In Your Pants with Dr. Susie G - Bringing Your Sexy Back After Prostate Cancer

Episode Date: February 8, 2018

Prostate cancer is common. By the time a man reaches 50 years old, he's got a 42% chance of developing prostate cancer but very few actually die from prostate cancer itself. So don't freak out! It's common to find prostate, cancerous cells in younger men and it's normal to increase with age. It's only a small percentage that experience symptoms or are life-threatening. In today's episode, we're talkin' all things prostate, how to lift your nuts to your guts and how to bring your sexy back after prostate cancer. Today's guest comes to us all the way from the 'down under', Jo Milios is a men's health physiotherapist and clinical researcher specializing in prostate cancer rehabilitation, pelvic floor dysfunction and pelvic pain. Her research covers quality of life issues following surgery for prostate cancer with a focus on erectile dysfunction and Peyronie's disease. It's time to open up the conversation about men's health, so be sure to share this convo with all the important guys in your life.

You're listening to In Your Pants with Dr. Susie G, the physiotherapist for your private, helping you get in the know down below. Hey friends, it's Dr. Susie Gronski and welcome to another episode of In Your Pants, where we destigmatize private parts and social taboos. This is definitely not the place to be shy, so I hope you're ready to get in the know down below. in today's episode we're talking all things prostate how to lift your nuts to your guts and how to bring your sexy back after prostate cancer today's guest comes to us all the way from

down under sorry joe i couldn't help myself joe melios is a men's health physiotherapist and clinical researcher specializing in prostate cancer rehab pelvic floor dysfunction and pelvic pain her research covers quality of life issues following surgery for prostate cancer with a focus on erectile dysfunction and Peyronie's disease which we'll talk a lot about later in the show so no more beating around the bush guys it's time to welcome joe to the show joe thank you so much for being here with us today i know what a busy woman you are these days helping men regain their sexuality back after prostate cancer is such an inspiration and you've certainly been and inspiration to me as I've shifted my focus to men's health exclusively. I've always wanted

to know the story behind your passion. So what's the spark that started the fire, Jo? Oh, thank you so much, Susie, that warm welcome. The spark that started the fire. Well, it probably goes back to my early childhood when I really wanted to be a classical ballerina as a profession. and I ended up developing scoliosis and having to wear a back brace for quite a few years during my teenage years and so my shift of focus came from wanting to be a dancer to wanting to be a physiotherapist and I ended up pursuing that and did work with quite a few dancers

and then along the way my brother became a urologist and he and I had always planned to work together in some capacity and I thought he might do sort of orthopedics or sports medicine or something, but rather he chose urology and I thought that would be the end of that. But then he came back with the opportunity to work together in pelvic health, at which point I didn't reject, but I started looking and found that there was so little content

within the men's health physiotherapy profession that I really had to start digging my own kind of pot of knowledge and basically what I needed to do was follow my brother around watch him do surgeries for prostate cancer and various things but mostly just listen to his hundreds of patients over the years to really understand what men's health was all about that's wonderful and I'm glad you brought that up it's listening to hundreds of men and their concerns and their fears and their worries, which can be such a vulnerable thing for a man, I feel, in our culture and society in general. I don't know what it's like in Australia, but I'm assuming that it might be very similar. Absolutely. And I've had the

good fortune of teaching a lot in the last 12 months in Europe and New Zealand and also around Australia and South Africa as well. And wherever I go, I think it's a very similar concern. And I have two sons and a daughter and, um, I'm, I'm constantly talking with them about their private parts with all my children, just opening up the conversation about health and making sure they're cluing into their body from an early age. Right. That's wonderful, Joe. Wonderful. And you, you spoke about teaching all over the world. Tell us about, I think some of your classes are named nuts to guts which is such a great slogan for a class or a tagline it's awesome and so what do you mean by that and what do the guys need to know about their nuts

oh thanks izzy well again it was all about the language um a few years ago i had one guy come into my office and he'd just been on a mining uh camp where he had some instruction from a and they were talking about what to call their balls or their testicles and he said you know everyone felt more comfortable with the word nuts and I was like oh that's really interesting and then it just came to me so what what I need to do for men with prostate cancer is make sure that prior to their surgery that they have a strong pelvic floor and I really wanted to be able to use some language that made them feel comfortable and break down a little bit of of a barrier initially when first meeting them so nuts to guts is basically the lifting of your

