This podcast is for you, the Modern Man. I'm Dr Anne

Truong, your host. I'm an intimate health medical doctor

and best selling author of the book, Erectile Dysfunction Fix.

I'll do a deep dive into sexual health and performance and how

it affects men of all ages and backgrounds. So let's get

started, and be sure to visit my website at

sexualhealthformenpodcast.com for more information and

resources from the show. See you on the inside.

Hello there, Modern Man. I am so excited in this episode. I have

Dr Arthur Burnett. He is a Professor of Urology in Johns

Hopkins for 40 years, and he actually has a unique experience

with Viagra that we're going to talk about, because he has so

much experience and knowledge on men's sexual health that we can

probably talk about days on but we're going to dive into some

important issues. So welcome. Dr Burnett.

Well, thank you for having me, Anne. It's my

delight to be with you, Dr Anne Truong. Dr Truong, thank you.

Yes. Well, thank you. So let's dive into this.

Now, before we started, you actually has helped pioneer

research that led to the development of Viagra. So from

your perspective, tell us the story of how this came about and

how you contributed to the research on Viagra, and how

Viagra became such a common ED medication.

Yes, well, my interest in sexual medicine

almost had a foundation with some of this, and to some extent

serendipitous. But I think at the same time, as Seneca might

say, the philosopher from 2000 years ago in Rome, Chance favors

the prepared minded, and I certainly had the thought back

in my training at Johns Hopkins in the 80s, believe it or not,

that we just were not addressing men's health concerns very well.

And back when I was a junior resident, I was a little

dismayed that my chief residents would say, Oh, this patient's

coming in with the complaint of having something wrong with the

directions. And of course, back then, we weren't even that

precise with terminology. We just say, just put everything

together in terms of impotence and use that almost really

negative term, but give them a prescription of an herbal

supplement, you know, him being and if he comes back in a month

or two, and it still says he's got erection problems, and we

got to think about doing a surgical device called a penile

prosthesis. And back then, that was the era that we were kind of

on the heels of, of thinking about the kind of the ideas of a

psychotherapy and behavioral problems and interpersonal

problems. And it was it psychological and this and that,

but I think we started to understand that really, there

were really a science to erection disorders as a physical

problem, in many instances, leading up to cardiovascular

disease and other conditions, which we'll get into. But back

then, I was scientifically interested in how to address the

problem better. And we started really a journey back then, some

scientific work, collaborating with the neuroscientists here at

Johns Hopkins, and we figured out that the elusive chemical

that drove the chemical process from nerves, the nerve endings

that drive the blood vessel tissue and the penis to work, is

this drug, or is this chemical called nitric oxide. Nitric

oxide, which everybody kind of throws around these days. And of

course, nobody believed it back then. It was a gaseous molecule.

But it was really found out that really the science of many

disorders in the body do have gaseous molecules that are made

kind of on demand, not the traditional neurotransmitters.

And actually I figured that out and wrote a science paper back

in 1992 who'd have thought a urologic surgeon is writing a

paper in the journal called Science, and that was the

How did you learn that nitric oxide erection? I

foundation for how we learned about how erections are driven

by this chemical process.

mean, how did that come about?

So basically, what I had initially had

thoughts about was there were disorders of erections that were

uncontrolled, called priapism, and it's occurred commonly in

certain patient populations, such as those with sickle cell

disease. And believe it or not, in the cardiovascular

literature, as well as the hematology literature, we're

starting to understand that there was disorders of the

hemoglobin metabolism, red blood cells and things of that sort.

And we start to understand that there's a kind of a chemical

process involving nitric oxide, involved in blood vessel

functions. And so I said, Well, this may have something to do

with penile erection. I knew that the neuroscience group at

Hopkins was working on studying this new chemical in the brain.

And I said, Well, let's kind of turn, turn our attention to

maybe thinking about as a neurotransmitter or some sort of

agent that ran the the functional process in the penis,

and just seeing these different connections as science normally

goes, somebody has an idea based on somebody else doing something

else, and we kind of think about maybe new connections, new

insights, new directions to take science. And I said, what I

think this might be something we should be studying in terms of

the the blood vessel function in the penis, and there may be

something to it and and once we understood. That we had these

chemicals that were released in the brain can be released, but

based on certain chemical pathways that were being

described, I started to study that in the penis. And lo and

behold, that was indeed the mechanism that made the blood

vessel tissue in the penis work and open up and create

erections. And so it was kind of a connect matter of assembling

different insights that I was taking from different

disciplines, here and there. And then I kind of realized that

this was this basis for how erections would work.

Gotcha, so you did the research on it. So then, how

did Pfizer got a hold of "Okay with this medication that we're

using for the lung? I believe they were using a pulmonary

edema, right? Or pulmonary hypertension.

