. I'm in public. I can't pee my pants." And so, you learn this

34:50

countenance. But as we age, like many things, the bladder kind of goes rogue and just ignores the the brain's advice

34:57

and just squeezes when it wants to. So, patients, they'll put keys in the door, they'll hear running water, and

35:03

all of a sudden, they'll get this crazy urge to go to the bathroom. And if you're lucky, you make it in time. If

35:08

you're unlucky, you don't have a bathroom there. You're more likely to have accidents. And so women, like one

35:13

of the main reasons women visit urologists is for urinary incontinence. Not only stress incontinence from when

35:20

you cough or sneeze, you lose urine, but this urgent, you know, this is very, very common, but men also have urgent

35:25

continents. And so this can be treated by addressing bladder health. And so that's why I think a study is long long

35:32

overdue for women to see if seialis will help with these overactive bladder symptoms like they do in men because

35:38

they do. And then is it cardio protective in women? Uh these are questions that need to be answered with

35:43

a randomized control trial. If a woman was taking seialis in the

35:50

indication would not be I suppose it would be off label for overactive bladders.

35:55

Yep. Yep. until we get an indication to be off label. But off label doesn't mean wrong. Oh, totally

36:01

right. And a lot of patients will think, you know, this is off label, this is wrong. No, off label means as a physician, I have to tell you the risks

36:07

and benefits of of this therapy and then you decide if it's right for you just like many other things in life. So yeah,

36:14

it's a study that needs to be done and uh there have been studies to look at sexual function and these classes of

36:19

drugs and it does increase blood flow to the genitalia. you know, sexual function and orgasm in women is uh a lot more

36:26

complicated, sophisticated. A lot of other things have to happen for orgasm to occur. There isn't this obvious yes,

36:32

no, penis hard, penis soft kind of thing in women. And so the these drugs have been disappointing for sexual function

36:39

in women. However, it doesn't mean they they might not help. Thanks to one of the sponsors of the show, Bon Charge.

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your entire order. Simple, proven, designed to support your biology. I want

37:59

to talk about the bladder. You you brought it up. I think it's a great topic. Now, I have heard you say that

38:06

one in seven men who see a urologist already have irreversible bladder damage. It's crazy, but uh we did a big study

38:14

where we looked at men visiting the urologist. We tested them and they they tested in this zone where we called, you

38:20

know, basically uh the bladder was no longer squeezing like it like it can. So the bladder put simply is a big old pump

38:28

and over men's lifetime they the bladder has to empty through the middle of the

38:33

prostate and out the urethra. So as women go older get older they don't have problems with the pump getting weak

38:39

because their urethra is relatively short and they don't have this prostate which can get bigger with time. But men

38:45

they have a prostate which gets bigger as we age. So very similar to problems with erections. So 50% of 50-year-olds

38:51

will have an enlarged prostate. 80% of 80-year-olds, so on and so forth. And of the men with enlarged prostate, half will be symptomatic. So if you have this

38:59

pump which is struggling to empty because it's trying to squeeze urine

39:04

through the middle of this doughut, which is the prostate, the bladder gets tired after a while. It's a pump that

39:10

fails. And if men allow that to progress, one in seven come to me and

39:16

the pump's already gone. What does that mean for them? Well, either they will need to catheterize the rest of their life to get the urine out, either in and

39:24

out or have a catheter in, or they'll need a very aggressive surgery in the hopes that they'll be able to pee on

39:29

their own by what we call credoing, bearing down, basically just pushing the

39:35

urine out. So, it can be avoided if when men get symptoms, they go to the

39:40

doctor relatively early and either they get a surgery early because that's the best way to preserve the pump. What

39:46

would the symptom be that they are just getting would it be urinary retention or

39:51

this feeling where they're having to go a lot but they can't go and feeling like there is urine still that they still

39:59

have to pee. Yeah. It's the former. It's pushing or straining to go. Men who can't empty

40:04

their bladder effectively. Right. So one test we'll do is we'll have guys pee into a machine. We'll measure how strong the stream is. We'll give them a score