testicles up towards your belly to perform a pelvic floor muscle contraction and then I just usually work a combination of doing some of those quickly and some of those slowly but it always seems to resonate with a guy so first of all they have a bit of a chuckle and a big smile and I can see their eyes more or less rolling back as they're cueing in and feeling it and they sort of go quiet for a moment and then I go and show them on the ultrasound a real-time ultrasound and we do that just trans-abdominally so it's again not too confronting for them and they can usually see a really nice elevation of their pelvic floor and then a relaxation in coordination with their own nuts to guts actions. Now it's really been interesting because

a few years ago in Australia there was some research done and they had four different verbal expressions to ask men to do this pelvic floor contraction and one of them was to squeeze the anus another was to stop the flow of urine another one was to shorten the penis and a fourth one I can't quite recall but shortening the penis was the one that was shown on the ultrasound to be the most correct to cue the right area however when I started using that with my patients the look of horror as I listened to shorten their penis was like an immediate do not go there so right right right if anything they want to gain length not shorten length absolutely this also led me to backing it up because I popped into a sexology conference lecture once by a psychologist

and they were discussing this psychological issue they deal with called SPA or small penis anxiety and the opening comment was that the most looked up internet topic all around the world is the size of a man's penis so that sort of confirmed that perhaps it wasn't a statement that most men would feel really comfortable with so nuts to guts is here to stay. I love it that's wonderful so you deal a lot with you know prostate rehab and prostate cancer so tell us a little bit about you know prostate cancer i know it's common i think the most recent statistics that i read were that every one in seven men will be diagnosed with prostate cancer in their lifetime is that correct that's pretty much the way the the rate is around the world in australia we have more

prostate cancer being diagnosed than breast cancer. And we have a lot more funding, a lot more health public campaigns for breast cancer versus prostate cancer. And we know from all the research being done that if there's a family history of prostate cancer on the first line male side of either father, brother, grandparent, uncle, that there's a one in two chance that the next generation man will unfortunately be diagnosed with prostate cancer if there's any breast ovarian or uterine cancer on the female side there's actually a one in four risk of a male developing prostate cancer and this is a highly genetic passing down of of the genetic code unfortunately which is very different to breast cancer where there's more like a one in ten

relationship there and so what we're really trying to achieve is a little bit more knowledge that yep prostate cancer is something to look out for and it's the most commonly diagnosed cancer in all around the world so so it's most common so i'm not sure if you've heard the controversy now this article was written back in 2010 but richard ablin he's a researcher professor of immunology and pathology uh in the states he wrote an article i don't know if you know about this article but i'm just gonna throw it out there he wrote an article for the new york times in 2010 called the great prostate mistake did you do you know about this article familiarize me because there's been a couple of controversial articles but what's this one so he claims that over 60

percent of prostate cancer is being over diagnosed and unlikely to cause death he also claims something like 3% ever die, ever die from it. Um, and he mentions that it's, you know, one, it's a normal regression that prostate cancer will normally regress in a man or two. He claims that you can actually die from something else quicker, even not related to prostate cancer. So I'm curious, and hopefully this isn't like a charged question for you, but I'm just curious through what you think about, you know, what do you think about his approach to the wait and see approach because that's what he pretty much recommended and my second follow-up question would be how accurate is PSA testing and detecting cancer cells that can kill you versus those that

won't okay they're really really great questions and it has been very controversial and it really probably needed to be because once the PSA test became available about 25 years ago the number of men being diagnosed with prostate cancer rapidly went up and once someone had a PSA reading that showed that there was an elevation then the doctors and health physicians were quick to jump on it and treat it which meant a lot of men were actually being treated too quickly or unnecessarily leading to the side effects from surgery such as urinary incontinence and erectile dysfunction so there definitely was a huge flourish of that diagnosis and And what basically happened was at the early stage of PSA testing,

it wasn't so clear as to which cancers really needed to be monitored and which prostate cancers needed to be removed. So over the last 25 years, there's been an increasing sort of perfection on the various ways of testing. And now we use an MRI, it's called a polymetric MRI, which gives like a 4D sort of look at what's going on, and that can usually confirm prostate cancer as well. But the most important thing with a PSA test is that there's a baseline.

