Unzipping Taboos: Candid Conversations about Sex - Masculinity & Medicine: Men, Sex, and Prostate Cancer

Episode Date: April 22, 2026

Prostate cancer is one of the most common cancers in men—and one of the easiest to ignore.In this episode of Unzipping Taboos, we sit down with Dr. Arthur Burnett—Professor of Urology at the Johns Hopkins School of Medicine, Patrick C. Walsh Professor of Urology, and Director of the Male Consultation Clinic at Johns Hopkins Hospital—to unpack what men’s health conversations too often avoid.From what the prostate actually does to why prostate cancer can develop silently, we get clear on what every man—and everyone who loves one—should know.We talk about the reality that “no symptoms” doesn’t mean “no risk,” and why waiting for something to feel wrong can come at a cost. Dr. Burnett walks us through screening, who’s most at risk, and why factors like family history and race—particularly for Black men—matter more than many people realize.And this conversation goes beyond the clinical.We get into what happens after diagnosis—the treatment decisions, the impact on sexual function, and the often unspoken emotional weight men carry when their sense of identity and masculinity feels tied to their bodies in new ways. From medications to devices to surgical options, we unzip what support and recovery can actually look like—and why silence and stigma only make it harder.This is a candid conversation about advocacy, awareness, and showing up for your health before something forces you to.Because when it comes to prostate cancer, what you don’t feel can still matter—and what you don’t talk about can cost you.If you have a story, thoughts and/or a topic or question for Dr. Sue and Charlie please share your ideas here: ⁠⁠Show suggestions

Hey, everyone. Welcome to Unzipping Taboos, candid conversations about sex with Dr. Sue and Charlie. We're here to explore the questions you've always been curious about, but maybe don't always feel comfortable asking out loud. No judgment, no shame, just open, honest conversation. So zip down and let's get candid. Today, I'm very excited about our episode and our guests that those of you watching can see with us. We're going to be talking about talking with Dr. Burnett about men's health and prostate health and all all the things that go into that. But before we do, I want to introduce or hey, check in with Dr. Sue. Hi, Charlie. Hi, how are you? I'm too. I'm so excited about this. This is this is Yeah, we've been talking about doing this for a while. So I'm

super excited. So my intro, which I know you're about to ask for is going to be so short. All right, we'll get to it. So we're gonna keep it really simple. So I have a PhD in human sexuality education. I work primarily in academia doing all the academic thing, academic, the academic things. And then I also do consulting out in the real world because everyone deserves information about this. So that's me. I think it's my shortest bio ever. Because Dr. Burnett, I really want to get to you. So Charlie, your turn. Super short. Super short. I'm Charlie. I'm the curious co-host here on Unzipping Taboos. Really just want to understand more about how we human together and barriers that may have been conditioned into us or some self-inflicted

barriers to getting information and just kind of experiencing each other and life fully. So that's me that's probably my shortest intro so that's how excited we are we really are dr burnett thank you again so much for joining us today would you please tell our listeners about a little bit about yourself before we absolutely dive in well thank you for welcoming me and it's such a joy to be with you guys you guys are just wonderful and i can see the excitement and we're gonna address some important subject matters that you know we're pleased to help the audience understand so by way of background, my name is Dr. Arthur Burnett. I go by Bud, so you guys know that that's absolutely fine. I happen to be a full professor at Johns Hopkins. I came here to medical

school. I say here, I'm not really an institution at the moment. I'm at my house, but I came to Johns Hopkins about 40 years ago as a medical student and then trained in urology, became a surgeon scientist, became an educator, became an entrepreneur and a researcher, an advocate for patients, an ambassador in many ways with regard to sexual health. So I've worn a variety of hats, but all surrounding men's health and the best for men with regard to their sexual function. And in your spare time, did you do some writing, I believe? Yeah, I've done that. It kind of comes along with the territory. Well, we really want to do some stuff on prostate health. I know that for me, I've done some work with prostate cancer survivors and their family and in just advocating for men's health.

This is the area that people get really confused about because they hear words, they hear terms, they hear they're supposed to get checked, they're not supposed to get checked, they're supposed to do things. Then maybe there's like a blood test. It's just very confusing. And so I'm really excited that we get to talk to you to kind of clear up some of those basics. If you could start, and if it's okay with you, starting like basic 101, like what is the prostate and like what does it do? Absolutely, absolutely. So, you know, we can walk our way through all of this, but no doubt you're right. You know, there's, you know, a lot of discussions out there about this mysterious organ, the

prostate. We hear about prostate cancer, we hear about men's health, and there's a lot of confusion potentially out there because there is mixed messaging that goes on. The prostate gland is an organ that's situated in the deep pelvis in men, not women, in men. It's right at the base of the bladder. urine passes through it and it's kind of one of these organs that has mystified us over many many years for clinicians as well as scientists why do we even have this organ you can live without it so what is it really doing well it may actually provide some secretions that have to do with

urine passage or maybe have something to do with some secretions having to do with passage of male sperm, and some of that role in reproductive functions. So, and it can have a lot of pathology related to it, okay? Pathology in that it can become obstructive, and it can turn into cancer. And so, you know, there's a very devilish organ that we don't need. Why is it there? And why is it causing so much trouble? But that's what it is. I feel like the older I get, the more I'm learning how many organs we don't actually need. Someone I know just had their spleen taken out and someone's like, well, you don't really need that as an adult. And I'm like, okay, thank you. I appreciate you also clearing up the fact that women don't have prostates. There was one

point where they were trying to convince people that the skeins glands in women were the female prostate and that caught on for like a year. And I still find myself every once in a while having to make sure i'm saying like there is no prostate gland in women well homologous structures but but they're really and and they're derivations for structures that are that occur in men and women that are somewhat similar but it's not really the same now yeah and so so you know yes depending on how you want to look at it here i think we should probably still differentiate the this organ in men But it's an important organ, and to take it further now, we know that it can create problems in men. We talk about here the obstruction of prostates.

