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Aug. 9, 2023 - The Megyn Kelly Show
01:34:22
20230809_testosterone-libido-and-infertility-deep-dive-on-m
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Erectile Dysfunction as a Warning Sign 00:14:53
Welcome to the Megan Kelly Show, your home for open, honest, and provocative conversations.
Hey, everyone, I'm Megan Kelly.
Welcome to the Megan Kelly Show.
Today we are bringing you something a little different, something that's actually really important.
And I think you're going to enjoy whether you're a man or a woman.
Today's show is a deep dive on men's sexual health.
And we have a world-renowned expert with us.
Next week, we'll be doing a full show on women's sexual health, but obviously the two are very much related.
Full disclosure, I got this idea from Dr. Peter Atia, who's been on the show, whose book has been on the New York Times bestseller list for a long time now, very talented longevity doctor who's a friend of the program.
And he did, he did two shows like this, and you should check out his podcast as well.
And I thought this is a great thing, and I bet my audience would really like it.
And don't we need a little break from politics every once in a while?
Good God.
I know I do.
So this is a topic that does not get anywhere near the attention it deserves, but it does impact millions of men every year, millions.
In fact, I've heard some doctors now in preparing for today's segment refer to erectile problems as an epidemic, an epidemic for men.
So if you are suffering from this, you're not alone.
And you may be too embarrassed to talk about it, but you shouldn't be too embarrassed to listen to a talk about it.
And so we'll get to that today.
And we will hear from you.
We're going to take calls later as well.
Today we'll be discussing men's sexual function, changes during aging, STDs, porn, all of it.
And as we dive into some of the major issues, we will discuss causes, effective treatments, and just lifestyle changes.
Even if you never want to talk to a doctor about this stuff, we'll give you some lifestyle changes you can make that could improve your function and your sex life.
And if your sex life is off, the relationship is off, right?
As Dr. Phil used to say, when sex is good, it's 10% of the marriage or the relationship.
When sex is bad, it's 90%.
Nothing's off the table.
I'm excited to bring you this conversation.
Today with me is Dr. Mohit Kara.
He's a board-certified urologist with expertise in sexual medicine and testosterone who works as a professor of urology at the Baylor College of Medicine.
Welcome to the show, doctor.
It's great to have you.
Thank you so much for the invitation.
Yeah.
Okay.
So I want to cover it all, but let me start here.
So I think women have an advantage in this department in a way because we go to an OBGYN pretty much at least once a year.
And we do that in addition to our primary care physician.
So this is a person who, if you get a good one, takes your overall health as a woman into consideration.
It's not just, forgive me, a VAG doctor.
You know, she's, she's checking out the whole woman, you know, your energy levels, your sleep, the breasts, yes, down south and Rio, all the stuff.
But like whenever I leave my GYN, I feel like, okay, I'm well looked after.
She wants to know everything.
She wants to know about my blood pressure.
She wants to everything.
And I feel like there's not, you know, men don't really have that.
They don't have that extra on top of the primary care physician.
I think they do the turn your head and cough thing when they go to the primary care physician.
But for most men, that's about it.
Am I right?
So I think you nailed it.
I mean, you have to think about this.
Erectile dysfunction affects 40% of men at 40, 50% at 50, 60 at 60, 70 at 70.
You live long enough, a man's going to get erectile dysfunction.
The problem is that many men are embarrassed to talk about it.
I think one of the best studies I've ever seen came out last year, 1,500 men between the ages of 18 and 80, and they put out a survey.
And what they found was that 40% of men, 40% of men had some degree of sexual dysfunction, but 50% of them said, I don't know where to get the help.
70% said, I wish I could get the help.
And what was surprising is that 53% of those patients didn't even tell their physician.
Now, I think one of the problems is if you look at physicians, they don't ask the question: Do you have erectile dysfunction?
My wife is a primary care physician and she says, Look, I have about 15 minutes to go through diabetes, hypertension, obesity.
Erectile dysfunction tends to be at the bottom of the list.
So, again, it's a patient embarrassment problem, and physicians aren't asking about it.
That's so troubling because not only does it affect your relationship and your happiness and your wellness, but now in reading up for today, I realized it actually can be a clue that something else is wrong, like potential heart disease even could be related to, in particular, ED.
Is that correct?
You're so right.
So, I think that one of the best barometers of a man's health is his sexual health.
Why?
Because not only does it encompass your physical health, but it also encompasses your mental health.
And so, sexual health is one of the best barometers of our overall health.
But you bring up a very good point.
There was a study that came out in 2005 that showed if a man gets erectile dysfunction today, 15% of them will have a heart attack within seven years, 15%, which is quite large.
That same year, other studies came out showing that if a man has a heart attack, typically 39 months prior, he started developing erectile dysfunction.
And we know this because the coronary arteries are much smaller, one to two millimeters.
Excuse me, the penile arteries are much smaller, one to two millimeters, compared to the coronary arteries.
So, if you're going to block an artery, you're more likely to block the penile artery before you block the coronary arteries.
So, I really do think that a young man who has ED and no other signs, this could be one of the first signs of having a potential MI in the future.
And if you are too embarrassed to talk to your doctor about it, let's say your doctor is a female, then get a male doctor or just somehow work up the nerve because now you're talking about your actual life.
And what if, like, what a great canary in the coal mine?
You know, if you're just like, it's not great to have ED, of course, but like, much rather have to fix that problem than have to fix a heart attack.
I read the following: is it true?
The penis works on blood pressure.
Yes, so it's important that, you know, when the important part of the penis is blood going in and blood going out.
And so, the way you get erectile dysfunction is not enough blood coming in, or the blood's coming out too fast.
And so, it's a very clever system.
The artery goes down the center, and then the veins are on the periphery.
And so, the first sign of erectile dysfunction is typically the blood is coming out too fast.
This is called venous leak.
So, what does a patient tell you?
They say, Doc, I can get the erection, but I can't maintain the erection.
He's telling you, Look, I got one of the first signs of ED, which is called venous leak.
So, there's many ways to fix this.
One way to fix it is to increase the blood flow.
And that's what many of these pills do, like Viagra or injections, or to decrease the outflow.
But again, this is the most common type is venous leak.
And this is so like you don't want to just get a prescription for Viagra.
You want to figure out what's going on.
That could fix the symptom.
But if this is linked to high blood pressure or heart disease, you need to get to the bottom of it.
It's not a matter of just like getting your friend's Viagra.
You know, you really need to know.
Well, so let's talk about erectile dysfunction because I can say, like, I'm sure, thankfully, I haven't had this issue in my life.
My husband and I are still relatively young.
But I think as a woman, I would start blaming myself if my husband had this.
I'd be like, something happened.
I gained weight.
It's my, and then I can see how this would turn into an issue really quickly between the couple.
Yes, Megan, ED has a devastating impact, not only on the patient, but on the couple.
And I didn't go through these statistics, but 30% of men, 33% of men who have erectile dysfunction are severely depressed because they have ED.
37% of men who have ED have severe anxiety.
And you talked about this earlier, but we know that couples that engage in sexual activity have a significant improvement in the quality of relationship, say 2X.
Those that do not engage in a sexual activity have a significant decrease in the quality of relationship, almost 4X, so double.
So again, sexual sexuality is really important for the couple.
When a man starts getting erectile dysfunction, something very interesting happens.
He starts avoiding sex because he says, what's the point of engaging in sexual activity if it's going to maybe work or not work?
I'm tired.
It's 10 o'clock at night.
I might as well go to sleep.
We call this subconscious aversion.
They tend to avoid it.
And so the female partner or the partner in general takes this as rejection.
And she says, or he says, I'm not, why are they not interested?
What is going on?
But inside the brain, the patient's saying, I just don't want to go through all the frustration of this not working.
My gosh, I, it's reminding me, this is an off-color story.
So forgive me, but a friend of mine once had a sexual interlude with a man.
P.S.
It turned out he was gay.
So this is why the problem was manifesting, but he couldn't get an erection.
And finally, after a long time, he got one.
And I remember her telling me about it after the fact.
And her statement was, it should come to me in this condition.
And I think there is an expectation in normal relationships where the person is not secretly desiring somebody of the opposite sex by women that it should come to me in this condition without thinking, oh my God, maybe he has a problem.
Like maybe, what if I were just really cool about this issue and we talked about it and I were supportive of him in fixing it.
So, but that, I guess as a doctor, that would make you ask, is this a new thing or is this something you've always struggled with?
Right.
So remember that as men get older, they acquire comorbid conditions, diabetes, epidemic in the United States, obesity, metabolic syndrome.
Think of other risk factors like smoking, certain medications like a beta blocker.
How many people aren't a beta blocker?
It's notorious for causing erectile dysfunction.
Remember, beta blockers are used for hypertension, thiazides.
So as we get older, as we develop new conditions, we start taking new medications that can make a significant impairment on erectile function, but we start getting more conditions that are associated with ED.
So this is the issue.
I forgot to mention one of the things earlier.
You know, in that survey I talked about, 44% of men, 44% of men did not mention to their partner that they had ED.
Now, you may say, how did they not mention it?
What they do is they just stop engaging in sexual activity, right?
Which is a problem.
But as these men get older and they start developing more and more sexual dysfunction, our job is to try to find out what we can reverse, reversible causes of ED.
Now, my dream, my wish is that, you know, lifestyle modification, diet, exercise, sleep, and stress reduction, again, diet, exercise, sleep, and stress reduction are very powerful tools in preventing a man from ever developing erectile dysfunction.
So to me, that's a form of a prevention, preventing ED.
So that, and those are the key things to every area of well-being.
Like if you improve those four things, everything about your life will improve, not the least of which is your longevity.
And you know what I recently discovered is I wear this Fitbit now.
This is my, this is in honor of my friend's son, the orange band, but this is my Fitbit.
And the reason I've been wearing this Fitbit nonstop is because your Fitbit, if you wear it overnight, will monitor your sleep.
And it will not just monitor how many hours of sleep you got.
It'll tell you how many hours of REM sleep you got and how many hours of deep sleep you got, which are not the same thing.
