Dr. Michael Eisenberg: Improving Male Sexual Health, Function & Fertility

25:19So is there a not one for one, but is there a tight correlation between obesity and testosterone levels? I would say that you cannot predict. I think that sort of would be the take home. And so I think that, you know, more information is always better. You know, when I see patients in clinic, you know, some patients are walking around, you know, with everything is totally normal. They're very healthy. All the numbers come in at the normal range, but sometimes when men, you know, look totally normal. They talked about taking care of their life, they exercise, you know, five, seven days a week. Their testosterone levels can be very low.

25:51So even despite, you know, having what we would consider should really give them, you know, symptoms. They're able to compensate, you know, maybe they've lived their whole life and that they don't know what normal is. Now we get them, you know, to sort of normal levels. A lot of times they feel better again because they had no idea how they should feel. But I think that that's just sort of important that everybody, you know, should be screened. I think that, you know, testosterone, seem and quality. There have been shown to even be barometers of health. So, you know, men with lower testosterone levels of higher risk of, you know, heart disease, diabetes, mortality.

26:24The same studies exist for seem and quality as well. And, you know, again, they may have sort of a similar relationship and explanation why that may be. But I think it's hard to just predict, you know, based on appearance, what, you know, testosterone will be, what seem and quality, what testicular functional be without actually getting some objective data. And actually, if you look at the trend of test of seem and quality decline over time, kind of getting back to some of those earlier points you're making. If you were to overlay that on the known association between obesity, it's effects on seem and quality that actually doesn't explain the whole decline because the, you know, the reported decline in seem and quality is about 50%.

27:03But if you just, if you were to say, well, what would we expect if, you know, we look at, you know, because we were able to track exactly how much fat are we are now. Then we used to be that actually explains about a 10 % decline. So I think there is, you know, to your point, something more. And it is not something that you can just identify by high. What are the dues and don'ts as it relates to, I don't want to use the word optimizing. It's gotten me into trouble before because word optimize or optimal suggests that there's a perfect number that one should all attain if possible. But in reality, optimal is a day to day thing, at least.

27:41But what should people avoid in order to get their sperm quality as high as possible their testosterone level. Again, here I have to be careful. I don't want to say as high as possible because some people might not want excessive antigen. But at the high end of normal, perhaps would be the ideal for many people. What should people do? What should they avoid? And here I'm setting aside any prescription clinical treatments that such as testosterone injections or things like a Chorionic Genetic, Human Chorionic Genetic, Genetic, Tropin, things that we can talk about a little bit later. But what should every male be doing in order to optimize these health parameters?

28:22Yes, so I think that there are some risk factors that we do. We'll start with semen quality. So we talked about heat. I think that's a big one. So hot tubed sonas trying to avoid those some light data on sea warmers. Any time we kind of get this external heat source to the scrotum. The testicles are outside the body because they need to be a little cooler. So anything that warms them up can certainly be a problem. Could I just briefly interrupt there to ask. We've done episodes on sauna and some of the health benefits of sauna. Is it sufficient for somebody to bring in a cold pack to the sauna and put that in their groin?

28:55I actually suggested that. That's actually what I do when I go into the sauna. And I have suggested the song podcast. Not just for people who are trying to conceive because it seems like heat, as you mentioned, is bad for sperm. Not quite as bad for testosterone levels, but is it also true that heating the testicle too much is generally bad for endocrine function and males. And therefore, if one is going to go into a hot sauna for 20 minutes or more to essentially cool the scrotal area. Yeah, I mean, I think this per madagentist or sperm production is certainly a lot more sensitive. You know, whether you can sort of thwart the effects of external heat with a cooling pack.

29:37I think it makes sense. There are studies that have looked at different ways to cool the scrotal and have compared. You know, Steven quality before and after and there's some data that may help. It gets depends how long you're going to spend in the sauna and how cold, you know, that pack is going to remain. So ice pack and in the sauna for 20 to 45 minutes. And is ice pack still cold afterwards? Yeah, they actually sell. And by the way, I have no relationship to any of these companies, but they actually sell cold packs that are designed to be worn in your shorts. So if you go to a, you know, I'll go to a Russian bonya every once in a while now.

30:08I guess I'm outing myself. Yes, I have a, yes, I have a cold pack in my shorts when I go to the Russian bonya. But, but they have a sort of an insulation so that you're the cold, the very cold surfaces cold enough, but it's not right up in contact with the scrotal skin because that could get. I want to make a bad joke and say you get sticky that situation. You don't want it get being so cold that it actually would stick to the skin and then it could potentially damage the skin when you try and remove the cold pack. So it has a thin insulating layer. And yeah, that's essentially what it is. Yeah, I mean, frostbite to the scrotal is not theoretical.

30:46It can certainly happen. So you do want to be careful. So I mean, in theory, that should be, that should be adequate to sort of, you know, to decrease the risk of that particular effect. You know, I keep coming back to health. How important that is to maintain, you know, adequate sperm production because I think these two are very linked. There have been studies that show that men with more comorbid conditions, so obesity, hypertension, hyperlipidemia is these sort of stack up. We see a decline in testicular function. So lower testosterone levels and lower sperm quality. So I think, you know, taking ownership of your, your health, I think is important as well.

31:20You know, a lot of times fertility tends to be one of the first touch points that some men have with healthcare, you know, because generally what brings men to the doctor and it's usually pain or, you know, kind of a problem. So, you know, if men are in their 20s and 30s, getting ready to start a family or 40s in some cases, sometimes they haven't seen a primary care doctor. So some of these things, some of this relationship has not been established yet. So I think, you know, thinking about ways to start that, I think would be important to you. And then I know you don't want to talk about testosterone, but testosterone is actually a fairly common problem that we see in fertility clinics.

31:53I would say that, you know, estimates say maybe about one in 20 infertile men are that way because of testosterone. So I think when, you know, people get testosterone in different places and hopefully, you know, whatever provider you're getting it from tells you that one of the side effects of this is lower sperm production. It's actually been tested as a contraceptive and, you know, with some other agents that can actually be fairly effective. So we just want to make sure that, you know, if men are starting testosterone, they're doing it for the right reasons that they're doing it safely. I think about testosterone replacement therapy, although as we were talking about before we started recording, I am really on a push now to rename what people call TRT testosterone replacement therapy because indeed some people have low testosterone and need it replaced the R and TRT.

32:38But I think what you're referring to, if I'm not mistaken, is that there are probably millions of young men and older men taking exogenous testosterone injections, creams, pills, pellets, you know, any number of nasal sprays now, you know, any number of different routes of delivery of exogenous testosterone. And that dramatically reduces one's endogenous testosterone production and dramatically reduces one's sperm count and maybe even quality, maybe talk about this a little bit later, but maybe even can, there's, I've been told that it can perhaps introduce a DNA fragmentation within the remaining viable sperm as well.

33:21So do I have that correct? You're saying that you see one in 20 men have issues with fertility because they are taking testosterone. So their testosterone levels presumably are going to be high and normal or more, but they are doing presumably not testosterone replacement therapy, but they're doing what I call testosterone augmentation therapy, meaning they were somewhere in the 300 to 900 nanograms per deciliter range, but decided to start taking testosterone anyway. And then their sperm count essentially diminishes to nail or close to it. In some cases, yeah. So I mean, I think there's various reasons that you would take testosterone.

33:59I think, you know, some people have been treated, you know, years ago, and so they do need a replace testosterone, you know, but some people do it for augmentation. I just usually say testosterone therapy, just so I'm sorry. You kill the R. I like that. That's better than the TAT, which doesn't have a good. Okay, just testosterone therapy. Yeah, okay. But if you had, you know, for example, we take 100 of my infertile patients that come into see me in clinic, at least five of those men will be infertile because they're on testosterone therapy. And some of them do have that suspicion. They say, you know, I'm going to level with you.

34:30This is why my levels are probably low. But a lot of men were not told that, you know, when they start a therapy. So I think certainly for reproductive age men, that's in a very important conversation to have. Because there can be some other ways that we kind of maintain sperm production. I think sperm cryopreservation is a good option for these men as well. Or there may be other therapies they can think about just because of reproductive toxicity. What about HCG, human -chorianic, gonadotropin? I hear about a lot of people go on testosterone therapy who take HCG every other day or so. Typically, the dosages that I hear about because people write to me about this stuff all the time, really it's one of the most commonly asked questions.

35:09I get many questions about many topics, but I would say a full 10 to 20 % of them are about penises or testosterone. That was a perfect thing. Right, exactly. So a number of those guys who are taking testosterone will be prescribed HCG to stimulate sperm production, in dodging a sperm production to maintain healthy sperm presumably because they either want to conceive or intending to conceive in the future. Is that the best line of treatment for maintaining fertility while people are taking testosterone therapy? Yeah, that's one of the therapies that we use and I think it can work well. Just a low dose usually again for those that know 500 to 1000 units every other day is usually adequate.

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37:13So if somebody is not taking testosterone exogenously, they've gotten their body fat level down to a point where they're not considered obese. So they're hopefully doing some cardiovascular exercise each week, maybe doing some sport or some resistance training too with the intention of maintaining all around good health. Stave off, you know, cerebral vascular, cardiovascular issues. What are some of the other don'ts? I'm going to assume that smoking cigarettes or vaping cigarettes is bad. Are there any studies that have looked specifically at vaping and sperm quality or testosterone levels? And is there any evidence that smoking cigarettes is good for testosterone levels or sperm production?

37:55I feel like nowadays we just say don't smoke, but the data or the data who knows maybe nicotine can help sperm. I have no idea. Right. It's possible. I don't think we have the data on that yet. But yeah, I mean, I think to your point, I think lifestyle factors are certainly a big one. And you know, some of these potentially kind of unhealthy habits. So smoking is certainly something you should not do. There have been lots of studies to do linked that to lower quality. And we get all the different measures that we look at. Also looking at fertility, these men tend to have longer time to get pregnant.

38:28Alcohol, I think, is another very common question we get asked as well. And I think for that, there's, you know, I think less of a strong association that we've seen. So there, you know, there have been some studies that show that very high levels of alcohol. I guess that's sort of subjective. What some would consider higher or not. But, you know, when you get above maybe 20 drinks a week, there have been some effects. But you have a lot of drinking. I would think that's a lot. Yeah, but some people don't. But yeah, I didn't have a soda on alcohol. I think anything more than two, I know people are going to, you know, bulk at this.

38:59But, you know, I think any more than two drinks per week is where you start to see some negative effects on some health parameters. But, you know, I'm not a detailer. So, yeah. Yeah. But when you get to this 20 drink, that's when we started to see some effects on semen quality. But, you know, the thing about that is that usually if these men are drinking 20, they're doing other things to smoking. There can be other drug use as well. So it's hard to tease that out. But in general, that's, you know, I think certainly anything in moderation is probably, you know, it's probably better. And so that's how I counsel patients.

39:31I think, you know, again, it's very rare that I see men that are at that level. But I certainly let them know what I do. There's some new data coming out of the, that we've started to work on looking at. If there are different sensitivities to alcohol, so, you know, some East Asians have a mutation that leads to flushing. And so that may put those men at higher risk when they mix alcohol. We may see some, you know, slightly lower sperm parameters. You mean skin flushing because they don't make alcohol dehydrogenous. Exactly. Yeah. And is it, I've heard about that in Asian cultures. Is there an Asian population?

40:05Excuse me. But is there any evidence that other populations might have slight variance on alcohol dehydrogenase that perhaps maybe they don't lack it altogether? But they have, I don't know, there are hypomores for whatever gene makes alcohol dehydrogenase. And therefore they don't metabolize it as well. And therefore the toxic form of alcohol is active in their system longer. Is there any evidence for that? No, I think you're exactly right. I mean, I think the one that we think about is East Asian cultures where it can be, you know, depending on, you know, the region like Chinese Taiwanese, probably about 40 to 50 % of the population has, you know, mutation in the ALD, each two gene.

40:45But other populations and people of African ancestry, there's a rate of mutation. I think I'm not going to remember the exact percentage, but I think a few percentage points is some individual Hispanic ancestry, Ashkenazi Jewish ancestry. So in this particular gene, there's a mutation, not the same one that East Asians have. But, you know, again, I think it gets to why mutation, you know, where we see sort of negative fights would persist. And the hypothesis that, you know, millennia ago, potentially it, you know, gave some sort of benefit for maybe an infectious disease or something similar to cystic fibrosis.

41:20Why, you know, again, this mutation would persist in our population if there's not, you know, you know, some sort of advantage to those carrying it. But we do see another, you know, other men as well. So I think if, you know, it's a simple question, do you flush? If you flush, then maybe alcohol may have, you know, more of a harm than someone else. And then, you know, I get, sort of getting along the lines. I think drug use is also something that we should try and, you know, we do counsel patients about because I can also negatively affect seem quality. Do you think it's fair to say that, okay, moderation is best, but if somebody had the option to either not drink or drink in moderation, that they should not drink.

