94 Erectile Dysfunction, Premature Ejaculation, and Treatments with Dr. Irwin Goldstein

*DISCLAIMER* This message contains adult themes and is not intended for little ears

 

94. Erectile Dysfunction, Premature Ejaculation, and Treatments with Dr. Irwin Goldstein

 

**Transcription Below**

 

Psalm 139:13+14 (NIV) “For you created my inmost being; you knit me together in my mother’s womb. I praise you because I am fearfully and wonderfully made; your works are wonderful, I know that full well.” 

 

Dr. Goldstein has been involved with sexual dysfunction research since the late 1970's and has authored more then 350 publications in the field. His interests include penile microvascular bypass surgery, surgery for dyspareunia, sexual health management post cancer treatment, persistent genital arousal disorder, physiologic investigation of sexual function in men and women, and diagnosis and treatment of sexual dysfunction in men and women. Dr. Goldstein is Director of Sexual Medicine at Alvarado Hospital, Clinical Professor of Surgery at University of California, San Diego and practices medicine at San Diego Sexual Medicine. He is also Editor-in-Chief ofSexual Medicine Reviewsand past Editor ofThe Journal of Sexual Medicine. He is Immediate Past President of the International Society for the Study of Women’s Sexual Health and a Past President of the Sexual Medicine Society of North America. He holds a degree in engineering from Brown University and received his medical degree from McGill University. The World Association for Sexual Health awarded the Gold Medal to Dr. Goldstein in 2009 in recognition of his lifelong contributions to the field, in 2012 he received the International Society for the Study of Women’s Sexual Health Award for Distinguished Service in Women’s Sexual Health, in 2013 he received the Lifetime Achievement Award by the Sexual Medicine Society of North America, and in 2014 he received the ISSM Lifetime Achievement Award from the International Society for Sexual Medicine. He is happily married to his college sweetheart Sue, and together they have three children and five grandchildren.

 

San Diego Sexual Medicine

 

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Gospel Scripture: (all NIV)

 

Romans 3:23 “for all have sinned and fall short of the glory of God,”

 

Romans 3:24 “and are justified freely by his grace through the redemption that came by Christ Jesus.”

 

Romans 3:25 (a) “God presented him as a sacrifice of atonement, through faith in his blood.” 

 

Hebrews 9:22 (b) “without the shedding of blood there is no forgiveness.” 

 

Romans 5:8 “But God demonstrates his own love for us in this: While we were still sinners, Christ died for us.” 

 

Romans 5:11 “Not only is this so, but we also rejoice in God through our Lord Jesus Christ, through whom we have now received reconciliation.” 

 

John 3:16 “For God so loved the world that he gave his one and only Son, that whoever believes in him shall not perish but have eternal life.”

 

Romans 10:9 “That if you confess with your mouth, “Jesus is Lord,” and believe in your heart that God raised him from the dead, you will be saved.” 

 

Luke 15:10 says “In the same way, I tell you, there is rejoicing in the presence of the angels of God over one sinner who repents.”

 

Romans 8:1 “Therefore, there is now no condemnation for those who are in Christ Jesus”

 

Ephesians 1:13–14 “And you also were included in Christ when you heard the word of truth, the gospel of your salvation. Having believed, you were marked in him with a seal, the promised Holy Spirit, who is a deposit guaranteeing our inheritance until the redemption of those who are God’s possession- to the praise of his glory.”

 

Ephesians 1:15–23 “For this reason, ever since I heard about your faith in the Lord Jesus and your love for all the saints, I have not stopped giving thanks for you, remembering you in my prayers. I keep asking that the God of our Lord Jesus Christ, the glorious Father, may give you the spirit of wisdom and revelation, so that you may know him better. I pray also that the eyes of your heart may be enlightened in order that you may know the hope to which he has called you, the riches of his glorious inheritance in the saints, and his incomparably great power for us who believe. That power is like the working of his mighty strength, which he exerted in Christ when he raised him from the dead and seated him at his right hand in the heavenly realms, far above all rule and authority, power and dominion, and every title that can be given, not only in the present age but also in the one to come. And God placed all things under his feet and appointed him to be head over everything for the church, which is his body, the fullness of him who fills everything in every way.”

 

Ephesians 2:8–10 “For it is by grace you have been saved, through faith – and this not from yourselves, it is the gift of God – not by works, so that no one can boast. For we are God‘s workmanship, created in Christ Jesus to do good works, which God prepared in advance for us to do.“

 

Ephesians 2:13 “But now in Christ Jesus you who once were far away have been brought near through the blood of Christ.“

 

Philippians 1:6 “being confident of this, that he who began a good work in you will carry it on to completion until the day of Christ Jesus.”

