TODAY'S GUEST: Max McCullen, sexologist and men’s sexual health consultant

I'm extremely happy to welcome Dr. Max McCullen to Hard Conversations!

Dr. Max McCullen completed undergraduate studies at University of the Pacific and The University of London and then his research led him to the Institute for the Advanced Study of Human Sexuality in San Francisco, where he acquired a Doctorate of Education in Human Sexuality and Gender Studies.

In 2004 Dr. Max began working for GlaxoSmithKline Pharmaceuticals (GSK), one of the largest pharmaceutical companies worldwide. This experience contributed to his understanding of medical treatments for male sexual dysfunction. He became familiar with how Viagra, Levitra, and Cialis function on a biological level and their social implications. His expertise naturally transitioned into him working with some of the most prestigious Urology offices in Southern California. After GSK he worked with Boston Medical Group (BMG), an international, clinic based organization, comprised of board certified Urologists and other specialties. With BMG, Dr. Max was not only their spokesperson doing radio interviews and lecturing but worked as the physician liaison connecting patients with doctors for treatment. He also worked as a consultant for University Specialty Urologicals, based in San Diego, meeting with Urologists all over the west coast to train them on various treatments for men and women’s sexual health issues, including hormone replacement therapy. During this time he also hosted online webinars for patients with questions; he also has a written and video blog series and does private consultation for patients. As of 2016, Dr. Max has been consulting for American Medical Systems and Boston Scientific in the OR.  This new exciting venture allows him to assist urologists in surgery, implanting Artificial Urinary Sphincters and Inflatable Penile Prostheses.  He also consults for NXthera, promoting their new BPH treatment Rezum which utilizes water vapor to ablate the prostate.

• WEBSITE:

  https://drmaxmccullen.co

YOU'LL LEARN

• Information about PDE 5 inhibitors

• How Viagra, Cialis, Levitra, etc. all work

• How penile injections work, how they help

• The detriments of sexual shame

• Information about penis pumps

• Information about penile implant surgery

• Penile implant surgery is very helpful

• Alternative medical treatments for erectile dysfunction

• Erections are complicated

• And more!

THANK YOU FOR LISTENING to my male sexuality and sex therapy podcast!

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And lastly, if you have any questions (or would like answers to previously submitted voicemail questions!), head on over to Tim’s website.

About the Show

Introducing Hard Conversations, a podcast about male sexuality, and all things erectile, from the latest natural erectile dysfunction treatment to the best ed medical treatment. Therapist Tim Norton expands the conversation about male sexuality, adds context to why we struggle as a society to have hard conversations and breaks down how in a sex-positive environment there really is no room for taboos, judgment, or shame when it comes to penises.

YOUR online sex therapy and couple’s therapy HOST:

Tim Norton is a sex positive sex therapist working in private practice. He offers online therapy, online sex therapy, online sex coaching, and therapy and coaching for somatic symptom disorder.

Tim obtained his bachelor’s and master’s degrees from the University of Southern California. Tim is a proud member of American Association of Sex Counselors, Educators, and Therapists (AASECT), the Los Angeles Sexological Association, and works part-time with the Pain Psychology Center in Beverly Hills.

Hard Conversations Podcast Transcript

Tim Norton: This is Max McCullen, who has worked in the sexual health field for 18 years. He worked for Boston medical group, Glaxo Smith, Kline, and a host of urologists all over California. He completed undergraduate studies at the university of the Pacific and the university of London. And then his research led him to the Institute for advanced study of human sexuality in San Francisco.

He has his doctorate degree in gender studies and human sexuality from the Institute and currently works for Boston scientific. 

 Dr. Max McCullen Welcome max. Thank you, Tim. Great to be here. 

Tim Norton: Yeah, I'm so excited. [00:01:00] So how did you find your career path? How did you get into sexual health?

 Dr. Max McCullen That's a great question and I'm not really sure.

I can't pinpoint one exact thing that happened. I've always been very interested in human sexuality. I think. The first time human sexuality hit me and this hole, this will date me a little bit, but I was watching the movie grease in the theater. And when I saw,  Olivia Newton, John come out in the black tights, I realized what all these, the men and women were talking about and fighting about and why my parents didn't get along.

And I realized the power of sexuality from Olivia Newton. John probably started right there. So after that, I just was always interested in it. And then. Did some undergraduate work in it and realize that it's when I started, I actually researched graduate degrees in human sexuality in the state of California.

And couldn't find one UC school or one state school that offered a graduate program in human sexuality. And I thought that was so. Funny, because what field [00:02:00] of study affects us more impactfully than our own sexuality, right. It kind of almost imprints everything we do. Definitely.  so I found the Institute,  in San Francisco, which obviously wasn't a UC or a state school, but they were doing some of the best work at that time.

And so,  I started to study there and then got involved, as you already mentioned with the medical side of things. Yeah. And that kind of brought me to where I am today. I'm still, I'm still treating men for,  sexual dysfunctions medically. 

Tim Norton: Right. And that's actually why I was really excited when we met, because in my.

Current social circles. I mean more of the mental health practitioners, sex therapists, I mean a lot of sex educators.  so I don't have a lot of access to that information regarding things like surgeries and Viagra and, and all the different medications outside of books and outside of just, you know, lectures that I go to and things like that.

So,  I'd like to talk [00:03:00] a lot about that today and, you know, and what you've done and the kinds of things that,  the, the options for, for guys struggling with,  erectile 

 Dr. Max McCullen issues. No, absolutely. And when you approached me, I'm the complete opposite, right? I'm always around the medical. Personnel. So I don't get to interact with the great work that,  your side is doing on how to help men out, you know, psychogenic only, so yeah, I think this could be an ongoing discussion for a long, long time.

