The Penis Is a Check Engine Light: What ED Says About Your Heart | Dr. Tobias Kohler

21:27But when I look at the data, people who take statins, you have less dementia, hard stop. You know, when you're born, your LDL is 50, five zero. And so I spent, I was lucky to spend a half day in clinic with this guy named Dr. Kapesky. He's like one of the world's premier preventative cardiologists, you know? And so I am lucky to just spend some time with him occasionally. And he's going to be part of the Princeton Five guidelines, by the way, which are coming soon.

21:52Dr. Gabrielle Lyon:You guys already started number five? Yep. Yep. Yep. Yep. Yep. Yep. Yep. more focus on testosterone, much more focus on women's health, and then evolving data because the field is moving very, very fast. So that's exciting. But what Dr. Kapeski says is, you know, you're born with an LDL of 50. If you ever have had a cardiac event, so if you see something on a CT scan in the heart that looks like plaque, if you've had a heart attack, your LDL goal should be 50. That's really low LDL. It's very low LDL because I've actually had Tom Brenna who's on the dietary guidelines and he talks about LDL cholesterol and the dietary guidelines really are, I don't know how to say this, but they seem to be somewhat of a medical intervention.

22:39Dr. Gabrielle Lyon:LDL above 130, those with an LDL above 130, it's like 24 % of the population. Yep. It's true. But the guidelines are talking about reduction of saturated fat this would be a nutrition plan so if we were to just actually think about dietary interventions who's it meaningful for it's meaningful for someone who has a cardiovascular risk especially when it relates to ldl cholesterol and cholesterol yeah the average ldl i believe of somebody who has a heart attack is like 106 or something so like you can there are plenty of people with normal cholesterol that still get heart attacks but we do our best to to make it better so the other thing that Dr.

23:19Kropesky taught me is that if you don't have a cardiac history, your LDL goal should be 100, which again, is double as you were as a baby, but is clearly a lot lower than what I used to be prior to starting a stat.

23:30Dr. Gabrielle Lyon:Yeah. And then the question becomes, what's the optimal goal? So we're talking about the outcome for prevention of heart disease, but I'm sure it has a function and that there is probably an optimal number, just like we think about, okay, here's the optimal number for testosterone. I recognize that to each his own, for some people, it's 600, for someone else at 700, but there is probably a mean to an optimal range for, I again, hate Jesus word, optimization, as opposed to prevention of heart disease. Right. Again, I would just continue to lean on diet, exercise, sleep, stress mitigation. And then, you know, GLP-1s I think are a good thing.

24:11They're going to move the needle like anything bigger than anything else we've ever had in terms of reducing cardiac risk.

24:16Dr. Gabrielle Lyon:Do they have an effect on sperm quality or testosterone levels? Sperm quality, not that we know of. But there are receptors from what I read and learned. Yeah, but so far, no evidence that it's going to cause any craziness, but it's early. Or positive. What about, you remember there was that study about metformin and its impact on spermatogenesis and fertility? Yeah. There's no doubt that people who are on GLP-1s are going to have some benefits because they're going to lose weight and their hormones are going to be optimized, their inflammation is going to be reduced, and likely the fertility is going to be better.

24:53And that's what the preliminary evidence is showing. But it's relatively early. Whenever we talk about risk to something, I think it's often that people think about, well, what's the risk of doing that?

25:03Dr. Gabrielle Lyon:Yeah. Right? It's the same thing with the, you know, if you have a hypogonadal man and you've got some providers that are very worried about the potential risks of getting the testosterone back into the normal range. Well, we know that we do nothing. The risks of heart attack, all-cause mortality, cancer is a lot higher than when we intervene. So we have to keep the baseline risks in mind as well. And as far as, you know, T levels and erectile function, weight loss helps. Pull step. You had said something that I'd really like to dive into a bit more, and it was this idea of super physiological doses of testosterone.

25:40Dr. Gabrielle Lyon:Again, this is going to be an extrapolation, and most women are not, I don't want to even use the word abusing, but again, I don't even have the vocabulary to frame it up. They're not necessarily abusing testosterone because there's significant changes that would then happen with lowering the voice and these side effects. But for men that go on super physiological doses of testosterone, there are changes that happen. And you have looked at that and published data on those changes. I think testosterone is like any other substance. It's a normal part of the human physiology. Too low is bad. There's a range where things are good.

26:21And then when you redline, then bad things happen. We know that people really push the boundaries of super therapeutic testosterone levels, several thousands, right? They have more than normal T-level. Let's just arbitrarily say 500. We're talking about people that are pushing 2 ,000, 3 ,000.

