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Interviewer: You've likely heard of postpartum depression in regards to the mother of a new baby. But did you know as many as 10% of fathers face their own sort of postpartum depression? And it can happen before or after their child is born. But unfortunately, men are unlikely to discuss it or get support. And untreated, it can impact the emotional health of the father and his ability to be available for his baby and the mother.

Jamie Lea Hales is a licensed clinical social worker, and she specializes in helping couples with their mental health during and after pregnancy. I didn't know postpartum depression was a thing that men could have. Does it have a particular name when men have it, or is it just male postpartum depression?

Jamie: Actually, it really doesn't have its own special name. You would think that it might, but the reality is we just refer to it as perinatal mood and anxiety disorders because it can hit moms, dads, partners, grandparents, and caregivers really just in general. So it's much more broad than I think we initially realized.

Interviewer: And what causes it?

Jamie: I think it comes from a combination of life stressors, changes, loss of identity, and also the fact that your brain can change as you become a parent.

Interviewer: Wow, that's really interesting. So is it all in the brain? Is it all chemical related or are there other factors that can contribute to male postpartum depression?

Jamie: Outside of the changes to the brain, realistically when you have a new baby enter your life, whether it's your first or your fifth, there are going to be some compounding psychosocial stressors that come along with that. It is one of the biggest changes that you can go through.

Interviewer: And what kind of stressors are the most common to contributing to perinatal mood disorders or postpartum depression in men?

Jamie: First and foremost, lack of sleep. I cannot hit that one enough because it is the thing that I see over and over again. If you are not taking care of yourself, if you're not getting enough rest . . . And when I mean enough rest, I mean four- to five-hour chunks at a time. For both parents, this is probably the key to keeping yourself well.

Interviewer: Are there other types of stress guys talk about that can lead to male postpartum depression?

Jamie: When we look at some of our male patients, the pressure to provide financially can actually increase stress quite a bit because there are dueling priorities between being home, helping out, and being more involved, which we are seeing a lot more men being more actively involved in their child's caregiving, but also the dual pressure of having to be at work as well.

I mean, I don't want to completely gender that because that can 100% be the reverse as well. But it's just a lot.

Interviewer: And I've heard another major form of stress for men can be these expectations about what it's like to be a father or the kind of father they want to be. Can you tell me more about that?

Jamie: We all have this idea maybe in our heads of what parenting is supposed to be or should be. And when you actually get into the thick of it, a lot of the time, it doesn't line up with exactly what you thought it would be. And so there can be kind of an interesting grief reaction.

If you had a difficult relationship with your parent, you may have a lot of pressure on yourself to do better than they did. Or if you feel like you had the ideal parenting situation and it's not . . . And some people do. I mean, some people really do feel like, "My dad was the best. He was the best that I could possibly hope for." And then when they feel like they're not living up to what those expectations might be, that can be really, really difficult for people to accept.

And it takes some time I think, especially if you're not going to therapy or talking with somebody openly about this, to be able to resolve and say, "Okay, but I get to decide what type of parent I am going to be," and whatever that is, is okay.

Interviewer: Right. It doesn't have to be what you see on TV or in the magazines or what the guy down the street is doing.

Jamie: Absolutely.

Interviewer: We create those own realities ourselves.

How do most men experience this when they describe to you how they're feeling? What are the words they use?

Jamie: A lot of the time, it's just "I'm not feeling like myself." There's a loss of identity, I think, coming into being a parent.

And some of the symptoms that we see more frequently with men is irritability. Lots of "I've been really snappy with my partner a little bit more, just quick to anger in general."

We also see an uptick in use of substances. So more frequent use of whether it's prescribed to things that they've been given to help with sleep or anxiety, or even just increase in alcohol use because there is that stress and trying to figure out how to kind of mellow out. That's something that we see pretty frequently.

Interviewer: Are some fathers more likely to be impacted by male postpartum depression than others? Are there some things we know?

Jamie: Definite risk factors are preexisting mental health conditions. You are far more at risk for experiencing a PMAD if you are already struggling with mental health conditions.

Now, that being said, it does not mean that it will necessarily get worse. It's just something to be very much aware of, which is why we talk about a lot of this from a preventative standpoint.

Also, if you are somebody that has struggled with depression or anxiety prior to having kids, staying on your medication and continuing to work with that is going to be pretty key.

Another risk factor that I would definitely want to touch on is when a pregnancy is unplanned or unwanted and you haven't had adequate time to truly process through that and kind of wrap your head around it, that can be a risk factor as well.

So I highly encourage people who are in maybe a situation that they're not 100% sure about to talk with their partners about it well in advance during the pregnancy so that you can work on communication and really just work on trying to set yourselves up for a healthy plan for self-care once baby actually gets here. It's important for both people, and I always like to include both partners as much as I can in our process.

Interviewer: At what point, if a guy recognizes some of the symptoms you talked about, should he be concerned and seek some additional help to get some tools to help get through this time?

Jamie: If you notice it at all, if it's really impacting your day-to-day life, it's impacting your relationships, impacting your work, that's a great time to reach out and get some help. I think that there is benefit potentially to getting on the internet and looking at some just online resources, just trying to understand it better and get some education.

Interviewer: And of course, make sure that the resources you're reading are reputable from medical institutions, that sort of thing. Are there other resources online you like?

Jamie: The online resources I do really enjoy because I think it's a good way for dads to find a community of people who are struggling with the same things and are being open about it without having to search too hard or run the risk of feeling like the person in their life is just going to say, "Well, suck it up."

If it looks like it is getting worse or you just don't quite know how to wrap your head around it, I think that speaking with somebody who is in the mental health field could be very warranted.

This is a really common thing. We see this. Statistically, it could be 10%, but I think it's much higher than that. So please reach out for help if that's something that you feel like you could be struggling with or even if you're just unsure. There is no shame in that.

Interviewer: For men that aren't quite to the point where they feel they need to see a professional, you've talked about an acronym called SUNSHINE that can help with postpartum depression. Does this apply to both women and men?

Jamie: Absolutely.

Interviewer: All right. Let's go through this, because this is a tool right now that our listeners could take away and start implementing right now and see if it helps. So let's talk about SUNSHINE.

Jamie: One of the wellness acronyms that we use quite frequently in our work is actually SUNSHINE. So what it is, is a series of different things that you should be thinking about when it comes to your mental and physical well-being during pregnancy and the postpartum period.

So it stands for sleep, understanding, nutrition, support, humor, information, nurture, and exercise. So those are all points that I think would be helpful in the preparation phase for having a kid, to think about, "How am I going to still try to get some of these things?"

And it's going to vary depending on where you are in that process. During the early stages, your focus may be on one of those things. And throughout the process, it might be able to expand into something else.

So I always advise my patients not to think about it as if you're not doing each and every one of these things, you're failing at your postpartum experience or you're failing at therapy. But just make sure that you are keeping them somewhere in the back of your mind because you are still an important person and your relationships are still important, whether you've got a baby in the picture or not.

Interviewer: So just give us one sentence for each one of the items in SUNSHINE. So sleep.

Jamie: Four to five hours as often as possible. Uninterrupted.

Interviewer: Uninterrupted. And try to get the standard eight to nine, otherwise?

Jamie: Absolutely, if you're able to. What that will likely look like, however, is especially in the early days taking turns potentially with your spouse, because they also need that time.

Interviewer: What about understanding? Expand on what that means.

Jamie: Understanding can mean a couple of things. You could again reach out and try to get a better idea of what other people's experiences have been like. Or you could also just get some education around what perinatal mood and anxiety disorders actually are.

Interviewer: And then what about nutrition?

Jamie: Nutrition, that's a tricky one. So this is not a great time to start a brand new diet plan. It's probably not going to be the top of your list of things. What we do want to make sure is that you are making sure you're actually eating and fueling your body. It's really, really easy to put your focus all on everybody else and sort of forget that you have needs also.

Interviewer: All right. So make sure you're eating and try to get as much nutrition as possible, knowing that maybe you might have to use some convenience foods.

