← The Dr. Gabrielle Lyon Show
The Dr. Gabrielle Lyon Show
Erections & Testosterone - Shocking Link to Muscle Mass & Men's Health | Dr Tobias S Kohler
01:11:23
Loading summary
Transcript162 lines
- [00:00]
A
Men with more muscle mass have better erections. Men with less muscle mass have horrible erections, have low libido, have lower testosterone.
- [00:07]
B
You just got the attention of every male listener on the planet.
- [00:11]
A
150 minutes of exercise per week decreased the rate of erectile dysfunction by 20%, 300 minutes by essentially 40%.
- [00:20]
B
Erectile dysfunction is one of the earliest signs of heart disease. What do you mean by that?
- [00:25]
A
If the penis is failing, you should assume you're going to have problems with your heart soon. Until proven otherwise, anything that is good for the ticker, the heart is good for the penis and vice versa. We know that men who don't get erections commonly get penile shortening. So you lose length the penis, how.
- [00:41]
B
Rapid and how much?
- [00:42]
A
If you've got a consistent lack of erections for three months, you lose centimeters of length.
- [00:48]
B
That's a lot.
- [00:49]
A
Significant. The best overall marker for overall health in men is erectile function. Why? Because you have to have excellent vascular integrity, excellent overall health, and the penis requires normal mental health. There are many men who have never had a normal erection their entire life.
- [01:13]
B
Dr. Tobias Kohler, welcome to the show.
- [01:16]
A
It's a real honor to be here.
- [01:18]
B
You are a professor of urology at the Mayo Clinic in Rochester. You have treated patients with urological problems for over 20 years. A woman 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 a man go to a urologist and say, I would like this penis size?
- [01:42]
A
Well, no, unfortunately. If we could change penis size, I think it'd be busy operating currently. But what we can do with penile implants is guarantee an erection every time with no worries, no anxiety, no pill shots or anything. It's a great surgical solution to a problem that's been around for a really long time.
- [02:02]
B
How long have penile implants been on the table for people?
- [02:07]
A
Yeah, most people are really surprised to know that's 50 years. 5. 0. We just had our 50th year anniversary last year. This treatment for erectile dysfunction actually preceded pills, shots, vacuum devices, pretty much anything else. And that's one of the reasons actually why it's covered by insurance, because it's the oldest treatment.
- [02:26]
B
Wow. I'm fascinated. You have to break this down. Erectile dysfunction is a huge problem.
- [02:33]
A
Yes.
- [02:34]
B
Dr. Mo Cara, our very good friend, says 40% of men at the age or over the age of 40 have it. 50% of men have it at 50 and so on. So erectile dysfunction is a major problem.
- [02:47]
A
Absolutely.
- [02:48]
B
Probably the first line solution isn't surgical.
- [02:51]
A
Is that of course, the first line solution is to prevent it from happening in the first place. And that of course, is based on foundational pillars of health. Diet, exercise, sleep, stress, mitigation. Those are the core tenets that are going to keep your penis healthy for a long time. But sometimes in life we get, I don't know, prostate cancer or whatever, we need a surgery and you get collateral damage. And so it's from that collateral damage that often men will develop problems with erections that no longer are responsive to pills. And once that happens, you can make the decision to fix it definitively with a surgery.
- [03:29]
B
Can you walk me through just on a very high level, how, how does that work? How is that surgical procedure implemented?
- [03:36]
A
Well, I guess the first thing to understand is that in order to get a good erection, you have to have blood flowing into the penis and that blood has to be trapped there, right? So when you look at why rectums stop working, 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 often mitigated, are addressed with pills or shots or even exercise, right? So if you exercise, you get better blood flow to the area, you can fix these problems. That's one set of reasons why the penis fails. The other one is the blood isn't trapped there appropriately. So you have to develop. What these surgeries try to do is mimic mother nature. And instead of blood flowing into the penis, we put a kind of lining inside the penis, a prosthesis where men will pump normal saline or salt water into the device. And when they pump the device, the fluid is transferred from a holding tank or reservoir, which is typically hidden next to the bladder or somewhere in the abdomen. And so they'll pump the fluid into the penis and they'll keep the erection for as long as they leave the fluid in there. Right? So you know, you can have an erection for four hours, for 15 minutes, it doesn't make a difference. And then when you're done, you hit it to flight button. And then normal saline goes back to the holding tank. So as a surgeon, when I do an implant, I put in 3, 4 ounces of fluid, 100 milliliters or so of saline, and that same saline powers the device for the next many, many years.
- [04:59]
B
The average device wait the same saline, it's recycled.
- [05:03]
A
Exactly. So it's essentially when the fluid's in the reservoir and not in the penis, the penis looks normal, flaccid. Nobody can tell you how?
- [05:10]
B
No one can tell. What about the pump?
- [05:12]
A
It's like a third testicle, but hidden.
- [05:15]
B
Wow.
- [05:16]
A
So most men who are single who have an implant, their partner has no idea.
- [05:21]
B
Holy cow.
- [05:22]
A
Yep, yep. So it's completely hidden. It's completely locke improve. The joke is, of course, if you leave it inflated all the time.
- [05:27]
B
I just got that.
- [05:30]
A
Not so hidden. But you can decide when and where it's going to happen. And so it takes away all the anxiety and problems that people have when they're thinking about having problems with sex. And on average, these devices last. Half of them last 20 years. Right. So they tend to outlive most other prosthetics. They outlive breast implants, pacemakers, hip implants, these kind of things. It's amazing because they have functional parts, but at 5 years, 5% break. At 10 years, about 10 to 15% will have broken. 15 years, 30% break. So they have a really long longevity. And most guys who get an implant will die with it working. The average age of implantation is around 70 years of age or so.
- [06:12]
B
But wait, what's the average year? The average age of implantation?
- [06:16]
A
Average age of implantation is about 68. Around 70.
- [06:19]
B
But if someone came in who was younger, would there be any issue of, let's say someone has major performance anxiety and they're 50?
- [06:30]
A
Yeah. The strength of the implant is that it works really well every time. One of the weaknesses is that if other stuff still works, then you know, you don't want to do an implant because that other stuff won't work anymore.
- [06:42]
B
I see.
- [06:43]
A
So it's a surgical decision. And once pills fail, that's the decision point. Do 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 insurance. Completely invisible. Very spontaneous. And the other thing which people always ask me is like, well, does it feel the same?
- [07:02]
B
The answer is yes for both parties.
- [07:04]
A
Yes. Yes. Again, the partner doesn't know you have a prosthesis unless they're, like, in the medical profession or very, very observant. For the man who gets the implant, a sensation is essentially unchanged.
- [07:17]
B
Does it change the size of the penis?