26:38Dr. Gabrielle Lyon:Do you get worried? And I know that this is going to be a tricky answer. Do you get worried at 1 ,000? Kind of. I'm not certain. And no one would be certain, right? My answer is going to lean on people checking their T-levels when they're young. So back to this fact that the boys that become men don't have a primary care doctor for 20 years, if not more. What if we checked their testosterone level when they're 25? They're healthy. They can eat poorly and they still stay thin. It's very annoying. Right? They're basically in the best shape of their lives. Their T-level at that point when they're healthy is a very important number.

27:20Most of the time it's going to be 500 or so. Right? There are some published T levels per decade of life and it does go down. There are.

27:29Dr. Gabrielle Lyon:Yeah, there are. It's pretty rare to get above a thousand naturally. Considering that as a kind of max upper limit of normal is a very reasonable thing from my perspective. I don't claim to have all the answers, but when I look at the science, you know, the guidelines will tell you shoot for a level around 500. It's very easy to remember. A thousand is probably running a little too hot because we do have very strong evidence that if you're running at 2 ,000, 3 ,000, you get cardiovascular disease. And it's that I want to pause here because this is a really good education for the patients listening to us and the doctors who are going, wait, from an anabolic steroid perspective or performance enhancement, that there are reasons why these things happen.

28:14Dr. Gabrielle Lyon:And I've learned this actually from you, that there is cardiac remodeling, that there are things that happen that I would love for you to pause and explain because there are providers and also patients, they have to understand this rather than it just be kind of, well, you're going to get cardiovascular disease if your testosterone is a thousand over two years because it probably takes more time. But again, you've got 20-year-olds that are growing up in the online culture and the YouTube space where it has unintended consequences. Complicated answer. But first of all, when I'm advocating for checking a baseline testosterone level at age 25, like before I stick the needle in or the phlebotomist does, I want to ask them, how do you feel?

29:02If the answer is good, everything's working, penis is working, all systems go, then that T is what you need to do well. And if the answer is horrible, then well, it's not really a true baseline because you're not at your optimal.

29:18Dr. Gabrielle Lyon:Oh, I like that. Right. So when you check your level at 25. Regardless of the number. Right. You want to know, are you feeling well or not? And by definition, remember, to treat people with low T, you need to have both symptoms and a biochemically low level, which you can debate what that level should be. But if they feel well from the get-go, and presumably they're in their prime because they're 25, that is a good baseline for them that you can use in the future. Now let's talk about abuse. You got a guy who feels well, his T is 500, but he wants an edge. He wants to get bigger, faster, stronger, faster, faster twice.

29:57When I ask guys like Chad, a testosterone expert, You know, what are the reasons why people will start these androgens? One of the common reasons is I want to become a professional athlete. I want to win. Like I want to have my fastball be 105 instead of 92, whatever it is. The problem with that thinking though is like, if you're not a good enough athlete in high school or college to already be elite without enhancement. Sorry, just not good enough, man. Right? You're never going to be a pro because you're just not good enough. You have to have so much natural talent to make it as a professional athlete, unenhanced.

30:33And then you have to also be lucky enough to avoid an injury along the way to make it to the pros. But people who think they're going to take a shortcut by using anabolics to get bigger, faster, stronger. Remember, as soon as they stop, they're likely to feel horrible and lose many of their gains. And if they get caught and they now have to perform unenhanced, they're not going to be good enough. Right. So this fallacy to like, I want to become an athlete. I want to be a professional, make lots of money by using steroids. It doesn't work very well.

31:02Dr. Gabrielle Lyon:It makes me think about early on in my career, there were individuals that were coming in and I didn't quite know what to do with them. And ultimately, I send them to urology. They would come in and they would say, doc, I started at testosterone at a lower number. Maybe they start at 75 milligrams a week. Then they increase it and then they increase it again. And then somewhere along the line, it's almost as if the higher the testosterone number gets, which is what they think they need, the worse they feel. And I don't know if that is psychosomatic or is there a down regulation of receptors that happens?

31:41Is there a sweet spot where we can teach people that, you know, I'm all about bigger, faster, stronger. But is there a point of diminishing return? Yes. I mean, and, you know, people who use androgens or abuse them, they very rarely will recommend it to their to the general public. Right. They're like, yeah, don't do this. This is a very hard lifestyle for a variety of reasons. Getting back to these initial reasons why people start. So athletics is another one. The other one is kind of vanity. How to how you're going to look. This is, I think, the most dangerous one because steroids alone, without training, without dialed in nutrition, you're going to get bulkier, but you're also going to get fatter because you're ravenously hungry.

