Doctors Are Removing Testicles for This | Dr. Susan Macdonald

Testicular pain and pelvic pain, similarly, is neuropathic pain. I do not think we should chop off testicles. But people are doing it. But people are doing it, and people are doing it at double the rate of a nerve-licing procedure that actually has phenomenal success rates. If someone is sitting there at home thinking, gosh, you know, I think that I'm sitting a lot, maybe it's prostitutes. Is it a small progression? Does it impact the way that they can train or work out? Or is it something that is irritating all of a sudden? They're like, oh my god, I woke up one morning and my balls hurt. People who carry a lot of stress in their daily life, it manifests in some way. I'm a big believer in the mind-body connection. I saw patients over and over, had been invalidated and told it was all in their head. Just routine things that happen to people in life. And then it's like a switch flipped and they became a chronic pain patient. When I was 15, I remember having a tachy arrhythmia. I remember playing tennis with my brother and my heart rate went double time and slightly irregular. I got the halter monitor, I got a cardiac workup, and they're like, yes, you have an arrhythmia. And I said, what should I do? And they said, it's stress and caffeine induced. What are our solutions for pelvic floor dysfunction? One of the most important things about having chronic pain, whether you have chronic pelvic pain syndrome, understand that if you... Dr. Susan McDone, welcome to the show. Thank you. You had me at, I was watching one of your grand rounds, and you had me at the comment, it was just cut it off, just chop off the balls. And I was like, wait a second, is that a thing? And are people really doing that? Yes, it's a thing. Yes, people are doing it. And no, please don't do that. Friends, don't try that at home. Yeah. Well, yeah, please don't do it yourself. But also don't go to a doctor who offers you that option, ideally. So the analogy I make all the time is, get neuropathy in their fingers and toes. And in your geriatric practice, I feel like you have to have seen this, right? Do we chop off their fingers? Not unless they're... Well, right, but you have been black and like little mummy fingers. That's a different story. But generally speaking, no, we know that that is neuropathic pain. And testicular pain and pelvic pain, similarly, is neuropathic pain. So I do not think we should chop off testicles. But people are doing it. But people are doing it. And people are doing it at double the rate of a nerve-licing procedure that actually has phenomenal success rates. And the thing is, we just need to disseminate that information and boom, that is why I am here today. We're talking about a lot of things. And you are very rare in your training and very rare in what you're doing. First of all, I know that men have a pelvic floor, but I didn't really think about it. And when I finished my fellowship, I started a practice, sorry, joined a practice in New York City. There was a patient, he was a very high-powered lawyer, has access to everything. And he was having what he described as prostate pain. Again, prostatitis, he'd been seen by multiple urologists. They put him on rounds of antibiotics and he seemed to potentially get better in a short period of time, but it completely derailed his life. I was not able to, we eventually put him on an SSRI, but this is something that is not so uncommon. No, it's really common. So firstly, thank you, you were on the right path, actually, with the SSRI. It's true, people have this pain and it gets labeled as prostatitis. It's like the 60s saying prostatism. And they have perineal pain and pelvic pain. People have chronic orcalgia or ball pain, if you want to call it that. And they just have this pain and we don't know why, and nobody really knows what to do with it. It's kind of like, you know in the 90s when prozac came out and mental health just kind of like exploded? So that person who couldn't get help is the perfect reason why we created these guidelines for chronic pelvic pain and for chronic orcalgia or chronic ball pain. There are so many people out there who have pain and it gets mislabeled as prostatitis or epididymal orchitis, which is, oh my god, I'd say that three times fast. It's a mouthful. Yeah, I have trouble spelling it. But it's an infection. Those are both infections theoretically, and so they get antibiotics, antibiotics, antibiotics. And yeah, they do have some temporary relief, but that's not what's going on. It's not what's wrong. It's not the root of the problem and they don't get better. How many men and in terms of each group are we talking about? So RJ is sitting here. One of the producers for the show probably has never had testicular pain. Maybe he has, maybe he hasn't. Is it something for, something in their 30s? So most men that I see by and large are people in their like 20s to 50s? These are, yeah. So these are like active, functional people in the prime of their lives who get pain and we don't know why it starts and we don't know the exact mechanisms and nobody has a great treatment. But we do have some options. We have a lot of options and we have a better understanding of why now. So testicular pain we know represents about 5% of all urology visits. So that's a lot, right? Like all of the reasons to come to a urologist. One in eight Americans is going to get a kidney stone. So kidney stones are a ton. Then you've got like, you know, all the peeing problems that we deal with. We've got cancers, erectile dysfunction. There's a lot of reasons to see a urologist. So the fact that testicle pain represents 5% of all urologist visits is huge. How many urologists focus on testicular pain in general and have good treatment? I want to say none. No, it's not true none. It's like 30 of us in the country. It's very few. It's very few. I mean, it's very rare that you have a patient sitting in front of you that has been to five other specialists within their field. And that's again, you know, as I think about, we don't always see about the patients that we can help. Yeah. But the ones that we can't, I think really stick with us. They do. They do. And then I want to dovetail that with that's just testicle pain, right? So the person you described had pelvic pain like prostatitis. We don't know because those patients are, they come in with a very nebulous symptom complex. They don't come in like labeled perineal pain on their forehead or prostatitis. They come in with, you know, pain here or pain over here, pain that radiates down their leg or all kinds of different pain. Chronic pelvic pain syndrome. It presents so differently to some. C.P.P.S. Yeah. C.P.P.S. It comes in with so many different presenting symptoms. So when it comes into my office, it might be labeled as low urinary flow or rectile dysfunction, um, suprapubic pain, perineal pain. So many different things. So they don't come in with their diagnosis. So it's really hard to categorize like how many patients do we have in this country who have chronic pelvic pain syndrome? The answer is a lot. I just don't know how much is a lot. Also the idea of pelvic floor, the male pelvic floor. Yes. Deeply important. So let's talk about that. So when I started my practice, um, I had done, you know, four years of medical school, six years of residency and one year of fellowship. And in that year of fellowship doing male reconstruction, which is completely unrelated to this topic, um, I first learned a little bit about male pelvic floor, the pelvic floor dysfunction. And then I went out in practice and I saw pelvic floor dysfunction everywhere I looked and started to think I was a crazy person. I went back and read the chapter about chronic pelvic pain syndrome and like the pelvic floor in men and how pelvic floor dysfunction could play in, which about half of those patients have pelvic floor dysfunction. One sentence. There was one sentence in the whole chapter. And so then I went on this like deep dive. I spent years just like reading everything I could get my hands on on like what is going on with these patients who are getting antibiotics and not getting helped. I don't like when a patient leaves my office and I have no idea what's wrong and how to help them. Right. Like I feel inadequate and I go the extra mile and we all need to learn and grow. Right. And if I did urology and medical school and had no idea about men's pelvic floor and you did medical school and you did a residency and you had no idea about pelvic floor. Right. Let's agree that our medical training taught us nothing about this. Yeah. So then you get into practice and when I started telling my patients as I was building my expertise in this matter, I think you have pelvic floor dysfunction. My male patients would go Google. Do you know what they find? Vaginas. Totally. Wall of all vaginas. Listen, as a woman who has a vagina, I will tell you what is pelvic floor dysfunction. Well, here's how we know. Pain on intercourse. You sneeze and you tinkle. Yeah, it doesn't happen. Like you should case and burrow for all of that. It's not so uncommon for women to discuss it among themselves. Right. There's even pelvic floor specialists. Right. Public floor physical therapist. There's all of that. Women hear about their pelvic floor all the time because it relates to childbirth and sex and sex after childbirth and life after childbirth. So you learn how to train your pelvic floor. Okay. So interestingly, the pelvic floor, men and women both, but men in particular, you have this muscle group. Okay. You have a hammock of muscles called the pelvic floor, which is there essentially to allow you to walk on two feet. It keeps all your guts in. Right. And so it's a muscle complex. We call it the levator, a nine muscle complex. The pubococcigias, pubo rectalis. So nobody learns about their pelvic floor and these men, they have the same pelvic floor that we do so they can walk upright and those muscles hold their guts in, but also those muscles have things that run through them. So it's a muscle complex of three pubococcigias, pubo rectalis and ilio coxiges. And so like your iliac cross are out here and your pubus is in the front, your coccyx is in the back, and it's like a sling, a hammock, if you will, of muscle so that like everything just doesn't fall down when you stand up. Do men have the same symptoms? For example, urinary incontinence. No. So men have very different symptom complexes that go with pelvic floor dysfunction than women, but they're equally pathodemonic. So meaning like in people words, when you come to my office, it takes me now after 10 years of practice and reading and deep diving, it takes me like two minutes. You talk to me for two minutes and I know. How does a man know that he has pelvic floor dysfunction? So he won't know. The pelvic floor favorite as well. And let me tell you the entry of that. But there's two particular flavors of this that come into me quite commonly. So someone will come in and they'll say, so as a reconstruction is how this happened is men have strictures. They have a blockage in their penile urethra. So the urethra