We say prostate enlargement by prostates getting bigger. Guys are very concerned about all of that. There's some nuances there. The prostate does not always have to be enlarged. It can be obstructive even with regular-sized prostates. As men get older, the prostate can be obstructive, and it can cause a lot of voiding dysfunction. Separate from that is prostate cancer, which oftentimes does not have symptoms related to it. The symptoms of an obstructive prostate is, you know, slow stream and hesitating to avoid

and not sure you're emptying well and a lot of urinary frequency and getting up even at nighttime and all these kinds of things. Maybe retention, feeling I'm not getting all my urine out, so I'm retaining urine. These may be more benign symptoms, really, that many, many will acquire as they get older. Prostate cancer, on the other hand, is where the prostate develops cancer in it. Cancer develops within the prostate but does not necessarily have symptoms. In fact, really, it doesn't have any real warning signs. So that message I do want the audience to hear early from me with this discussion that's so important here as we talk about prostate cancer.

And, of course, we're going to get into a lot of other important aspects surrounding this. But just from the outset, you know, men are all too often reluctant to go to the doctor, all too often to say, well, if something gets bad, I'll go get checked out. I'll wait until I get symptoms. Let's just make it very clear right here, right now, that symptoms don't necessarily mean cancer. And then also to understand that, you know, do these symptoms have to occur to prompt getting into the doctor's office? Well, yeah, if they're bothered enough, go get checked out because there may be some interventions we can offer, but that may have nothing to do really with prostate cancer. I think that's such an important point. The absence of symptoms does not mean don't go to the doctor and have the conversation, the proactive approach.

And that goes a little bit to the conditioning piece that I'm always curious about, because I'm sure there's much you've had to battle in combating some of these hesitancies or the, well, it wasn't bad enough or anything along those lines with your patients. Well, there's that. And there's also the stigma that surrounds, you know, fellas concerned about anything that impacts what's going on down there kind of thing. Virility. you know and anything that could potentially adversely affect one's manhood you know men are oftentimes raised to say you got to be macho kind of shrug it off you know deal with the pain get get on with it you know that's that's unfortunate sometimes here particularly surrounding some health conditions so you know we we understand that but it's good we're talking about it and

i think we need to bring the light here that men should get checked out uh prostate diseases and And prostate cancer, which I'm sure we'll delve into a little bit more, is prevalent and it can take your life. So we need to make sure that we address it. Yeah. And we cannot stress that enough. I'm sure you've seen the numbers that came out of the Cleveland Clinic. They did the mention a campaign for a few years running. And it was saying like men would rather clean toilets and do household chores and go to the doctor. And that they do. They wait until like body parts are almost falling off before they're like, OK, maybe I'll make an appointment.

So I know we've just said it twice. I want to say it one more time. No symptoms does not mean you're okay. So if you're waiting for that to happen, you've waited too long. So then the next question is, because there's some confusing stuff. I know we talked about this in the pre-show. The CDC has kind of said not everyone needs to get screened, but there's a difference between screening and having a conversation with your doctor.

So who should have these conversations? Who should get tested? What age? tell us everything yeah so so let's let's dig down deeper and and then you know we we you know preface with just the fact that prostate disease is somewhat mysterious the organ is kind of mystifying uh there's controversy out there surrounding it because there are mixed mixed messages uh messaging out there may well be that you know prostate cancer is a is a cancer uh so So it is a true cancer, but it affects older men, and it moves slowly and, you know, doesn't necessarily need to be treated.

And then on top of that, you know, with the concern that getting treated can impact one's functional abilities in a different way, there's a lot of hesitancy to move forward with that. So I think that explains some of where, you know, the various organizations, even the government now is trying to say, well, let's try to define who should really get checked out. But at the same time, now, I'll just offer to the audience the reality that prostate cancer is prevalent. It occurs in about one in nine men. One in nine men. Among African-American men, it's one in six. And that's another kind of storyline we could talk about. But the bottom line is it's very common.

But what's challenging is that we know that prostate cancers are not all the same thing. It really is a broad spectrum disease. and some prostate cancers really are fairly low profile, not likely to progress, okay? And that may explain why some men might say, oh, my neighbor down the street said he's just going to be monitored. Well, you know, after he got worked up, we may have found that his presentation is such that monitoring is the right thing to do. On the other hand, the other option of the spectrum as prostate cancer is that it really do have a very aggressive potential in that man's, his clinical presentation to where untreated or just putting into a monitoring mode is

not going to be the right thing to do. Right. Absolutely. And so really, both of these kind of presentations are true. And that's why it's so important to get in, get checked out, understand what your risk is, find out what's going on. given the prevalence of this. And in fact, a lot of prostate cancers, we're all going to tell men to be monitored if it fits a certain profile. Others, we're going to tell guys, hey, don't

mess around. This can take your life. Yeah. And I think the piece that the guy missed there in the story of like, well, my neighbor had it and he was told to monitor, but he knew he had it. Like that's the piece that I find sometimes of like, you can't get medical advice when we don't even know what's happening with your body. Like you have to go in and get the diagnosis and they have to figure out what's happening um you can't do it you can't do what the guy down the street's doing if you don't have the same type so well well and unfortunately the shame of all things is i guess that's the easy way out for many men but that shouldn't be the case and we should just tell it that you know you can't rely on dr google you can't rely to your neighbor who's not medical

