Speaker 1: Let's talk about it.
Speaker 2: Let's talk about the marrow. Let's talk about it. Let's
Speaker 2: talk about the man. Hero. Welcome to the man. Welcome
Speaker 2: back to the mailroom. Jordan Runta in the house. How
Speaker 2: you doing, man, You sound a little stuffy. Maybe talk
Speaker 2: to me about what's going on in your life right now?
Speaker 3: Man, Man, I went up to Uh, visiting my folks
Speaker 3: for a Memorial Day. I grew up on a on
Speaker 3: a lake in central Massachusetts. Seems like the perfect place
Speaker 3: to do some grilling, hanging out by the dock. But
Speaker 3: I got here and the place was yellow, just palling everywhere.
Speaker 3: And I've got nuclear grade allergies.
Speaker 2: Right now, sorry, everybody, spring is sprung. No, man, I
Speaker 2: think you know you're like half a register from Berry White.
Speaker 2: We should we should lay down some tracks. No, it's
Speaker 2: all good. You wear it well, But allergies suck. I
Speaker 2: have been blessed to not have those. But yeah, bummer, yeah,
Speaker 2: do you do a lager and all that stuff?
Speaker 3: Everything right now?
Speaker 2: Yeah, just the whole cocktail. See what works? Yeah? God
Speaker 2: bless you. How's your home? It was good? Ye know?
Speaker 2: Just did my run, got in the sunshine, worked on
Speaker 2: my citrus grove. I mean, all kinds of just fun
Speaker 2: California things to do. Citrus grove, what is sits grove?
Speaker 2: So I, you know, we moved back to California. I
Speaker 2: grew up here, as you know pretty much, and uh
Speaker 2: and I was gone for almost twenty years, and I said,
Speaker 2: if we're moving back, I really I gotta have an
Speaker 2: orange tree. I gotta have a lemon tree. We actually
Speaker 2: grew a lemontree in Colorado that I would take out
Speaker 2: every winter. I would bring in rather than in the summer.
Speaker 2: I would take it out and it would grow it
Speaker 2: on the deck. I mean, I was so citrus fixated
Speaker 2: because to me, that's like the sign of just you know,
Speaker 2: it's live and it's so good and fresh fortress. And
Speaker 2: I remember the first summer. It took two to three
Speaker 2: years of growing this lemitary about four or five feet.
Speaker 2: You know. It was a big ass planter and we
Speaker 2: had it on rollers so I could roll it in
Speaker 2: and out in the Colorado sun, which is amazing and
Speaker 2: it's incredible. But obviously the winter is we had to
Speaker 2: bring it inside into our little solarium. And I was
Speaker 2: growing this lemon and I was so excited. I had
Speaker 2: this beautiful lemon. It was green, it was just starting
Speaker 2: to get a little bit yellow, and then a squirrel
Speaker 2: ate it. And it was the worst. The thing that
Speaker 2: was so bad about it because I love my nature
Speaker 2: and our wildlife, but it just it hated it. It
Speaker 2: cut it, it bit it out, and it tried to
Speaker 2: eat it. It was like, this sucks. And so this lemon
Speaker 2: that I'd been nurturing for months to have my first
Speaker 2: lemon off my Colorado lemon tree, this goddamn squirrel ate it.
Speaker 2: So I was so pissed didn't get to enjoy it.
Speaker 2: And then finally, you know, got the call to come
Speaker 2: back to the UCLA, and I said, we're having trees.
Speaker 2: And so it started off with like one lime tree,
Speaker 2: and then I got a couple mire lemon trees. And
Speaker 2: now I've got navels and pomegranates, which I know is
Speaker 2: not citrus. But during my little grove, I've got grayfruit trees.
Speaker 2: I've got a couple of Eureka lemons, a couple of tangerines,
Speaker 2: cumquats kalmandan, you know those little delicious cum quite like
Speaker 2: varieties are fantastic. Yeah, So I have about thirteen or
Speaker 2: fourteen trees that I love to tend to is sort
Speaker 2: of my my outdoor therapy and getting a little bit
Speaker 2: of the sunshine. So yeah, and I'm not allergic to
Speaker 2: any of those things. So sucks to be you. Man.
Speaker 3: I was gonna say, my hometown is the birthplace of
Speaker 3: Johnny appleseeds.
Speaker 2: We're an apple no way there? Yea, all right, what's
Speaker 2: your favorite apple variety? Is it? Is it cosmic crisp?
Speaker 2: Gotta go? Oh really? Okay? Yeah, I got turned on
Speaker 2: to the cosmic crisp, which are absolutely fantastic. But yeah,
Speaker 2: Fuji's are great. Yeah, they're kind of a West Coast thing.
Speaker 2: I think they're grown in Washington, but they're they're pretty delicious.
Speaker 2: So that's what I got going on.
Speaker 3: You were a man of many talents.
Speaker 2: I don't know about that.
Speaker 3: Musicians, surgeon major and grove master.
Speaker 2: Grove master. Yes, I did spend time when I was
Speaker 2: a kid. I had a really good friend whose dad
Speaker 2: had a citrus farm in Alvocado Farm, so I did
Speaker 2: learn a few things when I was growing up, and
Speaker 2: we spent the weekends down there in San Diego, so
Speaker 2: I had that. But bottom line is just great to
Speaker 2: have your own fresh citrus so cool. So that's my deal. Hey,
Speaker 2: should we do something like medical or do you want
Speaker 2: to just let's talk about citrus And well, we did
Speaker 2: start out with allergies for example C vitamin C scurvy
Speaker 2: where you get limeys. From no offense to my British listeners,
Speaker 2: by the way, I won't call you limeies anymore. I promise.
