In Your Pants with Dr. Susie G - Shockwave therapy for erectile dysfunction

Episode Date: May 8, 2020

There is something super exciting bubbling in the world of data, research, and scientific tests: electro-hydraulic shockwave therapy for erectile dysfunction and pelvic pain! Dr. Rachel Rubin is my guest on this episode of In Your Pants! A urologist and one of only a handful of doctors fellowship-trained in male and female sexual health (this knowledge and expertise is not as common as you think!). She practices in Washington, DC and is an active educator through professional networks and social media. Tune in to our chat about: commonly used medications by urologists and their impact on male sexual health (like Viagra, Cialis, Flomax, Tamsulosin, Finasteride and injections), low-intensity shockwave therapy for ED, PE, and pelvic pain, her involvement in the first clinical trial on shockwave therapy in the US, and so much more!

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 guys, it's Dr. Susie G here and welcome to another In Your Pants podcast episode. I'm so excited that you're here with me today. On today's show, I've got guest Dr. Rachel Rubin, and she's a urologist and one of only a handful of doctors that are fellowship trained in male and female sexual medicine. She practices in Washington, D.C. and is an active educator through professional networks and social media.

Today, we're going to be talking about some of the commonly used medications by urologists and their impacts on male sexual health. We're also going to be chatting a lot about a new modality called low-intensity shockwave therapy for erectile dysfunction, pain, premature ejaculation. We're going to be talking about what does the research say so far. Dr. Rubin also shares with us her current clinical trial in the US. She's the only one. They're the first ones to be doing this at her office.

And we're also going to be talking about just sexuality, intimacy, and how improving your sexual health can actually improve your partner's sexual health and function as well. So we're going to be going into the research about that. So you don't want to miss this show. It's a really good one with some very practical advice and words of wisdom from Dr. Rubin. And I hope you enjoy the show. Dr. Rubin, thank you so much for being on the show today. I'm so excited to have this conversation with you.

Thank you for having me in this crazy world we live in. It's so exciting to be learning technology and being able to advance telehealth and telemedicine. Yes, and this will probably be posted at some point in the future. So I'm going to just brand this as the COVID-19 era that this is being recorded in. And yes, crazy times indeed. So again, thank you so much for taking the time to be here with me and the listeners today. Happy to be here. Well, let's just get started about, let's just tell everyone what you do and what your passions are in your work.

So I'm a urologist. I am one of the very few people in this country that are fellowship trained in both male and female sexual medicine. So there are a lot of fellowships around where you get extra training in male sexual dysfunction, but actually only one in the country that even acknowledges female sexual health, which is pretty astounding. And so in my practice, I'm in Washington, D.C., and I have a private practice that is completely focused on women's and men's sexual health. And so we do really long visits. We see men, we see women, we see couples, we see non-binary folks, anyone who has sexual problems, which ranges from, you know, the 14-year-old with pelvic pain to the 98-year-old and everything in between, which is really, really exciting. Oh, that's so great because we know that there's such a need for your type of work and my type of work, especially when we're talking about men's sexual health. We were just talking about this off the camera, but how that is just such a need to support men in their sexual health, urological health, etc.

You know, we get really bad training in medical school about sexual function. We learn how to say, oh, do you have sex with men, women, or both? And don't get pregnant, don't get an STD. But we have a really, really not good training in sort of how to go beyond that. And I don't know you, but I rarely go to the doctor where I spend more than 10 minutes for anything. And so I've never had a doctor really ask me about my sexual function. I've never had a doctor really seem to care about that. And yet sexual health is this thing that everybody doesn't really know much about. We didn't get good classes in school growing up. And so how do we do a better job to take care of people? Because sexual health is just health. Problems happen. And what do we do about those problems? Right.

And they're really important because, you know, Maslow's hierarchy of needs, pooping, peeing, and sex are basic physiological needs of everyday function. All right. Well, I've got two out of three. I do urology and sexual health, but I'm going to stay away from the poop part of it. The poop part. Well, physical therapists will take care of that as well. And the GIs.