professional you can't just compare yourself to somebody else who are all different right and prostate cancer really has various presentations to it so that's that's really what it comes down to. Now, a deeper level of discussion for you guys to think about is indeed prostate cancer in general, among cancers we can get in our bodies, does progress somewhat slowly. So you're right, some of the guidelines that we're hearing from the government, and I don't want to get in too much of the weeds with the audience, but recommendations that men after a certain age maybe don't need to be checked. Maybe men don't need to even be checked until they're a certain age anyway. So there is an attempt to try and define the most at-risk age range. But I think

that we still need to think about certain populations, men who have had family histories of prostate cancer, men who have come from African-American descent. They may need to get checked out a little earlier than the standard kind of 50 or 55-year cutoff. The government has most recently recommended men between the ages of 55 and only the ones should be screened. well, you know, we may be missing a lot of guys in the front end where prostate cancer can occur in men in the 40s or early 50s. And on the back end, you know, while it's kind of the thought here that stop screening at age 70 is not going to progress in that man's lifetime, well, the reality is many men are living longer. And if your health is good, you know, I think many of

us urologists are going to tell men, hey, listen, if you have at least a good 10-year lifespan ahead of you, keep getting checked. Don't just abandon getting checked just because you hit 70, where some of the cutoffs have been. Some men are going to live in their 80s and 90s, and if you're really in great health, continue to be checked. Now, the dilemma occurs, and I have to be honest with you now, because I'm a busy, active urologic surgeon. I have too many men, young men who get diagnosed too late, and that's a shame. But I also have the opposite end of the spectrum, guys that are 80s and sometimes even 90s getting PSA values every three months. We're going to talk about PSA in a moment. But this is kind of the screening test that at least is what we have

standardly available at the moment as the most common way of screening for prostate cancer. But, you know, once guys get in that age range, I think we need to help inform them that we got to back off a little bit. Because prostate cancer does progress slowly enough that once you get in the very older age ranges, that we're not likely to be really too aggressive about our treatment because we're going to be concerned that our interventions may bring more hazard to that man than the real threat of the disease. And so we really have to be cognizant that we should be very careful in older men, I think, that men need to hear this, but also among our medical practitioners

that may be listening. We don't need to be screening guys in their late 80s and 90s and things of that sort. That just doesn't make sense. Yeah. Like glad they're on top of their health, but also maybe not necessarily every three months. It's interesting you say that idea about being past 70. I was talking to a group of older men, older folks. It was mixed gender. And we were talking about STIs because, as I'm sure you know, the STI risk starts to go back up after 50. And I had a guy be like, I'm 70. So what if I get a disease? And we're hopefully living longer than 70. You still have a lot of life left. So if you are at that 70, you don't just get to write off and do whatever you want to do. so I have like three questions I don't know Charlie if you have any that I have I have a

couple but I'm not sure they might be related or the same so I'll let you start so the question I have because I I have done some prostate cancer education in the community and I had a guy be like can I just go to urgent care and have that done and I'm like that's not really the place to do your prostate cancer check so he said do I absolutely need a urologist or can I go to my primary care. So I'm going to put that question to you. Does someone have to go to a urologist? Well, that's a fair question. And I think that's a great question. That's a great question to ask because, and I'll tell you from my perspective, that I want all physicians, all clinicians, so not just physicians, clinicians, that includes nurse practitioners, physician assistant. We use

this word, APPs a lot. These are allied professionals that play roles in doctor's offices to recognize that we all can play roles looking after our men, okay? And part of the concern is historically, yes, we used to do what was called the finger wave, the digital rectal exam. And maybe only urologists need to be doing that. And for the fellows out there, some of you may know what that is. That's a gloved finger that goes into the anal canal to feel the prostate to see whether something really feels hard or suspicious as an irregularity that might signal something's really likely cancerous about the prostate. The truth is, is that's kind of gone by the wayside. And even as urologists, I think, accept that it's very unlikely that somebody's

going to have a unique finding on a rectal exam that was not going to be otherwise brought to some level of concern based on the blood test, the PSA that is simply done. And so probably 95% or more of the time, if that's irregular, that's going to guide us more to do something than the rectal exam will. So all individuals in healthcare can be involved in this test. And I advocate for all to be involved because us urologists are increasingly uncommon. There's only about 8,000 neurologists in America. And so we're not that common to have trained to be high-level surgeons like we are. It's hard to get appointments many times with us. We're just not that extensively in practice as other clinicians may be. So just get screened, at least by any medical

professional. Get your PSA test. If that's abnormal, then it's our job then as urologists to receive that referral and then distinguish whether that PSA elevation, which can be confounded by many other conditions affecting the prostate. It's not a prostate cancer of my creation. It's just not right with the prostate, which oftentimes can just be a large prostate or periodic infections of the prostate or other kinds of conditions that don't always reflect prostate cancer. But once you've gotten screened now, had at least initial discussion, a consultation with

your regular doctor, if it's outside the normal range, that should then prompt the urologic consultation. Right. Yeah. So, guys, if you're hearing this, like you don't have to go find a brand new doctor and establish care with a urologist just to do the test. So if you have a primary care that you like and you have a relationship with, start there and hopefully they they can guide you if that PSA test is high. um i'm glad you brought up the digital rectal exam because that is the the number one fear i run into for men they're like i don't want to have something stuck up my butt i'm like that's great it's not the 90s anymore we're not really doing that for testing but there was a there was a there was a cartoon i'm trying desperately to remember what it was where they were making fun

