Speaker 1: Let's talk about it.
Speaker 2: Let's talk about the Maro. Let's talk about it.
Speaker 3: Let's talk about the man. Hero, Welcome to the Man,
Speaker 3: Welcome back to the mailroom. Jordan runs in the house,
Speaker 3: Doctor Jesse Mills here in the midst of our Payrone's
Speaker 3: Disease series, something that is really a big part of
Speaker 3: my career, dedicated probably at least forty fifty percent of
Speaker 3: the men that I see these days for all the
Speaker 3: treatments I do, a lot of them are coming to
Speaker 3: me just for Perrone's Disease. So we're going to really
Speaker 3: dive into this over this multi part series. But first,
Speaker 3: tell me what's up with you man? What's what's new
Speaker 3: in Jordan's world?
Speaker 4: Not too much gearing up for summertime, going to visit
Speaker 4: some family, going to New England boys and going to
Speaker 4: the camp. I know we talked about lobsters last time.
Speaker 2: I forgot you cold lobster or worm lobster.
Speaker 4: Yeah, I know it's a divisive issue in the New
Speaker 4: England territories.
Speaker 3: Well, I mean I think you go cold and the
Speaker 3: mayonnaise can kind of ruin the tenderness, you know, But
Speaker 3: I don't know these are one of these false dichotomies.
Speaker 3: Why can't you just love both man, but you know,
Speaker 3: just alternate. Monday's cold. Yeah, speaking of cold, you know
Speaker 3: it's do you know what June gloom is? If you
Speaker 3: heard this term in Britain, we are suffering from June gloom,
Speaker 3: this Pacific inversion layer. Everybody thinks it's sunny in southern California.
Speaker 3: We're hosting the World Cup here in Sofi Stadium, and
Speaker 3: and I'm afraid our tourists are thinking what happened to
Speaker 3: all the sunshine? But give us, give us a few
Speaker 3: hours somewhere around eleven to twelve, it burns off. But
Speaker 3: it's a It is a grade A. I don't get
Speaker 3: to see my Santa Monica Bay. That's almost pentameter. We're
Speaker 3: going to work that out anyhow. We we are Russian, yes,
Speaker 3: Russian literature right know, and language. And here I am
Speaker 3: talking about Frescois de la Peroni. So I've known Mara Heman,
Speaker 3: she's our guest today spoiler alert for years actually, and
Speaker 3: she's been doing just amazing work up at the University
Speaker 3: of Washington in Seattle, where she's an associate professor. She's
Speaker 3: fellowship trained in mail reproductive medicine and surgery, just like me,
Speaker 3: Just like a lot of our guests, she also is
Speaker 3: an outstanding clinician. One of the things that I think
Speaker 3: stands out about her bio is how dedicated she is
Speaker 3: to patient care and patient advocacy. And again, as we
Speaker 3: talk about these very sensitive issues that guys have, this
Speaker 3: needing somebody like Professor Heeman in your corner is huge
Speaker 3: and so very excited to have her on today to
Speaker 3: talk about interlegional therapy. She is a graduate of Rush
Speaker 3: Medical College in Chicago, where I believe she grew up.
Speaker 3: We'll confirm that with her when she walks into the
Speaker 3: mail room here. Also a surgical resident intern at Loyal
Speaker 3: University in Chicago, and then finished her residency also at
Speaker 3: Loyola in in Chicago, and then did her fellowship at
Speaker 3: you dub as it's affectionately known up in Seattle, where
Speaker 3: she has stayed on as associate professor and she keeps
Speaker 3: advancing through the ranks. So very excited to have her
Speaker 3: on today today. We're really going to mostly talk about
Speaker 3: interleagional therapy, meaning we talked a little bit about this
Speaker 3: before with pills, pokes and procedures, and with this in mine.
Speaker 3: She is going to talk about the procedure aspect of it.
Speaker 3: So there's no FDA approved therapy for this that is
Speaker 3: not interleagional, but yet we try a lot of off
Speaker 3: labeled things. I'll probably pick her brain on that, and
Speaker 3: then what we really want to talk about today is
Speaker 3: collagenate's therapy. Maybe she has some opinions on verapamil, which
Speaker 3: I still use.
Speaker 2: We'll see about that.
Speaker 3: And anyway, let's let her into the mail room, Professor human.
Speaker 3: I just am so excited to see you on the
Speaker 3: mail room. Welcome, Welcome. This is Jordan my on air
Speaker 3: producer Ombre Extraordinaire and Brooklyn Nighte as of the last
Speaker 3: decade or so.
Speaker 2: So how you did? Tell me?
Speaker 3: Tell me what's new in your life and your crazy, busy,
Speaker 3: overscheduled world.
Speaker 5: Yeah, good morning, it's so great to see you too.
Speaker 5: Life is exciting. As you know. We just matched our
Speaker 5: new fellows for the andrology program here at UW and congrats.
Speaker 5: We're thrilled. We have our graduates going out to their
Speaker 5: you know, top choices for jobs and it's just more
Speaker 5: people going out into the world to take great care
Speaker 5: of men. So we're absolutely delighted to be part of
Speaker 5: their education.
Speaker 3: That right there actually summarizes Mari to t is that
Speaker 3: when I asked her how she's doing, she said how
Speaker 3: everybody else.
Speaker 2: That is she's responsible for is doing. I mean, that
Speaker 2: is a sign of.
Speaker 3: A true caring, compassionate person. And it's so on brand
Speaker 3: for you and so so excited to have you talk
Speaker 3: about something else that that obviously affects other people, given
Speaker 3: that this is a disease of the penis. So this
Speaker 3: is why I think you're perfect candidate for this is
Speaker 3: because you've dedicated your career in a large part to
Speaker 3: Pirroni's disease as well. So exactly what I'm here for, Jordan,
Speaker 3: Professor Heman, He professor Heman, Jordan Runta.
Speaker 2: So nice to Yeah, yeah, it's gonna be fun.
Speaker 3: So we've done this this about four part series or
Speaker 3: in the midst of this four part series on Pyne's
Speaker 3: that kind of looks at the history of it, looks
Speaker 3: a little bit that the our AUA guidelines and what
Speaker 3: we do with Perroni's disease, and so what I really
Speaker 3: want to get out of you today is kind of
Speaker 3: a narrative about mostly about Zyaflex and which is the
Speaker 3: collagenase And that's the only have to approve therapy since
Speaker 3: about twenty thirteen, and so I just want to get
Speaker 3: after your thoughts on well, first of all, who is
Speaker 3: the ideal candidate. Talk to me a little bit about
Speaker 3: the ideology of pernis and how you approach you guys.
Speaker 3: So if I just walk into your office, I'm fifty
Speaker 3: five years old, I developed a curvageure. Just give me
Speaker 3: the professor human treatment understanding, walk me through that.
Speaker 2: What that looks like?
Speaker 5: Yeah, certainly. So I think the most important thing I
Speaker 5: share with my patients is that this is a clinical diagnosis,
Speaker 5: so there's no need for any advanced testing, there's no
Speaker 5: need for biopsy things like that to confirm. We make
Speaker 5: our diagnosis as clinicians based on the history. So the
Speaker 5: story a patient tells about noticing a curvature, noticing a bump,
Speaker 5: blump or ben things like just any changes in shape
Speaker 5: to the penis. Sometimes pain occurs, so it's really the story.