41:58Would that be even better? Is there any evidence for that? I mean, it seems like nowadays we take the stance that not smoking at all is better than smoking a little bit. Actually, when I was a postdoc at Stanford from 2005, yes, 2005 to end of 2010, you could still smoke on the Stanford campus. I'm not a smoker, but there was this collection of, I have to be careful what I say here, there was a particular group on campus of postdocs and graduate students that would, you know, that would colonize this little area outside the hospital and smoke because that's where you could smoke. That was eventually eliminated as a possibility.

42:33You can't smoke on the Stanford campus as far as I know, but they would smoke right outside the hospital. Actually, a lot of the hospital workers would, you know, take a cigarette on their break. This is very common. Yeah, exactly. Yeah, and this was common all over the country, right? This isn't unique to Stanford, but nowadays you just don't see that because it's not allowed. And we hear don't smoke. It's terrible for XYZ and everything, every other letter of the Alp, but with alcohol, we tend to hear that if you're going to drink drinking moderation, it's not clear exactly what number that is, but is it possible that zero alcohol is better for sperm and endocrine health than any alcohol or is that not not a fair assumption?

43:14I mean, I think it's a good question. I think, you know, the your point about tobacco is an excellent one because I think any smoking is bad. But alcohol, I think we don't have that data for yet. And so I think it's harder for me to make that recommendation to patients, especially because, you know, people do it for different reasons. And if it's not necessarily going to help them, you know, harm them in social situations or other things. Yeah, I usually just, I usually give them the moderation one unless again for the very high drinkers. I definitely talk about that. You mentioned other drug use.

43:45I'm going to assume that unless prescribed for sort of post surgical pain or something like that that benzodiazepines, heroin, opioids, if any kind are just bad for sperm and testosterone. I think we could probably make that a short discussion, right? Yeah. Yeah, you know, I can't imagine any of that would be good for reproductive health. Yeah, that's true. I mean, there's again, you'd imagine or maybe maybe not, but there's not a lot of data on it. It'd be difficult to enroll or maybe easy to enroll, but a lot of those studies have not been done. But there's limited ones of, you know, people in rehab where they have shown, you know, these associations with, you know, addicts or users and lower quality.

44:27So, yeah, that's how we talk to patients. What about cannabis? I did an episode of this podcast about cannabis and I did highlight some of the medical applications of cannabis. I also highlighted that very high THC cannabis. May predispose, especially young males to later psychotic episodes. There were more and more data coming out about that all the time. I got a lot of flack for saying that, but that's my take on the data. And I know a lot of people use cannabis recreationally and in a kind of pseudo therapeutic way. I say pseudo therapeutic because I think a lot of people use cannabis to manage their anxiety and as an alternative to alcohol.

45:10For a number of reasons, what is the relationship between cannabis use and testosterone and sperm production or I should say sperm quality. Yeah, so this is also a very common question. Again, with wave of legalization across the country, I think more and more men and women are exposed to it. So, again, there's data that the more men are exposed to it, it can lead to some harm in terms of sperm morphology and sperm numbers as well. One of the landmark studies was about 1200 men and it found that men that use cannabis daily had significant lower concentration, motility, morphology compared to those that didn't use it.

45:52So, I think that's generally how men are counseled, but there's also other data that shows really a null effect. And I think that it goes into probably the composition, how men are taking it, the frequency because a lot of that data is not well teased out in a lot of these studies. So, I think I sometimes struggle with this with patients because some of them are taking it for some what they consider legitimate reasons, anxiety, sleep, pain. And if there's not sort of very convincing evidence that it's going to help and they're taking it maybe lower than the threshold where I know that there's good data that'll cause harm.

46:30I guess I'm trying to be sort of honest about where we are, but I think with a lot of things related to sperm, I think our level of evidence is not great. Are there any common over the counter medications that can negatively impact sperm quality and or testosterone? Things like non -steroid anti -inflammatory, drugs, talonol, Advil type stuff, ibuprofenacetamenefin, things of that sort that I and others might not be aware of. I'm not probing for anything in particular here. I just I know that a lot of over the counter drugs have effects that we're just simply not aware of. Yeah, I mean, I think we probably need more data, but I think currently we think all those are safe.

47:12I'm curious about the pituitary. Pituitary gland, as many listeners of this podcast already know is a gland that receives signals from the brain. The gland sits near the roof of the mouth. I think that's fair. And releases critical hormones into the bloodstream that control the output of testosterone from the testes as well as output of hormones from other glands. I know a number of people end up playing sports like football or rugby or even lacrosse or even soccer. I've read or date on this, you know, they're heading the soccer ball quite a lot or martial arts or they get a head injury at some point.

47:54And I certainly hear a lot from people who played these high contact sports. And then to their surprise later, they have diminished testosterone levels. I also work with a number of military groups that talk about this, you know, that they leave. And maybe it's from combat related stress, etc. But they wonder whether or not there's any traumatic head injury or maybe pituitary injury related impairment to the bloodstream. And the reproductive axis that includes brain, pituitary and the testes. Do you see that? And if somebody played a contact sport in particular contact sport where the head was hit or they were hitting things with their head often, or if they have a TBI or had a TBI that the reproductive health can be impaired.

48:44That's fascinating. I have not. I mean, I think it's interesting. I guess, you know, what the pituitary does. You've obviously covered this before. But it does go to a lot of our therapies. I mean, so, you know, for your listeners, you know that pituitary produces two hormones LH, luteinizing hormone and FSH follicle stimulating hormone, which then stimulates the testicle. So the luteinizing hormone hormones stimulates the latex cells to make testosterone. And then the follicle stimulating hormone or FSH stimulates sperm production. So both of those are very key, you know, in terms of production.

49:17And interestingly, when exogenous testosterone is used, you know, it shuts down that axis, as you know. So we get less of these getting out of tropins, this LH, FSH, to stimulate the testicle. And the other sort of reason that sperm production is lost with exogenous testosterone is actually the interest of stochron is much higher than serum levels. So, you know, our serum levels are, you know, between 300 and 900 nanarets for a desolate are on average. But in the testicle are probably tenfold higher, at least. So when men are given exogenous testosterone, not producing their own, the levels of testosterone in the testicle, which are necessary for sperm production are much, much lower.

49:58But it's interesting because I think I'm not aware of sort of how traumatic injuries would do that. Okay. That's good to know. I'm curious about the nonendocrine, nonchemical, so effects on sperm quality and testosterone levels. So here I'm thinking about a bunch of news stories I heard a few years ago about how bicycle seat pressure on the prostate, or maybe it was other portions of the, it was the nervous running to the penis itself. We're surrounding areas, maybe it was pelvic floor related and somehow you'll tell us I'm sure was impairing sexual function. Was it impairing sexual function in any way by impairing testosterone levels, cutting off blood flow to the testes?

50:53And here perhaps the most important thing to ask straight off is, is riding a bicycle bad for male reproductive health and sexual health? Yeah, these are great questions. These again, living in the Bay Area, working in the Bay Area, cycling is very, very popular. So these are questions that I get a lot. So I think, you know, in general, like we talked about before, anything that's good for your heart, it's going to be good fertility. So it could diet and exercise, maintaining good body weight. And so I always try and encourage physical fitness. I think that's important. But, you know, it's maybe possible that some particular activities may put men at more risk.

51:31So I think cycling could be one of them if, but it would sort of depend on exactly why we think that may be a problem. So I guess the theory is heat. If you're in the saddle for a long time, you know, for these prolonged, you know, rides that men take, you know, on weekends, you know, hours. That maybe if there's too much heat exposure, that may be the mechanism where sperm production would decline. So there happens some studies that maybe five hours a week would be, you know, that may be too much. So if you're above that level, this firm counts, showing to be lower, if you're less than that, that may be okay.

52:02So when I talk to patients about it, I try and just encourage them to, you know, stand up in the saddle to try and again, sort of air things out to try and dissipate heat. If that's the mechanism, we're going to think regarding sexual dysfunction. That is thought to be pressure as you're alluding to. So, you know, the way that the saddle is configured, ideally all the pressures put on our iscule tuberosity that are our sit bones. That's what I'm sitting on now. But on the saddle, you know, there's obviously kind of the rigid nose. And if there's too much pressure on that, that actually squeezes between the iscule tuberosities where, you know, the main blood flow to the penis goes and the main nerve supplies too.

52:40And so if there's compression on this, you get this sort of lack of blood flow or ischemia, and you can get a nerve practice as well if you crush these nerves. And so that over time can lead to problems. So, you know, some patients will say that, you know, after I cycle, you know, things are numb down there for 30 minutes or a day. Or I don't get erections for that sort of a same amount of time. Or sometimes, you know, men just sort of, you know, ride through it. And, you know, hopefully things come back in a day or two. So that's, that could be the mechanism. And there are some saddles that, you know, hopefully it'll be a little safer.

53:13And, you know, I think that this sort of first was noted probably around 2000 or so. And there is a big redesign in terms of saddles, to try and make them a little bit more, you know, anatomically correct, to try and minimize some of this. And there's, you know, cycle fit that can be done or saddle fit rather that can be done at some of the cycling shops to try and, you know, look at your body position, look at your size and try and find a saddle that's safer. You know, this doesn't happen to everybody. I would say maybe if you were to survey cyclists, maybe 20 to 30 % of men and women tend to be susceptible to this.

53:50So I think if you are having discomfort when you cycle, whether it be pain, numbness, or you notice dysfunction, things certainly you should, you know, think about changing saddles or think about changing riding style. You know, there's other strategies that are sometimes used, but, you know, it's absolutely something that everybody should be aware of. I meant to ask this earlier, but I seem to recall a study that drew a correlation between amount of walking. And maybe it was sperm quality, but I think it was testosterone levels. You know, maybe some other metrics of male sexual health. Forgive me, I'm not recalling the details now.

54:27Is there any evidence that walking more, standing more, maybe even using a standing desk, is beneficial for, you know, pelvic floor health, blood flow, prostate health, who knows, could be any and all of those things. In some way that is beneficial for sperm quality testosterone level and or overall male sexual health. Yeah, I think, you know, one of the ways that we can characterize activity is step count, right? I think I know I have a watch that tells me bad something that I look at every day and kind of strive for. And it turns out that the more active you are, it's been shown sort of looking at, you know, large national data pools across different age ranges that it is associated with testosterone levels.

55:08So being more active, I think is very important. And that's another thing that, you know, everybody can do to try and improve for a testicular function broadly, but testosterone specifically. And do you know whether or not that can be separated out from the relationship between being more active and less obese? I mean, is this something that's independent of obesity? In other words, can we incentivize people to walk more? Simply on the promise of improved sexual health? Well, I don't know, the sexual health will be a different one, but we can, I think there is association between testosterone levels and step count across different BMI straight up.

55:45So I think, you know, whether you're have the ideal body weight, whether you have a few pounds to lose perhaps if you walk more, you will see higher levels of testosterone. Okay. And another question I meant to ask earlier, and then we can close the hatch on on exogenous testosterone therapy, at least for the time being, maybe we'll come back to it is assuming that somebody can maintain adequate sperm production through the use of HCG or some other therapy, or perhaps they don't care if they're still making sperm because they've already had children or they don't care to have children, maybe they've banked sperm in any event.

56:18Assuming that somebody takes testosterone therapy because they were prescribed that, let's say in your clinic, let's use you in your clinic as an example. And they are happy with the psychological and physical consequences of that, and they are comfortable with the trade offs. Is there any increased risk of, say, prostate cancer or other forms of cancer? And here I'm going to assume that this person is keeping their lipid levels in check. You hear about some hyperlipidemia with testosterone therapies. Let's assume that they're either taking a statin or they're not taking a statin, they're getting enough cardiovascular exercise that things are in check in terms of LDL, HDL, APOB and all of that.

57:02And their testosterone levels are now high normal and they're feeling better. And they don't have to worry about sperm production because they're either maintaining it or it's been banked or they don't care about that. Is there an increased risk of prostate cancer? My understanding is the answer is no, but what's the real deal? Does taking testosterone therapy, assuming all other things are being held in a, in check in a healthy check, does it increase the risk of any kind of cancer? Yeah, I mean, this is a, you know, another great question because I think there's a lot of myths around testosterone and that's one of them.

57:35You know, the origin is that prostate cancer is thought to be or is sort of androgen mediated. You know, one of the Nobel Prize, you know, again, decades ago was awarded because it was found that when we lowered man's testosterone, the prostate cancer would regress dramatically. So that put that association between testosterone and prostate cancer. So then the concern began if we were to, you know, either replace testosterone or augment testosterone, give a man testosterone, is that going to alter his risk or increase his risk? So I think we have pretty convincing data, but that's not the case.

