Regaining Sexual Health After Prostate Cancer

Guest Introduction and Credentials 0:00

Hello everyone. Thank you once again for joining me here at the Prostate Cancer Summit. I'm Doctor Geo Espinosa, your host and I know I say this all the time, but no, I really do have another special guest. His name is Doctor Justin Dubin, a urologist who specializes in men's health at Memorial Health Care System in South Florida. Justin grew up in Wayne, new Jersey. So he he's a local guy. He he's a local guy from the northeast. Graduated from Johns Hopkins University in 2010 with a B.A. in biology and minor in entrepreneurship and management.

He then attended Rutgers, Robert Wood Johnson Medical School. Doctor Dubin completed his training in urology at the University of Miami in 2021, and his fellowship in andrology at Northwestern University. Doctor Doman is passionate about men's health. I know that for a fact. I know that firsthand. He's been on my podcast. We've had side interactions and the passion is contagious with Doctor Dubin, and you'll know why. And he has published so many papers on male fertility and sexual health, and has been quoted in New York Times and different high level sources and resources like New York Times publications.

He is the co-host of the men's health podcast Man Up A Doctor's Guide to Men's Health, through which he hopes to destigmatize men's health topics and motivate men to improve their overall life. And I've been a guest at the Man Up podcast. Justin, thanks again. Man, I really appreciate I, I so appreciate when you say yes to me to be on my podcast and now here because I know how busy you are. I know about your life a little bit and, and, you know, I always appreciate you taking time off to to do this.

Joe, thanks for having me on it. And listen, anytime you invite me anywhere, I'm going to join you because you are one of those people who are so good at you know, curating good quality information, from people who really know their stuff. And it's always an honor to be, you know, in that circle of people. So any time you're asking me to partake in something, it's always going to be. Yes. Because, you know, not many people can do what you're doing right now. And I'm always so impressed by you, and how passionate you are for helping people.

And it's an honor to be part of this summit, for sure. I appreciate him. That's touching. Thank you very much. I really appreciate that. It's funny how, you know, it's almost like, yeah, I if I, if I, if I, if I tell them, yeah. Doctor Doom is going to be on know he's he's my friend. That's my boy. And we just kind of just met. But it's almost like, yeah, when you've been around the game long enough, you either connect or you don't. It's like when you start, if you start dating and you're you're 18.

Yeah, give it 3 or 5 years. You think a 30s, 40s, 50s. In my case I don't need to. I don't need to see you or interact with you, you know, for for years. It's like either you know, the deal. So you and I are like, kindred spirits, right? Absolutely. Man. You did some training in northwestern, and then I would I would have thought, hey, man, just stay in Chicago. You know why, why, why go to Miami? But I guess that, you know, you don't like that Chicago cold weather, Is that. What have I got to tell you?

I think Chicago actually may be the best city in the country. You know, I hate to agree with you because I think new York City.

Prostate Cancer Treatment and Sexual Health 3:24

I want to believe New York City is. But I, I love Chicago when I go to Chicago, I mean, when they have the air in Chicago, I love it. Yeah, there's Summer city in the country, hands down. But I do. At the end of the day, I think the quality of life. I really love living in South Florida. I live in Miami, I practice here and Broward County, actually a little further north. And, I do I do love living in Florida. I love being by the ocean. You have a nice Houston. You have a nice view of your balcony.

I do, I got a nice view on the water. I can't complain, man, I can't complain. You're handle. Because part of what I know, what you do and where you live is because of your Instagram handle. You mind telling our audience what that is before we get going? At Justin Dubin, M.D., you can find me on Instagram, Twitter and TikTok. You can follow us on socials for at the man up part as well, too, at Man Up on Instagram. I'm more active on Instagram, and TikTok with those, socials than Twitter. But I'm all over the place with my personal account, so always welcome you guys to to join on on there.

And the man Up pod is on all podcasting platforms so including YouTube. So you can find us there. And Doctor Geo here has an unbelievable YouTube channel. So I'm sure you are all familiar with it. But, you know, I'm always honored to join him on his podcast. And it's really just wonderful content. And everyone please follow. Justin brings again, it's high quality stuff. You not always going to get high quality information. Trust me. I look at everybody's information just to see what they're doing and oftentimes they leading you in the wrong way.

Doctor Justin Dubin and his a podcast. You want to you want to join that? Thank you. Justin. Prostate cancer. You get treated. And then it's like, you know, a lot of guys, make their decision, their treatment decision for prostate cancer based on will it help, you know, what happens to my sexuality. And I have a way of looking at this like so. So I remember when I did training in urology at Columbia and a lot of the conversation is that, well, don't make a decision. Make a decision was going to cure your cancer, not in sexuality.