40:11

and then and that can be predictive of the need for surgery etc. But more importantly, we measure how much is left behind after they go. And if that number

40:18

is zero, you're good. However, if that number starts climbing, you pee out 400,

40:23

you leave 100 behind. You wait another year, you pee out 300, you leave 200 behind. Pretty soon, the ratio is

40:29

nothing comes out. You leave everything behind. So, that is the best way to kind of predict this loss of bladder function

40:36

is by seeing how much is left over. Other signs can include knowing you're not emptying. So, that can sometimes

40:41

lead to frequency. uh getting infections, right? Because you're going to attract infections

40:47

because our number one defense against infection is peeing out the bacteria. And if you are not emptying your

40:52

bladder, well, basically there's like a little swamp in there where the bacteria are like swimming around having a field day and then manifesting with

40:58

infections. How would a woman um know that she has

41:04

the equivalent? Women will very rarely have these obstructive symptoms because they don't have the the hardware to to

41:10

cause the bladder to to malfunction. But the important lesson here is that, you know, the bladder causes this mischief.

41:17

It wants to squeeze all the time. And there are many lifestyle factors that lead to more bladder mischief and make

41:22

you have to pee more often and make you miserable. But and so sometimes men will come to urologist saying, "Doc, my prostate's horrible." Uh, and no, they

41:30

have the same thing that women have, this overactive bladder. urologist's job is to separate like what the problem is,

41:36

but for men that have struggling urinate, you have to rule out the pump problem because if you don't, you're

41:42

gonna have to get a catheter lifelong. And that's not what you want, believe me. In terms of, you know, what can we

41:48

do about the overactive bladder, this kind of irritative symptom type of thing, not pushing or straining, but having to go off and running to the

41:54

bathroom, having to get up in the middle of the night, like basically having accidents when you don't want to. These are bladder behaviors. So

42:00

not not prostate behaviors. That's that's we have to talk about this. We need to

42:06

to clarify this. You have also said which I thought was brilliant. How many times you pee in the

42:11

meta analysis uh I think from: 2015

42:19

best literature you combine it and you try to come up with conclusions. So this met analysis said that men who have nocuria

42:25

that's greater than two times at night. Uh they get up three times a year or more are 30% more likely to die of all

42:33

causes, heart attacks, these kind of things. Now does that mean that if you pee three times in the middle of night,

42:38

you're doomed? Of course not. This is not a causal relationship. It's a coral

42:43

relationship. Meaning the answer probably is that if you're getting up three times in the middle of the night to pee, you've got other stuff going on.

42:50

One, do you have sleep apnnea where you can't sleep soundly and that's making you pee more often? Two, do you have

42:55

edema in your legs because you have heart failure, you have to pee more often in the middle of the night. Three, do you have metabolic abnormalities? You

43:02

have diabetes which makes you pee more often. All these kind of potential risk factors will make you pee more. So, it's

43:08

the fact that you're peeing tells tells me you're unhealthy. If you again, if you mitigate that unhealthiness, if you

43:14

lose weight, you start to exercise, you reverse your diabetes, guess what? you won't pee as often. Right? So, it's all

43:21

a lot of these things are reversible in life with human body is amazing if we treat it right. Would is there a a normal amount of

43:29

times someone gets up? And again, I'm thinking about my dad, shout out to Nate in Ecuador, probably embarrassed. You

43:34

know, he often says, "Okay, well, I'm waking up in the middle of the night uh 2 3

43:41

again. You lost me at 3:00 to go to the bathroom." Yeah. Yeah. He is 74. Would that be prostate? Would

43:48

that be bladder? Would it be impossible to tell? Yeah. So, it's typically unusual to have

43:54

to get up in the middle of the night less than age 50. Right. Once fine, but

43:59

once you start getting it more and more often, we know as we get older, again, the bladder loses capacity. As we get

44:05

older, we tend to make less hormones that prevent us from peing in the middle of the night. Specifically, we make less ADH. If you have sleep apnnea, the the

44:13

body perceives this lack of breathing as high blood pressure to the chest and so

44:18

it sends out naturatic peptide which makes us spill salt into the urine which pulls fluid with it. So again, these

44:26

other medical coorbidities will make us have more nocturia. So, I'd say if you're getting up more than three times

44:32

at night, you first should look at lifestyle factors and then obviously look to um improve the other metabolic

44:39

components that we just discussed. But yeah, you're at risk for other things because that that's a warning sign that stuff's going on.

