Professor Vaibhav Modgil

0:04Hello and welcome to The Midpoint. Today's episode is one I've been wanting to do for a long time and I finally think I have the perfect expert to talk to. Today we're going to talk about erectile dysfunction with Professor Vaibhav Modgil. And if you're listening to this as a woman and you think, oh, hang on, I'll just fast forward, this isn't for me. Well, hold on, because even if your partner is OK or appears to be OK right now, he may well suffer in the future. And it's not just middle-aged men who have erection issues. There are younger men increasingly presenting themselves with problems.

0:37And many of those issues that men are presenting with indicate something a little bit more sinister. So do listen up if you can. And just to reassure you that Professor Modgill is indeed an incredibly eminent voice on this topic. He's a consultant urological surgeon and andrologist at Manchester Andrology Centre, which is Manchester Royal Infirmary, part of Manchester University NHS Foundation Trust. And he is Honorary Clinical Professor at the University of Manchester and Editor-in-Chief of Trends in Urology and Men's Health. He serves on very many associated medical boards. He mentors surgeons and he's the male fertility lead at St Mary's, Manchester.

1:16He's produced 60 academic papers since 2019. So in short, what this man doesn't know about erectile function isn't worth knowing. Let's go meet Professor Modigil. Professor Modigil, can I call you Phoebe? Phoebe's fine. Because I've heard that's what people call you. Quite right. Yeah, or prof, maybe. We'll go with Phoebe. I've given quite an upsum of your incredible career, eminent career to date in your introduction, to kind of reassure the listener that we do have, I think, probably one of the best people on the planet to talk about this topic. And it's been one I've been wanting to get stuck into for a while.

1:52what drew you into urology and this area in the first place though? Good question. Firstly, thank you very much for having me. Let's hope I live up to it. I haven't heard the intro but let's hope I live up to it. To be honest, I always wanted to be a surgeon from a very early stage and like many things in life, it was probably more being surrounded by people who I looked at and thought, I want to be a bit like you. and most of them happened to be at that time when I was training I was young urologists and then I think it was a case of once I'd done my general urological training I met people who were men's health specific specifically men's sexual health surgeons and reproductive health surgeons and I got more and more drawn into that because a I don't think it's particularly well served um but b and I'm sure we'll come on to it in the goodness of time, I think there's a lot to be said about the stigma that goes with it still, even in 2026.

2:56So it was a combination of things, really. But that's probably where it came from. Let's get stuck into it then, because men do still find it difficult to talk about their erectile dysfunction or functionality generally, don't they? It's not something that you hear them talking about in the same way that women can talk to each other about their gynecological issues 100 right and you've you've you've come on to two things there so number one the difficulty that men have and number two why is it that our female counterparts don't have the same difficulty um i don't think we really have a complete answer for it it's multifactorial but men historically have always struggled less so now i think because of the advent of social media the internet information being widely available.

3:50That's a double-edged sword because widely available information doesn't mean that it's reliable. There's an incredible amount of misinformation out there. And so men, I think, struggle to present to a doctor, a surgeon, even to their own partners sometimes, with things that are deeply intimate to them. You know, erectile dysfunction, if we look at the figures, It's about 300 million men across the world, if not more. And when you say dysfunction, are we talking, is it all the same? You know, are there degrees of? No, so there's always degrees of, you know. So, and this is what I say to patients when they come in, you know, is it that you do not develop an erection at all?

4:37Is it that you maybe do develop an erection, but actually it's not what you deem to be 100 % of what it used to be? is it that you develop an erection, but you can't sustain an erection. So you do have to tease out what the issue is. But it's a broad term encompassing all of those things. And if you look at the prevalence, it's over 300 million. And we could talk about figures all day, but even in the under 40 age group, it's probably somewhere between 8 % and 12%. It's about 50 % to 55 % in the 50 % and above age group. And it's pretty linear, you know, so it's about 60 % at the age of 60 and 70 % at the age of 70.

