The Checkup with Doctor Mike - The Truth About Low Testosterone, Sexual Health, & No Nut November | Dr. Rena Malik

Episode Date: November 10, 2024

I'll teach you how to become the media's go-to expert in your field. Enroll in The Professional's Media Academy now: https://www.professionalsmediaacademy.com/ Listen to my podcast, The Checkup with Doctor Mike, here: Spotify: https://go.doctormikemedia.com/spotify/CheckUpSpotify Apple Podcasts: https://go.doctormikemedia.com/applepodcast/ApplePodcasts Follow Dr. Rena Malik here: YouTube: https://m.youtube.com/@RenaMalikMD Instagram: https://www.instagram.com/renamalikmd/?hl=en Facebook: https://www.facebook.com/RenaMalikMD/ TikTok: https://www.tiktok.com/@renamalikmd?lang=en X/Twitter: https://twitter.com/renamalikmd Podcast: https://open.spotify.com/show/30xyW3ExCD3f9FZR8Wf2Mn 00:00 Intro 01:03 Male Scams 08:47 Low Testosterone 49:06 Premature Ejaculation / Urination 1:02:24 Penis Size / Erectile Disfunction 1:19:51 Semen 1:24:07 Prostate Cancer 1:32:22 Hormone Therapy For Women 1:38:16 Alcohol / Herpes / Kidney Stones 1:44:32 Why Choose Urology? 1:48:51 Teaching Kids About Sex Help us continue the fight against medical misinformation and change the world through charity by becoming a Doctor Mike Resident on Patreon where every month I donate 100% of the proceeds to the charity, organization, or cause of your choice! Residents get access to bonus content, an exclusive discord community, and many other perks for just $10 a month. Become a Resident today: https://www.patreon.com/doctormike Let’s connect: IG: https://go.doctormikemedia.com/instagram/DMinstagram Twitter: https://go.doctormikemedia.com/twitter/DMTwitter FB: https://go.doctormikemedia.com/facebook/DMFacebook TikTok: https://go.doctormikemedia.com/tiktok/DMTikTok Reddit: https://go.doctormikemedia.com/reddit/DMReddit Contact Email: [e-mail] Executive Producer: Doctor Mike Production Director and Editor: Dan Owens Managing Editor and Producer: Sam Bowers Editor and Designer: Caroline Weigum Editor: Juan Carlos Zuniga * Select photos/videos provided by Getty Images * ** The information in this video is not intended nor implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images, and information, contained in this video is for general information purposes only and does not replace a consultation with your own doctor/health professional **

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It's on your mind the next time you have sex, you're stressed about it, am I going to get an erection? You're not in the moment, you're not present. And so you're not going to get an erection, right? You're stressed. And then now you've just created this vicious cycle of issues with ED. I'm thrilled to sit down with Dr. Rina Malik, a renowned urologist and content creator

who's unafraid to tackle those under-discussed topics in sexual, hormonal, and pelvic health. If you've ever had a question, you were too embarrassed to ask, or if you've been curious about issues that often go unspoken, I made sure to cover it all in our conversation. We're diving deep into the complexities of testosterone replacement therapy, or TRT, weighing its potential benefits and risks and debating its role in modern health care.

And while we do get a little penile-centric, this episode has valuable takeaways for everyone as we cover testosterone's impact for women, prevention of kidney stones, and tips for communicating openly about intimacy. So let's get into it. Please welcome Dr. Malik to the check. a podcast. Wow. There's so much I want to talk about. I'm so excited. Obviously excited to have you back

on the channel this time in the podcast format where we can really get into the nuance. Because as you and I were talking off camera, we feel like that's lost, especially in the sexual health space. It's so lost. Yeah. What are you seeing these days when it comes to the loss of nuance? I think it's just all or nothing, right? Pornography's all bad. Masturbation's all bad. testosterone is all good. Hormones are the best things for you, right? And there's nuance, right? There's nuance to all of that in terms of who's it good for, who's it bad for, and why?

Have you seen negative repercussions with your patients on this where they've been misled by something they've read online? Absolutely. I mean, I see patients who come in taking a list of supplements and you like really dig into it and you're like, well, of course you know why your lipids are off or your sodium's off because you're taking all these supplements and you don't know what's. in them. And so, and they don't even know what's in them, right? They just take them because they heard something and they heard someone and they tried something and, um, and those have real

repercussions. For sure. And I'm going to get into the specifics of supplements that are touted for some of these issues in a bit. The big thing is a lot of these supplements, what they say is even in them, isn't in them. Absolutely. Because no one's controlling this with the exception of the FDA if someone gets hurt and now they're concerned, they have to launch an investigation. But that's like trying to put out the fire after it happened. Absolutely. And, you know, there's a list of medications

of sexual health supplements on the FDA website. It's like a lot of the ones that get the gas stations. Those are ones that often get put on that list, but they have, you know, actual regulated substances in the supplement. So you might think you're doing something natural, but you're actually just taking to dalafil or sildenophil in the supplement form, which we don't know how much is in there. Could it be dangerous?

Could it cause real potential harm? Absolutely. Yeah, the big one that I worry about is interactions with other medications, especially when it comes to cardiovascular health. Because if we think about who's using these medications to get better erections, it's people who are older,

who have higher cardiovascular risk, who may be on cardiovascular medications, and then they're combining things, not even realizing that. Yeah. That's why I harp on the primary care of it all to be able to flag issues before they happen. Absolutely.

And, you know, I think with medications like for erections, the people who have erectile dysfunction are those that have cardiovascular issues, right? The number one cause is vascular disease. And so we talk about this often in urology, like it's a canary and a coal mine. Very often, when you have ED within seven years, 15% of those guys will have a heart attack, right? So it's the first sign of a cardiovascular issue. and now you're taking these medications, potentially you've got something like nitroglycerin

for chest pain that you put underneath your tongue for a potential heart attack. You take those two together, your blood pressure drops to a very low level, and you're now at risk of death or you need to go to the ER. Yeah, it's such a scary situation to occur. What I've seen happen more and more, and I'm curious if this come across your plate, these websites that allow a patient to basically request a prescription medication, by self-diagnosing, but then they put in some symptoms, they put in what medications they're taking, and then someone reviews it, apparently a doctor, maybe they have a five-minute

virtual encounter, and then they get the medicine sent to them. I see a lot of issues with this. Do you have any concerns about these types of websites? Yeah, so I think, one, I'm happy about the access because I feel like a lot of people don't have access. They're not going to see a doctor. They won't do it, right? They're just going to suffer in silence, and I do really realize how devastating sexual dysfunction can be. Certainly, I think things like Sildenafil and Hidalifil for the majority of people are very safe. As long as you can have sex, you can likely take Tadalafil, any of those medications, unless you're on a medication like nitroglycerine or nitrate. Those are really the biggest contraindications. So I'm less worried about those,

although I still think it's really important because this is a real place where you can get these patients and get them referred into primary care. see a cardiologist and manage the reason that you're having ED, right? Like, I want people to have a good sex life, but I also want them to have good health, right? And that's first and foremost. So if we can fix your vascular problem, which could be cardiovascular, then we can hopefully potentially improve your erections, but also give you a better life, right? A healthier life.

It's literally a situation of plumbing, right? So if you have a blockage in your penis, you odds are have a blockage somewhere else, especially as time goes on. And that's why that rate pops up of people having a heart attack after taking these medications or experiencing their first erectile dysfunction episode. What's interesting to me is we have these two forces that are pulling on the general public. You'll force one who pushes people to say, we need to prevent everything. We need to ultra-screen for everything. We need to get ahead. And that a lot of times gets overblown in the executive health space where promises are made to VIP patients about preventing every issue.

And then on the other side, you have people saying, just give me the pill. I want to get online and make it as easy as possible. I don't want to be screened for blockages elsewhere. I just want the pill. And it's so weird how these two forces are both not great. But if you talk about one, Camp A talks about you, but if you talk about the other, Camp B then talks about you. And there's that loss of nuance that we started with. And, you know, I think that really, like, this is such an important space to really look at, like, the big picture. You know, we think about, like, I will see people in my clinic who are appearing very healthy, right? They're physically very fit.

They look great. They have issues with erectile dysfunction because they have high cholesterol, right? And they don't know they have high cholesterol because no one's ever screened them. And so I'll screen them and be like, look, we can keep giving you pills. We can keep making sure you get. erections. There's so many things we have to offer you, but if you don't fix your high cholesterol, it's just going to continue to get worse, right? You're going to need more and more treatments to fix this problem. And I know it's hard. I know it's not easy to make lifestyle changes,

but those are at the core of improving your sex life. Yeah. So as often as doctors are labeled drug pushers or pill pushers, we are trying to focus on prevention and lifestyle modifications. It just, the buy-in is always not there. Yeah, it really depends on the person, you know. And like, I think a lot of times people are seeing a lot of information, like, oh, cholesterol doesn't matter, right? Or they're seeing these things. And so they're like, well, no, everything's great. I'm doing perfectly well. And, you know, my other doctor says, I'm fine. And I'm like, well, clearly you're not. If you're having an issue and you're in my clinic, you're not fine, right? And so I think there's just, we really need to realize that, yes, we want to fix you

as a person. We want to get to the root cause of the problem. And most people very often come to our clinic and they want a quick fix. And that's not a problem. We can offer that. Thankfully, science has advanced to the point where we can help you in a pinch with a medication. But that doesn't mean that we're ignoring the problem. Yeah. And there's a more optimal way to do it. And in medicine, usually more optimization is bad. But in this situation, we're optimizing in a healthy way with limited side effects because you're getting people to change healthy lifestyle or create healthy lifestyle habits. Now, let's take a step back before talking about riteal dysfunction and talk about this issue of low testosterone. Everywhere you look these days, there's either an

advertisement for it, a podcast host talking about it. Recently, I saw that there was a clip saying that testosterone levels have absolutely been demolished in society. Is that true as a first statement? Are we as a species having a crisis with low testosterone? Well, there is, is certainly more low testosterone now than there was, let's say, a few decades ago. And that's for a variety of reasons. One is that we are seeing more comorbid conditions. So we know that as you have more diabetes, more high cholesterol, more high blood pressure, those things are correlated with having lower testosterone. So we're seeing people who are more unhealthy and then we're seeing lower testosterone. There is also an age-related decline, although that's not going to explain

all of it, right? So as men age, their receptors get less sensitive to the testosterone that they are getting in their body, and so they're not seeing the benefits of it. There's also potentially endocrine disrupting chemicals. I don't like to harp on this because people get really overwhelmed, and we're drinking out of plastic water bottles. I don't think every so often it's okay to be exposed to endocrine disrupting chemicals. It's everywhere. It's in our urine. It's in our blood. If you look at studies, you're going to find it everywhere. But you can make smarter decisions choose to try to cook in, you know, where that's not plastic, heat up things that's in not plastic and, you know, drink out of glass and metal if you can, right? And this isn't

the biggest factor. It's not. That is, A, it's not the biggest factor. And B, it's not the most modifiable risk factor. Correct. Because when we're talking about risk factors, we're talking about ways people can take action. So you can't change your age, for example. You can't change your genetics. So harping on that doesn't give much value. So when companies start talking about talking about all the poison around us. It's like, just give us the three things of simple changes we can make and let's move off this point. Yes, exactly. So I don't want to harp out too much. And then there's potentially some like evolutionary changes. Now this is really theoretical, right? Because people, we are having lower infant mortality rates. And so there's

less pressure to keep like having good semen production, good sperm production into older age because we don't no longer need to have as many babies, right? So potentially there's an evolutionary. meaning that like you know 100 years ago infant mortality rates were high so you would be having babies like you know 10 15 babies and maybe five of them would pass right from infant mortality and so in order to propagate the species there was this evolutionary pressure to continue having more and more children potentially and that created a higher level of disaster but i think that that was how it was naturally oh like a natural selection correct correct and then you know also reproductive technologies maybe we're not we're not

now selecting for genes that would have higher rates of testosterone again these are all theories there's not um there's nothing to really harp on there but the other big thing is you know we've talked about age but and comorbid conditions but sleep right people are not sleeping well people sleep very poorly people don't prioritize sleep i'll sleep when i'm dead sleep is a really important component of having normal testosterone levels and exercise so doing high doing some resistance training resistance training or high-intensity interval training is really beneficial for testosterone levels. Now, those things together, which not many people are participating in, make more and more levels of lower testosterone.