That makes sense intellectually, but it sort of didn't sink in. I was like, hey, can it be like one A and one B as opposed to, yeah, don't even think about sex is think about cure. Why? Well, for a lot of people, quality of life matters and it matters more than even longevity. So this is like how I look good on my years rather than how long of my years. Right. And sexuality for a lot of men, you know, reasonably so matters. So how many, you know, what's your take on on that approach and just worry about the cure.

You know, whatever's the best cure don't even, you know, don't worry about sexuality. All of that later. Yeah. There's ways to deal with that later. I'm not undermining the fact that, you know, prostate cancer is a life threatening condition. But can we have a serious conversation around that as well? So what are your thoughts on that? I think that's a really excellent point. And I think we're at a point and you're going to listen to it all over through this summit is that, you know, there is good news.

And it's one of those things I tell people, you know, I when you have prostate cancer, you know, in general survivability is there, right? Most people are not going to die of prostate cancer. And we've we've advanced in the medical field to neurologists, oncologist, radiation oncologist. They've done such an amazing job in treating prostate cancer that we're no longer talking about, you know, well, whether I will have life. It's really a conversation of life after prostate cancer. And, I think the good news is, no matter what the the treatment, you have, if you are concerned about your erection specifically, we will be able to find a way to get you where you want to be.

You know, going through cancer sucks. Life after cancer should not. Right. Very, very simple. And if we said thank you. And I think that when we're talking about erections, you know, I think we need to understand how erections work to set our expectations for what's going to happen after. But really when when we're talking about options, the data really shows if you're thinking about radiation, if you're thinking about, you know, a prostatectomy. I think the most important thing when you're thinking about the baseline of what your erectile function is going to be, no matter what you choose, best, your erections are going to be what they were before.

They're not going to magically get, you know, better, right? So if I see patients come to me for some reason, you know, and this is fair, right? Some people are not sexually active prior to getting treatment. And then they come to me, they're interested in erectile this. They're treating erectile dysfunction. And you know, some of them didn't know what their baseline erectile dysfunction was because they weren't sexually active. But they have a new lease on life. They want to be active. They you know, they're they're you know, they went through something and they want to, you know, be active and you can't expect to have something where you couldn't penetrate with your erections prior and to be able to penetrate after.

It's just not how it's going to work. And, you know, when we're looking at the data for erectile dysfunction, after prostatectomy, after radiation therapy, you know, it's kind of all over the place. Right. And I think that it's always been a controversial thing to say, like which one's better in terms of erectile dysfunction. Which, which one's better. In terms of satisfaction with your erections. Because the truth is, you know, I think a lot of people are choosing their options based off of, like, what you're saying, survivability, but quality of life and other things.

Right? You know, they don't want to get a surgery because they don't like the idea of, you know, having something removed from them, or they don't want to have specific quality of life measures that maybe surgery would have as opposed to, radiation therapy or people don't want to get androgen deprivation therapy, so they go into surgery. So I think a lot of those things are the real dictators of what's going on. And dictator, no pun intended. Right. Many puns in this conversation, folks. So yeah, don't be be ready.

Don't be alarmed. Many puns. But the point is, you know, most of the data really suggests you have about, at best, like a 30 to 50% chance, of getting, return it to your previous erectile dysfunction in both radiation, brachytherapy and prostatectomy. Right. And there's so many factors involved, you know, the like how how aggressive your disease is, your Gleason score, how aggressive your treatment is. And that that dictates all of those things in addition to your baseline erections. So it's really a very personal and personalized decision based off of your personal preferences, based off of obviously, the aggressiveness of your disease and your goals for quality of life after.

Well, but once again, I think at the end of the day, if you have erectile dysfunction before or you develop it after, and you're not happy where you want to be, there is a path for you to be happy with your sexual health. Lovely. Well, sad. Well, sad. So we, you know, so on this summit, I've had the great honor interviewing. I mean, we have 4 or 5 specialists and experts in sexual medicine. I mean, I'm I'm thrilled. And we take the full spectrum, right? So what are some natural approaches we have that a lady, doctor Twan, who and Truong who?

It's based out of Virginia, has a peanut rehab center where, she does the shockwave therapy and the PRP and so forth. So that's kind of the bridge between natural. Okay, that doesn't work. Some Pde5, okay, injections, blah, blah, blah, blah, blah, right. That's his thing.

