Erections & Testosterone - Shocking Link to Muscle Mass & Men's Health | Dr Tobias S Kohler

20:07It's like literally getting a lightning bolt to the penis. The penis is becoming ischemic. There's no blood flow because essentially blood flows in, but can't flow out. So then you have oxygen deprivation. So it starts to hurt and it starts to hurt more and more. And this is like 11 out of 10 erection. And if that happens, if you go to the emergency room and we take care of it right away, no problem. Then you learn your lesson. Never do that thing again that you just did. However, if you wait because you're embarrassed, after 24, after 36 hours of private room, it's broken forever. What happens if...

20:41Well, you get ischemic. So all the smooth muscle in the penis dies. So it's like a heart attack of the penis. And that's one reason why men sometimes need penile implants. Because once you have this devastating loss of penile function, nothing except surgery would potentially fix it.

20:56Dr. Gabrielle Lyon:Don't wait. Don't delay care. How big of an impact, you know, from a family practice or geriatric perspective, we use trazodone firstly at times and not at high doses. There is a little black box warning that says this could cause priapism. I've never seen it. I don't know any physician that has seen it or any of the physicians in our practice. Is that something common or is that just another black box warning that just has not died yet? Well, I think you're going to do great on the test because they always ask that question. But no, I have seen it before. And so a lot of the psychotropic medications that can be used that have central effects actually can cause pribism.

21:38There's a really long drug list. Cannabis is another really big one that's pripistic, meaning it can cause pribism. So we're seeing increasing rates of pribism in our emergency rooms now because of the legalization and the social acceptance of cannabis. So just another public service announcement.

21:53Dr. Gabrielle Lyon:I think it's a great public service announcement because people believe, many people believe that these drugs are benign, including cannabis. I personally don't think so. I think that the data would also suggest otherwise in various domains of health and wellness. Yeah, I think both alcohol and cannabis really disturb REM sleep. REM sleep is critical for kind of the brain self-healing for psychiatric wellness and for the production of hormones. So the vast majority of your sex hormones are produced during REM sleep. So if you want to sabotage that, sleep lousy and you'll do a good job and you'll feel lousy as well.

22:31Dr. Gabrielle Lyon:I'd like to acknowledge one of the sponsors of the show and that is Peori. This podcast has allowed me to speak to extraordinary experts and they have one unifying message. There are only a few core compounds that we need in the diet. And one of those is omega-3 fatty acids. Piore's O3 Ultra Pure Fish Oil, which is third-party tested and certified by both the Clean Label Project and IFOS, so you know what you're putting in your body. It is safe, pure, effective. It is tested for 200 contaminants and Piore publishes all their results online. I've teamed up with Piore to get you an amazing offer, 20 % off site-wide, even on already discounted subscriptions, which means you can save nearly a third off.

23:19Dr. Gabrielle Lyon:All you have to do is go to puori.com slash Dr. Lyon and use the code Dr. Lyon at checkout. You mentioned exercise, penile vascular health. This is the first time I've probably ever said those words together. I'll just say them again, penile vascular health. Exercise increases blood flow. So are there things like I saw Austin Powers and he has the penis pump. It would also make sense if we exercise our muscle that perhaps something like that would also work. You know, the guys may take advantage of the statement, but the penis is a use it or lose it organ. Okay. So when the penis goes in the garage for an extended amount of time, meaning no erections, like no sex, no physiological erections that normally occur in the middle of the night.

24:13Now, why would that happen? You just had a prostate surgery and you had to stun the nerves. You have significant diabetes. You've basically just gotten to the point where the erections aren't happening very often. We know that men who don't get erections commonly get penile shortening, right? So you lose length of the penis.

24:30Dr. Gabrielle Lyon:Everybody wants to know how rapid and how much. Yeah. So on average, if you've got a consistent lack of erections for three months, you lose one to two centimeters of length which is a half inch to an inch in length and every millimeter guys fight for right that's a lot it's significant yeah it's actually earlier in my career as as i was a urologist at the va and we were doing prostatectomy surgeons the patients would say after the prostate surgery say doc i think my penis is shorter i'm like no no you're just a little bit fatter you know it's hidden more you know and then they kept saying it and And that was like one of the first studies I ever did.

25:06And we actually measured and it's true, guys lost penile length. The good news is, is that if you exercise the penis with a vacuum erection device, you can regain that length back. So it's not about like physically shorting the penis. It's about having scar tissue in the penis. And if you have a uniform scar with erection, the penis looks shorter. If you have a non-uniform scar, you get this curvature, right? And that's Peyronie's disease. is loss of elasticity on one side or one part of the penis. And like a balloon, if you put a piece of tape on a balloon, you inflate it, the balloon's going to curve where that piece of tape is.

25:41That's what Peyronie's disease is. And again, that's something that's very common in men, about 10 % of men above age 50.

25:47Dr. Gabrielle Lyon:10 % of men above age 50. You do support the use of, what do you call it? A penile enhancement device? What are they? Yeah, so vacuum erection device. A vacuum erection device. It's an adjunctive tool to help men kind of rehab the penis. We often have men use it prior to surgery to optimize length, to facilitate an easier surgery to support that. Again, it's a use or lose it organ. So as a long-term treatment for significant problems with rectums, the vacuum rectum device is not awesome, right? You can imagine you're with a partner and you're like carrying this thing around. Going through a TSA pre-check or going without TSA pre-check, yeah.