 

**Transcription**

 

[00:00:00] <music>

Laura Dugger: Welcome to The Savvy Sauce, where we have practical chats for intentional living. I'm your host, Laura Dugger, and I'm so glad you're here. 

[00:00:17] <music>

Laura Dugger: Today's message is not intended for little ears. We'll be discussing some adult themes, and I want you to be aware before you listen to this message. 

Equip for Health is a health and wellness company that works with anyone who wants to achieve great health through simple, sustainable daily changes. They are passionate about improving health from the inside out and having a health journey that is both result-driven and enjoyable at the same time. Check them out today at equipforhealth.com, and make sure you use the code SAVVY at checkout to save 10% on their online course. 

We've received feedback that you all especially appreciate the episodes about sex. Men and women have written to us to share how this podcast feels like a safe place to learn more about helpful treatment options that are available for this private part of their lives. [00:01:18] 

When I first practiced marriage and family therapy, my husband and I were living in San Diego, and I was told about Dr. Irwin Goldstein, who practiced in San Diego and was one of the most sought-after sexual medicine doctors in the world. 

As a therapist, we often collaborate with medical professionals to offer clients the best care possible, so I frequently referred clients to Dr. Goldstein. Now, I'm excited for you to hear this interview with him, as we discuss a few topics we've never discussed before on the Savvy Sauce, including erectile dysfunction, premature ejaculation, and other fascinating relationships between other parts of our bodies and our genitals. God's intricate design of our bodies continues to amaze me, and this is an exciting field to learn more about. 

Here's our chat. 

Welcome to the Savvy Sauce, Dr. Goldstein. 

Irwin Goldstein: Laura, thank you so much for doing this. It's a privilege and an honor, and I look forward to a great next hour. [00:02:18] 

Laura Dugger: I've been looking forward to this for a long time. For listeners who are unaware, your work is very unique. So will you just start us off by sharing how you originally got into this field? 

Irwin Goldstein: I had no idea I was going to end up doing sexual medicine. It was an evolution of a series of forces. I'm from Montreal, Quebec, Canada, and I was a classic Canadian playing hockey and excelling in hockey. I ended up being recruited to Brown University in Providence to play four years of college hockey, which was an absolute blast. I enjoyed every minute of it. 

While I was at Brown, I snuck in a biomedical electrical engineering degree. That was the era of Vietnam, and I decided that there were really no jobs for engineers. That was a sad realization. A bad time. My brother was an M.D., he suggested that I do my engineering through sort of an M.D. relationship. [00:03:18] So I met with the engineers at Brown, and they said that it would be a wise idea to do biomedical engineering via an M.D. degree. 

So I ended up going back to Montreal, McGill University, to do medical school, and I fell in love with medicine. You know, medicine is... each organ in the body is a machine. It's like an amazing engineering machine. I ended up going into urology as a subspecialty area. We helped people. It was a lot of fun. We had a lot of procedures, a lot of diagnostic procedures. 

Through serendipity, the doctor who was my mentor trained in 1973. What happened in 1973 in our field is that a penile implant was developed, and he was one of the original penile implanters. When he started doing penile implants... my first penile implant was 1976. That takes me way back. But urologists entered the world of sexual medicine through the ability to help men with erectile dysfunction through surgery. [00:04:17] 

At the time, in the 70s, it was pretty much exclusively sex therapy, and only a small percentage of people thought they had a biologic basis. When I was entering urology in 1977, we could totally change a man's life who had struggled through, you know, sex therapy approaches, psychiatry approaches, mental health approaches. 

And the reality was we didn't know how penile erection occurred physiologically. There was no physiologic understanding of that. So in 1980, when I graduated urology, I applied to the NIH, and I was awarded a three-year clinical research investigator award, and we studied the erectile physiology. I was funded, at the end of the day, for 23 consecutive years to study erectile physiology. 

One of the outcomes of our research was actually to describe what was the actual chemical involved when you were sexually aroused that actually activated the erectile tissue. That ended up being nitric oxide. [00:05:17] So in 1991, our paper was the very first paper describing nitric oxide. 

That, of course, led to Viagra, and that led me to paths that were remarkable. I mean, how many billions of people have used Viagra? I was the first author on the Viagra paper in the New England Journal of Medicine. We got tons of phone calls. My staff hated me throughout that process. 

But what was fascinating by all the people calling us, asking us about Viagra, more than 90% were women. That was another major event in my life, realizing that there was no parallel path in gynecology to the parallel path in urology for sexual medicine. 

