For years, urology has operated under the assumption that high testosterone was a risk factor for prostate cancer. Thanks to new research, we are now learning that low testosterone could be a greater cause for concern. At the forefront of this research is Dr. Ananias Diokno, Professor of Urology at Oakland University William Beaumont School of Medicine and University of Central Florida College of Medicine. He and Dr. Lutz have worked together in the past, when Dr. Diokno served as Chairman of Urology at Beaumont Hospital in Royal Oak, Michigan.
This isn't the first time that our guest has been front and center for a major new development in urology. He worked with his mentor, Dr. Jack Lapides, to make intermittent self-catheterization the new norm for patients at home. We spend some time talking about the special relationship between the two men.
At nearly 80 and still very active, Dr. Diokno talks about the role of natural supplements in his life, and how it's helped him with gout and severe cervical arthritis. There may also be implications here for natural ways to boost testosterone in the body.
Ananias suggests men have their testosterone checked around age 30 as a baseline, then to have it checked routinely in order to stay ahead of risk factors for BPH and prostate cancer.
MIU Men's Health Foundation Website:https://www.miumenshealthfoundation.org/
Dr. Lutz: Welcome to the On Call for Men's Health podcast. And I'm Dr. Michael Lutz. This is where we talk about things you don't want to talk about, but these are conversations that could save your life. Or the lives of the me you love. Thank you for joining us. And today we're going to talk about the testosterone truth with Dr. Ananis Diokno. I've known Dr. Diokno for a long, long time, and it's been a great journey together. And I'm in my urology career, as I'm sure is his urology career. Dr. Diokno actually is a professor of urology at the Oakland University William Beaumont School of Medicine in Rochester, Michigan, as well as the University of Central Florida College of Medicine. He was a professor of urology at the University of Michigan, and I've known him as the chair of urology at Beaumont Hospital in Royal Oak, for which he served for 23 years. And after which he served as the Chief Medical Officer and executive vice president for Beaumont Health System for another seven years. He's currently retired from his clinical practice, but he continues his urologic research, teaching and education.
And as you'll learn today, you'll know why he's truly a leader in urology. You know, I've known Dr. Diokno for a long time. He may not remember this, but the first time I met him was when I was an undergraduate at the university of Michigan. And I interviewed for the University of Michigan medical school. He interviewed me, it was a long time ago.
And I just wanna say, thank you for being here.
Dr. Diokno: You're welcome.
Dr. Lutz: Your area of expertise for all of these years has been in neuro urology and bladder dysfunction. And you are one of the main implementers of intermittent self catheterization, caring for people who are unable to empty their bladders efficiently or effectively.
It can be done in many ways, but back in the days before the discovery that Dr. Diokno and Dr. Lapides created clean intermittent self catheterization, where you can just place a catheter for a few seconds to drain out the urinary bladder and then take the catheter out. We used to leave people on catheters long term, and they would have to have the catheters placed by a sterile technique wearing gloves and other sterile cleansing devices.
Dr. Diokno's research with Dr. Lapides showed that you only have to have a clean technique with soap and water, and you can reuse the catheters. They can just be washed in soap and water. Just using this clean technique can be more than adequate to drain the urinary bladder effectively, safely, and reduce the risk of getting recurrent urinary tract infections.
My first question to you is what contribution do you believe has really changed a tentative of urology? And do you think intermittent self catheterization was one of those?
Dr. Diokno: Certainly before that many men and some women also with the spinal cord injury. That were suffered from the effects of injuries during war and during accidents became paralyzed.
And when they're paralyzed, they have lost their bladder function. And in the days before clean intermittent categorization, they have to wear in dwelling Foley catheters. And if they have to be intermittently catheterized, they have to use some sterile gloves and they have mask and gowns and very, very expensive.
And because of that, they minimize the amount of catheterization, which has to be done regularly. So when we introduced intermittent categorization by the clean technique and Jack Lapides, my father of urology, who thought about this and introduced this in 1972 was met by significant resistance. We had to fight our way forward in order to ultimately get this accepted, not only by the nurses, by the doctors, not only by the physical medicine rehabilitation who has been taking care of spinal cord injuries, but urologist who were very resistant to this idea until it was proven beyond doubt after several years, that it is very safe and it actually saved lives.