Penile Rehabilitation After Treatment 11:30

And we're not. She's doing Botox. I guess that's the thing now. Yeah. There's some you know, they're starting to research it, for sure. Well, some people are already the trifecta doing that, but the trifecta is on, PRP, shockwave therapy and Botox, so. And maybe you get a twofer, right? Just just hit me up right here while you're at it. And then is the more aggressive things, like, like, you know, beads and all that, tri mix. And then we have an ex we had an expert on, you know, VDS, and, and and talk about different equipment and rings.

And so for beautiful I want to kind of take it forward to, you know, what we do medically now understand many of our listeners and this prostate cancer summit, they're kind of alternative and natural medicine, mind it. Well, here I am not your perfect doctor, you know, perfect functional medicine. Perfect. Now, what I learned in over 20 years, started at Columbia and then NYU. I've learned. What are these guys doing that works? I'm not looking at these guys. You're up, you guys. Urologist saying what?

That doesn't. For example, not a big fan. Never been a fan after. Right. Or five out of reductase. And I'm not a I'm not a fan of anything since day one. Right. Been very careful with, for fluoroquinolones, for prostatitis since day one. Very strong Achilles. I saw the Achilles tear early on before it was even black labeled. Right. So I'm like, nope, nope. I'm not I don't know, I'm not. But what what works, what actually works? And let me put my biases aside. What works? Well man, I see try mix.

I mean, other than many people that I've seen with priapism where they get an erection, this, you know, doesn't come down and they need to go to the E.R. but when they get it right, right. That's pretty good. If you don't mind injecting your penis. And then penile implants. Penile implants to me. And, and I always say I don't want I don't want my body to be opened for anything, but again, that's my own thing. Who knows, right, I have I had hopefully some control about my health destiny, but I know it's not 100% right.

God forbid I'm in a situation. I am a I am a Cuban guy, you know? And you know, you know how he rolls living out there in Miami. Hey, maybe I'm better as big over here right? I would never say never. And then when I see these outcomes from some of the practitioners that I've seen who do penile implants, I'm like. And these guys, the satisfactory rate is high. And I was like, this is pretty darn good. And they come and say, no, it's great. And we're great live. I'm enjoying sexuality. My got my manhood back.

And you said something very keen and I want you to talk most, but I'm sort of caught up here. You said something really important. You said you're. And I'm going to paraphrase, you know, your your, your your health can actually you don't have to succumb or think about or, you know, be overly anxious about prostate cancer after the treatment. You should continue on with your life. In my mind, you get to thrive, not only survive after prostate or despite prostate cancer, and that comes with it. Look, start exercising.

They they start doing all the things they eat better. And their blood pressure, they lose weight. These guys are right. The one thing sometimes is their sexuality. So let's talk about what that process is. So let's say they get treated for prostate cancer. Let's talk about three scenarios. So keep it simple. If you don't mind prostatectomy alone. Radiation and or with ADT. And then when they have when they do all of them right. So they do prostatectomy. They get their prostate followed by radiation.

So I think salvage salvage radiation. And so these three types of people, what's the process with these guys. So I think one at a time and just take it away. Yeah I want to just highlight how erectile dysfunction works and how it's impacted by these patients. First, because I think that that's going to really give us an understanding of of what's going on and how these patients are potentially being impacted differently. Okay. So, you know, in order to get a good erection, you need five things. All right.

If any of these five things go wrong you can have erectile dysfunction, right? One you need good blood flow to your penis. Right. And you know we think normally smoking vaping you know heart disease in in patients like this if you have prostate cancer you're going to have compromised blood flow to your penis either by surgery or radiation okay. So surgery radiation, both compromise good blood flow. They can compromise, especially radiation. It can compromise your tissue as well. Good nerves is number two.

When you think diabetes, you think surgery is, you know, surgery. Obviously, a prostatectomy is a big one here, with compromising your nerves. Radiation also does the same. Three you need good testosterone. Now, in general, people who have cancer are at higher risk for having low testosterone, whether and if they've been treated, they definitely do. And especially in men who are on ADT, that's literally the goal here is to deplete you of your testosterone. So these patients not only feel, you know, may have erectile dysfunction, but they may have signs and symptoms of low testosterone, low energy, low libido.

You know, some mood swings, issues like that, some bone health issues. And then for you need to be aroused. And obviously when we're talking about cancer for patients, you may not feel sexy. You're going through cancer, you know, you're being treated. And a lot of people, too, sometimes during that process are not feeling up for it. And then five is a good state of mind. And, you know, a lot of times these things are big changes in your life. You're going through it with your family, your personal life, your work sometimes.

So, so a lot of these things, you know, oftentimes all five factors are being compromised for, for a prostate cancer patients. And I think that when we're talking about all three of these patients, we always have to set expectations. And I think expectations are going to really get you to where you want to be before. Right. So things you need to understand, assuming that where you were before was is pretty good. Correct. Now things that and I'm telling you this now because this is part of my rehabilitation process for all of these patients.

