S05- Episode 3- Hard Truths: What Every Man Needs to Know about Erectile Dysfunction

[00:00:02] Leslie Ann Seon: Seon180. Coming up in 5, 4, 3, 2 1. Be bold. Take risks. Lead by example. Believe in your power. Say what you feel, Mean what you say. Join me at Seon180 on this journey of discovery, discovery and advancement. Hello and welcome to the podcast Seon180. I am your host, Leslie Ann Seon. This podcast is all about igniting conversations and empowering lives with rail talk, real people and real change. With over 20 episodes across four seasons, we have featured inspiring voices from the Caribbean and the Diaspora, diving into topics like health, politics, the arts, leadership, finance and many more topics that truly matter to our community. I invite you to check out my website at the podcast seon180.com or your favorite podcast platform to catch our latest episodes and follow us on Facebook and Instagram for updates, advice and engaging discussions. Today, I'll be chatting with Dr. Jonathan Noel, based in England. on the topic Hard Truths: What Every Man Needs to Know About Erectile Dysfunction. Our conversation will center on causes, lifestyle factors and treatment options and we're delighted to have Dr. Noel with us here today. Dr. Noel is a double robotic surgical fellowship trained urologist. He was born in the United Kingdom and attended medical school at the University of the West Indies in the Caribbean. He is a third-generation surgeon following in the footsteps of his grandfather and father. He returned to the UK to specialize in urology where he developed expertise in prostatectomy techniques. He has deployed a safe and effective radical surgical approach to prostate cancer. He has built tremendous experience in the diversity and care of patients working in three healthcare systems across the globe. His research portfolio includes analysis of emerging robotic systems, augmented reality, and artificial intelligence platforms with a focus on their impact to healthcare delivery. That has all led him to be a leader in prostate cancer diagnosis at Lewisham and Greenwich NH Trust for the Southeast London Cancer Network. He is the Medical Director of the Global Robotic Prostate, which launched in 2023 to deliver services at internationally renowned independent hospitals. Dr. Noel focuses on improving patients’ experience and outcome through their diagnostic and treatment journey. Hello Jonathan, thank you and welcome to seon180. [00:03:14] Dr Jonathan Noel: Hi. Thank you for the introduction. It's real humbling to be on your show. [00:03:21] Leslie Ann Seon: Great to have you. I am humbled to have you because I know that you're a very busy surgeon and it's lovely to have a bit of your time to speak on perhaps a sensitive topic, and we're going to dive head on into it by asking you to give us a little explanation to have a better understanding of erectile dysfunction. What is it? How common is it amongst men? And the physiological and psychological causes of ED. [00:03:54] Dr Jonathan Noel: Thanks for the opportunity to speak on what is really a taboo subject in some arenas. Most men typically don't like to volunteer that they do have issues with regard to maintaining or even attaining an erection. So, I define erectile dysfunction as the ability to actually have engorgement of the penis or if you do have engorgement of the penis, the ability to penetrate all the way to completion of ejaculation. If you're not able to do those two things, then you have erectile dysfunction. How common is it? About the age of 40, some studies will reference about 50% of men will have some form of erectile dysfunction. Of course, you can stage it from mild, moderate, severe, sometimes it's transient and you know, we'll go into more the causes of it and then we'll probably make sense why I define it like that. But the physiology you asked me about, so I'll just briefly describe how it happens. It is developed from your nervous system, from the vessels in your body, but also from your psyche as well. You know, stressors are probably one of the biggest causes of erectile dysfunction. Doesn't necessarily mean something's wrong with your vessels or your nerves. It could be something that's going on in relationship at work, so you know, it's important to really dive into the, the nuts and bolts of what is happening. But for the most part, the reason behind an erection happening is stimulation. You get a bunch of enzymes being released, they allow the blood vessels to open up and then blood flows into the penis and it engorges until ejaculation occurs. And that's it really briefly. [00:05:41] Leslie Ann Seon: Yes. Well, that's quite a good introduction for us to figure out how we navigate through this topic. Certainly, one of the things I'd like to bring up because I was struck by the age group that you mentioned. What are the common causes and the risk