5:19And of course, the impact that that has on people does vary with age. Because if you look at population data in terms of, you know, how often is a 25-year-old likely to engage in intimacy? Well, it's probably looking at population data somewhere around twice a week. At 50, that goes to once a week. At 75, it goes to once a month. So how it affects the patient does depend very much on their individual circumstance. So you touched on a few different things there. Age in terms of the perception being, oh, it's a midlife type thing. You know, you're on a podcast called The Midpoint. But actually, in reading up on your notes ahead of this, a lot of younger men are experiencing issues.

6:06And in your introduction, I also say to our audience, of which probably there are more women than men who listen to this podcast, cast, you know, whoa, whoa, whoa, hold on, this might not be your husband, but it could be your son. And it could also another young man that you know, is that an increasing problem? I think the presentation of erectile problems, I don't necessarily want to call it dysfunction. And this is anecdotal, really, from my practice, you know, over the last 10, 15 years, it is increasing. Whether or not that's organic and what I call genuine erectile dysfunction, i.e. a vascular issue or a nerve related problem or an anatomical problem or a hormonal problem, in younger men that tends to be extremely unlikely.

6:53It's normally driven significantly by psychogenic components. So it's their perception of what is normal. It's perhaps even to do with what they've seen online. And again, you know, pornography 30, 40 years ago was nowhere near as easily available as it is now. So the advent of pornography becoming so available, as well as the sort of the bombarding of information that young men get on social media contributes to what they think is abnormal, but actually might very well be normal. You know, So if you look at online data on what is the normal stretch, penile length or erectile length, you know, what is the amount of time that an average male will sustain an erection before they ejaculate?

7:44We call that intravaginal latency time. If men don't know what normal is, well, the perception always is that these sources can prey on their insecurity and then tell them, oh, perhaps you're not normal. And the major issue becomes that once that seed is sown, it's very difficult to then backtrack from there. So in younger men, it is predominantly psychogenic. Right. And can they come through that by kind of reversing those psychological effects? Absolutely. And I think that's where the power of conversation is, you know, unrivaled, where psychosexual counseling, reassurance. you know, giving them the right information.

8:31And, you know, when it comes to things like, you know, testosterone, for example, you know, you ask most young men and they'll tell you on their Instagram feed, Facebook, X, TikTok, whatever it might be, they'll see adverts because they're targeted, you know. And even in major sporting events, et cetera, you know, half time you'll see adverts for pills or things like that. And to some degree, that's good because we're having a conversation about it. but actually in other ways is deeply damaging as well. I want to talk about testosterone, but we might get to that a little bit later on because specifically around the area for midlife men, how it drops off and whether they should consider boosting it in the same way that women do in their HRT combinations.

9:17But sticking with the functional kind of issues that men present with, if we say largely it does tend to be slightly older men and the younger men are a smaller cohort of your patients, your clients, your patients. Of your patients. Is it normal stuff that happens with, you know, kind of, you know, should they just think, well, like, this is normal, it's middle-aged and this is what happens? Or can they be helped? Yeah, so with erectile dysfunction, and I think it's not often I would turn around and say, you know, if there's going to be one thing that you take away from this podcast, let it be this.

9:57but I feel pretty strongly about this. Erectile dysfunction in a man, particularly above the age of 40 or certainly 50, is one of the most valuable indicators that your body can give you. Because the link between erectile dysfunction and cardiovascular disease, for example, a man's overall well-being is inextricable. You know, they are very, very closely linked. So if we delve into some of the data on that, we know that men with erectile dysfunction at, say, the age of 50 and above are far more likely to have. Now, let's start with the psychological aspects of it. So 33 percent of those men will have significant degree of anxiety.

10:4860 to 65 percent of them will be depressed. We then move on to the cardiovascular impact. So we know several studies have shown a link between developing erectile dysfunction and a subsequent cardiovascular problem within two to five years. So if a man's listening to this or if a partner or if anybody else is listening to this and they know someone that might apply to you, you have to ask, why is it happening? And we're a society that's deeply obsessed with let's just fix it. And how do you fix it? Well, you look at data again. even in men younger than the age of 45 on online pharmaceutical access to drugs like viagra the big the big online agencies that that supply this stuff about 60 to 65 of their clientele are actually under 45 and the vast majority of those probably don't need it and so what do we say when a man develops a erectile function you know they might have a conversation in a pub or with their mates and they'll say oh i i take this pill you you might want to try it which is fine because it's there to treat erectile dysfunction but what's not fine is not understanding the underlying basis of why it's happening in the first place and presumably as is the case with a lot of men anecdotally and i'm sure there is data to back this up they present later with problems yeah they wait longer yeah they absolutely do so another very famous study they looked at men with coronary artery disease.