44:45

It's really interesting because just again as a practicing physician training in say family medicine and even

44:51

geriatrics would be here's some flowmax. I'll see you next time. It's a very dangerous approach. one,

44:58

you're making the assumption that it's the prostate. It could be bladder. It could be the fact that this person's drinking eight liters a day. And we can

45:05

talk about bladder irritants in a second. We are definitely talking about bladder irritants because you just killed half the list. I just

45:11

Yeah. The other thing though is that phmax is a drug that you know it's temps

45:16

and there's all these other drugs which will improve the strength of the stream but it doesn't protect the pump. So

45:22

actually the worst thing you can do for guys with obstructive symptoms is to give them flowax because then you won't

45:28

see them again for another 10 years but by the time they've come back now the bladder has had the damage that's

45:33

unreversible irreversible. So phmax is not a drug that will pro protect you long term. So if you have true prostate

45:40

enlargement, I'm an enthusiast for early intervention that is doing procedures

45:46

that will help you know take away some of the resistance in the prostate so men pee better and they protect their long-term bladder function. You can use

45:53

medications to have this effect as well. And these drugs are typically firs the ones that actually physically shrink the

45:59

size of the prostate. Kind of a chemical surgery if you will. These drugs will prevent the need to go to the emergency

46:05

room because you can't pee. The need for surgery in the future. But if you just give somebody flowmax and say, you know,

46:11

you know, see you see you when I see you, you're at high risk for having that person have long-term bladder damage. It's a really important message. I do

46:17

think that it is very common where people think it is. It's again, and part of that is media, which is also another

46:24

reason I'm so excited to have you on. I know that you speak all the time, but to have you on to podcast is huge. And

46:33

you're able to reach a lot of people just by having the conversation. I was very disappointed to see your lifestyle

46:40

changes for urinary frequency notes. Extremely disappointed. Yeah. I'm going to share this list.

46:46

Okay. I just want to let you know that you have ruined my Wednesday. Um not even going to be drinking any more

46:53

carbonation right down there. The seas of urinary

46:58

frequency consumption. Caffeine. Constipation. Cocktails. Coke. Zero. You

47:04

just hurt my heart. Citrus also hurt my heart. Carbonation, cigarettes, I don't

47:09

smoke. Couch potato, not doing that. Capsain, spicy foods, we are not friends

47:15

any longer. Talk to me about this. Yeah. So, if you're having urinary frequency, that's bothersome to you. Uh

47:21

the big three are how much you consume, right? The more all of it.

47:26

Yeah. The more you drink, the more you pee. This is just simple math, right?

47:32

Obviously, we need to drink a certain amount to be healthy. But you know, the person who said you need to drink eight glasses of water per

47:39

day may have been selling water, right? So everything is about risk balances. And if you are miserable because you're

47:45

peeing all the time, try to cut fluids to some degree and see if that helps. The second biggest thing we see is

47:50

caffeine. So caffeine uh acts as a diuretic and also makes us pee in small

47:55

amounts, so inefficiently. And the higher dose, the more it affects us. So if you're going frequently, if you have

48:01

several cups of coffee, you'll notice that the frequency always is around the time you drink coffee or caffeine.

48:09

Constipation is a huge one. So the bowel and the bladder share real estate. And

48:14

if you're really constipating, you struggle with that. Not only are there probably neural pathways or nerve

48:20

relations between the two organ systems, if the rectal vault is filled with gas

48:26

and stool, it's literally squishing the bladder. your bladder capacity is decreased and you have to go more often.