factors? We know that in the Caribbean there is proliferation of chronic diseases: hypertension, heart disease, diabetes. How do these play into erectile dysfunction? [00:06:14] Dr Jonathan Noel: I'm glad you went straight through it because we know that non communicable diseases are on the rise, particularly in westernized countries. And the Caribbean, no doubt, is one of those areas that have been influenced by westernized diet. Lots of processed food, lots of red meat, high alcohol consumption, all of these things lead to erectile dysfunction. So, it's no surprise that as you become older, more than 40, there will be some impact on your erection. So, we spoke about diabetes, high blood pressure but that in and itself requires treatment or medication. And it's the medication, usually, that causes the side effects. But certainly, as you get high blood pressure and diabetes, the flow of blood to your penis becomes impaired and hence that's why you get erectile dysfunction. In fact, if I could really break it down, I think the penis is almost the barometer, or the test of what is going on in your heart and your brain in terms of blood flow. [00:07:18] Leslie Ann Seon: So, it acts as an early warning sign, then? [00:07:21] Dr Jonathan Noel: Absolutely, absolutely. You know, most men that will present to my office, whether that's face to face or virtually for a consultation, they say, oh, I've never been to the doctor and they're proud of it, but I have erectile dysfunction. And when you really dive into it and investigate the causes, newly diagnosed high blood pressure, newly diagnosed diabetes comes up, sometimes even heart disease. So, the penis really is a barometer for other conditions going on, and I don't think it should be ignored and not spoken about. It should be volunteered to the GP, through general practitioner. [00:07:55] Leslie Ann Seon: And that's a big problem for us in the Caribbean with our machismo, so to speak. You know, the males are very shy to raise these topics, period, or even with their doctors. I'm curious, though, how does one determine that it has become a medical problem? Is this something sustained over a period of time or just occasionally? How do you know when you actually should go to your doctor. [00:08:27] Dr Jonathan Noel: With regards to erectile dysfunction, obviously, one needs to present to the doctor just as a general checkup, but if you volunteer, you're having symptoms in your life about erectile dysfunction relationship issues, I think it's up to the general practitioner or the urologist to really dive into why. And I always teach, you know, my residents, my medical students, that they learn how to look for four things, which is the vascular causes, so things that would affect the blood vessels—high blood pressure, diabetes, you alluded to—endocrine or hormones that are having symptoms of low testosterone or abnormal hormone production, such as gynecomastia, which is what we refer to as man boobs. You know, these things can be a result of a hormone that's overproducing and that can cause erectile dysfunction. And then there's obviously the nerve causes, how they suffered a trauma, they fell on, sustained injury to their back and the nerves that supply the erections are impacted and then there's trauma, and then there's obviously trauma, which kind of falls into nerve injuries. So, have they had a trauma on their pelvis, on their penis, in the past, etc. Because some people will not volunteer that and just live with it. So, once you dive into why, then we can curtail investigations. But the investigations, I always tell the medical students, is erectile dysfunction may be the first presentation of someone with a heart condition or a blood flow problem. [00:09:59] Leslie Ann Seon: And this is the reason why it's important to raise it with their doctors as early as possible. You know, a lot of the times in the Caribbean, alcohol is used as the cure all, you know, whether it's for pleasure or just, you know, getting over anxiety or stress. So, it's important, I think, for men folk to understand how much that can contribute to ED. But I'm also particularly curious about the psychological aspects that you discussed earlier, Jonathan—stress, anxiety and depression contributing to ED. Can you expand a little bit more on that? [00:10:35] Dr Jonathan Noel: Absolutely. You know, when we take history as doctors, it's our job to not only find out what medical issues are going on, what surgeries they've had. We need to find out what the social side of things are. Is that person happy at their job and their relationship? Is there a new relationship? Perhaps they're not married, and they have new partners quite frequently. That, again, can be something that can add to erectile dysfunction because there's that anxiety around performance. But psychological stressors are one of the things that I would say can be manifested