And if you can get like an hour, 15 of REM sleep and if you can get two hours, like over an hour, hour and a half of deep sleep, that's awesome.
And if you're not getting that, you could do something to address it.
You know, there are all sorts of things.
You don't have to go on a prescription medication.
You could exercise more.
You can take whatever tryptophan, that stuff.
That's a supplement.
There's all sorts of things, but like fixing sleep is, I would say, like one of the first things, no?
Right.
So you nailed it.
So I take care of a lot of patients and they tend to say, Look, Doc, I eat healthy and I exercise, but they don't sleep and they're stressed through the roof.
And that's 50% of it.
It's all four.
If you decided today that you were going to focus on just one of them: diet, exercise, sleep, or stress reduction, it would have a profound effect on your quality of life.
And imagine if you did all four.
And so what you just said is exactly what I tell my patients.
I don't have a pill stronger on the planet, stronger than diet, exercise, sleep, and stress reduction.
Not only will it help your physical health, but actually it helps your sexual health as well.
And fatigue, poor sleep, is one of the reasons why many patients don't engage sexual activity.
Poor sleep, increased fatigue, lower libido.
And then if you have poor sleep, you tend to make more, I think, poorer food choices the next day, right?
Because your will power is down.
You don't feel good.
You seek comfort in food.
And so it's like a downward spiral.
It's a snowball effect, right?
It's a snowball effect because they're all interrelated, right?
So if you exercise, you'll sleep better.
If you sleep better, you'll eat better food.
It's all related.
If you sleep better, exercise, and eat good food, you tend to see stress as not as big as it would be, right?
So one of the big reasons why we see stress is such a big thing is because we're fatigued.
If you're not so fatigued, stress typically doesn't look as big.
So it's all related.
And so when patients come in and say, Doc, just give me the Viagra and the testosterone, I say, there's more to it than this.
You know, this is a partnership, and your 50% is diet, exercise, sleep, and stress.
My job is to modify and make sure that your hormones and your medical condition is optimized.
But together, it's a partnership.
And if we do the partnership, those patients tend to do the best.
So if you are suffering from ED, any form of it, you know, like a light form or a severe form, and you go to the doctor, he's going to tell you, think about those modifications in lifestyle.
And then what's the first line, medical defense?
Is it Viagra?
And also now I read about sialis.
Is that basically the same thing as Viagra?
What's that?
Let's talk about it.
So there, think of it like three different categories.
And the first category is going to be medications.
And there are four types of medications, but they're all like Viagra: there's Viagra, there's Cialis, there's Levitra, and there's Stendra, four different types of medications.
Stendra has the fastest half-life, and so it has an onset is actually as fast as 15 minutes.
Cialis has the longest half-life, so it's 17 hours.
So many patients will take a daily sialis every day and it lasts throughout the day.
And so these medications.
What does that mean?
What does that mean?
Because of course, you know, as a woman, I'm like, no woman wants to see a 17-hour erection coming at her.
Yeah, great question.
Medications and Penile Prostheses 00:02:03
So this is very important.
So sialis is the only medication that has a daily dose and an on-demand dose.
And the daily dose is a five-milligram dose that you take every day.
And the on-demand dose is a 20-milligram dose that you take several hours before sex.
One of my favorite medications is that daily dose of sialis.
Why?
Because when a patient takes that daily dose of sialis every day, over time, the muscle in the penis becomes stronger.
To me, it's like rehab.
It's making the penis stronger.
Let's be honest: Viagra is not a cure for rectal dysfunction.
Because if you remember, I said ED 40% at 40%, 50% at 50%, 60% at 60%.
Viagra only covers your problem that night.
It doesn't cure you.
It just covers your problem while the disease gets worse every day.
So giving someone daily sialis to me is more like a curative preventative measure.
So most of my patients are on daily sialis every day.
What's nice about it is when they engage in sexual activity, many of them don't need to take a pill.
They're always ready.
And that really works well for young patients who like the spontaneity.
So again, daily Seals, very effective.
And what about those other two that you mentioned?
I've never heard of those.
Why would you go with those two over the first two that are better known?
Yeah, so one of them is cost.
So remember that these used to be very expensive.
It could be $20, $30 a pill.
But if you've heard of GoodRX, if you've heard of Mark Cuban's new company, Cost Plus, the medications are now very cheap.
You can get 90 pills for less than $20.
Anybody can.
So that's very affordable.
But in the past, we had to work with the costs.
The newer one you have not heard of probably was Avanafil, which came out in 2015.
So it's the newest one that came out.
But again, we have four pills that we can use to treat men for rectal dysfunction.
If one doesn't work, you can always just switch it for another one.
So sometimes some patients respond better to one than the other and side effect profile.
Now, in this first category, I also like to offer patients a sex therapist because sex therapists are extremely effective in helping with this condition.
Vacuum Devices and Sex Therapists 00:05:12
And we also want to consider lifestyle modification, stop your smoking, change your medications.
There's also something called a vacuum erection device, which many men can use.
It's exactly what it sounds like.
It's a vacuum.
It brings in suction, makes the penis erect.
They place a band at the base of the penis and it maintains the erection.
Sometimes if those are not effective, I'll go into something called penile injections.
Those are very effective.
It's a small injection that the patient places at the base of the penis and it induces an erection within about five to 10 minutes.
The erections can last about one to two hours.
So even if the man has an orgasm, it still stays erect.
And then the last option, which is a great option, is something called the penile prosthesis.
Now, the penile prosthesis was invented exactly 50 years ago here at my institution at Baylor by a guy named Dr. Brantley Scott.
And now it's used throughout the world.
And it's a very effective form of treatment for rectile dysfunction.
What is it?
So it's a surgery that we do.
I typically form these surgeries.
It takes about 45 minutes to do the procedure.
And it has, if you think about the anatomy of the penis, there are two cylinders, and each of those cylinders have muscle and carry blood in them.
So when the man gets erect, those cylinders expand.
And what we're essentially doing is putting balloons inside those cylinders.
There's a small pump that goes in the scrotum, and there's what we call a small reservoir that goes behind the pubic bone that holds water, say normal saline.
So when a man wants to engage in sexual activity, he just pumps the pump in the scrotum.
It fills those balloons and gives him a very good erection.
He engages in sexual activity as long as he wants.
When he finishes engaging in sexual activity, he'll release the pump and all that fluid will go back into the reservoir.
So it's extremely effective.
If a man took off his clothes, you would not be able to tell that he has a penile prosthesis.
But really, what it's done is revolutionize the way we treat ED because essentially a man can have an erection as long as he wants, whenever he wants, and it's very effective.
I mean, if you were having sex with a man, would you know that there was a pump?
Well, many women would state as that they really can't tell the difference when a man has a penile prosthesis.
If a woman was to touch his scrotum, she would be able to tell that there was a pump there.
But during sexual activity, it's reported that the sensation is the same.
The satisfaction rate is very high with the penile prosthesis, over 90% for patient and partner with the penile prosthesis.
And that's higher than almost any other treatment I can offer a man.
How painful is that surgery and the recovery from those implants for the man?
Yeah, so you'll be surprised.
It's very well tolerated.
I tell patients to take the first week off and during the second week, you're about 50%.
By the third week, you're back into your normal activity.
We typically have the patients come back in about two weeks and cycle the pump.
But with new techniques in pain control, it is very well tolerated.
All right, now you mentioned sex therapist.
What is a sex therapist?
And like, how could they help you with ED?
Right.
So many patients have psychogenic ED.
And these are younger patients who have psychogenic ED typically.
So maybe it was a bad relationship.
Maybe it was something that went on, stress.
And what they do is they work through the reason why you have sexual dysfunction and see if there's something that they can do psychologically to help you.
Sometimes they give you homework, you and the partner.
They like to sometimes meet with you and the partner to talk about ways to slowly get back into engaging in sexual activity.
But they can be very effective.
The only problem is, is that when most men come into my clinic, they say, Doc, just give me the pill.
I don't have time for a sex therapist.
What's revolutionized our ability to treat men with sex therapy is the internet.
And during COVID, many of the sex therapists were offering this benefit through Zoom.
And so this has really been great because men say, look, I don't want to drive in and go into a sex therapist's office, but a lot of them say, I don't mind doing the Zoom call.
And that's been very helpful.
I'm curious, is it usually the woman or is it usually the man, if you know, who suggests a sex therapist?
Well, so I suggest the sex therapist to both women and men, and women typically take me up on the offer.
Men typically don't, which is unfortunate.
Now, sometimes when a woman will go to a sex therapist, the sex therapist will ask if you can bring your partner, and sometimes the partner will go.
But the sex therapist is very helpful to just talk through the issues.
Sometimes, you know, there are many psychological issues that could be affecting or withholding the patient from engaging in sexual activity.
And it's very healthy to talk about it.
You'll be surprised how many times couples don't communicate or talk about their sexual problems with one another.
Oh, no, I wouldn't be surprised.
I remember seeing some comedian talk about how it was a guy and he was saying, for the love of God, would you women please give us direction in the middle of sex?
You know, whether it's up or down, like give us some direction.
We won't even pull over to ask for directions because we rely on only maps.
Like we're too embarrassed to say we're lost.
Never mind down there.
We're definitely not going to say we're lost.
So just volunteer direction.
So no, I wouldn't be shocked.
Stem Cells and Testosterone Therapy 00:15:44
That sounds just right.
What about insurance?
Does insurance cover any of this?
Viagra, Cialis, sex therapy, any of it?
What you'd be surprised.
So one of the best payers for the penile prosthesis is Medicare, right?
So Medicare, the government is a very good payer.
So a lot of patients are 63, they're 64.
They're just waiting to turn 65 so they can get their penile prosthesis, which is which is very interesting.
But now it doesn't matter about insurance for the oral pills because as I mentioned earlier, you can pay cash.
Mark Cubans cost plus.
I looked last, it was $9 for 90 pills, which was amazing.
Cash, no insurance.
Good RX, $20 for 90 pills.
So that's very affordable for most Americans to pay this amount for the medication.
So that has been very, very helpful.
What's also interesting, the penile injections I mentioned, these are compounded and they come out to about $3 an injection.