Jamie: Absolutely. And preparation going into this can be really helpful for that, making sure that you do have some healthy things around the house. But I'm certainly not going to judge you if the thing you ate for lunch was a bag of M&Ms. Just get something in your system if you can.

Interviewer: Support.

Jamie: Support is something that we should start generating right from the get go, whether it's our family, improving our communication with our spouse, whatever that looks like. It's good to try and bring your support system in as long as that's a safe thing for you to do.

Interviewer: All right. And humor. Crack lots of jokes?

Jamie: Definitely. Hey, dads are known for their dad jokes, right? That's a thing for a reason. But being able to laugh at the situation sometimes really can help. Not only does it increase your endorphins and just make you feel better in general, but sometimes being able to find humor in the absurdity that can come along with parenting is not a bad thing to do.

Interviewer: Good tension release a lot of the times, yeah. Information.

Jamie: Information. Get good information about these things. Get good information about your mental health. When I say go to online resources, I think finding ones that are specific to dads' mental health through Postpartum Support International are great. I would suggest don't go down the social media rabbit hole of things that will probably make you feel worse about your parenting.

Interviewer: Does information also include just learning more about what it is to raise a child?

Jamie: Absolutely.

Interviewer: Because to me, that would be a major stress point. I have a friend that I don't know how many books he read before his child arrived, and he said it just made him feel so much better.

Jamie: Yeah, I think it can be a real help to people just having a better idea of what that could look like. The caution I will put on that is that there is a perspective for pretty much anything you can find out there. So maybe get some guidance from your pediatrician before you just delve into something.

Interviewer: Yeah, make sure you're getting some of the good books. Nurture.

Jamie: Nurture comes back to the self-nurturing piece of this. It is okay to talk about how you are feeling.

Interviewer: And feel. It's okay to feel. A lot of guys struggle with just even doing that or identifying what the emotion is.

Jamie: Yeah, absolutely. Or feeling like a dad in general. It's a big shift and we want to make sure you're taking care of yourself.

Interviewer: And it's okay to say, "Hey, I'm doing okay. I'm an okay dad." I mean, if you can't say, "I'm a great dad," go with, "I'm an okay dad," I suppose.

Jamie: Being a good enough dad is good enough. It's different for everybody. And people always balk a little bit about that idea, but there is a whole theory around the good enough mother, and so we do actually talk about that quite a bit. Dads fall into that category too.

Interviewer: And finally, in SUNSHINE, you have exercise.

Jamie: Again, I'm not saying go out and start a whole brand new plan and get a gym membership and do all the things that you've been trying to accomplish, but get some movement. That movement can just be going out for a walk once a day just to get some vitamin D and stretch your legs.

Interviewer: It's good for the body and the mind.

Jamie: It is.

Interviewer: Exercise, like you said, releases all those endorphins and makes you feel good, helps reduce that stress.

If those things aren't working, what's the next step that you would recommend a man take?

Jamie: I would recommend reaching out to even if it's just your primary care physician to say, "I'm struggling with this. This is hard." If you are actively involved in child's doctor's appointments, you could even talk to your kid's pediatrician about how you're feeling. They have a lot of really great resources.

Interviewer: Jamie, this has been a very informative, great conversation. I know it's going to help a lot of dads-to-be. Any kind of final thoughts as we wrap up this conversation that you would really want somebody to take away after listening?

Jamie: There are times when you're in the early stages where it just feels like everything is falling apart, but you're definitely not by yourself. You're not the only one that has struggled with becoming a parent or feeling like it's going to be like this forever. It's truly not. Get some support, and at the end of the day, it will get better and you're not by yourself.

The clinical trial is looking for participants in Utah and elsewhere. Find out if you qualify for the study by clicking here.

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Scot: Who has a dog?

Troy: Sorry.

Scot: Was that yours? Was that Charlotte?

Troy: That was Charlotte. If I didn't let her in the room, she would be scratching at the door. So that's where we are.

Scot: Today on "Who Cares About Men's Health," we're going to learn more about a new male contraceptive. It's a gel. It's in clinical trial, but you're going to learn more about the contraceptive. You'll also learn how you can participate in the clinical trial if you wanted to.

This is "Who Cares About Men's Health." My name is Scot Singpiel I bring the BS. Bringing the MD to the table is Dr. Troy Madsen.

Troy: Hey, Scot.

Scot: And our guest today is Dr. David Turok. He is an OB-GYN and also a family practice physician. He is interested in family planning, and he is . . . Are you running this clinical trial? How are you involved exactly?

Dr. Turok: Yeah. I am the site lead for the Utah site, and there are 10 other sites.

Scot: All right. So, Dr. Turok, tell me about this male contraceptive gel that you're running the clinical trials on. What do we need to know?

Dr. Turok: So this is an awesome opportunity for our team and for men in Utah to make a real contribution to increasing the range of contraceptive methods that are available for people. So this is the first study that's been available for people in Utah for a male hormonal method. And this study is looking at a gel that will be applied daily on the shoulders. Literally, this study rests on the shoulders of male participants.

Scot: And what's in the gel? What's going on here?

Dr. Turok: So it's a combination of progestin or progestogen called nestorone and testosterone. And the way this stuff works is very similar to the way the birth control pill or the patch or the ring work in female contraception. Basically, this outside hormone tricks your brain into not producing the sex hormones. In women, it prevents ovulation, and in men, it prevents sperm production. It also prevents testosterone production, and that's why the gel also has some testosterone as add-back.

Troy: Interesting. So it's going to actually maybe drop your body's production of testosterone, but not necessarily affect your body's level of testosterone?

Dr. Turok: Correct. That's the goal.

Scot: Yeah. Okay. Explain that. I'm not buying into this quite yet. What did you just say, Troy?

Troy: I'll let David explain it. I'm guessing.

Scot: I would think a lot of men would be like, "Oh, I don't know about putting something on that's going to decrease my body's level of testosterone." That didn't sound like a great idea.

Dr. Turok: Right. For decades, we've been willing to have millions and millions of women across the globe use methods that interfere with their normal hormonal cycle in ways that are safe and effective. And this is similar to that.

So the bottom line on this is there's messaging from the brain at two levels in the brain for gonadotropin-releasing hormone, and then for FSH and LH in the pituitary. And those sex hormones trigger the production . . . There are two groups of cells in the testes that are affected by those. And getting these hormones from the outside, as application of the gel will produce, essentially deactivates one group of cells that makes sperm and the other group of cells that makes testosterone among other things.

And at that point, in order to avoid side effects that people would not like, the testosterone in the gel essentially adds back what you need.

Scot: Obviously, I'm the one without the MD, so you're going to have to explain this to me a couple of times. But we've done previous shows where we've talked about men who take testosterone, and it can cause side effects like testicle shrinkage and other sorts of things. What is preventing this from causing those types of side effects of taking artificial testosterone?

Dr. Turok: First of all, it's dosing. There likely will be some decrease in the size of the testicles. Not as much as people who are using high levels, for example, of injectable testosterone. And the other side effects are . . . There are some minor cholesterol changes with decreases in HDL. There's maybe a slight bump that can happen with hematocrit, the amount of red blood cells that you have circulating in your body. And the progestogen, the nestorone, can also cause a slight increase in weight.

There are very few things that are side-effect-free. But the vast majority of people who have used this combination and others like it have had very few side effects.

So, in the last large study of a combination of an injectable progestin and testosterone combination, there were fewer than 10% of people who quit the trial because of side effects. And if you compare that to studies of oral contraceptive pills in females, that's actually quite favorable. So I think we're seeing something that's headed in the right direction.

And again, we can only get the answers for newer and better methods if people are willing to participate in trials like this. And this is not just, "Hey, here's something you can try and tell us how you like it." This is a rigorously designed study that's going to have up to 400 couples in it. Everyone is going to get the same evaluation. It's going to be extremely thorough, looking at those outcomes that we talked about, pregnancy and side effects, as well as blood tests with chemistry and looking at people's blood levels of the drugs, of the hormones, of their red blood cell counts.

We're going to have enough people to really evaluate this to see if this is truly safe and effective. And the early signals are from this study and others like it that they are very favorable.

