Men's Sexual Health after Transplant

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Men’s Sexual Health After Transplant

May 1, 2024

Presenter: Jeffrey Albaugh, PhD, APRN, CUCNS, Urology Nurse Specialist, Jesse Brown VA Medical Center.

Presentation is  53 minutes long followed by 9 minutes of questions and answers

Key points:

• The most common sexual problem reported by men after transplant is erectile dysfunction.
• Sexual difficulties have also been reported in men after CAR T-cell therapy.
• Diet, exercise and weight control are monumentally important to sexual function.

Highlights:

(00:05:58): On average, females  take four times longer to reach orgasm than men -  roughly 13 minutes for women,  2.8 minutes for men.

(00:08:30): High blood pressure, diabetes and high cholesterol, as well as some blood disorders can reduce blood flow to the penis.

(00:09:00): Strong nervous conduction between your brain and your penis is essential for sex, and can be interrupted by head or neck problems, back problems and radiation or chemotherapy that affects the nerves.

(00:10:41): Low testosterone level (hypogonadism ) can decrease desire but plays a small role in achieving an erection and climax.

(00:22:03): It’s important to communicate about sex with your partner and healthcare team to avoid misconceptions and get proper treatment.

(00:27:46): Sex counselors, therapists and educators can help people improve their comfort in communicating about sex.

(00:34:06): Beware of men's clinics that do not use urology trained professionals.

(00:40:28): Testosterone replacement therapy has as many negatives as it does positives. It's a controlled substance for a reason.

(00:45:46): The most non-invasive treatment for erectile dysfunction is a vacuum constriction device, but pills are, by far the most popular option.

(00:49:03): Penile injections work for 70-80% of patients. Penile implant surgery is also an option.

Transcript of Presentation:

(00:00:01): [Jordan Sexton]:   Introduction. Good morning and good afternoon. Welcome to the workshop, Men's Sexual Health after Transplant. My name is Jordan Sexton  and I will be your moderator for this workshop.

(00:00:10): Introduction of Speaker. It's my pleasure to introduce today's speaker, Dr. Jeffrey Albaugh. Dr. Albaugh is a board-certified advanced practice urology clinical nurse specialist with over 30 years of experience caring for men and women with sexual problems. He is also a board-certified sexuality counselor. He currently works serving our nation's veterans at Jesse Brown VA Medical Center in Chicago and was previously the Director of Sexual Health at NorthShore University HealthSystem. Dr. Albaugh is the author of the book, Reclaiming Sex and Intimacy after Prostate Cancer Treatment. Please join me in welcoming Dr. Albaugh.

(00:00:46): [Dr. Jeffrey Albaugh]:  Thank you so much. I really appreciate the opportunity to present and thank you to all of you who are here with us today and those who listen in the future. I'm really happy to share my information and my insights from my many years of experience.

(00:01:01): I've been working with men and women with sexual dysfunction for over 30 years. My only goal today is to enlighten and empower you with some of the information you need to move you forward in your journey towards healing. I really appreciate the opportunity to be here.

(00:01:17): The term “men” in this talk refers to individuals with a penis. Everybody’s welcome. I want to start out by saying that when I use the word ‘men’—you'll see that word even in my title, ‘men’—what we're really referring to is ‘people with penises.’ So if you don't identify yourself as a man, that’s okay. In the literature and everywhere, unfortunately ‘men’ is the term that is used. But all are welcome; we don't want you to feel like you're not acknowledged or that you're excluded because you don't identify as a male or a man. That is okay. I'm happy to answer questions for anyone and everybody, regardless of your sexual identity or sexual orientation.

(00:02:03): You’ll hear me refer to people as ‘partners’ — you may have a partner or partners — all that's okay. This is a no judgment zone. We don’t have any judgment in my clinic because you're already pretty brave to walk into the clinic or ‘walk into’ a talk. You didn't have to walk in — you got to do it virtually today. But even to be a part of a talk on sexual health is brave because there can be a lot of stigma around it. But that's just what we're going to talk about today: sex.

(00:02:33): Hopefully you'll find it interesting and entertaining as well. If we can't keep you awake with a talk about sex, I think we've got a big problem today. We’re going to talk about a lot of things so feel free to ask questions. I will have time to answer those at the end.

(00:02:56): Background about Dr. Albaugh. This is about you and your journey towards healing, and I want to help you in any way that I can. It's been an interesting journey and I work with a lot of different patients with different medical issues. Certainly, a lot of patients with oncological or cancer issues. My area of expertise is urology and sexual health. I also do some couples counseling at the VA, and so I'm happy to share information about any and all of those subjects with you today.

(00:03:31): I always get a kick out of what patients call me in the community. I think I've been called pretty much everything in both of my clinics. An easy one that they call me quite frequently is Dr. Love, and I can own that, that's good. I see both men and women.

(00:03:55): But the male patients have told me that in the community they’ve referred to me as — and I thought this was pretty creative — ‘the penis whisperer.’ I thought that was a creative title to call me. Interesting. At any rate, I do work with a lot of people with penises who may or may not identify as males. We're going to talk about a lot of different things today and I hope all of it is helpful to you.

(00:04:26): going to start with Masters and Johnson who did this incredible, really cool research. In fact, we'll never be able to do research like it again. I do a lot of research. My PhD is in sexual health research. Oftentimes when outside people — like the government — come in to look at what to make sure everything is done properly , they choose my research because it's sensitive, because it's on sexual issues.

(00:04:50): Masters and Johnson did this research where they paid people to have sex in front of them or masturbate. They learned an enormous amount of information and it was incredibly enlightening. You can imagine that would be really difficult to get through an institutional review board in this day and age for research. But they learned so much and I'm so grateful that they conducted the research they did.

(00:05:11): What is the usual sexual response cycle? Research showed the sexual response cycle starts with excitement. It's this desire's there — this excitement — and that builds. Your pulse increases, your blood pressure increases, your tactile sensation increases, the sensation on your skin increases — it all increases so you can feel more and feel better. And excitement occurs. That builds and builds, but we don't want it to go on forever because we don't want our pulse to keep going up, our blood pressure to keep going up, those kinds of things.

(00:05:34): So, we reach a plateau where it feels really good, it feels really fabulous, but we haven't had an orgasm yet. Some people like to hang out in that plateau area for a while where it's feeling so good, so wonderful, and then it can build to orgasm and then resolution. Sometimes in women, they may be multi-orgasmic, so that orgasm phase may happen several times before a resolution.