So if someone has a higher reading, then it needs to be followed up and reassessed to see if there's a subsequent high reading. Quite often a PSA level will drop up and down in a normal sort of week within a man. It's also related to ejaculation. so if a man ejects his PSA will usually rise for 48 hours afterwards also if he rides a bike it can rise for 48 hours afterwards so it's really important to exclude quite a lot of factors and to make sure that over time that there's a change in the PSA level which is rising at a rate higher than what would be expected for that man's particular age only then should we go on to

do a biopsy to actually see if there's any active prostate cancer cells and the way we can biopsy things there's actually four stages of what's called sorry five stages of what's called the Gleason score and those are looked under a microscope and pathologists actually work out whether or not it's a high grade cancer or a low grade cancer if it's a low grade cancer then usually it can just be monitored with just regular PSA testing if it's a high grade cancer it then needs to be classified as to whether or not it's surgically okay or going to respond to surgical treatment or has it got to a point where surgery is no longer an option and that radiotherapy and hormone therapy need to be activated so a really big controversy around that but very interesting

Australia is about two or three years behind the United States and what happened was your American Urological Association a couple of years ago rejected all PSA testing and said that because of basically discussions like Richard Abland that we were doing too much testing. Australia decided to also become a little bit conservative but continue to do PSA testing. What basically happened was there was a sudden surge in men in the last two years in the United States with getting more advanced prostate cancer presentations again so this was something that was unexpected but advanced prostate cancer basically means excuse me that it's um oh sorry I need my water excuse me it basically means that the prostate cancer is so advanced that it's no longer a

curative possibility that it will be more like a palliative care treatment so Australia has now looked at america's lead and decided that we do need to be following our midway approach and we pretty much recommend everyone between 50 and 69 being assessed for their psa and that anyone with a family history from 40 years of age to be tested with a baseline psa and for yearly tests so that's a long answer to that question but i hope it fills in a few gaps no it certainly does and just what are the normal levels or what should the levels be if a man is curious or any of our listeners the best thing to do is actually to just dr google it um because every every age group has a certain level so between 40 and 50 it's a level of one uh between sort of 50 and 60

it goes up between a normal range of being 2.5 to 3.5 or something like that uh i haven't got the numbers right in front of me but the general general recommendation is to be within that mean for your age group and doctors just really need to do a comparison from one test to the next every year the digital rectal examination is an interesting one here in Australia it's now recommended that PSA is the only required test and if there's any abnormalities then the doctor is referred to a urologist for a digital rectal examination and we do that because apparently there's a lot less probing going on all around the world with less training in doctors and less experiences it's no longer

being recommended as a baseline test. What I do know from my brother and we recently did a presentation together is that only about five percent of cases are actually picked up by the dre and in this five percent they may not show a psa change or rise so it is quite important to still have it in the assessment toolbox wow yeah and i know they're still doing it i mean all the men that i see they they get dres digital rectal exams i have not heard of that but honestly i do question because i've actually had a gentleman recently come into my office and say you are the by for the most thorough person that has assessed my prostate and when i went into the urologist it was like not even a second and and you know and the guy was like i don't even know what he felt

how could he even felt anything i didn't feel anything you know so i questioned like is this a one-two chop kind of thing or what yeah yeah but uh again it's just the stigma uh one thing i've learned a lot of the time is that men aren't very comfortable with getting uh that test done men are usually the ones inserting rather than being inserted there's all sorts of jokes that are around but um quite honestly a lot of my patients have discussed that it makes them feel like they've crossed to the other side or they've you know sort of behaved in a way that they're embarrassed or ashamed of which is really interesting when you're a female just to hear how absolutely quite traumatic it is for a man to to have a dre uh so right yeah really really

interesting conversations there too right now before they get a biopsy are they doing this uh polymeric mri first before they're doing a biopsy is that how it works or um well basically the urologists deciding which goes first we have the test actually cost about $700 here in Australia which would be about 500 US dollars maybe and we know that the MRI will actually determine where the high-grade cancer is so what some of the doctors are doing is getting the MRI done first and then targeting their biopsy, which leads them to much better, more effective, more accurate biopsy results. But some of the doctors are not doing that because they don't want their patients to have that out-of-pocket expense initially and do the MRI just before

surgery. But it usually is included now. Okay, that's great. I mean, that makes sense to be more precise and do the MRI first. So yeah, that's what I was thinking. Okay, awesome. And so what options so let's say a man is diagnosed or has prostate cancer what options do they have regarding prostate cancer you mentioned radiation surgery can you talk a little bit about those processes sure well the first one they can have is something called active surveillance which means they're actually not getting treatment at all they're just getting their psa um annually checked or six monthly checked because they're the ones that have maybe had a biopsy and it showed only a low-grade prostate cancer is evident.

So they're just basically encouraged to look at their diet, lose a little bit of weight, maybe go on some supplementaries like turmeric and all the various things that are recommended these days and basically have that as an option without treating. And that's apparently about 60% of men in Australia. That's the way they're actually monitored in Italy. so that's one level then when you get to the point where it's a Gleason six or seven that usually means and there that's a number out of ten

it's at a point where it really needs to have some intervention so we generally then look at offering a man the opportunity to know about all options with something called brachytherapy being a a seeded form of radiotherapy where there's gold seeds actually placed inside the prostate, and then they're radiated afterwards. Then there's just normal external beam radiation therapy where men have to have about 39 treatments over a seven-week period.