Troy: That's great. And for anyone who's listening who wants to participate, what kind of benefits . . . Obviously, a huge benefit is just contributing to science, which I'm sure you and I would agree is a great benefit. I don't know if Scot would agree.

Scot: Yeah. How much am I going to get paid?

Troy: Scot, that's what we're getting at. Is there any financial . . . Scot is like, "Where's the money? Show me the money." Is there a financial incentive to participating or any other benefits?

Dr. Turok: This is not a casual study. The demands of participants are significant and people are compensated for their time and effort and, I think, in a reasonable and generous way. But the combination reimbursement, if you go through the full trial for a couple, is over $3,000.

Scot: Is another prerequisite for the couples you're looking for couples that are open to if it doesn't work that they were planning on having children anyway? Because you're using a trial for a birth control method that you're not exactly sure of the efficacy yet. They could end up becoming pregnant, right?

Dr. Turok: That is an absolute risk. And people who are entering the study need to be willing to accept that. This is something where there's going to be very close observation. So we're going to be checking people's sperm counts regularly, every month throughout the study.

In normal use, something like that wouldn't happen. But this is something where if there ever was a problem or somebody had initially had a low sperm count and then it came back up, we would be able to identify that and ideally intervene before there was a risk of pregnancy.

And again, that coupled with the inherent relatively low risk of pregnancy makes this a safe and reasonable thing.

Scot: Is there a minimum amount of sexual intimacy? Is there a minimum amount of sex that you have to have while you're in this study?

Dr. Turok: Yeah.

Troy: Is this an additional incentive? Is that what you're trying to get at, Scot?

Scot: Maybe. I don't know.

Troy: Like, "Well, we've got to have sex at least three times a week."

Scot: "The study says so."

Troy: "The study says. This is for science."

Dr. Turok: Yeah, that is for couples to determine. But the minimum, the only requirement . . . And this is true for all contraceptive efficacy studies, not particular to this. But couples have to have at least one episode of intercourse where they're relying only on this method each month for that month to count in the efficacy data. So that's true whether we're studying an IUD or a pill or a new injection or the ring, anything.

Troy: And so hearing this, maybe someone is listening and thinking, "Well, I don't know that I want to be part of a study. I don't know that I would qualify. I don't know that I have the time to do this." But maybe they're thinking, "This sounds really cool." What do you think longer, bigger picture, if this next phase is successful, before this actually becomes a realistic option for men to use? Would you say realistically five years out before you think this would potentially be available by prescription?

Dr. Turok: Five years would be greased lightning.

Troy: So that would be a very optimistic scenario?

Dr. Turok: Yeah. In 2007, I wrote this paper that was a summary. It was called "The Quest for Better Contraception: Future Methods." And I was a young contraceptive researcher at the time and really wanted to do a landscape analysis of all the methods that were out there. And there was a section in that paper on male hormonal methods. 2007. And at the time, for that and several other things, we were like, "Yes, we're 5, maybe 10 years away." And we're still 5 or 10 years away, but we've made significant progress.

All of these things take time because the FDA wants to assure that these are truly safe and there are not going to be harms associated with newly approved medications. This certainly seems like it's on track and has great potential to deliver a safe and effective method over time that will be reversible.

And that's another aspect of the study, looking at what happens when you stop it. How long does it take for sperm counts to come back? And that hasn't been an issue in any of the male hormonal contraceptive studies. Nearly all the participants have had return to normal fertility.

Troy: So it's a ways out. If there's a guy now who's 20, maybe by the time he's 30, he could look at using this.

Scot: Well, sounds more like if there's a guy that's 20, maybe his son will be able to use it.

Dr. Turok: No, no, no.

Troy: I didn't want to go that far with it.

Scot: Troy, we're running out of time here. Do you have any final questions?

Troy: Yeah. Have you talked to anyone who's used this? And if so, what do they say about it? Do they like it? Do they find it's fairly convenient? Any personal feedback you've gotten from any participants?

Dr. Turok: Yeah. So the feedback from some other people who've participated at other sites has been extremely favorable and people have been very satisfied. The gel is easy to use. It's easy to apply. The desired results are delivered, and actually, the decrease in sperm counts is occurring a little bit faster than anticipated, which is great, but still takes two to three months. And the initial efficacy signal has been really good.

So the participants have really done a great job and have had very few concerns and negative aspects of feedback thus far, which is great.

Scot: Cool. We'll put the link to your survey site on our website. Thank you very much, Dr. Turok, and thanks for caring about men's health.

Interviewer: Here to speak with us about vasectomy reversal is Dr. James Hotaling, a urologist and the director of the men's health program here at University of Utah Health. Now, Dr. Hotaling, when it comes to a procedure like this, what are some of the reasons a patient might be looking for a reversal?

Dr. Hotaling: About 6% of people who have a vasectomy will ultimately want it reversed. The most common reason is that they have gotten divorced and have a different partner and want kids with that new partner. Although we do see couples who have had kids, had a vasectomy and then decided they want more kids. So those are usually the most common reasons people want it reversed.

Interviewer: I've been seeing some rates that say, "Hey, you know, a reversal is only 30% to 90% effective." How effective is a procedure like this?

Dr. Hotaling: Yeah. It works about a 90% to 95% of the time.

Interviewer: Oh, wow.

Dr. Hotaling: So it's pretty effective. It depends a little bit on how far out you are from your vasectomy. If you're like 20 years out, it has a lower chance of success. Although it, you know, that chances of success still may be like 80%, 85% than if you're two years out, just because there's more scar tissue.

Interviewer: And we're determining success by being the ability to get pregnant.

Dr. Hotaling: Yeah. That's exactly right. You're determining success by having swimming sperm in the ejaculate.

Interviewer: And so what other factors besides just length of time since you've had the procedure?

Dr. Hotaling: Yeah. A little bit it can be exactly how the procedure was done. When you go back in there, you can either put the vas deferens back to the vas deferens, and that has the highest chance of success rate. Sometimes you have to put the vas deferens back to the epididymis or the sperm-holding tank, and that's smaller and that has like a 60% to 70% chance of success. It's lower. But if you can put the vas deferens back to the vas deferens, that success rate is really high. So if you look at all comers, you end up around 90% to 95%. That's really the biggest thing in determining the success rate and then also just, like we mentioned, how far out you are from having the reversal and to some degree just how the individual surgeon did the vasectomy.

Interviewer: If someone say listening to this and considering whether or not they should have their vasectomy reversed, what is, you know, what is the ideal candidate for a procedure like this? Like is anyone say, you know, not a good candidate? What makes a good person for this?

Dr. Hotaling: That's another really good question. So obviously somebody who wants to have kids in the future and somebody who if the wife is younger, that can be helpful, although it's not impossible to do it if their wife is older. Also for couples who want, you know, multiple kids, it can be helpful as well. And just cost considerations. You know, the cost of a vasectomy reversal is a lot less expensive than the cost of in vitro fertilization. It's like a third the price. So that's kind of the other option, the other consideration.

Interviewer: And is reversal ever covered by insurance?

Dr. Hotaling: No.

Interviewer: Okay. So it's out of pocket?

Dr. Hotaling: It's always out of pocket. Yeah.

Interviewer: What are some of the risks with getting this type of procedure, of getting it all back together?

Dr. Hotaling: Well, the biggest risk would be that it wouldn't work, which is really, really low. You know, the recovery is usually pretty minimal, a little bit of bruising, but not terrible, sore for, you know, maybe five days afterwards. We do use long-acting numbing medication that lasts for four days. So patients really don't have much pain from that. And then you have to take it easy for three weeks or so. In terms of the complication, some patients can get pain that lasts longer than that afterwards. As I mentioned, the chance that it couldn't work or just chance of some bruising or a very rare chance of infection, although that is exceptionally, exceptionally rare as in I've been doing this for eight years and I've only ever seen it happen once.

Interviewer: Wow.

Dr. Hotaling: So that's not common.

Interviewer: Okay. So here on The Scope we've talked before about vasectomies and what the procedure is like, what to expect. It's an outpatient procedure, you come on in and, you know, you heal up for a week or so, right? With a reversal, you know, like the day of the surgery, what are they expecting?