(00:05:58): There’s a mismatch between when men and women are reach a climax during sex. But there’s a little problem here. That is, men take about 2.8 minutes on average — without trying to delay or do anything special from start to finish — and women take about 13 minutes before reaching climax. That presents a disparity, about four times longer for women. These are generalizations, of course. But if a woman with female parts, who identifies as whatever way they do with those female parts,  takes about four times longer to reach climax than a male does — if she's partnered with males — then there’s a little bit of disparity there.

(00:06:36): To overcome that disparity, some men make sure that foreplay is based on their female partners. With this thinking, their female partners are either on the brink of orgasm or already orgasming even before very much stimulation is performed on the male partners. That way, climax can then be synchronized. Sometimes that can be important for people. That's the sexual response cycle according to Masters and Johnson. It's a bit more based on the male model than the female model. But that is the model that they came up with and we've learned a lot from it. It's not perfect, but it does give us some good information.

(00:07:18): If nervous conduction between the brain and the genitals during sex is interrupted,  sexual dysfunction can occur. So, what happens? Genital arousal starts with stimulation. There’s also a psychogenic element, involving your mind. Stimulation therefore is tactile on the skin — on the penis, on erotic zones across the body — as well as through sexual thoughts. These sexual thoughts are integrated in the brain along with the physical stimulation. That travels down the spine to the peripheral nerves and into the penis. So, there's a communication loop between the penis and the brain, and the brain and the penis, and back and forth. That nervous conduction between the brain and the genitals is essential for both men and women because when that nervous conduction is interrupted, sexual dysfunction can occur.

(00:08:03): Eventually, in both the male and female anatomy, the genitals become engorged with blood. Inside the penis, there are three ‘cylinders’ that become full of blood, and those cylinders — as they fill with blood — press against the superficial veins and lock the blood in the penis so that you attain an erection and it stays.

(00:08:30): High blood pressure, diabetes and high cholesterol as well as some blood disorders can reduce blood flow to the penis. What could impact blood flow? Suffering from a comorbidity (when a person has more than one disease or condition at the same time) is one cause of reduced blood flow. Common comorbid conditions  are high blood pressure, diabetes and high cholesterol. But blood disorders, such as sickle cell and multiple myeloma, can affect blood flow as well.

(00:09:00): Nervous conduction between the brain and penis can be impaired by head or neck problems, back problems and radiation or chemotherapy that affects the nerves. Strong conduction between your brain and your penis or genitals is essential. Having lower back problems like lumbar disc issues or any head or neck or any back problems can affect proper conduction.

(00:09:17): Radiation can cause nerve damage because it can hit those peripheral nerves. I see prostate cancer patients who have had surgery during which the nerves had to be pulled off the prostate to remove it or have had radiation; those patients will most likely have issues with nervous conduction between the brain and penis. Any kind of radiation to treat other diseases might damage nerve conduction. Some chemotherapeutics might even cause neuropathy or nerve damage. So, any of these examples could cause problems with nerve conduction. To recap, blood flow and nervous conduction are essential to erectile function.

(00:09:55): There are different types of male sexual dysfunction disorders. There’s the desire disorder where a patient has low libido or desire. Now desire is made up of a lot of different things, so we have to pull it apart to see what is really going on.

(10:13): What you do about desire is very different than your desire. If you think about sex like most men might — every day, often multiple times a day — that's all normal. But what you do about it — having sex with a partner or partners or masturbating — is very different from the sexual thoughts or desire. So, when we’re talking about desire, we're talking about the sexual thoughts, the need for sex, the push towards sex.

(00:10:41): Low testosterone level (hypogonadism ) can decrease desire. Hypogonadism is a syndrome in which you have low testosterone along with symptoms brought on by low testosterone. Those symptoms could include erectile dysfunction, but the hallmark sign is a lack of sex drive. You don't think about sex much anymore. You can also experience decreased energy, decreased mood, decreased concentration, fatty weight gain, lots of different symptoms. Several symptoms, along with low testosterone is what hypogonadism is. Those are the desire disorders.

(00:11:13): Erectile dysfunction is the inability to attain and keep an erection hard enough for sexual relations with a partner. So you can't get and stay hard enough for sex even on your own. You know when you can’t get and stay hard enough and that is what erectile dysfunction is.

(00:11:32): An orgasm disorder is premature ejaculation, when ejaculation happens too quickly. You have no control over it, it causes distress and often happens within a minute or less of vaginal penetration.

(00:11:43):  Some men have the opposite problem, however, which is difficulty reaching climax, which can be caused from nerve damage. The blood flow can get into the penis, but if you have nerve damage, the communication between brain and penis is blocked which can affect both erections and the ability to reach orgasm.

(00:12:14): The most common problem for which men seek help is erectile dysfunction. The most common one, by a landslide, that brings men into the clinic is erectile dysfunction. Inability to get and keep erections sufficient for sex. But I do see all the different disorders.

(00:12:24): Sexual dysfunction. What happens after transplant? Why are we even here today talking about this? Well, it's really important and I salute the people who planned this conference because oftentimes sex and intimacy are overlooked because there are many other critical things to talk about. But this is also a part of the human journey. I'm glad that they include these topics in the discussions each year.

(00:13:00): Sexual problems are often not discussed by doctors and patients. But why are we talking about it? We’re talking about it because 62% of transplant patients and 79% of partners reported that sexual function had not been discussed with them. Nobody asked them or talked to them about these issues. And we know from research that patients are reluctant to bring it up with their providers as well.

(00:13:37): In one study, over 68% of men reported sexual difficulties prior to transplant, due to previous therapy. In one study, erectile dysfunction rates hovered around 68% prior to transplant, caused by other treatments — chemotherapy and/or radiation, for instance — aimed at achieving remission status before transplant. The the erectile dysfunction rate jumped to 100% one month after transplant, but was down again to 60% one year post-transplant. So, the majority of patients will struggle with sexual issues, but are they being addressed? That's why we're here today to talk about it.

(00:14:13): Most men reported were erection and ejaculation issues. That makes sense because a transplant could affect blood flow and nervous conduction, and erections and ejaculation are dependent on proper nervous conduction back and forth between brain and genitals. In one study, 57% of men reported significant sexual issues. of life.

(00:14:46): Multiple studies found sexual dysfunction adversely impacts quality of life. It is part of the human journey to be sexual. It’s okay if you aren't sexual or don't want to be sexual. But if you desire a happy and healthy sex life and you're not able to function, then it needs to be addressed.