You guys can take care of the GI stuff. Right. That's awesome. Well, let's kind of jump right in into sexual health and I think medication use, because this has been something you've tweeted about before, about being careful with what type of medications are being prescribed for men and if they're really necessary, like Flomax and finasteride. Let's talk about those medications and the implications of sexual health for men. Happy to. Yeah, I've been tweeting a lot about this recently because

anytime you take a medication, there are potential side effects. Now, as a physician, when I prescribe these medications, it's important to explain what the side effects are. But it's also hard to tell people all of the side effects. But the really common ones can really surprise people. And there's also, both for men and women, if you take medications that affect hormone balance, there are consequences. Now, sometimes there are good consequences, right? If I have a woman in menopause who has hot flashes and I give her estrogen, she feels better. That's a good consequence of that hormone. If I give a woman a birth control pill, she may have increased in low libido or sexual pain. That's a bad consequence of a hormone, but it prevents pregnancy, which is

a good consequence, especially in this quarantine age. Babies really complicate things a little bit with childcare. So for my male patients, many medications can affect sexual health, whether it's a blood pressure medication causing erectile dysfunction or urologic medications, which can affect erections and sexual function as well. So happy to go into details. Some of the common medications that guys are on for urinary health, medications like alpha blockers, Flomax, things that help you flow better and pee better. When that channel of urine is open and wide, the urine and the ejaculate then go the path of least resistance. And so what happens when you take medication like Flomax, many guys will experience what we call retrograde ejaculation. So they may

notice decrease in their ejaculate or complete absence of their ejaculate, which if you do not warn a man about this, it is shocking. He will call the emergency room and say, doc, what the heck just happened to me? Now, if you tell him before he takes the medications, Mr. Smith, this is going to potentially cause a decrease or a lack of ejaculate. and your partner may not mind because your partner may find it less messy. It's not dangerous. It's not going to hurt you. It's going to just be surprising. Then when it happens, he says, oh, Dr. Rubin told me about this. It's really no big deal. I still experience orgasm and man, am I peeing? Great. Usually it's okay. That being said, I have quite a number of men who I've seen

who said, God, I wish the doctor had told me about that. I actually really like my ejaculate it. And I wouldn't have taken this medication if I had known that. And I think it's what you're saying is just, we need to do a better job of educating guys about what they're taking and the impacts on their body it has. You know, it's really complicated, but informed consent is really important. I take care of a lot of men who are prostate cancer survivors, and many of them wish that they had more conversations about quality of life before they had their treatments. Now, I see men before they have their treatments at times, and it's hard to really understand what erectile dysfunction

is going to look like, what stress incontinence is going to look like when you've never had these issues before. And when you are here, there's cancer in your body. We have to kind of do the pros and the cons and figure out how to treat that. So these are complicated issues. Absolutely. And just even having that talk of you have cancer in your body, cancer of your prostate, you know, we might be talking about all these things, but what is really being heard is cancer, cancer, cancer. And I want this out of my body. Let's do this. Just the word cancer causes sexual dysfunction and pelvic floor dysfunction, I'm sure. Yeah, 100 percent. Very scary. OK, so let's talk about you mentioned blood pressure medications. There was a recent article not too long ago, and I can't remember who written it, but there are some there's some things you can do with blood pressure medications or there's a combination of blood pressure medications that are less impactful on sexual function. to you? So if you, and I'm happy to share the recent AUA guideline update on erectile dysfunction, it's sort of, we have lists of what are the common medications that can

be harmful for erectile dysfunction. That doesn't mean go off your blood pressure medications. High blood pressure is very bad for erections. Okay. We can talk about the cardiovascular impacts that we see with erectile dysfunction, but we, it's nice to know about if you say, okay, this metoprolol, I need it to live, but it may worsen my erections. Well, then your doctors can work together to kind of say, okay, how much do we need this medication versus a different medication? And it's a little bit of a trial and error. Do we add something to help with erections or do we switch around the medications that may be causing the underlying problem? And it's a little nuanced and it's not the same for every patient that I see, which is why

if you only have a 10 minute visit with someone, there's just, there's no way. Right. Right. That's really difficult. Okay. So definitely individualized. I'm hearing definitely have taken consideration of the person in front of you. Now, what about like Cialis, Viagra? I wouldn't say off-label use, but for those guys who are younger or perhaps healthy and their erections are healthy in their older age, but choose to use it anyway. I mean, are there any ramifications of using these medications for just their own natural function or what is your thought? What do you think? What are your thoughts on using Cialis and Viagra when you kind of don't need to use it, but are using it? I guess that's my question.

