Sex, Intimacy, & | Jeffrey Albaugh, PhD, APRN, CUCNS |

[00:00:09]Hello, welcome. I am so glad you have taken time out of your busy, miraculous life to be with us right here, right now to learn more about intimacy and relationships so that you can love better and live better with your life.

[00:00:25]My name is Dr. Dr. Jeff Albba and I am here for one simple reason, you. To help you get the information you need to make informed choices and to have a better relationship and improve your sexual health. No hidden agendas. That's why I'm here. So, uh I am excited to share this information with you and let's get going.

[00:00:51]All right. Well, first off, I have definitely um I have definitely worked with patients for many, many years. I've had the pleasure and the honor of helping many patients uh at Northwestern Memorial, Northshore Endeavor Healthcare, and at the Jesse Brown VA for over three decades. So, I've worked with lots of patients who have shared the most intimate details of their life so that we could help them have better sexual health, live and love better.

[00:01:22]That is really my only goal. So, I'm just here to share that expertise with you as well. My patients are amazing and uh I really feel it is an honor and a privilege to help them. And so, uh they've come up with quite a few nicknames for me. A lot of people who uh come to hear me speak like when I talk about the different things they call me, but of course this one's not too big of a shock. Um they've come back to me say, "Dr. Dra, you know what we call you? We call you Dr. Love." That's a good one.

[00:01:49]They call me Dr. Love. I can go with that. Um sometimes one group came to me and I love this one. Um it was interesting and they said because of the work I do, uh they said, "You know what they call you out in the field, Dr. Alba? They call you the penis whisperer." And I said, "Okay, I can claim that. I can understand that. That makes sense." Basically, it's like trying to get things moving back in the direction they really need to move. So, without further ado, why are we even here to talk today about any of this?

[00:02:22]Well, we are here for several reasons, and that is cuz we all need connection with others. Do you think that's true?

[00:02:29]Can you just isolate yourself and live in your own little bubble? Yes, that is totally totally possible. But you are hardwired for connection with other people. You might know Daniel Gleman from his from if you've ever heard of emotional intelligence. Daniel Goldman literally wrote the book on that. He wrote a second book and he pulled all the research together on it. He followed it with another book called Social Intelligence. And what he found with that research was that every single one of us, you, me, Dr. Moyad, all of us, we are all hardwired for connection to others. It's not optional. What happens to babies if they don't connect to another human being? They literally die.

[00:03:16]It's called failure to thrive. Make no mistake, we are hardwired for deep connection with other human beings.

[00:03:24]If you remember back in school Maslo's hierarchy of needs Abraham Maslo amazing work and when we look at that love and belonging so we have basic needs food oxygen basic needs love and belonging is another basic need it's not like self-actualization it's a very basic human need so all of us need to feel love and belonging and we're hardwired for connection with others so we all crave and need deep meaningful connection.

[00:03:57]We all and when they've done research, Bnee Brown's done a lot of research around this and she said what people want more than anything else is deep meaningful connection with others. But she also says from her research, what people are most afraid of is deep meaningful connection with others. So we're most fearful of what we most need and want. So we shield ourselves because vulnerability as Dr. Bnee Brown says is the only path to love, to belonging, to creativity.

[00:04:30]We shield oursel because vulnerability is the path to sadness and hurt and other emotions that are harder to sit in. But it is literally the only path.

[00:04:40]Vulnerability is the only path to love and creativity and relationship.

[00:04:48]Well, I have to share with you. You all know everywhere you look out there, sex is everywhere. It's on billboards. It's on TV. It's it's all over the place. So, is that true? Yes. And when I was up in Michigan visiting, Dr. Mark Moyad gave me these two bottles of wine. One is called safe sex and one is called sex.

[00:05:08]Even the wine bottles have this information there. But my point is here, even though sex is everywhere you look, you see things with sexual content all over the place, often times sexual dysfunction is not spoken about, is not talked about, is not dealt with. So that's why we're here today to talk about intimacy, relationships, and sexual function.

[00:05:34]Those are things that are often not talked about, and there's many misconceptions about what's real and what's not real. I don't share with you information that's my opinion. I share with you information that's researched or evidence-based, scientificbased.

[00:05:49]That's my goal is to give you what you need to make informed, empowered choices about your intimacy and sex life, whether that's after prostate cancer treatment or for whatever reason you have sexual dysfunction, you or your partner. So, let's start with some definitions. What is sexuality? Okay, first off, there's a certain part of sexuality you're born with, the chromosomes that give that sense of um more male or female. It's multi-dimensional. There's lots of different dimensions to it, but it changes as we move along. That's really important. So what you believe sexuality is as a 5-year-old or understand it to be is very different than what you believe or understand it to be as a 25year-old or a 55year-old or an 85year-old. So it changes it's dynamic and it's culturally derived. People use the average year that a p a person loses their virginity in China is completely different than the average year that a person loses their virginity in the United States.

[00:06:55]religion, culture, everything out there influences sex and sexuality and intimacy. I tell my patients, we're going to go through a lot of questions.

[00:07:05]Please bear with me. But everything can affect sex and sexual health. And so many many things affect that. Some people think of sexuality as the collective characteristics relating to sex and love. So that's sexuality. But when we talk about sex in this talk, we're speaking of genital and body stimulation for pleasure. It may include oral stimulation. That means uh using your mouth, manual stimulation using hands or vibratory stimulation and or it may also include penetration like intercourse. So it may include p penetrative things. But we say sex is any kind of genital stimulation that involves pleasure pleasuring each other and um is this the real purpose of that is pleasure. So that's what we call general stimulation. It doesn't have to be penetrative to be called sex in what we're talking about. Everybody's different. So everyone's needs are different and every person is responsible for their own orgasms. We all believe, oh, it's my job. We get performance anxiety around it's my job to make sure that you have pleasure and orgasm. But here's the truth. It's my job as an individual in the world to make sure that I can get my needs met, that I get to where I need to go with pleasure and orgasms. We're all responsible for ourselves. That removes some of the pleasure saying, "You need to make me climax. You need to give me pleasure. You need to rock my world. I need to ask for and work with you and we co-create this beautiful space where we can have wonderful pleasure. So it it's a group effort but ultimately we're all responsible for our own sexual health and our own orgasms.

[00:08:57]Now intimacy is really important too.

[00:08:59]Intimacy refers to a deep and meaningful connection and that's characterized by emotional closeness, trust, really important and mutual understanding. And this is where you feel truly known.

[00:09:13]Truly known. Truly accepted and truly valued.

[00:09:18]That's really important. You feel known.

[00:09:22]You feel accepted. You're seen. And you're valued. That's connection.

[00:09:27]That's intimacy.

[00:09:31]Hatfield says intimacy is a process by which two people attempt to move towards complete and total communication on every level. That's really important because that means verbal communication um non-verbal communication on all levels we feel deeply connected and we have complete communication using all those avenues. So a couple's fighting I want you to think about this for a minute. When that couple's fighting, they're not speaking to each other. Can they have sex?

[00:10:03]Yeah. You don't have to speak to each other to have the act of sex. Can they have intimacy?

[00:10:09]No. These are two distinct concepts that work together and they're both really important to to think about when we think about our sexual goals and our sexual health. Intimacy cannot be done if you're not speaking to each other on a basic level. You can't have communication on all levels and on a meaningful, profound level where you feel known, accepted, and valued.