In 1998, we started our first fellowship for women sexual health. Basically, from 1998 to the present, we just opened up a sexual medicine clinic for men and women. It's really been an exciting opportunity to have here in San Diego now, a biopsychosocial facility, you know, 6,000 square feet. [00:06:20] 

We have two pelvic floor physical therapists. We have a sex therapist. I have two NPs, nurse practitioners. We have about six or seven medical assistants. We do about seven or eight research projects and clinical research for studying how things happen and what treatments are available. We do them in a sham-controlled or placebo-controlled prospective trial. Really very cool all the amazing things that are going on. It's been the most joyful ride that I could possibly imagine. So I didn't plan on going to this field, but through serendipity, it took me here. 

Laura Dugger: That is so fascinating. Now I would just love for you to tell us your mission at San Diego Sexual Medicine Clinic and what sets you apart and makes you one of the most sought-after doctors in the world. 

Irwin Goldstein: Wow. That's quite an accolade. Thank you for saying that. I don't know if it's true. But our vision is that we're an international facility that is dedicated to the study of the diagnosis and treatment of men and women or humans with sexual health issues. [00:07:28] We're completely dedicated to that endpoint. 

We spend hours with individual patients. We see the different biopsychosocial aspects, and we sort of merge discussions from psychology to biology to pelvic floor physical therapy and sort of better manage patients with these issues. It's so amazing and shocking how few facilities are really dedicated to that, where there's so many people who have these problems. But we've managed to be at least in San Diego now for 13 years. 

Laura Dugger: Previously on the Savvy Sauce, we've given so much airtime to women and sexual issues, and listeners can go back through our previous episodes and see all of these are still available to download. But now, Dr. Goldstein, I think it would be helpful to first focus more on men, and specifically, let's start with erectile dysfunction. If you don't mind sharing, what is it, who is affected, and what are the treatment options available? [00:08:33] 

Irwin Goldstein: I guess fundamentally, from a sexual perspective, the ability to achieve and maintain an erection that is sufficiently rigid to achieve vaginal penetration. His inability to do that creates shame and embarrassment and humiliation and all kinds of negative aspects.

The physiology of this has only recently been described. It's a pretty fascinating system where there are two erection chambers in the penis. There's an artery that delivers sufficient pressure that would allow the penis to become rigid, at least in an axial direction, in the up-and-down direction, so that it can penetrate through the vagina. 

How much force must the penis bear without buckling, i.e. its axial rigidity, to actually penetrate the average vagina in the United States? It's one kilogram, 2.2 pounds. That's the average vagina. That's not every individual vagina. [00:09:34] 

My whole point is, coming from an engineering background, it became very obvious to me that you could make something as emotionally complex and complicated, yet describe it biologically as a... I don't want to say simplistic, but more hydraulic-based explanation. 

I just had a 21-year-old person who flew to San Diego from Brooklyn to get evaluated because, at age 15, he had acne, took a medication called Accutane, and he believes the Accutane injured his ability to have an erection. He didn't understand why he had these problems. His parents were there. It was a big deal. We unraveled it with his three-hour visit. He ended up having scarring in his erection chamber that we identified on what was called a grayscale ultrasound. 

I guess my whole point of erectile dysfunction, there are psychological reasons, there's neurologic reasons, there's vascular reasons, there's hormonal reasons. [00:10:39] It's just really a detective's game to basically understand the diagnosis. 

For this 20-year-old who just was in the office, the explanation was, you can't study what's wrong with an erect penis, i.e. erectile dysfunction when you study it in the flaccid state. That point is so obvious, yet it's so apparent that most doctors can't make a man in an office have an erection to actually study it and find out what's wrong with it. 

Once you realize that, that's what you have to do, you have to generate a facility that has the ability to achieve penile erection in anyone who walks in the door, so that you can then study it in the erect state and figure out what's wrong with it. 

Depending on the diagnosis, management is the outcome. If it's a hormonal problem, we of course will deal with hormones. If it's a neurologic problem, we have a collaborative effort with a spine surgeon. One of the amazing things we're doing here, our work with spine surgery is simply unbelievable. [00:11:40] We can deal with neurologic issues and then the vascular issues, depending on what we find on the ultrasound studies. 

In summary, erectile dysfunction is the inability to sustain this one kilogram of force where the penis now buckles with the application of a force on the glans penis. Our job is to have the penis be able to bear a kilogram or more weight using as many strategies as we can, both physically and psychologically. 

Laura Dugger: With that, it sounds like it's not targeting just one age group or one demographic of males. Is that right? 