58:08You know, there's lots of longitudinal data and spanning decades where if man is given testosterone, it doesn't change his risk. The reason for that in sort of seeming contradic, you know, this is contradiction between, you know, prostate cancer, a therapy where we lower testosterone, where if you give a man testosterone, it doesn't change his prostate cancer risk, is not certain, but there's this popular model called the saturation model. So that once there's enough testosterone in the body and it tends to be a fairly low level that all the sort of the prostate testosterone receptors, you know, you kind of think of as have been filled.

58:43So if you were to give man more testosterone, it doesn't change anything regarding the prostate cancer, prostate growth, any of that. So it is, it is safe when we're looking at prostate cancers is an outcome. Getting back to prostate health and neural innovation of the penis and blood flow to the penis, you mentioned the bike seat related issues. Are there other things that men should do in order to maintain prostate health, stay off prostate diseases, and to maintain healthy blood flow and neural innovation of the penis for obvious reasons and we'll get into the specifics of those reasons. And our later discussion.

59:24Yeah, I mean, I think that, you know, I always kind of think of the penis as a user to lose it organ. So that doesn't mean that you have to have sex, but you know, normally we get erections every night. So that should be maintained. And if there's any reasons to sort of suspect that that may not be going on, usually in my practice, that would be from, you know, some pelvic surgical intervention or something like that. Sometimes we can intervene to try and maintain that. You're talking about spontaneous erections during sleep. Right. So, and short of assigning one's partner to check frequency and to mess.

59:58What is the way that men would know that that's happening? Are you talking about waking up with an erection? Is that requisite for knowing that nocturnal erections are occurring? Well, yeah, I think you, yeah, you kind of caught me. I think that's a good question. So I think a lot of times you won't know, but I think if you have sort of normal response, you know, when either by yourself with a partner, I think that generally means that you are going to get normal erections. So I think I guess when I say use it or lose it, it doesn't mean necessarily that the man has to stimulate himself or kind of make sure that he does have, you know, adequate function because usually most of that normal function just occurs, you know, with his nocturnal penile two messes, which we all get.

1:00:40You know, I think sometimes men do notice when they wake up at night, sometimes in the morning you wake up with an erection and men notice that, but the absence of that doesn't mean it's not happening. It likely is just, you know, most people sleep through it, which is normal. Otherwise, men would never get any sleep because it happens many, many times a night. So I think, you know, again, if you're not having normal function, I think that's something you should probably see, you know, a physician amount. And then same for like your anary function, I think if it bothers you, if there's, you know, if you're waking up at night, you have to go to the bathroom often, if your stream is getting weaker, those are all sort of complaints that we hear about.

1:01:14What is often, my understanding is that it's normal to wake up perhaps once during the night to urinate. And this is of course assuming, and again, forgive me for all the caveats, but I've done this long enough that, you know, if I don't get really granular about some of this, then she was like, well, what if I drank, you know, 32 ounces of flu, right before sleep, and I'm urinating three times for night. Well, we're assuming that people are tapering their liquid intake as they approach bedtime. And that waking up once, maybe twice, but once in the middle of the night to urinate is normal for somebody, let's say age, I don't know, 18 to 40, and maybe from 40 to 100, that number might be in the one to two times per night.

1:01:58Is that about right? Yeah, I mean, I think once a night, yeah, is normal for a Muslim. And then I think, you have things start to bother you. I think you can certainly see somebody, but it's hard to get better than once or twice a night for a Muslim. My understanding is that there's a pretty good relationship between the nocturnal erection and the amount of REM sleep, rapid eye movement sleep that one is getting. That this tends to be more frequent toward morning as the proportion of rapid eye movement sleep increases. I don't know if that's true or not, but I found a couple of studies that at least point in that direction, no pun intended.

1:02:32So that raises a bigger issue that we haven't talked about yet, which is getting adequate amounts of quality sleep each night. And I think for most people that's seven to nine hours, ideally, which means getting sufficient slow wave deep sleep as well as rapid eye movement sleep. But nowadays a lot of people, including young people who are not working excessive hours are getting, you know, four or five, six hours of sleep per night, is there a direct relationship between getting less than sufficient amounts of sleep and sperm quality testosterone levels and sexual health? Yeah, I mean, I think certainly there's reasonable data for seam quality and there tends to be, you know, we call like in science, sort of a U -shape relationship so that it's not sort of linear so to get more sleep things are better.

1:03:20There's sort of there's this concept of too much sleep and not enough sleep. So the ideal, I think, is you pointed out is seven to nine hours and for men that are not getting that seam quality tends to be low or and then for men getting too much. We also see a decline and, you know, why that is is not certain is again, if you're able to get that much sleep, maybe there's other things as well that we should look at. But so I think kind of getting in that ideal sleep amount is best for seam quality and probably for broad to stick out function as well. You keep bringing up seam quality in a way that makes me wonder whether or not is seam quality a proxy for overall vitality and health or is testosterone level a proxy for overall vitality and health.

1:04:05It sounds like seam quality is the metric that you keep coming back to in a way that I have to assume reflects your, you know, your clinical experience and the many papers that you've authored in this area. I think for people that hear seam quality and who are not interested in conceiving children now or who are which of course could include people who have already had children or who don't want children. Seem quality sounds like something that relates to fertility. But is seam quality something that is a good goal for those who are interested in overall male vitality and health? Is it one of the better metrics of overall male vitality and health?

1:04:50Well, I think, you know, it's, I think it's an excellent marker for overall health. I think there are studies that support it can be a measure of how healthy you are. You know, if you look at men with more health problems, they can have lower seam quality. But also if you look at seam quality, just by itself, and then you look into the future, how these men tend to do. If they have higher seam quality, they tend to live longer, need to go to the doctor less, lower rates of cancer. So I think there's a lot of different ways that seam quality may be a good barometer of health. You know, why that link exists, I think is not known, but there's lots of theories.

1:05:29So one is that, you know, probably about 10 % of the male genome is devoted to reproduction. And so it makes sense, given that we only have about, you know, 24 ,000 genes in the body, that there's a lot of overlap. So one gene that plays a role and reproduction may play a role in the cardiovascular system or the neurological system. And so if we get the first, you know, sort of sign that reproduction is not perfect, there may be some other health consequences down the line. Another sort of hypothesis is that, again, sort of going along this line that reproduction is one of the first things that we see is that, you know, gestation is sort of very critical to our, you know, existence, right?

1:06:19And so we know that, you know, premature children have higher risk of cardiovascular disease or have been studies to show that. But we also know that, you know, these gestational effects can also play out on reproductive function too. So that also may be kind of a link, you know, sort of early seeding a reproductive function. And then that's maybe the first marker that we're going to have for other health effects later on. There are also just sort of sort of inherent sort of similarities between reproduction and some other sort of social effects. So, you know, kind of one sort of confounding factor when we're looking at some of these studies I talked about looking at mortality, for example, and the seem inequality.

1:06:58Is that, you know, there's sort of factors that necessarily involve reproduction. So children and having a partner and having a partner prolongs life, having kids prolong life, even though it feels like kids are killing you. If you look at studies, men with kids tend to live longer. So, you know, that's another possible explanation. But I think, you know, really sort of this health, you know, linked between fertility, I think it's sort of a powerful one. So I do think it should be a barometer. I think that, you know, it should be a sort of when I've given lectures on this, I call it the six vital sign.

1:07:33I think it's something that we should probably check because if there is, you know, sort of lower levels that may tell us about something else going on. You know, when when men come in for fertility evaluations, a lot of times we do diagnose, you know, these new medical problems. Sometimes we diagnose cancer, you know, sort of alluding to some of the questions you've asked diabetes and some other, you know, very significant genetic conditions as well. And, you know, the first way that we would identify it is reproductive failure because there's sperm counts are low and other things. So it is something I think that it's sort of, it's very important, I think, for people to realize.

1:08:08And it would be great. I think, you know, another, I think, advantage to like the Centers for Disease Control, for example, to start tracking it. Would it be a good idea for males in their 20s and 30s to get a sperm analysis to have a baseline? I confess I'm 47 now. One thing I wish I had done in my 20s was to get my blood hormone profiles and lipid profiles done when I was in my teens and 20s because I'd have something to compare to. I started doing that in my mid 30s and I'm so glad I did because I can now compare to my mid 30s levels. I started including sperm analysis about eight years ago with the intention of freezing sperm and did that because I was also reading at that time about the increased risk of the sperm.

1:08:53I think that it's a risk of autism in offspring of males older than 40 something that I really would like your take on, but it seems like it's inexpensive enough to do a sperm analysis. I think now that people can get it done at home, they have male male kits. Although I don't understand how the motility could be maintained if you're mailing your sperm back at room temperature or, you know, tending through the post office. Everyone's imagining all these sperm traveling through the postal service. It's out there out there folks. Yeah, what are your thoughts should should people invest the I think it's a couple hundred dollars to get a sperm analysis more costly to get the DNA fragmentation then you get up into the low thousands.

1:09:37But if people have the disposable income, is it a good idea for them to do? I mean, I think it's a worthwhile test. I think more information is always good. You know, I think sort of one of the same reasons that, you know, you're talking about checking like lipid levels or we tell men and women to get blood pressure checked. I think, you know, getting that sort of early health indicator, I think can be important. I think, you know, going back to not knowing exactly why stemen quality is telling us about health, what the exactly link may be. You know, means that if somebody is coming in with a low sperm counter, that completely absence sperm count.

1:10:11It's hard to know exactly how to counsel that that person other than though maybe reproductive difficulties. But I think just as sort of a marker for reproductive potential, I think it's useful. And like you said, I think it's become a lot easier one of the innovations in the space. And you know, somebody that, you know, is in the reproductive world, I think it's just really great to see sort of this influx and capital and new companies coming in that trying to just decrease the barrier to, you know, getting a cement. It used to be up to go to a lab schedule and appointment. Sometimes they would send you to a bathroom, which can be uncomfortable.

1:10:44You know, people are doing, you know, you know, people doing a bathroom just next to you or trying to collect. So they would send them into a common space, but common space, they would even give them the quiet room with the, with the red light, which is right what I hear they do now. Yeah, some of them do have videos. So there are some higher level. Oh, I didn't even mean videos. I just, I think that, okay, yes, I've done this. I'll just say, I mean, I've been trying to normalize things related to all aspects of mental health as a health. So, yeah, I decided to free sperm and basically they sent me to a room.

1:11:15I went to a university, basically, it actually wasn't a Stanford, but different university. And, yeah, they put the cup through the window. They give you the cup. They, they close the door and they tell you that as long as that red light is on over the door, no one's going to walk in. And then they leave. And I think the assumption now is that you figure it out one way or another, how to provide the sample. And then you put the sample back through the thing. And then one thing these clinics really need to work out is that anytime you're walking out, you see the people processing your samples, you walk out.

1:11:46So there's all this, this a feigning of, you know, anonymity, but really it isn't there. You know, because they're like, see you later and you're like, great, you know, they rarely ask you questions on the way out. But it's a pretty simple process overall. And I must say that the data are informative. You get the, you know, you get the volume number, motile, forward and motile. I did opt for the DNA fragmentation data. And I just love data. So I think it's really interesting. But again, maybe this is a good time to flag this, what this set of findings, I believe that there seems to be a small but statistically significant increase in the number of autistic births due to pregnancies where the male was over 40 at the time of conception.

1:12:36So I figured, you know, why not freeze some sperm and it's relatively inexpensive. Yeah. Yeah. So I think paternal age is also, you know, something that's increasing in this country. So over the last 40 years or so, we've seen that the average paternal age is increased from about 27 and a half to about 31. And I should say this is all fathers. So birth certificate data birth data is collected at a maternal level. So, you know, when a child is born, somebody comes in to collect data on the birth. So they ask, you know, all the characteristics of the mother and they also ask characteristics of the father, you know, age, education, obviously region of the country, the child was born.

1:13:15So we don't know, you know, what number child that was for the father, we know for the mother, they do ask, you know, it's your first second, third, et cetera, child. So the father and fortune, we just have data that sort of all lump together. But over the last again, 40 years, we've seen that increase. Interesting, over the last 40 years, the youngest father was 11 and the oldest was 88. 11, quite a span. Yeah. 88. Goodness, unrelated. I want to know. I know. Goodness. It's an atomized data. But I love it. I have to ask this, sorry to take us on a slight tangent. But what is the average age of puberty in males in the United States now?

1:13:56Yeah. So asking about, I guess sort of spramarky when like sperm production begins. So there are a lot of markers of puberty secondary sexual characters that beard growth deepening of voices. They happen at different rates and different people. But yeah, thank you. At what point are, yeah, males undergoing puberty at the level of that we're talking about here. Yeah, so it's yet there has been data that we're going through puberty a little bit earlier now that we used to. But it really varies. So you don't I think it's not. You know, just like testosterone ranges between like 300 and 900. That's a wide range for anybody.