[00:10:34]Intimacy is just as important as the sex piece of it. And we'll talk more about that. And when patients come see me, what they're seeking is more connectedness, more meaning in the relationship. And that's the intimacy part.

[00:10:50]So, we're going to talk just a little bit about couples relationship. There's so much to say about it. I was trained uh by the Gottman Institute as uh for couples therapy and then I also trained with Andrew Christensen who does integrative behavioral couple therapy, IBCT. So, you'll hear some of that research. Everything I tell you is researchbased coming through with what I'm saying. John and Julie Gottman studied over 3,000 couples for over 30 years. They have done amazing research looking at what do couples do, what works, what doesn't work, what leads to divorce, what leads to staying together.

[00:11:29]And they found this house model that I think you'll find really helpful. The foundation of your relationship house, this is your relationship, your sound relationship house, that great relationship. the foundation, what it's all built on is a friendship. It's built on a deep, meaningful relationship, and that's a friendship. That means uh a lot of things to a lot of people. I know my wife and I before we got uh to dating, we were really good friends. We were dating other people. So, definitely our marriage of 40 years is built on a solid friendship.

[00:12:08]Love maps are just exploring and and looking curiously at who your partner is, what they're doing. Even though you may think you know everything about your partner, you can never know everything.

[00:12:20]So, um, the Gottman Institute created these love maps to ask questions of each other. You know, that you may or may not know the answers to. Who today do you really admire and want to be more like, for example, but there's so many different questions. So building love maps and then sharing fondness and admiration. You should be deeply fond and admirable of your partner. So we do exercises to work on and build that in couple therapy to enhance that foundation, that friendship.

[00:12:52]Turning towards means what happens when your partner tells you something or walks in the room or or wants your attention for some reason. Do you turn towards them or do you turn away from them? Do you turn or do you look out of your phone or your screens and towards your partner? Do you respond to them? Do you engage with them? That's turning towards and that's very helpful in a relationship. Turning away is being engrossed in something else or ignoring that person that can lead to problems.

[00:13:24]And so turning towards is another thing that builds up that friendship. And then that overall positive perspective that no matter how much my wife and I disagree, I believe she is one of the most amazing, beautiful human beings in the world. And I believe our marriage is incredibly important. That there's overall positivity. Cuz what Gottman found was it's not the negativity negativity that destroys a marriage.

[00:13:50]It's the lack of positivity that destroys a marriage. there's nothing there to fight for because the positivity isn't there. So, building that foundation of positive perspective and a solid friendship is what your whole relationship with your partner is built upon the house. So, that's the foundation, the friendship. The house is conflict is inevitable.

[00:14:16]Make no mistake about it. Conflict is inevitable and conflict. So, what are you going to do? You didn't marry yourself. I wouldn't want to be married to myself. You married someone different and that makes you deeper, richer because it gives you two really distinct perspectives or paradigms that makes you stronger and better. My wife is incredibly detail- oriented and I'm a big picture person. But now we get the benefits of when because of our relationship sometimes the detail is what saves us in a rel in a circumstance and sometimes the big picture. We get both perspectives because we're different and we see the whole world through these different lenses that make us stronger and better. So, learning how to manage conflict is what we spend a lot of time on in couple therapy and that is a Gottman technique and it's really important to manage that conflict as it arises and deal with it and don't just let it fester and sit. So, that's the house. The foundation was the friendship. The house is managing conflict. The walls super important are trust. Trust and commitment. Trust that we that I believe in you and I and I and I trust our relationship and I trust you. Sometimes that can be challenged and difficult. People come in with fidelity and lack of trust issues. And that's that's a certain thing you work on in couple therapy. But trust is the walls. The walls that hold up the roof to your soundhouse relationship.

[00:15:44]Commitment is the other thing. If you're always dangling, now of course there are reasons you should leave a a a relationship like if you're being abused, especially there's domestic violence or interpersonal violence is never okay. It doesn't matter who it comes from, male, female, non-gender, it binary, it is never okay. But so commitment is really important, too. I'm not going anywhere, but I'm also not going to continue to tolerate this situation. We will have to work this out. So, commitment and trust are the walls. And last, the higher level thing is creating meaning. Meaning is a huge deal. Victor Frankle literally he had hidden in his coats his research about how important meaning was when he was uh thrown into Ashwitz in Nazi Germany. And he kept, you know, it it was, of course, they they took everything away from him, but he continued that research after he came out of the most horrific circumstance to say, "Hey, even under horrific circumstances like I went through, meaning is everything in life.

[00:16:54]So creating shared meaning is a really big deal." And that's the upper level, sort of the attic of our soundhouse. So the f foundation is friendship. The house is managing conflict and learning how to navigate disagreements and differences. The walls are trust and commitment. And the addict is creating shared meaning. Okay.

[00:17:16]So Masters and Johnson did this incredible research way way back in the 1960s. We would never be able to replicate it because it's very sensitive. It starts with excitement.

[00:17:27]It's like a desire, an excitement um is where it begins and that builds it. We have tactile sensation where I feel more on the skin level. We have increased blood pressure. We have increased pulse increases in all these things that build towards excitement. Now, we don't want that to go on forever because we want it to plateau. We don't want our pulse to keep going up, our sensation to keep going up. We want it to plateau, which feels really good. Now we're in this space where everything feels so fabulous and so good and then orgasm occurs which is sort of like um orgasm leads to that feeling of satiation or resolution. Now you see a little problem here when they timed it for men start to finish was about 2.8 minutes without delaying it in any way and for women four times longer 13 minutes. So when males and females are partnered together and um in in those type of relationships they have a man has to be very cognizant that foreplay focuses on a female. These are generalizations and this is most people not everybody. Everybody's different. Know who your partner is. But so it takes a woman four times longer.

[00:18:37]So foreplay should focus on that partner more who's going to take longer so they're on the brink of orgasm or close to it before we even start other things on the other side. So we can time that a little bit together in terms of timing those orgasms simultaneously or close together. So but you see a little problem there. Why? Because the clitoris and the penis internally are very similar organs. So the the structures inside the clitoris, the the erectile cylinders in there, the blood flow into there, the smooth muscle are almost identical in the clitoris and the penis.

[00:19:16]DNA turns one into a clitoris and one into the penis, but the clitoris is more internal. So you can imagine it's going to take more work to cause a climax on something that's mostly buried underneath versus something like the penis that is more external and easier to get to and stimulate in ways. So that's part of why we believe that there's a disparity between how quickly and how slowly um males versus females climax. Okay. So here's what it looks like in the model. It starts with desire. Then I'm really being aroused by your touch, by what we're doing together, by stimulation of genitals and breasts and wherever feels good. We hit plateau orgasm. This second line is the female who can be multiorggasm uh multiorggasmic and then resolution.

[00:20:10]So that's what we're talking about here.

[00:20:12]That is the uh sexual excitement response cycle. This is for men and women both. But this is primarily even though the slide says it here. This will keep you on your toes. This is more of a maledriven model because um it really has to do a little bit more with the men. And I'll tell you why uh on this next slide that's so important. Okay.

[00:20:34]Rosemary Bassan, this is a researcher's nightmare. When she went to do her research, you're supposed to use a model. She used this model from from and applied it to females. That's why I put female on top of it. She tried to apply that to women and a over a third of the women that she started interviewing said, "It doesn't start with desire."

[00:20:56]See how it starts here with this model?

