Hey guys nick drossos, dr andrew steinberg, and welcome to another episode of have the covet balls to talk about it. The covet balls talk about it so guys and girls. We are back covet hit. We we took a little break from filming. We got a lot of questions, a lot of comments. 2021 is back and we’re back strong, so we’re going to be posting every wednesday, a brand new episode of have the boss talk about it, great subjects, great guests, yes, super fascinating guests and today we’re going to talk about a topic we’ve covered, but we have some different twists to it different twist to it and again it’s probably one of the. I think, one of the hottest or most common questions we get is erectile dysfunction, yeah men and the reason why 50 of 50 year olds have erectile dysfunction some degree of it. We’ve mentioned this before so, let’s talk about sex baby 2021, let’s spice it up all right. So, as nick mentioned, we’ve talked about different aspects of erectile dysfunction and other sexual dysfunctions, and I wanted to just sort of focus on one area, something called restorative therapy. The story, because much of erectile dysfunction has to do with, I mean there’s a psychological aspect of it and all that stuff we talked about, but much of it has to do with blood flow or poor tissue in the penis, which is either not allowing the blood in the blood is leaking out too quickly. Pour a nerve nerve damage to the to the penile sponge tissue and much of what we do to treat that, and I would say, the vast majority of people at least go through viagra or cialis levitra that doesn’t fix the tissue. So very simple, anatomy lesson: the blood vessels in the penis and in the heart and the body they open up, they dilate with something called nitric oxide. Okay, we’ve I’ve heard of that before. What is what is nitric oxide? It’s it’s a it’s a molecule that works on the blood vessels to relax them so, for example, in the heart it opens up the blood vessels to allow more blood through now, if you’ve ever seen, someone with angina okay chest pain from from a heart disease. They take this thing, a spray or a little tablet under their pill called nitro nitro, nitric oxide right, so they take that it opens up the blood vessels to temporarily allow blood vessels blood to go to the heart so with erectile dysfunction, the natural or with erections the natural mechanism. The end point of the nerves that go to the penis is the release of nitric oxide. Okay opens up the blood vessels, more blood flows in penis swells, okay. So what does viagra? Do? It works on that mechanism? Nitric oxide gets broken down quickly, so it goes away so viagra cialis they actually block the breakdown of the nitric oxide, so the nitric oxide hangs around more and you get more buildup of nitric oxide and and more dilatation of the blood vessels. More blood flow, better erections. But when the viagra wears our cialis wears out of your system, it goes back to the normal thing, the nitric oxide breaks down and and goes back to a normal flaccid state. But so when you take it, it does work. It works great because again it works with the natural system. You have to be excited, you have to get the those nerves to cause the release of nitric oxide and swelling of the penis, but it doesn’t change that these blood vessels are damaged. That’s why you’re having the erectile dysfunction? How can someone know the difference? Well, there are signs different ways of of measuring it. We can do a penile doppler, a penile ultrasound, where we can actually measure the blood flow into the penis, and we compare that to what the normal should be. Okay, but there are treatments out there, and I want to stay off the bat that, although we’re doing some of them and we’ll get into them, they are considered experimental, but they actually are believed to fix and improve that tissue okay, so they are helping to restore the natural blood flow for some people who take viagra or cialis or other means. This may allow them to not need these medications or or aids anymore, and for people who are so bad in their blood vessels that viagra cells don’t work properly. Well, it may improve it enough that they start to work effectively. So there are. There are a couple and, and the the commonest one that I think seems to be the the runaway winner for now is shockwave therapy. Okay and when I mentioned shockwave therapy, we’re not giving electric shock to your penis and- and it’s not cpr- we’re waking up your penis. What it is, it’s a a probe, a gun that we put on the on your penis, okay and it administers acoustic shock wave sound waves. Does it hurt it feels like it does not hurt? It feels almost like a vibration. Okay, you can even hear the sound waves to the penis feels like a vibration. I’ve tested it myself, not painful at all. Okay. Now the the theory of how this works are multiple theories, but it’s it’s believed to on one end cause a little mini trauma to the tissue. Okay, and that brings in the healing process, which then heals some of the tissue. It may release some growth factors or angiogenesis factors, factors in the body that lead to growth of blood vessels, okay, vegf that there’s a bunch of them and also even possibly awaken or summon the stem cells. The stem cells are the cells in our body, which can differentiate or turn into other cells and and and and lead to healing and any kind of injury. That’s what happens on the cellular level, so shockwave has been around for many different medical treatments, there’s a more high-intensity shock wave, which we use to crush kidney stones and for the lower intensity, which promotes these healing. It’s been used in wound healing for diabetics and joints