- [07:20]
A
Great question. Like everybody always asks, you know, can you add an intro to doc? Right. And again, like, the answer is no. Essentially, mother nature gives you certain length, and then you're kind of stuck with that. Now there is debate as to whether or not when you get the implant, whether or not you lose a little bit of length. When we actually do good studies, the answer is no. But patients do have this perception because they tend to remember the majesty of their erection when they were 18 compared to now, when they haven't had sex for 10 years. Some men have, you know, this perception that the means is somewhat shorter. So you really have to counsel about that. Right. So as a surgeon, it's all about risk, benefits, ratios. And if a patient comes to me and says, doc, I want to have a consistent erection without having to use pills or shots, without fear of it not working, they're going to be happy, right? If they just want to have penetrative intercourse with their partner, if they come to the expectation that they're going to be enhanced somehow in terms of lengthwise, 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, 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 happy.
- [08:33]
B
I love it when people are happy. Both parties. Mental health and erections definitely seem to be tied. You say, and you've said this before, that erectile dysfunction is one of the earliest signs of heart disease. What do you mean by that?
- [08:48]
A
Problems with erections is like the check engine light sign going off, where if the penis is failing, you 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 flow into the penis is essential to get a good erection. The blood vessels going to the penis are 1 to 2 millimeters, the main ones, and the blood vessels in the heart are 3 to 4 millimeters, the blood vessels in the carotids, 7 to 8 millimeters. So as atherosclerosis happens, this kind of endothelial plaque, the crud that grows inside the vessels as we age and if we don't take care of ourselves especially, you get narrowing of those vessels. And as those vessels narrow, the smaller vessels will have danger signs first, right? So if you have asclerotic disease, according to many, many studies that have been repeated several times, first problems, the erections happen. And then if you don't do anything and the disease progresses, the first heart attack typically occurs three to five years later, and then the first stroke a couple years after that. And then finally, people have pain with walking or something called claudication, because you start to get narrowing of the femoral vessels, which are gigantic. But even those can manifest with pain and problems with blood flow as they narrow down. So because this narrowing typically follows this pathway, it, if you have problems with erections, it can predict heart attacks very reliably. And so the number one kind of risk factor in young men and even older men to predict heart disease that doesn't have any other warning signs is the penis. And the beauty of this is that anything that is good for the ticker, the heart is good for the penis and vice versa. Right? So if you want to have better erections, exercise, lose weight, eat right, get good sleep, mitigate stress, that will have positive effects on the erections as powerfully as many pills do, if not better. And at the same time, you're going to be on the right side of the grass longer because you're much less likely to have a heart attack.
- [10:47]
B
It makes me think as physicians screening early detection screening, I wanted to take a moment to let you know about something new we've created. It's called Forever Strong Insider and it's the premium subscription to the Dr. Gabrielle Lyon Show. As a Forever Strong insider, every week you'll get ad free episodes, written summaries with key takeaways to help you retain the most important insights from the show. A community Q and a segment where you can submit your own questions for upcoming guests. We're going to call this the Strong Seed. And behind the scenes content, A closer look at how I prepare, train, travel and navigate daily life. Go to foreverstrong supercast.com let's keep getting stronger together. How would someone know that they qualify for having erectile dysfunction?
- [11:39]
A
Yeah, so the definition is a persistent problem with getting and maintaining erections adequate for intercourse for greater than three months. So let me be clear. Many young men will have a bad night, okay, Maybe there's some, some alcohol involved or some other chemicals. Maybe you're nervous because you're with a new partner for the first time. Most men in their lifetime will have a couple episodes of performance anxiety. And so if it goes back to normal after you kind of get your confidence back, and often we have to give pills to make that happen to get confidence back, then it's not a true warning sign for cardiac disease. But if it's a persistent problem, then indeed you should be at least screened for cardiac disease. And so recently there was a panel that I was involved with called the P4 Consensus Panel. And we basically wrote in this document that if men have problems with erections, you do an assessment of cardiac risk. And if they qualify, which is most men, you should get a coronary calcium score. It's a CT scan of the heart which looks for calcifications, and that's a really good also predictor of future heart events. In this recent guideline, we know the evidence is so strong that the penis is predictive of cardiac problems that we've also instituted this additional testing based on the diagnosis.
- [12:58]
B
It makes me also think about when you go to your physician for a regular annual physical, they might do an ekg, obviously, blood pressure, you know, in office glucose, stick, maybe a handful of things. Listen to your heart, listen to your lungs. Do you think that if blood flow to the penis is an indicator of health, would it make sense that we do a normal Doppler screening just like someone does? I don't know, an echocardiogram.
- [13:31]
A
Getting a penile Doppler is a very smart thing to do if you're worried. But frankly, the easiest thing to do for the physician is to ask, do you have problems with sex? That's the screen. And if the answer is yes, then that leads to more questions. And then let's turn around from a patient perspective. As a patient, you have to take responsibility for your own health. If you go to the doctor without a plan, a lot of things that you want to get addressed won't get addressed. If you have problems with sexual function as a man or woman, there are many, many good treatments available. But you have to ask, right? You have to be bold, you 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 benefits that will, will come from that question. And as physicians, we need to do a much better job of asking routinely about this. The first time I ask a patient, they may be embarrassed, they may be shy. But then the second time that I 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. The other thing that often happens in modern day medicine is patients will come and they won't ask the question until the last 30 seconds. The hand, proverbial hand on the doorknob question, right? So you have a set amount of time with your physician in modern day medicine, and as the doctor's leaving, they say, oh, by the way, there's this as well. Don't do that. Because you shortchange the ability to ask further questions to get good treatment. Ask the important stuff first.
- [14:51]
B
That makes a ton of sense. And people come to you as a urologist at Mayo Clinic, who is an expert in sexual 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 motivated. Are you seeing erectile dysfunction increase in.
- [15:12]
A
Our youth in general, as our society gets less healthy, clearly erectile dysfunction rates will go up again. If you look at metabolic disease disorders, diabetes, obesity, cardiac disease, these are all increasing with our society. And as these go up, problems with erections will occur as well. I mean, if you think about it, the body has a primary job of protecting the brain and everything that supports the brain function. And as we become unhealthy, it makes intuitive sense that the body is willing to sacrifice a few of the organ systems here or there, whether it's fertility or erections, which aren't essential to keep you alive in that moment. Right. And so as an example, if a patient has cancer, they'll often. They'll have a low sperm count, right? Because the body is diverting resources to take care of the primary problems. It doesn't have time to nurture the penis and keep that part healthy. So it makes intuitive sense that as we become a healthier, problems with erections also occur. The other thing is, you know, psychogenic, ed. So psychogenic means like performance anxiety. Now, 50 years ago, when Masters and Johnson started doing groundbreaking research on sex, they said 90% of problems with erections is in the man's head, okay? And 10% is organic. We know that to be completely opposite. Wrong. So 90% of erections are vascular or of true organic origin. Only 10% are purely psychogenic or from anxiety or depression. And so what does that mean? That means that we need to screen for it. And if it is truly psychogenic, often we can support patients by increasing confidence. But again, as we get unhealthier, problems with erections will get higher and higher.
- [17:01]
B
What role does alcohol and or cannabis use play in erectile dysfunction at while.
