Penis Health, What Every Man Needs to Know - Dr. Amy Pearlman

24:02That's one thing that I've learned, one of many things that I've learned from Larry, which is if I say no to help this person, they're going to do it anyway, just under no supervision. Right? And so I welcome a lot of those guys into my clinic. And I say, well, how can we do this safely? And how can I continue monitoring you? Right? But so I don't have a cutoff. Now, if someone comes in and their levels are in the 700s or 800s, right, I'm going to look at their free testosterone. Because sometimes in those guys, their total testosterone is very normal. But maybe their SHBG is on the higher side of normal.

24:37And maybe their free testosterone is on the lower side of normal. So there are some patients there where I'm going to put on testosterone therapy. It's very context dependent. Let's say we take that same 40-year-old and he, let's say, is interested in having kids, right? He's interested in either current or future fertility. Well, Gabrielle, that's how I could hurt him because I can wipe out the sperm in his ejaculate in a very short period of time.

24:58Dr. Gabrielle Lyon:What is the percentage of, and they don't typically use, just to be clear, doctors are not utilizing testosterone replacement therapy or testosterone for birth control. Right. But it can, and the numbers are pretty profound, it can really reduce spermatogenesis. Yes. And, you know, especially with like these longer acting formulations like the injectables versus like the daily formulations. And they're doing a study right now actually at Baylor with Dr. Kira's group where they're looking at putting patients on oral testosterone, they're using chisotrex, and they're looking at sperm parameters to see if on these doses they're putting patients on, if it can preserve fertility in these patients, which would be huge.

25:41Because really in our AUA guidelines, the American Urological Association, you know, our guidelines say that if someone is interested in current or future fertility, we should not consider testosterone. But I'll tell you, this is a very gray zone, something also that I've learned from Larry Lipschultz, which is if someone is, let's say, interested in future fertility and he's 35 and he's really struggling and has low testosterone, why would I not treat him with testosterone, make him suffer potentially five, 10 years until he builds his family, until I treat him. There are ways that we can still help this guy, right?

26:11And your prior podcast guests have discussed this as well, cryopreservation, so freezing sperm, you know, we can put them on HCG at the same time as they're on testosterone therapy or potentially with oral testosterone, right? Where at certain doses, maybe we can preserve their fertility as well.

26:27Dr. Gabrielle Lyon:It is arguably the most interesting aspect of medicine from my perspective, is this, I don't want to say it's largely untapped, but getting into this area of antibiotic agents is where the future has to lie, especially with the use of GLP-1s. We have to be able to bring these to the forefront, which other groups or other populations have utilized. They're in wasting in HIV treatment. Physicians use antibiotic agents because it helps save lives. It saves their life. The idea of utilizing testosterone when someone's levels are quote normal, there's no difference in terms of cutoff, right? We'll say, okay, if your testosterone is 250 for a 21-year-old male versus an 80-year-old man.

27:19Well, and the other thing too is, and maybe it doesn't matter either. Maybe that's the thing, right? Because an 80-year-old with a level of 300 or let's say even like 400 might benefit just as well from testosterone as a man who's 50 who has a testosterone level of 400.

27:38Dr. Gabrielle Lyon:What are the risks of having low testosterone? So we know that low testosterone is a risk factor for heart disease, which is interesting because a lot of people are concerned about being on testosterone and that risk for causing things like heart attack and stroke. And I know your episode with Dr. Mo Kira really delved into this with a TRAVERS trial. And so this recent evidence is informing us that testosterone therapy does not increase risk for things for heart attacks and strokes. Now, it's important to keep the following consideration in mind is that the TRAVERS trial used topical formulations.

28:12If you were to ask me, Amy, what formulations of testosterone do you typically use in practice for your male patients? I rarely use topicals. The two most common formulations I use are oral testosterone and injectable testosterone. And I tend to dose people a little bit higher. So our AUA guidelines would, you know, would say, okay, get someone within, let's say 450 to 600 range. I routinely have patients that are higher than that range. In the TRAVERSE trial, the goal was getting people to like 350 to 700s in terms of testosterone. So can I say that the cardiovascular safety of testosterone with topical therapies has the same safety profile as, let's say, testosterone cipionate, where I'm getting levels at 1 ,000 or 1 ,200?

28:59I can't say that. I cannot. But what I can say is this. Testosterone injections have been around for about 50 years. Actually, they came out the same year, this is interesting, that the Sony Walkman came out. They've been around for a long time. So if they increase risk for heart attack and stroke, we would have seen it by now. And testosterone injections are the most commonly used formulation of testosterone therapy worldwide. So we would have seen it in your practice, in my practice, and in studies.

29:35Dr. Gabrielle Lyon:I like what you said about what is going to do harm to the patient in forming these decisions. What level of testosterone do we believe or does the literature show would be harmful? We don't know. We don't know. But we look at the downstream effects, right? And there is a Morgenthaler. He is just a wealth of knowledge that completely changed the landscape of how we think about testosterone. And he was on a panel at one of our society meetings, I would say about maybe four years ago. And the question for this panel was, is super physiologic dosing of testosterone dangerous? So he was saying that it's not.

30:18And there was another one of our colleagues that was saying that it is dangerous. The thing is, it's a data-free zone, right? There is a theoretical concern.

30:28Dr. Gabrielle Lyon:Mechanism by which people would be concerned, is it hemoglobin hematogrid? Right. So that's what I'm looking at, right? And so if we look at the downstream effects of raising someone's testosterone, it's going to be their hematocrit. So because we can increase the thickness of their blood, it's going to be estrogen. It potentially could worsen sleep apnea. So that's why I'm screening all these patients for sleep apnea. And then I took their lipid panels because in some circumstances, it might raise LDL and lower HDL. So I'm tracking all the potential downstream effects. So I don't really worry about the testosterone level in and of itself.

31:05Dr. Gabrielle Lyon:It is an important point and it really is nuanced. In one hand, I'm thinking about your young 25-year-old patient that are coming in and maybe they have been misguided. Maybe they have utilized anabolic steroids. And I use the word anabolic steroids very specifically here, as opposed to oftentimes I'll refer to anabolic agents. It is a different environment when someone is using a medication for performance enhancement outside of the oversight, say, as a physician. And then, of course, there are some agents that are illegal. but in the gym bro landscape i don't know how else to say it there is a potential for abuse and in any sport right there is a potential for steroid abuse maybe part of that comes from we don't have a lot of good studies or data would that be fair to say for example some of the other black market anabolic agents that people are using to build muscle again when they're young which can then affect their fertility.

32:16Dr. Gabrielle Lyon:And where I'm going with this is that that, in my mind, is the same conversation as saturated fat got a terrible reputation. Saturated fat, do you know where that reputation came from, Amy? No. Okay. Let me tell you. Tell me a story. Saturated fat got that reputation during war times when they were hydrogenating whale blubber so that people had enough calories to not starve to death. Hydrogenated whale blubber was not intended to be used, for example, for 30 years. It was a short-term fix for an immediate problem, starvation, which then changed the entire way the medical community thought about saturated fat, the layperson thought about saturated fat, how our guidelines are at 10 % saturated fat.

33:13Dr. Gabrielle Lyon:Hydrogenate whale blubber is different than, say, saturated fat that you might find in red meat. Similarly, that anabolic steroids that are not available for off-label use or FDA-approved use that an individual may take to build muscle or enhance performance is different. You know, maybe it's used in horses or animals, is different than FDA-approved amibolic agents, testosterone that are studied in humans and that are utilized for specific conditions. Yeah. And girl, that was a long story to get to the point. But like you said, context is everything. As we have these young guys going out or young ladies going out and using these anabolic agents that perhaps are not even used in the US, and then that affecting fertility and are laced with other types of use gets translated over to a testosterone of 1200 is dangerous.

34:19Dr. Gabrielle Lyon:What I'm understanding from you is that these things are not the same. They're the same and they're very different. You know, a lot of the bodybuilders will use the same medications that I use in clinical practice and that you use in clinical practice, right? They'll use HCG. They'll use Clomid. They'll use enclomiphene. They'll use testosterone cypionate. The doses are oftentimes different, right? Bodybuilders might use up to 10 times the doses that I would ever use in clinical practice. And because they're driving up the testosterone level so high, they oftentimes need estrogen blockers and HCG, you know, to cycle on and off with.

34:54But they're also stacking them with a lot of other things.

34:56Dr. Gabrielle Lyon:They are stacking them potentially with other things. Yeah. And anabolic agents, sex, testosterone has gotten a really bad rap. Yeah. Because of the misinformation of, and it's not even misinformation, it's the assumption that that's what we're only talking about. Right. Things like HCG, things like enclomaphane, things like testosterone. when there are other agents that, you know, I've had patients come to me that had been taking ecopoise. I mean, these are not available for human use or various agents like that. And that, in my mind, we don't know what the effect on cardiovascular health is.

35:39Dr. Gabrielle Lyon:But that is not the same as a testosterone level that is, again, from my perspective. So I don't freak out when I see a level of 1 ,200, right? I sit down with a person and I say, how are you feeling? Right? I mean, I'll have guys that come in, let's say I put them on a starting regimen of, let's say, 100 milligrams of testosterone a week. And I'll see them back with labs. And let's say their testosterone level is 700, right? And they feel better, but they say, but I wonder if I can feel better, better, right? I would guess that a lot of people would say, your level is in the target range. That's awesome.