48:32

So, a lot of guys that struggle or guys and gals struggle with uh urine frequency, you get constipation under

48:37

control, they're better. Same with little kids, right? Little kids when they have accidents at school, uh when

48:43

they have when they have accidents in the middle of the night, it's almost always constipation. You fix that, that gets better. That's a great parenting tip. I didn't

48:50

know that. And so some some of the other ones um which you which you mentioned they can be more of a risk for some

48:57

individuals than others. Right. So humans are genetically variable for some for some people if they eat spicy foods

49:03

that's capsain and they'll have to pee every 15 minutes. Some people are are really sensitive to carbonation. You

49:09

know some people are more sensitive to artificial sweeteners like those in Coke Zero. So I uh have problems remembering

49:15

stuff. So, I basically try to put the letter C in front of everything uh to remember what things can trigger bladder

49:21

overactivity. Speaking of bladder, let's uh I suppose I should get this right. Uh move up. I

49:28

better get this right considering I'm married to a urology resident. Kidney stones.

49:33

Mhm. Who gets them and how frequent is it? Is

49:39

it men versus women? Is there predisposing factors?

49:44

Yeah. Let's talk about it. Kidney stones affect about 10% of all humans. Uh there's predominance in in

49:50

men over women. Slight predominance. The main risk factors forming stones is um

49:56

lack of fluid consumption. So this is the other end of the scale. We just talked about overconumption. Under consumption of fluids is the number one

50:03

risk factor for stones, right? And when you form stones like all the time in Texas because it's always hot here. So

50:09

when you're sweating and I almost burst into flames when my my plane landed here as I got off. Um yeah, very hot here and

50:18

humid. But basically uh if you're dehydrated chronically, you're at risk

50:24

for stones. The other things that are very important are salt consumption

50:29

uh and excessive u artificial sugars uh or true sugars. They tend to form more

50:34

stones. The bottom line is uh also there's a strong genetic predisposition. So, if you have somebody who you had a

50:40

dad or a brother with stones, you're more likely to get them. And they're they're very very common. If you drink more, you can prevent them. And if you

50:47

think about this, uh I tell my patients this analogy, like if you're constantly flooding the kidney with all this extra

50:54

fluid, there's no way a stone can start to form in the kidney and then eventually pass and cause shenanigans.

51:00

So if you're like if you're in a like in Minnesota we we like where it's never hot

51:06

where no it's it's really hot for like three months then it's really cold for another nine months. Uh sometimes people

51:13

will will go down a river in an inner tube and so I I I say it to patients like you're going down the river in the

51:19

inner tube. Imagine you're a small particle at the bottom of that lazy river and how as every second goes by

51:26

calcium or different minerals start to add to the size of the stone. But now if you switch to a white water rafting part

51:33

which we don't have in Minnesota by the way but we you don't no it's not not that exciting in terms of uh a state for

51:40

that kind of activity. Uh there's no way of a stone can form. So the inside of the kidney is like that lazy river if

51:46

you don't drink enough, but if you consume enough fluid, you're very unlikely to form stones. As simple as that.

51:52

Mhm. Would there be certain things that could predispose people to stones? For

51:58

example, I've heard very high dose vitamin C. Mhm. Does it seem to be different for every

52:04

person? Again, because you had said some people um artificial sweeteners might be an irritant to one person versus

52:10

somebody else. Yep. Biologic variability applies to everyone, but highdose vitamin C can be

52:16

a risk factor. Excess calcium, so both too much calcium and too little calcium, dietary calcium or

52:23

dietary calcium. Yep. Okay. Uh you know, your gut has to reabsorb calcium and if there's too much in the

52:29

gut, it spills over into the blood. So actually the recommended daily amount allowance of calcium is probably the

52:35

right amount. The extremes of either end are stone promoting. But again, the number one way to prevent stones is to

52:42

drink more fluid. Real uh lemon juice added to fluids can also actually prevent stones through some citrate

52:49

metabolism. Some some ways that we get away. Guys and gals who form recurrent stones will often be put on potassium

52:55

citrate, a pill that alkalinizes the urine and thus prevents stones. Um the

53:01

bottom line is if you form a kidney stone, you got to figure out why. If you form a second kidney stone, you need extensive testing and figure out what

53:07

medication you should get to prevent them. From what I hear, they're very painful.