(00:15:09): Multiple studies found that the majority of men post-transplant had abnormal hormone levels — mostly elevated luteinizing hormone (LH) or follicle stimulating hormone (FSH) — and those elevated LH and FSH levels will affect testosterone. Going through transplant may also affect hormones like estradiol — estrogen in your body — and prolactin.

(00:15:33): 38% of men had decreased testosterone levels which is necessary for sex drive, but plays only a small role in achieving an erection or climax. The main function of testosterone is to give you your sex drive. It has a very small role in erections, and it has a small role in climax, but it has a big role in desire and sex drive so that's important to consider when you think about testosterone. Low testosterone is not the main reason for erectile dysfunction — roughly only 5% of men with erectile dysfunction have testosterone deficiency — but it is one of the main reasons for a lack of desire, a lack of sexual thoughts and drive towards sex.

(00:16:23): Short explanation of what bone marrow/stem cell transplants involve. Let's talk about that. But before we do, I want to say that when we talk about a blood stem cell transplant, it's a hematopoietic stem cell transplant, but it can also be called a bone marrow transplant or a stem cell transplant interchangeably. It can be autologous where they use stem cells from yourself, or it can be allogeneic, using stem cells from a donor or a relative.

(00:16:55): Prior to a transplant, patients typically receive high doses of chemotherapy and/or radiation to destroy their disease and make room for healthy new blood stem cells. If the dosage of chemotherapy and/or radiation is high enough to completely suppress the patient's immune system, that's called a myeloablative transplant. But when a less aggressive combination of chemotherapy and/or radiation is used to prepare a patient for transplant, it’s called a non-myeloablative transplant.

(00:17:30): A blood stem cell transplant is used most often to treat patients with multiple myeloma, leukemia, non-Hodgkin's lymphoma, Hodgkin's lymphoma and myelodysplastic syndrome. A blood stem cell transplant can also be recommended for genetic or inherited disorders like sickle cell disease, thalassemia, immune deficiency diseases, Wiskott-Aldrich syndrome, neuroblastoma — a number of different diagnoses. That’s a little background on transplants before I talk about CAR T-cell therapy.

(00:18:05): What is CAR T-cell therapy? When we talk about chimeric antigen receptor T-cell therapy — referred to as CAR T-cell therapy — that’s a treatment that removes T-cells from the blood and inserts a new gene into them to make it easier for those T-cells to fight cancer. The new cells are called CAR T-cells. The CAR T-cells are then infused into the patient to begin fighting cancer.

(18:31): CAR T-cell therapy can cause cytokine releasing syndrome, which is one of the most common side effects triggered by the immune system response. It occurs when the modified T-cells are introduced into the patient's bloodstream. The T-cells start targeting cancer cells — which is their job — but they can simultaneously release a large number of cytokines which are proteins that can cause the immune system to ramp up and overreact. That can lead to fever, low blood pressure, muscle pain and other flu-like symptoms; sometimes more severe side effects can occur.

(00:19:00): CAR T-cell therapy can trigger neurotoxicity. We talked about how that is critical for sexual function and erections. And it al can cause blood disorders.

CAR T-cell therapy may also impact blood flow that is so important for erections. And finally, patients undergoing CAR T-cell therapy are more prone to infection.

(00:19:31): In a study of sexual dysfunction after CAR T-cell therapy, severe sexual problems were reported by 23% of patient 30-90 days after CAR T therapy, and 5% of patients than 90 day after CAR T. From this particular study, you can see that when people were asked to rate the severity of their sexual dysfunction on a scale of 1 to 10, with 10 being the worse case, they rated it a little under 2 out of 10 with only 14.3% reporting that it's severe at 30 days or less post-CAR T. When we look out a little further — 31 to 90 days — they rated it about 2.5 out of 10, but with a jump to 23% reporting the sexual dysfunction as severe. Consider, too, some would've reported it as moderate or mild. After 90 days, the rate drops back down to 5.3% reporting as severe. But remember, you still have people reporting the sexual dysfunction as both moderate and mild.

(00:20:19): In the same study, sexual dysfunction was brought up by less than 10% of patients. And this was a study including 40 patients at 29 centers with 15 caregivers and 15 experts from nine centers. There was diversity in age, sex, race and ethnicity but less than 10% of the participants interviewed brought up sexual dysfunction. Again, people don't always talk about sexual dysfunction, although we know people can be struggling with it.

(00:20:47): That's why we're here, to talk about some of the sexual issues in case you are struggling with those things. So that you know there is help, there is hope, and there are treatment options.

(00:21:05): There are many causes of sexual dysfunction. Any treatment that you go through that may cause changes in the blood — such as decreased blood cells and blood flow — could impact genital arousal and sexual function. While getting and maintaining an erection is often the primary issue for men, it’s sometimes the ability to climax too. But the number one concern is the ability to get and keep erections.

(00:21:32): Chemotherapy and radiation can both impact sexual function as well as fertility. Radiation therapy can impact blood flow leading to erection issues and it can impact nerves, resulting in orgasm challenges. Some types of chemotherapy may impact hormones, such as testosterone levels and damage nerves, like alkylating agents. So hopefully you're understanding a little better how cancer treatments may impact sexual function and cause some sexual dysfunction.

(00:22:03): It’s important to communicate about sex. So, do we talk about sex? Well, our vocabulary tends to be pretty limited when it comes to sex. It may be “ah,” “uh,” “yes,” things like that. But often we don't speak in full sentences about sex, and we're not comfortable talking about sex in general. But it is important for us to do so.

(00:22:22): So even though sex is everywhere in our culture — in movies, in culture, on billboards, it's everywhere — we don't talk about it. Even if you don't want to think about or talk about sex, you can't avoid it. It's around you. Very interesting.

(00:22:39): Several studies found more than 90% of healthcare professionals do not talk about sex with their patients. Study after study shows primary care providers don't talk or ask about it. Oncologists don't talk or ask about it. Nurses don't talk or ask about it. This isn't everybody, but what the studies show, is that most people do not talk about it. In a lot of studies, greater than 90% of healthcare professionals do not talk about sex with their patients.

(00:23:02): Patients don't tend to talk about it either for a variety of different reasons. They're embarrassed. They're like, “Is it okay to talk about it? Is it okay to bring it up?” One patient told me they brought the subject up to their oncologist and the oncologist is like, "I'm trying to keep you alive. That's really my focus." And my patient said to me, "I just want to feel normal. I want to have sex. That's part of the normal human journey. Is that too much to ask?"