36:16But again, I go back and I ask myself, but maybe this person would feel better at a little bit of a higher level. And again, what's the worst thing that could happen, right? But I'm looking at his estrogen. I'm looking at his hematocrit. I'm tracking his symptoms. And oftentimes I'll offer to go up on the dose. And oftentimes those patients will feel better at slightly higher doses and I'm not hurting him, right?

36:36Dr. Gabrielle Lyon:And that's a really important point for, I think, physicians to hear and also people. How do we know how high to go? Yeah. Typically, the maximum dose that I would use total in a week would be 200 milligrams for testosterone cypionate. Now, when I put people on the oral medications like Kaisotrex, we know from the studies that about 75 % of men will end up on the highest or second highest dose anyway once you titrate them. So I oftentimes actually start those guys on the highest dose just from the get-go, you know? But I've gotten levels up to, let's say, even on the oral testosterone agents, sometimes up to 1 ,800.

37:15But again, context matters. I know their levels are not always at 1 ,800, right? Their levels peak three to five hours after they take oral testosterone. So the other times of the day, it's lower than that, you know? And that's why they tend to have actually fewer side effects with the oral agents. But I just don't get scared of the numbers. But part of that is just listening to conversations with a Morgenthaler. and in some of the podcasts that I've done, I like to, I bring experts on where I'm like, okay, I know you were on the guidelines. I know what the data tells us and what the guidelines say, but take me, take me into your clinic.

37:50What are you doing? What do you worry about, right? That's where I've learned the most is when I just sit down with the experts and I'm like, what are you worried about? What's the worst thing that could happen? That was actually a conversation I recently had with Larry Lipschultz on peptides, right? And I said, because for many years, I was telling people, you know, no, I don't like, I'm not going to do peptides. I don't know where to like source them. There's no evidence to support their use. I don't think it would be helpful. Just take your testosterone. And I sat down with Larry and I said, Larry, how long have you been prescribing peptides for?

38:22And he said, three to five years. And I said, so you have at least hundreds of patients on peptides. Is that right? He said, yeah. I said, what's the worst thing that you've seen? He said, some injection site reactions. I said, that's the worst thing that you've seen. And I Think about all these medications that we put people on that are FDA approved, used on label. And I would argue that testosterone therapy, when prescribed at clinically appropriate doses, is one of the safest medications we can put people on. One of the safest. You've asked before, what are different medication interactions with other medications?

38:56I can't think of a single medication that interacts with testosterone where I couldn't put them on it. Isn't that crazy? There are very few other medications we can say that for.

39:07Dr. Gabrielle Lyon:And it is even crazier how misinformed people are. If a 25-year-old had been abusing anabolics, is there hope for recovery? Yes, there is hope for recovery. And here's the problem. Here's where we have kind of a data-free zone, is a lot of those young men that may have been abusing anabolics never had their baselines checked. So we don't know what we're trying to recover them to. So when I was doing these educational sessions with the fraternity guys, and so I'm watching these men who were like six feet, eight inches playing basketball, like sweating because I'm thinking, oh my God, I'm going to be educating these guys in a few moments.

39:53And so we went into their film room, a beautiful room. There were 15 dudes, you know, sitting in the room. And it was fabulous. Like they wanted to know this information too, right? But here's the message here, is we have to engage these young men. We can't poo-poo them, right? I understand they want to gain muscle. That's fabulous. I want everyone to gain muscle. How do we do it safely? We check their baseline, right? We don't say you don't have a place in our healthcare system. We say, Bill, come on in and have a seat. I know you're going to do this regardless. How can we do it safely, right?

40:25So let's talk about how we do it safely. We check their baseline hormones, right? We check their testosterone, we check their estrogen, their hematocrit, and we check their sperm health. That is a big key, right? Because if someone is coming in, let's say they've been on testosterone therapy and let's say they were doing it outside of the healthcare system, now they want to have a child.

40:45Dr. Gabrielle Lyon:Do you think they do it outside of the healthcare system? because if someone goes to their doctor and says, I'm 25. And, you know, as I think about this, I have had patients that are very young and they're like, I feel terrible. Their testosterone is low. And it was very early on in my practice. I didn't feel comfortable treating them. And they had been to endocrinology. Yeah. And the endocrinologist, I mean, this one patient, he had a testosterone of 180. Oh, my gosh. He was in his mid-20s. Yeah. And the endocrinologist was afraid to treat him with testosterone. So these guys, obviously, because the system is broken and because we're just not educated routinely in men's health, like you pointed out, where do they go?

41:32Dr. Gabrielle Lyon:They go to the gym or their friends or online now. Yeah. And here's the thing. We oftentimes talk about the implications of treating someone and the potential side effects. We don't talk about the implications of not treating someone. That's what I worry about for that guy in his 20s. The implications of leaving him as a 25-year-old at 180 for potentially, what, one or two decades of his life, bone density, the way that he feels when he wakes up and goes about his day, his sleep, his bone health, muscle health, all of those factors. That's what I worry about, right? So the issue is we have not been taught how to help men in their 20s and 30s.

42:17We poo-poo them. They come in, they say, I'm concerned that my orgasm isn't as pleasurable as it used to be. I'm concerned my ejaculatory fluid looks a little different. I want to know how often I should be having sex. Is porn bad, right? What do you think about marijuana and sexual function? I mean, it's easy to say no, no, no, no, no, no to all of those things, right? It's easy to say, oh, you're 20 years old and you have ED. Well, go see a sex therapist. We have not helped that person. And so why would that person come back until he has like a huge issue decades later? So that's a big issue.

42:56I see a lot of guys that come in with very normal questions. So one would be, I'm concerned about my penile size. I ejaculate too quickly. I wanna last longer, but they may not meet those standard definitions of premature ejaculation, which would be like within one or two minutes of penovaginal intercourse. But what if someone lasts 10 minutes and they want to last 15 minutes? We can still hop that guy, right? But if he doesn't need that classic definition, then he's going to be told, well, you're in the normal range, right? You know, how often should I be ejaculating? Most providers don't know how to answer those questions.

43:33And then our young men lose faith in the healthcare system. And that's a huge problem, right? But baseline testing is really key. So when I was doing these fraternity sessions, I would have people raise their hand and say, Dr. Perlman, I'm injecting 300 milligrams once a week of testosterone cypionate. Can I still get someone pregnant? Yeah, you can actually, because it doesn't work as a contraceptive for everyone.

43:55Dr. Gabrielle Lyon:What percentage does it decrease sperm production? Isn't it typically at least 90 %? That's a good question. But the problem is we don't test a lot of these people at baseline. And by the way, the dose doesn't necessarily matter. It's the effect, right? Yeah, yeah. Just to be clear, if someone is taking 100 milligrams of testosterone versus 300 milligrams, is it true that the 300 milligrams isn't going to necessarily suppress it more than the 100? Everyone responds differently. You know, same thing with testosterone levels. There are some guys where I have them on 0.3, you know, milliliters of testosterone a week and their levels get very high, you know, versus others that are in 200 milligrams a week.

44:37And I've learned over the years, people don't look a certain part that you would think bigger guys need more levels of testosterone. And that's not always the case, you know? So I think making semen analysis testing accessible to young men is really important. And that was one of my messages to these young men is, okay, I know you're going to do whatever you're going to do, but if you are, think somewhat in your mind that you might be interested in fertility at some point in your future, get a semen analysis. Thanks, some sperm, you know. And now they have more at-home testing technologies, which I think of as kind of like under this wearable technology heading, is where people can do things in the comfort of their homes that give them data.

45:22Now, when it comes to at-home semen analysis testing, it depends on what question you're looking to answer, because not all kits are created equal. One, you could answer, there's this really cool technology called Yo, and you produce a sample at home and you put the sample on a slide and you look at it under like a microscope. That's what I would encourage young men to do.

45:41Dr. Gabrielle Lyon:If somebody is listening to this, because we're going to, I'm totally going to try this. If we think about the nutritional implications of sperm. So how long does sperm live? So it takes like three months for sperm to mature. Someone could take a yo test at baseline before they start a diet and exercise program to say that that's their intervention of choice. And three months later, potentially, I don't know how good these slides are, they should see some kind of difference. Yes. And I encourage people to be an N of 1. They can be their own experiment, right? What about the young guy that's using a lot of marijuana?

46:19Yeah.

46:21Dr. Gabrielle Lyon:that doesn't want to believe, I'm thinking of one patient in particular, doesn't want to believe that the alcohol and marijuana are affecting his sperm count or sperm health. So what I would say to him is be your own experiment and not in a way that's like patriarchal, but just be your own experiment. You know, I've had the, you know, men in fraternities ask me, uh, Hey, Amy, what's the impact of marijuana on sexual function? Hey, that's a great question. The research would suggest that marijuana in general is not helpful for testosterone, erectile function, or fertility, but some men get benefit, right?