Speaker 2: That's sort of a seventeenth or eighteenth century insult. But
Speaker 2: it's a supplement that works. Vitamin C is a supplement
Speaker 2: that works, so you heard it here. Not all supplements
Speaker 2: are bad. Yeah. I I was thinking about talking about
Speaker 2: ejaculatory disorders because when we started this gig a while back,
Speaker 2: one of our first guests was Natalie Finnger Goldberg, who's
Speaker 2: a sex therapist, and we brought up premature ejaculation, brought
Speaker 2: up delayed ejaculation, touched on a little bit. But it's
Speaker 2: something that's so common in my practice that I thought
Speaker 2: maybe we actually do a little Q and A with
Speaker 2: what's on your mind, as well as a little physiology
Speaker 2: for our an anatomy I guess for that matter, for
Speaker 2: our listeners out there, just because I think it is
Speaker 2: something that you can't talk about it enough, and it
Speaker 2: just always comes up and it can be vexing for
Speaker 2: my guys as well as the partners there with. So
Speaker 2: let's talk about it. Welcome to the mailroom. Let's talk
Speaker 2: about it. Yeah, so talk to me about Well, you
Speaker 2: tell me what you know about premature ejaculation, delayed ejaculation.
Speaker 2: What's the difference between ejaculation and orgasm?
Speaker 3: For example, Okay, ejaculation actually is the release.
Speaker 2: Of boom sperm, the money shot.
Speaker 3: And orgasm is something more internal.
Speaker 2: Orgasm is the euphoric feeling of when one expels a
Speaker 2: load of semen. Yeah, so that's the difference between jaculation orgasm.
Speaker 2: So there are guys the most common are men after
Speaker 2: prostate cancer surgery where we take out their ejaculation organs,
Speaker 2: which are the seminal vescals in the prostate where the
Speaker 2: fluid is made, but they still have orgasms. Sometimes they
Speaker 2: have more intense orgasms afterwards because they don't have that
Speaker 2: fluid to expel. So the same muscles are just squeezing
Speaker 2: joy and euphoric feelings up in the brain, and so
Speaker 2: orgasm is that sensation and ejaculation is the fluid. So actually,
Speaker 2: I think that's a reasonable place to start. So I
Speaker 2: think about ejaculation an orgasm in physiologic anatomic term. So
Speaker 2: there is a nerve that is on the tip of
Speaker 2: the penis in the area we call the frenulum, which
Speaker 2: if if you're standing up looking down at your penis
Speaker 2: and you see the head right on the opposite side
Speaker 2: of that head, so at the six o'clock position, that's
Speaker 2: an incredibly sensitive part of the penis. And it's also
Speaker 2: we call an ejaculatory reflex arc, which comes about midway
Speaker 2: into your spinal corrid around T ten to T twelve
Speaker 2: somewhere in there, and it is what causes us to
Speaker 2: have a orgasm through stimulation, which would be you know,
Speaker 2: either hand, mouth, vibrator, orifice, anus, vagina, however, whatever you know,
Speaker 2: there's a lot of different ways that guys can can
Speaker 2: generate an orgasm and an ejaculation, and it does stimulate
Speaker 2: that T twelve reflex arc. And so even in guys
Speaker 2: with spinal cord injuries, interestingly enough, if their injury is
Speaker 2: above that area, they can actually still have an ejaculation
Speaker 2: and potentially an orgasm because that arc is intact. So
Speaker 2: that's the beginning of this. The deeper center for orgasm
Speaker 2: actually is in the tiny sympathetic nerve fibers that surround
Speaker 2: the prostate. And so there are guys that talk about
Speaker 2: having prostate orgasms, and that's a real thing too, because
Speaker 2: you can stimulate the nerve fibers right at the level
Speaker 2: of the prostate, usually through rectal massage. Rarely can guys
Speaker 2: do it through the perineum because it's a little bit
Speaker 2: too much skin in the way. But essentially that's the
Speaker 2: other way to have an orgasm is through prostatic massage.
Speaker 2: And now we go up to the brain and there's
Speaker 2: about five different hormones that are necessary for a guy
Speaker 2: to be able to have an orgasm in av Just
Speaker 2: guess one. You have five different ones, So just give
Speaker 2: me one. I feel like you're one of my medical students. Now.
Speaker 2: Dopamine Yeah, okay, that's yeah, damn dope mean good. Yeah,
Speaker 2: I mean, that's that's number one. Don't mean, is that
Speaker 2: feel good hormone? So that's one. Yeah, Number two. You
Speaker 2: googling this colo yep, dopamine, serotonin, oxytocin. Wow, there's two more.
Speaker 2: I mean the big one that like you know everybody
Speaker 2: and everybody and everybody's on it, the big T man testosterone. Oh,
Speaker 2: du and then the last one is prolactin. So you
Speaker 2: got the three hard ones. Yeah, yeah, So any disorder
Speaker 2: in any of those or any drugs that we take,
Speaker 2: can cause disorders and ejaculation based on how they perturb
Speaker 2: any of those levels from testosterone to dopamint to everything
Speaker 2: in between. So in order to have a good intact
Speaker 2: orgasmic response, and by the way, those are pretty much
Speaker 2: the same in women as men. All those hormones are
Speaker 2: conserved across across gender, and so even testosterone. So women
Speaker 2: that have hypo arousal disorder, it was very difficult for
Speaker 2: them to get aroused or have orgasms often have low testosterone.
