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Diane Newman: Welcome to UroToday and our online medical education program. I'm Diane Newman, a urology nurse practitioner. I'm really excited today because I'm pleased to introduce to you a colleague of mine, Dr. Amy Pearlman, a board-certified urologist. I got to know Amy when she did her urology residency at Penn Urology, University of Pennsylvania, several years ago. But now, she practices in South Florida and is the co-founder of Prime Institute. Thank you, Amy, for coming on and sharing with us your services that you're providing there to men.

Amy Pearlman: It's such a delight to be here with you today, Dr. Newman. Thank you so much for having me.

Diane Newman: So tell me a little bit about what your practice is about. What exactly are you doing?

Amy Pearlman: I'd love to. So I'm co-founder of Prime Institute, but I didn't start off my dream job right out of training. And to go a little bit further back, I did my undergrad at the University of Miami. I did medical school at Baylor College of Medicine. I did urology residency at the University of Pennsylvania. That's where I knew of you, but we didn't really interact that much, and it wasn't until I left that I realized the importance of the pelvic floor and the role of pelvic floor physical therapy, really, after any type of prostate treatment.

So it really wasn't until after I left where I was like, oh my gosh, I had a world-renowned expert at the University of Pennsylvania that I could have picked your brain so much during that time. But hey, it's never too late for us to come around, right? And then I did my fellowship at Wake Forest in Winston-Salem, North Carolina, and that fellowship year was really in men's health, genitourinary reconstruction, and male infertility.

I started my first job; I was on faculty at the University of Iowa in Iowa City. And I had no ties to the Midwest. It was a bit of a big move for me to go to Iowa City, but I absolutely loved it. And Dr. Newman, I think my biggest fear when I first got there was that I was going to live there and work there the rest of my life because I just, again, I had no ties there, no family. And I really—I'm glad I built the foundation of my career there.

But what I found being in a big academic setting—and this had nothing to do with the University of Iowa in particular—is that time is a limiting factor for all of us. And so many of us, we're taught how to make our visits more efficient, and how to make it seem like we're in the room for 10 minutes when we're only in the room for 5 minutes. And my thought was like, but what if—how do I reconcile the fact that I need to be in the room for an hour when I only have them scheduled for 15 minutes or 30 minutes. And I was kind of tired of running two hours behind in clinic. So I took the biggest risk, I think, in my adult life. And I joined my twin sister and we started our own concierge urology and gastroenterology practice, actually, in Coral Gables, Florida.

Diane Newman: Well, this is really exciting. And I'm glad you gave us your history. And it's interesting what you said in the beginning. I've had so many residents come through Penn and they said exactly what you have said after they've gotten out: "I wish I knew more about the pelvic floor." And you know that it comes no matter who you're seeing. And you need to spend the time with these patients. And that time is really a commodity that we don't have. So I'm really excited to have you give us your knowledge and expertise on what you're currently doing.

Amy Pearlman: Yeah, and the other thing, too, is as a urology trainee and even as a urologist, I mean, we're trained as surgeons. So oftentimes, in our training, we're not necessarily happy in clinic. We're happy when we have a scalpel in our hands and we're in the operating room. And so it really wasn't until I was in my own practice that I really started delving in and learning more about some of these therapies that are very non-surgical. They're very conservative. They're things that people do at home. They don't require a prescription.

And what we found is that when there's a therapy that doesn't require us to write a prescription, I think as urologists, we tend to not know as much about them because we are not really necessary for our patients to acquire it. And yet our patients are looking to us for recommendations on how to actually use these devices. So what I've done over really the last probably four years is I reach out to the inventors of these different devices and companies, and I'm looking for this behind-the-scenes view. Talk to me about your device, how does it work, what should I be telling my patients.

I don't think it's enough for us to say, call customer service. I mean, we can say that, but I think it's really an opportunity for us to learn more about these technologies, to really understand the engineering, not only behind the erection, but behind the devices that will allow for optimized erectile function and erectile fitness and just structure of the penis.

Diane Newman: Well, this is really exciting. So show us a little bit about what you do with these men because you're right, there is such an unmet need. So I'm really excited that you're going to be able to share this with us.

Amy Pearlman: Yeah, I'm very much looking forward to sharing the tips and tricks. But before I get into what you should actually do when you're kind of setting up these therapies, I think we have to begin with why does this matter. Why does this topic even matter? And the reality is, regardless of the type of therapy that our patients may be going through when it comes to something like prostate cancer treatment, whether it's hormone therapy, surgical therapy, radiation, doesn't matter, the penis will change. So we just have to acknowledge that.

And it's not necessarily the fault of the treating provider. It's just that's what happens, and that's how we are created, and it just has to do with anatomy. So then the question becomes, what do we do about it? So I always like to start off with this analogy, and this is exactly what I show my patients in the clinic office as well, is I show them a sponge and I tell them your penis is just like a sponge. It really is.