46:59And so, yeah, maybe the research shows that in general it's not good, but maybe for gym it is. And that's important to know, right? So I love this space of at-home, real-time technologies. Now, the important thing to keep in mind when it comes of semen analysis testing is semen analyses are also a very crude measurement of fertility, right? And they can change drastically from one day to the next. So I don't look at one analysis and say, this is your health. We get a couple of them and we trend it, right? So these at-home technologies, what I will say is this, is they are good for screening. They are good for accessibility.

47:44They are very cost effective. But if I need to answer a clinical question, and if someone is like actively going through fertility or they want to freeze as much sperm as possible for the future, I'm not going to be using an at-home kit. I'm going to send them to a facility so that they can get this, you know, the semen analysis. They can look at it under the microscope in real time and really give me all of those parameters. So I think the at-home technology is really good as a screening tool. If it's going to change my clinical management, if someone is like on testosterone, is not actively looking to have a child, but wants to know, hey, what is the impact of my testosterone regimen in terms of my swimmers?

48:21Do an at-home test. And you can get a general idea of what's happening, right? Do you see any sperm? Is there any sperm available, right? And I think that those are good. It's all about data points, right? You can't trend what you don't measure. People love data, especially men. Men love data. this is a way I think to engage them earlier on. So the other aspect that you've also mentioned on some of your podcasts, you've asked about the role of ultrasound in looking at penile blood flow. And I don't know if that question has been answered yet the way that you want it answered, because you're looking for a way to objectively assess penile tissue health.

48:57Is that where you're getting with that, right? Much like an echo, right?

49:03Dr. Gabrielle Lyon:How, why is it that we can look under ultrasound, the quality of our thyroid, the functionality of our heart. How can we use these tools to also not discriminate against our sexual function or our, you know, sexual parts? Yeah. Doppler ultrasound is a very commonly performed ultrasound of the penis, but it has its limitations. And so like in my clinic, I don't even do penile Doppler ultrasound because it doesn't change my management. It's not wrong. It's in the guidelines. A lot of my colleagues will use penile ultrasound. But here's the thing. When you put an ultrasound probe on the penile vessels, you get a baseline, you know, velocity of the blood flow, right?

49:46But that's not the test. The test is you inject a very powerful medication into the penis, usually something like Trimix, and you see how the body responds.

49:58Dr. Gabrielle Lyon:What is that? Trimex. So it's a combination of medications that increase blood flow to the penis. So it's papavirin, alprosadil, and fentolamine. It is very powerful. It's the most powerful medication we have to induce erections. So what does that tell me? It tells me how a person responds when I inject a very powerful medication into their penis. But if that person doesn't normally inject that very powerful medication into their penis, it's not replicating their erections when they're at home. And the chairman of urology, when I was at the University of Pennsylvania training for residency, Alan Wein, he was talking about testing, right?

50:36And specifically he was talking about urodynamic testing, which is a test that we can do to assess bladder function. But he said, look, if we get a test and it doesn't replicate the patient's symptoms at home, it's a worthless test.

50:49Dr. Gabrielle Lyon:Does anyone support erectile dysfunction or erection challenges? you think about testosterone, you think about Tadalafil or a vasodilator, does someone also utilize these injections? Yes. So this is a medication they would also inject themselves at home, right? But if I'm talking to a patient and he says he has some erectile function issues, and let's say I give him a script for Tadalafil or Cialis, and he takes it and he says that he now gets great erections, he's telling me without me even having to do an ultrasound that his body is responding normally. If I give someone a prescription for Trimix and he says he gets rock hard erections, he's telling me his body responds normally.

51:29So in my practice, I don't really see that test in the office as giving me great information. Although some people like to see the data and they like to see the number. So I get it. If we were to image the genitalia,

51:43Dr. Gabrielle Lyon:what is it that we would be looking for? In my mind, it would be blood flow. Are there other structural components that we would just, again, as in any organ system that we would be looking for. So an ultrasound would also be commonly used for guys who are coming in with Peyronie's, which is scar tissue in the penis, kind of like a lump bumper curve. Again, I have a urology, you know, obviously a fellowship training position here. People ask a lot about Peyronie's, but they don't ask about it directly. What is Peyronie's? How does someone know that they have it? What does it look like? So oftentimes people with Peyronie's will come in and they'll say they woke up one day and their penis looks different.

52:22There's a curve in the penis. It's not as long as it used to be. But also what I find is guys who, let's say, they don't have any issues when they have an erection, like their penis is still straight, but you can feel scar on exam.

52:36Dr. Gabrielle Lyon:And does this come from having sex with a not fully erect penis? Is it because potentially there are vascular issues? I mean, what is the, how does someone get peronies? Yeah. So if someone is having sex with a partially erect penis, it's going to put them at higher risk of a flexion injury, right? But think about what the penis goes through over its lifetime. It's an unboxing ring. Even though we don't think about sex as being traumatic for a lot of people, it essentially can undergo these micro-traumatic events. And if you think about if you like cut your arm or someone cuts their arm, everyone heals differently.

53:19Some people you would never have known that they hurt themselves because you can't even see their scar. And other people develop keloids where it's a very obvious scar on their arm. It's the same thing that happens with the penis. Some people can have a micro-traumatic or traumatic event of the penis, and he'll totally fine from it. And others won't. The problem is, as healthcare providers, we expect that our patients will bring up concerns of theirs that are relevant. And oftentimes our patients will expect that we are going to bring up the relevant concerns. And what happens? Nobody brings up the concern.

53:56Or it's interesting, same thing in the testosterone, the erectile function space. You know, the reality is a lot of people think that urologists love talking about all the topics that we've discussed so far. Gabrielle, the minority of urologists care about this conversation.

54:10Dr. Gabrielle Lyon:There are not that many female urologists, period. Yeah, yeah. That makes sense. And then there are not that many female urologists trained in sexual Yeah. And I'll tell you, the reason why I think a lot of urologists don't care about testosterone is because we will never operate on someone who has low testosterone to treat that. There's no surgical intervention for low testosterone. And as urologists, we are trained as surgeons. For those individuals who are not in healthcare, there are two types of doctors. Yeah. To be fair. Yeah. Maybe there are three. There are surgeons and then there's everybody else.

54:50Dr. Gabrielle Lyon:A urologist is a surgeon. Right. And I think that that is an important distinction. and surgeons, they operate. And so when we're in training for five to six years, do you think we want to be in clinic talking to patients? No. And the times that we are in clinic, oftentimes like in my training, I had a very good training, but most of the clinics I was in were cancer clinics where we were talking to patients about bladder cancer, prostate cancer, and kidney cancer. It was rare that I was in a clinic where we spoke to guys about testosterone. And I think it's similar in the menopause space, which is a guy comes in, he's middle-aged, or a woman comes in and she's middle-aged, and she's complaining about all these vague symptoms, feeling fatigued, can't lose weight, sleep is poor, can't build muscle.

55:46It's like the tale of the middle-aged male or the tale of the middle-aged person. And as a surgeon, that's a lot of complaining. We just want to look at an image, see that there's a problem, and fix it. So I think by default, it's a very uninteresting thing for us. In fact, I hate it when patients came in with low T symptoms. And part because I thought I was going to kill them with testosterone. And even though our testosterone guidelines from the AUA are very good, they're also a bit overwhelming. Because when you look at the charts of all the different ways that we can treat someone who has low testosterone, it's like two pages of all the different formulations.

56:27And even within those formulations, there are huge dosing ranges where you could do 50 to 200 milligrams once to, you know, every two weeks, you know, once a week to every two weeks. And so you look at it and you say, so where do I begin? And then you don't even want to start because you don't know if you start low, do you start medium, do you start high? You know, which formulation do you choose even within the gel population, right? And so it becomes a little overwhelming. And it wasn't until I was at the University of Iowa and was directing the men's health program, this was my first year on faculty, and I realized that people were coming to me expecting that I was the expert and I wasn't the expert.

57:17And I realized I need to become the expert that they expect me to be. And so I went where they tell us not to go. Where do you think I went for information?

57:25Dr. Gabrielle Lyon:I could come up with quite a few places, but the internet? Yeah. I went to Facebook and I joined a closed testosterone replacement therapy support group. And I read posts from men and women all over the world telling me, not me personally, but sharing their experiences, their protocols, what worked and what didn't. And I learned that a lot of people that were on topicals felt better on injectables. I was like, great. I just learned probably what would have taken me 10 to 20 years of clinical practice to learn just by reading Facebook. But the thing was, I didn't see enough patients that were coming in for low testosterone in those clinics.

58:08Dr. Gabrielle Lyon:You know, it's not what people are thinking about. Yeah. Well, and I didn't see the follow-ups, right? So in training, we see patients at one static point in time. We happen to be in a clinic. We see them. It could be they're coming in initially with these concerns. But it's rare that we are actually going to be in clinic the next time that they're seeing us in clinic three months later. We're in someone else's clinic or we're in the operating room. So we never know if we help that person. So for the first time, really, when I was on faculty and I was seeing my own patients back in clinic, did I see the impact that testosterone could have?

58:47So I went from hating to see these patients coming in with low T concerns to looking at my schedule at the beginning of the day, seeing that I had three to five low T follow-ups and saying, thank God, because what other medication can you think of and all the medications that you've prescribed where we can improve the pep in their step, their energy, potentially their sleep, their ability to gain muscle, their ability to potentially lose weight, their depressive and anxiety symptoms, their erectile function, their libido. I mean, on a good testosterone replacement therapy program, you can improve all of those symptoms.