So again, very affordable.
So, you know, the take-home message is there are treatments out there and they're affordable treatments if someone out there is suffering from erectile dysfunction.
Now, what are these?
I have listed here, other treatment options, stem cells, PRP, and shock therapy.
What's that about?
We have to talk about this because over the past 10 years, there has been a boom in these three areas.
As I mentioned earlier, there's no real cure for ED, but over the past 10 years, there's been a quest to cure or reverse erectile dysfunction.
And the way that this has been going has been looking at stem cell therapy, shockwave therapy, and PRP.
Let's first talk about shockwave therapy because it's the most commonly used.
Back in 2010, a European physician by the name of Dr. Vardi started taking a shockwave machine, very similar to what we use for kidney stones, a shockwave machine, and applying those shocks to the penis.
Now, I'll be honest, when I first saw that, I thought it was ridiculous.
This doesn't make any sense, but it's actually brilliant because what you're doing when you give those shocks to the penile tissue is you're tricking the body to think that there's some kind of trauma.
When the body thinks that there's some kind of trauma, it starts bringing in growth factors, new blood vessels, stem cells to heal that area.
And so there's been a huge boom in the U.S. to use shockwaves to help reverse and cure ED.
The problem is, is that there are different types of machines.
There are class one machines that actually don't do very much at all, almost nothing.
And these are called radial machines.
And there are class two machines that are and class three machines that are actually that are more effective.
And patients, many providers are buying the class one machines and charging patients $500 to $1,000 a treatment when it really doesn't do very much at all.
And that's my concern.
So if you're going to use a machine, you want to use one that's focal.
We like the electrohydraulic, the electromagnetic machines.
You just want to use it where it's legitimate.
And I just want to quantify that this is still investigational.
This is not mainstream.
So more studies need to be done to say that we can call this standard of care.
So more studies need to be done.
So shockwave may be beneficial.
I have to mention a very cool phenomenon.
So if you think about ED, there's a very large placebo effect.
If I give 100 men a sugar pill and I tell them, you're going to have the best erections of your life if I give you the sugar pill.
30% of men come back and say, this was the best erection I ever had because there's a huge placebo effect when it comes to sexual dysfunction.
And so if you're giving someone a shockwave that doesn't do anything, you better believe 30% of people are telling their friends, this is the best thing since sliced bread, when really it's a large placebo effect.
Yes, your description of it reminds me of what we women are doing to our faces.
You know, you can get the microneedling, which is like you're damaging your face and that's supposed to stimulate collagen and make the face younger.
You know, it's kind of similar concept, like to stimulate not estrogen.
That's not what's coming out, but something else that's going to help the ED.
Yes.
Stem cells is the other one.
I just got to mention that.
We've been using stem cells for a long time.
We were the first to use an FDA approved product for stem cells where you take the fat out of the man's abdomen, you put it into a machine.
The machine's called an accelerator.
It would give us 37 to 50 million stem cells.
We'd inject those stem cells into the penile tissue and we would see if it would improve erectile function.
So there may be some potential benefit with stem cells, but again, it's still investigational.
And then the last one is PRP.
Now, PRP has the least data, and PRP is really platelet-rich plasma.
And some people may call it the pripus shot or the P-shot.
And the rate for that is anywhere from $1,500 to $3,000 in injection, but it really has the least amount of data to support it.
So I just caution a lot of patients.
They come in and they say, you know, I spent $3,000 for the P-shot.
I spent $6,000 for the shockwave and nothing's really happened.
And so you just got to be careful to counsel that there may be some potential benefit, but you don't want to say that, you know, this is main treatment as of today.
That middle one, it's like, well, so you didn't solve your ED, but your waist is slimmer.
You know, your belly's flatter.
Stem cells.
Yeah, tiny little light bow going there.
All right.
Well, all that is so interesting.
Now, in terms of prevention, you told Peter Atia, patients who are not using the penile muscle will start getting atrophy.
That's terrifying.
So it's a use it or lose it situation?
What about what does that mean for guys who aren't partnered up or don't have anybody interested in them for whatever reasons?
Just constant masturbation.
How often?
Like, what does this mean?
You nailed it.
So that's exactly right.
So think of the two penile muscles are just two muscles running in parallel, just muscles, just like your arm as a muscle.
So if you lift weights every day with your arm, what happens?
It hypertrophies and gets bigger.
If I put your arm in a cast for six months and I take the cast off, it atrophies, right?
So atrophy means that you weren't using it and the muscle contracts.
One of the best examples I can give you is we see men after a radical prostatectomy.
That's prostate cancer surgery.
Second most common cause of cancer in the world in men.
This year will be 300,000, almost 300,000 men diagnosed.
When you have that surgery, many times men will have erectile dysfunction immediately right after.
And what you'll see is you'll see some atrophy of the penile tissue.
And so the goal is to try to continue to keep that muscle going.
You can use a vacuum erection device.
I really like them using the daily sialis.
That makes a big impact, in my opinion.
And you're right, more sexual activity keeps the tissue healthy.
As men stop having sexual activity, and then it becomes more and more difficult to get the erection.
As it becomes more difficult to get the erection, they have less sexual activity and it just spirals, right?
So it's very important to use it or lose it, just like you mentioned.
Well, of course, that has everybody asking, how often, right?
Because this is the most men want it more than the women are willing to do it, just as a general biological evolutionary principle.
But like, what does that mean?
You know, is there a number you can put on that?
How often must they use it?
Yeah, so there's not a number to show, but I can just tell you statistically what people are doing.
So if you look at couples or young people between 25 and 30 years of age, couples, they're engaging in sexual activity two times per week on average.
When you get to roughly 50 years of age, it's about one time per week.
And when you get to roughly 70 to 75 years of age, it's about one time per month.
You can see the trajectory.
What's interesting though on that slide is that as you get to 80 years of age, you start seeing an uptick.
So if you live till 80 and you're healthy, you start engaging in more and more sexual activity on that graph.
But the reality is that two to twice a week, I would say, would keep the tissue healthy.
The problem is that women go through menopause at roughly 52 years of age.
When a woman goes through menopause at roughly 52 years of age, there's a precipitous drop in her testosterone, which is one of the number one drivers for sexual desire.
And there's a significant drop in estrogen in the vagina as well.
So now she has a low desire for sex and she has pain when she engages in sexual activity.
So she doesn't want to engage in sexual activity.
And thus, I believe men will start developing more atrophy of the penile tissue when their partners go through menopause.
My mom's 82 and I was giving her a hard time about this subject.
We were just joking around the other day and she said, Megan, when you're 82, you can fulfill all of your sexual fantasies and then you realize you don't have any.
I mean, but you're right.
On both ends, it's a user-loser situation because like the less, the less you do it, the less important it is to you.
And the more you do it, the more you sort of keep everything alive and you want it more.
I think that's true for men and for women.
There's so much more to discuss.
I want to get to libido.
We have to talk about testosterone.
You mentioned testicular cancer, infertility.
And there's so many topics.
The more I got into this, the more I was like, this is all fascinating and lots I want to talk to you about, including we'll spend some time on boys who are coming of age because that's tricky too in today's day and age.
Stand by.
More with Dr. Mohit Kara right after this.
All right, so I would love to talk to you about testosterone and libido.
I thought testosterone controlled libido.
And in preparing for today, I realized that's not true.
So, men who I think are suffering a loss of libido, I think a lot of them probably go to a doctor like you and say, I need testosterone.
But what's really going on there?
Can you talk about both of those things?
Absolutely.
So, listen, testosterone is just a piece of the pie.
When a man has low libido, there could be multiple factors.
It could be his relationship with his partner.
As you mentioned earlier, it could be stress.
It could be fatigue.
It could be hormones.
And not only is it testosterone, but there are four hormones we worry about.
We tell the mnemonic pet, prolactin, estrogen, thyroid, and testosterone.
So, there are many factors.
It could be neurotransmitters.
So, example, dopamine, serotonin could be affected as well.
So, I tell patients when you come in and you have low libido, they say, just give me the testosterone.
It's going to fix everything.
I say, it's not going to fix everything, but it will help.
It will make a big difference in your libido.
What are the signs and symptoms of low testosterone?
Low libido, erectile dysfunction, decreased muscle mass, increased fat deposition, poor sleep, some depression.
And many times, when you replace the testosterone, many of these patients can see a significant improvement in these signs and symptoms.
Is it true that antidepressants can lead to some libido problems?
And so, you know, people, maybe you don't need an antidepressant.
Maybe you need some testosterone.
I don't like, how does that interact?
Right.
So, now you nailed it.
So, antidepressants are notorious for shutting down a man's libido.
They also shut down the ejaculatory time.
So, if a man ejaculates in seven minutes and he takes an antidepressant, it could take 20 minutes or longer.
In fact, one of the treatments for premature ejaculation is to give them an antidepressant.
So, many times, if they come in and they have low libido, you want to look at the medication list and you say, oh, you're on an antidepressant or you're on an anti-androgen.
There are many meds that can cause low libido.
What's interesting is that there is one antidepressant that doesn't cause low libido.
It may improve libido, which is welbutrin.
So, many times I'll try to get them off the antidepressant like Prozac or Lexapro and put them on a Welbutrin type of medication to help improve the libido.
But it's multifactorial.
Again, a lot of times it's a relationship issue as well.
And so, I say this testosterone is not going to fix your relationship with your wife.
It may improve your libido slightly, but there are other factors you have to focus on.
And the women have to participate.
You know, the more you telegraph to him you want him, the more it will help.
I mean, if you're walking around all day saying, like, I'm not into it, get off of me.
No, it's a no again, the less he's going to want you.
I think that one of the things that turns the guy on the most is him thinking you want him and you want it.
Right.
Megan, you nailed it.
So, listen, I got to tell you a story.
So, when I started my practice back in 2008, I was able to get these men these amazing erections, great libido.
Everything was fantastic.
And then they would go home and they'd have no one to have sex with because the wives would say, We haven't had sex in 10 years and now he wants to have sex.
And they were furious.
Many women called, they were very upset, said everything was great before he met you, and now we're fighting all the time.