and and certain different areas. There are different types of shock waves and it’s quite confusing and there’s even some technologies or radial waves, which aren’t exactly sound shock waves which promote themselves based on the fact that they do the same as shock waves, but they’re not and they’ve never been proven. So, unfortunately, these things aren’t really regulated to that point, you can make claims that aren’t necessarily true so like how do you you take the penis and you just yeah, so we have a technician and you come in and they they put this probe on into different areas of the penis, usually five different positions. You have to be hard flaccid, like does it you mo? Usually it’s done in the flaccid there is. There are some experts in the states which believe it should be done in the erect phase. Okay, but the vast majority of us do it with the flaccid okay faster and do it in different areas about 1500 shocks, 1500 shocks, meaning like 1500 times. How long does that take 20 minutes, 20 minutes 25 minutes, and we do it over a series of six 12 18 sessions: wow, okay, okay, doesn’t so there’s no pain in no pain, no pain, and it takes time because obviously you’re, building up new blood vessels or blood flow. So it’s not something that works right away. Although interesting enough, some people do feel like they have improvement within a couple of weeks. I don’t know if there is something happening that early or there’s a psychological aspect of it, so it is considered still to be by most of the sexual medicine societies or your neurological societies to be experimental. There are lots of studies out there. I think the the latest good news for this technology is the european urology association, which just classified it as one of the standard therapies for vascular or blood flow issues. So I think that’s a sign and there are many studies which show a significant improvement. There are many studies which show an improvement, but not necessarily significant. So and we don’t know what the best technology is. We don’t know how many shocks to deliver, how fast, what time period is six better than 12 and so on. So I think from that point of view it is experimental and all I can say is we’ve been using it for three four years and we’ve had some some some patients who have had some great improvements for it, but you you check on before. If it’s psychological or physical, are you only yeah, but it’s it’s hard to it’s hard to tell, though it’s hard to tell in some cases it’s not the first thing I would push on an 18 year old, who got drunk and couldn’t get an erection the next day, but in your typical 45 year old diabetic, high blood pressure. Maybe who makes sense that they have vascular problems, I think without further testing. It is worthwhile to give it a shot. It seems to be very safe. The incidence of side effects or complications is, I don’t remember, seeing any of them, but like any medical procedure, I think we get. We have to be careful and it’s not a cheap technology. In fact, it cost three thousand dollars for for twelve sessions and and and then about, according to most studies that I’ve seen where there has been a beneficial, significant effect about 30 of people don’t respond at all. So you see these patients who spend money and are desperate to get get back and get a better erection and feel like they’ve wasted three thousand dollars, so it’s quite discouraging for that population, but there is that 70 that does get the results. There is that 70- and that’s still, I think in my experience- I I don’t want to generalize and in in very many studies and the studies are starting to become longer and now there’s there’s been some where they control it with a sham. So what is a sham? It’s a procedure where the patient thinks he’s getting treatment, but he’s not no one. So one part of the patient group will get the actual shock wave and the other one they’ll put a little plate in front of it. So they’ll feel the vibrations of the machine. They’ll hear the machine, go click, click click but they’re, not actually getting those sound waves. So that’s where you can compare- and you can just see that in one group the erectile score goes up a small amount and the other one. It goes up a significant amount, so there have been wow several studies that are really starting to come out. There’s some great ones underway across the world right now, so we’re going to have a lot more data and then once it becomes more acceptable- and I I my gut feeling is- it will become mainstream, at least in the medical community, because in terms of these startup little clinics run by, I don’t know what they’re buying these machines self home machines, which are don’t do anywhere near the same thing. So there’s so much it’s it’s a free-for-all out there, but I think once we get the real knowledge and data that’s coming in, I think it’s going to be much more mainstream. Is it a service that’s offered like in many clinics? It’s like the first time we we were, I think, the first ones to have it in in montreal. Maybe in quebec, at my clinic steinberg, urology or elna sexual wellness, you can check the websites for that. I I believe, to my knowledge, there’s two other machines in montreal and of interest. There was a sex therapist who does a tv show a radio show on cjd who was talking about it? The other night randomly and my patient coordinator was listening and she was talking about there’s no machines in montreal. You got to go to ottawa or california, so I guess we’re not doing a good word of getting a good job and getting the word out, but yeah we’ve been doing it for three or four years and, in my opinion, opinion there there’s