Well that also, where they started, is really

studying the heart for angina, chest pain from poor

circulation. And there's whole family of agents called

phosphodiesterases. So super family at least 11 or maybe more

now, and they actually have different localizations in the

body, believe it or not, this is how our bodies work. But they

had created this drug back then. It was called UK 92 480, just

kind of these pharmaceutical companies just come up with,

like, letters and numbers, and they were studying it in

chemical trials back in the early 1990s for men having chest

pain. The Amazing story back then was a lot of the men were

saying, Hey, I don't know about my chest pain, but I wake up

every boy with better erections. And in these phase one trials

they were doing with several men, and then they're in their

clinical center, and that's where they backed into thinking,

Wait a second, I'm hearing about the science of erections that

involves the pathway that controls this nitric oxide

release called phosphodiesterase type five. And these agents then

were realized that they were selective for that enzyme, and

by inhibiting those that enzyme, that enzyme actually with the

brakes on erection, and by blocking those breaks, it would

facilitate the erection response. And so they said,

moment, we don't need to be developing this drug for chest

pain. It may actually be something that we might turn

into a drug for erectile dysfunction management. And so

it's kind of serendipity, a little bit on that side, but

also kind of having Eureka, open moments to see that we were

describing, and some other groups as well. Now we describe

this as a as a physiologic mediator. I did some science to

show that it works in the in a live animal model. I showed that

it actually is released by nerve endings. That was a foundation

for the science article. And so that, along with some other

groups in the country, also doing some scientific work in

various ways, led to this basic foundation from which Viagra

came. And Viagra, even though his drug developed initially for

for heart drug, it then turned and pivoted to an erectile

dysfunction drug. And that's and that's kind of the story behind

it. Now, yes, it has been used for pulmonary hypertension,

because the enzyme PDE five, phosphodiesterase type five,

also is highly expressed in the lung. It's highly expressed in

the genitalia, believe it or not, that was, that was the

sweet spot about how it worked, because you could take something

orally, and then it can circulate in the body, and it

would only blocking enzyme in certain parts of the body, and

one part was in the genital region. And men and women,

believe it or not, and therefore, anything that

involved this nitric oxide chemical pathway with the right

stimulation process causing blood vessels to react, the

brakes on it were being inhibited by the drug. And

that's so it was studied for that. It was studied for

pulmonary hypertension because of the high expression in the

lung tissue as well. And so that's how we make discovery

with drugs. We understand the science, and then we kind of

make some observations, and then redirect drug therapy sometimes.

So you did the research on it, and then Pfizer

got a whole of that and developed the medication

sildenafil?

Yes, yeah, it was called UK-92, 480,

initially. And then once it was said, well, let's pivot from

angina clinical trials, heart pain clinical trials, as angina

is obviously but let's now go to erectile dysfunction clinical

trials. And all through the 90s. Now everything was a lot of

clinical trials related to erectile dysfunction. And then

it can emerge, got a name called sildenafil, and then it got a

brand name that we know now as Viagra.

So, I mean, I think Viagra came out in 98 right?

That's right. It was FDA approved in 98 and then,

of course, there were some, some other close cousins that came

out in the few years thereafter, also known as phosphodiesterase

type five inhibitors.

That's right, so let's just kind of talk a little

bit about that. So that way, audience, men, and the majority

of the people that watches our channel, men, over 55 and 99.9%

men, let's talk about the different type of ED medication,

the PDE-5 inhibitors, and for what indication? So we cover

sildenafil, which is Viagra, and then the next one is tadalafil,

which is Cialis. How did they differ? When to use what?

Yeah, yeah. So a good point to make. And of

course, there always is that question. When I see in my

clinic, you're right. Patients say which, which is better if

the different ones out there, why are they and why? The

accused, one or the other. I kind of half jokingly say, Well,

is there a difference between Coca Cola, Pepsi Cola, RC Cola?

Well, the answer is, is they're all kind of colas, but maybe one

has a different effect in one person's body, or a better taste

or whatever. And that's why we have these different drugs out

there. There is a true difference in some of the

pharmacology these drugs, even though they work in a similar

sort of way to promote the erection response. And one thing

about Tadalafil, which is Cialis, is that it's formulated

slightly differently by the manufacturer, such that it's

degraded in the body somewhat more slowly. And therefore it

says this is what we call a longer half life. And therefore,

with all these pills taken about an hour before they reach a kind

of a high level in the blood circulation, an hour later, that

then finds its way to the penile tissue and so forth. But one

thing about tadalafil is compared to sildenafil and

vardinofil and some of the others that are currently

available, is that it has a longer half life. And therefore

you can try sexual activity, not just an hour later, but it may

actually still be in your system half a day later, or maybe even

a day day or so later before finally breaking down

pharmacologically. And therefore it's been billed as a weekend

drug. It may be billed as a drug that has a potential advantage,

whereby just taking one pill, you can have multiple

opportunities for sexual activity, whereas the others may

get out your system somewhat more rapidly and perhaps less

than a day.

Why? Why they recommend it taken every day?

Why is it some men take low dose tadalafil every day?

So that's a different kind of storyline. And

what's going on with that is that the FDA did approve the use

of tidelife at a lower dose for those who have urinary issues,

and it's kind of used as a drug that you take almost in a

regular fashion, to treat a condition like a blood pressure

pill or something like that, that keep the effect of the drug

as it should be done. And so it's been shown that, yes, it

does relax the blood vessel tissue of the penis, but also

may have some sort of effect in the lower urinary tract to

facilitate voiding, maybe having something to relax the tone of

the urine outlet, or, who knows what. We don't fully understand

exactly what it's doing, but it has been shown to have benefit

in men having urinary symptoms. So this daily dosing for that

purpose is what's being done also, and I consideration is

taking it on a regular basis may allow a man to develop kind of a

steady state effect in his system. For that man to say, I

have sexual activity, maybe 1015, times a week, and I just

want to have it kind of my system. And therefore it's there

for that purpose. But the big question is this, is it taking

it daily? Is it more potent? Does have a greater effect on

creating an erection? The answer is, the evidence not very clear

for that, I think most scientific work would say that's

just not true. Rather, it's just a convenience for those who are

sexually active a lot, and maybe they help those with lower

urinary tract symptoms.

When do you decide to prescribe Viagra and versus

Cialis for ED?

Well, I think that the discussion is to

understand what that patient may sense is his goals with sexual

activity. If he feels that I just want something that's very

potent on something on some market a little bit longer, and

maybe go with sildenafl, if, on the other hand, the patient's

saying I want something that has a longer half life, that I have

sexual activity with a weekend kind of escapade, and I want to

have it in my system all weekend. And it's saying I don't

mind having a drug in my system no longer, and understanding

that do that some patients don't want it in their system that

long, any kind of drug, and they just want something out of their

system. And there may be a slight difference in the in the

side effect profile, too. That should be mentioned. It's

thought that dialysis or tadalafil may have a slightly

less headache kind of effect, because about one in six guys

will get headache sensations with sildenafil, there may be

some other aspect of effects on facial flushing and indigestion,

where there's some PDE five function elsewhere in the body

that the drug can have some effect on, although now, since

Cialis now todalafil, has had a greater effect on causing some

lower extremity kind of aches or back spasms in some patients

that we don't see what's so dangerous. So again, this makes

the point that different people's bodies behave

differently. There may be differences in just how

different people's bodies metabolisms work, just like

there's different responses to Coca Colas. And so some person

may try one and say it's helping. But unlike some of the

side effects you can, may come back try another, maybe more,

more at least, attractive to that patient based on less side

What's your approach to evaluating a man

effects maybe.

with ED?