And so, essentially, what you want to do is if you're going to raise one partner's libido, you should raise the other partner's libido or just leave them both low.
But you don't want a discrepancy between one libido and the other.
And that's why in 2008, I started treating women for female sexual dysfunction.
And just by treating one partner, you actually can improve the libido of the other.
In other words, if I skyrocket a woman's libido, the libido and sexual function in a man also improves.
So, the take-home point, this is a couple's disease.
You just can't focus on one person.
This is a couple's disease.
By treating both, you're actually treating the whole entire couple.
That's so good.
That's so good to know.
Now, what about testosterone?
Because you hear it mentioned all the time now.
This guy's on it.
He's on it.
He needs to go on it.
Who does need testosterone?
It's important to realize that there is some abuse with testosterone.
And there are many several years ago with a study showing that 27% of men who started testosterone never even had a blood test prior to starting testosterone.
Many men will get it from the gym.
It needs to be monitored.
There can be some significant side effects that can affect your health.
One meaning that your red blood cell count can get very high, which can affect your health, and it can cause infertility.
So many young patients do not know that taking testosterone makes you infertile.
Then they come to our clinic and they say, no one told me that it could make me infertile.
So the reality is that younger men, we try to stay away from using testosterone.
We try to use meds that make them make the testosterone.
That's safe, right?
Helps keeps their fertility, makes it safe.
But the perfect candidate for someone who needs testosterone is someone who has a low testosterone value.
And most of the country uses the number 300 nanogram per deciliter, and they have signs and symptoms.
So you have to have both low testosterone value and signs and symptoms.
And then we go through the seven different treatment options we can offer you to see if we can improve your symptoms.
And so what a guy who goes on testosterone, let's say two months later, what do you hear?
Like, how has his life been improved?
So not everyone sees a significant improvement, but the majority of men in our practice do see a significant improvement.
And that means my sex drive has gone up, my energy has gone up, my muscle mass.
Remember, bodybuilders take testosterone because they get very cut in the gym.
It's the same testosterone, right?
The difference is bodybuilders are starting at a normal level and they're trying to go super high.
We're going from someone who's low and just getting him into the normal range.
But they say, my muscle mass, I've lost weight.
My energy, my libido, my erectile function has improved.
Some patients report improvements in depression and sleep.
We don't talk about depression, but in 2011, I published a big paper, almost 850 patients, and looking at men who have low testosterone.
And you'll be shocked to find that majority of these men actually suffer from some degree of depression.
And in our study, when we gave men testosterone back, many of these men saw significant improvement in their depressive symptoms, even if they were on an antidepressant, suggesting maybe a synergistic effect between testosterone and an antidepressant.
Now, I don't want the listeners to think that you should use testosterone to treat depression, but I definitely think that if you suffer from depression, you should check your testosterone level because adding it may help.
Male Menopause and Depression Links 00:14:34
How do you take testosterone?
Yeah, so there's many ways to do it.
The new exciting ways to do it are the oral testosterone levels or testosterone pills, excuse me.
So oral testosterone came out in 1970 called Andriol.
It's called endecanoate.
And it was available throughout the world, but it never made it to the United States.
In 2019, the U.S., we got our first oral testosterone endocanoate pill called Jetenzo.
And then last year, we got two more, Talando and Kaisotrex.
So now we have three oral testosterones on the market, and they're very good, but you have to take it twice a day.
And Americans don't mind taking pills.
So these medications are very effective in raising the testosterone level.
And they have a very good side effect profile.
So they don't have too many side effects compared to the other ones.
But most Americans will use an injection or a gel or a cream.
And I like the injections because they're very easy to get.
And most of my patients will inject into the fat twice a week.
I ask them to take Sunday and Thursday.
Because if you inject Sunday, these peak in 24 hours.
So if you inject Sunday, you're ready for Monday.
If you inject Thursday, you're ready for the weekend.
And they're very, very effective.
Other forms, as a gel, you rub a gel on your shoulder every day.
There's a nasal formulation.
There are patches that you can use.
There's pellets.
So a patient comes in once every three to four months and I insert a tiny pellet in the fat and that dissolves over three to four months, which is also very effective.
So as you can see, there are numerous different types of formulations.
It's just really what the patient prefers.
What are the risks?
Is it, you know, is it like a heart attack?
What, what, you know, there's got to be some downside.
I'm glad you brought that up because in 2015, there was some concern that testosterone causes a heart attack.
And that year, the FDA had requested that there be a large trial conducted to assess if testosterone causes a heart attack.
This trial was called the traverse trial.
Started in 2018 and it ended this year in January.
And two months ago, the article was published and I was one of the authors of this article.
It was 5,200 patients randomized placebo-controlled trial, five years.
And what it showed was there was no increase in heart attack.
So finally, we got the study that shows no increase in heart attack.
But there can be some side effects.
In other words, if you want to monitor the red blood cell count, it can get elevated.
You can get hypertension.
Some people get an increase in blood pressure.
So you want to be careful.
We talked about infertility as well.
Some patients at very high levels can get what we call roid rage, some changes in behavior.
So you just want to be careful as well.
So we wanted to monitor.
Good news, 2018, the AUA, the American Neurologic Association showed no increase in prostate cancer.
So that's important to know that as well.
Oh, yeah.
Yeah.
Thank God.
So should every, like when, when should a man get his testosterone tested?
Like a lot of guys feel tired and as they age, maybe libido falls a little.
You know, how do you know I want to have this tested and see where my levels are?
So most guidelines would say you should get your levels tested if you have symptoms, right?
Low libido, low energy, erectile dysfunction.
That would be a good time to get your levels checked.
I believe that every man in their 40s should get at least one testosterone level because later on in life, you could compare the drop to see where you started, be very helpful.
And to me, the best blood test for a man's overall health is his testosterone.
It's a marker of fertility.
It's low testosterone.
It's been implicated in cardiovascular risk, low testosterone, prostate health, so metabolic syndrome.
So I think testosterone to me is the best marker of overall health.
And I think men in their 40s should at least have one testosterone value checked.
Now, I am not asking you to diagnose RFK Jr., but he put out a videotape of himself.
He's 69 doing like push-ups and all these athletics without his shirt on.
And he looks amazing.
He looks great.
He doesn't look 69 at all.
And he looks ripped.
And then the internet was set on fire with people saying he's on testosterone, which in his case, they thought would be controversial because he's not a big pharma fan.
But is it possible for a 69-year-old man, not him, but one in general, to look ripped, to be totally fit, to be agile, to be spry without testosterone, without taking it?
Absolutely.
So I used to think that there was this concept called male menopause.
Just like women go through menopause, I would tell my patients there's something called male menopause.
As you get older, your testosterone will get lower and lower, and then you will need to start testosterone.
But male menopause is not true.
Actually, you can see many patients in their 70s, even 80s that can have normal testosterone as long as they are healthy.
The reason why the testosterone falls is because we acquire comorbid conditions as we get older.
Diabetes, obesity is one of the worst, metabolic syndrome.
As you acquire those conditions, your testosterone will fall.
But if you maintain overall good health, you should not see a precipitous drop in your overall testosterone levels.
A slight decline, that's true, but it's not a precipitous drop.
So if you take care of yourself, eat healthy, exercise, sleep, maintain your stress, it's not unheard of to have someone at that age be in good shape and be ripped.
See, this is why, like, all these weight loss drugs that everybody loves to rip on, this is why I think that they could be key.
I mean, if you're obese and you cannot lose the weight, look at all the health benefits that could come to you if you potentially, you know, use, well, let's say you don't have a gastric bypass or what one of the other procedures.
You use one of these drugs, your sexual function could go up.
Your testosterone could go up.
You would feel better.
Your brain health will go up.
You'll sleep better.
Your heart attack risk will go down.
There's so many good things.
Megan, you nailed it because I've been treating men for many years.
I treat many women many years and will use hormones to help them feel better.
And over the past two years, we found that there's something else that actually makes them feel fantastic and it's weight loss.
If a man or a woman loses 20 or 30 pounds, the libido goes up, the sexual function goes up.
They sleep better.
Weight loss has a profound effect on a patient's overall health and sexual health as well.
And so many of these medications like semaglutide, we do use in our practice because it does affect their overall sexual health.
Lower testosterone levels are associated with obesity.
The best study I found was that if you lose 10% of your body weight, you'll increase your testosterone by 100 in men.
If you lose 15% of your body weight, you almost increase your testosterone by 300.
So that's a big, big bump.
And so weight loss really makes a big impact, as you mentioned, not only on testosterone, but sexual health.
It's funny because I had comedian Andrew Schultz on the show a year ago or so, and he's hilarious.
And he's made the point to me a couple of times that women get very self-conscious when they're having sex with their partners or taking off their clothes, especially in the early part of a relationship.
Oh, God, I've got this insecurity.
I've got that insecurity.
Something weird happened in the act, you know?
And he was basically like, we don't care at all.
We don't care.
All we want is access.
But the truth is for a man or a woman.
Yes, if we feel we look good, we're going to want sex more.
So it's like not necessarily about attracting your partner.
It's about in your own head.
Absolutely.
Body self-image has a profound effect on a person's libido, right?
If I take care of a lot of women, we put them on medications to help them lose weight.
If she loses 30 or 40 pounds, she feels very sexy.
She feels very good.
Her libido goes up significantly just with the weight loss alone.
Putting her also on testosterone therapy in addition has significantly increased her libido.
So it's not just about giving her testosterone.
It's really the whole thing, sex therapy, lifestyle modification, but weight loss has a profound effect.
And like I said, we are going to get, we'll do a deep dive on women's health next week too, but testosterone is potentially available to women.
I know a couple of women who are on it and they love it.
But there are also ways of like increasing your drive as you get older without taking testosterone.
We'll talk about that for women as well.
So there's all sorts of options available.
Yeah, what were you going to say?
We got a minute before.
Just make sure you know it's off label.
So you can't walk into Walgreens today and say, give me testosterone for women.
It doesn't exist.
It exists for men.
So you have to get it compounded or get a cream.
But there are two new medications.
We can talk about them that are really good for libido and women that just came out over the past eight years.