Dr. Lutz: You know, we all have our heroes and people that actually teach us the right way to help us on our journey. You've talked about Dr. Jack Lapides. I actually did also have the chance to meet him when I was an undergraduate before I went on to medical school and he was actually friends with my father. Who's a previous urologist.
Dr. Diokno: And a respected one too.
Dr. Lutz: Well, you're sweet. But. You said, if Jack had not died, he probably would've received the Nobel Prize for the introduction of intermittent self catheterization. I agree with you. I think that has been a such a change and it was actually rated in the Journal of Urology as one of the top 100 major urologic contributions of the 20th century.
So why did Jacko Lapides become your hero? What was it that made him so special and such, a leader in your eyes?
Dr. Diokno: It started when I was still in the Philippines, I was one of the twelve medical students from the Philippine medical school that was chosen to do my 12 month internship at Clark Air Force Base.
In Angeles City in the Philippines, this is the main air base of the US Air Force. And while I was there, I was lucky that during my first month of rotation was urology and I happened to meet, you probably also know Bob Ross and also a man by the name of Joe Hart. Both of them really took me to the wings and taught me a lot of urology during my first month of internship at Clark Air Force Base.
And one thing that Bob especially introduced me is in neuro urology and neurodynamics and coming from Wayne State, he said, you must go to Wayne County, General Hospital, if you want to really work with Jack Lapides because he is the chief of urology at, that place. And fortunately I was matched to have interned there.
And when he and I met, there seems to be a nice relationship that existed. And some people say, "Oh, you know what? Because you can see eye to eye with Jack," literally speaking, because we are about the same height. He's very meticulous, very dogmatic and very outspoken. And if he believed that you are wrong, he will tell you in front of you.
And a lot of people are not happy to be told if they're wrong. But anyway, I found him to be very honest. I found him to be straightforward. Although he's a big disciplinarian, which I feel like what I had when I was growing up in my family, but also he's a thinker. He always had one step ahead and saying, what about this?
So he challenges you. And I was so excited about it to the level where I started volunteering to do a lot of work that are coming out of his mind. And so then he assigned me to do the review of these 12 papers, or charts, that he started clean intermittent catheterization. And that led me to recognize how safe and effective clean intermittent catheterization is.
And then that led the paper, that he asked me to be part of that paper. And then also when I was an intern after just a month, he called me to his office. I didn't even have to apply. He called me to his office and said, I heard that you're interested in being a urologist. I would like to offer you the one position that is available in urology at Wayne County General, where he was the Chief of Urology at that time.
So he found something in me and I have found something in him, way back in the Philippines. And when I came, I said, this is really the man that I really want to work with. But I'm just a little international graduate. And the chances of me being picked will be minuscule. He has never appointed a foreign medical graduate in his training program at Wayne County. But he offered it to me. I didn't even have to ask.
Dr. Lutz: You know, after Dr. Lapides retired, you, out of an act of kindness and respect, you created a Diokno-Lapides essay contest. What made you decide to create that kind of a contest? And what was your goal in having a contest of that nature?
Dr. Diokno: When he retired and I was the chair of urology at Beaumont, we had many weekends together in his house and we had been drinking wine and we are looking at the backyard, which is very nice. Forested. And during winter, it's beautiful. And he asked me to be his medical guardian, if something happened to him. And I said, well, of course, I'll be happy to do that.
Not knowing that that will ever happen. And he said, oh, by the way, when I pass away, I would like my body to be donated to the anatomy class at the University of Michigan. I almost fell off my chair when he said that, because said, I, I, I said, are you really sure you want to be disected? And he said, well, of course.
You know, once you, you pass away, your body is there to be used by somebody else and it'll help medical student. Then this medical student will help other people and therefore will help mankind. That's how good he is. And so actually before he passed away, We decided that through Marion Laboratories who was at that time promoting Oxybutynin, Ditropan, which is sort of my baby.