Got it. So unlike what other podcast hosts and guests have said when they want to harp on one specific point, it's clearly a lot of things. And then let's narrow down the things that are under our control where we can make the biggest benefit. You said exercise. So high intensity or high intensity interval training, resistance training, that helps with testosterone.

Yeah, and specifically of the large muscle groups. Right. So the larger muscle groups, and it needs to be strenuous. You know, large muscle groups resistance training about twice a week. Trying to get rid of these chemicals in our everyday worlds could be a valuable thing, not necessarily mandatory, but easy swaps, like not microwaving plastic, not reusing these types of water bottles. basic changes could be a valuable thing.

If we're doing grade levels, it's a grade level C or D. Yes, yes. It's not, really, please don't fixate on endocrine disrupting chemicals. They are, everyone has them in their body. We are, it's in modern society. There's really nothing you can do about it. And then sleep. We're trying to maximize getting seven to nine hours to sleep.

As an adult, older age, we can cut that down slightly. But in general, you want to be. getting good quality sleep prioritizing. Anything else that I'm missing on this? Stress reduction. Okay. So we know that as your stress level increases, your cortisol increases, and that essentially very simplistically reduces your testosterone. And so we're stressed. We're in a chronically stressed society, right? And so reducing your stress by whichever means work, right, whether it's exercise, meditation, spending time with loved ones, going for walks, whatever it is, but making that a priority. Yeah, it's the chronicity of the stress of it ongoing for

such a long period of time, which truly creates a toxicity. Because we've also, I've seen the pendulum swing in some ways of people being so afraid of stress. And acute stress, acute challenges are really good for the body. And it's mandatory almost for healthy living. But when it starts ongoing for years at a time without ever having a break in that stress pattern, that's the issue. And when patients ask like, when should I think about stress, it's when you haven't had a break from the stress. And there are, you know, a myriad of ways of talking about stress and dealing with stress. Yeah. So that's interesting. Okay. Anything else we're missing? Um, yeah, I think whatever's good for your heart and good for your brain is good for your hormones and good for your, I say,

good for your erections and your genitals, right? So, so any of those things that people will tell you, your primary care doctor will tell you about improving heart health, improving brain health, those things are going to be good for you overall. But Dr. Malik, I heard on a podcast that there's some supplements that can help me boost my testosterone. So I've done an extensive review in all the supplements that are available for testosterone, maybe not all of them, but the large majority of the ones that are touted. And I will tell you that the data is very minimal. And to be quite honest, we're never going to see high level evidence for supplements of any

kind because people will buy them without the evidence. And so there's no pressure on the companies to create this data. So in terms of supplements, you know, Tonkat Ali is one that there is some data on, but I will say I've had patients take it. It's not, it doesn't make a really meaningful difference. And a lot of times people are taking supplements at the same time as doing all these lifestyle changes. So how can you really parse out what is good or what is bad? Now, everything else that I've looked at, the data is very, very sparse. one of the very popular supplements that's talked about a lot for doja agrestis has no human data

whatsoever it has been studied in rats in mouse models but has never been studied in humans and so i don't really know why people are taking it so blindly because there's literally no evidence to support its use do you think it's irresponsible to have health experts come on and talk about the benefits of these supplements before we have human trials i think absolutely i think that it's one thing to share your own experience, but realizing that if you have a very large audience that's seeing you talk about supplements and saying, I took it, it was great for me. But you're also working out all the time. You're sleeping great. You're optimizing your health in a hundred different ways. So how could that be just from that supplement alone, right? And so I think

it's potentially harmful, right? To share that information and say, well, I took it and it was great. Because yes, you are adding the caveat that you did it and it's not in studies and you're giving the data, but that's a powerful statement. Yeah. It reminds me of the Goop or Gwyneth Paltrow model where she will go on after her COVID situation and say, I'm not recommending any of these things, but here it worked for me. Like you just guaranteed that people are going to buy into it and that legally you're safe because you said I'm not recommending it. Or Gary Breka and Dana White coming together and Gary Breka or Dana White saying, He changed my life. And it's, okay, he got you to stop drinking.

He got you to start exercising, sleeping more, manage your stress, and then sold you red light therapy, tanning beds, or whatever these things are. That's not why you got better. You got better because of the lifestyle changes. So it's sad to see the weaponization of good quality information in this health space. That's why I appreciate the work you do so much, because you're actually giving people actionable steps that they can make a difference in their lives, but you're all also not painting it as a rosy road or a way to profit off of it because the amount of products

in the sexual health space is incredible. Yeah, you know this. I think there's so many things that we could market ourselves as doctors and be billionaires, but like none of us, I mean, at least people who are giving quality content are not doing that, right? We're not sitting here making a quick buck. So when someone is giving you advice about something and then on the back end, they are benefiting financially off of that, you have to take a second.

right and just be like could they be honestly good people yes could they really be selling a good product absolutely but they could also be trying to financially gain off of that and the way we decide that is not based on whether we think they're a nice person or we're against making money we do it based on the evidence and the evidence right now as you said and you've done a deep review of this it's not there and as a practicing physician in this space if there was a way to help your patients that was as simple as taking a supplement, how fast would you be helping your patient to take that? Absolutely. I love like having a patient come back and being everything's wonderful, right? I don't get those results when I tell them to try a supplement. I get those results when I prescribe testosterone replacement

therapy in a safe and efficacious way, right? They come back saying, I feel great. That is what every doctor wants. We want our patients to come back and say, I feel great. And so none of us are here saying we want you to take this pharmaceutical agent because we think, you know, we're benefiting off it. No, we want to make you feel better. And thankfully, we have rigorously studied options that are going through very high levels of quality control that we can offer you. Yeah. The reason why pharma makes a lot of money is because they have to invest a lot of money in proving pharmaceutical works, what the side effects are, what interactions with other medications are. They have the legal liability that if something goes wrong, you can hold them accountable. But a supplement company, they'll

formal C, disband it, throw it away, and you got hurt and now what happens? You have no one left to hold accountable for this issue. So I always warn people away from that because so many people say the term of, I want to do this naturally. And it's like, all right, well, let's make lifestyle changes. That's natural. But I don't know necessarily that's going to fix everything that's going on. You might need help pharmaceutically. And then we have that discussion. And you mentioned actually testosterone replacement therapy and doing it in efficacious and the correct way. I find that testosterone replacement therapy has been hijacked these days, a lot by fitness bros. A lot of people who look great themselves and try and sell themselves as an expert, they have

no qualifications to be talking about testosterone replacement therapy and the nuances of what it's like to have the discussion with a patient, to see the side effects with the patient, to have to deal with those side effects. Are you seeing the spike in testosterone replacement therapy requests for prescriptions, or is it more so you find yourself needing to prescribe it? It's both. But I think that absolutely there are more people who are seeing, oh, I have fatigue. I have these very vague general symptoms, which could be related to low testosterone. Absolutely. And there will be times where I'll see a patient who's like, I'm so fatigued. I've gone to my primary. I've done everything. And I check their testosterone's low. Absolutely, we do see that.

So I don't want to discount that. But, you know, they'll see these, oh, yeah, I feel kind of I feel, you know, very tired. I feel very fatigued. And, um, and I check their testosterone and it's fine. And even their free testosterone, which is a marker of how much testosterone is available to their bloodstream is fine. Um, at that point, you know, there's probably not going to be any benefit to taking testosterone replacement therapy for those symptoms, right? Now, people who take testosterone replacement therapy off label for muscle enhancement, potentially, right? But that's not what that's, that's, that's recreational. That's not safe. It's not what we're looking for, right?

We're looking to optimize your health in terms of mood, in terms of sexual function, which means low libido and erectile dysfunction, which means in terms of if you're gaining weight and not able to gain muscle mass like you used to, if you're able to prioritize your fatigue and brain fog, which sometimes becomes very strong when you have low testosterone, those are the things that we're trying to improve. And it can be very dramatic in patients who have symptoms, right? they can feel just very much not themselves they have difficulty getting out of bed going to work doing the things they used to do but there's a fine line then between optimizing someone who's really

symptomatic versus someone who's like yeah I'm sort of symptomatic and I see all these ads for testosterone and I want it yeah or they think that I don't have any of those symptoms but I could be better yes which happens from time to time especially with younger folks trying to jump on these these bandwagons I think that there's a lot of crossover with mental health issues and people who request testosterone replacement therapy prematurely. So the same hyper macho men who make fun of the commercials from pharma and say, oh, they always ask questions that of course you're going to say yes to. They fall victim to the same advertisements for sexual health.

Of course you're going to say that maybe your erections aren't as good as they were 20 years ago. Of course you're going to be more tired. So you're falling for the same trap that the pharmaceutical marketers are laying out in every aspect of this case. When I found out my friend got a great deal on a wool coat from Winners, I started wondering. Is every fabulous item I see from Winners? Like that woman over there with the designer jeans. Are those from Winners? Ooh, are those beautiful gold earrings?

Did she pay full price? Or that leather tote? Or that cashmere sweater? Or those knee-high boots? That dress, that jacket, those shoes. Is anyone paying full price for anything? Stop wondering. Start winning. Winners, find fabulous for less. If I'm a person who has symptoms of low testosterone or is concerned about testosterone, or maybe I should even go back earlier that being that on primary care,

I feel like I should not be screening the general population for low T. Is that correct? Yes. If they have symptoms, absolutely. if they are asymptomatic. And what are these symptoms that we... So symptoms, again, would be low sexual desire, depression or mood changes, brain fog, or feeling, you know, cognitively a little bit slow. Sometimes erectile dysfunction. This is a big misconception. A lot of guys think I have ED and I'm going to take testosterone, it's going to go away. The amount of people who have ED solely from hormonal issues is like 3 to 6%. Wow. So it's really more often from vascular. And I think everyone has psychogenic ed. everyone does, right? It affects your, you're stressed about your sex life, right? So, um, so that's a big

one. It does help with erections, absolutely, especially nocturnal erections, but it's not going to necessarily cure your ED. Um, it's going to help with muscle mass and reducing fat gain. If you're obviously doing lifestyle changes with it, you can't just take testosterone and, you know, you're going to magically be, um, have a six pack or something. And, um, and so those are the big ones. You know, those are the ones that we really try to focus in on. So when someone is saying, look, there's a change in who I am in the way I'm feeling. I have no desire for sex. I'm feeling a little depressed. I'm, you know, I can't like concentrate at work in the Zoom meetings that I used to concentrate. And those are signs where, yeah, we should absolutely screen you. The pattern that

I've noticed is people usually come in for the cognitive changes, the mental health symptoms, and tie it to low T. And for my understanding of the stance from the American Urological Association, Endocrine Society, is that those are rarely on their own associated with just a testosterone issue. Is that true? You know, I will say that I think sometimes clinically that's the first thing that gets better, is their brain fog often clears and they feel better, especially when they're really low.

But yes, there's sort of threshold values where once you get to a certain threshold, you're going to start seeing sexual side effects probably first, and then you may see some of those brain fog symptoms. it. And then in this situation, when a patient has symptoms, and we're checking the testosterone level to see if it is, in fact, low, that's a diagnostic. We're not screening anymore because now we're trying to diagnose a problem. And the correct way of doing this is making sure that a patient has two checks of this, early morning checks, which doesn't always get done. And in fact, I've seen numbers as high as 25%, 30%, where people will go to these hormone clinics that are popping up all

across the country doing fantastic marketing, and they're not even getting their testosterone level checked before getting a prescription, or they're not getting adequate follow-up, or they're not following the guidelines. Is that a concern for you? Absolutely. So there was a great paper by my colleague, Justin Dubin, where he was a secret shopper. So he went to these testosterone clinics, and he, you know, went through the process of getting his testosterone checked, and his testosterone was within the normal range. And he asked for testosterone, and he got it, in many of the cases, there was no discussion of side effects, particularly the more damaging side effects, like potentially a stroke or pulmonary embolism. There was no discussion

about follow-up, and when you're on testosterone replacement, you need follow-up. You need to assess your hematicrit, which is a measure of how thick your blood is, which then puts you at risk for all these other things. You need to be checking your PSA, which is a blood test for prostate cancer, you need to be checking your testosterone to make sure it's not going too high, that it's staying within the normal range. And then depending on which formulation, you may need to check triglycerides or lipids or liver function tests. And so depending on what you're getting, you may need to do a number of different tests every six months. And so that's a really important part of getting testosterone replacement. And so that was really the concern that these

people, these clinics, at least the ones that he went to in the study, were not following these protocols, right? So I have no problem, again, with access. I have problem with people not providing basic standards of care. Now, the early morning thing is really important because when they defined these levels for testosterone, they did them in an early morning time. And the reason it's important is because testosterone is released as a circadian rhythm, meaning that it's released the highest in the morning, and then it declines, there's a little bump again, and then it decreases and increases overnight. And so if you check it, especially in a young guy, late in the day, it's going to be low, lower and potentially lower than normal.