59:28Dr. Gabrielle Lyon:Thank you to Timeline for sponsoring this episode. Time isn't just about how long you live. It is about the quality of those years. It's having the energy you need to move through your day without fatigue. The strength to pick up your kids, your grandkids, who knows, someone else's kids. And the clarity to show up as your best self. Now, that kind of strength does go deeper than muscle. It starts with your mitochondria, the energy-producing engines inside your cells. We've learned about mitochondria, I don't know, in our fifth grade science class. And here's the reality. As we age, those mitochondria decline.

1:00:04Dr. Gabrielle Lyon:In fact, it's one of the key hallmarks of aging, and it directly impacts strength, recovery, and overall how we feel. One of the ways your body protects itself is through mitophagy, which helps clear out damaged mitochondria and replace them with healthier ones. And you're thinking, okay, so why is she talking about this? Well, I use Timeline powered by Mitopure because it contains urolithin A, which is a molecule backed by over 18 years of research and multiple human trials. It works at the cellular level to support mitochondrial renewal. It's not a quick fix or a stimulant. It does support your body from the inside out over time.

1:00:44Dr. Gabrielle Lyon:And if you've been considering trying it, it's a great time. Timeline has just lowered their price and you can get an additional 20 % off your first month when you go to timeline.com slash lion and use the code lion, lower price, same science, bigger biceps. Hey, living longer doesn't mean living less vital. when um we think about this younger generation because we really haven't talked about that you're the first urologist and again the joke is i have the number one men's health podcast what do they need to do and what do they need to think about before they or let's just phrase it this way have a healthy sexual function is it even sexual function because what you're really talking about is overall health.

1:01:34We're talking about overall cardiovascular and metabolic health. And as a byproduct, their sexual health will get better. So what do these guys need to know? In addition to just their normal structure and function, right? They need to know what they need to eat. And oftentimes we just tell people eat healthy. That's not good enough. They need examples. You know, they need examples of what are good protein sources? How much protein should I eat, right? I mean, a lot of these guys that are in their college years, they're going to the gym. They're super curious about what foods to eat. They want to do a good job.

1:02:09We need to tell them the details. Eating healthy is not good enough, right? They want to know what supplements should I take.

1:02:16Dr. Gabrielle Lyon:Talk to me about supplements because you have very specific supplements for sexual supplements. Yeah. My conversations used to be shorter because I would say I don't recommend supplements because they're unregulated. That's not really a good response, right? And there's actually a ton of research on supplements, right? So I was doing a little research on you. Obviously, I've known about you for quite some time, but there are certain supplements that help with NO2 biorealability and vasodilation. Yeah. So nitric oxide supplements can be helpful, but I use them selectively. And that's in part because most of the time, if someone comes in and wants to increase blood flow to their penis, regardless of whether or not they have erectile dysfunction issues.

1:02:55Honestly, I will offer Tadalafil to pretty much anyone that walks into my clinic. Now, I try to get people off medications, right? I'm very, I'm not anti-medicine, but I want them to take the fewest number of pills to reach the goals that they're looking for, right? And medications like Tadalafil, the way that they work is they don't give someone nitric oxide. But when someone is aroused and they release nitric oxide, the problem is their body breaks down the nitric oxide that they release. So the way that Cialis and Viagra work is they prevent your body from breaking down the nitric oxide that you've released.

1:03:28So for my patients who, let's say, tell me, well, I want to take something natural. I don't want to take a pharmaceutical. What I like about something like Cialis is it is regulated. I know what they're getting, right? But nitric oxide can play a role in guys who, let's say, they're on Cialis and they're not quite getting the benefit that they want. If I add a nitric oxide supplement, research would suggest that they will get better benefit than if they take either Cialis or the nitric oxide supplement alone.

1:03:57Dr. Gabrielle Lyon:Is that from a hardness of erection or length of time of an erection? Oh, good question. So I think, and honestly, I think I found one study looking at a combination. So it's not, you would think there would be more studies on this, but it was like one study that looked at the combination effect. And I think that they looked at a questionnaire like IIEF, which doesn't really, it more so acts, you know, asks about like satisfaction. It's very subjective measurements, you know, of erectile function. And I would say in my patient population, I see a similar, you know, result. But if someone is looking to improve their erections, I'm typically putting them on Cialis versus starting them a nitric oxide supplement because it's a lower pill load, right?

1:04:40The nitric oxide supplements, it typically requires more pills to take in a day.

1:04:43Dr. Gabrielle Lyon:One side of this is making nitric oxide, which is vasodilator, which is a vasodilator. The other is maintaining nitric oxide all for the vasodilation for increased blood flow. Two separate. We have a very low threshold as well in our clinic, Strong Medical, putting men and women on CELUS. Not for sex. I mean, again, it's not for, quote, sexual health, but it is for vascular health. Yes. You also do a number of other things in your clinic, which makes you a very popular person. Because behind you in a hot pink bag, you have a variety of instruments. Yeah. Which it's no, again, we are making light of it, but not really.

1:05:26Dr. Gabrielle Lyon:I mean, these are serious conditions or medical experiences for people. But you do have a bag of, I'm shocked that you didn't get stopped by TSA, of an assortment of tools to help with erection. Like to take a step back. And I talk about genital health. Even if someone, let's say, is not sexually active and has no interest in being sexually active, we talk about their penis and let's say their clitoris too as just another part of their body. And that's where I can open up this discussion. if I have someone in my office and let's say a parent's in the room or a spouse is in the room or a child or a friend, when we talk about the health of a body part, it kind of takes some of that stigma out of it, right?

1:06:08We just talk about blood flow to another part of your body. So you had mentioned pretty liberal use of Cialis in your patient population. It's my favorite medication, right? I mean, I have two medications that I love. One is a daily Cialis and two is testosterone for people that I think would benefit from it. I take Cialis every day as a pre-workout. I learned this from my patients.

1:06:28Dr. Gabrielle Lyon:Do you take it as a pre-workout or do you just take it at the beginning of the day as a pre-workout as it helps the workouts or the half-life is short? Yeah. Great question. And I don't know the answer to that, right? I take it about 30 minutes to an hour before I hit the gym. Do I notice any changes in my workout on the medication? I will tell you no. When I go to the I typically stop in the sauna first for a couple of minutes, but the sauna is a new thing that I've been doing. So I noticed when I do the sauna and I take the Cialis, my veins really dilate. I don't know if that impacts my workouts at all, but I don't have any side effects from the medication.

1:07:05Dr. Gabrielle Lyon:I trained in nutritional sciences. And one of the things that we see with aging is splenic extraction, is blood flow decreases. The idea that, and it'd be interesting to see, the idea that someone would quote, preheat the body to increase blood flow prior to training for nutrient delivery would be a great thing to look at because it's so easy. Back to the vasodilation, the Cielos component, because of your bag of tricks behind you, I know that you're going. Yeah. And we'll get into that. Don't worry. In a very specific way. Some of the off-label uses of some of the medications that I routinely prescribe.

1:07:43And I had these guys that were, you know, working out at the gym a lot and they said, I like it as a pre-workout. So now, and this is completely off label, but even in guys who come in, you know, who say, yeah, I don't have any erectile dysfunction issues. I'll say, look, I like a daily Cialis for the following four reasons. My goal is if you don't want to take it, totally get it. Not a problem. Let me know if you're interested in the future. But one is it just makes erections easier, right? Two is I've had a lot of my male patients say they like it as a pre-workout. And I don't know if the impacts in men are different than in women, but I tend to find that my male patients really feel the impact as a pre-workout, where then they don't have to go to some random store to get some random pre-workout.

1:08:22They can just take the Cialis. Andrew Huberman did a wonderful podcast on hair restoration maybe a couple years ago, and I watched it. He kind of went through all these potential therapies and the potential role of Cialis as part of a hair restoration program, and my patients love hearing that. Now, do I tell them it's going to grow your hair back? No. But I tell them, look, it might increase blood flow to your scalp and could be part of a restoration program. And four, a lot of these guys that we're seeing are hitting their 40s and 50s. What I mentioned was prostate puberty. So it can help relax the tissue and the prostate surrounds the urethra.

1:08:59So I will tell you, I have a lot of patients that don't have any problems, right? And in our clinics, we're used to treating problems, Like what diagnosis code do you have so I can put this in as an ICD-10 code? And I've had so many patients over the years say, okay, yeah, I don't have any problems. Yeah, let me try the medication, throw it in. Let's see what it does. And they come back and they say, Amy, I love it. And I don't know exactly why they love it because I'm not treating a pathology. And a lot of these guys too are poo-pooed out of clinics because, you know, they'll say, doc, my erections are quite what they used to be, right?

1:09:33will say, oh, are they sufficient for intercourse?

1:09:35Dr. Gabrielle Lyon:You know, you were listing out that these young college kids don't have answers for normal function and normal questions. Yeah. What is a normal erection? So everyone's normal is different. And that's why I take it very seriously when someone says my erections aren't quite what they used to be. But a common response from a health care provider is, you're 60 years old. You're not 19 anymore. But what if we could get him back to when he was 19 and had really hard erections? Why is that such a bad thing? You know, I think getting guys really rigid erections is a preventative strategy for trauma to the penis.