Speaker 2: So you got to have hormones and you got to
Speaker 2: have nerves. And those are really the two different ways
Speaker 2: that we think about orgasm. And so when we think
Speaker 2: about disorders of orgasm and ejaculation, we think about him
Speaker 2: as a spectrum of timing. And what I mean by
Speaker 2: that is there are men that have incredibly shortened ejaculatory
Speaker 2: responses where they what we often refer to as premature
Speaker 2: ejaculation or rapid ejaculation, where briefly after stimulation, sometimes even
Speaker 2: prior to penetrative intercourse, a man will ejaculate and that
Speaker 2: is almost always a reflex issue. And when I try
Speaker 2: to unshame this and a guy comes into me, because
Speaker 2: again this is something guys get judged with, they get
Speaker 2: compared to other partners. It's an incredibly shameful thing for
Speaker 2: guys to go through, and it doesn't have to be
Speaker 2: the reason for that is that that when I went
Speaker 2: to medical school and I did my rotations, one of
Speaker 2: the rotations that we did is a neurology where we
Speaker 2: all walked around with their reflex hammers. Maxwell's silver hammer
Speaker 2: for Beatles fans out there, which I think he used
Speaker 2: for very different purposes, but it probably started off as
Speaker 2: a reflex hammer, and there's this little rubber mallet that
Speaker 2: you would hit right under the knee cap, and that
Speaker 2: that was a great way to test our reflexes. I'm
Speaker 2: sure at Viera, any high school physical everybody remembers sitting
Speaker 2: down in the doctor's office with their knees hanging over
Speaker 2: the bed and she or he hit your reflex and
Speaker 2: you kicked your knee out, and we graded that from
Speaker 2: zero to two, I believe, or two plus where a
Speaker 2: guy could be hyper reflexic. So those knees. That knee
Speaker 2: reflex and the same thing we can do in the
Speaker 2: elbow is very important for our ability to know how
Speaker 2: well we're doing neurologically. And if a guy has diminished
Speaker 2: reflex or hyper reflects here, there could be a neurologic condition. Well,
Speaker 2: I kind of look at ejaculation the same way, because
Speaker 2: I just said that reflex arc at the tip of
Speaker 2: the penis is very important for determining how much stimulation
Speaker 2: you need to form an ejaculation. Some guys the wind
Speaker 2: blows funny boom, you know, they ejaculate. Some guys they
Speaker 2: can have penetrated sex for minutes upon hours and not
Speaker 2: be able to ejaculate, and a lot of that is
Speaker 2: delayed reflex. So that's the way I look at this.
Speaker 2: I talk about physiology, and you know, I'm good friends
Speaker 2: and colleagues with Natalie find Get Goldberg, who we had
Speaker 2: on a few episodes ago twenty odd and we talk
Speaker 2: about that a lot of my sex therapists, you know,
Speaker 2: they want me to correct the physiology so that they
Speaker 2: can deal with the psychological manifestations of the physiologic or
Speaker 2: anatomic abnormality. So whether it's about the size of a
Speaker 2: guy's penis or whether it's about how quickly they ejaculate,
Speaker 2: there are things I can do anatomically and physiologic to
Speaker 2: improve those. So then my therapists job is a little
Speaker 2: bit more I don't know, synergistic. We work together better
Speaker 2: that way. So that's the anatomy the physiology of an
Speaker 2: ejaculation in six short minutes. I'm just guessing on the time.
Speaker 2: So what can go wrong? So a guy can either
Speaker 2: come too fast or he can not come at all,
Speaker 2: And what can we do to treat all of those?
Speaker 2: And so I think what I would love for you
Speaker 2: to do, because I just feel like I talk all
Speaker 2: the time, Jordan, I want you to put on your
Speaker 2: journalist hat and pretend like I'm not Ringo star, but
Speaker 2: you know, as a Rolling Stone journalist extraordinary, you know
Speaker 2: in your former life interview me. Tell me what you
Speaker 2: want to know about ejaculation, the good, the bad, and
Speaker 2: the ugly.
Speaker 3: Well, what are the most common issues that you see
Speaker 3: in your practice.
Speaker 2: I think the majority of guys, and I think this
Speaker 2: bears out in the literature and surveys, is that most
Speaker 2: men are more concerned with premature ejaculation. It is something
Speaker 2: that especially happens, we think in younger people, and often
Speaker 2: it starts off with less experienced men because all of
Speaker 2: this is new to them and their nerves, and so
Speaker 2: it's something that is prevalent, and there are all kinds
Speaker 2: of treatments out there, including a lot of off label
Speaker 2: things that we use. In fact, there's actually no FDA
Speaker 2: approved drug for premature ejaculation, So whatever I write for,
Speaker 2: if I'm writing a prescription, it's not going to be
Speaker 2: FDA approved. But yeah, I would say premature ejaculation is
Speaker 2: the most common one. So the first thing I want
Speaker 2: to do is rule out any other things going on.
Speaker 2: You know, I do a full evaluation. Often I will
Speaker 2: even check hormones because a you know, I just don't
Speaker 2: want to miss anything. But most of the time the
Speaker 2: guy with premature ejaculation is perfectly healthy. Otherwise it doesn't
Speaker 2: really indicate any other underlying hormonal pathology or any neurologic dysfunction,
Speaker 2: And it's just a matter of how do we diminish
Speaker 2: that trigger, how do we diminish that T twelve reflex
Speaker 2: arc or that pathway at the frenulum. And so for me,
Speaker 2: the common treatment for this is is to do something
Speaker 2: to diminish the sensitivity, not to the point where the
Speaker 2: guy is numb, or not to the point where he
Speaker 2: could spread any treatment I give to him to his partner,
Speaker 2: especially having penis and vagina sex or P and V sex.
Speaker 2: But there are really good over the counter topical creams
Speaker 2: and sprays. You can get them online. You can get
Speaker 2: them at CVS target, I think, anywhere that and I
Speaker 2: don't endorse any of these, but they're pretty easy to
Speaker 2: find and Google is to help decrease that sensitivity so
Speaker 2: that when a man's having direct stimulation of that area,
Speaker 2: they don't have that quick trigger. And so I think
Speaker 2: that's first line anybody. It's safe, it's effective, and most
Speaker 2: of the time guys don't complain that it gets to
Speaker 2: the point where they can't have any sensitivity at all.
Speaker 2: It's just enough so they can have incredibly meaningful sex
Speaker 2: and last longer than they would without it at all.
Speaker 2: So that's my first line therapy.
Speaker 3: Now do you see have you noticed in your practice
Speaker 3: that younger men these days are having more issues with
Speaker 3: ejaculation than men previously.
