The Intimate Link: Heart And Sexual Health

Aaron Spitz, MD

The Penis Book.

Joel Kahn, MD, FACC

The Penis Book. I am going to click there. It is an eggplant. If you notice the lapel of this handsome man in a moment, we all appreciate it if you had to have some symbol that is not a bad symbol for a urologist. I am sorry. I have already spilled the beans as a urologist in Southern California. Author of that great book, which I have read. It is an amazing book, and I encourage everybody to read it. 

He is a leading authority on the topic. We are going to talk about male sexual health and the connections to heart disease. He also is a fertility expert. When The Doctors show was recording and filming in Studio 29 at Paramount, Dr. Spitz was a regular there with Travis Stork and the rest. Many of him because in the great documentary in 2019, The Game Changers, Dr. Spitz, played a prominent role, playing himself as a leading urologist. Talk about the relationship between diet and erectile function with three volunteer athletes. It was an amazing part of the movie. Thank you for being here, Dr. Spitz.

Aaron Spitz, MD

Thank you, Joel. It is a real treat, and it is an honor to be invited to your program because I know how high quality the work you do is. I feel legitimated being invited to share information with you and your audience. Thank you.

Joel Kahn, MD, FACC

Kind of you. We feel excited, too. For anybody. Let me just throw this out there. Is anyone listening, or watching from Southern California, you are a busy urologist, but people can see you.

Aaron Spitz, MD

Yes. I have a practice in South Orange County, California, and we are a large urology group practice takes care of all aspects of urology. However, I specialize in male sexual function and male fertility.

Joel Kahn, MD, FACC

Okay. Important topics. There is even a report in the news this week about cell phone use in male fertility. The relationship is not a good one. Get that phone out of your pocket, guys. But we will have to talk about that at a different summit in more detail. Why do you think I invited you to a reversing heart disease summit? I am setting up a question. But you are taking histories from men all the time and having erectile issues. What is the connection that you, as a urologist, are aware of with your specialty and my specialty overlapping?

Aaron Spitz, MD

Yes. Well, now that I have been in practice for over 20 years, I have had a chance to dig into human physiology. I have concluded that the purpose of the heart is to pump blood to the penis. I imagine that is why.

Joel Kahn, MD, FACC

Wait, everybody. Just a minute, everybody. Write that down, please. That may be the sentence of the entire summit. The purpose of the heart is to provide blood flow to the penis. Oh, my God.

Aaron Spitz, MD

It is a happy accident that also provides blood flow to other parts, too. But that is principally the most important function of the heart, at least in my world.

Joel Kahn, MD, FACC

Amazing. That explains that connection and where it goes. The health of the heart goes with the health of the penis. I think this would be a reasonable conclusion.

Aaron Spitz, MD

Yes. No, indeed. Of course, I am being a little facetious, but it does turn out that the penis is an excellent indicator of heart health. That is because the penis is a structure that is primarily comprised of blood vessels. Little, tiny blood vessels—a tiny sponge-like matrix—filled up the chambers of the penis that give us an erection. The health of all of those blood vessels mirrors exactly the health of the bigger blood vessels in our body, especially the blood vessels that feed blood to our heart and keep our heart pumping strong. 

Long before the coronary arteries, the arteries that feed blood to our heart, start to clog up and get the disease. Those little, tiny blood vessels in the penis show signs of disease. That penis, therefore, is a canary in the coal mine. When we start to see problems with the penis, it is not too late to save our hearts, and it is also not too late to turn things around for the penis itself. But several years before a heart attack or stroke, a man will notice a weakening of his erections.

Joel Kahn, MD, FACC

I apologize to some of you because this is a great interview, but my third of three dogs wandered through a gate and is joining me for this interview hopefully will be quiet, or we will have to return them to the shelter. We got him. But he is too sweet to turn her back on Lucy. I apologize; I am not having any gas. I am just so excited about what you are saying. Erectile dysfunction. You called it a canary in the coal mine, and there are going to be people who are wondering, What the heck is that analogy? Can you just break that baby down a bit?