[00:20:58]It doesn't start with that for me. So, Rosemary Bassan, this is a researcher's nightmare. She's like, "Are you kidding?" Okay. So, she said, "I need to see what's going on with this woman, these women." And this can happen with men, too. But she created a really incredible model that she found because that's over a third going towards half of people especially women and these were in her study it was women said it doesn't start with desire for me. That's not how it starts. What they said was it starts with emotional intimacy. It starts with remember how I talked about connection. It starts with connection.

[00:21:40]Engage with me. get my attention, get cause emotional intimacy, which is I feel seen, heard, and valued. And then that motivates that sexually neutral woman to be like, "Okay, I'm into this."

[00:21:55]You start to kiss. We start to embrace.

[00:21:58]We start sexual stimulation. And then that leads to, "I'm becoming aroused."

[00:22:04]The vagina starts to moisten and widen.

[00:22:06]This is what happens during arousal. The clitoris becomes engorged. the penis becomes engorged. This is what's happening. And then way over here after arousal, we have arousal and desire.

[00:22:20]This is called response of desire. Now I'm like, "Yes, now I want to continue.

[00:22:25]This feels so good. I want to continue on with it." And then we have more emotional and physical satisfaction. I feel connected to you and more emotional intimate. And now it goes round and round and round. So, it's about connection. And I really find this model valuable when I'm working with my patients because where did it fall apart? And for some of us, it's not this hormonal desire that we see here. That desire, that hormonal, oh my gosh, this need I feel I feel a need for sex. I feel strongly driven for sex. Of course, that can be present in men and women definitely. And remember, women have a tenth of the testosterone. Men do. A tenth. And that's before menopause. But both can have very strong that lustful desire. But responsive desire is something that comes about from interaction, engagement, and connection.

[00:23:19]That's important. So as we get older, responsive desire becomes more and more prevalent in men and women. Um, and so it is an important concept to understand.

[00:23:30]So, when we're talking with our prostate cancer patients in particular, uh, with this with the PCRI, why is it so important to talk about sex, intimacy, and and all of this stuff? This is why radical prostatectomy outcomes. And these are studies. Now, remember, studies are expensive, so they're not going to keep doing them over and over, but these are some landmark studies that were done. Um, and you see in this first one, which was pensen at all, and that was 2008. It was a five-year study. They found that 78% about eight out of 10 men at 2 years after treatment reported difficulty getting and keeping erections. That's what erectile dysfunction is. Difficulty getting or keeping erections for sexual stimulation or sexual activity. And then now we look 5 years later, 72% were still struggling with erectile dysfunction, difficulty getting and keeping erections. This is when they ask patients directly and that's the only studies I will quote you, not studies from providers or anybody else. Studies that are patientbased and patient focused. When they asked you, the men with prostate cancer, this is what they found. That's astounding because when you look in the research, if you look it up on AI or wherever you want to look, look it up, you'll see how prevalent is erectile dysfunction with prostate cancer and you will see 0 to 100%.

[00:24:58]That's why depending on how you define it, depending on who reports it, but all I care about is the men who experiences experience erectile dysfunction. What do they report? And that's what these studies are for. Anyway, that's a big study with like 1,300 men from all over.

[00:25:14]And that's what they found. So then this other study was done, Resnik, and this was 2013. So that's like 5 years later.

[00:25:23]These are some landmark studies. And they found that erectile dysfunction in men after radical prostitctomy almost the same numbers, 78 to 87% at 2 to 15 years after after their prostate cancer treatment. Here's an another study. It's the prostate uh prostate test for cancer and treatment trial in the UK. So looking at the in London, greater than 95% of the men were struggling with erections right after surgery because right after surgery is when it's the worst because they had to pull the nerves off the prostate to get it out.

[00:25:56]There's no other way to get it out. They have to peel the nerves off the prostate. They dissect them off and even when they preserve them perfectly, they were never meant to be touched. they become traumatized and they're not usually working well in most men right after surgery and you see 95% of those men said that and then 85% 6 years after the radical prostctomy said that too. So and this is a study that uh that you see from 2022 when robotic prostctomy robotic prostatctomy did not change the fact that they have to dissect your nerves off the prostate to get it out.

[00:26:32]There's no other way to get it out if they remove it. So radical prostatctomy involves dissecting the nerves off. And this is why this is so important for these men in particular and you if you're one of those men.

[00:26:45]What if you do radiation therapy? Well, here's again that study from the UK showed 74% that's still most of the men had erectile dysfunction. And you look at that way out after surgery. So, so radiation therapy also when you look immediately radiation therapy causes a slow erosion of the nerves and the problems with erectile dysfunction. It's not going to be immediate whereas radical prostatitectctomy is immediate.

[00:27:14]So, um remember that that's really important to understand. So, we want to compare two or more years out when both in both cases you're going to see problems. So they usually compare in studies two or more years out because that's where we've kind of evened what's really going to happen long term from radical prostatectomy where it's terrible right away and gets better over the first year or two and radiation therapy where it's okay right as you finish radiation therapy and it gets worse over time. So we like to look two years out at what's happening in erectile dysfunction to know longterm what are the effects and the number one complaint after surgery is erectile dysfunction difficulty getting and keeping erections. What if you do androgen deprivation? Lots of things.

[00:27:59]Not only does it affect your libido, but it can also affect erections. It can affect testosterone works all over your body. It can affect your mood. It can affect your energy. It can affect your concentration, your muscle max. muscle mass, many many things. So all that to say that the most common side effects of prostate removal, prostate radiation or hormone ablation ere is erectile dysfunction. So the number one issue is sexual side effects when you have prostate cancer treatment with radical prostatctomy in particular.

[00:28:36]That's different from focal therapy, but removing the full prostate, prostate radiation, full gland radiation because there's also focal radiation or hormonal ablation. Any of those things cause erectile dysfunction in the majority of men. Ejaculation doesn't typically occur when your prostate's been removed or fully radiated um because the ejaculate comes together in the prostate and is expelled, stored, and then expelled from the prostate when you ejaculate. So, there's another little gland in there, but when your prostate's gone, that other little gland is the only thing producing anything remotely like what you ejaculate. Um, so mostly ejaculation doesn't really occur after you've had your prostate removed. Certainly completely removed, it doesn't occur.

[00:29:26]Um, there's one little gland that may cause a little bit of fluid to come out like that. You may leak urine. That's called climacturia. But the ejaculate that used to be there doesn't happen when the prostate's been completely removed. And neither when it's been really radiated the whole prostate. It doesn't you don't usually ejaculate much or you may not ejaculate at all. The tiny copper's gland may put a little ejaculate and it can even hypertrophy.

[00:29:51]That means enlarge and you may ejaculate some from that but in general ejaculation changes so fluid doesn't come out. The penis may seem to kind of disappear up into the body. It's like the turtle's head. It sort of retracts, which is a really weird, scary phenomenon for most men. And so, if that's happening to you, it's not unusual. It's because of increased muscle tone right after surgery. The muscles sort of tighten up and the penis sort of pulls in. It does relax and resolve somewhat in men sometimes as they start getting erections back if they start getting erections back because that causes muscle activity and blood flow. And muscle activity and blood flow means exercise inside your penis. And when it doesn't happen, muscles can atrophy or shrink that means shrink.

