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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. The next topic I want to talk about is erectile fitness. Dr. Newman, have you ever heard of that sort of term?

Diane Newman: No, I have not.

Amy Pearlman: So oftentimes in medicine, we are focused on dysfunction, ED. But what happens before erectile dysfunction? Well, the erection has—I mean, there's erectile fitness that happens before dysfunction. And when we think about how we identify or evaluate, assess men who come in with erection issues or dysfunction, and especially after prostate cancer treatment, the ways that we assess them are oftentimes—we'll ask them some questions.

Oftentimes the time that we spend with patients is limited by time, so sometimes we can't go down some of those rabbit holes that we might otherwise want to go down. We use validated questionnaires that have come out really over 20 years ago, some of which were validated to assess the efficacy of something like Viagra for ED. We might do a penile Doppler study, which is an ultrasound technology, where we're looking at blood flow in response to a very powerful injectable medication.

Now, the problem with a lot of those technologies that we have is many of them assume a monogamous, heterosexual, penis-in-vagina intercourse. And while there are things like the erection hardness score, where someone can assess that even outside of being in a partnered relationship, they're very subjective measures. They also ask questions regarding sexual satisfaction with intercourse, which we know has everything to do and yet nothing to do with the hardness of the penis. And yet we're relying on a lot of those scores to tell us about erectile function and to really differentiate between mild, moderate, and severe ED.

Some of the drawbacks, too, with things like Doppler ultrasounds, is we are assessing the response of the blood vessels to a very powerful injectable medication. But what if that person is not doing injections at home? Then that really—if they got a great erection in the office, OK, that tells us that in response to this powerful medication, their penis is working, but it doesn't tell us about their erectile fitness or function in the comfort of their home when they're trying to either self-stimulate or be with their partner.

So I'm always open to learning about technologies that can be used in the comfort of one's home to really understand what's going on outside of the doctor's office. And we really didn't have anything until recently. And full disclosure, I am on the scientific advisory board for this FirmTech Company, which gives me a lot of inside scoop about this device. And so I want to share some of those technological advancements with you. And a lot of people don't know about this device, and so I think this topic is really relevant to folks.

So this device here is basically a smart erection ring. And oftentimes, when we talk about bands that go around the penis, we talk about penile constriction bands. And I think that terminology may be a little bit outdated. Who wants to put a constriction band around their penis? I also think they're incredibly underutilized. They can be incredibly helpful tools, but they currently don't show up in our AUA guidelines as being a tool for erectile function. And guys, even as young as when they're in their 20s, they might get great blood flow in the penis, but they can't maintain the blood in the penis. The veins just open up too soon.

So erection rings can be very helpful, but they don't give us information, until this guy came out. So this is the TechRing by FirmTech. And how the person would apply this is he would drop the testicles into this ring. And then it's designed like the back of a bra strap, where it easily just fits into this clamp right here. And then it has a pressure sensor and a strain gauge in it.

So the person will connect this device via Bluetooth to their smartphone, and it will tell the person how many erections he's getting, how long they're lasting, and how firm his erections are. And because this device is not made out of silicone—it's made out of elastomer—it's a little bit of a looser material, so it can actually be worn all night long. Compared to the other erection rings on the market, which are typically designed like the O-rings, where they're tight. So you have to wait until you get the full erection before you put it on. And it doesn't allow more blood flow into the penis. So there's a time limit there. You really don't want to leave them on for longer than 20 or 30 minutes.

But because this is made out of a different material, you can wear this all night long. And it provides that real-time information which, as a urologist, or in your practice, we will never be able to provide to our patients. If they say, well, what is the impact of me doing this strength-training routine versus aerobics and the time of day, or if I change my diet to a vegan diet versus this diet, what is the impact? I can tell them what some of the research shows, although the research is admittedly limited.

But the person, if they use a device like this, they can be an n of 1. They can be their own experiment where they can assess in real time what is the impact of vaping on their erectile function, what is the impact of incorporating aerobic exercise into their daily routine. They can get that information in real time. And I think, first-line therapy for any condition that we treat is lifestyle modification. But what no one teaches you or I is how do we get people to change behavior.

Diane Newman: Right, right, right, right.

Amy Pearlman: We can list off all the things we want them to do, but when they come back three months later, how often do they actually change their behavior? So if we could give people real-time information to tell them whether or not what they're doing to themselves is good or bad, that could be a game-changer. Where I think—

Diane Newman: So then, where do you recommend this? What do you usually—when do you introduce this? I guess that's my question—when would you introduce this?

Amy Pearlman: For any man coming into my office. And I use—I have men who see me for hormone concerns, erection concerns, orgasm, ejaculatory concerns. Some men come in because they want a well-man's visit. They don't know what they need to worry about. And they're hitting their 40s. And they say, I want to sit down with you, and I want you to walk me through what I need to know at this stage of my life. And so I talk about this device with all of those guys, regardless of why they're coming in.