of how terrified the main character was to have that test done and i think it scarred generations for like, I'm going to have to go in and have this very invasive test. So just to repeat what Dr. Burnett is saying, it's a blood test. It's the blood test. That's really what we're looking at right now. Yeah, let's start with that. And who knows, you know, as we make advances in medical science, we may actually have even simpler things as the years go on. But I can tell you, you know, yes, back in the 80s, back when I trained, which is now a few decades ago, we didn't have these kind of tests so we also were doing rectal exams and feeling that was really going to pick up prostate cancer uh and unfortunately much of the time by the time we felt something irregular

it was too late for many guys anyway so the psa test that this and you know in these in these modern times is not a perfect test because it doesn't always mean prostate cancer so i want to make that very clear but if it's outside the normal range and there really is a kind of a zero to four normal range of that uh just for the audience to hear uh that in general we'd like to see values within that normal range. If it's outside that range, then get a urologist involved at that stage. Thank you. I want to ask, you had mentioned, you know, talking with your provider to do the screening test. What if you run into an instance where a provider says, oh, you know, not, you don't really need to do that yet, but you feel like, no, maybe I should, or I just,

I want to know for my peace of mind or something along those lines. How can men approach those conversations when they start to get that resistance and or how can their partners help them advocate for themselves? Yes, yes. Well, you're right. They've got to advocate for themselves and partners can support these men because we all need to have good supporters everywhere. But I think that the point made here is just that, you know, you're responsible for your health with good information that we're sharing here.

I hope that men can understand that you can say, you know, I'd like to get this test and I'm requesting it. And I think it's part of my best prostate health, you know, evaluations and just insist on it. And if your physician is resistant, well, they may have to identify somebody else to go get it done. Um, but, uh, yeah, the, the, the information that, uh, needs to be obtained by getting the PSA test and guiding your best care, it sometimes does get lost on some primary care doctors who are busy. And I accept that they're very busy, got a lot going on. Hopefully somebody is not dismissing, uh, somebody, meaning your healthcare provider

is not dismissing the importance of prostate cancer. And if they are, that's unfortunate, but, but certainly I can understand men, particularly men who are potentially at higher risk. Young men, men of family history, they may say, well, you're not 55 yet. You don't need to be checked. I've seen this happen too often. Guys walking in my door who's now in his still early 50s, or maybe he's late 50s, and he said, I didn't get checked. His PSA is just way outside the normal range. And I just know that this was already changing perhaps years ago. So again, the message I'm trying to share with the audience is, you know, if you want to get it, request it. Certainly if you're a high risk group,

definitely request it and advocate for yourself. Just insist on it. And then if you need your spouse there to, or a partner to help kind of can tell that physician, that clinician to say, I want this. Well, hey, gang up on that person if you got to, but go ahead and get that PSA, right thing to do. Yeah. And I, oh, go ahead. So one of the things that I usually advocate when you, when you know you need a test done or you want to have a test done and they're refusing, I always make, tell people to make sure that they're documenting that they were refusing the test. So say, okay, you're not letting, you're not doing the PSA test. I want that in my, I want that in my file. I want that you to put that in the summary of notes today that I asked for this

test and you said no. And what patients tell me is a lot of times I'll be like, okay, fine. It shouldn't have to come to that. But there are ways of advocating for yourself. And that's one of those ways of saying, I'm not going to wait or explain to me why you don't think I need this and then document that as well. So just a little note, hopefully it doesn't come to that though. Yeah, hopefully it doesn't come to that. And I do appreciate that some do have some resistance out there. Some of my colleagues in medicine are thinking that maybe some men don't need to be treated. Maybe that's their personal point of view.

But I really have a major worry, if you will, that we can't just dismiss this risk. I've seen it happen. And the unfortunate sad truth is I think, you know, we always talk about, you know, well, let's not do the diagnosis because it may lead to overtreatment. Well, you know, there's two separate things here. Diagnosis and treatment. Just because you're getting tested doesn't guarantee that you're going to go through a treatment. Right, right. Let's at least get evaluated, and then let's have a healthy discussion.

And then with a healthy discussion, we determine risks and benefit, individual circumstances, you know, and go forward from there. So it's not like it's, you know, we suddenly become dumb and then say, oh, get the test because that means you're going to just go ahead and get surgery or get radiation right out the gate. No, it's not a matter of here. let's evaluate if something's abnormal then we define your risk and then we help you decide what's the right thing to do right yeah at the risk of oversimplifying it let's let's know what kind of puzzle we're working with first before we figure out what pieces we're going to start putting together right like it's those those conversations i want to go back a little bit to risk factors you've named two important factors that was one of the questions i got charlie dr

as you sync up. So you've mentioned family history, prostate cancer, men of African American descent. What are some other key risk factors that for our audience to understand to do this self-advocacy to maybe ask for screening earlier than recommended? Well, I think those are the most important things in terms of just, you know, risk groups. You know, certainly there's further discussion just surrounding lifestyle and considerations regarding exposures and things of that sort that I think are a little bit more vague. Occupational exposures, kind of work environments, things of that sort. So I don't want to kind of overstep what I think scientific evidence would support. But I think we do have enough to believe that family history, if you've

You've got, you know, a father of older brother, brothers, that increases your risk from, you know, at least by like one in nine to about one in six. And then for African-American men, that's already one in six. And if you have another first degree relative, that's kind of what I'm suggesting. It brings your risk down to maybe one in four. So, gosh, these are odds. These are real odds here. So be aware of that. So I'm going to address this specifically to some of my students who told me that smoking is not a risk factor for prostate cancer because you smoke up here, but your prostate is down there.