in men is like roughly six inches. Their P tube is longer than our P tube. And so you can get scar tissue and then their stream is weak because they're basically peeing through a coffee stirrer. So it's like drip, drip, drip, drip, drip. And they know they're not 60, they're 30, right? So it's not their prostate. They're not an old guy. They're like, well, why don't I pee well? And so a lot of them will come see me saying, I think, you know, I have a blockage in my urethra. And so that's how that got to me. And that's how I got the expertise. So then I looked and we would do, cystoscopy would put a camera in, clean, perfectly normal. Do you see the stricture? So no, no, no, that's what I'm saying. They don't have a stricture. Okay. So there are stricture patients and I treat those patients when we do surgery and we reconstruct their urethra. But so many patients had symptoms that mimicked a stricture. And they come find me. I see. It's a 30 year old. It's a 30 year old normal guy who is active, has a job, all those things. Maybe he doesn't even have pain or maybe has a little bit of pain, but he has weak urinary stream when he ejaculates. He'll have pain for two to three days. Not ejaculation. And sometimes he has pain in his testicles and he doesn't know what. And so what it is, is a stricture is a blockage. Think of it like a shower curtain of scar tissue in a tube. And so you can't get the pee through. However, pelvic floor dysfunction, it's like those muscles. Remember I said you, there's a hammock of muscles. There's things that go through those muscles and all of those things create the symptoms that go with pelvic floor dysfunction. So there's a hole for your rectum. So these people are constipated, but you can't ask them if they have constipation. You know that. You have to say like, do you have a bowel movement every day? No, no one ever has constipation. But if you say, do you have a bowel movement every day without straining, they're like, no, I poop once a week and I say, okay, we should talk about that. And then, you know, the urethra goes through like the penis. And then the, the spermatic cords go through. And that's where the testicle pain from pelvic floor dysfunction comes in. So they can have any number of symptoms with all of those structures. That's why this is so confusing because it presents with like 10 different symptoms. And it all goes back to the underlying like cause or etiology of the pelvic muscle dysfunction. You know, I can't help but think about, obviously, we focus a lot on muscle-centric medicine. Yes. I can't help but think body composition, does that play a role in pelvic floor dysfunction for men? You know what, I'm not so sure of body composition, like the fat muscle component does, but what I do think plays a component is high muscle tone. People carry stress in different ways. We all know people who, like for instance, people get tension headaches when they're stressed. And that's because their trapezius muscles tighten and they don't even know they're carrying that tension there and then it gets referred, right? So there's people out there getting Botox to their neck muscles and it cures their headache. Similarly, I think as high functioning people, you and I, there's lots of people, you described a lawyer, right? Lawyers, high stress, high function. People who carry a lot of stress in their daily life, it manifests in some way. I'm a big believer in the mind-body connection. So I'm going to tell you a story. Before I was a doctor, when I was 15, I remember having a tachyirhythmia. I remember playing tennis with my brother and my heart rate went double time and slightly irregular. Before I knew anything about medicine and it would happen sporadically, like once in a blue moon, like once every six months or something. As I went through residency, it became more and more frequent. And by the time I was a chief resident, it was happening every day. And I could put the pulse oaks on my finger in clinic and my heart rate was 160. So like normal heart rate for the viewers, 60 to 90. So my heart was doing double time and slightly irregular. At the point where I was like feeling a little woozy, I thought, oh, I should get a cardiac workup. I might stroke out and die. So I did the whole thing. I got the halter monitor. I got a cardiac workup and they're like, yes, you have an arrhythmia. And I said, what should I do? And they said, it's stress and caffeine induced, which of course I had both lots of coffee and lots of stress. And then I graduated. Stopped. Stopped. When I wasn't a surgical resident anymore, when I was working nine to five and sleeping and spending time with my family, I didn't have an arrhythmia for like a year. Wow. And then I had to take my oral board. So to be a board certified urologist, you have to go into a little room for two days and let them ask you anything you've learned in the last 10 years. It's all fair game. And if you don't pass, you basically can't keep your academic job. Like you kind of have to be board certified to be an academic urologist. So stressful, needless to say. And the people I work with used to say, you're so cool. You're cool as a cucumber. You look so ready. And I'd say, oh, my body knows differently because, and I was pregnant at the time I started having my tachy arrhythmia again, like cloth cork every single day for the month leading up to that exam. So for me, that is my manifestation of stress. My heart will tell me when I am more stressed than I should be. For other people, they have their pelvic floor. And even when they come to me and we get things under wraps, I had a patient who came to me with a note like this, like if a surgeon who usually writes a three line note, writes a dissertation in the chart, there is a problem. And we got his symptoms under control. And then he said, I'm going back to school. And he was excited. He was like, yes. And I said, oh no. And why? Because he was a single parent going back to school and he knew how much stress that would put on him. And I thought, oh, your symptoms are going to come back. And we're going to need, it's a waxing and waning course. And when you're under stress, your muscles tighten. You're not doing it consciously. Even if you're just tight. And so the levator in, these are not smooth. Are these smooth muscles? They're not. No, these are skeletal muscles. They're skeletal muscles. But the difference is where everyone can say, this is my bicep. Flex my bicep. Relax my bicep. None of us are taught contract my pelvic floor. And I literally just did relax my pelvic floor. For men, are they, for women, they talk about kegling. Kegling. Right. Kegels, kegels. Potato, potato. Yeah. What about for men if a, because what I'm hearing you say is that it's not a low tone. It's high tone. They have high resting tone. Their muscles are clenching all the time. It's squeezing their urethra shut. That's where the pain from ejaculation comes. So they're your retral sphincter is squeezed shut. And when the ejaculate, which is high velocity propelled, it hits a ball. Of course that hurts. Right. And then the testicles, many patients tell me they feel like their testicles are getting like pulled up into their body. It's like their cremasteric muscles around their spermatic cord are being squeezed or activated. They have trouble relaxing. They'll have anal fissures or hemorrhoids because they have trouble relaxing their sphincter muscle as part of their pelvic floor. Clearing up when to use, is it kegels or kegels? Do we know? I, I, I, I say kegel, kegel. Yes. I know. I think I say both. Tamino, tamano. Yes. Some people, so for example, with urinary incontinence, you have to learn to use the you have to learn how to contract those muscles. Yes. How ladies for a little, okay. Kegels is your best friend. You have a child and then you like sneeze, laugh and you tinkle a little. You want to kegel. You do want to tighten those muscles so that you can strengthen your sphincter muscle and not having comets. But the chronic pain, the chronic pelvic pain is the opposite. You wanted those that's a high tone. So you want to reduce the tone. Correct. Exactly. So one of the things I ask people and we know from data that it's better if you go to a pelvic floor physical therapist, like a specialist, you can't just call up a physical therapist and say, like, Hey, I have perineal pain. You have to ask them if they have specialized training in pelvic floor. So sometimes, you know, my patients come from two hours around and if they're far away, I said, what did you do in your visit when they went to someone close to them? And if they tell me kegeling and that's all they did, that is wrong. They're tightening those muscles and kegeling to learn how your muscles feel and then learn to relax them is okay. But it shouldn't be the only thing you do. It makes sense. And that's a, it's an important point to clarify because again, one is potentially that the muscles aren't strong enough. Correct. Post pregnancy, but you don't see that in the male population. No, it's too tight. Too tight all the time and they have high resting tone and we need them to get that to relax. To chill. The statement someone is anal retentive. I mean, that's kind of what we're talking about. Yeah, like that's on point because they're, they have high tone and they're not relaxing and pooping well. Now, when I think about say, shoulder dysfunction or neck tension, you can do yoga, you can stretch. What are our solutions for chronic pelvic pain syndrome? Or do we say, what are the solutions for pelvic floor dysfunction? Is there a way to have unified those are like a Venn diagram in my mind now, this hasn't been proven or disproven. Daniel Shasky is at the Cleveland clinic wrote a really nice paper where chronic pelvic pain syndrome patients about half of them on exam will have pelvic floor dysfunction. And so we, we all as urologists do a bunch of rectal exams. It is perhaps my least favorite thing that I signed up for as part of this field. But when you're doing that rectal exam and our new guidelines, it explains what's called a 360 DRE. If you swing your finger laterally, you'll feel the pelvic muscle struts. And I always tell people, you know, when we describe prostate exams to medical students, we say, okay, touch right here. They're like the hypotherm, our M and N's you touch this piece of your hand and it simulates what a normal prostate should feel like. So if you reach in and you swing side and you press, firstly, the patient will say out, but secondly, it feels like you're bicep tendon. It's tight. It's tight and hard. And it shouldn't be. And so then that elicits the pain for the patient. And then you have a diagnostic hint that like that patient has pelvic floor dysfunction. This episode is brought to you by Manacora Honey. When it comes to your health, it's not usually the big changes that make the difference. 