26:24Right. But we do have better treatments that are more subtle, more hideable, less embarrassing. Surgery being one of them, pills being another. But yeah, I think vacuum devices play an important role. The other thing about vacuum devices that men should know is that you can get blood to flow into the penis with this negative pressure, right? But then you take the cylinder off and the erection goes away within 10 seconds, right? So you have to somehow trap the blood. and trapping the blood we talked about in the beginning is in is essential keeping erections so as the veins uh become uh mal as they malfunction as we age or if there's more scar tissue around the veins after fibrosis from surgery for example those veins no longer could be compressed adequately so what happens is blood flows in but the veins don't get compressed like they should so blood flows out at the same rate very similar to like a tire with a bunch of holes in it.

27:18Okay. So you can hook up an air compressor to the tire. It'll look like it'll get hard, but then as soon as you start to drive on it, it goes flat. That happens in men too. And so if men describe to me, Hey, I can get erection, but then I lose it when I, when I start to try to have sex or when I, you know, uh, with intermission, then I'll know that's probably a venous leak. And that venous leak can be treated best with surgery. But the other thing you can try are these constriction bands where you're essentially trying to crush the vessels from the outside. Never use a metal band on the penis.

27:50Dr. Gabrielle Lyon:That also sounds really painful. Yeah, I know. As urologists, you know, I've had cases where I had to call in, use like a neurosurgical drill. We have the fire department, you know, try to cut off these metal rings. I had one gentleman use a titanium ring. That is not a good plan because it gets stuck. So if you're going to use a ring or a band to support erections, which is a reasonable thing to try, use something that is, you know, elastic. Yeah, there you go. That would make much more sense than something that doesn't expand. Thank you to one of the sponsors, the one and the only Cozy Earth.

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29:03Dr. Gabrielle Lyon:You can try these sheets during the hottest nights of the year. Well, I guess hopefully all your nights are hot, if you know what I mean. And if you don't love them, you can return them hassle-free. But trust me, you won't want to. They have a 10-year warranty on all bedding products. Go to CozyEarth.com and use the code DRLYON for up to 40 % off best-selling temperature-regulating sheets, apparel, and more. Trust me, you'll feel the difference. Let's talk about drugs. And when I say drugs, I'm talking about PDE5 inhibitors, Viagra, Cialis. There was a massive review. It was 1.26 million people found that regular Cialis use reduced major cardiac events by 22 % and lowered all-cause mortality by 30%.

29:54Dr. Gabrielle Lyon:Do you think there is a place for people that are healthy to be on these types of medications like Cialis? Yeah. If you ask me if there's data to support that for all patients, not yet. from a personal standpoint i believe so like my read on the data is these are preventative drugs that can prevent significant disease do you know the story of viagra it's an interesting one so viagra was initially a drug developed um and they were tested in england and so it was initially a drug designed to treat angina chest pain so you get all these men who have a history of chest pain you give them viagra say okay when you get the chest pain take the drug see what happens turns out lousy drug for chest pain like doesn't work and so that's what nitroglycerin does right it reduces reduces pain with um you know lack of blood flow to the heart and then the people who are doing the study are like uh back to the drawing board and they're like send us the drugs back and like they weren't getting them back like what is happening patients never keep these drugs and so of course, the patients noted that their penis was working better on these drugs.

31:04And that's how Viagra was born. It was initially a heart drug for angina, but then we developed into a penis drug. And Cialis had a similar history. And so it's not that surprising as we look back at the data, which has been in front of us now for 20 to 25 years, the men who take these drugs consistently seem to have a much lower risk of heart disease. The mechanism is unclear. It probably has to do with endothelial health, the inner lining of the blood vessels being healthy, has to do with maybe decreasing clotting in the major blood vessels. You get drugs like Viagra and Cialis, Sildenafil, Tadalafil are the names.

31:43And if you take them, not only do they help erections, we also discover that Tadalafil, which is a drug that stays in your bloodstream for 24 hours, used to be called the Weekender, it actually helps with urinary symptoms as well. And then now... Helps how? It helps with these urgency, frequency, getting up in the middle of the night type symptoms. So Tadalafil has an FDA indication for urinary symptoms or LUTs, lower urinary tract symptoms. And so I write for these drugs a lot because I find every excuse I can to give them to men, whether they have problems with erections, whether they have problems with urination, and then they get this likely benefit of cardiac protection.

32:23So it's like this triple threat drug, which by the way, is like 25 cents a pill. You can get a prescription, you know, through Mark Cuban's pharmacy or goodrx.com, literally three months for 30 bucks. So even if insurance doesn't pay for it, it's worth it. And so we routinely use these drugs and they're massively effective, restore confidence, probably good for you overall, help with urination. I mean, it's great. There are downsides to any pill, but you know, they're relatively low with this class of drugs. One in 33 men will stop because of side effects. One in 33. That can include headache, facial flushing, maybe worsened reflux disease.

33:00But 32 out of 33 men are like, I'm good. I'll take the reflux.