32:30You're taking all these calories in. And so achieving that aesthetic look of, I don't know, pick a number, 12 % body fat, six pack, whatever it is you want, ain't coming just from tea. that's coming from eating perfect, from training perfectly. I mean, we haven't figured out the training perfectly yet. We've got many good ideas, but I mean -

32:53Dr. Gabrielle Lyon:Or genetics, there's a genetic component. Exactly, genetics as well. So, and then professional bodybuilders who are successful - Oh yeah. They're genetically sensitive to this stuff. They are. Two of our friends, Matt and I always joke, they work harder than anyone, but they are naturally extraordinary. And they cannot be compared to, I don't know, someone who aspires to do that without the genetic. There's probably a threshold for the amount of muscle someone could put on. And I am curious about this idea of androgen insensitivity. Do individuals that go into an abuse lifestyle, because I know that testosterone is a Schedule 3 drug, just like ketamine, but it is not addictive per se.

33:41Dr. Gabrielle Lyon:It doesn't have withdrawal symptoms, which is an interesting, it doesn't have the definable withdrawal symptoms of increased heart rate, increased blood pressure, depending on the drug. But if an individual continues to increase their dose, is there a tolerance built where they then must continue to increase their dose to get the same effect? I think there is undoubtedly. If you're acclimatizing to T levels of 2000, over time, what's a T level of 500 going to do for you? So essentially you have this new set point where you expect your energy level to be 13 out of 10, your erection's 11 out of 10, and now all of a sudden you take the T away and you feel horrible.

34:24And, you know, that's a big problem for some guys when they're redlined so much, they never feel as good as they want to. So they end up on lifelong androgen replacement therapy, which is typically higher than the average Joe who's normalizing back into the 500 range. That's pretty common. Is there ever a return to baseline? For the guys that really hit it hard, I doubt it. I think there's always probably some irreversible sequelae, whether it's in the brain or at the receptor level. Again, I can't say with absolute certainty. You can't say with absolute certainty. No one is going to be, I mean, if you don't know.

35:03I don't want to come across as a guy that pretends he has all the answers. I guess the message here is if somebody is certain, be wary. Usually wrong.

35:12Dr. Gabrielle Lyon:Except for protein. Right. Except for that, I'm right. And we're just going to carry on. I'm kidding. So, yeah, it's one of those things where I think medicine and interpreting science and data requires a certain level of humility. I try to combine with what people who have experienced in this domain tell me and what I read from the studies and literature. I want to point one thing out too, which I thought was fascinating. Up until the early 80s, even after the East Germans were winning in every event, East German women specifically, people were denying the fact that steroids could help with sports performance.

35:51It was absurd.

35:52Dr. Gabrielle Lyon:Do you know why that was? I don't know. and then they're like oh i guess we should study it right so some beautiful trials done in the 80s where they're giving guys like high dose tea 400 milligram injections right really high getting levels which someone's listening to this they're like oh shoot that's high i didn't know yeah no that's shooting for levels of 2000 approximately like the average tea level in these guys that were treated these were normal guys off the street they took and they started giving them a really high dose T. But they randomized the trial to exercise, weightlifting program, alone, no steroids, or steroids alone, no exercise, double placebo.

36:31And the last group of course is both exercise and steroids. And when you looked at bench press score and squat score, which I would, you know, be like the ultimate kind of predictor of how strong you are, those two huge muscle groups, right? The guys who exercised but didn't take steroids had better results than the guys who didn't exercise and were on this crazy dose.

36:55Dr. Gabrielle Lyon:Wow, I'm actually surprised. So you need the stimulus, right? Now, of course, the magic of the study where you see this crazy explanation as to why, you know, the Eastern Europeans were winning is when you combine the lifting with the high dose T, then the strength just goes off through the roof. But I think it's important to understand that it's the exercise initially is the stimulus that causes the change in strength, in physique, in functionality. And so why not focus on that, max that out before you do anything that is potentially can give you a heart attack, give you horrible deep acne for which you will have scars the rest of your life, will irreversibly maybe change your physiologic set point of what you can do.

37:40There's all these negative sequelae that are reported for the people who are in the extremes. You can potentially avoid just by doing kind of the normal stuff, which admittedly is hard.

37:50Dr. Gabrielle Lyon:The idea that we have to exercise, there's this, in my mind, an exercise deficiency syndrome. If we have and would live a life that involves picking heavy things up and are largely less domesticated, we wouldn't have to have artificial exercise. I know if you're familiar with Michael Easter's work. I am. So I love his books. I love how he thinks. And it's the 1 % rule, right? When you go, I don't know, you're in the mall and there's the escalator and the stairwell and they're right next to each other. Everybody knows it's better to go up the stairs. Everybody knows it, but only 1 % do. So it's that kind of mindset to kind of have the fitness happen.

38:33And I totally agree. We have so much less physical activity in motion. All our meetings are online now.

38:39Dr. Gabrielle Lyon:Could we potentially dose testosterone lower if there was a certain threshold of physical activity? I don't think we'd need T in the first place if we had normal physical activity, right? It's almost like a compensation for the inactive lifestyle. Absolutely, 100%. Because when you're inactive, you get obese and then your T goes down. A lot of guys come to you that have potentially abused steroids. it's not just testosterone alone. It's a combination of testosterone plus anabolic agents that are potentially say not even used for a human. Right, oh no, I mean, people who are really trying to get as huge as possible, it is never just one agent, right?