Well, my approach is to first reassure

him and give him confidence that he's not alone, that he's not

somehow singled out, that he's not less of a man because of the

problem we're certainly nobody's trying to be judgmental by any

of this, and we understand that in many cases, it's not really

your personal fault. I try and tell them it's not your personal

fault, but things are changing in your body, and let's try

understand the causes behind it. See we can address. Things. And

so I think from the outset, it's a matter of being non

judgmental, giving us some confidence. Let him know he's

not alone, that we can find a solution. Let's try to

understand what the problem is. And then, very precisely, now,

because you mentioned Ed erectile dysfunction, we are

using a more euphemistic term than where we were back and when

I trained in the 70s and 80s, where we use this term

impotence, back then we just threw everything together. So

this thing is not working, pointing between the legs, and

just say that's the problem. And here we need to understand

whether it's an erection problem. Is it an ejaculation

problem? Is it a sexual desire problem? All of these things are

on the spectrum of men's sexual health, and I think we're

defining the condition more if it really the trouble with

getting an erection now, we go down a certain path of what we

can do to understand the causes there and what interventions

make sense, and we very forthrightly and non

judgmentally, go forward with what our options are and and try

to get that man back on track. So what's the workup that's

involved? Well, the workup, I think, largely, is having a good

evaluation with a history and physical examination. Going back

to the old time medicine, the William Osler and those Larian

method here, not just throw patient in a CT machine that

somehow pops out. What the answer is, let's just try

understand the problem. Let's understand the clinical history

of that patient. So the workup is getting a very thorough

review of his current history that says, health presentation,

what kind of sexual disorder we're talking about, and then

understand his health history, his past clinical conditions,

he's having, any medications he's on. Understand what are

what we now have really well defined ways of thinking about

what are factors that are causative for erectile

dysfunction? If we do have to do an evaluation, sometimes we will

do a penile ultrasound test, but usually that's for somebody who

has a severe enough presentation that we're contemplating doing

something surgical about the penis, or something that sort

including a penile prosthesis. Nowadays, I think we're we have

a list much more conservative approach. We have the pills, we

have other options like vacuum pumps and penile injections, all

of which are non surgical, all of which can be explored with

with knowledge that they're not going to be irreversible

options. And so sometimes it's a matter of just kind of figuring

out what the patient wants to do with all the options on the

table, and if they're certainly not irreversible options.

Irreversible, would be a penile prosthesis or some sort of

surgical fix. Then let's explore options that he may feel is

right for him, and we go, go down the path that way.

So how long do you have a man on medication for

before you say, Okay, well, it's time to go to the next step?

Well, it depends on each person's response to the

to the therapy. Now some men indeed, because of maybe the

severity of their presentation and maybe a severe history of

cardiovascular disease or diabetes, and they're just not

responding well to these medications. I'm not going to

say here, try this for the next two or three years and come back

and talk to me then. No, that patient may say, let me give a

trial of it if it's not working, let's get you back in a few

months, and let's kind of go over some other options. That

may have to be a little bit more likely to be effective. So it

comes down to what's going on with that patient and how he

wants to proceed

Right. Now, are you doing PRP for ED?

Immediate answer is, is I'm not personally doing

it. Do I feel that it's something that is a potential

option? I think that it is. At the same time, I'm very

forthright in talking with my patients to say, some of these

complementary and alternative options, I think do have some

interest. They do have some potential advantage in terms of

having at least some rationale in their use. At the same time,

we are still struggling to know how effective they really are,

that they maybe they may be effective under certain health

conditions, maybe certain circumstances. We're still

trying to understand and define this. And from that perspective,

I'm very just truthful with patients that these may be some

things we're still studying in our clinical trials, that if

we're offering it to you, from my perspective, there may be

those who can present it to you and present it hopefully in a

way that they can just forth widely say these things may or

may not be successful, but don't get disappointed. They're not.

Let's explore other options that are a little bit more

traditional and coming from a traditional background at Johns

Hopkins that we can explore, but these, I think these other

options just have to go a little further to make sure they're

within our our well defined, accepted guideline statements.

Do you what your do that institution is that, do you

add, like a lifestyle modification, like diet,

exercise, stress reduction, in treatment regimen?

Well, absolutely, absolutely. And I

think that that's something that's pretty much automatic for

men's health and women's health and everybody's health. I think

we unfortunately live in a society that we've modernized

ourselves to the point that we're actually doing damage to

ourselves. We're not getting enough exercise. It's easy just

to ride in a car then then go take a walk and half a block to

get something done. We have processed foods that we know are

don't have the nutrients in. There don't have the benefits in

there and, but they're fast and and maybe just pull it out the

refrigerator and eat it, or go to a fast food place. These

things have low nutrient value. So I do coach patients about

that. I think it's fundamental for your cardiovascular health,

for your keeping the weight, keeping your weight down, keep

your keep away from diabetes, keep your penile function where

it needs to be. So I support all of that, not only just activity

and diet, but even just good living, sleep hygiene, getting

your rest, avoiding cigarette smoking, not excessive alcohol

abuse. I won't advocate no alcohol, because I don't think

that that's being fair to everybody, but yeah, but

everybody can have a little bit of a occasion to have a toast,

of a celebration, or something that sort but. But but I think

that the reality is is all of these things that are life's

pleasures in some some instances, we may need to be a

little rigorous about what we're doing here.