33:04Dr. Gabrielle Lyon:Give me extra flushing. And this is Cialis. Do you prescribe five milligrams of Cialis daily? We do too in clinic. It's going to be the most effective because it's in your bloodstream constantly. So if you believe the data that it's cardioprotective, it makes sense. So you need to have it in your bloodstream the whole day, as opposed to like a window, which Viagra or Sidenafil gives you a four-hour window of efficacy, whereas Cialis is 24 hours. You only see men, to be fair, right? For the most part, yeah. Especially where I am now in my job and primarily men's health. I used to see a lot of women for stones when I was in Springfield, Illinois.

33:41Stones are very, very common for a urologist.

33:43Dr. Gabrielle Lyon:Yes. Did you, at that time, use Cialis in women? This is a study that clearly needs to be done for a variety of reasons. Number one, overactive bladder. This is symptoms where people have to pee so often that it negatively affects their life. And like 40 % of all humans above age 50 have overactive bladder. And this... Really? 40 %? It's super, super common. You know, my dad's always saying, I have BPH. I'm peeing 100 times a night. It lets me meditate. I'd love to dive into that because there's a lot of misconceptions about the prostate it being at fault for everything. But when we get older, we get physiologic changes in the bladder.

34:23So like the bladder capacity goes down and our sense of urgency and the sense of stretch is increased. So we end up peeing more often at lower volumes. Just like many things as we get older, things tend to get worse. As you're, when you're a baby, when you're born, the bladder just squeezes when it wants to. And then age four or five, the bladder takes commands from the brain says no no you can't squeeze now i'm in public i can't pee my pants and so you learn this continence but as we age like many things the bladder kind of goes rogue and just ignores the

34:56Dr. Gabrielle Lyon:brain's advice and just squeezes when it wants to so patients they'll put keys in the door they'll hear running water and all of a sudden they'll get this crazy urge to go to the bathroom and if you're lucky you make it in time if you're unlucky you don't have a bathroom there you're more likely that have accidents. And so women, like one of the main reasons women visit urologists is for urinary incontinence, not only stress incontinence from when you cough or sneeze, you lose urine, but this urge incontinence, you know, this is very, very common, but men also have urgent incontinence. And so this can be treated by addressing bladder health.

35:29And so that's why I think a study is long, long overdue for women to see if Cialis will help with these overactive bladder symptoms like they do in men, because they do. And then is it cardioprotective in women? These are questions that need to be answered with a randomized controlled trial.

35:45Dr. Gabrielle Lyon:If a woman was taking Cialis, the indication would not be, I suppose it would be off-label for overactive bladders. Yep, yep. It could be off-label. Exactly, until we get an indication to be off-label. Off-label doesn't mean wrong. Oh, totally. Right, and a lot of patients will think, you know, this is off-label, this is wrong. No, off-label means as a physician, I have to tell you the risks and benefits of this therapy and then you decide if it's right for you. just like many other things in life. So yeah, it's a study that needs to be done. And there have been studies to look at sexual function and these classes of drugs, and it does increase blood flow to the genitalia.

36:22Sexual function and orgasm in women is a lot more complicated, sophisticated. A lot of other things have to happen for orgasm to occur. There isn't this obvious yes, no, penis hard, penis soft kind of thing in women. And so these drugs have been disappointing for sexual function in women. However, it doesn't mean they might not help.

36:42Dr. Gabrielle Lyon:Thanks to one of the sponsors of the show, Bond Charge. Man, if you're a mom out there and you've been carrying the whole team, I got a different form of therapy for you, and that is red light therapy. And listen, good light impacts sleep, hormones, mood, and even your ability to recover and focus. Bond Charge has created science-backed tools to help me live in better alignment with my circadian biology. Artificial light is overloading us. They have blue light blocking glasses that are a staple in our house. They have red light. They have red light light bulbs. They also have infrared PMF masks to help chill my body, relax my muscles, and support full body recovery.

37:28Dr. Gabrielle Lyon:If you've never tried red light therapy, this is the time to do it. They have some of the best devices that I've ever seen. Great for skin, mitochondrial health, and overall resilience. If you care about your skin, if you care about your sleep, if you care about your body and want to try something new, check out bondcharge.com slash Dr. Lion. Use the code Dr. Lion to get 15 % off your entire order. Simple, proven, designed to support your biology. I want to talk about the bladder. You brought it up. I think it's a great topic. Now, I have heard you say that one in seven men who see a urologist already have irreversible bladder damage.

38:11It's crazy. But we did a big study where we looked at men visiting urologists. We tested them and they tested in this zone where we called, you know, basically the bladder was no longer squeezing like it can. So the bladder, put simply, is a big old pump. And over men's lifetime, the bladder has to empty through the middle of the prostate and out the urethra. So as women get older, they don't have problems with the pump getting weak because their urethra is relatively short and they don't have this prostate which can get bigger with time. But men, they have a prostate which gets bigger as we age.

