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Scot: Welcome to a very special Valentine's edition of "Who Cares About Men's Health." Did you hear that, Troy? Did you hear what . . .

Troy: That wasn't me. That was Mitch.

Dr. Smith: That was Mitch 100%.

Mitch: All of our very special episodes give me such anxiety. What is the topic today, Scot? Let us hear. What's Valentine's Day going to be about?

Scot: Yeah, you guess what our topic for Valentine's episode is going to be?

Mitch: I don't know. Emotional openness or . . . I don't know. What is it?

Scot: Vasectomies.

Mitch: You know what? I'll give it a solid B-plus. I think this is a good thing. Yeah, love this. Okay, great.

Troy: It works for Valentine's Day.

Scot: Does it? Did you get the tie-in? I was afraid you wouldn't get the tie-in.

Mitch: No, I feel it.

Troy: V-Day has a whole new meaning.

Scot: Actually, a vasectomy could be an amazing gift because women have traditionally borne the responsibility of birth control, right? And sometimes it impacts their hormones, and some of it is uncomfortable, and some of it is a daily grind, it's a responsibility, or all of the above, right? So what if you could take that weight off of your wife and put it on you?

From what I understand, a vasectomy is one of the most effective forms of birth control, and it can remove a lot of stress when you're having sex. But there are some crazy things on the internet about vasectomy side effects, and there are also some legit concerns. And we're going to find out what's legit, what's not, plus also how to figure out if vasectomy is right for you and your partner and what to expect.

This is a Men's Health Essentials episode about vasectomy for the vasectomy curious of "Who Cares About Men's Health," providing information, inspiration, and a different interpretation of men's health.

My name is Scot Singpiel. I bring the BS and I'm on Team V. The MD to my BS, Dr. Troy Madsen.

Troy: Hey, Scot. I just want to know did you give your wife a vasectomy for Valentine's Day? Is that how this kind of all came up?

Scot: No, I got it a couple of years ago.

Troy: But not on Valentine's Day.

Scot: But not on Valentine's Day.

Troy: I just wanted to know how many men have actually done that.

Mitch: What do you put in a box or card for that?

Troy: Yeah, exactly.

Scot: Always with his unique perspective, Mitch Sears.

Mitch: Hey. Hello. I'm not concerned about this, but I am curious to learn more about it.

Scot: All right. And the most manly guy on the planet because, get this, he performed his own vasectomy on himself.

Troy: This is amazing. This actually blew my mind when I heard this, so I hope you're going to describe this in detail for us.

Scot: It's urologist Dr. John Smith on the show.

Dr. Smith: Man, I thought my wife was the only person who loved to start conversations with that story.

Troy: That is seriously the manliest thing I've heard.

Scot: I know.

Troy: I have sutured myself up and I tell people that, and they're like, "Whoa, are you serious?" But to tell someone I did my own vasectomy, that would just be next level. I've never heard of that before.

Scot: Yeah, on a scale of one to awesome, how do you feel about that, Mitch? That John did . . .

Mitch: I just can't even imagine. Did you have to? Were you in an emergency vasectomy situation, or what was going on?

Dr. Smith: I mean, all of that is up for interpretation. My wife and I had surprise twins during the beginning of the pandemic, and that was a shocker. And so once we had the twins, she literally looked at me and said, "When are you getting your vasectomy?"

Scot: And going to another provider never was something you considered?

Dr. Smith: I mean, I considered it. I probably should have done it. I mean, probably not the brightest move I've ever made in my life, but it's worked out just fine. I mean, it was one of those where someone no-showed their vasectomy. I wasn't going to throw that stuff away, so I made the executive decision to just do it.

Mitch: You just sat down and did it?

Dr. Smith: Yeah.

Troy: And just to clarify for any listeners who are thinking of doing this, this is a . . .

Dr. Smith: Don't.

Troy: . . . procedure you do on a regular basis.

Dr. Smith: Oh, yeah. I mean, volume-wise, I'm one of the highest-volume vasectomy folks at the University of Utah.

Troy: So this is not an unfamiliar procedure. But you did it on yourself. That's amazing.

Scot: This is a "don't do it at home" sort of . . .

Troy:Yeah, don't do this at home.

Dr. Smith: I would not take what I did and make it something that's the smartest thing I've ever done.

Scot: So, as a guy who had the procedure, I had a misconception. I thought that I was going to show up and there was going to be an operating room full of people, right? I thought there was going to be just a ton of people, but there wasn't. There was one guy. That's one of the things we're going to talk about, one of the misconceptions people have.

But before we get into that, John, what are some of the crazy things that men hear about vasectomy on the internet that they ask you about?

Dr. Smith: I mean, a lot of them will come in and they'll be like, "I'm going to be able to have an erection? I'm going to be able to . . . I'll still ejaculate? This won't impact my testosterone levels? I'll still feel and have testosterone?" Pretty much anything that you can think of when it comes to your genitals being in the crosshairs. There's a lot of misconception out there.

Scot: And it's not true. All those things you said . . . I'm not going to all of a sudden have the desire to start watching Hallmark Channel movies or something, right? My voice isn't going to get higher.

Dr. Smith: No, not at all. And so yeah, a lot of the misconceptions are there. It doesn't change erectile quality. It doesn't even change the amount of ejaculate. The sperm themselves make up about 5% of the ejaculate. And so there's not even a really noticeable decrease in the amount of ejaculation. Your testicles make the testosterone and sperm. They don't stop making testosterone because you got a vasectomy. All those things are all misconceptions.

Scot: Mitch, Troy, have you heard about any kind of crazy things about vasectomy that you've wondered about? I've got one here that I saw on the internet.

Mitch: Yeah. The big one that I've ever heard and when I've talked to people before, they're like, "Ew, no, I'm not going to do that," is the sexual dysfunction stuff. It's the, "I won't be able to ejaculate again," or, "It won't be the same," or, "I won't have . . ."

Scot: Or the pleasure, right? It's going to be less pleasurable.

Mitch: Yeah. And I guess none of that is true.

Dr. Smith: It'll be less pleasurable if you had another kid that was screaming in the background. I'm just kidding. That was terrible of me. But consequence-less intercourse does have its appeal.

Scot: Yeah. And on the other hand, it's really almost freeing. It can make sex better because it's one of the most effective forms of birth control, if I understand correctly, right?

Dr. Smith: Yeah. It's very effective. The pregnancy risk after a vasectomy is 1 in 2,000. And that's not 1 in 2,000 ejaculations, by the way.

Scot: Sure. Okay. I mean, it kind of just makes things freer. And then knowing that I took the responsibility on and my wife doesn't have to go through the stuff she used to have to go through anymore, I think it's cool. I mean, that's my take.

I've seen on the internet that sperm will build up and that could be a problem. Is that true?

Dr. Smith: Very rarely is that a problem. There's a 1% risk of chronic testicular pain after the procedure, which that is one of the possible reasons you could have the chronic testicular pain. But oftentimes, that is not the case. The sperm have a life cycle, they die, and then they're absorbed by the body, so it doesn't really hold true.

But some people do notice chronic testicular pain and they get a vasectomy reversal and the pain goes away. So there is some thought that there may be some truth to that, but it's not a common thing.

Scot: I will admit that was the one potential side effect that I was concerned about, because that could impact your life for the rest of your life. But it's a very, very low chance.

Dr. Smith: You've got a 1% chance of chronic testicular pain is what most of the literature will say. That chronic testicular pain, often there are ways to mitigate that. It sometimes will involve another procedure or another surgical intervention to get rid of that pain. It is a rare occurrence. But when it happens, it's definitely not something that you're going to be like, "Man, I'm so glad that happened to me."

Scot: Troy, any misconceptions you want to clear up?

Troy: I don't know if it's a misconception. I know some people have talked about some of the pain they've experienced after a vasectomy and . . .

Scot: Like just procedural pain? Pain from the procedure itself?

Troy: Yeah, procedural pain. And I know it's a common procedure to have around the Super Bowl. I think some places make a big push then because the idea being that you're going to just sit on the couch all weekend and have an ice pack on your groin to ease the pain.

Scot: Or March Madness, right? You've got an excuse to sit around and do nothing.

Dr. Smith: We've done a Vas Madness a few years.

Troy: Vas madness, yeah.

Dr. Smith: Where you get them in and do it before the tournament.

Troy: And is that common? Are people typically saying, "Hey, I'm just going to have to sit on the couch for two or three days because it hurts too much to walk"? Or is that more of an excuse to watch a lot of basketball?

Dr. Smith: I'm not going to sell anybody out here. Most of the time, we recommend after the procedure to take it easy for a couple of days, about 48 hours after the procedure. Some folks are a little bit more aggressive. Some folks are a little bit more conservative as far as telling you to take it easy for four or five days.

I usually tell my patients ice 20 minutes on, 20 minutes off, for the first couple days and then get back to your routine as it feels okay. No heavy lifting for about five days after the procedure. You can't get in a pool or hot tub or submerge it in water for about 10 to 14 days while the small incision heals. Other than that . . .

I mean, some people will tell you that you can have sex within a couple of days. Some people say wait a week to have sex. It varies between who does your procedure.

Some people will say you can shower the night of the procedure. Some people say to wait to shower a couple of days after the procedure. Again, there's not a huge variety of people that are getting infections or anything from this.

Troy: No running?

Dr. Smith: I usually tell people they can go running when things feel better. I can tell you that I know a couple folks who went golfing the day after they did their vasectomy. Not that they did their own, but after they had their vasectomy done. And they said they were fine. There were no problems.

The big thing that you worry about when you are too active too soon is a small blood clot in the scrotum. Not the kind that goes to your heart or lungs, but a hematoma is what they'll call it. Just a collection of blood in the scrotum. And it makes things a lot more sensitive and painful during the recovery and makes the recovery a little bit more miserable for a couple of weeks.

Scot: Also, I've read that some people are concerned it can cause prostate cancer or it's been linked to cardiovascular disease. Talk about that. That's not true, though, is it?