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It's a tiny small upgrade, but those are the things that build real long-term results. Please go to Manacora, which is M-A-N-U-K-O-R-A dot com slash Dr. Lion, and you can get 25% off your starter kit. I love this honey and I use this honey almost every day. In urology residency, I did family practice for one of my residencies. We are taught that a DRE, a digital rectal exam, is really for the prostate. Yeah. You are feeling for the size, the, um, yeah, pretty much the smoothness. We were not taught anything about testing the muscle. Me neither. But is that now happening in training? No. So me neither. So, um, I, gosh, I learned that 360 DRE about six or seven years in as an attending. I was starting to do it without knowing it had a name and had been published. In year three, I was starting to touch people's levator muscles and elicit this tenderness and write about it and talk about it. And once I started talking about it, that got me plugged into the other people on the guidelines panel. So Mike Pontaria Temple became my mentor and, um, told me about the other facets of neuropathic chronic pelvic pain and some of the other modalities to help. But no, it is not taught. It's not talked about. I would venture to say most of our urology residents are not learning it. Chronic pelvic pain syndrome, we're going to look at when it was given, if it was given an ICD-10 code. The reason I bring this up because through my framework of muscles under medicine, yeah, on the opposite end of sarcopenia, I didn't get an ICD-10 code until 2016. Yeah. Sarcopenia. Yeah. If you can't name it, you can't treat it. It's taught in the American healthcare system, having the money behind it, like it's a code and RVU, blah, blah, blah, to treatment, it's FDA approved, all of that. Like we are a nascent field. We're just beginning to understand chronic pain and have treatments. Can we talk about chronic pain and the brain? Yes. And what you're looking at and how that ends up affecting the physiology? Yeah. So one of the most important things about having chronic pain, whether you have chronic pelvic pain syndrome, or you have fibromyalgia, or you have some kind of irritable bowel disease, et cetera, understand that if you consistently have pain in your life, you fear that next episode of pain and they have done functional MRI studies that show that your gray matter actually changes, your control of the pelvic floor changes, and your register for pain changes. So what would register to a non-chronic pain patient? I'd say a two or a three. Registers to them as a seven. The way I'll put that into like a real world example for you is, I love this episode of Family Guy where Stewie's like, mama, mommy, mama, mama, mama, pee, mama. Sounds like my morning. Right. It's every over stimulated mother. So the thing is you're primed. So even one mama, one mama is okay. But like when you get to your already creeping towards the top of your, you know, it's triggering as people say. And so the thing is these people live in chronic pain. And so when they start to get a little bit of pain, the fear and the anxiety play into that. And it revs higher. It pers, it literally feels more painful to them. And so I think part of what's problematic is as providers, you see someone in your office and you lightly graze their testicle and they go, ah, right. And so like it seems melodramatic. It seems like overacting. It seems psychological to be frank. And, but it's real. It's real. And they feel it that way. And, and so many providers brush them off because of a perceived disconnect. Provides for spam and residents. You and I both know all of them. When we're doing intakes in the ER in training, oh, oh, it's a pain seeker. Yes. Medication seeking. People are invalidated constantly. People with chronic pain because the degree of pain that they feel in response. And that's what they're feeling. And we have no measure for it. We can't prove it, but in their body, they're feeling eight and nine out of 10 paint. They're in pain and it was just light touch for the younger guy or younger guy, whatever. When we say younger, yeah, less than 65. Yeah. Under 65. Is it that's younger. My, my clinic to spring chicken younger. You and geriatrics 65 and up is considered geriatrics. Is there a slow progression? Is this, if someone is sitting there at home thinking, gosh, you know, I think that, I don't know, my testicle is irritated or I'm sitting a lot. Maybe it's prosthetitis. Is it a small progression? Does it impact the way that they can train or work out? Or is it something that is irritated? All of a sudden they're like, oh my God, I woke up one morning and my balls hurt. So I think that yes and yes. So I before, and we're hinting at the rest of this podcast, but before I was a cancer patient, I had deep and unabiding sympathy for chronic pain patients. That is kind of what drove me to the deep dive to quote the statue of liberty. Give me your tired and huddled masses. I saw patients over and over who'd been given antibiotics, who'd been invalidated and told it was all in their head, who had the craziest stories of how it happened, whether it was like, I got whacked in the testicle one time by my grandchild and now I have chronic pain that won't go away or, you know, like I lifted something one day, like very just routine things that happen to people in life. And then it's like a switch flipped and they became a chronic pain patient. And now this young, let's say 30 year old, this young 30 year old who's a dad, can't get on the floor and play with his children. And do you know how devastating that is and how badly he wants to do that? And he tries to go to his job. He can't work. And his construction company doesn't understand why an able-bodied man with no obvious pathology, no CAT scan that says you're dying, can't work. Because we don't have a scan that proves pain, right? Like everybody comes in and wants to know why they have pain and I'm like, I'm gonna use another analogy. When you come in, you want to know why you have pain? All we can do is pictures. If I pop your car and it's not starting and I like pop the hood and I'm looking for why it doesn't start, can you tell me why it doesn't start? No. Only if like the battery terminal is not hooked up, right? If I just take a picture of the engine. I know nothing about cars, but I'm assuming. Me too. Me too. But here's the thing. Okay. So an ultrasound is a picture. CAT scan is a picture. MRI is a picture. It's a neuropathic pain, right? All it shows is your anatomical structures. There's no functional study for pain and registering patients' pain. So it's almost imaginary. It's non-imaginary. It's very real. Is this why it took so long for phagramyalgia to become... So for those of you who are listening or watching, phagramyalgia has a diagnostic criteria. I think it's a pretty long list. Out of my wheelhouse, but similarly, if I bromyalgia is something you can't put your finger on that is devastating and is packed. Yeah, it's like most pain points. And there's a coincidence of chronic pain syndrome. So there's a higher incidence of people who have one pain syndrome having another pain syndrome than should be in the population. And for the longest time, also complex regional pain syndrome, as a psychiatry resident, there was only, I mean, there was a handful of patients that, maybe two patients that had come in and they were sent to psychiatric emergency when in fact, the pain is real. And so what you're saying... It's real. It makes a lot of sense because we don't have a way of classifying it or figuring it out in terms of imaging or diagnostic criteria. That's a real challenge. You said something earlier about how these muscles, you know, when you have a tight neck or tight shoulders, how do we begin to think about treatment? Going back to the patients and the mind, body connection, there's a lot of things you can do for yourself. So I direct my patients towards YouTube and public floor physical therapists who will explain how to lower your resting tone, deep breathing, meditation, stretching. These things are actually really helpful. And then I know it sounds just absolute quackery. Can you stretch these pelvic floor muscles? Well, yeah, like stretching is going to like relax them out a little bit. You know, if you have a Charlie horse in your calf and you do stretching exercises, that's going to help. Everybody knows that, right? In my mind, I can visualize that. Right. Everyone can think of the calf or your arms, but you just, like, you can't visualize your pelvis and how you're going to relax your pelvis. But you know, people do. People come up with stretching exercises and it works really well. Deep breathing exercises, guided meditation. And then another key factor is, and I find this particularly difficult in the male population, I think women acknowledges more so than men, forgive the generalization, but we know that stress and unaddressed emotional turmoil affects our body. Right. And so I know when I need to have, you know, a girl's day, that's what we do. We do a girl's day for stress relief, but men don't necessarily acknowledge that they're conditioned by society to be stalwart, stoic, to hold and be strong. And so all that does is actually increase their resting tone and make their symptoms worse. So I try to get them to acknowledge the stress points in their life, whether that's, you know, grocery prices are going up and I'm having trouble paying for my mortgage, financial stress, or their stress in my marriage. We're really not getting along or, you know, my son is special needs and that's tough. And that's something to, you know, like it can create some family dynamics that are unpleasant. Whatever is the pain point in your life that's causing stress, two things. One, address the pain point, work towards making the point point better. And two, come up with coping skills to deal with the pain point. Now, firstly, I'll be the first to acknowledge that I had bourbon to deal with some of my pain points. And that is not how it should be done. But, but like it's a gateway and then you can get into the meditation and the yoga and the stretching and all of the healthy things you can do. What about, um, heating pads? Yes. I do want to cover medication because we have a lot of physicians that listen and I was, again, I will link the, there's a grand rounds, the one that you did at Baylor actually, I think it was Baylor. You put a slide up there, there was Gabapentin, there was, I believe it was also Amtriphaline. Yeah. So those are the, so, so first let's start with like the easy stuff. In my first visit, a lot of these patients have seen about six providers who've told them it's an infection. And so I have to roll that back with them. And I have to say like, no, it's a pelvic flutist function, right? And the look I get when I tell someone with scortal pain that some mural acts is going to call, who like fixed their scortal pain. I mean, I get a lot of looks like you are an absolute quack. So my first visit with people is trust building. And I say, what have you got to lose? It's a $9 bottle of mural acts. Like just go try it. If you guys don't know what that is, it's for a conservation. Yeah. It's for conservation. I give it to my kids. You literally put some powder and some water and it helps you poop better. But the thing is I heard this great lecture in medical school, three people