Dr. Hotaling: So they'll, you know, they won't have anything to eat or drink after midnight. They'll come in, in the morning. You know, they'll get an IV put in. They'll get drifted off to sleep. They'll go to sleep. Once they're asleep, we make two small incisions, one on either side of the scrotum, and then we go in and find where the blockage and we bring a high powered . . . we have this new digital microscope, it's like a $700,000 microscope that actually allows us to see in 3D with special glasses on.

Interviewer: Wow.

Dr. Hotaling: It actually is really helpful to do the procedure. So we bring that in. Then we put the tubes back together again with 12 sutures that are finer than a human hair and then put the local numbing medication and close everything up. Each incision is shorter than an inch on either side.

Interviewer: Oh, wow.

Dr. Hotaling: So two incisions, really small. Then you would wake up with some . . . And all the stitches melt away on their own. You'd wake up with some sort of biologic superglue over the incisions and then some gauze on the scrotum. And then you'd go home later that day. And most patients just take some Ibuprofen and Tylenol and that's it.

Interviewer: Wow. And you were saying that it's take it easy for a little bit and then three weeks until you're back to . . .

Dr. Hotaling: Yeah. It's really just no like sex, bike riding, or heavy lifting for three weeks. But you could be back on your computer doing work the next day. Often if I do the surgery on a Thursday, patients are back at work again certainly by Monday. And if I did the surgery on say a Tuesday, often by Thursday or Friday.

Interviewer: Once they're all healed up and once they're feeling good, how do we know, I guess, if it was a success?

Dr. Hotaling: Yeah. It's a great question. You know, we have had patients who get pregnant before we ever checked the first semen analysis.

Interviewer: Wow.

Dr. Hotaling: But usually we check in like 8 to 10 weeks, we check the sperm test. And it can take up to a year, even up to a year and a half, depending on the type of like reconstruction that we do.

Interviewer: Oh, wow. So it's not just you magically are?

Dr. Hotaling: Most patients, when it's successful, have sperm right away.

Interviewer: Oh, wow.

Dr. Hotaling: But it can take longer.

Interviewer: Okay. So, you know, you'll do a test and find out if it was successful and go on from there?

Dr. Hotaling: And then we would repeat it again in three to six months if we didn't show any sperm.

Interviewer: And I would imagine that this type of procedure is something you want to make sure you go to a good doctor, a good surgeon, or a good urologist. You know, what should a man be looking for in a doctor to perform this?

Dr. Hotaling: Yeah. So typically somebody who's done a fellowship in male infertility, which both myself and Dr. Gross here have. We're actually getting another partner, who's starting in September, who's also done a fellowship in male infertility. So you want someone who's fellowship trained. You want someone who does a lot of these. And I think also doing it, you know, in the operating room with the patient asleep, with kind of the best equipment you have, and we sort of tick all those boxes here. Some people do do them in the office with local numbing medication. You know, I don't believe that that's necessarily the best way to do it in my opinion.

Interviewer: So we're looking for someone with a fellowship, someone who's performed the procedure a few times and probably a lot of times, right? And a good center, right?

Dr. Hotaling: Yeah. That's exactly right.

Interviewer: For a patient who is considering getting this procedure done, what is it about say University of Utah Health or maybe another medical center? What is the things that a big center like ours can offer to them with their procedure?

Dr. Hotaling: Yeah. Typically we can also . . . we offer the ability, because we have a full IVF lab and andrology or sperm lab, we can do a little biopsy of the testis at the same time and freeze some of that testicular tissue in case the reversal doesn't work, you know, and you could use that, which saves the patient a significant amount of money because they don't have to have another procedure in case it doesn't work. You want somewhere, you know, that does a lot of them and really has the best equipment.

Interviewer: You were just telling me that you have fellows, you have other . . .

Dr. Hotaling: Mm-hmm. We have other people that we work with. And the surgeons here are still doing the entire surgery, but we have really good assistants. A lot of places, it may be, you know, a surgical technician who's assisting the surgeon, and it really helps to have, you know, great assistants, or if it's a super complicated case, myself and my partner, you know, we'll sometimes do those together.

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Troy: Do you ever tell clients to think about baseball?

Scot: I thought it was basketball.

Dr. Smith: I've never told someone to think baseball.

Dr: Madsen: Is it basketball? See basketball is interesting. You know, I've heard think about baseball. I don't know. Baseball is an incredibly boring game. Maybe soccer. Some people like soccer. It's pretty boring though.

Dr. Smith: Golf. I think of Austin Powers. It was Margaret Thatcher naked on a cold day.

Scot: Yeah, right.

Troy: Is that what it is?

Scot: Health is more than supplements, ripped abs, or crushing in athletics. It's a state of physical, mental, and social well-being and it's not an end. It's the means to an end. The currency that enables us to do all the thing we want to do, and the podcast is "Who Cares About Men's Health?" We like to give you inspiration, information, and a different interpretation to better understand and engage and feel better today and continue to be able to do those things we want to do today and in the future as well. My name is Scot. I am the manager of thescoperadio.com, and I care about men's health.

Troy: And I'm Dr. Troy Madsen. I'm an emergency physician at the University of Utah, and I care about men's health.

Dr. Smith: And I'm Dr. John Smith, a urologist at the University of Utah, and I care about men's health.

Scot: Dr. Smith is back. It's always great having Dr. Smith on the show. You know, one of our premises is here is that whenever you talk about men's health it seems like a lot of times it all comes back to our pieces and parts and we are more than our pieces and parts, but sometimes we are our pieces and parts and that's why you're here today, to help us with our pieces and parts, so thank you.

Dr. Smith: Thanks for having me.

Troy: Certain pieces and parts, yes.

Dr. Smith: I always appreciate being here.

Scot: Long way around the shed for that. Today it is ask a urologist. We like to bring in Dr. Smith to answer some of the questions that you have. A lot of different ways you can get them to us. Through our Facebook page, you can send a private message. You can put them on the wall. You can send us an email hello@thescoperadio.com. Troy's got the listener line. Sometimes we get calls on the voice mail listener line. What's that number?

Dr: Madsen: Yeah, that number is 601 55-SCOPE.

Scot: All right, and these questions sometimes you might be a little shy asking them, and if you do not want to use your real name, you can use an alias or a pseudonym, you know, like some sort of a generic name, like John Smith.

Dr. Smith: I love it.

Troy: I want people calling in to tell us it's Scot Singpiel.

Scot: I don't want that.

Troy: That's what I want. I want them to just start calling in and saying that . . .

Scot: That's funny. We've got three questions here. Question number one for Dr. John Smith is, strangely enough, from somebody named John Smith using a pseudonym there, we think. Do exercises for premature ejaculation work? So sometimes you might get mails, emails. You might hear people talking. Is that how you handle that issue or no?

Dr. Smith: It is definitely one of the ways that we handle premature ejaculation. There's behavioral, topical therapies, like behavioral, psychological, topical therapies and then oral therapies that we use. But I'll go over some of the behavioral therapies that actually I've seen patients utilize and actually find benefit from. So one of them is called the pause and squeeze or the squeeze technique. If you're someone who, you know, kind of struggles with this, the way you would do that is when you feel the sensation that ejaculation is imminent, you stop sexual intercourse and squeeze the head of the penis until the sensation to ejaculate goes away.

Scot: Physically?

Dr. Smith: Physically. And then once that urge is gone, then you can resume sexual activity and that can help you kind of elongate that sexual experience. There's also the stop-start technique. That's kind of exactly what it sounds like. You stop penile stimulation until the urge to ejaculate goes away. Again, when ejaculation feels like it's imminent, right on the doorstep, you just kind of cease, kind of just pull back, wait for that to go away, and then reintroduce yourself into the sexual encounter.

And the third one they call the quiet vagina, or that's the way it was described when I was in residency and fellowship. The female stops moving and the male stops moving and the . . . until the urge to ejaculate goes away. This one I found from most of my patients tell me that's less effective for them because there's still some stimulation there being in the sexual act still that makes it a little bit more difficult, but if that works for you, then that's another one.