Dr. Smith: No. A lot of that has been debunked. I mean, there's a lot of literature out there about other things as well that say that. But there's no clear link to getting a vasectomy and then having prostate cancer. There were some articles that came out and most of that has all been debunked, and it's not true.

Scot: And then I didn't know this. There's a no-scalpel vasectomy. Is that kind of the common way now, or what?

Dr. Smith: Well, it's all a gimmick, right? You've got to open up the scrotum to get where you've got to get to start. So it's one of those where you've got to make a hole in the scrotum at some point, whether you poke a hole with a sharp instrument, whether you use a scalpel, you've got to open it up anyway. There's no magic to just the vas deferens just coming out without making some kind of an opening in the skin.

Scot: Do I need to be concerned about, first of all, the way they're making the hole? I mean, is one way any better than the other really?

Dr. Smith: Honestly, no. I mean, the scrotum is very robust as far as its healing capacity it's going to be fine. In three to four weeks, you're not even going to know that somebody was there regardless of how they got in.

Scot: All right. And then as far as how they're actually going to . . . if they're tying or if they're cauterizing the vas deferens, does that make a difference? Should you request one over the other?

Dr. Smith: Well, most people will cauterize and then do something else, or just cauterize. And so the cautery is the one thing that the American Urologic Association says is best practice, is to have mucosal cautery of the lumen of the vas deferens. And so that's something that I'm pretty sure everybody does.

And then on top of that, some people will put clips. Some people will do something called fascial interposition. And that's pretty much where there's an opening in the fascia of the scrotum, and sometimes you'll tuck one end of the vas deferens underneath and put a clip or a stitch over the top of it.

So it's kind of like putting one of them in the basement and one of them in the upstairs so that they can never meet again, is kind of a way to think of it. They call it fascial interposition.

Some people will just tie a ligation stitch around both ends. I mean, there are different variations. You could talk to 50 different urologists and have 50 different ways to do it.

Mitch: What's the thinking behind that? Is it just if the two somehow accidentally meet up again it will heal?

Dr. Smith: Right. So the thought is that you can have someone who's . . . I call them super healers because I don't know of any other way that this happens. But where you can have those mucosal ends grow back together and just recanulate and make a tube again.

I mean, that happens. Very rarely does it happen. I have a friend of mine who actually had it happen where he had a vasectomy done, and he told me he actually had a second vasectomy done. I haven't confirmed that in his medical records, and he still says he has active sperm.

Mitch: Is he Wolverine?

Dr. Smith: He has to be, man. I checked for adamantium, but I did not see any on first glance. I'm not sure.

Troy: Did he know it had reconnected because he had another kid, or what? How did he find out?

Dr. Smith: Usually, we have folks get a semen analysis in 8 to 10 weeks. Some people say six to eight weeks. Again, it varies between folks that are doing this. You get to a semen analysis that looks to see if there are any mobile sperm, how much sperm there are if there are any, and if they're moving. And that gives you a good idea of whether you should lose the protection or not.

Troy: Well, speaking of reconnecting . . . I'm going to put this out there as a misconception, and maybe it's not. But the misconception being that it's very easy to reverse a vasectomy. If you get it done and you want to have it reversed in five years, it's a simple thing to do and you can go on and feel confident you're going to have kids at that point. Is that a misconception?

Dr. Smith: So a lot of it depends on time. The vasectomy reversal can be done. The longer that things are scarred down, the less successful the reversal is. But the reversals are pretty successful. I mean, a high number, we're talking three-quarters or more of them, are able to have sperm there after the reversal procedure. Also, individual doctors have different kinds of success rates that they'll quote you.

The thing that you've got to realize with that, though, is insurance is not going to cover that. So you're going to hit that on your own. It's going to cost you $6,000, $8,000, $10,000, depending on where you get it done, cash to do that.

Obviously, insurance paid for you to get a vasectomy so that they wouldn't have to pay for another kid. And so a lot of that becomes out-of-pocket expense for the person who gets the reversal.

Scot: So I think a lot of guys want to know what the procedure is like. It was almost a non-event. I was a little intimidated going into it. Like I said, I thought it was going to be this big procedure. I think it was done in like 15 minutes. The pain wasn't super bad. I went and bought a couple bags of peas and iced like I was told to and took it easy for two or three days, and everything was great.

I'd read some of the crazy stuff, that it was going to decrease your sexual pleasure, and yadda, yadda, yadda, and none of that happened. And it just feels great not having to worry about it. Is that pretty accurate? Did I describe the procedure pretty well? I mean, just kind of the overview, John?

Dr. Smith: Yeah. I mean, it's a simple procedure that's done in the office. And I don't want to simplify anything because surgery is never a big deal until it's on you. And then obviously, when it's on your genitals, it's an even bigger deal. But it's a very commonly done procedure. It takes 15 to 20 minutes, maybe 30 minutes, in the office. It's minimally invasive. I do mine through a single incision that's about a centimeter to a centimeter and a half long. Numb things up with lidocaine and just take care of it.

Scot: Don't even feel it. Don't even know. It is kind of weird though because you're sitting there in a chair, and you're kind of watching the doctor do it, but you're not seeing what the doctor is doing, because you've got some blankets or something up there. So you know something is going on and you're actually kind of seeing that something is going on, but I didn't feel a thing.

Dr. Smith: Yeah, once you're numb . . . I mean, the worst part is the numbing. When I did mine, that was the worst part, was getting numb. And most men when they're done, they're like, "Oh, the numbing was the worst part. After I realized I was numb, I could just relax and hang out."

Scot: I don't even think the numbing was that bad, really. I don't remember it.

Dr. Smith: Listen to this guy. What a tough guy. "It didn't even bother me, man. My name is Scot."

Scot: I still don't measure up to you, but . . .

Troy: Yeah, I think you're trying to outdo John on this one, Scot.

Dr. Smith: It hurt, man. I did not like numbing it up. I'm not going to lie to you. That was the worst part by far. But again, once it's done, that is the part that people say is the worst.

And then you had a great recovery. Most people do have a good recovery like that. I was very similar to that. I had some minimal discomfort for a few days. Bruising for 7 to 10 days in and around the scrotum.

I did not get a hematoma, thank goodness. I mean, they happen about 1 in 20 to 1 in 30 vasectomies. So they're not super common, but they're the most common "complication" that you have after the procedure. If you do get one of those, your recovery is not quite as fun. I tell you guys it gives you the man flu for a couple of weeks. You're not going to want to do much. But that's kind of what to expect for it.

A lot of guys come in they're like, "Man, I was really worried and scared about this and it wasn't as bad as I thought." I hear that quite a bit.

Troy: And you mentioned insurance coverage earlier too, John. It sounds like this is covered by insurance.

Dr. Smith: So a lot of insurances will consider this preventative care. You need to check, obviously, with your insurance company. But if you think about it, it makes sense for them to pay for a vasectomy. Then you don't have to worry about taking care of another kid on the insurance for 18 years, or 26 years. And so a lot of them will have that.

So we'll have a mad rush at the end of the year where people think that they've met their deductible and they need to go get their vasectomy. But then a lot of times, if you look at your insurance coverage, you could have done it into March, April, May, it didn't matter because it was considered preventative care.

Now, not every insurance is that way, but a lot of them are because it's advantageous for them to obviously have that done to decrease another kid coming on to the policy.

Troy: Yeah, a calculated decision on their part.

Dr. Smith: Yeah, exactly.

Scot: As we get ready to wrap this up, what type of guy would be a good candidate for a vasectomy? Are there some people that are better candidates than others?

Dr. Smith: Almost everybody is a good candidate. Oftentimes, if there is a difficult exam or something where we think it needs to be done in the operating room, it can be. Most everyone is able to be done in the office.

Obviously, a good candidate would be someone who's not interested in fertility any longer and does not want to have any more children. And so those folks would want to come in.

We have them have a consultation to go over all the risks/benefits before they have the actual procedure, and then come back for a second visit for the actual procedure. That way, they have the ability to do that.

Also of note, when we talked about insurances, government insurance makes you wait 30 days from a consultation to have the procedure done so that you have time to think about it.

I was told when I did my training that that was because some places were doing the vasectomies on people who were in mental hospitals, things like that, without consent. And so the government changed it to where they had to have consent and wait 30 days, and yadda, yadda, yadda.

But all of the government insurance does require a 30-day wait period and a form to be filled out. So Medicaid and other government insurance, you have to do that.

Scot: Something I remember, I had my consult and they asked me the same thing. They asked me how many kids I have. Zero. "Are you positive that you don't want to have kids?" Well, I'm to the age and my wife's to the age where that's probably not even a smart thing from a health standpoint, and we've decided that that's the case. And they did ask if I talked to my wife about it. You would recommend that as well? This is a conversation that should be had between both partners. You shouldn't just go out and surprise . . . do the Valentine's Day vasectomy surprise.

Dr. Smith: Right. If you've already had that conversation with your partner, and you guys have decided that's not what you're going to do, then I think you're pretty safe. But I think it is a wise thing to talk to your partner. If you don't have a partner, then obviously it doesn't apply.

Troy: And I have to ask this too, John. Let's say someone out there is thinking they're not married, but they don't want to worry about the issues with possible pregnancy with partners, and so they decide to have a vasectomy. How effective is a vasectomy at preventing STDs?

Dr. Smith: It's not at all.

Troy: So you're still using a condom for those guys.

Dr. Smith: Yeah, absolutely. I mean, that's not going to stop an STD in their tracks at all. That's just going to make it so you're not going to get someone pregnant, but it's not going to stop transmission of any of that stuff.

Scot: By the way, I think Troy knew the answer to that question.

Troy: I had to ask it.

Dr. Smith: Was Troy baiting me in?

Troy: I was baiting you. I had to ask it. I think that maybe potentially that could be a misconception, that you think, "Hey, I had a vasectomy. Great. I don't have to worry about pregnancy."