[00:30:40]Muscles um and and the blood flow and stuff it will change things. So blood flow is affected, nervous conductions affected and muscle structures are affected within the penis. So these factors impact how how a man feels about himself and how he interacts in his intimate relationship. and it really can affect quality of life. Now, some men may not be sexually active anymore and not care about it anymore. That's perfectly fine. If it's a not a problem for you, that's not a problem. And that's okay. If sex is not the highest priority or even a priority at all, that is okay. If that works for you and your partner, there's nothing wrong with that. But if it is for you or and or your partner, that's when it becomes really challenging.

[00:31:26]So, we have lots of different therapies out there. I'm just going to briefly touch on these because we could talk about them forever, but I wrote a book on it called Reclaiming Sex and Inimacy.

[00:31:35]And the second edition is completely available for free to download. And I'll tell you how to do that as we finish up when I get to resources. But that will tell you the good, bad, and ugly of all these therapies. Um, but I'm just going to hit on a few things with them for now. And so, first of all, I think what's really important for you is to uh for most couples that I work with and most men or or with or without a partner, and it's a very different landscape to navigate when you have no partner versus when you're in a long-term relationship or a relationship a lot of times. And if you're listening partners, you're living every step of this with that that that your partner with prostate cancer. you are living it and kudos to you because you go through each piece of it. We always say in the group that I run at Gildas Club, the zero prostate cancer group that I run at Gildas Club, we always say I don't know who it's harder on, the the the patient or their partner or the people who love them. It's hard on everybody. But um so what are your goals? Intimacy is about communication on all levels. So a lot of times we don't know how to communicate about about sex. the the extent of our vocabulary are grunts or ah yeah that's not a conversation and usually the conversations don't happen in the throngs of intimacy or during sex but they can happen and should happen outside of there where you talk about I really oh gosh I am so enjoying our sex life um I just was thinking to myself wouldn't it be fun conversations around it you'll never get comfortable communicating about it unless you start communicating ating about it. So, communication on all levels and connectedness is what intimacy is about.

[00:33:22]Do you want intimacy? It means you have to be able to communicate on all levels.

[00:33:26]Do you want connectedness? Bnee Brown says connectedness is feeling seen, heard, and valued and not judged by the other person. That's connection.

[00:33:36]Seen, heard, and valued. You can see my my thoughts on intimacy mirror very closely with her thoughts on connectedness. So, I give her a lot of credit because I love that definition that you feel seen, heard, and valued, then you're connected and not judged.

[00:33:53]If sex is about pleasure and connectedness, there's a myriad of ways of getting there. Trust me, there are so many ways to get there. Men and women can go can both climax or orgasm with or without intercourse or penetration, with or without a hard penis. They are wired separately. The pedal nerve system is more important to orgasm whereas the cavernosal nerve system is what's important to erections. So if it's a blood flow problem mostly and and remember the cavernosal nerves are the ones that they dissect or pull off the prostate to get it out, not the pedal nerves. So most men can still have a good sensation and enjoy that climax orgasm feeling, but they even without any erection because the pedal nerves are intact. They don't touch those when they do your surgery. Typically, they may be slightly affected or altered because they're nearby, but they don't have to be peeled off to get your prostate out in a radical prostatctomy.

[00:34:56]They're not right there that they would be radiated with radiation therapy.

[00:35:00]Sometimes they are adjunctly affected ad agently you know along with things but not directly usually affected. That doesn't mean that people don't sense orgasm different. When you look at the researches how orgasm feels afterwards, men say the most common thing men say is it feels different but it still feels good. The second most common thing they say is it feels similar to what it did before even though I don't ejaculate.

[00:35:29]This is after prostatctomy removal of the prostate. The third most common thing and this is a small percentage only about an average of uh 6 to 10% will say I have a more intense climax or orgasm after surgery than I did before.

[00:35:44]That's a very small percent. Some people say it doesn't feel the same and it's not as enjoyable as it was. It's diminished. That's not the majority of people, but some people say that. Most men I worked with and most men in the study said, "I'm still glad I get the sensation even though nothing comes out, and I'm still really glad I enjoy it, and I do enjoy it." Um, but you could be any of those men. You may, it may feel different. You may be upset about climax. You may be thrilled that it's still there. Um, but anyway, so that's important. There's many ways to enjoy affection.

[00:36:21]connection and pleasure. All kinds of ways to do that. Don't let that suffer because of the problems you're having with sexual dysfunction. First off, it's nobody's fault that you have this problem. It's nobody's fault that you have prostate cancer. It's not your fault. It's not your partner's fault or anyone's fault.

[00:36:41]How can you live your best wholehearted life given these circumstances? Uh that's really what we try to look at.

[00:36:48]So, communication is really key. And you don't get better at communicating about sex unless you start communicating about sex and talking about it. And when something's wrong, it's monumentally important to communicate. Communication is such a important piece of marriage, relationship, um, connectedness.

[00:37:06]Communication is everything. So, it's a really big deal.

[00:37:12]So, we try to help people expand their thinking about sex. It's not just about penetration and erections and hardness.

[00:37:18]It's about so much more than that. There are many, many ways to experience sexual pleasure. Manual stimulation, stroking of the penis, stroking of the clitoris, u rubbing the clitoris and penis together, oral stimulation of the genitals or the breast or wherever it feels good. Um, I would just had a patient, a female patient talking to me in my sexual health clinic. This is weird, but she, you know, she says to me, this is what she was telling me.

[00:37:46]This is weird, but um I feel like I I climax, but it's not from clitoreral stimulation or genital stimulation. It's from breast stimulation and kissing and hugging and and and nothing's going on on the genitals at that time. And that's sometimes how I reach orgasm. And that is absolutely true and possible. It doesn't always have to involved, but it mostly involves pleasuring and genital stimulation on the p penis and the clitoris. But that's not the only way.

[00:38:15]And and um every person's different.

[00:38:18]That's really important. And intimacy, that deep connection is very very important. And some of the excitement comes from what will it be this time?

[00:38:27]This time we took intercourse and penetration off the table and we're just doing other things to enjoy other ways.

[00:38:33]Um what will we do this time? Do we both want to have an orgasm this time or is this time focused more on you or focused on me? That anticipation and mystery and curiosity is so important and play having fun. Fun is highly underrated. Very important.

[00:38:50]Okay. So, there's four major problems according to Gottman when it comes to a relationship that you want to avoid. Who wants to be criticized? Criticism. So, when we're talking about therapy and treatment and couple therapy, these are the four things we try to avoid. No one wants to be criticized. You know, I'm It really irked me when you moved that check off my desk. You always touch that stuff on my desk. Criticism. So, criticism and then expletives like always and never. So, contempt, making it personal. Oh my gosh, I can't believe you did that again. That's something that you It's just all the time I deal with this contempt. Rather than really um treasuring and admiring and believing your partner is the best thing, that contempt comes out. It comes out easily.

[00:39:37]It's hard to avoid criticism. It's hard to avoid contempt. But these are the things that are really destructive to a relationship. Defensiveness. So then what happens is while you're talking, I'm not even hearing what you're upset about because I'm thinking, I don't do that. I can't believe you think I do that. I'm really not hearing. I love this other person. And they're trying to tell me what they're upset about. How can I tune in and be curious about what are they so upset about? If I as if I as desperately want to understand them as they as I want to be understood, we'll get there. That curiosity and that listening, really really listening and not becoming defensive is really important. But we get defensive when somebody criticizes us or we feel like we're being attacked in any way, shape or form. Sometimes even when they're putting it perfectly, we can become defensive. All of us. So then we say, "I won't say anything." That's called stonewalling. That's another problem.