Speaker 5: And then a physical exam, So physical exam that we
Speaker 5: do as experts confirms the presence of scar tissue in
Speaker 5: the penis, and that is essentially how we make our diagnosis. Now,
Speaker 5: We do have some advanced testing we can do and
Speaker 5: I know, you know, Jesse, you do this in your
Speaker 5: clinic as well, called a penile duplex Doppler ultrasound that
Speaker 5: helps us really refine the objective parameters of someone's disease.
Speaker 5: So that means, you know, how much curvature do they
Speaker 5: actually have? Is it as they think, maybe forty degrees
Speaker 5: or is it actually you know, with a really significant erection,
Speaker 5: is it more like sixty degrees. We also look at
Speaker 5: pen L blood flow, so we're able to see how
Speaker 5: good are your erections objectively, not just you know, based
Speaker 5: on your home report. We can look at the scar
Speaker 5: tissue using the ultrasound to see is it just collagen
Speaker 5: or does it have some calcified component, And this really
Speaker 5: can inform our decision about treatment. And I do often
Speaker 5: use pen L dopplers to inform my treatment making, you know, guidance,
Speaker 5: but not every single time. I think it's a really
Speaker 5: you know, our guidelines would suggest we need some objective
Speaker 5: data about the curvature. Photographs from home aren't always super reliable.
Speaker 5: We know that from some research from your but you know,
Speaker 5: I think, you know, the clinical diagnosis is really important.
Speaker 5: The history is really important, but we do have some
Speaker 5: advanced testing for guys who want, you know, more data.
Speaker 3: Yeah, yeah, you reminded me the photography story. I practiced
Speaker 3: even almost I think the first year of practice was
Speaker 3: when the iPhone came out camera phones and so so
Speaker 3: I still had guys that would come in, you know,
Speaker 3: with printers eight by ten images of their penis. That
Speaker 3: that I think I horrified. I had a twenty two
Speaker 3: year old, fresh out of college receptionist that was kind
Speaker 3: of going through the medical charts for the day, and
Speaker 3: then all of a sudden eight and a half by
Speaker 3: eleven penis is looking her straight in the eye, and
Speaker 3: I think I lost her because of that.
Speaker 2: I think she went on into orthopedics instead.
Speaker 5: So, Jesse, that's where I started. I started as that
Speaker 5: administrative assistant when I was eighteen, an expert in Peyroni's disease,
Speaker 5: and I wasn't scared. I'll just say that I was treated.
Speaker 2: Yeah, exactly.
Speaker 3: See, so that this is the road less traveled in
Speaker 3: career pathways. So I lost a receptionist and then I
Speaker 3: gained a colleague here, so it could go either way. Yeah,
Speaker 3: but I'm glad you bring that up. Because a lot
Speaker 3: of guys will come in. In fact, I had somebody in
Speaker 3: my office yesterday who had just he had images of
Speaker 3: his penis literally over the last three years. And you
Speaker 3: know those little those little kids books where it's you know,
Speaker 3: you flipped the pages really fast and it's an animation. Yeah,
Speaker 3: he did that with his phone. He had seven hundred
Speaker 3: images where he rapidly fired through to show the peronis
Speaker 3: and as you know, and it was very, very mild changes.
Speaker 3: But to him it was important objectively to see the
Speaker 3: history of how his penis has changed over time. But
Speaker 3: from a clinical usefulness, I was not able to look
Speaker 3: at that photo and say, oh, yeah, this is what
Speaker 3: We've got a treatment plan based on that. So I'm
Speaker 3: glad you brought that up. So why did this happen?
Speaker 3: Professor Hayman, I'm your guy in your office. I mean,
Speaker 3: what did I do wrong to my penis that caused this,
Speaker 3: this curvature, this deformity.
Speaker 5: Yeah, I usually explain to men. I mean the history
Speaker 5: is you probably hear for this from your patients that
Speaker 5: the vast majority of men there's no traumatizing injury, there's
Speaker 5: no major event where they're having sex slip out of
Speaker 5: their partner injure the penis, and you know, the rest
Speaker 5: is history kind of thing. I would say ninety nine
Speaker 5: percent of men don't have something like that happen. So
Speaker 5: we think this is the result of micro traumas to
Speaker 5: the penis, and that is just a result of having sex.
Speaker 5: As men get older, erections inherently lose a little bit
Speaker 5: of strength. We know that ED is sort of a
Speaker 5: change of aging for most men. And as erections lose strength,
Speaker 5: they get a little more susceptible to injury. Having sex
Speaker 5: leads to these little shearing injuries of the layers of
Speaker 5: the thick connected tissue that holds the blood in when
Speaker 5: men get an erection, that's called the two albiginia and
Speaker 5: this shearing leads to a little bit of blood entry
Speaker 5: into the layers and then in probably some in a
Speaker 5: genetically susceptible person man, a cascade of scarring occurs. And
Speaker 5: so it's these cells that come in, fibroblasts, inflammatory markers,
Speaker 5: They come in and lay down scar tissue, and that's
Speaker 5: all that's happening, is really the development of scar tissue.
Speaker 5: This is not a cancerous process. It is an exuberant
Speaker 5: scar tissue disorder, just like people who develop keloids or
Speaker 5: you know, really bad scar tissue when they get a
Speaker 5: cut in their skin, and so it's it's it's quite common.
Speaker 5: One in ten men. There are some associated conditions where
Speaker 5: they can develop scar tissue in the hands that leads
Speaker 5: to curvature. And so we know that there are some
Speaker 5: true genetic you know, relationship with that kind of scarring disorder,
Speaker 5: but for the most part, you know, we think it's
Speaker 5: probably just some genetic susceptibility.
Speaker 3: Yeah, I mean, you brought up cancer, and I think
Speaker 3: we borrow in pironius, which again it's very important for
Speaker 3: people out there. If you have a lump in your penis,
Speaker 3: it's almost maturedly not cancer, get it checked out obviously.
Speaker 3: But we do talk about Nutson's two hit hypothesis and
Speaker 3: cancer a lot where you have some underlying genetic susceptibility,
Speaker 3: as Marrow was saying, and then the second hit is
Speaker 3: some kind of insult, and that micro trauma is is
Speaker 3: about the best that we have, you know, because you're right,
Speaker 3: I mean, in my practice and yours too, I'm sure
Speaker 3: about eighty percent of guys have no wild story about
Speaker 3: how this happened. And I think We brought this up
Speaker 3: on a previous episode where I say, just imagine being
Speaker 3: that businessman off on a trip from LA to Chicago
Speaker 3: and you come back home with a bent penis and
Speaker 3: you have to try to explain it to your partner.
Speaker 3: And so this is where we have to disavow any
Speaker 3: sort of shame or guilt associated with this, because right,
Speaker 3: it just it just happens. And we also talk about this,
Speaker 3: the diminished directile function over time is super important because yeah, guys,
Speaker 3: guys in their twenties is say, Doc used to be
Speaker 3: able to hang at gym towel on my penis and
Speaker 3: you know, now maybe a washrag, And that's sort of
Speaker 3: the metric for aging of the penis as we go
Speaker 3: in our forties and fifties and sixties, which is the
Speaker 3: demographic that we see. So so no, I love that,
Speaker 3: and I think that's super important for guys to you know,
Speaker 3: sort of disavow themselves of any any wrongdoing that.