38:48So very similar to problems with erections. So 50 % of 50-year-olds will have an enlarged prostate, 80 % of 80-year-olds, so on and so forth. And of the men with enlarged prostate, half will be symptomatic. So if you have this pump, which is struggling to empty because it's trying to squeeze urine through the middle of this donut, which is the prostate, the bladder gets tired after a while. It's a pump that fails. And if men allow that to progress, one in seven come to me and that the pump's already gone what does that mean for them well either they will need to catheterize the rest of their life to get the urine out or either in and out or have a catheter in or they'll need a very aggressive surgery in the hopes that they'll be able to pee on their own by what we call credavoiding bearing down basically just pushing the urine out so it can be avoided if when men get symptoms They go to the doctor relatively early and either they get a surgery early because that's the best way to preserve the pump

39:45Dr. Gabrielle Lyon:What would the symptom be that they are just getting would it be urinary retention? or This feeling where they're having to go a lot, but they can't go and feeling like there is Urine still and they still have to pee. Yeah, it's the former it's pushing or straining to go Men who can't empty their bladder effectively, right? So one test we'll do is we'll have guys pee into a machine. We'll measure how strong the stream is. We'll give them a score. And that can be predictive of the need for surgery, etc. But more importantly, we measure how much is left behind after they go. And if that number is zero, you're good.

40:20However, if that number starts climbing, you pee out 400, you leave 100 behind. You wait another year, you pee out 300, you leave 200 behind. Pretty soon the ratio is nothing comes out. You leave everything behind. So that is the best way to kind of predict this loss of bladder function. is by seeing how much is left over. Other signs can include, and knowing you're not emptying, so that can sometimes lead to frequency, getting infections, right? Because - Urinary tract infections. Because our number one defense against infection is peeing out the bacteria. And if you are not emptying your bladder well, basically there's like a little swamp in there where the bacteria are like swimming around having a field day and then manifesting with infections.

40:59Dr. Gabrielle Lyon:How would a woman know that she has the equivalent? Women will very rarely have these obstructive symptoms because they don't have the hardware to cause the bladder to malfunction. But the important lesson here is that the bladder causes this mischief. It wants to squeeze all the time. And there are many lifestyle factors that lead to more bladder mischief and make me have to pee more often and make you miserable. And so sometimes men will come to the urologist saying, Doc, my prostate's horrible. And no, they have the same thing that women have, this overactive bladder. The urologist's job is to separate like what the problem is.

41:36But for men that have struggled in urinary, you have to rule out the pump problem. Because if you don't, you're going to have to get a catheter lifelong. And that's not what you want to believe me. In terms of, you know, what can we do about the overactive bladder, this kind of irritative symptom type of thing, not pushing or straining, but having to go off and running to the bathroom, having to get up in the middle of the night, like basically having accidents when you don't want to. These are bladder behaviors.

41:59Dr. Gabrielle Lyon:So not prostate behaviors. That's... We have to talk about this. We need to clarify this. You have also said, which I thought was brilliant, how many times you pee in the middle of the night can predict the likelihood of death. So big meta-analysis, I think from 2015, meta-analysis is when you take all the best literature, you combine it and you try to come up with conclusions. So this meta-analysis said that men who have nocturia, that's greater than two times at night, they get up three times to pee or more, are 30 % more likely to die of all causes. Heart attacks, these kind of things. Now, does that mean that if you pee three times in the middle of the night, you're doomed?

42:39Of course not. This is not a causal relationship. It's a correlated relationship, meaning the answer probably is that if you're getting up three times in the middle of the night to pee, you've got other stuff going on. One, do you have sleep apnea where you can't sleep solemnly? And that's making you pee more often. Two, do you have edema in your legs because you you have heart failure, you have to pee more often in the middle of the night. Three, you have metabolic abnormalities. You have diabetes, which makes you pee more often. All these kind of potential risk factors will make you pee more.

43:08So it's the fact that you're peeing tells me you're unhealthy. Again, if you mitigate that unhealthiness, if you lose weight, you start to exercise, you reverse your diabetes, guess what? You won't pee as often, right? So a lot of these things are reversible in life. The human body is amazing if we treat it right.

43:24Dr. Gabrielle Lyon:But is there a normal amount of time someone gets up? And again, I'm thinking about my dad. Shout out to Nate in Ecuador, probably embarrassed. You know, he often says, okay, well, I'm waking up in the middle of the night, two, three. Again, he lost me at three to go to the bathroom. Yeah. He is 74. Would that be prostate? Would that be bladder? Would it be impossible to tell? Yeah. So it's typically unusual to have to get up in the middle of the night less than age 50, right? Once fine. But once you start getting up more and more often, we know as we get older, again, the bladder loses capacity.

44:04As we get older, we tend to make less hormones that prevent us from peeing in the middle of the night. Specifically, we make less ADH. If you have sleep apnea, the body perceives this lack of breathing as high blood pressure to the chest. And so it sends out natriuretriatic peptide, which makes us spill salt into the urine, which pulls fluid with it. So again, these other medical comorbidities will make us have more nocturia. So I'd say if you're getting up more than three times at night, you first should look at lifestyle factors and then obviously look to improve the other metabolic components that we just discussed.

44:41But yeah, you're at risk for other things because that's a warning sign that stuff's going on.

44:45Dr. Gabrielle Lyon:It's really interesting because just, again, as a practicing physician, training in, say, family medicine and even geriatrics would be, here's some Flomax. I'll see you next time. It's a very dangerous approach. One, you're making the assumption that it's the prostate. It could be bladder. It could be the fact that this person's drinking eight liters a day. And we can talk about bladder irritants in a second. We are definitely talking about bladder irritants because you just killed half the list. The other thing, though, is that Flomax is a drug that, you know, it's Tamsilose. And there's all these other drugs which will improve the strength of the stream.