Right. Is if you come to me, you say, I'm going to get chemotherapy, I'm going to get radiation, I'm going to get ADT or I'm going to get surgery, I'm going to you're going to come in and I'm going to say to you, listen, you know, there's a good chance immediately after surgery you're probably going to have erectile dysfunction. In fact, if you have radiation, it's more progressive. But there's a good chance, you know, at least 50% of you, around 50% of you will have erectile dysfunction. But not only that, there is risk of shortening of your penile length.

A lot of people think about that only with with prostatectomy. But it is also there's data suggesting that radiation can decrease your penile length. You by how much in comparison to prostatectomy. I think prostatectomy is around two centimeters. There's been some data that it's almost similar, like 1 to 1.8 centimeters. In length. Now that doesn't, you know, so so these are things that people come to me, they say, I didn't know that was going to happen. And there's are ways to prevent that. So expectations are important because this is how I'm going to give you a recovery protocol.

You may have an ejaculation, which means that well, if you have a prostatectomy, you definitely will, right. We're removing your prostate. We're removing your seminal vessels, and we're disconnecting your vast difference, which means that when you orgasm, you're going to have a dry orgasm. Nothing comes out okay. That, and sometimes 30% of the time you actually may have something called climax turiya, which is, when you orgasm, pee comes out. Why? Because, you know, you've removed the, the, the area.

Your sphincter is a little bit, you know, not as tight. And then it takes some time to recover. And oftentimes people do recover. But I think about 50% of men end up having at least one episode, or 30 to 50% of men who have at least one episode of this. And so I do often see that. So you have to be able to expect these things and even in radiation with the nerves, as we discussed. And nerves are important for your ability to ejaculate as well. And, you know, and also your prostate and your seminal vesicles are still getting radiated.

So a lot of these guys, I think about 72% in one study, had at least once at one episode or lost the ability to ejaculate forward. So these are all side effects of treatment and they're all kind of the same. Now, if you're going to start beforehand and knowing all of these things, the most important thing I can tell anyone for any of these treatments is that the earlier the data shows, there's a lot of different ways you can do a penile rehabilitation, especially after after you're treated or during your treatment in cases like radiation therapy.

But the earlier you start, the data consistently shows, the more effective the treatments will be. You know, and I how early is early? I say usually within six months. Some of the data is within one month. I mean like but you know, some people are starting to put people on medications a month before they're getting treatment. So yeah, start even starting. Even Kegel exercises may help with erectile dysfunction afterwards. That's part of my program where I have them do cables right before for both reasons, not only for urinary incontinence.

Yeah. So I think that, you know, the, the the thing that's with penile rehabilitation is that it is it is hard to get very good strong data in like what's the best protocol. Right. Because you know, you can't do a randomized trial. You can only compare your protocol versus not doing it or like and having a comparison which often, you know, is going to be better. But most of the data does show that earlier intervention versus delaying your intervention. Actually, especially for penile length preservation is very important.

And so, you know, the standard protocol, I think that I really usually like is something like a daily cialis or a daily Viagra. I always prefer cialis because the half life of cialis is longer and lasts about 30 hours. And your system Viagra is about 6 to 8 hours. So you pop a daily cialis. You can start that even beforehand. It improves blood flow to your penis. And something like a vacuum erection device. And also the penile traction device is something like a restore X device. There is data showing that those actually can also improve your penile length and improve your erections.

So this one, how does that last one work? It sounds like like you carrying something with you. Is that what the one with the. I see that the a UA where your penis is, is attached to something or like a belt around your neck or. Oh, no, it's not that crazy. Actually. It's a really wonderful device. You can buy it online. I give it to patients. It's often used for Peyronie's disease, for, for improving curvature. And you can improve length with it's protease disease, but they've actually used it in post prostatectomy patients and, what, what it basically is you have a, a clamp that clamps onto the tip of your penis, and you put your penis through a hole and it retracts it and it pulls it.

And if you do it about 20 minutes a day, the data shows in about, you know, 3 to 4 months, you can see, preservation, significant preservation of your penile length early on after treatment or during treatment with me. I don't think I saw any treatment, any any data on radiation therapy. I did see some on prostatectomy. I, it's called restore X. It was created and designed by a urologist.

Penile Implants: How They Work and Risks 23:00

It's really wonderful. I do use it for proneness. I do often recommend it. And also a vacuum reduction device, obviously. And you've talked about it you mentioned already. But vacuum erection devices have also shown to be improve erectile function. And sexual or sexual satisfaction. But the important thing with the vacuum erection device, the data only shows it works in combination with Viagra or us. So these are all, you know, all synergistic protocols. Now, you mentioned intra cavernous injections.