Speaker 2: Yeah, the penis is a pretty durable organ.
Speaker 3: Okay, so this guy walks in your office and and
Speaker 3: you've established his pernis, you can feel a non calcified lump,
Speaker 3: and that's I kind of led the witness there a
Speaker 3: little bit. But if you if you explained that, tell
Speaker 3: me who is a good candidate for collagenation and just
Speaker 3: walk me through a little bit about what collagenase is
Speaker 3: or zyoflex we can use the trade name as well.
Speaker 5: Yeah, so zyaflex is an enzyme. I explained it to
Speaker 5: patients that this is an enzyme treatment that gets injected
Speaker 5: directly into the scar tissue to help dissolve it to
Speaker 5: relax the penis backstraight. I like to explain that the
Speaker 5: a rectile chambers are that fill with blood to give
Speaker 5: a man in erection are like two circus balloons. They
Speaker 5: want to blow up straight and long. And when this
Speaker 5: scar tissue is essentially causing a restriction on one side,
Speaker 5: the cause of the tethering upward. Generally upward is the
Speaker 5: most common direction of curvature. By dissolving that scar tissue,
Speaker 5: we allow the penis to then relax back into a
Speaker 5: straight position. So it's sort of like a medical scalpel
Speaker 5: where we can just sort of insize the scar tissue
Speaker 5: with this interlagional therapy. Interleagional is just a fancy word
Speaker 5: for saying inside the lesion or the scar, it is
Speaker 5: an enzyme treatment that has, like you mentioned, has been
Speaker 5: empty approved for over ten years now, since twenty thirteen,
Speaker 5: it's been used in probably tens of thousands of men.
Speaker 5: Very safe treatment, and it's really applicable to many men,
Speaker 5: so we use it. You know, the most sort of
Speaker 5: industry safe way to describe the best candidate for it
Speaker 5: is someone who has over thirty degrees of curvature and
Speaker 5: a plaque that we can feel, so scar tissue that
Speaker 5: we can feel. It's important to know that in the
Speaker 5: FDA approval trials for this, men with downward curvature were
Speaker 5: not included, but that doesn't exclude those men from treatment
Speaker 5: in the modern era. So in the modern era, the
Speaker 5: direction of curvature doesn't really matter to me. Severity of
Speaker 5: curvature may not matter. It just may inform a little
Speaker 5: bit of my counseling of men about how much benefit
Speaker 5: they may get from zioflex. But you could essentially give
Speaker 5: zioflex as a treatment to anyone. I know. Jesse and
Speaker 5: I have had debates at our national meetings about this
Speaker 5: and we get you, yeah, no, it's okay, we get
Speaker 5: assigned to pro versus con But in reality, I do
Speaker 5: think that there are many men in whom zyoplex will
Speaker 5: work well because even if you a guy may need
Speaker 5: surgery down the road, it may downgrade the severity of
Speaker 5: the surgery he needs. So anybody with essentially curvature greater
Speaker 5: than thirty degrees and a plaque that we can target
Speaker 5: with our needle is a reasonable candidate.
Speaker 3: You said so much there, and I got to recap
Speaker 3: the idea of ventral curvature or guys that curve down
Speaker 3: is something that you're right was we did not sit
Speaker 3: in the original impressed trials is what led to the
Speaker 3: FDA approval of this medication, and it was really at
Speaker 3: the time we were so nervous that we might mess up.
Speaker 3: The urethra and the ventral tend to be in what
Speaker 3: we call the septum, which is the space between the
Speaker 3: two circus balloons, as you called the corporate cavernosa, which
Speaker 3: I like, I've never used that, but this guy's a
Speaker 3: totally different image of the that's.
Speaker 2: Right, you are, you are very professorial.
Speaker 3: So the septal plaque that's by the urethra, we avoid
Speaker 3: it because we just didn't know. And and since that time,
Speaker 3: in fact, there have been some phase two studies looking
Speaker 3: at using zio flex, which, as you said, it's just
Speaker 3: an enzyme. It just dissolves abnormal tissue to treat urethral strictures.
Speaker 3: And so once we did some of those studies to
Speaker 3: see that we weren't actually injuring the urethra at all,
Speaker 3: it allowed some of us to say, gosh, well maybe
Speaker 3: we should start treating these guys. Because we'll talk about
Speaker 3: surgery in a whole another episode. But but getting rid
Speaker 3: of ventral plaques or sceptial plaqu surgically is really really tricky.
Speaker 3: It's fraught with complications, injury to the urethra and the
Speaker 3: blip supply to the corpus bungdariosum. And so that's a
Speaker 3: that's a surgery most of us don't really recommend. And
Speaker 3: so if you had something non invasive such as sieflex
Speaker 3: or interlegional, great. And then we have a few papers
Speaker 3: coming out, I don't think they're I guess they're kind
Speaker 3: of in bargoed that they have been accepted. Looking at
Speaker 3: as you were saying, modern series for septal plaques, and
Speaker 3: the inside information is that that they do just the same.
Speaker 3: Like you know, we'll talk about outcomes and successes here.
Speaker 3: I'll probably be my next question for you. But but
Speaker 3: the ventro plaques tend to do just as well. It's
Speaker 3: just different real estate, different different location, a little closer
Speaker 3: to the urethra. So that's one thing. Great point. The
Speaker 3: second and actually I think i'll just ask you is
Speaker 3: a question in because it will kind of go into
Speaker 3: how how guys do with this medication is the idea
Speaker 3: of staging. Maybe I shouldn't even call it staging, but
Speaker 3: the idea that you can take somebody with a severe curvature,
Speaker 3: say seventy degrees, and then get them to say forty degrees,
Speaker 3: which is, you know, not bad until you know, not
Speaker 3: quite a fifty percent improvement, but somewhere in there, and
Speaker 3: and yet potentially downgrade the severity of the surgery. So
Speaker 3: walk me through, walkby through what you counsel guys on
Speaker 3: your success rates with zioflex. And also, I think I
Speaker 3: can't emphasize enough because this is something we get a
Speaker 3: lot from insurance companies and just in general in the
Speaker 3: medical community, is that that this is a drug, but
Speaker 3: it's actually, as you said, a medical scalpel. So you
Speaker 3: have to have that drug in very qualified hands to
Speaker 3: do a good job. So there's there's a level of
Speaker 3: certification we have to go through called MS certification to
Speaker 3: be able to even inject the drug. And then training
Speaker 3: like your fellowship where you actually train people to do
Speaker 3: this on a on a basis on you know, when
Speaker 3: they're out in the community. So yeah, I mean, fire Away,
Speaker 3: talk to me about results. Unpack a little bit more
Speaker 3: of what we just talked about there.
Speaker 5: Yeah, So, like you said, I mean, the people who
Speaker 5: are administering zioflex have some certification, right, So even to
Speaker 5: get zioflex at your hospital, that hospital has to have certification.