Aaron Spitz, MD

Yes. Many, many years ago, before we had all the advanced technological sensors that we have now, coal miners would bring canaries with them to sense toxic fumes down in the mines. The canary was much more sensitive to the fumes than humans were. If they saw that canary drop dead in the cage, well, it was too late for the canary, but it was not too late for the miners. They could get out of there and be saved. 

When we see our penis drop dead, it is still not too late for our heart and our brain. We can get out of whatever bad habits or bad foods we have been eating that led to that canary in the coal mine dropping over and starting to get healthy and restored. You cannot bring the canary back into the cage, but you can bring your penis back. That is the difference.

Joel Kahn, MD, FACC

Now, a lot of people are listening, saying this is the most time I have heard the word penis in 5 minutes. Just get used to it. It is okay. We are two doctors talking with each other. Many people who are listening here are females. Females, no males. Please do not ignore this topic. You might be married to one. You might be friends with them. You might be working with them. You might hear this conversation, and it has been decades of this relationship, but this early warning detector system. No heart symptoms, and no clue of heart disease, but the penis is not working, and the visit to the urologist is important. But not all urologists are keyed in like Dr. Spitz. I wish they all were. That it is not just a prescription for a medication or a blood test for your testosterone. It is a thought about your heart. Just tell us a little bit. You mentioned that blood flow is the key to healthy erections, which all of us are listening to because at one point somebody had a healthy erection that led to a pregnancy. It is a normal life. Tell us a little bit more about arteries, healthy arteries, and male sexual health. Just any comments?

Aaron Spitz, MD

Yes, absolutely. An erection is a hydraulic event. There are these two chambers that are in the shaft of the penis, with my two fingers side by side. Inside the chambers is this sponge-like matrix of tiny blood vessels, and some arteries pump blood into the penis. Of course, those arteries eventually branch from your aorta off your heart. As the blood fills those spongy spaces, they expand with blood. As they expand with blood, they stretch out the lining of that chamber, making the lining wider and longer. That is what an erection is. It is those two chambers getting longer and wider because they are being filled up with blood. 

The reason that that spongy space can expand as it grows with blood is that the cells that line all of those spaces are tiny little muscle cells that can stretch out nice and wide. As we age and as our body deteriorates from poor lifestyle choices, poor dietary choices, age itself, or perhaps other medications, disease states, what have you. Those little muscles that can stretch get fibrotic and they cannot stretch anymore. Even though the artery is pumping blood into those two chambers, the blood can only fill them up so much. It is only a partial expansion. It is only a partial lengthening. That is what erectile dysfunction is. If we can keep those tiny, spongy blood vessel spaces nice and stretchy, which means keeping them healthy and youthful, we can preserve our erections longer.

But those changes in those spaces can happen as early as in our 30s. We may not notice it yet, but by our 40s, about half of men are starting to notice some weakening in their erection. By their 60s, 60%, 70s, 70%, and 80s, 80%. That is because those spongy spaces are now fibrotic and will not expand anymore. Not only do they have to expand to fill up the chamber, but the blood that goes in will drain back out. If they do not expand so much that they squeeze off the veins that are returning the blood out of the penis. Some men can get a partial erection and then lose it away because it was not enough not only to fill the chambers but to pinch off the return of the blood back out of the penis. Because when the penis fills up, that blood gets trapped in there temporarily. It is not just pumping, pumping, pumping; it is a big blood vessel. It fills, and it traps. The artery in the penis, too, can get disease. It can get clogged up with atherosclerosis—just the arteries to your heart and the arteries to your brain. But, well, before that happens, just those little tiny blood vessels themselves becoming fibrotic is the most common reason that we have trouble with erections.

Joel Kahn, MD, FACC

As an incredible explanation, and I hope everybody gets it, the plumbing, the hydraulics—I keep thinking of the Woody Allen movie, Everything You Want to Know About Sex, and that great scene where he was dressed up as a sperm. If you have missed that movie, please go back and watch it. It was released 35 years ago. 