Yeah. It could be fruitful for both of us to learn exactly. You know, what we do. And, and I guess the goal, and this is kind of what you mentioned is if you can bring those two worlds into a synergistic. Treatment paradigm, then that would be really impactful for men because they're both, they're both a huge part of it.

Tim Norton: Absolutely. Absolutely. And I think,  We need more of it throughout medicine, throughout mental health. However you want to distinguish it, but especially with sex, [00:04:00] you know, I've, I've looked at a lot of websites, have a lot of urologists and I don't see them mention anxiety reduction or, or therapy a lot of the time.

And, and it's unfortunate is because even if there is a real obvious,  biological cause, which oftentimes there is, or,  It 

 Dr. Max McCullen helps. And even if there is, you know, biological causes, which we're going to talk about, but of course that's gonna affect you. It emotionally as well. Absolutely. It's going to affect you.

Tim Norton: So, so all right, well, let's get into it. So one of the first typical medical treatments that you mentioned is PDE five inhibitors, right? What is that? 

 Dr. Max McCullen So, right. So basically what generally happens. And I think this is a pretty,  normal course for most men is they will bring up to their primary care physician.

That they're having an issue and, and the primary care physician will generally give him a prescription for Viagra. [00:05:00]  many times they will,  refer him to a urologist, but generally what's going to happen is that primary care guy is going to give him the Viagara. Unfortunately, a lot of those primary care guys don't follow up.

So, so hopefully they are, if it's a good primary care and let's say six months, Hey, how did that Viagra workout? Because a lot of guys just give up, but it doesn't work.  and then they'll go to urologist and then, you know, go down the, the whole,  treatment paradigm,  that we'll go into later. But,  to answer your question, a PD five inhibitor is essentially a medication that causes nitric oxide to be put into your system, which,   Has a kind of dual action.

It it's a, it's a muscle relaxer and then it's also a vassal dilator. Okay. 

Tim Norton: And yeah, so dilator. So basically it sounds to me like it, it makes your, your veins 

 Dr. Max McCullen wider. That's exactly what it is. You nailed it. Yeah. Where'd you go to medical school. [00:06:00] Yeah. You nailed it. So, yeah.  opens up the, the, the two corporal cavernosum and your penis and allows the blood to go in there.

 so first it relaxes the muscle and then it. And ends up once the blood goes in there, it's able to cinch up the, the, the,  Bobo cavernosa muscle. So the blood doesn't leak out. So it kind of traps it in there for a little while. And what's interesting is Viagra was a complete mistake. As a lot of things are in science.

 Pfizer was doing a study on pulmonary hypertension and the people. Once they started to interview people about the study, everyone started to say that they were, yeah, I hate doc. I can breathe better, but guess what else is happening? So Pfizer went, ding, ding, ding, you know, multi-billion dollars later.

They, they got the indication for ed. So it was a complete, complete,   mistake that they came up with Viagra. But,  so Cialis Levitra, you don't really hear about it anymore. I used to sell that to GlaxoSmithKline, but they're all the same medication. They're all called PD five inhibitors.

[00:07:00] Phosphodiesterase five inhibitors and they have the same basically mechanism of action. It's just like a delayed.  onset. So you would be like,  you know, Tylenol,  delayed 

Tim Norton: reaction. Yeah. And I I've read about this phenomenon before of a vassal dilation and. At a glance. I think it's counterintuitive because we're talking about relaxing a penis.

When guys in that moment kind of want the opposite. Right. They want an intensification of they because they didn't want it hard. So can you shed any light on, on how that works or why the paradox 

 Dr. Max McCullen with that? Well, I mean, I think that's a great, that's a great question. And yeah, I mean maybe some of the anxiety that men do go through could cause.

Could cause that to be, to be an issue because they're not able to relax because, and yeah, so that's kind of counterintuitive, but your muscles have to relax for the blood to flow into [00:08:00] the penis. Okay. And that's an important component of how Viagra works is it relaxes the muscle and then the muscle, once the blood goes in there and the penis becomes gorged.

There'll be th there's it, it wants to stop venous leakage. There's a term that urologist we use called venous leak is that means the blood can get in there. And we've most men have experienced that. Right? You get hard in the beginning. And then all of a sudden down the, throughout the course of you having sex things kind of start to slow down a little bit.

Well, that basically means that you're not keeping the blood in there. That's what, that's why people use penis rings by the way, because as we get older,  the P the venous leakage can start to happen more often.  so. I'm not sure if I answered 

Tim Norton: your question, answer my question perfectly. Okay. And so different PD, five inhibitors, they'll either,  slowly make the VESO dilation occur or all, all at 

 Dr. Max McCullen once kind of.

Right. Exactly. So Viagra has a little bit of a. Quicker [00:09:00] onset of action. And then Cialis is delayed over time. So see out that, you know, the whole way that the Cialis, the way they market their medication and the way they've designed it is that it's a, it's a delayed release, extended release. So for instance, you're able to,  Have sex, like over the course of a couple of days and it stays in your system like pharmacologically.

It means it has a larger half-life. I mean, we don't have to get into all that, but it just means it stays in your system a little bit longer. Viagra gives you that instant boom, and you're going to have probably a bigger reaction quicker, but then it's going to die over time. So in, you know, let's say eight hours that Viagra probably isn't going to kick in as much, whereas the Cialis will stay in your system a little bit less longer, but it won't give you the initial, the initial,  Erection that I, in terms of my experience of biography gives you.

Tim Norton: Okay. So we could almost say like one night sex, Viagra weekend sex. [00:10:00] Exactly. 

 Dr. Max McCullen Yeah. I think that's a great, that's a great way of looking at it. Okay. 

Tim Norton: And so you worked with those medications for a long time, or worked with guys who had varying degrees of success with those medications. What did you notice.

Would it w were there some guys that could just take it forever and it was fine. And maybe other guys that couldn't like, what, 

 Dr. Max McCullen what, what happened? That's a great question. And I don't think people realize that in. And, and is that 50% of men cannot tolerate PD five inhibitors. So 50% of men either,  I should say 50% of men.