Speaker 5: You as a provider have to have certification. So if
Speaker 5: you're seeing someone who is offering this treatment, they have
Speaker 5: gone through some training and approval by the manufacturer. So
Speaker 5: that's you know, that's a good thing. That's the way
Speaker 5: we keep people safe. I usually like to quote the
Speaker 5: Impressed trials when I talk to patients about success rates.
Speaker 5: So I usually say that in the trials, the average
Speaker 5: improvement was about thirty five percent. So that's not thirty
Speaker 5: five degrees, but thirty five percent, which means, like you mentioned,
Speaker 5: for a guy who has seventy degrees of curvature, he
Speaker 5: may recognize a thirty degree improvement and that's really really significant,
Speaker 5: going from seventy to forty. So we do know from
Speaker 5: another study that the best outcomes for men undergoing Zyeflex
Speaker 5: treatments come from men with great erections and actually more
Speaker 5: severe curvature, so they tend to do a little bit better.
Speaker 5: I also say that, you know, treatments are inherently going
Speaker 5: to be on a bell curve where some guys just
Speaker 5: don't really respond very well, many are going to be
Speaker 5: kind of at that average median, and then some may
Speaker 5: have really robust improvements like eighty percent. And so I
Speaker 5: think we want to capture everybody, and I really counselmen
Speaker 5: as they go through the series. I know we haven't
Speaker 5: really kind of described the treatment with Zyeflex, but it's
Speaker 5: essentially to boil it down, it's about eight shots over
Speaker 5: a six month period, and I check in with them
Speaker 5: for every single cycle to see how are you doing?
Speaker 5: Are you seeing improvements? And should we keep proceeding. And
Speaker 5: it's very rare for me to see a guy want
Speaker 5: to stop early, because they do. We know that there
Speaker 5: are typically sequential improvements, so each cycle tends to give
Speaker 5: a little bit more and more benefit. So I you know,
Speaker 5: I usually want to encourage them to continue because we
Speaker 5: do see continued improvement, but I want to make sure
Speaker 5: it's the right treatment for them, and if they're not
Speaker 5: getting any benefit, we can always stop. But thirty five
Speaker 5: percent is average, but they may do better again, Guys
Speaker 5: with better erections are probably going to do better.
Speaker 2: Yeah.
Speaker 3: I can't believe I'm going to go on record as
Speaker 3: saying this, but the a couple of years ago, a
Speaker 3: few of our biggest insurance carriers started to mandate something
Speaker 3: which was not on label. In fact, I rally against it,
Speaker 3: which was that we had to have every two injections
Speaker 3: we had to have a check in with the patient,
Speaker 3: a separate office visit to monitor their progress. And in
Speaker 3: the old days and other insurance companies that don't that
Speaker 3: don't mandate that for us to continue coverage, I just
Speaker 3: was ask them how they're doing right before we gave
Speaker 3: them another shot. And it's interesting when I and most
Speaker 3: of the time we're able to do it with video
Speaker 3: visits and know we're able to document kind of verbal
Speaker 3: improvement and curvature and just show that we're on the
Speaker 3: right track. But I get so many questions, and really
Speaker 3: it's a value add little visit, you know that we
Speaker 3: can see how they're doing in between. And again I
Speaker 3: rallied against it because you're busy.
Speaker 2: I'm busy.
Speaker 3: You know, we see thousands of people a year, and
Speaker 3: I thought, geez, here's another guy. The label says we
Speaker 3: were supposed to get eight injections before we reassess, and
Speaker 3: now I got to do it every two and you
Speaker 3: multiply that in the number of afflicks I do, and
Speaker 3: then all of a sudden, I got hundreds, literally hundreds
Speaker 3: of new office visits every month that I have to
Speaker 3: get through.
Speaker 2: But it actually is kind of cool.
Speaker 3: I mean, these guys, it's, you know, the difference between
Speaker 3: talking to this sounds very crasp, but a clothed man
Speaker 3: about his erections versus a guy that's ready for another
Speaker 3: shot changes the dynamic a lot shocker.
Speaker 2: But I'm glad you brought that up. So how do
Speaker 2: you do you do the same thing? Do you do?
Speaker 2: I mean, you know, we have a.
Speaker 3: Lot of the same insurance carriers in Washington as in California,
Speaker 3: so I'm sure it's you know, some of it you're
Speaker 3: seeing too, But talk to me about what that visit
Speaker 3: looks like for our guys, and I'm really glad you
Speaker 3: also brought up this is a sequential series of injections.
Speaker 5: Yeah, so usually ours is kind of rolled into the
Speaker 5: same visit. So they have the cycles are two shots
Speaker 5: within a few days of each other, four weeks where
Speaker 5: they are recommended to have no sex. You know, this
Speaker 5: is this is a medical, serious medical treatment, so they
Speaker 5: need to have a little bit of restrictions, just like
Speaker 5: a surgery. Two weeks of reprieve, and then they go
Speaker 5: back into their next cycle of two more shots. So, uh,
Speaker 5: the entire series of eight shots takes about six months,
Speaker 5: and we roll that sort of check in into each
Speaker 5: of the first injection in each cycle. So they come
Speaker 5: in at the six week mark for their second cycle,
Speaker 5: and we're having that check in before we prep the medication.
Speaker 5: So there's no pressure to sort of proceed because we
Speaker 5: don't have anything, you know, ready for them. Yet they
Speaker 5: give us the thumbs up and then we and then
Speaker 5: we get it going.
Speaker 3: So talk to me also about modeling in terms of
Speaker 3: what you do in the office. Maybe explain what modeling is.
Speaker 3: Jordan has an idea of a penis model that is
Speaker 3: not what we're talking about here, so that I know
Speaker 3: what you're thinking, Jordan, I know, I know you, But
Speaker 3: talk about penl modeling, not Runway, not Milan here, and
Speaker 3: also talk about how guys should be doing this at home.
Speaker 3: What are the adjunct procedures that you recommend for success
Speaker 3: with this interlgional therapy.
Speaker 5: Yeah. So penal modeling is very well described by the
Speaker 5: manufacturer of Zyoflex. So there are stretches that men do
Speaker 5: in length and then stretches that they do to bend
Speaker 5: opposite the curvature. There are some that they do with
Speaker 5: the directions and they do mostly flacid, and that is
Speaker 5: just aiming, you know, to while we have destabilized this
Speaker 5: plaque or loosened the plaque, we want to kind of
Speaker 5: put stretch over it to encourage the straightening. And so
Speaker 5: the way our clinic works is they come in for
Speaker 5: their first cycle, they come in two days after the
Speaker 5: second shot, and they received modeling training from one of
Speaker 5: our pas so our physician assistants. They then do that
Speaker 5: at home. I really encourage them to do this because
Speaker 5: it's their way of putting skin in the game to
Speaker 5: optimize the treatment. And then after that in subsequent cycles,
Speaker 5: we don't do additional training it's you know, it's pretty
Speaker 5: self explanatory. It's you know, several minutes a day, but
Speaker 5: it's it's not an onerous task. I do talk to
Speaker 5: them about using penal traction. So this is a stretching
Speaker 5: tool that can be added to zyaflex, and this there
Speaker 5: is sort of one option on the market that was
Speaker 5: developed by a urologists one of our colleagues, doctor Trost,
Speaker 5: who developed this penal traction device second generation that allows
Speaker 5: stretching and length, but also bending opposite the curvature, So
Speaker 5: that is an adjunctive tool men can use is to
Speaker 5: really add more to the modeling. So it's hard to
Speaker 5: hold your penis for thirty minutes in a bent position,
Speaker 5: but this device allows that, and some of the research
Speaker 5: from our field has shown additional benefits on top of
Speaker 5: the Ziefflex alone. There are some downsides to trying traction,
Speaker 5: which is mostly just that it's uncomfortable to wear this device,
Speaker 5: but I think it does add benefit if a guy
Speaker 5: can tolerate it and tolerate the out of pocket expense
Speaker 5: for it.