[00:40:31]So, criticism, being critical, contempt, making it personal, making it mean, defensiveness, uh trying to, you know, get I don't do that. [clears throat] What are you talking about? Instead of listening to what's wrong or just listening, which is my wife's taught me over and over, just listen. Don't fix it. Just listen.

[00:40:50]Defensiveness is really destructive. And then I won't say anything at all. That's stonewalling. So this is from the Gottman Institute and I have share with you um where you can go on the Gottman website and learn more.

[00:41:03]So communication is critical but did I tell you how to communicate better?

[00:41:07]Avoid criticism, contempt, defensiveness and stonewalling. So how do you do that?

[00:41:14]You be specific. Forget about who fault, shame or blame. We live in a culture that looks for somebody to blame. forget about it and figure out what can we do to make it right or better. Is it really going to help us to find fault to figure out everybody's faults or and that's just criticism. So be specific, forget about fault and work on fixing problems.

[00:41:38]Move from fault to fixing. Um really important. And then accept and and so also accept some of the blame yourself and fix it. Find a way to fix it. But even when anytime that my wife and I disagree, I always have something that I did wrong in it. I can guarantee you that. And I can tell you I can my wife could list them out for you, but I could list them as well. What I did wrong. And I always try to look at what did I do wrong? Can I own it? And how can I do it differently? But we we remove shame and blame and we look at how can we fix it most importantly and find something to be positive about, something genuine to be positive. You may need to take a time out. A timeout means, you know what? I'm feeling flooded. I'm feeling triggered with this conversation that's getting so heated. Let's step away from it. Let's come back to it in an hour or two. Let's both step away from it or let's uh take a rest from it. Sometimes people will be overnight or a day. Let's process it.

[00:42:35]Think about how we both could come back and be better in this. So, a timeout can be an essential thing, but always have a plan to come back. Don't leave it sitting and festering.

[00:42:47]Use I statements instead of you. You know, you took that check. You always do that. Your mother used to do that. Are you on your medication? You statements get us nowhere. Remember, when you point one finger, all the rest of these fingers are pointing back at me. I And so, you can't say, "I'm really disgusted with you. I feel frustrated when the check is I can't find the check on my desk and I don't know what happened and I really need you to respect that space on my desk and let me know if you move anything. So I statements. I feel this.

[00:43:20]And you can't say I feel you're nasty.

[00:43:22]That's not a feeling. I feel frustrating. I feel hurt. Eye statements.

[00:43:27]The goal of the listener is to reiterate what your partner says. So you better be listening. If you're not listening, we got a lot of problems. We could do a a whole session on this. So, I'm going to kind of briefly move through the rest of this. Be concise. Don't use expletives.

[00:43:42]Oh my gosh, you did it again. And I can cite the other 23 times that you did it.

[00:43:46]This time when the I felt this when this very specific thing happened on this circumstance and I need this from you.

[00:43:55]Be concise. They don't need a dissertation because you can't reiterate back as the listener. You cannot reiterate back. It shouldn't be more than a few sentences when you're trying to tell your partner or loved one something really important. So, be succinct and concise. Watch your body posture. You know, when you start tightening up and stuff, it's it builds tension in the room. Use positive bids.

[00:44:18]That means be more gentle. When you're I know you're upset and you want to tell this to your partner, but if you desperately want to tell to them, we tell you soften it up. Nobody wants that hard ball when you're sending that message. You do this, you do that. It's not going to get you anywhere. I feel this when this in particular happened and it was upsetting to me and I need this from you. So, be gentle. If you can start with something loving, you know, I so appreciate all you do to keep things in order. This is a leadin to the discussion about the check, but you don't want to say, "I so appreciate how order you how orderly you keep the house, but don't say that." And I really want to recognize you for that. I felt really upset when the check. Okay. So, positive, gentle, supportive efforts so that you can really send your message in a way that can be um caught or heard by your partner in a really productive manner. Restate your feelings as softer emotions like instead of anger, what's under the anger, the sadness or anxiety?

[00:45:26]I feel castrated by what you did. Those are strong words. Can you soften it up?

[00:45:32]And then create uh and use an eject button. That's the timeout button. And then taking time out when it's needed and always coming back to it. So those are just a few. We could spend a lot of time on this and and I don't want to do that today. I just want to give you some insights.

[00:45:47]We improve intimacy through connection, through emotional connection, taking time. The greatest gift you can give your partner is your time and full attention. We've all been in restaurants where people were buried in their phones. That is not quality time.

[00:46:03]Prolonged eye gazing, looking into each other's eyes as you speak, increases dopamine, which makes you more attracted and more want to be in relationship with that person. So, taking time, giving them your time and full attention and genuinely showing interest and communicating that in loving ways to your partner. Increasing physical touch.

[00:46:25]Physical touch increases dopamine and neurotransmitters that cause you to want to be more connected and loving with your partner. So, physical touch, actually a 15 to 20 second hug will increase dopamine and neurotransmitters in your brain that make you want to be with that person more. Uh, increasing intimate communication, resolving conflict, and figuring how can we make it better, talking about that, showing appreciation. What do I really what am I grateful? Gratitude is such a powerful thing. What am I grateful for with my partner? acknowledging your partner for something true and real that you're grateful for. And you're going to have to be vulnerable. I said earlier it's the only path. Try something new. That increases neurotransmitters in your brain and increases excitement.

[00:47:12]Something new or different. That can help too. And then making sex a priority. People are like, "I don't want to schedule sex." Well, the only way it happens sometimes in our busy life is to be scheduled into your life. It doesn't mean you have to do it at this exact time on that day or in this exact way.

[00:47:30]You can put all kinds of spontaneity in there, but make sure it happens. I have couples who tell me, "Every Sunday morning it happens. Whether we whether we whether it should or not, we make sure it happens." And I'm like, "That's great." Um, and a lot of people don't think about morning when erections are sometimes a little better, when energyy's a little better, when we're not exhausted from the day. So, my patients give me all kinds of amazing amazing suggestions over these decades that I've worked with countless patients on all these things. Um, the five love languages uh really is Gary Chapman's work and it's you may not have heard of it. Um, and it's not deeply entrenched in research, but um, a lot of my couples find it helpful. So, you can look that up and it'll talk about like words of affirmation or acts of service. Those are two of the love languages. What is your partner's primary love language and how can you speak that into that relationship with them? So there are different love languages. Most people have a primary one, but all five can be important to many people. But what's the primary language and how do I speak love in? Sometimes your love language is different. So you speak love back into that relationship with your primary language, but it's not your partners. So you do these acts of service for them, but their primary one is is not acts of service. It's words of affirmation or quality time together.

[00:48:56]So those can be important. Have fun together. Fun and play are highly underrated and they are incredibly important in relationships and in life.

[00:49:07]Definitely in life. So have fun and play. Play is just doing things. The only purpose is to enjoy and have fun.

[00:49:15]So have fun and play. And we've done I'm going to talk later about the podcast, but we've done podcasts specifically on how to infuse fun and play into your relationship and into intimacy.

[00:49:27]So then we have several treatments that I'm going to briefly go through. And again, you can download my free book.

[00:49:33]You can find out more about these. I try to um lay out the good, bad, and ugly of them because they all have good and bad.

[00:49:39]In the perfect world, you thought it and with very little provocation, there it was, your erection. But in terms of erectile dysfunction treatments, the oral agents by a landslide are the most popular by a landslide because they're easy, they're simple, and we're used to pills. Millions, if not billions of people have used them across the country since they were introduced in the 1990s.

