WEBVTT - Your Penis Has Changed: Finding a New Normal After Peyronie’s Disease 0:00:00.560 --> 0:00:01.640 Let's talk about it. 0:00:03.680 --> 0:00:09.920 Let's talk about the Maro. Let's talk about it. 0:00:11.880 --> 0:00:18.080 Let's talk about the man. Hero, Welcome to the Man, 0:00:19.120 --> 0:00:23.080 Welcome back to the mailroom. Jordan runs in the house, 0:00:23.280 --> 0:00:26.840 Doctor Jesse Mills here in the midst of our Payrone's 0:00:26.880 --> 0:00:29.880 Disease series, something that is really a big part of 0:00:29.920 --> 0:00:34.120 my career, dedicated probably at least forty fifty percent of 0:00:34.159 --> 0:00:35.839 the men that I see these days for all the 0:00:36.000 --> 0:00:39.159 treatments I do, a lot of them are coming to 0:00:39.200 --> 0:00:41.400 me just for Perrone's Disease. So we're going to really 0:00:41.640 --> 0:00:45.120 dive into this over this multi part series. But first, 0:00:45.120 --> 0:00:47.159 tell me what's up with you man? What's what's new 0:00:47.200 --> 0:00:48.040 in Jordan's world? 0:00:48.440 --> 0:00:51.240 Not too much gearing up for summertime, going to visit 0:00:51.320 --> 0:00:53.800 some family, going to New England boys and going to 0:00:53.840 --> 0:00:57.160 the camp. I know we talked about lobsters last time. 0:00:58.560 --> 0:01:02.400 I forgot you cold lobster or worm lobster. 0:01:02.720 --> 0:01:05.080 Yeah, I know it's a divisive issue in the New 0:01:05.080 --> 0:01:06.120 England territories. 0:01:06.200 --> 0:01:08.360 Well, I mean I think you go cold and the 0:01:08.400 --> 0:01:10.960 mayonnaise can kind of ruin the tenderness, you know, But 0:01:11.640 --> 0:01:14.000 I don't know these are one of these false dichotomies. 0:01:14.000 --> 0:01:16.440 Why can't you just love both man, but you know, 0:01:16.880 --> 0:01:19.959 just alternate. Monday's cold. Yeah, speaking of cold, you know 0:01:19.959 --> 0:01:22.800 it's do you know what June gloom is? If you 0:01:22.840 --> 0:01:27.800 heard this term in Britain, we are suffering from June gloom, 0:01:27.840 --> 0:01:31.920 this Pacific inversion layer. Everybody thinks it's sunny in southern California. 0:01:31.959 --> 0:01:35.200 We're hosting the World Cup here in Sofi Stadium, and 0:01:35.200 --> 0:01:37.600 and I'm afraid our tourists are thinking what happened to 0:01:37.600 --> 0:01:40.560 all the sunshine? But give us, give us a few 0:01:40.560 --> 0:01:43.399 hours somewhere around eleven to twelve, it burns off. But 0:01:43.560 --> 0:01:45.520 it's a It is a grade A. I don't get 0:01:45.560 --> 0:01:49.200 to see my Santa Monica Bay. That's almost pentameter. We're 0:01:49.200 --> 0:01:54.720 going to work that out anyhow. We we are Russian, yes, 0:01:55.040 --> 0:01:57.880 Russian literature right know, and language. And here I am 0:01:58.000 --> 0:02:03.760 talking about Frescois de la Peroni. So I've known Mara Heman, 0:02:03.880 --> 0:02:08.440 she's our guest today spoiler alert for years actually, and 0:02:08.800 --> 0:02:10.920 she's been doing just amazing work up at the University 0:02:10.960 --> 0:02:14.320 of Washington in Seattle, where she's an associate professor. She's 0:02:14.360 --> 0:02:17.760 fellowship trained in mail reproductive medicine and surgery, just like me, 0:02:17.919 --> 0:02:20.120 Just like a lot of our guests, she also is 0:02:20.160 --> 0:02:22.760 an outstanding clinician. One of the things that I think 0:02:22.919 --> 0:02:26.120 stands out about her bio is how dedicated she is 0:02:26.160 --> 0:02:28.760 to patient care and patient advocacy. And again, as we 0:02:28.800 --> 0:02:33.320 talk about these very sensitive issues that guys have, this 0:02:33.760 --> 0:02:36.919 needing somebody like Professor Heeman in your corner is huge 0:02:36.919 --> 0:02:40.240 and so very excited to have her on today to 0:02:40.280 --> 0:02:44.840 talk about interlegional therapy. She is a graduate of Rush 0:02:44.880 --> 0:02:48.280 Medical College in Chicago, where I believe she grew up. 0:02:48.320 --> 0:02:50.560 We'll confirm