So can you address that for me? Right. Well, you know, these things come up and then you heard me kind of allude a little bit to the kind of exposures and this and that. you know, the cigarette smoking story is an interesting, you know, certainly it's connected with various cancers of the body, including lung cancer. I think where we stand with that with prostate cancer is it's not necessarily linked with causing prostate cancer, although it may have something to do with more aggressive prostate cancers or even causing prostate cancers to progress. So in general, cigarette smoke is not a good thing. Whether we have great evidence to say that it causes prostate cancer i don't think we really can say that but i do think that that it

still does contribute to the threat of prostate cancer in the ways i just described and so be aware of that but oh my gosh just something goes on up here doesn't go down there i mean i don't know i was trying to tell you know i was trying to do the whole there are carcinogens and you put carcinogens in your body it's going to increase your risk of all the things yeah yeah it's not it goes all over the place so yeah well they're they're they're late teens early 20s they think a little bit differently sometimes like your body's in two different halves or something yeah i think sometimes i think they do um i want to go back to the race issue because i talk about this a lot um in some of my minority health classes um like i so when i'm especially when i talk about

women's health and i talk about the the incidence of breast cancer being so much lower for black women but then the incidence of mortality is like i think last time i checked it was like 35 40 percent higher um so i i know you have already talked about the prevalence difference between men in general as one in nine and african-american men being one in six i don't know if you feel comfortable but can you talk about also the prognosis and how that changes for i don't even just want to say african-american men i think i think it's all men of color but sure sure sure yeah, we say brown and black men. You know, the reality is prostate cancer can affect different ethnic groups. I mean, it's high in Scandinavian countries as well. It's high in some of the

Caribbean countries. So it's not like exclusively, you know, they can generalize. But part of the issue, I think, is this. I mean, the mortality rate in America with African-American men for prostate cancer is two and a half fold higher, which is just alarming. But I think that reflects a great deal of health care access issues and maybe some other kind of life circumstances that disproportionately affect men of color who may not be in environments that give them the best access, the least likely exposures to various kinds of carcinogens. We've used that term already. I think we're still working through some of this. There may be some genetic issues going on here, Um, although I think as we learn in our world here that, that, um, you know, our genetic

backgrounds are very complex, you know, and just, just looking at somebody doesn't tell you everything. So the reality is just kind of saying that is, I think perhaps simplifying a little too much, but, but, um, cause I mean, even among, you know, African-American men, they, they, they're all over some Caribbean, some from Nigeria, some from, you know, North Africa, some from South Africa, somebody, I mean, so it's, it's, it's not all that easy, but, But I think that the unfortunate thing that accounts largely for some of this is healthcare access. And too many men, I think, unfortunately, are diagnosed late when the disease has progressed.

I think there is good evidence out there that stage for stage with cancers, okay, and with prostate cancer, the outcomes can be similar. So, for example, in the military system, men tend to be able to get access to health care system easier than perhaps in the general public. And so for men of all ethnic backgrounds, if they're diagnosed early, the same sort of outcomes will be favorable. If they're diagnosed late, they'll be unfavorable. So I think health care access is a big factor here. And there may still be a host of other things in play, too. you know environmental exposures diet um perhaps lifestyle issues maybe not enough men are you know who are who are just working three jobs you can get to the gym as easy as somebody else you know

things of that sort so there may be all these kinds of factors that are in play as well so it's a complex story it's a complex story and i just want to add to that when we say health care access we don't just mean being able to get to a physician it also means being able to take time off work to get to a physician. So what you were saying, like the person working three jobs or the person working two jobs who doesn't have really easy access to mass transit, I would also say that it's also a lack of access to education, that there are places where we're not doing any boots on the ground education to get these messages out. So for folks who are like, what can I do about this? You can talk about this. Like there's things you can do to help the men in your family

and the men in your life. And it's encouraging them to get checked, but also just spreading the information. I couldn't agree more. I couldn't agree more. Absolutely. Primary prevention is my thing. I have so many questions, Charlotte. I don't know if you wanted to go for it. Okay. So I want to get into the sex side of it because that's what I do. So I know we've talked about PSA. I know we haven't said the words here, but we said it as something we want to address. If you could define a radical prostatectomy for us because i and then any other terms around that you think people should know sure sure sure well i mean again we're getting into this discussion you know now i mean the topic area of just the impact of intervening for prostate cancer and

we've already stated the prostate is kind of in this area of the body that can impact one's abilities here sexually and for many men that's a big big thing for all men i would i would think You know, you want to preserve your best functions. So a huge portion of our discussion. So radical prostatectomy is a term that describes the total removal of the prostate. So the word radical, I think, unfortunately, maybe implies to me that something is done that's excessive or something that's done that's not well controlled or something of that sort.

I mean, what it really implies is that the entire prostate is removed, and it's distinguished from some other descriptions of prostatectomy. Prostate removal is what prostatectomy means, but there's ways of removing portions of the prostate that's not an entire removal of the prostate, which has been the traditional way for managing prostate cancer, and if you think about it, you know, it can be analogous to women having breast cancer now. I mean, back in the early years of Halsteadian surgical traditions, the whole woman's breast would be removed.

