260 ‒ Men’s Sexual Health: why it matters, what can go wrong, and how to fix it

Mohit Khera is a urologist with expertise in sexual medicine. In this episode, he provides an overview of male sexual health. He first goes in-depth on erectile dysfunction, shedding light on its prevalence across different age groups, diagnostic methods, and its intriguing connection to cardiovascular disease. He then ventures into Peyronie's disease, penile fractures, penile enlargement treatments, prolonged erections, premature ejaculation, and anorgasmia. Mohit then delves into the intricate workings of testosterone, DHT, and estrogen, emphasizing their physiological significance and interplay. He explains blood tests for diagnosing low T, the correlation between symptoms and blood levels in cases of low T, and the various methods for increasing testosterone. He concludes with a conversation about the role of testosterone in patients with prostate cancer and addresses concerns surrounding DHT, finasteride, and post-finasteride syndrome.

We discuss:
0:00:00 - Intro
0:01:18 - Mohit’s career path and interest in sexual medicine
0:03:25 - The anatomy of the male genitalia
0:05:06 - The prevalence of sexual dysfunction & impact on quality of life
0:08:58 - Erectile dysfunction (ED): definition, diagnosis, pathophysiology
0:13:41 - The history of medications to treat ED and the mechanisms of how they work
0:18:21 - Relationship between aging & erectile dysfunction and Mohit's approach to treating patients
0:29:14 - The impact of lifestyle on sexual health & the association between ED and cardiovascular disease
0:37:52 - Causes and treatments for Peyronie’s Disease & penile fracture
0:48:32 - The value of ultrasound for ED diagnosis and management strategies
0:51:55 - Various treatment options for ED: injections, penile prosthesis
0:59:38 - Priapism (prolonged erection)
1:05:40 - Shockwave therapy as a treatment for ED
1:11:46 - Stem cell therapy for ED
1:15:48 - Platelet-rich plasma (PRP) injections as a treatment for ED
1:18:36 - Premature ejaculation (PE): prevalence, pathophysiology, and treatment
1:26:34 - Anorgasmia: causes and treatment
1:31:52 - Sex hormones, impact of aging, symptoms of low T, & considerations for testosterone replacement therapy (TRT)
1:44:49 - Methods for increasing endogenous testosterone
2:00:03 - Testosterone replacement therapy: various forms of exogenous testosterone & weighing risk vs. reward
2:11:03 - The physiology and purpose of testosterone and DHT, why some men feel fine even with “low” testosterone, personalized approaches to treating low T
2:18:25 - Post-finasteride syndrome
2:26:42 - The role of testosterone in prostate cancer and addressing the notion that TRT could increase risk
2:38:29 - The effects of testosterone as an adjunct to therapy for estrogen-sensitive breast cancer in women
2:40:08 - Resources for those looking for healthcare providers
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About:
The Peter Attia Drive is a deep-dive podcast focusing on maximizing longevity, and all that goes into that from physical to cognitive to emotional health. With over 60 million episodes downloaded, it features topics including exercise, nutritional biochemistry, cardiovascular disease, Alzheimer’s disease, cancer, mental health & more.

Peter Attia is the founder of Early Medical, a medical practice that applies the principles of Medicine 3.0 to patients with the goal of lengthening their lifespan and simultaneously improving their healthspan.

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In this episode, we discuss:
0:01:18 - Mohit’s career path and interest in sexual medicine
0:03:25 - The anatomy of the male genitalia
0:05:06 - The prevalence of sexual dysfunction & impact on quality of life
0:08:58 - Erectile dysfunction (ED): definition, diagnosis, pathophysiology
0:13:41 - The history of medications to treat ED and the mechanisms of how they work
0:18:21 - Relationship between aging & erectile dysfunction and Mohit's approach to treating patients
0:29:14 - The impact of lifestyle on sexual health & the association between ED and cardiovascular disease
0:37:52 - Causes and treatments for Peyronie’s Disease & penile fracture
0:48:32 - The value of ultrasound for ED diagnosis and management strategies
0:51:55 - Various treatment options for ED: injections, penile prosthesis
0:59:38 - Priapism (prolonged erection)
1:05:40 - Shockwave therapy as a treatment for ED
1:11:46 - Stem cell therapy for ED
1:15:48 - Platelet-rich plasma (PRP) injections as a treatment for ED
1:18:36 - Premature ejaculation (PE): prevalence, pathophysiology, and treatment
1:26:34 - Anorgasmia: causes and treatment
1:31:52 - Sex hormones, impact of aging, symptoms of low T, & considerations for testosterone replacement therapy (TRT)
1:44:49 - Methods for increasing endogenous testosterone
2:00:03 - Testosterone replacement therapy: various forms of exogenous testosterone & weighing risk vs. reward
2:11:03 - The physiology and purpose of testosterone and DHT, why some men feel fine even with “low” testosterone, personalized approaches to treating low T
2:18:25 - Post-finasteride syndrome
2:26:42 - The role of testosterone in prostate cancer and addressing the notion that TRT could increase risk
2:38:29 - The effects of testosterone as an adjunct to therapy for estrogen-sensitive breast cancer in women
2:40:08 - Resources for those looking for healthcare providers

[HARRYSANDHUTEAMBOSS]

You conduct the best interviews - you let them speak - you interject for the viewer clarity - you ask the right questions - you rarely miss any key points.