53:12

Yep. Yep. I've seen many tough individuals uh be not so tough because of the pain from kidney stones.

53:18

I don't wish that on anybody. There is something I do wish on people and that is uh muscle mass. Wait uh

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amazing and it will not break the bank. You gave an amazing presentation at the

54:43

Androgen Society and just recently at Baylor because I heard from the residents. There is a connection between muscle

54:52

mass, psychopenia, and sexual function. Absolutely. Muscle mass is imperative for longevity.

54:59

If you want to live a long time, you have to move iron. You got to be strong. You got to keep it that way. We have

55:04

this age- related sarcopenia where you will lose muscle as you get older related to hormone production. But if

55:10

you fight to be elite in our age now, I'm going to put us as young. Uh we'll

55:15

be fine when we're 90. So that's my paradigm like we're right now we're in we're in preparation for a geriatric dathlon. This is Peter's concept. It's

55:22

amazing. So you got to be really healthy now. So muscles does so many things and your book Forever Strong talks about the

55:30

metabolic capacity as like one of the biggest organs humans have to control

55:36

insulin sensitivity to control inflammation. And that's not surprising at all that when you look at well done

55:42

studies, men with more muscle mass, have better erections, men with less muscle mass have horrible erections, have low

55:48

libido, have lower testosterone. Uh it's all about overall health. Again, think to the paradigm about how the body is

55:54

willing to give away its erectile function if it has to sacrifice something, but it's going to keep brain

56:00

function. And as we get sicker and unwell, the penis is the first to go. So

56:06

don't get unwell, stay strong. So when men train, when men lose weight, when

56:12

men gain muscle, erections get better. Aerobic activity is as powerful as P5

56:18

inhibitors, the drugs like Seialis U that we talked about earlier in helping with erections. A modest 10% decrease in

56:26

body weight is as powerful as pills in helping with erections. Not only all the

56:31

other benefits of keeping on the right side of the grass. So again, if you take good care of your body, your body will

56:36

take good care of you. Anything you do for penis health is good for cardiac health. So, it is not surprising at all

56:42

that there's a direct correlation between muscle mass, strength, grip

56:47

strength, and erectile quality. You just got the attention of every male listener

56:52

y on the planet. Yeah. Well, good. Or at least um good because listening to this show

56:58

because who doesn't want better erectile function and better penis health?

57:03

And and you know, just to jump in, we use the penis as a falcrum for behavior change. It is very difficult for the

57:11

average man to change your behavior if you tell them listen your blood pressure is eight points too high. But if you

57:17

tell them listen, if you lose a little bit of weight, if you start exercising, just minimal gains, 150 minutes a week

57:24

of exercise, 30 minutes five times a day, you'll see tremendous improvement. And so we can use this as a fulcrum to

57:30

get guys to be healthier. In Canada, the cigarette packages have like this flaccid cigarette on the side and it

57:37

basically says smoking is bad for erections. So, we should lean into this fact and get people to be healthier

57:43

because yes, sexual function is very sensitive to overall health and we should use it as a way to get people to

57:48

be healthier. Is there a dose, you said 150 minutes of moderate to vigorous activity? Is there a known specific dose that is good for

57:57

penis health or vascular health primarily? I mean, I know that we're talking about vascular health in

58:03

general, but again, as a urologist, I thought that we would focus on your organ of longevity, the urologist organ

58:10

of longevity, uh, versus Yeah. my definition, right? Right. Do we know is there a dose

58:15

at all I think from last year: 2024

58:20

database from like the early: 2000

58:25

basically it found that 150 minutes of exercise per week decreased the rate of erectile dysfunction by 20%. 300 minutes

58:33

by essentially 40%. Something very close to that. So you know intensity and

58:38

duration as it gets higher you get improvements. There is a eventually you plateau. It's like if you do a thousand