1:14:32I think for most individuals, you know, puberty is, you know, probably 12 to kind of 15, 16 in general. So I just give sort of a very wide range when we're going to say that's okay. And you know, some of the data I'm basing it on is when sperm production begins and boys. And it's actually, you know, not that simple to be able to figure that out because, you know, we don't generally talk to, you know, young boys about how to master out of collect and then check on that. But there's something called first morning boy, did you're on where we can actually look at that and there have been some studies on and they see if there are sort of, you know, nocturnal emissions, whether they're sperm in there.

1:15:07And so generally, it probably starts around. And there earliest would be kind of 11, 12, 13, but usually most is probably a little later. So maybe I'll refine that puberty and move it a little bit later. 14 to 16 is when probably about 70 80 % of boys are going to have produced, started producing sperm. My understanding is that in females, puberty is also shifting earlier. Perhaps at a more dramatic rate than appears to be the case for males. Well, I think there is some data for males too. I think, but again, for your listeners, I don't want to, you know, have this onslaught of, you know, pediatrician seeing kids that haven't, you know, when boys haven't gone through puberty by a certain age.

1:15:48So I think it's still fairly wide. Let's get back to age of the father and issues like autism. What are the data there? And this to me is a practical issue because I think if there's one obvious takeaway from our discussion today, it's that males should probably not wait until they're trying to conceive in order to assess their reproductive health at the level of sperm quality to stosterone levels, perhaps, but at least sperm quality. But, but perhaps men should also be freezing their sperm if in fact, conceiving children after 40 places their children at far greater risk for autism. My understanding is that the rates of autism are somewhere between one and 80.

1:16:36You'll hear as high as one in 50 male births, but I think it's probably more like one and 60 to 80 is that right. And that the age of the father is a risk factor. Yeah, I think that this gets in sort of the larger issue of, you know, how men sort of perceive fertility. So, you know, we know that as women age fertility declines, but the oldest father of his 96 so the biologic potential certainly persists. Wait, I want to know how long he lived to see how long his child grow up. He conceived at 96. And supposedly, supposedly, yeah, well, I'm assuming he did not meet his grandchildren, at least not the grandchild of that child.

1:17:12So, wow, how long did he live? You know, I, well, so this is a man in India. It's just sort of a famous story, but supposedly he had a child. He had that child with him on like they're waiting at a bus stop. He fell asleep. The child was kidnapped at a legitimate or so. Yeah, dreadful sort of a horrible end, but the wife was also not not battled, but in her 50s. Like it's so. Yeah. Wow. And tragic and incredible story for separate reasons. Okay, I'll get my head around this 96 year old conceiving a child. Okay, please continue. Yeah. So people I think are men think that the sort of the, you know, there, you know, for fertile road is sort of infinite.

1:18:02But I think that's very much not the case. So as you're alluding to people have looked into risks for older fathers. So, you know, about a hundred years ago was first noticed that dwarfism or a condra pleasure was more common and last born children. So eventually that link was made. And since then other conditions too. So there's like these neuropsychiatric conditions you're talking about like autism is certainly one bipolar schizophrenia. People have looked at and also linked that with older age, you know, less attainment in school, you know, failing grades. All that has been shown to be a little bit more common with older fathers.

1:18:36So, you know, why I think all these exist. There can be sort of different explanations. You know, one explanation for the autism association. I'll talk about. You know, some of this more genetic or kind of mutational reasons about one thing that some people say is that, you know, could be sort of a hereditary trait. And so it may be that, you know, men that display some sort of autistic characteristics. You know, maybe they take a little longer to meet a partner. And so it's sort of delayed child wearing. So maybe that's that's one possible explanation. But I think, you know, there's been a lot of convincing evidence that there could be, you know, real epigenetic changes that occur with age and mutational changes that occur with age.

1:19:20I think I read a statistic and you would know more of being a neuroscientist that 84 % of the genes in our body expressed somewhere in the central nervous system. So that sounds about right. Yeah. Yeah. I don't want to stamp my name to that. But that sounds about right. So it's estimated that every year we generate about two mutations in our, you know, sperm DNA. So you can imagine that, you know, a 40 year old is going to have, you know, 20 or 40 more mutations. And so that rate does go up. And if you're just randomly sprinkling mutations, you know, in, you know, genome that they're more likely to sort of manifest and, you know, maybe neuropsychiatric conditions.

1:20:07So there are, you know, data convincing data that shows that that does occur. Now again, there's billions of base pairs in the body. So these random mutations likely most of them will not result in anything, but there can be some meaningful. And so, for example, a congrapal age, it's due to a mutation and fiberglass growth factor receptor. And what's interesting is that this condition is not that rare, right? Based on sort of these rare mutations, you'd expect this would, you know, occur maybe about one and a hundred million. But it turns out these conditions occur in about one and I think 30 to 50 ,000 or so.

1:20:41So there's sort of the discrepancy based on sort of mutation or rate that we expect based on age and the rate that we actually see. So the explanation for this is something called self -spermaticolinial selection. So what this suggests is that some of these mutations that occur randomly occur in proliferation pathways. And so it gives the sperm that contain these sort of advantages over their, you know, brothers and sisters that don't have them, for example. And so then they outcompete the other sperm. And so they're more likely to lead to a child rather than sort of a random. It's mattering you can actually see that some of these mutations are more common and older men than younger men if you look, you screen for some of these mutations and, you know, some of these pathways.

1:21:20Again, the longer that we're exposed to wife, there's just more likely to be, you know, different chemical exposures, other exposures. And so people have looked at epigenetic signatures sort of these signatures that, you know, the dictate which genes are going to be expressed in which aren't. And there are different patterns between older and younger fathers. And, you know, why what triggering those is not known, but there are differences. So those could also potentially explain, you know, some of these risks that we see. You know, it used to be that people thought that, you know, if you're an older father, maybe there's a lot of advantages, you know, for the kids, right?

1:21:51Because if you're more resourced, right? I always tell patients that, you know, when they come to see me for like correction problems or anything, I always say nothing gets better with age. Right? And that's mostly true, although they pointed out that salary often goes up with age and wisdom goes up with age. So you would imagine if you're more resource, maybe the kids are going to also have an advantage to that. But, you know, again, there's a lot of convincing data that that's that's probably not the case. There's even there's one study that I saw that showed that if you look at MRIs of brains of children just after birth, they're actually a little smaller for older fathers, compared to younger fathers.

1:22:25So I think there are some, you know, sort of talking about kind of neuro cognitive development, some of those effects. And there's also been studies looking at cancer risk too. So, higher risk of breast cancer, prostate cancer and adult children, higher risk of, you know, leukemia or CNS cancers and children as well. So I think the more we look, the more we find out of these associations with paternal age. So I think it's something certainly to be aware of. I think talking about mitigation strategies, I think for education to be important for, you know, couples to try earlier, individuals to try earlier to conceive.

1:23:02You know, if we think it's a mutational reason, I think, you know, certainly freezing sperm, I think is a good option as well. My understanding is that analysis of DNA fragmentation in sperm doesn't, does not allow for selection of the best sperm on the basis of DNA composition translated to English. What I mean is in order to tell whether or not the DNA are mutated in sperm, you have to kill the sperm basically. So, and since in a given pool of sperm, so to speak, there will be forward motile, non -motile, twitchers, twitching in place, dead sperm, some percentage of dead sperm or a motile sperm is presumably normal, some small percentage, hopefully.

1:23:48And that some might have some DNA fragmentation some might not. So, is the way to address this averages, what I'm hearing here is that if you haven't already had kids or if you want more kids, that you might want to know about your sperm quality, I would say you do. And that if you can afford it, you might want to take a look at DNA fragmentation data. But having done this, what one receives is a chart that goes from red to green, good. And then they put the arrow, hopefully in the green zone. And then you say, oh, good, you know, I'm in the green zone, I don't have fragmented DNA in my sperm.

1:24:26But really that's an averaging of all the sperm, right? It could be that as you age that some percentage of those sperm have fragmented DNA. And if one of those is the one that successfully wins the egg, so to speak, fertilizes the egg, then that fragmented DNA containing sperm is going to propagate that into your offspring. So, are there any technologies that can allow men to select or for or improve the DNA of their sperm, not just the motility? I mean, yeah, I wish, right? That's sort of the holy grail because I think you pointed out sort of a variant of right, the Heisenberg uncertainty principle is that we can't, if we identify which sperm is bad, we're necessarily going to destroy it.

1:25:10So to tell, you know, which one is harboring these mutations would be great. But I think we're not there yet. I mean, one thing that we do do is wash sperm. So we do sort of select the most modal sperm. We clear out the dead ones. And I think embryologists are pretty good at telling which sperm they think are better. But again, we don't have any real objective data to try and understand, you know, which are harboring something or other. But I think if we understood more about this link with age or again, other conditions, hopefully we would be able to stop some of this pass through. Let's get back to the prostate.

1:25:42This incredible gland. Tell us about the prostate. I think we hear about the prostate. We hear about prostate cancer. People might have heard that it's involved in the ejaculatory response. It's involved in erections. It's involved in a number of things. If you give us a catalog of things that the prostate does, I mean, you spent a lot of time thinking about this gland. And what are some of the cooler things that it does that we don't know about? You know, how do we keep it healthy? And what are the consequences of not keeping healthy? Yeah. So the prostate is a gland about the size of a walnut.

1:26:18It sits behind the bladder and it's involved in reproduction. It produces some of the proteins enzymes that are necessary for, you know, sperm to be supported and ejaculate to kind of keep the sperm healthy and the female reproductive tract. So, you know, it functions in reproduction and then basically after reproduction is done, it doesn't really serve any useful function. So then it just becomes a problem, essentially. So the erythra, which is where we pee through so it connects the bladder, you know, to exits the body, runs right through the prostate. And as we age, the prostate does get bigger.

1:26:51That's sort of a known thing. And as the prostate gets bigger, it creates sort of more resistance in this pipe. And so it makes the bladder have to work harder. And that leads to a lot of the symptoms, you know, that we've been talking about already, you know, waking up at night, weak stream, this need to urinate urgently. Sometimes feeling like you're not emptying all the way. So it's sort of a consequence of the prostate for being there. In terms of ways you can keep the prostate healthy, I think that there's really nothing that, you know, necessarily that you can do. I think that, you know, one thing I talked to patients about when these sort of symptoms start is to know some of the triggers.

1:27:25So, you know, like you mentioned drinking a lot before you go to bed. So if you don't want to wake up at night, that's not a good practice. You don't even want to go into bed through a little dehydrated, just so you can try and last the night. There are some, you know, particular drinks or foods that tend to be more irritating. So like spicy foods acidic foods those can sometimes irritate the lining of the bladder and make you have to pee a little bit more. You know, caffeine is a diuretic. So it makes us urinate more. And it also can also irritate the bladder and give you that sensation alcohol will do the same thing.

1:27:57So I think, you know, kind of knowing some of those triggers may kind of stay off some of the symptoms a little bit. But, you know, again, if you enjoy those vices and you're willing to tolerate it, that's okay too. I'm hearing more and more about a practice of people taking low dose to Dalifil, Cialis, low dose, meaning in the neighborhood of 2 .5 to 5 milligrams per day, not necessarily for erectile dysfunction, but for prostate health and was. Somewhat surprised to learn that those drugs were actually developed first for treatment of prostate health to increase blood flow to the prostate. Is that true?

1:28:35And is there good reason to think about taking 2 .5 to 5 milligrams of to Dalifil per day simply for maintaining blood flow to the prostate and thereby maintaining or improving prostate health? I mean, certainly it can do that. It can definitely help with some of these urinary symptoms that we've been talking about, you know, looking at placebo control trial sort of a high level of evidence does show that, you know, low dose of to Dalifil is 2 .5 to 5 milligrams, these daily dosing can help with these urinary symptoms. So I think that not necessarily is a preventative measure, but for men that are bothered, you know, otherwise I think most men probably wouldn't want to take a pill every day.

1:29:14But certainly if you have some of these symptoms, it can definitely help with urinary bother. And then the added benefit is you also alluded to as it can help with erectile functions as well. Even at the 2 .5 to 5 milligrams dose. Interesting. Yeah, my experience is that there are a lot of people who would love to take pills every day. There seems to be a kind of binary distribution where. And here I'm just thinking about the male stay here from because I hear from course males and females. But I get a lot of questions about what can I take what can I take what can I take. And but as you point out, there's also a category of men who seem to not want to take anything, not want to measure anything, not want to take anything, but especially not take anything.