(00:23:26): No, it's not too much to ask. That person was very brave to ask, and I would hope that that doesn't happen when you bring it up with healthcare professionals because we do want these things to be addressed but often patients don't tend to talk about it. Partners don't tend to talk about it either. So now we have this silence, and we have these unspoken words, but everybody's affected by it.

(00:23:49): Strategies to have meaningful conversations about sex with healthcare providers. What can you do about talking about sex? It's important. Prepare your questions. Whenever you're going to see a healthcare provider, prepare your questions ahead of time. Get everything ready so that when you walk in there, you've got your questions written down. Because when they start talking and everything starts happening, you may forget about the things you wanted to ask about. So have those questions written down and ready to ask your healthcare provider.

(00:24:13): Plan when and where you want to talk about sex with your partner. This is tricky too, because right in the middle of sex may not be the greatest moment to say, "Hey, I wanted to talk to you about orgasms or something." When you're in the heat of the moment, it may not be the greatest moment to talk about it. At a different time, consider sitting down and having a discussion along the lines of, "Hey, I really care about you. I really love you. I want to satisfy you. It really matters to me that our intimacy and sex life is fulfilling for both of us, and I want to talk about it a little bit." I think it’s really, really important to do that.

(00:24:50): Lack of communication causes misperceptions. Our mind never stops. That voice in your head never stops talking. When your mind is forced to fill in the blanks because you haven't had the conversations, the way we fill in the blanks usually ends up being negative. So, keep in mind that misperceptions often happen.

(00:25:10): Here's a great story that demonstrates that very point. I had a patient and their partner come in for help with his sexual health issue. They told me a story about a time when they were having sex, but he was struggling with his erection. In the middle of sex, they stopped for a minute and he's like, “Oh...” And she's like, "What's going on?" He just said, "Well, I am seeing someone." So she cracks him across the head. And he's like, "I don't get it. Why did you hit me?" And she's like, "What do you mean you're ‘seeing someone’?" And he's like, "I mean, I have an appointment scheduled to see someone for my erectile dysfunction."

(00:25:51): Now you can see how two people can perceive things completely differently. The poor guy got cracked across the head because she thought he was seeing someone else sexually and he was only trying to tell her he was seeing me, and that he had an appointment coming up to address the issue that he was having while they're having sex. That's why sometimes during sex is not always the best time in the heat of the moment to talk about those things because a lot of things are going on in the bedroom at that point.

(00:26:21): Performance anxiety can impact your ability to achieve an erection and talk with a partner about sex.  What are the obstacles to communicating about sex? For one, a fear of not being able to perform well. Performance anxiety is real. Anxiety is adrenaline. If you start worrying about sex, if you start freaking out about sex, you don't even have to look down. I guarantee you, you're going to lose your erection because anxiety creates adrenaline, adrenaline is part of fight or flight, and it makes erections go away. Performance anxiety creates a real physiologic response that makes your erections go away.

If you've had issues in the past, it's hard not to worry about it, and as much as you try to redirect your mind back to ‘sex, sex, sex,’ you end up thinking, ‘What's it doing?’ ‘Oh my God, I lost it before.’

You can't go there. You have to stay on ‘sex, sex, sex’ and nothing but sex.

But that fear of not being able to perform is one of the obstacles. ‘I don't want to talk about it. I don't even want to think about it because what do I know?’ Some people think that. Well, what does anybody know when they get into the bedroom? Nobody knows much until you learn and you discover. Or you read or you go to presentations like this one.

(00:27:26): A lack of comfort talking about sex historically can make addressing sexual dysfunction more difficult. The less we talk about sex, the more we avoid issues like this and other sexual issues. It doesn't usually help to avoid. The more you talk about sex, the easier it is to talk about it.

(00:27:46): Sex counselors, therapists and educators can help with communication about sex. I'm board-certified as a sexuality counselor. There are sex therapists, there’re sex counselors, there’re sex educators, there’re lots of people out there who can help with this. There are some great resources from the American Cancer Society and other groups as well. I'll give you a couple resources at the very end of this presentation that you may not have. So, talk about it. Like we're doing today. We're talking about it. We talk about it all the time in my clinic and it's great. Feel free to ask your questions and talk and we will get to those.

(00:28:21): Psychosexual education can help you better understand how sexual organs work. What can we do about it? That's important too. Are there things we can do? Well, certainly. Sometimes just learning. Psychosexual education is empowering. It's important. It's a really big deal. I think it's really important for you to understand how your body works. I've had some of my female patients who I’ve offered a mirror to and they're like, "I have never even seen my vulva or my vagina." We can take a scope and look up inside and I can put an image of that up on the screen for people to see. Same thing. People are like, "Well, what's under my testicles?" And I can show them the perineum and things like that which you can't easily see.

(00:29:04): Although men are pretty familiar with their penis and their body in general, they don't always understand how it works. So, they'll come in thinking, "Oh, I have erectile dysfunction. It's got to be because my testosterone's off." That's rarely the reason for erectile dysfunction. I think information and knowledge is empowering and I hope you feel empowered with some of that after we finish today.

(00:29:30): Behavioral therapy helps individuals and their partners improve sexual satisfaction. Behavioral therapies — I’m referring to ‘working on things.’ Because if you don't get in there and work on it, it doesn't get better. It usually gets worse. You and your partner working together on things. We talk in the clinic and we work on different things in the clinic, but we give you homework to do at home and our homework's good.

I always say this isn't like homework that is painful or excruciating to do at home. Sex should be fun. Intimacy should be fun. So, when you do my homework, please have fun. That's always my caveat with patients. Please have fun. Don't make it not fun. One lady said, "Oh, as soon as he gets out the pills and I know we're going to have sex, my blood pressure goes up." That doesn't sound like fun to me. We don't want that. We want a culture that's fun.

(00:30:14): Issues unrelated to transplant or CAR T-cell therapy can impact sexual health. Sometimes there can be issues. Believe it or not, one out of three women and one out of four to five men have been sexually assaulted in their life. Counseling can be important to process this. Sometimes it’s a matter of getting over the hurdle of, “I have some anxiety about sex because I've had problems in the past.” In this case, investigate counseling.

(00:30:34): Diet, exercise and weight control are monumentally important to sexual function. When you're in your best health in terms of cardiovascular health, now you're having better blood flow. Diet, exercise and weight control are monumentally important to sexual function. They're not the only thing, but they're amazingly important. That means a good body mass index, a good height-weight ratio, a heart-healthy diet. If it's good for your heart, it's good down below for your erections.