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Absolutely, you know, like I said, Make it simple and

realistic. So that's ED. Let's move on to something that's not

as sexy. A subject prostate. Even urologist friend of mine

are saying that's not sexy. Let's not talk about it. But is

it a very important part of men's health, because it's

located right next to the penis, and it affects a lot of men. I

mean, the prevalence of prostate enlargement. It's the same as

like, ED, because it affects, yeah, men as they get older. So

let's just kind of like clear up, does enlarged prostate cause

ED or vice versa?

Well, you, to answer your question that they

don't cause each other. There may be associations with that,

and then we I can briefly just give you some background on my

answer. But I guess the pre the point you're making is indeed

the prostate is located in the pelvis. Various diseases related

to prostate including prostate enlargement that is commonly

associated with the ordinary symptoms prostate cancer, which

is not usually associated with urinary symptoms, but has an

association with regard to how it's treated, not just having

prostate cancer, but it. But the connection between the prostate

and men's sexual function is a topic worthy of discussion. And

I think there needs to be really some discussion, not to keep it

in the in the in the arena of a taboo subject, but bring it out

in the open. Let's talk about it so men are informed and then

know how to take action in the correct way understanding what

what is the association of prostate health and sexual

health? We need to make sure that's discussed.

So what is the association between enlarged

prostate and ED? Does it usually kind of go with one another? So

if you have ED, let's check your prostate. Or if you have

enlarged prostate, let's check to see if you have ED?

Yeah. So just to be, to go right to the chase,

the answer is, is the enlarged prostate is, I think, a bit of a

imperfect way to think about prostate health. But many men

have big prostates with no issues. A lot of men have small

prostates that have a lot of issues. So prostate size, in and

of itself, is not even really an issue. Prostate size is not

cancerous. Cancer can happen whether your size is prostate is

big or small, all right, so that's a whole different issue.

So let's make sure it's clear about that. So really, just

talking about having a big prostate, I think that is

something that we've, maybe even in our medical arenas, have kind

of communicated to the general public, is a big deal. The

reality is, is the men's prostates do start to get

somewhat more enlarged as they age. Because we all age, okay,

we get a little more gray hair on our head, maybe a few

wrinkles on our bodies. Well, the process get a little more

enlarged. And we do know that as men get older, they do happen to

have a greater instance incidence of lower urinary tract

symptoms with aging. Women too. Women too. As they start to get

older, I have it, have have some urinary symptoms too. So so just

saying, it's all about a big prostate. That's not true,

because we even have guys who who have smallest prostates and

have urinary symptoms. And the opposite is true. Some guys with

big prostates are doing great, but the association with sexual

health is one that we think that there may be changes in the

body, cardiovascular changes that have to do the blood vessel

function in the in the lower urinary tract, the way the

bladder functions in men and women, the urinary outlet and

the urethra and the urinary channel where urine comes out

that may have vascular changes as well in terms of the health

of that tissue, as much as it can affect the health of the

tissue in the penile area and in women, maybe another discussion

you'll have with. But somebody's expert in female sexual as well.

Say, Yeah, women, as they get older, they'll start to have

tissue changes in that part of the body they have to do with

their sexual responses. So it's really more a matter of of your

overall metabolic and cardiovascular health in your

vascular system, affecting tissues and area and various

areas of the body, and having urinary symptoms and sexual

dysfunction problems just kind of are hand in hand, but they

don't cause each other. It's just maybe something upstream is

changing these functions in the body simultaneously.

Interesting. So you said something very interesting

is that men that have small prostate can have urinary

symptoms. And just for our listeners, what we're referring

to is going to the bathroom many times at night, and then you go

to the bathroom, you feel like you have to go again after 30

minutes. And then when you go do number one, you urinate. It

takes like 10 minutes instead of just a few minutes. So those are

kind of the common urinary symptoms. Now, what is the

pathology when you have a small prostate, but yet you have the

urinary symptoms?

Well, again, it comes down to, I think, a matter

of, again, these urinary symptoms, which include, as

you're saying, frequent urination, some some of the

urges to go slow stream, maybe getting up at night a few times,

all of these kind of urinary symptoms, again, may be just

indicators of vascular changes and tissue changes in the lower

urinary tract area, in the urinary outlet area, where the

prostate sits at the base of the bladder. And these are just

changes that don't have anything to do with prostate size,

necessarily. And now, yes, some men, they get tighter prostates,

not just in large but tighter prostates, and that means it's a

little more of the bladder has to try and squeeze that urine

out, and that leads a lot more bladder agitation and creating

kind of the kind of a sensory awareness that your bladder is

doing a lot of funky things as the months and years go by. So

yes, men have more urinary symptoms along those lines, but

both men and women, there are going to be just aging related

changes, and those changes in the vascular functions of the

urinary tract, whether the prostate is big or small, can be

small, you can start to have these symptoms just because,

guess what, you're having some blood vessel changes that make

those tissues in that area start to kind of misbehave. And that's

what the issue is.

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Can you prevent urinary symptoms and or enlargement? Is there

something that you can do in your lifestyle to prevent that?

Well, that's always a thought here. What else

can we do for your listeners that can say, well, what can I

do aside from just getting older and then maybe having genetics

in play, you could be see many times some of the different

people's bodies are different on the inside as they are on the

outside. Some guys just genetically have bigger

prostates or more obstructive prostates as they get older. But

the answer is that, again, good health in general, good balanced

diet, good lifestyle adjustments. We think, in the

long run, that probably is even beneficial for blood vessel

system and and tissue functions that have to do with the

urination as well. So is there anything you can drastically do?

Probably not. I have by the same time, I tell people it's never

too late to get healthy, never too late to do lifestyle

adjustments, and so always consider that. But if a person

starts to practice this early in their adulthood, even younger,

maybe, and then just carry it through a lifetime of just

healthful habits. I think that'll probably put you in good

stead to have a better preservation of your sexual

function, better preservation of your urinary function.

