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The Peter Attia Drive
#260 ‒ Men’s Sexual Health: why it matters, what can go wrong, and how to fix it | Mohit Khera, M.D., M.B.A., M.P.H.
Jun 26, 2023
02:33:12
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Quick takeaways
- Lifestyle modifications, such as diet, exercise, sleep, and stress reduction, play a crucial role in improving sexual health.
- Erectile dysfunction (ED) can be a warning sign of underlying cardiovascular problems, with 15% of men with ED experiencing a cardiovascular event within seven years.
- Peroni's Disease can be treated with medical interventions like collagenase injections, surgical procedures, or the use of traction devices.
- Assessment of arterial and venous function, as well as lifestyle modifications and cardiovascular risk reduction strategies, are important in managing ED and promoting overall cardiovascular health.
- Treatment options for erectile dysfunction (ED) include medications like PDE-5 inhibitors, injections, and penile implants.
- There is emerging evidence that testosterone therapy may have a protective effect against the development of prostate cancer and that testosterone therapy is safe in prostate cancer patients.
Deep dives
Importance of Lifestyle Modifications for Sexual Health
Lifestyle modifications, such as diet, exercise, sleep, and stress reduction, play a crucial role in improving sexual health. These modifications can have a significant impact on the quality of erections and overall quality of life. Studies have shown that lifestyle changes, including weight loss and adherence to a Mediterranean diet, can lead to improved erectile function. Additionally, lifestyle modifications have been found to enhance endothelial function, which is closely linked to both erectile dysfunction and cardiovascular health.
Diagnosis and Treatment of Erectile Dysfunction
Erectile dysfunction (ED) is a prevalent condition, with 52% of men over the age of 40 experiencing some degree of ED. Diagnosis often involves using validated questionnaires and assessing arterial and venous function via ultrasound. Treatment options for ED include oral medications like Viagra, Cialis, Levitra, and Stendra, which inhibit phosphodiesterase enzymes and increase cyclic GMP levels. For patients with venous leakage, a constriction band or tourniquet may be used to enhance rigidity. In cases of arterial insufficiency, alternative treatment options such as penile injections may be considered. Lifestyle modifications, including diet, exercise, and stress reduction, should also be emphasized.
Peroni's Disease: Causes and Treatments
Peroni's Disease is characterized by a curvature of the penis due to the formation of plaque in the tunica albuginea. It is often associated with trauma during sexual activity. Treatment options for Peroni's Disease include medical interventions like collagenase injections to break down the plaque, surgical procedures to remove or bypass the plaque, or the use of traction devices, which can help straighten the penis. The choice of treatment depends on the severity of the condition and individual patient preferences.
The Link Between Erectile Dysfunction and Cardiovascular Health
Erectile dysfunction (ED) has been found to be closely related to cardiovascular disease. Studies have shown that ED can be a warning sign of underlying cardiovascular problems, with 15% of men with ED experiencing a cardiovascular event within seven years. The connection between ED and cardiovascular health is attributed to shared risk factors and endothelial dysfunction. Assessment of arterial and venous function, as well as lifestyle modifications and cardiovascular risk reduction strategies, are important in managing ED and promoting overall cardiovascular health.
Treatment options for erectile dysfunction
The speaker discusses various treatment options for erectile dysfunction (ED), including medications like PDE-5 inhibitors, injections, and penile implants.
Different types of premature ejaculation
The speaker explains the two main types of premature ejaculation: lifelong and acquired, and discusses the various treatment options for each type.
Factors affecting testosterone levels
The speaker discusses the factors that can affect testosterone levels, such as age, obesity, and comorbid conditions, as well as the importance of free testosterone levels in determining symptoms and treatment.
Options for testosterone replacement therapy
The speaker explores different methods of testosterone replacement therapy, including medications like chlomiphene and HCG, as well as injectable testosterone and pellets. He highlights the pros and cons of each option.
The safety of testosterone therapy in prostate cancer patients
There is a common concern that testosterone therapy may increase the risk of prostate cancer. However, multiple studies and guidelines have stated that there is no association between testosterone therapy and prostate cancer. In fact, there is emerging evidence that testosterone therapy may have a protective effect against the development of prostate cancer, as seen in studies using bipolar androgen therapy in patients with metastatic prostate cancer. These studies have shown improved quality of life and even improved overall survival in patients treated with high-dose testosterone. The saturation model of testosterone and PSA levels suggests that raising testosterone levels within the normal range does not significantly increase PSA levels. Overall, the evidence suggests that testosterone therapy is safe in prostate cancer patients.