Scot:Yeah. Woohoo.

Troy:You're right. Not a big concern. Far more effective at preventing pregnancy than condoms or oral contraceptives, but doesn't do anything for STDs.

Dr. Smith:Absolutely.

Scot: Yeah. You might forget that. I could definitely see that.

Well, if you're considering having a vasectomy, of course, if you have any concerns or questions, if you've seen something crazy on the internet that we didn't address today, then definitely talk to a urologist.

If you have other concerns, like what it's like, for some reason other guys that have had them, it's been my experience, love to talk about them. I don't have any qualms about it.

I don't know if there are some people that think it makes you less manly or anything like that, but from my personal experience, I'm really glad that I got one.

I will admit it was a little strange thinking that this is it. I've made the decision that under no circumstance . . .

You do consult men that this is not a reversible procedure, even though there is potential to reverse it if you've got the cash and if you do it soon enough?

Dr. Smith: Correct. I usually tell people that this is reversible, but I don't do it to be reversible.

Scot: Yeah. Right. Your job is to do it so it works and those things don't grow back together. But beyond that, I mean, it's been great. So I would highly recommend it if you are done having children and you don't want to have to worry about birth control anymore.

Dr. Smith: I concur.

Scot: If you have any questions, you can email us. The email address is hello@thescoperadio.com. And we've just given you a Valentine's Day gift idea, so you're welcome. Just don't make it a last-minute gift. Have that conversation.

Troy: Last-minute gift. Yeah, it sounds like maybe the gift would be proposing the idea rather than coming home and showing the incision on your scrotum.

Scot: Yeah, that's a good idea. Thank you for listening, and thank you for caring about men's health.
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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.

Scot: You guys want to hear an epic tale?

Mitch: How epic?

Troy: I'm ready.

Scot: Should I tell it in my epic tale voice?

Troy: Please.

Scot: There are other people around though and I think they can hear me, so I'm feeling a little shy about it right now.

Dr. Smith: Let it go.

Scot: The office I . . . Listen and you shall hear the tale of two guys and testosterone therapy. One guy got amazing life-changing results, the other none, nothing, nada, zip, zero, bupkis. In the telling of this tale of T, we hope we can help all men learn why T works for some guys and not others. Was that epic?

Troy: That's epic. Who uses the word bupkis anymore, though? Bupkis?

Scot: This is "Who Cares About Men's Health," providing information, inspiration, and a different interpretation of men's health. And today, to tell the tale of T are the "Who Cares About Men's Health" players. I am Scot and, obviously, I bring the BS. Balancing my BS with his MD is Dr. Troy Madsen.

Troy: I'm not part of the tale of T, but I'm excited to learn more about it.

Scot: But your name begins with T.

Troy: Oh, that's right.

Scot: Producer Mitch is also in the mix.

Mitch: Hey, there. I didn't know we were players. I kind of like that.

Scot: And Dr. John Smith is from the Division of Urology at University Utah Health. And he's going to talk us through testosterone therapy in our tale of two different guys with two very different experiences with testosterone. Dr. Smith, as always, it's great having you on the show.

Dr. Smith: Gentlemen, thank you for having me.

Scot: By the way, your shows that you do with us are quite often the most listened to shows. And I don't know if it's because the topics you talk about are just really that interesting to people, or if it's because you have lots of family members. But I don't care. It doesn't matter to me.

Dr. Smith: We Smiths are a large clan.

Scot: There's kind of this implied thing and . . . I don't know. Maybe it's just me, but I think it's a lot of guys, that testosterone is kind of a cure-all for men who are suffering from fatigue, or struggling to lose weight, or struggling to put on muscle mass, or their sex drive is reduced. So it's kind of like, "All guys should be on it," right?

But we've talked about testosterone on the show before and testosterone therapy, and it's not a magic bullet. It works for some guys, and some guys, it doesn't necessarily work for. The only time it's a magic bullet apparently is if you're Mitch. We're going to hear about his pretty amazing story with testosterone.

And then, on the other hand, we're going to hear about my experience that I had with it that I haven't really talked about on the show, because I had a hard time putting it into words and figuring out what that story was. But after hearing Mitch's story, I figured out what my story is.

And I think in this process, we could kind of learn a little something about testosterone therapy, that it's not this universal cure-all. And Dr. Smith would back that up, right? It's not a universal cure-all like the ads would have you believe.

Dr. Smith: Well, I think a lot of it depends too on your patient selection. A lot of guys come in because they hear about a guy like Mitch where it changes things for them, their life is great, they have a lot of benefit from it. And they go get their testosterone checked, and they may not even have low testosterone. It may be something else. And so you do see a relative benefit for some and not others based on lab results and other things.

Scot: So, back in Episode 102, Dr. Smith talked about how maybe some guys with low testosterone might slip through the cracks because their doctors aren't necessarily familiar with hormone therapies or they're not comfortable with them as opposed to Dr. Smith, who's studied this and has put in more time as an expert. Not saying anything bad about anybody else. It's just that he's had a lot more experience with it.

So that conversation made Mitch seek a second opinion that's made a huge difference in all aspects of his health. And I think this is a great chance to hear Mitch's story, what he was struggling with, and then the process that he went through to finally get on testosterone therapy and find out how that's impacted his life.

And I think it's a great story of how testosterone therapy can help some men, and how you also kind of need to be an advocate for your own health sometimes. You have to kind of work through the system. So, Mitch, tell us your story.

Mitch: It was very interesting. The recording of that particular episode was like smack dab in the middle of a yearlong struggle with some really, really severe fatigue, right? And we're talking physical, mental. Every day I was just tired. I was dragging myself, and I felt it in my joints. I felt it in my brain. And it just kind of kept getting worse and worse.

And we talk about on the show, "Oh, yeah, get more physical activity. Change your diet." If you're so tired all the time, the idea of getting up and running for 30 minutes, I'd be completely worn out for the rest of the day. I would just be that physically exhausted.

And it was even my therapist, my mental health person, who was saying, "Hey, you're obviously not doing the work that we're doing every week because you're so tired. You're so out of it. We can't help pull you out of whatever's going on if you're this out of it."

So after kind of talking through it and just struggling with all of this, I decided to go to my PCP. And I told him, "Hey, I'm dealing with some severe fatigue. It's been going for a very long time," blah, blah, blah. But I was like, "Hey, what could be wrong?" And so he did a whole bunch of panels. We ruled out things like diabetes and all these other conditions. He took tons of vials of blood out of me, and they all came back normal.

And he kind of said, "Well, why don't we try some lifestyle changes?" So I tried. For months, I was doing healthy meals every day. I was going to bed at a certain time. I was trying to drag myself out of bed every morning just to go on a little jog or working out. I was doing everything I possibly could, but I still was tired and I was putting on weight.

And even when I went back and I said, "Hey, I've tried the things and I don't mean to backseat doctor, I'm just a podcaster, but I have a feeling that something else is going on. I'm not lying to you. I really am doing all the things I think I'm supposed to." And the response was to prescribe me antidepressants. There was such a confidence in my doctor that it must be something mental that's causing my exhaustion.

And I took him at face value, so I went and I took the antidepressants. I tried it out and had kind of weird motional swings for a week or two. And I don't know, it still wasn't going away.

And about that time is when we recorded the episode. If there's any love letter to the show and the idea that talking about health can be a huge change for people, we had a conversation about this very thing where it's like, "Hey, sometimes your PCP might not feel super comfortable giving you hormone therapy because they're not super trained in it."

And after hearing that, I decided to reach out to Dr. John Smith because what better men's health person to talk to you than someone I've already interviewed? We got the test done, and sure enough, my levels were pretty low. They were under 300. We took both of them in the morning to make sure we were minimizing any other potential things that were going on. But I had really low testosterone.

Dr. Smith: Mitch, I love your story because your PCP is awesome. The fact that he took the time to go through all of those things with you and make sure that it's not something else. I have a lot of people's PCPs who won't take that time. Not that they don't have the time, but sometimes PCPs are overwhelmed.

But bless his heart, or her, for going through the time to get the blood work and make sure all those things are normal. Because I've found plenty of folks who come in who have thyroid issues or other issues that are causing their fatigue. So I just wanted to put a plug in for your PCP and some kudos and a pat on the back for taking the time to really make sure that they covered all their bases.

Troy: I'm curious too, John, hearing this, what do you think happened with that blood test with the testosterone level with his PCP? Because it sounds like it was above 300 and then when you tested it was well under 300. Do you think that was testosterone levels dropping over time, or maybe just the way the PCP did the test? What's your take there?

Dr. Smith: So I've had patients who've had three or four testosterone levels done. They'll have one that's in the low 300s, and then the next one will be like 240. And then they'll have one that's like 380. And so it does vary based on diet, exercise, and some of those things that are going on. We don't fully know 100% why, but it is variable. But most of the time, those people who are lower tend to be lower on average.

And so insurance requires two morning draw testosterones. And the AUA, or the American Urologic Association, has also kind of backed that up of two morning draw testosterones that show a low level.

Scot: And what if a patient is at, like, 320? Three hundred is the lower limit. Is it up to a doctor's discretion at that point based on symptoms, or how does that work?

Dr. Smith: Patients who are symptomatic in the low 300s, sometimes they do benefit from testosterone where their body does need to be a little bit higher in that normal range. And so taking the opportunity to try it. Like you said, some people it's great and it works, and some people don't notice a huge benefit when they are supplemented in that range.

But sometimes it's worth a try, especially if you've tried other things, you've got other lab work, and everything looks normal. Well, let's try it and see if we can benefit you and help your fatigue and those other things.

So it is kind of doctor discretion and having that conversation with your patient of, "Hey, this is may be very helpful and it may not. Let's find out and just see."

Troy: You mentioned also insurance coverage. Does insurance require levels less than 300 to pay for the treatment?

Dr. Smith: Usually they do want to see low levels of testosterone before they'll pay for treatment. A lot of them aren't sticklers. If you're like 330, 320 and you have a second level that's like 289 or 301, they're usually pretty good about making sure that things are taken care of.