And then there is the radical prostatectomy surgery, and that can be done either open laparoscopically or via a robotic-assisted technique. And then there's also the option of having any of those treatments in combination with androgen deprivation therapy or hormone therapy, which is basically giving man medication, usually it's injectable, where they have their testosterone suppressed, which basically puts them into a female-type menopausal situation. and exercise is now considered a part of treatment for prostate cancer as well so every man now diagnosed is encouraged no matter what state he's at to link up with an exercise program so we have plenty of men around australia in particular that are covering all those bases i have one patient at the moment who's been on active surveillance for nine years he's actually

84 and he participates in my exercise program a couple of times a week he's been doing it for the last five years and his PSA just isn't rising so there's never been any treatment for him so if prostatectomy is involved they remove the prostate I know you deal a lot with this how can a man regain his sex life back because I know oftentimes the pelvic floor function is compromised and urine control is often a common issue so what is what is your approach and what does that look like? Okay well basically we know that if you're having a radical prostatectomy we would expect 99% of men to have both erectile dysfunction and urinary incontinence and the pelvic floor muscle training has had extensive research to show that it is helpful at the recovery of both

in men and women. What we don't know is whether or not pelvic floor exercise training is helpful in men who have radical prostatectomy surgery so does it basically help improve their erectile function so that's what my own research is currently looking at because um in about um 2005 a wonderful physiotherapist in you know uh united kingdom doctors a great story did actually do quite a bit of research that showed that men who had erectile dysfunction if they did three sets of pelvic floor exercises per day consisting of each set having 10 pelvic floor lifts and let go for up to 10 seconds three times a day that 75% of them had either complete recovery or improvement of their erectile dysfunction issues and that's been backed up by research since but not in the

prostate cancer population too much because the biggest issue that occurs in prostate cancer is that the nerves that are responsible for erectile function are wrapped around the prostate. So when you move any of those nerves, the cavernosal nerves, then there's going to be some damage sustained. So what the doctors are trying to achieve initially is something called nerve sparing. So their goal is to have as much of the nerve tissue left alone as possible

and to either do something called bilateral or unilateral nerve sparing. and all i'm trying to do as a physiotherapist is enhance whatever they've actually got going on naturally for them by giving them lots and lots of education on anything that would help improve erectile function through basically the promotion of blood flow in any capacity so i spend a lot of time pelvic floor exercise training reinforcing that but also i work a lot with sexual health physicians and neurologists here in Australia regarding penile rehabilitation, which is the use of any device or medication or tool to actually assist erectile function recovery

following a radical prostate. That includes medications like Viagra and Cialis. I do lots of education on that because I find the doctors are just handing over scripts with not much kind of information around them. and then vacuum compression devices and then there's penile injections with exercise as well I always say any blood flow including you know self-stimulation masturbation is important to get the blood flow through such as the cardiovascular exercises achieving the same in whatever capacity even if they're doing a 45 minute walk every day so I come from it from

many angles and see my role as like a lot of education as well right and i know we talked about this at some point on one of our forums together but the mental and psychological impact that these men go through because these are things that they in my opinion are often not discussed even before they have surgery and then they come out of surgery and it's like they almost feel that they've lost a spark of their manhood because of all of the aftermath of having a prostatectomy. Can you speak a little bit about that and your experience? Yeah, sure. It's, it's much more than a loss of a spark of their manhood. It's, it can be quite devastating. And this is what I was hearing. So when I first started working with my, my brother, um, I quickly worked out that the

continent side of things was improving if men were compliant with their pelvic floor exercises and their caffeine limitation and various things but what really concerned them was their lack of sexual function and that even in all the research I've been doing it's it's way higher on their distress scores as to the erectile function issues so we actually know that when men are first diagnosed they are in a bit of shock because they told they have cancer and they often only hear that and they might never be told that they're going to also have erectile dysfunction but usually I know here we always have that conversation a couple of times prior to the surgery but I've had so many guys completely forget that conversation or feel very um uncomfortable with

asking questions about it pre-operatively because I've been very concerned about the removal of the cancer so my own kind of passion has really been about making sure men have from the very first moment an open conversation with me that they've got two side effects of which both will happen both of equal concern and importance to me and should be to them and it needs to be conversations that they have with their doctors and their their partners at opportunities particularly if they want to ask questions to try and write them down perhaps if they're a little embarrassed to ask or just to never feel that that's not a conversation that's not okay to have because I've learned that when men don't have their manhood

or their erectile functions happening, they often don't feel like men anymore and with that a lot of loss of self-esteem and depression and anxiety. And it's a very real thing. We know that before the surgery only about 18% of men are concerned with their sexual function, but a year later about 70% are because it takes at least two years to get sexual recovery back. And unfortunately, the research shows that only about 30% of men are getting their sexual function back at two years postoperatively.