on a train in a pelvis, the old school bussy. And so it's like a prostate, a rectum and a bladder. And like, if your prostate's too big or let's say your rectum's big, you're not pooping well. If your rectum is a 500 pound man, then your bladder and prostate is like this and they're both uncomfortable. So like if you get people to poop, then the space in their pelvis opens up, their muscle tone, relaxes, et cetera. So in my first visit, I catalog their symptoms. I asked them what bothers them the most. I validate that it's real and not in their head and that I you're in the right place and I will help you. And then I also go through my thinking on a whiteboard. I like literally rip off house all the time. I love he Lurian house and the whole cast. That is a differential diagnosis on a whiteboard. I write down here are the things that I'm thinking. This test will rule this out. This test will work for this. And then I told them my thinking transparently. And then I usually try to counter to what we're taught in medical school, shotgun the visit and get as much done because the problem is these patients have been through the ringer already. They're distrustful of what I'm saying and I need to make an impact to get them to come back. So I give them flow max for their urinary symptoms. And how does that work? Will you so flow max would treat pelvic floor? It's not treating the pelvic floor, right? I love visuals. You're letting them get a little bit better. Symptomatic improvement. So here's the bladder. My wrists are the prostate and this is the urethra. So it works on the prostate, but it also relaxes open the bladder. Right? And so that allows them to pee easier and then they have less hesitancy. I tell them to take a hot bath for 20 minutes if they're not trying to have children because it lowers your sperm fertility as we talk about. So if you take a really hot bath, I say do it before bed because then they'll get good sleep for the first time in a while and we know how important sleep is. I tell them two weeks of an NSAID because an NSAID is an anti-inflammatory. So I'm not just aiming at their pain. I'm trying to decrease the inflammation. Like if you have a muscle pull that is continuing to get those nociceptive like pain chemicals in your body that are flaring and causing the pain to get suppressed so that we break the pain cycle. So I do all those things in the first visit and then I recommend some home stuff like check out, you know, Stephanie Pendergast and pelvic health rehabilitation YouTube. She gives a longer form than I can do in the office. I say, take, you know, check out these stretching exercises and just see if these help you. So I give them like five things, throw a pasta at the wall, see what sticks. And if I can get that patient even 25% better, if I can make a dent, they will come back to me in my office because I am the first person who made them feel a little better. Then I can get into the really left field stuff, the stuff that I know that works that they've never heard of and they'll think I'm absolutely crazy for mentioning. When I say, hey, we're going to give you, you know, Simbalta, we're going to give you an SNRI for your neuropathic pain. The physician who's listening to this and again, I, you know, I feel, I mean, I feel badly. I'm just thinking about this other young patient that I had. I've only had two patients that have come with these symptoms over the years, but one was a really young guy and we ended up sending him to urology. And I don't know what the outcome was because it was definitely outside of the, of my wheelhouse, but listening to, I mean, he, that's what he definitely had. The medication part, if we're giving them Simbalta, this is again. So Simbalta is completely off label and a trick I picked up from my anesthesia colleagues. It's not even written about yet. It's actually my, my project for this year's national conference. Just, it, it's been very effective in my practice. For chronic, um, Squirtle pain and pelvic pain, both Simbalta, uh, Gabapentin, Gabapentin, Lyrica or pre-gabalin, amitriptyline, um, the medications you think of for neuropathic pain, we're using those same medications for chronic pelvic pain and chronic orcalgia or chronic bulk pain. I had, uh, so this lawyer would go on rounds of antibiotics and the odd part is when he was on the antibiotics, it seemed to make the pain better. Is that some kind of anti-inflammatory effect? I can't explain that, but so, so firstly, the placebo effect is about 30%. So to some degree, I think the placebo effect explains some of it. However, I've heard that story so many times, credibly by people, I genuinely believe something is happening that the antibiotics are helping temporarily. I just don't think that they're addressing the underlying issue. So I don't dismiss patients when they tell me they feel better for like a few days after the antibiotics, but I just say, you know, they've seen urgent care, they've seen ER, they've seen primary care, they've seen people like maybe in APP, in neurology before getting to me. So five or six people and they've had multiple rounds of antibiotics and they'll tell me they're better for a couple of days and then it comes right back and I'll say, well, it comes right back and everyone's tried that. So let's try something different. Do you know what the definition of madness is? Like let's go down a different road. He ended up going to Ugly, Florida and was getting injections. They felt that it was related to the prostate. I don't know that there was a full resolution beyond medications to address the neuropathic pain. Are there other things that individuals are utilizing or is it, if I think about it, to the female lens, you treat pelvic floor dysfunction and the pain gets better. They don't have pain on sex anymore. They don't, they do the pelvic floor exercises. They don't have urinary incontinence. However, for some women, they might need surgery. They might need a surgical repair. How do we think about crossover from the area that we know really well, women, to what that looks like for men? So I think when you address the pelvic floor dysfunction, the symptomatology does improve remarkably, but I view it as a predisposition. You know how we talk in cancer about the one to hit, you know, you have a genetic predisposition and then something changes in your cell line and that's how you get cancer. So I think about it like these are patients who are high stress patients with high resting tone. And when we teach them how to lower their tone, whether it's pharmacologically or stretching or whatever, yes, their symptoms get better, but life is life. Life happens to us all. So I never think that I have cured my patient, even if we've worked for three years and they're feeling great and they don't need me anymore. I say, this is going to happen again, right? Like it's going to come back and here's what you do and then like you re-engage me and we work again. So I think it's a waxing and waning course over the course of a lifetime dependent on life events and stress that your body is put under. Pharmacology is one way. You can do the stretching and everything also. And muscle relaxers. And muscle relaxers we use. Is that something? Yes, you can take systemic. I favor, you know, tizanidine is a really great drug. You can use rectal suppositories just to affect the pelvic floor. So I've used Valium or baclyphine, which is a relaxer. You tend to use those later down the algorithm because of the addictive potential. And then like I said, the neuropathic pain medications. And then if you want to get really left field. So when I was on this guidelines panel, top of the guidelines, so you were part of the group that wrote the guidelines, the treatment guidelines for C.P.P.S. Yes, call it. Again, this is a chronic pelvic pain syndrome, say it three times fast. Yes. So chronic pelvic pain syndrome and chronic orcalgia. Thankfully, we got a guidelines panel together to our national organization's credit because so many of these patients weren't getting the help that they needed. And, you know, beautifully, we had so many different people from different facets of medicine come together and give their viewpoints because there are a lot of different ways to approach this. And so you would think a guidelines panel is somewhere where you go to like give your expertise, but really what happened is they let the person who barely qualified. I was like the junior most attending on this panel. Everyone else was much better published and smarter. And I learned from them so incredibly. And then I learned things that I didn't even know existed. So Larissa Bressler is really big into acupuncture and what acupuncture can do for chronic pain. And the data is there, the evidence-based medicine, the studies have been done. It's real, it works. Similarly. In the perineum, to my acupuncture. Well, I don't know where they put the needles off the top of the hand. I have seen it in the perineum. I believe it. For this. And the perineum is the space between, would you say? No man's land, the space between your scrotum and your anus. Like if I sit, spread eagle, it's like right there. If you are not watching this, you should be because she just demonstrated it. I have seen my best friend who's actually still my best friend. He's a pain specialist at Madigan in Madigan. He's an interventional pain specialist and he did sports medicine. He is Russian and he is very interested in some of the more alternative treatments. In residency, as he was going through his acupuncture training, he was doing acupuncture in the perineum. Yeah, you don't even hear about it. The other thing is, so after doing that panel, I found out we had an acupuncturist at our institution and started referring. The other thing that was really. But do you think, not just to pause here, as I'm thinking, okay, so people are taking action items. It's probably similar to pelvic floor physical therapy that you go to a specialist? Yes, you do. So it's not just I, I don't want to, can you imagine? Yes. Going to like a generalist and being like, hey, right here. I need acupuncture because of this grotal pain, the acupuncturists, they might not know what to do and they're probably acupuncturists that focus on chronic pelvic floor pain. Right. So similarly, there was a study done for pelvic floor physical therapy, which I would say is like the main say of pelvic floor dysfunction. And we didn't really get into, but like going to a pelvic floor physical therapist is one, two, and three on my list. It's that important. It's that important. I don't put it up front because there's a lot of rectal exams and telling a man, I'm going to sign him up for like regular rectal exams is not an appealing person to that person that has never heard about pelvic floor therapy. Yes. So you know how when you have tushed in here, people say, oh, you have a knot and then they work on her. She's, um, yeah, I'm gesturing. I forgot it's a podcast. Okay. So I'm just, both. So you are only listening to this. So I'm gesturing in my shoulders and in your trapezius muscle, like right around your neck, everyone will feel kind of like