[00:50:01]And they were actually introduced as a cardiac drug to lower blood pressure and help the heart, but they didn't work that well. They slightly lower the blood pressure and they can help with pulmonary um edema in terms of heart, but they didn't work that well as a cardiac drug or an anti-hypertensive.

[00:50:19]But they do have a little bit of those trait those traits. But after the study was finished and they went to collect the drugs back to see were they taking them, how many are left and you know what was left, the men didn't want to give the pills back and they started talking about their erections and that's how these drugs came to be. literally was they were discovered because these drugs were being used for other purposes to help the heart and blood pressure and they found that they actually help erections. So um there's several of them. Selenapil, Venaphil, Teddalapil, Evanapil and my most important thing I would say to you is timing can be important. So um most of them the first three all increase and start getting in your bloodstream in about 30 to 60 minutes but they don't peak for about 60 to 90 minutes in your blood in your body. These are generalizations and so you need to take it about an hour to an hour and a half before sex if you want everything it's going to give you.

[00:51:20]Another thing about these pills is when you've had a surgery right after surgery or you've had uh you're really struggling with erections right after surgery especially they may not work because the communication between your brain and penis is not quite there at that point and may not completely come back and that's why they may not work especially right after surgery but they may but how they work right after surgery may be completely different than how they work 3 months 6 months or a year later. Don't forget, you may need to try them at various times or throughout your course of recovery as you start recovering erectile function and the nerves start recovering, rejuvenating, whatever those nerves are doing to to um recreate that cre creation, that connection between your brain and your penis back and forth.

[00:52:11]Super important because that's how so when men get excited, it's all put together in the brain in the frontal lobe. All put together here, the message goes from the central nervous system down the autonomic nervous system or the spine to the peripheral nerves. That's where the cavernosal nerves surround the prostate. Bund on the right, bundle on the left, and go to your penis. When the signal hits your penis, it it causes the chemicals in your penis like nitric oxide and cyclic GMP to be activated because of that stimulation that you're feeling when you're stimulated with sexual thoughts or stimulation directly on the penis. that causes those neuro those neurotransmitters inside inside your penis those uh important chemicals like nitric oxide and cyclic GMP to be activated so that it causes they cause smooth muscle relaxation and basil dilitation the muscles open up the blood fills your penis and you become hard so to put that together you need nervous conduction between your brain and penis back and forth communication and blood flow into your penis to become come engorged. When it fills quite a bit, it pushes against the veins and locks the blood in your penis and you got an erection. Nervous conduction and blood flow. It's a neurovvascular event. this these pills work on you by blocking this en there's an enzyme called phosphodiestrase type 5 and if we block the PD5 now that keeps nitric oxide cyclic GMP this cascade of things that causes the muscles to relax in the blood flow that keeps that in check so it's like math with a double negative if we inhibit the inhibitor of the chemicals in your penis that make you hard so let me say that again we inhibit the inhibitor of the chemicals that make you hard. Now, we have more chemicals in your penis so that when you get excited, and only when you get excited from sexual thoughts or stimulation on your penis or even better both, you could get harder. That's how the drugs work. But remember, they peel the nerves off your prostate. So, the drugs don't work a lot of times, especially in the beginning, because the nerves are traumatized. They're there, they're present, but they're not working right. And that's why the pills aren't working, especially in the beginning.

[00:54:26]But they may start working as things start working again down there with the communication between your brain and penis. So don't forget that doses go as you see and they're dosed differently.

[00:54:38]And most people um sometimes for penile rehab people will take them every day.

[00:54:42]There's lots of things we could talk about with those, but um my most important thing is that to know especially after prost and after radiation too, give them a chance regularly to see if they're doing more or less at different junctures in your healing process. Okay? And work with your provider or prescriber on how you should use them. Should you use them daily, even when you're not having sex, for a little bit of um potential rehab?

[00:55:10]And that's very controversial because they didn't help everybody. You know, um when you look at the research on does it help to take a pill every day, really the research pretty clearly shows not necessarily. And that's because are you a pill responder or not? But if you are a pill responder, in other words, when you use it, you see more activity in your penis than when you don't, then it may be helping you because it's causing more blood flow, more things to happen within your penis. So, lots of things to think about with oral agents. But um let's move on because then we also have a vacuum pump. You put your penis inside that cylinder you see there and then you pump manually with that pump you see attached or there's a button and that's a battery operated pump. They do the exact same thing. Most people like the manual one because you can control the pumping really well and if you don't have dexterity problems, problems with your hand, that works just as good if not better than the uh battery operated.

[00:56:06]Most people just use the manual pump.

[00:56:08]Uh, and then great, when you pump that pump, it creates a suction inside of that cylinder that forces the penis. So, the penis is inside the cylinder and it and it's not completely erect or partially erect. And you always want to start with, this is a really important key. If you get a partial erection, if you get some fullness or thickness, always put that in there as hard or full or thick as you can because the more you start with, the more your penis is ready for even more blood with the vacuum pump and it will work really easily and simply if you start with a partial erection um as the more you start with the better. So, you put that in there, but it's not completely hard. And then it's in the cylinder and you start to pump and it start the suction creates physic physics. It basically pulls more blood in your penis, so you're harder inside the cylinder. Great. But you can't have sex inside the cylinder. That ring you see there goes on the edge of that device right next to your penis.

[00:57:04]And when you transfer the ring to your penis, you can get it out of there and into your partner. So, the vacuum forces the blood in. And this device, we did an excellent podcast on this. This device takes good teaching, practice, and patience. And so you have to practice with it every day till you learn to get a painless even liftoff erection. That's a big deal. Practice with it every single day till you learn to use it.

[00:57:30]Your provider or their nurse or PA, their physician assistant or their their advanced practice nurse, those people should be able to give you tips and show you how to use it. We also did an excellent podcast uh Kathy Marches and I on this that shows how to use the vacuum pump. But that one-on-one training with your provider or prescriber or someone who is trained with that vacuum pump is really valuable. And then practice every day till you learn how to use it without the rings. And then how do you use the rings? You may want to use it for stretching. Lots of things to think about with a vacuum pump. But practice and patience and guidance is essential if you have that. I've only met a few people out of all the over a thousand men I've worked with that we couldn't get it to work in some way, shape, or form for those men.

[00:58:15]finding the right ring. There's lots of tricky nuances. It's messy. It's not perfect, but the good thing is it's completely non-invasive and it does work. Research shows in 90% of patients and in my own practice, I've found very few patients who we couldn't get it to work right. It's still messy. It's still cumbersome. You still may hate it, but it's noninvasive and it works.

[00:58:37]Everything is good and bad. And the more invasive we get, the more risks or downsides and the less people that will do these things. Almost everybody will try a pill, but not everybody should try a pill. It's prescription and you need to see if it's right for you.

[00:58:51]When pills don't work, some people like, I don't want to deal with the pump or anything else. I'll we'll just have non-penetrative outer course. We'll we'll have manual stimulation, all those things we talked about earlier because I don't want to deal with that. And that's okay. You don't ever have to use a vacuum pump. You don't ever have to give yourself a shot in the penis. You don't ever have to have penile implant surgery. You decide what happens in your body. But if you're willing to try it, this again, we're going from least invasive pills. Now, we have the vacuum pump, which is totally non-invasive, but you still have to be careful and be trained, right? And, um, it has a 90% efficacy. Pill pills have in general about a 70% efficacy rate, around a 70% efficacy rate. Um, they all have good and bad. Pills, you can get side effects. Most people don't, but some people do. Some people feel like crap on the pills. Some people the pills don't work for. Everything has good and bad.