You know, I think it's a new, it's an interesting question that you ask. You always want to work with your doctor who's prescribing these medications. You don't really want to borrow your friend's Viagra or Cialis. You want to make sure you're getting it from a physician and you're understanding what those side effects might be. No medication is benign. No vitamin is benign. No physical therapy session is benign. And so you have to be with a professional who understands what's happening to your body. So the way these medications work, it's a class of medications, Viagra, Cialis, Levitra, Stendra. They're PDE5 inhibitors, which is a wonky way of saying they're muscle relaxers.

they work on smooth muscle of the body to relax the penis muscle, to let blood flow in and to make that erection strong. Now, unfortunately they act throughout your whole body. And so many guys will complain of chest pain, which can be indigestion. Guys can have runny noses. They can have flushing. They can have muscle aches. So these are not medications that don't come with side effects. And so it becomes the risk benefit. Many guys get headaches. And so if you don't need it at all, your erections are strong. I'm not sure many guys who are going to say, oh, I would love to have a headache tonight and have my penis work the same way it works if I don't have a headache. And so it becomes the risk benefit. Now, if I have a young guy who has really, really bad

anxiety when it comes to sexual functioning. And anxiety is adrenaline, which contracts muscles. And so if I'm trying to get his brain to calm down and his muscles are contracted, so he loses his erection, then maybe giving him something like a muscle relaxer, like Viagra or Cialis is sometimes very helpful and not that risky in terms of I'm worried about causing much harm. These are pretty safe medications. And so I think it's, again, a nuanced approach. They're over the counter in, I believe, England. And so they wouldn't be over the counter if everyone was so afraid of them causing harm. But if you take a whole bottle of aspirin, which is over the counter, obviously that's very dangerous. So you really have to

understand how the medication works and why you're using it. Exactly. Great answer. Thank you so much for clarifying that. So moving into some other modalities other than medications is a new thing, I think, low intensity shockwave therapy, particularly for sexual dysfunction or ED. And I know you mentioned you're doing some clinical trials in your office as well. Can we talk a little bit about what's going on in the research world with that? This is probably the most exciting, most fascinating thing that's going on in the world of erectile dysfunction right now and also controversial. So they used to, in about the 80s, they had this thing called shockwave. It's an electro-hydraulic shockwave that they would put on someone's back. And it was a big

sound wave, really powerful sound wave that went through the side and was able to break up kidney stones. And it was crazy. You didn't need surgery to get kidney stones out. It would break up the kidney stones. And everyone said, well, that must cause so much damage to all the surrounding tissue. And so research went into figuring out, well, if you, you know, how do these sound waves really affect the tissue? And a basic science research showed that if you lowered the intensity of the wave, you actually improved sort of angiogenesis, tissue activation, a stem cell response. It was actually an anti-inflammatory and good process. And so, of course, someone in Europe said, hey, what happens if I put this on my penis? Of course, it was Europe. Of course,

right? We wanted to know, okay, what happens? About 10 years now, there's been a lot of research coming out from our European friends that show a very specific type of acoustic wave put on the penis in an unfocused fashion can clinically significantly improve erections. Now, a recent studies showed it may work as well as Viagra or Cialis. This is the first time we have something with data behind it that shows meaningful improvement in your body's own tissue. It's really important that people understand that because Viagra, Cialis, injections, penile implants, these are all band-aids that are working around the problem. This could be a treatment that actually fixes the underlying tissue health. However, it's not perfect. If you get a guy who