Speaker 2: You know, I think it's what it is is just
Speaker 2: becoming much more prevalent and much more talked about. And
Speaker 2: you know, one thing we also didn't talk about, which
Speaker 2: is huge in the zeitgeist is ejaculate volume and this
Speaker 2: idea of loadmaxing and shooting ropes. And again that goes
Speaker 2: back to what it all goes back to. It seems
Speaker 2: like on when we talk about sex on this podcast,
Speaker 2: is what are your expectations based on what you see
Speaker 2: on the internet or in pornography, And so it goes
Speaker 2: back to the athleticism of some of our adult entertainers
Speaker 2: that are able to ejaculate volumes of semen and be
Speaker 2: able to hold their ejaculation through what seems like interminable
Speaker 2: sexual relations, and that to the average guy, especially some
Speaker 2: that it's not so sexually experienced, thinks that that is
Speaker 2: what they aspire for. And again, as we talk about
Speaker 2: so often in the show, most people, especially well I
Speaker 2: should say most people that have vaginas are not orgasming
Speaker 2: through penetrative intercourse, and so sometimes too much can actually
Speaker 2: be too much, and so this is not the goal
Speaker 2: as to how long they are you able to hold
Speaker 2: out before you orgasm. But if you do have a
Speaker 2: partner that does orgasm through vaginal intercourse and you can
Speaker 2: time it, then this idea of simultaneous climax is a
Speaker 2: pretty great aspirational thing, but functionally it doesn't really happen
Speaker 2: that often and is something more in romance novels uh
Speaker 2: and fireworks on scene. So again, don't aspire for something
Speaker 2: that probably doesn't exist that often in nature.
Speaker 3: Back it up a little bit and talked about too soon,
Speaker 3: too late for lack of that in real numbers, what
Speaker 3: is a realistic what is the normal amount of time?
Speaker 2: And I hate you we're normal, but yeah, I love it. No, Actually,
Speaker 2: there are there are clinical definitions of what we consider
Speaker 2: premature ejaculation, and really the best definition I have is
Speaker 2: that anytime that a patient or his partner is not
Speaker 2: satisfied with the length of time prior to ejaculation and orgasm,
Speaker 2: that is what I would consider not long enough. Because
Speaker 2: there are some guys that that again have such severe
Speaker 2: I think is reasonable to say premature ejaculation, rapid ejaculation,
Speaker 2: that they're having an orgasm prior to even having penetrative sex.
Speaker 2: And so that's on one end of the spectrum. The
Speaker 2: typically greed upon term is you know, somewhere under a
Speaker 2: couple minutes, you know, the average sexual exponse from insertion. Again,
Speaker 2: this is based on penis and vagina sex for the
Speaker 2: most part, because that's what we have standardized questionnaires for. Unfortunately,
Speaker 2: we don't have great other alternative methods of having sex
Speaker 2: for anal and oral intercourse, but it is this two
Speaker 2: minute to five minutes is kind of a normal time
Speaker 2: from insertion to orgasm, and so that means anything greater
Speaker 2: than that. If, again, it's causing discomfort to either the
Speaker 2: patient or the partner, then that could be delayed ejaculation.
Speaker 2: And so really the sweet spot depends on the couple.
Speaker 2: You know, for some it's the partner comes first, and
Speaker 2: then it's just a matter of the man or the
Speaker 2: person with the penis that is able to finish whenever
Speaker 2: at their leisure. Because the other person has already achieved orgasm,
Speaker 2: then premature ejaculation delayed ejaculation becomes less of an issue.
Speaker 3: And there are some men who struggle to orgasm during
Speaker 3: partnered sex even though when they're alone. That is not
Speaker 3: a problem of performance anxiety or any kind of other
Speaker 3: psychological issues. Are there some physiological reasons for that?
Speaker 2: Yeah, I mean there are. I mean I think that
Speaker 2: I kind of not joke about it, but I do
Speaker 2: want people to kind of think about the fact that
Speaker 2: if a man has been used to the feeling of
Speaker 2: his own hand and grip strength for a long period
Speaker 2: of time and spends a lot of time in masturbation,
Speaker 2: then that's a feeling and that's a neurologic conditioned response
Speaker 2: that when he goes to have penetrative intercourse with the partner,
Speaker 2: it may not feel the same way to those nerves,
Speaker 2: and so there can be a desensitization to that. I'm
Speaker 2: not here to judge on what the appropriate amount or
Speaker 2: the ratio of a single versus partnered sex should be, because
Speaker 2: I don't think amy has an answer that, except for
Speaker 2: if it becomes a problem where it's pathologic and somebody
Speaker 2: is having more partnered or more solo sex than partnered sex,
Speaker 2: and the partner's like, hey, what's going on, then that
Speaker 2: becomes a problem. But for sure, it's not as simple
Speaker 2: as just a psychological issue of saying I can orgasm
Speaker 2: with my partner, but I can by myself. But it
Speaker 2: can be definitely a relationship issue that needs to be explored,
Speaker 2: and really the therapy for that depends. Sometimes it is
Speaker 2: sex therapy, sometimes it is not having solo sex and
Speaker 2: manual sex for a period of time and then engaging
Speaker 2: in normal penetrative intercourse with a partner. That can help
Speaker 2: some guys through this. But yes, a conditioned response is
Speaker 2: for sure, and it's a neurologic issue. And if you
Speaker 2: desensitize the penis or you get used to only one
Speaker 2: sensation to orgasm, it's the same thing with positions. I mean,
Speaker 2: there's some men that can only orgasm in one position
Speaker 2: versus another position, and it's that same condition response. Some
Speaker 2: of that isn't pathologic as long as you're okay with it.
Speaker 2: In other words, as long as as you and your
Speaker 2: partner are okay and you're both sexually satisfied, then everything
Speaker 2: else is just judgment. And we don't judge here, man.
Speaker 2: I guess dovetail with that.
Speaker 3: There's a phrase it's become very buzzy of seeing on
Speaker 3: the internet lately. I was curious, if it's crossed your
Speaker 3: path and your practice death grip syndrome, does that mean
Speaker 3: anything to you?