45:20But it doesn't protect the pump. So actually, the worst thing you can do for guys with obstructive symptoms is to give them Flomax. Because then you won't see them again for another 10 years. But by the time they've come back, now the bladder has had the damage that's irreversible, irreversible. So Flomax is not a drug that will protect you long term. so if you have true prostate enlargement i'm an enthusiast for early intervention that is doing procedures that will help you know take away some of the resistance of the prostate so men pee better and they protect their long-term bladder function you can use medications to have this effect as well and these drugs are typically five maris the ones that actually physically shrink the size of the prostate kind of a chemical surgery if you will these drugs will prevent the need for to go to the emergency room because you can't pee the need for surgery in the future.

46:07But if you just give somebody Flomax and say, you know, see you when I see you, you're at high risk for having that person have long-term bladder damage.

46:15Dr. Gabrielle Lyon:It's a really important message. I do think that it is very common where people think it is. It's again, and part of that is media, which is also another reason I'm so excited to have you on. I know that you speak all the time, but to have you on to podcast is huge and you're able to reach a lot of people just by having the conversation. I was very disappointed to see your lifestyle changes for urinary frequency notes. Extremely disappointed. I'm going to share this list. I just want to let you know that you have ruined my Wednesday. I'm not even going to be drinking any more carbonation. Right down there.

46:56Dr. Gabrielle Lyon:The C's of urinary frequency. Consumption, caffeine, Constipation cocktails coke zero. You just hurt my heart citrus also hurt my heart Carbonation cigarettes. I don't smoke couch potato not doing that capsaicin spicy foods. We are not friends any longer talk to me about this. Yeah, so If you're having urinary frequency, that's bothersome to you The big three are How much you consume right all of it? Yeah the more you drink the more you pee this is just simple math right obviously we need to drink a certain amount to be healthy but you know the person who said you need to drink eight glasses of water per day may have been selling water right so everything is about risk balances and if you are miserable because you're peeing all the time try to cut fluids to some degree and see if that helps the second biggest thing we see is caffeine so caffeine uh acts as diuretic and also makes us pee in small amounts, so inefficiently.

47:57And the higher dose, the more it affects us. So if you're going frequently, if you have several cups of coffee, you'll notice that the frequency always is around the time you drink coffee or caffeine. Constipation is a huge one. So the bowel and the bladder share real estate. And if you're really constipated, you struggle with that. Not only are there probably neural pathways or nerve relations between the two organ systems, if the rectal vault is filled with gas and stool it's literally squishing the bladder

48:28Dr. Gabrielle Lyon:your bladder capacity is decreased and you have to go more often so a lot of guys that struggle or guys and gals struggle with uh urinary frequency you get constipation under control they're better same with little kids right little kids when they have accidents at school uh when they have when they have accidents in the middle of night it's almost always constipation you fix that that gets better that's a great parenting tip i didn't know that and so some Some of the other ones, which you mentioned, they can be more of a risk for some individuals than others, right? So humans are genetically variable.

49:01For some people, if they eat spicy foods, that's capsaicin, they'll have to pee every 15 minutes. Some people are really sensitive to carbonation. You know, some people are more sensitive to artificial sweeteners like those in Coke Zero. So I have problems remembering stuff. So I basically try to put the letter C in front of everything to remember what things can trigger bladder overactivity.

49:22Dr. Gabrielle Lyon:Speaking of bladder, let's, I suppose I should get this right, move up. I better get this right considering I'm married to a urology resident. Kidney stones, who gets them and how frequent is it? Is it men versus women? Is there predisposing factors? Yeah. Let's talk about it. Well, kidney stones, in fact, about 10 % of all humans, there's predominance in men over women slight predominance the main risk factors for forming stones is lack of fluid consumption so this is the other end of the scale we just talked about over consumption under consumptions of fluids is the number one risk factor for stones right and when you form stones like all the time in texas because it's always hot here so when you're sweating i almost burst into flames when my my plane landed here as i got off um yeah very hot here and humid but basically uh if you're dehydrated chronically you're at risk for stones the other things that are very important are salt consumption uh and excessive artificial sugars or true sugars they tend to form more stones the bottom line is also there's a strong genetic predisposition so if you have somebody who you had a dad or a brother with stones you're more likely to get them and they're they're very very common if you drink more you can prevent them And if you think about this, I tell my patients this analogy, like if you're constantly flooding the kidney with all this extra fluid, there's no way a stone can start to form in the kidney and then eventually pass and cause shenanigans.

51:00So if you're like, if you're in a, like in Minnesota, we, we like.

51:05Dr. Gabrielle Lyon:Where it's never hot. No, it's really hot for like three months and it's really cold for another nine months. Sometimes people will, will go down a river in an inner tube. And so I say it to patients, like you're going down the river in the inner tube. Imagine you're a small particle at the bottom of that lazy river and how as every second goes by, calcium or different minerals start to add to the size of the stone. But now if you switch to a whitewater rafting part, which we don't have in Minnesota, by the way, but we - You don't? No, no, no. It's not that exciting in terms of a state for that kind of activity.