has absolutely terrible erections, he's not going to be a porn star after a shockwave treatment. Okay. It's also really important to understand that this 10 years of data are on many different machines, many different ways, energy levels, many different number of treatments. There hasn't been a lot of standardization of it which has created this big snake oil market of people who say they have shockwave machines or branding their shockwave machines and they all work differently and many of the energy levels are completely different many of the focuses some of them are very uh their focus level is the size of a pen eraser as opposed to an unfocus which gets to the whole shaft pretty much and so it's really hard and a lot of people are charging a large

amount of cash to get these treatments. And they're selling hope for men. And so we're very lucky. We have been involved. We're going to be a part of one of the first real placebo-controlled, randomized controlled trials for shockwave, electrohydraulic shockwave therapy. We have the machine from Germany that is the real electrohydraulic shockwave. And we're going to do science, right? It's all about science. You have to, you have to put these to the test. You have to do research. And so we're combining with a couple of other universities and big research centers where we're going to bring guys in and do a scientific test of these shockwave treatments. That's the way to do it. We have to force science to move into the future,

but you also have to understand that it might not work. Right, right. And I have two questions. The first question that I'll ask is, have you noticed any, particularly with these unregulated frequencies and intensities, and we don't have the doses quite yet, right, or standardization, have there been any harmful side effects? So what I will say is it's hard. I can't speak to all the machines because there are many different machines out there. Some machines are being used in veterinary offices. Some machines are being used by chiropractors. Some machines are being used, and there's different types of technology that are being used.

So some of these ballistic radial waves, and I'm by no means an engineer who can speak to all the details, but some of them are very painful. Some of them require you to put lidocaine on the area and they're actually damaging or hurting the tissue to bring in that activated response of healing, as opposed to some of the other technology, which isn't painful. And it takes a longer time to notice that stem cell activation. And so where I haven't, there's always risks. Anytime someone tells you that there is zero risk, zero harm that can happen, you always want to be a little skeptical of bad things can always happen. And you also want to know who's doing this treatment for me. If you have a naturopathic

doctor who's never worked on genitals before doing your penis shockwave therapy, you may want to take a step back and say, what does this person know about my anatomy down here? If your dermatologist is putting an injection of platelet-rich plasma into your penis, you may want to step back and say, hmm, does my dermatologist fully know all of the things that can go wrong with my penis right now? And so I think it is really important to work with a professional. Same thing happened on the female side with lasers, you know, something like the Mona Lisa treatment or some of these other technologies for vaginal health. Do you want your dermatologist doing your vaginal treatment or do you want someone who understands vulvar health, you know, giving you that treatment? So I think

that's really important, important point. There's also some excitement with the technology is actually doing the therapies in the erect state. So if you inject the penis and so it can be full of fluid, the shockwaves work better in fluid. And so we're doing some research to say, well, if we inject you into the erect state and do the shockwave treatments, can we get a better response? Got it. Got it. And so who would, so my question would be then what if there's, Well, there's, I feel like there's always some sort of psychological component to erectile dysfunction. Like, you know, if it happens once you're, we're going to be thinking about it again. And I think that's quite normal, but to some extent, you know, how do you, how do

we address that component as well? Especially if it's not, um, a blood flow issue per se. I mean, is this, am I thinking about this wrong or? No, not wrong at all. So, you know, that's why I love what I do because this is a biopsychosocial approach. Okay. Your brain, last time I checked, was attached to your body. So if your brain, if you're running for, tell your patients, I say this all the time. If you're a guy and you have a tiger chasing you, do you want to have an erection? You're going to get eaten. Okay. So this idea of adrenaline, adrenaline contracts muscle. So if you're in your head and you have anxiety and you're with your partner and you say, oh, is it going to work tonight? Is it not going to work tonight? Is the Viagra going

to kick in? You have now created adrenaline, which is actively squeezing out your penis muscle like a sponge, squeezing it out so that it is not hard. And so of course the brain is a huge component, which is why a lot of times the placebo response is very strong. Because if you tell someone, hey, you've gotten this shockwave therapy, your penis is going to be good. Or you've taken this Viagra, your penis is going to be good. That calms the tiger in your brain, which allows relaxation, which is going to make the tissue work better. And so not that there's anything wrong with the placebo response, but that's why we need to do research and scientific studies to say, okay, what is real and what is a placebo? Yeah. And in your studies, do you know, or can