12:19And that's, you know, coronary artery disease for people who are listening is things that affects the blood vessels that effectively supply the heart. So thickening of the blood vessels or some degree of blockage to those blood vessels. And they found that on average, the time lag or certainly the time between developing erectile dysfunction in men with coronary artery disease to them developing angina, angina is chest pain or shortness of breath when you exert yourself it's 39 months months so what is the link then are those men they've obviously got this pressure on their heart right so is it their diet their lifestyle are they overweight generally and are they like that already with the when they're when they're you know not having the functionality they want it's it's all of the above.

13:11I remember being at med school and one of our tutors in med school saying, you know, medicine's not that hard, guys. It's basically all about blood supply going to where it should go. And you sort of thought, well, what am I doing here for five years then if that's all it is? But actually, he was completely right. Because like any part of your body, if blood doesn't get there when it needs to get there, that part of your body is going to suffer. So it's a vascular problem, predominantly erectile dysfunction. So it makes complete sense. Now indulge me if you would for a second, but there is this thing called the artery size hypothesis.

13:49The average diameter of a penile artery is somewhere between one and two millimeters. The average diameter of a cardiac artery is probably somewhere between two and four. And the average diameter of the carotid, which goes up towards your brain is somewhere between four and eight. So it makes complete sense that if your erections go first, because you've got a vascular problem, a blood supply problem to the penis, well, as it gets worse, where's it going to go next? It's going to go to your heart. And if it doesn't go to your heart, then it's going to go towards your brain. Right. You know, so that's where you get the correlation between heart attack.

14:29You get the correlation in figures between erectile dysfunction and stroke. so when men present you with a problem and they are overweight and their diet is poor they're probably not sleeping very well either how receptive are they to making those big lifestyle changes and when they do how quickly do they notice a change in their erectile function how receptive are they some are some aren't i drive a pretty hard line um in that i say you know So you've been given a wonderful opportunity. You're feeling miserable. You've got anxiety. And you lack intimacy in your relationship or whatever situation you might be in.

15:11So all these things are deeply important to you. And isn't it great that if you want to improve all of these things, actually you're just going to improve your overall health in the process. And how are you going to do that? You absolutely have to lose weight. Because losing weight will help your serum testosterone go up. You know, so studies again showing if you lose 10 % of your body weight, you can raise your serum testosterone by two nanomoles per liter. Okay, so that's 10 % of your body weight. Now, admittedly, it's a bit more nuanced than that. You don't want to lose lean muscle mass. You want to lose fat percentage.

15:45If you sleep well, you know, another fascinating study which showed men that sleep less than six hours versus six to eight hours versus over eight hours. So those were the three groups that they put them in. If you slept less than six hours, your erections suffered. Interestingly, if you slept more than eight hours, your erections weren't far better either. The sweet spot was probably somewhere between six to eight hours. So you've got to sort your sleep out. You've got to get the fat percentage down. You've got to get lean muscle mass up. And therefore, and you will know this only too well, the the huge emphasis now on strength training you know strength mobility flexibility 20 30 years ago it was all about you've just got to do HIIT training and cardiovascular exercises and walk around the block 10 times that's not a bad thing of course it's a great thing to do but but we underestimated I think the the power of strength work its subsequent impact on a man's serum testosterone and therefore insulin resistance and the sort of metabolic outcome that you get from that.

16:53And young men who have succumbed to being bombarded with messages of how they should look and the things that they should take and some of those things as you point to are not things that you would you know particularly want to put in a young man's body whether it's you know steroids and other powders that convince them they're going to get bigger and stronger and bulk up quicker how are they affecting their because we hear these anecdotes that you know testosterone yeah yeah testosterone um and it's rife you know and again it's at multiple levels so there's one thing taking testosterone there's another thing taking testosterone which you think is testosterone but you don't really know where it's come from you don't know how much of what is in the injection and you've no way of measuring the outcomes.