And then another one is . . . they call it sensate focusing. You kind of . . . the best way to describe this would be to kind just start with non-sexual stimulation but stimulating yourself where you have sexual self-awareness by gradually progressing from non-sexual touching to sexual touching and then into the act of sexual intercourse itself to try to kind of ease things up and get the body more acclimated to a longer lasting sexual encounter. Some people would just call that foreplay, but if you wanted to get the $500-term for it, that's what we'd call it.

Scot: That was the medical term, medical school-issued term.

Dr. Smith: It's pretty much that. You know, those are the options that for most folks that we'll offer to them to kind of try and see if they work, and then beyond that there are some topical things that patients can use. I don't know if you wanted me to talk about any of that stuff, but we can go into any of that that you want to.

Scot: Yeah, I think just knowing that there's some stuff out there. So there's some things you can do in the moment it sounds like, and then there's some topical things that would make you less sensitive I'd imagine. Those things in the moment over time will then you'd be able to build up endurance if you do those or . . .

Dr. Smith: So it generally does help to continue those things, and once you kind of get your body acclimated to that, you have to do them less often, and sometimes hopefully not at all, but I've had a lot of patients who said they've had success when they've actually tried and performed those.

Scot: I've heard some guys say that just even talking about it to their partners helped because some of it can just be in the brain. It could be psychological, and once you kind of share that fear or whatever that it can just kind of go away. So I don't know if there's any validity to that. It's worked for a couple of guys I know, but . . .

Dr. Smith: I think it definitely can be. One of the things we always offer anybody who's having any sexual dysfunction one way or another is an opportunity to talk to a sex therapist because sometimes that can help. Having open, honest communication with your partner is also nice. I have a couple of patients who've also said that when their partner also talks to them kind of maybe a little dirty talk during sexual intercourse, that that can make the sexual encounter shorter for them. So they've asked their partner to kind of quiet down because they're very visual and audio stimulated person where that can make things worse too. So anything that you can do to try to help with that situation I think is worth a shot.

Scot: All right. What about, like, Kegel exercises? Do those work? Is that how do you pronounce that?

Dr. Smith: Yeah, Kegel, Kegel. I mean, I think you could say tomato tomato. It doesn't really matter. People understand what we're talking about, and at the end of the day any . . . you can try that. I don't know that that's as effective as the other things that we mentioned, but I think that's something that you can try, and again, if it's beneficial for you, then I would say continue it.

Troy: Yeah. I mean, it sounds like some of those are things where, you know, people may notice it. It may come and go, but other times . . . is more your takeaway if it's there all the time you probably need to do something about it where some of this stuff might come and go and not be an issue?

Dr. Smith: Exactly. If it's there and it's something that's there more often than not, come in and kind of be evaluated. If it's something that happens every once in a while, the majority of the time it's nothing. It's just that adhesion that goes away within a day or so and you may notice it once every so often. But when it becomes a more chronic issue, that it's happening more and more frequently, then you definitely want to come in and have it evaluated.

Scot: I had no idea there were so many reasons you might have two streams. I thought there was going to be one, but it sounds like yeah. That's interesting. All right question number three, and . . . well, I'll throw it out there. Question number three. Does wave therapy really work for erectile dysfunction? And it's from John Smith. Dr. Smith and I did a Scope piece on this. So we have a full link Scope piece where we talked about wave therapy and how to make that evaluation, whether or not that's something you want and how to ask the right questions. But let's just briefly cover it here on this podcast, and if you want more information, you could go to thescoperadio.com and do a search for it. So Dr. Smith.

Dr. Smith: Sure. So there's multiple different kinds of wave therapy. You may listen to the radio. You may see things on TV. There's an acoustic style wave therapy, and then there's a low intensity shockwave therapy. They're not equivalent. They're not the same. The low intensity shockwave does have research behind it that shows that it is beneficial for erectile function to help with the regrowth of blood vessels and help to improve erectile function.

Again, there are caveats to all of these things, but the acoustic waves don't have any data that shows that they're effective for erectile function. There are some other studies outside of urology that show that it can have some benefit there, but in the urologic sphere it's not been shown to be effective, and so the answer is yes but you got to be very honest with the patients and let them know because it's not for every patient. It's for someone with mild to moderate erectile dysfunction, not somebody who has a severe erectile dysfunction after they may have had like a prostatectomy or something like that. Those patients oftentimes don't see any benefit, but the folks with the mild to moderate erectile dysfunction there's some emerging literature and data that shows that it's very helpful.

Troy: By acoustic waves you're talking about just like ultrasound. Like, people are putting ultrasound on and saying this is helping?

Dr. Smith: Yeah, it's more of a sound wave. Sometimes it's called a gains wave or, you know, an acoustic wave. It's a very different waveform than a low intensity shockwave.

Troy: But bottom line is acoustic waves don't work. Shockwaves do.

Dr. Smith: They do. Again, you got to be judicious about the people that you do treat with it, and, you know, we have one at the university actually. We just obtained it a couple of months ago, and we've started using it on a few patients. We've had a few good outcomes so far, and so, you know, as we continue down that road, maybe we'll put out some more literature here in the future with how things are going.

Troy: Given some of the stuff I see in the ER, I'm going to add the caveat don't try it at home.

Dr. Smith: Right. That's always a very good lesson to learn is don't try this at home.

Troy: Electricity might help but don't try it at home.

Scot: The thing I learned from the conversation that I had that you could go listen to the whole thing with Dr. Smith is that there are kind of a lot of different reasons for . . . you know, different conditions of erectile dysfunction. There's a lot of different treatments and really you should have somebody that knows how to navigate that, like a urologist like Dr. Smith, to kind of work you through that sort of thing. That's what I ended up with, and if wave therapy is kind of where you end up, then that's great, but I think that discussion needs to happen, and I think Dr. Smith would agree with me on that.

Dr. Smith: I would agree 100%. It's something where if you do have issues or concerns, definitely following up with someone who does it on a regular basis and is reputable to take care of you.

Scot: All right, there you go. Three questions, man, Bam, bam, bam, and done. Nice work.

Troy: Done. We just need to tell our listeners there are other pseudonyms besides John Smith, Scot. So if we can get the word out there, try Scot Singpiel next time. It's a very common name. You could use that one.

Dr. Smith: Very common.

Scot: I think Troy Madsen, very common.

Troy: Very common. Scot Singpiel is just yeah . . . I know a lot of Scot Singpiels so . . .

Scot: Dr. Smith, thank you for being on the show and thank you for caring about men's health.

Dr. Smith: Hey, thanks, guys. Really appreciate it.

Scot: And thanks for checking out the podcast. If you enjoyed this particular episode, do us a favor, subscribe. Or if there's somebody in your life you think would find this episode useful, share the word with them.

On "Who Cares About Men's Health?" just to kind of give you a brief overview, we talk about the core four plus one more to stay healthy now and in the future, and we do episodes based on nutrition, activity, sleep, emotional health, and genetics. We also do shows like this, which are very specific to men, we call "Men's Health Essentials." So answering the questions that men would have about their health. Then we also have a show called "The Sideshow," which is just us having a little bit of fun.

So if you like this episode, check out some of the other "Men's Health Essentials" especially with Dr. Smith, or check out some of our other flavors as well so we can help you care about your health. Be sure to check the show links. We'll have links to anything that we talked about in the show in addition to links to contact us. Thanks for listening to the podcast and thanks for caring about men's health.

If you want to learn more about wave therapy for ED, Dr. John Smith goes into more detail in this Scope Radio interview: Does Wave Therapy for Erectile Disfunction Work

Contact: hello@thescoperadio.com
Listener Line: 601-55-SCOPE
The Scope Radio: https://thescoperadio.com
Who Cares About Men’s Health?: https://whocaresmenshealth.com
Facebook: https://www.facebook.com/whocaresmenshealth

Interviewer: At-home male fertility tests that you get over the counter. You go to the drugstore, you get the fertility test, you take it. Does that give you helpful information? Are they accurate? Are they worthwhile? That's what we're going to find out today from urologist Dr. John Smith. What is your take on those over-the-counter, at-home male fertility tests?