Regular exercise. Starting slowly with a few minutes a day and working towards about 150 to 200 minutes a week of cardio. It's all about your heart. If it's good for your heart, it's good for your penis because blood flow to your penis is critical.

(00:31:20): Of course, we have hormonal therapies for men — testosterone and things like that. The vacuum device. We have pharmacological agents, we have pills, we have inserts that go in the penis called intra-urethral suppositories. We have injections that go into the penis. We have surgeries.

(00:31:35): Most herbal remedies for sexual dysfunction don’t work well. We're going to talk about herbs for a minute. There are a few herbs that are out there that have some science behind them. Most of them do not. So be very careful, because most of the herbs in general don't work as well as the medicinal options.

 But there are a few things like Korean red ginseng and L-arginine and L-citrulline that can be helpful and are backed by science. But they're still not usually as efficacious and have the scientific rigor of things like PD5 inhibitors like phosphodiester and five inhibitors like sildenafil (Viagra®), tadalafil (Cialis®), vardenafil (Levitra®) and so on. But everybody out there wants your money, so be very careful. I'm going to talk a little bit about that because even some of the clinics, they're after your money. Most of the things don't work, and some of them can be dangerous. There are a few resources out there that have a little scientific rigor, but not a lot.

(00:32:38): Consult a urology, advance practice nurse with expertise in urology when seeking help with sexual difficulties. Be careful when you're seeking medical care. In general men go to urologists or the urology community, urology professionals, advanced practice nurses like nurse practitioners, clinical nurse specialists like me, physician assistants. People who have expertise in urology, which is expertise in what is normally referred to as male genitalia, penises, scrotums, testicles. And so those are the expertise of the urology department. I'm board-certified in urology — all of urology, but especially sexual health.

(00:33:14): Beware of herbal remedies because they're not regulated. The main things out there that have a little bit of scientific evidence to support them are Korean red ginseng — which is Panax Ginseng — as well as L-arginine, L-citrulline, things like that as well. But you have to be careful with those things.

(00:33:36): We used to use something called Yohimbine. It comes from the bark of a tree, so you’d think natural is better, but it actually was causing heart issues with people, which is why we no longer use it. So be very careful because even things in nature can kill you. Remember, some of them can be poisonous, and some can cause other problems. A lot of people don't realize the FDA has enough trouble keeping up with drugs. They don't keep up with herbs at all.

(00:34:06): Beware of men's clinics that do not use urology trained professionals. These are cosmetic clinics, typically. They can work on your face, and they can work on your penis all in one visit. Beware. Sometimes they're called youth clinics or men's clinics. They advertise well, they promise manhood, enhanced performance, all kinds of great things. And I'm not saying they never help anybody, but I've had a lot of patients spend a lot of money for nothing with them.

(00:34:32): What men like about them is they're quick and have easy access. They have substandard evaluations. You should have a physical exam, a history and physical. My visits are one hour long for all my new patients in the VA. Every patient I see for a full hour. Their partners usually come with them. It's an in-depth evaluation. It's not done over the internet. It's important to be fully evaluated.

(00:34:57): In general, we find poor care in these men’s clinics, which is provided by non-urology trained professionals. You'll see their billboards all over Chicagoland where I live. You'll see their late-night TV ads. They will zap your penis, they'll take blood out of your arm and put it in your penis. They're doing things that are not yet FDA-approved and not shown to work with men with significant erectile dysfunction.

I've literally seen men spend thousands of dollars on these things. One man said he spent $15,000. I've had quite a few say they’ve spent $3,000, $4,000, or $5,000. These are retail men's clinics, and they have 85,000+ visits annually and online, 100 to 250 million annually. They utilize unproven treatments. I love it when people actually help people, but I hate it when people waste money.

(00:35:45): I am one of the cheapest people you will ever meet in your life. I hate when people waste money on things that aren't helpful. Be careful. There are a lot of people out there who want your money and they know you're desperate. Go to urology-trained professionals or sexual health experts.

(00:36:06): Chemotherapy, radiation, transplant and surgery can impact fertility. Is fertility affected by different treatments? Yes. Chemotherapy, radiation, transplant and surgery can impact fertility. If you're going to go through any of these treatment options, you may want to bank sperm prior to your treatment. It takes about 72 days for your sperm to mature and be ready. Remember, it's going to take months — sometimes years — after treatment for your sperm to fully recover, so having sperm banked and doing that before any treatment, if possible, is a great option.

(00:36:39): Be aware that damage may occur to sperm through chemotherapy or radiation. If you haven’t banked sperm prior to treatment, it's not recommended to impregnate a partner for a full year following treatment. Some people wait two to five years after transplant for optimal sperm recovery, but after a year it can be recommended to move on.

(00:37:06): Desire has to do with hormones and expectations. We talked about this earlier. That's the sum of the forces that lean us towards and push us away from sexual behavior. That's what makes you go, "Oh, I want to have sex. I have this strong desire." Some people think of it as libido. It's about sexual thoughts, it's about forces that push you towards sex. It's the subjective and motivating feeling. It's triggered by both internal and external cues, which may or may not result in overt sexual behaviors and sex. Drive is biologic. It's hormonal. It has to do with dopamine and serotonin in your brain, but it also has to do with expectations.

(00:37:47): You've been taught what's okay — what's not okay maybe — but then your desire may not line up with that. Is something wrong with you? No, not necessarily. Culture says things and comes up with norms that may or may not fit with you. If that causes conflict for you, then it might be appropriate to see a counselor or work with somebody because it can really cause some distress in people when they're like, "Well, what I want sexually and what happens to me sexually doesn't line up with what I've been taught is okay or what's right sexually." But what you've been taught — and what society or religion or whoever says is okay — is not necessarily what's okay and right for you or others.

(00:38:30): Fatigue, going through difficult medical procedures, depression and anxiety motivation to have sex can be low. Motivation's really important. We just talked about how your beliefs and values come into play and can be in great conflict with your sexual identity, with your sexual performance and with your sexual preferences. Well, motivation's a big deal too. When you're exhausted and fatigued and you're going through these really hard treatments, your motivation for sex may be low. When you're depressed or anxious, your motivation may be low. When you're in the middle of dissertations and things like that, your motivation may be low.

Motivation, expectations, wishes and drive — they all affect desire. It’s important for us to understand why and how desire is affected by different factors within you.