I, I S I misspoke 50% of men can't get to goal. On PD five inhibitors. Now what that means is they may be on,  nitrates. So it's, you know,  it's a health concern, so they can't take it. Right. Cause it lowers your blood pressure so much. Or they have an adverse reaction. A lot of guys have flushing. Like my dad for instance, has really bad headaches.

He can't take Viagra.  or simply there's a, there's an issue over time because. [00:11:00] Viagra works, like I said, with your vasculature, right? So increasing blood flow to the penis. Well, if you're having other comorbidities like diabetes or atherosclerosis, which you know, or hypertension, which causes issues in your vasculature, the effect of Viagra will diminish over time.

So 50% of men that try Viagra, it's not there. They're not going to get to where they want to go. 

Tim Norton: I see. Okay. They, they don't exactly say that on the commercials do not. Okay.  and, and this goes, without saying this, this podcast is in no way, a medically sponsored podcast where we're not, we're not saying go out and take.

 Dr. Max McCullen Great. Are you saying Pfizer is not going to write me a check for this 

Tim Norton: interview? There is not paying max nor myself for this interview. And,  you, you do always want to consult your medical doctor when taking any of these medications. Although in London, they've started selling,  sildenafil. They started selling generic Viagra over the counter.

[00:12:00]  Dr. Max McCullen See that to me, I have heard rumblings about that. And to me that seems. I think there's gotta be some sort of a thing where a doctor's riding off on it somewhere because if a guy walks in that has heart failure or is on nitrates and he gets, and he hasn't consulted a physician, that guy could die. So there's, I got, I feel like there's gotta be a discussion or some sort of a prescription.

Or something like a prescription or at least a consultation. I don't think the, well, you know, the United States is so more, it's more litigious than Europe over here. I don't think it would fly because you'd have to have that consultation because it can be dangerous for a certain type of patient. But I have heard that I need to look into that and see exactly what's happening.

So tell me, tell me what you. Well, 

Tim Norton: I I've just seen the,  the headline brief articles, tweets and things like that, but I got the sense that they were going in and seeing essentially a pharmacist. 

 Dr. Max McCullen So maybe be that's maybe that's the consultation and [00:13:00] the pharmacist saying, Hey, you realize that if you're this patient, it's not to your benefit.

So maybe that's what's happening. Yeah. I don't, I feel like that wouldn't fly in the United States. Yeah. What do you think. I 

Tim Norton: think we'd be a long way away from that. Yeah. Although now there are these startups where you can get your generic or regular pills online, correct. Seeing a, a virtual, 

 Dr. Max McCullen virtual urologist or telemedicine and the stuff that's happening now, it's growing.

More and more rapidly. And so that's happening. Yeah. And the good news is for the other problem with Viagra, this is really exciting. You know, I mean, as we all know with drugs, branded drugs are they have the best efficacy, but they're also expensive. So there are generic options for people. I do work with a company that distributes generic sildenafil, which is actually indicated.

Remember earlier, when I talked about that, it was originally for pulmonary hypertension. So this medication is indicated for pulmonary hypertension, not erectile dysfunction. So they can get it a lot cheaper. So if [00:14:00] any of your listeners, you know, want to, you know, just go into their urologist or primary care and ask them for the generic form of, of sildenafil, which is the chemical name of Viagra, their physician should know that they at this date at this time, people should not be paying.

 retail for Viagra. That was other options out there. Okay. 

Tim Norton: And it's, it's literally the same product. 

 Dr. Max McCullen I mean, I would say it's probably the efficacy is going to be a little bit better with the branded, but you're going to pay three to four times. Right. So why not take two pills of the generic? That's going to save you 50 to a hundred bucks as opposed to taking one pill branded.

Tim Norton: Okay. Okay. Well, good tip. So. So you, you work with guys in various capacities and so, and you see them in, and at some point pills aren't working, they go to urologist and there are other options. There are other medical options. Correct. So next on [00:15:00] the list that you mentioned was injection therapy. Yes. So that sounds right.

I don't want an injection 

 Dr. Max McCullen there. What I heard when I heard about that option before I, you know, went into it and really saw it done. And, and, and I haven't had it done, but I've obviously been in the room many times.  I was, I was pretty much freaked out about it. I said, why wouldn't anybody want to do that?

But believe it or not, they do it in a part of the penis that has little to no nerve endings in it. So there are, as we, as we all know, there's certain parts of the penis that are more sensitive than others. And they do it at the nine and six o'clock sides of the penis where, and they use a very, very thin diabetic needle.

So what you would inject insulin into your stomach with, and the guys from what the patients that I've talked to, it feels like somebody slaps a rubber band,  medium strength onto the penis. So it's a, it's a little bit of a prick. Let's say no pun intended, but that it's not very painful at all. And,  it's.

The [00:16:00] efficacy it meaning how good it works is off the charts. I mean, gun to get an erection. Oh, 

Tim Norton: okay.  what are they injecting into your penis? 

 Dr. Max McCullen So there's a bunch of medications. Again, these are Vasso dilating medications they're used for other things, but,  I mean the names of them are prostate gland in the, the branded name would be Caverject.

That might be some of your listeners will remember having a doctor talk about Caverject.  there's.   fentanyl amine and they use these just for, you know, different medical reasons, but they just basically increased blood flow to those certain areas. So,  it's called,  the, the doctors refer to it as Trimix.

So a lot of times, if you go to urologists, that's the term that they will use, because it will be prostate landed,  attributes and phentolamine, which they will put together in a mixture and then inject that into the penis. 

Tim Norton: Okay. Yup. And so they. How long does the,  how [00:17:00] long does it last? How long does the injection?