That would almost go way up to the armpit and up near the shoulder and everything, just right down to the bone almost. The muscle barely covering some of the rib cages. I think we've learned over years that that's just really excessive, and there could be more modified resections and even lumpectomies done. So we're evolving in the world of prostate cancer to consider whether we can do less extensive surgery, but radical prostate means this implies that we have to get into the pelvic area, remove the prostate in entirety, not to leave any tissue behind this prostate

origin that could still evolve into a cancer and be a threat if you don't remove it in entirety. So that's what a radical prostate means, and it's just one form of treating prostate cancer because there's radiation. There's now new focal therapies that are coming along, which are getting to the point here that I was making that we may be able, with better imaging and better ways of really assessing prostate cancer risk, remove just parts of the prostate or treat parts of the prostate very effectively as we undertake new interventions here, new ways of getting to treating prostate

cancer. But traditionally, it was the entire removal of the prostate. so what impact can that have or some of the other things like just doing radiation or just doing partial um surgery what impact can that have i guess i want to say does it always have impact on sexual functioning because i think that's men's fears and if it does yeah if it does what kind of impact could it have and could they just take a drug to fix that because you know that's the question that comes after sure sure well we're drilling down a little bit more layer by layer so so i said that's deep in the pelvis because what that implies then is that some of the

structures that have to do with how erections occur how our sexual function occur how our sensations occur in the pelvic area uh is not just uh just what you see physically right right in the front of somebody's pelvis you know there are structures deep within the pelvis that regulate all these functions too and it's and it's very much in the proximity of the prostate right And one of the big things we've talked about for years and years is that the regulatory nerves that almost encase the prostate and run to the root of the penis, and these nerves, under proper stimulation, either with sexual thoughts or even the local stimulation that reflexively make these nerves work, stimulation of the pelvic area, These nerves then regulate blood flow that gets into the penile area that makes an erection happen. So that's a quick anatomy lesson and physiology lesson right there. And all interventions, whether it's surgery or radiation, just because of the precarious location of the prostate right near the root of the penis deep in the pelvis can change men's functions there.

So, yes, there is some concern there that all treatments. and the reason i say that is there's kind of the thought that well surgery will do damage but radiation won't well the truth of the matter is is all interventions in that part of the body can have some potential risk and then again we're modifying our practice we're getting better with surgical precision we're getting better with how radiation is administered so to get to your further point here you know does this happen in all men can things be still preserved to some extent. And maybe if it's preserved to a large extent, maybe some simple interventions may still be possible. And all of that is true. All of that is true. We're progressing in how we're doing these

treatments better. In many men, we're able to preserve some of the surrounding tissues of nerves and so forth, blood vessels that run to the root of the penis better. And we're understanding how to execute these procedures where we can maximally preserve the best functional outcomes, even while we treat the prostate cancer properly because you don't want to undertreat and say, well, we saved the nerve, but you're good. But you, you know, we love a lot of prostate cancer and that's no good. Right. So we're trying to make sure we achieve all of the necessary end points here to bring, bring forward the best outcomes.

So then I don't, I saw, I saw Charlie. No, I'm staring. You're trying to figure out if you've got a question. I'm absorbing this all. This is so great because I think, you know, many of us have men in our lives that we care about and so i'm i'm just i'm so grateful for all this information because not just for men to advocate but for those in their lives that that love and care about them um to help them feel more comfortable being proactive and and kind of take this you know this taboo away from from early screening and prostate health and prostate cancer. Yeah, I think we just have to try and help our men understand that, but understand

that, yes, there may be some potential adversity with regard to sexual function, but all is not, you know, necessarily end of the world here, doomsday and whatnot. I mean, we do have some interventions, and some men with better preservation of structures, they'll get maybe erections fully back or partially back and may need a little help, and we have different interventions, which we can get into that may still allow that man to have conquered his prostate cancer now, which is absolutely necessary. And then we'll work with through other therapies that should be active in the bedroom again. But as one patient astutely told me many years ago, 30 years ago, when I was his prostate cancer surgeon, and he said, Dr. Burnett, I've wrestled

with this for six months. And I realized the ultimate form of erectile dysfunction is to be a dead man there it is i said well you're absolutely right you know so so you got to be alive to be to even be functional right so so we we and of course he went ahead had a surgery with me and we did one of the more purposeful kind of purposeful kind of nerve sparing surgeries and he regained his function it did well so so great but you got to move forward yeah we were hoping you were going to get that quote in yeah um and i just want to remind folks that sex play is not just about penetration like you can do other forms of sex play that don't require a hard penis there are other parts of your body that you

can use stimulation for it does not mean the end of your sex life um just because you have gotten this diagnosis but a question i used to get a lot from folks who are about to go through treatment was do they have to abstain from sex during treatment um especially those who are going through radiation, they were afraid that it would somehow impact their partner. Yeah, yeah. So, I mean, certainly a thought here. Are you going to transmit a disease? Are you going to transmit cancer if it's developing in the prostate and you're having sexual

intercourse, let's say? Are you going to transmit cancerous cells that get passed along in some way? And that's certainly been investigated and studied. There's no evidence that really supports that that happens. But really an understandable question. I think that's a good question to ask, but I would share with the audience that there's really no evidence that suggests that that should occur. And in a lot of ways, being intimate with your partner makes you happier and makes you feel better, and that can help. It can also be a lot of, if you're rushing around to go from visit to visit or having these things and you're feeling fatigue, that can impact your sex drive, but it does not mean it's not coming back.

We've talked about this on a number of episodes that there are so many things that impact our sex drive that have nothing to do with our bodies and more about fear and concern about how my partner is feeling and just feeling. Sometimes guys feel like less of a man because there's something wrong with them, even though there's nothing wrong with them, but that can impact their functioning. I'd love you to dive into I know you said something about the different interventions for for men when it comes to sexual functioning. I would love to dive into that. I don't care about anybody else anymore. It's all about my interest now. Well, if you're thinking about it, I'm sure a lot of your audience is. Sunzip it all. That's nicely done.