(00:39:13): Symptoms of hypogonadism (low testosterone) include low sex drive and fewer spontaneous erections. Previously, I told you that hypogonadism means low testosterone blood levels. There are many consistent symptoms of hypogonadism. Low sex drive is a hallmark symptom. Decreased spontaneous erections is another one. That means erections you get every day. Your penis literally goes up and down while you sleep to keep itself in shape when it's working right. That's why you wake up with ‘P erections.’  I know you guys know what I'm talking about because this is life as a male. From the day you're born until it stops working right you wake up with erections in the morning and at night. Your penis mostly goes up and down while you sleep. It literally goes up and down about four to six times a night. It's erect about two hours or so out of every 24-hour period roughly, give or take.

(00:39:58): Your penis literally ‘exercises’ as the smooth muscle and blood flow changes within your penis as you go from hard to soft. It’s critically important to have those spontaneous erections when you're not trying to have sex. All the other things that come into play like anxiety, decreased energy or mood, poor concentration, reduced muscle bulk or strength, increased body fat, decreased physical performance — when these things are affected, that could be a symptom of low testosterone.

(00:40:28): Testosterone replacement has as many negatives as it does positives. It's a controlled substance for a reason. Usually within a week or two, you know if it's helping or not. I’ve heard people say, "Wow. I forgot how it even felt to feel this way." This is from a person who it's probably really helping.

You must meet certain criteria. First, you have to have a certain low blood level, and symptoms must accompany it, for your insurance to pay for it. In addition, you must have two early morning testosterone tests drawn because your testosterone builds up while you sleep.

So, first thing after you get up, that's when your testosterone should be drawn. If it's below the normal threshold and you have symptoms, then your insurance sometimes will pay for testosterone replacement.

(00:41:16): But testosterone is a hormone, so it has a good side and a bad side. That's why you'll see ads during a football game that say, "If you have low T, call us and you should ask your doctor and start on testosterone replacement." And then five minutes later you’ll see an ad that says, "If you had a heart attack or a stroke and you'd like to sue your doctor, we will help you do that because you were on testosterone and weren't monitored well."

 So, testosterone offers both the good and the bad. Make no mistake about it. It must be administered like every treatment with correct supervision to make sure everything goes well and safely. And it can be done that way, but it can be a little tricky because it could have both good and bad results.

(00:41:56): Testosterone is not recommended for breast and prostate cancer patients or if you have an abnormal digital rectal exam or elevated PSA or prostate cancer. It’s not recommended if you have high hemoglobin blood counts because that means the blood is a little viscous and you don't want to add testosterone — which can make blood more viscous, leading to heart attacks and strokes, hence the lawyers jumping in. It’s also not recommended for patients with untreated severe sleep apnea, severe prostate issues like benign prosthetic hyperplasia as well as prostate cancer or uncontrolled heart failure. And if you are trying to father a child, it’s not recommended because testosterone can cause infertility. When you're on it, you usually don't produce sperm.

(42:38): There are many ways to deliver testosterone. There are injections and there are topicals, which are the most popular. Injections are the classic way. You usually get an injection every other week or every week. Topicals are gels or patches. In addition, there's a patch that goes in your mouth, along the gum. There's a pellet that goes under the skin and is placed in the clinic. There are also testosterone pills.

(00:43:04): There are other ways to reclaim desire besides using testosterone. Desire is not just about testosterone. Anticipation and the mystery: “Maybe this time we'll have oral sex or manual sex, or maybe I'll manually stimulate the clitoris, or she'll manually stimulate my penis or he'll manually stimulate my penis.” Whatever you like. The mystery can be fun. You need to feel like you're worthy of pleasure, that you're worthy of feeling sexual satisfaction and desire.

(43:26) Don’t feel guilty. It’s nobody’s fault when you have erectile dysfunction, difficulty climaxing or pain during sex. It's difficult, but we try to remove all the guilt, the blame and the pressure. It's nobody's fault when you have erectile dysfunction, it's nobody's fault when you have difficulty climaxing, it's nobody's fault if you have pain during sex. The essence of sexuality is giving and receiving pleasure oriented towards touch and connecting with each other. The goal is deep connection with your partner — for many people who are partnered — and pleasure. It's supposed to be fun. Procreation can be the one other goal as well. It requires intimacy, pleasure, mystery and eroticism. And it's developing this whole ‘yours, mine and ours’ bridge to desire. Working together towards desire can be really important.

(00:44:18): We’re programmed to think about sexual pleasure as penetration but ther are other ways experience intimacy and pleasurable sex. Let’s think a little differently about intimacy. We're taught and programmed. Okay. In terms of foreplay, it's about breasts and genitals and everything, but intercourse, but we're always headed towards penetration with a partner. Whomever the partner is, that's where it's headed. We're programmed that way, but it's not the only way.

There are many, many ways to experience sexual pleasure. Manual stimulation of the genitals or other erotic zones in the body. Oral stimulation of the erotic zones. Toys and things. Vibration. As well as penetration of partners or a partner. The excitement comes from the anticipation and the mystery of where the intimacy will lead to today, in this particular circumstance. It may be different today than it was yesterday. It may be different tomorrow. That makes it exciting. Intimacy is connectedness on all levels. It's really connecting deeply with your partner.

(00:45:15): We don’t connect well when we're freaking out or anxious about things or if we're afraid to even kiss or touch or be affectionate because we're like, "Oh my gosh, they might expect something and I know my penis is not working right." And so now you stop hugging, you stop kissing, you stop connectedness. And if you have a partner or a spouse or whatever, they're thinking, ‘What's going on? Why aren't we connecting? Why aren't we even being affectionate?’ This is how it can all fall apart because of sexual dysfunction sometimes.

(00:45:46): The most non-invasive treatment for erectile dysfunction is a vacuum constriction device. We have lots of different things. We have the vacuum constriction device where you put your penis inside that cylinder that you see here. That cylinder is where your penis goes, and then you pump the pump. When you pump the pump, it creates a suction inside to make you harder. Once you get harder, there's a ring. You can see the ring on the edge of the device; you push it off the edge of the device to the base of your penis. It's completely non-invasive and it's physics. It forces more blood into your penis and the ring traps it there. It works for about 90% of patients.

(00:46:18): But it's cumbersome. It's awkward. You have to wear a ring during sex. It's far from perfect. ‘Perfect’ is: you think about sex and without much provocation, there's your erection. You know what that's like. And I wish I could give that back to all my patients. If I could do that, I would be the most popular man on the face of the Earth. I guarantee you that. But we have to work with what we have. The vacuum pump is our most non-invasive option. That's why I started with it. It's not the most popular.