[00:59:43]So, we got pills. We got a vacuum pump.

[00:59:46]I want to stop right here and say one thing. There's tons of stuff out there.

[00:59:50]There's all kinds of herbal concoctions that are not governed by the FDA. All kinds of things that'll make you harder, longer, bigger, wider, all kinds of things. Many of them have no research to support them. What I'm telling you is what the Sexual Medicine Society says are the the true five treatments. the pills, the vacuum pump, the aroxin, the penile uh injections, and the implant surgery. That doesn't mean there are no herbal things that work, but there are many things that are out there that say they're going to help you, especially after prostate surgery or radiation. And most men will tell you they do not help.

[01:00:29]So, you need to look at the research behind them and see how they use them and is it right for you. But I'm talking about things that have really good solid research to support them. They're still not perfect. They all have good and bad.

[01:00:41]Make no doubt about it. And they may or may not be right for you. And none of these one things are right for any one person. Okay. So, that's the vacuum pump. Lots of practice, lots of patience, and learn how to use it properly. And then it works in most people, but it can be messy. It can be cumbersome. You have to wear a ring during sex. Some people hate all those parts of it. But what people like is it's noninvasive and it works good and bad with everything. You decide is it right for you. Aroxen is the newest thing. In 2023 it was FDA cleared. It is over the counter. It is a topical that you work into the glands or head of the penis. So you work it into the glands or head of the penis and um see if that is helpful for you. You put it on. It usually works in most men within 10 to 15 minutes. You can wash it off to make to try and make sure it doesn't transfer to a partner or you can wear a condom to make sure because there's very few side effects, but the number one side effect can be irritation to the skin or rash or something like that. So, always try it somewhere where a rash like on your wrist to make sure you're not allergic or have a weird reaction before you try it on the glands or head of your penis.

[01:01:51]60% of the men had an erection within 10 minutes. 60% of the patients had a significant erection and were able to have sex. So, um, we're excited that it's there and that it was found because it's a totally different way. How it works is it sort of cools and then warms the skin, which stimulates that nitric oxide, which is one of those chemical mediators in the penis that helps the blood smooth muscle relax and the blood flow in. That's how it works. And so, um, again, it doesn't work for everybody. And it's got like that maybe 60% uh success rate. So, again, is it right for you? It's a topical. Be careful. You don't need a prescription.

[01:02:31]It is over the counter. Try it somewhere that is less sensitive than the head of your penis first to make sure you don't have a weird reaction and then try it on your penis.

[01:02:41]Injections. Um, people used to call me the injection king because I did so many injections with patients over the years and that's true. But I will tell you from the beginning, injections are not for everybody. There are patients who will never do injections and never should do injections because they aren't right for everybody. But why do people like them versus uh and the dropout rates are higher than the vacuum pump, but why might somebody like it over the vacuum pump? Because you don't have to wear a ring during sex. You don't have to use all that gel and lubricant all over the place. You get a fairly um you get a fairly strong erection that even when you climax may not go away. Now, the downside is you better make sure it goes away before you go as go to sleep because one of the risks is an erection that will not go away. You've heard about it in the commercials, that 4-hour erection. That is not a good thing, people. It is not good. Your penis is you can you don't want to have no blood flow in and out of your penis for long periods of time. When you have an erection, blood is not flowing freely back and forth. It is trapped in your penis. So, you have that erection. You don't want that for hours on end and it is a medical emergency and you have to go to the emergency room. I have never in my practice seen someone get that from pills even though they talk about it and it may occur very rarely but I have seen it in up to 10 to 15% of men who do shots. So you have to know what to do to go to the emergency room and get it resolved. So there are some very serious things you have to know how to deal with with this. Now remember 85 to 90% of men will never have a priapism and and do fine with the injections. Uh in terms of that you also could get scarring in your penis. Those are the rare things that are more serious. The most common complaint with injections is pain. Of course you could have needle pain but more in common is one of the drugs can cause a throbby headachy pain in your penis and that's not conducive to sex. About a third of men get that, but you can get other things like bleeding and bruising, different things.

[01:04:44][clears throat] You always need to learn to do and do injections under the guidance of a prescriber. You should always do your first injection in the office. You do it your not your first, but one of your injections in the office, either your first or subsequent one under supervision to make sure you're comfortable doing it, to make sure you didn't have any adverse reactions and to know the reaction that you had. and then they'll do more teaching from there. We did an excellent podcast on this, but nothing replaces one-on-one training that has to happen with penal injections with a with a expert health care professional like a nurse or doctor or assistant, someone who can teach you and supervise you to do your first injection and make sure you're okay. That's super important because as we get more invasive, we get more potential, not that they happen that often, for things like permanent scarring in the penis that causes curvature or deformity or other things that can occur. I've had people who did injections for a decade and never had problems and love them.

[01:05:45]But the dropout rates are more than 50%, cuz remember they don't work for everybody. Efficacy is about 80% about um 75 to 85% in the studies. Um, so it doesn't work for everybody. That leaves that leaves like 15 to 25 or so percent that it doesn't work for. So it could be up to a quarter. And then um also side effects and other things. So dropout rates can be high on injections. But if you're trained properly and you get comfortable with it, I've had people who again really like it. I have people who hate. I'm so glad we have all these treatments. But make no mistake, they have good, bad, and ugly. I try to tell you as much as I can in the book and different things so you can make your own informed decision. I don't try to talk you in or out of any treatment. You should never be talked in or out of any treatment. You decide what happens in your body. You look at the facts and make your own decision. Then we have surgery about now again only 1 to 2% of men with erectile dysfunction will do surgery. But of the men who do 80% or more of them are happy. And in my clinics, all the clinics I've worked in, many of the men are very happy and so are their partners because this goes where you go. You can use it as much or little as you want. But it's totally permanent. Once you put all this in your body, like a new knee or a new hip replacement, when you put these cylinders and pieces all in your body, even if you take it out, you'll never be the same. This is a permanent solution that some people do. It's permanent. It goes in your body. It may have to be replaced if it malfunctions or becomes infected. And eventually, if you have it long enough, it will have to probably be replaced. But the most common side effects are pain. It's a sensitive place to have surgery. Um, so it's going to hurt. It gets better. It really does over time. But even a month or two later, just like a new knee, you go to use your penis or you go to walk on your new knee and it hurts a little bit. So there's things Don't walk on your penis.

[01:07:37][laughter] All kidding aside, um, this can be life-changing for some men, but most men do not opt for this because it is a surgical procedure. It's an elective surgery and there's inherent risks in that. But the men who do and their partners, if you're well informed and you weren't talked into it, the huge majority of them are very happy with it.