that with her when she walks into the 0:02:50.560 --> 0:02:54.919 mail room here. Also a surgical resident intern at Loyal 0:02:55.040 --> 0:02:58.880 University in Chicago, and then finished her residency also at 0:02:58.960 --> 0:03:03.040 Loyola in in Chicago, and then did her fellowship at 0:03:03.120 --> 0:03:07.239 you dub as it's affectionately known up in Seattle, where 0:03:07.240 --> 0:03:09.720 she has stayed on as associate professor and she keeps 0:03:09.760 --> 0:03:12.600 advancing through the ranks. So very excited to have her 0:03:12.639 --> 0:03:15.799 on today today. We're really going to mostly talk about 0:03:15.800 --> 0:03:19.640 interleagional therapy, meaning we talked a little bit about this 0:03:19.760 --> 0:03:24.560 before with pills, pokes and procedures, and with this in mine. 0:03:24.960 --> 0:03:28.040 She is going to talk about the procedure aspect of it. 0:03:28.120 --> 0:03:32.240 So there's no FDA approved therapy for this that is 0:03:32.320 --> 0:03:34.639 not interleagional, but yet we try a lot of off 0:03:34.680 --> 0:03:37.120 labeled things. I'll probably pick her brain on that, and 0:03:37.200 --> 0:03:40.120 then what we really want to talk about today is 0:03:40.440 --> 0:03:44.560 collagenate's therapy. Maybe she has some opinions on verapamil, which 0:03:44.600 --> 0:03:45.200 I still use. 0:03:45.200 --> 0:03:45.920 We'll see about that. 0:03:46.400 --> 0:03:50.120 And anyway, let's let her into the mail room, Professor human. 0:03:50.200 --> 0:03:53.040 I just am so excited to see you on the 0:03:53.120 --> 0:03:56.160 mail room. Welcome, Welcome. This is Jordan my on air 0:03:56.200 --> 0:04:01.520 producer Ombre Extraordinaire and Brooklyn Nighte as of the last 0:04:01.760 --> 0:04:02.680 decade or so. 0:04:02.680 --> 0:04:03.800 So how you did? Tell me? 0:04:04.200 --> 0:04:07.760 Tell me what's new in your life and your crazy, busy, 0:04:07.840 --> 0:04:08.960 overscheduled world. 0:04:09.960 --> 0:04:11.760 Yeah, good morning, it's so great to see you too. 0:04:14.080 --> 0:04:17.200 Life is exciting. As you know. We just matched our 0:04:17.240 --> 0:04:21.599 new fellows for the andrology program here at UW and congrats. 0:04:21.920 --> 0:04:24.720 We're thrilled. We have our graduates going out to their 0:04:25.200 --> 0:04:28.800 you know, top choices for jobs and it's just more 0:04:28.800 --> 0:04:31.400 people going out into the world to take great care 0:04:31.440 --> 0:04:34.400 of men. So we're absolutely delighted to be part of 0:04:34.400 --> 0:04:35.039 their education. 0:04:35.680 --> 0:04:38.680 That right there actually summarizes Mari to t is that 0:04:38.720 --> 0:04:41.120 when I asked her how she's doing, she said how 0:04:41.160 --> 0:04:42.200 everybody else. 0:04:42.000 --> 0:04:44.640 That is she's responsible for is doing. I mean, that 0:04:44.760 --> 0:04:45.440 is a sign of. 0:04:45.400 --> 0:04:49.080 A true caring, compassionate person. And it's so on brand 0:04:49.080 --> 0:04:52.240 for you and so so excited to have you talk 0:04:52.279 --> 0:04:55.919 about something else that that obviously affects other people, given 0:04:55.960 --> 0:04:58.560 that this is a disease of the penis. So this 0:04:58.680 --> 0:05:01.320 is why I think you're perfect candidate for this is 0:05:01.360 --> 0:05:03.960 because you've dedicated your career in a large part to 0:05:04.040 --> 0:05:08.120 Pirroni's disease as well. So exactly what I'm here for, Jordan, 0:05:08.480 --> 0:05:12.000 Professor Heman, He professor Heman, Jordan Runta. 