you talk to us about how you're going to control for that? Yeah. So, I mean, everyone's going to get treatment, meaning you will have a sheet over you and the shockwave is going and you don't know whether you're getting the energy or not. And so everyone has the same treatment protocol, but you're blinded to the idea of if there's actually any energy going on. And so we will know ultimately, and we're looking at more parameters than just how do you feel. We're actually looking at ultrasounds and doing a stress test to the penis to say, how is the blood flow? Has the blood flow improved? Has scar tissue decreased? We can see scar tissue on ultrasound. And so if we can understand how that's decreased or if it's decreased, well, it's a home run. It's

a home run and it's very exciting technology. We are cautiously excited about this, but we're also very nervous about all these people who aren't trained in this, who are already selling it and not necessarily studying it. And they may ruin it for all of us because we're taking advantage of people's hopes. Right. Which is totally unethical. So sad. Well, you mentioned a couple of things about scar tissue. So it made me think about Peyronie's disease. Potentially, could this be another modality that might be very helpful? I know ultrasound is being used in a similar way in the physical therapy world. Do you have any... It's a great question. So for anyone, Peyronie's is curvature of the penis, and it's typically

an injury of some sort where scar tissue forms in the casing of the penis. If you think of the penis like a sausage, it's the casing of the sausage that gets scar tissue on it. So then the muscle is not able to expand fully and it curves around where the scar tissue is. And so shockwave actually has been looked extensively in Peyronie's disease and it works well for people who have pain. So if you're in the early stages of Peyronie's and every time you get an erection, you have pain, it works really well to decrease the pain and decrease how the plaque changes. But if you're someone who is in a chronic disease, you've had 30 degree curvature for a year or two and it's not painful, there hasn't been good data to show that the shockwave therapy helps with that. Now, that being said, it could help with the muscle inside of the penis to help make that healthier. And there are some research studies going on right now where if you put a

plaque softener like Zyaflex or Interferon and then do the shockwave treatment, could that be beneficial? So there are still experimental things going on. If you have these problems, you want to work with a physician who is thinking outside the box and who is willing to do experimental therapies, but in the setting of gathering data and working with societies and really trying to understand this better, as opposed to just taking your money and promising you the world right exactly and again not posing harm we do no harm first and and transparency and consent as you said earlier on in our conversation so right yeah absolutely yeah okay so you spoke about pain so that was my i know i had many questions before i said i have two questions

um this is probably like the fifth question i already had so pain um cpps cp chronic prostatitis I know that's an umbrella term. So actually, there's some pretty good data. If we're still on shockwave here, there's some good data that the shockwave does help with chronic pelvic pain. Again, we're going to have to see that placebo response. But there was a small study outside of Cleveland Clinic that did it in actually the same shockwave machine that we're doing our clinical trials on.

And so if you put this shockwave at the perineum and it has some penetration to it, and so it can get to some prostate inflammation, guys are reporting improvements in pain, improvements in urination. But again, we need to do larger trials with placebo control to see what improvements they're getting. I think my thought in the home run is going to be synergy, like everything in the world, synergy, right? If we work, if we maybe try the shockwave and physical therapy, uh, oh my gosh, the, the, I would love to do that study because I think physical therapy is so important for anyone who has pelvic, any man who has, um, chronic prostatitis or pelvic pain or anything he's told is going on with his prostate. There's no reason not to try physical therapy.

A hundred percent. Yeah. Because, you know, there's so much out there that says, you know, you can have these biomarkers of inflammation and potential bacterial pathogens even in asymptomatic groups um so you know is it truly you know again an itis and and how do we kind of work with within this realm i think like you mentioned earlier biopsychosocial approach like patient-centered person-centered let's especially quell the fears around what's going on in the world it's so interesting i had this call yesterday in the world of telemedicine i'm now talking to patients over the you know on