And so it can be helpful, really, for anyone. And I think a big point that I want to make here is regardless of the technology, if we're talking about an erection band, traction therapy, a penis pump, no one has to have a problem or a dysfunction to benefit from using any of those devices. A perfectly healthy man with a perfectly functioning penis can still benefit from using some of these therapies.

So even if someone just wants to know what's happening with their nighttime erections, that is reason enough to use something like this because I have no way of really tracking nocturnals, which is the biggest indicator of someone's erectile health. Yes, there's a RigiScan, but there are limitations to the RigiScan. You have to go to a health care provider who actually has the RigiScan device, which, at this point in time, a lot of people don't have access to that device.

But what can be really helpful with this device, especially in the setting of the man after prostate cancer treatment, is they want to see improvement. And it's so hard for us to tell them to keep being patient. It can take up to two years for the erections to come back. But if the guy starts wearing this, and let's say he sees a flat line, but then let's say at six months, he sees some blips, that EKG is moving, that is reinforcement that he should continue taking the tadalafil, that he should continue using a vacuum pump, that his body is recovering like we expect that it will.

And so I think for confidence that someone knows their body is healing and recovering can be really a game-changer. But not only can this provide data, it's also used as just a really good and comfortable erection ring, so it can be used during sexual activity as well. You can track erectile function during sexual activity, and it just helps keep the blood in after treatment as well. And especially guys after prostate cancer treatment, a lot of them tend to have issues with venous leak. And so really clamping down on those vessels to keep the blood in the penis can be really helpful as well.

Diane Newman: So then that sends the data then to your phone, type of thing. So it's a Bluetooth. And then what do you see then? Just numbers going up, or is it like a graph? What is actually shown?

Amy Pearlman: So you get a graph. And then what it also does is it computes an erectile fitness score. Now this company has, I think, more erection data—it's anonymized data—than any other company in the world. And we have thousands and thousands of tracings. And so one, I think we're going to get a lot of really good information in terms of what is normal nocturnal erectile fitness like for men, because right now we say three to five, but that's based on very limited work.

And in terms of erectile recovery after prostate cancer treatment, that's relying on us to give out questionnaires at certain intervals or doing Dopplers at certain intervals. But let's say you want to know what happens at six weeks and seven weeks and eight weeks and nine weeks versus the standard 3 months, 6 months, 9 months, 12 months. Then this allows you to get that data at different intervals.

But what they're doing with the erectile fitness score is somewhat gamifying it, but trying to make it as easy to comprehend as possible, because some people will like looking at those graphs, and some people want to know, is it a 6 out of 10, or am I at an 8 out of 10? And so they're coming up with an erectile fitness score which averages some of the recent data to give that score.

Diane Newman: This is really exciting because you're right. All the Doppler, the RigiScan, we can't use those. We don't. And the thing is they're done in the office, but that doesn't really give us real-time data. So I think this is really exciting. Again, this is something really new I didn't know about. Are they testing in different age groups, or what are they concentrating on as far as for testing?

Amy Pearlman: Yeah. So a lot of people right now are getting it from just direct to consumer or purchasing these products. And so the question becomes, well, who are these people? Are they healthy people? Are they people who have erectile dysfunction? I recommend these products a lot for my clinic. So a lot of my patients have underlying ED.

But really men of all ages are using these devices. I think there's a huge opportunity for us to engage men in their 20s in their health. And so often we wait until someone has a problem. I think some of the most meaningful work that I've ever been able to do was to get into fraternities. I started this work when I was at the University of Iowa. And then I've since educated a fraternity in South Florida.

I've been in front of hundreds of fraternity men. And people say, well, what are you doing in front of them? And they don't want to hear it, and they're not going to change their behavior. But Dr. Newman, that is completely false. So many of these men have so many good questions about their bodies. They want to know what they should be eating and what their exercise routine should look like. They want to know what the impact is of vaping on their erectile fitness.

And I think non-invasive therapies like this, like someone would wear an Apple Watch or an Oura Ring or a WHOOP, this is just another one of those wearable devices that can help engage people before they have a problem to better understand their bodies and perhaps make better lifestyle changes even outside of the doctor's office.

Diane Newman: I love what you just said because you're right. We have so many wearable devices for blood pressure, heart rate, O2 sat. Why not for this? And you're right. To keep it—really to maintain your health is what you're saying. Maintain penile health or fitness. I love that term—penile fitness.

Amy Pearlman: And it's really just understanding what matters to this person sitting in front of us. For some people, it might be their sleep, and for some people, it might be reducing their blood pressure. And for other people, it might be they want to have amazing erections. So we have to ask what is that relevant factor and then figure out how do we track it. You can't measure what you don't track. And now we can actually track these factors.

Diane Newman: Well, that was very, very exciting. I mean, again, very informative. Something I didn't know about. So I really appreciate your coming on to educate our viewers. Thank you so much.

Amy Pearlman: Thank you so much for having me.