The benefits of testosterone therapy in breast cancer patients
While the use of testosterone therapy in breast cancer patients is still an area of ongoing research, there is evidence to suggest that testosterone may have a protective effect against breast cancer. Some studies have shown that testosterone therapy in women with breast cancer does not increase the risk of disease recurrence. Other studies have suggested that testosterone therapy may be used as an adjunct to therapy, particularly in estrogen-sensitive breast cancers. However, more research is needed to fully understand the role of testosterone in breast cancer and the potential benefits of testosterone therapy in this population.
The controversy surrounding finasteride and its potential side effects
Finasteride is a medication commonly used to treat conditions such as benign prostatic hyperplasia (BPH) and male pattern baldness. However, there is ongoing controversy surrounding the potential side effects of finasteride, particularly post-finasteride syndrome (PFS). PFS is a condition where patients experience persistent sexual and neurological symptoms even after discontinuing finasteride. While the prevalence of PFS is not well-established, studies have shown that a subset of patients may develop these symptoms. The mechanism behind PFS is still unclear, but it has been hypothesized that epigenetic changes or hormonal imbalances may play a role. It is important for healthcare providers to inform patients about the potential risks of finasteride use and to engage in shared decision-making when prescribing the medication.
The shifting paradigm on testosterone and prostate cancer
Traditionally, there has been a belief that testosterone may fuel the growth of prostate cancer. However, recent studies have challenged this notion and suggested that testosterone therapy may not only be safe but also potentially protective against the development of prostate cancer. Clinical trials using bipolar androgen therapy in patients with metastatic prostate cancer have shown promising results, with improvements in quality of life and even overall survival. Additionally, there is emerging evidence that testosterone therapy, when used appropriately and in the normal physiological range, does not significantly increase prostate-specific antigen (PSA) levels. These findings indicate a shifting paradigm in the understanding of testosterone and its relationship with prostate cancer.
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Mohit Khera is a world-renowned urologist with expertise in sexual medicine and testosterone therapy. In this episode, Mohit provides a comprehensive overview of male sexual health. He begins with an in-depth exploration of erectile dysfunction, shedding light on its prevalence across different age groups, diagnostic methods, and its intriguing connection to cardiovascular disease. He then ventures into Peyronie's disease, penile fractures, penile enlargement treatments, prolonged erections, premature ejaculation, and anorgasmia. Shifting gears, Mohit delves into the intricate workings of testosterone, DHT, and estrogen, emphasizing their physiological significance and interplay. He explains blood tests for diagnosing low testosterone, the correlation between symptoms and blood levels in cases of low testosterone, and the pros and cons of different methodologies for increasing testosterone. He concludes with a thought-provoking conversation about the role of testosterone in patients with prostate cancer and addresses concerns surrounding DHT, finasteride, and post-finasteride syndrome.
We discuss:
- Mohit’s career path and interest in sexual medicine and infertility [3:00];
- The anatomy of the male genitalia [5:45];
- The prevalence of sexual dysfunction, its impact on quality of life, and the importance of seeking help [7:15];
- Erectile dysfunction (ED): definition, diagnosis, pathophysiology, and more [11:00];
- The history of medications to treat ED and the mechanisms of how they work [15:30];
- Relationship between aging and erectile dysfunction and Mohit's approach to treating patients and prescribing medications [20:00];
- The impact of lifestyle on sexual health and the association between ED and cardiovascular disease [29:30];
- Causes and treatments for Peyronie’s Disease, penile fracture, and more [37:30];
- The value of ultrasound for ED diagnosis and management strategies [47:45];
- Various treatment options for ED: injections, penile prosthesis, and more [50:15];
- Priapism (prolonged erection): what is happening and when to seek treatment [57:15];
- Shockwave therapy as a treatment for ED [1:02:45];
- Stem cell therapy for ED [1:08:15];
- Platelet-rich plasma (PRP) injections as a treatment for ED [1:12:00];
- Premature ejaculation (PE): prevalence, pathophysiology, and treatment [1:14:45];
- Anorgasmia: causes and treatment [1:22:00];
- The interplay of sex hormones, the impact of aging, symptoms of low testosterone, and considerations for testosterone replacement therapy (TRT) [1:26:45];
- Methods for increasing endogenous testosterone [1:38:45];
- Testosterone replacement therapy: various forms of exogenous testosterone, weighing risk vs. reward, and more [1:52:30];
- The physiology and purpose of testosterone and DHT, why some men feel fine even with “low” testosterone, personalized approaches to treating low testosterone, and more [2:02:30];
- Post-finasteride syndrome [2:09:00];
- The role of testosterone in prostate cancer and addressing the notion that TRT could increase risk [2:16:15];
- The effects of testosterone as an adjunct to therapy for estrogen-sensitive breast cancer in women [2:27:15];
- Resources for those looking for healthcare providers [2:28:45]; and
- More.
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