on zoom and video. And I had a young guy who said, every time I have sex with a new partner, I have burning immediately in my penis. So I go straight to the doctor. I get all my STD testing. It all comes back negative. I take antibiotics and the pain goes away. Is it the antibiotics? I said, well, if all the testing is negative and I know he has pelvic floor dysfunction. And he said, well, Dr. Rubin, you know, I went to see the physical therapist and in one session, things are so much better, right? In one session, I said, well, that's going to be the key, right? To figure out what is a musculoskeletal problem. I have a lot of guys who complain of penile burning, urethral burning, and it turns out it's their back pathology or their hip pathology or

their pelvic floor pathology. And my pelvic floor physical therapists understand that, But my doctor colleagues, this is shocking to them, right? This is, I am a wild card to them because I'm bringing up all these things that your colleagues have understood for a very long time. Right. Well, we thank you for being the wild card. You're welcome. And for the wonderful kind compliments and gestures.

I'm so grateful for all the things that you do. And we just need to get, get more of the word out there because it shouldn't be a, the problem is, is people are getting referred to physical therapy too late. And that's a big issue is you get these train wrecks that come in to see you where is if you got into their care earlier, you could have prevent so much just, just worsening of disease. Right, exactly. And, and we're a team, so I love that.

And we, we need definitely more practitioners on board saying the same message, because I think that's part, as you're saying, there's so much stuff out there and there's confusing and mixed messages and there, and, and to this day, uh, men are hearing, well, there's nothing I can do for you. You're just going to have to live with it. This, Oh, you got this, you know, you're screwed basically. And then that, then that is a seed planted. You cannot, you cannot take that back. once it's said it's like toothpaste you squeeze it out good luck trying to put that back in it is so complicated and one thing i value is my relationship with physical therapists in in they all have my phone number they all have my email they all can help me they know that they

are my equal team members to say okay how do we get this person better whether it is with hormones therapy medications injections pills uh shockwave therapy more physical therapy, relaxation support. What do we need to do to work as a team? And we do the same with the mental health crowd as well. And how do we do that biopsychosocial approach to get people better? A hundred percent. Yay for teamwork. Thanks, Dr. Rubin. It's still a challenge. We still have our challenges. That's right. Well, one step at a time, right? I mean, one foot in front of the other. There's so many metaphors for that. The key is listening to people,

giving them empathy, validating what's going on with them and letting them know it's not normal for you to be in pain. It's not normal for your erections not to work. And even if it is normal and a part of aging, there are so many things we can do to make it better. And it may mean that you have to do things that you didn't have to do when you were 19, but figuring, getting your head around that and working with a team to say, that's okay. How do we change the dance? That doesn't mean stop intimacy altogether. And it happens too often, right? Oh, well, my wife has pelvic pain and I have erectile dysfunction so we don't even hold hands anymore and that's where it gets really sad because it's hard to recreate intimacy when it's been lost for so long well exactly and

and I think this is a great era that we're living in right now because of the social distancing and all that that's going on of we finding creative ways as human beings to remain socially connected in different ways and intimate in different ways and that might challenge some people's views on their meaning of what sex is and what intimacy is. And I think this is a great conversation to be having around that is how do you, how can you still have a profound experience? How can you still feel connected with your partner or partners, uh, in the midst of, of adversity or, or changing in the environment? And, um, yeah, it's just kind of showing us we can't stay fixed in one way. And it's such a good point. And what I will say to men who have prostate cancer or who experience

a back injury or something, or my female patients who develop problems, the dance changes, right? I saw a really sweet couple recently where she said, I can't have an orgasm anymore. And I said, well, what used to work for you to have an orgasm? She said, well, my partner would just put his penis on this one area and it would work and I would get an orgasm. I said, okay, well, have you tried other things? Have you tried vibrators? Have you tried hands? Have you tried other ways? And She said, nope, I haven't tried it, right? And so it was giving her that permission to say, okay, now we have to try new things, new positions,

new devices, new ways to, how do we enhance and make intimacy better? That doesn't mean penetration. That doesn't mean orgasm for many people. But how do we give you pleasure? Because at the end of the day, why do we try to fight coronavirus? Why do we try to stop cancer?