58:45

minutes, you're not going to get perfect erections. But even a modest amount of exercise really moves the needle. And

58:50

then if you really are exercising 300 minutes a week, that's an hour 5 days a week, which is a great goal, you'll see

58:56

a 40% improvement in erections. I'm going to just lay out a handful of other statistics and numbers because I

59:02

think they're so powerful. studies showing men who maintain muscle mass strength are 66% less likely to report

59:09

multiple sexual issues. Older men, this was fascinating but not

59:14

surprising. Paropenia was linked to 2.7 times greater risk of moderate to severe

59:20

ED. Both those studies are um you know excellent in that you know a lot of them they're self-reported studies and where

59:26

the people are quantifying their own strength. the the one study about the uh muscle mass that's from like a bunch of

59:32

Scandinavian patients and the people who reported that they still were strong had awesome erections the people who said

59:39

yeah I feel a little bit weaker than when I was 10 years ago they had lousy erections and lousy libido too what is the role of testosterone and

59:46

erectile function and testosterone is essential uh to a certain point right so if you have

59:52

normal testosterone and you give more testosterones uh testosterone there typically isn't uh of added benefit,

59:59

right? So a mistake you'll make is like assuming if somebody comes in with a normal, you check their tea, it's normal, but they have problems with

:: 00:05

erections by giving the testosterone that typically doesn't fix the problem. Remember the main ideology of erectile

:: 00:10

dysfunction is probably a vascular blood flow problem. So you got to fix the blood flow. If testosterone is very low

:: 00:16

though, um then penis ain't going to work. How would you define very low? Well, you know, if you want to use the the

:: 00:22

scientific definition, a repeated measurement of testosterone less than 300 or free testosterone less than five.

:: 00:29

Uh, so if it's low, if you give testosterone back to those men, they typically will see a better better

:: 00:35

erections, especially when they're trying to use pills. Seialis, Viagra, they rely on testosterone for nitric

:: 00:40

oxide synthetase or the chemicals that are required for erections. If your tea is low and you give tea back, the pills

:: 00:48

will work better. Again, I just can't stress enough though, if you take good care of yourself, your tea will stay

:: 00:54

normal. There's data where, you know, people who are look healthy in their 70s

:: 00:59

and 80s, their testosterone is way higher than people who look unwell and is really low. Yeah.

:: 01:05

My let's just uh throw Nate Dog under the bus again. We ran his labs and I'm

:: 01:10

looking at this testosterone of over 700. No, that's amazing. And I I would argue that the best single blood test for

:: 01:17

overall health in men is testosterone. Uh in women maybe, but maybe there's a ratio we need to look at. And then along

:: 01:24

those same same lines, the best overall marker for overall health in men is erectile function. Why? Because you have

:: 01:31

to have excellent vascular integrity, excellent overall health, and the penis requires normal mental health. If you're

:: 01:37

anxious, if you're depressed, the penis ain't going to work. So you can be in great physical shape, but if you're

:: 01:43

unwell from a psychiatric uh perspective, whether it's depression or

:: 01:49

whatever it is, anxiety, because you're having stress at work, again, the penis ain't going to function well. So all

:: 01:55

systems have to be on full go for the erections to be awesome. So that's a really reassuring thing. If you're a

:: 02:00

70-year-old and you're getting great erections, you're probably pretty healthy. Is there a point of no return? For

:: 02:07

example, when we image the brain and we see microvascular disease of the brain, the brain is arguably a large very

:: 02:14

active organ. There is a lot of it. The brain can make up for itself, meaning

:: 02:20

uh it's not just a pendant typically in this one area, but the penis is smaller. If there is vascular damage to the

:: 02:28

penis, is there an ability to recover to a limited extent? Uh like many other

:: 02:34

things. Um but sometimes you get age related um you know vascular disease

:: 02:40

maybe it's untreated hypertension for a long time or you have significant athoscerotic narrowing or plaque or

:: 02:47

maybe smoke for a long time. Sometimes the damage is so extensive that no matter how much you exercise no matter