1:29:56And then there's the other group. And the other group somewhat surprisingly seem to be the longer, excuse me population, maybe grew up in the YouTube era or maybe in the era where sexual health was discussed more openly than it was certainly when I was in college. I mean, the extent of sexual health discussions at my high school, I went to a very good high school, where it only takes one sperm, which is a point I was true for IVF, but more is better if you're trying to conceive naturally. And there were discussions about communication and consent, obviously super important. And then they just kind of turned us loose to learn from our friends and other sources.

1:30:35And family sometimes had the discussion sometimes didn't. Different families, different discussions, obviously. So very, very little information nowadays. I think there's a lot more discussion about these things. And so the 20 to 40 year old male crowd seems to be the crowd that are asking, yeah, what can I take? These are also the people who are getting on testosterone therapy early, perhaps without the need. I just want to flag that because I think I understand correctly. You're seeing a lot of testosterone therapy that perhaps people don't need. Well, I think it's a mix. Some people probably do need it, but I think that before starting it, everybody should be aware of all the risks.

1:31:19And you've kind of highlighted some, but testosterone, any any medication right is going to have some rest. And so everybody needs to be aware of what those are and for testosterone reproduction is certainly one of them. And if they're not already doing all the other things, getting adequate sleep limiting their alcohol and take not smoking, getting exercise, etc. Seems that testosterone therapy would not be the primary entry point, like first workout, all the basics. I think that's the big difference. I think nowadays, the what should I take question comes up early when people aren't necessarily doing all the other things that they could do to promote their health.

1:31:52Anyway, this is observation wall in my part. You're the one who's clinic they're showing up to. I have a question about UTIs. We hear about UTIs, urinary tract infections in women pretty often. Do men get UTIs? If they're getting more than one UTI per year, is that abnormal? Should men be examined for this bladder, urethra, prostate, penile architecture? I know there are ways that people can come in. I was reading about this prior to this episode that can ingest a die and then they can die image the whole apparatus. Without having to cut anything, is that worth people doing or is that only under conditions where people are experiencing some vexing issue?

1:32:43I think that some of those tests should only be done if there's a problem. But I think a male urinary tract infection is rare enough that it should be evaluated. Women have very short urethras, but men have a very long urethra. It has to go through the entire penile urethra, the prostate, the urethra up into the bladder. The way a urinary tract infection would happen, one way would be that a bacteria actually gets all the way back. That's just a much longer trek. If something rare like that does happen, we look for anatomic causes for that. There can be different scar tissue in the urethra. For example, there can be stones in the bladder.

1:33:18There can be stones in the kidney. Sometimes men are emptying their bladder all the way. So those men should be evaluated because there can be some pathology that we could hopefully identify and correct. Let's talk about erectile dysfunction. I put out the call for questions in anticipation of this episode and no surprise. At least 30 % of the questions from males were about erectile dysfunction. Or questions about what's normal in terms of libido level. Interesting. We'll deal with the first question first. What are the most common causes of erectile dysfunction? Are they hormonal in nature? I think that's a common belief that if people are experiencing erectile dysfunction, that it's because their testosterone levels are too low.

1:34:07Hence, all the interest in testosterone therapy. Or are there other, say, blood flow related, pelvic flow related, neural, brain to body, neural connections that are responsible? I'm guessing it's all of these things. How do we parse this? And tell us about erectile dysfunction, what you most commonly see, what you most commonly do in order to treat it. So, erectile dysfunction is the inability to consistently achieve and maintain an erection. It's fairly common. Of all the conditions, I see that's definitely the number one. If you look at men over the age of 40, over half will have some trouble with erections.

1:34:52Under age of 40, it's probably about 15 to 20%. This is a very common condition that we see. In terms of the etiology, it can vary a little bit. We used to think that they were primarily psychogenic. But that was years, that was decades ago. Now we know that most of them are organic. So, it's actually a blood flow issue. So, the most common conditions just sort of nationally would be the same things that cause blood flow problems anywhere in the body. So, I have blood pressure, diabetes, you know, atherosclerosis, anything that can impair blood getting to the end organ. And sometimes, you know, there has been data that, you know, trouble with erections can actually predate other more, you know, serious, you know, vascular conditions.

1:35:31So, the blood vessels in the penis, the penal arteries are about one millimeter, you know, in the heart and the brain that are much larger. So, you know, it's much easier to include a small vessel than a large vessel. So, that's why there have been some studies to support that it's sort of an early marker for vascular disease. So, I think looking at those risk factors, you know, of sort of lifestyle obesity again is another is a common one. Endocrine disorders actually fairly small. It's probably less than 10%, probably around 5 % or so. Pelvic cancer treatment is another very common one after, you know, treatment for prostate cancer, whether it be radio therapy or surgical therapy, blood or cancer.

1:36:10Sometimes rectal colorectal cancer, that treatment also anytime it were, you know, involving some of the nerves and the, the vascular and the pelvis that can also impact erectile function as well. What about hernia? Hernia, that should be separate. So, sometimes if they're, you know, I always say that medicine you can never say never. But, you know, generally if that was going to manifest as a rectal function, it would probably be due to maybe some pain symptoms can really happen during this early post operative period, but the blood supply of the nerve supplies is separate. So, you said something very important for people to hear.

1:36:48So, I'm going to highlight it. You said that less than 10 % of erectile dysfunction is due to a hormonal issue. I don't know how much time you're spending on YouTube and the internet, but that is going to be a shocker for a lot of males out there because so much of the discussion around testosterone is around libido and sexual function. So, it's key for people to hear that. It's also key for them to know about this other 90%. When you say blood flow issue, then what is the common first pass for treatment? And again, I, and forgive me for listing this off over and over, but we are assuming here that people have gotten their body weight down.

1:37:30They're sleeping enough. They're not ingesting excessive alcohol. They're not smoking or vaping. They're not smoking cannabis or doing the edibles, although we wish to talk about edibles and cannabis and endocrine effects. We'll do that later. Doing all the things right, avoiding doing the wrong things too often or at least completely. So, we're assuming they're doing all that correctly. Their testosterone levels are somewhere in that 300 to 900 nanogram per desolid range. That's typical for the so -called reference range. At least in the US, I think it goes up to 1200 or maybe 1400 in other countries, but as other countries like to point out.

1:38:09But it starts at two. No, I'm just kidding. But assuming they're doing everything correctly, and it's not a testosterone issue, then if it's a blood flow issue, meaning they haven't had treatment for some pelvic cancer, what is the first line of treatment? Yes, so assuming that lifestyle, and all that has been optimized, medical treatment has been optimized, there's a lot that we can do. I always tell men, as long as they have a penis, we can always make it hard. So, there's a tremendous amount. I'm sure that you're the most popular doctor in your field. That usually does kind of ease everybody.

1:38:45So, usually we start with oral therapy. So, phosphatesterase inhibitor therapy. So, that would be like, so, dental or Viagra, Tidalophil, Cialis, Avannaphil, Stendra, or Verdinophil, Lovitra. Would you be willing to talk about some of the specifics there? Are you, is the typical thing to put people on this 2 .5 to 5 milligrams per day low dose, or to give the higher doses that are more commonly used for rectile dysfunction per se? I think it depends, you know, why we're putting them on it, and how much sex they have, too. You know, on average, people probably have sex, you know, part of sex may be once a week on average, you know, when we're looking at men, and there are kind of 30s and beyond, you know, sometimes it can be a few more times a week than that.

1:39:26But, you know, if they're having sex every day or very often that sometimes a daily dose can be useful, but generally most men are on just on demand, because they're going to fall into that, you know, maybe about, you know, a few times a month category. So that's usually where we start, and you know, there's sort of a titration that can be done, you can go slightly, you know, higher doses or lower doses. So usually we start in the middle to the higher doses, and you know, we talk about some of the side effects they may have, but those probably help 60 to 70 % of men, and they work well. You know, in terms of another common question is how do we decide which one we're going to start?

1:39:59Sometimes insurance will tell us which one we're going to do. That's a common one. You know, all these medications tend to be somewhat similar. One difference tends to be the time of onset, you know, how quickly they reach peak levels in the body, and then also how quickly they're cleared from the body. So, to Dalifl is somewhat different, and then last longer, the half -life is about 20 hours or so. So it's sort of marketed as a weekend pill. So some people like the idea of that, you know, taking a pill on Friday, so having some left on Saturday. But for others, you know, we start with one of the other ones.

1:40:31The fact that these drugs like to Dalifl also call Seattle is Seattle is the brand name. And Viagra is that a brand name? It stands for, what is the generic name? Oh, still down a fill. So because they are effective in such a large percentage of cases, what does that say about the vascular system of all these males that are having erectile dysfunction, but then it's getting resolved by these drug treatments? Is that, in other words, somebody comes into your clinic, they're having this issue, you prescribe one of these drugs, they come back and say, everything's working great, or maybe they don't come back, they just send an email, say everything's great.

1:41:15But do you need to have a discussion with that person about their overall vascular health? Because a few minutes ago, you told us that the fact that they weren't getting erections due to what now appears to be a vascular issue can be resolved for the penal tissue. But is it going to solve their other vascular issues or should those people be on the lookout for cerebral vascular cardiovascular disease that can potentially cause things at least as bad as erectile dysfunction and maybe worse? Yeah, absolutely. Well, I think they should be screened. So, you know, sometimes I'm diagnosing in the first doctor that they're seeing in a long, long time.

1:41:49But otherwise, I do encourage them to see a primary care doctor to be screened for blood pressure, lipid levels, fasting, blood glucose, all those things, again, sort of for early markers or some of these. Sometimes they're identified sometimes not, but I think we kind of talked about sort of the ideal patient that's perfect body weight, nothing else is going on, but that's very rare entity. So usually there's something that can be done to be optimized. And I don't, I try not to be alarmist about this, but I do want to encourage men to sort of take ownership of the health because that sometimes can improve, you know, some of these conditions.

1:42:21But again, we have terrific medications for men in whom we cannot. What are the common side effects of these drugs? So they're vasodilators, they open up blood vessels, so we get some off target effects. So headache, facial flushing, backaches, like cramps, indigestion, nasal congestion, those would be the most common. Before the last Super Bowl, there was some press about the fact that a lot of the players were taking these drugs at low dosages before the game, presumably to increase blood flow to their muscles and brain. Is that what the rationale was? I think so, yeah, you know, another is we talked about sort of how cycling may lead to erectile problems or sexual problems.

1:42:57There's has been some data looking at taking like biagro or one of these medications, see all this to the alpha before a ride. Again, to try and increase circulation to decrease the chance of any of the negative effects of prolonged saddle pressure. So it sounds like just increasing blood flow and lowering blood pressure slightly is just a good thing all around. Yeah, I think there's really a benefit because these medications were originally I think is your alluding to or developed as a blood pressure treatment. And this was sort of an amazing off target effects that has turned into a billion dollar industry.

1:43:28So you mentioned about 10 % or less of erectile dysfunction is due to endocrine issues. Is it 60 to 70 % can be resolved with with these blood flow enhancers? I know it's a terribly non non clinical non scientific way to describe the biagrosialis to the alpha. So, what about the remaining percentage and are there other treatments that you prescribed or given in which cases do you need to resort to I guess more invasive approaches? Yeah. So another therapy we have is your retral suppository. So you can actually put a medication in the tip of the penis and send them to the rest of the penis. Also inject its suppository or gel or a jelly.

1:44:16Yeah. So it's also a base of dilator. Sort of the concept is very similar. Sometimes that you know is is okay for men and tolerated. It's safe for partners as well. It can tingle a little bit. So we definitely let men know because one of the main medications does cause like a little bit of a burn as well. Why would somebody do this as opposed to taking the pill form of the drugs we were just talking about? Mostly efficacy would be a big one. And so this this this can sometimes help where others cannot. So that's one. Penal injections are another common therapy. So the efficacy of penal injections are probably 80 to 90%.

1:44:54Again, we're injecting base of dilators into the penis. So the idea just opens up blood vessels easier to get into key directions. You can imagine there's a huge psychological barrier to putting an edel in your penis. Is this something that the patients are doing for themselves at home or that you're doing? Is it long lasting? Is that something you do with the clinic and then they come back every few weeks or so? No, yeah, this is an on demand treatment. So we we teach them how to do it the first time I do it with us in clinic. Ideally, we try and get a reaction that lasts probably 20 to 30 minutes.

1:45:23So we usually started a low dose and then they just increase at home until they get you know a reaction that lasts for that amount of time. Is it's injected subcutaneous or actually into the goodness of the meteor tissue of the penis? That's right. Yeah, into the erectile bodies directly. Yeah, and they you only have to inject one side. They do communicate with each other. Most of them say it's fine. It's a small. It's a very small gauge needle about as big as you know a few strands of hair. I'm an appointment over in ophthalmology and I've seen injections into the human eyeball and it is incredible how fast and how painless that procedure is when it's done by the right person.