Speaker 3: Yeah, that's right, about six hundred bucks these days. And
Speaker 3: the only warning I put on traction, I'm a little
Speaker 3: bit agnostic. I think for guys that are very compliant.
Speaker 3: I got to ask, you know, for my guys with
Speaker 3: young kids in the house, where you know, it's hard
Speaker 3: to walk around with this medieval device that looks like
Speaker 3: an erector set. Just to give you an idea in
Speaker 3: your mind, Jordan, imagine these steel cylinders or steel pillars
Speaker 3: that then connect to the base of the penis as
Speaker 3: well as another little clamp that comes out towards the
Speaker 3: head or the corona of the peaceus. And it's these
Speaker 3: these rods that then you can put in additional spacers
Speaker 3: every half centimeters or so as you're stretching the penis
Speaker 3: and against you know, there's the other incentive to this
Speaker 3: is that you may regain some link with it, but
Speaker 3: it is you got to put, as you said, a
Speaker 3: lot of a lot of skin or penis in the
Speaker 3: game for sure to be able to do it, but
Speaker 3: but be can be effective. My word of warning that
Speaker 3: that we've seen a few times, and I think Professor
Speaker 3: trost Is also commented on this is that you really
Speaker 3: want to make sure you don't have so much swelling
Speaker 3: or bruising or skin blistering, which can be some of
Speaker 3: the side effects we're going to talk about here in
Speaker 3: a second with eye flex, where you can get tissue
Speaker 3: breakdown because that the clamp at the head of the
Speaker 3: penis if you have any bruising in that area, and
Speaker 3: you have really you know, the penis. The skin of
Speaker 3: the penis is about the same thickness as the skin
Speaker 3: of the eyelids, so it doesn't take much to cause
Speaker 3: bruising or even blistering of the skin. So make sure
Speaker 3: that your skin is intact. If you're listening you're in
Speaker 3: the middle of eye flex and you run out and
Speaker 3: buy attraction device, that that's our only kind of be
Speaker 3: careful until that skin is fully healed.
Speaker 2: But yeah, so then to talk to me about what
Speaker 2: could go.
Speaker 3: Wrong with eyeflix, What are the things you worry about
Speaker 3: with your patients or what are your common concerns that
Speaker 3: they've come to you with.
Speaker 5: So it's so interesting to see my patients after their
Speaker 5: first cycle when they you know, may see swelling and
Speaker 5: bruising and this is the first time they see it
Speaker 5: and it can be shocking. And then the fourth cycle
Speaker 5: where they've seen that this happens, it goes away and
Speaker 5: they're just so much more comfortable with that kind of
Speaker 5: just reaction and they know it's sort of a side
Speaker 5: effect of the treatment. So that's just to say that
Speaker 5: swelling and bruising are expected. I say that about one
Speaker 5: hundred percent of men experience bruising at some point in
Speaker 5: the treatments cycles. It can be like a little pinpoint bruise.
Speaker 5: It can look like a tiger stripe, or it can
Speaker 5: look pretty dramatic, like a big purple penis Jesse. You
Speaker 5: have categorize these and sort of codified a hematoma staging scale.
Speaker 5: That is really helpful to sort of share with patients
Speaker 5: that this is. You know, there can be a range
Speaker 5: of outcomes, but I tell them that this is expected
Speaker 5: and it will go away on its own. I say
Speaker 5: that blood blisters can happen again, those heal on their own.
Speaker 5: They can get swelling sometimes. You know in men that
Speaker 5: bruising and swelling can go up onto the pubic bone,
Speaker 5: and you know, I wouldn't be surprised to see that.
Speaker 5: So hopefully I try to allay some of those concerns.
Speaker 5: But our nurses are always available to answer questions about
Speaker 5: this and to review pictures, so we offer just you know,
Speaker 5: really a lot of support through the treatment cycles. I
Speaker 5: say that this enzyme is very powerful, and part of
Speaker 5: that sort of power means that it can weaken those
Speaker 5: strong connective tissue that hold the blood for interaction, and
Speaker 5: if that weakens enough, that can cause a tear, and
Speaker 5: that's called a penal fracture. Penal fracture can look very
Speaker 5: you know, especially dramatic, so big purple penness. We mostly
Speaker 5: treat this with just observation and just allow it to
Speaker 5: resolve on its own. And so I think patients are really,
Speaker 5: you know, feel a lot of they feel well supported
Speaker 5: and just knowing that this will go away and it
Speaker 5: doesn't need you know, some crazy surgery to help repair it. Yeah,
Speaker 5: I describe that that's about one in a thousand. So,
Speaker 5: especially if they follow our instructions of no sex for
Speaker 5: four weeks after injections, that should be a really rare outcome.
Speaker 5: But again, it is something that typically goes away on
Speaker 5: its own. There's some more rare sort of side effects,
Speaker 5: like being allergic to the medication. I've never seen that
Speaker 5: in my practice. I don't know if Jess, you've ever
Speaker 5: had any of that experience.
Speaker 2: Have not?
Speaker 5: Yeah, you know, these are the things that are kind
Speaker 5: of on the label for us to describe when we
Speaker 5: talk about the medication, but those are really I mean,
Speaker 5: that's the most common side effect is just local sort
Speaker 5: of tissue injury because this is such a really advanced
Speaker 5: powerful enzyme.
Speaker 2: Yeah, I think that sunds it up well.
Speaker 3: The one thing that that we've also described that came
Speaker 3: out post talk was the was back pain. You know,
Speaker 3: there's this a strange low back paint. It's about in
Speaker 3: at least in our series that we published a few
Speaker 3: years ago, it's about five percent of guys, but it's
Speaker 3: actually lower than that if you look at it's an
Speaker 3: accumulated effect, and so it's rare. In fact, I think
Speaker 3: maybe a zero percent chance of a guy getting back
Speaker 3: pain with his first or second injections. But guys that
Speaker 3: need eight and then sometimes you know, about twenty percent
Speaker 3: of my population, and I'll ask you about what your
Speaker 3: experience with we call multiple rounders is. But at twenty
Speaker 3: percent or so of my men potentially will need some
Speaker 3: fraction of another series. If they got forty percent better,
Speaker 3: they're not quite ready for surgery. They may not need it,
Speaker 3: but the back pain incidence goes up pretty significantly after
Speaker 3: those first eight injections and so that's something that we
Speaker 3: council guys. It's self limiting, just like you were saying
Speaker 3: with the other issues that we see, the bruising, even
Speaker 3: a small corporate rupture. There was this old you know,
Speaker 3: in our general surgery days, there was this classic book
Speaker 3: called Principles of Surgery, and one of the chapters.