39:20Dr. Gabrielle Lyon:It's like 10 to 15 agents. Let's say a guy was like, okay, I'm gonna take testosterone and I'm gonna be completely reckless with my health and I'm gonna take 400 plus milligrams of testosterone a week. Will there be a cap to how much stimulus that person can get on muscle with testosterone alone? My understanding is the muscle is essentially boundless in its ability to respond. I have also seen that. So the muscles keep getting bigger, bigger, bigger. The tendons and ligaments, maybe not so much. The other thing that makes the data tricky about understanding the true risks of endogen abuse is not only this multi-drug cocktails, you know.

39:57So, you know, you're not just talking about tea anymore, which we do have some studies on. But all these other agents, I don't know, thyroid agents to help lose weight, aromatase inhibitors to drive up tea and lower E, sometimes diuretics. And then I think if you're willing to take a cocktail of eight to ten things and you are benching some absurd amount and you pop a peck or a shoulder or whatever, you're not going to be very shy about taking Vicodin or some other kind of strong pain medication so you can get back to the gym. So you get this polypharmacy too, where now you're starting to, the data gets confounded with these other agents that people are willing to take and other kind of risky behaviors that people are willing to take.

40:42When you look at the data about the WrestleMania participants, right? Their risk of cardiac mortality is something like 100X to the general population. Because again, it's kind of those rock and roll lifestyle and these things kind of gang up on you. And then by the way, weight gain was a big predictor of mortality too.

40:59Dr. Gabrielle Lyon:Even if it's muscle gain, is it because of the stress on the heart? Well, yes. There is definitely conduction abnormalities with increases of heart size, which some of the studies have been reversed. I was going to ask you. Yeah, some get better, but - Is it because it atrophies? This is very interesting because I know people that love to run marathons and you think about the increase in cardiovascular size and maybe that you shouldn't run more than nine miles a week. again, I don't know the number because I know maybe people that run a lot more than that. There is cardiovascular hypertrophy. Then kind of remodeling and normalization.

41:33So in others, they die of a heart attack before it gets the chance to remodel.

41:37Dr. Gabrielle Lyon:Terrible. Is the hypertrophy different from anabolic use, anabolic steroid use? And again, we're saying anabolic steroid use is a testosterone that causes cardiomegaly. maybe a different way to look at it is it's not only the change in heart size but it's the change of heart structure that affects electrical signaling and you know a lot of people that drop dead from steroid abuse it isn't a typical mi it can be because your your lipids can be adversely affected and there are case reports of people just dying with crazy high lipids you know they use steroids. But most often it has to do with an arrhythmia, right?

42:19So a problem with electrical signaling, you go into V-fib and it's, it's, it's lights out. There are good studies from, you know, countries where steroids are much more legal and they show definitive changes in electrical cardiac signaling. And, you know, if you combine high-dose steroids with, I don't know, 500 milligrams of caffeine for your pre-workout and then a little bit of bad luck, maybe it's over. So that's one of the risks we take. And, you know, getting back to this thing about vanity, wanting to look good, like acne, horrible, deep cystic acne. It was like 50 % of people who really use a lot of steroids.

42:55So again, that's really kind of counter to the look you're after.

42:57Dr. Gabrielle Lyon:Yeah. Right. You want to look good, take your shirt off, but like, you don't look good because you've got this horrible cystic acne or receding hairline, you know, sometimes very noteworthy in women, you mentioned voice changes, which are irreversible. Same thing with clitoral megaly in women. Women on high dose testosterone, the clitoris permanently enlarges and never goes back to the size. So when people are kind of randomly deciding to start this based on information from social media, you really have to be careful. Yeah. Some of these changes, like you're mentioning, are absolutely irreversible.

43:31Dr. Gabrielle Lyon:But the reversible changes are what is, Like if we can get to people younger that are potentially on an abuse trajectory, I think back to when I started my career and I was seeing bodybuilders that were coming in because it was, you know, you just, there's always an influx when you open up a practice of various individuals. And where I was living in New York, there just, there was a higher population. And these guys were bigger and they were also, their blood pressure was just uncomfortably high. would that be a precursor or is this something we're like okay because your blood pressure is high we know your heart is pumping you've already been doing this for a year we're moving into two years if we don't do something about this you're at a 10 to 20 risk for an arrhythmia something like that yeah i think the scary thing is that we don't have that number all right it's a little bit of the randomness there's the person who you know grandma betsy or whatever who ate bacon and drank a fifth of the bourbon every day and she lived to 100, right?