1:45:58Nobody should try that at home on their own. But when it's done by a skilled ophthalmologist, it's just striking. You know, you think about needle in the eye. You know, what's worse? It's like the childhood rhyme right sticking needle in my I can't think of anything worse, but maybe you know an injection or the penis sounds almost as bad. But you're telling me that if patients are prescribed this so they can do this with with limited if any discomfort. Well, it does have a high dropout rate. Surprise, surprise. Yeah, he knows excited about it. You know, it's I guess the mood can sometimes be affected, but a lot of couples are very comfortable with it.

1:46:31Again, it's very efficacious. The man can do it. His partner can do it. So it does work well. And I guess here we're sort of ascending the list of invasiveness. Right. What what is that the sort of top tier of invasiveness for a proctile dysfunction? So then we go into peanut implants. So there's actually a surgical procedure we can do to put a device inside the penis that can help men be hard when they want to. And that comes in sort of two main forms. There's either non inflatable or inflatable. So the non inflatable sort of a bendable. It's you know, has sort of a metal core. And so when men don't want to have sex, they bend it down when they're ready for sex, they can kind of bend it out.

1:47:13It's really just they are on demand. Yes. Yeah. Interesting. Yeah. So it's very simple to use sort of the more, I guess, kind of natural form of be the inflatable. So when you're not using it, it's deflated. And then when you're ready to use it, it's inflated. And you inflated it with basically a pump that's in the scrotum. So all this is sort of surgically implanted inside a man all under the skin. And unless you know what you're looking for, it'd be very difficult to tell if a man has it or doesn't have it. But when he's ready, he pumps it up and it moves fluid from a reservoir, which usually is also surgically implanted into the penis to get a rigid erection.

1:47:50What is the relationship between psychological arousal and erection as it relates to these technologies? I mean, the way you're describing it sounds purely mechanical. We're talking about nocturnal erections, which I suppose people could be having erotic dreams, but I don't think that's a prerequisite for nocturnal erections at all. Right. So is the idea that if adequate blood flow is achieved, then any signal from the brain can initiate a cascade of blood flow that creates the erection? Or is it the case with some of these treatments that sounds like blood flow is almost autonomous? Right. Well, I think a lot of these, yeah, the blood flow is not adequate.

1:48:32And that's why we're having to sort of go beyond. But generally as you point out, there's different stimulation, whether it be visual, tactile, or factory that sort of starts that cascade that releases neurotransmitters in the penis that leads to this vasodilation naturally and then get erections. A few years ago, I was reading about vasopressin inhalants. There was a bunch of stuff hitting the market. By the way, I don't suggest that people get experimental with this stuff. As a neuroscientist who also knows the thing about neuropeptides and neuromones that can impact the hypothalamus, I just covered my eyes and cringed when I think about people inhaling vasopressin thinking, oh, yeah, there's a study that vasopressin increases sexual desire or something like that.

1:49:19But nowadays, I'm reading a lot more about a really interesting peptide treatment, which I think is an FDA -approved prescription drug, which is relates to a melanocyte stimulating hormone that comes out of the medial pituitary that is used to increase sexual desire. It's prescribed for women, but men are starting to take it. And it seems to have, at least from what you read on the internet, a pretty profound impact on libido and on erectile frequency and persistence. Is this something that you're using in your clinic? Yeah, what about these peptides that people are inhaling and injecting? Some of them are taken in oral form, but most often, I think it's nasal and halent, or it's a subcutaneous injection.

1:50:13Yeah, so those are not ones that we use in clinic, but I think looking at just sexual dysfunction broadly, there are a lot of things that we do try and help. And one of the things that relates to that is it's been a proposed treatment for it is this concept of delayed orgasm or delayed ejaculation. So I think everybody is familiar with premature ejaculation, where men ejaculate too quickly. But on the other end of the spectrum, there's men that takes a long time to ejaculate, and what that is is sort of defined differently. But generally, most people would say like sort of two standard deviations about average.

1:50:49So on average, probably around five minutes or so, two standard deviations would be kind of 20 to 25 minutes. So for men that take that long to ejaculate, that would be considered delayed, or sometimes they don't ejaculate every time that they have relations. So for those, I think there is a need for treatment because there's no FDA -approved therapy for that. And so that's why I think providers are trying some of these other more experimental things. There's some that we use, just not that one in particular. There's also some devices that have been tried as well. But it's a challenge because you know that I certainly really feel for these men.

1:51:23It's one of the pleasures in life, and some of them are never able to have sex or only, or sorry, never able to orgasm and some are only able to do it very rarely. So we do want to offer them benefit. What about pelvic floor health more generally? The topic of pelvic floor health is something that comes up more often around female reproductive health and urology. You hear about kegels, kegels, kegels. I don't know. I guess we'll have to ask him. So it turns out kegel, kegel, was a person who named the exercise after himself. Whether or not he did them or not, I do not know. But my understanding is that kegels are a pelvic floor strengthening exercise.

1:52:06And my understanding is that some people experience urinary or sexual dysfunction because of a overly relaxed AK weak pelvic floor. But that some people have the exact same problems because of a hypercontracted AKA overly tense tight strong pelvic floor. Meaning don't run out and start doing kegels just because you heard about them. They're not good for everybody. They might be bad for certain people. But what about pelvic floor health? I mean, should men be paying attention to pelvic floor health? Should men be doing pelvic floor exercises? I mean, I think it's really key that you say that because you know, not everything you hear about is good.

1:52:45And I think it's not good for the right person. So there are certainly men that I see that have very, you know, just a lot of attention, a lot of anxiety. Sometimes these men, you know, urinate every hour. I mean, there's other things that you can just tell. They're just sort of very wound up. And I think for that man, you know, one of the issues you kind of alluded to as you probably needs to relax more. So, you know, pelvic floor physical therapy can still benefit you because there are some just different feedback exercises that could be done to help with relaxation. So, you know, any neurologist office, there's usually a list of a lot of different providers around the region that can help with some of these.

1:53:16Kegel exercises, though, can be useful. You know, for example, for prostate cancer rehabilitation, some of these men, where we're trying to kind of rebuild some of the strength or maintain or improve continents in these men. We do want to strengthen some of these muscles so that they can sort of recreate or replace what was lost when the prostate was removed. So I think for the right man, they can be useful, but yeah, it could be a dangerous tool in the wrong hands. And you mentioned that if people want to learn more about pelvic floor therapy, they can contact their local urologist and find a good pelvic floor, good male pelvic floor specialist.

1:53:52Do they tend to specialize male female? They're usually pretty much gender or sex agnostic. So they usually are able to help all. And forgive me for asking for an abridged anatomy lesson here, but could you describe the pelvic floor muscles and how they relate to the bladder prostate urethra penis anatomy that you talked about before? Because I have the picture of the bladder urethra prostate penis in my brain. I know my life experience where the testes and scrotumare relatives all of that, but now I'm trying to figure out. So the pelvic floor, a bunch of muscles that are attached to the pelvis, but how do they interact with those organs?

1:54:37Yeah, it's a good question. So they sit beneath the sort of in the perineum, so the area between the scrotum and the anus and beyond too. So they basically support all the structures there. They support the base of the penis, the prostate, the bladder, the rectum. And they kind of keep main adequate tension to keep all those structures up. They relax when different functions are necessary. They're very important for ejaculation. Some people think that they kind of trigger some of the orgasmic response as well. Sometimes men will have pain in that area and the perineal area can transmit to other parts of the body like the scrotum.

1:55:15One of the one cause of scrotal pain and there can be many can sometimes be pelvic floor dysfunction. So I think, you know, again, pelvic floor therapy can be useful for sort of a constellation of symptoms against some urinary symptoms as well. So I think for some patients it can be helpful, but you know, again, if you get things too tense, that can sometimes be harmful. So presumably these pelvic floor therapists also help people achieve a more relaxed pelvic floor if that's what they need. Exactly. Got it. Going to some of the questions that came back to me when I solicited for questions and anticipation of this episode several, not a few.

1:55:55Let's say a couple dozen people asked about split urine stream. Is that a signature of prostate overgrowth? Is that a urethral issue? Is it perfectly normal? I'm assuming here they mean a split stream of urine that doesn't unify at any point. They're talking about a consistently split urine stream. And for those of you that don't know what I'm talking about, we're talking about a urine stream that's actually two urine streams. And we're assuming one urethral opening because I hit the literature on this. And there is a case of failure to fully fuse the urethral duct during development where some I'm assuming small fraction of males have a urethral opening on the back.

1:56:37So the base of the penis and at the tip of the penis. Let's rule that out as a possibility for now. But now that it's on the table, what percentage of males have that two urethral openings? So well hypospatius which you're describing where the actual meadis is not at the tip, but it's kind of along the proximal urethra or even further down sometimes in the scrotum. I'm probably about 1 % of births. And usually it's recognized at birth and oftentimes it's surgically corrected because it's better to prepare it early rather than later. So ruling that out, what is the cause of split urine stream and is it a signature of a larger issue?

1:57:17You know, one of the reasons that we urinate sort of from an evolutionary standpoint right is to, you know, basically deposit and sort of a convenient time are ways. And we don't want to get it everywhere because we don't want to sort of label ourselves with smell of urine because that'll be easier for predators to be able to identify. So just similar to today, we'd like everything to get in the toilet without creating a mess. So anytime there's turbulent flow. So it's certainly a signal in issue. So it could be like a urethral issue is you're pointing out a prosthetic issue and adequate speed, you know, of getting urine out to meadis.

1:57:53So you definitely should see, you know, a physician to get evaluated because there's likely some issue that can be improved. The most popular question I received from males, however, was about perhaps no surprise. So it's just penis length. You're an expert in this actually, not just because you're a urologist male reproductive health expert, but you published a study recently on the changing trends in penile length. Tell us about that study. I have so many questions about the methodology because I have to assume this didn't involve self report. Right. Those were excluded. Yeah. Yeah. So lying was excluded.

1:58:42I'm being suspicious here, but yeah, how was this study done? I mean, pretty incredible study. And the results are, I don't know if they're surprising or not. I first I thought, oh, this is surprising. But the results were only surprising in light of what you were talking about earlier about sperm and testosterone levels. I think I'll let you describe the study now, rather than than giving people the punch line here. Yeah. So I mean, the worst thing was that we were looking at, we wanted to know average lengths for another project that we were doing. And, you know, going down the rabbit hole, this has been reported for decades.

1:59:15You know, there's different reasons that people have reported penile length. You know, sometimes they do it just on volunteers against sort of get the average lengths of different populations. Sometimes it's done pre and pro surgically to try and understand what changes would occur. So we just sort of called the literature found data on 55 ,000 men all over the world. And wanted to see if there was a, you know, sort of a time pattern with that. And similar to your hypothesis, we assume based on all the other data that we would likely see a decline. You know, whether it be chemical environmental exposure, but if nothing else, if we're getting bigger, you know, the functional penile length should decline because, you know, the super cubic fat pad will get a little bit bigger.

1:59:55And so we'll kind of lose penile length with that. And so much to our surprise, the super cubic fat pad, excuse me, being the pad of fat directly over the penis. Right. Right. And so, you know, if that gets bigger, that'll necessarily compromise penile length. But, you know, as you alluded to, we found is actually the opposite that the penises were getting. And getting longer with time. So how it's measured measured differently. So one of our inclusion criteria was that all the studies had have measured sort of in an office sort of in a clinical setting. So whether it be a, you know, a clinician or whether it be a researcher that actually did it.

2:00:28So there's different ways you can measure penis. You can just do a stretch length. So you kind of stretch it up as much as you can and then use sort of a ruler to measure how long it is again from the steep as you can get, you know, the tubic bone, ideally up to the tip of the. The glands are the. Okay. So here's what he's describing. He's talking about measuring from the top, not on the bottom. Believe it or not, people ask questions about this, measuring from the top, not from the bottom, no cheating. You're talking about stretching the penis while it's flaccid, presumably, and then measuring from essentially contact with a location that's contact with the pubic bone to the tip.

2:01:03Right. Okay. So that that length was recorded in 50 ,000 men. Wow. Yeah. So that was one. And then we also looked at a right length. And so there's different ways that an erection can be achieved sort of in a clinical setting. So one is you get asked to man to stimulate himself and then measure. So that was some of the studies. And then the other method. So you alluded to earlier, as you can inject a man with a medicine to give the direction and then measure it. And did 50 ,000 men participate in that aspect of the study? It was less. No, that was I think that was about probably 10 to 15 ,000 men.

2:01:36I have to wonder whether or not it's easier difficult for people to recruit subjects for these studies. I don't know. I could see it going both ways. Yeah. Some of the studies actually had a tremendous number had about like 15 ,000 men. Some individual studies contributed that. And actually interesting after we published it, there were some men that volunteered for the next study to be measured. I'm sure you'll hear from some of them after this episode. What was the major finding? So the major finding we wanted to do is just give normative data. We found that it varied around the world, so based on different regions, the average is lengths, you know, varied a little bit.