There is good data from Doctor Moll Hall is over by that. You know, men using early on in your cavernous injections. Do you have a better erectile function 18 months later? And, and so that is one option. I typically don't use it because I think it's a little bit more hands on. And I feel like most not to be putting again, but like, you're literally stabbing. You're like, you're you're injecting yourself, which I think a lot of people, they've they're going through it already. And I think they want a little bit more passive.

And I haven't had much success in offering that early on. And I think it's a lot of work with educating and making sure that they're doing it. So, so I have not had much success, but if it's something you're interested in, the data does show that it works. And by the way, for the audience, this is literally injecting the shaft of your penis. With this medicine. And, and I tell you, it works. You'll you will get an erection. There's no question about it almost immediately to. Yeah. So I mean, now let's go back.

So these are kind of the early on options. Now let's go back to your teeth. Now let me ask you one question before you move on. Is there a difference with the approach. If the guy only had a prostatectomy, let's say that at least one of the nerves were bundles were saved or I, I plausible I don't think like honestly for all of those patients, if you had a prostatectomy, radiation therapy, or like a combo of all of them, I think my approach is pretty much the same. And I'll tell you why, because I'm only going off of the person in front of me, and I, I just explained to you the nerves and the blood flow are still compromised.

And all of these the only one that, like I may have to treat a little bit differently is the ADT patient, the patient who's also getting ADT because, you know, sometimes your libido is not there, even if you're getting the erections or your energy is not there. And that's something hard to treat. I do sometimes offer off label options for patients who cannot. Obviously, if you can't, if you're on androgen deprivation therapy, testosterone replacements not an option. And I'm sure you're going to have someone on talking about testosterone replacement therapy in the role of a prostate cancer or a post prostate cancer.

But we're not talking about that today. But, you know, there are off label options for men who have low libido because they're on ADT that I have provided, things like Slovan Sarin, which is approved for women, Braemar PlanetSide, which is PD 141, which is also approved for women. These are options that, you know, are not necessarily mainstream. I'm not recommending, you know, every practitioner do this if they're not comfortable. But these are inherently other things that can maybe help you achieve your erections or your desire to get the erections that you really want, that you wouldn't be able to because your testosterone is 20, you know, it's low.

And so, you know, maybe that, is one difference, but I agree with you on key goals is improved erectile dysfunction as well. So I think that the pathway is often the same for all of these people. And it's kind of a choose your your journey. Right. Some people are more interested in just doing a Viagra. They don't want to do the vacuum erection device. They don't want to do the restore acts. They want to just do, cialis and see how it goes. And I think the important thing here is when we're talking about recovery for all of these things, other than ADT, because you're probably going to be on it for, you know, 666 to 18 months, for the standard post prostatectomy or radiation patient, you know, your erectile function is going to achieve, you know, it's baseline in about 12 to 18 months.

Some people really say up to two years. So, you know, there is room for improvement for your erections for a long time. So the restore and the rehabilitation process can take a while. Having said that, and this is very, very important. And this is something I truly believe that I think, you know, we're starting to be more aggressive for if your penis doesn't work six months out and you're not responding to anything, that doesn't mean we just say, let's wait another year before we change something, right?

You know, we we talked, here. You want to go? No. Go ahead. I'm listening. Okay. So we talk about, you know, encounter cavernous injections. If someone's not happy, they're on the they're on the protocol and they're not. They're sexually active. They're they're trying to be sexually active. Three, six months after surgery. And Cialis and Viagra, the VD, the restore isn't working. I'm not saying. All right, well, you got a year. Let's just see if it gets better. No. Absolutely not. We are here to help you.

We want to achieve your goal. Now you've gone through the process. So, you know, the point is I am happy to advance you through the algorithm, which is, you know, often the intra cavernous injections. If it doesn't, if you know, your erections are not responding to the orals and you know, I have no problem giving penile putting penile implants in men three months after they have radiation and their penis just doesn't respond. You know, it's three months after they get a prostatitis, 3 to 6 months after they get a prostatectomy.

You know, often these guys, they have poor erections prior and then they just have no erections after. Why would I want to make sure that they recover from, you know, their procedure, they recover from their radiation. But why delay the inevitable? For someone who's been through so much, if we can give them that satisfactory life sooner and they're and they're highly motivated and perhaps and again, you like as you said, this is this this session is not about testosterone, but, you know, they can even get their testosterone back in some cases.