- [17:08]
A
Trying to have sex? Alcohol and cannabis can have this kind of strange role. Sometimes it can make erections more difficult to achieve because, again, your body's busy metabolizing alcohol. Erectile performance is often impaired. That is the most common scenario where somebody drinks too much and then tries to have 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 thought going through your head, it's not gonna work. It's not gonna work, it's not gonna work. So the you Know, it's very interesting why that makes the penis fail. So if you're running from a bear as a man, Right. It clearly does not make sense to have a strong erection. Right. You want to divest resources away from the penis. 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 run. You want to shunt blood towards the muscles so you can escape and run faster. But obviously the penis is not a good thing to put energy into at that time. And so that's why when you're worried about erection, when you're trying to have sex, it never works because your adrenal glands kick in, you make a little adrenaline. Adrenaline is the most powerful anti erectile chemical that we have.
- [18:16]
B
Say that again.
- [18:17]
A
Yeah. So adrenaline, the most powerful anti erectile chemical we have. If somebody has priapism. What's priapism? When you have an unwanted erection 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. You know, we inject adrenaline directly into the penis and the erection goes away within seconds. The joke is you show the patient the needle and you use a giant needle, just like, I'm going to stick this in there. And then all of a sudden, erection goes away, trigger this natural adrenaline rush, which, you know, is what we use to make it go away.
- [18:51]
B
I did not know that. To be fair, I've never had to treat priapism. Is that common?
- [18:58]
A
Priapism is most commonly occurs after men get a prescription for penile injections, a medicine that we give to create erections. And then occasionally we'll have patients that don't need these type of drugs use them because they think it's gonna be awesome.
- [19:15]
B
Okay, what kind of medications are we talking? Yeah, so these are every Matt over there. My producer wants to take notes.
- [19:21]
A
Yeah. So penile injections are various chemicals which essentially their main job is to vasodilate the blood vessels in the penis so that blood flows in. Right. And so they go under the branded drugs like Edex. But most men will use compounded agents, something called Trimix, where it has a series of different chemicals all playing different roles to help improve blood flow. But it's safe in men who have problems with erections. But it can be a little sketchy if you don't have problems.
- [19:51]
B
So don't go for a good time. Yeah, it's not gonna.
- [19:57]
A
Not a good idea. And I guess the public service announcement 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 have to ask me if you think you have prabhupism, you don't have prabism. It's like literally getting a lightning bolt to the penis. The penis is becoming ischemic. There's no blood flow because essentially blood flows in but can't flow out. So then you have oxygen 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 happens, if you go to the emergency room and we take care of it right away, no problem, then you learn your lesson. Never do that thing again that you just did. However, if you wait because you're embarrassed after 24, after 36 hours of privacy, oh, gosh, it's broken forever. And actually, what happens if, well, you get ischemic. So all the 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 penile implants. Because once you have this devastating loss of penile function, nothing except surgery would potentially fix it.
- [20:56]
B
Don't wait, don't delay care how big of an impact. You know, from a family practice or geriatric perspective. We use trazodone for sleep at times, not at high doses. There is a little black box warning that says this could cause prabism. I've never seen it. I don't know any physician that has seen it or any of the physicians in our practice. Is that something common or is that just another black box warning that just has not died yet?
- [21:26]
A
Well, I think you're going to do great on the test because they always ask that question. But, no, I have seen it before. And so a lot of the psychotropic medications that can be used that have central effects actually can cause pribism. There's a really long drug list. Cannabis is another really big one that's priapistic, meaning it can cause priapism. So we're seeing increasing rates of priapism in our emergency rooms now because of the legalization and social acceptance of cannabis. So just another public service announcement.
- [21:54]
B
I think it's a great public service announcement because people believe, many people believe that these drugs are benign, including cannabis. I personally don't think so. I think that the data would also suggest otherwise in various domains of health and wellness.
- [22:11]
A
Yeah, I think both alcohol and cannabis really disturb REM sleep. REM sleep is critical for kind of the brain's self healing for psychiatric wellness 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 you'll do a good job and you'll feel lousy as well.
- [22:31]
B
I'd like to acknowledge one of the sponsors of the show and that is priori. This podcast has allowed me to speak to extraordinary experts and they have one unifying message passage. There are only a few core compounds that we need in the diet and one of those is omega 3 fatty acids purees O3 ultra pure fish oil, which is third party tested and certified by both the Clean label project and IFOs. So you know what you're putting in your body. It is safe, pure, effective. It is tested for 200 contaminants and Peoria publishes all all their results online. I've teamed up with Puri to get you an amazing offer. 20% off site wide, even on already discounted subscriptions, which means you can save nearly a third off. All you have to do is go to peori p u o r I.com DrLion and use the code DrLion at checkout. You mentioned exercise. Penile vascular health. This is the first time I have probably ever said those words together. I'll just say them again. Penile vascular health. Exercise increases blood flow.
- [23:43]
A
Absolutely.
- [23:44]
B
Are there things like I saw Austin Powers and he has the penis pump. It would also make sense if we exercise or muscle that perhaps something like that would also work.
- [23:59]
A
You know, the guys may take advantage of this statement, but the penis is a lose it or use it or lose it organ. Okay. So when the penis goes in the garage for an extended amount of time, meaning no erections like no sex, no physiologic erections that normally occur in the middle of night. Now why would that happen? You just had a prostate surgery and you had to stun the nerves. You have significant diabetes. You've basically just gotten to the point where the erections aren't happening very often. We know that men who don't get erections commonly get penile shortening. Right. So you lose length of the penis.
- [24:30]
B
Everybody wants to know how rapid and how much.
- [24:33]
A
Yeah. So on average, if you've got a consistent lack of erections for three months, you lose 1-2 cm of length, which is a half inch to an inch in length. And every millimeter guys fight for. Right.
- [24:46]
B
That's a lot significant.
- [24:48]
A
Yeah. It's actually early in my career as, as I was urologist at the VA and We were doing prostatectomy. Surgeons, the patients would say after the prostate surgery, say, doc, I think my penis is shorter. 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 studies I ever did. And we actually measured. And it's true. Guys lost peanut length. The good news is, is that if you exercise the penis with a vacuum erection device, you can regain that length back. So it's not about like physically shortening the penis, it's about having scar tissue in the penis. And if you have a uniform scar with erection, the penis looks shorter. If you have a non uniform scar, you get this curvature, right? And that's disease. Peyronie's disease is loss of elasticity on one side or one part of the penis. And like a balloon, if you put a piece of tape on a balloon, you inflate it, the balloon's gonna curve where that piece of tape is. That's what Peyronie's disease is. And again, that's something that's very common in men. About 10% of men above age 50.
- [25:48]
B
10% of men above age 50. You do support the use of, what do you call it, a penile enhancement device. What are they?
- [25:56]
A
Yes, a vacuum erection device.
- [25:57]
B
A vacuum erection device, an adjunctive tool.
- [26:00]
A
To help men kind of rehab the penis. We often have men use it prior to surgery to optimize length to facilitate an easier surgery. There's data to support that. Again, it's a user or elusive organ. So as a long term treatment for significant problems, the rectums, the vacuum rectangular device is not awesome, right? You can imagine you're with a partner and you're like carrying this thing around.
- [26:20]
B
Like going through TSA PreCheck or going without TSA PreCheck.