Speaker 2: Well, I can only imagine. But obviously we have different feeds,
Speaker 2: you know, mostly I mostly get updates on my sabermetrics,
Speaker 2: on my Dodgers and my in basket, but Okay, Jordan. Again,
Speaker 2: I'm not judging that I've not had any death grip
Speaker 2: syndrome feet, but it sounds like, yeah, guys are probably
Speaker 2: using way too much man old grip strength in order
Speaker 2: to induce an orgasm, so they're used to that incredible
Speaker 2: level of grip strength or just the right amount of stimulation,
Speaker 2: which again goes back to the whole deal is if
Speaker 2: you're only doing it one way, then that can condition
Speaker 2: that response so that that's the only way you're ever
Speaker 2: going to orgasm and your partners don't stand a chance.
Speaker 2: And I think that is much more common than we think,
Speaker 2: and one that probably does take a lot of retraining
Speaker 2: and maybe a little bit of sex therapy, but mostly
Speaker 2: probably neurologic reconditioning so that they can have a better
Speaker 2: sex life and not induce death grip syndrome in order
Speaker 2: to have that same ejaculatory response. That's sad. Yeah, I
Speaker 2: haven't heard of death grip syndrome, but boy, but now
Speaker 2: I can't unthink it or unsee it. Probably, and I'll
Speaker 2: go back to my office today and have three guys
Speaker 2: that have death grip syndrome in my clinic because of you.
Speaker 3: Now, death grip weren't they one of the big four
Speaker 3: in the post punk.
Speaker 2: Yes, that's right exactly. They were. They open for Circle Jerks.
Speaker 2: So there you have it, death Grip syndrome. If not,
Speaker 2: we're doing it. We're starting our own band right now.
Speaker 2: DGS Baby catch DGS at CBGB's Oh yeah, seventy eight
Speaker 2: that show. I was there, man, I was in the
Speaker 2: front row with the Red Hot Chili Peppers wearing socks
Speaker 2: on their dick. Yeah, I think you're thinking of Death
Speaker 2: Grip for cuty I mean, they really launched this entire
Speaker 2: choking vocals kind of indie punk sort of thing. It was.
Speaker 2: It's really big in the late nineties, early two thousand's
Speaker 2: Death Grip for Cutie. I think they're probably Hall of
Speaker 2: famers by this point. Oh man, we could go on.
Speaker 1: So yeah, we're keeping all of this.
Speaker 2: Of course we are. Yeah, because again, I mean the
Speaker 2: theme of this is also you're probably gonna be okay
Speaker 2: that there are so many treatments, so we you know,
Speaker 2: getting past past what we were talking about with the premature.
Speaker 2: And I'm by the way, not trying to reroute you
Speaker 2: at all, because I could talk punk rock forever, but
Speaker 2: you know, somewhat a medical show. I think we're still
Speaker 2: in that category, haven't quite got to the entertainment level yet.
Speaker 2: But rerouting to thinking about premature ejaculation, So topical spraise,
Speaker 2: topical creams first line. But there is a whole branch
Speaker 2: of relatively good data on looking at starting guys on SSRIs,
Speaker 2: which you talked about as one of the hormones in
Speaker 2: that ejaculatory pathway serotonin. So if you can modulate serotonin
Speaker 2: levels through taking the drugs that we usually prescribe for antidepression,
Speaker 2: that could be a game changer for some guys. And
Speaker 2: I think that's really really interesting, and I've certainly used
Speaker 2: those over the twenty odd years I've been treating guys
Speaker 2: with premature ejaculation to a good effect, and you often do.
Speaker 2: I always started a lower dose, and again this by
Speaker 2: no means as medical advice, just so we know this,
Speaker 2: but if you were in my office and you were
Speaker 2: actually my patient, I do often start at a lower
Speaker 2: dose then I would when a guy would be treating
Speaker 2: depression with antidepressants, and sometimes that can be effective at
Speaker 2: just taking that serotonin level to the point where where
Speaker 2: a guy's ejaculatory threshold gets up a little bit takes
Speaker 2: a little more stimulation to make that release and to
Speaker 2: cause that orgasmic cascade which then leads to ejaculation. So
Speaker 2: SSRIs are I would say first to second line therapy
Speaker 2: for this and the other therapy that some people have
Speaker 2: tried is more of a dopamine modulator, and that's something
Speaker 2: called ultram tramadol Is is a generic name. Now, problem
Speaker 2: with tramadoll is it's also considered a little bit along
Speaker 2: the controlled substance narcotic pathway, and so it never I
Speaker 2: was years ago part of a clinical trial or an
Speaker 2: advisory board looking at bringing tramadol on at a slightly
Speaker 2: different dose than what we use for postoperative pain as
Speaker 2: a as an premature ejaculation FDA approved drug, and it
Speaker 2: ran into a couple of problems. One is, it was
Speaker 2: already generic, so there was no market for this because
Speaker 2: you could write for it anyway, and it was pennies
Speaker 2: on the pennies on the dollar. But two is because
Speaker 2: the concern is that it could be habit forming, and
Speaker 2: it was never really panned out very much as being
Speaker 2: habit for me, especially at the dosing and the on
Speaker 2: demand way that we would prescribe it. For a pre
Speaker 2: mature ejaculation because you just took it ahead of sexual accounter,
Speaker 2: just like you would take a drug like sildentiphil or
Speaker 2: to dalaphil for rectile dysfunction. But again it never got
Speaker 2: AFTY approved. Only thing made to a clinical trial may
Speaker 2: not have even made it past that advisory board because
Speaker 2: you know, I think from a financial standpoint, it's really
Speaker 2: tough to go to the FDA and getting a drug
Speaker 2: approved that already as an indication and as generic there's
Speaker 2: just no notion, just no money in it. But Tramadah
Speaker 2: will be another one that some people use. There also
Speaker 2: are medical devices out and there are a couple of
Speaker 2: these that do have that I think are pending FDA
Speaker 2: clearics that are available overseas that essentially are like nerve
Speaker 2: stimulators that you wear behind the testicles in that area
Speaker 2: that we lovingly referred to as the taint or the perineum,
Speaker 2: where you place a little patch that's the size of
Speaker 2: a poster stamp, and it actually hyper polarizes or causes
Speaker 2: the nerves to fire a little bit less aggressively and
Speaker 2: it can delay the ejaculatory response. And the clinical trials
Speaker 2: and that are actually pretty good, and so that's a
Speaker 2: device that will be a disposable that again somebody wire
Speaker 2: just prior to intercourse, and it can be so discreete
Speaker 2: that your partner may not even know that you have
Speaker 2: it because it's so small. It's just a couple of
Speaker 2: little electrodes, and it's safe. It's not going to shock
Speaker 2: you or anything. But it is something that can cause
Speaker 2: a little neurostimulation to delay ejaculation. So I'm kind of
Speaker 2: interested in that. Again, don't have right now, have no
Speaker 2: financial interest in any of the companies or no consulting
Speaker 2: for any of those companies, but certainly as an observer
Speaker 2: and an intellectual, I think that could be a new
Speaker 2: future for guys with premature ejaculation.