It's so we have more time with our loved ones, more time with the people who matter in our family. and experience pleasure in our lives. So pleasure should be promoted, supported, and really focused on by the medical community. And we're doing our best. And you have to do that through that biopsychosocial approach. It is not owned by the mental health world.

It is not owned by physical therapists. And it's certainly not owned by me as a urologist. But I play a small role in all of this. And I will fight as much as possible to shout it from the rooftops. Oh, what a positive message. Thank you, Dr. Rubin. That was amazing. Well said. Well said. Now, I know we were already talking about this, but there's this last topic I wanted to kind of brush up on is how when we improve, you know, help with ED or any type of sexual related issue that a guy is

having, there was something you tweeted recently that it helps with female sexual function. I think you were at a conference somewhere where someone spoke about this, but can you, can you talk about that a little bit. Yes, happy to. I love science. I love data. I love tweeting out articles. So if you want to follow me on Twitter, it's RachelSRubin1. It's not a great handle, but RachelSRubin, R-U-B-I-N 1. I have an Instagram handle. I'm learning how to use Instagram, so maybe you can teach me. It's at Dr. Rachel Rubin, I think. So recently we tweeted out from a conference that showed if you give a man, I believe it was with Levitra was the study, but you give a man a PDE5 inhibitor, a muscle relaxer, and you give a woman a sexual health

questionnaire before and after a certain amount of time, her sexual function goes through the roof in terms of improvement. And we've seen it with if you treat Peyronie's disease. So if you do a Zyaflex injections to straighten out a curve in Peyronie's disease, and you give the partner a questionnaire before and you give it to her after, huge improvements in her sexual function. And it actually is shown on the other side too. I think if you treat, I haven't, I won't speak to what the studies are, but I know at least personally, if you treat a female who has pain or menopausal dryness and you treat that, her partner's sexual function is going to get better as well because sex is about a

team approach, right? And you certainly can have great sex by yourself, but you can improve your partner's sexual function if you feel confident, if you feel happy, if you're having pleasure, if you're in it and your brain is focused and in the moment as opposed to in your head saying, is it going to work? Is it not going to work? Yeah. And the one on top, not below guys. I just had to, I mean, it's just my flavor. I love it. You have to joke. If you can't have fun, if sex is not fun, you're not doing it right. Right at the end, you have to be able to laugh and have fun and really feel comfortable with the person you're with. And if that's not happening,

then you need to take a step back and say, what are we doing wrong? And how do we do better? Nobody is so good at sex. They can't get better. I say that over and over again. So how do we work? We all are overachievers, right? We have, we hire consultants. We hire people to do our gardening. We hire people to do all these things. And so how do we, uh, you know, find these coaches and find people to say, well, how do we make sex better? How do we make it more fun? How do we talk about it more. And you talk about it, not when it's happening. You do the debrief, you do the pre-brief. You say, you know, what do we want? How do we get better at this? And it's really fun and it's important to do. Oh, I love it. What a great note to end on, Dr. Rubin. Thank you.

That was amazing. You mentioned a few, a few handles that you're on, but can we summarize how else our listeners can connect with you? Absolutely. So we're doing a lot of telemedicine these days, but so we're in Washington, DC. Our website is Intim Medicine. Maybe we can post that somewhere. Absolutely. I'll link everything. Intimmedicine.com. Intimmedicine.com. And we're in Washington, DC. We all do, we do phone calls before we ever come down and see us. So we know that you're in the right place. We take a lot of time with people. We love to see couples whenever possible. And I'm loud on social media. And so please don't hesitate to reach out. And we'd love to work with you. Oh, that's great. We'll definitely link all of that information in the podcast show

notes. So our listeners will be very informed. So thank you so much again, Dr. Rubin for being on the show. Much appreciated. Stay home, wash your hands. Likewise, and much love to you and everyone on this planet. These are some difficult and challenging times and we're here to support each other. And I'm so glad again, we're having these conversations to stay connected. So as always, to our my listeners out there in loving wellness for your pelvis. This is Dr. Susie G signing off. Bye. 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

our rating and review. We'd love to hear your feedback. Thanks again. I have two questions. This is probably like the fifth question I already had.