And that's you can get them a prescription for these medications.
We should talk about that.
My one friend said she was getting her testosterone from Australia because they actually had a version that was for women, which led me to say, like, how effed up are we here in America that like half the population is not being serviced with this?
Why are the Aussies thinking about the ladies and the Americans aren't?
Like, we got to step up our game.
All right, Doc, stand by.
I want to get into a lot of other things, including most men obsess about size.
They're obsessed about size.
They think women are obsessed with size.
I don't know if that's true.
And also deformatives.
A lot of guys have them and it's very embarrassing and it could be painful.
Much, much more to go through, including cancer and porn.
Don't go away.
And don't forget, folks, you can find the Megan Kelly Show live on SiriusXM Triumph channel 111 every weekday at Noon East, the full video show and clips at youtube.com/slash Megan Kelly.
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And you on Apple and elsewhere can find our full archives of more than 600 shows now.
Okay, so I had one follow-up question on testosterone, Dr. Carroll.
One of our viewers and listeners on Twitter wrote in with this on the subject of low T, low testosterone.
Is there an epidemic of it?
You know, are we falling?
You hear a lot of, you know, experts suggest all the plastics, you know, the water contamination we read about are causing like an epidemic of low T that may be manifesting in a number of different ways in our society.
Is that true?
Though it is true, and there is a study looking at testosterone levels decade by decade, showing that our testosterone levels are dropping.
Now, what that may correlate with is where if you look at obesity decade by decade, it's now an epidemic in the United States, diabetes and epidemic.
So maybe those comorbid conditions are contributing to the low T. What's also interesting, remember, a man needs testosterone for sperm production.
So our sperm counts are also going down.
Men's sperm counts are going down as well.
And it all may be related.
Does it have anything to do?
I mean, I know this is thin ice, but do you think it has anything to do with the trans craze and like so many more people saying that they're trans?
Is there any study underway to see whether these things are related, low T in a man who might be then confused?
No, I don't, I have not seen any studies like that whatsoever.
I really think if you look decade by decade, you know, the T levels go down.
But if you look at a graph and superimpose it, obesity every decade is going up.
Diabetes is going up.
It's really an epidemic in the United States.
And it's no surprise that you'll start seeing those lower and lower testosterone levels correlate with those rises in those comorbid conditions.
And it's unfortunate, but I do think that as men tend to lose weight, tend to take care of themselves, we should start seeing a return in the other direction.
But we have work to do.
Is it, if a man has low sperm count, this is a weird question, but is it a fertility issue given how many sperm they produce, you know, just on a one-time basis?
Like, does it matter?
They've got so many.
Let's talk about it.
Very important.
So 15% of all couples in the United States will have some infertility issues.
And we know that 50% of the time it's a female factor.
30% of the time it's a male factor.
And 20% of the time, it's combined, male and female.
So indirectly, 50% of the time, the male is involved in infertility.
And you're right.
The average used to be roughly 80 million per ML.
The numbers are coming down, 80 million sperm per ML, but you have to multiply that by how many MLs you have.
The average man has 1.5 to 5 milliliters of seminal fluid, so that's important.
And you have to multiply that by how many are moving.
Let's say a man has 100 million sperm, but none are moving.
Well, that doesn't help me very much, right?
So they have to be moving.
And it's an odds game.
So the odds game means the more you have moving, the greater the chances for fertility.
And so, yes, you know, as it sounds like a lot, but again, the more you have, the greater the chances for fertility.
Okay.
100 ML, you mean on for each ejaculate or how many 100 ML?
100 million sperm for what?
Yes.
So each ejaculate will typically have 1.5 to 5 milliliters of fluid, 1.5 to 5 milliliters of fluid.
And each milliliter, a normal cutoff, should be roughly about 60 to 80 million per milliliter.
So that's a lot of sperm.
Now, yeah, it's a lot.
But you only need the new guidelines came out.
The cutoff for when you may fall in trouble is 15.
So as a man falls below 15 million per milliliter, that's when we start seeing more difficulty in natural conception.
And so there are new technologies available now to help men.
Remember, male infertility is not hard.
Either he's blocked or he's not making it.
There's only two options.
He's either blocked or not making it.
And we just have to figure out what side he's on.
And then we can treat that side to make it better.
And while we're on the subject of making babies, I heard another urologist giving a talk at Google saying that withdrawal actually works pretty well.
I was like, that's exactly the opposite of what they told us when we were young Catholics, and especially girls growing up.
It was like, if that thing comes anywhere near you, you're pregnant.
I would be very careful on that technique for your fertility to trying to avoid pregnancy.
The most common form of birth control in the world is vasectomy.
It takes less than 10 minutes.
It's extremely effective.
They talk about the failure rate as one in 2,000.
And so, I mean, I've never seen it, but that's the failure rate.
But it is a very, very good form of birth control.
Stretching Devices for Length Gain 00:10:22
But the men don't get that because they're afraid.
They don't want the procedure, right?
They're worried it's going to hurt or lead to ED.
Right.
Yeah.
So what they think about is men worry that they may lose their ejaculatory volume.
Remember that 90% of the seminal fluid comes from the prostate or the or the seminal vesicles, which means that if you do a vasectomy, a man loses only 10% of his seminal volume.
In fact, if I remove a man's testicles, he will still have 90% of his seminal fluid.
So that's this misconception that I'm going to lose a lot of fluid and it's going to feel different.
But the reality is that's not true.
So you basically don't notice.
Very mild.
You really don't notice.
Okay.
Okay.
All right.
So let's talk about something called Peironi's disease, which I understand is sort of a, I don't know if we should say disfigured, but it makes the penis look different.
And I guess a fair amount of men suffer from this.
What is this?
This is so important because so many men suffer from this.
Up to 9% of men suffer from Peironi's disease, but not many people have heard of it.
And what I want you to think about when Peuroni disease, it's an abnormal curvature of the penis when it's erect.
When the penis curves greater than 60 degrees, it's prohibitive for intercourse.
And the most common cause for Pirones disease is injury to the penis, a buckling trauma during intercourse.
And so these men are very, very depressed.
It's a disfigurement.
And now there are treatment options.
The first FDA approved treatment came out in 2015 called XyFlex, which is an injection, which I place into the plaque and break the plaque up.
I think the best way I can explain it to patients is this.
I have a balloon.
I put a piece of duct tape on the balloon and I blow the balloon up.
What is going to happen?
Everything's going to expand except that tape and it's going to curve in the direction of the tape.
That's the exact same thing.
So those injections are trying to break the tape off and let the penis become straight again.
Or I can do a surgery called a placation where I put stitches on the opposite side and straighten the penis.
But again, this is something that many men suffer from and they don't discuss it because they don't think there are any treatment options.
So you get this by like having rough sex where you get injured.
It's not really a disease.
It's trauma.
And so remember, in a theoretical sense, sex is trauma to the penis, right?
And what happens is if you start getting a small amount of erectile dysfunction, that's when you're in trouble.
If a man has 100% rigid penis, he's not going to injure it.
If he has a 70, 80% rigid penis, he will be able to penetrate, but he's going to undergo a buckling trauma that's going to injure that penis.
And then he starts getting a scar in that area.
And then it starts curving over time.
Now, besides the injections, there are other treatment options.
There is a stretching device called the one we use is called Restorex.
And he wears a stretching device for 30 minutes, twice a day at least.
And that can help also improve curvature as well.
But there is an FDA-proof treatment.
And when many times patients come into my office, they say, I never even knew that there was a treatment for this condition I've been suffering from.
Right.
Right.
And I'm sure it's embarrassing and it's painful, as you point out.
So.
Yeah, so you can get treatment on Peyronis.
And this is the thing that's you're not alone if you have it.
You don't have to live like that.
What about guys?
Because the unspoken thing is guys worry about penis size.
I really think having spent, you know, 52 years with women, this is not the issue that the movies and television would have men believe that it is.
I think it's more about technique and loving your partner and all that stuff.
But there are guys who are obsessed with it.
And now you hear more and more about the micro penis.
Why are we having so many micro penises in today's day and age?
And what about size?
What can men do if they really do want to work on this?
Right.
So there is an obsession.
There are many men who are obsessed with penile size.
So just a good way to think about there was a study that came out in 2014.
The average erect penis was 14 centimeters or 5.5 inches.
Now there's variation depending on race and age, but that's just one way to think about it.
In the flaccid state, if you look at a flaccid man without an erection, the average growth in that study was roughly four centimeters.
Now, 26% of men grew more than four centimeters, but these are just some rough numbers to remember.
But there is an obsession, and there are many ways to increase penile length.
I'm not a big proponent on doing surgeries to increase penile length.
I think one of the safest ways to increase penile length if a man is bothered by this is to use a stretching device.
These devices, any part of our body, if we apply traction, will change.
Braces will change.
You put anything on your ear, any kind of traction will change the body.
It's called the plasticity of the body.
So a stretching device can be very effective, but you just got to do the work.
But I am not a big proponent on surgical procedures for penile elongation.
Is a stretching device just like stretching the skin?
So now you just have sort of a long, flabby penis as opposed to, you know, if it's not going to get erect and do the thing that you want it to do, who cares?
It's actually stretching the entire penis.
The penis has two bodies called cavernosal bodies.
Think of them like cylinders.
It's actually stretching the cylinders to make the penis longer.
And what's really interesting about those studies was that it actually increases the girth as well.
So remember, these are off-label.
So I just want to be very clear.
These are not indicated for penile elongation on label by the FDA, but off-label use, not only does it increase penile length, but it can increase penile girth.
And for the Pirones patients, it can make the penis straighter.
So an easy way to do it, as long as you're willing to put in the time.
What are we talking about here?
Like, you know, if you watch television late into the evening, or at least you used to be, you know, these ads would come on trying to get men to call in and get some sort of penile supplementation, a device, whatever.
That all seemed like bullshit to me.
But you're saying there actually is something.
I imagine they should get it from their doctor.
And is it a painful situation?
Like, what is it?
A machine?
What is it?
Very interesting.
So you're right.
These originally came from the porn sites.