Speaker 3: That's interesting that you prescribe BSSRIS for us. So I
Speaker 3: was going to ask you about what happens because you
Speaker 3: hear all these stories about people being put on anidepressants
Speaker 3: and then the libida goes down right in extreme cases
Speaker 3: or yeah, extreme cases, perhaps I should ask you how
Speaker 3: do you deal with kind of the inverse of that?
Speaker 2: Yeah, yeah, I mean I think that's a big problem.
Speaker 2: So that goes back to why we discovered this would
Speaker 2: be an interesting therapy for guys with premature ejaculations. The
Speaker 2: guys are on full depressant doses. So you know what,
Speaker 2: I have not been able to have an orgasm since
Speaker 2: I've been on these medications, and my depressions better, but
Speaker 2: now I'm kind of upset about this untoward side effect.
Speaker 2: And so there is a balance, and there are a
Speaker 2: couple of medications that do better for treating depression that
Speaker 2: have less orgasmic effects, and those you can certainly talk
Speaker 2: to your primary or psychiatrists prescribing and they'll know what
Speaker 2: they are that that you can try those instead, because
Speaker 2: they have some of them have dopamine pathways and some
Speaker 2: of them have nor epinephrin pathways, and so they do
Speaker 2: modulate different than just pure serotonin reuptake inhibitors, and so
Speaker 2: so that's definitely where that having a conversation on. And
Speaker 2: when I see a guy that's on more traditional pure SSRI,
Speaker 2: that might be my first thing is check back in
Speaker 2: with your psychiatrists, because there maybe something out there that
Speaker 2: is a little bit better for sexual function that still
Speaker 2: gives you the benefit of not having the depressive sentence
Speaker 2: I got you on that medication in the first place.
Speaker 2: So yeah, there are better alternatives out there than the
Speaker 2: classic SSRIs that have been out for thirty five years
Speaker 2: now at least.
Speaker 3: Are there any ways that you could think of offhand
Speaker 3: that men well meaning who are maybe too shy to
Speaker 3: go speak to a doctor about this, will try to
Speaker 3: help their own treat their own what they may be
Speaker 3: used performance anxiety or rectile dysfunction or ejaculatory disorders and
Speaker 3: actually accident and make it worse. There things that guys
Speaker 3: should absolutely not do. That maybe are myths out there
Speaker 3: that are our old wives tales that people should steer
Speaker 3: clear of.
Speaker 2: Yeah, I mean, I guess for ejaculatory dysfunction or erecti dysfunction,
Speaker 2: there really are very few and no reasonable supplements that
Speaker 2: I would recommend. So I'm sure it's just it's a scary,
Speaker 2: scary world out there. And again a lot of the
Speaker 2: supplements that are on the erectodysfunction pathway, especially ones that
Speaker 2: may have any effect at all, have contraband still dentifiled
Speaker 2: to dala fill in them. So the ED the pharmacologic
Speaker 2: ED drugs are in there, and I would hasten and
Speaker 2: hazard to guess that that maybe some of the vitamins
Speaker 2: or supplements that people would be marketing for premature ejaculation
Speaker 2: may have ssriyes in them and in the same level,
Speaker 2: don't know that at all. But Sirch stands to reason
Speaker 2: that if you can go to a truck stop and
Speaker 2: buy a truck stop viagra that actually has viagrant is
Speaker 2: not just horny goat weed and gin sing and el
Speaker 2: citraline or something, it does actually have an active FDA
Speaker 2: approved ingredient. And I bet they're doing the same thing
Speaker 2: on premature ejaculation. So the answer is, yeah, don't just
Speaker 2: don't know, go talk to your physician about it and
Speaker 2: get on a real pathway that even if it's off
Speaker 2: label like the SSRIs are for premature ejaculation, it's still possible.
Speaker 2: And that really the same with delayed ejaculation. And I
Speaker 2: think the other thing that we talked about with Natalie
Speaker 2: finding a goldberg that I think is really interesting is
Speaker 2: that there may be a role for pelic floor physical
Speaker 2: therapy and both improving ejaculatory response from a premature or
Speaker 2: a delayed ejaculation standpoint. And there are pelvic floor exercises
Speaker 2: that can make us have a little better control of
Speaker 2: our ejaculatory response. So again I would go to pelvic
Speaker 2: therapy before I think about buying any supplements that would
Speaker 2: report that or any medical devices that don't have any
Speaker 2: good data behind them. So yeah, be careful what you
Speaker 2: come across because it's an incredible market out there of
Speaker 2: things that you can try that really don't have efficacy,
Speaker 2: and potentially some of them have dangers, like hidden prescription
Speaker 2: drugs that you may have a response to. For example,
Speaker 2: if you're already on an antidepressent, you still have premature ejaculation,
Speaker 2: then you take a drug that may have or a
Speaker 2: supplement that may have snuck in some you know, that
Speaker 2: could not be great to be overdosing on that same thing.