And what are some factors to the lack of progress or return of sexual function besides the, you know, you mentioned the nerve sparing, bilateral, unilateral, what's left? What other contributing factors come into play? Yeah, well, the most important thing is that it's the loss of the nocturnal erection. So I have a colleague in Sydney, psychologist Patrick Lombroso, who came up with a coin phrase of housekeeping erections. And men are typically getting six to eight erections a night or housekeeping erections, which basically means that they're getting like a 10-minute erection with full expansion

on blood flow while they're sleeping and during their rapid eye movement or dreaming sleep. And this actually keeps everything going physiologically. so the nerve damage actually means that these stop happening and Patrick's always said this equates to about 2,000 lost erections per year regardless of any sexual activity so it's like turning a major tap off overnight for these men who often go into the surgery average age sort of 60ish but often I get men in their 40s who have good very good erectile function prior to their surgery and wake up the next morning with no function so that conversation needs to happen that for the first six months if they don't start priming their own erections in some capacity

over time there's going to be shrinkage and fibrosis development of their penile tissue which is going to lead to their penis shortening quite a lot it can shorten on average about two and a half centimeters or up to four centimeters over time um hence short in the penis i don't think it's also relevant here uh too compatible with what men are generally seeing and feeling uh and really just again lack of conversation but we do say the phrase here use it or lose it and the first six months of laying down and keeping that penile tissue healthy is so important to ensure that when the nerves do start recovering that there is something to work with and not just sort of tissue that's disused and atrophied and that this

brings me to my next question is the topic of Peyronie's disease which is a huge part of your research as well you know can you tell us a little bit about that and and what you've seen that could be done about Peyronie's yeah well Peyronie's is a really interesting one because I'd heard of it but hadn't really had conversations with men about it and I knew that it meant that a man would have a curvature in his penis and that that would probably be a you know difficult thing to deal with but it wasn't until I had one of my patients knock on my door close to three years ago he was one of my younger patients who'd had a radical prostatectomy at 45 years of age and he was finished with me in terms of he'd had full continence recovery within a month of his surgery

his sexual function was improving and that he felt quite comfortable his PSA levels had cleared down to zero and he was really quite comfortable with things and after three or four months I said it's in your hands now you don't need to see me but I'm here for a backup and I now have changed my protocol because of this patient but he did knock on my door approximately a year after his surgery looking quite distressed and tearful actually and he said can I please chat to you? And I was like, absolutely, but just wait five minutes. I'll bring you in between patients because when a man is asking for help and they're desperate and tearful, it's a situation that has happened to me very often at all. So, uh, I really need to

seize that moment. Anyway, this guy, uh, basically wanted to show me a picture of his penis and he said please don't you know be um you know kind of perturbed by this i'm i'm not trying to be rude but this is what my penis looks like and quite seriously i was really shocked and i was immediately quite distressed for him so his penis was like bending at an angle of about 85 degrees to the left and then rotated upwards and he said is my cancer back he thought that because he could feel lumps in his penis when it wasn't erect when it was flaccid and when it was erect when the blood flow had profused to all those areas it was showing that it was markedly bent and so he was terribly distressed by this and had been reading up and thought that he'd developed penile cancer

and I basically said to him we need to get this medically assessed first there's penile scans Doppler scans that we can do I think it's something called pyrones but I'm going to help you sort this out so my trusty brother who always comes to my rescue when I'm trying to work out slightly complicated things I sent him the photo and he said bring him in anyway we went and had this Doppler scan at that stage my brother said the only treatment for this man is surgery and surgery we really wait about two years for because we want to get it to a point where it's this condition is stabilized because it takes about two years to stabilize and basically it's just when there's reduced blood flow to an area in the penis in the cavernosal tissues it starts to

tighten up and develop these plaques which over time can develop into a calcification in its early phases it's more like a hard like pea-sized nodule that can get thicker and bulkier and um this is what this man was feeling uh so over the years probably i don't know thousands of dollars and thousands of research and medicines have gone to trying to treat this condition but it's remained elusive it's a very difficult one to treat um so i i decided to see what what was going on and found that in reticuloprostatectomy there was up to 19 percent of patients actually having this problem arise after a year of their surgery which compared to one to three percent of the normal population so this was screaming at me really because that meant that one in five