And then in 2010, we started using these devices medically, but they have been significant advancements in these types of machines.
It's basically a device.
It's a traction device that's spring-loaded.
A man can control the amount of spring and tension he can use.
The rest direct is very nice because you can actually bend the penis in the opposite direction where you're curving.
So if a man's penis is curving up, he can wear the device and it will bend it down for 30 minutes, twice a day.
And that's been shown to significantly improve the curvature and the length and the girth.
But you are right, Megan, these actually came from penile elongation porn sites in those late night videos.
We just have adapted them since 2010.
And now use them more medically.
Again, it's off-label.
So I do think it's important that patients know that.
And I definitely think you should speak to your provider or your physician as opposed to just going to get them for some counseling.
That is unbelievable.
Wow, who knew?
Okay, good to know what's out there for the guys who have to labor under this problem or this, you know, if you feel embarrassed about it.
Let's talk about ejaculatory issues because there's premature ejaculation and then there's like delayed ejaculation or no, no ejaculation.
Some men have a problem of not being able to do it at all, which seems like a really tough problem.
But can you talk about those are three problems that a lot of guys deal with?
Big problems.
Think about it.
30% of men in the U.S., one out of three, suffers from premature ejaculation.
That is an astounding number.
And there's two types of premature ejaculation.
There's the type where someone has it their entire life, that's important, or someone who has it acquired.
In other words, everything was going great till I was 40, and all of a sudden I started getting premature ejaculation.
And we treat them a little bit differently, but both of them have to have three components.
One is that you have to have a loss of control, meaning you tried not to ejaculate, but it just happened.
That's loss of control.
Number two is that you have to have a decreased ejaculatory time.
And we now use two minutes if it's lifelong.
If it's acquired, it's about a 50% reduction of what you're used to having.
And then you have to be bothered by it.
And that's really important because if a man comes to me and says, look, I ejaculate in 30 seconds and I'm fine with it, then it's not an issue.
So those are very important.
And what you want to do is start some medications.
And the medications, as we talked about earlier, were those antidepressants.
Antidepressants significantly delay the ejaculatory time.
So I think that is very, very important.
Sex therapy, really, really helpful.
I think that could be very helpful.
And then also we sometimes use off-label medications like Tramadol or Flomax or some Afl blockers.
These are all in the guidelines.
So again, this is treatable.
One of the best treatments also, which you can get online, is a lidocaine spray.
It's called promescent, and they ship it to you and it numbs the penis so that your excitement's not that high.
And then you can go longer as well.
So the lidocaine spray is simple, easy.
Will you still have a climax if you do that?
You won't if you put on too much spray, right?
So you've got to kind of up to eight sprays.
The more sprays you put on, the more numb the penis becomes.
Then does that numb your partner too?
You wipe it off before you engage in sexual activity, but it penetrates the skin and gets in there.
So it numbs the penis.
And so when it numbs the penis, you can go longer because there's not that heightened sense of excitement.
Okay, now here too, I read that, what was that?
Hold on, I wrote it down.
Okay, if you have premature ejaculatory problems, that when you're masturbating, you have to, quote, masturbate for longevity.
You shouldn't rush through it.
Like basically, you need to practice extending the minutes.
Is that true?
So there is a technique, a start-stop technique and squeeze technique, but these are done by a sex therapist to teach you how to delay the time.
I've never, we never counsel truly with masturbation itself because the problem is really when you're having sex with your partner typically.
And two of the best techniques out there are called the start-stop technique.
So when you're about to get increased pleasure, you stop or you can squeeze the glands, which takes away the ability or desire to ejaculate.
So these techniques are a cure.
So I tell patients, if you're looking for a cure, go see the sex therapist.
Mayo Clinic Restorex Technique 00:02:56
If you're looking for a band-aid, take the meds.
But I really, really think that a sex therapist, this is a high value for a visit with a sex therapist.
Very important.
I'm going to get to the other problems as well, but we have a couple of callers, so I'm going to fold them in throughout the next half an hour while we have you.
Scott in Pennsylvania has a question about something we were just discussing.
Scott, hi.
Thanks for calling in.
Your question for the good doctor.
Oh, I cannot believe i'm calling a national Radius show about this.
But hey, what the heck, you only live once, why not?
Um, so I had P Tarone's disease.
I got the Xyaflex and it's very bizarre.
It seems to work like, as the doctor probably is.
You get four injections over so many months, and I got the first two.
Seemed to really help, and then it got worse or back to normal at the second two.
So I have, you know, appointment to go back to my doctor and we're going to talk about, you know, what to do.
But I think you answered my question.
So you're saying, like he said, there is surgery available, but could you do the injections again?
Would that help?
Or you just mentioned like the traction device.
So I should probably do that.
That's what you're saying.
What are your thoughts, Doc?
Great question.
So remember, it's a total of eight injections.
And if you complete the eight injections, on average, patients see about a 30 to 35 percent improvement.
And not all men will see that amount of improvement, but it varies.
But if sometimes what happens is you may develop a new plaque along the shaft.
So you're treating one, but if you have Peroni's disease, you have a higher predilection of having a new plaque somewhere along the shaft.
So you may be seeing a manifestation of another plaque.
Now, I do think that if you want to get the full effect of the medication, finish the four rounds or the eight injections.
And then once you're done, say, okay, where am I?
And if you decide you want to go more conservative, you can use the stretching devices, again, off-label, or you can do the surgery.
What's nice about the surgery is it will fix the problem.
It's a plication procedure.
The only downside, biggest downside of the plication procedure is you will lose some penile length.
You lose about four millimeters for every 10 degree of curvature.
So some men say that's a no deal breaker.
Four millimeters, that's a small for every 10 degree of curvature.
So if you're 40 degrees, 1.6, so every 10 degree.
So it can vary.
But you're right.
Why does he, if he wants to get the machine that you were talking about that, you know, strengthens it and or lengthens it and straightens it, what is that thing called?
The one that I use is called Restorex.
It comes out of the Mayo Clinic.
There are many different types.
But what I like about the Restorex out of the Mayo Clinic is it bends the penis in the opposite direction as it's pulling it.
So not only is it making it larger, but it's helping with the curve as well.
That's why I typically use that.
Again, off-label.
So guys, I hope what you're taking away from this conversation is this, it may sound scary to talk about, but it's not that scary to talk.
Drugs to Boost Female Libido 00:09:23
We should be talking about it.
You want good sexual health.
It's part of your overall health.
There's nothing wrong with you if you have a curved penis or if you have ED or if you have premature ejaculation.
These are all normal things that can be addressed.
You just have to be willing to matter of factly discuss it with your doctor and get the help you need and that you deserve.
Jones has got a call.
Jones is calling from Oklahoma and has a question for you, Dr. Kara.
Jones, what's your question?
Okay, I'm on cytolopram Selexa, and that basically takes the sex drive to zero, which is very frustrating for my wife.
And we're both in our 50s.
So is there something I've tried a couple of different medications?
It's all the same as far as close to the Selexa, but the sex drive is just gone.
Is there something I can do to improve that?
So very helpful.
And that is true.
Selexa side effect is a significant decrease in libido.
What's really interesting about these medications is that there's a dose response curve, meaning that if you're on a high dose, let's say 60 of Selexa, could you possibly come down to 30, still get the benefit, but you will have a significant improvement in libido and sexual function.
So one option is to try to get down to only the lowest dose that you need.
So, that will preserve your sexual function the best you can.
The other option is to try, as I mentioned earlier, a different antidepressant like Welbutrin.
Now, I do want you need to speak to your provider, make sure they're comfortable with this, but there are other types of antidepressants that actually enhance libido and sexual function and ejaculatory time, such as Welbutrin.
So, you may want to ask if that can be an alternative, or you may want to see if you can lower the dose.
If you can't, then we use other types of medications to try to do what we call a workaround to get you there.
Because it is, I mean, if you're not having sex, it's depressing.
And having sex, just the stimulation, not to mention climax, all that stuff is very good for your mental health and your well-being.
So, it's like that these drugs that are supposed to cure your depression, but actually cause you not to be able to have any sexual function are not, you know, it's one step forward, two steps backwards.
Um, so it's a good, it's a good question to ask.
Let me ask you about the men who can't ejaculate.
That's also a problem, apparently, for some guys.
Right.
So, this is either delayed ejaculation or an ejaculation, means I can't ejaculate at all, and that can be very frustrating.
Now, in this population, you have to ask them, is there any problem with masturbation?
They say, Yeah, with masturbation, no problem, but with my wife, it takes forever.
Then, that's a psychologic issue, and they need to see a sex therapist.
So, that's a very important question.
But delayed ejaculation typically can happen with medications like antidepressants.
And typically, it has the same three components: they have to be bothered by it, no control, and they basically have to have a delayed time.
Typically, we do two standard deviations.
Up to 20 minutes can be a delayed ejaculation, and it's a problem.
And there's no FDA-approved treatment for this, so we use off-label medications.
And so, any medication that can increase dopamine in the brain may be beneficial.
Anything that increases norepinephrine may be beneficial, and anything that decreases serotonin may be beneficial.
There are male vibrators, Vibarect has been used to help men with their ejaculatory time as well.
So, that may be beneficial.
Absolutely, check the testosterone level because if the testosterone level is low, that could be an impact as well.
So, there are many things that we have to do to look at to improve the ejaculatory time.
I know we talked about this earlier, but there are some off-label medications.
One of them is the one for women.
So, in 2015, there was a drug called ADD, ADDYI, that came out.
First drug ever for women for sexual dysfunction.
It's a big deal.
So, in 2015, if I walked into Walgreens, I said, put on the table all the medications for men for sexual dysfunction.
They put out 33 drugs.
I said, Give me all the drugs for women for sexual dysfunction.
Zero, not one for sexual dysfunction till that year.
And what does ADDI do?
It increases dopamine, increases norepinephrine, decreases serotonin, and it's the first drug ever for women, FDA-approved, strictly to increase her desire for sex.
That's the FDA approval, strictly to increase her desire for sex.
So, several years later, I went to the FDA and said, I want to give it to men.
I want to do it in a clinical trial.