 Dr. Max McCullen Yeah. And so, so,  part of the reason why injection therapy became,  well, First of all it was around before Viagra. So they were, they were using it and perfecting it even before Viagra came onto the scene, which is like right in the eighties and early nineties.  and then obviously it kind of fell out of fashion because Viagra started working so well.

But as we talked about a lot of men, aren't going to get to go on Viagra and,  you have immediate erection and it doesn't have to go through, you know, your. First pass metabolism. So you're going to have less side effects, you know, Viagra can have side effects and depends on what you've eaten. So if you're putting the medication right there, boom, you're going to get an erection and it's going to last for about 45 minutes to an hour.

 the, there are drawbacks of course, right? Some guys don't like needles.  [00:18:00] you're. You have higher risk of priapism, meaning an erection that won't go away. That can be very dangerous to the tissue. We've all probably heard the commercial, the Viagra commercials. If you've had an erection for longer than four hours, go to the emergency room, it can cause,  Tissue death.

It's very, very dangerous to have that, to have an erection that won't go down that can happen way more likely with injection therapy. So you have to kind of know what you're doing. That's why a lot of times when you go into a urologist, they'll do it in the office, kind of show you how it's done and you'll get a partial or three fourths of erection.

And then they'll discuss how you can do it at home. Okay. 

Tim Norton: Okay. All right. So that's, and then how much of those costs, 

 Dr. Max McCullen so the cost is, is generally going to be higher than Viagra, or of course the, the generic,  I would say generally, they're going to sell you up a six months supply and it could be anywhere from 500 to a thousand 

Tim Norton: dollars.

Okay. Six months supply figuring you're having sex like three to [00:19:00] five 

 Dr. Max McCullen times a week. Okay. 

Tim Norton: Okay. So yeah, 

 Dr. Max McCullen I don't know how you'd break that down. Cost-wise but that's generally they, they sell them in like lump packages.  cause it's just not. Profitable for them, I guess, to do it any other way. The other problem with, with the injection therapy is they have to take cut because they're pulling different medications from different pharmacies or compound pharmacies, the supplies, an issue.

So I've had that be a problem where. Urologists have asked me if I know pharmacies that do this, I would set them up with a pharmacy and this has happened more times than I want to deal with. As they said, Hey, they're having, they're having supply issues with one of the medications that I combined. So then the patient basically was out of luck.

So he had to wait until they got enough of the medication there to combine it. So then they had the medication already. There's also sterility issues. It has to be refrigerated. Right. You can't like, leave it in your car on a hot summer day and then use it. It has to be [00:20:00] kept at a certain temperature.

Whereas if you have a pill, you can leave it in your car. You can take it whenever you want. So traveling is an issue, right. Because you have to have a needle in a sword. Okay. 

Tim Norton: Okay. Interesting. And then, okay, so. For the guy who doesn't want the pill guy doesn't want the injection. What's next. Usually you've mentioned a vacuum.

So yeah, 

 Dr. Max McCullen the vacuum and the injection, I would say are kind of like the second, a and second B sometimes urologists are going to go for the vacuum device before the injection, because it can work at times synergistically with. Viagra. So remember when we talked about venous leakage earlier, so the guys can get hard and maybe it doesn't stay hard or maybe the Viagra is just kind of working halfway, but you're getting a little bit of extra blood flow.

So now what you can do is you can put a suction device on the penis, basically. That's just literally physically pulls the, the blood into there because you're co you're forcing [00:21:00] it. And then there's a ring at the end. So basically you put a cylinder over your penis. You want to create an airtight seal?

Some of them are hand held back in the day, like 50 years ago that it would be, it would actually be a PO a pump that you would do manually with your fingers. But now they have battery powers and you basically turn it on. It does make a noise. So it's not very sexy. Right? You wouldn't want to do it. In the S it's not discrete if you're going to do it next to your partner.

So you'd basically have to get up, probably go in the bathroom. It kind of makes a little bit of a humming noise as the battery kicks in. There's a button that you push. It kind of goes, mm. Literally physically sucks the,  blood into there. And then you, before you put the cylinder over your penis, you put a rubber ring around the tip of it.

And then you just slide that ring off the cylinder onto the base of your penis. And that keeps the blood in there and maintains the erection and then you can have sex. Okay. It's not very comfortable. I [00:22:00] did try one of these because I, obviously, when I was talking to patients, I wanted to be able to,  know what it felt like.

I didn't want to inject myself to know what it felt like, so I didn't go that far, but,  it's not w it was comfortable cause it feels like this cinching feeling. So even though it does work, it's just, it's not sexy. It's kind of embarrassing. It's not very discreet.  but there's no side effects, right?

You don't have to worry about any of the side effects with Viagra. You don't have to inject herself.  and you see it's pretty benign. If people, if someone does not want to use any medication at all, that could be. And 

Tim Norton: I imagine from like a sex positive viewpoint, you could. Play with your partner, get comfortable with the 

 Dr. Max McCullen machine fun experience to play around with it.

Absolutely. You could try it on. If you're with a female, you could try it on her. If you know, two males, obviously they could have fun with it. I mean, so [00:23:00] that's a great point, you know, and it could be something that you can incorporate into your 

Tim Norton: right. I think I heard people talking about that at like,  a talk on sexual disabilities, like people who have sexual disability, that's going to be something that, that 

 Dr. Max McCullen would be, that's a great, that's a great option, right?

Tim Norton: Okay. And well, a funny side note, I was at a, I was at a blow jobs class, as you know, we end up at classes in this field and the fruit around the class was his all kind. Yeah. Okay. 

 Dr. Max McCullen Was it like P prosthesis and dildos as though? Oh yeah. 

Tim Norton: All kinds of toys, but the instructor mentioned that. There's a blowjob technique that basically mimics a vacuum.

Interesting. That, of just sucking the blood. 