Also, there's variability. That's why we've recommended to get it checked twice, because it might be low one time and it might be normal the next. We want to make sure that we're catching that it's truly low both times. Before we put you on a medication that has real side effects, and the one side effect I do want to mention that a lot of young men don't realize is infertility. So infertility is not guaranteed, but it is certainly a very likely sequelae of taking to sex.

replacement. So if you're young and you want to have children, the longer you take testosterone replacement therapy, the more likely you are to have infertility. And within 18 months, the large majority, like 70% or higher will have infertility. Yeah. And we're talking about all these side effects. It's important to note, but also at the same time we want to balance it because we want to be nuanced in saying that there's these side effects, but if you're low and you're having symptoms, usually the benefits will outweigh these potential risks, especially if we're monitoring correctly, to try and minimize those risks. Absolutely.

But in someone who has a normal level and you're getting these risks, you've drastically decreased whatever benefit you may get, and you're increasing the risks and not having follow-up. So the scale sort of really shifts into way more risk, way less benefit. Absolutely. And yet, a lot of young people are using it to get into this superphysiological state, which means like a higher state than normal. what are the risks do they change from what you just mentioned when you're getting into the higher

levels of it yeah so we don't know the exact like level like where is the high where you're going to get that danger but so basically when you think about this right there's receptors on your cells that sense the testosterone and once those those receptors are saturated that's it that you're getting the most benefit you're going to get now the reason that people will go to superphysiologic levels is because you may still see some benefit in muscle gains right and so some people will want to go super physiologic, although it's not necessarily safe. Now, what are the dangers? So we can extrapolate from the anabolic steroid data. When you're taking high levels of steroids, like super high levels, there are real dangerous risks, liver failure, renal failure,

problems with left ventricular hypertrophy and heart issues, arrhythmias, heart attack. So really, there are some very severe potential dangers when you're taking very high level. of anabolic. Now, if they go up a little bit, that's probably not an issue because if you think about the way we prescribe testosterone, it's going to go up right away after you take, say, an injection or you get a pellet, and it's going to go up and then it's going to come down, right? So you are probably at some point going up a little bit above physiology, and that's okay. It's really the danger when it's high for sustained periods of time at very high levels. Right. Now let's talk about specific populations here. When I've talked about testosterone replacement therapy in the past,

there's been some individuals who've created videos saying you don't necessarily need to have a low testosterone level to benefit from TRT. Is that true? So basically there's total testosterone. When you think about total testosterone, that's all the testosterone in your body, about 45% is bound to SHBG, which is sex hormone binding glabulin, and that is not available to your cells. The rest is either bound to albumin or available as free testosterone for your body to use. Now, some people naturally have a high SHBG. SHBG goes up as you age. And so sometimes you will see that while they have a normal testosterone or close to normal testosterone, their SHPG is so high that the free amount is low. And so in those cases, yes, you can benefit from testosterone,

but that's, again, very nuanced and looking at those numbers, knowing how to interpret those numbers and knowing the data. Right. And this is a very extreme situation that we're selecting here, very specific. That still can be teased out using lab work. Absolutely.

But if they have completely normal lab work, so the sex hormone binding globulin is normal, the testosterone's normal, but they have low T symptoms. Is there any value of using testosterone then? No. At that point, no. If all the numbers are looking normal,

your free testosterone, your SHBG, your total testosterone, if that's all looking normal, there's really no value at that point to taking testosterone. At that point, you're probably investigating other causes, looking at other hormones, prolactin, what have you, all these things, to make sure that the patient is not suffering a true medical problem

and you're masking it. Yes, you should do that for all the patients. So before you start testosterone therapy, you should be checking prolactin, which is a hormone that's in the brain that can be released and can cause low testosterone, LH, FSAH, estradiol. Those are other hormones that are in the pathway that can affect testosterone production. So generally speaking, when you see a specialist or a primary care doctor, they should be checking those levels before you even start testosterone because you might miss a prolactanoma or something crazy that a patient has because you didn't check those things. And a PSA.

And a PSA, yes. So a PSA, as we mentioned, is a test for prostate cancer. And the reason it's important is that if you have prostate cancer and you take testosterone, it will enhance the growth of prostate cancer. I want to be clear, it does not cause prostate cancer. So the reason to take it, if you have a normal PSA, is fine and safe. It's not going to cause prostate cancer. But if you get prostate cancer, it can absolutely cause growth faster of that cancer. If you have true low testosterone, you have symptoms of low testosterone, you take TRT,

what impact does that have on male pattern balding and BPH? Great questions. So male pattern baldness, if you have a job, genetic predisposition to hair loss. So maybe your father, your brother lost their hair, then it may accelerate that genetic predisposition. If you don't have a genetic predisposition, then it may not affect your hair growth at all. So I think it's important to realize, yes, it can cause male pattern hair loss, but it's not a guarantee, especially if you don't have a genetic predisposition. In terms of BPH, so there's now been very good studies,

meta-analyses of thousands of men looking at the development of symptoms, what we call lower urinary track symptoms. So that's straining to urinate, having hesitancy, maybe waiting for your stream to start, waking up at night to urinate, maybe having a stop and start stream, or sometimes even going very often, going very urgently to the bathroom, those symptoms, which are often caused by an enlarged prostate. So does testosterone cause the enhancement of BPH? And so what they found in looking at these is that they're not seeing an increase in luts with the administration of testosterone. So they've done some very, very strong high quality data looking at this and essentially it does not. And that's surprising a little bit because the way that I've

always learned about BPH occurrence is due to the presence of testosterone and you would think as having more you would increase that situation. Why do you think that doesn't happen? You know, it's so interesting you bring that up. So it's because of D.HT. So testosterone converts into dh t which then causes an enlargement of the prostate but if you think about it bph increases as men age and testosterone is actually decreasing as men age so it's not exactly correlative so bph is caused somewhat by hormones but probably only up until you know you're you're reaching like your 20s and then but beyond that it's probably less of an issue now taking away dh t will shrink the prostate we know that that's some of the medications we use do that but essentially giving testosterone

doesn't seem to affect the prostate. In terms of other causes, it's often inflammatory. So there can be some inflammatory process that causes enlargement of the duplication of the cells. And then that duplication of the cells creates more inflammation. That's why we see BPH. And obviously there's genetic components.

There's a whole host of things that play into the enlargement of the prostate. But at least for now, we can safely say, and there's been a very good randomized city called the Traverse Trial that recently came out looking at testosterone supplementation, looking at specifically PSA and lower urinary track symptoms, and they saw no difference in terms of prostate cancer incidents

or lower urinary tract symptoms in the men who got testosterone replacement. And that's for people who needed it. Absolutely. Hypogonatal men, yes. So in individuals, if they were taking it to try and get in a super physiological dose, is there any evidence to say they might have issues with Lutz or? It's possible, certainly because more of that testosterone is going to be converted to dh t and so potentially absolutely i mean some of these especially if you're taking

anabolic or you're taking some of these supplements that work on the cholesterol pathway they're they're affecting so many different pathways that they may be shunting more to dh t more to estrogen and causing a whole different host of side effects and that's why it's really hard when we say you know oh you shouldn't take these it's because we don't really there's there's so many things being activated and to monitor all those things safely and to make sure you're not harming yourself, it's not that easy. Yeah. It's very tricky when the hormonal profile affects so much of the body and there's so many variables that are impacting those same parts of the body. Yeah, I mean, when we explain it, we explain it very simply, right? You get hormones from your

brain that send signals to your testicles and it creates testosterone, but it's so much more complex than that. I think that's, again, where the nuance comes in. Yeah. Okay, now moving on to another special population, those who are 65 and older who have low testosterone on a lab but don't have symptoms, are we treating them with testosterone replacement therapy? So there are some people who would say yes, and I think it really depends. There is certainly, we know that men who have low testosterone have higher rates of metabolic syndrome, which means like diabetes, high cholesterol, and we know that these men potentially have, there's even some data that suggests potentially mortality being more higher in men with low testosterone. Even during COVID, we saw men with low testosterone, did more poorly

with COVID. So I think there is benefit to having testosterone in the physiologic range. But if you're having zero symptoms, it may mean that your receptors are pretty well saturated, even at a low dose. Because I can't look at that level of granularity from one single blood test. So I think you and I know this, but we want to look at the person, want to see how are they feeling? How are they doing overall? If they're otherwise healthy and they have no symptoms, and I don't see any reason to put them on a medication. And also, we really shouldn't be checking the testosterone. Exactly. Yeah. So I guess that doesn't come up for me very often because I don't check it if there's no symptoms. Exactly. So it's an interesting, because what ends up happening with me is someone else checked it and they end up in my office and they say, hey, I found this out. Do I need to treat it? And there's that shared decision making that we kind of employ of discussing risks and benefits and also the many unknowns in this situation. How often does the situation occur in those who are older that take testosterone replacement therapy? They get in a situation where it encourages them to exercise more. They take on a little bit more risk because now their testosterone levels, a little

higher and they get tears in their pecks or their bicep muscles. Is that happening often or is that more in super physiological doses? That's more in superphysiologic doses. So we definitely see it in anabolic steroid users, right? They're going to, you're going to see more tears. But certainly people who are at normal physiological levels of testosterone were not. And actually, you bring up a good point is that some of these guys, they don't even really remember what it was like to feel normal physiologic, right? And so when you give them testosterone, and sometimes it's okay to give a month trial and see how they're feeling, right? And sometimes you do, and they do get more energy. They can exercise. They can walk outside more. They feel more vitality, more vigor, and that actually

leads to a better, healthier life. But again, this is very nuanced and thoughtful. And so you've got to talk to your doctor about it and decide if it's right for you. But yeah, I think, no, I'm not worried about tears or pecks or anything, you know, going to the gym and really hurting themselves. As long as they're being, I mean, they can hurt themselves in any way, shape, or form, right? So if they exercise and do strength training, I'm less worried about them falling and hurting themselves that way. Yeah. Is there any piece of misinformation specifically surrounding testosterone therapy that you are like, we got to set the record straight on? There's so many. Well, let's start with the sexual activity or masturbation impact testosterone. Oh yeah, that's a great one. So I think a lot of

people think that semen retention will increase testosterone levels. We are near November. Yeah, no, not November. And, you know, actually I learned this recently from a guest on my podcast, Eric Sprinkle, where No Not November was a joke. It came about as a meme. And it became this thing that people took very, very seriously in terms of trying to better oneself, improve their testosterone and make themselves more focused and energized and more manly. But there's really zero scientific evidence that abstaining from masturbation or ejaculation in any way, shape, or form is going to improve testosterone levels. There is one study with like young 20 year old guys, 10 of them who abstained from ejaculation for 21 days and they saw a very small increase in testosterone.

That is not clinically significant, right? Yes, there's a numerical increase, but does that mean they actually were any different clinically? No, probably not. And there's this whole thing, well, they've been waiting for 21 days and the anticipatory cue of potentially being able to either have sex or ejaculate will also increase your testosterone, right? And, and there's this whole thing. And so I think people have taken that one study and they have made havoc with it. So have you ever prescribed a patient of yours to participate in? No, not November? Never. Never. In fact, you know, in the old days in urology, we used to actually tell guys who had potentially prostititis to ejaculate more frequently. We would say ejaculate twice a week

because maybe you'd clean your pipes and it'll help with the pain and discomfort you're having from prostititis. And so I think probably that's actually an indicator of pelvic floor dysfunction. So what I really worry about with No Not November is not that they're abstaining. That's fine if you want to abstain. What I worry about is that when you're abstating, people are often tensing their pelvic floor. And so what happens when you tense your pelvic floor, which is this bowl of muscles that we all sit on and that everyone has men do to. And when you're doing that, you're tensing because you really want to ejectly and you are forcing yourself not to, you're then creating dysfunction. Now, what happens when you have dysfunction? Well, you might get erectile dysfunction

because there's not as much blood flowing through those muscles that are tense. You might get back pain. You might get urinary urgency. You might find yourself being constipated. You might have hip pain. Like, there's a whole bunch of symptoms. You can even have pain with erections or pain with ejaculation eventually when you do ejaculate. And so that is the one thing I really worry about because that can be very harmful and very difficult to treat requires pelvic floor physical therapy and many, many months of treatment before you reverse yourself back to the way you used to be. I really want to dive into this next part of the conversation, but I want to tie a loose end on the testosterone. The conversation that comes up a lot is around cardiovascular risk. Is there an

improvement? Is there a harm in taking testosterone replacement therapy? And actually, there was an instance where I had a guest on my podcast who said he was on TRT, but then it ended up coming out that his doctor said that he was normal, but he can get him better, and that he's going to be stronger, and he's going to get jacked. And I said that, well, you're exposing yourself to all these risks, cardiovascular risk. And a lot of people, I think including yourself, pointed out to me that, hey, TRT on its own, when used appropriately in people who have low testosterone and symptoms, actually potentially decreases that risk or that risk isn't there. Is that risk there for people who are using it recreationally?