So, I got permission, I got an IND to give it to men in a clinical trial to see if I can improve their libido.
So, I do think there's some other medications that we can use.
Is Addy, is that like an oral tablet?
How does that work?
It's an oral tablet that she takes every single day, strictly to increase her desire for sex.
Now, I worry, like, I don't want men slipping this into their wives' coffees in the morning.
There you go, honey, I'll make it for you again.
This needs to be regulated.
The woman needs to choose, and it has to be done.
Now, there's two drugs.
There's a new one that came out after that called Vilecy, which is an EpiPen that she injects 45 minutes before sex, strictly to increase her desire for sex.
So, now we have two drugs out there strictly for low libido in women.
Oh, that's awesome.
I'm very glad to hear that.
And I would think like that when I was reading about the like the delayed ejaculation, like that, that would be a deal breaker for a lot of women too.
It's like you want it to be the sweet number of minutes.
It can't be too short, but it can't be too long either.
We're busy and we're tired.
And it's like, I don't have 45 minutes for you.
And it's like, you know, get up and get down.
Like, we're going to have to get down to business.
So we should talk about it again and see a urologist.
By the way, is it like a urologist?
Is that your first line of defense?
Like, I'm having an issue.
I got to get a urologist.
Well, yeah, for these types of issues, which are more complicated, I would definitely see a urologist.
For strict ED, I mean, you could see your primary care physician, you know, but when it gets to more like, you know, detailed delayed ejaculation, delayed orgasmia, a significant PE, premature ejaculation, Peironi's disease, that's where you absolutely need to see a urologist.
Can we talk about masturbation and porn?
Because I just feel like this is ruining the sex lives, somewhat ironically, of a lot of men.
They think it's going to help the sex lives and it does exactly the opposite.
And I think probably double, you can double that impact on the young men, you know, the teenagers who have discovered online porn.
Can you give us your thoughts?
Yes.
So it's been a big problem because as pornography increases, what happens is the libido and erectile function of men decline the more pornography that he sees.
And the reason being is because he now has a new reality, expectation.
He expects X because he sees this on the screen and he gets Y.
And there's a big delta from what he's expecting and what he's getting.
And so that tends to cause decreased desire to engage in sexual activity with your partner, decreased erectile function, decreased libido.
And that's an issue.
And so a lot of times we have to send these patients, a sex therapist is very helpful to help them with their porn addiction.
Porn addiction is a reality, particularly now that we have the internet.
And so, you know, whenever you see someone, particularly a younger patient who comes in who has ED, why is this 35-year-old having ED?
You have to ask them about their pornography usage.
If a man is just masturbating all the time, is that going to cause problems?
And same question for a woman.
You know, like I, does that increase your desire for your partner or does it decrease your desire for your partner?
You know, I have not seen any study suggestion that it may increase or decrease.
There's no negative long-term effects of masturbation that I'm aware of.
I do know that when patients engage in sexual, for example, if a woman starts, has an orgasm after a long time, it's been some time, that reminder of the pleasure that is associated with it may signal her to engage in sexual activity again.
If she's not having sex for a long period of time, then it's just out of sign, out of mind.
So the pleasure itself is a reminder, maybe I do want to engage in this again.
Because, you know, we're telling them use it or lose it.
But if they're with a sexual partner who doesn't want to do it, or they don't have a sexual partner, so they only have themselves as their last option, but porn could be bad for them.
Like, I guess you're just supposed to use your imagination.
Like, what's the way forward?
Yeah.
So the way forward, obviously, is to limit porn to, I would say, to also work on the quality of the relationship.
You know, there's this big difference between men and women.
It's called stress.
This is one of the dichotomies.
If a man has a very stressful day, typically that man will want to engage in sexual activity to relieve his stress.
If a woman has a very stressful day, then the last thing she typically is thinking about is sex, right?
So in order to engage in a woman into sexual activity, you want to relieve her stress and that will increase her desire to engage in sexual activity.
So there are many things that you can do to work on a relationship.
And that's where sex therapist comes in to enhance the amount of times the couple will engage in sexual activity.
These always get circulated on the internet, but like whenever the study comes out showing the more housework the man does, the more sex he gets.
Opioids, Alcohol, and Sexual Damage 00:05:17
I totally believe it, right?
It's just like if you're feeling overworked and underappreciated and dirty all day, like physically, actually physically dirty, you don't, you don't want it.
But if you see your husband pitching in and you're both working together towards a common goal, you're just, you're a little lighter on your feet.
That's it.
That's actually, that's one of the best ways to engage, have sex with your wife is to reduce her stress.
Men, listen up.
All right, wait, I want to take another call and then we'll take a break and we'll take more calls when we come back.
Let's go to Matt in Michigan, who has a question for Dr. Kara.
Hi, Matt.
What's your question?
Hi.
I'd like to first thank you for taking my call.
But secondly, I wanted to know I've been on opioids, actually, per cassette, 10, 3, 25, whatever it is, for over 20 years.
And I have noticed for a long time a difference in the sex me and my wife have.
So I wanted to ask: number one, does it take longer to ejaculate?
It seems like sometimes when you're on opioids.
And number two, I went because of the testosterone level, I thought might be low.
So I got the ageless male pill and started taking it.
And then I had Ponome from with, I got them in my lungs and everything.
And a doctor said that's because you're taking the testosterone pills.
Get rid of them.
So I just wanted to touch base on those two things.
Let's talk about that.
You bring up a very important point.
Three things can happen with opioids.
The first thing is that when a man take opioids, 74% of those men will have a precipitous drop in their serum testosterone levels as early as four hours.
So any man who's on chronic opioids, I strongly urge you to check your testosterone level.
It's the number one, one of the number one reasons why a man will have a drop in his serum testosterone.
Opioids will also delay the ejaculatory time, as you mentioned, significantly, and they can also lead to erectile dysfunction.
So clearly, you want to check your testosterone.
I don't believe in using a lot of the over-the-counter testosterone boosters, which you're mentioning.
If someone needs testosterone, I think they should get their testosterone level checked and see a provider and get a prescription if it's warranted.
So I think, you know, this concern that testosterone causes a cardiovascular event was really mitigated by the recent traverse trial, which showed that there was no increased risk in cardiovascular events.
But I do think that more studies are done.
In the traverse trial, there was a slight, when I say slight, 0.4 to 0.9% increase in DVT.
So I think more studies need to be done in that area.
Deep vein thrombosis?
What is that related to pulmonary embolism?
Yes, there was.
And so it was very small, statistically significant.
So I don't want to discount that at this point.
Okay.
What about, well, we're on the subject of sort of dulling yourself.
Alcohol.
What, what's like, who should be questioning their use of alcohol when it comes to sexual function?
Yeah.
So remember that alcohol can cause significant damage to the testicles.
And the way you want to remember is 40 grams, roughly 40 grams of alcohol can cause damage to the testicle.
Each drink that we have on average is about 14 grams.
So that two drinks is fine.
When you get to that third drink per night, you're starting to cause some testicular damage.
Wait, wait, wait.
Like permanent, permanent testicular damage?
Well, it depends how long you drink.
So, not one night, but if you're chronically drinking greater than three drinks per night for an extended periods of time, then you can be susceptible to permanent testicular damage.
And so, you just want to be a little bit careful.
So, alcoholics tend to have a higher rate of infertility and lower rates of testosterone.
And so, that's important to remember that.
So, alcohol in moderation is okay.
One of my favorite diets is the Mediterranean diet.
And the Mediterranean diet, I think, is probably the best diet for longevity and overall health.
And it encourages daily use of alcohol in moderation.
And so, I do think it can be beneficial, but I think anything in excess can be an issue.
People use it as a to dull their inhibitions, right?
So that they can go ask the woman out at the bar, but that's not all.
It dulls, you know, for men and for women, right?
So, it's like, be aware.
Be aware.
Hi, Scott.
Go ahead.
Hi.
Just have a question regarding a resug, which is a reversible male vasectomy.
I first heard about about 10 years ago, and it seems like it's been stuck in the approval process for all this time.
And I'm trying to figure out if it's ever going to be approved or not.
Yeah, there are many types of products that are coming out for a reversible vasectomy.
One of them, obviously, is putting, for example, a gel or a binding agent that can put into the vas deferens, and then it will dissolve over time.
HPV Vaccines and Prostate Cancer 00:07:48
None have made it out yet.
My concern is that, you know, being almost 100% is not 100%.
So we have to make sure that in the clinical trials, the chances of an unwanted pregnancy are almost, at least, almost as good as a complete vasectomy.
And I think that's what they're struggling on is getting those numbers.
What about on the subject of, you know, pregnancy and so on?
You said the withdrawal, don't count on it.
Condoms are obviously the best to prevent against STDs.
But what about STDs and male health and male birth control?
For a while, they were working on the male birth control pill.
Is that still a thing?
And also, can we talk about the HPV vaccine?
Because we had a debate on that about whether boys should be getting it, whether girls should even be getting it.
But what are your thoughts on those two things?
So you're right.
So one of the best ways to control against STDs is condoms, right?
That makes a big difference.
But the reality is, is that, you know, you can still get the STI.
And so, you know, we tell patients that, you know, the Gardanella, you're talking about the HP vaccine.
Those are typically best used in patients prior to getting engaging in sexual activity.
That's the best time.
So you look at the teens, women prior to engaging in sexual activity.
That's the best time to get the vaccine.
Remember, the HPV is a very prevalent condition.
People, when they come to me and say, I can't believe I have HPV, I say, you know, you'd be surprised.
Up to 30% of patients can have HPV in certain populations.
They just don't know it.
And most of these, particularly like even herpes, will stay dormant and they will not manifest until there's a stressful situation.
Stress meaning weather, stress and just some mental stress, getting diabetes, immunocompromise.
Many patients don't know it that they have these conditions.
And is that treatable or no?
Well, you know, herpes obviously is treatable.
HPV is treated as usually it's surgical.
When we see patients coming with HPV lesions, we'll use electrocottery.
We'll use freezing.
There's medications you can use as well to for the HPV lesion.
So there are things you can do, but unfortunately, they come back, right?
Because they usually stay dormant.