Two quick questions as we wrap up our first segment of this interview. Those are the ones from a urologic perspective. A 45-year-old man walks into your office and says, my family doctor says, I should talk to you. I have had erectile dysfunction for the past year. Just forget the cardiology implications. The canary. What are you going to recommend in your starting workup for that situation?

Aaron Spitz, MD

Well, the foundation of treatment is going to be letting him know that this is something that he can improve with some natural means, such as diet, exercise, and habits. One of the keys to healthy blood vessels—those little spongy blood vessels being nice and stretchy—is that they have plenty of nitric oxide. Nitric oxide is a very important molecule that gets released, and it lasts for a few moments, triggers relaxation and stretching of the blood vessels, and allows for an erection to happen. Nitric oxide is what is harnessed by Viagra, IRA, and Cialis. These pills. The reason they give erections is because they allow nitric oxide to last longer and work better. But you can naturally increase the nitric oxide in the penis with dietary choices. Vegetables and fruits give you much more nitric oxide than animal products do, particularly green leafy vegetables. When you are a young man in your 20s, up to your mid-30s, you make all the nitric oxide you need. You do not have to supplement it. But as you start hitting your mid-30s, your cells start making enough nitric oxide, and you do need to supplement it with what you are eating. 

One thing for this guy is, Hey, what diet do you have? Let us move you into a more plant-based diet. Secondly, exercise. When you are exercising and your muscles are contracting, they will release molecules that help protect nitric oxide in your bloodstream and even boost nitric oxide. 

Just the shearing force of blood pumping through your arteries faster causes a release of nitric oxide into those blood vessels and also into the penis tissues. Get off the couch and make sure you are doing regular, vigorous exercise. Are you drinking a lot? Are you smoking? Are you doing a lot of marijuana? A lot of people in California are doing a lot of marijuana because it is legal and there is constant chronic use of marijuana, smoking, cigarettes, and drinking excessively. All of these things kill your erection. They damage the nerves and the blood vessels. Let us limit that, because a typical 45-year-old may not realize that the amount of recreational substance use he is doing is all that harmful for him because, in his twenties and his thirties, frankly, he was pretty bulletproof. But now it is starting to catch up to him. 

Now, once we have addressed all that and we are taking a look at his medication list, maybe by now he has had some high blood pressure and he is on an antihypertensive, a beta blocker, or hydrochlorothiazide.  That is going to hurt his erections, too. Maybe he can get shifted to a different antihypertensive, or maybe with the same diet, exercise, and lifestyle recommendations. You can get rid of his high blood pressure and get off those medications. Also, is sugar under good control? Diabetics have nerve damage and blood vessel damage to the tiny little nerves and tiny little blood vessels that are in the penis. Is your sugar under tight control? If not, let us get it under tight control. That’ll help your erections and sleep. Are you getting enough sleep at night? Because testosterone is a key molecule for penis health, If a man’s testosterone levels are too low, those little blood vessels also get fibrotic, and they do not stretch well. The only time a man makes testosterone is when he is in REM sleep, deep sleep when he is dreaming. If a guy is not getting enough sleep at night, he is not getting enough REM sleep at night. His testosterone level might be lower than normal. 

Or if he has sleep apnea, which is constantly at a subconscious level, waking him up, he may not be consciously awake, but he cannot get into that deep REM sleep. If he has sleep apnea left untreated, that is depriving him of making normal levels of testosterone. Not only that, the stress of the sleep apnea is making his body release a bunch of adrenaline to cope with that suffocation that is happening through the night. That adrenaline causes those little spongy spaces in the penis to constrict just as the muscles can relax. Nitric oxide and adrenaline constrict them down and keep the blood from flowing in. 

These are all the natural approaches to non-pharmaceutical approaches, but even so, men often still need, in the short term anyway, and sometimes in the long term, pharmaceutical intervention. That is where pills come from viagra, Cialis, and Levitra. They have the generic names sildenafil, tadalafil, and vardenafil, and they all work in a very similar way. What they do is let the nitric oxide that is getting into the system, even though it is less than it used to, last much longer, and activate those muscles much longer to stretch and open up than they normally would. That is how it works. so I may well provide that man with a prescription for one of these pills.