However, that being said, certain forms of testosterone replacement are fairly inexpensive with discount programs like GoodRx, and SingleCare, some of these websites online that have kind of created relationships with pharmacies to give people discounts. So it's not this cost burden if insurance did ever balk it and your doctor was like, "Hey, I think you'd really benefit."

Troy: So I have to ask you this just because you kind of went that direction too. If someone's paying out of pocket, what does it cost?

Dr. Smith: So injectable testosterone is by far the least expensive. And depending on what your dose is, you can get two or three months for $20, $25.

Mitch: Oh, wow.

Troy: Oh, wow. That's super cheap.

Dr. Smith: So it's not this killer expense. And then other forms of it, if you want to be fertility friendly and things like that, there are some other off-label uses for medications like clomiphene, which we've talked about, or Clomid. And that again is something that you're going to pay $20, $30 for a few months' worth of medication. So the cost burden is there but $20, $30, if it changed your energy level and a lot of those things, is completely worth it.

Troy: That's surprisingly inexpensive. As someone who's purchased over-the-counter omeprazole, I will say that's a whole lot less expensive than treating yourself for heartburn.

Scot: Wow.

Troy: I'm surprised at how inexpensive that is.

Scot: So what was Mitch diagnosed with? Was it just low testosterone or is there a specific name for it or?

Dr. Smith: So the $500 word is hypogonadism. Everyone else just says low T. But it's the exact same thing.

Scot: I'm going to choose low T.

Troy: I know. Hypogonadism just doesn't sound good. Let's go low T.

Dr. Smith: Low T works very well.

Scot: Yeah. So I was surprised when Mitch told me what his particular treatment option was because . . . and I'll get to my story in a bit. I used a rub-on cream, which I think is actually testosterone, right? But it wasn't testosterone that Mitch got. It was something else.

Dr. Smith: So Mitch was put on a drug called Clomid. And this drug stimulates the brain, the pituitary to produce hormones. One is called luteinizing hormone. The other one is called follicle-stimulating hormone. And these two hormones stimulate the testicles to make testosterone and sperm. And in that way, we were able to alter the body's production of sperm and up-regulate it. And so that's what the drug that Mitch had, or has, does.

Now, the creams and the injections are giving exogenous testosterone into the body and actually causes the body to kind of shut down its own production because we're giving the body this exogenous testosterone. And so that's kind of the difference between those two, even though both of them are very beneficial for patients.

Mitch: So with the medication I'm on, my body and my testicles are capable of producing testosterone, but for one reason or another, it wasn't making enough. And so we're now putting a drug into jack those numbers up. Is that how it kind of works?

Dr. Smith: Exactly.

Troy: Talking about the Clomid . . . I don't know that we ever really talked about why Mitch is on Clomid versus exogenous testosterone. Mitch, was that a decision you made kind of hearing side effects and what's involved in each one? Or, John, is that typically first-line treatment? What was that decision process?

Mitch: So Dr. Smith was really, really good. We had a conversation, right? He talked through the different options and he said, "Hey, some patients prefer this over this. Here's why." Here's blah, blah, blah. And so, for me at least, it was a joint decision.

And it sounded like, for me, that Clomid was the easiest entry point, right? See if my body can make this stuff anyway, and if it can, great. If not, we can try something else. And taking half a pill every other day is a whole lot easier for me than getting injections or a magic cream or whatever. So I thought I would start with that first.

Scot: Dr. Smith, does Clomid work for some men and not quite so well for others? Are there kind of some criteria that you would use to have that be the first thing, or is that generally the first thing you try?

Dr. Smith: No. I usually have a conversation, like Mitch said. I like to lay out the options because I feel like the more information the patient has, the better off they are.

And some people prefer to take a pill versus giving themselves an injection versus having a cream. Each one of them has a plus and a minus to them. And so having that conversation, giving them the options, letting them know what is available, and then what fits best for their lifestyle. That's how I like to do it personally.

Clomid may not work for some people because if the testicles of a certain individual are not able to produce sufficient testosterone, then the Clomid isn't going to help. No matter how much we stimulate the testicles, if they're unable to produce what we need them to produce, it's not going to make a difference. And so in certain individuals, that isn't an option that works.

We'll try it and then they'll come back and their labs haven't changed and they're like, "Well, what happened?" And I say, "Well, your testicles just can't produce anymore, so you need to be on exogenous testosterone. We need to give you testosterone because you can't make your own." So those would be the people who Clomid would not work for.

Scot: So is there anything else we need to cover about what Mitch is on? Should we just get to Mitch's results? Is there anything else to that part of the story, Mitch? You went through this.

Mitch: No, not really. I got on a cheap pill and things turned around. It was awesome.

Scot: Yeah, but drastically, the kind of drastic that we make fun of. Like, it's the silver bullet. We spent a lot of time . . . at least I felt like I did. Maybe Dr. Smith didn't. But upon reflection, I wanted to communicate this is not a silver bullet, right? You still have to do these other things, and you should try these other things. But for you, it was kind of a silver bullet.

Mitch: Yeah. It was night and day. It took me about a week to notice anything. So I show up to the pharmacy, I pay my $30, I get this big pile of meds, and I just start taking one. And after about a week, that weekend I woke up feeling like I had had the first full night's rest that I've had in years, right? I just woke up and felt amazing.

And it kept going. I could keep having energy. When I got done with work I actually felt like I could do something in my evening, like I could work out, or go for a walk, or do a hobby, or something, rather than just crash in front of Netflix and order GrubHub.

And it wasn't just that. I was suddenly able to work out without feeling completely wrecked, right? It used to be I'd do a hard set at a gym or something like that and I would just . . . it would drain the last bit of energy I had left in me, and so I just would crash.

And it just felt good mentally. Mentally, I was able to be sharper. I was able to focus on things. This brain fog and overall physical fatigue that was going on completely disappeared. And then on top of that, I lost 25 pounds in a month.

Troy: That was the crazy part.

Mitch: After years of struggling with weight and doing everything I was supposed to and never seeing anything, suddenly a month after getting on this medication, I lost all of . . . It's slowed down now. I'm not continuing to lose all this weight. But it's like something suddenly fell into place and my body worked.

Troy: You lost weight, and you also put on muscle mass too, didn't you?

Mitch: Yeah, I did. But we don't know the exact number.

Scot: He's got to be honest about that.

Troy: You're just downplaying that part. "Yeah, I'm pretty ripped now."

Mitch: I am not ripped, but . . .

Troy: You probably are.

Mitch: No.

Troy: I haven't seen you in a couple months. But this was how long ago? When did you first start the treatment?

Mitch: This summer actually, so a couple months ago.

Troy: So it's been a couple of months. That's what I wondered too with treatment. Is it like there's sort of this honeymoon phase where everything is great and you feel good, and you lose weight, and then after a month, everything kind of levels off or maybe there's a little bit of a rebound? But it sounds like, in your case, everything is still good. Things are going well.

Mitch: I mean, I'm not still losing two or three pounds a week, but I still have my energy. I still feel mentally sharp and good. And they're talking about maybe even minimizing and taking me off of some of my mental health medication I've been on because of how much better I'm doing.

Troy: Wow.

Mitch: Yeah, big change.

Troy: That's great. No, that's huge. John, is that typical? Is Mitch's experience typical?

Dr. Smith: I think Mitch is at the higher end of what people experience. I will say most people within the first year, the testosterone literature will tell you that you'll have a body mass change where you'll lose about 2.5 kilograms of body fat and you'll increase lean muscle mass. So that's something that you see across the board.

Mitch is probably someone who is in better shape than most of my patients. So folks who are a little bit more out of shape may not notice that muscle mass change as much as Mitch did. Because Mitch has done a very nice job of staying in shape and taking care of his body and being in a good body mass to start, and that makes a huge difference for patients.

But I would say Mitch is on the higher end of people who have done very, very well and are very pleased with their treatment.

I would say, overall, most people who get a benefit, they do maintain that energy improvement and things like that.

On a caveat, if you have the desire to go to the gym and you're just too tired, the testosterone isn't going to make you want to go to the gym. But if you had that inherently before and the fatigue was impacting you, once you get that energy back, you're going to want to go back to those things that you enjoyed, if that makes sense.

Scot: Mitch also talked about how mentally he was feeling better. Is that common that the testosterone can help there? What do you think is going on with that, Dr. Smith?

Dr. Smith: So there is some debate on that, but overall, when you have more energy, you feel better, you're able to go and do the things that you like to do, you have the energy to go do the things you like to do, your mental health status changes, and you feel better. And I think that just stands to reason.

People who get a good result from hormone therapy of one reason or another, they tend to be happier. They tend to feel better. Because when you feel better and you're able to go and be active and do things and have energy to do things, overall you do feel better. Overall, things are just better.

Scot: All right, Mitch. Now the dark side. Are there any side effects?

Mitch: But they're all testosterone related. It's not like the medication . . . It's like Dr. Smith was talking about earlier. I used to have to shave maybe once every week and a half. Now I'm shaving twice a week. So we'll see if I can . . .

Scot: Like a regular teen wolf.

Troy: Wait a second. You used to only shave once every week and a half? Was this because you wanted to grow out a beard and then you'd shave it off, or . . .

Mitch: No, I couldn't grow any facial hair. I've always been a little baby face. So yeah, I'm having to learn how to shave all over again and more frequently.

Troy: But to say more frequently, just twice a week, though.

Mitch: Yeah. That's a significant change.

Troy: From every week and a half, yeah.

Mitch: I'm doing that. I got a little bit of acne on the body. I've been like zit-free since I was 18, 19, and now I'm getting little bumps on my body every now and then. But nothing, a little bit of whatever little special acne stuff or whatever won't help.