Irwin Goldstein: Yeah. We just actually placed a penile implant in a 16-year-old. That's a little young, but he was in a major car accident, had a bad pelvic fracture, and was unable to have an erection. He was really miserable. We spent a lot of time with him, a lot of psychological help. The penile fracture really injured the nerves and the blood vessels to his penis and both he and his parents decided that was the correct thing to do. He's absolutely now in college, doing well, being happy, being not embarrassed, and having a normal life. [00:12:54] 

We see from teens all the way up to 90-year-old men. I haven't dealt with a 100-year-old person yet, but I would definitely work with anyone at any age.

Laura Dugger: For someone listening who's curious about this, whether they struggle with this or maybe their spouse does, what are some warning signs that would alert them they may be struggling with erectile dysfunction? 

Irwin Goldstein: The penis has to be hard enough to enter the vagina and stay hard to maintain thrusting. A penis that sort of loses erectile rigidity in the process of thrusting or isn't rigid enough to enter the vagina in the first place or any orifice in the first place is very frustrating to the person. 

There is usually an explanation for it, and it requires some person with detective skills to unravel the various reasons. There are biological, psychological, and musculoskeletal. A facility that we happen to have assembled, which has the ability to look at all the different angles and contributions to the dysfunction is I think the ideal way to understand what's wrong. [00:14:04] 

Once you understand what's wrong, we're really good at fixing it, because it takes out the mystery. If it's a hormonal thing, we'll work until we resolve the hormonal thing. Neurologic, we'll fix the neurologic. If it's vascular, we'll really work in depth with vascular. We have some really new, fabulous, what we call disease modification strategies, as well as some very good symptomatic treatment strategies where we're able to really help the penis get and maintain its rigidity so that function can occur. 

Laura Dugger: I'm so grateful for people like you who are able to do this if someone maybe has experienced trauma, or you talked about that male who had been in a car accident. 

Irwin Goldstein: Let me tell you another quick story. This was an 18-year-old who presented with erectile dysfunction. At age 14, he was diagnosed with lymphoma. He had one year of multiple different chemotherapy agents. The irony of all this is one of the chemotherapy agents causes scarring of the muscle of the heart so that he always had to see a cardiologist through the last four or five years to make sure the agents that cured his lymphoma, because he's now cured of it, didn't cause damage to the heart muscle. [00:15:16] 

Of course, the muscle of the heart and the muscle of the penis are really parallel and analogous tissues. Of course, no one thought that the chemotherapy could injure the penis muscles, but of course they did. All of his erectile dysfunction [inaudible 00:15:32] going to chemotherapy, he was said to, "Oh, this is psychological. You're worried about the cancer, blah, blah, blah."

Then he finally ended up on our doorstep. We did the appropriate grayscale ultrasound studies during full erection. You can see the scarring of the penis. The erectile tissue homogeneity was not there. All I'm saying to you is it's not really a mystery. It's a hydraulic failure, and you just have to unravel the basis for the hydraulic failure, and then we can get on to treatment. 

Laura Dugger: That's incredible how your background with first engineering and then all of the other medical school all come together. Let's talk about another prevalent issue then in males. Can you just teach us more about premature ejaculation? [00:16:16] 

Irwin Goldstein: Well, that's one of our coolest things that we're doing right now is we're actually curing premature ejaculation. I can't tell you how exciting that is. There's another serendipitous story. We love serendipity. 

We have this machine called penile shockwave, and we didn't really discuss it during erectile dysfunction, but we purchased the machine for men with erectile dysfunction. This is a device that generates sound waves that travel faster than the speed of sound. Since ours is electrohydraulic, it comes out over 3,000 miles an hour out of the probe into whatever tissue you're aiming it at. 

So for men with erectile dysfunction, we generate this energy with the idea of activating stem cells, endogenous stem cells within the penis, so that they can replicate and then make more downstream cells, which is a healthy muscle, to make the penis more functional. So that's the idea. 

In certain patients, as we apply the shockwave energy to the various parts of the penis, the front part, the side parts, what we call the dorsal and ventral parts, there's an area called the frenulum, which is the sensitive part of a man's penis. [00:17:23] It's on the front part of the penis called the ventral surface. 

In usual, we can use relatively high energies to deliver the appropriate shockwave energy into the penis. In some men, when you apply the shockwave energy to their front part of the penis, they scream with pain. And it's like, wow, what am I doing? And we have to lower the energy dramatically. And then it dawned on me, every one of those people who couldn't tolerate the energy at the front part of the penis had what? Laura, what's the answer? 