Speaker 2: As if you're taking any drug and then you take
Speaker 2: another one at a truck stop, or if you have
Speaker 2: heart conditions that you need to take medications where those
Speaker 2: drugs are absolutely contraindicated. Yeah, he could end up really
Speaker 2: harming yourself. So yeah, really be careful of anything that
Speaker 2: you see over the counter and anything in the supplement world,
Speaker 2: anything you can buy online.
Speaker 3: It was a broad question, but I'm interested in your
Speaker 3: take on it. What is the healthiest way to think
Speaker 3: about ejaculation and performance because I feel like so much
Speaker 3: of it is people getting in their own heads.
Speaker 2: Yeah, you know. I think it goes back to if
Speaker 2: it's with a partner, it's having that communication, you know,
Speaker 2: and what feels good to both you and the partner,
Speaker 2: and then having that discussion, especially if you have a
Speaker 2: history of having either difficulty achieving orgasm or premature orgasm.
Speaker 2: Those are two things that your partner should know because
Speaker 2: a lot of people will take it personally if a
Speaker 2: guy has delayed orgasm and they're with a new partner
Speaker 2: and he has a physiologic or neurologic reason, or he
Speaker 2: is on medication that he has to be on, and
Speaker 2: you don't communicate that upfront, and you're ten minutes, fifteen minutes,
Speaker 2: thirty minutes, sixty minutes into an in session of intercourse
Speaker 2: and it hasn't happened. That person may take it personally
Speaker 2: if you didn't say, hey, look, I just got to
Speaker 2: let you know ahead of time. This is kind of
Speaker 2: an issue for me. So again, it goes back to
Speaker 2: communication being the most important thing to any sexual encounter,
Speaker 2: either pre game, intro game, or postgame, and especially postgame.
Speaker 2: If you find something that really did work, then you
Speaker 2: want to be able to talk about that and say, hey,
Speaker 2: this was really effective for me. This was great. You
Speaker 2: got to let that partner know, so you got to
Speaker 2: know what to look forward to next time.
Speaker 3: The main takeaway from a lot of these episodes lately
Speaker 3: has been talk about it.
Speaker 2: Yeah, man, let's talk about it. These are things that
Speaker 2: also that it's so hard to talk about. And I again,
Speaker 2: I always go back to how grateful I am for
Speaker 2: the career I have where men are able to come
Speaker 2: to me and speak with me and talk with me
Speaker 2: about these conditions that they may not have had that
Speaker 2: conversation with their partners yet. And some times I hear
Speaker 2: back from them and say, you know what, that was
Speaker 2: actually the best thing we ever did is we sat down,
Speaker 2: we talk about it. And my advice I always hear
Speaker 2: from my sex therapy colleagues is that you want to
Speaker 2: talk about sex not in the bedroom. You want to
Speaker 2: talk about it somewhere else and then bring it to
Speaker 2: the bedroom. So you know, if you're going through your
Speaker 2: x's and o's and your chalk talk, you do that
Speaker 2: in the locker room, and then you get on the
Speaker 2: field and you play your game. So don't start doing
Speaker 2: a game plan mid game. Don't call audibles, and sex.
Speaker 2: That seems very restrictive. Maybe I don't want to say that,
Speaker 2: maybe you should call audibles and sex, but I think
Speaker 2: only when you're to the point where you communicate and
Speaker 2: you're such a field marshal that you have commanded the situation,
Speaker 2: that you can do that. But for the most part,
Speaker 2: it's really good to talk about this so that everybody's
Speaker 2: expectations are on the same playing field, the same level,
Speaker 2: to know what we're all getting ourselves into this with
Speaker 2: this beast with two backs. Damn we got Shakespeare today,
Speaker 2: Jordan Wow right to flow host punk and Shakespeare host
Speaker 2: Punk and Shakespeare, same episode. You heard it on the mail,
Speaker 2: So yeah, I think right. For all of these things,
Speaker 2: it's it is just knowing that there are therapies out there,
Speaker 2: also knowing that, especially for delayed orgasm, the medical therapies
Speaker 2: are very very limited. You know, we really just we
Speaker 2: have zero FDA proved. But there are some things at work,
Speaker 2: you know. One of the things we talked about is
Speaker 2: prolactin is one of the hormones that has to be
Speaker 2: at a good level for an orgasm, and if you
Speaker 2: have your prolactin levels too high, it can actually inhibit orgasm.
Speaker 2: So there are medications off label used for other reasons
Speaker 2: that you may have some success with. The classic one
Speaker 2: is something called kabergoline, which lowers the prolactin levels. We
Speaker 2: use it for guys that have or women too, that
Speaker 2: have pituitary tumors where they're secreting too much prolactin, and
Speaker 2: we knew that again, that's another cause of delayed ejaculation
Speaker 2: that you should see your doctor about, because if you
Speaker 2: had normal orgasm, normal orgasm. Let me tell you a story.
Speaker 2: Actually I remember this when I was in fellowships this
Speaker 2: twenty plus years ago, and I saw a very nice
Speaker 2: he was a PhD student and very smart, obviously, and
Speaker 2: he was in his thirties and they were coming to
Speaker 2: us for fertility issues and the main problem was that
Speaker 2: he couldn't provide a sperm sample, nor could he orgasm
Speaker 2: with his partner. And the partner was taking it very personally,
Speaker 2: as would happen, and he said, look at this has
Speaker 2: never been a problem before, but all of a sudden,
Speaker 2: I've not been able to orgasm. And I said, well,
Speaker 2: that's interesting. I mean, no saddle traumas, you're not riding
Speaker 2: your bike six hundred miles a day. You're not doing
Speaker 2: any don't have any numbness, No, no numbness. Everything's fine,
Speaker 2: no pelvic trauma. And we test all his blood work
Speaker 2: is to stostern levels, all of his hormones, and then
Speaker 2: we also tested his prolactin, and his prolactin came back
Speaker 2: in the five hundred range, which normal is anything less
Speaker 2: than sixteen. And so this guy had a pathologically highest
Speaker 2: secretion of prolactin, which prompted us to do an MRI
Speaker 2: of his pituitarylant because that's what you gotta do. And
Speaker 2: he had a big, fat tumor on his pituitary plant
Speaker 2: called a prolactinoma. That's the most common reversible cause other
Speaker 2: than medications of delayed ejaculation or change in orgasm is prolactinoma.