or six of my patients was going to end up with the same condition so I put my hat on and went to work on that. And what have you been doing for that Jo? Okay well I wanted to try and come up with something non-invasive because always when I've been dealing with these men with prostatectomies I've been really mindful of trying to minimize all of their digital examinations and things I've always used ultrasound as my primary approach when assessing men for pelvic floor unless I'm dealing with pelvic pain when I do both but it occurred to me that something like ultrasound is normal everyday therapeutic ultrasound might be a helpful way of addressing this and I started looking into research and found that there had

been one paper done in 1983 which had looked at this and one physician had done a group of 26 patients with pyrenes disease and used ultrasound and found that 19 of those men had shown some improvement and that there was recommended for further research but no further research was done so that was really quite enlightening and I spoke to several physicians and sexual health doctors and I said what do you think of my idea and they said well I'd be surprised if it hasn't been tried before because everything else has and shockwave shockwave therapy is the current thing of the moment anyway um right it it appeared that there wasn't too much going on it was almost like physical therapists had the ultrasound as their tool and no one else was really using it

um so i started working with this guy and within just in a few short weeks those um plaques that he could feel started to soften up and then we basically started using a vacuum pump in conjunction with the ultrasound and he'd confessed that even though I'd recommended he'd never used that vacuum pump. So in those initial eight or nine months when his erectile function was improving, he didn't actually do the full stretching so he missed out on his full erections. What surprised me and the radiologist that I was working with that as we went along with just the ultrasound initially the area of fibrosis in this patient started to diminish and then he had actually had some small calcified regions which completely resolved and this was a great shock

for the radiologist because we only have one person in Perth Western Australia that does these assessments and he said if I hadn't seen it with my own eyes I would never have believed it then it came to just straightening out the curvature and that's when I became a little bit more proactive with a vacuum pump because there has been quite a bit of research to say the vacuum pump does help in the straightening but my goal was to soften the plaque and then stretch it just as we would with any other soft tissue muscular type injury in in any human body so it was the combination of the two physical non-invasive therapies that I'm pleased to say I've had some really promising goals with and not just in the men who've had it for a short period

of time but even those who've had it for a number of years have been able to benefit clearly though if the calcifications have come to a certain size and I've got men who have presented with these three centimeter calcifications in their penis they will not respond to the ultrasound so my intervention really is going to be about education once again and letting men know to check their penises and to be aware that if they notice any change in angulation or curvature that's potentially a sign of Peyronie's disease but not only that it's potentially a sign of cardiac vascular disease and I've coined the phrase that hard health is a mirror of heart health and that's because there's research around that abounds with the knowledge that if erections are beginning to

diminish that is potentially a normal aging process because we know that 10% of men every year after the age of 40, sorry, 40% of men at the age of 40 have signs of erectile dysfunction and it goes up 10% every decade. So 50% of men at 50 and 60% of men at 60 will start to have this happen. But if there's a sudden change or just a diminishing over time, this is an indication that the small blood vessels perhaps aren't dilating and they can really mirror what's going on the large heart vessels. So Peyronie's can be a good indicator of other things as can the erectile dysfunction generally be. So it's just one of those things that men should be on the

lookout for. Right and that's fabulous. Thank you for that summary. You mentioned one to three percent of the normal population will present with Peyronie's. What other risk factors other than surgery or direct trauma to the penis can predispose a man in your opinion to having these plaques accumulate okay well we actually now know that it's about 10 of men that normally um get this problem and i think again because in the us there was a study done where men being screened for prostate cancer were just asked in a questionnaire of whether or not they had pyranies or any of these plaques and it's always felt that you know up to three percent of men was the was the standard but it turned out it was 9.8 so that was that was one thing um what we now

know from that is there's a genetic predisposition so um if there uh there's a 33 chance that any man who has it um his father especially if he has something called dupuytren's contracture which is a uh the fifth finger tendon contraction um into a flex position that's often uh a clue that so there's a one-third risk if a man has this that he will also have Peyronie's and that if his father has this that there's a one-third chance that he will also potentially have Peyronie's that it's the white Caucasian population that is more likely to have Peyronie's and also very interestingly if there's an A positive bedtime I learned that from another physiotherapist in South Africa when was there just a couple of months ago and then diabetes and smoking and and obesity and weight