Rght. Great. I'm glad to hear that. So let's talk

about prostate cancer. Yeah, right. So is it a man? When do

you recommend a man gets screened? Because let's not even

go into the controversy of PSA level and all that. But like,

what do you recommend a man to get screened for prostate cancer

or and then when to get PSA level?

Sure. Well, this is, again, a very important

subject. Should not be a taboo subject, because it's important

that we say you should get screened. And why is that so

important? Because it's so prevalent and it can claim

lives. I think that prostate cancer, debated by some out

there, is the leading cancer men in the United States, maybe

second to skin cancers. That may be a bit more. But among solid

tumors, prostate cancer is prevalent, and we know about one

in nine men. One in nine men will get prostate cancer, one in

nine. So that's highly prevalent, and one in six black

men, which we get into. It's a little further discussion on as

well. So so really, your point about getting screened has

relevance, because we want guys to know that this is something

maybe they should be getting screened for. Given the high

incidence of how it occurs, just but the fact that prostate

cancer is out there in society to such a degree that screening

is something to consider. Now, screening has had a great deal

of debate over the years, and the debate just fundamentally

is, is, does that mean that we're just putting people

through some sort of some, some sort of screening mill, or some

just trying to overdo and over diagnose prostate cancer,

because there is such a thing now that prostate cancer is,

I've always said to patients, is a broad spectrum disease. Not

all prostate cancer necessarily is that lethal. And as we learn

more about prostate cancer, we're starting to find some

subtypes of it that may be better managed just for

surveillance, but getting screened is key because it is

common. It will take lives. There are more aggressive forms

of it, and men should consider, particularly for your African

American race, or if you have, if you have a strong family

history, have a discussion with your doctor and perhaps get this

blood test called the PSA prostate specific antigen. It's

a blood test, and there's a normal range. As for many lab

tests we get that there's normal lab values. If it's outside the

normal range, that may raise a flag, then that may say, okay,

my primary care doctor screened me, but now I should be going to

see a urologic surgeon like myself to really further assess

why that PSA is outside the normal range, and then we carry

out further diagnostic tests to make a diagnosis. But screening,

it typically is the PSA blood test, then men should at least

be aware of the risk for prostate cancer, and if they're

at least have a high risk factors, really make sure that

you have at least a discussion. Now, the one last thing I'll say

before your next question is, is, who should get screened, why

and when? And the answer is, is there a variety of guidelines

out there? There is the thought that men between a certain age

range should be getting PSA checks. There has been the

thought that men between the ages of 55, and 70, according to

the US Preventative Services Task Force, a government agency,

those are the ages that men should be getting annual PSAs,

many other societies, even neurologic societies, make the

point that that may be a little too tight when as a window. And

many, many men, particularly African American men, may need

to think about age 45 or age 40 at least getting a at least one

speed, PSA, then just to at least know where you stand. And

then on the opposite end of the scale, should we stop at age 70?

Well, the answer is, is maybe not, if a man could still

acquire prostate cancer at 75 and die when he's 80. And he's

supposed to be living up to 9095, why did we stop so early

and checking his PSA? So in general, maybe a rule of thumb

is, if you still have at least have 10 years of longevity, get

your PSA once a year. The reason why we kind of don't want guys

getting it too old is because we're concerned that prostate

cancer, in general, does take five to 10 years to progress,

and we don't want older men it's still in maybe the best years of

their life, their golden years, and want to have still a lot of

fun out there. We don't them pursuing a treatment that may

have some potential for side effects and may significantly

impact their quality of life, whether it's surgery radiation,

and you get too old age range where it may not have made a

difference in that person's lifespan. And so we have to kind

of proceed in an intelligent way. Screen guys appropriately

discuss their risk, consider what interventions make sense

and what ages understand there are, there are other health

factors in their life, what the expected longevity, and then

make some really intelligent decisions about who should get

screened. And then even going further with decisions for

treatment.

So does a normal PSA, which is less than four, is

a normal PSA mean no prostate cancer?

Well the answer is, is even if you have a PSA in

the less than zero to four range, okay, that's the normal

you use as a cut off. We've used that customarily, based on some

early population studies. We're going back a few decades, but

the answer is, is yes. Can you have prostate cancer? Even if

your PSA is in the normal range, it has been shown so just so

sometimes, it's not just a matter of a PSA on any just one

occasion being a 4.1 or higher. I mean, it's possible guys have

had a PSA for a couple years around one or 1.5 and now it's

3.5 and then rechecked is 3.6 that kind of gives us a clue,

something's starting to change and and maybe that's an

opportunity then to do a workup, then not wait till it now comes

back a year or two after that, now it's 4.1 or 4.5 or whatever.

We've made a big gotten a better jump start on addressing

prostate cancer, picking up the signal that something start not

staying where it was not staying at his baseline level. And

therefore that might give us a clue that that man might need to

go ahead and get checked out, even though his PSA is still

less than four.

What is your protocol for checking out an

elevated PSA? Let's say, assume it's over four. And I guess what

you were talking about before was the, I guess the

progression, the speed of progression of higher PSA level.

But there's always some confusion as to like, Okay,

well, your PSA is a 4.2, 3 different levels before he

should go to urology for further workup, or it does he need to go

right away to get evaluated and possibly do a biopsy?