- [26:24]
A
Yeah, right. But, you know, we do have better treatments that are more subtle, more hideable, less embarrassing, surgery being one of them, pills being another. But yeah, I think vacuum devices play an important role. The other thing about vacuum devices that men should know is that there's. You can get blood to flow into the penis with this, with this negative pressure, Right. But then you take the cylinder off and the erection goes away within 10 seconds. Right. So you have to somehow trap the blood and trapping the blood we talked about in the beginning is essential for keeping erections. So as the veins become, as they malfunction as we age, or if there's more scar tissue around the veins after fibrosis, from surgery, for example, those veins no longer could be compressed adequately. So what happens is blood flows in, but the veins don't get compressed like they should. So blood flows out at the same rate. Very similar to like a tire with a bunch of holes in it. Okay. So you can hook up 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, it goes flat. That happens in men too. And so if men describe to me, hey, I can get erection, but then I lose it when I start to try to have sex or when I, you know, with intermission, then I'll know that's probably venous leak. And that venous leak can be treated best with surgery. But the other thing you can try are these constriction bands where you're essentially trying to crush the vessels from the outside. Never use a metal band on the penis.
- [27:50]
B
That also sounds really painful.
- [27:52]
A
Yeah, yeah, no, as urologists, you know, I've had cases where I had to call in use like a neurosurgical drill. We have the fire department, you know, try to cut off these metal rings. I had one gentleman use a titanium ring. That is not a good plan because it gets stuck. So if you're going to use a ring or a band to support erections, which is a reasonable thing to try, use something that is, you know, elastic. Yeah, there you go.
- [28:12]
B
That would make much more sense than something that doesn't expand. Thank you to one of the sponsors, the one and the only, Cozy Earth. If your sheets feel like a paper towel from a gas station bathroom, life is too short. It's time to upgrade. I've been obsessed with Cozy Earth bamboo sheets. They are temperature regulating, guaranteed to give you a comfortable night's sleep. Made from viscose from bamboo. Holy cow. They're incredible. I just like stay wrapped up. They help me sleep several degrees cooler. Cooler temperatures facilitate the body's natural drop in or temperature which leads to faster sleep onset. And hey, if you are a woman who is experiencing night sweats, then these are your go to sheets. And we've partnered with Cozy Earth to bring you 100 night sleep trial. You can try these sheets during the hottest nights of the year. Well, I guess hopefully all your nights are hot, if you know what I mean. And if you don't love them, you can return them hassle free. But trust me, you won't want to. They have a 10 year warranty on all bedding products. Go to cozyearth.com and use the code DrLion for up to 40% off. Best selling temperature regulating sheets, apparel and more. Trust me, you'll feel the difference. Let's talk about drugs. And I have, and when I say drugs, I'm talking about PDE5 inhibitors, Viagra, Cialis. There was a massive review. It was 1.26 million people. Found that regular Cialis use reduced major cardiac events by 22% and lowered all cause mortality by 30%. Do you think there is a place for people that are healthy to be on these types of medications like Cialis?
- [30:04]
A
Yeah, if you ask me if there's data to support that for all patients, not yet. From a personal standpoint, I believe so. Like my read on the data is these are preventative drugs that can prevent significant disease. Do you know the story of Viagra? It's an interesting one. So Viagra was initially a drug developed and they were tested in England. And so it was initially a drug designed to treat angina, chest pain. So you get all these men who have a history of chest pain, you give them Viagra, you say, okay, when you get the chest pain, take the drug, see what happens. Turns out lousy drug for chest pain, like doesn't work. And so that's what nitroglycerin does, right? It reduces pain with lack of blood flow to the heart. And then the people who are doing the study are like back to the drawing board and they're like, send us the drugs back. And like they weren't getting them back. Like, what is happening? Patients never keep these drugs. And so of course the patients noted that their penis was working better on these drugs. And that's how Viagra was born. It was initially a heart drug for angina, but then we developed into a penis drug. And Cialis 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 for 20 to 25 years, the men who take these drugs consistently seem to have a much lower risk of heart disease. The mechanism is unclear. It probably has to do with endothelial health. The inner lining of the blood vessels. Being healthy has to do with maybe decreasing clotting in the major blood vessels. You get drugs like Viagra and Cialis, Sildenafil, Tadalafil are the, you know the names. And if you take them, not only do they help erection, we also discovered that Tadalafil, which is a drug that stays in your bloodstream for 24 hours, used to be called the weekender. It actually helps with urinary symptoms. As well. And then now helps how it helps with these urgency, frequency, getting up in the middle of the night type symptoms. So Tadalafil has an FDA indication for urinary symptoms, or luts, lower urinary tract symptoms. And so I write for these drugs a lot because I find every excuse I can to give them to men, whether they have problems with erections, when they have problems with urination, and then they get this likely benefit of cardiac protection. So it's like this triple threat drug, which by the way is like 25 cents a pill. You can get a prescription through Mark Cuban's Pharmacy or goodrx.com literally 3 months for 30 bucks. So even if insurance doesn't pay for it, it's worth it. And so we routinely use these drugs and they're massively effective. Restore confidence, probably good for you overall help with urination. I mean, it's great. There are downsides, any pill, but you know, they're relatively low. With this class of drugs, one in 33 men will stop because of side effects. One in 33, that can include headache, facial flushing, maybe worsened reflux disease. But 32 out of 33 men are like, I'm good, I'm gonna take the.
- [33:04]
B
Reflux, give me extra flushing. And this is Cialis 5 milli. Is it? Do you prescribe 5 milligrams of Cialis daily? We do too. In clinic.
- [33:14]
A
It's going to be the most effective because it's in your bloodstream constantly. So if you believe the data that it's cardioprotective, it makes sense. You need to have it in your bloodstream the whole day as opposed to like a window, which Viagra or Sildenafil gives you a four hour window of efficacy, whereas Cialis, 24 hours.
- [33:30]
B
You only see men to be fair, right?
- [33:32]
A
For the most part, yeah. Especially where I am now, my job and primarily men's health. Used to see a lot of women for stones when I was in Springfield, Illinois. Stones are very, very common for a urologist.
- [33:43]
B
Yes. Did you at that time use Cialis in women?
- [33:49]
A
This is a study that clearly needs to be done for a variety of reasons. Number one, you know, overactive bladder. This is symptoms where people have to pee so often that it negatively affects their life. And like 40% of all humans above age 50 have overactive bladder. And this really 40%, it's super, super common.
- [34:09]
B
You know, my dad's always saying, I have BPH. I'm peeing 100 times a night. Lets me meditate.