Laura Dugger: Premature ejaculation. 

Irwin Goldstein: And I said, Oh my... this is another form of a penile dysesthesia. Let me explain a dysesthesia. So, aesthesia is feeling. Anesthesia is the profession that takes away feeling so you can operate. Dysesthesia is dysfunctional feeling. We finally had a tool, which we have never had before, and it ended up being the shockwave, that actually was able to identify a man who had a penile dysesthesia, a region of his penis that was so severely hypersensitive that any touch resulted in him having an ejaculation. [00:18:30] 

So, we've now been able to map out the region of the dysesthesia. We can take a Q-tip and point out that on the side of the penis, a Q-tip causes like, say, a sensation of a 1 out of 10. But when you touch the frenulum and the region around the frenulum, that's like a 12 out of 10. And if you go like 3 millimeters off the frenulum, you're back to the 1 out of 10. This is really oval region of amazing supersensitivity. 

So, we've now developed an in-house surgical excision of the hypersensitive tissue with now resolution of people's ability to control ejaculation. It is really fascinating, I have to say. We have to do more of them. We haven't really published this stuff yet, but we've done a whole number of them, and we've really changed people's lives. So, it's very cool. 

But that's probably a subgroup of PE. I'm sure not everybody has that. But it's been really fun to unravel at least this subgroup of men.

Laura Dugger: I can't imagine how exciting that would be once you make a discovery like that and you can help so many people. [00:19:33] 

Irwin Goldstein: Well, you know, it's the link between... we do men and women. So, most doctors or urologists do men, and most gynecologists only do women. So, it's not that many who do both. But if you have the ability to do both... we treat genital dysesthesia all the time in women. 

One of the genital dysesthesias that we treat are women who have unwanted, unremitting arousals all the time, persistent genital arousal. We see women with persistent unwanted itch, and they can't wear leggings, they can't wear anything tight on their body because it just itches everywhere. And that's another neurologic thing. 

So, the fact that we're familiar with genital dysesthesia through the woman's world allowed us to now identify a new genital dysesthesia in men. But nobody's really thought of it that way because, of course, most healthcare providers in this field sort of separate into the two genders, but don't do both. 

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Laura Dugger: Are there any other common issues that you see people struggling with on a daily basis that you could easily treat if they would be willing to make an appointment with you? 

Irwin Goldstein: I saw a whole bunch of people today, but since they're fresh in my mind, there was a, what, 27-year-old woman. She's actually a physician assistant who is on birth control pills for contraception. It's so sad. There's like 30-plus million women on this. 

The nature of birth control pills is that they raise a protein that's made by the liver called sex hormone-binding globulin. But it's actually a protein or globulin that binds the sex hormones and thereby renders them unavailable to the tissues. They're stuck inside this globulin. [00:22:47] 

One of the consequences of birth control pills is that everyone, all 30 million women, have a low testosterone because one of the things that the sex hormone binding globulin is very efficient at binding is the sex hormone called testosterone. So 30 million women are being, I'll use the word iatrogenic, meaning that doctors are doing this, causing a low hormonal state in women while they're getting what they believe to be is a safe and efficient contraceptive method. 

Well, the low testosterone has consequences in people. They have low interest. They get depressed. They get sad. They have muscle strength weakness. They have soft bones. But in particular, the opening to the vagina is very testosterone dependent. That area is called the vestibule. It's a region very poorly examined by most providers. You have to stretch it laterally because it's facing in the anterior-posterior position and the front-to-back position. 

If you examine women with pain, and there are, God knows, millions and millions of women with pain who have entrance pain during sexuality, it's being caused by their contraception. How crazy sad that is. [00:23:58] 

So you ask something simple to do. If you're a woman with sadness, low libido, and entrance pain, and you happen to be on the birth control pill, let me tell you a very simple strategy would be to change contraceptive systems to an actually more efficient system called the LARC, long-acting reversible contraception. An example would be an IUD or an example would be the Nexplanon or Implanon, the glass rods that go on the arm. Those do not affect SHPG. They do not affect testosterone. They do not cause the sadness. They do not cause the pain. And then we would provide a little bit of testosterone cream to get testosterone back into the tissues and resolve the pain. 

So that's easy-peasy. It's just that it's missed by so many people. So many women are on the pill, they just assume, since all their women friends have pain, they say, Oh, it's just natural to have pain when you have intercourse. I don't know anyone who doesn't have that. That's sort of sad. 

Laura Dugger: That's very sad because pain would always be a signal that your body is trying to let you know about something. [00:25:01] 

Irwin Goldstein: Yeah. But some people say, well, it's sex, and it's stretching my vagina, and it's supposed to be associated with pain because all my girlfriends have pain. It's not true, though.