Well, the quick answer is, sometimes it's worth

getting at least another check before you just overreact,

because sometimes we've seen the spurious numbers, a number that

just with with that may have spiked for reasons that are not

clear. It could be a lab mishap, or just man just having

something else that triggered his PSA going up, maybe a little

bit of a prostate infection, maybe prostate irritation, some

other things that confound the PSA measurement make it

erroneous. That is so it confounds it. We know that some

men may have a PSA is a little more elevated because they did

get a true prostate infection, prostatitis, or maybe their PSA

is trending up because they just happen to have a larger prostate

genetically, and that PSA is higher because there's more

prostate bulk, making the PSA more prostate tissue there that

is responsible for that. So some other things can throw the PSA

to be elevated. Oftentimes, if you've had a steady PSA and now

that suddenly looks different, particularly if it's only been

like one value. I always tell patients, let's just repeat it

first. Let's repeat it. And if it looks like it's it's

elevated, well maybe we should proceed with further workup. And

what's that workup consists of? Well, you asked me what that is

and and typically that's a prostate biopsy that is to take

a sample from the prostate tissue sample that these require

urology Doctor clinic visit and discussion and then planning

ahead for a quick outpatient procedure called a prostate

biopsy. That's where we are here in 2025 now who knows where

we'll be in 2030 or 2040 we might have something as easy as

spitting in a jar and somehow get sent off to the lab, and we

already know what signals are there on a molecular level that

tells us what we can't do right now, but right now we need a

tissue diagnosis, because you're hearing me say that PSA could be

elevated for other reasons too. So that alone can't make the

diagnosis, but it is enough of a smoke screen to tell us

something might be out of out of kilter. And with that, let's

proceed ahead with the next step to try and determine whether

prostate cancer is the explanation.

Well, thank you for going over that. So we talk

about screening. So let's talk about prostate cancer. What's

the incidence? You said it's one in nine and one in six black

men. Why is it higher incidence than black men?

Yeah, yeah. So I, figured i'd tweak you a

little bit with that question on that. And the answer is, is that

we don't fully understand, I think there may be a number of

factors that have to do with with why that incidence is

higher. The other thing that's remarkable to say is the

mortality rate, the death rate from prostate cancer in black

men, is two and a half fold higher, two and a half fold

higher. And also, I think, other under resourced populations and

situations also are associated with health maladies. So health

access is a big deal. Big deal for certain populations that I

think has to be put on the table and say that's a factor there,

but it's also now. Are black men disproportionately affected by

environmental factors. Are they, do they also have some genetics

that play a role in all of this. Is a tumor biology that might

the body is handling certain kind of lifestyle, things that

men in black communities may have more than other

communities. So there's you can see there's a whole host of

things that may have to do with the adversity of prostate cancer

and black men, and we're still studying this in our scientific

communities. We're trying to understand why that is so, but

at least to just say, okay, the population based studies

epidemiology that we say has shown that there is this

difference, and given the so called Ethnic Disparities with

various factors in play, they may just be the disease state,

but it may be some other aspects of healthcare and healthcare

system and lifestyle, all these things, there's a lot within the

equation here that accounts for the higher rate.

Yeah, that's very, very interesting. So when do you

determine that the prostate needs to come out, or the

surgery called prostatectomy? Because we see a lot of men that

get that. So when does that determination occur?

Well, we carry out the biopsy, as I mentioned,

and then that gives us some information. By the pathology

review of that of the tissue specimens taken, and if prostate

cancer is found, with pathology doctors confirming this by doing

their complete evaluation, they'll come back and help us

know as the front line people here urology doctors aware along

the spectrum of risk profile the tissue is telling us is that

high risk prostate cancer, low risk prostate cancer, or

something in between. The pathology can inform us of this,

and we use this terminology of grade, which refers to the

aggressiveness level of the prostate cancer that can be

informed by how the tissue looks under the microscope, fitting

certain description profiles that then tell us whether it's

high risk type, intermediate risk type, or low risk type. So

we have to be so the bottom line is, define it first and then

define the patient. Understand, again, as I talked about a

little while ago, what other health conditions is that man

facing? Why? Much longevity is that I might approach a man

who's 50 years of age in completely great health, very

different than a 78 year old gentleman who has heart disease,

diabetes and now has prostate cancer, and then try to figure

out, even if they same sort of prostate cancer, how aggressive

I need to be to treat it in a young young man who's got three

decades ahead of them versus somebody else who might say,

Okay, you're somewhat older and we don't need to be putting you

through a prostate surgery. Maybe radiation will be enough

that we may have to go kind of a little bit more of a less

invasive approach. But surgery is probably the right option for

that man who's got still pretty good longevity, 10, 15, 20

years, wants to be definitively treated also, if he has a more

high risk prostate cancer, where radiation may or may not be as

effective, then we have to kind of then understand the disease

for that man and his health profile for that man, and then

kind of decide where we go with with what options we would

otherwise offer.

That makes so much sense. So a lot of men that have

the prostate remove have ED. How does that happen? Why is there

such a high incidence of ED after prostate surgery?