So if you're using it to super physiologic levels, like very high levels, absolutely there's a risk. Now, if you're using it within normal levels, there's probably not a risk. In fact, as I mentioned, that study that was done the Traverse trial also looked at cardiovascular outcomes. They saw no difference in cardiovascular outcomes from men on TRT versus not on it. And that changed for us, because before in our education, we thought there might have been a risk.

Absolutely. Like, even in the guidelines, it said it's controversial. And so I would counsel my patients based on the American neurological association. saying we have mixed data and now we can confidently say based on this really high quality randomized control trial that there's not really a cardiovascular risk and even the stroke the blood clot risk when you look at some meta analyses looking at this it's actually it's very very low in fact it might not be there I don't want to say that it's not there because it's not the best evidence that we have but certainly it's very very low so I'd say when you're taking it as prescribed and monitored

and safely, you're not at risk for cardiovascular issues. Now, you should be screening again for cholesterol and those other things because some of the formulations may affect your lipid panel. And so I think there are, again, there's factors at play there. And certainly you need to check your blood thickness with your hematicrit because as that thickens, you put yourself at higher risk. Yeah, the polycythemia of it all. For individuals who are already going into thinking about TRT that have a high cardiovascular disease risk. So whether they have high cholesterol, they have diabetes, they have hypertension that's poorly controlled, are those patients candidates for TRT or do they need to get their risk factors under control first?

I mean, they should ideally get their risk factors under control. It does not preclude them from getting testosterone replacement, but they do need monitoring and it may preclude certain options. For example, oral testosterone can affect your lipid panel. So you just want to make sure that you're getting the optimal formulation of testosterone. And, you know, at the same time, you should be working on those risk factors because you may be able to naturally boost your testosterone. Because once you're on testosterone, I think the important thing here is once you're on it, your body's not making its own testosterone, right?

So you are now committing yourself to taking testosterone replacement therapy, potentially for life, right? Yes, you can get off it. You can take other medications off label to help boost your natural production of testosterone, but for the majority of people, that may be too costly. It may not be covered by insurance. And so you might be committing yourself to a life of taking TRT. And so I think the best kind of action is always to optimize those health factors. Because again, if you're sleeping better, if you're exercising, if you're getting all the

other things right, and you're working on improving your heart health, you may not need testosterone. Yeah. I want to set the record straight on something that I said in one of my other podcasts that I don't think was clear in talking about risks of people who take superphysiological doses, meaning too much testosterone when their levels are normal. I said that the risks aren't there for them, specifically talking about the cardiovascular risk, that if you have low T, symptoms of low T, you take T, the cardiovascular risk isn't there. But I also said the fertility risk isn't there. It's there. Oh, it's there. So fertility risk is there, irrespective of whether you're taking it in the right way or the wrong way. And it's important to talk to your doctor about your

fertility because there are ways to go about that. What are some of those ways? Absolutely. So one is you can get a semen analysis at baseline. If you are thinking about being fertile, get a semen analysis at baseline. Make sure there are no abnormalities when you start, right? And then you have a baseline to compare to. You probably want to get it regularly checked. Now, it depends on how far away you are from trying to conceive. So if you're more than a year away, you can take testosterone and then every six months you cycle off and take something called HCG. Now, if you're close, like 12 to six months, then you want to switch to HCG and not take testosterone replacement therapy. And same thing. So you want to essentially, there's different protocols that we

have available to us. But essentially, depending on how far away you are, you sort of want to optimize your bodies or maintain your body's ability to create testosterone, which then helps your sperm be created in the adequate numbers, with the adequate motility and all the things that you need to then conceive. Yeah. The reason why I was highlighting that it's a bigger problem for those who are in the super physiological range is, A, they have more of this issue. And B, the people that are prescribing it to them are not doing this conversation and discussing the potential options of timing and all of these things. And but I want to be clear because a lot of people will say,

oh, well, I'll just take it and use it as the birth control. It is not birth control. So I want to be very clear that it is not at the point where you're getting to zero sperm. It's like the hot tub thing. People are like, oh, I just, I was in a hot tub, so I'm good. Yeah, no, no, no, you got to, we don't have male birth control yet. Right. Yeah. Which is on the horizon, though. It is.

I've seen some clinical trials, at least, rumoring to start. I don't know. Have you seen the start? There are some, there are some clinical trials. There's hormonal ways and non-hormonal ways, and I don't know which one's going to get there first, but there's certainly some investigations ongoing. Good. All right.

Well, I'm glad that was a pretty complete coverage of testosterone. This episode is brought to you by Square. You're not just running a restaurant, you're building something big, and Square's there for all of it, giving your customers more ways to order, whether that's in-person with Square kiosk or online. Instant access to your sales, plus the funding you need to go even bigger. And real-time insights so you know what's working, what's not, and what's next. Because when you're doing big things, your tools should to. Visit square.ca to get started.

now getting back to the conversation of pelvic floor talking about no nut November a lot of men will try strategies to decrease their issues with premature ejaculation and they try things like edging interrupting their urinary stream how do you feel as someone who focuses on the pelvic floor strategy wise good bad or neutral yeah so edging is fine i think that's actually one of the techniques that we recommend like a stop start technique. So what it is essentially is you're getting to climax and when you're about to, you get close, you have your partner or yourself squeeze the head of the penis, you wait and then you restart again. You do that three times. Then on the fourth time, you let yourself ejaculate. So you don't want to take it to extremes. I know there's some people

who will edge for hours and hours and days and days or, you know, that's probably going to create harm for the pelvic floor. So I think that in and of itself, when used correctly, is a great technique. Now, in terms of stopping your stream, so we often use it as a technique to tell people how to learn to do a kegel exercise, but it's not something you should do every time you urinate. You do it to learn where those muscles are, particularly for men where they don't really think about those muscles very often. It helps them identify the muscles so they can do those exercises without the stream. Now, why do those, right? Is that going to help with premature ejaculation? So hegel exercises are often used to strengthen the pelvic floor. So we We often women know about this because very often after having babies, they may have some leakage with coughing and sneezing. And so Kegel exercise will help strengthen the pelvic floor and potentially improve those issues with leakage or with prolapse, like a bulge in the vagina. With men, we often use them when men have a prostate surgery. So after they have a prostate surgery, they have leakage. And so we help them strengthen the pelvic floor that way.

In terms of using them for other purposes, so they're often touted to improve organs. maybe improve your ability to control your orgasm. And I think it's fine as long as it's not creating harm, right? Because as I mentioned, these things went overdone can create pelvic floor dysfunction and then can create those issues that I described earlier. And so I think the issue then with that is just overdoing it. And back to the thing about No Not November, the other issue is that many times men will have a nocturnal emission during No Not November.

And the shame that comes with that. That's a wet dream for folks. Yeah, a wet dream, sorry. Yeah, so many men will have a wet dream, right, what we call a nocturnal emission. And so for many men, that is a huge shame point. They're trying to abstain from ejaculation for a whole month. They have a wet dream. And maybe they'll go on these message boards and talk about it.

And they'll be shamed and bullied and told that they failed. And this is a physiologic, like a normal process in your body, where you're going to have wet dreams, right? If you don't ejaculate enough, either you're going to. going to have it at night or your body's going to absorb that sperm and semen and that's it, right? Like there's not much more that's going to happen. And so there's no magical thing happening in your body. Why does the body do that? It's basically just so during nighttime, men will have erections overnight, right? Every three-ish showers or so men will get an erection at night.

You won't know about it most of time you're sleeping through it. But that's your body's way of protecting itself. So it's creating blood flow to the people's like exercising while you're sleep, right? It's getting blood flow to the penis, which normally doesn't have a lot of oxygen in it. So this is your body's way of saying, hey, I'm going to maintain good blood flow, maintain the health of the penis. And women have it too to the clitoris. And so it's doing that. And then sometimes, you know, with there's friction in the bed, it can create the sensation of your body having an ejaculation. It's a reflex, essentially. It's a spinal reflex. It's not something that you have any forebrain control over. Got it. In talking about interrupt

stream, the reason I brought that up is because I know from a neurologic standpoint, the sphinctors and the control of bladder contraction, making sure that you don't harm that process is of utmost importance. Is that more of a focus with urination in women versus men, or is it equally important to think about? Equally important. I think that pelvic floor dysfunction is very underdiagnosed in men. I see it very often because obviously I check for it. And so that requires a pelvic floor exam. So it's more than just a prostate exam. We're actually palpating the pelvic floor muscles through the rectum to see if they are tense and if that reproduces some of the pain that a patient may have or maybe reproduces urgency even. And so we are seeing that, especially during COVID,

I saw a ton of pelvic floor dysfunction. Guys were sitting all day at their computer, women too. And so they weren't actually using those muscles normally and those muscles were tensing because They were sitting all day. They weren't getting their normal activity of walking and stretching. And so absolutely, we see it in men and it's really important. The same way it is for women is to have normal urinary streams, meaning don't stop and go. If you can avoid it, try not to strain when you urinate. If you're a female, like sit, relax, spread your legs, bend forward and have a nice dream.

If you're always hovering to urinate over the toilet, that's going to create pelvic floor dysfunction. For men, the same thing. you want to sort of relax and breathe and let the urine flow, for some men's sitting is actually more beneficial in terms of... Yeah, there seems to be like a country-specific situation where some countries, it's totally normal for a man to sit to urinate, but in other countries like the U.S., it's really frowned upon. What's that about?

I don't know. I think that it's, again, I think that's cultural, but absolutely there's, I think in Germany, I think is the country where the majority of men sit, whereas in the U.S., like very few men sit. And I'm not sure why that, I think it's, cultural, but really the reason to sit is if you find that your stream is better when you're sitting, because some people may have an enlarge prostate, which makes it difficult to urinate.

So sitting sometimes allows you to increase a little bit of the pressure on the bladder to help the bladder empty a little bit better. But again, you don't want to be straining too much, but if it helps you eliminate your urine better and you're relaxed and your pelvic floor is relaxed, then great. Yeah. for men that are concerned about developing BPAH, is there anything lifestyle-wise that can aid in the prevention of getting BPAH? Absolutely.

So as we mentioned earlier, BPAH, one of the factors is an inflammatory factor, and that's due to inflammatory factors that are related to things like, you know, we know that men who have diabetes have higher rates of BPAH. So other comorbid conditions, again, trying to avoid things like that. diabetes will help prevent BPH. There's also data on aerobic activity. So 150 minutes a week of aerobic activity has actually been shown to prevent BPA. So, you know, it's good for your heart. It's good for everything else. It's also good for your prostate. In terms of diet, having a sufficient amount of lycopene in your diet, which could be from tomatoes or watermelon, can be

potentially beneficial. And then those are really like the most common things. And then I think the one thing about BP that people should know is that if you're struggling to urinating, it is worth talking about it with your doctor. Because I don't know which person is going to be fine well into their 90s and which person's bladder is just going to give up, right? They're going to keep pushing and pushing and pushing urine through that prostate around and then eventually those muscles get weaker.

And so I don't know which person that's going to be. And so if we can catch it and help you relax the prostate a bit or maybe shrink the prostate with medication or even prevention, we may see that we're seeing benefit and potentially preventing harm when you're 80 or 90 years old. And from a disproven standpoint, Saw Palmetto, all these things do not have evidence to help with the prostate. Right? There's no supplements that I'm aware of that are helping in this situation.