17:45So it's dangerous. It's very dangerous. And, you know, across the board with testosterone, you know, there was a time when it was seen as the sort of fix-it-all agent. Then there was a time where it was very much the villain. And the truth is, is neither. Testosterone replacement therapy performed appropriately in a patient that needs it, and we can come on to why they might need it, is absolutely the right thing to do. But testosterone in a young man, for example, will make them infertile. Now, in my practice, when I see young men taking testosterone, and it's all the things that you would expect, you know, in terms of their reasoning, they want quick gains for the effort that they're putting in.

18:30Some might not be putting that much effort in, but they still want quick gains. Now, others are putting an incredible amount of effort in, but they want to feel like Superman. And testosterone can make some people feel like Superman. And it will do because there's a reason it's banned in elite sport. So but the negative impacts of that in terms of fertility, in terms of the effect that it can have on your full blood count, the risk to your heart, it's colossal. And there is really no reason that a young man should be on testosterone because, you know, in many ways you're at the peak of your powers when you're young.

19:06You're already producing more than enough testosterone. And if you train well, sleep well and eat well, your testosterone will absolutely look after itself. So when does it start to normally drop off? Yeah, so there's good data to show that, you know, 30, 35 onwards, you start to notice some dropping in that. But again, it's multifactorial. And we get really obsessed by this idea of a drop in testosterone. But you have to remember that true testosterone deficiency is more than a blood test. it's a drop in your blood test with the symptoms so if you feel great and your serum testosterone result is slightly low well a it could be an anomalous result but b we will probably run other blood tests to try and understand why your serum is coming out as low but you look great you feel great so it might not be what we think it is but in a man with true testosterone deficiency hypogonadism is is the medical term for it you will have a situation where they will have symptoms so they will normally say libido is low um generalized lethargy low mood low strength just a general lack of get-go i always say that you know for a guy with true testosterone deficiency it's like taking twins giving one a 20 kilo rucksack to put on their back and go about their daily business and saying to the other one, you don't have to have that rucksack on you.

20:30You know, it does negatively impact them. But more than that, it will have significant impacts on your bone mass density. So it's not dissimilar, actually, when you have that conversation about female hormones, hormone replacement therapy. It's not drastically different. But you'll find that a lot of that stuff, you know, the answer is not, oh, here you go, here's testosterone straight away. Now, sometimes it is. So if I've got a man who's grossly overweight, really struggling to get to the gym and their testosterone is really, really low, they don't want to have a family. So fertility is not an issue for them.

21:08Why wouldn't I give them testosterone? But I'd be monitoring it extremely closely because actually by giving that man testosterone, I might give them the get up and go. It's the crutch to get to the gym, to make the lifestyle changes. And then they might get to a stage where they don't necessarily need testosterone you know so um there is uh a bit a bit of kind of a conflict of opinion seems to be when you look online about whether or not if you've had prostate cancer when your testosterone dramatically drops off you should have a supplement of testosterone you are in favor of of this potentially being a managed situation absolutely so how does that work so we did a study last year um where we looked at 20 years worth of literature um in our research collaborative and i think it was 12 studies we looked at and it showed that men who were definitively managed for prostate cancer in whom testosterone was low when they were given testosterone therapy there was no difference between those that were given testosterone therapy and not given testosterone therapy in terms of their chances of prostate cancer recurrence.

22:19So there was another study in the British Journal of Urology in 2020, which showed similar data. And so, again, it's about doing it right in the right patient and doing it carefully. Now, having prostate cancer doesn't mean that you're going to have a low testosterone. It depends on the modality of treatment that you've had. So, you know, there are a huge number of men who have prostate cancer and don't have any treatment for a number of years, if ever. There are those that will go on and have a radical prostatectomy, you know, and we can talk about that in a minute. But there are also those that will then have radiotherapy and hormones.

23:02So all those things have different effects on a man's testosterone. It doesn't just mean, oh, OK, you've been given a diagnosis of prostate cancer. You're definitely going to have a low testosterone. That's not right. But the group in which people get twitched in terms of giving them testosterone are the ones that have been treated, definitively treated. So they're radical. They're radical prostatectomy group. And that's completely understandable. And I've got colleagues that still go to our annual meeting and other conferences around the world. People say, oh, I'm not taking that risk. Not on my watch, because I just don't know how that's going to turn out for the patient.