Well, it occurs with prostate surgery, but also

occurs with radiation. And I'll make that point very clear for

your listeners, because some there's so much, I think, myths

out there and misinformation. Oh, get radiation. It's not

going to affect your erections. That is not true. That is not

true. The truth about radiation, and I'll get into surgery in a

moment, is that after radiation, many men may have some radiation

early side effects of being a little fatigued with radiation,

having hormone shots that accompany radiation that fatigue

you. But they may say, a few months later, I'm feeling pretty

good, and I'm still having erections. Things are good. My

sexual function is kind of good, blah, blah, blah. But ask that

same man two or three years later, probably more than half

the men who have radiation with a little time of radiation

affecting the body, more than half will have erection

problems. It happens with surgery too. And I think the

bottom line is this, the nerves and blood vessels that run into

the base of the penis, deep in the deep in the pelvis that make

erections happen, can be affected by whatever treatment

is brought to prostate cancer. That is, is more than just some

of the simpler treatments for opening up the urinary outlet

for benign enlargement or something like that. But whether

it's surgery or radiation to treat prostate cancer, is deep

in the pelvic area. The prostates in a very unforgiving

part of the body, is a very precarious part of the body that

is right at the base of the penis. And any intervention that

affects the blood vessels and the nerves that regulate how the

erection process occurs deep in the pelvis, are there going to

be change? It's just a surgery. You see it more immediately,

because we do the surgery, and then you're going home, and you

feel like, as you're recovering next week or two, or three or

four, where are my erections? And then may take as much as a

year. And some men are maybe even longer, two years to get

the erection recovery back, because those nerves and blood

vessels have to heal, and they're kind of shocking, and

they need this time to heal up. Okay, but guys don't have

immediate erections, but they start to get it back, perhaps

get erections back and well performed prostate surgeries,

and men who are intact prior to surgery, that recovery could be

as high as 70 80% in those kinds of situations there okay, as I

said, radiation, you think you're fine, but then you lose

it. And so it's kind of like a different natural history

directions. You don't have it initially and but they come back

with surgery. You feel they're okay, but then you lose the

later with radiation. So any treatment for prostate cancer

does have that risk, and I think men have to be prepared to

understand that risk. They have to know that we do have some

strategies in both the disciplines of surgery for our

surgeons and the discipline of radiation therapy for the

radiation oncologists, that we're trying to minimize the

side effects. We're developing improvements in each of our

specialties to try and target the prostate better and have

less of the side effect issues. But the side effect issues may

still be there with either way of going, and men need to just

know the truth about that. Have the the really, the the honest

expectations brought to them about there are going to be some

changes at the same time. It's not doomsday. It's not doomsday

because we got options, and we just need to kind of work with

that man and say, Okay, let's just be forthright about it, and

let's talk about what we can. Can offer. Some men, even with

surgery, they'll respond to the pills, but there's also the

vacuum pump. They're injections. And some men, it may be that

their erectile dysfunction after surgery may actually be that

impaired, and they may have to go forward with maybe a penile

prosthesis surgery. But same thing for radiation, some men

may respond as if you know alternative interventions, but

some may find that as time goes on, the erections really are not

that responsive to anything, and they want a penile prosthesis.

And that will happen in that scenario as well.

Okay, gotcha, I like the way how you explain

that as well. So you post a surgery, do they enter some type

of penile rehab program?

Well, that's a good point, because that's kind

of widely advertised out there. Get your penile rehab. Brings a

lot of smiles, like, what rehab? What's that? I mean, I don't

know if I get an orthopedic surgery or back surgery or leg

surgery. I gotta go to the physical therapist and do work

that, work that, that part of the body over and kind of. Have

healed up better. Well, what kind of things do you do with a

penis to make it rehabbed? And the answer is, is, well, yeah,

we joke around a little bit about it, but the read The truth

is, is we do want to bring attention to the importance of

acknowledging having sexual dysfunctions after treatments

for prostate cancer, that we should not deny the reality that

can occur, that there are ways in which we should approach the

issue, in terms of the biology, the psychology, the sociology

and social issues with partners, in other words, giving attention

to the survivorship and how we can work to try to improve

quality of life. Work with various therapies that may have

true physical effects on the penis, although we're still

trying to work out what really can make the penis recover

faster with surgery or prevent some deterioration over time

with radiation. But rehab should have the connotation of a bio,

psycho, social and cultural kind of multi dimensional approach,

and that's what we kind of mean by penile rehab.

Right. I like that, definitely. But like you said,

how many percentage of men that have prostate cancer surgery or

prostatectomy regain back erection again without the

penile implant?

Well, I think that the true statistics are

probably going to be in order, about half the men. But again,

let me make sure it's clear we're talking about men who have

quality surgeries. We know that in the modern era of doing these

surgeries, and I've done about 3000 of these in my 40 years

here at Johns Hopkins, that we do these surgeries. Excuse me.

Excuse me. Well, where we know that the soft tissue that

surrounds the prostate, they carry a lot of the nerve tissue,

we can gently dissect that away from the prostate, like taking

the layers off the onion and then remove the onion, but not

damage some of those tissues. They may get shocky for a while

and but they'll recover. And we call that nerve sparing surgery.

Nerve sparing radical prostatectomy. If those

surgeries are done very well with good quality surgical

dissection and technique, those men are favored to get their

erections back, as long as he had good erections going into

surgery too. So again, and that man, as long as he's good

health, so if you have all the right attributes, good health,

pre operative erections, quality surgery, at least 50% of those

guys should be getting their erections back. And maybe even

higher, according to some statistics. But it's kind of a

little bit over the mat, all around the map, but, but again,

if you don't have a good nerve spraying operation, if your

erections were somewhat compromised before surgery, if

you're already having some health issues from some pre

diabetes, cardiovascular changes, blood vessel changes,

high cholesterol changes. You smoke cigarettes a little bit,

all these kind of things imply that you've already are

changing, that the vascular blood vessel function to the

penile tissue, and you're kind of the three legged stool. The

second leg getting kicked out means that the stool is going to

fall over. And so we want guys who had the best opportunity to

get the recovery to be the four legged stool, maintain your best

health and then have a good quality surgery. Those men, I

think we can expect to have high likelihood of getting their

function back.

That is so true. So men, if you're listening to

this, take care of yourself. Take care eat healthy. Do 30

minutes of exercise four times a week, and don't smoke, and

moderate your alcohol and sleep. And so if you get prostate

cancer later, you may just do well, because if you have four

legged stool there, you recover, instead of having a three legged

stool like Dr Burnett say. So, wow. We certainly talk about a

lot, but let's talk about something that we all need to

talk about, which is, why is sexual health remains such a

taboo subject for so many men and even doctors? it should be,

if pain is considered the fifth vital sign, it should be the

sixth vital sign, but yet it's still taboo. It's not talked

about. Why is that? Why do you think that is?

Well, I think that it's a taboo subject

because it is a sensitive topic, and it has kind of associations

with embarrassment, has associations with privacy,

associations with the maybe subject matter that may be

thought to be a youth potentially offensive or just

inappropriate, first a certain kind of public dialog. I'd like

to think that we can kind of move away from some of that

realm and still be very professional, be very upstanding

of in discussing these issues, because I think they impact our

lives. They impact our lives in serious ways, the sexual

function of men and women is certainly something that is part

of their health, their general health, and again, and as you're

hearing, could even be an indicator of your overall

health. So we got to just kind of accept that reality. Have

individuals like myself who have very authoritative, if you will,

and knowledgeable and credible backgrounds in the field to help

guide men and couples to move forward, to recapture aspects of

their life that they may have kind of pushed aside. Then we

need to just bring it, bring it forward as a subject matter that

we can address. The other thing is, I think we are able to

address it better than we did back, maybe back when I trained,

when things were kind of dismissed a little bit, and. And

then, as we bring things out in the open a little bit more and

just talk about things being a true aspect of one's general

health, hopefully we can over to overcome the taboo.