- [34:15]
A
I'd love to Dive into that, because there's a lot of misconceptions about the prostate being at fault for everything. But when we get older, we get physiologic changes in the bladder. So, like, the bladder capacity goes down and our sense of urgency and the sense of stretch is increased, so we end up peeing more often at lower volumes. Just like many things. As we get older, things tend to get worse. As you're. When you're a baby, when you're born, the bladder squeezes when it wants to. And then age 4 or 5, the 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 continence. But as we age, like many things, the bladder kind of goes rogue and just ignores the brain's advice and just squeezes when it wants to. So patients, they'll put keys in the door, they'll hear running water, and all of a sudden they get this crazy urge to go to the bathroom. And if you're lucky, you make it in time. If you're unlucky, you don't have a bathroom there. You're more likely to have accidents. And so women like. One of the main reasons women visit urologists is for urinary incontinence. Not only stress incontinence from when you cough or sneeze, you lose urine, but this urge incontinence, this is very, very common. But men also have urge incontinence, and so this can be treated by addressing bladder health. And so that's why I think a study is long, long overdue for women to see if Cialis will help with these overactive bladder symptoms like they do in men. Because they do. And then is it cardioprotective in women? These are questions that need to be answered with a randomized controlled trial.
- [35:45]
B
If a woman was taking Cialis, the indication would not be, I suppose it would be off label for overactive bladders.
- [35:56]
A
Yep, yep.
- [35:57]
B
It could be off label until we.
- [35:57]
A
Get an indication to be off label. But off label doesn't mean wrong.
- [36:01]
B
Oh, totally right.
- [36:01]
A
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, benefits of this therapy, and then you decide if it's right for you, just like many other things in life. So, yeah, it's a study that needs to be done. And there have been studies to look at sexual function and these classes of drugs, and it does increase blood Flow to the genitalia. You know, sexual function and orgasm in women is a lot more complicated, sophisticated. A lot of other things have to happen for orgasm to occur there isn't this obvious? Yes, no penis, hard penis, soft kind of thing in women. And so these drugs have been disappointing for sexual function in women. However, it doesn't mean they, they might not help.
- [36:42]
B
Thanks to one of the sponsors of this show, Bond Charge man. If you're a mom out there and you've been carrying the whole team, I got a different form of therapy for you and that is red light therapy. And listen good. Light impacts sleep, hormones, mood and even your ability to recover and focus. Bon Charge has created science backed tools to help me live in better alignment with my circadian biology. Artificial light is overloading us. They have blue light blocking glasses that are a staple in our house. They have red light, they have red light light bulbs. They also have infrared PMF mats to help chill my body, relax my muscles and support full body recovery. If you've never tried red light therapy, this is the time to do it. They have some of the best devices that I've ever seen. Great for skin mitochondrial health and overall resilience. If you care about your skin, if you care about your sleep, if you care, care about your body and want to try something new, check out boncharge.com doctorlion use the code Dr. Lion to get 15% off your entire order. Simple, proven, designed to support your biology. I want to talk about the bladder. You, you brought it up. I think it's a great topic. Now I have heard you say that one in seven men who see a urologist already have irreversible bladder damage.
- [38:11]
A
It's crazy, but we did a big study where we looked at men visiting the urologist. We tested them and they tested in this zone where we called. Basically the bladder was no longer squeezing like it can. So the bladder, put simply, is a big old pump. And over men's lifetime the bladder has to empty through the middle of the prostate and out the urethra. So as women get older, they don't have problems with the pump getting weak because their urethra is relatively short and they don't have this prostate which can get bigger with time. But men, they have a prostate which gets bigger as we age. So very similar to problems with erection. So 50% of 50 year olds 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 Pump which is struggling to empty because it's trying to squeeze urine through the middle of this donut, which is the prostate. The bladder gets tired after a while. It's a pump that fails. And if men allow that to progress, one in seven come to me, and 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 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 their own by what we call crude avoiding, bearing down, basically just pushing the urine out. So it can be avoided if when men get symptoms, they go to the doctor relatively early, and either they get a surgery early because that's the best way to preserve the pump.
- [39:46]
B
What would the symptom be that they are just getting? Would it be urinary retention or 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 have to pee?
- [40:00]
A
Yeah, it's the former. It's pushing or straining to go. Men who can't empty their bladder effectively. Right. So one test we'll do is we'll have guys peeing a machine. We'll measure how strong the stream is. We'll give them a score, and then. And that can be predictive of the need for surgery, et cetera. But more importantly, we measure how much is left behind after they go. And if that number is zero, you're good. However, if that number starts climbing, you pee out 400, you leave 100 behind. You wait another year, you peel 300, you leave 200 behind. Pretty soon the ratio is nothing comes out, and you leave everything behind. So that is the best way to kind of predict this loss of bladder function is by seeing how much is left over. Other signs can include knowing you're not emptying. So that can sometimes lead to frequency getting infections. Right, because urinary tract infections. Urinary tract infections. Because our number one defense against infection is peeing out the bacteria. And if you are not emptying your 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 infections.
- [40:59]
B
How would a woman know that she has the equivalent?
- [41:05]
A
Women will very rarely have these obstructive symptoms because they don't have the hardware to cause the bladder to malfunction. But the important lesson here is that the bladder causes this mischief it wants to squeeze all the time. And there are many lifestyle factors that lead to more bladder mischief and make me have to pee more often and make you miserable. But. And so sometimes men will come to urologist saying, doc, my prostate's horrible. And, no, they have the same thing that women have. This overactive bladder urologist's job is to separate, like, what the problem is. But for men that have struggle in the urinary, you have to rule out the pump problem, because if you don't, you're gonna have to get a catheter lifelong. And that's not what you want, believe me, in terms of, you know, what can we do about the overactive bladder? This kind of irritative symptom type of thing, not pushing or straining, but having to go often running to the bathroom, having to get up in the middle of night, like, basically having accidents when you don't want to. These are bladder behaviors.
- [42:00]
B
So not. Not prostate behaviors.
- [42:04]
A
That's. That's.
- [42:05]
B
We have to talk about this. We need to clarify this. You have also said, which I thought was brilliant, how many times you pee in the middle of the night can predict the likelihood of death?
- [42:14]
A
So big meta analysis, I think, from 2015, meta analysis is when you take all the best literature, you combine it and you try to come up with conclusions. So this meta analysis said that men who have nocturia, that's greater than two times at night, they get up three times a pee or more, are 30% more likely to die, of all causes, heart attacks, these kind of things. Now, does that mean that if you pee three times in the middle of the night, you're doomed? Of course not. This is not a causal relationship. It's a coral 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. One, do you have sleep apnea, where you can't sleep soundly, and that's making you pee more often? Two, do you have edema in your legs because you have heart failure, you have to pee more often in the middle of night? Three, do you have metabolic abnormalities? You have diabetes, which makes you pee more often? All these kind of potential risk factors will make you pee more. So it's the fact that you're peeing tells me you're unhealthy again. If you mitigate that unhealthiness, if you lose weight, you start to exercise, you reverse your diabetes, guess what? You won't pee as often. Right? So it's all a lot of these things are reversible in life. Human body is amazing if we treat it right.
- [43:26]
B
Is there a normal amount of time someone gets up? And again, I'm thinking about my dad. Shout out to Nate in Ecuador. Probably embarrassed. He often says, okay, well, I'm waking up in the middle of the night. Two, three. Again, you lost me at three to go to the bathroom. He is 74. Would that be prostate? Would that be bladder? Would it be impossible to tell?