And after we chitchatted last time, I'm growing my hair out. I've got this awesome mane going these days, and I started to see it coming out in my comb. So went to Dr. Smith and was like, "Hey, I think I might be losing some of my hair." And he's got me on Propecia. Haven't had any side effects with that. And I guess that'll help control any hair loss that might be involved.

But any of those changes, I would not trade for the world. Being a little hairier, a little zittier, and maybe a little thinner in the hair, I am fine. I would much prefer that than just being tired and miserable all the time.

Troy: So you're going to have this killer beard going on and shave your head, but you're going to feel good.

Mitch: Yeah, 100%.

Troy: Take it.

Dr. Smith: Mr. March of the "Who Cares About Men's Health Podcast," Mountain Man Mitch.

Mitch: We'll see.

Scot: I've been looking for a name for you. I think we might have it there. Thanks, Dr. Smith. I like it.

Troy: Triple M.

Scot: Yeah, that's good. Are there other side effects that some guys would experience in addition to what Mitch is talking about?

Dr. Smith: So those are very typical. Increased testosterone can increase male-pattern baldness. You can get some acne, increased body hair, facial hair, those types of things. Kind of like when you're going through puberty, some of those similar things when the testosterone levels kind of raise like that.

We always watch the red blood cell count because it will stimulate that. Testicular size changes in the case of people who are on exogenous testosterone. It doesn't happen with the Clomid like Mitch is on.

Those are the big ones that most people see. The medication that Mitch is on, the Clomid, some people will have a little bit more of a moodiness or mood swings. They feel like they would cry during a Hallmark movie kind of a thing. Their emotions are a little bit closer to the surface.

I had a guy literally tell me that one time. He's like, "I feel great. I feel like I'm going to cry at a Hallmark movie." And I said, "Okay, so your emotions are a little bit closer to the surface." And he's like, "Yeah, that's kind of what's going on." And so that's the biggest thing with Clomid that people tend to see. But that's pretty typical.

Scot: So after hearing Mitch's story, I got curious about testosterone again myself because I feel like I kind of have the same things. I feel like I've been exercising and doing the right things, but losing body fat is difficult. I feel like I kind of have low energy and some of those things.

I had tried testosterone before back around 2010, so 13 years ago. I had just turned 40 and it really didn't work for me. So I thought, "Well, I'll get my levels tested again and see how they look." And my levels came back right in the middle, like at 650.

That's about as average as you can get, right, Dr. Smith? Because I am the most average man on the face of the earth. You ask me my skills and ability in anything, it's going to be average.

Anyway, with that number, I made the assumption that testosterone therapy is really not going to help me. Would that be a good assumption to make, that that's probably not the issue?

Dr. Smith: Yes. If you're asking me the question, I would say yes. Because if you're in the normal range, there's not a lot of benefit to be had. Now, some people may disagree, but I look at you have a certain number of receptors for testosterone. And if you think about it like a parking lot, if you have 600 parking spaces and 1,400 cars, it really doesn't matter how many parking spaces you have, you're not going to be able to fit all the cars.

And so with a normal testosterone in a normal range, you're going to be saturating those parking spaces, aka those receptors, that the testosterone interacts with. And so the benefit ratio of taking someone with low testosterone where there are too many open parking spaces, so to speak, to someone who's got almost all the parking spaces full all the time, you can see how the benefit would be there or wouldn't be there. And so normal testosterone, adding more doesn't necessarily improve things.

Scot: So I'm going to say, first of all, you have the best analogies of any of our guests ever. Every single episode, you just nail it with an analogy. That was awesome.

Troy: Parking spaces. That makes perfect sense.

Scot: That was fantastic. So I'm going to try to keep my story short when I tried testosterone for the first time. I tried it for a couple of years and really didn't notice any benefits, and it was a lot more hassle than it was worth.

So I had just turned 40 and I was working at a place and there was this guy that was really super muscular. He was younger, and he was like, "Oh, man, as soon as I turn 30, I'm going to go to the doctor and get testosterone therapy." Because he is under this impression that you start losing testosterone as you get older, which is true.

And then you see the ads in the media, and there, again, this seems to be recurring in my life, low energy. I've always wanted to put on muscle and I've always found it difficult even when I weight train. Losing the fat is difficult even when I feel as though I'm doing things right.

So I had another friend who started testosterone, had some results like Mitch. It gave him this energy and drive again. So he referred me to this particular doctor. I got the test. They got the levels. They put me on the cream. I did that for a couple years. After a few months, they ended up putting me on some pills to balance the hormones that the testosterone cream was causing.

And I also didn't like the fact that since I was using the cream, I had to be really careful my spouse didn't get near it. And I really wasn't noticing any difference. So I just ultimately kind of ended up quitting that.

Fast forward to the last episode we did, I thought, "Wow, I wonder if I could go back and pull those old labs and see what my testosterone levels were." And even back then, they were around 600 and 650.

So what this physician and I were trying to do is we were trying to optimize, get at that upper level thinking that that's going to make me feel even better.

And after learning from you, Dr. Smith, and your awesome parking space analogy, it makes total sense why that didn't help me. So in that case, testosterone really wasn't the solution for my problems or my perceived problems of energy and whatnot.

So in a way, I'm kind of jealous of Mitch, but also in a way, I'm glad to know that everything is okay. And maybe now I can kind of be a little bit more honest with myself. Am I going to bed at a decent time? Am I eating the way I need to be eating? Am I getting enough calories? Could there be some other reasons why I feel like I'm tired, or is it just my perception?

So that was my story, which is very drastically different from Mitch's, but I think it really illustrates that if you don't need it, getting more is not going to necessarily help.

Mitch: So did you have any response to the treatment? Did you feel anything other than just kind of the same?

Scot: No, not really. I think at first I kind of thought maybe I did, but that could have been the placebo effect. I don't know. Ultimately, I didn't notice a whole lot of difference over the long term. And that, in combination with the downsides, is kind of why I just decided to stop.

Dr. Smith: Scot, that's been a little while ago. Have you had your levels rechecked recently?

Scot: Yeah, I just had them rechecked after Mitch had such success with his treatment and found that they're just dead in the middle.

Troy: They're still . . .

Scot: That's that 650 level.

Troy: Okay. So still 650. Yeah, maybe I missed that. Because you were 650 years ago, and just everything has stayed exactly the same. Clearly no benefit for you to go on testosterone at this point.

Scot: Yeah. So what was the difference there between my experience and Mitch's experience, Dr. Smith? Do you have any more insight to that?

Dr. Smith: So we kind of talked about this a little earlier. Mitch had low testosterone, so adding more cars to the parking lot made sense. For you, you could make the argument that you may have even changed the cars in the parking lot initially because when you start testosterone, your body is going to shut down your production. And so you're really just keeping yourself at that same level.

And I don't know what your labs looked like, if they rechecked your labs and things. But I've had people who've come in to me from other outside places who've said, "I've been on testosterone for about a year and a half." And they bring me their original labs and they're kind of like yours or kind of in the middle of the range, 550, 600. And I look at their numbers on testosterone and they're, like, 720. And so really, they didn't do a whole lot other than shut down their body's native production.

Now, I've had some people come in who were just being dosed up very, very high, who their testosterone levels were off the charts. And some of them said, "Oh, I feel great." And some of that, I'm guessing, is placebo.

But I've had some patients who, at a higher range, they do say they feel better. And I don't know that it's all placebo. And so there could be some benefit to that.

But being in the normal range, you're not going to get a ton of benefit. And so I think that's really where we look at it and we say there's not a whole lot more that you need to do.

And I would say that some of the patients I have that come in, they'll get sent by their primary doctor after they've had a couple of testosterone tests that are in the normal range. And they'll come in and I'll look at them and they may be . . . Their body habitus may be larger.

I'll ask them questions like, "Do you snore?" Because I've diagnosed plenty of folks with sleep apnea where they get that treated and they feel like a million dollars. And it wasn't their testosterone. It's that they were waking up 30 times a night because they were having sleep apnea events during the night. Things like that I've seen.

You have to ask the questions around to get to the answer for some of those folks. Some people may be on extreme diets trying to lose weight and they're like, "I'm just tired." And I'm like, "Yeah, you're eating 500 calories a day. I don't know why you would be tired."

Things like that are going on where you've got to ask the questions because you'll get to the answer. "Hey, well, if you start eating 1,200 calories or 1,500 calories, you'll probably have more energy because your body is not going to try to store everything thinking that it's never going to eat again."

And so some of those things I see in folks where they have symptoms but their testosterone is in that middle of the road, kind of like yours was, Scot.

Troy: Speaking of levels, I know we're talking about you, Scot, but I've got to bring it back to Mitch. Mitch, do you know what your level is now?

Mitch: It's in the 700s.

Dr. Smith: So he's not through the roof, but he's pushing towards the upper end of the normal range.

Troy: Yeah. Nice.

Scot: I mean, I feel completely great with my decision now in retrospect, because I think being on it could cause more problems for me when I didn't have a problem to begin with, right? Because there are downsides. Doesn't your body kind of stop making it if you're putting cream on long enough?

Dr. Smith: Yeah.

Scot: Any take-home messages? What are the take-home messages here, Troy? What do you think? What did you get out of this episode?

Troy: My take-home message from all this is if you're experiencing something like Mitch experienced, it makes sense to get your testosterone level checked. And it also makes sense to pursue treatment when treatment will work. And if the parking spaces are full, there's no point in putting more cars in the parking lot. That's my takeaway.

Mitch: Sure. That's a good one.

Scot: How about you, Mitch?

Mitch: I think the big one for me is to talk to each other about health. I would not have been on this kind of journey, I would not have advocated for myself, I would not have sought out a second opinion had I not talked to other men on this podcast and in my life about testosterone, about their experience with it, etc. I would not be where I am today or thinking about my health the way it was if I did not talk to other men about my health.

Scot: Dr. Smith, do you have something that you'd like to throw out as a take-home message?