44:32Dr. Gabrielle Lyon:And you're like, what's the secret to health? And she's like, smoking. Right? So I wish there were an easy answer to that question, but there's not. That's what makes it tricky and dangerous. Do you think we'll ever have that? Because we have dosing for, we could be like, okay, at this dose, a statin's gonna do this, right? Is that fair to say? At this dose, heparin's gonna do this. Well, again, biological variability. All humans are different. I don't know if we're gonna get that number. It's a tough one. I mean, when we look at the trials of what happens to men, there's only seven right now where the T was consistently at 2 ,000 or higher.

45:07Only seven trials. Well, because most of these experiments are being done off the books. The data isn't great. And it's confounded, like I said before, because of difference in other abuses and lifestyle changes. And getting back to those WrestleMania people, it was the weight gain that happened after they stopped training. So they were used to eating 3 ,000 calories a day.

45:31Dr. Gabrielle Lyon:3 ,000, probably 6 ,000. Whatever the number is. There's a lot to talk about. Yep. And then you stop the training and all of a sudden it's all fat mass you're gaining instead of maintaining your muscle mass. And then you really start to have problems. People might be like, Gabrielle, why are you harping on this steroid testosterone issue? And the reason is, is because I think it's the way of the future. With the increasing use of GLP-1s, we are going to be on a trajectory. And I think you and I are very much aligned on this, that we are going to trade, as robust as that sounds, obesity for sarcopenia.

46:07Dr. Gabrielle Lyon:And then the question becomes, what kind of agents do we have? But what is the safety profile of what is going to be needed? Because, you know, when I think about the aging population at 74, can we start a 74-year-old male on testosterone? You're probably like, yeah, sure. But what is his, if he's sarcopenic, what is the realistic amount of muscle, healthy muscle that he's going to be able to build? versus if we accelerate sarcopenia earlier to an earlier age and sarcopenic phenotype of youth, which I believe it has to happen, how do we begin to think about treatment protocols in this younger generation that is going to be sarcopenic?

46:53And people might be like, Gabrielle, that's stupid because sarcopenia is a disease of aging.

46:58Dr. Gabrielle Lyon:And I would say, well, it's a disease of aging because of what we know now, but that's through the framework of frail elderly. Yeah, there's plenty of people that are the so-called skinny fat. Absolutely. And what is that? That's sarcopenia. Yeah, sarcopenia there. And there's really good data what looks at surgical outcomes. Yes. Of body metrics, muscle to fat ratios. And if you get a surgery with this muscle fat ratio, you're likely to do very well. However, the opposite is true when you don't have any muscle at your core. So what do we do about agents? Is there utility for some of these anabolic agents?

47:35In the absence of, you know, the people being able to exercise, I guess, yes. But again, I just want to go back to these foundational things. Like, just get more active, man. It's like park your car farther away from the grocery store. Just take the initiative and start doing these things.

47:51Dr. Gabrielle Lyon:One of the things that you, I know, deal with a lot is erectile dysfunction. and with erectile dysfunction is vascular disease. With vascular disease, is it safe to say there is scarring of the penile tissue of Peyronie's disease? Is that a fair pathway? Yeah, so Peyronie's disease by definition is scarring the penis. Most notable when your penis starts to bend in the direction, right? So last episode, we talked a little bit about how men can lose penile length. Which made you the most popular guest. in the history of popular guests, because you said men could lose like half an inch. Yeah, yeah, yeah.

48:27And it's a user-lose-it organ, whether it's from -

48:29Dr. Gabrielle Lyon:Everyone immediately tried to find a sexual partner. Right, radiation or diabetes. So the people who actually lose length of their penis, they get uniform scarring. So the penis is still straight, but it's shorter. Peyronie's disease is simply scarring of one portion of the penis, and the penis always bends towards that side, up, down, left, right, most often upward, it turns out. And that typically happens from a trauma to the penis, which people don't notice, at least we think it does. And that happens as a result of problems with erections. So Peyronie's disease is intimately tied to ED because you get these micro traumas in the penis and your body inappropriately scars the softness-freshy tissue and turns it into the scar area.

49:11And so you get a new curve.

49:12Dr. Gabrielle Lyon:Is there signs and symptoms to look for? Yeah, so parent disease has different stages. So the initial stage, active phase involves pain. That's how it hurts. And then like, if you watch yourself get an erection, the area that fills out last in your penis, that's where the scar is forming. Because literally the blood can't flow there anymore because that tissue is scar. And so like, as a man's getting an erection, like we test for this all the time in the doctors office. We can do an armist erection test and like, yep, there's the scar. and then that part finally fills out and then it curves towards where that exactly went.

49:47So I'd say to the man who has pain, either a new penile deformity or a new onset of curve, that's peremoid disease. It's not cancer. It's not STD.