(00:46:42): Pills such as sildenafil (Viagra®), vardenafil (Levitra®) and avanafil are the most popular treatment option for erectile dysfunction. We have lots of pills. We have sildenafil, vardenafil and avanafil to name a few. We have multiple pills. Most of them are taken on demand before sex because most people don't want to take a pill every single day when they're not having sex daily. Most of the time a pill is taken on demand before sex about an hour or two ahead of time on an empty stomach. Avanafil is absorbed twice as fast, so it's usually taken about 15 to 30 minutes ahead of time on a fairly empty stomach.

(00:47:12): Pills are easy. They're discreet. By a landslide they're the most popular. I can answer questions about them. I teach people how to take them all the time. Food and fat can delay absorption; that’s really important. Most pills — even though they may say you can take them with food — work better on a fairly empty stomach. Pills like sildenafil, vardenafil and tadalafil will take 30 to 60 minutes just to get in, and about an hour to two hours to give you the full effect. Those are some pointers about pills. Some people are like, "I don't want to deal with any of that. The vacuum pump, the shots, none of it." Some people move on and the second most popular was the vacuum pump.

(00:47:48): The urethra suppository MUSE® only works 40-50% of the time and is currently not available. MUSE® is a urethra suppository that has been on back order for about a year and a half or more, almost two years now. They came up with it because men said, "Oh my gosh, I don't want to give myself a shot in the penis. That just sounds God awful." Even though it's a super small, super fine needle, it's still a weird thing to do to yourself. And some men were just like, “There's got to be another way.”

(00:48:08): They tried every other way, and the only thing they can come up with is a little rice-sized grain suppository that goes down the wet urethra after you pee. To apply, you put the suppository applicator down the urethra — it goes down inside of the urethra —after which you push the suppository out of the applicator and then you take the applicator out. Roll your penis between your hands to help the suppository dissolve. It only works in about 40% to 45% of patients. I think that's why it's not super popular. It's very expensive, and the drug company still hasn’t — after almost two years — brought it back to market, although it's supposed to be coming back at some point.

(00:48:43): We do have patients on it, especially at the VA where I work, because we are allowed to give them two of these a month for free as part of their benefits or with their copay. In the private sector, I have very few people using it because it doesn't work for most people and they cost about $100 to $150 a piece.

(00:49:03): Penile injections work for 70-80% of patients. Shots can cost the same amount, but they do work in 70% to 80% of patients, which is a lot better than 40% to 45%. They work for most patients — they don’t work for everybody — but now you have to give yourself a shot each time you want to have sex. Injections can be done safely. There can be side effects. I've taught thousands of patients to use injections and to use the vacuum pump over the years. Lots of people using all these different therapies for many, many years.

(00:49:32): You can also have a penile implant, which is literally like a replacement of the mechanisms in your penis. They put cylinders in your penis, a pump in your scrotum and a reservoir in your abdomen. When you pump that pump in your scrotum — that feels like a third testicle — it moves the fluid out of the resting chamber in your abdomen into the chambers in your penis to make your penis hard. When you're done, you hit the release button and the fluid goes out of the penis chambers into the resting chamber.

(00:49:59): It's permanent. It's a huge step. Only about 1% to 2% of men who have erectile dysfunction will opt to have surgery, but it does work. It goes where you go, but it's a big step and it's a permanent step. Because like a knee replacement, if we take it out just like you took out your new knee, you'll never be the same again. You’ve got to understand, once you cross that bridge, it's challenging to come back.

(00:50:23): There are various strategies to deal premature ejaculation.  You can also have disorders like premature ejaculations. So, men for years have used things like distraction. 27 divided by three is nine, nine divided by three is three so on.

(50:35): Positioning. Men usually last longer on the bottom because the friction is different. If you last longer on the bottom, start on the bottom if you have premature ejaculation and then move to whatever position you want when it doesn't matter anymore.

(50:46): Stop-start method. I don't like the squeeze technique because if you squeeze the penis right before it goes, it usually goes.

(50:54): If you haven't climaxed for a week or two, you're going to climax quicker. Some men will masturbate in anticipation that within 24 to 48 hours, they will have sex with a partner — and they can last longer — or they'll turn around and have sex again if they lose it. But as you get older, that period between getting an erection after that may last longer.

(51:15): Layered condoms and numbing agents. Wearing a condom or multiple condoms can decrease sensation. You can use numbing agents — like Promescent® Fast Acting Spray — but they will numb your penis and they can transfer to your partner, especially the ones that come inside the condoms. If they do get on partners, then everybody's numb. Nobody's having a good time.

(00:51:33): Antidepressants like Sertraline and Clomipramine and Paroxetine, used off-label, have been shown in studies to delay climax. They change dopamine and serotonin levels in the brain.

(51:50) If you have delayed climax, sometimes vibratory stimulation can help even in patients suffering from spinal cord problems. Sometimes it helps, sometimes it doesn't.

(51:59) Summary of key points. My key points: sexual dysfunction is quite common after transplant. Most of the men reported it in the studies.

 Sexual and intimacy issues can be addressed. There's help. We can help you.

Communication is critical, and learning to communicate about sex with your partner and others is really, really important because it's often not talked about.

It is possible to have an incredibly fulfilling, enjoyable sex life and intimacy after cancer treatment with the help of expert providers.

(00:52:31): Video libraries and other resources for patients can be helpful. I hope that information has been helpful. I do have videos on many of those treatments. I used to work at NorthShore University HealthSystem and they have a whole video library still there. Here’s the link to it: northshore.org/urological-health/patient-education/sexual-health-videos. If you type in North Shore sexual health Albaugh, you'll find my videos. I have a whole group of videos for men and a whole group for women.

Sexhealthmatters.org is the link for the Sexual Medicine Society group, and there's lots of information on there too. Lots of resources for you as well. Any brave souls who have questions?

(00:53:07): [Jordan Sexton]:    I can help moderate the questions for you.

(00:53:10): [Dr. Jeffrey Albaugh]:  Okay, go for it. I'm ready.

(00:53:13): [Jordan Sexton]: Yeah. Absolutely. What is the difference between testing for free testosterone and total testosterone and which is more important?