1:10:11I don't think we have to wait for a decline before we treat someone.

1:10:15Dr. Gabrielle Lyon:Will everybody get some form of Peyronie's or is it really based on repetitive use without a heart erection? Oh, good question. Not everyone will get Peyronie's. We don't know what the true prevalence is because who's asking? And if patients don't come into the healthcare system or they don't feel comfortable bringing it up, they don't know. So the prevalence ranges are so variable depending on what studies you look at. It's a problem if it's a problem. So for guys to be born with some degree of curvature is very normal. Just like, you know, women, we're born and sometimes we have breast asymmetry, right?

1:10:54The body is definitely not perfect. Peronies is a problem if it causes pain, if it changes the shape of the penis where it becomes difficult to have intercourse. But even in those circumstances where it doesn't cause issues, I still think it's important to optimize erectile function to mitigate issues in the future, minimize trauma. We cannot just limit the discussion to safe sex, condoms, and STIs because men and women need to know that you need to have safe sex, And I don't just mean condoms there. It means you kind of have to be careful with your genitals. It means if you're a woman and you're on top, you can't just like go to town.

1:11:34You have to be careful. There are so many times men come in and they're like, oh my God, there was some position we were doing and I hurt myself. And sometimes all it takes is one scenario. And it's important that men and women who are young know that. So they know that they need to be careful with some positioning.

1:11:51Dr. Gabrielle Lyon:I never thought of that. Okay. Because some of the most devastated patients I've ever seen in my life are men who develop Peyronie's because they were never taught that this could happen to them. That's important because if people are somewhat reckless with their sexual behaviors, and again, you're not saying safe sex versus not safe sex. You mean physically safe sex because that is not the same for a woman, right? she doesn't get some form of peronies? Not in that sense, right? But she could definitely have pain. But it might not create a lasting deformity. Correct. Young guys need to know about that.

1:12:34And importantly, that there's something to do about it. Because a lot of these distressed guys that come into clinic think that there are no solutions and we can actually fix the problem.

1:12:43Dr. Gabrielle Lyon:What else do young guys need to know about their sexual health? Yeah. So they need to know the impact of lifestyle behaviors, right? And we've kind of discussed this and thinking of themselves as their own experiment. I think that's where I'm going to go in my bag of tricks. And she wasn't lying. I do have a hot pink bag. Please tell me to not travel on TSA with a hot pink bag. Oh, of course I did. Of course I did. You know, when I go to a lot of these conferences, I usually bring these products and it's so funny. I just wonder what they're seeing when they're looking on the other side of the screen.

1:13:16Actually, I went to, I was giving a presentation in Dubai a couple of years ago. And thank goodness I wasn't presenting on sexual wellness products because I would have brought these products with me and I would have been detained. Okay. I want to talk about one of my favorite analogies. Well, one was the pen analogy. The other is a sponge analogy.

1:13:32Dr. Gabrielle Lyon:And for people who are just listening, she's holding up two sponges. Yeah. Look at these two sponges. Tell me what you see in terms of differences. Do they look similar or different? They look different. They look similarly different. Okay. What do you think? What's different about them? One, so both for you guys who are just listening to this, they both have a abrasive surface on the top. One looks like the soft spongy part is a little more fluffy. Yeah. And the other one looks like it's a little, you know, you've used it, maybe you cooked eggs and then you used it and now it's all beat up. Yeah.

1:14:06So this one looks like a healthier sponge, right? The penis is a sponge. This is exactly what the penile tissue is. This surface right here that you would like scrub to get grime off of a dish, this is the tunica albigenia. This is the tissue that surrounds the erectile tissue. This is a tissue here that engorges with blood that becomes erect during an erection. And these two sponges are different. This is a sponge that I would put under the faucet and use daily to do dishes. It's a pretty healthy looking sponge. This is a sponge that I would put under the faucet, do dishes, and then say, I'm not going to do dishes for six months.

1:14:47This is an unhealthier sponge. Now, if I put this sponge under the faucet six months later, it will expand, but not like it did six months before. So when we talk about medications like daily Cialis, even in someone who's not sexually active, for example, it's like putting the sponge under the faucet every day to preserve the penile tissue health. Because what do I see so often in terms of my male patients coming in who have erectile dysfunction? They've lost size. They've lost length and girth. So you ask, what else do these 20-year-olds need to know? They need to know they need to keep their tissue healthy.

1:15:22They need to know that daily erections are really important for tissue health, even outside of sexual health. And they need to know how to maintain those daily erections. Somebody to have healthy penile tissue should get erections daily.

1:15:37Dr. Gabrielle Lyon:Yes? How many times a day? Yeah. So that's a good question. And also a difficult question to answer, right? Research would suggest that a normal number of, let's say, nighttime or nocturnal erections is three to five. The problem is, who's counting? Who's counting, right? If you ask your male patient, do you get nighttime erections? He has no idea unless he's waking up with an erection, right? You could ask him, do you get morning? Would you get morning erections? Well, maybe he's not waking up with an erection, but maybe he had three erections during the nighttime. We don't know. And men don't know.

1:16:13And that's where I want to talk about the next thing out of my goodie bag, right? And you like wearable devices and personalized medicine. And so this is essentially a Fitbit for the penis, okay? Now, full disclosure, I am on the medical advisory board for this company. The company is called Firmtech. Because as we discussed before, people love data, especially our male patients. Right now, the diagnostic tools to assess erectile function. So we look at the questionnaires. I don't use questionnaires.

1:16:38Dr. Gabrielle Lyon:I mean, questionnaires are terrible for any aspect. In the nutrition space, it's terrible. Like when I go to the doctor's office and they make me fill out a questionnaire, I get so freaking annoyed, even if it's only five questions. Why? Because there's no space for comments. Because I don't fit within a pretty little box of a check mark. because I want to do 4.5 and I don't want to have to choose between four or five. They're annoying. And I feel bad because over the years I've given my patients so many questions. And then we have the Doppler exam, right? But that necessitates an injection into the penis.

1:17:10And then we have the RIDGIS scan, which has been considered the gold standard. The what is it? RIDGIS scan.

1:17:15Dr. Gabrielle Lyon:RIDGIS scan. So you put these rings on the penis and it's a machine and they go home with the machine and it measures nocturnal erections. The problem is that machine is not readily available. So most people don't have access to it. So let me give you kind of a lay of the land in terms of this device. It has a pressure sensor and a strain gauge. So the man would drop his scrotum in here, the testicles, and then he just clamps it like that. Okay. And this goes around the base of the scrotum. This goes around the base of the penis. When the penis becomes erect, it pushes on the pressure sensor and it pulls on the strain gauge.

1:17:50Those numbers go into an equation and gives me a nice little EKG. And now there's actually a provider platform where I can log in. And if my patient gives me access, I can pull up their tracing on my computer. Before they walk in my office, I know what's going on, right? So I had a patient, this was probably two months ago, come in. He was seeing me for erectile dysfunction and low libido. How old is he? He was in his, he's in his 30s. He came in and he walked in my office and said, Dr. Perlman, I know my erections are good. You can look up my tracings. Right now I'm just concerned about my libido.

1:18:23Because this gave him the data he needed in terms of his nocturnal erection. So this can be used actually during any type of sexual activity and during the nighttime.

1:18:32Dr. Gabrielle Lyon:To tell or test the strength of the erection? Yes. So it looks at how firm the erection is, how long it lasts, and how many he's getting. And it gives a tracing. And we know pictures are worth a thousand words. I can look at a tracing and within two seconds, know what's going on with my patient. Now, someone may say, well, okay, my tracing shows that I'm getting three great erections at nighttime. Dr. Perlman, why can't I maintain my erection when I'm with my partner? Well, this is also treating the most common reason for ED, which is venous leak, right? You get enough blood flow into the penis, but the blood doesn't stay in the penis.

1:19:12So this is also works as like a fancy erection ring or cock ring where it traps the blood in the penis. So when you talk about you and you've asked, we've spoken about this before and you've asked your other podcast guests, what is the impact of marijuana? I would tell a patient, track it. See what the impact of marijuana is on you. Or if someone says, you know, I mean, I would counsel my patients that the best thing is cut out all alcohol, right? But that's not realistic for a lot of people. So I would say, see how much you can get away with when it comes to your erectile function. if your erectile function is what matters to you.

1:19:44Because not everyone's going to be interested in tracking their erectile function, right? For some people, they might want to track their A1C or their cognitive function. But as we kind of spoke about, erectile function is a big motivator for lifestyle change. So if this is a motivator, I would say, see what happens with your tracings when you drink two beers versus three. It is incredibly common, right? We think about just veins throughout our body. We think about like varicose veins and having leaky veins. So that's one thing. venous leak can also happen after prostate surgery for prostate cancer.

1:20:14It can also happen if someone has Peyronie's disease. It is a very common thing. We see it even in guys in their 20s.