49:58Dr. Gabrielle Lyon:That's good for people to know. Yeah, it's pretty rare to get a painful condition of the penis that's cancer. It will take some time to get better and sometimes it will get better, sometimes it'll get worse. But what I would say to that person is, number one, you've proven that you can get Peyronie's disease. Are certain people at risk and others are not? Yeah, I think they're more predisposed. Like people who have dupurtenous contractures or other kind of fibromuscular scarring diseases are more likely to get Peyronie's disease. What if someone has like a rheumatological condition or something with connective tissue disease?

50:30Dr. Gabrielle Lyon:Are those individuals... Undoubtedly, they're at higher risk. Okay, going to be at a higher risk. Dupurtenous contractures being the most common thing you see in the hands of those. And so men who have dupurtenous are much more likely to get Peyronie's. I say to those men, their job is to make sure they have 10 out of 10 erections when they're having sex. Because again, it's this micro trauma, which most often happens in men with erection is not quite as good as it should be, where that leads to the Peron's disease. People ask a lot, and I see this as a search, that Viagra versus Cialis, which is better?

50:58Depends what your goals are and which medicine you can tolerate. So I write for a lot of Cialis because it's kind of set and forget it. You take it typically once whenever you want, but during the day. It used to be called the weekender in France because... I thought that was a bag. It basically gave you an erection that lasted, that was much more functional over the course of the weekend. I'm not saying they had an erection for 40 hours.

51:23Dr. Gabrielle Lyon:No, because that would be priapism. There you go. Then people would say, maybe you're on trazodone and it's a medical emergency. Right. The one question I got right on medical boards. So, yeah. I'm sure you got many more right. Cialis also has the advantage of treating urinary symptoms. How does it do that? A bunch of different proposed mechanisms, but essentially increasing blood flow to the bladder and making it less spastic. I have read that. And then also this potential cardioprotectant effect, protecting the endothelium. Which is super cool. Yeah, it's amazing. It really is amazing. Combine Cialis with beetroot juice, maybe a little L-arginine.

52:00Like I said, I think in the future there will be medications specifically, cocktails that will involve statins plus PD-5 inhibitors, probably.

52:08Dr. Gabrielle Lyon:Statins for decrease in inflammation or for? Overall cholesterol, decrease in inflammation, and then, again, endothelial protection for the PD-5s. There's probably some pills already in development right now for that. Which you may or may not be able to talk about and sound like you know. We talked about the penile implant. Why do I have an obsession with this? Because it's so fascinating that we see plastic surgery as breast implants or nose job, you name it. And while not for cosmetic purposes, individuals can get a, it's a medical intervention, right? A penis implant or a penile implant. With other body parts like breast implants, it does destroy the tissue.

52:49Dr. Gabrielle Lyon:It flattens out the tissue. I think that there's also an effect of when people get prosthetics placed in their glutes or other places that when you remove those, there is damage to the tissue. Sometimes people have to have penile implants removed. And you said something to me that was shocking. Okay. That you now have a dysfunctional penis, like your penis will not work. That's correct. That's a big deal. It is. However, you have to remember that men who get P &L implants, P &L prosthetics, they don't get it until it doesn't work anymore. Okay? So, if a man is getting normal erections, it would be crazy.

53:30It would be crazy. You cannot change size or girth in that way. As a matter of fact, you're going to lose a little bit. And you're never going to be as good as when you were 18. So that's something I tell every guy that put a P &L implant in. If you get a knee implant when you're 65, you're never going to be as fast as you were when you were 25.

53:48Dr. Gabrielle Lyon:Good analogy. It's actually a really good analogy. Why? Because you get knee pain, what's the first thing they tell you? Exercise, physical therapy. You get ED, what do we tell them? Eat better, exercise. Your erections will get better. When that fails, you go back to the orthopedist. They say, how many still hurts? They say, okay, try these anti-inflammatories. Try these pills to help with the medication. Whether it's glucosamine, whatever it is. What do we do for guys? We give them pills. Cialis, Viagra, Levitra. That eventually fails. Will it always fail or not necessarily? So of all the men we put on Cialis, Levitra, Viagra, two thirds it will work.

54:25One third it will never work because the penis is too sick in the first place. And of the men in which it works, on average it will last five years. If they have severe ED.

54:36Dr. Gabrielle Lyon:So they already have cardiovascular disease, right? Well, or another problem to have ED, neurogenic disease. Okay. So there's different cause for you, right? Maybe they had a surgery. Getting back to the point here, when you take the pills, they work for most for five years. And if you keep that level of health, they will work forever. Do you ever get off the pills? Is it possible to? Absolutely. Wow. If you turn things around to get healthier, you can get off of them. Or if you recover from a surgery, so to speak. But then eventually, most guys will come a point where the penis gets sicker and the pills aren't good enough anymore.