And so if I were to put this sponge under a sink faucet and say, you know what, I'm not going to do dishes for a month, and then maybe every couple months I'll just say, OK, I'm going to do dishes and I'll use this sponge. And I ask, what does this sponge look like after a year? And everyone has the same look on their face, and they kind of pause a little bit and I say, it looks like pretty old and crusty. And they're like, yeah, exactly.

And so I tell them the goal of penile rehabilitation, everything that we're going to discuss today, is we want to get this sponge under the faucet every day. And that is going to lead to a healthy sponge. And it's never too early, and it's never too late to start a penile rehabilitation program. And even though today we might focus on the person after, let's say, prostate cancer treatment, this conversation is actually relevant to every single man at every stage of his life.

Diane Newman: Well, it's interesting you bring that up because I used to always say to men, OK, start with the penile pump. And start with it immediately. It's almost taking your penis out to the gym. And I love the term you use, "penile rehabilitation." They need to understand that. And they're very, very receptive to that. And as long as you explain it to them, they're so excited that the cancer is gone, it's taken care of, and that then they want to really understand how to get back to as normal functioning as they can.

Amy Pearlman: Absolutely. And I think one of the reasons why I developed such a passion for having this conversation is I saw so many men that were several years out from their prostate cancer treatment, and they were coming to me for erectile dysfunction. And I asked them, oh, do you have a vacuum pump? Have you been using it? And so many of them said, no, I don't even know what you're talking about. Or, yeah, I used it for a little bit and then stopped using it.

And so when I got into this conversation of why it matters for them and their genital health, they actually were not—like some of them were excited to hear about it, but the guys who had been pretty far out from their treatment were kind of upset, and they were frustrated that this was the first time they were hearing this conversation. And they would oftentimes ask me, is it too late? Can I still get something back of what I've lost? And what I've seen, again, like I briefly mentioned, it is never too early and it's also never too late. And I think people also need to hear that message.

Diane Newman: That's a really great message, and I agree with you 100%. So show us a little bit about what you do then.

Amy Pearlman: Absolutely. So I'd like to begin by talking about penis pump or vacuum pump therapy. I think that's a really good place to start. And one of the most important things that we can do for people is recommend a product. Because if we say, go online or go into an adult store or go on Amazon and just get a penis pump and start using it, it is so overwhelming. It's like going into a Walmart, and you want to make a protein shake in the morning, or a nice coffee, and you walk down that aisle and you see so many options. And some are pretty simple and some are very complex, so what do you do?

Well, you either buy the cheapest one, the most expensive, or you walk out empty-handed. And none of those three options are actually really good options or lead to really great outcomes. You probably need a product somewhere in the middle where, let's say, a friend or someone who tried it and said, you know what, I use this coffee machine or I use this blender, it makes a really good shake and I recommend it.

But in training, we're oftentimes not told or taught about these products. And so when I was at the University of Iowa, I actually worked with a pharmacist at a nearby compounding pharmacy, and he did all that research to find a lot of the good products. And so I then relied on him to tell me, OK, what do you recommend? And then what I tell my patients, when they come back for follow-up, if they tried something, I ask them, did you like that product? And if they liked it, I'll recommend it to others. And if they don't like it, I stop recommending it to other people.

So I like this product right here. It's the SomaTherapy. It's by Augusta Medical. And just by the way, I'm just putting that out there. I'm not endorsing that product in particular. I just find it is a good product for a lot of my patients. And it's somewhere in the mid-range of pricing. I like this one here. It has a manual attachment. And so this product here is about $199, which there are some that are actually very good that are less than $100, but you don't need to spend $1,000 on a penis pump.

Now, they also have iterations where you can actually take off the manual part right here. And if the person prefers more of an electronic one, then you can just fit this one on and then tighten it like that. So this one here is battery-powered. So the person would just push that button right here to create the suction. And then the button on the bottom right here will let go of the suction. With the manual one, they would just push this lever right here to create the suction. And again, this would release the suction.

So let's talk about some tips and tricks. I think people know that part, but there are some other subtleties that really make the difference between these working and not working. So when guys come in and they say the penis pump didn't work or it was too uncomfortable, that's not where the conversation ends. I go through the following basics. There is an insert here that will go in. So you want to put this in the device. But then someone, depending on the size or the girth of their penis, might need to put an additional insert in there. So that would look something like this. And then you would put it in here.

You don't want it to be too tight around the penis because that will cause discomfort. But you also don't want it to be too loose, because if you create too much suction, it can actually draw a testicle in. And as you can imagine, that can be uncomfortable. So we'll put this insert in. Next thing the person wants to do is take lubrication, water-based lubricant. You want it to be water-based so that's much easier to clean out of the device. And it's impossible to overdo it on the lubrication.

So you want to put lubrication around the base of this insert as well as along the inside of the canister. And you also want to put lubrication on the penile shaft as well. That way when the penis goes into the canister, it slides in and doesn't get stuck to the side of the canister. And once the penis is engorging, it's not going to get stuck on the inside of the canister as well. So lubrication is definitely your friend there.