1:20:20Dr. Gabrielle Lyon:And this is a, quote, compression stocking for venous leak. Correct. And I have changed my terminology over the years. Oftentimes, these devices are called constriction rings. That terminology sucks. So I've changed my terminology to erection ring. And I think heterosexual men miss the memo. If you talk to men who have sex with men, they use cock rings all the time, coming from a place of abundancy, not from a place of deficiency. So when I'm trying to encourage my patient to use an erection ring, I tell them the same thing. Like, don't tell your partner you want to use it because you can't maintain your erection.

1:20:56Tell your partner, babe, you are so sexy. And I want you to experience pleasure for as long as possible. What do you think if I try this ring? Who's going to say no to that? So I like devices like this because it gives men the control. It gives men the data. It's going to encourage behavioral changes that you and I recommend all the time, but we don't necessarily have the metrics that we need to encourage those changes.

1:21:21Dr. Gabrielle Lyon:Does this need to come from a healthcare provider? No, that's also beautiful. Patients can just order it online. It's super easy. It doesn't require a healthcare professional to look at the data. It's very user-friendly. It will actually compile the last several tracings and will give a patient their erectile fitness score. So it's like an aura ring. You don't need a doctor to interpret that data. Before there's erectile dysfunction, there's erectile fitness. Why wait until there's a problem? And if you get the guy who's 25 years old to see what his baseline function is, then you know when he's 35 years old, if there's a change.

1:21:58Maybe he still has a normal erection, but if it's changed from when he was 25, that delta is impactful. It's the delta. This company is currently working on one for women. Because when we talk about, we started this conversation with the penis is the canary in the coal mine. It tells us incredible information about underlying cardiovascular health. We know the number one killer for women is cardiovascular disease, right? We know clitoral blood flow is probably the same canary in the coal mine for women as erectile function is for men. And now we're going to be able to track it.

1:22:37Dr. Gabrielle Lyon:I definitely want to try it when it comes out for women. Yeah. I mean, that's so cool. Yeah. It also can be a fun thing in a partnership. Rather than making it a male problem or a female problem, it's like, hey, babe, want to track something? Let's hack our sexual health is kind of like a fun thing to do. That's epic. Yeah. I love it. Do you want me to find any other things in my toolbox here? All right. Let me go in this fun tool bag. All right. Have you ever seen like a penis pump before? Not in person. Okay. So for those of our listeners and watchers who have seen Austin Powers, they pull out a penis pump in Austin Powers.

1:23:14This is one of the most underutilized tools, I think, in all of medicine. I want to explain why. This is a vacuum pump. Okay. A lot of people get nervous about these pumps. There are lots of ones that are available, right? So when I have patients that say, which one do you recommend? I used to tell patients, oh, just go on Amazon, go to a sex shop, get a vacuum pump. Terrible advice. That's some of the worst advice I could have ever given. Why? Because if you want to get a blender, you go to Walmart, you walk down the blender aisle, there are so many options. There are cheap ones. There are fancy ones.

1:23:42What do we do? We either get the cheapest or the most expensive. We're going to be pissed either way, right? Typically, maybe like a middle range one that's not too fancy is going to be the ideal product, right? I was never really taught about erection pumps despite many years of training. Why? Because they're not surgical. They're a little bit cumbersome, right? And I was thinking about it more from an erectile dysfunction treatment option where I don't think this product has its best utility. Because taking out a vacuum pump before wanting an erection is a little bit cumbersome. I would say that's a true statement.

1:24:11Where I find the value of a vacuum pump is in restoration of the penis, is in maintaining penile health.

1:24:17Dr. Gabrielle Lyon:Which you had mentioned erectile fitness. Erectile fitness. Question is obvious. You go to the gym three days a week. You train a certain amount of reps and sets. Is there a certain schedule or regimen for erectile fitness? Yeah. The muscle that you talk about and the muscle that I focus on, I mean, it's all muscle. It's different kinds of muscle, right? You're talking about skeletal muscle. I'm talking about smooth muscle. But it's kind of similar, right? So people say, how many days a week should I get erections? Well, I mean, what would be your recommendations for exercise? Every day? Every day.

1:24:50And that's what I would say for erectile function too, to optimize erectile fitness, right? And structure and function. For guys that are, let's say, getting daily erections and maybe they're tracking it with an erection ring, that's great. They're rehabbing their penis already.

1:25:03Dr. Gabrielle Lyon:Rehabbing would imply that they're not where it should be. Or let's say exercising their penis daily. Because I would agree. Using the term rehab is saying that there's some sort of pathology or issue. If someone, let's say, is not getting daily erections and I put them on Tadalafil and then they're getting daily erections, great. That's going to help preserve their penile tissue long-term. But let's say despite taking a daily Tadalafil or they don't want to take the medication or for some reason they can't take it, that's where I would add an erection, a penis pump like this. Okay. Very important.

1:25:32You wrote your book, The Playbook, and I want to give you a tactical manual or playbook when it comes to using these devices because I've had so many patients come into my clinic and they say, Doc, I got a vacuum pump. It doesn't work. Gabrielle, these do work. I've had guys that say, Doc, I got a vacuum pump. It's too painful. They don't have to be. It's just no one ever sat down with them to teach them how not to make it painful. So this one right here is a manual one. There are also ones that are battery powered. It doesn't matter which one you get. I typically have patients use the manual.

1:26:01Key things here, lubrication is your friend. It typically comes with a water-based lubricant. You want to use water-based because it's very easy to wash out of this device when you're done with its use for the day. You put lubricant on the base here of the vacuum pump. You put it on the inside of the vacuum pump canister and you put it on the penis, okay? It's also very important that the person trims their pubic hair because if the pubic hair is too long, it won't get a good seal. I've had many patients where they say it doesn't work. They never got the seal. So then you put this kind of on the pelvis, put a little bit of pressure on, wiggle it around a little bit to get a good seal.

1:26:33This is so key. Listen to what I'm saying. Do not go to town on the lever. If it's a battery powered one, do not go to town on the button that turns it on. Way too much pressure, way too quickly. It will be painful. you might draw a testicle into the canister. Do it like this. Push this two or three times. Relax. Let blood go into the penis. Do it again, right? Short repetitions. That way you will do it so it's not painful.

1:27:03Dr. Gabrielle Lyon:And the goal of this is increased blood flow. Yes, it pulls blood into the penile tissue to stretch it out. It can be a game changer, especially for guys who have lost length. They've lost girth. they're not getting good erectile function because in real time, they see their penis engorge. And you know what it tells them? I still got it. If someone doesn't use their penis, can we expect a certain amount of shrinkage of length and girth? Yeah. And I think Toby Kohler mentioned this on his podcast when he was a guest on your show. I think he said it was like an inch, like in just a couple of months, right?

1:27:41Now, here's the good news. Men can restore size that they've lost. And I have some guys that, let's say, had their prostate moved for prostate cancer. They haven't had erections in 10 years. And when I talk to them about penis pumps, they say, wait, there was something I could have been doing over the last 10 years to prevent this from happening. And I say, yes, but it's never too early and it's never too late. And some of the happiest men I've seen over the years were guys that started using a penis pump and they've gotten some of their size back and they're happy people. Now, I will say this, Gabrielle, some of the most frustrated, annoyed patients I've seen over the years are ones that were never told about these devices.

1:28:23And they're pissed that over the last five years, they had changes that didn't need to occur.

1:28:28Dr. Gabrielle Lyon:This episode is brought to you by Bond Charge. Now, my husband looked at me the other night and said, should I be scared? And honestly, fair. I was sitting in the dark with a glowing red mask strapped to my face. Um, I don't have time for a 5 million step skin routine. I just don't. But I do have 10 minutes while I'm answering emails or pretending to read before I pass out. The Bond Charge Red Light Face Mask uses red light and near infrared wavelengths to support skin health, which again, it's a great way to scare your husband. It's lightweight and it's portable. It doesn't feel heavy or uncomfortable.

1:29:06Dr. Gabrielle Lyon:Since I started using it consistently, my skin looks the following. smoother, and just overall more healthy. I didn't have to add another complicated thing in my life to get the job done. Go to bondcharge.com and use the code Dr. Lion to save 15%. And listen, many of us make a ton of various investments, but skincare and something that works is an investment that you will not regret. Go to bondcharge.com and use code Dr. Lyon to save 15%. If someone is not in a relationship, would masturbations suffice or is this a totally separate activity? So both can be helpful, right? I think masturbation is one of the best ways of coping with life stressors.

1:30:00It is a dump of dopamine in our brains, right? It's incredible.

1:30:04Dr. Gabrielle Lyon:You know, because I'm just thinking about my male patients, they would just be like, okay, now I'm going to do this and then I'm going to do that. Is this just too much? So I would say, however someone is going to get their daily erections, whether it's with a penis pump, Cialis, masturbation, sex is totally fine. For guys that have lost size, if they really want to see if they can expand the tissue, then I would actually encourage them to also incorporate a penis pump. Now, do they have to use this for the rest of their lives? No. I tell people like, use it, give it a good college try for three months and see what you can get.

1:30:36When they use it on a regular basis, I don't know that I've had any patients say they did not benefit from a penis pump.

1:30:41Dr. Gabrielle Lyon:If an individual has not lost size, will this potentially improve size and growth? That's a fabulous question. That is a data-free zone as well. I think a couple of reasons why that study hasn't been done. One is that as urologists, we are treating pathologies. We are not taught how to address the man that comes in that says, this is a size penis I've had all of my life and I'm looking, are there different ways that I can enhance my penis? I was never taught how to answer that question in training. I was taught how to tell people no. So there are averages and the averages were based on like a collection of 15 ,000 people, right?