23:38And heaven forbid, they'll get a recurrence for their prostate cancer. And certainly that applies probably even more to the group that have been given. Because this is the thing that I think people find difficult to understand. If you've had your prostate removed, how you can get a recurrence of prostate cancer. And that is, you know, because I know from Kenny's experience, obviously he's every six months he's got one coming up has to do with blood. Yeah. And I get to how if you haven't got a prostate, how are you going to get prostate cancer? Because I try and kind of think of it in women terms.

24:06OK, so women who know they've got the BRCA gene and have a double mastectomy. so that they can't get breast cancer. But it's not the same thing. No. Well, it is and it isn't. I mean, I'm not a cancer pathologist or a cancer specialist. But the entire idea of surveying people in terms of doing blood tests, scans, etc., also hinges very closely on the kind of disease they had in the first place. Not all prostate cancers are the same. so if you've got a localized prostate cancer and it's been definitively treated the surgical margins are negative and depending on the initial grade of your prostate cancer your likelihood of might be drastically different to an individual who for example had a high grade prostate cancer but nonetheless they all require surveillance right so it's not a one-size-fits-all with regard to absolutely not it's really it's really nuanced good results for people that you are treating who've had prostate cancer yeah well i've got patients who've had prostate cancer and i've given them uh testosterone therapy but again it's all about the conversation that you have you know medicine is at least 50 counseling your patient you know gone are the days where you say to the patient you're not doing that you are doing this you need to have a conversation and say look, here are the potential pros and here are the potential cons of this.

25:30I can't tell you all the time exactly how it's going to go, but what we're going to do is watch it very, very closely. So provided it's giving you symptomatic benefit and your blood tests are behaving how we want them to behave, by all means take it. So in your bio, I've read the work you do with penile implants. I have no idea what that is. Okay. So that's probably, well, you're not alone. Let me put it that way. So traditionally, the treatment of erectile dysfunction has been lifestyle factor treatment. So the things that we've talked about, lose weight, get fit, sleep well, eat well. If that doesn't work, then men will most commonly take Viagra, you know, the blue pill, as it's known to many men, results are pretty good from that for the vast majority.

26:18And that is just taken when they want to have some kind of intimacy? Depends what kind of formulation they take. So there are tablets that you can take once daily. So some of my patients, you know, which is, to be honest, my preferred way of giving the tablet to my patient because life doesn't work that way. And, you know, you can't always, men and women both like a degree of spontaneity. So there are formulations. You can take it once in the morning. Forget about it. Go about your day as normal. and then hopefully it will kick in just as and when it needs to kick in. If tablets don't work, there are things like vacuum devices and injectables.

26:55So men can inject their penis as and when they want to be intimate. Now, again, it doesn't take a rocket scientist to know that for some men, you know, some men might turn around and say, yeah, actually, I will try a vacuum device and place a ring at the base of the penis. If that's what it takes to have intercourse, then yeah, I'll do it. And if I need to have an injection, you know, 30, 40 minutes before I'm hoping to have intercourse, I'm happy to do that as well. Now, there are those men in which that will work and they'll say, this works for me and that's great. And there are those men that will turn around and say, I'm not doing that, Doc.

27:30I'm really sorry. You know, I'm going away for the weekend. I'm not packing my hand luggage full of injections or a vacuum device or whatever it may be. so in men in whom either injectables have failed or vacuum devices have failed or men that don't want to do that penile implant surgery is a is a brilliant option and a penile implant is a device that consists of two cylinders that sit in the penis now the the inflating permanently so there's nothing to see on the outside world the the one that i most commonly put in is called an inflatable device there's also what we call a semi-rigid device which is more crude um and sort of less dare i say flexible in terms of offering a man the ability to have the penis in it in a flaccid state or an erect state so we can come on to that correct correct and but if you've got a patient who's got several comorbidities someone with really poor uh you know dexterity or hand function well that might be the right thing for them.