0:05:12.360 --> 0:05:15.240 So nice to Yeah, yeah, it's gonna be fun. 0:05:15.760 --> 0:05:20.000 So we've done this this about four part series or 0:05:20.120 --> 0:05:23.200 in the midst of this four part series on Pyne's 0:05:23.240 --> 0:05:26.600 that kind of looks at the history of it, looks 0:05:26.600 --> 0:05:30.039 a little bit that the our AUA guidelines and what 0:05:30.080 --> 0:05:33.160 we do with Perroni's disease, and so what I really 0:05:33.200 --> 0:05:35.000 want to get out of you today is kind of 0:05:35.000 --> 0:05:38.839 a narrative about mostly about Zyaflex and which is the 0:05:39.040 --> 0:05:42.240 collagenase And that's the only have to approve therapy since 0:05:42.279 --> 0:05:45.080 about twenty thirteen, and so I just want to get 0:05:45.120 --> 0:05:49.440 after your thoughts on well, first of all, who is 0:05:49.520 --> 0:05:52.640 the ideal candidate. Talk to me a little bit about 0:05:52.640 --> 0:05:56.120 the ideology of pernis and how you approach you guys. 0:05:56.120 --> 0:05:58.360 So if I just walk into your office, I'm fifty 0:05:58.360 --> 0:06:01.359 five years old, I developed a curvageure. Just give me 0:06:01.400 --> 0:06:05.960 the professor human treatment understanding, walk me through that. 0:06:06.040 --> 0:06:06.760 What that looks like? 0:06:07.360 --> 0:06:11.159 Yeah, certainly. So I think the most important thing I 0:06:11.200 --> 0:06:14.120 share with my patients is that this is a clinical diagnosis, 0:06:14.160 --> 0:06:18.920 so there's no need for any advanced testing, there's no 0:06:18.960 --> 0:06:22.320 need for biopsy things like that to confirm. We make 0:06:22.320 --> 0:06:26.120 our diagnosis as clinicians based on the history. So the 0:06:26.160 --> 0:06:31.000 story a patient tells about noticing a curvature, noticing a bump, 0:06:31.080 --> 0:06:34.680 blump or ben things like just any changes in shape 0:06:34.680 --> 0:06:39.600 to the penis. Sometimes pain occurs, so it's really the story. 0:06:39.760 --> 0:06:43.000 And then a physical exam, So physical exam that we 0:06:43.080 --> 0:06:46.359 do as experts confirms the presence of scar tissue in 0:06:46.400 --> 0:06:51.479 the penis, and that is essentially how we make our diagnosis. Now, 0:06:51.520 --> 0:06:53.880 We do have some advanced testing we can do and 0:06:53.960 --> 0:06:56.440 I know, you know, Jesse, you do this in your 0:06:56.440 --> 0:07:00.920 clinic as well, called a penile duplex Doppler ultrasound that 0:07:01.000 --> 0:07:05.480 helps us really refine the objective parameters of someone's disease. 0:07:05.520 --> 0:07:08.240 So that means, you know, how much curvature do they 0:07:08.279 --> 0:07:11.720 actually have? Is it as they think, maybe forty degrees 0:07:11.800 --> 0:07:14.880 or is it actually you know, with a really significant erection, 0:07:15.080 --> 0:07:18.080 is it more like sixty degrees. We also look at 0:07:18.080 --> 0:07:21.040 pen L blood flow, so we're able to see how 0:07:21.080 --> 0:07:25.200 good are your erections objectively, not just you know, based 0:07:25.240 --> 0:07:28.720 on your home report. We can look at the scar 0:07:28.880 --> 0:07:32.600 tissue using the ultrasound to see is it just collagen 0:07:32.880 --> 0:07:36.200 or does it have some calcified component, And this really 0:07:36.240 --> 0:07:41.840 can inform our decision about treatment. And I do often 0:07:41.960 --> 0:07:47.160 use pen L dopplers to inform my treatment making, you know, guidance, 0:07:47.200 --> 0:07:50.360 but not every single time. I think it's a really 0:07:50.960 --> 0:07:53.400 you know, our guidelines would suggest we need some objective 0:07:53.440 --> 0:07:57.960 data about the curvature. Photographs from home aren't always super reliable. 0:07:58.000 --> 0:08:01.680 We know that from some research from your but you know, 0:08:01.760 --> 0:08:04.880 I think, you know, the clinical diagnosis is really important. 0:08:04.920 --> 0:08:06.840 The history is really important, but we do have some 0:08:06.920 --> 0:08:10.320 advanced testing for guys who want, you know, more data. 0:08:11.120 --> 0:08:15.800 Yeah, yeah, you reminded me the photography story. I practiced 0:08:16.280 --> 0:08:19.080 even almost I think the first year of practice was 0:08:19.080 --> 0:08:21.480 when the iPhone came out camera phones and so so 0:08:21.600 --> 0:08:23.720 I still had guys that would come in, you know, 0:08:23.760 --> 0:08:27.920 with printers eight by ten images of their penis. That 0:08:27.920 --> 0:08:30.080 that I think I horrified. I had a twenty two 0:08:30.160 --> 0:08:32.800 year old, fresh out of college receptionist that was kind 0:08:32.840 --> 0:08:34.400 of going through the medical charts for the day, and 0:08:34.440 --> 0:08:36.240 then all of a sudden eight and a half by 0:08:36.280 --> 0:08:38.839 eleven penis is looking her straight in the eye, and 0:08:38.880 --> 0:08:40.280 I think I lost her because of that. 0:08:40.320 --> 0:08:43.000 I think she went on into orthopedics instead. 