Dr. Smith: I love it. I'm super happy for Mitch. And I'm also happy that you were able to kind of find your way. You mentioned it earlier about being an advocate. I tell patients all the time, "I get to see you for 15 minutes and you know your body a heck of a lot better than I do. And so if you think something is wrong . . ." Like Mitch, he was like, "There's just something missing here. What is it?"

Being an advocate for yourself and finding someone to have that conversation with about these things, because it can make the difference. Or it may not make the difference, but at least you'll understand the reason why and you can then make the informed decision of which way to go.

So I think that, for me, was the take-home. You guys both did that in your own way even though you ended up in two different places.

Scot: And those gentlemen are the two tales of T today on "Who Cares About Men's Health." Great conversation. Guys, as always, it's a pleasure to get together and talk about men's health. Dr. Smith, it was great having you on the show. Thank you for listening, and thank you for caring about men's health.

Dr. Smith: Take care.

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Scot: They say kidney stones are more painful than childbirth, if you can believe that. I suppose people who have had kidney stones would think that. This is "Who Cares About Men's Health," a Men's Health Essentials. We're talking about kidney stones today. Is there anything you can do to prevent them?

And we've got the cast and crew here today. My name is Scot Singpiel. I bring the BS. We've got Dr. Troy Madsen. He is the MD to my BS.

Troy: Hey, Scot. I've never given birth to a child, but I imagine it's painful and I imagine kidney stones are much more painful.

Scot: Producer Mitch is also on the show.

Mitch: Hey. So I'm looking at this pain scale, not to derail too far, but out of 50, a kidney stone says it's 42, and childbirth is a 32, and a really bad tooth break is a 19.

Scot: Oh, wow.

Mitch: I'm excited to hear more.

Scot: Dr. John Smith is a urologist. He's going to help sort us through the kidney stones. How are you doing today?

Dr. Smith: Oh, living the dream, gentlemen. Thanks for having me.

Scot: You ever have kidney stones?

Dr. Smith: I have not, but I've seen enough patients that have that I drink four liters of water a day to make sure I don't have one.

Scot: It's one of those things where when you see somebody that has it, you start doing the things that are going to prevent you from getting them. Is that actually one of the good things to do? Is it caused by not drinking enough water, or can you prevent them by drinking more water?

Dr. Smith: Absolutely. So the old Chinese proverb of the solution to pollution is dilution is correct.

Mitch: I love that.

Scot: Is that a Chinese proverb?

Dr. Smith: I don't know. It was told to me when I was training by one of my mentors and he said it was a Chinese proverb, but it doesn't sound like one to me. It just sounds like good advice.

Scot: Yeah, sure.

Troy: That's funny. So you've heard that in your urologic training, and then I hear it all the time with toxicology, with overdoses. "The secret to pollution is dilution." So, anyway, it crosses multiple specialties

Dr. Smith: And the orthopedic colleagues will say, when they're rinsing out a joint that's infected, that that's the solution.

Troy: Yeah. There you go.

Scot: So, with kidney stones, what's causing those things? Is it because of something I've eaten or something I'm doing, or are they more hereditary? What's the story on that?

Dr. Smith: Yes.

Mitch: Well, no. That's a really good question. I've got a buddy, he's a listener, and I don't want to go too far into it, but I've seen him go through kidney stones. It seems like he gets them every single year. And I know he does a lot to drink all his water, he's done some things to change his diet, but he still gets them. So what could be causing them other than lifestyle, I guess?

Dr. Smith: So I don't know. Troy, do you want to jump in here? I'm happy to go over my spiel that I give my patients who are the chronic kidney stone guys and even the ones who are first-timers.

Scot: I think we want to hear that, don't we, Troy? I mean, I could listen to Troy anytime. I don't always get to listen to Dr. Smith.

Troy: Scot gets tired of listening to me, so please go on.

Dr. Smith: Man, that was some shade, Scot. Wow.

So when I have folks that come in and we talk about kidney stones, there are a couple of different reasons that people get them. And usually, for folks that are first-timers who've never had a kidney stone before, they meet . . .

The other day I had a patient in his mid-40s who came in, never had a kidney stone, and we started discussing stones. Most commonly for folks who aren't predisposed genetically or have some kind of a metabolic issue, it's usually a hydration issue. And so dehydration will put you at risk for stones.

I usually use the analogy of if you ever made those salt crystals or sugar crystal things as a kid where you had that pot of tons of salt or sugar and you dipped a string in and you made those crystal things. You guys ever do that?

Mitch: Yeah.

Scot: Yeah.

Troy: Yep.

Scot: That's what's going on?

Dr. Smith: It's similar to that, because the more concentrated your urine is, the more stuff that's in there that could form a stone. And all a stone is, is a crystal that forms and it's made of different material. The most common ones are calcium-based. A dilute urine will not form a stone the way that a concentrated urine would. So that's the first thing I tell people to do. To drink plenty of fluids is going to keep them from having a concentrated urine. That's number one.

And I usually say there are four things that you can do to prevent a kidney stone regardless of the kind of stone you make, regardless of why you get them.

Number one is hydration. And I usually tell people you want to make at least two to two and a half liters of urine per day. Now, that's a hard one to do because nobody just measures their urine every day. And so that generally means . . .

Scot: Let alone in liters. I mean, what are we doing with the metric system here? We're in America. Come on.

Dr. Smith: Well, but in medicine we use the metric system, unfortunately. But I usually tell folks if you go get those big packs of water at Costco or the supermarket, those are a half a liter each. Those 16.9-ounce bottles are a half a liter each. So you should be drinking four to six of those a day.

Scot: Yeah, or one of those big sodas. Those are two-liter bottles of soda. Now you're talking.

Dr. Smith: Sure. See, now we're talking things. So if you drink at least 6 of those a day, your body uses between 500 and 750 milliliters of fluid a day for metabolic purposes, and so you're not making urine out of that. That's just what you need to be alive. And so anything above and beyond that gets turned into urine. That's why I say you need to drink two to three liters of water per day. To make two liters of urine, you've got to drink around three liters.

Troy: Now, Scot just mentioned he's going to go start drinking those two-liter bottles to measure it. What about drinking soda? Is that going to increase your risk?

Dr. Smith: So it can, depending on the type of stones you make. Obviously, the more stuff you have in your body that your body has to metabolize and break down and put into the urine, the more stuff is in your urine, the more likely you are to make a stone.

And so, for some folks, they're really predisposed to that, so it can make a difference for them. And for other people, it may not make a huge difference. That's something where when we get to the diet-related stuff I usually mention, but the first thing is just drinking plenty of fluids.

The second thing that anybody can do would be to decrease the amount of salt in your diet. And so that means soda. Oftentimes diet soda in particular has a ton of salt in it, as well as other processed foods. Pre-made stuff that you buy at the supermarket has a ton of salt in it.

Your body gets rid of excess salt in the urine and oftentimes the other solutes, the things that are going to help make stones, will follow that salt out into the kidneys and make urine. So that's another thing that you can avoid.

The third thing you can do is avoid animal protein. Now, that doesn't mean beef. It means any kind of animal protein -- fish, pork, chicken. Those create a high acid load in your system and decrease the pH of your urine. And when your urine pH is decreased, that increases your risk of stones. Stone formation increases when you have a low pH in your urine.

And that leads into the fourth thing that I usually tell people. Alkalinizing your urine in some way with lemon, lime, fresh fruit, berries, things that have citrate in them will cause a base to form in the urine and increase the pH.

So those are the four things you can do. Without knowing what kind of kidney stone you have if you've never had it analyzed and you have chronic stones, those are the four things you can do to decrease your risk of stones.

Scot: So coming back to our core four, kidney stones are caused by the types of foods that we're eating and drinking. It's totally diet based, right?

Dr. Smith: So not necessarily. Obviously, the dehydration thing is huge, but someone who has . . . So Mitch's buddy probably has a metabolic issue where his urine makeup predisposes him to having stones.

And so oftentimes, for folks in that situation, we'll do a 24-hour urine test and look at what's in the urine and what's spilling into the urine to see what's high level. If there are high levels of calcium or high levels of certain chemicals, high levels of nitrogen from animal protein, high levels of just salt, and different things that can predispose you to having stones, we definitely look at those.

Scot: How much does genetics play into whether somebody develops kidney stones or not? I would imagine that there are plenty of people that aren't drinking water and eating high salty foods and never get stones, or is that not true?

Dr. Smith: No, I think there is definitely a genetic component. How strong it is, is very difficult to kind of put your finger on. The literature shows that there can be some predisposition for folks who have family history.

And I've seen that anecdotally in my practice. Folks who come in at a younger age with stones oftentimes have family members who have chronic kidney stones. So I definitely think there's a correlation for those folks. Absolutely.

Scot: And you talked about the different kinds of stones. What's that about?

Dr. Smith: Well, there are a few different kinds of stone. The most common are calcium-based. There are calcium stones, multiple different kinds of calcium stones, but the important part is they're made with calcium.

Now, that doesn't mean don't drink milk, don't eat calcium. You actually want to have a normal amount of calcium, but not overdo it and not underdo it, which has been a misnomer for people. They're like, "Oh, I'll just stop drinking milk, I'll stop eating calcium, and it'll fix my stone problems." And it actually has been shown to make it worse in some of the literature. So you don't want to cut that out completely, but you also want to make sure that you're not eating other foods that may be problematic.

So calcium oxalate is the most common types of stones. And when you have a high oxalate diet . . . So coffee has oxalate, tea, spinach. Dark green, leafy vegetables have oxalate in them. There are other foods that have oxalate. Some people will say, "Oh, you've got to go on an oxalate-free diet," when in reality if you have calcium and oxalate in your gut, your gut can bind those things and it actually gets put out in the stool instead of going into the system. That's why you don't want to cut out calcium completely.

I mean, there are a lot of dynamics to kidney stones that kind of make it difficult, and knowing what type of stone you have can be helpful. So the calcium stones, we can kind of base things on diet.