by that person having difficulty performing in front of a partner. But then at nighttime or in the morning, they note that they have normal erections, you know, completely normal, nighttime normal or even masturbation, they'll have normal erections, but when it comes to actually intercourse, it's difficult. That tells me it's a psychological component. That tells me they need specific counseling towards the issue. [00:11:43] Leslie Ann Seon: So, would that be part of your discussion with the patient, if he comes to you with these issues? Would you be asking questions along those lines? Do you find them to be open when you probe with these questions? [00:11:57] Dr Jonathan Noel: That's a really good question. You know, in the NHS, certainly the turnaround for new patients is 10 minutes. You can't dive into that in 10 minutes. So, often erectile dysfunction consultations have to be repeated. A follow up investigation, a follow up visit. Men need to open up and be comfortable with their doctor, you know, and usually it comes about the second or third visit that, oh, there are some psychological issues going on and you probably would have done all the blood tests and screened everything else until that time comes when they actually get to the root of the problem. But that's okay. You know, I think it's important that men take their time to open up about this because this is a disease that can be managed and it is a long-term, you know, journey. I don't think it's going to be sorted out with one visit. [00:12:47] Leslie Ann Seon: So, they have to be prepared for the long haul, so to speak. [00:12:52] Dr Jonathan Noel: Exactly. And the benefits will be, will be amazing, especially if you pick up things to do with high blood pressure, diabetes, you know, it can be lifesaving in some instances, you know. So, I think it's something that we should really take seriously and talk openly about. [00:13:08] Leslie Ann Seon: And I'm glad you raised that because now we can sort of dive into the connection between erectile dysfunction and the overall health of the patient. Once you've sort of determined there's a clear diagnosis of erectile dysfunction being suffered by the patient, can you walk us through what type of steps you would take in determining actual underlying causes and what else might be going on, what tests you might be ordering for the patient? [00:13:40] Dr Jonathan Noel: Great, great, great question. So, someone has erectile dysfunction from the history, from speaking to me, often you have to examine the patient to see if there's any clues so you can tailor your investigations. You know, having the benefit of working in different healthcare settings, you see that the Caribbean and the UK are very good at rationalizing investigations, whereas some other countries will throw everything in the kitchen sink at the patient to investigate. So usually, you know, examine the patient. There may be some elements or scars that they've had, trauma, etc. What's really important was really important, you know, over 50 in particular, is that the prostate is examined and assessed because sometimes advanced prostate tumor cases can present with erectile dysfunction. So, you don't want to miss that and address everything else. So that's important. That's why I say examination is so key. But, you know, for the patient who doesn't have cancer and is not a contributing cause and may have your regular lifestyle contribution, then you would do blood tests. We check their hormones, testosterone, their blood sugar level, their cholesterol level and then some hormone profiles. And typically, these things can turn around within a few days. Once they're back, depending on what we find, we will tailor treatment accordingly. Some patients already have a diagnosis. They come with, oh, you know, doc, I've been, you know, being managed for high blood pressure for years now. I've been on this medication, and there's some medications that cause erectile dysfunction. [00:15:25] Leslie Ann Seon: Really. [00:15:25] Dr Jonathan Noel: So, you can, you can definitely switch to a different type of medication that will cause less erectile dysfunction. So, it's certainly one of those things that has to be to be dived into for sure. [00:15:40] Leslie Ann Seon: So that requires. Sorry, that requires a lot of discussions with the patient, Jonathan. [00:15:47] Dr Jonathan Noel: Well, you can typically get all of that in one consultation. Your history should include medical history. You know, if they're on medication, they'll tell you what they're on. But, of course, if it's somebody who is completely, you know, naive to anything and doesn't know they have anything, then yes, it would probably be a journey of a few investigations and a few tests to get there. But for the most part, you know, the cause is sometimes obvious. And it's common that non-communicable diseases contribute. The high