[01:07:59]And I've had many come back and say, "I don't know what I waited for. I really liked it." But um so I would say again that leaves about maybe um 10 to 20% who aren't happy. And they're usually unhappy about pain. They're usually unhappy about shortening because they have to set it back a little. If they don't set it back a little and leave some of your tissue, it can come through the end of your penis. So, there's size differences. They try to work around that as much as they can. But, I would go in thinking I won't be quite as large as I was. It's not a lot when I come when I'm fully inflated with the penal implant as I was when I was fully inflated with my own erections. Okay, that's a good way to go in and understand it. And then I think you won't you'll have realistic expectations. So size changes is the second biggest complaint. Some people say sensation changes, but most people say it feels good and I'm able to now have intercourse and that's really wonderful. But some people have difficulty orgasming or diminished sensation. That is not common, but again that's something that's brought people back afterwards, especially with re-implantations where they had to go in and take one out and put in a new. The more surgery they do, the more scar tissue, the more potential complications to your penis. So, and they can last just like anything mechanical, five years, 10 years, 15. I've even seen them last 20 years, but like a refrigerator, it may go out in two years. It may go out in 15 years. So, um, if you have one long enough, you may need to replace it.

[01:09:26]Lots of things to think about. I lay it all out in the book. Make sure you know each of these treatments fully before you make your own informed decision on, is it right for me? And that's all that matters. You and your partner's opinions are the only ones that matter.

[01:09:41]Uh what about women? Real quickly, I just like to touch on this because a lot of especially with prostate cancer, that doesn't occur in young patients in their 20s and 30s typically. So, this is going to happen in most commonly in your 60s,7s, things like that. So, but women are also struggling with their own issues. Remember, they have a tenth of the testosterone. We do a tenth. If we had half, we'd be like, uh, they have a tenth before menopause and then it decreases just like ours does with aging and menopause. Most people's decreases over time. So that's where the drive is not as much, but they also get because of lack of estrogen, shrinkage and dryness of the vagina.

[01:10:26]uh this is the number one complaint of women that brings them to the gynecologist or to healthcare providers is vaginal dryness and atrophy. Um it's called um genital urinary symptoms of menopause. It can also cause urinary tract problems and bladder problems. So we use things to normalize and estrogenize locally not systemically the vagina. And there is a cream, there is a ring, and there is a tablet. And they all work equally well. The creams and tablets initially are taken every day for one or two weeks and then only twice a week typically, sometimes three times a week, but often just twice a week. A little goes a long way. But when we reestrogenize that area that's so estrogen dependent, it makes a world of difference in these women. They even sometimes and you always it's prescription check with your prescriber but even with breast cancer and cancer dependent um and hormone dependent cancers some people are able to safely use these there are also non hormonal um moisturizers that keep the keep things moist and supple but I can tell you est these local estrogen estradile therapies work very well for vaginal dryness and atrophy and most women in their lifetime after menopause cause at some point will need something to help with this. And also a lubricant for during sex. A water- soluble or a silicone lubricant just helps with friction during sex, too. Lubricants are different than moisturizers. Moisturizers keep the tissue supple and moist in the way it's supposed to be. Lubricants are for friction during sex.

[01:12:05]These are some non hormonal uh moisturizers. Neoen was developed by an Asian um gynecologist. Uh Neoen vulver soothing cream. It's non-medicated cosmetic. Um, oh no, New is the one that was developed by the Asian gynecologist.

[01:12:21]But New Neoen is a vulvver soothing cream. That's very different than a a moisturizer or a lotion, but I wanted to mention it because it's it's something that some people find helpful. Um, hyaluronic acid, it sounds terrible, but it's in these vaginal moisturizers cuz it brings like 200 times more water into that area. Um, and that's in different products that you'll see, but you need the guidance of someone to help you with a moisturizer. Vitamin E, vaginal suppositories can be helpful for some women too for soothing and and especially when you have pain like vulvadenia and things. Replenins has been around for years and it's a vaginal moisturizer. Luven uh lina ky liquids, all these different things that are vaginal moisturizers and these are non hormonal. And then Newe as I said earlier was developed for both odor and moisture and that was developed by an Asian gynecologist and you can find that online as well. Uh so there are non hormonal ones if you're just scared to death of the word estrogen because of cancers and things like that. Here are some resources for patients. Um my podcast is called Dr. Jeff talks about sex and intimacy and that website at the top of that is my podcast. You can download, you can find my book on there, Reclaiming Sex and Intimacy After Prostate Cancer, and download it free.

[01:13:44]And that's all thanks to the generosity of my amazing patients who gave to the foundation that supports educating my patients and all the research that I've done with patients that you'll see in the book, too. So, drextalk.com is where you can find 75 podcasts with relationship experts with urologist experts. Um, prostate Brian Healthan who's also part of this program did one of the podcasts on prostate cancer. One of his associates did one on BPH. Lots of good segments on sexual health and relationships on Dr. Jeff Sex Talk and my books there too. You can download it for free. You can also get to a link to buy a hard copy of it if you like that for you with cancer. NCCN has some wonderful websites of some resources for patients as well. dralba.com is is the book website. You can go there, too. And it has a link to the podcast website. You'll get to me either way.

[01:14:43]Cancer.org. That's the cancer society.

[01:14:46]They have some wonderful resources for cancer patients specifically as well. um and cancer.gov too. And then lastly, um sexual health matters is the sexual medicine society's website with information for patients. And also you can find providers there like urologist and gynecologists, sexual health expert um providers, um advanced practice nurses like myself, physician assistants. A lot of times we're the ones because the urologists are surgeons and they like to do surgery and we do some of the medical things like manage sexual health for um in the clinics. Uh so sexualhealth matters.org or the SMSna which is the sexual medicine society of North America smna.org hit on find a provider and you will find uh providers that are experienced in sexual health. ASET, which is the American Association of Sexuality Educators, Counselors, Therapist. I'm a certified sexuality counselor. You will find us on that site. Hit on find a provider and then you'll put in information on what area you're in and that will help you find a therapist, a sex therapist, couple therapist type person. There's been so much to unpack and talk about. It is the greatest honor and privilege of my life to work with patients. And so I truly appreciate this opportunity to share my expertise with you listener. I hope you know that you are so much more than the prostate cancer. You are so much more than the erectile dysfunction. You are so much more than that and you are enough. That is just the truth. So how do you navigate your way through sexual dysfunction after all these issues? I hope that's been helpful what I provided for you. There's some great resources out there and I'm sure Dr. Moyad and I will talk more about that. But my hope and prayer and wish for you is that you have better sexual health that you you can't necessarily recreate what was, but you can recreate and co-create spectacular and have wonderful loving relationships, intimacy, and sex after prostate cancer, after erectile dysfunction, whatever you're struggling with. You are not defined by disease in any way, shape, or form. I hope all that has been helpful. It's never my goal to persuade you or dissuade you what you should do. It's to help you get information and explore options, real options with research to support them.

[01:17:17]So, thank you so much for your attention and I hope it's all been helpful. Oh, I had one more slide. Let me share with you one more slide. Dr. Moyed said I should add one. Um so my key points were really that sexual dysfunction occurs after prostate cancer. What did I say?

[01:17:34]Eight out of 10 two years um 72% 5 years after is what the research shows. So very common after prostate cancer treatment with surgery, radiation, um androgen deprivation sex and also one out of five men in their lifetime will have erectile dysfunction. It is so so common. Sex and inimacy issues can be addressed successfully. There is hope. I hope if nothing else, we've given you incredible hope because there are treatments out there. Um, you and your partner can find your way to incredible connection, intimacy, and sex.

[01:18:07]Communication is [music] critical. So, start talking about it, especially when things are wrong. And know if I don't leave you with any other message, it is possible to have an incredible enjoyable sex and intimate life after cancer treatments, after erectile dysfunction.

[01:18:27]>> [music]