We were able to create a contest in his honor to be funded by Marion Laboratories. And fortunately it gets started back in 1984 when I was starting at Beaumont. And so, year after year after year, we were able to do that. And then when I retired my chancellor said that, you know, because of my helping in organizing and promoting this and maintaining the Jack Lapides essay contest, Mike added my name and become Diokno Lapides Essay Contest in neuro urology and neurodynamics, and you can look at the 30 some winners that have gone through, and they are really giants in their field right now. Really has done very, very well.
Dr. Lutz: I did. I saw some of the winners, including Mike Chancellor. So it was nice to see that he actually was able to show his worth, which we know. And we see as we work with him at Beaumont. You know you're approaching 80. And if people listen to this, they'll have no clue that you sound like an 80 year old man, cuz you do not. You sound like a young, vivacious man that I still remember from when I first met you. Your personal health is important and you talk about about how important your health is. A lot of people talk about diet, I'm going on a diet, I'm dieting this, but what they don't realize is diet isn't what you do, it's lifestyle. So what do you think is kind of your lifestyle that has actually made it so that you could have the successful run to where you're at right now.
Dr. Diokno: You are hitting topics that are very close to my heart and to my brain, I guess. And I'm also fortunate that I have been highly involved with the geriatric society. The American Geriatric Society, the Gerontological Society. And ultimately, now I am one of the leaders of the Geriatric Urologic society. So I have been involved with many of this. And what strikes me is exactly what you said that longevity with good quality of life can be attained only with good lifestyle. And a good lifestyle involves yes, nutrition, but you have to be a wise nutritionist for yourself and your family. Fortunately, my wife has been watching my nutrition as well, but also to be physically active. So those are the two. You have to keep moving, having physical activity, but at the same time, you have to put into your body some good food and good nutrition, not necessarily just dieting, but make sure you have the right combination of food.
And now I am discovering a lot of things we have demonized before, or we have been promoted that are really not very good. So anyway, good nutrition, physical activity, but also a significant part of lifestyle is to be happy and to have less stress. You cannot be angry. You cannot hold within yourself. You have to be forgiving.
You have to enjoy, you have to look at the positive things of other people. You have to look at the glass half full rather than half empty. And try not to keep the grudges, because if you are angry, it'll always be in your heart. And stress is the number one killer, I believe. And that's the one that prevents you from rejuvenating and regenerating your whole body cells.
Dr. Lutz: Yeah. I always talk about staying active and keep moving because if you keep moving the bad things, can't catch you. And I think that's one of the things, but we're getting smarter. We talk about sedentary death syndrome and we know that a number of diseases are caused by just sedentary status. And we're very thankful that one of the advantages now with all the smart watches now, is it keeps you moving.
It reminds you if you've been sedentary, if you haven't been moving. Also keeps track of your sleep pattern. And I'm a real believer in that there's a lot of articles that show a benefit of getting proper sleep and restfulness, and that it'll actually improves avoiding the risk of mental health issues, dementia.
And also there's studies regarding prostate cancer that actually can reduce the risk of disease development and progression by getting proper sleep patterns. And we know metabolic disorders actually suffer as a result of people who do shift duties and don't work through the proper circadian rhythms.
So we know that sleep activity, lifestyle, diet, nutrition, and you've led into stress, all play a major role in how you're gonna be well. You actually briefly touched on a role of supplements and how you believe that there may be some supplements that could be beneficial in improving your health and longevity. So do you want to kind of talk a little bit about that?
Dr. Diokno: Oh, absolutely. I have been a believer of plant supplements since 15 years ago. At that time. I was having significant amount of attacks of gout. Filipinos are prone genetically to gout. And I am one of those who started to have gout. After being in Argentina and having a lot of wine and a lot of baby steaks that are heavily associated with uric acid.
So anyway, I got my gout and I have to take Allopurinol or Zyloprim in order to prevent gout from happening. And one day my wife, 15 years ago, came and said the father of my friend has been taking celery seed tablets, and he has never had anymore attack since he started taking it. Begrudgingly I started taking it, but I kept my Allopurinol.