- [43:51]
A
Yeah. So it's typically unusual to have to get up in the middle of night less than age 50, right? Once, fine. But once you start getting up more and more often, we know as we get older, again, the bladder loses capacity. As we get older, we tend to make less hormones that prevent us from peeing in the middle of the night. Specifically, we make less adhesive. If you have sleep apnea. The body perceives this lack of breathing as high blood pressure to the chest. And so it sends out NATO atriotic peptide, which makes us spill salt into the urine, which pulls fluid with it. So, again, these other medical comorbidities will make us have more nocturia. So I'd say if you're getting up more than three times at night, you first should look at lifestyle factors and then obviously look to improve the other metabolic components that we just discussed. But, yeah, you're at risk for other things because that's a warning sign that stuff's going on.
- [44:45]
B
It's really interesting because just again, as a practicing physician, training in, say, family medicine and even geriatrics would be. Here's some Flomax. I'll see you next time.
- [44:56]
A
It's a very dangerous approach. One, 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 talk about bladder irritants in a second.
- [45:07]
B
We are definitely talking about bladder irritants because you just killed half the list. I just.
- [45:11]
A
The other thing, though, is that Flomax is a drug that, you know, it's Tamsulose and there's all these other drugs which will improve the strength of the stream, but it doesn't protect the pump. So actually, the worst thing you can do for guys with obstructive symptoms is to give them Flomax, because then you won't see them again for another 10 years. But by the time they've come back now, the bladder has had the damage. That's unreversible, irreversible. So Flomax is not a drug that will protect you long term. So if you have true prostate enlargement, I'm an enthusiast for early intervention that is doing procedures 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 medications to have this effect as well. And these drugs are typically 5ri is the ones that actually physically shrink the size of the prostate. Kind of a chemical surgery, if you will. These drugs will prevent the need for to go to the emergency room because you can't pee the need for surgery in the future. But if you just give somebody Flomax and say, you know, see, when I see you, you're at high risk for having that person have long term bladder damage.
- [46:16]
B
It's a really important message. I do think that it is very common where people think it is. It's again. And part of that is media, which is also another 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 you're able to reach a lot of people just by having the conversation. I was very disappointed to see your lifestyle changes for urinary frequency notes. Extremely disappointed. I'm going to share this list.
- [46:46]
A
Okay.
- [46:47]
B
I just want to let you know that you have ruined my Wednesday. Not even going to be drinking any more. Carbonation. Right down there. The C's of urinary frequency consumption. Caffeine, constipation, cocktails, Coke zero. You just hurt my heart. Citrus also hurt my heart. Carbonation, Cigarettes. I don't smoke. Couch potato. Not doing that. Capsaicin, Spicy foods. We are not friends any longer. Talk to me about this.
- [47:17]
A
Yeah. So if you're having urinary frequency, that's bothersome to you. The big three are how much you consume, right?
- [47:26]
B
All of it.
- [47:27]
A
Yeah. The more you drink, the more you pee. This is just simple math, right? 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 day may have been selling water. Right. So everything is about risk balances. And if you are miserable because you're peeing all the time, try to cut fluids to some degree and see if that helps. The second biggest thing we see is caffeine. So caffeine acts as a diuretic and also makes us pee in small amounts. So inefficiently and the higher dose, the more it affects us. So if you're going frequently, if you have several cups of coffee, you'll notice that the frequency always is around the time you drink coffee. Coffee or caffeine. Constipation is a huge one. So the bowel and the bladder share real estate. And if you're really constipated, you struggle with that. Not only are there probably neural pathways or nerve relations between the two organ systems, if the rectal vault is filled with gas and stool, it's literally squishing the bladder. Your bladder capacity is decreased and you have to go more often. So a lot of guys that struggle, or guys and gals struggle with, with urinary frequency, you get constipation under control. They're better. Same with little kids, right? Little kids, when they have accidents at school, when they have, when they have accidents in the middle of the night, it's almost always constipation. You fix that, that gets better.
- [48:48]
B
That's a great parenting tip. I didn't know that.
- [48:51]
A
And so some of the other ones which you, which you mentioned, they can be more of a risk for some individuals than others. Right? So humans are genetically variable. For some people, if they eat spicy foods, that's capsaicin, they'll have to pee every 15 minutes. Some people are really sensitive to carbonation. Some people are more sensitive to artificial sweeteners like those in Coke Zero. So I have problems remembering stuff. So I basically try to put the letter C in front of everything to remember what things can trigger bladder over activity.
- [49:23]
B
Speaking of bladder, I suppose I should get this right, Move up. I better get this right considering I'm married to a urology resident. Kidney stones. Who gets them and how frequent is it? Is it men versus women? Is there predisposing factors? Yeah, let's talk about it.
- [49:46]
A
Well, kidney stones affect about 10% of all humans. There's predominance in men over women. Slight predominance. The main risk factors for forming stones is lack of fluid consumption. So this is the other end of the scale we just talked about. Over consumption under consumption of fluids is the number one risk factor for stones. Right. And when you form stones, like all the time in Texas because it's always hot here. So when you're sweating. I almost burst into flames when my, my plane landed here as I got off. Yeah, very hot here and humid. But basically, if you're dehydrated chronically, you're at risk for stones. The other things that are very important are salt consumption and excessive artificial sugars, or true sugars, they tend to form more stones. The bottom line is also there's a strong genetic predisposition so if you have somebody who had a dad or a brother with stones, you're more likely to get them. And they're very, very common. If you drink more, you can prevent them. And if you think about this, I tell my patients this analogy, like if you're constantly flooding the kidney with all this extra fluid, there's no way a stone can start to form in the kidney and then eventually pass and cause shenanigans. So if you're like, if you're in a, like in Minnesota, we, we like, it's never hot. It's really hot for like three months, really cold for another nine months. Sometimes people will, will go down a river in an inner tube. And so I, I say it to patients like, you're going down the river in the inner tube. Imagine you're a small particle at the bottom of that lazy river. And how as every second goes by, calcium or different minerals start to add to the size of the stone. But now if you switch to a whitewater rafting part, which we don't have in Minnesota, by the way, but we don't. No, no, no. It's not, not that exciting. Right. In terms of a state for that kind of activity, there's no way a stone can form. So the inside of the kidney is like that lazy river if you don't drink enough, but if you consume enough fluid, you're very unlikely to form stones.
- [51:51]
B
As simple as that. Would there be certain things that could predispose people to stones? For example, I've heard very high dose vitamin C. Does it seem to be different for every person? Again, because you had said some people, artificial sweeteners might be an irritant to one person versus somebody else.
- [52:12]
A
Yep. Biologic variability applies to everyone. But high dose vitamin C can be a risk factor. Excess calcium. So both too much calcium and too little calcium.
- [52:21]
B
Dietary calcium or dietary calcium.
- [52:24]
A
Yup. Your gut has to reabsorb calcium and if there's too much in the gut, it spills over into the blood. So actually the recommended daily allowance of calcium is probably the right amount. The extremes of either end are stone promoting. But again, the number one way to prevent stones is to drink more fluid. Real lemon juice added to fluids can also actually prevent stones through some citrate metabolism. Some ways that we get away guys and gals who form recurrent stones will often be put on potassium citrate, a pill that alkalinizes the urine and thus prevents stones. The 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 medication you should get to prevent the them.