blood pressure and the poor blood sugar control are probably number one. And alcohol consumption, excess alcohol consumption, I should say. [00:16:30] Leslie Ann Seon: Yes. Well, we know Grenada has some terrible figures per capita in terms of alcohol consumption in particular, but across the Caribbean, and you know that that really is one of the number one problems. Actually, I'm curious with the age group that you mentioned. I'm hearing you speak about 40 and 50, etc. This is sort of like the critical period where the ED might arise in men. [00:16:59] Dr Jonathan Noel: Absolutely. I think after 40, you know, you got to realize that your body changes, your metabolism slows down. Everything you used to eat in your late 20s, early 30s, you probably will not metabolize and get rid of as easy—things like your weight, your waist circumference, your body mass index. You should be looking at what is normal for your age and what is overweight. And if you fall into that category, you know that you're at risk for developing things like high blood pressure and diabetes. I don't think people know enough about that and it's one of the things that, you know, podcasts like these can help spread the message. You should know what a healthy weight is for you. You should know what a healthy body mass index is for you, which is just a fancy formula that references your weight to your height. So, as long as you can aim towards a healthy BMI, then you're already a step ahead of the curve. But you should also exercise every day, fifteen minutes, just a walk, you know, take the stairs, take the elevator? There are just little things you can do every day to help address your activity and hopefully, you know, cure erectile dysfunction. But you asked about investigations. One of the things I just wanted to say was that the psychological contributing factors of erectile dysfunction, the way we can really confirm that is we give patients a home test. The little ring that they put on the base and at the tip of the penis and then it measures the rigidity overnight. And if it's rigid, then we've got our answer. There's no erectile dysfunction. It's more performance anxiety. [00:18:44] Leslie Ann Seon: Okay, interesting. So, Jonathan, do you have some tips for maintaining overall sexual health as men age? [00:18:58] Dr Jonathan Noel: Great question. Maintaining that, I think usually it's something to do with, you know, whether it's communication of what's bothering you at home or at work. I think partners usually are very receptive to communication, particularly, you know, when it comes to marriages and relationships. I think they, you know, that's an avenue that we have to explore. I would express that, you know, couples therapy is something that should be involved as a way of managing erectile dysfunction and intimacy issues. In terms of patients who may not have a long-term partner or who have few partners ever so often, I know that that can be sometimes a challenge because there's no sustained way of feeling comfortable perhaps. And that again will probably require psychosexual counseling. Not with a couple, but it's one on one. But in terms of advice, I would say, you know, exercise is so important because it encourages blood flow to all of these organs. And the penis is an organ, but it requires the blood vessels to be healthy and your tractor to be going in and out through the arteries and the veins, regular intervals. And how do we do that? Well, we exercise, we keep our weight down. We go through smoking reduction or cessation and alcohol reduction as well. I think once you can do those things and you have healthy erections when time comes to perform, then you know that you're doing your best in terms of your overall health. I'd say just keep it very simple. I mean, I think, I'm not speaking about anything that I think people don't know already, you know, but it's difficult to execute and, you know, the penis is one of those organs in men that will definitely tell you if things are going in the right track. [00:21:03] Leslie Ann Seon: Yes. And so many times we look for shortcuts and, you know, the easy way out, so to speak. I have it on some authority that some of the fastest selling pills in pharmacies is what they refer to as the hard-on pill. So that takes me to the treatment options that are available today. We know there are medications like Viagra, et cetera, I'd like to know how they work and are they really effective and then we'll get into some of the more advanced treatments. [00:21:35] Dr Jonathan Noel: Great. Yeah. So, the medication that everyone knows or heard about is the trade name Viagra or Cialis. But Viagra is more commonly known because it was a big boomer in the stocks in the 90s when it was launched. Now these medications work as inhibition, or they stop the breakdown of an element called nitric oxide. Nitric oxide allows the vessels in the