And after about a month for the first time, I did not get any big ,swollen toe. That is where my attack is coming from. And so I started cutting on my Allopurinol. And after about a month, I have discontinued my Allopurinol. I continued my celery seed tablet and have been taking it now for 15 years and believe it or not have never had any attack of gout.
So there is something in plants. And then also about seven years ago when I was still Chief Medical Officer at Beaumont, I developed severe cervical arthritis. I had a lot of pain and I could hardly turn my head to the right or to the left and I couldn't function for a few days. So I got my MRI and they said, oh, 50% of this and 50% of that.
And you could consider doing a laminectomy. I said not, not, not in my, not for a while. So they sent me to a physical therapist at Beaumont and supposed to be the best at that time and gave me a lot of physical therapy and how to do it and so forth. And my pain disappeared significantly, but I was still having a stiffness.
And somebody told me, I said, I'll take Glucosamine Chondroitin, and that will disappear. And I also have some friends who said that they spared their knee surgery by taking Glucosamine Chondroitin. So I started taking Glucosamine Chondroitin and after two weeks of taking it, when I'm driving and you have to look to the left before you turn change, I can move my neck without any problem at all. And my mobility is so good without any pain. So I've been taking Glucosamine Chondroitin with that. So those are the two supplements that I have been taking 15 years ago. And then about five years ago with the other one. And then lately after doing my 10 month review of the paper that they wrote on testosterone, and then I pursue the different options of how to supplement your body with testosterone.
And as we all know, we have been aging and the after effects of low testosterone is obviously very significant. And on top of that, you know, we have the saying in our profession that if you get old enough that you will get prostate cancer. So then I correlated that, well, maybe because the low testosterone.
So I started looking into supplements about that. And then I started looking at it at PubMed and other scientific journals. And I was amazed to find out that there are several plant supplements that are measured to produce increased level of testosterone. And so I started using it myself.
Dr. Lutz: You wrote this absolutely landmark article about the truth of testosterone.
Do you feel like this is also gonna be fighting the resistance and do you kind of have a game plan in your mind as to how you're gonna actually get this as part of urologic dictum?
Dr. Diokno: I am glad you asked this question, Mike, because I just feel right now that I am in the same stage as I was when I was sort of thrown by Jack Lapides at the forefront, because he wrote the paper, but I was the one who was fending off all of the attacks that are coming from the nurses within the hospital setting. Of the rehabilitation specialists that are coming and telling us that we are doing the wrong thing. We're gonna kill people. In the world of urology we're in. There are many, many skeptics, and they try to change it by continuing to push for a sterile technique.
And now after this paper has been published. I have received a few comments saying how dare you write this type. You may be killing more people and you may be causing a lot of use that is unintended because of what you have written that this is not causing effect. This is association, et cetera, et cetera.
And so my feeling is that the data should speak for itself. And the paper has been referenced very carefully to the level we're in most of the names that you will see in this 74 references I believe, or 76 are all well known, respected, recognized leaders in their field who had just spoken about this finding.
But had been left in the PubMed and no one has connected the dots until I started looking at this. And then suddenly my jaw was falling down as I'm reading and finding that my God, this is totally opposite of what I've learned and what I've been doing and what I've been practicing. And the more I read, the more I recognize.
You know, might there are many more coming out of this that correlates with our findings, the urologic dogma is that we have to avoid the use of testosterone because it could initiate the development of prostate cancer and benign prostate enlargement. And my findings is that when properly established the use of testosterone could be a friend rather than a foe.
Dr. Lutz: So just outta curiosity, do you think that it's the support you're getting or is it the resistance that you're receiving that actually makes you strive for more?
Dr. Diokno: Oh, I really feel elated. I have to say that the comments I have received that are negative are very few and in between, but the positive ones are significant.
And one thing that I have noticed, like what you commented is, you know, I have been thinking about this. I really believe this, but so far we have not done anything, but everyone who's been reading this, who've been submitting their reports is saying that more studies are needed. Sometimes they worry that they made a mistake in their reporting because it is contrary to what is known.