0:08:43.080 --> 0:08:45.640 So, Jesse, that's where I started. I started as that 0:08:45.800 --> 0:08:51.760 administrative assistant when I was eighteen, an expert in Peyroni's disease, 0:08:51.920 --> 0:08:55.360 and I wasn't scared. I'll just say that I was treated. 0:08:57.480 --> 0:08:58.439 Yeah, exactly. 0:08:59.000 --> 0:09:02.120 See, so that this is the road less traveled in 0:09:02.160 --> 0:09:06.000 career pathways. So I lost a receptionist and then I 0:09:06.040 --> 0:09:10.000 gained a colleague here, so it could go either way. Yeah, 0:09:10.040 --> 0:09:11.920 but I'm glad you bring that up. Because a lot 0:09:11.920 --> 0:09:14.120 of guys will come in. In fact, I had somebody in 0:09:14.120 --> 0:09:18.559 my office yesterday who had just he had images of 0:09:18.640 --> 0:09:21.720 his penis literally over the last three years. And you 0:09:21.760 --> 0:09:24.240 know those little those little kids books where it's you know, 0:09:24.520 --> 0:09:27.400 you flipped the pages really fast and it's an animation. Yeah, 0:09:27.440 --> 0:09:29.439 he did that with his phone. He had seven hundred 0:09:29.480 --> 0:09:33.040 images where he rapidly fired through to show the peronis 0:09:33.280 --> 0:09:36.600 and as you know, and it was very, very mild changes. 0:09:36.640 --> 0:09:39.560 But to him it was important objectively to see the 0:09:39.640 --> 0:09:42.199 history of how his penis has changed over time. But 0:09:42.840 --> 0:09:45.160 from a clinical usefulness, I was not able to look 0:09:45.160 --> 0:09:47.280 at that photo and say, oh, yeah, this is what 0:09:47.320 --> 0:09:49.920 We've got a treatment plan based on that. So I'm 0:09:49.960 --> 0:09:53.400 glad you brought that up. So why did this happen? 0:09:53.520 --> 0:09:55.920 Professor Hayman, I'm your guy in your office. I mean, 0:09:55.960 --> 0:09:59.280 what did I do wrong to my penis that caused this, 0:09:59.280 --> 0:10:01.520 this curvature, this deformity. 0:10:02.000 --> 0:10:04.560 Yeah, I usually explain to men. I mean the history 0:10:04.600 --> 0:10:07.920 is you probably hear for this from your patients that 0:10:08.080 --> 0:10:12.800 the vast majority of men there's no traumatizing injury, there's 0:10:12.880 --> 0:10:16.360 no major event where they're having sex slip out of 0:10:16.360 --> 0:10:20.560 their partner injure the penis, and you know, the rest 0:10:20.640 --> 0:10:23.600 is history kind of thing. I would say ninety nine 0:10:23.679 --> 0:10:26.920 percent of men don't have something like that happen. So 0:10:27.000 --> 0:10:30.880 we think this is the result of micro traumas to 0:10:30.920 --> 0:10:33.880 the penis, and that is just a result of having sex. 0:10:34.760 --> 0:10:38.840 As men get older, erections inherently lose a little bit 0:10:38.880 --> 0:10:42.360 of strength. We know that ED is sort of a 0:10:42.440 --> 0:10:46.680 change of aging for most men. And as erections lose strength, 0:10:46.840 --> 0:10:50.800 they get a little more susceptible to injury. Having sex 0:10:50.920 --> 0:10:54.559 leads to these little shearing injuries of the layers of 0:10:55.000 --> 0:10:58.280 the thick connected tissue that holds the blood in when 0:10:58.320 --> 0:11:01.920 men get an erection, that's called the two albiginia and 0:11:01.960 --> 0:11:04.920 this shearing leads to a little bit of blood entry 0:11:05.040 --> 0:11:09.280 into the layers and then in probably some in a 0:11:09.360 --> 0:11:15.640 genetically susceptible person man, a cascade of scarring occurs. And 0:11:15.679 --> 0:11:20.000 so it's these cells that come in, fibroblasts, inflammatory markers, 0:11:20.040 --> 0:11:23.240 They come in and lay down scar tissue, and that's 0:11:23.280 --> 0:11:27.000 all that's happening, is really the development of scar tissue. 