Have you seen it being more and open since the

80s? We're still somewhat behind here.

Well, I think we are making progress, but I think

the other thing that's a bit perverse that I will bring out

first discussion, and maybe we'll just, and we'll kind of

get into this a little bit more is just perhaps misdirection in

terms of what it is with male function, or even female

function. I mean, there's a lot of kind of myth surrounding men

should be able to get erections instantaneously, of all ages,

that all men should have a penis of a length that's a ruler or

something. Men should be able to have sexual prowess and and

carry on with a sexual act for hours. And in fact, I think our

media and maybe even some of our industry is contributing to some

of this, this misdirection, even, let's say guys who are

have normal function at age 25 and young women on some of these

ads are saying, I'm telling my man to use this pill. Because I

think they're just kind of creating these kind of scenarios

that then almost have a, I think, a tone in which it

redirects and misdirects and undermines the confidence and

that should be proper masculine understanding and behaviors. So

I think that it's a bit of a taboo subject, but also a

subject matter that's not correctly addressed in our

current society. I'd like to think that we can address men's

health in a more forthright way, in a more correct way than where

we've been.

Well, that's why we're having this conversation

on YouTube. We work globally. Anyone in the world can listen

to this and comment on this, because both you and I are

passionate about, and we want to bring this to mainstream

conversations and not something that is shameful, that is in the

closet. And like you said, good sexual function is really good

general health. And we know the research study shows that good

sexual function correlate with longevity. You live longer,

you're more happy, you're more healthy. And if you have good

sexual function, more so that we should really be focusing on

sexual function, and it's not just something that you talk

about behind the scene. So having said that, I thought we

had such good conversation. So where can our listener find out

more about you? You said that Dr Burnette had written many books,

and he has one that's about to come out, but he has some pretty

good ones that he has there as well. Can you show us some of

the books that you've written?

Sure. Well, the most couple books you looked him

up on amazon.com the one here having to do with just

celebrating Black Urologists in America. But one I'd like to

really focus on is the Manhood Prescription. And essentially

that's one, but basically this is one here called Manhood

Prescription. And what it is a book I wrote about two years ago

now, a little bit kind of clinical, but yet, yet, it has

information that the lay public can pick up and understand

various disorders of the penile area and achieve some better

understanding about how to manage these conditions, how to

ask the right questions and how to take care of your own health

better. At the same time, the next book that I'm coming out

with here in 2026 it really focuses on manhood in a way that

really helps men understand themselves better. Understands

what it is to to, yes, be masculine. Let's get away from

the Marlboro Man myth. Let's get a little bit more in terms of

guys who are doing the right healthy thing. Understand what

it is to have the proper maleness that get away from the

masculine toxicity issues out there that I've kind of alluded

to a little bit. Let's talk about what it is to build good

relationships. And our society has so many negative role

models, negative influences. Men and women are not having good

relationships anymore. Everybody's into their their

iPhone on their in their hip pocket. Too much pornography is

going on. I'd like to kind of help guys understand what their

best maleness is all about. And that's this is what this book is

going to address here, where we're working to get this out

the door. And again, being a urologic surgeon involved in

male health, involved in the science of erections and science

of maleness, and also having major roles that I have had over

the years, not just being a surgeon and a scientist, but

also a healthcare advocate, involved with policy and doing

other sorts of things in terms of men's health, I'd like to

bring kind of my background to help guys feel that they're

understanding the the best ways in which they're going to be

able to correct their concerns about their best health. So so

find this book on amazon.com, I look for mine coming out.

What's the name of it? What's the new book that's

coming out?

Well, we're tentatively saying Penis

Confidential, which tentatively suggested, yes, it's a book on

maleness and and women may want to read it too. But we're going

to have discussions for young men, teenagers and young men,

about what's important, about what they should be looking for,

about how they need to live their lives better, all the way

up to the older man with prostate cancer and

understanding that he's still in the game too, and we want to

make sure He preserves his best maleness and best men's health

as well. So we're going to have a lot of discussion with this

book. I hope it'll be exciting for population to want to pick

it up and just look my name up. I'm on amazon.com or if you want

to get a hold of me, just look up Johns Hopkins on websites.

I'm glad to see many want to come my way and have a

conversation as well.

Okay, so what website should they go to to

find out more about you? The

Johns Hopkins website. Just Johns Hopkins

Urology. Okay, you'll find it. Just make it easy, Johns Hopkins

School of Medicine, and then Urology.

Well, we'll put that link, and we'll put the

link to your Amazon book as well. And I'm looking forward to

hopefully have a signed book of your penis, confidential book,

and we'll get you back again to the show to talk about that

book, because I'm going to read it cover to cover. And then

let's dive into that, because I really like what you said about

you want to cover that aspect, so we have another interview,

and maybe in 2026 to discuss about the book, okay.

Oh, let's be my have spent some time with you.

All right. Well, thank you so much. Dr Burnett,

for being in the Sexual Health for Men Podcast and YouTube

Okay, Modern Man, you are not alone and you don't have to

suffer anymore. ED can feel isolating, frustrating, and even

channel and men listen to this twice, because the information

defeating. The endless guessing, the quiet shame, the weight of

not feeling like yourself is exhausting. But here's the

truth, you are not broken. You are not alone. You don't have to

figure this out alone anymore. The Get Wood Now Boost Program

that you heard today, may one day save your life and really

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will guide you have a sense of how you should really continue

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at getwoodnow.com. I'll see you there.

Thanks for listening to the Sexual Health for Men Podcast.

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next time.