28:32How do they make it work then? So the malleable device or the semi-rigid device is purely a directional device. So they'll point it up when they need it and they'll point it down. Yeah, so as I say it's a very crude device. The other one is the inflatable and 99 % of people that come and see me get an inflatable device. And they inflate it when they need it. They inflate it when they need it. So the two cylinders sit in an area of the penis that once upon a time used to fill with blood. and no longer does. Right. And there is a pump that sits in the scrotum somewhere around, I say somewhere around, ideally between the two testicles, but lower.

29:13And that pump, when it's activated by the man squeezing the pump, drains fluid from a reservoir which sits in the abdomen. And again, nothing to see. So what I can do after we've had this conversation is put a link on wherever that may be. it's on our NHS website as well, to show exactly how it works. And one of our patients was really, really kind and actually said, you know, I had no idea, I couldn't even imagine how this might work. And now it works and I'm so happy. I'm happy to come in and be filmed and do an almost instructional video of this is how I inflate the device, this is how I deflate the device.

29:51Very generous of them. It is very generous, yeah, but it's helped so many people. I'm sure, yeah. Because if you can't see it, it's very difficult. How many of those devices are currently fitted in men in the UK? In the UK, I think the figures, it could be anywhere between 350 to 450, 500. Right. Because some of them do need changing. You know, their average lifespan is about 10 to 15 years. That was quite long then. Yeah, yeah, absolutely. And, you know, across our unit in Manchester, we're a high volume unit and we see really good results. And I would say to any man, it sounds frightening. I 100 % understand that.

30:27and I'll never sit here and say I know what it's like because I haven't got one but at the same time you know I've done a few and the vast majority of patients are really happy and I say to all of them as much as I'd love to think it's because they think I'm the world's best surgeon it absolutely isn't I think the thing that drives satisfaction in these men is the huge psychological shift that they experience from no autonomy no spontaneity their confidence is in their boots, and then suddenly this device allows them to sort of be in charge of their destiny. You know, they can have perissive intercourse or intimacy as and when they wish to.

31:09And an orgasm. And an orgasm, and some can ejaculate as well. How does it work when they have climaxed, finished? What happens? They control when the device goes down. So they just make it go down again. And if they don't want to make it go down, then they can keep it up. okay that's the clip i think the social media um so um so so there are lots and lots of different ways for men to to reach a better um state than their than their carolian as we've just talked about there um do you would you if a patient came to you and they were showing very unhealthy lifestyle choices and they were would you resist putting a pump into somebody who wasn't prepared to make, you know, it was a quid pro quo.

31:51You've got to do this first. Yeah, I think you do. I mean, to be honest with you, historically, we used to have this thing about men almost earning their penile implant surgery. We don't really do that in any other aspect of healthcare. You know, there used to be this dogma about, oh, they've got to have an injection or, you know, they've got to try a vacuum device. Well, what if they don't want to? It's a choice thing. What's really important is that they're counseled appropriately so that they know what options exist. And if a patient turns around to me, having read up about the options, the patient's been to my clinic a couple of times, says, I don't want that.

32:30I don't want to inject my penis when I wish to be intimate. Well, I think they're perfectly within their rights to make that decision, you know, so long as they know that injections exist. Yeah. So, you know, if you look at the satisfaction rates from penile implant surgery, they're pretty staggering. I don't do another operation that gives that level of satisfaction to a patient. And in terms of the other reasons why a man, and we discussed kind of the psychology and obviously the vascular elements. If you're a young, healthy man and you have an issue, could there be something else that's going on?

33:05Yeah, of course there can. And, you know, that's for every patient. And so when you go and see a clinician, you know, if a young man comes to see me, it's not a case of, oh, it's all in your head, mate, you know, and dismiss it. That's the worst thing you can do. Because first things first, you've got to acknowledge what it took for them to walk into your room, particularly for the younger patient. I'm massively reassured if they walk in with a parent or their partner or a friend, because I think at least they've shared that burden. because you can't underestimate the burden of something like that on a young man.