Laura Dugger: I love that you shed light on this topic. But let's transition to a topic that many other listeners are interested in, which is hormones. Can you just give us a hormones 101? 

Irwin Goldstein: We can talk first men, then women. Critical hormones in men, of course, are testosterone. Testosterone is a product made by the gonad called the testicle. It's under regulatory function by messages from what's called the hypothalamus and pituitary. They release what are called gonadotropins, which are proteins that stimulate the testicle. 

So there's two kinds of low testosterone, one where the testicle itself has failed. That's called primary testicular dysfunction — sort of like a menopause situation. Just today we had a guy who, at age 15, 16, 17, 18, did intense weightlifting. [00:26:04] I don't know if you know about weightlifting, but the trainers sort of sell you anabolic steroids. His testicles shriveled because they were no longer needed to make testosterone. He was taking so much outside source testosterone so he could be the weightlifter. 

But now that he's finished weightlifting, he has essentially no testosterone in his body. He's a young guy, and his testicles are really the sizes of raisins. Testicles are normally egg-sized. So that's primary hypogonadism. We call that hypergonadotropic hypogonadism because the gonadotropins are elevated trying to stimulate the testicle. So that's one type. 

The more common type is where the hypothalamus and the pituitary won't release the gonadotropins to stimulate the testicles. So that's called hypogonadotropic hypogonadism, and that's called secondary hypogonadism. So we have good treatments for that. We have drugs that actually increase the amount of gonadotropins to help stimulate the testicles. [00:27:02] 

So testosterone is widely FDA-approved as a treatment for men as opposed to women. We have all kinds of strategies, both endogenous and exogenous, to treat men with low testosterone. 

Another important hormone is thyroid. It's sort of more common to have women with low thyroid, but men do have low thyroid. We pick that up more often than we should. There's another one. I have a healthcare provider who's a colleague of mine who had really low interest in sex, and we got a bunch of hormones in his prolactin, which is actually a hormone released by the pituitary gland to make breasts make milk, prolactin. 

His prolactin was about 20 times higher than it should be, so we got an MRI of his pituitary gland and a little tiny tumor called a prolactinoma there, and we treated his prolactinoma with medication. His libido came back, and he was very happy. He's a good friend of mine. Sort of weird that it was a friend that had that tumor. [00:28:01] 

But hormones in men on a 101 level mean that every person who walks into your office with a sexual dysfunction should have at least 9 or 10 hormones measured, including the thyroid and the prolactin, and, of course, testosterone. 

Now for women, the big issue is, of course, menopause. Menopause happens at age 51 on average. There's a lot of controversy that hormones are going to kill you and cause cancer and cause heart attacks and strokes. Most of that is just false, incorrect information. 

A correct situation for a woman would be careful monitoring of hormones with blood levels that they're in an appropriate level and what we call vulvoscopy monitoring, so we can actually monitor the tissues. During vulvoscopy, a woman, I call it evening the score, a woman can actually, who normally can't see inside the vagina to see the tissues, they actually watch their genitals on a monitor while we're actually doing the examination. So they get to see all the inside tissue and all the damage that low hormones do. 

And what's cool is that as we give back the hormones in the monitored way, so we can follow them and keep them at an ideal value. [00:29:09] We can watch the tissues become not atrophic, not painful, not erythematous, not with pallor, not with any of the usual findings that you see in women with menopause. So hormones are a fabulous and very safe way to maintain sexual function in human beings who have sexual dysfunction. 

For women, we do three sex steroid hormones. We do testosterone, estrogen, and progesterone. Of course, we also follow thyroid and prolactin, but for men, it's primarily testosterone. For women, it's three, testosterone, estrogen, and progesterone. 

Laura Dugger: That is fascinating. So, for women, it's menopause that will usually be the onset of the hormones really affecting their sexuality. Are there any other likely contributors or seasons of life for men or women that would throw things out of whack? 

Irwin Goldstein: So, I've discussed with you the issue of women and birth control pills, because that certainly throws their hormones out of whack. [00:30:10] Just to refresh the memory, the sex hormone binding globulin, it gets too high, and it binds all the testosterone, so their actual, what's called free testosterone, is quite low. So that's medication that throws hormones out of whack. 

But men have their own versions of bad hormones. A lot of men find that their hair is thinning. They don't like that, and they want to have a full head of hair. So there's a drug called Propecia, or finasteride, that is a strategy to increase hair. Well, it's a strategy that stops the dihydrotestosterone, which is the hormone that is not happy to hair. High dihydrotestosterone injures the roots. 