:: 02:53

how many pills you take it ain't going to work right. Yes, there is a point of no return. Very avoidable if you never

:: 02:58

get there in the first place, but that's where surgery comes in. For men who may

:: 03:04

have had a reason that their penis has failed them or maybe had a period in their life where they're very unhealthy,

:: 03:09

you know, we can restore normal sexual function with surgery. Often times we can restore it with lifestyle change,

:: 03:16

but not always. And so, you know, take good care of yourself and but then even if it fails, there's no reason to give up hope. We can fix it. I have a

:: 03:23

question that I um I don't know if you've ever seen and I don't even know if it's a thing. Is there ever something

:: 03:29

where a penis cannot get an erection? Maybe it's a genetic defect of vasculature

:: 03:34

all the time. Really? Oh, yeah. All the time. So, when I look at the the age range of patients that

:: 03:40

have put a peel implant in, it's 18 to 98. Wow. Okay. So that's, you know, I'm, if

:: 03:46

anybody out there is 100 years old, please come see me because I want to say I put an implant in 100-year-old. So

:: 03:52

that 90year-old did great, by the way. But some people are born with this congenital venus leak where the Venus

:: 03:59

trapping just doesn't work or some men are born with uh, you know, some kind of

:: 04:04

a genetic defect or whatever it is where they've never had a good erection their entire life. So, I've had patients come

:: 04:10

to me where like they're actually having pain with their erections because they've never stretched the penis before.

:: 04:15

Wow. Uh, so, but you know, the surgery can fix it. Uh, and there are many men who

:: 04:22

have never had a normal erection their entire life, like age 16, 17, 18, we see them for the first time, it's like never

:: 04:28

never had a good one. So, that's fixable. That's treatable. You know, I'm I'm really grateful that that that

:: 04:34

surgery is available and can be done and can be done well. Seeing you in San Francisco, you gave a great lecture and

:: 04:40

I have never seen a doctor, an MD talk about

:: 04:46

moving iron, eating protein, and building muscle

:: 04:51

all in the same sentence with testosterone replacement therapy.

:: 04:57

Please tell me what some of your thoughts are regarding what people are

:: 05:02

actually after. I when I was in Springfield, Illinois at the beginning part of my career, I uh was lucky enough

:: 05:09

to meet uh a guy named Chad and we've actually published uh some work together

:: 05:14

on anabolic steroids. we've given some talks together and so you know I uh I

:: 05:21

consider myself a curious guy and when he came to me for help I learned a lot

:: 05:26

more from him than I could help him and then I really kind of dove into the literature when I asked Chad hey you

:: 05:33

know tell me about um super physiologic tea levels like what dose are you using

:: 05:39

and when I'm talking about super physiologic T levels I'm referring to consistent testosterone levels greater

:: 05:45

than a thousand So bodybuilders, you know, they'll go for tea levels of 3 4,000 or they won't

:: 05:50

even check. They'll just they'll just go super high and just give take more if it ain't working. And I wanted to know what

:: 05:56

the motivations were uh as to why people would start. I had some intuitive thoughts, but I wanted to ask somebody

:: 06:02

who was an expert. And then uh I'm a huge fan of yours. I'm also a huge fan of Mike is Retell as well. and the way

:: 06:10

um he communicates testosterone use and working out and getting fit. I mean, I'm

:: 06:16

a huge consumer, right? Like I've changed how I worked out because I'm now 50 because I don't want to injure

:: 06:22

myself, right? So, I've taken a lot of advice to heart. And so, I wanted to

:: 06:27

know, okay, what is the main motivation for a lot of people to to start, you

:: 06:32

know, super physiologic tea? And the two main ones, there are many, but the two main ones are athletic performance and

:: 06:40

essentially looking good or vanity. I'm going to say now athletic performance,

:: 06:46

uh, I think Chad summed up pretty well is that if you need help from

:: 06:53

testosterone to perform well in high school, to be elite in high school, you're not good enough. if you need help