The other type of stone that we see in folks is uric acid. Those are probably the second most common that I see. Those ones can actually be "melted" with medication and alkalinizing the urine, making the pH of the urine go up. So that's one where if we know that someone makes those and we keep their urine pH up, we can decrease the size and the amount of the stones that they make with the pH of the urine.

Scot: Which stones are the prettiest stones?

Troy: Calcium, of course.

Dr. Smith: They're all beautiful. They're all terrible.

Troy: Well, the calciums are kind of nice and shiny and it almost looks like a pearl.

Scot: Are you serious, Troy? Do they really?

Troy: I don't know.

Scot: I thought maybe you knew.

Troy: I just know they show up really well on an X-ray.

Dr. Smith: They do. That's the calcium.

Troy: Yeah. I don't know how they look when they come out exactly. But I can say hearing this, though, it sounds like the key is, like you said, John, drink lots of water, try to avoid eating too much meat, avoid salt, fruits and vegetables. Those are the keys. I mean, that just kind of gets back to a lot of what we talk about. Just healthy diet in general.

But hearing this, we talked just a little bit about the pain with kidney stones, but I can tell you when I see someone in the ER with a kidney stone, I don't know that I ever see anyone on a regular basis in the ER who has more pain than a person who's there with a kidney stone. You can tell. You walk in the room, they're writhing. They're pacing around the room, kind of holding their side. It's just incredible pain.

Every time I see them, I kind of have the same feeling you do. It's just like, "Hey, I want to do everything I can to avoid this." And if it means drinking tons of water and just watching my diet, it's well worth it just because that looks absolutely miserable.

Mitch: So what are some of the symptoms, I guess? I mean, we're talking about the pain itself and how to prevent them, but what are the actual symptoms? Is it just, "I've got pain in my stomach"? Or where do we feel it and things?

Dr. Smith: Well, I think Troy could probably answer that because he has them come in, but usually it's a pain in the flank, which is kind of the upper outer portion of your back on either side. And as the stone kind of travels down the ureter, that pain can migrate to the low back, even into the groin.

And I usually tell folks when stones are sitting in the kidney, they don't usually cause pain because they're not obstructing. They're not bothering you. But when they start blocking the flow of urine and they get into the ureter, the small tube, your body tries to get rid of that by peristalsing, just the way it does when it moves food through your intestines.

And so at that time, the stone, once it gets into the tube is where you start to have the pain and it usually starts in the flank and then moves down.

Troy: Yeah, and that's exactly what I see. People are kind of holding their sides. So if you were to kind of reach around, hold your sides of your abdomen, that's typically where they're feeling the pain. I push on their stomach, their belly doesn't hurt, they're not really tender, but it's just a deep, severe pain. And they'll tell me it comes and goes, it's sharp, sometimes it's better, sometimes it's worse. John, it's exactly like you mentioned, that spasm where that ureter is spasming. That's when they really seem to have severe pain.

Scot: And then is the treatment painful too? I mean, is this the double whammy of not only does the thing hurt, but the treatment is going to hurt bad as well?

Dr. Smith: Well, what Troy does for people doesn't hurt. They really love Troy. They don't like it when they come and see me after they've seen Troy.

Scot: Okay. Because Troy gives them . . .

Troy: I just give them pain meds.

Scot: And then you send them to John.

Troy: Exactly. But it's great, though, because there is a non-narcotic and non-steroidal anti-inflammatory medication that we give intravenously. And it just works beautifully for kidney stones. So it's not like we're just knocking people out with narcotics. Some people need narcotics, but so many people, I give that medication and they're just like, "Wow. I feel better."

Scot: What's the treatment then, Dr. Smith?

Dr. Smith: So there are a couple of different treatments depending on where the stone is at and different things. I mean, there's a little bit more to it here, some nuance. But if it's moving down and it's relatively small, oftentimes we'll offer people to pass it on their own. We call it medical expulsive therapy. It's not pretty, but it gets rid of the stone.

And so we give them some medication to help the stone pass. And after we do that, we let them kind of do their thing and pass the stone on their own for a couple of weeks. And if it doesn't pass, well, then we bring them back and we offer them surgery. Stones can be . . .

Scot: Ugh.

Dr. Smith: Go ahead.

Scot: No. I just went, "Ugh."

Mitch: Yeah, ugh.

Troy: Two weeks of that. Yeah.

Scot: Yeah. I don't have to say anything other than ugh.

Dr. Smith: I mean, I'll give them a little bit more than two weeks if they're really confident that they're passing it and they're not wanting to do anything surgically.

But the other options that we have are if the stone is visible on an X-ray, just like Troy alluded to earlier, sometimes we can do what's called an extracorporeal shock wave lithotripsy. Some people just refer to it as lithotripsy, where we use an external shock wave beam to break up the stone, and then you still have to pass the fragments. And that's only if we can see it on an X-ray to target and hit it.

Scot: So those are my two options? Either give birth to that stone myself or . . .

Dr. Smith: No, there are other options. I'm just saying those are the two . . .

Scot: Oh, okay.

Dr. Smith: I'm going from least invasive to most invasive here.

Scot: All right. Get them busted into shards or have surgery. Yeah, that's more reasons why to drink more water, I guess.

Dr. Smith: Exactly. So the third option that I offer folks is called a ureteroscopy laser lithotripsy, where we go up with a small, thin, flexible camera and we find the stone and we blast it with a laser.

Scot: Oh, that sounds badass.

Dr. Smith: It's pretty cool.

Mitch: It's all pretty cool, but miserable.

Dr. Smith: Yeah. And usually, with that, they have to put what's called a stent, which is a small, thin, flexible plastic tube from the kidney to the bladder. And they are miserable. I always tell patients, "It's miserable. You keep it in for about a week to let things heal and then you take it out in the office."

Troy: And I think Scot, when he thought that was really cool, I think it's probably worth telling him how you get the laser up to the stone.

Scot: Oh, no.

Mitch: Oh!

Scot: No, I'm good.

Troy: You're good? Okay.

Dr. Smith: Well, there's no cutting, Scot, so you can use your imagination.

Scot: Yeah. Just thread that thing right up there, huh?

Dr. Smith: Yep. Just like throwing darts.

And then the last thing that we do for stones if they've gotten too large to pass and they're in the actual kidney, we can do what's called a percutaneous nephrolithotomy. They use the term PCNL because it's way easier to say. And that's where we make a small incision in the back and we go into the kidney and we actually are able to remove the stone in larger pieces that way.

That's obviously the most invasive way to do it, and we do that for much larger stones. You've got to have a stone that's a centimeter and a half or larger, or at least that much volume of stone in the kidney before we would contemplate doing that.

Scot: Troy, can these stones get so bad that you're going to see somebody in the emergency room that has to have an emergency surgery because they just can't urinate anymore?

Troy: I can't say I see them where they can't urinate, because usually it's just in one of the ureters and so the other kidney is working, although you could have it, I guess. I've rarely seen it where it's so bad that you can really see it's impacted their overall kidney function.

The more concerning thing I see is when you get an infection along with the stone, and those are the cases where they're definitely admitted to the hospital.

But yeah, if it's a really large stone, like John mentioned . . . Usually the cutoff we use is six millimeters, but even there, I think sometimes our urologists will say, "Give it a little time. Let's see what happens." But if they've got a big, centimeter and a half stone just lodged in there, yeah, those are cases where the urologists will admit them and do something sooner rather than later.

Dr. Smith: Good point, Troy. When you have an infection above the stone blockage, those folks can get real sick real quick. And those are the people that emergently get surgery. And oftentimes we don't treat the stone immediately. We treat the infection. We put a stent in and give them antibiotics and come back another day to take the stone out. They're just so fragile as far as their health goes at that point that oftentimes they need antibiotics to clear out that infection before we're able to treat the stone.

But Troy is right. Anything 5 millimeters and under have a 75% to 80% chance of passing on their own. Now, that to be said, I have folks who come in with two-millimeter stones who are unable to pass them and folks with seven-millimeter stones that pass them and they said it wasn't a big deal. So, again, it's all relative to the patient. But once you get these larger stones, definitely surgery is much more frequent for those folks with larger stones.

Scot: Hey, Mitch, we're wrapping this up. Do you have anything you'd like to share?

Mitch: I'm just very uncomfortable and trying to drink my water off camera. That's what I'm doing right here right now.

Scot: You went and got some more water.

Mitch: I did. And I'm saving everyone from the sipping noises, but yeah, a refill was necessary.

Scot: These lifestyle changes that we make, Dr. Smith, is there a percentage of reduction of risk that they will do that we know about?

Dr. Smith: That's a tough one. I don't know that there's an actual percentage of risk. I would say when you do it, if you are a chronic kidney stone patient, we usually follow your 24-hour urines to check your risk assessment. But folks who have a stone and pass a stone and then hydrate themselves can really reduce their risks just by doing those things.

The numbers that I know and usually quote people is if you have a kidney stone that requires surgery, 50% of folks who have that issue will have another episode of a kidney stone within a year. And so that's why I usually tell folks the more you can do to drink and keep them away, the better off you are.

Scot: Well, it was a fun topic. I still don't know which stones are the prettiest stones, which makes me a little bit sad, but that's okay.

Dr. Smith, thank you so much for being on the show, and educating us on kidney stones, and telling us what to do. Would you like to summarize, Mitch? What are you going to do? You're going to drink water. What else?

Mitch: I'm going to just drink all the water and I'm going to make sure that I'm not having too much salt in my diet.

Scot: Watch the processed foods.

Mitch: And watch the processed foods. I need to eat less taquitos.

Scot: And maybe a little lime in your water, it sounds like. Is that right, Dr. Smith?

Dr. Smith: Yeah.

Scot: Get that pH down. Is that what that . . .

Dr. Smith: It won't hurt you.

Scot: No, that's getting that pH up, isn't it?

Dr. Smith: Yeah, pH up. Correct.

Scot: Yeah.

Mitch: Okay. So preventing scurvy and rocks in places I don't want rocks. Got you.