Dr. Lutz: The crux of our conversation is today about aging, male related diseases of the prostate, as well as the role of testosterone. And I think we need to talk a little bit about the truth of what testosterone is. So I think just briefly, like, what do you think testosterone's role is in the male?
Dr. Diokno: Just to start with when I started reviewing the role of testosterone in men, the first thing I did was try to learn exactly what the role of testosterone is with the prostate gland and our body first.
So first I reviewed the embryology and it's amazing to know. From the very first few days, that one cell and then two cells and four cells, and they start dividing that the testosterone is already working to create the male genitalia and the accessory gland, but the testosterone is coming from the mother and that the cells that are multiplying the fetal cells that are multiplying are sending messages to the mother to produce a little more testosterone to develop this cells that are in this developing embryo and then ultimately the testes during the fetal life started producing testosterone to continue to make the male genitalia and the prostate to develop. . And so once the baby's born, the testes will gradually increase its production again, slowly during the first few years.
And then when the male gets to be in the pubertal stage, there's a surge of production of testosterone that stimulate the prostate to grow and mature. And the cells mature by the age of say 25 or no later than 30 years. And that is when the highest level of testosterone is produced at that time.
And then after that, the prostate matures, but then it's just a maintenance after the age of 30. The testosterone will gradually decline, maybe go to the age of 40. We really don't know exactly, but by the age of 30, 35, the testosterone will gradually dwindle down until we die. And interestingly men varies in terms of the amount of testosterone.
We know that the range of normal is from about 250 to about 950. Wide range. And there are people that have a higher level and men and some that are lower level. Testosterone stimulates maturation of the prostate cells up to the age of maybe 30 or so. And then after that, the prostate matures and all testosterone do is to try to supply so that they continue to live and continue to function.
Because all living cells, their job is to survive and maintain their species by reproducing and at the same time to do the function that they were destined to do. And in case of the prostate gland, the function is to produce some secretions, prosthatic secretions, whose job is not only to lubricate the prosthatic urethra, but also to provide some support to the spermatazoa.
So in the process of reproduction, it helps the spermatazoa to swim freely all the way up into the uterus and into the Fallopian tube. So that is the job of the prostate is to produce the secretions that not only lubricate the urethra, but also to try to help the sperm mature and able to swim up into the Fallopian tube.
After the age of 30, maybe 40, the testosterone level starts to decline and decline could be gradual, but it could be precipitous. And this is one of the area that some scientists believe is more serious and dangerous than a gradual slow decline. And also having just a specific number to call that you are hypogonad.
If your testosterone is less than 246 nanogram, which is the magic number that the American and European guidelines have adopted is probably very restrictive because the range is so wide.
Dr. Lutz: There've also been statements made that men with centripetal obesity and have a lot of visceral fat steals the actual functionality of the testosterone.
Do you think that's actually a true statement? And do you think that if men were to lose weight and get rid of some of that centripetal obesity that would improve the actual testosterone levels that they have?
Dr. Diokno: I think it is the other way around in the sense that I think it is the low level of testosterone that creates the centripetal or the android obesity, because the lack of metabolism, the low energy, the increase hunger are the ones that is making someone develop the metabolic syndrome. And I believe that if they prevent from developing hypogonadism, we may not see this epidemic of publicity among men. Yes, if we are very active, that is one way of stimulating our hypothalamic pituitary gonadal access to stimulate production of testosterone. So a physically active fit man has a higher chance that he will not have obesity. He will not have a wide, big waistline and protudent belly and hanging boobs because of the increased metabolism. And because of the physical activity, he will not see all of these telltale signs of hypogonadism.
Dr. Lutz: One of the comments you actually make in your article is that low testosterone is really the issue.
It's not the high testosterone, it's the underlying cause of aging related prostate glandular diseases such benign prosthatic hyperplasia and prostate cancer. Can you talk a little bit about what makes you think that?