 Dr. Max McCullen And so you'd probably, you're probably creating an airtight seal cause that's, that's, you know, if you, if you don't do that, that's such an, the whole premise, right. So you'd have to be probably pretty far down on the yeah. 

Tim Norton: Well, and, but while the penis is [00:24:00] flacid, that wouldn't be as hard or difficult and then true.

So I was, I haven't actually. Seen it, but he swore by the technique and it was certainly compelling. Interesting. Yeah. So for all you a blow job givers out there that might, you might have a new, a new calling.  so next along the list, you mentioned something I haven't heard of 

 Dr. Max McCullen therapy. Yeah. Pellet therapy.

Let me back up for one second. The one thing I wanted to, to throw out there is. When I mentioned that you can use a vacuum erection device synergistically with Viagra or Cialis. One thing you would never want to do is use it if you're doing injection therapy. Okay. Yeah, because it's gonna, it's going to increase your chances for the priapism.

Okay. So if you're, if you're injecting, try mix into your penis and you're not getting an erection, there's something wrong with the medication. And I would not. Jump [00:25:00] into a vacuum erection device. Also, it could be maybe you didn't, maybe it's taking a second to kick in. Next thing, you know, you start using the vacuum erection device.

You get too much blood in there. So just to throw that out there as a caveat to listeners who. Would want to try that with injection therapy only used the vacuum was with Viagra. 

Tim Norton: Okay. Okay, good. Thank you.  that helps. So pellets, 

 Dr. Max McCullen so pellets. Yeah. So this is called, this is a brand name called muse. That's maybe what people would remember it by if a doctor ever brought it up, essentially what it is, it's a trocar, which would be a delivery device, basically.

 Has a small opening. It's kind of like a Turkey Beyster, but very small. And it's basically the same medication as prostate gland in it, which is the same main medication that you would put into the injection therapy. But for people who don't like needles, you would actually put a pellet into your wreath really into your penis.

[00:26:00] So Paul, like through the whole of you, 

Tim Norton: you're doing it yourself, 

 Dr. Max McCullen correct. Just put, put the end of the delivery device or the very small Turkey Beyster into your urethra deposit, the pellet and the pellet dissolves into the tissue. And you get the vassal dilation by having the immediate topical application of the, of that medication.

 I haven't. Had it done or seen it done. And I've heard that it's painful. I heard it's actually more painful than the injection that's okay. Yeah. So, okay. So then it's not as popular anymore, 

Tim Norton: right? Okay. Not as popular anymore. 

 Dr. Max McCullen  well, you know, there's always a patient that's like deathly afraid of needles, right?

Sure. Viagra doesn't work. Doesn't want to do the vacuum device cause he thinks it's embarrassing. Right? That's the guidance. And so there's that going to be that guy out there? That's like, Hey, that's for me. And maybe he's not as sensitive. 

Tim Norton: Maybe he's into your wreath [00:27:00] replay right there. There's a whole section at that, a lot of sex stores for your replay.

And,  they might stay like the pain in there and they might not mind it. It might not even bother them at all. Okay. So then hormone replacement, 

 Dr. Max McCullen right? Okay. So, you know, we've all kind of heard of this. I'm sure there's commercials ad nauseum about it, essentially, as we get older, We lose after 40, we lose 10% of our testosterone production a year testosterone.

So important for,  well, definitely women have testosterone as well.  but for men, you know, our mental acuity is tied into our PR you know, testosterone, our,   muscle.  formation muscle retention is all tied into testosterone. And of course your sexual functioning is tied into testosterone energy levels.

 you definitely want to go get your levels [00:28:00] tested before you do this, because if you and there's, there's, you know, I'm trying to think of one of the medications, but maybe you remember too well, they say,  Take this pill and you'll it creases your testosterone. I see commercials about all the time.

It's kind of dangerous because what happens is you, you run the risk of your body, basically what your body is going to say, Oh, well, I have all this now, free testosterone running around that you've put in artificially and then your body will stop producing natural testosterone and you run the risk of your body.

Totally shutting down and not producing any more testosterone. Which is worse, so, Oh no. Yeah, you don't, you don't want that to happen. So what you want to do is if you, as I would recommend any guy over the age of 40 to go get your testosterone levels checked, you can go to your primary care. You can go to like any sort of,  nephrologist or endocrinologist, probably do it more so than anybody, but any primary care will know how to do it and he'll come back and he say, yeah, you know, it's a little low [00:29:00] or Hey, guess what?

You're not, you're really low. And then you're like, boom, well, that's the problem. That's my problem right there. You know, it's not.  that I'm not turned on by my girl. It's not that I have Vasso dilating problems. It's that I'm producing. Absolutely no testosterone. So that's an option, but you're not going to know that until you get your level.

Tim Norton: Okay. And then, so that would, is there a connection between testosterone and blood fell? Blood flow? 

 Dr. Max McCullen So that's, it's funny because,  as far as my, my research,  Has like, basically shown me is that it's still, there's still some question marks about,  erectile dysfunction. What we do know is there's like five key components to getting an erection.

Okay. You have to be visually stimulated, right? If you take a Viagra pill, for instance, that w that has to work with the rest of your body, right. Not the injection, but if you take a Viagra and you go to like an insurance [00:30:00] seminar, you know, and there's nobody that you're tracking the two in the room and you don't have 

Tim Norton: insurance seminar kinks, that's not 

 Dr. Max McCullen your paraphilia is isn't.

Sure. All right. You're not going to get an erection. So men, I have to be, it has to start here. I'm pointing to my head for the viewers at home. For anything to work. So that's number one, number two. Your, your brain kicks in your endocrine system or your hormonal system. So the testosterone picks up your dopamine, your serotonin levels start picking up.

You know, you, you know, as we all know when we're, when we're turned on,  you feel good, right? Like, cause if I look at a picture of a beautiful woman, I feel, I feel good. I feel kind of like, Hey, that's that's because your serotonin levels is jumped up. Right. So, so your testosterone levels jump up. And what that does is that kicks in the rest of the.