Right? Just, just and that's the only area that's incomplete. And we can help them with that. I think that'll be great. So then how does that so how does a penile implant works? Take us take us through that process. What what would a patient go through? How long does it take? What's that process? So a penile implant? There's different versions, but it's a surgically implanted device, you know, that can help men with erectile dysfunction get an erection. And it's. You know, what's important to understand is these implants, they are hidden in the body.

They can be used at any time without any planning, without any waiting. You know, obviously all the other things we talked about are all about timing or medication timing and injection and, and, you know, in general, there's two types. Right. There is the inflatable penile implant, which is really the the gold standard of the implant. It's been around for a long time, like over 20 years. And you know, there's how it works. It's a closed system where you have a pump in your scrotum and I'm a little bit, you know, older.

So, I mean, I'm sure everyone who's listening this is to, if you think about the Nike air pumps of your shoes, you know, you have a pump that in your scrotum, it's completely inside. You cannot see it, but you can feel it almost as a third testicle. And it allows you. And when, when, when it's time we put the implant, there's two, the two, balloon like, structures that we place inside your penis. And then we place a reservoir with that has, like, sterile saline inside this contained device. And when it's time to have an erection or you want to engage in any sexual activity, you pump up your scrotum like that.

Nike air pump on your shoe, and it fills your penis with the same thing, and it gets you hard, like you were 18 years old again and you have full sensation, full or full orgasm. Unless you're having orgasmic issues for other things, obviously. And, and you, you know, you're back to being you. What's pretty amazing about it is that even if you orgasm, right, you control of your erection state goes up or down. So you can keep going. Other rounds could keep going. You probably last longer than before the surgery, before you had, Well, here's the thing, right?

Defining how you last longer. Right? I mean, you can orgasm and then keep going this way because you're not going to lose your erection. I don't know the data on premature versus the late ejaculation, in terms of, penile implant and its role there. So I don't want to comment on it. But, you know, it is a wonderful device. And there's another there's delayed ejaculation, if you want it to be delayed, if you don't want it to be, I guess possibly, I guess what you're saying is the orgasmic aspect of it.

We don't know if they get a faster orgasm or right. Right. I don't believe to be the same. It should be the same. Right. I anticipate most of the time it's the same. And then there's the second device, which is a semi-rigid implant. Right. It's a, two rods that are in your penis. It's just simply the rods. There's nothing to pump up. And the silicone rods are kind of just hard all of the time. So you bend it down, you've done it up. When? When you want to have sex and you have full sensation, full orgasm.

And it's a little bit simpler. Some people, it's better for patients who have maybe bad arthritis in their hands. They can't pump, or they're just very intimidated by the whole process of pumping and deflating things. So so there I've placed many in, in, of both in people and the overall satisfaction is incredibly high. High 90 high. And in the 90s percentile. Often patients who get them, they say, I can't believe I waited this long to get an implant, because obviously, I think there is this idea of a stigma of, you know, addressing men's sexual health in this manner.

But I got to tell you, I think more and more people are considering that option. I'm still stuck on the fact that, you know, whatever Nike Air pumps are, because you don't look like you were around when these things were. I think I had them when I was like five years old, to be fair. Like I was just like, all right, all right. That makes a little sense. All right, all right. You got, man. You had air pumps at five. I don't know, I think so, or I just remember being at, like, Foot Locker and playing with them.

Right. Exactly. It's so. If I am listening and I had prostate cancer surgery or radiation or where I think, like, look, this thing hasn't worked in years and I want to get back in the game. And I want to get an implant. I'm listening to him like, yeah, where do I sign up? What are the downside? What's the downside? What are the side effects? What are the adverse events that may happen from, it is a surgical procedure. So what can go wrong. So I think first off, you have to be the right candidate, right?

I think, in general, most people with a penis are a good candidate. Okay. For a penile, obviously, you need to have is a penis for the most part. Yeah. Enhanced. Well, you might not need hands, right? We talked for this. I read your blog. But, you know, I, I think, most people are good candidates, but there are things that, you know, obviously, the one thing that I am very adamant against is people who have very poorly controlled diabetes, diabetes, when we're talking about anything that has to do with a prosthetic going into your body, the biggest and most concerning risk is infection.

The the the risk of infection in general is very, very low. Like 1 to 2%. It does increase to around like 2 to 4%. Maybe, maybe a little lower. And some people say in my hands it's a little lower or, you know, like people have their own, have their own numbers, which is fine, but overall the risk is very, very low. However, you know, if you have poorly controlled diabetes, there is data suggesting, you know, first off, the healing process is not as good to risk of infection is higher. And when I talk about infection, what happens when we have a prosthetic infection?