Then another thing that I see that people aren't necessarily doing is making sure they get a good seal. So a tip here is move this back a little bit back and forth. Some people, if they have a lot of pubic hair around the base of their penis, might need to trim their pubic hair. And then some people, too, will actually prefer getting in a warm shower before they use their pump. That can help get some of their own blood flow in their penis, and can warm up the penis as well. Because one of the criticisms of this device is some people will say it makes my penis chilly, which is fine, but if you warm it up ahead of time in the shower, that can also be helpful.

OK, so we get the good seal here. And then my other recommendation is don't just go to town on this lever. All right. That can draw too much pressure into the penis. And that's where I see men have a lot of pain. So what you want to do is once you get that seal, push this like two or three times and then relax for a couple of seconds, let that blood go into the penis. And then do it again two times. And I can feel it on my hand, I can feel that suction being created. And you just keep doing this very slowly, off and on, until the penis becomes erect and you should feel a stretch, but it should not be painful.

And then I don't have people necessarily hold their erection the entire time for like 10 minutes, but they might do repetitions just like they might do bicep curls in the gym. So they might hold that erection for, let's say, about two minutes, and then they can get rid of that suction using this button here. And then they do it again to get a goal of 5 to 8 erections. So that whole process can take about 10 minutes. That's what I recommend to my patients who are not getting daily erections, is to use a device like this for 10 minutes a day, and that just really, again, it's just like putting this sponge under the faucet every day is exactly what this vacuum pump can do for someone.

The other thing that I discuss with patients is that even if they're not sexually active, that's OK. If they care about the health of their penis just like any other body part, that is reason enough to start a penile rehab protocol and I'll start people on this protocol really a month out after prostate surgery.

Diane Newman: Yeah, and the thing is what you're talking about really is just keeping the blood flow into the penis, which is like what happens with nocturnal erections. So you want that physiological effect to be happening. And that's exactly what rehabilitation of the penis is. And I think this is really—it's very healthy, isn't it?

Amy Pearlman: Absolutely. And the big concern that men have after prostate cancer treatment or after they have erectile dysfunction is that their penis gets smaller. It gets smaller both in length, and it gets smaller in girth as well. So it's even outside of just treating erectile function, and yes, these devices can be great to get someone an erection, but I think really where their power is and where I really emphasize their use for patients is for penile rehab to get some of that length and girth back that they've lost, or to prevent their penis from losing size.

Diane Newman: Well, I used to recommend this. And I mean, I never had—I never explained it as you were, Amy. That was so very clear. When would they start this, though, after treatment, like, say, after prostate cancer surgery? When do you recommend that?

Amy Pearlman: Yeah, so after prostate cancer surgery, I would recommend they start using it about a month after. And when I was at the University of Iowa, I made sure that I reached out to all of the urologic oncologists and I said, when I'm seeing these mutual patients that have had surgery, is there anyone who has an issue with me starting this rehab protocol using a vacuum pump one month out? And no one had an issue with it.

Now, I think so often when these patients see someone like you or see someone like me, they're not always seeing us that early on in their process. So ideally, ideally, Dr. Newman, these patients, we would see them before they have treatment. We would have them get their device before they undergo therapy. We would have them start to use it before they undergo treatment. So they know how to use it. So when they're a month out, then they can start—they already know, there are no questions, and they can actually hit the ground running with this. That would really be the ideal scenario.

Diane Newman: Yeah, I agree with you 100%. It's almost like we say about doing pelvic floor muscle exercises. Start them before surgery, so you're right. And then get used to it and understand how to use it. And then when you can start and be comfortable with it. So this is really exciting. Do you see a lot of men then who come—how do they get to you?

Amy Pearlman: Well, I do some—I do videos online for YouTube and I do different podcasts. So that's how some people find me. And we do some online advertising for my business. And then it's interesting, I do get referrals from some urologists who are in academics. And I always appreciate those referrals because it's usually for patients who it's not that they don't know how to treat them, it's just they don't have the time built into their clinic schedule to really sit down with someone for an hour or an hour and a half and talk through all of these options.

Time, not expertise, is their limiting factor. So that's where I get actually quite a few referrals, is for men who—they want to bring in their suitcase, they want to bring in their vacuum pump, and they want to sit down with a urologist and they want to show me how they're using it. They want me to show them how to use it. And in a lot of healthcare systems, just time does not allow for that.

Diane Newman: Yeah, you're 100% right. And you have to spend the time with these men because I agree with you. To really show them, especially when it's a device, it's almost like we do with catheters or whatever, we need to have that time. Well, thank you very much. That was really, really helpful.

Amy Pearlman: Awesome. Yeah, I think there are tips and tricks that people can always implement when it comes to these devices. You can use a vacuum pump if the penis is completely flaccid, or if it's partially erect, or even if it's fully erect to really engorge that tissue. All of those scenarios are fair game. So I would say if you're after prostate cancer treatment and you're thinking, what are things that I can do early on to optimize my genital health, one of the most important things that you can do, or you can tell your patients, is to get a penis pump.

Diane Newman: Thank you so much. That was really helpful.