penis to open up and then blood flows to the penis. So, if you allow nitric oxide to just be present and not be broken down because you've taken this pill that allows it to flourish, then you get better erections. The thing about it is that some patients that I prescribe it believe that they take it and it's an instantaneous result. And if it doesn't do that, then it's not working, and they give up. Both strategies are wrong, and the understanding is that it has to be taken at least half an hour to an hour before intercourse. It has to be taken with stimulation, whether that's by sight, feel, or etc. You know, these things have to be done, otherwise you will not get the result that you're expecting. The other thing is, particularly in the Caribbean, as we enjoy lots of our food and they may be oil based, fatty meals inhibit the actual action of these medications. So, if you've had a fatty meal and you take your Viagra, I'm telling you, it ain't gonna do nothing. And then you'll give up. [00:23:11] Leslie Ann Seon: Yes. [00:23:12] Dr Jonathan Noel: So I, I definitely tell patients, you know, don't give up, you've got to keep at it. The dose range can be adjusted. Usually, GPS or non-specialists will start you at a very low dose because they're a bit apprehensive about the side effects. So, you know, make sure you're taking it right, which is half an hour to an hour, with stimulation, and make sure you're avoiding fatty meals. [00:23:37] Leslie Ann Seon: Good advice there Jonathan, good advice. So, let's talk about some of the non-pharmaceutical treatments. I know you gave us a great summary on lifestyle changes. I understand that therapy and pelvic floor exercises can also aid in this process. Is that correct or should that be used in conjunction with one of the other treatment options? [00:24:03] Dr Jonathan Noel: I do think that pelvic floor exercise is one of the underutilized things in a man's overall health and how they carry on in life. And it's beneficial in two ways. It can benefit the way men pass urine, can have control of their bladder because the muscles are strengthened and allow you to hold urine better. But it also encourages blood flow to the penis, to the organs in your pelvic floor, makes it stronger and as we age, like our bicep doesn't get as strong in our 60s and 70s as it was in 30 and 40. It’s the same with your pelvic floor muscles. There are muscles there and they don't get utilized very often. So, you've got to actually know how to contract them. Obviously, women know a lot more about it after childbirth, Kegel exercises. But you know, the men stare at me as if they've never heard it in their life. And then the partners looking on, like, well, this is what I used to do, join the club, you know, and I think it's an important strategy to use that. You spoke about non-medicinal. Besides pelvic floor exercises, there are some vacuum assisted devices that encourage blood flow to the penis. There's like a ring and it's a suction device and it encourages blood flow. And that can also help with erectile dysfunction recovery. So, I would say that that's something that could be explored. Of course you need to be shown how to do it. It can be a bit cumbersome, but that's something that doesn't require a pill and is mechanical. So, with pelvic floor exercises, I wholeheartedly say is a must for many reasons, but erectile dysfunction management is one of them. [00:25:44] Leslie Ann Seon: Good, good. So, I want to get into your specialty, your role with Robotic-Assisted surgery and integrating robotics with regenerative medicine. Can you spend some time telling me how this is done? At what point would it be done? What are the risks? And of course, obviously the rewards, because most men will cringe at the thought of surgery in that area, you know, so I need you to bring some comfort and assurance in how much this is working well and how much it reduces, you know, the risk of tissue damage, for instance, or infection, etc. [00:26:24] Dr Jonathan Noel: Well, look, thank you for allowing me to speak on something I'm very passionate about, which is pelvic surgery or prostate cancer. We know it's the number one cancer in men. Lung used to be the actual number one cancer in men worldwide, but certainly in the Caribbean, among the black population, prostate is numero uno. And in regards to, you know, the management of it, certain men shy away because they're worried about the risks of surgery and what that means for their erectile function. And I don't, you know, dance around it. I do say that to remove the prostate gland will cause a measure of change in your erections, but it doesn't mean it's the end of it. Now for techniques that I use, which is to spare the nerve tissue that is around and very close to the prostate, I do that regularly because for patients it means their erections can come back as well as their continence of urine can