Mechanisms, which now start your, your nerve innervation. So you have to have the nerve impulses, have to go down and, and talk about the, those muscles relaxing and [00:31:00] opening up, and then the blood flow. So all these things have to happen right at once you have to be turned on, you have to have hormonal output.

You have to have nerve innervation and you have to have a vessel dilation. So. To think about that. Yeah. It's pretty amazing what our bodies go through. And I don't know if, but like women really appreciate what's going on physiologically. It's complicated. It's complicated. So I think men need to give, give, we need to give ourselves a break, right?

Because that's a lot to go. And as you get older, right? None of us run as fast as we did when we were 16, we can't lift as many weights. So. Okay, listen, give yourself a break that, Hey, I don't get as hard as I used to, but there's a lot of things going on in my body and there's options out there to get me to the point where I can maybe not be like I was when I was 15, but I can still have sex and have a great time and have a great sex life.

Right. So,  yeah, there's a lot of things going on. And to answer your question, we don't know [00:32:00] exactly which one's going to carry the load more, but we do know testosterone is a key component. We just don't know. If it does more innovation than vessel dilation or more this or that or whatever, so, okay.

There's still some question works. 

Tim Norton: Okay. And then finally, and this is this, this last. Technique, this last process is what you do a lot of lately are these, are they implants surgical implants, right. And for the viewers at home, you can't see him. He is in scrubs because sexy scrolls right here and well, because as a part of your job, and you mentioned this earlier, you had, you attend these surgeries, correct?

You are present to these surgeries. Why? 

 Dr. Max McCullen  Two reasons really,  the devices are very, very expensive, so they want a representative of the company to be in the room. In case let's say you didn't have a representative there. And the scrub nurse opens up the device and drops it on the [00:33:00] floor. Well, now it's now it's not sterile anymore.

Well, that's a $708,000 piece of equipment. So the D the hospital might be in a. Discussion with the manufacturer saying, Oh no. Yeah, we didn't use that. If the reps in there now it's, it's our responsibility. If it gets dropped it's on us. So we're responsible for all of that. The other thing is, is that surgeons, you know, doctors know a lot about a lot.

Right.  and they're dealing with prostate cancer. They're dealing with urinary issues, bladder issues. They're dealing with. A whole, whole erectile dysfunction. They're dealing with female urology, you got all this stuff. And so they might not do this surgery more than once a month or once every two months.

So we're supposed to kind of just be in there in case. That doctor has any questions. Hey, by the way, how much am I supposed to fill up the rest? Well, you know, it's, you know, you want to fill it up to at least 60. [00:34:00] And so just kind of to be there in case. And also the scrub nurses do a lot of the prepping of the devices.

So you need to be there to walk through them with that process, if the doctor's doing his surgical,  Techniques to get ready to implant the device. So basically you're just kind of there to make sure everything's kosher. 

Tim Norton: Okay. And so these, these implants,  tell us more about them. I think everybody to get an idea should probably Google,  pictures of penile implants and you know what they look 

 Dr. Max McCullen like.

I'll leave. Well, I have one with you today. We can take some pictures and,  you know, I can actually give you one right now. Let's say you can kind of,  maybe.

This is basically, I just I'm handing Tim one right now. So you have that in your hand and that's a penile. That's a penile implant and we'll take a picture of that and you can put that on your, on your website so people can see, and of course they can Google it. If you Google [00:35:00] Boston scientific,   penile prosthesis, or American medical systems, penile prosthesis, there'll be pictures and videos that you can, that you can pull up and take a look at,  essentially the main device.

That is the best-selling device.  now is,  called a three-piece,  penile prosthesis. And it there's a reservoir or a balloon. That you put in your abdomen as a pump that goes into your scrotum. And then there's two balloons that go into your corporate cavernosum. So the penis is made up of three basic cavities.

Your, your corporate spongiosum is your urethra. So that's where you urinate and ejaculate out of. And then there's two cavities below that, which is your, your cavernosum. And that that's what fills up with blood. Okay. So that's how you get an erection. What the doctors do is they go in and it's kind of brutal to, to watch actually they take dilators and just.

[00:36:00] Work, all that tissue out of there. And they just kind of basically just slough it all aside and, 

Tim Norton: and max is making kind of a punching grinding motion. Like they're, they're literally clearing out 

 Dr. Max McCullen the tissue, the tissue out of the, yeah. And they actually don't bring any tissue out, which is interesting, but they're really aggressively just opening up these cavities.

Where's the incision. So the incision is mid. Mid glands under the penis. So let's say the scrotum it's in between the scrotum and mid penis. So, yeah. So let's say, let's say that the top of your glands, which is where your head, your helmet is two centimeters below that on the underbelly of your penis and about a centimeter and a half above your.

Well, your scrotum starts. They make two incisions right here, a gauge again, they're putting two balloons in there. Right? Right. So these two balloons are going in there [00:37:00] and they, they do, they shot them because they want to make sure that this is there's no bubbles through there because basically what runs on saline.

So to get the erection, they're moving saline in between these three.  parts of the, the device. So the, again, the pump, the balloons and the reservoir. So when you, the pump, it transfers the saline from the balloon or the reservoir, which is in your abdomen into the cylinders, which are in your penis. You get an erection when you're done having sex.

There's a deactivation button. That's in your scrotum. You push the deactivation button and you, with your hand, gently squeeze the penis. Downward and that transfers the S the saline back into the reservoir, into your stomach, and then it sits there until you're ready to have sex again. 

Tim Norton: Okay. And you, you described this to me before and also described it pretty, flatteringly like [00:38:00] pretty with guys saying they.