Yeah, supplemento is the most rigorously studied supplement. like I've ever seen. Yes, so they've done Cochran reviews. They've done these huge studies on Saw Palmetto, and ultimately they've shown no significant benefit with Saw Palmetto in terms of improving BPAH. And there's so many supplements, stinging nettle, Pigeum, there's so many,

and all of them have really no significant evidence, or if they have evidence, it's like one study. And so it's a really one small study and one small subset of men, usually young, healthy men, which are not the men who are having BPH. And so I would say, that generally speaking, there are no supplements.

And I think the reason that some of these supplements work is because of the placebo effect. So we know that when you take a placebo, a medication that has, you think is going to help you, up to 40% of the time, it will help you because your brain is super powerful and believing that that's going to help. And especially when it comes to subjective symptoms, like pain, like discomfort from urination, those are things that under the brains control, therefore placebo effect will help a lot. versus some things that are not under the brain's control, like whether or not you have plaque in your arteries,

less placebo impact there, more objective measures. And that's another thing I think if you are reviewing data or people talking about data, I think it's important to like, what was the outcome? Was it a survey that someone filled out? Or was it, did they look at an ultrasound? Do they look at something that was objective that can't be changed based on just, you know, how someone feels?

Yeah. Going back a little bit to the testosterone, you mentioned surveys, what are the things that testosterone is not proven to help with that people oftentimes will seek out help for? Yeah, I don't think it's going to like magically make you, like I said, it's not going to magically fix your erections or make your erections really strong. It may help, but it's a small subset of people. I think it's not going to automatically improve your muscle mass like dramatically, right, if you're doing nothing else. I think people just think they're going to take it and they're going to magically be like a

different person. It's not going to make you more masculine or more, it's not going to increase penile length. I think a lot of people think that maybe it'll help with penal length or girth. And there's actually a great position statement from the European Urologic society showing, you know, reviewing this evidence and there's no evidence of that. Because I know in young kids, sometimes we'll use testosterone for for young kids, for hypospatous, other reasons. And they do see some increasing length. But we don't see it in adults. So there's really no benefit in terms of that. I think those are really the big ones. I think it's not magically going to fix all your problems. Even like quality of life measures, right? I've seen those don't necessarily go up by

starting testosterone replacement therapy. Yeah, I think, you know, it depends on what you're coming in for, right? I would say that generally you will feel a little better. You know, you're not going to be transformed in terms of feeling like, you know, everything is 100% better. And I think you'll see improvements in different domains and it just depends everyone you know is a little bit different and I've had patients try and say wasn't for me I didn't like the way he made me feel which is also totally reasonable and can happen absolutely and sometimes people don't like the side effects like some men will get breast enlargement or we call gynecomastia and they don't like that um some people will get more acne some people will feel like they're a little bit more nervous or a little bit more

aggressive and these are again checking your levels sometimes they're too high causing those is that some people just don't do great because of that. And then it may be either that you don't take to assassin or you try a different formulation if you really want to try. Got it. What is this magic number of 21 times of masturbating slash having sex that is so mystical? There was this one pretty well done study looking at prostate cancer and how often men ejected. So they they looked at these numbers in categories like 0 to 7, 7 to 14, 14 to 21, above 21. And, and And so they looked at, and they controlled for, you know, a whole host of things, age, comorbid conditions, lifestyle factors as best they could in a study. And what they found was that men who ejaculated 21 times or more per month were less likely to develop prostate cancer than those who ejacled less than seven times a month.

And so, yes, this is interesting data. There's some theories that, again, it may help prevent what we call the prostate stagnation hypothesis, meaning that there's not the factors that may cause prostate cancer are getting ejaculated out. And so you're getting, you know, cleaning the pipes, so to speak. And so that may be beneficial. Now, does that mean you should aim for 21 times? Like you get 20 and you're not good? No, absolutely not.

And does it mean that you have to be doing that if you don't like to? Like, say you don't enjoy masturbation or you don't have a sexual partner? No, that's okay. I think it's just a matter of like, it's not a bad thing, right? I use it to say, like, if you masturbate or have sex 21 times a month, it's not going to increase your risk. It's not going to hurt you, right? But don't use it as a weapon either to say, oh, we have to have sex 21 times a month

because it'll help prevent prostate cancer. Yeah, that's always really interesting because I see people use it as almost like the 10,000 steps. Oh, you didn't hit your 10,000 steps. Unhealthy. You hit 9,000. It's like, this is a general guideline. Well, the whole 10,000 steps, as you know, is not a real evidence-based thing.

Well, it was done by a pedometer. companies. So anytime they're trying to sell you a product, that's going to be interesting. For individuals who are thinking about penis size, they come into your office, they say, I'd like to increase penis size. What does the conversation look like? So I think first and foremost is, you know, why? Like what's going on for you that you feel like, you know, you need this? Is it your partner saying something? Is it you've always felt this way, you know, just to sort of investigate that further. So from like a healthy standpoint, what is a reasonable answer? And what would you consider an unhealthy potential reason?

You know, I don't think, I don't like to call them healthier or unhealthy, right? Because everyone has their reasons. So like if someone is like, well, my partner's really unhappy, I would say, well, are you happy? Like, well, because there's no really, just to kind of hit the high point, there's no really safe evidence-based way to increase penile length necessarily, right? That's going to be lasting. And so, yeah, we can talk about the options that are available. I don't offer many of them. But in terms of like, are they going to be, is this something that you want as an individual? If your partner wants it and like, this is something you're doing for them, that's it's still an important discussion. But I think it's important to think about like, well,

you're the one who's going to take on the risk potentially if you decide to do something. And then, you know, if there is a large number of men who have what we call small penis anxiety, so where they are preoccupied with the size of their penis. and they've been always felt that way and they may have a normal size penis but it's been distressing to them in those cases I'm like you know you really need to see this needs to be a multidisciplinary discussion

you need to see somebody with mental health expertise to sort of work through the thoughts around this preoccupation before we can talk about doing anything so I think that's more of a it's not unhealthy it's just that we need to do a few more steps right in terms of what can you do to increase penile length so there's a lot of things out there's a lot of data out there

in terms of things that have been tried. In terms of things that are non-surgical vacuum erection devices or penis pumps have not been shown to increase penis size or penis girth, although people will report that they do. Certainly when you're using them, they do, but after you're done using them, it goes back to normal. In terms of things that naturally work, weight loss is great because as you increase your weight, you're also increasing the weight of the mons, which is the area right above the penis, which then makes the penis appear shorter.

There's still erectile tissue that goes all the way down into the pelvis and turns into the perineal area. And so if you lose that weight, you will see more of your penis. Also, even just shaving your pubic hair can make the penis appear longer. So those are, you know, free, easy ways that you can improve your penis length. Even anxiety can create some, for some men, a shortened penis. So when you're really anxious, if your pelvic floor tenses up, I have some patients to be like, oh my God, my penis just disappears. Like I get so anxious and it like really gets small.

And, you know, then they take a warm bath and things seem to normalize again. So those are sort of easy freeways. In terms of non-surgical ways that work, a traction device has been shown, which is essentially a device you wear on the penis and it's like basically a stretcher, right? It just stretches the tissues has been shown to benefit in terms of increasing length for about two centimeters in size. Now, the early studies were done with these traction devices. These them for like six hours a day. So really intense, like you have to buy in and really go for it for six hours a day. Now there are newer studies that I've looked at traction devices that maybe 30 minutes twice a day. But again, it's a commitment. And we don't know that after you

stop using the traction device, will you maintain that length? Hard to say. Because the studies have not gone out that far. In terms of surgical options, there's many surgical options that have been reported and studied. However, they have really severe consequences and potential side effects. I mean, the biggest one is that you could be dissatisfied, right? You could have a surgery on your penis and you could be really dissatisfied with the results. It could either not work and now you've had surgery on your penis. You could develop issues with sensation potentially. You could develop scarring. I mean, there's a whole host of things that could happen. And so generally, it's not offered by many surgeons. There's one option here that while the device itself has

and FDA approved, it's not routinely prescribed. It's called the penuma device. It's essentially a silicone sleeve that's implanted around the penis. Now, the studies looked really good, but as a practicing urologist and talking to other urologists, we've seen a lot of them have issues and need to get them removed and leaving men with really scarred tissues and problems. So I think this is a really serious issue that if you're deciding to do something, you may find someone who will offer you something for penile length enhancement. But it's really, really important to think about those risks. And I don't want to shame anybody. I think if you decide to go ahead with those risks, that's totally your decision. But if someone's only selling

you on the positives of something, then you take a step back, right? And think, okay, you know, there's no free meals, right? There's always a side effect. You don't want to make an impulsive decision in this area, especially with the lack of really good quality data. What is the number one cause of erectile dysfunction that you see? So vascular dysfunction as we talk to go. Over psychogenic. So in young men, probably psychogenic more often. But I tell all my patients and everyone that when you have ED, it's always psychogenic. It doesn't matter what the cause is. Yeah, I was going to say, right? Like when you have, the first time you have a problem with an erection, you're thinking about it. It's on your mind the next time you have sex. You're stressed about it.

Am I going to get erection? You're not in the moment. You're not present. And so you, you're not going to get an erection, right? You're stressed, and then now you've just created this vicious cycle of issues with ED. And so I think everyone has psychogenic ED, but in terms of the primary cause, vascular dysfunction as in, you know, middle age to older men, it's probably the primary cause. So very often, high blood pressure, high cholesterol, diabetes, all those things are causing issues with blood flow. And so as you mentioned, it's a plumbing issue. The blood vessels to the penis are one to two millimeters in size. The blood vessels to the heart are three to four million. meters. So when these get clogged or there's issues causing decreased blood flow through them,

you're going to see issues in the penis before you see it anywhere else. And so very commonly, that's probably the number one cause of ED. And I've seen a lot of individuals be wary of taking medications like sildenafil or tadalphil because they're worried about having an erection that lasts longer than seven hours or something that they've heard on television. But correct if I'm wrong, my understanding is that even the research didn't bear out that happening. And this has kind of been an oversold potential side effect that didn't happen. Absolutely. In the studies, there was maybe one patient, I think. I may not be right on the exact number, but it was really very unlikely. I think it may be one patient who took too much. But generally, if you're using it as

prescribed, the likelihood of getting an erection that lasts longer than four hours is exceedingly low, if not virtually not present. And even if you take higher doses, my understanding is also that there's a limiting effect of how much these medications can actually have a side effect from that standpoint. Is that true? Yeah. It's very unlikely to get what we call a priapism. Now, if you do other medications like injections into the penis, that risk is much higher.

But with the pills, it's very, very safe. And generally speaking, it's very, it's not going to cause heart issues. It's not, there's a lot of fear around, is it going to give me a heart attack? am I going to be, is it going to affect my heart? And generally speaking, it's very, very safe. It's very safe. It's very effective. The only real contraindication is if your doctor tells you you can't have sex because

you're not well enough to have sex and you shouldn't be taking them. And if you are taking any nitrate pills. What about this situation where young folks are starting to get these medications from some of those websites that we talked about earlier? They become members. They get them mailed to their home. And they feel like they can't perform. them where it becomes almost like an addiction. Have you seen that happen? So you do find people

who, you know, get a dependence on them where they feel like I need to use them. But the other way that I actually, I see that, but I also see men who have psychogenic ed, young men, and I'll say, look, we're going to take a low dose of today, I feel every single day for a couple months. You're going to get the confidence back that you can get an erection. And once you're no longer spiraling in your head about your ED, and ideally with, you know, a sex therapist or a psychologist, also working with you, then we'll be able to get off of it. And it may just help you in that short period of time while we sort of get things corrected to have an erection, get the confidence back that you're able to perform.

So there's sort of both coins of it. I think when used correctly, it can be really beneficial. And there's people actually using it recreationally for muscle blood flow and all these other things. And there's some data to support that maybe it increases vascular health or muscle blood flow. But ultimately, I think it's, it's, probably safe and the dependence is an issue potentially. But I wouldn't, if you're using it because you're actually having issue with erections, I think it's okay. I think when you're

using it for the issues of like just, oh, I want to have a better erection. Then sometimes that's where it gets a little murky. And also some of these medications are also used for BPH as well, not just for erectile dysfunction. How does that work? Where is the like mechanism by which these medications can help with BPH. Yeah, so the todallifil is the one that we, you can take sylidinophil daily too, but it doesn't have as long of a half-life. So today,afil has a, has a less for about 36 hours.