come back a lot faster. And what robotic technology allows us to do is we can see a lot better. We allow the computer to help us define where nerves and vessels are. So, it's really fancy stuff, but it's stuff that's been around for 20 years and it's a real kind of career ambition of mine to bring it to the Caribbean, where there's so many men with prostate cancer that could benefit from it. But I think it starts from the beginning. I think men need to be very aware of their health. Erectile dysfunction is one of the things that many to present with, but they also need to present to their GP and be prostate aware, know their family history, get checked early, because the earlier we can find prostate cancer, the better we can spare all of those nerves that you will have and rely on to have erections. You talked about investigational and tissue regenerative strategies. We looked at amniotic membranes, which is harvested by donor placenta tissue from women, and companies have actually used it as a scaffold—a little tissue that's packaged and we put it on the nerves that are left behind. And it's been shown to allow nerves in men to regenerate a lot faster than without it. It's one of those things that was studied very well when I was in Florida and has studied less well in Europe. But hopefully we'll be able to bring it to the Caribbean along with robotic technology. And of course, awareness being the first thing, without awareness we can't move forward. But certainly, you know, with, with the regeneration of nerves, it's not only that, it's about the patient being in their healthiest state when they come to surgery. So, you know, they have a part to play. Certainly, you know, patients who have diabetes, high blood pressure, are overweight and poor erections before surgery certainly really can't reap much benefit after surgery. But men who are, you know, perhaps younger, healthier, normal erections, they can keep their erections almost certainly to the order of more than 85% if we get them early. [00:29:36] Leslie Ann Seon: Yes, yes. And Jonathan, by robotic-assisted surgery, help us with a visual of what this entails in terms of the equipment, the precision of it, the length of the surgical time spent getting this done and what men should look out for post-surgery. [00:29:58] Dr Jonathan Noel: Great. So, in terms of robotic surgery, it's beginning surgery, you're put to sleep for the procedure. You have six tiny little cuts on the tummy, and it allows little keyhole ports to be put into the body so you can perform the surgery with a lot more accuracy. And what the robot is, it's just an interface. You know, I don't turn it on and go and have coffee. I have complete control. I'm always there. It just allows me to make my hand into probably a 5-millimeter instrument and work within the body. So, I'm using my hand motions outside of the patient on a computer. But what's inside the patient is actually a 5-millimeter instrument doing all the work. So, the trauma is less, patients can go home the next day, blood transfusions are a thing of the past. You know, people get back to work quicker. I think the benefits are immense. And it's not only in my specialty, in all surgeries, we're finding that patients just recover much faster now. And it will be less burden on any healthcare system to have patients in and out of hospital in 24, 48 hours. And essentially, the cost has always been a hindrance. And so, it's come back to me by my colleagues in the Caribbean that the cost is just not there. But, I do tell them that the cost of a patient staying in hospital for a week with complications would probably be a lot more than the upfront cost of a robotic system. So, I think it's. It's one of those things that can definitely be sought after and looked at. But in terms of surgery for, you know, patients at the extreme end of erectile dysfunction, I'll just pivot over back to that because that's the main topic. I should mention that patients who have erectile dysfunction at an extreme state where medication and pelvic floor exercises and the vacuum don't work, some men may opt for an implant, and that's something we should probably discuss for a minute. [00:32:01] Leslie Ann Seon: A penile implant? [00:32:05] Dr Jonathan Noel: Correct. Yeah. So that is an implant that is malleable, that can be in a rigid state, but can just be tucked down and then obviously put back up when necessary. Or there are the inflatable ones where there's a little button and it inflates water into the penis, and you can press a button to deflate it. So, the inflatable one sounds a bit nicer, I suppose. And both are an offer, and we do use it for patients who are in the extreme stage of erectile dysfunction. And it's one of the things that colleagues of mine who specialize in urology from the Caribbean are certainly learning and we hope to roll it out soon. [00:32:49] Leslie Ann Seon: And this works on a medium to long-term basis. [00:32:52] Dr Jonathan Noel: Really, really, really good question. The failure rate at 15 years is close to probably 20%. What do I mean by failure? Either the pump actually stops working, there's an infection, or the mechanical break and then they have to revise it, or they simply just remove it. Most times after 15 years, men with erectile dysfunction, they may be very happy to just continue on with their normal tissue and not have it, but if they want to revise it, they can get a fresh new implant inserted, but it does last a good period of time and it is one of those things that should be performed by people who do it regularly. This isn't something to do once a year. It's a very technical operation, but one that patients have very high satisfaction with. [00:33:45] Leslie Ann Seon: This is excellent news, I think, for our men folk out there, Jonathan, and we certainly need specialists like yourself and others to introduce this to the Caribbean and to perhaps train our surgeons in the Caribbean on these types of contemporary techniques for treatment, because it certainly brings a lot of hope and optimism for men who suffer with this condition. This is a stigma that I feel needs to be broken. And part of the motivation behind this podcast is to deal with topics that are sensitive or taboo, to provoke thoughts, ideas, actions, even, you know, cooperation across the seas from our experts like you. And one of the things that I think we often need to do is to impart to men that they shouldn't hesitate to seek treatment for erectile dysfunction. And, I'd like to close off a little bit by ending on a positive, encouraging note and asking you to tell us a little bit of the success stories or advancements in neurology that offer hope for men with erectile dysfunction. [00:35:00] Dr Jonathan Noel: Thanks for that. I think it's a really good way to end. I think there's more awareness now of erectile dysfunction. I think more men are coming forward a lot earlier. I'm seeing a change in the new generations coming up and how they approach their health care. So, people do know whether it's through apps, etc. what their normal heart rate, blood pressure should be, and how their response is to exercise. So, they're really taking care of themselves. So, I think there's certain apps out there that can tell you whether things are going in the right direction in the overall health and I think erectile erection should be looked at as a barometer to your overall health. I don't think one should focus on it. I think one should look at what are the other things that could be causing it and am I doing my best to address it—whether it's being a little overweight, and exercise and drop the weight; whether it's, you're a heavy smoker, well, then, you know, you need to address the smoking. And certainly, there's an awareness on the part of public healthcare physicians to make non communicable diseases a more aware topic, whether it's by putting alerts on a pack of cigarettes or on alcohol bottles. You know, “surgeon general says this will cause heart attack, stroke, but also erectile dysfunction.” So, I think there's more awareness now, which is good. And I think that it's hopeful that we've got new medications now that are a lot more affordable, like the Viagra, the Cialis. These are very affordable. But it's all about giving people the awareness and education that they need to seek treatment and not suffer in silence. And certainly, podcasts like this is a way to help spread the message. And I look forward to sharing my contact details. If there's anyone out there who wants to, you know, consult and have some more information, I'd certainly be very happy to do that virtually. So that's, I think, the positive is that the world is connected through. Thanks to you through the zoom, this opportunity, and I look forward to, you know, speaking more and asking more colleagues to join and any other interesting topics that you find and deem worthy. So really, thank you for the opportunity. Men, come forward. Speak about your health. Don't suffer in silence. And just take care of yourself. You know what to do. We spoke about it and now it's time to just action it. [00:37:32] Leslie Ann Seon: Great messaging, Jonathan. Thank you so much. This means a lot and certainly to our audience. It's extremely informative and gives us an opportunity to really think about it, what we need to do ourselves, personally, and how we can get assistance from specialists like yourself. Thank you for spending your Sunday afternoon on the podcast Seon180. I'm looking forward to coming back to you on some more topics, Jonathan. So, I hope you don't think you're escaping with this one. [00:38:03] Dr Jonathan Noel: Not at all, no. No, I'm very happy to do it. [00:38:07] Leslie Ann Seon: Thanks a lot. Have a good one. Okay. Jonathan: Okay. Bye. Cheers. Bye.