been some great success stories and I think something to look forward to we’re going to be seeing more and more about that. The next most popular treatment for restorative therapy, erectile dysfunction, would be prp, okay, sort of touched on this briefly and what is prp so prp is platelet-rich plasma. Okay, your blood has plasma the watery part of it. It’s got red blood cells, white blood cells and platelets. Okay, red blood cells, carry the oxygen white blood cells are helped in the immune system and and fighting infections, and so on and platelets are are primarily for clotting. So when you cut yourself, it forms a clot, it’s the platelets which start that, but they’re also involved in healing they released a factor. Sorry, multiple factors which call in other cells to start the healing process. So prp we take your blood okay in a centrifuge in a test tube spin it in the centrifuge and that separates the red blood cells and the white blood cells, and then we’re left with this plasma, yellow, stronger particles consuming like yeah, it’s just it’s just the the plasma, the liquidy part with platelets full of platelets, okay, okay and then we add a little bit of calci to activate these platelets to release their growth factors, and then we inject it into the penis. Like you mean when you say inject it into the penis not like through the hole. No, so I do it in five different spots, one two, three, four on the shaft and one in the head of the paper and we freeze the penis beforehand. Okay, so it just sounds painful. Like sounds horrible, but it’s not it’s. It’s very well taught at first we put on a numbing cream, and then I give a little local freezing and, by the time, we’re ready for that most patients don’t actually feel the injections and again, the theory of this is these growth factors are stimulating growth and rejuvenation, and and healing and improvement of the blood flow and the the healthy tissue and stimulating healthy tissue to the penis. What’s the percentage of success rate, if you want to so this is much less studied than the shock wave. Okay, that’s one of the the primary concerns at this point. The studies I’ve seen have similar effect. It’s about two-thirds, one-third two-thirds will have a good improvement, but again there are much less studies, there’s not a lot of studies which is placebo controlled. So there is, I know at least one or two going on now in the states where they’re actually injecting prp into one group of patients and and water or or and just a benign liquid into another group and they’re, going to follow them and and measure their erections and their blood flow and ultrasound and so on. So we I went to the the guru in the states, dr reynolds who’s really pioneered this technique to learn how to do it back in alabama. We’ve been doing it for again about three years and again, I’ve had some patients who have had improvement on it now, just because I’ve had dozens and dozens of patients or improve on it being a man of science. I can’t say that that’s proof that it works, but the studies are coming in slowly and more and more clinics are starting to do it and we need that data. We need that research to really prove it and again what is the proper technique? What is the proper concentration of platelets? It’s injecting it in two places as good as injecting it in five places. Do we need to do one session or do we need to bring it back in six weeks and six weeks after that? We don’t know that, and you see, unfortunately, even people advertising I’ve seen it as a cure for peyronie’s disease, and these are unproven claims and I think all my patients know that a this is experimental. We have some so you they know that absolutely not okay yeah. We have some some belief. It makes sense that this works or or why this would work. We’ve used prp for other medical problems, hair growth, injecting to the hair and aesthetics and into joints. So there’s there are a lot a lot of science. This is not witchcraft, so it makes sense the science behind it makes sense, but we don’t know all the details of what’s the best way to do it. It seems to be harmless, at least and and and again, two-thirds according to our experience or one-third. According to our experience, the patients who go for this will not ex get a benefit, so patients have to know the limitations before they go into this, and- and so I think, I think, that’s important, but there’s also some some groups who believe that combination therapy shock, wave and prp together, because they both attack it for from different angles, can be even that much better. So is it a little bit of trial and error and well it it is, but it it it’s. It shouldn’t be ultimately yeah right. We need this, we need to you kind of have. We need to know me like you’re trying you’re yeah, so we need to first come when it gets a little bit more accepted. Then people are more likely to come on board and start to produce studies. So I think that’s what’s happening I’m just this week. There’s the north american sexual medicine society and listening to some of the the gurus in the field. Talk about it and the fact that they’re talking about it and undergoing studies to me is a great sign. So we’re we’re gonna learn we’re gonna, get there. We’re gonna know how best to use it, but I think there seems to be a lot of excitement about it. It seems to be promising, and now there are limitations, no one’s gonna. It doesn’t raise the debt, so if you have severe erectile dysfunction, most studies show that this isn’t gonna. This is, I guess, from mild or yeah. It seems to both of these things. The prp and the shockwave seem to work better in mild and moderate erectile dysfunction and