0:11:27.080 --> 0:11:32.480 This is not a cancerous process. It is an exuberant 0:11:32.520 --> 0:11:36.000 scar tissue disorder, just like people who develop keloids or 0:11:36.360 --> 0:11:38.400 you know, really bad scar tissue when they get a 0:11:38.440 --> 0:11:42.880 cut in their skin, and so it's it's it's quite common. 0:11:43.000 --> 0:11:46.880 One in ten men. There are some associated conditions where 0:11:46.920 --> 0:11:48.960 they can develop scar tissue in the hands that leads 0:11:49.040 --> 0:11:51.760 to curvature. And so we know that there are some 0:11:52.880 --> 0:11:56.560 true genetic you know, relationship with that kind of scarring disorder, 0:11:56.640 --> 0:11:58.680 but for the most part, you know, we think it's 0:11:58.720 --> 0:12:01.600 probably just some genetic susceptibility. 0:12:02.280 --> 0:12:04.240 Yeah, I mean, you brought up cancer, and I think 0:12:04.280 --> 0:12:07.280 we borrow in pironius, which again it's very important for 0:12:07.360 --> 0:12:09.320 people out there. If you have a lump in your penis, 0:12:09.360 --> 0:12:12.360 it's almost maturedly not cancer, get it checked out obviously. 0:12:12.440 --> 0:12:16.120 But we do talk about Nutson's two hit hypothesis and 0:12:16.200 --> 0:12:20.200 cancer a lot where you have some underlying genetic susceptibility, 0:12:20.240 --> 0:12:23.000 as Marrow was saying, and then the second hit is 0:12:23.040 --> 0:12:25.720 some kind of insult, and that micro trauma is is 0:12:25.720 --> 0:12:27.800 about the best that we have, you know, because you're right, 0:12:27.840 --> 0:12:30.120 I mean, in my practice and yours too, I'm sure 0:12:30.120 --> 0:12:33.520 about eighty percent of guys have no wild story about 0:12:33.520 --> 0:12:35.360 how this happened. And I think We brought this up 0:12:35.400 --> 0:12:38.439 on a previous episode where I say, just imagine being 0:12:38.520 --> 0:12:41.360 that businessman off on a trip from LA to Chicago 0:12:41.400 --> 0:12:43.680 and you come back home with a bent penis and 0:12:43.679 --> 0:12:45.520 you have to try to explain it to your partner. 0:12:45.840 --> 0:12:48.720 And so this is where we have to disavow any 0:12:48.800 --> 0:12:52.040 sort of shame or guilt associated with this, because right, 0:12:52.120 --> 0:12:55.720 it just it just happens. And we also talk about this, 0:12:55.920 --> 0:12:59.679 the diminished directile function over time is super important because yeah, guys, 0:13:00.040 --> 0:13:01.800 guys in their twenties is say, Doc used to be 0:13:01.840 --> 0:13:03.680 able to hang at gym towel on my penis and 0:13:03.880 --> 0:13:06.360 you know, now maybe a washrag, And that's sort of 0:13:06.360 --> 0:13:08.600 the metric for aging of the penis as we go 0:13:08.679 --> 0:13:11.880 in our forties and fifties and sixties, which is the 0:13:11.880 --> 0:13:14.560 demographic that we see. So so no, I love that, 0:13:14.600 --> 0:13:16.240 and I think that's super important for guys to you know, 0:13:16.280 --> 0:13:19.200 sort of disavow themselves of any any wrongdoing that. 0:13:19.280 --> 0:13:21.720 Yeah, the penis is a pretty durable organ. 0:13:22.160 --> 0:13:25.040 Okay, so this guy walks in your office and and 0:13:25.120 --> 0:13:29.720 you've established his pernis, you can feel a non calcified lump, 0:13:30.000 --> 0:13:31.599 and that's I kind of led the witness there a 0:13:31.640 --> 0:13:35.320 little bit. But if you if you explained that, tell 0:13:35.320 --> 0:13:38.400 me who is a good candidate for collagenation and just 0:13:38.400 --> 0:13:40.920 walk me through a little bit about what collagenase is 0:13:41.000 --> 0:13:43.720 or zyoflex we can use the trade name as well. 0:13:44.240 --> 0:13:47.800 Yeah, so zyaflex is an enzyme. I explained it to 0:13:47.840 --> 0:13:51.360 