55:12Now what's next? It's a medicine that goes into the side of the penis, intracabernosal injection. And it's pretty good at giving guys erections that are usable in most men that have failed pills. Not all, but most. And then eventually either the guys say, no, I don't wanna do this anymore. And that's quite a few men. Or it stops working again. And then you say, okay, it's time for surgery to fix it. But it's a surgery. It has risk of surgery. And so the guy who gets the knee replacement, Is he walking? Is he running a marathon the day after surgery? Of course not. He's walking to the mailbox, maybe.

55:44And then a few months later, he gets used to it. And now he's maybe jogging around the block. But he's never going to be running the same 100 meter dash time that he was when he was 18. Similarly for guys, they get surgery. There's a month recovery period. They start to use it. It's a little bit goofy at first. And they get used to it. And then it's the best thing since life spread for them. That's what most patients say who get it. Like 90 to 95 % of men who get implants will say, this is awesome. I'd recommend it. But the point of this very long story is that, you know, we don't do the surgery unless the guy wants it because it isn't working.

56:18Right. So the time where we think about surgery is when the pills fail and either nothing works or guys don't want to do the shots. And we used to, our guidelines used to say, yeah, listen, I'm not touching you with the scalpel until you do all these things. Now we've changed our stance and said, you know what, whatever the patient wants, as soon as they fail pills, If they don't want to mess around with these injections, which not many men do, they can get the surgery and they can do fine. So yes, when I put the implant in, if I take it out, it ain't going to work. No matter what, you cannot reverse it back.

56:48You can't die to exercise your way back. But it wasn't working before I put it in. So essentially they're going back to baseline. And in terms of having to take it out, do you have to take it out? The only time you have to take it out if it gets infected. That's relatively rare. If it breaks, you can leave it in. Maybe you want to swap it out. If you want it to work. Some guys say, no, I'm retiring from being sexually active. Other guys say, absolutely, let's switch it out. And we do. Can we touch on sexual rehab? We've got a lot of things that we know are going to cause problems with your sex life, certain surgeries in both men and women, particularly pelvic surgeries, any surgery that affects either the blood flow to the genitals or the nerves.

57:32There are things we can do to help rehabilitate the nerves and the blood flow or spare them in the first place. Right. So-called prehab. Before you do the surgery, you kind of optimize things so they take less of a hit. The number one predictor of a guy having problems with erections after a prostatectomy, a surgery to remove the prostate for cancer, is how good or bad the erections were before they had the prostatectomy. but people with great erections they'll have they'll have to have this surgery because it's a cancer that is threatening their life and so you do a surgery and sometimes there's collateral damage in the vicinity of the prostate live the nerves and the blood vessels that feed the penis those nerves either get temporarily or permanently injured or those blood vessels same same approach so the field is moved to the point where well we know there's probably going to be some negative side effects from doing these type of surgeries.

58:25How can we help guys best recover as quickly as possible? And it involves using pills, using vacuum devices to help stretch the penis and exercise it. And that helps prevent loss of length of the penis, the shots that we talked about. And then if that fails, typically about a year after a surgery in which we know the erections are kind of gone, I'm not coming back, we'll do the surgery if guys want to fix it.

58:51Dr. Gabrielle Lyon:What percentage So someone has a radical prostatectomy. They had aggressive prostate cancer. They get the surgery. They recover, full remission. They move to the shots, right? This is kind of like the next pill's shots. What are the chances that they will be able to maintain our erection with just the shots? So if someone's listening to this and you're like, oh my gosh, do I actually get the surgery or not get the surgery? Before I give you the specific number for surgery, not all prostate cancer is the same and not all of it merits surgery the next day. Some of it you just watch and you die of something else.

59:29But presumably you're treating a guy who has aggressive prostate cancer where if they don't treat it, they're going to die likely within the next five to ten years. You've got different options. All of them hurt to me. But you saved a life. Correct. So you're making a trade. And there's really no prostate cancer treatment that is an active form of treatment that doesn't have consequences. Whether it's taking away hormones, whether it's giving radiation to the field, whether it's freezing the prostate, whether it's cutting it out and throwing it in a bucket, the prostatectomy of the scalpel. They all have consequences.

1:00:04Yeah, well, that's kind of how, you know, you have to think about it. if you think of the anatomy, you've got a bladder, you've got a prostate, and then you've got the check valve, which controls urination, and you've got this urethra. You take out this prostate, you send it to the pathologist, and next to that prostate are the nerves and the blood vessels that are very important to help with erections. So there's this collateral damage. But yeah, you're going to live a long time. The good news is we can fix it. But this whole rehab that we're talking about is a series of things that the patient can do to take the initiative to maximize their chance that they won't need the surgery, that they won't need injections, that they'll get away with just pills.

1:00:47So the number of men that get away with just pills, somewhere in the range of 25 to 50%.