I’m not against trying it, because what I say to patients who have severe or are not sure if it’s going to work or they’re going to fall into the group doesn’t work. I say well, look. Let’s say I tell you, there’s a two-thirds chance that this is going to work. Well, if we don’t do anything yeah, it’s a zero percent chance. It’s going to work, absolutely just keep. If you want to stay, how you are with the viagra or cialis or using a pump whatever it may be. That’s that’s fine, that’s great! When should the person make the transition? Well, so there’s there’s two points: there’s someone who’s wants to avoid medication or is on medication and wants to try to get off it. Okay, that’s a good point and then there’s those who are not responding to the medication and they sort of need to go to the next step, and there are other different things that we can do, but they want to I’ve been taking viagra for 15 years. It doesn’t seem to be working anymore. What else do you got so that that’s that’s where that discussion comes in as well, wow there’s also something which is called stem cells. People were doing that. I mentioned that shockwave and these can waken the stem cells, but they were actually injecting stem cells, and that is the the fda and health canada and just put a stop on that, because we really don’t know, is there a risk that these things can cause cancer or or what are the long term so because that’s something more more advanced, and that was really put a stop on that and saying these need to be done under serious scrutinized studies with irb, which is the internal review board, which actually look at the studies and say yes, this is ethical study this so that has been put on hold and I I know there are some studies going on and and and not even necessarily in human studies. I mean there’s for shockwave, for example, and prp. There’s animal studies, rats, stuff yeah. They study erectile dysfunction in rats or mice. So a lot of science to be discovered still in the field. But to me this is the sort of the the the greatest step we’ve taken since the discovery of viagra. So those are pretty much years ago. Vagrasalis, you have doing the shock therapy prp like or stem cells, which is the last one, so stem cells yeah not yet, but that’s pretty much all the options well. Well, no, I mean there’s there’s medications that you can inject yourself, self-injection of medications, so it’s a little bit stronger than viagra because it doesn’t have to be taken and swallowed and to be passed through your stomach. I don’t even know that existed, yeah, alprostadil, caverjet, tri-mix or different names. So it’s like, I guess it’s an injection of viagra, then right yeah, it’s not viagra, but yeah, but it’s something that relaxes the blood vessels and patients come into my office and I tell them to go to the pharmacy and pick up the prescription and I actually show them how to self-inject like a diabetic will inject. But again these are stuff that doesn’t improve the health of the penis. It’s just it’s like. Basically, just putting on a band-aid for that moment, yeah and and it and it works, but it’s not it’s. It’s not going to get you to have spontaneous good erections on its own, but again for severe for severe cases and more significant cases, it’s great and then and then surgery putting in an- and I think it’s always interesting. What you said is that what’s good for the what’s good for the heart is good for the penis so but do any of these? Maybe it’s a silly question. Do any of these help for overall health? No, because they’re, very localized therapies, right, they’re, directed right at the penis just strictly, for that it won’t help the blood flow of your heart or other functions. No okay. They are huge, being studied shock wave to the heart, to improve the blood flows, the heart and so on. And it’s beyond this my knowledge and beyond the scope of this. This talk, but there are, the shock wave has been used in studies in different fields for sir, as as his prp platelet therapy. But it’s it’s it’s exciting times, and this is restorative therapy, for erectile dysfunction is definitely the next frontier, for I think it’s an important topic. We’ve talked about it before and I think one or two episodes, but for men, it’s it’s it’s a big topic, because it’s our masculinity, it’s how we feel men and obviously, as we go older, we’ve talked about testosterone therapy. We’ve talked about erectile dysfunction, and I think that that’s something that for men as they get older is such a big concern in fear, so yeah we’re living longer, we’re living. You know, and we were younger when we’re older and we want to it’s an important part of of relationships, an important part of life to maintain a good sex life, and I think the thinking that this is a recreational part of medicine and is is is being washed away, and this is part of your health and welfare good. So that’s what got me more, passionate and excited about about sex awesome about sex therapy. That’s guys I mean we’ve done a couple of episodes on this, but I mean we know so much. I’m sure that we could still yes talk about it and we’re going to get a video out there of nick doing shockwave therapy. So, okay, so angie wants me to do the shock therapy and producer johnny. I think I should do the shock therapy thumbs up. Okay, what guys I’m gonna do shock therapy. If only andrew guarantees me I’m going to be like a greek god, you’re already there so guys. I want to thank you for watching this episode of have the balls to talk about. It takes balls to talk about it. We want to thank you guys for watching make sure to subscribe, hit the bell and we’ll see you guys next week you.