51:41There's no way a stone can form. So the inside of the kidney is like that lazy river if you don't drink enough, but if you consume enough fluid, you're very unlikely to form stones.

51:50Dr. Gabrielle Lyon:As simple as that. Would there be certain things that could predispose people to stones? For example, I've heard very high dose vitamin C. Does it seem to be different for every person? Again, because you had said some people, artificial sweeteners might be an irritant to one person versus somebody else. Yep. Biologic variability applies to everyone. But high-dose vitamin C can be a risk factor. Excess calcium. So both too much calcium and too little calcium. Dietary calcium or... Dietary calcium, yep. Okay. You know, your gut has to reabsorb calcium. And if there's too much in the gut, it spills over into the blood.

52:30So actually, the recommended amount allowance of calcium is probably the right amount. The extremes of either end are stone promoting. But again, And the number one way to prevent stones is to drink more fluid. Real lemon juice added to fluids can also actually prevent stones through some citrate metabolisms and some ways that we get away. Guys and gals who form recurrent stones will often be put on potassium citrate, a pill that alkalinizes the urine and thus prevents stones. The bottom line is if you form a kidney stone, you got to figure out why. If you form a second kidney stone, you need extensive testing and figure out what medication you should get to prevent them.

53:09From what I hear, they're very painful. Yep, yep. I've seen many tough individuals be not so tough because of the pain from kidney stones.

53:18Dr. Gabrielle Lyon:I don't wish that on anybody. There is something I do wish on people. And that is muscle mass. Wait,$3 ,000? Three? Wait, is that number right? I've spent more money on skincare. My pores should be tax deductible, maybe even have their own trust fund. And thank goodness that I found OneSkin because OneSkin doesn't just make empty promises. It's research driven, minimalistic and tested for beauty, skin health and longevity. OneSkin is the first topical skincare backed by peptide science that targets skin aging at the molecular level. I slather this on all day. They have a peptide that is designed to reduce the accumulation of dead cells or zombie cells that drive inflammation, tissue breakdown as we age.

54:10Dr. Gabrielle Lyon:Now, this isn't about cosmetic quick fixes. It's about changing the biology of your skin, strengthening the barrier, improving firmness, hydration, elasticity with clinically tested ingredients. So if you are focused on aging well from the inside out, it's time also to think about your skin. It should get the same level of care. Go to oneskin.co for 15 % off. Use the code Dr. Lion. It is amazing and it will not break the bank. You gave an amazing presentation at the Androgen Society and just recently at Baylor because I heard from the residents. There is a connection between muscle mass, sarcopenia, and sexual function.

54:54Absolutely. Muscle mass is imperative for longevity. If you want to live a long time, you have to move iron. You've got to be strong. You've got to keep it that way. We have this age-related sarcopenia where you will lose muscle as you get older, related to hormone production. But if you fight to be elite in our age now, I'm going to put us as young, we'll be fine when we're 90. So that's my paradigm. Right now we're in preparation for geriatric decathlon. This is Peter Atiyah's concept. It's amazing. So you've got to be really healthy now. So muscles does so many things in your book, Forever Strong, talks about the metabolic capacity as one of the biggest organs humans have to control insulin sensitivity, to control inflammation.

55:38And it's not surprising at all that when you look at well-done studies, men with more muscle mass have better erections. Men with less muscle mass have horrible erections, have low libido, have lower testosterone. It's all about overall health. Again, think to the paradigm about how the body is willing to give away its erectile function if it has to sacrifice something, but it's going to keep brain function. And as we get sicker and unwell, the penis is the first to go. So don't get unwell. Stay strong. So when men train, when men lose weight, when men gain muscle erections get better aerobic activity is as powerful as p5 inhibitors the drugs like cialis that we talked about earlier in helping with erections a modest 10 decrease in body weight is as powerful as pills in helping with erections not only all the other benefits of keeping on the right side of the grass so again if you take good care of your body your body will take good care of you anything you do for penis health is good for cardiac health so it is not surprising at all There's a direct correlation between muscle mass, strength, grip strength, and erectile quality.

56:49Dr. Gabrielle Lyon:You just got the attention of every male listener on the planet. Yeah. Well, good. Or at least we're listening to the show because who doesn't want better erectile function and better penis health? And, you know, just to jump in, we use the penis as a fulcrum for behavior change. It is very difficult for the average man to change your behavior if you tell them, listen, your blood pressure is eight points too high. But if you tell them, listen, if you lose a little bit of weight, if you start exercising, just minimal gains, 150 minutes a week of exercise, 30 minutes, five times a day, you will see tremendous improvement.

57:28And so we can use this as a fulcrum to get guys to be healthier. In Canada, the cigarette packages have like this flaccid cigarette on the side. And it basically says smoking is bad for your erections. So we should lean into this fact and get people to be healthier because, yes, sexual function is very sensitive to overall health, and we should use it as a way to get people to be healthier.