patients that this is an enzyme treatment that gets injected 0:13:51.400 --> 0:13:54.240 directly into the scar tissue to help dissolve it to 0:13:54.520 --> 0:13:58.440 relax the penis backstraight. I like to explain that the 0:13:58.720 --> 0:14:01.960 a rectile chambers are that fill with blood to give 0:14:02.000 --> 0:14:04.880 a man in erection are like two circus balloons. They 0:14:04.920 --> 0:14:08.080 want to blow up straight and long. And when this 0:14:08.240 --> 0:14:12.280 scar tissue is essentially causing a restriction on one side, 0:14:12.679 --> 0:14:15.360 the cause of the tethering upward. Generally upward is the 0:14:15.360 --> 0:14:21.760 most common direction of curvature. By dissolving that scar tissue, 0:14:21.760 --> 0:14:24.480 we allow the penis to then relax back into a 0:14:24.520 --> 0:14:27.880 straight position. So it's sort of like a medical scalpel 0:14:27.920 --> 0:14:31.000 where we can just sort of insize the scar tissue 0:14:31.040 --> 0:14:35.840 with this interlagional therapy. Interleagional is just a fancy word 0:14:35.880 --> 0:14:40.560 for saying inside the lesion or the scar, it is 0:14:40.680 --> 0:14:43.440 an enzyme treatment that has, like you mentioned, has been 0:14:43.440 --> 0:14:47.080 empty approved for over ten years now, since twenty thirteen, 0:14:47.480 --> 0:14:50.200 it's been used in probably tens of thousands of men. 0:14:51.160 --> 0:14:55.120 Very safe treatment, and it's really applicable to many men, 0:14:55.400 --> 0:14:58.640 so we use it. You know, the most sort of 0:14:59.440 --> 0:15:05.280 industry safe way to describe the best candidate for it 0:15:05.400 --> 0:15:08.200 is someone who has over thirty degrees of curvature and 0:15:08.400 --> 0:15:10.600 a plaque that we can feel, so scar tissue that 0:15:10.640 --> 0:15:13.440 we can feel. It's important to know that in the 0:15:13.720 --> 0:15:17.960 FDA approval trials for this, men with downward curvature were 0:15:17.960 --> 0:15:21.720 not included, but that doesn't exclude those men from treatment 0:15:22.040 --> 0:15:26.040 in the modern era. So in the modern era, the 0:15:26.080 --> 0:15:30.240 direction of curvature doesn't really matter to me. Severity of 0:15:30.320 --> 0:15:33.720 curvature may not matter. It just may inform a little 0:15:33.720 --> 0:15:36.880 bit of my counseling of men about how much benefit 0:15:36.920 --> 0:15:40.720 they may get from zioflex. But you could essentially give 0:15:40.840 --> 0:15:44.320 zioflex as a treatment to anyone. I know. Jesse and 0:15:44.400 --> 0:15:47.480 I have had debates at our national meetings about this 0:15:47.600 --> 0:15:53.040 and we get you, yeah, no, it's okay, we get 0:15:53.040 --> 0:15:57.000 assigned to pro versus con But in reality, I do 0:15:57.160 --> 0:16:00.480 think that there are many men in whom zyoplex will 0:16:00.480 --> 0:16:04.120 work well because even if you a guy may need 0:16:04.160 --> 0:16:07.720 surgery down the road, it may downgrade the severity of 0:16:07.760 --> 0:16:12.720 the surgery he needs. So anybody with essentially curvature greater 0:16:12.760 --> 0:16:15.200 than thirty degrees and a plaque that we can target 0:16:15.240 --> 0:16:17.880 with our needle is a reasonable candidate. 0:16:38.640 --> 0:16:41.880 You said so much there, and I got to recap 0:16:41.960 --> 0:16:46.240 the idea of ventral curvature or guys that curve down 0:16:46.680 --> 0:16:48.840 is something that you're right was we did not sit 0:16:48.920 --> 0:16:51.760 in the original impressed trials is what led to the 0:16:52.480 --> 0:16:55.560 FDA approval of this medication, and it was really at 0:16:55.560 --> 0:16:57.760 the time we were so nervous that we might mess up. 0:16:57.760 --> 0:17:00.840 The urethra and the ventral tend to be in what 0:17:00.840 --> 0:17:03.680 we call the septum, which is the space between the 0:17:03.680 --> 0:17:06.760 two circus balloons, as you called the corporate cavernosa, which 0:17:06.800 --> 0:17:09.240 I like, I've never used that, but this guy's a 0:17:09.240 --> 0:17:12.000 totally different image of the that's. 0:17:11.840 --> 0:17:14.360 Right, you are, you are very professorial. 