And so you're chronically having to address.
But if you get the vaccine, then you don't have to deal with it.
It'll significantly reduce the risk, but the best time to take the vaccine is before you're sexually active.
Yeah, yeah, right, exactly.
Okay.
Right.
And we did a whole show on those vaccines, so you can go back and check it.
Steve will get me the episode number for our audience.
Okay, let's see.
Okay, a lot of people calling in with some questions.
Good for you guys.
Appreciate that.
Let's talk to, yeah, Gary in Mississippi, who's getting to a topic we haven't yet discussed.
Hi, Gary.
What's your question?
Hey, Megan.
Hi, Doc.
Listen, thanks for all this.
I'm a prostate cancer survivor, you know, and having gone through the process of treatment and then my sexual health after that.
Could the doctor just kind of touch on the thought process that men go through when we're facing treatment and ultimately, you know, keeping that sexual function going?
You bring up a really important point.
You know, it is devastating when a man undergoes a radical prostatectomy or surgery for prostate cancer that the next day, immediately, most men will have erectile dysfunction.
Now, over time, their erectile function will regain in many men, not all.
And so think about it.
If you're 55 years old and you're going to have this surgery tomorrow and then the day after you say, okay, so I can't have sex with my wife, it can be very devastating because it's abrupt.
It's all of a sudden.
And so there are many programs we try to do called a penile rehabilitation program.
Put patients on daily sialis.
We have them on injections.
We have them on vacuum.
We may use testosterone early in certain patients to help regain their sexual function.
So the comment we used earlier about use it or lose it, you want to make sure that you're using the tissue and exercising it because over the course of that year, those nerves undergo something called neuropraxia.
They get paralyzed.
But as they start recovering, then you're going to want to make sure the tissue is healthy so that everything can come together and you can start engaging in sexual activity and having erection.
So we do think that it's important, I do, for penile rehabilitation after this type of surgery.
And also, I just want to be fair, the surgeon skill makes a big difference.
Those surgeons that are very good and have done a lot of these cases tend to have very good outcomes because of the experience in avoiding injuring what we call the cavernosal nerves during the procedure.
Just quick note, it was episode 565 where we had our HPV debate 565.
So we're talking a little bit about prostate cancer.
Can we spend one minute on testicular cancer?
I did not realize how important self-exams are for guys on this.
As a woman, you hear about the breast self-exams in the shower at least once a month.
You're supposed to be feeling for lumps.
That's also true for guys and the testicles.
18 to 35.
Just remember those numbers, Megan.
Men 18 to 35 should be examining the testicles.
We say at least once a month because that's the prime years for the testicular cancer.
And the best way to think about this is if you make a fist, if you make a fist and you press between the knuckles, that's the consistency of normal testicular tissue, just kind of soft, spongy.
Then if you move over and feel the knuckle, that's the consistency of what a tumor would feel like.
So what you're trying to do is make sure that you're not feeling the knuckle and you're feeling the consistency between the knuckles, the spongy area.
So very important for men to do self-testicular exams between those ages.
Is it true that pot use makes you more likely to get testicular cancer?
I have not seen data to support that.
Okay.
What are the risk factors for getting that?
Well, I mean, the risk factors are an undescended testicle is the biggest risk factor.
So some children are born with a testicle that's not descended all the way.
That testicle that's not descended all the way has a very high risk of having testis cancer.
What's interesting is that when you bring the testicle down as a child, we bring it down.
The reason we bring it down is because we want to be able to examine it so that if it does get cancer, we would know.
So leaving it up in the abdomen, you'll never be able to know because you can't examine it.
Even if you bring that testicle down and you're able to examine it, you also have a higher risk of having testicular cancer in the other testicle.
So you really want to examine both testicles.
But again, those testicles that we bring down have a higher risk.
Okay.
Well, that's good to know.
But it's very treatable, right?
Testicular cancer.
Like all the more reason to get ahead of it.
Very treatable, but this is one where you catch it earlier.
I have a much better outcome, right?
So that's really important.
Sometimes men will say, I felt something, just ignored it.
I felt it.
It got a little bit bigger.
I thought it'd go away.
Because with a problem with testicular cancer, it's not painful.
So there's no pain.
It's just a mass.
And so as the mass gets bigger, you're thinking, ah, I think if it was very painful, most men would try to go in and get some kind of treatment.
But there's no pain.
It gets larger.
And the problem is this can metastasize very quickly into the abdomen.
And so, and it requires sometimes chemotherapy or radiation.
And so the take-home message is if you feel a mass in the testicle, please go to your urologist and get it checked out.
While we're on the subject of 18 to 35-year-olds, for those of us who have, you know, young teenagers, like I have a 13-year-old boy, I have a 10-year-old boy.
Is there anything we need to be thinking about for them as they sort of mature into young adulthood?
Finasteride Side Effects in Teens 00:05:08
You know, to me, it's crazy because they say like the average, like 50% of all 12-year-olds have seen porn already.
This is crazy.
I realize that like they're capable soon of actually having sex, but like, and they're biologically wired to be able to do it at a very young age, but they're not mentally ready at all.
So what in your business, you know, what should we as parents be thinking about?
Yeah, you know, I don't see a lot of kids.
Obviously, I'm more on the adult side, but you're right.
I have teenage, I have a teenage boy, and so the issues are relatively the same.
The problem is the access to pornography is rampant.
You know, many of them have their own iPhones and they can see different things whenever they want.
The thing I worry about at that age is that many of them do take testosterone in high school.
They take testosterone in high school because they want to improve their athletic performance.
And that's where they get in trouble because they don't have the maturity or understanding to know that by taking this enhancement drug, they can become infertile.
So that's what I worry about in my business.
No, that's very smart.
Oh, gosh.
I dated a guy a long, long time ago as a bodybuilder, and he was taking steroids.
And I'd never even heard of steroids.
I didn't, I mean, there's a short little couple week romance.
And I remember running around being like, hey, he's on steroids.
He might know.
And he was like, don't stop telling people that.
But we were young.
And I'm sure he had no idea that those also carry these kinds of risks.
Okay, let's get to Corey in British Columbia who's got a question for you, Doc.
Hi, Corey.
What's your question?
Hi.
I was on an SRSRID pressing and I'm experiencing genital numbness, even after I saw you.
I've been off medication well over a year and I'm still experiencing this.
What's the issue here?
Sorry, go ahead.
Yes, you know, he said he's genital numbness after a medication.
Yes.
So there are two phenomenons.
One is SSRI, where patients take an antidepressant, and even after they stop the antidepressant, they can have persistent sexual side effects.
The second one is with a medication called finasteride, which has been documented where they take finasteride typically for hair loss.
And after they take the medication, after they stop it, they have persistent sexual side effects.
It doesn't happen in all men, but it does happen in some men.
And I think that it's real.
The problem is, is that trying to find the etiology, why does it occur?
We don't know.
And what's the best treatment for it?
We still don't know.
Many times when patients come to see me for, for example, post-finasteride syndrome or post-SSRI syndrome, we try to work around it.
We try to use medications such as daily sialis to increase the blood flow into the penis to help with blood flow, to help with nerve regeneration and growth.
We try to use testosterone as well, but it's a very delicate situation because I don't have a cure, nor do I know the etiology for why it occurs.
That sialis sounds like a great drug from what you're saying.
Let's go to Kaya in Nevada, who has a question about her husband.
Hi, Kaya.
What's your question?
Hi, Kaya.
Hi, Megan.
This is Kaya.
I just, my husband has an enlarged testicle that he did have looked at.
And the doctor said he could aspirate it, but he preferred not to.
And that was probably 10 years ago.
And it's just getting bigger.
So an enlarged testicle typically means something called a hydro seal.
And let me explain what that is.
The testicle has a casing around it.
Think of it like it's in a sac.
And sometimes when the testicle is injured or there's some trauma, what they'll do is develop fluid between the testicle and the sac.
And the sac will get larger and larger and larger.
And that's fluid around the testicle.
So it's not necessarily that the testicle is larger, but there's a significant amount of fluid around that testicle.
So you can aspirate it and put a needle in and remove the fluid, but it has a very high recurrence rate, up to 90%.
Will those patients recur and you'll keep aspirating for life?
So one of the best ways to treat it is to go in and remove the fluid.
This is surgical.
And then I remove the sac.
And once you remove the sac and the fluid, the problem is typically solved.
Now, I don't know much about your husband's condition, but you just do want to make sure that you're not missing anything else like a testis tumor or something else.
But it sounds like to me that this is a hydroseal.
Ron in Georgia has a question about POT.
Hi, Ron.
What's your question?
I'm just curious about the effects of cannabis on testosterone levels.
Yeah, so we do know that excessive use of cannabis can significantly reduce testosterone levels and cause erectile dysfunction.
I've never seen a study talking about the quantity.
Like, hey, if it's one joint a day, two joints a day.
I've not seen that.
But we know that patients who do have excessive sex with cannabis use will see a decline not only in testosterone levels, but also sperm production as well.
Okay.
And last but not least, I'm just going to repeat.
John in New Hampshire's got a question about motivating sexual desire.
I'll just paraphrase it.
I think we covered that, but just sum it up in the time we have left for the guys who worry about that.
Multifactorial Causes of Low Desire 00:00:55
Yeah, so remember, sexual desire is multifactorial.
It's not just about a pill.
It's about your relationship.
It's diet, exercise, sleep, stress reduction.
It's about some meds that you're on that could cause an impairment in sexual desire.
Just don't think if I take testosterone, the world is going to be great.
It's multifactorial.
Doc, this has been so interesting.
Gosh, thank you so much for sharing your expertise.
We could have gone for another hour, I'm sure, because so much to cover.
Really appreciate you sharing all your knowledge with us.
My pleasure.
Thank you so much for the invitation.
You bet.
Dr. Mohit Kara.
And don't forget, next week, we will be doing our women's sexual health show.
And you can email in now if you have questions or thoughts on today's show or questions in advance of that show, Megan, M-E-G-Y-N, at MeganKelly.com.
Okay, looking forward to that as well.
Thanks for listening to the Megan Kelly Show.
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