Thank you. So different treatments. So what are the options? Yeah. You know, it's amazing that I think we have evolved with the way we think about sexual function, the way we've evolved with how we have to help men understand what is the basis for their dysfunctions and what our range of options are. You know, I trained back a few decades ago, at least on the side of thinking about, you know, is sexual dysfunction entirely a psychological thing?

Is it an aging thing? Is it a hormone thing? And then we evolved to understand that, yeah, there is kind of that side of it in terms of performance anxiety. But a lot of it has to do with physical impairments from the underlying condition, whether it's diabetes, cardiovascular disease, or in the setting of prior prostate cancer treatments. and in that realm which we call somatic uh conditions um and of course sexual function is a mind-body experience you know so all these things need to be kind of synchronized but there really is a physical aspect to it then i think what do we really have to address the problems the the nerves that maybe aren't firing well the blood vessels that aren't responding

now we've evolved some great oral therapies here in the past 30 years um and i had some role in the original science of that way back in the early 1990s. And we now understand there's pills that can be effective, but not in all men. And before that time, we only had herbal supplements with very unclear benefit. We also have other options beyond oral therapies now. We have what are known as vacuum erection devices, which is an external device, external now, brought over the penis area and then using kind of a mechanism to create a vacuum, then you draw blood in the penis and then the constriction band is released to the base of the penis.

And that can hold the blood engorgement, whereby kind of an erection-like state is there and the man can proceed ahead sexually. So that's an option. It's nothing invasive about it. It's an external device, a little bit intrusive, a little bit kind of non-spontaneous, but that is an option. Another option that, again, is beyond the oral therapy

is what we call intracarbonosal pharmacotherapy, fancy way of saying penile injection therapy, which is a way of delivering medication to the penis area by direct delivery with a small diabetic needle attached to a small diabetic syringe toward the side of the penis at the base, not at the head of the penis, but toward the base where you can deliver medication to the penis by direct delivery. and that then mimics the chemicals that our bodies just aren't quite delivering at the level that we need from the nerves that may have been damaged and or the tissue itself just needs some sort of more high power juice that gets right into it and so that's a therapy that men can do they come in

for a training session learn how to do it and then in the privacy of their own homes and their bedrooms, I'd say they can go about self-injecting and get an erection response that's driven by the drug effect with kind of an intent to have it there that resembles an erection but goes down within a certain amount of time, within an hour hopefully. So these are the two main next level options to be offered. There have been a variety of other things that have been explored over the years. There was an intraurethral suppository technique that I think has been out there. It It came out in the mid-1990s, and 1996 was approved, but it's kind of faded over the years because its efficacy has not been too great.

So I mentioned it just for the audience. I said Dr. Burnett didn't mention this other technique I heard about called medicated urethral system for erection, which is kind of this intraurethral suppository. But this largely followed out of favor just because the efficacy is in question. So these are your kind of second-line treatment options, if you will, that are beyond the pills but not surgical. Okay. Now, if we go to the next thing, which is, you know, a surgical intervention, that is a matter of what we call penile prosthetic surgery. So doing a procedure where we actually put a device within the penis, of course, it's more or less an internal splint that can create stiffness and nothing is sticking out of you.

we've got to go through a surgery to have this done now. But it's very normal looking to your body, but you can manipulate the device in such a way to create an erection-like effect. And it's stiff enough to have intercourse. But everything else in the penis is stable. Sensations are fine. The way it feels sexually with a partner is probably going to be about the same. So it just really resembles what a normal erection would be, but with an internal stiffener if you have if you will and so but that's a step further than than these other non-surgical things and i want patients always to hear that this is not is meant to be irreversible so you can't go back to other things now so you need to be aware that this would be an option that

you feel that this is the right thing for me yes it's spontaneous it's party is easy to have sex with it and so forth but you but it's an irreversible option uh if and if for any reason and you're thinking, well, maybe I'll try this, and then I'll go back to injections some later time. That's just not going to work because it really is a surgery that changes the structure of the penis internally, whereby these injectables or even vacuum pumps are not going to work well if you decide that, oh, I want that taken out now. Let's see whether these other things can work to go back that direction. So in general, we think about penile prosthetic surgery as an option that is more third-line, second-line options,

first-line options, and where they're contraindicated or you may just feel it's just not right for them. They want something that is, by their own preference, a little bit more spontaneous, and they accept that this is an option they want to move forward with. So those are really the main options that are on the table for consideration here that follow what we think are true guidelines. and on top of that now of course i always want to say that again you heard me kind of start off

saying there is this mind body aspect of things so i don't want to kind of diminish the side of things that have to do with you know you know proper understanding about sexual activity the importance of the couple's relationship understanding your own behavior your mood and how you have to be kind of be prepared for sexual activity all these things are important we shouldn't diminish men to the penis and just what we're going to make it stiff alone i mean it should be all of the above and um and lifestyle uh it still plays a role i mean you think men come to me and they want me to fix them up but they keep smoking they're three days a day and way out of shape and you know eating the fast food place every day you know i mean you got you gotta do

something a little bit better about your general health as well so you can see on different levels we should be doing the right thing we're talking about intervening it is you know it's really having the right broad understanding that we're talking about your entire physical health your mental health and your physical health, in addition to whatever a urologic surgeon or a sex health expert can do. Yeah. Thank you for all of that. When I talk about sexual dysfunction in class, we've talked about the medication.