0:17:14.480 --> 0:17:19.359 So the septal plaque that's by the urethra, we avoid 0:17:19.359 --> 0:17:21.440 it because we just didn't know. And and since that time, 0:17:21.480 --> 0:17:23.440 in fact, there have been some phase two studies looking 0:17:23.480 --> 0:17:25.639 at using zio flex, which, as you said, it's just 0:17:25.680 --> 0:17:29.760 an enzyme. It just dissolves abnormal tissue to treat urethral strictures. 0:17:29.800 --> 0:17:32.240 And so once we did some of those studies to 0:17:32.280 --> 0:17:34.600 see that we weren't actually injuring the urethra at all, 0:17:35.040 --> 0:17:38.120 it allowed some of us to say, gosh, well maybe 0:17:38.119 --> 0:17:40.760 we should start treating these guys. Because we'll talk about 0:17:40.800 --> 0:17:43.400 surgery in a whole another episode. But but getting rid 0:17:43.440 --> 0:17:47.440 of ventral plaques or sceptial plaqu surgically is really really tricky. 0:17:47.480 --> 0:17:50.280 It's fraught with complications, injury to the urethra and the 0:17:50.280 --> 0:17:52.560 blip supply to the corpus bungdariosum. And so that's a 0:17:52.840 --> 0:17:55.520 that's a surgery most of us don't really recommend. And 0:17:55.560 --> 0:17:59.040 so if you had something non invasive such as sieflex 0:17:59.119 --> 0:18:02.040 or interlegional, great. And then we have a few papers 0:18:02.080 --> 0:18:04.240 coming out, I don't think they're I guess they're kind 0:18:04.240 --> 0:18:06.800 of in bargoed that they have been accepted. Looking at 0:18:06.920 --> 0:18:10.119 as you were saying, modern series for septal plaques, and 0:18:10.160 --> 0:18:14.080 the inside information is that that they do just the same. 0:18:14.200 --> 0:18:16.360 Like you know, we'll talk about outcomes and successes here. 0:18:16.880 --> 0:18:19.000 I'll probably be my next question for you. But but 0:18:19.080 --> 0:18:21.280 the ventro plaques tend to do just as well. It's 0:18:21.320 --> 0:18:24.840 just different real estate, different different location, a little closer 0:18:24.880 --> 0:18:28.919 to the urethra. So that's one thing. Great point. The 0:18:29.040 --> 0:18:31.920 second and actually I think i'll just ask you is 0:18:31.920 --> 0:18:35.200 a question in because it will kind of go into 0:18:35.280 --> 0:18:39.720 how how guys do with this medication is the idea 0:18:39.760 --> 0:18:43.199 of staging. Maybe I shouldn't even call it staging, but 0:18:43.400 --> 0:18:46.119 the idea that you can take somebody with a severe curvature, 0:18:46.560 --> 0:18:50.520 say seventy degrees, and then get them to say forty degrees, 0:18:50.560 --> 0:18:52.840 which is, you know, not bad until you know, not 0:18:52.920 --> 0:18:56.679 quite a fifty percent improvement, but somewhere in there, and 0:18:56.680 --> 0:18:59.639 and yet potentially downgrade the severity of the surgery. So 0:18:59.680 --> 0:19:03.240 walk me through, walkby through what you counsel guys on 0:19:03.880 --> 0:19:07.600 your success rates with zioflex. And also, I think I 0:19:07.640 --> 0:19:10.560 can't emphasize enough because this is something we get a 0:19:10.600 --> 0:19:13.679 lot from insurance companies and just in general in the 0:19:13.720 --> 0:19:16.960 medical community, is that that this is a drug, but 0:19:17.080 --> 0:19:20.159 it's actually, as you said, a medical scalpel. So you 0:19:20.240 --> 0:19:23.600 have to have that drug in very qualified hands to 0:19:23.720 --> 0:19:25.800 do a good job. So there's there's a level of 0:19:25.840 --> 0:19:29.480 certification we have to go through called MS certification to 0:19:29.480 --> 0:19:32.120 be able to even inject the drug. And then training 0:19:32.280 --> 0:19:35.600 like your fellowship where you actually train people to do 0:19:35.640 --> 0:19:37.439 this on a on a basis on you know, when 0:19:37.440 --> 0:19:40.760 they're out in the community. So yeah, I mean, fire Away, 0:19:40.800 --> 0:19:42.960 talk to me about results. Unpack a little bit more 0:19:43.000 --> 0:19:44.840 of what we just talked about there. 