knots. They'll say, and they'll go get a massage and people will say you're tight and they'll intentionally work on that knot. And what they're doing, as we know, is myofascial release. And so internally, public floor physical therapists will insert a digit into the rectum. Now ladies, we have another aspect. We have the vagina and you can work on the vagina, but for men, I'm sorry, it has to be the rectum. So they have to get rectal exams and then they use their, um, digital manipulation to find their trigger points and like work on myofascial release. You can also inject anesthetics into the trigger point. That's another thing or Botox to like freeze those muscles and calm the tension. All of that exists. I actually retrospectively reviewed my data one time, maybe five years in and of the men I diagnosed with pelvic floor dysfunction, 44% went to pelvic floor physical therapy. And I think that's because one, it is onerous to go to something week after week after week. It is a commitment. Were you expecting you to be higher? Yes, I was hoping it would be higher, but I was not shocked. It was so low because I knew, you know, they weren't coming back to me. They didn't, it's multifactorial. So firstly, none of this data was out there. None of it was talked about. So when I said these left field things and they Googled pelvic floor dysfunction and saw vagina, they just thought I was a quack. They don't know that it's more like I'm on the forefront and looking at what things are coming down the pike and it's going to be very humbling for, I mean, to have to as a, I mean, as a woman, because I went to pelvic floor therapy when I was pregnant. Because I don't know, this is as a physician, you know, it's good. You should be doing it. And I don't, even if I was like, I'm not going to be doing this. I don't care. And as physicians, we obviously don't always leak the best patients, but we have knowledge and awareness of the things that we quote should be doing. I think, you know, as I just even think about my husband or my dad, it would be very, yeah, they'd be like, no, I'm just not a chance. I'm going to suffer. Yeah. So I think that that's why my first visit with them, I consider a trust building visit. I give them easy, easy things to do, like watching YouTube and stretching and a pill that they can take every day and hot bath. Thank you to Timeline for sponsoring this episode. If you're a frequent listener to the show, you know, I believe that muscle is the organ of longevity. It regulates metabolism, protects independence and supports long term health. 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What percent are going to get better with those alone versus public floor therapy? Is it required? It's not required. It is a small percentage. I make a small dent. I don't cure their pain, but I make a small dent in their pain, and then they start to believe in the credence of what I'm saying. Meaning if they don't go to public floor therapy, where is there a potential for them to have resolution? Maybe. So maybe, maybe it depends if they're just chronic pelvic pain, like neuropathic pain versus pelvic floor dysfunction. If you really have pelvic floor dysfunction and you don't go see a pelvic floor physical therapy, if you're moderate or severe, you need that pelvic floor physical therapist. That's the truth. And so my job is to explain it to you, to get you to trust me, to get you some buy-in so that you'll go to that person. I'm not the person who fixes you. I'm just the person who gets you to the person who fixes you. Neuropathic pain. There are certain potentially comorbidities. Is that fair to say that we, it might be, if someone is diabetic, is that, again, as I think about this area. But honestly, I would have to tell you, these are 20 to 40 year-old men. These are not diabetic. Right. So what, are there comorbidities that come along? So it can be. Again, we know that fibromyalgia has a hair coincidence, irritable bowel disease, depression anxiety. Irritable bowel disease, that makes sense to me. Right. Because it's like inflammatory bowel disease. Yeah. Make that all makes sense to me. As true as, I guess what I'm trying to understand is from a patient perspective, also as a provider perspective, if we know that, for example, someone has type 2 diabetes and we know that they have had elevated blood sugar for, again, people will say the cutoff is above, you know, 126. I think that the glucose levels are affecting microvascular disease at much lower levels. Yes. But again, we will, until it's quote, oh, you have pre-diabetes or diabetes, but the damages are already being done. As I think about these young, healthy, so-called healthy individuals, from a pathology perspective, is it maybe Lyme disease as a comorbid condition? Are there we don't know? First of all, no one's really like devoting the time and the study to this, but secondly, not from what I can see. Sexual trauma. So, oh, thank you for mentioning that. So sexual trauma, there's a huge coincidence. It's very high. The, it's just baddie to me. And how I learned that is the number one reason when someone seeks me out as a female urologist, of which there's only 11%. So it's 89% male urologist. And I probably know half of you know. You probably do. You probably know half of you. Shout out to Rena Malek. To Rena Malek and Danny Vales. Yeah, Danny Vales. Yeah. There's very few women in urology. But when someone specifically requests a woman and then says like, I will only see a woman in urology, um, commonly, exceedingly commonly, it's because they have a history of sexual abuse by a man and they don't want to have a male doctor. At least that's been my anecdotal experience, because what happens is, and this is how I learned this for better or worse, I am fair. I'm not always nice, but I'm definitely fair. So, so when I would go into the room of these patients, I didn't always get that disclaimer from the front desk. So I would go into the room, I'd send a male resident, because most of my residents are men, into the room and they would kick the male resident out. And then they would demand to see me and me only. And at first I would perceive that as them being a difficult patient, like they just don't want to talk to a resident. They only want to talk to the attending. And then when I would go in, they would explain that they didn't want to talk to a male doctor. And I would double down and I'd say, you know, I got thrown out of a lot of rooms and didn't get to do exams. And it was merely because I had a vagina and that doesn't affect my ability to deliver good quality medical care. What's good for the goose is good for the gander. This young man, yes, he has a penis, but he's also an excellent physician. Our genitalia does not affect our cognitive abilities. So, but then they would eventually disclose. And now, as years have gone on, when someone requests me, I know, and I try to practice trauma informed care. And I say, you know, a lot of my patients, and you tell me if this resonates with you or not, but they have something in their past that was traumatic. It could have been, you know, it could be like a veteran with PTSD from the war, or it could have been, you know, they had an untoward experience with a family member, or it can even be something like, you know, sexual abuse, or maybe just like childhood neglect, adverse childhood events. And then I just let, I open the door and it's up to the patient to step through it. I do not drag it out of them and make them relive their worst life experiences. But I had, I remembered, I remember vividly just like one random day in clinic, a resident presented to me, I heard pelvic floor dysfunction all over the presentation. And I call it my spidey sense. I said, spidey sense is tingling. I was like, I just think there's something more to this. So I said those words, and the patient said back something like, you know, stuff happens with babysitters. And the resident looked me and like just like with his head around and looked at me like, how did you know? And I thought, you know, I don't know, like, it's just very common. I think, you know, I hear on Instagram, I can't remember who said it, but your body keeps score. And I think that when you have physical abuse, sexual trauma, you do have tightened tone, your muscles, your body is in constant fight or flight, trying to survive and guard itself. And I'm not an expert. And that that's just my, it makes a lot of sense. I've seen, I still see patients. And oftentimes, as you were mentioning, those open ended questions, when things can't get resolved, doesn't, you know, it's just, for example, sleep, that you have good sleep hygiene. Maybe they're taking melatonin and then maybe it's tracidone. And they just, you know, there's something, they just can't sleep. And it's because there's something unresolved. Yeah, there's just this very high sympathetic drive. And that, that makes sense. Progression. How does the clinical picture look in terms of progression? Neuropathic pain, dermatonal tracks, is there a pattern that you expect to see? So for example, fibromyalgia, it has, and I can look it up, it's there, I don't know, 13 points where it could be. So I diagnose, I make it really simple when I give my lectures and stuff. And for pelvic floor dysfunction, there are a couple of red flags that just tell me right off the bat that you have pelvic floor dysfunction. I call it testicle pain plus. So, so again, I thought it was being gas lit and a little crazy because it wasn't being talked about and no one, you know, I was reading, reading, reading, but I kept seeing it everywhere. So I did this project. You kept seeing it clinically or clinically? Every day in clinic, I would see like, if I saw 30 patients, I would see five to 10 pelvic floor patients who were coming to me as other things who were coming to me as weak urinary stream or rectilus function, like other things that I do. But then when we got into the meat of the visit, it was pelvic floor dysfunction. So, so what happened is I took, I did a research study mostly just to try to understand, right? When I took every patient who had chronic or calgea, and I took everyone who had chronic or calgea, but then I did the rectil exam and diagnosed their pelvic floor dysfunction. And keep in mind, it's an under-representation because not every patient lets me do a rectil exam. I give them the right to refuse for obvious reasons and a fair number of them refuse. So just the small number who have ball pain and tight muscles in their pelvis and looked at their symptom profiles, so much more likely to have constipation, so much more likely to have urinary symptoms, like multiple factors more likely, and their urinary symptoms are different. Their urinary symptoms are weak stream and hesitancy because they're being blocked because their ability to pee through that closed sphincter is weak. So it's not always BPH? No, it's not. It's not BPH in a 30 year old guy. It's not. It's not period, end of story. It's not. But they manifest like that. And so for them, they think like the average person thinks, okay, you have a stricture, you have a blockage. But when they investigate