Master of your craft, Pete.

Thank you

[christykirkendolwatsonm.d.]

As a physician in the TRT/HRT world this was phenomenal and changed my practice! SOOOO much information. Keep more like this coming!

[charleneshaver]

As the wife of someone who has recently developed Ed, this is gold! It was a great way to help my husband. He watched the podcast, and it is helping guide us through the interventions with his urologist. We never would have known where to look for help! Dr Khera explains everything is such a calm reassuring way, that it really put my husband at ease. He had talked to the NP at our PCP's office, who presented all the options in a much scarier way, not intention, I'm sure but my husband was convinced, "I'm getting old, this happens to everyone and why bother." Such a same bc we've always had a healthy robust sexual relationship, and now bc of this information, there is hope. Thank you both Dr Attia and Dr Khera.

[rethinktestosterone]

More conversations like this are needed! Well done Dr. Khera and Dr. Attia!

[GarySBCA]

Great episode. Your video setup is always top notch but Dr Khera speaks so clearly and concisely and having him on-site took it to yet another level. The interplay between the various hormones and drug treatments coupled with individual situation is so complex it’s mostly beyond the ability of the average patient to make sense of. Even if that was the only thing I took away from this podcast it still would have been totally worthwhile. No one else is doing these kind of discussions at this at this level. Bravo!

[afkVahn]

Post-Finasteride Syndrome (PFS) has utterly destroyed my life. I suffer from genital numbing, penile tissue deformations and shrinkage, zero libido/arousal, ED and other physical symptoms. This has been going on for a years and it’s driving me to suicide because no one is taking it seriously and the suffering is inhumane. Please doctors, I don’t want to be another statistic in this. Help us with raising more awareness, funds and research. It’s so badly needed for all the people who are suffering from this horrific disease.

[AC-nsgu]

Thank you so much Dr. Khera and Dr. Attia for shedding light on Post Finasteride Syndrome (PFS). This condition is devastating and we badly need support. I am a 27 year old man who has been suffering for 4 years and my life has been totally destroyed. I am broken neurologically, physically and sexually.

I’ve spoken to countless men all over the world who are being subjected to inhumane torture as a result of finasteride. I’ve even had a good friend take their own life because of PFS.

[petermartff]

Dr. khera is great at explaining this topic. Very knowldgable and communicative. Great questions by Dr Attia

[kentwright]

Dr.Attia, This is an excellent lesson that is absolutely a residency-level lecture for any physician who treats men. Many thanks for your work!

[randallsample]

Oh, man, the parts of this discussion regarding prostate cancer really hit home. I was diagnosed with a high grade, high volume prostate cancer and underwent a radical prostatectomy about a year and a half ago, at the age of 62 (relatively young for this to happen, and in otherwise very good health). Dr. Attia is absolutely right in his recommendation of surgery. For me, the decision was a no-brainer, very clear. Nonetheless, there is the possibility of biochemical recurrence. If that were to happen, I'd really hope that the principles of the Transformer Trial have become more well known and applied! Excellent episode.

[poostenbrug]

Thank you for shining light on PFS and all your hard work doctor. I myself have PFS and have been suffering for 7 years. Started when i was 22 after only 5 months of finasteride. 0 libido and 0 erections. I was always healthy and exercised a lot. I've started TRT a year ago as a hail mary but still no effect on erections and libido.

[allisa-vilp]

Please help these young men (and old) who are suffering from PFS (Post Finasteroid Syndrome). It is so tragic and life changing. It reminds me of damage that can result from benzo withdrawal. Please please use your platform to shed light on this. (Oh just saw you discussed this later in the broadcast, but more is needed)

[Snapkrackpop]

Dr Khera is has been my doc for a few years now. He really is one of the best MDs out there. He has been treating me for hyposexual desire disorder. I’m thrilled to see him in this show as a guest.

[supermellow]

This is one of the best, most informative podcasts I’ve ever heard.

[monroetinker]

Great episode thank you for this information. I worked primary care as an NP for over six years and I can't tell you that males have an extremely difficult time talking about sexual issues in general. Just getting patients into the office to control diabetes and hypertension let alone a annual physical is a challenge itself. Ty Dr. Attia.

[RachelE.Goodman]

Fantastic conversation - its missing and needed! For clinicians also!!! I hope Dr. Khera is teaching therapists and other health professionals.

[aaronbailey]

Ok, this is really crazy. In 2017, at age 35 I started having ED issues. 2 years later I had a massive heart attack. This podcast should’ve happened 6 years ago! 😆

[ethanbaggoo]

Thanks for putting a spotlight on pfs - many of us sufferers appreciate it greatly

[davidgrimes]

Mohit was a fantastic guest! Just his smile is contagious! 😃 I also loved the discussion about PFS. At this point I think the most important question for any patient to ask a new physician is: what non-consensus views do you hold and why. If they can't come up with anything move along!