So you use a five milligram dose every day. And it also, as a site, works on the relaxation of the prostate. So helps with urinary stream somewhat as well as ED. So I love using it for men who have both those issues because they don't have to take one medication to help with both. Interesting. thing. And then for individuals who are seeking erectile dysfunction support and the pills aren't working, what other options exist? Yes. So in terms of the guidelines, there are options including

intraurethral suppository. So a pill you put in the urethra. I don't find those work much better than the medication. So I very infrequently prescribe them. There's vacuum erection devices. And those are distinct from penis pumps that you get, you know, at a sex toy company. These work by increase. And they work similarly, but these have vacuum limiters and they have safety issues, safety controls on them. So essentially how they work is they, it's essentially a vacuum, creates a negative pressure, blood flows into the penis, it makes it bigger and longer, and then you have a constriction band that you put at the base of the penis and then you take off the vacuum

and you can then have sex with it. They work very, very well. They do have a learning curve and they feel a little different because it's not all arterial blood flow going into the penis, it's venous blood flow, and so it may feel little bluish. It may feel a little cooler, but it works. So I think once you get over the learning curve of how to use it, it can be very effective. And it's a one-time cost, which I really like for patients because you buy it once and you can use it. You don't have to keep paying for a prescription or other things. And then there's what we call intra cavernosal injections.

Now, these people get really scared about, like, oh, I'm going to inject my penis. No, thank you. Don't even sign me up. But they are very, very effective. They are about 80% effective. So whereas the medications are like 60% effective. These injections are basically a amount of, there's either one or three medications, one to three that basically increase blood flow to the penis. And so you inject it and within, you know, minutes you're having an erection.

Whereas with the pills, you have to take them at least an hour before sex. And so these work really well. They're usually a very small needle. So most people don't have pain with them. It's just about getting over the apprehension of using them. And then the, risk with them is a priapism. So the erection that lasts longer than four hours, because if you take

too much, that can be difficult. And as long as you take it as prescribed and don't go overboard, it's usually not going to be an issue. And what's the treatment for that? So in terms of, you know, you can try some Sudafed at home. It doesn't often work, but, you know, it's weird home. You can have some on hand. If it doesn't go away, you need to come to the emergency room. And the reason is, people joke like a four-hour erection that sounds great. It's not great. Because at that point, you're not getting any blood flow to your penis anymore. And so after four hours, now you're trying to create damage to the penis, right? There's a potential of scarring and fibrosis. And that can then make it so that you won't be able to get an erection in the future. And so you want to avoid that. And so you want to

get to the ER as quickly as possible for us to be able to either extract that blood from the penis or try a variety of maneuvers to get that out. That's always like reminds me of the sex sent me to the ER episodes that we reacted to because it's so, it sticks in your mind as a fear, oh my God, this is going to happen, or you see the commercials of the guy calling and saying, hey, this is going on with me. What do I do? Always very interesting to see people's worst fears play out in their minds when it's a little bit overstated. Yeah. Yeah, it's not that common. I will be honest. I mean, we do this is what we see in the ER all the time. It's not that common. Like as a resident, I remember you see your first one and then you don't see one for, you know,

months. And so it's very, very uncommon. And so unless you have other issues that are predisposing, you like sickle cell disease or things like that. So not to worry, follow your doctor's instructions and you'll be fine. For sure. In talking about psychogenic ED, something that was taught to me, and I'd like to fact check my education from 10 years ago with you, my understanding was that when you are trying to get an erection, we call it point, parasympathetic kicks in. When you're trying to ejaculate, shoot, that's your sympathetic.

And if you're nervous, your parasympathetic can't kick on because that's your rest in digest. And the same thing on the other end of the equation. If you're too excited, your sympathetic is too excited, therefore you have a premature ejaculation. Is that a whole true? Absolutely. And interestingly, I just reviewed this study. And again, these are small studies, but I found it really interesting because it was an easy thing you could do at home, was doing high intensity interval training for seven minutes a day for two weeks, helped with premature ejaculation. Interesting. And I found this interesting. And the reason they thought that it worked was because it balances the parasympathetic and sympathetic nerve system.

It also makes you really focus. When you're doing that high-intensity work, you're like seeing your body in movement and you're focusing on where your body is, and so that helps you then use that focus during abstaining from ejaculation. And so I think there's a lot of things that, you know, we can do without medications that can be helpful.

And yeah, absolutely balancing your nerves during the time of, you know, kind of being relaxed and intimate and present I think being present is really, really valuable. So we know also that when you do mindfulness activities, so there's a study where they had women who had low desire and they put them in a trial where they did mindfulness, 20 minutes of meditation or mindfulness every day.

And they saw that they had improvements in desire and basically all these different areas, arousal, orgasm, these areas of sexual function just from being more mindful and being more present. And we know the same for men. So I think just generally overall working on your thoughts and your feelings during the time of sex can be really important. And I love to say this. I think sex is play.

And we become very anxious and stressed about sex. But if you allow yourself to play and have a good time with your partner, you're almost always going to have fun. And it's going to be the way you want it to be. And if it doesn't, it's okay. Yeah, exactly. Just try again the next time. The thing that I tell patients to focus on to see if something is going on from the nervous, system during their times of sex is their breathing patterns. I feel like it's an easy marker for

them to catch, whether they're holding their breaths or they're breathing normally diaphragmatically breathing. And changing that can impact your vagus nerve stimulation because the diaphragm's involved in it. Do you ever talk about breathing with your patients during sex? Yeah. I mean, I think that's a great point. I have not talked about it in general, right? I think that diaphragmatic breathing is super important for relaxing the pelvic floor, which also plays a role in orgasm. So having generally a relaxed pelvic floor and lengthen and normally functioning pelvic floor will generally overall help your sexual function. And so we talk about diaphragmatic breathing in terms of working on relaxation. And that's an easy thing. It's just breathing. We just do it every day,

right? And so working on that can be really helpful. And I think, yeah, just taking the stress out of sex, right? And talking about sex. And I think we don't talk about it enough. You know, like talking to you, what are you into? It's a simple question. What are you into? Right. And that's not, it doesn't have to be so loaded and just be like, okay, good. Like now I know. Now I know what you like and I can tell you what I like and we can go into the bedroom with a roadmap. So now we're not worried like, are they going to like this? We already know. Exactly. You already know. So you have a good line of communication. And it helps with partner selection. People over or underestimate that all the time. They find a partner and they're like, oh, they don't like what I like. Well, did you talk about it ever? Like if you never discussed it, you're really just rolling the dice that you might not like what the other person doing so communication really there is key what uh why are guys obsessed with increasing semen i don't know i'll be honest with you i think it's i think it's you know a visual that we're seeing in erotic films right where they're they're using ways to make it augment the amount of semen volume that comes out and these it's a it's a movie it's a production right but people forget that it's a production

and they see this like oh i need more and some of them absolutely feel uh like it's more pleasurable when they have more. Like we know that things going through the urethra for some people can be pleasurable. But the real thing is as you age, your pelvic floor muscles weaken, which is part of what helps you shoot the ejaculate out. And so when they weaken, it doesn't shoot as well. It sort of dribbles. And so that's part of it too.

And then it's going to be variable day to day. Depends on how much fluid you drank. Depends on what you, maybe what you ate or drank can affect that. And so I think it's just realizing like as long as you're having. having a norm, but the only reason it matters is if you're trying to conceive, right? You want to make sure that the ejaculate is getting where it needs to go. It's getting into the vagina so that it can get into the uterus and where it needs to go. And so that's really when it matters. And otherwise, if it's an issue and it's causing decreased pleasure, then, you know, we can work on it. We can

certainly try to make sure you hydrate more, abstain between ejaculations. So don't ejaculate every day, maybe go every three days or every two days. And you'll notice an increase in volume, right? And so there are things that you can do but I think ultimately it's you know why does that matter and if it does that's fine we'll work on it but it's not something that's mandatory for pleasure or for health or for health at all yeah and is there anything one can take either prescription or supplement based that impacts that at all not to my nods anything that works really well I think really hydration and taking time between orgasms can be really or ejaculations can be really helpful and then in terms of if you're getting a weaker ejaculate than doing strengthening exercises can

be helpful. Okay. And how did the pineapple get so ingrained in sex culture? I recently had a guest who was talking about his family, of all things, and he said that his parents would leave a pineapple outside their door, and that meant that they were into polyamory, or the idea of pineapple changing the taste of your semen. What did the pineapple ever do to anyone? I don't know. I mean, the pineapple thing, you know, for the taste of ejaculate, so anything that has high fructose, right, may increase or the sweetness of your ejaculate, but it's not going to happen like you drink a glass of pineapple juice now and then it's going to be different, right? Like, it's like an ongoing dietary thing, right? And you and I both know pineapple has a lot of sugar in it, right? So not

everyone should be drinking a ton of pineapple juice. I think generally speaking, if you lead a healthy life, you drink a lot of fluids, you eat some fruits and vegetables and you're not smoking and you're not, you know, overcaffeinating, your ejaclet's going to taste fine. And I think that's really the important thing. Like, if you like pineapple juice, by all means, in moderation, go ahead, you know. If you're with a partner and they tell you that they feel like something's off, what would you tell that person, investigation-wise, what would you do? Yeah, I would say for, well, well, depends on what's off.

So the taste is off. I would say, investigate what you're eating and drinking. So look, has something changed? Is the color change? Does it look red or bloody, right? That's when I get concerned. Again, if you get blood in the semen, it's very unlikely to be anything. cancerous or dangerous, but it is something to just get investigative, right?

And, but just to reassure people that if it happens, it's usually not a sign of cancer or anything like that. And then if it's other colors, not to worry, really doesn't, no red flags from that. In terms of like, yeah, did you, were you dehydrated? Were you, did you smoke that day? Did you have a lot of caffeine that day? You know, just sort of investigate, maybe for a few days, drink a lot of fluids, hold off on ejaculating, and then just try to, again and see if it goes back to normal. Does SDI ever enter the conversation with that? You know, I don't know that they change the taste necessarily. I mean, they may. And again, I think if you're concerned, it's so reasonable to get evaluated, you know, get it checked out. And so,

yeah, in terms of like other things that can help, I don't think there's anything, but I wouldn't worry, right? I think just, it's probably just a factor of what you ate and drank that day. Moving on to a topic that is really of utmost importance for me as a primary care physician, because I do a lot of screening and I want to do prevention, PSA's prostate cancer screening. When it comes to preventing cancers, we want to be doing screenings that will help catch cancers early where we can meaningfully act on them. The answer that we're getting is valuable for all these people, or at least universally, and that the patient ultimately wants the treatment if they do find something, because that's an important thing that we don't talk about often.

And when it comes to specifically PSA screening for prostate cancer, it's kind of been a rocky road. I've seen some debate amongst urologists and primary care physicians as to when this should be implemented. The United States Preventive Service Task Force, which is the organization we use to decide when we're going to give screenings to individuals. Currently for PSA, it's a shared decision making where you discuss whether or not an individual should get one. What's your overall stance on screening an average healthy 45-year-old man or 50-year-old man? So in terms of 40s and young 50s, I would say one depends on family history. So if they have a family history, they're African-American or other risk factors. They may put them at higher risk for prostate cancer.

They should at least get one baseline value and potentially start screening early. In terms of, I 100% agree with shared decision-making because prostate cancer, one, is very slow-growing. prostate cancer does not all need to be treated. And the treatments have potential downsides, right? You can develop things like erectile dysfunction and continents, other issues with treatment for prostate cancer. And there is some degree of regret in men who get prostate cancer treatment. And that's treatment. There's also side effects to biopsies and downstream tests that are not even treatment yet. So I think there is a real important point to have a discussion. I think I see it a lot actually in older guys where they're like 69 there's no they're past 69 they're 75 right and I tell them

look if you are how old was your dad when you passed away if he was similar to you in health and he passed away in his 80s I would not screen you anymore because likely if I found prostate cancer today and you've never had you've had screening and you don't have prostate cancer it's not going to kill you something else will and I think that's a really hard pill for men to swallow that oh and then I'm like, well, if you got prostate cancer, would you want to have surgery or radiation or, you know, variety of other things that we have available to men for prostate cancer? And, you know, if not, then really there's no value in finding out if you have it because it's going to create anxiety. It's the treatments are, the diagnostic treatments are not without risk.