2:02:11But generally on average, erect penis is probably between about five to six inches somewhere in that neighborhood. So that was kind of the take home. That was the average, the average for right length. Did you publish the full distributions? We didn't know that we were we're our plan was actually to make a follow on study. So we could show everybody, you know, I guess probably they were interested where they kind of fell on the graph. But it was fairly, you know, it was normally distributed. Yeah, I would think that despite the, you know, the wide availability of pornography that. That the distributions with the scatter plots of all the data would be interesting to men.

2:02:51For the same reason that the testosterone by function of age data, published as a scatter plot in that textbook I referred to earlier, right? Very interesting because the scatter plot distributions, I feel like point to other takeaways that one can be in their 70s and have testosterone levels equivalent to a male and health email in his 30s that one can be in their 30s and have testosterone levels that are twice as much or half as much as as age match cohort, this kind of thing. I think there's value in that. So what what other takeaways arrived with the data from the penis length study that perhaps we didn't we didn't hear about like what did you find most interesting about about the data?

2:03:36Well, that there was any change over time, you know, this was a fairly short study was probably about you know 30 years or so. But we did find that peanut length has been increasing over time. So, you know, that was just sort of fascinating that we would see sort of in such a short interval of time that there would be a change number one, but that we would see a lengthening number two. So, you know, again, similar to the concerns that arose for these, you know, relatively short period of time where you would see changes in seeming quality. You know, it suggests something sinister, right? It's unlikely to be a genetic change because that would take, you know, centuries probably certainly several generations of the fact that this happened so quickly was just surprising.

2:04:16This brings mind some of work that I was involved in years ago. When I was a master's student, I studied early organizing effects of hormones on the brain and body and I'm sure this has been updated since then, but my recollection is that during embryonic development, males are exposed to a certain amount of dihydrotestosterone, not testosterone, but dihydrotestosterone, which organizes the brain male as they used to say. Now the verbiage around that would probably be a little bit different, but the idea is that males are born with phenyl tissue, of course, but then it's during puberty that the same hormone dihydrotestosterone then exerts an activating effects on the genitals and the genitals grow during puberty, penis length increases.

2:05:11So assuming that the study that you did was on males post puberty, right, assuming it was, then it would imply that something's changing about the levels or the signaling related to dihydrotestosterone. How could that happen? Do we have any ideas about what might be happening? I mean, this is the opposite of environmental endocrine disruptors preventing sperm from being as high quality and numerous as they could be or environmental factors, either in utero or post utero, suppressing testosterone levels. We're talking about the opposite effect. We're talking about dihydrotestosterone levels, presumably being higher in males over the last 30 years and thereby longer penises.

2:05:57Right. So I mean, I think there's different conjectures that you could make about why this could happen. I mean, it could be maybe endocrine disrupting chemicals in utero, some early exposure that some of the mothers had to kind of androgenic effects during the male programming window that may have led to some longer lengths. Another hypothesis we had is that if males are going through puberty earlier, the earlier one goes through puberty, the longer length tends to be. So maybe that provides sort of this link. So earlier puberty tends to be longer, potentially means longer duration exposure to dihydrotestosterone longer penises.

2:06:33Yeah, you may be surprised to know you might not be surprised to know that there is a subculture online. I know because they contacted me in anticipation of this episode of post pubertal males who take a combination of dihydrotestosterone and low levels of growth hormone in efforts to try and increase their penile length. And the ones taking dihydrotestosterone, they're not taking pure DHT, they're taking things like oxandrolone, which very closely mimics the structure of DHT. They report some success. Fortunately, they did not send me pictures. Otherwise, it would have just forwarded them to you for your next study.

2:07:20But this stuff is happening in post pubertal males. So it all rests on this dihydrotestosterone hypothesis, just a point of interest. Yeah, I don't know. Physiologically, it doesn't make sense by that work as you're pointing out post pubertalian. Unless they're doing other things, you know, some sort of stretching exercises or like gelking, but yeah, I would not recommend that. Thank you. That was the response I was looking for. So that community will be listening with open ears. Don't do it. As long as we're talking about DHT, dihydrotestosterone, it's only fair to discuss the drugs that many people take to suppress dihydrotestosterone in hopes to keep or grow their hair.

2:08:09Things like finasteride, do tasteride. Some may be many, not all, people who take these drugs, particularly in oral form, experience sexual dysfunction issues, and other issues related to suppressing DHT. That said, my understanding is that these drugs are also quite useful, maybe even life -saving in some cases for staving off certain forms of prostate cancer. What are your thoughts about finasteride to tasteride? Do you see people coming into your clinic who are having sexual dysfunction or other types of issues because of their hair or attempt to maintain or grow their hair issues? And equally important is that we talk about so -called post -finasteride syndrome.

2:08:56I got a lot of questions about post -finasteride syndrome because I'll describe it in a couple of minutes. It sounds pretty devastating for these people's lives. And I'll explain why it's so devastating for them in a moment. But what about finasteride, you tasteride in these drugs that are effectively DHT blockers? DHT levels, if they get too high, indeed can miniaturize the hair follicle because people lose their hair, typically up front or in the back, so -called crown or whatever widows peak or everywhere in some cases. It also induces hair growth on the back, beard growth as we understand.

2:09:36But then people go and take these drugs to try and maintain or grow their hair and oftentimes they have erectile dysfunction or other issues. Is that surprising to you? You know, I think the men that we see these side effects tend to be younger men in their 20s, 30s and 40s. And they take up as you're pointing out for hair loss. So before it was FDA approved for that indication at least finasteride was, you know, they did randomize controlled trials to look. And one of the other things that we'll talk about too is just reproductive effects. So they did, you know, lots of studies to see if there were changes in seam inequality, you know, for men on finasteride versus the placebo.

2:10:11And there were some very subtle changes, but, you know, sort of in post -marketing now we see these patients in clinic. You know, everybody to enroll in these studies had normal functions. So I think that's sort of important to understand. And obviously that's not life, right? The people come in with sort of different baselines and different amounts of reserve. And so we now know that there's probably people that are a lot more sensitive to these medications and others. And so there's some men that drop their sperm counts dramatically. And usually if we stop these medications, their sperm counts can recover.

2:10:40And usually this for a matagenic cycle is probably about two to three months. So usually in maybe three to six months, we usually see recovery for most men. But similarly for, you know, sexual function, I certainly have a number of patients, you know, the Duke of Plain of low libido erectile function, this post -bennasteride syndrome. You know, in the mechanisms, I think are less certain because, you know, measuring testosterone levels, which we do, you know, sometimes if antigens are low or even if and it seems to be in the maybe normal range or low normal range will try and increase testosterone through a variety of means testosterone, clomorphine sometimes will give.

2:11:13It helps some men, but not all. So I think the exact mechanism of what is going on here, what is changing, I think. You know, we need more, you know, more understanding about the exact sort of pathophysiology, you know, or neurochemically. It seems like a pretty serious trade off to either maintain a grow hair or lose sexual function. I mean, that talks about DHT and some of these side effects of finasteride detast tried on. In the previous episodes, and, you know, I'm not a clinician, but my encouragement is always for people to approach these drugs with a real level of seriousness, if not caution.

2:11:53The post -finasteride syndrome was described in these online questions as seemingly permanent, even though people had ceased to take finasteride or do test drive. So in other words, they were taking this stuff. They, I don't know how they felt while they were on it, but they stopped taking it and the sexual dysfunction issues don't seem to be resolving. Does that mean they should go see you or another male urologist reproductive health specialist? Yeah, I mean, oftentimes they do for, you know, these complaints. You know, they start to notice that when they're on the medication, then when they usually through online research kind of learn about this potential entity.

2:12:33Sometimes they discontinue. Now, some men do have resolution when they stop, but there is this permanence in some handful of men. You know, they've done, you know, MRI imaging to try and understand sort of, you know, more anatomically or functionally, what exactly is going on? I think there's so a lot of unknowns about it, but it can be, you know, permanent for some. So they come in, you know, and they see me and clinic erect all this function low libido. And then we go down all the host of treatments that we talked about and the evaluations that we talked about. Again, we have resolution and some, but there are some that seem treatment refractory.

2:13:03Yikes. That's my only response. I mean, permanent effects on sexual health in it as a consequence of an attempt to maintain one's hair. I mean, this is where, you know, in all seriousness, it just sounds like something that people need to think very seriously about because it, as I understand, there's nothing that can predict whether or not someone will have post -fenastride syndrome. Right. Right. And I did a bit of reading on this within the scientific journals as well. There isn't a lot of information as you point out because it's a fairly recent phenomenon that highlights a different issue.

2:13:42This may be the first time in history where young males are taking finasteride and do test ride. And that might be the cause of the post -fenastride syndrome. Right. I think you alluded to this earlier. Right. These drugs have proven to be very beneficial for older men treating prostate issues. Exactly. Right. So this is a post -fenastride syndrome. I think falls under the category of medical conditions that, you know, a few years ago, we would hear the same about chronic fatigue syndrome. Even fibromyalgia, not long ago, was considered one of these. Oh, is it all psychosomatic issue? Now, we now clearly know that's not the case for fibromyalgia, by the way.

2:14:22But I can recall a time not that long ago when people in the medical profession kind of like, oh, yeah, this is a real thing. But post -fenastride syndrome sounds certainly real for the people that are suffering from it. Exactly. Yeah. Okay. Well, the reason I'm spending so much time on this is that I get a lot of questions about it. And there are clearly a lot of young males who take finasteride or do test ride or are thinking of doing that for cosmetic reasons. And I think they should be aware of the potentially serious consequences. Yeah. Yeah. But you did say earlier that if someone has a penis, you can get it hard.

2:14:57So all is not lost even for these post -fenastride syndrome. Yeah. Good. Okay. We'll hold you that. You mentioned clomaphine. Could you explain what clomaphine is and what it's used for? Because again, we want this discussion to be centered around the real science, the real medicine. But there is a growing kind of sub -community of people out there who are saying, okay, testosterone therapy can cause us to be sperm, suppressive issues and perhaps some other issues. But doing nothing might not be an option for somebody who wants to increase their whatever libido, other aspects of of antigen function.

2:15:39And so there are a growing number of people out there who are taking clomaphine only in order to presumably increase testosterone. But my understanding is that it would impact the estrogen pathway as well. Yeah. What's clomaphine? What are your thoughts about people using clomaphine sort of off label simply to increase androgens? Yeah. It's sketchy to me for reasons related to changes in neural circuits. But you'll tell us how it works. Yeah. Well, thank you for including the off label disclosure. Anytime I talk about this, I always have to say say that. But so clomaphine is a selective estrogen receptor modulator.

2:16:18So basically it blocks estrogen. And so from our earlier discussions of how the pituitary works, you know, there's sort of an elaborate feedback loop between the pituitary and the gonads and the man the testes. And so what happens is, you know, FSH LHC is getting out of tropin stimulate the testicle to make sperm and testosterone. Testosterone is peripherally converted to estrogen and that feeds back on the hypothalamus to stop that. So again, you don't get an overproduction. So by blocking the estrogen receptor at the level of the pituitary or the hypothalamus, you'll stop that. And so the idea behind blocking that is that you'll get more production of FSH LH more of these drivers.

2:16:54So you get more testosterone, you get a higher stimulation of the testicle. You know, the hope is that for fertility that sometimes it can improve sperm production too. And there's some limited data that can help. But I think as you're alluding to, it's sort of a way to just augment your body's own production of testosterone. So it certainly does that. I think there's no question that testosterone levels do rise. I think that the reason that doesn't always help is because not every problem is solved by testosterone. We kind of talked about someone in this discussion, but also that you do need some estrogenic signaling as well.

2:17:26And so by blocking that, you know, even partially because there's also some partial haganist effects of chlamophine as well, it may limit it. And you know, it turns out that estrogen certainly is important for a lot of things as important for bone health, but sexual health too. It's important for libido. So that may be partially blunting some of the hope for benefits of testosterone. I found that men tend to be happier on testosterone than some of these other forms. And that could be a possible explanation. But one of the advantage of chlamophine, if we are thinking about this as a treatment for low testosterone hypergonnaisum, is that it doesn't have the same toxic effects on sperm production.

2:18:01So by maintaining the body's own production of testosterone, by maintaining production of FSH LH will continue to get sperm production. So for this reproductive age man that has low testosterone and symptomatic low testosterone, you know low, you know low energy level sex drive mood sleep problems. It can be a worthwhile treatment and it does help a lot of men, but not everybody. I've always been curious why if the goal is to increase sperm production, that the most common treatment is HCG human chorionic gonatotropin. Because as you mentioned earlier, luteinizing hormone and FSH follicle stimulating hormone are deployed from the pituitary and travel to the testes where they stimulate testosterone production and sperm production, but it's the FSH specifically that encourages sperm production.