33:43You know, young guys can get themselves in a really, really deep hole and it's difficult to get out of that. So the first thing I'd say to any young person or anyone who knows a young person who's listening is if you think that's going on, please try and initiate some form of conversation. You know, and there's several different ways of doing that. You also, you mentioned before, have fertility kind of experience as well. What are you noticing about male fertility patterns? Yeah, so it's not a big secret. We have seen a sort of global deterioration in sperm parameters over the last 20 to 25 years.

34:21And again, that's multifactorial. And it's for the same reasons that we see many of the other health problems that we see. So, you know, substance use is obviously a part of that. You know, again, take testosterone. There'll be no sperm in your ejaculate, depending on how long you do it. But actually, if you're a young guy, just don't do it. just don't take testosterone. You know, seldom do you need it. There are other ways to get you on testosterone. And can that be long-term? Absolutely. Long-term problems. It's not just a short-term fertility issue. Absolutely. You know, I've seen men who've been on testosterone therapy for a number of years.

34:53And the physiological problem that they get is once you take testosterone exogenously, i.e. from the outside world and put it in your body, your own body mechanisms that are there to produce testosterone stop working. Because the signals that you're giving your body is you don't need to make this anymore. And so that hormonal mechanism just shuts down. And when it shuts down, not only will you then be reliant on testosterone therapy for the rest of your life, but you will not pre-sperm in your ejacular. And these men end up having procedures under my care, such as testicular sperm extraction attempts, et cetera.

35:30And there's absolutely zero guarantee that they will be successful because they've so drastically altered the biology within the testicles. But it's not just the testosterone, is it? There's a lot to do with diet and other lifestyle. Yeah, so all the things that, I mean, almost all the things that I've mentioned that relate to rectal dysfunction, so obesity, you know, your diet, lack of exercise, lack of cardiovascular health, lack of strength training, which again maintains your testosterone levels. So it's multi-multifactorial. Yeah. Is it for you taken seriously enough on a kind of government and policy level?

36:10Well, last year we had the Men's Health Strategy, which was a very significant move in the right direction. And, you know, a lot of people have been lobbying for that for a long time. I mean, I think the Aussies have had one for several years. So that sort of thing will move things in the right direction. But you're speaking to someone that's got an inherent bias. You know, it'll never be enough for me. You know, take, for example, prostate cancer. we know so much about prostate cancer now you know so many one in eight men i think it is in england um will be diagnosed with a prostate cancer in their lifetime one in four i think for black men staggering staggering numbers of men what do we do with these men once they've had treatment well then there's an absolute vacuum of information you know and if you go you know and i'm sure you'll know this from Kenny's experience, but you say to a man, you've got to have a radical prostatectomy now.

37:09And by the way, there's a risk of incontinence. There's a risk of erectile dysfunction. And again, if you look at the data, and this is where it amazes me that more men aren't having penile implant surgery, because we know we take lots and lots of prostates out for prostate cancer. And by the way, that's exactly how it should be. Let's not forget you're dealing with a cancer that could potentially for that man shorten their life expectancy. So do you need to remove it? Absolutely. In certain cases, you do. Not all cases, but in certain cases, you do. However, if you look at what happens to a man's erections, again, really brilliant study came from Professor Freddie Hamdi's group in Oxford and the New England Journal of Medicine in 2023.

37:58They screened 82 ,000 men for prostate cancer. of those um they ended up randomizing i think it was 1643 of these men to three different treatment modalities and they gave you know the three options were you're going to have something called active surveillance or monitoring which basically means we'll do blood tests we'll do scans but we're not going to do anything to you there's a group that's going to have their prostate removed radical prostatectomy most commonly done robotically now and there's a third group who were going to have hormones and radiotherapy. And they followed this group through.

38:38Now, the first statistic, and these men were between 50 and 69, the first statistic, which is really, really important because we're obsessed with this idea of, oh, if you have a radical prostatectomy, it'll give you erectile dysfunction. 67 % of those men, when that study started, reported an erection that was sufficient for intercourse. Nobody had touched them yet. So that means a third of them didn't have erections that they felt were good enough for intercourse already. This is even before we've done anything. In the active monitoring group, who again, no specific treatment, just monitoring, at six months, 52 % had erections that were good enough for intercourse.