Dr. Smith: We see a lot of people for fertility at the University of Utah, and those at-home tests really are very rudimentary. They don't tell you a lot of information. They pretty much tell you if you have an adequate amount of sperm in the ejaculate or not. And that's really all they can tell you.

So if you had a positive test where it said, "Hey, you've got enough," that doesn't tell you if those sperm are alive, if there's any motion in those sperm, the morphology or the shape of those sperm. It doesn't give you really any other information. The only thing it tells you is if there's enough sperm there to hopefully not have fertility issues.

And the way these tests work is similar to a pregnancy test where it looks for a protein that's only on the sperm. And so that's how they quantify. So you've got to have enough of that protein in order to have the test come back positive that you've got a high enough quantity of sperm to have a normal sperm count.

Interviewer: But if partners have been trying to have kids and they have not been successful, and the man goes and gets this and finds out, "Oh, hey, I've got enough sperm according to this test because they detected enough protein," but you're still not having kids. You really haven't solved anything by taking the test, have you?

Dr. Smith: No. You really haven't. And that's the other part of things that go on. There's also two parties when you're trying to have kids. You've got the male side of fertility and the female side of fertility, and we're going to talk about the male side today.

But if you have been trying unsuccessfully, having unprotected intercourse for over . . . usually the definition is one year. Some people will say six months to a year. But all in all, if you've been trying and you haven't been successful and you get that at-home test and it tells you that there's enough sperm there, that still doesn't tell you that there's not necessarily a problem. Because if there's low motility, meaning you don't have any that can move and get where they need to be, the viability of things, so to speak, and then the morphology, the shape, if they're not the normal shape where they're not going to travel in a uniform way . . . there are a lot of things that go into a sperm test.

And so when we do a semen analysis at the University of Utah in our lab, we get the volume of the semen. It tells us the total sperm count, the sperm concentration, or how much there is per milliliter that's in the sample that we received. It tells us the viability, how many of those are alive and moving. It tells us the motility, how many of them are moving in an adequate amount to be beneficial for you. And then the shape and morphology. So it really gives us a lot more information.

However, the biggest thing I find for most patients is fertility may not be covered under their insurance. So they're looking for a quick test that can give them some information. And that test may or may not be helpful for them because if there is another aspect to the semen parameters that's not good, that's not just the number, then they're never going to see that on the test.

And so I think a lot of people are looking for a cost-effective way to just get some answers, but sometimes the most cost-effective way is just to come in and get a full semen analysis done with a fertility specialist.

Interviewer: Yeah. That way you can discover exactly what the issue is, and then go about perhaps solving that issue if there is indeed an issue.

Dr. Smith: Exactly.

Interviewer: So, from a male perspective, when you get this information back, generally then when you start solving the problem, is it going to be an expensive process or sometimes are there some simple changes that can be made that can make all the difference?

Dr. Smith: It's different for every patient. Some guys come in and they have a hormone-related issue that we can solve with some medication. That can really be an inexpensive fix. Oftentimes a lot of medications are still covered by insurance, which can be helpful.

And then in some men, if there is an issue where there is a low sperm count or no sperm count, some of the procedures to check and see if the testicles have viable sperm in them can be a little bit more expensive.

However, the real expense comes if you had to have IUI or IVF, which are insemination techniques. Most of the male stuff tends to be less expensive than that.

Now, again, when you're looking at things, fertility is not cheap by any stretch of the imagination. A lot of the procedures that are done to check for viable sperm within the testis can run anywhere from $2,000 to $5,000, but then a round of IVF can cost greater than $10,000 upwards, even much more than that.

So, when I talk about cost, it's very interesting because the male side of things generally is a skosh less expensive than the total amount that it takes to get the fertility solved in some cases.

Interviewer: So it is possible that you go and you get the test, you get some solid results, and it might be an inexpensive fix. That is not unheard of.

Dr. Smith: No, not at all, and we do a lot of that. And sometimes if the sperm count looks maybe borderline, we can also try some medication to try to bolster that sperm count for a few months and then do a retest type of thing.

And so a lot of times, we usually don't run right to the higher dollar surgical procedures, things like that, unless they're absolutely needed because we do understand that a lot of times this stuff isn't covered by insurance and we want to try to make it as best we can and most cost-effective for these folks.

It's a tough road. Fertility is tough. I see quite a few folks who we have success with, and it's great to see that, but any of those couples that are having trouble, I would say just get in and see if there's something that can be done to really help you because sometimes it is a simple solution.

Fertility can be one of the toughest portions of a relationship, but also one of the most rewarding. So I would say don't delay. Just get in and see if there is something that can be done to make things easier for you.

Interviewer: Wave therapy for erectile dysfunction. We're going to learn more about that today, including what is it and are all wave therapy machines created equal. Dr. John Smith is a urologist at University of Utah Health.

So I've heard of this thing called wave therapy for erectile dysfunction. Can you tell me a little bit how that works? What's going on?

Dr. Smith: Yeah. So the wave therapy machines, there's a few different types and we'll get more into that later. But the idea is, these machines put off a wave similar to like an ultrasound machine where there's a wave coming out of the machine and those waves are meant to help stimulate the tissue for regrowth of blood vessels is what you hear a lot of times on a lot of the advertisements.

And that's what a lot of the research has been shown to do is as these machines are used, that it causes the body to have an increase in the factors that cause regrowth of blood vessels and that's how they work.

Interviewer: All right. And how does that help somebody who is suffering from erectile dysfunction?

Dr. Smith: So a lot of times with erectile dysfunction, you know, it can be as simple as, you know, the blood flow issues. It can be not enough going in, too much going out, those types of things. But a lot of times these wave machines will help to regrow or regrow blood vessels to help more blood go into the penis. Because the erection is pretty much the two chambers on the top of the corporate cavernosa get filled with blood. They become very erect, they become stiff and rigid and that's what gives a good quality erection. And so the more blood flow you have and the more quality blood flow you have, the better quality erections you have.

Interviewer: So individuals that have erectile dysfunction, some of them, it might be because they're not getting enough blood flow. So the sound waves, if I'm correct on this wave machine, actually it helps stimulate more blood vessels. You get more blood in there and then it's just hydraulics. You fill that up and you get a better, more sustainable erection.

Dr. Smith: There's couple of different types of machines and you mentioned sound waves. The most of the literature has been done on the mechanical wave, more of the ESWL machines, a similar type wave that they use to break up kidney stones.

However, there's multiple types of machines. Some of the machines do use acoustic waves or sound waves versus these mechanical waves to do it. And the research has been done with the mechanical wave machines, which have been shown to do a lot more. And the acoustic wave machines haven't really shown to be super beneficial in the research.

Interviewer: So an acoustic wave-like when you get super close to a speaker and you can feel the vibrations, is that what we're talking about with those machines?

Dr. Smith: Similar, yeah. It's an acoustic style wave machine, whereas a mechanical type wave machine uses more of a mechanical pulse wave similar to like I said, breaking up a kidney stone with the shock wave. So they'll call that a shockwave treatment versus the acoustic treatment. And the shockwave treatment has been the one with a lot of the research done over in Europe and other parts of the world to show improvement in regrowth of blood vessels.

Interviewer: So not all wave machines for treating erectile dysfunction are created equal. Now, how do you know the difference? How would a consumer know which machine they're getting when they show up?

Dr. Smith: You would want to be very, you know, you'd want to ask the right questions. What type of machine do you have? There's quite a few different types of machines. And, you know, you'll hear a lot of different things from different people, but the acoustic machines, if you look at the research and actually looked up the studies, the studies have been done with the shock wave machines.

And the shock wave is not new, it's been around for quite a bit of time. It started with kidney stones, where they used to put people in a big bathtub to break up kidney stones. And now they have handheld units with this shockwave therapy and it's actually used quite a bit and is FDA approved in the sports medicine arena for things like plantar fasciitis and other issues that way.

And it's still experimental and not FDA approved for erectile dysfunction, but it is being used for erectile dysfunction as kind of an off-label use because there has been good data that shows increased growth, increased rejuvenation, or neovascularization where there's new blood flow in the area.