1:31:20And so you can look at like the flaccid and the erect gird. So I can look at a penis in my clinic and all my patients come in. I can just know without doing the measurements, yeah, you have a normal penis. But what's interesting is that we enhance our bodies all the time in various ways. And just like this weight management and GLP-1 discussion has become very polarizing because we think it's in many people out of vanity that they want to look good in front of the mirror, it's okay to want a bigger penis as long as we can do it safely. And so I've, a lot of my practices actually morphed into more of like a cosmetic urology visually and like the actual sizes.

1:31:57So we haven't, there's not a single study I found in PubMed that will look at a person coming in with a normal size penis without any pathology to see if this can increase their size.

1:32:06Dr. Gabrielle Lyon:Is it fair to say that a normal size penis is six inches? So 85 % of men are less than six inches when erect. and sometimes I'll pull up the graph in my office and show them that you're well in the normal here. You're actually above average. Now here's where it becomes a little bit tricky. If someone has a less than average penis, I will not bring out the graph because I don't want for them to feel that they're less than average, but we will talk about ways to still increase their size. You've clarified length. Now let's talk about girth. So the average erect girth is around four and a half inches.

1:32:44So most of my patients fall within the average right? The question becomes, can I help them? Right? And I think that's also something that men of all ages need to understand. We cannot tell this person, we cannot help you. Because again, they're going to lose trust in the healthcare system. They're going to try over the counter stuff that could even be dangerous for people. There are some really interesting documentaries. I don't know if you've seen them talking about enhancements for the penis. But what I will tell you is it shows a very drastic side of the penile enhancement space where it was showing one guy traveling all over the world and looking at guys that were putting these heavy weights on their penis.

1:33:23And there was one point to this documentary where he's in a hotel room in front of this guy that's about to take out this weird substance from like a Coca-Cola bottle and inject it into the penis. And you see this guy that's like, I don't know if I should do it, right? That's not the space that I live in. The space that I live in, and I just actually wrote this article for AUA News, and I'm so fascinated that the AUA has asked me now on two occasions to write articles for them on penile enhancement because they're a pretty conservative society, right? And this most recent article is talking about penile enhancement from a place of abundancy.

1:33:59And I've spoken about this abundancy theme throughout this episode. And I think that's where we capture people and engage them rather than poo-poo them. What we've seen, and we did a research project on this as well, is that guys that come in for enhancement are already functioning well. They're not these guys that come in with what we call small penis syndrome, okay? They're not devastated by their penis. They're coming in and they're asking what's possible. They're saying, Dr. Amy, I know I have a normal penis, but can you safely make it bigger? Their sentiment when they're sitting in front of me is I don't want to regret ever having met you.

1:34:39So what can you offer me that won't lead to any regrets? And so in those discussions, I talk about penis pumps and I say, look, if your size of your penis is the same that it's always been throughout your adult life, then will this be beneficial? Maybe, you know, not as beneficial as if you had lost size and were looking to restore size. It lies somewhere down a Reddit rabbit hole because there are plenty of people, both my patients and people online that say they use a penis pump and it's grown their penis, right? The important factor, it's not going to hurt anyone. So they can try it for a few months and see what happens.

1:35:14I would typically recommend every day, give it the old college try. And if you don't get any benefit after three months, then you probably don't need it, right? As long as you're getting daily erections. All right. The next device I want to take out is traction therapy. So this is also pretty popular online and there are lots of different traction devices out there. And let me call out the other elephant in the room. It does look like a medieval torture. Totally.

1:35:39Dr. Gabrielle Lyon:I was just like, oh my gosh. So the man would put his flaccid penis in this device. He would clamp down the tip of the penis like so. It's a spring-loaded mechanism. He would push this out and it will stretch the penis. Now, importantly, this device is called the Restorex. It was developed by Dr. Landon Trost, who's a fellowship trained urologist out of the Mayo Clinic. One of the most amazing, intelligent people I've ever met in my life. He does not sell snake oil. So everything that he says about this device is backed by research, which is something that I really appreciate about his message.

1:36:18Dr. Gabrielle Lyon:And what was the impetus for creating that? Peronies. Because he was actually part of a panel or a group of people that were writing recommendations on treating Peyronie's disease. And he had been recommending traction therapy. And that's why people with Peyronie's, they develop or can develop curves because scar tissue doesn't stretch like normal healthy tissue does. And when he was delving into the research, he actually realized there wasn't actually much research to support the use of traction. So he went to the engineers at the Mayo Clinic and said, I'd like to create a traction device, but this needs to be beneficial or show benefit within 90 minutes or less daily use.

1:36:56But if you look at the other traction devices out there, people will use them for like up to eight hours a day. You know, they might wear them all night long. So for a lot of people, that's time prohibited. So he came up with this device initially to treat guys who have Peyronie's. And the device has shown that when you use it to stretch the penis, you can also bend it in the opposite direction. It can improve curvature. Where I find this to be beneficial is in guys who notice curvature of their penis and they don't want to do other therapies, right? where they're, let's say, in the early stages of noticing changes in their penis, and they want to minimize any additional curvature issues, okay?

1:37:32Or in guys that use FDA-approved medications for the Peyronie disease, like Zyaflex, research shows that if you combine traction therapy with injectable medications, you get more benefit than using either one alone.

1:37:44Dr. Gabrielle Lyon:Would someone who doesn't have scar tissue use this? If thinking about an exercise muscle, someone stretching it post-training, or like yogurt for the penis? So they can, but it's a data-free zone. The other two populations of men he studied this in is in men with diabetes and men who have their prostate removed for prostate cancer who have noted penile length loss. So what I tell patients, again, similar to a vacuum pump, it's a data-free zone. It's a safe therapy. So I tell them, look, if you wanna use it to potentially gain length, be your own experiment and see if you gain length. But what I found in a lot of my patients, because I do a lot of girth enhancement, is oftentimes they'll come in, they get super excited about all of these things.

1:38:24They get the Restorix device and they don't use it. But here's the thing, and this is in discussions that I've had with Dr. Trost who invented it. I said, okay, so what do you tell your patients? You tell them 90 minutes a day. So he's actually studied this. He's looked at 30 minutes a day, 60 minutes a day, and 90 minutes a day. And you pretty much get the same benefit whether you do 30 or 90 minutes a day. So he tells his patients 30 minutes a day, five or more days a week for three months. If you use it longer or beyond those three months, people tend to get additional benefit. So that's what I tell my patients.

1:38:55I'm not saying use this for the rest of your life, but if you are truly invested in increasing the length of your penis, then this might help you. You know, but I think it also just depends on how stretchy someone's penis is. So it's variable, but you can't hurt yourself. I don't recommend any surgeries for penile lengthening. So when it comes to interventions, I would say traction therapy is really the safest thing that we have available.

1:39:17Dr. Gabrielle Lyon:And they do have approved surgeries for penile lengthening, right? They cut? Well, there are surgeries that people will do, like cutting the suspensory ligament. My concern with that surgery, and full disclosure, I've never done that surgery, but it would not be something that most of my colleagues within sexual medicine or urology recommend. I'm sure some people get great outcomes. Here's what I would be concerned about and what others and my colleagues are concerned about. The suspensory ligament helps support the penis. by connecting it to the pubic bone. So when it becomes erect, the penis lifts.

1:39:52Some of the most distressed patients I've seen in my clinic, I bet a couple of them, are ones that felt like they injured their suspensory ligament and they get erect, but they don't feel like they have stability of their erection when they're having sex, which makes them incredibly nervous that they're going to injure their penis, right? So that's where my concern is, is the studies that I've seen on cutting the suspensory ligament, they don't look at, you know, the penis and how it feels supported once they do that surgery.

1:40:22Dr. Gabrielle Lyon:And how it just functions within one. Exactly. So that's my concern. So I tell patients it's a data-free zone. Depending on how compliant you are and how interested, yeah, you could use, you could take your daily Cialis, you can use Restorix device, maybe 30 minutes a day, use a penis pump for 10 minutes a day and do all the things and see what you get after three months. But it takes a pretty motivated patients. So I tell patients, look, if you're not going to use it, don't buy this, you know, but if you're going to use it, it can't hurt. It's very safe. So these are two tools here that we know can restore size and still to be determined if they can grow a healthy penis.

1:40:59Dr. Landon Trost is currently enrolling patients in Utah to actually look at enhancements. So if you're interested, you can reach out to his clinic. You do have to go to Utah to his clinic, but he's comparing this actually with some of the other first generation devices to see if it can enhance the size of the penis.

1:41:15Dr. Gabrielle Lyon:Next. Oh, let's pop a little bit more here about some girth enhancement while we're on the topic. Okay. So I do a filler in my office. Okay. There are no FDA approved injectables when it comes to the penis. So we use medication that's off label. We use hyaluronic acid. Hyaluronic acid is pretty much in the water these days, right? So we know that hyaluronic acid when injected into the body is extremely safe. It's the same stuff we would put in the cheeks, in the lips, right, in our nasolabial folds. So we use it off-label in the penis, and we put it in between the erectile chambers and essentially the skin to increase the girth.