Joel Kahn, MD, FACC

That was absolutely one of the best, most concise explanations. I learned I did not know about REM sleep. People can wear an Oura ring if they want to track that and work on it. People get information from their updated Apple Watch on REM sleep or just do not go to bed at four in the morning and practice better sleep hygiene. That is the sleep apnea component. It is very easy now to do a home sleep apnea test and talk to your provider if you have concerns about low testosterone. 

We have been speaking with the author of The Penis Book, Dr. Aaron Spitz, from South California. I think it has been a wonderful discussion about the canary in the coal mine and why on a Reversing Heart Disease Summit. We also want to reverse erectile dysfunction because of this tight tag connection. We are going to come back after a short break with our premium members, who do not go anywhere. Okay, Dr. Spitz.

Aaron Spitz, MD

Alright.

Joel Kahn, MD, FACC

Thank you. Alright, everybody. Welcome back. We are going to go a little bit longer with Dr. Spitz here, who has been very generous with his time and his knowledge. The author of The Penis Book, who is a practicing urologist in Southern California and the star of The Game Changers movie. I am sure you all watched it but watch it again. You see. Yes, he was great in that natural way, there is The Game-Changers 2 coming up, right?

Aaron Spitz, MD

Yes, that is what I have heard. I do not know a lot of details about it, but I am pretty excited about it.

Joel Kahn, MD, FACC

Okay. But they have not signed a contract with you yet.

Aaron Spitz, MD

No, but I will tell you something interesting. The scene that we did in the movie for people who have not seen it was that we took three college athletes and gave them meat burritos for dinner: pork, chicken, and beef. Then we put a device on their penis to measure how many erections there were and how hard those erections were while they were asleep. Because men get erections spontaneously while they are asleep, they cannot control it. It is just a normal, natural function. 

Then we took those same three guys, gave them vegan burritos, and recorded their erections that night using the same device. We compared it to see if there was going to be any difference. These guys were normal. They had normal erections. But could one meal affect the erections differently from another meal, plant-based versus animal-based? Lo and behold, what we saw in these three guys was a 3–5 times increase in the number of erections they had that night. But that is just three guys. and Joel, you and I know that that is not robust science. That is not a true clinical trial. 

What I am excited to tell you is that there is now a true clinical trial underway in Maimonides Hospital, with Dr. Robert Ostfeld as the lead investigator. We are looking at many young, healthy medical students, and we are doing the same experiment with robust science. Does this difference play out? I suspect it will, but we will see what the data shows. It is very exciting that we have been able to go from a very flashy movie scene to now taking it to scientific scrutiny. I am excited to see how that plays out.

Joel Kahn, MD, FACC

Yes, that is very exciting. Although there has been a lot of growth in vegetarianism and veganism, if we can prove this point, we will catch them below the waist. If we cannot catch them above the waist, in terms of the healthy prevention messaging. Great. Well, in the last few minutes here, since you are such a wealth of knowledge, there has been in the news cycle constantly, a gentleman that I interviewed for the summit, Brian Johnson, who is a multimillionaire tech executive who has been focusing on reversing his age and uses a plant-based diet, which is humorous. His last name is Johnson, and he spends a lot of time talking about his Johnson, as is commonly described, and trying to anti-age his sexual health as much as he is trying to age his entire health. 

He is achieving great reversal of whatever measure of age. I believe he wore the same device that you used in the movie. He has the financial capacity to buy it. I think he did buy the same device, which he has been using in addition to a plant-based diet, exercise, optimal body fat, and lean muscle mass. He has been going through a procedure that is officially called low-intensity shock wave therapy, also known commercially as GAINSWave therapy. You have experience with it, and you give us the urologist’s perspective. Maybe the diet, the exercise, the REM sleep, and the reversal of sleep apnea did not do it all. Some guy wants a mechanical solution. Where does that fit in?

Aaron Spitz, MD

Yes. It has a role. I do perform low-intensity shockwave therapy for my patients as well because it does work. Now, it is important to know that this therapy, or any therapy, works on many, but it does not work on all. As with anything, always be aware of claims that this will make you 18 again, no matter what. That is not true. That is not true for Viagra. That is not true for any remedy. 