Speaker 2: And it's not cancer. It's treatable often with medication. And
Speaker 2: guess what the medication is, Kerbergline. And so we actually
Speaker 2: can take a guy with a brain tumor, which sounds horrific,
Speaker 2: and then reduce it by putting them on a drug
Speaker 2: that makes the tumor shrink, makes the prolactin levels go down.
Speaker 2: And this couple was not only able to he was
Speaker 2: able to have an orgasm, but they really able to
Speaker 2: ejaculate and make babies a good old fashioned way just
Speaker 2: because he had this this strange tumor. And I actually,
Speaker 2: you know, in my practice where certainly I take care
Speaker 2: of thousands of guys every year, but every you know,
Speaker 2: I would say two to three times a year, I
Speaker 2: will pick up a prolactinoma. So it's not the rarest
Speaker 2: thing in the world by any means, and so so kerbergline,
Speaker 2: we use off label to treat guys with an orgasm
Speaker 2: or difficulty achieving orgasm, even if they're proactin level are
Speaker 2: just a little bit high or even high normal. And
Speaker 2: there's studies out there on this, again not FDA approved,
Speaker 2: very off label, but relatively safe side effects. And so
Speaker 2: with proper patient counseling and selection, that is probably one
Speaker 2: of the more common things we see to help guys
Speaker 2: that delate ejaculation. But you got to make sure they're
Speaker 2: not anything more serious going on. First, the other crazy one,
Speaker 2: which isn't so crazy, but also because you either did
Speaker 2: your homework or just new you talked about something called oxytocin,
Speaker 2: which is part of those hormones, and there are guys
Speaker 2: that have low oxytocin that they may benefit from oxytocin supplementation,
Speaker 2: usually through a nasal spray, which also has There's a
Speaker 2: British Medical Journal article from like two thousand and six,
Speaker 2: so this is again not cutting edge by any means,
Speaker 2: but showing that guys that have delayed ejaculation by taking
Speaker 2: an intra nasal spray of oxytocin mid coitus. So it's
Speaker 2: almost kind of like, hang on, babe, I got to
Speaker 2: switch over here and just take a little puff, and
Speaker 2: that actually, because oxytocin is such a short half life,
Speaker 2: like on the order of about eight minutes, that it
Speaker 2: actually can improve that ejaculatory threshold and cause orgasm. I've
Speaker 2: had very limited success with that, but the guys that
Speaker 2: it worked for, they're super happy because it's safe. There's
Speaker 2: really no downside to it. And this is a compounded drug,
Speaker 2: is not there is no pharmaceutical form of oxytosin, so
Speaker 2: you have to get it from a specialized compounding pharmacy.
Speaker 2: But you can certainly talk to your local doc or
Speaker 2: your local sex med specialist probably to at least try
Speaker 2: a trial of oxytocin nasal spray or they have trophies
Speaker 2: under the tongue as well, but I think the nasal
Speaker 2: spray is the only one that's actually been really studied.
Speaker 2: So you got to make sure you're getting it from
Speaker 2: a great pharmacy that has a good track record, and
Speaker 2: another thing to potentially try to help improve that anargasmy
Speaker 2: or difficulty achieving ejaculation. I had heard of.
Speaker 3: Oxytosins supplements, I did not know that it was administered
Speaker 3: that way.
Speaker 2: Wow. Yeah, yeah, so again you're probably gonna be okay.
Speaker 2: Rule out the bad stuff. Number one. All we do
Speaker 2: in medicine, and the reason the only thing I have
Speaker 2: against telehealth or direct to consumer medical or supplement sales
Speaker 2: is you have to do the evaluation because no matter
Speaker 2: what condition we're going to talk about on the show,
Speaker 2: you need a good high level medical exam, most likely
Speaker 2: a physical exam, very most likely blood work before you
Speaker 2: can just treat this stuff and not worry about it.
Speaker 2: Because what if you did have something that needed medical
Speaker 2: treatment that could be reversible, could be serious if you
Speaker 2: didn't reverse it, and you just started getting brown paper
Speaker 2: bags in your mailbox every month, So not cool. You
Speaker 2: don't want to do that. You want to make sure
Speaker 2: you get the evaluation and you have a good doc
Speaker 2: that's in your corner, well, said my friend. Yeah, man,
Speaker 2: So we started with orange trees, ended up with some
Speaker 2: punk rock, and I was basically able to solve the
Speaker 2: entire problem of too much too soon or not enough
Speaker 2: too late. And we did it again on the mail room.
Speaker 2: That's what we do here, my friend, Joran, this is
Speaker 2: too much fun. I mean, I love our guests. I
Speaker 2: also just love hanging with you and talking through this stuff.
Speaker 2: So we should probably it again sometime. I'll let you
Speaker 2: get back to fighting your allergies and breathing in that
Speaker 2: beautiful Massachusetts lake air go, we're you gonna go fishing?
Speaker 2: Do you fish up there at all? I do fish? Actually, yeah,
Speaker 2: I got some bass up here. No, it's nice up here.
Speaker 2: Oh yeah, well that's right because you yeah, you were
Speaker 2: deep sea fishing in the Keys and now you're bass fishing.
Speaker 2: That's not bad, all right.
Speaker 3: Next career is a sushi chef.
Speaker 2: There you go. I love that. I love that. Well, everybody,
Speaker 2: thanks again for hanging out with us on the mail route.
Speaker 2: Thanks to iHeart Radio for making this all possible, and
Speaker 2: our sponsors and Jordan Runt above all thanks for making
Speaker 2: it all sounds slick man. Have a good one, Doctor Mills,
Speaker 2: thanks for doing it with us. We love you. Let's
Speaker 2: talk about it. Let's talk about the man. Let's talk
Speaker 2: about it. Let's talk about him. The Man.
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