1:41:48It is incredibly safe. It is incredibly effective. When my patients walk out after they have filler, they have a little bit more pep in their step than when they came in, right? So just like with all the other treatments we've discussed, like on the testosterone topic, I ask myself how I can hurt someone. Hyaluronic acid is 100 % reversible. I don't know of any other procedure we do in urology that is 100 % reversible. I can easily, with an enzyme, dissolve the filler if I need to. If we look at the different sizes here, each of these is an increase of an inch. So you can kind of see the different sizes here.

1:42:22If you are watching this, good for you.

1:42:25Dr. Gabrielle Lyon:It's this pretty epic episode. You are listening to this, please watch it as well. She is showing three cylinders with three various sizes of girth. And so when people say, when I ask them, what are your girth goals? Which is one of my favorite questions to ask. A lot of my patients, you would think, okay, if you think about the typical guy that comes into a clinic like mine, you would think that they would know exactly how big their penis is and exactly how big they want their penis to be. False. Oftentimes my patients come in and they've never measured their penis. Or they say, I'm not really sure.

1:43:00I think it's this. And I say, how big do you want to be? And they're like, eh, I'm not really sure. I kind of want to see how it looks on me. And then we can sort of decide. Or they might say, I want half an inch to an inch increase. Those are very realistic increases that we can get, right? I routinely get people an additional inch and sometimes even more than that. The question becomes how they want their penis to look. You have the tip of the penis. You have the shafts of the penis. Some people want to maintain that contour between the two. And if the head of their penis is on the smaller side, then at some point, the shafts will become bigger than the head, right?

1:43:29Some of my patients don't care. They have great girth. Sex feels amazing. And so they know that their penis doesn't look completely natural, but sex feels so good that it's a moot point.

1:43:41Dr. Gabrielle Lyon:If I think about women, women lose collagen and volume from their face naturally as they age. Does the same thing happen to men? Here's the other elephant in the room, right? So as men get older, oftentimes their penises get smaller, especially if they have erectile dysfunction, right? If they're maintaining their erections over their lifetime, they're probably not going to notice any changes. But the other elephant in the room is that all of our bodies change, right, in terms of laxity. The female bodies change, the male bodies change, and oftentimes as we get older, the vagina probably gets a little bit looser, right?

1:44:16And the penis oftentimes gets a little bit smaller, you know? And so we oftentimes talk about enhancement as a vain thing. If a guy can't feel his partner during sex, that's a functional thing. It doesn't matter if his erections are amazing, if he can't feel anything, or if she can't feel anything, what are we doing, right? And I think the next sort of thing of urology that I'm trying to tackle is normalizing this conversation of your anatomy, my anatomy, how do we optimize friction here? But even in the female space, it's a very polarizing topic in terms of vaginal rejuvenation. But I think there's a role for both of these things.

1:44:56But it's also a reason why, like over time, people just report reduced satisfaction during sex. I see it all the time with my patients. You know, if you look at the research, the most common sexual dysfunction worldwide is reported as premature ejaculation. That's not the most common thing I see in my clinic. The most common thing that I see when it comes to pleasure is men having difficulty reaching climax, or it takes them a long time to climax because their sensation is different. So what I hear from my patients is once you increase their girth and they have more friction, sex feels better.

1:45:28That's function.

1:45:29Dr. Gabrielle Lyon:What I'm hearing you say is there's a component that's just about the friction. Not necessarily nerve endings, but it's two compartments coming together. Correct. But also that's going to improve, you know, the sensitivity of the nerves. So going back to this work that we've done, people coming in from a place of abundancy, these guys are already having sex. They feel like pretty good about their bodies. And when you help them enhance it, they feel better. They're having more sex. Their relationships are better. But they're not, they don't have body dysmorphia. A minority of my patients I would consider to have body dysmorphia.

1:46:00So that's on the girth enhancement side. So I know a lot of your viewers are the ladies. That's true. So this is for you.

1:46:09Dr. Gabrielle Lyon:You're welcome, Lee. Thank me later. Okay, this is what we see from the outside when we're looking at a vulva and vagina, right? And so like the spot, the holy grail, they think is this little area right here. It's the tip of the clitoris. But the clitoris is this. Okay, this is the clitoris. And if you are listening to this, good luck explaining that. It looks like a wishbone. Women have just as much erectile tissue as men do. It hides behind the labia. So when we tell women, and this is true, right? A lot of women need clitoral stimulation to orgasm. And, you know, the majority of women can't orgasm with penovaginal intercourse.

1:46:51But I think the problem is we've never taught women how to orgasm with penovaginal intercourse. A lot of women are having sex with a flaccid clitoris. So this is what I explain to my male patients is think about how it would feel sensory-wise if you were trying to have sex with a flaccid penis. It wouldn't feel that good. And that's what we're doing to our ladies all the time. And so we need to engorge all of this erectile tissue in a woman for her to really enjoy the experience. So how do we do that? Well, one, you got to get in there, right? Don't just focus on this. Like get into all the nooks and grannies.

1:47:28I say that in all seriousness, right? Is stimulate all of this area, okay? Not just the tip of the clitoris. And we can use tools to help us do that. So I have people ask me. Actually, they don't really ask me. I just volunteer it. What some of my favorite products are. Okay. This is a wand. There are so many different varieties of the wand out there. I know it's big. Feel it. It's pretty. This is not my personal one.

1:47:56Dr. Gabrielle Lyon:You know what? It's so funny. I didn't even think twice about it. I'm like, okay. You want to know what I was thinking? What? I was thinking my kids are so nosy. Yeah. That if I were to have a wand at home, 100 % of the time, I'm sure they would use that as a microwave. I'm pretty sure. I mean, it's probably true. Or show and tell. I mean, who knows what they're doing when they go and they have their show and tell. What I like about wands is they offer full coverage. So you could put this and literally put it really anywhere along the genitals, and you are going to engorge and stimulate all of this erectile tissue.

1:48:34Dr. Gabrielle Lyon:Can I ask you a question? Yeah. Would that happen without a cognitive component? In my mind, and I don't know this to be true, but someone could brush against a man who would get an erection. Maybe not. Almost a reflex. Would the same, I mean, number one, is that true? I would say it's not true. I mean, young men, like when they're going through high school and their hormones are going crazy, they walk up to the chalkboard and they get an erection, right? Back when we had chalkboards. So yes, with like arousal or stimulation or thoughts, people can become aroused without even any stimulation, right?

1:49:08The largest sex organ is actually the brain, not even the genitals. It would be interesting once we have the technology to assess blood flow to the clitoris, whether or not you can get engorgement without, let's say, the brain arousal. Because like, for example, in men, I can inject Trimix, let's say even when a patient is under anesthesia, and I can induce blood flow to the organ. And I would guess that putting a vibrator to the clitoris would increase blood flow to the genital tissue, even outside of that person being like mentally aroused. And so this allows for full coverage where you don't have to be as precise.

1:49:42When you use a smaller vibrator, let's say a bullet vibrator, nothing against them, but you have to be more precise with those to get it on the right spot. Now, there are other technologies out there. Have you ever heard of like clitoral suction devices? No. So I haven't used this one either yet. So it's a lemon. And then if you push this button right here, I want you to kind of feel what the sensation is because it's very different from vibration. Vibration is wonderful. Vibration, though, if you use kind of the same setting, can be desensitizing, which a lot of people ask about is they say, I kind of lose sensation in the moment.

1:50:16And I've experienced that before, too. It comes back, right? And that's why I like vibrators that have different settings where it's not just a constant vibration. but pressure airwaves with these clitoral suction devices, it's a different sensation that tends to not desensitize the tissue. And so you would just like put this on the clitoris. You can also put it on the nipples for people who enjoy nipple stimulation. Now, some people will say they're big concerns. If I get used to these products, will I require them every time? Well, you just have to train your body, right? If you want to be able to climax with or without toys, then you need to train your body with and without toys.

1:50:53If the only way that you climax is with a toy, then you likely will require a toy to climax, right? It's like something, same thing like training at the gym. If you train a certain way, don't be, don't expect yourself to perform in a different way than how you're training. I look at these devices as adjuncts, right? There's a degree to which, I'm going to get personal here, I can experience an orgasm without toys. My orgasms are much better when I use a toy. So what do I do? I use a toy. And I don't want to have to choose between, let's say, you know, vaginal intercourse and using a toy. These toys oftentimes you can combine together.

1:51:30So it's about expanding our toolbox, expanding our experiences. Again, I'm going to bring up this concept, not coming from a place of deficiency. I would never tell a partner they're bad in bed, but I would say, I want to have the most amazing intimate experience with you. So let's use everything at our disposal to have the best sex ever, not just mediocre sex.

1:51:51Dr. Gabrielle Lyon:Dr. Amy Perlman, this has been one of the most educational, informative, and fun episodes that I have done. And I've been doing this for about four years. You are probably very popular when you come in with your bags, but in all seriousness, you are a highly trained physician. What I love is having transparent conversations, conversations that healthcare providers are not thinking about, should be thinking about to better the experience of our fellow human. Thank you so much for coming on the show. It's been such an honor being with you here today, Gabrielle.