So the strategy by taking finasteride, or Propecia, is to lower dihydrotestosterone. But just to remind you and your listeners, that dihydrotestosterone is actually a critical hormone for the health of the penis tissue. So, you can't get it both ways. [00:31:07] 

So if you want to intervene, you put your hair at benefit and your penis at risk. And we see countless men who are taking hair loss drugs who have sexual problems as a result of their ingestion of that treatment. 

Laura Dugger: This is so many different avenues that we wouldn't link together, and you found these correlations. 

Sorry to interrupt, but we just wanted to remind you to give us a rating and review on your favorite podcast platform. This helps more people discover The Savvy Sauce and ultimately hear the good news of Jesus. Thanks for partnering with us. We truly have the kindest and most helpful listeners. 

I'm just in awe of all of this. Is there anything else that comes to mind that we wouldn't be aware of? Like nursing moms, we've always heard that hormones change at that point or during pregnancy, but those are more expected. 

Irwin Goldstein: Yes. So during breastfeeding, so postpartum... We had another woman who walked in today who had an episiotomy. She had a sort of traumatic birth, and the episiotomy incision would not heal. [00:32:12] She's three and a half months out and the wound still has not healed. One of the doctors tried to cauterize it with silver nitrate and it still didn't work. It was very painful to the woman. The doctor wanted to operate on her, so she came to me for a second opinion. We're gonna figure out non-surgical strategies to help her non-healing episiotomy. 

But my point is, during breastfeeding where she is in, the hormones are extremely low. Estradiol is very low, testosterone is very low. The tissues aren't very healthy. It's almost the equivalent of menopause, but it's not really menopause. But the ovary is not roaring out with lots of hormones as it otherwise should. 

The dilemma, of course, at least that she has to face is I'd love to give her some hormones, but she doesn't want to put the child at risk by taking hormones. So we have to figure out a strategy to get the tissue happy but not hurt the baby. 

Laura Dugger: Yes, very complex. One more topic that I want to briefly discuss, because your practice is ahead of its time, will you tell us a little bit more about your new regenerative therapy and your state-of-the-art cutting-edge therapy? [00:33:22] 

Irwin Goldstein: Thank you for asking. 10 years ago in Europe, actually from Israel, the first-ever shockwave device was applied to men with erectile dysfunction with the idea that the energy would give mitochondria... I don't know if you know what mitochondria are. They're the parts of a cell inside the cytoplasm that provide energy. So we can actually increase the ATP, which is the energy source of a mitochondria in the stem cells that exist in the penis. They can replicate with ease and make more opportunity to make more downstream cells, which are the penis, healthy, smooth muscle cells. 

So that was the idea. It was proposed 10 years ago. And it's widely, widely used in Europe, all over Europe, all over South America. The FDA has more or less blocked the introduction of shockwave devices for the same indication in the United States until the usual trials are done, double-blind, placebo-controlled, multi-institutional trials, like Viagra had to go through. [00:34:22] 

Those are $500 million trials. So pharma like Pfizer can do that, but device companies don't have that sort of background. So it's been a situation where you could get this treatment in Europe, but you can't get it in the U.S., it was very frustrating. 

We did a clinical trial with shockwave, like five or six years ago, trying to get the FDA to allow us to eventually get the shockwave device in. The company realized it would be too expensive, so they dropped out. I was at a meeting, In This Wish meeting, International Society of Study of Women's Sexual Health, at a women's sexual meeting, and displaying was one of these shockwave companies. They finally got clearance from the FDA to get the device into the U.S. for three things: amelioration of pain, increasing blood flow, and connective tissue activation. 

So with that clearance, and the designation by the FDA that this device was non-significant risk, NSR, to humans, we were able to get the device into our office. [00:35:24] Now, we're doing the sham-controlled, prospective placebo-controlled trial for men with ED with the shockwave, but we're now using the shockwave for many, many other uses. 

We talked about premature ejaculation, but men who have these curved penises, Peyronie's disease. We're using shockwave therapy for that. We're doing women who have pain. We're doing vestibular shockwave therapy for their vestibules. This woman who had an unhealing wound from the postpartum, we're doing shockwave therapy on her wound. It's amazing for diabetic ulcers and other wounds to increase blood flow to the region, so we're helping her heal without surgery that wound I talked about. So that's been an amazing opportunity for us to help people. 