Interviewer: And what kind of wave machine does University of Utah Health have?

Dr. Smith: We just actually got a new wave machine and it is the shockwave machine. We made sure we did as much research as we could, knowing that this is kind of a hot topic. A lot of people are very interested. And I get asked about it quite a bit.

And so, in the men's health department, we had a lot of patients who came in and asked quite a bit about it so we did the best research that we could to find a machine that could possibly give us the best benefit.

Now we're very selective with our patients at the University of Utah, for who we would recommend this to because it's not covered by insurance, it's relatively expensive. And again, you have to pick the right folks in order to get a good result. For someone who has a mild erectile dysfunction, someone who's taking pills and doing rather well with them, they may be able to come off the pills completely or need a lower dosage of the pills.

This isn't for someone who has a severe erectile issue after they've had a surgical procedure like a prostatectomy or something like that. It's not going to give them their erectile function back in those instances. This is for a very mild to mild-moderate erectile dysfunction. Those are the people who've really seen a benefit from this machine.

Now, if someone really wanted to say, hey, can you do it? We could do it, but I would very much caveat that to this likely is not going to help you.

And that's really the biggest thing for me is making sure that patients understand the expectations because this is not an FDA-approved treatment for erectile dysfunction yet. However, in the future, it may be as long as the research continues to look promising.

Interviewer: And after those treatments, you said you continue to monitor the patient to see how things go. Generally, are there a lot of follow-ups after that or once the treatments are done and those new blood vessels have grown, generally they survive pretty well and things work out?

Dr. Smith: So depending on the patient's medical history, but a lot of times, right now, we're still working out our protocols because this is relatively new that we have this machine. But again, you know, a lot of these folks, if they're rather healthy individuals who may have just had a blood flow issue, you know, they should be good and it should continue to be beneficial for them for a duration of time.

For folks who may have other medical problems, like people who are diabetics, who are going to have vascular issues, people with cardiovascular disease who are going to continue to have progression of those things over time, those would be people who are going to continue to follow up with us and make sure that, you know, things continue to stay well.

Interviewer: If somebody is having success with the pills, why would they choose the wave machine? Why are people choosing to come off the pills?

Dr. Smith: That's a long discussion that I have with patients, because the big thing is, is people are always looking for the easy, quick fix. And a lot of times the advertisements that they've heard make the wave therapy seem like a quick fix. And, you know, with the shockwave therapy, it can be beneficial, but again, a lot of these people don't understand that, you know, sometimes they may not be a good candidate or it may not be beneficial for them.

So after that discussion, a lot of them will continue with the pills, knowing, you know, the cost of the procedure is relatively, it's not covered by insurance so it costs a little bit more than everything else.

But the main people who will come in and just say, I want to get off of pills, I don't like taking pills, and if there's any possible way I can not have to take pills or not have to do that because erectile dysfunction pills can be somewhat cumbersome. If you have to take them an hour before sex on an empty stomach that can be kind of less spontaneous or, you know, other things, if you've had side effects to the medication, those would be the people who would generally look for another alternative.

I would talk with a professional. Talk with them, ask the right questions. What kind of machine is this? What can I expect? And look at the literature, you don't have to be a scientist to be able to look at it and see, but look at what's been done. And there is some good information out there about it but the shockwave machine has been the one that's shown the most promise of being able to improve erectile dysfunction. I would just say, make sure you're getting what you think you're getting.

When the father of an iconic female pop star went public with the diagnosis of his breast cancer, it was clear that we don't think about our boys and men and this disease very often.

This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is "The Seven Domains of Women's Health" and a little bit of men's health on The Scope.

All humans have breast tissue as a developing fetus. Baby boys and especially baby girls often have breast tissue that can be felt under the nipple shortly after they are born that has been stimulated by the hormones of pregnancy. Boys in early adolescents may grow more breast tissue as their early hormones from the testes stimulate the breast cells until testosterone rises enough to suppress the effect of estrogen. And then we mostly forget about it.

Breast cancer in men is the same type of breast cancer as in women, cancer of the breast ducts called ductal cancer and cancer of the breast lobules is called lobular cancer. Breast cancer in men is uncommon and makes up only about 1% of all breast cancers. Men who do develop breast cancer do so at a later stage in life than women, with an average age of about 72. The rate of breast cancer in the U.S. is about 1.9 white men out of 100,000, and in African-American men it's about 2.7 in 100,000. And the lifetime risk of a man getting breast cancer is about 1 in 800.

So it's not so common, but the incidence of breast cancer in men has been slowly rising over the past 40 years. At least in one study of breast cancer of men in Britain, the exact reason for the rise isn't known, but the risk factors for men include anything that increases estrogen, obesity, liver disease, heavy alcohol use, and diseases where men make less testosterone. Of course, family history and genetics play a role. About one in five men with breast cancer have a close family member with breast cancer. Usually that's a woman.

Now, when a woman develops breast cancer, we think about her family history, the other women who are close to her genetically, mothers and sisters and daughters, and then grandmothers and maternal aunts. If there seems to be a family pattern, we often suggest genetic testing for women. If the woman with breast cancer is positive for one of the gene mutations associated with breast cancer, like BRCA1 and 2 mutations, we offer counseling to the family and suggest that the close women relatives be tested.

But we should be talking about whether the men should be tested as well. If a man develops breast cancer, we should offer him testing. If a man has a mutation in the BRCA1 gene, the chance of getting breast cancer is 6 in 100. And if he has a BRCA2 mutation, it's 1 in 100.

The signs of breast cancer in men are the same as in women -- a lump near the nipple, dimpling of the skin near the nipple, or nipple discharge or blood from the nipple. So families with genetic risk for breast cancer should consider testing and counseling the men in the family. There are no recommended screening tests for asymptomatic men, men without any signs or symptoms. And mostly, it is important for men who notice changes in their nipple or the tissue around the nipple, they should bring it to the attention of their clinician. Early detection is just as important for treatment in men as it is in women because who cares about men's health? We do.

And thanks for joining us on "The Seven Domains of Women's Health" because we love our men.

Interviewer: For men who have been diagnosed with an enlarged prostate, there are a lot of treatment options, but it can be a little overwhelming. And some men fear about the side effects of those treatment options. We're going to sort through that today.

Dr. Stephen Summers is a urologist at University of Utah Health, and he's going to help us better understand the treatment options available for an enlarged prostate and, more importantly, understand what you would want to weigh as a patient when you're having a discussion with your physician or urologist about those different treatment options. So you were telling me that sometimes men put off treating an enlarged prostate because of the fear of side effects. So let's start there. Treatment options have side effects. Do they all have side effects?

Dr. Summers: Unfortunately, any treatment option will have side effects. So the first one, I guess, that has the fewest side effects is lifestyle modification. So if you can lose weight and improve your diet, cut out caffeine, you may have some benefit. But once we start talking about medications and surgical treatment, it's a matter of weighing the side effect with the benefit that you expect to see.

Interviewer: Okay. So can you talk us through that a little bit? So, if I understand, the hierarchy is lifestyle changes first. And you've given us a great reason to want to do that to avoid the side effects of medication. But then it would be medication next. So talk us through, what are some of the options there?

Dr. Summers: Yeah. There are three categories of medications. But primarily, we start with alpha blockers. And the most common medication used is a medication called Flomax or tamsulosin. It works to open up the prostate and the bladder neck to allow the urine to flow through a little bit easier. For the most part, it's well tolerated, but the side effects that bother men with taking that medication can be dizziness. And so you get up all of a sudden, you may have some lightheadedness or a possibility of fainting. And the other one is something called retrograde ejaculation or a sexual side effect. And that is when a man orgasms, instead of having the semen come forward out the end of the penis, it goes backwards into the bladder. And that certainly can be concerning to a lot of men and is one of the main side effects of a lot of different treatments for prostate enlargement.

Interviewer: Is that something I should be concerned about?

Dr. Summers: No. It is a concern if you're planning to father more kids. Obviously, that is an important part of reproduction. But in terms of your overall health, it doesn't make a big difference. It doesn't impact the sensation of orgasm too much, but it's highly individual. In some men, that can be a real bother.