But for well-selected patients, it truly does improve erections. The way it works is that there are these low-intensity sonic impulses—shockwaves, we call them—that hit the penis. About 1500 to 2,000 of these impulses are delivered throughout a treatment session, which might last about 20 minutes. 

What these impulses are doing is fake, injuring the penis. What that means is that it does not injure the penis at all, but the tissues inside the penis respond as if they were injured with a healing mechanism. Growth factors are released, stem cells are mobilized, and the blood vessels of the penis are rejuvenated. Even some new blood vessels grow as well. When our bodies are injured, we have a healing response to grow new blood vessels in the tissue. This low-intensity shockwave is tricking the penis into having the same healing response. All those little spongy spaces of those muscle cells in there that are starting to get fibrotic with age get rejuvenated, the fibrosis goes away, they get more stretchy again, and new cells grow as well. so the penis can fill with blood and expand, widen, and lengthen better after the shockwave therapy. 

However, it will not work for everybody. It works best for men with mild to moderate penile fibrosis. If it is severe, it is not sufficient to reverse it enough to where you can have natural erections. It may downgrade how much medicine you need, but if you want to get natural erections off pills, it is best in that mild to moderate category. If a person is in the younger age range, from the 40s to maybe the mid-60s, it is going to work better in that population than a guy in his 80s. It is important to have realistic expectations. It is important for me as a urologist to select my patients appropriately, too. 

But if you look at all comers, for lack of a better word, it works for about 65% of men. That means it does not work for about 45% of men. Also, it causes no harm. That is the nice thing: even if it does not work if it does not get the desired outcome, it is not going to hurt the man. When it works, it can last for a few years. But we do not stop aging, and those changes keep happening. Eventually, the beneficial effect of it may wear down, but it can be done again. You can get booster therapy. 

One of the tricks with this for the patient is knowing which practice to go to to get their care from. It is not covered by insurance, and it is quite pricey, but not all low-intensity shockwave therapies are the same. Some devices are touted as providing low-intensity shockwaves, but they do not provide true low-intensity shockwave energy. Those growth factors in those stem cells are not being mobilized. They still make impulses, and they look at the machine and sound at the machine, but they are not the machine. 

It is important to be careful where you choose to have your therapy. Our practice has a best-in-class device, and typically you are going to find best-in-class devices in urologist practices. But when you venture outside of urology, into naturopaths chiropractors, and aestheticians, more often than not, those machines are not the real ones. Why do they not get the real ones? Because the real ones cost about three times as much. Also, they may not have the sophistication and medical understanding to know that they are not using the real ones. They may have all the best intentions, unwittingly purchasing a device that is not going to be very effective. It is an important thing to understand and to choose wisely. If you are going to select this therapy,

Joel Kahn, MD, FACC

Real wisdom from the expert, the author of The Penis Book, and the star of The Doctor Show. Although I missed that show. I know

Aaron Spitz, MD

Yes. Me too. 

Joel Kahn, MD, FACC

Yes, for a couple of years, but it was a great one when it was on a run. I had the pleasure of being on it several times.

Aaron Spitz, MD

Yes.

Joel Kahn, MD, FACC

Of course, The Game Changers movie. Dr. Spitz, thank you for taking your time and recording this relevant information. I think the message is that for guys and women who are in relationships with guys, erectile dysfunction is a heart event. It is a heart warning. Go see your knowledgeable urologist. But also, be sure you follow up with your primary care doctor. Arrange an appointment with a preventive cardiologist and get the full cardiac workup. Do not miss the clue.

Aaron Spitz, MD

Absolutely. I rely heavily on my cardiology partners when I am managing my men with erectile dysfunction. I want to know that that has been covered. I am not a cardiologist. I understand the relationship, and I want to know that my patients are in good hands from a heart standpoint.

Joel Kahn, MD, FACC

Good. Okay. At that comment, I think we will leave it there and say goodbye to Dr. Spitz and wish you a wonderful day. Thank you.