Diagnostic tests are not without risk. And so it's a really important thing to counsel patients. But I do think that screening is valuable because before PSA was available, we were seeing men with metacetic prostate cancer all the time, they would show up with, you know, testic, they would show up with back pain from metacetic prostate cancer and they would be in such intractable pain that before there was medications, we would take them for orchectomy. You'd have to like remove their testicles to get their testosterone really low and their back pain would go away immediately. And so we don't want to get to that point either. So I think it's really important to discuss those things and to identify prostate cancer. But then once you

identify it. So identifying it once as a blood test. The DRE is also controversial or doing a digital rectal exam. And that I would say that it's valuable for a urologist for sure because we're also assessing prostate size, other symptoms, especially if they're having symptoms of an enlarged prostate. If you're having symptoms of an enlarged prostate, you should do a DRE. If you're not, or you don't really feel comfortable, like a lot of primary cares don't do a lot of DREs in their training. So if it's not going to help you in terms of the findings of the findings of the the DRE, then don't do one. Because the large majority of prostate cancer is going to be found by a PSA. Only 3% of prostate cancers will be from a non-PASA. Yeah, because the region where you're

palpating is the rare region where the cancer would develop. Correct, correct. So it's not, I think that it's fine that primary care is don't always do it. I think that's okay. And then once you find, say, a number that's elevated, now it could be elevated for a variety of reasons if you have an enlarged prostate, if you have inflammation, if you had a catheter recently, whatever, right? All those things can cause an increase in PSA. So one number by itself may not be sufficient and should probably not be sufficient to just jump into a biopsy. You may want to repeat that depending on how much different it is from the one before. And then now we have MRIs to investigate as well. So there's more and more data in using prostate

MRIs to identify lesions that are concerning for cancer and then going for a biopsy that's more guided towards that lesion, which is definitely a newer change from when you and I trained. And so I think that's great that we have that technology, but then when you do a biopsy, there are risks.

There's a risk of small, one to two percent risk of getting very sick and getting infection. And so that is something we really want to avoid. There's risk of bleeding and there's risk of discomfort during the biopsy. And then once you have the results again,

what do you do with it? Exactly. What I'm curious to see is on the next revision of the guidelines, I want to see if the fact that more watchful waiting has been implemented in prostate cancer treatments, the fact that people who haven't been screened what their outcomes have been,

because that is really what drives screening for me, because it's difficult to have a patient come in who's 50 and say that there's no clear answer here. You want to be preventing instances of prostate cancer, but not in lieu of creating new problems. Absolutely. And the issue is that you guys have a really hard job. You have to screen for prostate cancer, get their colonoscopy set up, check their blood pressure.

I mean, there's like a hundred things you're doing for one patient. And so to have this really nuanced discussion about PSA, it takes time. And most of the time, people are just going to get the PSA. And they're doing what I mean? And then you're going to deal with the results of it. Yeah, it's tricky. And the DRE specifically, I feel like residents are doing less and less of these days. just because every time they do it and they say, well, what did I gain from that?

I'm like, well, you saw that their prostate's enlarged and it drastically changed since the last visit. But I am finding less utility in performing the test from a primary care standpoint. Yeah, I think generally if they have symptoms, most primary care doctors will start them on a medication for BPA. And if that doesn't work, then, yeah, then there's value in investigating further. Maybe they have overactive bladder and not BPH. But ultimately, I think, you know, yeah, I don't think it's always mandatory. And if it's going to keep some, a patient from coming into the doctor because they're worried about getting a digital rectal exam, then I don't want them to do that.

Yeah. I remember I did a fashion show. It's pretty random that they did a fashion show. It's called the Blue Jacket Fashion Show. And I walked in it several years. And it's hosted, I think, by some prostate cancer association and Johnson and Johnson. And they're doing it in benefit of it, to raise money, to get more research, cures, et cetera. And I remember they had a videographer for walking around, giving them a microphone to people, and they would have them answer a few questions. And at the end, they say, oh, do you mind just saying, go and get tested? So we can do a montage. And I remember when they put out their video, everyone has the montage, including some reputable doctors saying, get tested, get tested, get tested. And then you have me at the end saying,

go to your doctor and have a conversation about whether it's screening is right for you. And I feel like it's easy to sell get tested, harder to sell shared decision making. It's really hard to sell it. It is really hard. But it is a really important discussion because you always have to think about even now with at-home lab test, right? What are you going to do with that result? Right?

So you get a blood test. It's about you as a person. You're not a number. You're a person. So like really, you're a nuanced person with your own thoughts, your own beliefs. And so to have those discussions with someone who can know you and meet you and know what you want and then help you guide you. That's why we get this training. We can help guide you based on what your goals of life are. Yeah, for sure. We talked about testosterone therapy for men.

You talked about earlier before we started filming that there is a role for testosterone therapy treatment in women. Take me to do that. Absolutely. So I think a lot of women don't know that we actually have more testosterone in our bodies than we do estrogen. And so testosterone, just like it's a hormone for desire for men, it's a hormone for desire. for women. We have antigen receptors all over our bodies. We have them in the vulva. We have them in the brain. We have them in our muscles. So similar to how men get benefit from testosterone replacement, there's a theory, you know, likely that women also get similar benefits. Now the data is predominantly looking at what we call hypoactive sexual desire disorder. So low libido or low sex drive.

And so if when you are there, we see that when women have clinically low testosterone, They should have about a tenth of the amount of male testosterone. So if the number is 300 for men as your low number of total testosterone, your woman should have 30 nanograms per decilator. And so if it's lower than that and you're experiencing low desire, there can be a role for testosterone replacement therapy. Now, the issue is there is no on-label treatment for women for hypoactive sexual desire disorder with testosterone.

There are other medications we can talk about. But in terms of testosterone, what we have to do if we prescribe it is we have to either have them get the male ander gel, put it in a syringe, take one-tenth of the dose of a man and rub it on their calf or their thigh. There's no injections or patches. There is in Australia, but not here in the U.S. And so those can be compounded from a compounding pharmacy potentially. So there are options available that can be very effective in improving design. and potentially have benefit for muscle health, brain health, a whole host of other symptoms. But again, I think right now there's not a lot available to us unless you're going off label,

which then has a cost associated with it because insurance doesn't cover it. Now, there are medications available on label for premenopausal women with low desire. So there's one called phlebancerin, which is a pill you take every single night. It works, both of these work on the brain. So this one works on serotonin receptors. it turns some on, some off to essentially increase dopamine in the brain to then increase desire. And so you take this once every night. And in about 60, 40 to 60 percent of women, you'll see an improvement in desire slowly over probably three months. And so it won't be like

this, oh, I want to have sex. It'll be sort of very subtle nuance. And you might notice like, oh, I'm watching TV and oh, I finally feel like that person turned me on and they didn't before, right? But it can be really transformative. So that's wonderful that we have these options. The other one is called Vialisi or Brimelanatide. It's an injectable medication. It's an on-demand medication, meaning you inject yourself 45 minutes before you want to want. And that also works on melanocortin receptors to help with desire in the brain. So these are both working on the brain.

And this one also works quite well. It does have some side effects with nausea, which often you have to take an anti-aetic or medication for nausea at the same time. I was going to say it's great that we're talking about the side effects of these medications because a lot of times when they're marketed, they don't talk about the side effects. And when they market a supplement and they say there are no side effects, that should be a clear warning sign that it has no effect, period. Because anything that has a positive effect will always have some side effect. Like in this case, this medication has

nausea. Right. Right. So I'm really happy to hear you say that on these. Well, I think it's really important because, you know, these medications, like I always joke with my patients, you don't want to be horny and nauseous. Like, that's like the worst thing, right? So, you know, I think it's great that we have these things, but I do think that a function of why we don't have on-label testosterone or more options for women is because they have to go through much bigger hurdles in terms of testing to get these things approved. And one, you know, they often get pushback that women are more complex than men because they have a menstrual cycle. There's a lot of factors that go into getting these medications FDA approved and available to women and even having the diagnoses

covered by insurance. And so we're really at a disadvantage for women in sexual health. I mean, we know that the anatomy is the same, right? Women have a clitoris, men have a penis. It's the exact same anatomy. When you cut it in anatomy lab, it looks exactly the same. They function the same way. They engorge and lengthen and widen with arousal.

And so, you know, there's so much there that we can work with, but it's been just really understudied and under-investigated, undervalued. Really unfortunate that there exists a stigma, especially when it comes to sexual health in general. I'm actually surprised. Do you have trouble on social media with your content, like posting on different platforms? Absolutely. So I mean, YouTube's been very supportive, but on things like meta and meta platforms like Instagram, Facebook, TikTok, like very quickly, if you talk about sex, they're not going to share your content widely because they're worried that you might be talking about pornography or illicit material. But there's no. nuance there, right? And you and I see all the things on social media that are very sexual in nature that are definitely going viral. Whereas, you know, when you're trying to educate on sexual health, and it's, again, amongst all sexual health educators, like across countries, I have friends

in India, I have sex therapy friends, sex psychologists, like they're all struggling to get high quality evidence-based content out there, whereas someone who wants to sell you a supplement to make your dick bigger is, like, very easily. getting their word out there. It's hard to get that not flagged. We have the same thing with just every health condition that we ever touched on. And I think YouTube, as you said, is probably the best platform for that, where they want to have good info on their platform. Absolutely. So I applaud them for that. Something that we didn't talk about when we discussed erectile dysfunction is how does alcohol impact erections? Yes, this interesting concept. I dug into the data. We know

that chronic alcohol consumption, which is, you know, sedative. It can create erectile dysfunction. So when men abstain from alcohol use and they've been using it chronically over many, many years, their erections get better. Now, using it acutely, there's like this term whiskey dick, right? Like people having a lot of alcohol and then having difficulty getting erections. Yes, that can happen. But when you dig into the data, actually having small amounts of alcohol here and there are not really affecting erectile function, which is great, right? Certainly it has an effect on mood. It can make you sleepy, which can then make it more difficult to obtain an erection.

For some people, it makes them more relaxed and makes them less inhibited so they can actually enjoy sexual activity more. So it's out of spectrum, but I would say that chronic use daily, every day, large amounts is going to definitely impact your erections. What about from a circulatory standpoint about vasodilation related talcol, anything that you've seen with that on the research? Yeah, so the thought is that maybe, and I don't like to share this too much because I don't want people to start drinking just to make better erections, but perhaps drinking small. amounts will cause vasodilation and improve erections in the short term. And, you know, that may or may not be true in a large scale against smaller studies. Got it. Moving on off the topic off erections, but similar topic, why has there been this drastic

fear created surrounding herpes? I feel like there is a ton of content online stigmatizing herpes as if it's this deadly virus, and not to say it's without problems. why are people so afraid of herpes? You know, I don't know why people are so afraid of herpes. I think it's just something that you can visibly see. And I think that that makes it even more scary for your psychological aspect, whereas I think some of the other STIs are less visible.