Had wonderful results 

 Dr. Max McCullen with them. I was literally shocked. So when I sold Viagra and when I worked with other urologists and we would do a lot of clinics where I would show people how to use the vacuum devices, I would mention this and I didn't. Realize how high the patient satisfaction was until I actually started interviewing urologists that were doing a lot of them, you know, urology surgeons, and then talking to patients afterwards, it's got about a 90% patient satisfaction rate.

Wow. And then they interviewed their partners and the partners had a real, like over an 80, 90% satisfaction rate mom. I mean, I take all these numbers in, in,  You know, lightly because it's coming from probably research that the company did, but the point is, and the reason I believe that it is really high is these guys have exhausted all of the other treatment options that we've previously talked about.

Once they go here, Dave, Most likely, I would say 99% of these guys have tried [00:39:00] one of the options that we've been talking about. So they've probably, haven't been able to have adequate sex in a really long time. And this is,  this is, this is what you would call a cure. I mean, you are definitely going to get an erection for as long as you want.

It's not going to go down. You don't have to take a medication. There's really no side effects other than the fact of what can happen when you have surgery, which is a huge thing you want to consider. Once you're out of surgery and you had no complications, it's a cure. You're going to get an erection.

Hmm. So I think that's why you have a high patient satisfaction rate. 

Tim Norton: And is the Jackie elation the same? Yeah, it's 

 Dr. Max McCullen exactly the same because you're not going into the Corpus spongiosum that houses the urethra. So you're not damaging the urethra whatsoever and the sensitivity. Now I haven't had this done and I've talked to some patients, they tell me the sensitivity is the same.

Huh?  I would think that there's, there has to be a little bit of a diminishment simply because you're, there's going to be some nerve damage. Anytime you take a knife to anywhere on the body, there's going to be some nerve damage. [00:40:00]  However they're doing it at, at that area that I discussed earlier where there's not as much.

Right. And,  so 

Tim Norton: yeah, it's not the most sensitive part of the penis at all. Correct.  okay. So, and then you could obviously still have your, your penis pumped up for a blow job as well for receiving oral sex. 

 Dr. Max McCullen Anytime you want to get a hard-on, you can have it all day. You can pump it up. You can have it all day.

And you don't have to worry about what we talked about earlier. So you're not going to have any tissue damage because you have no tissue in there. Right. So when people say this is a cure for ed, I mean, I guess in a way you could say that now,  side it's expensive, it's expensive. It's expensive. A okay.

Also surgery's a big deal. It really is. There's lots of things that can go wrong. You're under anesthesia in an Orr, right. There can be infection. You know, there's infection issues. I've, I've, I've done one of these where there was an infection. They had to go back in, take it out, right. Put a bunch of antibiotic.

[00:41:00] So surgery is no joke. So that's something that, you know, that's why I think that these guys have tried other options before they go down this road, because I don't think any of us take surgery lightly. Right. Right. None of us are going to just. Jump into that without seriously considering what the issues are.

 there are a lot of insurances that are covering this now, and I even did a transgendered prosthesis surgery,  three weeks ago and it was paid for by an independent organization. Awesome. And then also some of the,  you know, government agencies are covering it for some transgender patients.  Obviously veterans have really good coverage, so.

Okay. 

Tim Norton: Yeah. Okay. Well that all, so those are really the options that you're seeing. 

 Dr. Max McCullen Medically. That's pretty much what we're talking about.  there's other people who have talked about,   PRP treatment, which would be platelet rich plasma. Essentially what they're doing is they're [00:42:00] taking healthy cells from other areas, putting that into the penis.

 and then what I guess pretty much what my understanding is of that is that the healthy cells kind of teach the, the unhealthy cells or start to replicate more healthy cells. Now, I guess what that could do is improve. I guess, if you have epithelial damage, meaning that the lining of your arteries, maybe it could help heal that, which would help you.

Like, if you had some sort of atherosclerotic plaque, it would maybe diminish that. So then you could get, I don't know. I mean, I'm just saying what would be the applications. I know they're using it for like knees and elbows and stuff like that. So maybe there's an application in the penis again, like when we're talking about there's all these different ways of.

Getting to ed. And so you would have to, it would have to work on a certain, certain patient type that it would help. Like for instance, if he has low testosterone, that's not going to help. Right. [00:43:00] It would have to be one of these, the other 

Tim Norton: things. Okay. And then you would actually, I think. I think it was you.

And we talked about this once before,  those over the counter, the other ones that like seven 

 Dr. Max McCullen 11. So yeah, I've done a little bit of research on that and these are,  medical, I'm sorry. They're herbal options. So, so again, let's go back to what we talked about. 50% of men are getting to go on Viagra. Well, that's an option for these guys and one of the most powerful components of, of these,  pills that.

Are sold over the counter is yohimbe B route and it has a really amazing reaction. I've tried it. I had a strong erection for a couple of days. It went down, but like any of the wind would blow it. I think got up again. It was much stronger than PD five inhibitors. Huh? You can buy them at seven 11 now.  And I think they're like couple more called rhino.

There's one called black Mamba. They're very, they're small [00:44:00] pills. There's one. And they have really colorful,  packaging. They're behind the counter. If he asked the guy,  you know, what do you have for, to get men going? Or if I kind of make my arm go up, like on erection and they using it, if the guy speaks Spanish or whatever, he'll know what I'm talking about.

Now, there are about 12 to 15 bucks a piece. So that's probably around that. The cost, maybe a little bit less of what you'd pay for Viagra, definitely more than what you would pay for the generic sildenafil, but they work. And I remember you and I talked about that. So that's an option for people. And I think,  some men are like a little bit afraid to take something over the counter.

Obviously we know when we take medications like Viagra, it's FDA approved. So we know it's gone through that process. Now, these haven't because they're verbal, so they don't have to.  but you know, yeah. You don't know what you're getting.  but,  there's a reason that every one of these liquor stores and everyone has seven Eleven's has these things because they [00:45:00] work.