- [53:09]
B
From what I hear, they're very painful.
- [53:12]
A
Yep, yep. I've seen many tough individuals be not so tough because of the pain from kidney stones.
- [53:18]
B
I don't wish that on anybody. There is something I do wish on people.
- [53:22]
A
Okay.
- [53:22]
B
And that is muscle mass. Wait, $3,000. 3. Wait, is that number right? I've spent more money on skin care. My pores should be tax deductible. Maybe even have their own trust fund. And thank goodness that I found One skin because one skin doesn't just make empty promises. It's research driven, minimalistic and tested for beauty, skin health and longevity. One skin is the first topical skin care backed by peptide science that targets skin aging at the molecular level. I slather this on all day. They have a peptide that is designed to reduce the accumulation of dead cells or zombie cells that drive inflammation, tissue breakdown as we age. Now this isn't about cosmetic quick fixes. It's about changing the biology of your skin. Strengthening the barrier, improving firmness, hydration, elasticity with clinically tested ingredients. So if you are focused on aging well from the inside out, it's time also to think about your skin. It should get the same level of care. Go to OneSkin Co for 15 off. Use the code DoctorLion. It is amazing and it will not break the bank. You gave an amazing presentation at the Androgen Society and just recently at Baylor because I heard from the residents there is a connection between muscle mass, sarcopenia and sexual function.
- [54:55]
A
Absolutely. Muscle mass is imperative for longevity. If you want to live long time, you have to move iron. You got to be strong, you got to keep it that way. We have this age related sarcopenia where you will lose muscle as you get older related to hormone production. But if you fight to be elite in our age now, I'm going to put us as young. We'll be fine when we're 90. So that's my paradigm. Like we're right now we're in preparation for a geriatric decathlon. This is Peter Attia's concept. It's amazing. So you got to be really healthy now. So muscles does so many things. In your book Forever Strong talks about the metabolic capacity as one of the biggest organs humans have to control insulin sensitivity to control inflammation. And that's not surprising at all that when you look at well done studies, men with more muscle mass have better erections. Men with less muscle mass have horrible erections, have low libido have lower testosterone. It's all about overall health. Again, think to the paradigm about how the body is willing to give away its erectile function if it has to sacrifice something, but it's going to keep brain function. And as we get sicker and unwell, the penis is the first to go. So don't get unwell, stay strong. So when men train, when men lose weight, when men gain muscle erections, get better, aerobic activity is as powerful as P5 inhibitors, the drugs like Cialis that we talked about earlier in helping with erections, a modest 10% decrease in body weight is as powerful as pills in helping with erections. Not only all the other benefits of keeping on the right side of the grass. So, again, if you take good care of your body, your body will take good care of you. Anything you do for penis health is good for cardiac health. So it is not surprising at all. There's a direct correlation between muscle mass strength, grip strength, and erectile quality.
- [56:50]
B
You just got the attention of every male listener on the planet. Yeah, well, good, or at least good, because listening to this show, because who doesn't want better erectile function and better penis health?
- [57:04]
A
And you know, just to jump in, we use the penis as a fulcrum for behavior change. It is very difficult for the average man to change your behavior. If you tell them, listen, your blood pressure is 8 points too high. But if you tell them, listen, if you lose a little bit of weight, if you start exercising, just minimal gains, 150 minutes a week of exercise, 30 minutes, five times a day, you'll see tremendous improvement. And so we can use this as a fulcrum to get guys to be healthier. In Canada, the cigarette packages have like, this flaccid cigarette on the side, and it basically says smoking is bad for your erections. So we should lean into this fact and get people to be healthier. Because, yes, sexual function is very sensitive to overall health, and we should use it as a way to get people to be healthier.
- [57:49]
B
Is there a dose, you said 150 minutes of moderate to vigorous activity. Is there a known specific dose that is good for penis health or vascular health primarily? I mean, I know that we're talking about vascular health in general, but again, as a urologist, I thought that we would focus on your organ of longevity. The urologist's organ of longevity versus my definition.
- [58:13]
A
Right.
- [58:14]
B
Do we know, Is there a dose.
- [58:16]
A
Study by Zhang et al. I think from last year, 2024, they looked at the NHANES data, which is like a community Cohort database from like the early 2000s and basically have found that 150 minutes of exercise per week decreased the rate of erectile dysfunction by 20%, 300 minutes by essentially 40%, something very close to that. So, you know, intensity and duration, as it gets higher, you get improvements. There is a, eventually you plateau. It's like if you do a thousand minutes, you're not going to get perfect erections. But even a modest amount of exercise really moves the needle. And then if you really are exercising 300 minutes a week, that's an hour, five days a week, which is a great goal, you'll see a 40% improvement in erections.
- [58:58]
B
I'm going to just lay out a handful of other statistics and numbers because I think they're so powerful. Studies showing men who maintain muscle mass strength are 66% less likely to report multiple sexual issues. Older men. This was fascinating, but not surprising. Sarcopenia was linked to 2.7 times greater risk of moderate to severe ED.
- [59:21]
A
Both those studies are, you know, excellent in that, you know, a lot of them, they're self reported studies and where the people are quantifying their own strength. The one study about the muscle mass that's from like a bunch of Scandinavian patients and the people who reported that they still were strong had awesome erections. The people who said, yeah, I feel a little bit weaker than when I was 10 years ago, they had lousy erections and lousy libido too.
- [59:44]
B
What is the role of testosterone and erectile function?
- [59:48]
A
And testosterone is essential to a certain point, right? So if you have normal testosterone and you give more testosterone, testosterone, there typically isn't an added benefit. Right? So a mistake you'll make is like assuming if somebody comes in with a normal, you check their T, it's normal, but they have problems with erections by giving the testosterone. That typically doesn't fix the problem. Remember, the main etiology of erectile dysfunction is probably vascular blood flow problem. So you got to fix the blood flow. If testosterone is very low though, then penis ain't gonna work.
- [60:19]
B
How would you define very low?
- [60:21]
A
Well, you know, if you want to use the scientific definition, a repeated measurement of Testosterone less than 300 or free testosterone less than 5. So if it's low, if you give testosterone back to those men, they typically will see a better erections. Especially when they're trying to use pills, Cialis Viagra. They rely on testosterone for nitric oxide synthetase or the chemicals that are required for erections. If your T is low and you give tea back, the Pills will work better again, I just can't stress enough though. If you take good care of yourself, your T will stay normal. There's data where, you know, people who are look healthy in their 70s and 80s, their testosterone is way higher than people who look unwell. My dad is really low.
- [61:04]
B
Yeah, let's just throw Nate Dog under the bus again. We ran his labs and I'm looking at this Testosterone of over 700.
- [61:13]
A
No, that's amazing. And I would argue that the best single blood test for overall health in men is testosterone in women. Maybe, but maybe there's a ratio we need to look at. And then along those same lines, the best overall marker for overall health in men is erectile function. Why? Because you have to have excellent vascular integrity, excellent overall health, and the penis requires normal mental health. If you're anxious, if you're depressed, the penis ain't gonna work. So you can be in great physical shape. But if you're unwell, from a psychiatric perspective, whether it's depression or whatever, it is anxiety because you're having stress at work, again, the penis ain't gonna function well. So all systems have to be on full go for the erections to be awesome. So that's a really reassuring thing. If you're a 70 year old and you're getting great erections, you're probably pretty healthy.