57:49Dr. Gabrielle Lyon:Is there a dose, you said 150 minutes of moderate to vigorous activity. Is there a known specific dose that is good for penis health or vascular health primarily? I mean, I know that we're talking about vascular health in general, but again, as a urologist, I thought that we would focus on your organ of longevity, the urologist organ of longevity versus my definition. Right. Do we know, is there a dose? A study by Zhang et al. I think from last year, 2024, they looked at the NHANES data, which is like a community cohort database from like the early 2000s. And basically it found that 150 minutes of exercise per week decreased the rate of erectile dysfunction by 20%, 300 minutes by essentially 40%.

58:35something very close to that. So, you know, intensity and duration, as it gets higher, you get improvements. There is a, eventually you plateau. It's like if you do a thousand minutes, you're not going to get perfect erections, but even a modest amount of exercise really moves the needle. And then if you really are exercising 300 minutes a week, that's an hour, five days a week, which is a great goal. You'll see a 40 % improvement in erections.

58:57Dr. Gabrielle Lyon:I'm going to just lay out a handful of other statistics and numbers because I think they're so powerful. Studies showing men who maintain muscle mass strength are 66 % less likely to report multiple sexual issues. Older men, this was fascinating but not surprising. Sarcopenia was linked to 2.7 times greater risk of moderate to severe ED. Both those studies are excellent in that a lot of them are self-reported studies and where people are quantifying their own strength. the one study about the muscle mass that's from like a bunch of Scandinavian patients and the people who reported that they still were strong, had awesome erections.

59:38The people who said, yeah, I feel a little bit weaker than when I was 10 years ago, they had lousy erections and lousy libido too.

59:43Dr. Gabrielle Lyon:What is the role of testosterone and erectile function? Testosterone is essential to a certain point, right? So if you have normal testosterone and you give more testosterone, Testosterone, there typically isn't an added benefit, right? So a mistake you'll make is like assuming if somebody comes in with a normal, you check their T, it's normal, but they have problems with erections. By giving the testosterone, that typically doesn't fix the problem. Remember, the main etiology of erectile dysfunction is probably a vascular blood flow problem. So you got to fix the blood flow. If testosterone is very low, though, then penis ain't going to work.

1:00:19Dr. Gabrielle Lyon:How would you define very low? Well, you know, if you want to use the scientific definition, a repeated measurement of testosterone less than 300 or free testosterone less than five. So if it's low, if you give testosterone back to those men, they typically will see a better, better erections, especially when they're trying to use pills. Cialis, Viagra, they rely on testosterone for nitric oxide synthetase or the chemicals that are required for erections. If your T is low and you give T back, the pills will work better. Again, I just can't stress enough, though. If you take good care of yourself, your T will stay normal.

1:00:55There's data where, you know, people who look healthy in their 70s and 80s, their testosterone is way higher than people who look unwell. My dad. And their T is really low. Yeah.

1:01:05Dr. Gabrielle Lyon:Let's just throw Nate Dog under the bus again. We ran his labs, and I'm looking at this testosterone of over 700. No, that's amazing. and i i would argue that the best single blood test for overall health in men is testosterone in women maybe but maybe there's a ratio we need to look at and then along those same same lines the best overall marker for overall health in men is erectile function why because you have to have excellent vascular integrity excellent overall health and the penis requires normal mental health if you're anxious if you're depressed the penis ain't gonna work so you can be in great physical shape, but if you're unwell from a psychiatric perspective, whether it's depression or whatever it is, anxiety, because you're having stress at work, again, the penis ain't going to function well.

1:01:54So all systems have to be on full go for the erections to be awesome. So that's a really reassuring thing. If you're a 70-year-old and you're getting great erections, you're probably pretty healthy.

1:02:03Dr. Gabrielle Lyon:Is there a point of no return? For example, when we image the brain and we see microvascular disease of the brain. The brain is arguably a large, very active organ. There is a lot of it. The brain can make up for itself, meaning it's not just dependent typically in this one area, but the penis is smaller. If there is vascular damage to the penis, is there an ability to recover? To a limited extent, like many other things. But sometimes you get age-related, um you know vascular disease maybe it's untreated hypertension for a long time or you have significant atherosclerotic narrowing or plaque or maybe smoke for a long time sometimes the damage is so extensive that no matter how much you exercise no matter how many pills you take it ain't gonna work right yes there is a point of no return very avoidable if you never get there in the first place but that's where surgery comes in for men who may have had a reason that their penis has failed them or maybe had a period in their life where they're very unhealthy, we can restore normal sexual function with surgery.

1:03:13Oftentimes, we can restore it with lifestyle change, but not always. And so take good care of yourself. But then even if it fails, there's no reason to give up hope. We can fix it. I have a question that I don't know if you've ever seen, and I don't even know if it's a thing. Is there ever something where a penis cannot get an erection?

1:03:32Dr. Gabrielle Lyon:Maybe it's a genetic defect of vasculature? All the time. Really? Oh, yeah, all the time. So when I look at the age range of patients that I put an implant in, it's 18 to 98. Wow. So if anybody out there is 100 years old, please come see me because I want to say I put an implant in a 100-year-old. So that 90-year-old did great, by the way. But some people are born with this congenital venous leak. where the venous trapping just doesn't work. Or some men are born with some kind of a genetic defect or whatever it is where they've never had a good erection in their entire life. So I've had patients come to me where, like, they're actually having pain with their erections because they've never stretched the penis before.