gain so this is a really interesting statistic um if if a man loses or gains sorry 16 kilos so about two stone in weight he loses an equivalent inch of penile length because everything sort of retracts back in it's known as fatal retraction because of the weight that goes over the the ones he was the fat pad causing compression and that retraction so as soon as you tell a man that if he's going to gain that weight that his penis is going to shorten they're pretty quick to get themselves into shape and and lifestyle choices um yeah lack of lack of exercise and yeah lack of general fitness bike riding as well um one time i remember being a parent at one of my um school assemblies with my children and there's a guy here that does some cycling for a children's

fundraiser called telethon and he had been on a push bike for 24 hours cycling um to raise money and um basically what happened was he said I said how did you go how are you feeling how are your legs goes my legs are fine but I do have numb nuts and he had this big laugh and he goes last year when I did this I couldn't feel my nuts for like four weeks and I was like that's not funny you're actually doing some damage there like there's some nerve compression going on like there's special seats that you can do to protect that area prostate health seats and this is not something that you know you should think is a normal thing to occur and then he said well there's actually a cycling group in Perth called the numb coccytus club and I'm like

so this is a really normal thing for men to get numb nuts from cycling that's not a good thing so you know again what can i say education knowing what's normal and um i always say that i think women are at an advantage because we have this monthly cycle and when we have menstruation if anything changes from one month to the next in the lead up or afterwards or during we can pretty much clock in with what's going on innately and the first thing we'll do is ask our mom or sister or girlfriend and check in with them and have a conversation and if they sort of you know confirm our worries or disqualify them then we're usually okay with it or go off to see a physician quite quickly whereas guys don't have that monthly kind of thing going on in their own body so I think

it's really difficult for them to cue into change like biologically sometimes and you know the sad thing is that men live five years less than women all around the world and um that's something that's really shocked me because i have two sons and a daughter and i don't like to think just because they're an xy chromosome that they're going to have five years left lifespan but it's it's it's fact right right and that brought me to my last topic with you is you know mouth you mentioned that men's health issues in general i think that most men and doctors don't focus on in mentioning or educating and you're so huge on educating and and we talked a little bit before we started recording but tell me more about you know why do you think that is and what is the psychological

impact that these men go through to one to even request or seek help um and and why that statistic is so actually daunting right five years less than women life yeah thanks Susie and this is really where it intrigues me and that's that's the conversation that I'm having a lot with others and it's great to have this conversation with you because I did have the opportunity in the last 12 months to do teaching two-day workshops in England, Ireland, Portugal, New Zealand, Australia and South Africa and whenever I go and do teaching I always try and work out where the men's health statistics are for the particular country i'm going to just to be relevant and every situation i was shocked to learn that there was this gap and often this five-year gap is even more so

so in south africa an average man lives to 59 and a female 66 so it's a seven-year gap in japan it's an eight-year gap in australia okay it's a five-year gap in the u.s it's a five-year gap a world health organization says an average man around the world lives to 68 and a female 75 in Australia it's 80 for men and 85 for women we're really high up there but wherever you go this five-year stat resonates and that is what I've been trying to pursue and historically speaking I think it goes back a long way that men do a lot of activity historically based on activity and with our society becoming less active as we sort of move from third world to first world and a lot of our downtime is sitting time that's when all of our sort of civilization

syndrome type issues of diabetes and obesity depression and anxiety are coming to the fore and now reduce cardiovascular fitness so I think that's possibly the biggest from my understanding but then culturally men have always been um the protector and the fighter and the warrior and for any uh thing to go wrong or for any signs of weakness to occur it's a pretty difficult thing to stand up and say hey i've got a problem um to another man and i can see it in in the men over 50 they've got a completely different um approach to their health compared to the men under 50 So there's this generational gap quite often. I'm delighted to see we have so many campaigns like April being

Testicular Cancer Month and International Month of Prostate Cancer being September and Movember being a campaign for men's health cancers and depression all around the world. So conversation around this topic hasn't been forthcoming but it is changing. And then lastly, I think that boys are just raised to be tough, to show resilience and to be strong and that showing any signs of weakness or being tearful is often they're referred to as a girl or as a sign of weakness so there's all these social

situations probably even worse in social media in some respects these days where everything's highlighted and yeah traditionally I think men just fear showing weakness so all of those things, but I, I'm not a guy. So I'm asking guys all the time and, um, learning from them. That's wonderful. And do you guys, do you feel that guys are very open when you ask them these questions or do they look at you like you're a chick? Why do you care? Yeah. Well, uh, I actually, I have asked that question to my patients as well. Um, surprisingly, they're usually really comfortable and they often say to me, I've spoken more to you about my penis on my private parts

than I have to my wife or to my partner. I have quite a few gay couples as well, and they're so open and it's brilliant to be able to have these conversations because I let them know from the first time I meet them that it's my priority, that their whole health is my priority. It's not just their continence, that their psychological health is tied into their physical health and that, you know, for them to feel them that we want to try and restore all functions.