2:18:55So why wouldn't a man who's taking maybe testosterone therapy or who perhaps just wants increased sperm counting quality take FSH instead of human chorionic gonatotropin, which is more or less a proxy for luteinizing hormone? That's a really good question. And so what FSH does, like you said, is it simulates sperm production. So it seems like it'd be a much more logical treatment and actually in randomized placebo control trials, it does do that. So one of the reasons it does do that, it does help. So it's beneficial and we should we should give it more, but one of the reasons that we don't is cost.

2:19:29So it's rarely covered by insurance and HCG a month of that is in the hundreds of dollars. So let's say like three to five hundred dollars, but a month of sort of therapeutic FSH is probably two to three thousand dollars. So that cost is really limiting. It takes two to three months to make a sperm. So, you know, men often have to be would have to be on it for several months, but there is reasonable data that would help and it does make a lot more sense that that should be given as adjuvant therapy with testosterone rather than HCG. But HG does work, you know, sort of everyone's surprised. It does actually help.

2:20:01But yeah, I agree there is sort of a contradiction there. So if the price came down, it doesn't, you know, this is another off label medication for that indication. It would be, it could be worthwhile. One hormone that we haven't discussed is prolactin. I'm familiar with prolactin from a variety of perspectives, but I always think of dopamine and prolactin as kind of a seesaw relationship. Dopamine is up, prolactin is down, you know, dopamine is elevated with sexual desire, sexual activity, post -adjaculation, prolactin goes up, sets perhaps the refractory period on erection and ejaculation for some period of time, and dopamine comes back up.

2:20:38But, you know, this kind of thing, and I realize that's far too simplistic that prolactin is doing many things in the brain and body besides that. But how often do you see hyper -prolactin amias, I don't know, plural prolias is clinically correct, but elevated levels of prolactin that are causing problems for men. What are some of the telltale signs of that? And this I'd like to use as a segue to talking about some of the sexual dysfunction that is commonly discussed around the use of SSRIs and other drugs to treat depression. And mental health issues that sometimes create endocrine and or sexual health issues.

2:21:21Yeah, so prolactin is sometimes, it's a diagnosis, hyper -prolactinemia, it's a diagnosis, making on that many times. I would say, you know, less than 1 % of the patients that we see will end up having that, but usually it's a handful of times a year because, you know, we see a lot of patients. Typically the telltale sort of symptoms would be, you know, ones of low testosterone, that's a common one. But, you know, in my practice, I see it a lot with no very low sperm production. So I've diagnosed several prolactin screening tumors, and the manifestation of that was, you know, that weren't getting pregnant.

2:21:54We check the sperm count, it was very low, you know, that mandates a check of testosterone, which is also very low, and then that leads to a prolactin, which is very high, and then that was diagnosed. So it's something I think to be aware of, but I don't know that there's not usually a lot of symptoms and sort of going to a clinician when you're having sexual dysfunction, symptoms, low testosterone, or fertility problems will usually, you know, be able to diagnose it if it's present. Are there any other hormones in the in the galaxy of sexual health -related hormones that fall into, you know, common clinical practice for you?

2:22:32I check estrogen as well. So I think that's another one. Again, because of the relationship with obesity, I think that can be important. Sometimes there's too much romanticization. And so sometimes that can be a problem. I think you just like we talked about normal estrogen signaling is important. I think too much can be bad. So there are some men where we do see manifestations that it can manifest as kind of a comastia in some cases. Male breast tissue. No breast tissue. And so I was told what was it that the male breast tissue is sort of like the appendix. It's there, but it's not very interesting.

2:23:04Right. Yeah. Everybody has some and we just don't want the growth to get out of control. Could you tell us about one of the world's most difficult to pronounce words, which is varicoseal? Yes. So varicoseal, it's a very common condition. Probably about 15 % of all men have it. And it's a very common cause of infertility. If you look at all the ideologies, it can be 30 to 40%. So basically what it is is dilated veins in the scrotum. So obviously we need veins to get blood out of the testicles. But sometimes it can be a little larger than average. And there's sort of a normal sort of thermal regulation.

2:23:36So if the veins get too big, it gets thought to warm up the testicle. The other thought is that it doesn't adequately clear some of the metabolites. So exactly the pathophysiology is somewhat debated, but I think those probably contribute. And it's something that everybody should be evaluated for if you're concerned about fertility. So again, we see it very commonly. Given the fact that a lot of men have it, about one in seven men have it. It doesn't always cause a problem, but maybe about 20 to 25 % of the time it does. So mental manifests with low sperm counts. We see sometimes discomfort, you know, ache, worst of the end of the day, then at the beginning, worst of activity.

2:24:10Any time blood can pool, sometimes it stretches and some men feel that. And then in kids, sometimes it can lead to either stunted, testicular growth or shrinkage of the testicle. It's also thought to be a progressive lesion. So the longer a man has it, the more damage it can do. It usually manifests around puberty in general. So it's not a concern for everybody, but I think certainly of couples are having difficulty conceiving, having discomfort in the area, and you have one. It's a discussion you should have. What about peronies disease? Yes, the peronies is a scarring of the penis, which leads to curvature or deformity.

2:24:44So the way erections work is everything swells. And you can imagine if there's a scar tissue, it doesn't swell symmetrically. So you'll get like a curvature deviation. Sometimes you can get an hour glass or sort of a banding. If you look it up on the internet, you can see a host of different deformities that men get. It probably present about 5 to 10 % of men. So it's very common. Sometimes it could be from injury, you know, from, you know, like a peanut fracture or other, you know, sort of less severe form of injury to the penis. Sometimes men have described hitting it on different things. Potentially that could lead to it.

2:25:17Sometimes it can manifest after prostate cancer surgery or other kind of surgery. Which can sort of stun the penis or, you know, injure some of the nerves to the penis. So that's another condition we see commonly. You know, obviously it can lead to bother, you know, interactions are not straight. That can just, you know, cause, you know, psychological bother to men. You can also physically make it difficult for a man to have sex. You know, sometimes it can limit certain positions. So that's another common complaint we see. I think it's something that men should be aware of. There's now awareness campaigns.

2:25:52Now that there's an FDA approved medicine for it. Collagenase or syphlex, which is a medicine that's all scar tissue. So that's one of the treatments we have for it. There's also, you know, different devices, sort of stretching devices where we try and just mechanically remodel the penis to allow it to be a little bit straighter. And then there's also surgical options too. So there's a lot we can do. I always tell men again, something they have penis we can make it, we can make it hard, but we can also make it straight. I'm wondering why in the study about penis life, testicular size and volume wasn't also measured.

2:26:28And that's something that we haven't discussed. What is the relationship between testicular size and volume and some of the other parameters we've been talking about. And maybe this is also a good time to highlight any kind of morphological signals that would warrant people coming to the clinic. So asymmetry and testicle size, for instance, changes in testicular size. Obviously a pea size lump. They taught us in high schools. A warning sign of potential testicular tumor or cancer. Yeah, we didn't really talk about testicles. Yeah, so I think that yeah, kind of being aware, you know, the average size of a testicle for a man is about, you know, sort of about a walnut.

2:27:13So it's about 16 to 20 CCs. You usually if you're going to measure it, it'd be about four to four and a half centimeters and longest axis to give you know your listeners or viewers some idea. If it changes, certainly let people know if you feel anything, let people know, although. Our, you know, national guidelines on screening practices recommends against regular testicular self exams, interestingly, because I think the concern is that it leads to more anxiety than cancers that it would diagnose. But I think you know, I always tell men, no one knows your scrotum better than use of you identify, you know, a problem you should bring it to attention.

2:27:50So, you know, the classic appearance or the way that a testist cancer manifests is a firm, painless mass that you kind of feel coming from the testicle. I find it interesting that at least as I understand women are encouraged to do regular self exams of their breasts for for lumps. So, but you're telling me that men are actually discouraged from doing regular exams of their testicles for lumps that could be cancer and feels like a unfair asymmetry. It does, I mean cancer, I mean both both seem very important. Oh, yeah. Well, I think there's no question obviously I'm very biased. Yeah, I was trying to say it so you didn't have to.

2:28:29Oh, yeah, I don't want to get in trouble with the US. I mean, I don't want anyone to get cancer. I mean, I so I don't even want a dog to get cancer. So, I'm surprised that they discourage self exam. But is it because men are getting it wrong? They're coming into the clinic thinking they have testicular cancer and then most of the time they don't? I think that's the concern that, you know, the number of cancers that are diagnosed versus the false, you know, the false, you know, lumps that they identify just lead to more anxiety and I've not actually, you know, causing more harm than good. I think it's the concern, but yeah, it was a surprising recommendation when it came down usually patients ask about it.

2:29:08And I certainly don't discourage them from doing these exams and I have we've certainly identified cancers through that means before. Well, I saw the episode of ER where the guy was having trouble breathing when he was an elite runner and it turned out he had testicular cancer and he had overlooked a lump on his testicle. So, I'm going to continue to self screen. Okay. Fair enough. Numbers time today we've talked about the potential benefit of getting a blood test for hormone profiles, lipid profiles and other things as well as a sperm analysis. My understanding is that one can only do that if they have the disposable income to elect to do that through some commercial online service.

2:29:45But is there any way that patients who have insurance can approach their physician in a way that this would be covered by insurance? I don't want to get you into any trouble here, but you know, it's always such a shame. It is such a shame when we're talking about something that is really pervasively related to health as a sexual health reproductive health. And people are not aware of a potential problem in the present or in the future that could have been mitigated simply because they didn't get a blood test or do something as simple as a sperm analysis. So, we can't be presumptuous in saying, oh, you know, $200 or $1 ,000, no big deal.

2:30:31I mean, for a lot of people, that's a huge deal. It's prohibitive for many people. So, how can people get this stuff assessed? Should they talk to their primary care physician? Should they call a urologist? What's the best approach? I think both are good strategies. I think, you know, insurance is becoming a lot more open to covering some infertility at least testing, sometimes treatment as well. So, I think a lot of insurance does cover that now. Sometimes we check cement analyses for other jacket or issues. But I think that, you know, again, as more of this data gets out, I think is more recognition how important the mail is.

2:31:06I think we'll get sort of more buying and coverage. Obviously, women have, you know, the automatic feedback of arbitrary cycles. So, they kind of know, you know, there's a problem they can bring that to the attention. But men don't have that feedback without some of these testing. Yeah, and we probably should have mentioned this earlier. So, forgive me. This was on me to mention that when we talk about sperm quality and we sort of shift it back and forth to semen quality, it's possible to have normal semen volume and have very low sperm count. We're not talking about the total amount of a jackal at per se.

2:31:38We're talking about the density of forwardly motile, healthy, non -DNA fragmented sperm in that semen. So, in other words, it's not sufficient to just assume because you can ejaculate that your sperm are healthy. That's exactly right. I mean, I think, you know, about 15 % of men have low semen quality, whether it be concentration, movement, shape, about 1 % of men have no sperm in the ejaculate. And that's something sometimes they have no idea about. So, the only way to know would be to actually do a formal test. Well, I'm encouraging people to get these parameters assessed. And I'm making that statement because it's very clear based on everything that you've told us today that sperm quality and hormone levels are just so important, not just for sexual health, but for urinary health and for reflecting prostate health and other aspects of whole body health.

2:32:32And sexual health relates directly to mental health. We didn't talk so much about the psychogenic issues, but the two go hand in hand. I wanted to thank you so much for coming here today and sharing so much knowledge with us. I mean, these really are the issues that males think about and wonder about and have questions about. And they do so to varying degrees, depending on where they're at in life. But I think especially for younger men who are hearing this, who are not at the point where they want to conceive. It's really important to start thinking about these issues for all the reasons you mentioned.

2:33:12I think these issues are really important for women to know about as well. Just as it's important for men to understand female reproductive health and not just to improve communication, but this after all is at the heart of the presence and proliferation of our species. So thanks for taking care of the male half. And thanks for doing the work you do. It's incredible. The large scale studies, the more detailed studies on smaller populations, you ask the questions that it seems many people are just afraid to ask and get right in there and come out with the really rigorous data and answer. So thank you so much for what you do.

2:33:53My pleasure. Thank you for highlighting men's reproductive health. Thank you for joining me for today's discussion with Dr. Michael Eisenberg to learn more about his research and his clinical practice. Please check out the links in the show note captions. If you're learning from and are enjoying this podcast, please subscribe to our YouTube channel. That's a terrific zero cost way to support us. In addition, please subscribe to the podcast on both Spotify and Apple. And on both Spotify and Apple, you can leave us up to a five star review. Please also check out the sponsors mentioned at the beginning and throughout today's episode.

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