1:04:15Wow. So, but, you know, the surgery can fix it. And there are many men who have never had a normal erection their entire life. Like age 16, 17, 18, when we see them for the first time, It's like never had a good one. So that's fixable. That's treatable. You know, I'm really grateful that that surgery is available and can be done. It can be done well.

1:04:36Dr. Gabrielle Lyon:Seeing you in San Francisco, you gave a great lecture. And I have never seen a doctor, an MD, talk about moving iron, eating protein, and building muscle all in the same sentence with testosterone replacement therapy. please tell me what some of your thoughts are regarding what people are actually after i when i was in springfield illinois at the beginning part of my career i uh was lucky enough to meet uh a guy named chad and we've actually published uh some work together on anabolic steroids we've given some talks together and so you know i uh i consider myself a curious guy and when he came to me for help, I learned a lot more from him than I can help him.

1:05:29And then I really kind of dove into the literature. When I asked Chad, hey, you know, tell me about super physiologic T levels, like what dose are you using? And when I'm talking about super physiologic T levels, I'm referring to consistent testosterone levels greater than a thousand. So bodybuilders, you know, they'll go for T levels of three, 4 ,000, or they won't even check. They'll just, they'll just go super high and just give take more if it ain't working and i wanted to know what the motivations were uh as to why people would start i had some intuitive thoughts but i wanted to ask somebody who was an expert and then um i'm a huge fan of yours i'm also a huge fan of mike israel as well and the way um he communicates testosterone use and working out and getting fit i mean i'm a huge consumer right like i've changed how i worked out because i'm now 50 because i don't want to injure myself right so i've taken a lot of advice to heart and so i wanted to know okay what is the main motivation for a lot of people to to start you know super physiologic tea and the two main ones there are many but the two main ones are athletic performance and essentially looking good or vanity i'm gonna say now athletic performance uh i think chad summed up pretty well is that if you need help from testosterone to perform well in high school to be elite in high school you're not good enough if you need help in college to perform elite level uh with because of steroids you're simply not good enough because by the time you ascend to the pros like you likely get caught you won't be able to use it and you won't be good enough so you have to have this natural ability to become a professional athlete and you also have to probably be testosterone sensitive you have to be sensitive to a lot of the agents that uh people use to have the outcomes that you desire but if you're using these these drugs to be good at sports you're never going to be a pro that's that's the unfortunate reality not to mention the fact that you have to somehow

1:07:36Dr. Gabrielle Lyon:navigate and not get injured along the way which again a lot of people are amazing but then they blow out their knee or whatever and then their career is done the more interesting one and interesting one and the one that i think needs more attention is the to use these drugs for aesthetics and i get the appeal because you know when you work out naturally uh and you do great you probably gain about 10 pounds of muscle in a year if you're doing everything perfectly you know better than i do your book goes over this beautifully but if you add high doses of steroids to it. And this, and there's a lot of science behind this and there's a lot of data, you know, you can gain that 10 pounds of muscle in about a month.

1:08:16So it's just so much more efficient. And, you know, there's a huge appeal there and I'm not here to tell people don't do this or do this, but I want people to know the true risks and benefits. The thing is, if you're chasing an aesthetic with these types of drugs, you're much more likely to look worse than better. Why do I say that? Well, because just because you take high-dose testosterone, sipionate or enanthate, along with many other drugs, doesn't mean you're going to be shredded. It doesn't mean you're going to have 8 % body fat and look amazing with your shirt off. Most people, first of all, you have to be sensitive to the drugs and you have to have perfect training and perfect nutrition, which is really difficult for everybody to do.

1:08:59There's books about it. It can be done, but it takes discipline. And so that's a baseline requirement. And then you take these drugs, And then there's the potential negative consequences, like 50 % of people get significant acne. So you're never going to want to take your shirt off if you've got horrible acne everywhere, or if you're growing hair in places you don't want and you're balding. And so the vast majority of people who take these, like, appearance-enhancing drugs, they'll actually look worse, not better. Not to mention that a lot of humans have this fantasy that if they look a certain way, they're going to be more attractive.

1:09:36but when you ask people what they find attractive being hyper muscular or being super jacked is not at the top of the list for many individuals so if you're leaning in to use these type of agents to look better number one it may not work unless you have perfect training otherwise and number two there's a lot of downsides and risk we didn't even go into the kind of negative things like sudden death or heart problems, depression, suicidality. But to use that as a lever to get to a certain look, I think is a mistake based on my read of literature.

1:10:10Dr. Gabrielle Lyon:Well, I'm looking forward to having you back on the show, Dr. Tobias Kohler. It has been an absolute pleasure. You are a gift to the world of urology and just an amazing and really fun human. Thank you so much for coming on. Thank you so much for having you. It's a huge honor. What you do here is so important. We did a recent trial or study where we looked at health media consumption. Like 93 % of all kind of internet material related to fitness, health, was rated low quality. I'm using these methods, discern method that we use in this paper. I'm proud to say that you're one of the great ones.

1:10:53You're getting the right information out there and letting the public decide. what's best for them and you know promoting positive healthy lifestyle that ultimately is the most important lever we have to be happy and live a long time.

1:11:05Dr. Gabrielle Lyon:I really appreciate that and the reason that we are great is because we have great world-class guests so thank you so much for coming on. Appreciate it.