and there's no blockage, everyone's stumped like, well, okay. It's in your head. Yeah. Well, they just say you're fine. Anatomically, you're fine. Like every study we get says you're fine and you're fine. But then the patient goes home with pain and a bunch of symptoms and they can't explain it. And imagine if you're 30 and you're trying to have sex with your wife, and then it's painful for like three days, you like literally have to lay on the couch and take Advil. It's deeply disturbing. So that's the thing. Those patients have pain after ejaculation. They have 14 times more likely to have constipation. They have urinary symptoms. So now I call pelvic floor dysfunction pain plus plus. Does it affect fertility? Not as far as I know. I mean, in theory, yes, I think the like the pelvic floor is squeezing the cords. But no, we no one's done the study. I don't have any indication that it does. What about hydrocele or some kind of surgical? Could a surgical correction, penile implant, I know that you do those, cannot cause pelvic pain, chronic pelvic pain. So the most common cause of pain in the groin area that I see that's post-op would be a hernia repair. About like 10% of people will get groin pain. But again, I send them back to their general surgeon or to the anesthesia pain clinic to deal with that. On the hydrocele front, the funny thing about that is what happens is patients have testicle pain. They go to the doctor. It's a little bit like that game when you're a toddler and there's like a square peg and a round peg and a, you know, what a star. We don't know what to put you in. So we're just going to call you a square and hit you in there. Right? So like they're like, okay, you have testicle pain, we'll get a testicle ultrasound. And then whatever comes back, and I kid you not, it's like varicoseal, hydroseal, spermatosil. Those are all benign findings. These are completely benign findings. But the patient understandably sees a long medical word on their ultrasound that was done for pain and comes to me and says, I have a hydrocele. And you know what I do? I say, I have freckles. Oh my God, I have freckles. I have freckles. They're right there. Look, yeah, but the freckles, the freckles not killing me and it doesn't bother me. And yes, I see it. And so the same thing is true. Varicoseals can cause pain. It's true, but they have to be like grade three. And there's a classic teaching. Varicoseals cause pain at the end of the day. Like varicose veins, you stand on your legs all day and then they, you don't get as much of an as return and then they really pop out. Similarly, varicose veins are on the testicle cause pain when you're like really working hard and it goes throughout the day. These patients have pain sporadically, they have pain multiple days every day, and they come with like, there's a grading scale for varicoseals. And some of these varicoseals we can only see on ultrasound. Like I don't feel them on exam, etc. So we call those clinically insignificant. So these clinically insignificant varicoseals come to my office and they're like operate on my varicoseal. That is not the problem. But you are one of a handful of urologists that are looking at chronic pelvic pain. Correct. If someone is going to another urologist that may be is out of training, has not been experienced. It's true. They could get a varicoseal surgery. They, they could and then then they won't be better. And that is problematic and part and parcel of like why I'm here trying to disseminate this information. Cause the surgery you really could get and should get and would help you again, this is just if you have testicle pain. So if just testicle pain, but not chronic pelvic pain, what we can do is we can inject your spermatic cord with a local anesthetic and that gives you temporary pain relief. And in my practice, you can do it a bunch of different ways. But I call that a dress rehearsal. I explain to the patient, this is not therapeutic. This is not designed to be your ultimate treatment. What we're doing is proof of principle. We're going to do this. You're going to take notes. Cause the other thing is you, me, everyone, we don't really know when we feel bad or when we feel good. What we notice is the transition points. When you feel horrible and you start to feel better, you notice when you feel great and you start to feel bad, you notice, but if you're feeling great, you don't pay attention. If you're feeling terrible, you just know you feel terrible. So we're kind of like just people. So I say, I want you to be mindful and present as the kids say three times a day. I want you to stop what you're doing and write down a pain score. Stop. What's my pain? One out of 10 post ejection. Yeah. And so I have them write it on a sheet and bring me homework so I can see the trajectory of how the block worked or didn't work. And then if the block worked, I say, okay, let's do a second block and now do the thing that caused you pain, put this block through its paces for my military guys to say, we're on with your pack on, you know, for my young guys who are trying to make a baby and like, go have sex, go see if that like, are we having pain, you know, do whatever and then come back and tell me. And then again, bring me the sheet. And if they come back and it worked really well, if I strip the nerves in a surgical denervation called a microsurgical denervation of this brimatic cord, which is such a mouthful, it's a little bit of trickery math, but I say there's an 85% you'll be half better. But in general, I'm so selective of my patients that anecdotally, I can tell you these patients are pain free, just about all of them are pain free, not everyone. And even of the patients who get half better, I look them in the eye and I say, knowing what you know now, would you go through the surgery again? And in my head, I'm thinking they'll say no, like it was a lot for not a lot. No, these patients are like over the moon. Thank you, doc. I feel so much better. Now I can do this. Okay, now I can play pickleball. Yeah, I have to take a little Advil first, but like, I can do things. I and many other doctors help make life livable. And what is life if you're constantly miserable? A lot of erectile dysfunction in a lot of young guys. Yes. More and more, I am seeing 17 year olds in my clinic telling me that they have erectile dysfunction. And what makes the visit tricky is their mother comes with them. I mean, I guess technically she has to because they're under. I don't think she has to, but it's very understandable. But like talking about their masturbation habits gets a little tricky with their mother in the room. I've never seen anyone talk about masturbation more comfortably than renalic after renalic. Well, let me try to live up to that bar. She says a high bar. Yes, she does. Why? Why is this happening? So, okay, I don't think we can prove causality, but what we know is that in the early 2000s, wifi and social media became, you know, ubiquitous. And now we can all stream anything we want on our phones anytime. And so my sexual education, when I was younger, when I was 17, my mother gave me the our bodies ourselves book. I did not know my goods. I did not know anatomy. I knew nothing. In fact, my mother taught humanities and on the cover of the humanities book was Michelangelo's David. And I remember hearing all these jokes about size matters. And I was literally like, he has such a small penis. I thought they were supposed to be big. I didn't know when an erection was. I was 17. So all of that is a plug for better public health education on bodies. They really don't know. And now you take that same setup where we have young people with no education of other bodies and their parts and how they work, except readily available pornography. And so like, you know, they can access it, they access it all the time. The data shows that people are accessing pornography at quite high rates, even in their use. And I had the genesis of this thought project was like an endocrinologist told me the same thing. I'm having a lot of 17 year olds come in, they want testosterone testing because their penis isn't working. And then they get sort of filtered to me that obviously pediatric urology was like, we deal with congenital deformities, we don't talk about sex. Could you could you do this? And I was like, well, talking about erectile dysfunction in a 17 year old is slightly different than a 65 year old, like long standing married man who's had sex for a long time. It's far more delicate of a conversation. The thing is, if we go back to operant conditioning, you remember Pavlov's dog, right? So yeah, so Pavlov would ring the bell and feed his dog. And eventually he would ring the bell and the dog would salivate because it triggers the response. So young people are operant conditioning their body to like the most intimate touch that they know and visually stimulating themselves for what I would call like Las Vegas or Disneyland style sex. It's just so much stimulation, so much activity. It's a lot. It's like sex cubed in on steroids. And that is the expectation. And so then I see, then after masturbating constantly and using pornography, they have a real life girlfriend who had, you know, hasn't had intercourse and is new. And they try to engage in what is real life intercourse. And they don't get the same level of stimulation, obviously, that pornography or their hand, which knows exactly where they like to be touched. We're all awkward in the dealing. We're all figuring it out. And so of course, they can't get an erection because it doesn't stimulate the same, you know, pleasure centers in their brain, etc. And they're conditioned to need that. It's kind of like, I say to patients, if you had a foot fetish, right, if shoes really did it for you and you secretly watched shoe related pornography every day of your life and you were married, and then your wife came in in like bathroom slippers and a bathrobe and said, honey, you know, it's date night. That's not the same. That's not going to turn your crank because over and over, you've conditioned yourself to want stilettos or whatever the case may be. For young, you know, 17 early 20s, is this a, again, a reptile dysfunction? Are we looking at diagnosis of exclusion or how as someone is listening to this or if a mom is like, okay, I have to have this conversation. Is there any amount of porn that is acceptable? Matt, the other videographer you met was saying that 78% of men are watching porn. How do we begin to make sense of all of this when we think about just the landscape of healthy relationships? That is a big question. No pressure. Far beyond my pay grade, but I do have two young sons and I do think about it. The only problem I have is with it being the first, you know, first entryway to people's sexual life. It's just not, it's not a gateway drug as the course would be. It'd be like doing heroin off the bat. I feel like the, and I don't know how we recreate natural progression of sexual experiences when this visual intense modality is so readily available to young people. We're entering a new landscape. It is evolving medicine in a way we're not, I