Dr. Diokno: This is the major surprise findings that made me decide to write this paper because I was expecting that we would support the idea that we have to be careful and minimize the use of testosterone among men, especially the aging man, which unfortunately, if you look at testosterone aging, it starts probably age of 40 because of the dwindling level of testosterone from that point on, but I was surprised to see many clinical reports from very respected andrologist who reported that men who were treated with testosterone for hypogonadism.
And if they, one of the paper is coming from the insurance database. More than 2000 men who received testosterone for hypogonadism and then a counterpart of hypogonad men who did not receive testosterone. And the surprise finding is that the mortality rate from heart attack and stroke is statistically, significantly lower among men who were given testosterone for not only two years, five years, seven years and more, in contrast to men who did not receive testosterone. And that to me was an eye opener because we always believed that testosterone can cause stroke and can cause heart attacks and so forth and so on. But it was the opposite findings. Again, we know for sure that using testosterone is very, very helpful in reversing the erectile dysfunction and men who takes it.
They will revive their morning erection. Their sustained erection will be better and their desire will be improved, et cetera. But one thing that I have also observed from the reports is that those who have been given testosterone, the incidence of prostate cancer is significantly lower compared to those who were not.
Dr. Lutz: So now with all this compelling data on the advantages of testosterone,replacement and normalization for an individual, particularly in the aging male, at what age should an individual get their testosterone checked?
Dr. Diokno: One of my 10 recommendations is that a man should have testosterone measured at about the age of 30 as a baseline. So that is sort of your goal post for which you can refer your level in the future. Again, we need to study what is the lowest, the lower level before it triggers the development of BPH and prostate cancer.
But I would not sway too far away from what my number when I was 30 to 35 and replace it. Now for those with symptoms, obviously you need to treat them. And by that time, if you know what your level was before, then you can chase it to about that level. You don't need to do it every year, but maybe every three to five years would be beneficial.
So you can watch the decline because if it declines too low, we are concerned that that may be triggering the development of BPH or prostate cancer.
Dr. Lutz: Well, I think the data from your research and the compilation of articles that you've put together, Is actually compelling and convincing. And I think that our viewpoint and perspective on testosterone and testosterone replacement therapy will be forever changed.
And I think this is going to be a landmark article as far as how we as urologists will address testosterone replacement therapy and will be looking forward to the data and the science on figuring out how to more accurately replace testosterone, monitor the replacement. And get people what we call to their normal levels, to what's relative for them and know what we're measuring and how to measure it.
You know, you mentioned that your personal mission was to improve humanity, and there's no question that your research here is definitely an aspect of improving humanity. You've educated and impacted so many people throughout your career, whether they be medical students or residents or people in the community.
Do you happen to have a story or a moment in your life that kind of exemplifies your impact on the community within which you've served?
Dr. Diokno: I cannot think of one specific one, but I can speak of many different instances of patients who felt hopeless, who feel that they have to they're ready to die because no one had found their diagnosis and so forth.
And come to me. And within a few seconds you can identify what the problem is and get the treatment because it's so simple and straightforward that they just miss one step in the diagnostic armamentarium that we have. And it's so gratifying. So there's many, many of this where in the patients are just so happy, and you take care of them and they come back to you.
Not only them, but now their husbands and their children and grandchildren, because they wanted you to take care of them. And I'm sure it happened to you and to many of us.
Dr. Lutz: Yeah. You know, with your enumerable contributions, I guess the one thing I'd like to know is how would Dr. Ananis Diokno like to be remembered?
Dr. Diokno: I would like to be remembered as someone who continue to move forward. And to try to answer questions that are vague or questions that are sort of not clear and to clarify it and in doing so, try to help humankind.
Dr. Lutz: And with that, I'd like to thank Dr. Ananis Diokno for this great conversation about the testosterone truth.
And thank you for joining us. I'm Dr. Michael Lutz, urologist and founder of the MIU Men's Health Foundation. And through our events, resources, and this podcast, we are dedicated to men's health, advocacy and awareness. We're focused on education, research and treatment of prostate cancer and men's health related issues.
For more information about the work we do and how you can get. Visit us online at www.MIUMensHealthFoundation.org.