0:19:45.400 --> 0:19:47.720 Yeah, So, like you said, I mean, the people who 0:19:47.880 --> 0:19:52.560 are administering zioflex have some certification, right, So even to 0:19:52.680 --> 0:19:56.120 get zioflex at your hospital, that hospital has to have certification. 0:19:56.920 --> 0:19:59.720 You as a provider have to have certification. So if 0:19:59.720 --> 0:20:03.560 you're seeing someone who is offering this treatment, they have 0:20:03.720 --> 0:20:09.000 gone through some training and approval by the manufacturer. So 0:20:09.040 --> 0:20:10.640 that's you know, that's a good thing. That's the way 0:20:10.680 --> 0:20:14.520 we keep people safe. I usually like to quote the 0:20:14.600 --> 0:20:17.440 Impressed trials when I talk to patients about success rates. 0:20:17.440 --> 0:20:20.800 So I usually say that in the trials, the average 0:20:20.840 --> 0:20:24.280 improvement was about thirty five percent. So that's not thirty 0:20:24.320 --> 0:20:28.520 five degrees, but thirty five percent, which means, like you mentioned, 0:20:28.520 --> 0:20:31.840 for a guy who has seventy degrees of curvature, he 0:20:32.000 --> 0:20:37.120 may recognize a thirty degree improvement and that's really really significant, 0:20:37.119 --> 0:20:40.200 going from seventy to forty. So we do know from 0:20:40.240 --> 0:20:45.200 another study that the best outcomes for men undergoing Zyeflex 0:20:45.200 --> 0:20:49.240 treatments come from men with great erections and actually more 0:20:49.280 --> 0:20:52.000 severe curvature, so they tend to do a little bit better. 0:20:52.760 --> 0:20:57.320 I also say that, you know, treatments are inherently going 0:20:57.359 --> 0:20:59.439 to be on a bell curve where some guys just 0:20:59.560 --> 0:21:02.560 don't really respond very well, many are going to be 0:21:02.640 --> 0:21:07.320 kind of at that average median, and then some may 0:21:07.400 --> 0:21:12.520 have really robust improvements like eighty percent. And so I 0:21:12.520 --> 0:21:17.919 think we want to capture everybody, and I really counselmen 0:21:18.040 --> 0:21:20.600 as they go through the series. I know we haven't 0:21:20.600 --> 0:21:24.600 really kind of described the treatment with Zyeflex, but it's 0:21:24.720 --> 0:21:27.720 essentially to boil it down, it's about eight shots over 0:21:27.760 --> 0:21:31.800 a six month period, and I check in with them 0:21:32.000 --> 0:21:34.760 for every single cycle to see how are you doing? 0:21:35.440 --> 0:21:39.080 Are you seeing improvements? And should we keep proceeding. And 0:21:40.000 --> 0:21:42.480 it's very rare for me to see a guy want 0:21:42.520 --> 0:21:45.920 to stop early, because they do. We know that there 0:21:46.000 --> 0:21:51.800 are typically sequential improvements, so each cycle tends to give 0:21:51.840 --> 0:21:56.119 a little bit more and more benefit. So I you know, 0:21:56.320 --> 0:22:01.119 I usually want to encourage them to continue because we 0:22:01.160 --> 0:22:04.480 do see continued improvement, but I want to make sure 0:22:04.480 --> 0:22:06.760 it's the right treatment for them, and if they're not 0:22:06.840 --> 0:22:10.280 getting any benefit, we can always stop. But thirty five 0:22:10.280 --> 0:22:13.000 percent is average, but they may do better again, Guys 0:22:13.000 --> 0:22:15.280 with better erections are probably going to do better. 0:22:15.960 --> 0:22:16.200 Yeah. 0:22:16.280 --> 0:22:17.560 I can't believe I'm going to go on record as 0:22:17.600 --> 0:22:21.639 saying this, but the a couple of years ago, a 0:22:21.720 --> 0:22:25.520 few of our biggest insurance carriers started to mandate something 0:22:25.520 --> 0:22:28.320 which was not on label. In fact, I rally against it, 0:22:29.080 --> 0:22:31.960 which was that we had to have every two injections 0:22:32.000 --> 0:22:34.320 we had to have a check in with the patient, 0:22:34.359 --> 0:22:37.760