Speaker 2: Talks about wound healing.
Speaker 3: And this is something that I always talk with patients about,
Speaker 3: is that the natural tissue. The reason that surgeons are
Speaker 3: lucky and better than our auto mechanics is that we're
Speaker 3: both mechanics. We're both plumbers in a way. But you know,
Speaker 3: PDC doesn't doesn't heal on its own. You know, radiator
Speaker 3: tubing doesn't heal on its own. But if we have
Speaker 3: a three millimeters rent in a tunic al Virginia, which
Speaker 3: is what you're talking about as a penal fracture of
Speaker 3: corporate rupture, our body heals it about a millimeter a day,
Speaker 3: so conferentially, and so in three days, even a small rent,
Speaker 3: which is usually what we find when we do imaging
Speaker 3: on corporate ruptures after Ziefflix, will heal without us doing anything.
Speaker 2: And that's the beauty of being a surgeon.
Speaker 3: As we have this wonderful biological machine called the human body,
Speaker 3: that that that cuts us a lot of slack, much
Speaker 3: more than, you know, than a manifold in a seventy
Speaker 3: eight BMW or a seventy two volvo?
Speaker 2: Is that right? Is that what you have? Jordan? See
Speaker 2: you so easier?
Speaker 3: Yeah, you're our penises are easier fixed than the seventy
Speaker 3: two volts.
Speaker 5: But I don't have to work on that very exactly right?
Speaker 2: Yeah, so good.
Speaker 3: So I think that that is a reasonably good assessment
Speaker 3: of the kind of the fair and balanced risks and benefits.
Speaker 3: So then how do you set your expectations for zye flex.
Speaker 3: You alluded to it a little bit with the impressed trials,
Speaker 3: but I want to I want to get back to
Speaker 3: something you said a little bit earlier and maybe just
Speaker 3: give me some at least some kind of back of
Speaker 3: the envelope data on the number of men that you
Speaker 3: do zio flex on. Then need something else, you know,
Speaker 3: how does how does that work? Or some guys listening
Speaker 3: right now, he had eight rounds or eight cycles, eight
Speaker 3: injections somewhere else and he's thinking, I may need to
Speaker 3: book a trip to Seattle to see professor, heman, who
Speaker 3: is the who are the guys or what do you
Speaker 3: do adjunctively if zye flex doesn't fully work and how
Speaker 3: often does that happen?
Speaker 5: Yeah? I mean so I would say that those guys
Speaker 5: in whom we have finished eight cycles of zyoflex and
Speaker 5: they may still have bothersome curvature. I usually like to
Speaker 5: get the objective data that we talked about earlier with
Speaker 5: the pen L Doppler ultrasounds. So I do that PENL duplex.
Speaker 5: I re establish degree of curvature. You know what that
Speaker 5: scar tissue looks like, using an ultrasound to determine maybe
Speaker 5: it is calcified. Maybe that's why you're not seeing the
Speaker 5: treatment response, especially for guys who aren't seeing any response.
Speaker 5: I think if guys are seeing sequential response and they
Speaker 5: really like the treatment and they want to proceed with more,
Speaker 5: I'm more than happy to offer continued cycles as long
Speaker 5: as their insurance will approve it. I think we live
Speaker 5: in kind of a really interesting era of medicine where
Speaker 5: we don't always make the treatment decisions, and we don't
Speaker 5: maybe even often make the treatment decisions. It's insurance companies
Speaker 5: that can dictate whether or not this is something they're
Speaker 5: going to be approved for, and that's an unfortunate reality
Speaker 5: that we live in as as healthcare providers. So in
Speaker 5: terms of the percentage of men that need further therapy,
Speaker 5: that's a great question. I really can't pinpoint my own
Speaker 5: sort of percentage, but I would say maybe fifteen to
Speaker 5: twenty percent go on to receive more than more than
Speaker 5: four cycles or some kind of surgical intervention after treating
Speaker 5: with the initial eight injections. I'm curious about your rates.
Speaker 5: You do more zyoplex than I do.
Speaker 3: So yeah, yeah, So we have a little bit of data,
Speaker 3: and I think you just reminded me we shared a patient,
Speaker 3: which is a pretty good story, I'll say here in
Speaker 3: the SEC but the yeah, I mean, so we looked
Speaker 3: at our studies somewhere around twenty nineteen, twenty twenty, and
Speaker 3: I think it may be in general sexual medicine.
Speaker 2: I can't remember wh it finally ended up or ijir.
Speaker 3: But essentially, you know, when I quote success, certainly I
Speaker 3: talk about the Impress trial because that's that's kind of
Speaker 3: what's written. But I also think you did a really
Speaker 3: good job of setting the expectation of hey, you could
Speaker 3: be you could get zero or you could get eighty
Speaker 3: percent or even one hundred percent better, and we really
Speaker 3: don't know. We we did this huge linear regression analysis
Speaker 3: a few years ago that came up with a complete
Speaker 3: null hypothesis and others. We could not find who the
Speaker 3: ideal candidate was for Zeieflix, excluding guys that had just
Speaker 3: pure calcified bony plaque that could only really be addressed
Speaker 3: with surgery. We knew that, so I didn't look at
Speaker 3: those guys. But we looked at diabetes, We looked at age,
Speaker 3: we looked at at how long they'd had the plaque,
Speaker 3: all of this stuff, and essentially it was still you know,
Speaker 3: rolling the dice and seeing how a guy did. But
Speaker 3: in that big series where we looked at everybody, including
Speaker 3: ventral curves, we had what we found was about eighty
Speaker 3: percent of guys had as satisfactory treatments. We kind of
Speaker 3: pushed away angulation because you know, I published a lot
Speaker 3: about angulation, which really bothers me on a soapbox for
Speaker 3: advocacy anyway, because if a guy comes in with a
Speaker 3: twenty nine degree curvature, I either have to say it's
Speaker 3: thirty or not treat him, because the insurance companies won't
Speaker 3: pay for anything less than thirty because that's the label.
Speaker 3: So that's a whole nother advocacy discussion we could have,
Speaker 3: but for that, just getting rid of angulation and just saying, hey,
Speaker 3: are you happy? Like if you went from seventy to
Speaker 3: forty and you could not have penetrative sex, and now
Speaker 3: you can have penetrative sex and your partner is happy
Speaker 3: with your forty degree curvature, that's a win.
Speaker 5: You know.
Speaker 3: I don't have to prove that I can take a
Speaker 3: guy with a seventy degree curvature and make him ten
Speaker 3: or zero and say I'm the best Eyaflex guy ever,
Speaker 3: I don't.
Speaker 2: You know. Again, that's not my deal.
Speaker 3: My deal is to make a guy happy and make
Speaker 3: his partner or partners happy with how things have turned out.
Speaker 3: So if you look at that eighty percent of guy
Speaker 3: is pretty happy with one round of Zyaflex, and then
Speaker 3: for the number of guys that either needed additional cycles,
Speaker 3: that number was somewhat smaller, as we were talking about,
Speaker 3: around twenty percent. But in terms of just looking at
Speaker 3: all over, if you look at guys after even two
Speaker 3: cycles or two rounds, so two sixteen injections, which is
Speaker 3: usually what happened for my surgical candadates is it's uncommon
Speaker 3: if I see any improvement in guys after just one
Speaker 3: one round that I won't offer another round if I
Speaker 3: can get it covered.