:: 06:59

in college to perform an elite level uh with because of um steroids, you're

:: 07:05

simply not good enough because by the time you ascend to the pros, like you will likely get caught, you won't be

:: 07:11

able to use it and you won't be good enough. So, you have to have this natural ability to become a professional

:: 07:17

athlete. And you also have to probably be testosterone sensitive. You have to be sensitive to a lot of the agents that

:: 07:23

uh people use to have the outcomes that you desire. But if you're using these these drugs to be good at sports, you're

:: 07:31

never going to be a pro. That's that's the unfortunate reality. Not to mention the fact that you have to somehow

:: 07:36

navigate and not get injured along the way, which again, a lot of people are amazing, but then they blow out their

:: 07:42

knee or whatever and then their career is done. The more interesting one interesting one and the one that I think

:: 07:48

needs more attention is the to use these drugs for aesthetics. And I get the

:: 07:54

appeal because, you know, when you work out naturally, uh, and you do great, you

:: 08:00

probably gain about 10 pounds of muscle in a year if you're doing everything perfectly. You know better than I do.

:: 08:06

Your book goes over this beautifully. But if you add high doses of steroids to it, and this and there's a lot of

:: 08:11

science behind this, and there's a lot of data, you know, you can gain that 10 pounds of muscle in about a month. So,

:: 08:17

it's just so much more efficient. And, you know, there's a huge appeal there. And I'm not here to tell people

:: 08:24

don't do this or do this, but I want people to know the true risks and benefits. The thing is, if you're

:: 08:30

chasing an aesthetic with these type of drugs, you're much more likely to look

:: 08:36

worse than better. And why do I say that? Well, because just because you take highdose testosterone and cipionate

:: 08:44

along with many other drugs doesn't mean you're going to be, you know, shredded. It doesn't mean you're going to have 8%

:: 08:49

body fat and look amazing with your shirt off. Most people, first of all, you have to be sensitive to the drugs

:: 08:55

and you have to have perfect training and perfect nutrition, which is really difficult for everybody to do. There's books about it. Um, you know, it can be

:: 09:02

done, but it takes discipline. And so, that's a baseline requirement. And then you take these drugs and then there's

:: 09:07

the potential negatives consequences like 50% of people get significant acne. So, you're never going to want to take

:: 09:12

your shirt off if you've got horrible acne everywhere or if you're growing hair in places you don't want and you're

:: 09:18

balding. And uh so the vast majority of people who take these like appearance

:: 09:25

enhancing drugs, they'll actually look worse, not better. Not to mention that a lot of uh humans have this fantasy that

:: 09:33

if they look a certain way, they're going to be more attractive. But when you ask people what they find

:: 09:38

attractive, being hyper muscular or being superjed is not at the top of the list for many individuals. So if you're

:: 09:45

leaning in to use these type of agents to look better, number one, it may not

:: 09:51

work unless you have perfect training otherwise. And number two, there's a lot of downsides and risk. We didn't even go

:: 09:56

into the kind of negative things like sudden death or you know heart problems these depression suicidality but to use

:: 10:04

that as a lever to get to a certain look I think is a mistake um based on my read

:: 10:10

of the literature. Well I'm looking forward to having you back on the show Dr. Tobias Kohler. It

:: 10:16

has been an absolute pleasure. You are a gift to the world of urology and just an

:: 10:22

amazing and really fun human. Thank you so much for coming on. Thank you so much for having you. It's a

:: 10:28

huge honor. Uh what you do here is so important. Um we did a recent trial or

:: 10:34

study where we looked at um health media consumption and like 93% of all kind of

:: 10:41

internet material related to fitness health is was rated low quality using

:: 10:48

these uh methods, discern method that we used in this paper. I'm proud to say that you're you're one of the great

:: 10:53

ones. you're getting the right information out there and letting the public decide what's best for them and

:: 10:59

you know promoting positive healthy lifestyle that ultimately is the most important lever we have to be happy and

:: 11:04

live a long time. I really appreciate that and the reason that we are great is because we have

:: 11:10

great worldclass guests. So, thank you so much for coming on. Appreciate it.