And so oftentimes, and also sometimes asymptomatic, right? And so people don't talk about them, whereas you can't hide herpes, whether it's type one, which is maybe on your face. And type two. And so I think because of it being so visible, it makes people really squeamish. And then they talk more about it because it's easy to talk about, but also like it's something that we know people have because we can see it. Of course. And I guess because there's an element of that it's random and sporadic. Like when you're the most stressed or you're not sleeping the most, that's when you get an outbreak. So it kind of takes away your control. I feel like that might play a

role as well because there's obviously some pain associated with it. There's the social stigma attached to it. There are rare cases where it can spread to other nerves and create these things. But those are really rare. Very rare. And we do have great treatments either for outbreaks or for prophylaxis inpatient. So those things are generally available. And I never understood why, like I think even talking to my nephews, their number one fear is herpes. My friends, whenever they would talk about, they'd like, I don't want to get herpes. And I never knew where that propagated from. Well, yeah, I think, again, I think it's, I think probably at someplace, someone started talking about it, so it was okay to talk about, whereas no one goes around

saying, I had chlamydia, I had gonorrhea, I had, you know, syphilis, which is again, very rare. But like, no one's going around talking about those things, but I think because it's visible and like, you may not see it, but someone else is going to see it, and then they can talk about it, right? So I think it's also like, I can't keep this a secret. Got it. Moving on to kidney stones, I'm seeing in my practice an increased diagnosis of kidney stones. Are you seeing that as well? You know, it depends on where you live. So certainly we have what we call the stone belt in the Midwest. Oh, really? And the South because when it's really hot and dry and people don't drink enough fluids, generally there's more, again, it happens. The reason that you get kidney stones,

very commonly is from dehydration. So lots of times people will get them. They're not hydrating well. But when you get recurrent kidney stones, it's often from a metabolic issue. And they, again, mirror the same metabolic issues that we're seeing a rise of, you know, nationwide. So more diabetes, more kidney stones,

more high cholesterol, more likelihood of kidney stones. So I think that's probably why you're seeing more of it. A kidney stone is the worst pain that one can experience. You have? Oh, gosh, it's horrible. I have not, but I have seen many. patients and you always know which patient in the ER has a kidney stone. They're like writhing on the bed. Unlike appendicitis where they're sitting still and don't want to move because

they have an acute abdomen. Exactly. So I think the one important thing is make sure you're hydrating well. And two is if you're getting recurrent kidney stones, make sure you get it worked up because there are medications available to help prevent kidney stones. So that means, you know, usually that's a blood test as well as a 24-hour urine test. And so make sure you ask your doctor about that because I think it's really important to prevent future kidney stones. You never know if you're predisposed to getting one. Maybe your family does. And so then you could be potentially proactive with that. And then the general recommendations are hydration, limit your salt intake, limit your high oxalate foods. And when I say that, people Google it and it's like

everything, right? But the things that are really high oxley are like spinach, rhubarb, so, you know, nuts. So if you're eating a lot of those things, just cut back. Increase your fruit and vegetable intake. In fact, that increases citrate, which helps prevent kidney stones. Crystalite is actually a really good kidney stone preventer. Yeah, I've seen like this is the one place where supplements actually can be a value where you have special juices that are formulated with high levels of citrate that change the acid base balance, right? Yeah. And then lots of red meats can also put you at risk for kidney stones. So I think there's things that within our diet and within our lifestyle habits that can really help prevent kidney stones and being, it is tough. It is really hard to get that amount

of hydration. We say two to three liters and it can be very tough, but absolutely worth doing because you don't want to get kidney stones. I've been meaning to start asking this question to all different specialists that come on my podcast. What drove you to become a urologist and are you happy with your choice? Absolutely. So I did not know what urology was. I'm sure, I don't know if you did, but going into medical school, I'd no idea what urology was. I didn't even think I was going to be a surgeon, but I went on my surgery rotation. I was like, oh, this is amazing. I love surgery. I love being able to work with my hands, have somebody go home that same day and, you know, get better. And so I didn't love general surgery. So I started looking at

the subspecialties of surgery. And I, in the end ended up with either E&T or urology. And I met urologist. I said, these are my people. These are like, they're happy. Are E&T sad? Oh my God. They're not sad. They're not sad. They're serious. They're more serious. Okay. So urologists are more fun. They're funny, right? Like you're taking care of genitals like you're just generally like you can't be that serious. It's like how pediatricians oftentimes have like funnier outfits when they go to work. Yeah. Yeah. So they just felt like you find your tribe and I'm sure you found yours. Like you find your tribe and you realize that okay, this is the people I want to work with each and every day. I loved what they were doing. They were on

the cusp of robotics at the time. You know, they did small surgeries, big surgeries. I mean, you could do any sort of thing when you got out of that. You could do a big surgery where you do a big open surgery. You could do a small minimally invasive surgery in the office. And so there was just a range of things you could do. You could take care of women. You could take care of men. You could take care of kids. And so you sort of take a chance, right?

You're like, oh, I like this and I'm going to apply for it. And I got in. And I was so grateful because it's been an amazing journey. I think that I do agree that you're all just a great people. I think they're funny. They're wonderful. They're smart. They're hardworking.

I think that we get to take care of our patients really most intimate problems. And especially in areas where they're really nervous. and we get to bring them at ease and help them through those things and we get to take care of them long term which many surgeons don't get to do that. So that was what really drew me to it and I'm just so grateful.

I think it's an honor to be in the position I'm in and I'm so glad I found urology. And you guys have your own specific match, right? It's different than all the other matches. How does that work? Early match. So I think us and ophthal, I don't know if ophthal changed, but when I was training, they were early.

And so you go through the same process, but you match in, I think, January or February. So you have to do everything earlier. So you do all your sub-internships and stuff during your fourth year pretty early. And then you match. You do interviews like not too much earlier than you guys, but we then match in, I forget if January, February,

but we match pretty early. And then, you know, you know where you're going to go, which is really nice. But it does make it difficult if you happen to be matching with someone else. Yeah, that does make it hard. I've seen the couple issue pop up. Yeah. For you getting a magic wand right now, you could say I could change anything about the field of

urology. What are you changing? I think that us urologists are really good at taking care of cancer. We're really good at taking care of kidney stones. Less, I think, attention is placed on female pelvic health and sexual health. I think that a lot of our research goes towards cancer. I think there's so much quality of life that needs to get attention and I wish we spent more time on them. Yeah. And I hear statistics like 70% of men over a certain age will have cancer already on a post-mortem analysis. So like yes, we know it's there. But what about the life before it that could be made so much better? And after it. Yeah. I think there's like for women with breast cancer, men with prostate cancer, they have issues they have to deal with that are very unique to

them and we need to be focusing on giving them a quality of life because the point of giving them life is not just giving them life worth living. Yeah, that's very valuable. It's like longevity, vitality, enjoyment, all of that needs to be taken to consideration. And that's why when you and I are talking about individuals who are not practicing clinical medicine, maybe as researchers or even as lay people giving advice, you don't understand how hard it is to triage a treatment, a diagnostic test for someone because you need to take so much information. and that's why we go through the schooling and the amount of patients we need to see.

Absolutely. Do you think we covered the topic, well? Is there anything we missed? We could talk a little more about communication because I think it's so important. People don't know. In what way? I think that we don't get taught

how to communicate about sex. We don't teach our young people about sex. The large majority of them are learning about sex through erotic films. And that's more and more accessible. And I think the really important thing there is that kids are getting access to pornography, on average at age 10 or 11.

Wow. So it means that they're getting, some are getting the eight, some getting at 14. But, you know, they're really, really young. Their brains are not fully developed. And as parents or educators, and I think educators have a lot on their plate, so it's probably not going to end up in their wheelhouse.

But as parents, we have to be talking to our kids about what they're going to see, what that means. Even if you do your best to have, you know, parental controls on everything. Someone's going to have a phone that doesn't have parental controls. Someone's going to have access to something that, you know, and your kid's going to see something that you didn't want them to. So I think bearing your head in the sand and thinking that they'll learn from somewhere is the wrong thing. And I think we have to be talking to our kids about their genitals, about what they look like, how they should act during sex, what's

normal sex look like. Have that conversation with me in a short form. What should it look like? Well, one, it's not going to be one conversation, right? So I've talked to my sons about sex to some degree, and it depends on their age, right? So we'll go on a walk. I don't have to look at them in the face. They don't have to look at me in the face. And I'll say, you know, what do you want to know? Like, actually my oldest son asked me, like, what is sex? Right? And so I said, okay, we'll talk about it. Like, give me a minute. Like, let me, you know. Let me game plan a little. And next time we go on a walk, I'll talk to you about it. And so I took that time to tell him, like, well, this is what sex is. This is the action.

of what happens during sex. The purposes of sex are usually to make a baby, but also people like it. It's pleasurable. And I said, look, I want you to always feel comfortable having this conversation with me. If anything you see or hear or want to know about, you can always come to me.

I think the worst thing we do is like, oh, we'll talk about it later and never talk about it, right? Because then they're like, no, I can't talk to my mom or dad about this because they don't feel comfortable talking to me, right? And then when he has an issue in the future, I hope he'll come to me, right? And then when we talked about pornography, I was like, look, you might see some movies or something that shows people doing intimate things or having sex, because he knows what sex is.

And I said, that's not real life. That's not what real sex looks like. And it may be confusing to you. And please, when you do, I want you to talk to me about it. And so it's, again, small moments in time where you bring it up and they start feeling very comfortable bringing it up with you. and it's hard and I think that this is not your fault

it's hard because we've never had this conversation right we've never had this conversation our parents never talked to us about it maybe it was like the birds and the bees right one talk don't have sex in my case right like but you know I think I think it's really important that we

take the onus on ourselves because right now pornography is so accessible so accessible and that's potentially harmful for younger kids Does the fact that the extremes do so well on social media and then end up being the extremes on pornography doing really well? How does that impact the mindset of the average person sex life?

Well, let me explain. So absolutely does. So let me explain one interesting fact I learned. So I had Debbie Hermanick-on. She's a sex researcher. And she wrote a book called Yes, Your Kid. And she basically, through her research, found that strangulation or choking has become so commonplace in relationships, like more commonplace, as commonplace is kissing. And this was

shocking to me, because that was not something when I was growing up was a thing. But now because of, you know, erotic material, kids are seeing this and then they're trying it out with each other. And it's fine. If you do it with consent safely and you enjoy it, that's all fine. But those things are not happening, right? They're not talking about it necessarily. They may not know how much pressure they're applying. Maybe their partner is scared and doesn't like it, but doesn't know how to say no. And so there's a lot of things there that I think people are learning from this material. And absolutely, I will see people who come in and they are like, my body doesn't look like that, or my genitals don't work like that, or I don't respond like that. Am I broken? Is something

wrong with me, right? And so I think that once you have a mature prefrontal cortex, like you can understand that that's not real life. But I think when you're growing up, and you don't know and that's all you see and that's where you learn how to have sex because no one talked to you about it then you're like well wait my partner didn't like that and i i did what they did on the show you know and and so you're really stressed and you're really like self-conscious and you've no one to talk to about it yeah it's uh it's almost why i think it's reasonable to set almost arbitrarily numbers for why for when kids can start smoking can start gambling can start gambling those things, once your prefrontal cortex is largely finished growing, you can have a better

grasp on what an addiction looks like. You can manage those things better. Your reasoning's better. But before that, it's Wild West. You have very little control over what's going on. Yeah. And yeah, I think in school, they do the best they can with the time they have, right? They teach protection. They teach consent. But like, there's so much more. Like, if you know what your anatomy works like and how it functions, I mean, you're going to do better in life because you're confident in your body and you know what how it works and i feel like this conversation will change 30 years from now because there's going to be novel ai robot whatever things going on and it's going to be completely different yeah and i mean i think there's a lot of catastrophizing about a robot that

potentially there could be benefit if used appropriately you know it's a tool like anything else um i can't go without asking the most common urologic question what is the most egregious injury you've seen. So I had a page. There's two. One is a patient. So urethral sounding is a thing where people put objects into the urethra. Now people find it pleasurable.

No shame. If you want to sound, that's totally fine. But you should do it with appropriate instruments. So something with a flared bass that's well lubricated so that you can get it out. So this patient was sounding with a toothbrush, with the end of a toothbrush. And got stuck. and he then broke off the end of the toothbrush.

So then it was just the like shaft of the toothbrush stuck in the urethra, which we then had to fish out surgically. Luckily we were able to do it with them. Took off the glands off the toothbrush. So that was one. The other one was a lot of times people will use constriction bands, but they'll make them at home. So constriction band is essentially a device you put on the penis to help keep the blood flow in the penis.

So a guy took like, a nut, basically like a big, thick, huge nut and put it on their penis and it got stuck because their penis then swells if you leave it on for too long. If you ever use a constriction band, you should take it off after 30 minutes to avoid this issue and it should be able to come off or be silicone or, you know, something that's easy to come off. So then we had to get a jiggly saw from the fire department and cut it off, which is not our area of expertise in using these instruments.

but unfortunately it's something we very, you talk to you also, I'm sure every urologist has had one story like that. So it's just use appropriate instruments. I don't mind. I have no problem with kinks or fetishes or anything. Just use instruments designed for that activity that you're doing. Urologists oftentimes have the best metaphors or the best puns. I saw a statement about how we were saying these testosterone clinics are almost everywhere.

One of the directors of the AUA said, these testosterone clinics are mushrooming all across our nation. And I'm like, great choice of vocabulary. Yes, you can always count on us to be good dinner company. Yeah, exactly. All right, well, thank you so much for continuing to put out the good info. Where can people see more info from you and what you're up to? Absolutely.

So you can see me on YouTube at Renamalik MD. I also have a podcast, Renamalik MD podcast, and really any social media platform. Awesome. Well, thank you for your time. This is awesome. Thanks for having me. What a pleasant and informative conversation with Dr. Malik. If we didn't ask some of the questions you were curious about,

don't hesitate to leave it down below in the comments. Also tell me what you thought about the episode. If you enjoyed it, please give us a five-star review as it really helps our podcast find new listeners. And if you're looking for another great conversation, check out my episode with reality TV star Harry Jousy and how he uses TRT in a less optimal way.

Thank you so much for listening and watching. As always, stay happy and healthy.