- [62:04]
B
Is there a point of no return? For example, when we image the brain and we see microvascular disease of the brain? The brain is arguably a large, very active organ. There is a lot of it. The brain can make up for itself, meaning it's not just dependent, typically in this one area, but the penis is smaller. If there is vascular damage to the penis, is there an ability to recover?
- [62:31]
A
To a limited extent, like many other things, but sometimes you get age related vascular disease. Maybe it's untreated hypertension for a long time, or you have significant atherosclerotic narrowing or plaque, or maybe you smoke for a long time. Sometimes the damage is so extensive that no matter how much you exercise, no matter how many pills you take, it ain't gonna work, right? Yes, there is a point of no return. Very avoidable if you never get there in the first place. But that's where surgery comes in. For men who may have had a reason that their penis has failed them, or maybe at a period in their life where they were very unhealthy. You know, we can restore normal sexual function with surgery. Oftentimes we can restore it with lifestyle change, but not always. And so you take good Care of yourself. But then, even if it fails, there's no reason to give up hope. We can fix it.
- [63:23]
B
I have a question that I.
- [63:26]
A
I.
- [63:26]
B
Don'T know if you've ever seen, and I don't even know if it's a thing. Is there ever something where a penis cannot get an erection? Maybe it's a genetic defect of vasculature.
- [63:35]
A
All the time.
- [63:35]
B
Really?
- [63:36]
A
Oh yeah, all the time. So when I look at the age range of patients that I put an appeal implant in, it's 18 to 98. So that's, you know, if 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 the 90 year old did great, by the way. But some people are born with this congenital venous leak where the venous trapping just doesn't work. Or some men are born with some kind of a genetic defect or whatever it is where they've never had a good erection in their entire life. So I've had patients come to me where like they're actually having pain with their erections because they've never stretched the penis before.
- [64:16]
B
Wow.
- [64:17]
A
So. But you know, the surgery can fix it. It and there are many men who 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 had a good one. So that's fixable, that's treatable. I'm really grateful that that surgery is available and can be done. It can be done.
- [64:36]
B
Well, seeing you in San Francisco, you gave a great lecture. And I have never seen a doctor, an MD talk about moving iron, eating protein, and building muscle all in the same sentence with testosterone replacement therapy. Please tell me what some of your thoughts are regarding what people are actually after.
- [65:04]
A
I. When I was in Sprungfield, Illinois, at the beginning part of my career, I was lucky enough to meet a guy named Chad. And we've actually published some work together on anabolic steroids. We've given some talks together. And so, you know, I consider myself a curious guy. And when he came to me for help, I learned a lot more from him than I could help him. And then I really kind of dove into the literature when I asked Chad, hey, you know, tell me about supraphysiologic T levels, like what dose you're using. And when I'm talking about super physiologic T levels, I'm referring to consistent testosterone levels greater than a thousand. So bodybuilders, you know, they'll go for T levels of 3,4000 or they won't even check. They'll just go super high and just give, take more if it ain't working. And I wanted to know what the motivations were as to why people would start. I had some intuitive thoughts, but I wanted to ask somebody who was an expert. And then, I'm a huge fan of yours. I'm also a huge fan of Mike Israetel as well, and the way he communicates testosterone use and working out and getting fit. I mean, I'm a huge consumer, right? Like, I've changed how I worked out because I'm now 50, because I don't want to injure myself, right? So I've taken a lot of advice to heart. And so I wanted to know, okay, what is the main motivation for a lot of people to start super physiologic? T. And the two main ones, there are many, but the two main ones are athletic performance and essentially looking good or vanity, I'm going to say. Now, athletic performance, I think Chad summed up pretty well is that if you need help from testosterone to perform well in high school, to be elite in high school, you're not good enough. If you need help in college to perform elite level with because of steroids, you're simply not good enough. Because by the time you ascend to the pros, like you likely get caught, you won't be able to use it and you won't be good enough. So you have to have this natural ability to become a professional athlete. And you also have to probably be testosterone sensitive. You have to be sensitive to a lot of the agents that people use to have the outcomes that you desire. But if you're using these drugs to be good at sports, you're never going to be a pro. That's the unfortunate reality. Not to mention the fact that you have to somehow navigate and not get injured along the way, which, again, a lot of people are amazing, but then they blow out their knee or whatever and then their career is done. The more interesting one, and the one that I think needs more attention is the to use these drugs for aesthetics. And I get the appeal because, you know, when you work out naturally and you do great, you probably gain about 10 pounds of muscle in a year. If you're doing everything perfectly, you know better than I do. Your book goes over this beautifully. But if you add high doses of steroids to it and this, there's a lot of 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 it's just so much more efficient. And, you know, there's a huge appeal there. And I'm not here to tell people, don't do this or do this, but I want people to know the true risks and benefits. The thing is, if you're chasing an aesthetic with these type of drugs, you're much more likely to look worse than better. Why do I say that? Well, because just because you take high dose testosterone, cipionator and ntha along with many other drugs, doesn't mean you're gonna be, you know, shredded. It doesn't mean you're gonna have 8% body fat and look amazing with your shirt off. Most people, first of all, you have to be sensitive to the drugs and you have to have perfect training and perfect nutrition, which is really difficult for everybody to do. There's books about it, you know, it can be done, but it takes discipline. And so that's a baseline requirement. And then you take these drugs and then there's the potential negatives, consequences. Like 50% of people get significant acne. So you're never going to want to take 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 balding. And so the vast majority of people who take these like appearance enhancing drugs, they'll actually look worse, not better. Not to mention that a lot of humans have this fantasy that if they look a certain way, they're going to be more attractive. But when you ask people what they find attractive, being hyper muscular or being super jacked is not at the top of the list for many individuals. So if you're leaning in to use these type of agents to look better, number one, it may not work unless you have perfect training otherwise. And number two, there's a lot of downsides and risks. We didn't even go into the kind of negative things like sudden death or heart problems, depression, suicidality. But to use that as a lever to get to a certain look I think is a mistake based on my read of the literature.
- [70:11]
B
Well, I'm looking forward to having you back on the show, Dr. Tobias Kohler. It has been an absolute pleasure. You are a gift to the world of urology and just an amazing and really fun human. Thank you so much for coming on.
- [70:27]
A
Thank you so much for having me. It's great. A huge honor. What you do here is so important. We did a recent trial or study where we looked at health media consumption, like 93% of all kind of Internet material related to fitness health was rated low quality using these methods discern method that we used in this paper. I'm proud to say that you're one of the great ones here. Getting the right information out there and letting the public decide what's best for them and you know, promoting positive, healthy lifestyle, that ultimately is the most important lever we have to be happy and live a long time.
- [71:06]
B
I really appreciate that. And the reason that we are great is because we have great world class guests. So thank you so much for coming on.