think, again, just, we're not keeping up with it. We're not able to keep up because instead of, you know, your kids going to some friend's house to, I don't know, play Mario Kart, they have access to YouTube. They're playing these games that are totally outside the scope of what should be available for young brains. And then subsequently are having a rectile dysfunction who knows what the young girls are thinking is normal. And it's just skewing. It's not enough to say that it is just dangerous because of the predatory nature. But I think that again, I was recently in Germany, and I was talking to this athlete, and he was telling me about his story. And one of the things that he said is that he was exposed to, knew he kind of had a come to Jesus moment per se. And he said, one of the things that really struck him was that when he was 14, he was exposed to pornography. And this then had implications throughout his entire life that then in his late 20s, early 30s is going, you know, this, that changed everything. I don't know how much we can shield people. It's just out there. I think educating is important. I had the sneaking suspicion because in the beginning I would see one 17 year old a year. And now I see two or three a month. And so I ended up doing a database research project where just you don't get a lot of detail in this. So we can't talk about like causality. Is it porn? What's driving this? But I can say from a national database that the incidence of ED in adolescence is doubling. Like it's rising now. It's very small. It's like the number is less than 1%. But it is going higher. And I think that's driven by pornography most certainly. This episode is brought to you by Manicora Honey. When it comes to your health, it's not usually the big changes that make the difference. It's the small things that you do every day. And one of the easiest places to start is to do simple swaps. And for me, that includes something as basic as the honey I use. I have been using Manicora Honey for years and love it because it's more than just a sweetener. It contains naturally occurring prebiotics and antioxidants. I just had a pack now. So it contributes to your overall health. You'll find it in my routine in practically every single way. In yogurt or fruit, using it when I travel or if I need something quick and easy on the go. They taste amazing. I bring it with me to avoid getting a sore throat and it has other medicinal properties. It's simple. It tastes amazing. And it's something my whole family uses. Manicora Honey is very special. 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Do they have any, you know, paraphernalia kinks that they, you know, quietly engage in but don't engage in with their partner? Like what's different? The other thing I think we should address is sort of the elephant in the room, which is there's a lot going on in the world today and mental health is not super great from a lot of people. And when I was getting together this article on like, all of the causes of erectile dysfunction and everything that could be done, I did this deep dive into MRIs and brain activation. And okay, firstly, Gabrielle, let me just tell you, someone gets paid to watch people have sex in an MRI scanner and watch their brain light up. But what's interesting is there's a sequence of events that happen. And I'm going to like paraphrase loosely for you. Okay. So the first thing is, you know, your hippocampus remembers what is good and what is bad. It's like the memory zone. And so if you have a positive association with a prior person, a prior thing, a shoe, a person, whatever, a position, et cetera, like your hippocampus is going to start being like, yeah, yeah, yeah, yeah, let's do that. And then you're going to do a thing. And let's say, and I like to use like the silly example of, let's say that I really like my index finger stroked, it's just, who turns my crank. So, so, so when you touch the first person ever who I've ever heard that, learn something new, again, no, but it's a joke, you know, so like, okay, so there's the part of your body that registers touch. So this is my right hand. And then, you know, in that portion of my brain that registers sense, the, you know, the sensation of touch. Okay. So that goes up to your cortex and registers touch. And then you have to assign a value to that touch. So deeper in your brain. And I think it's your amygdala, if I recall correctly, but like, it assigns a value and says, like, yes, I like that touch or no, right. So, you know, in one of the episodes in Sex in the City, someone licks her teeth when they kiss and that was a big no. Right. So we all have these visceral reactions and sensations to that. So, okay, stroke my index finger touch. Yes, I do like that. My brain says to me. Now, a key portion of that is your parietal lobe and your temporal lobe, my parietal lobe and my temporal lobe, like not right this second, but often maybe 90% of the day is going, did you put in the field trip forms for your school? Did you get the extra juice boxes? Did you send in that review paper? You know, like we all as busy people have a to-do list or things that we're worrying about and that's carried in that portion of your brain. If you do not turn off that temporal lobe, you will not succeed in sexual intercourse. Like your parts will not rev up. You have to, those parts of the brain get deactivated in order to carry out this activation process in your brain. So, okay, touch it. I like it. Yes, deactivate and then we go down the spinal column. We get an erection or engorgement of our clitoris is the case may be and, you know, now it's party time. It makes sense from, you know, there's this saying that women take a really long time to warm up and I think that men are very good at compartmentalizing and also from a physiological standpoint. It's, I don't know, the wind blows a certain way and he's ready and women are, again, they're parietal, they're temporal lobe or thinking about all these other things. Not to say that men aren't, but... Well, we talk about the mental workload that women carry in the house, right? So, two-hour sex researchers out there, hey, somebody, gender differences in the brain because women do take longer. Yeah. You know, my husband gave me this, I don't know if you've seen this book, it's like, what it's called like porn for, like porn for women and you open it and there's a guy's vacuuming the... I said it, they call it... Fully clothed. No, chore play. Chore play is what it's called. I saw an amazing Instagram where he was like, he threw his laundry on the floor and then he moved it and put it in the basket and the wife's like, totally. The porn industry has it wrong. So, there's the porn for men and then the what women really want. Yeah. Yeah. Disparate. Just want to throw that out there. Can we touch on penile implants? Let's do. You put in penile implants. I sure do. Who qualifies for that? I say this before you answer. Yeah. A woman could go to a plastic surgeon and say... You can just get breast implants. Double D please. Yeah, but those women are paying in a pocket. Tell me about penile implants. Who qualifies? So, firstly, penile implants are very expensive, more expensive than breast implants, I think, although I don't know the exact numbers. The thing is, most people get it covered by insurance. That's where the qualification thing comes in. One is aesthetic, typically aesthetic. So, breast implants are aesthetic. Not medical necessity. Is that why individuals would have to pay out of pocket for breast implants versus... I think that breast reconstruction after mastectomy would probably be covered. Breast implants and not scenario would be covered as medically necessary. Whereas if you're in a cup and you don't want to be, I don't think that insurance puts the bill for that. Similarly, in men, patients who have lost their ability to have sex after prostate cancer treatment, surgery, radiation, etc. Patients who have had long-standing diabetes and their nerves have been ruined and now it doesn't work. Interestingly, even patients who have volitionally smoked their whole lives can get their implant paid for. Basically, if the penis... A smoker can get a penile implant and they determine that it's medical necessity. Medical necessity is anyone who has erectile difficulty and typically has failed PDE-5 inhibitors, so Viagra or C. Alice. They want their testosterone checked to make sure it's not a low testosterone issue. And then, plus I'm right, if they've tried injections or a vacuum device first, and that'll usually get them approved and then they can have a penile implant. And not cosmetic at all. Well, it's functional, right? So the only way they can engage in penetrative intercourse at that point, if their penis doesn't work, is a penile implant. So for the listeners, it's a bit like if you imagine breast implants where I think it was like Bruce Almighty, they have a remote control and you can make them increase and decrease. So you have a pump and it makes it go up and down. The other thing I tell my... I live in a conservative area and there's three pieces to the implant. There's two cylinders that go in the penis like a hot dog and then there's a pump that shifts the fluid and then there's a fluid balloon. So if I act like the implant for you, okay, so here's my cylinders, here's the balloon and it's like a seesaw and I'm the pump. Okay, it's Saturday night, it's go time, all the fluids in the cylinder is ready. Okay, Sunday morning, it's brunch with the in-laws. No, no, no, all the fluid goes in the reservoir. So then you know, you either have an erection or not and that's what it's called, inflatable because it goes up and down. How often are people getting implants? Is this a common surgery? It's a very common surgery. It's common enough that there are people who that's what they do for their career. It's not only discussed that much, I'm aware. No, it's not, except at cocktail parties after people ask me what I do. You know, I think you're very popular. People would really find that interesting. It's sort of, it's both lovable and annoying for my husband because he says he's a computer programmer and people glaze over and then they ask what his wife does and I joke that I should put penis professional on my business card. You know, it's difficult sometimes to have these conversations because there's a lot of jokes that I would be saying and I recognize for the listener or the viewer that they might, those that are not in the medical profession, might find it really offensive. You know, talking about penis jokes, but I could do that all day long. Me too. That's why I signed up for the job. I literally, penis jokes was in the pro column of being a urologist. I mean, it's unbelievable. There's lots of memes that I get because you know, as my husband is in a urology program, sperm, surgical caps, it's a whole thing. All kinds of things. It's a whole thing. Anyway, I want to talk about your red hair. Yeah. Thank you. Before we started recording, you said, listen, Gabrielle, the idea of science communication is really important. And the idea of science communication is really important to you. Yeah. And