You know, we have to do a surgery. We have to remove the device, we have to wash everything out. We can often put in a semi-rigid, again. So you would probably have a semi-rigid, but at the end of the day, no one wants to have surgery. And, you know, you don't want to have a second surgery. We don't want to do this surgery again. It can cause, you know, fibrosis of your penis. It can cause potentially shrinkage and things like that. And so we don't want to put you at risk for that. The other thing is you have to be obviously a good, safe to have sex, right?

If you have heart problems and you're you're not even a good candidate for sex, obviously, you shouldn't be getting a penile implant. The other risks are some may differ with that opinion. I think knowing some of my patients, like. Yeah, I mean, I, I, I always have make sure that, you know, if I'm concerned, I'm sending my, my patients to a cardiologist to make sure that they're cleared for sex to avoid doing anything. I'm not giving them Viagra. Yeah. If you can't walk up two flights of stairs, you know, per hour, the the, you know, the heart guidelines, you know, you are not a good candidate for, for sex unless you get worked up by a cardiologist.

Yeah. So so that's something that athletic activity, sexual activity really is. Yeah. And I think that there's a, there's a huge issue or misnomer or misunderstanding or misinformation on Viagra and Cialis that it causes a heart attack. It does not. These medications aren't very safe. You know, what does it cause a heart attack? Someone who has an exercise or move their body. And now they finally have the motivation to have sex. So they take a pill that's going to give them a reaction, and then they have a heart attack from the strenuous exercise.

So it's not the medicine that's causing it is the activity that the medicine is motivating you to do. So yeah, that's just a side note there. The other thing is, you know, you can have a mechanical breakdown of the device over it, but but they do last a long time. Over 80% last ten years. And, you know, it's about a 1%, risk of a mechanical breakdown or, you know, a kink in the tubing or a leak in the tubes. That would require a revision. So, you know, these are some general risks, obviously, injury risk of injury to the area that you're operating in.

Risk of injury to urethra. There's risk of injury, you know, or bleeding. But in general, it's a very safe procedure. It takes about an hour to do, there's a small opening, and there's different approaches. You can make a small opening of your penis for some. Some use the penile scrotal approach. And a lot of times you can go home that same day. So, it is a, it is a great procedure with a high satisfaction overall, low risk, low mortality, you know, outpatient procedure for a lot of people. Obviously, you know, there's a lot of different people who have different situations where sometimes you keep them overnight or sometimes you need to be a little bit more careful.

But, you know, in general, I think, as long as you have a penis, as long as you take care of yourself, and you're motivated and healthy enough to have sex, I think, you're a good candidate for a penile implant now, is there? You said it. It can last about ten years. Does that depend on how often you use it? So if they use it every day versus once a week versus once a month, is that. I think it kind of depends. You know, I think it kind of depends where, you know, I do I do have guys who I've advised who just kind of like literally they were just using this thing like crazy and they yeah, I guess they ran it to the ground.

But then, you know, I have guys who use it and they're 20 plus years and they still are fine. So I don't think it's really fair to say I mean, I'm sure that more use of it probably puts you at higher risk. Just anecdotally, I'm not really sure of. I don't know if there's literature on that, wear and tear, I guess. Like, but listen, you're going to you're you're using that thing. Godspeed. You know, but I, I've, I've seen guys with the same one for 20 plus years and they've been using it every day, you know, and and they're fine.

I've seen guys just going through a run and, I used run through it in five years. But I've also seen guys who, you know, had hadn't used it in six years and just happened to be dysfunctional all of a sudden, you know? So, it's hard to say now, to be clear. The penile implant will not make your penis bigger and longer than what it was before. The surgical procedure for prostate cancer. Is that right? You read my mind. That's exactly where I was going next. So these devices, and this is what I tell people.

I can make you harder. I can make you bigger. If these made you bigger, I would be the richest man in the world, right? If I can make you bigger, if anyone can make it bigger, you'd be the richest man in the world. So what does it make you? As big as you were prior to your prostate cancer procedure. So? So what? I like to do it. The answer is it depends. Right? Like, some people have shrinkage, some people don't. Right. But what I like to do is any patient that I'm considering putting an implant in or they're interested, I will literally on the exam I will pull their penis.

I'll stretch it not to hurt them, but to stretch it out. And we call that stretch penile length. And usually I say like, listen, this is as long as I can probably make you when you are hard, right? This is as much tissue as my body as your body's going to give you. And when I put in a penile implant, you know, some people who joke around make it the biggest one possible that it's not. That's not how it works. I am fitting it to your penis right there. You know, we actually measure your penis during the surgery, and we are we are customizing the implant to be the length of your penis.