Speaker 2: As you said.
Speaker 3: But but the number is about seven percent of guys
Speaker 3: would need surgery post afflix. But that doesn't mean that
Speaker 3: they were cured. It just means that they were satisfied
Speaker 3: enough that they were done with that therapy. But yeah,
Speaker 3: so I mean, I'll give you one of your semi
Speaker 3: year guys. So we had a guy a few years
Speaker 3: ago who split his time between LA and Seattle, and
Speaker 3: he was he summered up in the in San Juan Islands.
Speaker 2: God bless that guy. What a great place to summer.
Speaker 3: It's not bad, Yeah, right, Sant Janaga most of the
Speaker 3: year and then San Juan's in the summer. He did
Speaker 3: something right, but I had I think we did one round.
Speaker 3: He went from sixty to forty, but I didn't know that.
Speaker 3: I said, hey, Mark, could you do me a solid.
Speaker 3: You did his ultrasound pinal duplex, just like you said
Speaker 3: you do for your guys that you're thinking second rounds
Speaker 3: on and essentially teet them up. So the next time
Speaker 3: he was in LA we took that forty played him
Speaker 3: so a little bit less of an aggressive surgery, and
Speaker 3: we'll talk about that in an upcoming episode. But the
Speaker 3: application was very successful and he essentially went from sixty
Speaker 3: to zero with a little bit of zie efflecs, a
Speaker 3: little bit of surgery, and a great outcome. And I
Speaker 3: think that's really important because there's a lot of a controversy,
Speaker 3: but a lot of debate at our national meetings about
Speaker 3: really high level urologists in sexual medicine that either believe
Speaker 3: that this drug is doing something, is effective, Yes it's expensive,
Speaker 3: a whole nother discussion on advocacy, but others that just say,
Speaker 3: you know, it doesn't work well enough, so we should
Speaker 3: either just observe or operate. And I think, you know,
Speaker 3: looking at it as a staging procedure is not a
Speaker 3: failure necessarily, but as a priming procedure. You know, again,
Speaker 3: we use cancer terminology a lot, almost as a deep
Speaker 3: bulking to say, let's take a guy that would need
Speaker 3: a massive surgery and bring him back down to where
Speaker 3: it's not quite so you know so massive, and they
Speaker 3: do well.
Speaker 2: So I'm glad. Yeah, we're pretty sympatico on.
Speaker 5: That absolutely, and I think it's just you know, you've
Speaker 5: kind of alluded to this concept that a guy who
Speaker 5: goes from seventy to forty may be really satisfied, but
Speaker 5: someone who presents with twenty degrees of curvature it may
Speaker 5: be really distressing. And so there's you know, we see
Speaker 5: that all the time, that's in the literature, this understanding
Speaker 5: that the degree of curvature doesn't really predict the amount
Speaker 5: of distress. And so I think that's where we kind
Speaker 5: of the art of what we do is in tailoring
Speaker 5: treatment and talking to men. And you know, one of
Speaker 5: my research residents who's coming to UCLA for fellowship next year,
Speaker 5: did a really lovely study on men going through paronis
Speaker 5: to these treatments, their experience and what's important to them,
Speaker 5: and it's it's really not all about the degree of curvature.
Speaker 5: It's about so much more than that, the emotions that
Speaker 5: are involved, the body, confidence, the relationship. It's really an
Speaker 5: interesting condition because it really affects so much more than
Speaker 5: just you know, the penis itself, and so our treatments,
Speaker 5: you know, have to be tailored.
Speaker 6: That's the bottom line.
Speaker 3: Well, you just you segue perfectly into the section of
Speaker 3: our show we call You're probably gonna be okay, and so, yeah,
Speaker 3: I couldn't have done it better. And so we do
Speaker 3: have this section every episode where we talk to our
Speaker 3: guests about, you know, case presentation or something where a
Speaker 3: guy may have something similar to what we're talking about,
Speaker 3: and you got to walk through either. One day, we're
Speaker 3: gonna have somebody that is not going to be okay.
Speaker 3: And that's okay too, because you know, there's not all
Speaker 3: sunshine and rainbows in medicine or Peperonie's disease. But here's
Speaker 3: a guy thirty five years old single. He developed Peroni's spontaneously,
Speaker 3: so it could have been that business trip, no trauma
Speaker 3: that he remembers. He's three months in. He's noticing a
Speaker 3: thirty degree curvature and is devastated. He's wrecked by that
Speaker 3: thirty degree curvature. Can't imagine actually being sexually active at
Speaker 3: this point. He's a total shut in. I know you're
Speaker 3: going to see two or three guys this week that
Speaker 3: have have this condition, and he hates how his penis looks.
Speaker 3: He's on, I mean, he perseverates on. He can't focus
Speaker 3: at work. As every other thought and is a rumination
Speaker 3: on why his penis curved thirty degrees and he's also
Speaker 3: noticing penal shortening.
Speaker 2: So tell me, is this guy going to be okay?
Speaker 2: What are you going to do for him?
Speaker 3: How do you support the mental health aspect, which which
Speaker 3: again we had that paper out a few years ago
Speaker 3: in to Journal Urology with my colleagues of Karlinska in Sweden.
Speaker 3: Just looking at the mental health toll of Peroni's disease
Speaker 3: is devastating for these guys. And it's something that a
Speaker 3: lot of physicians either joke about. It's kind of jokes
Speaker 3: on late night TV, Saturday Night Live and as much
Speaker 3: fun as I have in life and on the show,
Speaker 3: this is Yeah, this is one it's hard to tell
Speaker 3: jokes about. So, is this thirty five year old guy
Speaker 3: gonna be okay? Professor Human, what are you gonna.
Speaker 2: Do for him?
Speaker 5: Yeah? I mean I think that the most important thing
Speaker 5: for this guy is just his first reassurance and education.
Speaker 5: And I really like to just start by giving the background,
Speaker 5: you know, because they read all kinds of things on
Speaker 5: the internet, and I want to give them the real
Speaker 5: scoop on what's going on. So I really like to
Speaker 5: educate patients. It's kind of part of my role as
Speaker 5: an educator of our trainees, and I really see myself
Speaker 5: as an educator of our patients. And I do think
Speaker 5: that laying the groundwork of evidence based information is really
Speaker 5: helpful and can just get guys in the right mind state.
Speaker 5: I would really reassure him that he's in the right place.
Speaker 5: So a lot of guys have seen other urologists, they
Speaker 5: feel like they don't know what the diagnosis is. They
Speaker 5: have told been told by another neurologist that this isn't treatable,
Speaker 5: which is not uncommon for me to hear. And so
Speaker 5: I want to reassure him that he is in the
Speaker 5: right place and that you're seeing someone who's an expert
Speaker 5: and we have excellent treatment options. Yeah, I think it's
Speaker 5: you know, so that's really the basis of the first
Speaker 5: sort of counseling session. I want to understand more about
Speaker 5: you know, obviously his condition, but his mental state. It's
Speaker 5: I like to we kind of joke that we do
Speaker 5: a lot of psychoeurology because these are patients who are,
Speaker 5: like you mentioned, totally distraught, and you know, we have
Speaker 5: to team up with our partners in sex therapy sometimes
Speaker 5: for guys, or just in general, you know therapists who
Speaker 5: can help with some of the coping around this. But
Speaker 5: I do think that getting guys on a really solid
Speaker 5: treatment pathway, getting them the right information, and just seeing
Speaker 5: them through having good support from our nurses is really
Speaker 5: helpful to sort of take away some of that worry.