The last part of shockwave therapy that I can share with you that's really cool is the 10 years of shockwave therapy for rectal dysfunction has always been on men in the flaccid state. So the men just show up in the office and they come in and they shockwave the penis as it is as they enter, which is their flaccid state. [00:36:25] 

When I started realizing, that was ridiculous. There's a thing called acoustic impedance, which means that tissue that's very thin, like a flaccid penis being pushed on by a probe. The diameter is only like a centimeter or less. Whereas a full erection, you can get diameters of more than six centimeters. So the acoustic impedance would be very high in somebody who has a wider tissue presented to the shockwave. 

So we have now done for the last three or four months only shockwave therapy during men with penile erection, which has never been done before, but it makes the most sense. And it's very obvious that that's gonna be how all people do that in the future. 

Laura Dugger: Is there anything else that we haven't covered yet that you would like to mention? 

Irwin Goldstein: Anyone who has a sexual problem, we will unravel it as best as we can and work with them. That's just who we are. 

Laura Dugger: If listeners are intrigued after this conversation and they want to explore more options for treatment, where would you first direct them? [00:37:26] 

Irwin Goldstein: We have a website, San Diego Sexual Medicine. It's an inventive and exciting website with lots of information about men and women and their sexual issues. 

Laura Dugger: Our podcast is called The Savvy Sauce because "savvy" is synonymous with practical knowledge. So as my final question for you today, Dr. Goldstein, what is your savvy sauce? 

Irwin Goldstein: I'm a big proponent... my father taught me this, and I'm sure his father taught him this. So this has gone through the generations. I tried to teach my own kids and I think we were successful. We're big proponents of work hard, play hard. When I go to the office, I'm all working hard. But when I leave, I love playing hard. 

One of the savvy sauce things that I love doing with my wife is date night. So playing hard for us is date night. I encourage people to set a time in your life to just be together, do exciting and fun things and be intimate with each other and find that we can not only talk the talk, but walk the walk. [00:38:31] 

Laura Dugger: That's wonderful. Love hearing that. Dr. Goldstein, thank you for your skilled work that impacts so many people in one of the most private areas of their life. Your work clearly matters and I'm so very grateful that you educated us today. Thank you for being my guest. 

Irwin Goldstein: Laura, thank you so much for doing this. You're awesome. Your San Diego days were awesome. Good luck in your new place and thank you for doing this. Really appreciate it. 

Laura Dugger: One more thing before you go. Have you heard the term "gospel" before? It simply means good news. And I want to share the best news with you. But it starts with the bad news. Every single one of us were born sinners and God is perfect and holy, so He cannot be in the presence of sin. Therefore, we're separated from Him.

This means there's absolutely no chance we can make it to heaven on our own. So for you and for me, it means we deserve death and we can never pay back the sacrifice we owe to be saved. [00:39:34] We need a savior. But God loved us so much, He made a way for His only Son to willingly die in our place as the perfect substitute.

This gives us hope of life forever in right relationship with Him. That is good news. Jesus lived the perfect life we could never live and died in our place for our sin. This was God's plan to make a way to reconcile with us so that God can look at us and see Jesus. 

We can be covered and justified through the work Jesus finished if we choose to receive what He has done for us. Romans 10:9 says that if you confess with your mouth Jesus is Lord and believe in your heart that God raised Him from the dead, you will be saved. 

So would you pray with me now? Heavenly, Father, thank You for sending Jesus to take our place. I pray someone today right now is touched and chooses to turn their life over to You. [00:40:36] Will You clearly guide them and help them take their next step in faith to declare You as Lord of their life? We trust You to work and change their lives now for eternity. In Jesus name, we pray, amen. 

If you prayed that prayer, you are declaring Him for me, so me for Him, you get the opportunity to live your life for Him. 

At this podcast, we are called Savvy for a reason. We want to give you practical tools to implement the knowledge you have learned. So you're ready to get started?

First, tell someone. Say it out loud. Get a Bible. The first day I made this decision my parents took me to Barnes and Noble to get the Quest NIV Bible and I love it. Start by reading the book of John. 

Get connected locally, which basically means just tell someone who is part of the church in your community that you made a decision to follow Christ. I'm assuming they will be thrilled to talk with you about further steps such as going to church and getting connected to other believers to encourage you. [00:41:38] 

We want to celebrate with you too. So feel free to leave a comment for us if you made a decision for Christ. We also have show notes included where you can read Scripture that describes this process. 

Finally, be encouraged. Luke 15:10 says, "In the same way, I tell you, there is rejoicing in the presence of the angels of God over one sinner who repents." The heavens are praising with you for your decision today. 

If you've already received this good news, I pray that you have someone else to share it with today. You are loved and I look forward to meeting you here next time.