so part of my attention. Yeah. So part of why I'm here today, I admire deeply what you do, what Rita Malik does, um, Rachel Rubin, Ashley Winters, I've been really deeply inspired by some of the women in my field who have been brave enough to put themselves out there because I think as physicians, we want to help people, but we're not naturally people who seek out fame or really even want that. Like I enjoy anonymity, but I realized that just doing the research or just seeing the patients wasn't enough. I asked Rita Malik one time very early in our careers, why don't I do the YouTube thing? Like what, what, what, what spawns you to that? And she said, in a busy clinic day, I can reach what, 40 people. I can help 40 people. She says, if I post a video, it might get a million views. Like think of your reach. And I wrestled with that for a long time as a private person. And then I got cancer. And so I went from being a busy, active mid-career surgeon with a trajectory for sort of, you know, the top of my field. And then 2.5 weeks, I became a stage four breast cancer patient. And it was the shock of a lifetime. I had no family history. I felt a lump. I got a biopsy. And then it was just like boom, boom, boom, one thing after another. Like not only is it right, it's right left and lumped out. And I was like, oh, stage three right off the bat. No family history. Cool. And then I was praying for no mats, no mats, no mats. And I got my scans and I got the call and that just rocked my world. And I went on medical leave and I took a lot of time to think about what my goals were with time and my life. And they had ballparked me at seven years at that point. Okay, so it was 18 months ago. 18 months ago. So what, but we're got like 5.5 left by my maths. I'm doing very well, so maybe more, but, but you know, you have to plan for the worst. So I thought my goal was to have this storied career as an educator because I am the program director right now at Penn State and I teach residents how to be surgeons. And sometimes that means do better. You are not good enough to operate on a human do better. Like I consider it my job to make them the best that they're going to be before we unleash them. But I was going to train one person and then they were going to train the next and it was going to be like this like dynasty of my surgical abilities. But that's not going to happen now. My time, my time course is considerably shorter. And also it's, it's really tough with all of my treatments to churn and burn in the same way I used to. So I regrouped. I thought about, I took stock of my skill set and this very hard earned medical knowledge, a decade of practice, seven years of surgical training, four years of medical school. Like I'm not just someone who should just poof and never do it again, right? That would be a shame. I did consider it. I mean, people consider just, you know, hauling off to Bali and doing whatever they want with the finite time that we all have. I definitely thought about that. But I think that fundamentally helping others has always brought me joy. And when I thought about the people in chronic pain, which I had always had deep sympathy for how they were normal, young 20, 30, 40 year old guys. And then one day they woke up in chronic pain. And now every day, the first thing they feel in the morning is pain. And they can't live their life the way they want to. It's not that dissimilar from what happened to me one day I woke up and my life just like, it was like a bomb went off and I can't live like I used to. I have so many physical maladies and I got catapulted into menopause at 42 and 43. It's just after my birthday. That's the cruelest thing. I got my path on my birthday weekend. And it just radically changed my life. And so when I thought about time and the meaning of time and what do you do with time? Don't get me wrong. I have doubled down on family. I have doubled down on love. I have doubled down on gratitude for the people who help me help patients just are good, wonderful people. I firmly believe that in karma and what you put out in the universe, right? So I'm going to put it as much good out as I can and help as many people as I can. So I got brave. Now the red hair and the sparkle shoes, that's just me. I'm a punk rock girl and I love color and I love vibrance. And I am just not going to be I dressed the part for the medical regime for a long time. Like when we picture doctors, we don't picture you and me. We picture old 60 year old men in white coats, right? But that's got to change because you're awesome and I'm awesome. And so people need to know that, you know, people with muscles and amazing long black hair, like they got this, right? And like people with red hair and piercings, like we got this, like that does not change our cognitive function. That's just the window dressing. You know, stoicism. Typically right now in the space just in general, it's it comes through from a very male lens. Yeah. And that kind of strength that you put one foot in front of the other with a diagnosis that's, I would say most people, you know, I did palliative care in my training. They don't, they don't do what you're doing. You know, I keep hearing that my palliative care doctors and everybody I know keeps telling me like most people don't do what you're doing. I don't know how to be anything else. Like an Olympic athlete, you know, we're seeing all these Olympians on TV. I spend my whole life in pursuit of medicine and being a surgeon and helping people through that. And I can't do it in the same way anymore, but there's so much I have to do to help and so much purpose I have left and I have time. I have the gift of time. Some cancers will kill you quick. I have time. So I'm going to live big. I'm going to love big and dammit. I'm going to go on any podcast, any grand rounds, anywhere, anywhere, anyone is going to let me talk. I wrote a book or I'm writing a book. I started a YouTube channel to teach surgery. So I thought, okay, I can't be in the OR all the time. How do I disseminate what happens in the OR outside the OR? So I started a YouTube channel called surgical basics. And that is not tying and it's how to gown and glove. It's like the basics for medical students to accelerate their learning curve because I firmly believe video podcast is the wave of the future. It's how we all learn now our brains are hardwired for it. So whatever way I can disseminate the chronic pain information, I've picked up the men's health information and even cancer patient advocacy. So as a patient going through this journey, I've learned how much we leave to the patient. You go into an oncology visit for 40 minutes and it is so incredibly medically dense. They have to talk to you about the organ where you have cancer. They have to tell you about the type of cancer you have. Is it a good actor or a bad actor? They have to go through all the treatment options, make a decision. And then there's other things like with me with metastasis, we have to talk about like, should you get radiation or not? Or what are we doing about this? Or how much will this limit your functional ability? I think it's an insurmountable tasks. I think like our oncology team has so much to do. And if we say, I mean, forget that we say the average patient has a seventh grade reading level. I'm talking about me. Ostensibly a person with resources, time, money, and a medical education and MD. Challenging. So challenging. I pregame for my visits. I read stuff. I write lists of questions. I go to my visits. I take notes on my visits and I still miss things. I learned that my insomnia, which was probably like the thing that impacted my life the most after the cancer journey. Was that because of surgical menopause? It was the meds. It's the chemo meds I'm on. The chemo meds I'm on cause insomnia. And my doctor may have told me, probably did tell me, but there was so much else that we talked about. And so for six months, I would wake up like clockwork and I'd play a game with myself to figure out the time. And I got down to 15 minutes. I could guess within 15 minutes, was it 201? Was it 315? Was it 401? And one of my colleagues in the cancer support group used to say, swimming in your mind is a dangerous place. You ought to have a lifeguard because the quiet hours for cancer patients are lonely and the intrusive thoughts come in. And then I watched who's dying for sex. And Michelle Williams told me that my insomnia was due to my drugs. And then I reached out to another cancer patient and she's five years in and I said, does it get any better? She said, I still wake up every night at 3am. So you learn to manage is the answer. I, you know, as you're sitting here, and you're talking about chronic pelvic pain, penile implants, all of the things that people need or suffer from. And what your role is right now, which is to educate, to give back, to be of service. I think there's one more thing. And that's you're an example. What you're up against is, I mean, there's no words for it. It would be very easy to say, you know what, I'm out, I'm going to go away with my kids, I'm going to go on my hobby farm, peace out. But instead, you're like, wait a second, I'm here to contribute. I'm going to do this, I'm going to do this, I'm going to get up and get after it. Have you always been like that? Yes. But to be fair, I do the hobby farm in the kids. I just flip a switch. So, you know, there are, I thought about how to disseminate and then did the YouTube channel thing. And then I've paired with, I want to talk to cancer patients about all the things that we don't get talked about because the visit is so dense, like exercise and nutrition, which, you know, vibes with your wellness brand, the things that we could be doing for ourselves that we don't, you don't always know how to access that information. And actually, I had a hard time accessing it myself, even as a doc at a world-class cancer center. And so, I've started interviewing with oncology times, and that is talking with oncologists and it's for doctors about the other things they could bring to patients. And then I've started with Cura Today doing short form videos directed at the cancer patients to give them the tools and the autonomy to find their best doctors, best treatments, etc. To understand the stuff that, like the insomnia that, you know, you don't always get dealt with. And sometimes a lot of tips and tricks, some of it has come from palliative care, I have a great palliative care doctor. And some of it has come from just my support group. Somebody says, like, oh, this cream really worked for me or, you know, whatever. And so I guess I just, I want to do it all. I can't, I know I can't, I'm really limited in energy now. So I have to be very intentional about my time and my efforts. But let me just say, as I look you in the eye, there is nowhere else I would rather be in this moment than discussing this with you, Dr. Lyon, and helping chronic pain patients find the care that they need. And tomorrow I will turn this off, and I will be digging in the dirt with my sons. Dr. Sue McDonnell, you are extraordinary. Thank you. You're extraordinary. Thank you for having me.