Speaker 5: So it's it's not all about just the medical treatments
Speaker 5: it's all. It's also about the care of the whole person.
Speaker 3: Yeah, I love it. Now, that's that's great. You brought
Speaker 3: up yet another incredible pearl in that which is the
Speaker 3: internet can be a scary place for peronis. And another
Speaker 3: one of the other things we do a lot on
Speaker 3: the show is try to separate fact from fiction and myths.
Speaker 3: And there are so many topical creams, there's so many
Speaker 3: supplements out there for pernis.
Speaker 2: I had.
Speaker 3: I was the victim of a deep fake on the
Speaker 3: internet for me, you know, somebody that looked just like
Speaker 3: me selling Paroni supplements.
Speaker 2: It was terrible.
Speaker 3: I had to go through a lot to get it
Speaker 3: off of YouTube. But yeah, I mean there is nothing
Speaker 3: out there. Do you see a Peroni specialist? Because we
Speaker 3: are going to walk you through what does work and
Speaker 3: what doesn't and the rest of it can just kind
Speaker 3: of waste your time and screw you up even more so,
Speaker 3: So all right, I gotta do this because I know
Speaker 3: you've probably got to get to the operating room. But
Speaker 3: every episode I also have to ask my specialists in
Speaker 3: men's health, what do you do every day? What is
Speaker 3: your non negotiable to make you be present for your
Speaker 3: patients and your family, And just talk to me through
Speaker 3: what makes maoramorrow every day?
Speaker 2: What do you need?
Speaker 5: Yeah, that's a great question. It is ever changing. So
Speaker 5: I have an eighteen month old daughter and it's just
Speaker 5: the delight of my life to have a kid and
Speaker 5: just to watch her grow and you know, see her
Speaker 5: being a hilarious individual at age eighteen months. So that's
Speaker 5: really sort of rejuvenating to me. I'm a big I
Speaker 5: know you're a big into exercise, and so am I.
Speaker 5: It's of course harder, as you know a fairly new parent,
Speaker 5: but exercise is so important. It's so good for our
Speaker 5: mental health, for our physical health. So getting outside. I've
Speaker 5: been running more again, did a few ten k's in
Speaker 5: the past couple of months, and lifting weights and so
Speaker 5: that's you know, spending time with my husband and my
Speaker 5: daughter is really kind of the crux of what makes
Speaker 5: me happy these days.
Speaker 2: That's beautiful and and it keeps going. Yeah.
Speaker 3: I mean, my twenty one year old son destroyed me
Speaker 3: at the gym yesterday. So somehow thinks like he remembers
Speaker 3: his dad when he was thirty, not fifty five, and
Speaker 3: so he somehow thinks that I can still keep up
Speaker 3: with him. So you have that to look forward to,
Speaker 3: teaching your girl a lifetime of fitness and health. Jordan,
Speaker 3: what do we miss? Professor Human is here in the
Speaker 3: house in the mailroom. She delivered expertly, as I knew
Speaker 3: she would, and we had such a good conversation. But
Speaker 3: you haven't been too queasy, you haven't. You've been a
Speaker 3: little quiet.
Speaker 2: Yeah, yeah, you're doing.
Speaker 3: Jordan used to pass out when we talked about anything medical,
Speaker 3: so so I'm glad that you said surgical.
Speaker 2: Yeah that's right.
Speaker 3: Yeah, so when you talked about penal fractures, he was
Speaker 3: still staying upright. I don't think he has a bracemind
Speaker 3: him yet.
Speaker 4: Pillows all are on the floor, just in case I
Speaker 4: sent smart Smart. I mean, I'm just really glad you
Speaker 4: touched on a mental health piece because that was something
Speaker 4: but meeting to bring up over the last few episodes.
Speaker 4: I mean, do you recommend that your patients seem if
Speaker 4: a health professional kind of help coach through this, like
Speaker 4: I mean, I know, because you know it's a traumatic event,
Speaker 4: may I imagine?
Speaker 5: Yeah, I mean I think it depends on the patient.
Speaker 5: I think some absolutely may need that support. If you know,
Speaker 5: I'm perceiving. I don't do any like mental health screening
Speaker 5: questionnaires in the fifteen minutes I have to see a
Speaker 5: urology patient. It's a little bit beyond my scope. But
Speaker 5: I think that some absolutely, I would recommend. I think
Speaker 5: men who have partners with them have you know, a
Speaker 5: unique support system, which is wonderful, but that support system
Speaker 5: may also need a little bit of help. And you know,
Speaker 5: I do talk about this with couples as as you know,
Speaker 5: a new normal that they may experience with their intimacy
Speaker 5: after pay treatments. It's a new normal, just like after
Speaker 5: you know your spouse had your children and went through breastfeeding.
Speaker 5: That changes the body and changes your relationship a little bit,
Speaker 5: and so there are new dynamics at play. We have
Speaker 5: great sort of lists of supportive therapists and you know,
Speaker 5: sex counselors that we can offer just at a moment's notice.
Speaker 5: So it's not uncommon for me to sort of put
Speaker 5: that in my little after visit summary for patients to
Speaker 5: access if I think it's important for them.
Speaker 2: Yeah, another freaking brilliant analogy. That's that's great.
Speaker 3: Yeah, so you'll never you'll get your penis back, but
Speaker 3: it may not be the same one as before you
Speaker 3: had this as that's freaking brilliant asways.
Speaker 5: I remind that to a lot of patients because you know,
Speaker 5: I just you know, really it's hard for some then
Speaker 5: to sort of wrap their brain around the penis changing.
Speaker 5: And I liken it too. You know, our ears get
Speaker 5: bigger as we get older, certain parts of our body
Speaker 5: gets saggier, stiffer, crunchier, and the penis does change too.
Speaker 5: Oh not uncommon for men to experience that, but it
Speaker 5: still can be a little bit jarring, so important to
Speaker 5: recognize it is.
Speaker 3: And with dogs like you and me hanging around, we
Speaker 3: get to have those penises raging against the.
Speaker 2: Dying of the light. So this is what we do. Well,
Speaker 2: thank you, thank you so much, Mari.
Speaker 3: I hope you have the rest of a fantastic day,
Speaker 3: and again thanks for all your wisdom sharing it with
Speaker 3: our our listeners on the Mailroom and uh long Transit
Speaker 3: some Stevie ray Stratt.
Speaker 2: Let's get out of here. iHeartRadio, thanks so much and
Speaker 2: we'll see y'all next time.
Speaker 5: Thanks for the invitation.
Speaker 2: M hm. Let's talk about it.
Speaker 1: Let's talk about the Maro. Let's talk about it.
Speaker 2: Let's talk about the may Hero.
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