That's the Alprostadil, right, that you were talking about? Oh, that's one of the injectables. Yeah, that's right. And I was talking about that. And this girl's like, really, all of that for an erection? Kind of getting to this point of men are more than their penis. But I was trying to explain to her the importance of if if you're going through prostate cancer, that erection becomes so much more than just an erection. It's a feeling of I'm healing. It's a feeling of I'm beating cancer. It's a feeling of like I'm healthy.

So I don't I don't want to down. I don't want to overplay the importance of erection because you can still be a good sexual partner, even if you can't get a full erection. But I also don't want to downplay the importance of those erections when you have been terrified that that's never going to happen. so i just i just want to make sure we're centering kind of both opinions at the same time yeah i think that's important i think it goes back to that that the pieces of the puzzle when we're talking i mean we're all multifaceted humans physically emotionally um and that's to me what i'm hearing here is that this is one primary piece that is an indicator that fits into other pieces of of a man and it's not they're not men are not defined behind their ability to get erections but there is a mental piece there because there has been kind of social conditioning around around

that for men in our society and so it's that to your point dr burnett there are all the other pieces that go into this when you're exploring treatment and intervention possible treatment healing and and that that whole journey it's not only physical intervention yeah oh absolutely and one of the things that i'll even kind of get give my additional uh thoughts to share with you bring it is that is that you know they you know there is this thought here that men um you know and here it's controversy someone say well you know that men are more than their penises you know, they think about their penis too much. And at the same time, you know, I see men all the time in my clinic and I have to accept the reality that men are men, you know, and some do think

about their penis probably a little too much. But at the same time, you know, that is part of their identity, part of who they feel as a man. And I don't think we should necessarily diminish that. So we need to kind of just hopefully support that, but also kind of give them a broader understanding about what's going on. And for spouses now, because this is the message I'll share with you, you know, someone, you know, and I've heard this comment, we'll say, well, honey, don't worry about your erection. I'm going to love you just the way you are. Well, that's kind of okay, but it's not always okay because that man wants to hear that. What are we going to do to let me still be the man I want to be? And then, so I think that, you know, for the audience listening

to this, you know, I cringe a little bit when I hear that. And I think the man feels even more diminished. If you said, I'm going to love you, I'm going to love you even if you can't function as a man. Well, a man wants to still feel like they're a man and can function. And so while you're being supportive, you know, as a spouse, let's say, or a partner, be aware that the better approach might be, I'm going to love you, but let's address this too, because I know who your identity is, and I want to make sure you feel good about yourself. But there's some proactions that we can deal with. So let's do it.

And not just say, well, don't do the injection. You're not going to do the needle. I don't want to have you do this. And that just leads to a bad downward spiral. If a guy really feels like, I think I want to do this, or I even want to get a penile prosthesis. I have guys, I have two guys tomorrow. Both are in their 80s.

I'm doing penile prostheses on. Good for them. And one is even widowed. And he just said, and I talked to these guys, both of them, and they feel like, you know what, this is who I am. And I don't have a girlfriend right now, but you know it might happen sooner or later but i want to just be who i am there it is yeah i'm like okay and that's part of his identity so we should not try to diminish that and tell men well

you know you're thinking about your penis too much don't worry about it just just just you know live being a neutral person yeah well you know that's not the healthiest thing either yeah we we can't undo decades of of socialization that told you that that was who you are as a man and and be like, No, just kidding. Don't worry about it. Well, and to your example, I'll love you no matter what I think what what those caregivers and partners often miss, because there's so much fear and uncertainty when you're going through a cancer journey, as the patient, and as a caregiver, is that that almost shuts down the conversation. And it, it doesn't allow for, you know, people, caregivers particularly like tell me how are you feeling tell me how you're feeling well trying to

draw that out when you're not sharing your fears or your concerns or your what-ifs with them that that can often put up a wall with the the patient experiencing the cancer yeah sure sure and i think your point is well taken you know it is true that women's bodies change and they get older a little bit some some things that will happen and then maybe that woman's thinking i don't want to have sex anymore well you know that may be something that maybe has to be discussed and and obviously that's a deep conversation here but but but but but the point of it all is is is that that um you know the understanding where the spouse is coming from too and there may be some issues there uh so we have to but so the healthy thing is let's let's bring it all out

and let's just try and figure out what can be done to make sure both partners are happy going forward. Yeah. Do you have any last thoughts for us before we start wrapping up? I feel like we got everything, so. I think we've covered a lot of topic areas. I hope it's been beneficial to the audience by all means.

Forget the audience, it's been beneficial for me. And me. Me and Charlie. And me, yeah. It's really just for us, so. Well, we really appreciate your time, Dr. Burnett. again that was just incredible holistic information um so listeners take this listen share um just what an incredible incredible honor to have you on our show with us today thank you

well thank you for having me you guys are wonderful and i just feel that if we've been able to communicate some good messaging out there it's been very worthwhile yes absolutely and if you ever want to come back you are always welcome well thank you so much thank you and everyone i want to thank you for joining us on this episode of unzipping taboos we hope today's episode spark new thoughts new curiosity and will open up conversations worth having with those in your life that you know this this will impact remember that that curiosity is the key to breaking down barriers and embracing a healthier understanding of sex and relationships if you enjoy this show or any other show you've listened to please subscribe leave a review share it with someone

who you think might need to hear this and if you've got a question or a topic you want us to dive into reach out to us via the link in the episode description we want to give a very special shout out to our best friend of the show ali o'brien for our incredible theme music thank you so much ali and until next time keep the conversation going keep unzipping those taboos and everyone take care