(00:53:21): [Dr. Jeffrey Albaugh]:  Total testosterone is a very basic test. It's a great test to look at how much testosterone is in your body. And it's a hallmark test that your insurance company wants us to look at in terms of whether or not you have hypogonadism and if you are going to be eligible and reimbursed for treatments or eligible for those to be covered by your insurance. So, it’s important.

Free testosterone is the testosterone in your body that's unbound to proteins and things and actually does the work in there. So often as a first test, they will do a total testosterone. Then, if you're having symptoms and they haven't discovered everything, they may also look at a free and a total, which will also give them a percent free. It'll give them a lot more information about the testosterone that does things in your body. They both can be important, and they both can be valuable.

(00:54:17): It's a more advanced, more expensive test for a free and total, and it usually has to go to a special lab that has the right equipment to do it. So that's why it's not done as a basic beginning test. At some point if you're really struggling, especially with desire or libido issues, it can be important to get that free and total testosterone panel because it does give us information on all the testosterone in your body and in particular the testosterone that does the work in your body, which is your free testosterone.

(00:54:51): [Jordan Sexton]:   Could you please talk about the effects of transplantation and tGVHD (transfusion-associated graft-versus-host disease) on the effects of semen volume? And does watery semen mean that they don't have viable sperm? And could this semen count improve in the future?

(00:55:19): [Dr. Jeffrey Albaugh]:  These are excellent questions and they're great fertility questions. Remember, several of the treatments that you may have gone through — if you had radiation, if you had chemotherapy, if you had a transplant, if you had all of the above — all of them could have an impact on your semen volume and your semen production. So that's why I say it is important to sperm bank before you go in for a treatment. If your semen is watery, it doesn't necessarily mean that you don't have sperm in there. The only way to really know is through a sperm analysis, which looks at your sperm motility, how much sperm is there, are the sperm viable, all those different things. And as I said, it takes about 72 days. Think of it taking about three months for your sperm to mature and be ready after some of these treatments. These treatments can slow production of sperm. It can halt production sometimes. It just depends.

(00:56:18): That's why we always tell people to go into treatment knowing that it may affect fertility and why the recommendations usually say to wait one year to impregnate afterward treatment. Some people wait even longer to see if the sperm volume — sperm production — comes back around. Remember, we also need motility. We need movement. We need the sperm to do all the things it needs to do to survive in the acidic environment of the vagina and vulva, and to get where it's got to go and impregnate your partner. So great questions and the only way to really know is through sperm analysis, to see what's going on.

(00:56:59): [Jordan Sexton]:   Awesome. Next question: is it concerning if someone's partner is using an estrogen vaginal cream that comes in contact with the penis during vaginal penetration?

(00:57:11): [Dr. Jeffrey Albaugh]:  Great question. Many, many women have trouble and struggle with not enough local estrogen. So they use a local cream or a tablet or a ring. All of them work equally well. They should be using those during non-sexual times. In a perfect world, clean those off well before you're having sex. It's probably not going to cause much of a problem for a male to come in contact with it, but I've actually inadvertently had people use it as a lubricant. Do not do that. Your partner should not use that as a lubricant for friction because it's not going to be a good thing for your male partner — or people with penises — to come in contact with it. It's not going to cause a major issue. I wouldn't freak out if it happened. Trust me, I've had people who've done that — used it as a lubricant and it's been okay. But you don't need the estrogen and it is transdermal, so it will absorb in your system. So local estrogen should be used by partners on non-sex days or cleaned off before sex with a partner when a penis is going to come in contact with that.

(00:58:15): [Jordan Sexton]:   I think our last questions are: does exercise help your sex drive and are sexual function problems permanent? And can you get back to the same sex life as you had pre-transplant?

(00:58:29): [Dr. Jeffrey Albaugh]:  If I'm understanding correctly, you're asking if exercise is helpful — and I said definitely exercise can be helpful. Remember it's not necessarily going to reverse some of the things that have happened from your treatment, but in general, we need good blood flow, we need good nervous conduction and we need you to be healthy. You can never go wrong once you're cleared to go with a diet based on low fat, low cholesterol, low carb, high fiber, plant-based, lots of fruits and vegetables and minimal red meats and animal fat. If you eat red meat, go for the leanest red meats you can. And then exercise beginning with a few minutes a day, working towards about three hours a week of cardio. Cardio is what it's about. You can walk, you can run, you can use the elliptical. But if it's good for your heart, it's good for your body and getting your body back in shape is important and your penis needs the blood flow.

(00:59:24): But will it correct everything? Of course not. With my patients who've had radiation, surgery, chemotherapy and stuff, exercise can't always reverse the neuropathy or nerve damage that has surfaced. Being healthy can do a lot of things and I wish it could fix all those things, but it's not necessarily going to fix things like nerve damage or permanent blood flow problems. But it can't hurt and if you've been cleared and are ready, exercise will likely help. I've seen it turn things around dramatically for people. They were like 40 or 50 pounds overweight. They got really healthy, and they saw big differences in spontaneous erections, night erections, morning erections, erections with partners, and erection with masturbation. It is probably the most important thing you can do for yourself in terms of getting yourself in good shape cardiovascular-wise and sex-wise. I think that answered the question. Was there any more to it or did I get it all?

(01:00:27): [Jordan Sexton]:   Absolutely. There are more questions but unfortunately, we've run out of time. I just want to thank you so much on behalf of BMT InfoNet and our partners for your extremely helpful presentation, Dr. Albaugh. I think that this is such an important topic for us to feel confident talking about and sharing our concerns and really searching for answers with each other. Thank you.

(01:00:48): [Dr. Jeffrey Albaugh]: I know I saw a question about CAR T-cell therapy if I could answer that quickly. I'm not sure if you saw that part, whoever asked the question, but there are very limited studies and information and that's why you probably weren't advised about the sexual issues. But you can see from the study that I mention in this presentation on CAR T-cell therapy that some patients do report problems, but there's very limited information.

So, when you think about if you have the side effects from CAR T-cell therapy, like the cytokine release syndrome or the neurotoxicity specifically, or blood disorders, when you're having those issues, that could affect blood flow or nervous conduction and could affect your erections. That's what I would say at this point. But we don't have a lot of information due to very limited, very small studies at this point. That's probably why you weren't told much about it when you had that therapy. That's why I wanted to talk about it today with at least what we do know. I hope that was helpful to you. I'm sorry if I missed some of your questions.

(01:02:05): [Jordan Sexton]:   Awesome. Thank you again to you and to the audience for some amazing questions that I think are helpful for all of us. To everybody, please contact BMT InfoNet if we can help you in any way.