1:00:51Dr. Gabrielle Lyon:That's a lot. Yeah, it's reasonable. And again, especially if they've got great erections before. So basically the younger they are with the less cardiovascular disease, which would also make prostate cancer unusual in that age demographic, you would expect them to recover. So those would be kind of like the unicorn. But again, if you are getting a surgery, rely on your loved ones to help make sure you're checking all the boxes that are important to you. You're going to have the blinders on, cancer, cancer, cancer, cancer, I'm going to die, I'm going to die, I'm going to die. So that's all you can think about.

1:01:25But we had talked earlier about, on a different episode about preserving your fertility, right? That's very easily forgotten. And then all of a sudden, you've recovered from your whatever cancer treatment you got, and you're like, oh, time to start a family. Uh-oh, too late. That ovary's been radiated, or the testicle has been exposed to chemotherapy. Definitely should have cryopreserved either tissue or sperm. Same thing for people going to surgeries. How am I going to optimize my psychological health? How am I going to optimize my sexual health? Or whatever else is important. but it's very difficult for the patient who is the patient to think of all these things that's why you got to lean on your support network your family your friends and your physicians a good question is like what other than cancer this cancer treatment should i be thinking about what have other patients have experienced what kind of regrets have the patients had who've had this surgery like what mistakes did they make that i can avoid it's a very fair question and i'd argue that a good surgeon or a good practitioner that's going to be giving you the chemotherapy or the surgery, the radiation, whatever, hopefully should be talking to you about these things.

1:02:36But at the same time, I think you should come in with a list of questions that are important to you to make sure you get covered.

1:02:42Dr. Gabrielle Lyon:Dr. Tobias Kohler, always a pleasure. You are both hysterical and deeply professional and capable. Is there one thing that you want to leave us with? You've left us with so many nuggets to think about, but I really feel like you're on a mission to change, like you had mentioned earlier, men's agency? I want people to be proactive, not reactive. You got to take command of your own health. Get an understanding of how your body's supposed to work. There are so many resources available to you. Ask the tough questions, write them down ahead of time. Don't leave the question like, what about this doc as he or she is leaving the office?

1:03:21Come up with a game plan and then act on it. You're in charge of your own destiny. Take advantage of it. The human body is amazing. Before I go, I want to tell you a quick story. I have a guy who came to me because all of a sudden he couldn't pee anymore, right? He was having problems urinating. He needed a catheter. And so normally when I see this type of person, I'm going to talk to him about a surgery to help open up the prostate so they can urinate without a catheter. Turned out this guy had really bad prostate cancer, like really bad. And when I checked his PSA was in the thousands. Oh my gosh.

1:03:56Anything above 50 means bad prostate cancer. His PSA was really, really, really high. By the time he came to me and was diagnosed, he had a giant prostate cancer mass in his pelvis. He was on the verge of having horrible complications from it or even dying. This guy was a super successful physical therapist at Mayo Clinic who took pride in lifting weights every day. That was his thing. And he also has a neurologic disease where he has an assistant. He has trouble walking on his own, but every day he hits the gym and he's doing bicep curls, he's benching, he's doing tricep extensions. And he says to me, listen, the thing that I fear most is not necessarily to die, but is that if you treat my prostate cancer, I'm going to lose my testosterone, I'm no longer going to be able to be strong anymore.

1:04:46And so I really had to negotiate with him. Like, listen, man, if we do nothing, there's going to probably be some really bad events. We're going to need major surgery. There's going to be problems with the bowels and all these kinds of stuff. He's like, all right, man, I'll do it. I'll start this treatment. And the treatment involved taking away his testosterone, right? Which can be a treatment. So he was absolutely mortified of starting this drug because he thought he was going to lose all muscle mass. I said, listen, man, just because you don't have T doesn't mean you should stop exercising.

1:05:16I want you to lift as much as you can, just like you're doing now. Just see what happens. So I expect him to come back and be like, yeah, you know, I'm getting weaker, but I'm still exercising. I'm like, good for you. This is what I expected to tell him. Turns out he comes back to my office two months later and he's noticeably bigger. Like he's jacked all of a sudden in his upper body. I'm like, what is, dude, what is happening with you? He's like, I don't know, man, but I'm just hitting all my PRs. I've never been as strong as I am now. With zero testosterone, we intentionally took it away. Extraordinary.

1:05:51And why? Well, the answer is because his prostate cancer was so bad that he had so many anti-inflammatories. His body was system shunting all away his muscle development to just to keep him alive. He had all these inflammatory markers, his cytokines, making him weak and shrinking his muscle. So with zero testosterone, this guy, I'm sure, is stronger than many, many men of his age. And he was so proud. And man, should he be. And so that's the story. The body is amazing. This guy got strong with no T just because he was dedicated and he practiced every day.

1:06:26Dr. Gabrielle Lyon:Well, I am really grateful to call you a friend. And thank you again. The world is going to hear more from you, Dr. Tobias Koehler. Thank you.