39:24So what's going on there? They haven't had any treatment whatsoever. In the radical prostatectomy group, only 12 % of men had erections that were good enough for intercourse at six months. And in the radiotherapy group, who had hormones as well, only 22 % had erections that were good enough for intercourse. And if you take it one step further, six years following a radical prostatectomy, 17 % of men said that they could have intercourse. And that was without intervention at all? Yes. Right. So what does that tell you? It tells you that when we treat men for prostate cancer, we absolutely leave them with very significant quality of life issues.

40:13and so treating men for prostate cancer i'm i'm i'm all up for that and i think that's that's great and we've come such a long way and my colleagues that do that work do some phenomenal work um but we need to get better at the survivorship aspect of it and we need to get better at saying to those men are your erections okay because if they're not please do not suffer and silence. Come and tell us. Because they need not only pre-habilitation before their operation, but they need active rehabilitation. Because you're keeping them alive, but maybe removing some quality of life. Not some, but I would say, again, I'm biased, right?

40:53Because I just see men that come to see me about erections and testicle problems, but you're removing a really significant chunk of their life. And if you've got a man late 40s, early 50s, well hang on a minute that's that's colossal you know that that is absolutely colossal is it um you know we're told by female health practitioners that it's important for women's gynecological health if they can keep sexually active it is actually a positive outcome for the gynecological health yeah is it the same thing for men yeah absolutely i mean the penis is is 100 % a use it or lose it organ, you know, and people joke about that, but they shouldn't.

41:35Because again, going back to that analogy that I made at the start, it's a vascular organ. So if you don't get blood supply to it, then it's not going to do as well as if you do. So in terms of, let's go back to the prostatectomy patients. You know, what do you see in prostatectomy patients? You see penile length loss and you see penile volume loss. So when the patient comes to you in two to three years and they haven't been placed on a vacuum device, they haven't been placed on daily tablets, they've never had an injection. No one's made a concerted effort to help this man. They'll come back and they'll say, Doc, you know, I know you probably think this is my head, but I think my penis is smaller.

42:18It's not in their head. There's well documented literature to show that after a radical prostatectomy, men will lose penile size. Which again adds to the psychological issues. Of course it does. So now you've got a man who, you know, they look down and they think, gosh, I've had this really significant operation. Only I know how that feels. I don't feel drastically different otherwise. Still feel pretty young, actually. I still have libido. I still want to engage in intimacy. And I look down and my penis looks smaller. I'm not developing erections. And I really don't know what to do. and so I would say to anybody in that scenario you've got to go and see an andrologist you know which is the thing that I do a men's health surgeon, a reproductive sexual health surgeon and you know say I need some help here and you will get help you will get help you know and I say to my patients who are using vacuum devices after a radical prostatectomy I'm not giving you this device for you to develop an erection consider it physiotherapy for your penis That's what it is.

43:25And I want you to do it diligently. And if by 12, 24 months, 24 max, I'm a big advocate for early penile implantation for the reasons before mentioned about length loss, etc. But if you're trying injections, you're doing vacuum devices, you're using tablets, you're getting to that 12, 18 month mark, nothing's happening. Okay, we need to have a conversation about penile implant surgery. But you can only have that conversation if you're aware that it exists. If you're simply not aware that it exists, then you're not going to have that conversation. Yeah. Talking is everything as it is with so many issues.

43:59And as you say, you know, if you're listening to this and you think there's somebody in your world who could do with a conversation with a professional, then sooner rather than later with all of these things is better. And it seems from what you said as well that the treatments, you know, work and they're out there and it's not a hopeless case. if you know somebody or if you're a man listening to this and you've developed an element of erectile dysfunction you've got to ask yourself why and it's all very well taking a pill but it's fundamental that you understand the link between erectile dysfunction and your cardiovascular health there is ample data to show that erectile dysfunction is often followed within two to five years by cardiac disease or cardiovascular problems so you know i would say ignore that at your peril the pill the blue pill great it might help your symptoms but what's causing it and that's the bit we need to do a lot better uh thank you so much it's been absolutely fascinating to to chat and hopefully um it has been helpful to people for us to have this conversation because um it is it is one of those conversations i think that just feels it's still very taboo my pleasure thanks for having me thank you bb thank you

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