Interviewer: Yeah. Sure. Like I would imagine a lot of these side effects are going to be very individual.

Dr. Summers: Sure. Yeah. The other medications that we use, there is a medication that falls into a class called 5α-reductase inhibitors. There's a medication called finasteride or Proscar or Avodart or dutasteride,. These medications get at the effect of testosterone on the prostate. So they block the effect of testosterone on the prostate growth and over time can cause some shrinkage of the prostate. They are very slow medications to work, and you have to continue on those medications for life once you start them if you're going to experience the benefit of the treatment for them. The main side effects with those can be erectile dysfunction, problems with mood, energy level. It can cause occasional breast enlargement in men. And it does have the side effect of causing hair regrowth. So the medication that was commonly prescribed called Propecia is in this class of drugs. But there are more substantial sexual side effects, I will say.

Interviewer: Why would a man choose this particular treatment then over maybe the first one?

Dr. Summers: No. That's a good question. So, oftentimes, they're combined. So we will use both medications. There's pretty good data out there to suggest that both of them work almost synergistically together than using either one alone. The other advantage with the finasteride, that we were just talking about, is it does reduce the progression of symptoms and severity of the disease, and so you can reduce the risk of progression to the point where one might need surgery by about half. And so there are clear benefit with that.

Interviewer: And you said the one that you have to take for life, say I started, at six months later, I'm like, "Ah, these side effects, I can't live with these." Am I able to then take a different treatment option?

Dr. Summers: Sure. You can always change the treatment option. There is some controversy though, and I think it's important for men to know that there have been some men that have had persistent side effects even after stopping that medication.

Interviewer: Okay.

Dr. Summers: So some of those sexual side effects have lasted even once they've come off of it. Now, that's a very small percentage of men, but certainly, if you're one of those patients, that's going to be a concern for you.

Interviewer: Yeah. And then there's a third category of drugs as well?

Dr. Summers: Yeah. The other category of drugs works primarily on the bladder. It relaxes the bladder, so it treats the symptoms of the disease, but does nothing really to the prostate. And so you're really putting a Band-Aid on treating the symptom, the frequency, the urgency, the getting up at night, but you're not really addressing the problem. So a lot of times we'll use those medications in combination with these other drugs to help lessen or minimize the symptoms as we're focusing on the problem of the prostate itself.

Interviewer: All right. So it sounds like that, you know, you need to have a conversation with your physician about the risks and benefits of the medication. At that point, if that doesn't work or is it possible that a man just might not choose to do the medications because of the side effects that they would move on to surgery. Let's talk about that as a treatment option.

Dr. Summers: You bring up a great point. Sometimes we consider surgery even before medications when you're trying to minimize some of those side effects. So there are a couple of new or recently developed treatments that I think are important to highlight here. And I highlight them specifically because they do not have those sexual side effects that are so common with the medications. And we call them minimally invasive surgical treatments. They're done in the office with a local anesthetic. So it's a very quick recovery with little downtime or little missed work.

The first of those treatments is something called a UroLift. That is a device that is implanted in the prostate that holds back that prostate obstructing tissue and opens up the channel to allow the urine to flow through easier. The advantage with it is it's done relatively quickly in the office. A lot of men do not even have to have a catheter following that procedure, and it doesn't have any of the sexual side effects. So there's no risk of erectile dysfunction, there's no risk of retrograde ejaculation, and there's no risk of urinary incontinence following that procedure. Unfortunately, not all men are candidates for that procedure. It depends a little bit on prostate size and anatomy. But it can be a great option for a lot of men.

Interviewer: And are there other surgical options that you discuss with your patients?

Dr. Summers: Sure. I think it's important to really know all of the options, and so I like to review everything with my patients prior to entertaining any one of them. Another office-based procedure that we do is something called Rezūm. Rezūm uses steam or water vapor therapy in an effort to shrink or ablate and remove prostate tissue. And so, similarly, it's done in the office under a local anesthetic and with some mild sedation. We go in and I inject the prostate with the steam. And depending on the size of the prostate, you may get anywhere from 4 to 10 or even higher injections. And that steam destroys the prostate tissue, shrinks it down and opens up the urinary channel. Men following that procedure do have to have a catheter for a few days. The recovery can be a little bit longer, but there are no restrictions. You're able to go back to work as soon as you're able to tolerate things. It similarly does not have any risk of sexual side effects, including erectile dysfunction or retrograde ejaculation, and no risk of incontinence.

Interviewer: Is this one a little bit more of an option for men than the previous one? Because you said the previous one, you know, some men would not necessarily be a good candidate for it.

Dr. Summers: Yeah. So it has the ability to tailor the treatment a little bit more to a broader range of prostate anatomy, so different prostate sizes and three-dimensional constructs of the prostate. But both of them are, you know, often used interchangeably, and both are good options for a lot of men that are hopeful to avoid some of the bigger surgeries.

Interviewer: Is there a reason why a man might pick one surgery over the other if they were eligible for either one?

Dr. Summers: A lot of times it comes down to the recovery. It comes down to experience, provider preference too, and duration, you know, how long we've been doing those treatments and what's the long-term data and retreatment rates for each of those. So, you know, it gets into a little bit more in-depth discussion that I try to tailor to the individual. When they come seeking one of those treatments, we kind of look at the data and say, you know, "This is what I have that's published based on this treatment. And how does that fit with kind of your expectations and the symptoms that we're looking to treat?"

Interviewer: Getting close to wrapping this up, are there other options that we haven't covered yet that we should?

Dr. Summers: You know, I think one of the common questions I get in surgical treatments that a lot of men that talk about it is the TURP, and that stands for transurethral resection of the prostate. For some reason, men affectionately call it the rotor-rooter. It's an older treatment -- it's better around, you know, almost 100 years -- where urologists go in and using a resection knife in the operating room, with the patient asleep, we hollow out the prostate. It's still a commonly practiced procedure. Most urologists do a lot of them. It still has its place. And technology, of course, has improved as have the side effects. So we've, you know, gotten better at that procedure. But I think a lot of men come thinking that is their only option. And, unfortunately, they have, you know, all had a friend that has had this done and has had maybe a complication, and they fear and procrastinate putting off treatment because of some of the side effects of this older treatment option.

Interviewer: So did I miss something there? I guess I assumed that the surgeries would remove the prostate. And I don't know that I heard any of the things you talked about actually explicitly say removing the prostate.

Dr. Summers: Yeah. That's a common question we get too, and it's a bit confusing when you look at pictures of the prostate. So most of the treatment for benign prostate disease does not remove the entire prostate. We're removing the inside glandular portion of the prostate that's obstructing the urine flow. That is contrasted and much different than an operation that we do for prostate cancer. So if a man has prostate cancer, most of the time that cancer is on the outside of the prostate, and we have to remove the entire prostate. Whereas with benign prostate disease or BPH, that growth or enlargement is on the inner part of the prostate that's obstructing and pushing on the urethra.

Interviewer: And then does that affect the function of the prostate? Is it no longer functional at that point?

Dr. Summers: Once you remove the whole prostate, yeah. Certainly, it's no longer functional. In terms of removing a portion of it, you do lose some function. The function of the prostate is to secrete supporting fluid in your semen for sperm. And so, for most men that were treating prostate enlargement, that is less of an issue. But certainly, if you're a younger patient still planning on fertility or have fertility concerns, then we need to weigh that in with what treatment options we're considering.

Interviewer: Final question. How can a man go into this meeting with their urologist, armed and ready to have this conversation, other than listening to this great interview, of course?

Dr. Summers: Yeah. I think just being open and honest about what your symptoms are, kind of what your priority is, knowing that there are side effects and risks with any of these treatments, what's important for you. Is it that we're treating your nighttime symptoms? Are we improving your flow or your frequency? If you can identify what really bothers you the most, then I can tailor the treatment to fix or improve that symptom. It's really hard to certainly change things and reverse things to make it a 100% better, but if you can tell me what bothers you most, then I can highlight that and incorporate that into our treatment.