Okay. 

Tim Norton: So that's an option as well. Absolutely. Okay. Well, that's really interesting. And we started to touch on this earlier regarding all of the different things that have to be working on the same page in order for erections to occur. Right. And that speaks a lot to just general male sexuality, right? And, and performance anxiety.

And, and you said something to me when we were talking about this over lunch and how in our society, we really equate erections with intimacy. Yes. And maybe that's not the best path to travel down, but can you just speak a little bit more about 

 Dr. Max McCullen that? I think that men, and I don't know if it's, you know, strictly.

Adhered to, to this country or whatever, but we are socialized to equate our sexual prowess with erection. And not only that, but, [00:46:00] you know,  maybe porno style, vaginal penetration. I think that's kind of a lot of how we, a lot of us get our first. Sexual education from watching pornography. And that is not sexual intimacy to me.

I think that that's the wrong message to send. I think that you can have a wonderful sex life without that type of, you know, let's say aggressive vaginal penetration, you know, in and out, in and out aggressively. I think that a partial erection is. Great. You can still have sex. You can have amazing intimacy.

And that's just as important as, as any other type of sexual expression. Right. There's not one better than the other. So I think again,  yeah, I'm glad you brought that up because I think we need to give ourselves a break. We need to realize that we don't have to have these certain types of erections to have a great sex life.

There are things to help us now. And as long as we feel that we're [00:47:00] having intimacy with our partner,  that's really the goal. It's not, Y I see vaginal penetration, obviously there's other types of penetration for other partners, other partners. Right. So I don't, I don't, I don't want to strictly say that, you know, confined it to that, but yeah, it's not, it's not about penetrating.

Any anything and having, you know, an erection to do so we can express ourselves sexually.  without that norm that we've been socialized to, to feel is, is,  what it means to be a man sexually. 

Tim Norton: Okay. Well set. And I'm found myself curious, have you ever heard of urologists say something like that to somebody 

 Dr. Max McCullen or, or, and, and I, and I think the follow-up is, is an issue.

And I think that.  there's a huge psychogenic component to, to all this what we're talking about. And maybe that's something that we can talk about, you know, in another, [00:48:00] another discussion, but 100%, if you are anxiety ridden, okay. That changes your, your Vasso.  constriction your vassal dilation, your all the way, the blood flows through your body and that's gonna affect how you perform.

So there's a huge part of it. That's psychological.  and as you mentioned earlier, you know, there's so many different moving parts that we don't know which one actually causes what, right. So that should always be an adjunct part of therapy and urologists don't bring that up.   one of the things that I try and.

Talk to endocrinologists about is the fact that diabetes affects like three components out of that five tiered system that I talked about. Diabetes affects your hormonal output. It affects your, your nerve innervation and it affects your vasculature. Andrew cardiologists who generally treat [00:49:00] diabetes, don't even bring up erectile dysfunction to these guys.

Studies have shown that,  as you improve erectile dysfunction, those men are more likely to make lifestyle changes, which saves their lives improve. Right? Cause so once they're having sex, their sugars go down as a corollary system, they're now endocrinologist should mention erectile dysfunction to diabetics and they should mention the fact that they should have a psychogenic.

Therapy therapeutic part of that. Right. So I think they should, that should be a part of that because study after study has shown that those particular men, when their ed becomes better, Their life expectancy goes up, their sugars go down. Their depressive symptoms are reduced because they're getting laid.

So like, you know, if, if you're, if you can't have sex, it's like maybe why would I give up cigarettes? Why would I not eat what I want to eat? But, Oh, wait, I can have, I can start [00:50:00] having sex again. Yeah. Maybe I will lose that extra 10 pounds. Maybe I will start working out. And so I think a hundred percent that doctors should, should.

To,  refer them to somebody like you and also say, Hey, let's, let's also treat your ed while we're at it. 

Tim Norton: Absolutely. Huh? I it's again, shocking to learn when yet another field of doctors isn't, isn't talking about sex. Anytime I've ever gone on to Google scholar and looked at, okay, what's the latest on erectile dysfunction literature.

It's never more than three or four down before. There's a mention of diabetes. Like it's always, you know, that's where a lot of the research is going. So somewhere in there that they're, they're not reading their Gemma or they're just. Not the taboo. They're not bringing it up in there, but it's, it's a really common side 

 Dr. Max McCullen effect.

Th th that they're busy, right? These doctors are seeing a lot of patients. Ed is a long conversation. That's why a lot of the doctors bring in somebody like me, because they'll go, Hey, I'm going to bring in Maxis and erectile dysfunction. He's he's, he's an [00:51:00] ed specialist. And I can sit there with the guy for a half an hour, because there's so many different questions.

The doctors, a lot of times they don't have time. A, these endos, they're not paid to treat ed. They're paid to give the gut to get the guy's sugars down. Cause that's going to save his life right after that. He's like I got 25 people in my waiting room. I can't sit here for 20 minutes and discuss your sex life.

Is it that they don't care? Is it that they're too busy? Is it that they're not paid for it? Those are all things we can discuss, but the fact is is that you just nailed it. They're not, they're not having that car. Okay. For whatever reason, regardless of the reason. 

Tim Norton: Yeah. Okay. Okay. Well, gosh, this has been such a fun conversation.

Yes. 

 Dr. Max McCullen And I think we just barely hit the tip. Yeah. Iceberg. Yeah. So, 

Tim Norton: so we'll,  thank you so much for your time. I loved it. Yeah, and I hope to run into you out in the field soon and absolutely having hard 

 Dr. Max McCullen conversations. All right, Tim, I'll talk to you.

Shout outs to the sex, positive community, colluding sex educators, sex therapists, sex coaches, other fellow sex, podcasters, [00:53:00] sex, surrogates academics, sexual health, medical community, sex workers. The tantric community and everybody else involved with having hard conversation. .