And there is data, though, that you know, you can restore that length by more frequent usage of the device. Right? So, you know, there is the saying you don't use it, you lose it. So even people who have really long term erectile dysfunction can lose penile length. And and that and coaching and educating people that you know, they're they may not be where they were before is important. Right. And and I have literally had people walk out and say, thank you for telling me this. I don't think I'm going to be happy with that length.

I'd rather just to Eisai or something like that. And that's important to understand. Right. So, you know, but but there is data suggesting like the more you use it that you're loosening that tissue that was around there. Right. So, you know, you can restore some length back. But once again, I tell this to my patients to listen. I'd rather have a hard, functional penis that's a little bit shorter than a ten, ten foot penis. That doesn't do anything. Yeah, right. That's my personal. That's my personal stance. Right.

The other thing is important about the penile implant is there's no turning back. We are putting a device inside your penis. There is no longer good blood flow to your penis. If we take that device off, you say I don't want anything anymore. I'm taking that device out. Nothing's going to work. Once you go to the penile implant, that is the one stop shop. You got one option, and that is the penile implant. If it stops working, we got to do a revision to get you back

Closing Thoughts and Resources 42:00

to have an erection. And I think that's a very, very important point. All the other medications you can try and mix and do whatever you want. But once you're at the penile implant, that's the final line, and you're going to be committed to a penile implant. If you're going to have erectile function in the future. Awesome, awesome. Doctor Justin Dubin, thank you so much. I think that, I'm loving the way we're covering all the different elements of, male sexual health and erections after prostate, treatment, with all our guests.

And certainly you bring the goods. Of course, there's always, I thank you so much for enlightening, us. I mean, I mean, I know some of that information, but I always there's always one thing that like. Oh, I didn't know that part. I had a podcast interview with one of our colleagues, Valerie Root. And here's one of the things I didn't know. And it's fascinating. And correct me again if I'm wrong. Penile implant during a normal erection. Natural erection without a penile implant, there is erectile elements to the head of the penis.

We have an implant. The head of the penis does not get erect. And it. I didn't know those details. It that's that's right on. Right. Yeah. It gets to penetrate. But the head of the penis does not get firm any. You can't you can't have penis. You can't have glans fullness. To some degree. Some people just aren't happy with how it's maybe a little less full. So you can people use vacuum erection devices. They do still use, you know, restriction at these when I'm saying women after with an implant.

Yeah. You can still use those. You're not going to injure the device. The device is inside of your body. Right? So some people do use those for getting that area a little bit more full, if they want that. And most people don't. But, you know, of course people do asking, you know, I'm, you know, I'm happy to coach them on how to do that. So, so yeah, that's one thing I wanted to do before I forgot. I know that we talked about the five things for erectile dysfunction, and I'm sure you're going to address this on another, another one of your talks is that that lasting good state of mind I always offer patients who are struggling with erectile dysfunction after any prostate intervention, opportunity to talk with the sex therapist.

I think that there's an incredible value there because, you know, life is different after sex. Sex is different after, after prostate cancer, no matter what. Or and life is different and life is different. And sometimes your relationship with your partner is different. So I think that that's always just an extra thing that is important to address. And that's never something that guys like to talk about. But I have had a lot of success, with that. So, I always recommend if you guys are listening and that's something some aspect that hasn't been addressed talking to your urologist or one of the other providers, usually they have a good resource there for you to connect with.

Beautiful Doctor Justin Dubin, thank you so much, brother. I really appreciate your time. Where can people find you? And of course we're going to figure out how to have your, bio and everything connected to the summit. Awesome. This was great. It's always such an enjoyable experience with you. UGL so you can find me. I'm practicing in the South Florida memorial health care systems. So you can just Google my name and you'll be able to see my practice there. I am also, on socials at Justin Dubin, MD on TikTok, Instagram and Twitter slash X.

I'm also on the man up pod, which is at the man up pod on TikTok, Instagram, Twitter slash X, and we also have a YouTube channel I always recommend. Please subscribe. We're starting to really invest, some good camera quality and editing there. And also you can listen to the man at Pod on all podcasting platforms, Spotify, iTunes, Amazon. So, Doctor Joe, thank you so much for having me on. This was really wonderful. Thank you brother. Always great to see. Always great to see you and to have these type of conversations with you.

Thank you everyone, for and is, yet another amazing episode of the Prostate Cancer Summit. I know you enjoyed it. I know it was valuable to you. And look, at least it answers a lot of questions. It answers questions about you don't you don't know what you don't know. So what are the different things that what can do after, you know, prostate cancer treatment. You know, there's we have the full spectrum here. So I know this is valuable. Thanks so much for tuning in. And I'll see you at the next episode of the Prostate Cancer Summit.

So long.