a couple of men had said to me it's really comfortable to talk to you because you being a female I know that you you've got problems down there down under and so you know all about it only last week I actually had a another male physio come and do some observation in my clinic and this patient said to my surprise that he felt much more comfortable with a man being in the room talking about his anatomy than with me he said but now I've got to know Joe I'm comfortable with that but at first I was a little mortified that I was going to have to discuss this um when I'm doing my Peyronie's treatment and that's usually just using the ultrasound directly onto that fibrotic area then the man has to walk in and basically pull his

pants down and that may be something he's never ever done to anyone or to only his one long-term partner and so I couldn't imagine how more vulnerable a man would feel so I really have to be very very gentle and respectful in that situation and um it's taught me a lot on how to deal with all of those awkward moments because they're very real for men and um yeah I think they're so desperate to get help and to feel normal that they are prepared to to do this and um I've had 40 guys um volunteer for my Peyronie study and I thought that would be difficult to achieve and I've been surprised at how forthcoming they have been because obviously it's a it's a real big issue a lot of time it can stop them from having sexual function and the ability to

have any penetration as well as well as it being painful so yeah it's um it's a great question suzy well you answered it so eloquently and beautifully and honestly joe thank you so much for your time i know that you're a busy gal and it is your monday morning right is that correct but it's a great time i'm actually off to i work one day a week in a clinic that's especially devoted to men's health and a gp that's been working the field for about 20 years asked me to move my clinic to his clinic and i said no no i have my own building in my own clinic but i'll come and do one day a week with you and it's been awesome because there's psychologists and sexual health doctors so this is my monday where anything walks through the door seeing quite

a few transgender patients as well together now so we're trying to make it a comfortable conversation for everyone wow that's awesome joe again thank you so much joe for talking about such an important topic and helping men all over the world feel less shy about their private parts and encouraging them to be more proactive in their health you truly are changing the world for these men by opening up the conversation for them to be heard and to feel supported so kudos joe thank you for being you and for what you do my friend it is it's been an amazing inspiration across the board for all of us for me and all different colleagues and these men so thank you so much how can our listeners connect with you if they want to get in touch with you

or follow you on social media well thank you so much suzy um it's really humbling to have those words said about me but equally to you and what you're achieving in men with pelvic pain it's it's a burgeoning area and you're helping change the landscape on that to contact me i have a twitter name it's prostate jojo um jojo was always my nickname and a urologist decided that would be most fitting for me so i'm at prostate jojo i have um a website i actually have two so a website is just men's health physiotherapy all one word dot com dot au and then an exercise program that i run for men with prostate cancer it's www.prost.com.au and prost just means to your health it's a word that is used in Germany to say cheers and then I have I'm just on LinkedIn as well as

Joe Milios and I just wanted to add my the colleague I was talking about Patrick Lomboso so passed away this month sadly with brain cancer. But I'd really like to share his website as well because he's taught me a lot and he's dedicated to sex after prostate cancer. His website is www.lifeafterprostatecancer.com.au and he's a very knowledgeable man who's spent his last 10 years passionately helping men with a free e-book all about relationships that you can download.

So I really want to spread his work as well. And guys, it really is. I have checked out Patrick's website, and I'm so sorry to hear that because he does, just based on what you were saying, and I've never met him, but his passion for what he does really resonates through that website and through his words. Really, it's amazing. Yeah, and he does actually have a whole online website as well

called erectionrehab.com. So that's www.erectionrehab.com.au. and he went around the world so he was doing a phd as well to try and find all the best products for men that were medically viable and his wife is basically continuing his practice in sydney with the help of some other psychologists now that he was training up before he passed away at the young age of 52 and um yeah so that's a wonderful resource that people can get online help with their sexual health needs wonderful oh thank you so much for those wonderful nuggets joe again, thank you for your time. Thanks for being here on the show. This has been a fantastic

episode with you. I wish you a really wonderful day and keep on keeping on, my friend. Nuts to gun style. Thanks, Susie. Nuts to gun style. That's right. Thank you, Joe. Thanks for listening to today's episode. Be sure to head on over to drsusieg.com where you can get more information, show notes, and related articles on today's topic. Also, if you like what you're hearing, head on over to iTunes, subscribe to the podcast, and leave us a rating and review. We'd love to hear feedback. Thanks again. Is this a one-two-chuck kind of thing or what?

Yeah, yeah, yeah.