Scot: Dr. Smith, thanks for being on the podcast. Thanks for caring about men's health.

Dr. Smith: Troy, Scot, Mitch, it's always a pleasure. Thanks for having me.

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.

Scot: So will testosterone solve all my problems as a man? That's today on "Who Cares About Men's Health," providing information, inspiration, and a different interpretation about men in men's health. He brings the MD to the show. Ladies and gentlemen, Dr. Troy Madsen.

Troy: Yeah. Ready to talk about testosterone. I am curious, very curious. Where do we go with this? What do we do?

Scot: Offsetting the MD, I bring the BS. My name is Scot Singpiel. And Mitch, he's responsible for bringing the microphones. Welcome, Mitch.

Mitch: Hello. Hi.

Scot: I think Mitch needs some testosterone. You know how low key he is.

Mitch: It's low T day. I mean, based on everything I see on the internet, that's got to be what's going on.

Scot: Well, yeah. I mean, you go to the internet . . . I'm going to do my impersonation of the internet. You ready for this?

Mitch: I love it.

Scot: All right. You're, like, "You have low energy? You've got to get some T. You putting on a few pounds of fat? You've got to get some T. You having trouble sleeping? You've got to get some T." That's my impersonation of the internet. It's the answer to everything.

Troy: It is. It cures everything.

Scot: Yeah. So we're going to find out if that is actually true or not with Dr. John Smith.

So, Dr. Smith, what is the common complaint you get when somebody comes to you and they're interested in testosterone treatments? What problem are they trying to solve? What are they trying to cure? All the things I talked about? Something else?

Dr. Smith: Absolutely. I mean, I think the thing about testosterone is the symptoms are so wide-reaching -- fatigue, cognition, erectile issues. They've heard on the internet, or they've talked to a friend who's on testosterone, and they're like, "Man, it just changed my life. It fixed everything." Which in some people's cases that may be true, but for most people, it definitely can play a role in helping them out, but I don't think it's the cure-all that you're talking about, that the internet shows. It's not making Frank Thomas who he is today.

Scot: And that's dangerous, right? Because you can get testosterone without even having a face-to-face conversation with a doctor, right? You can essentially just order it online. Is that true or is that overstated?

Dr. Smith: I think some of the newer companies you've got out there that are making things available . . . hopefully you're getting at least a video conferencing going over your medical history with someone who's a medical provider, whether it be a nurse practitioner, a PA. Hopefully you're talking with a physician. If they're not doing it that way, they're doing it wrong.

But testosterone is one of those things where it can be very helpful. I have quite a few patients that are on it, and I think it is one of those things that can definitely benefit people. But the extent that it benefits them kind of varies between patients.

Scot: Testosterone, I get the impression that it's probably not a do-it-yourself sort of a thing. It's not something you want to, as a layperson, just dive into on your own. Why is that?

Dr. Smith: Well, there are certain . . . everything has a risk and a benefit, and testosterone is no different. For people who have low testosterone, replacing it can really make a difference. It can give you that increased boost of energy, help you with weight loss, help you with metabolism, help with sleep. It can help with erections. I mean, it can help with cognition in people who have low testosterone. However, it's not necessarily the thing that's going to fix all those problems.

And oftentimes I'll go through people's history and say, "Hey, man, your testosterone is normal. Adding more to the mix isn't likely to fix things. We should look at other issues." And so I think really just taking that deep dive and seeing if it's something that is right for you is important.

Troy: I guess, John, I've seen all this stuff Scot mentioned, you see all these things on the internet, you see TV ads, etc. Yeah, I think I wonder myself, "Man, is my testosterone low? Should I be worried about this?" At what point do you tell people, "You should get your testosterone level checked"?

Dr. Smith: I think if you've looked at some of the other . . . if you've talked to your primary doctor and kind of gone over things, the usual suspects of a thyroid issue or vitamin deficiencies, things like that that they check a lot, if those are all normal, I think it's completely reasonable to look at it.

Some people say, "Oh, well, my dad had low testosterone and I got it checked in my 30s." But if you look at the facts of the matter, about 40% of people over the age of 45 have a testosterone level of 300 or less. And so that's a decent amount of the population that's out there. And so I think if you have an interest in it, it's okay to ask to have it checked because it's better to know and to at least know what your options are where it may be a benefit to you.

Scot: And how do you do that, then?

Dr. Smith: So your regular doctor can check it. You can make an appointment with a men's health specialist like we have at the University of Utah. We have a men's health group with multiple different providers. We have nurse practitioners, PAs, and multiple MDs and DOs that can take care of your needs as far as checking the hormones. But that's the first thing that we do.

And hormones, ideally, should be checked before 10:30 in the morning because our bodies spike testosterone between the early hours of the morning. Usually people will say between 4:00 a.m. and 10:00 a.m. in the morning. And so we want to check it to see what your body is actually doing.

If you're low in the morning, the odds are that you're high in the afternoon are going to be really slim to zero because your body spikes it in the morning to give you that boost of the hormones that you need to get you through the day.

Scot: And when you take a look at that test, it's a range, right? So a man gets the test done and you've got some numbers and there's a range. And what does that tell you? Let's pretend I'm at the low end of the range, but I'm still considered normal. Is that somebody that you would suggest testosterone therapy for?

Dr. Smith: I think a lot of it is the discussion that you have with the patient. So the range is huge too. If you look at the range, most labs are between 300 and 1,000. Some are a little less, some are a little more, but just for intents and purposes of this discussion, about 300 to 1,000.

So let's say, Scot, you're at 350. Well, what does that mean? Insurance requirements say that we've got to get two tests that show a low value before 10:30 in the morning. So let's say we've done that. You come in, your first one was 350, your second one was 340 or 338. What do we do from there? Well, then we have a discussion.

And I think in a lot of those folks, it is reasonable to discuss therapy. People outside the normal range, it's obviously okay to discuss that as well, but people tend to feel better in a range around 400 to 700. Sometimes, some people will say 600 or higher. There's a lot of different variability out there between who you talk to about it.

But again, if you're feeling the symptoms of fatigue, decreased libido, decreased erectile quality, some of those things are really hitting you hard, and you're like, "I'd love to try testosterone to see if it would help some of those symptoms," I think it's completely reasonable to do that.

Mitch: But insurance won't cover it unless you are beneath that range?

Dr. Smith: Not necessarily. Insurance wants to see that you're in the low. Really, I think it's reasonable for anybody that's 350, 400, and below. You can talk to them about testosterone replacement therapy. And if there's benefit there, insurance usually won't balk at it. And if they do, and it is helping you, cash pay for this stuff is not obscene.

Mitch: I'll just disclose. Now, I had my testosterone levels checked after we did a previous episode, and my number is right around 400. And my primary care provider is like, "Oh, no, you don't need to. We don't need to. There's no need to talk about testosterone therapy." And so I've kind of put it in the back of my mind.

But then at the same time, you have the weird people on the internet that they say you need to be 600 or 1,000 or above to be healthy. And it's just like if I'm right there, I'm at the 400, maybe it would be helpful. What would you say to someone in my situation?

Dr. Smith: I think you've got to look at the whole picture, but I think it's definitely something that you could consider. Again, most primary care doctors don't do a lot of hormone replacement, so they're going to say, "Hey, you're well within normal range. We're not going to touch it. We're not going to do anything," because that's their comfort zone.

This is the thing that I do every single day where I get people sent from their primary care doctor to talk about this stuff. And I think it's an in-depth conversation of, "Hey, let's look at the whole picture. Is there anything else going on that's a problem, or could be seen as a problem? Do you have a thyroid issue? What is your BMI? How does your weight look? What's your exercise routine?" and things like that, because those things can be done before supplementing testosterone.

And there are some interesting numbers out there with diet and exercise. If people will lose weight of 10 pounds or so, you can increase your testosterone by 100 points by losing 25 pounds and getting diet and exercise.

But a lot of times, it's hard to get the motivation to go do diet and exercise when you're overweight and you're really lethargic. And so it's like, "Would testosterone help me get there?" and a lot of those things as well.

And so again, exercise 15 minutes a day for 6 months of moderate intensity exercise will increase your testosterone by 22 points. And then if you're exercising for 30 to 40 minutes a day, you'll increase it by 50 to 60 points. And so again, there are things you can do other than testosterone if you're kind of in that range, and any of those things fit.

Now, Mitch, I know you're super fit, so that doesn't really . . .

Mitch: Yeah, I'm the fittest guy.

Dr. Smith: . . . matter for you. But if those are things that you can do, those are modifiable things you can do in your life to increase your testosterone naturally.

Mitch: Got you.

Troy: You mentioned diet also, John. I mean, it sounded like we're talking more about weight loss here, but are there any kind of dietary changes in terms of foods you're eating or foods you can eat or even supplements that would increase your testosterone levels without actually having to go for any sort of hormone replacement therapy?

Scot: Raw eggs and meat, right?

Dr. Smith: Right. Exactly.

Troy: Well, sure. Yeah.

Dr. Smith: You've seen Gascon in "Beauty and the Beast." That's how he got so huge.

Troy: Exactly.

Dr. Smith: There are no real big things that are out there that are known to necessarily just be super beneficial, other than eating as clean as you can.

Testosterone is a hormone and hormones are built on a backbone of cholesterol, so they're kind of fat. They're built on fat. And so when you have excess fat tissue, sometimes the hormones like to hang out there because they don't love water. And so you'll find that people may have a higher testosterone level when they lose that body weight, because now they don't have as much body fat and that testosterone is able to kind of circulate. Plus, you're in better health and your body is able to just do what it does better.

Troy: Speaking of our concerns . . . obviously, Mitch has thought about it. I've thought about it. I know, Scot, you've told us before you've had your testosterone level checked. I think a lot of men wonder about this, and I think we get concerned and we say, "Hey, maybe I don't have a lot of energy," whatever it might be. Of those who come in to get tested, what percent really have low testosterone?

Dr. Smith: I mean, my practice is kind of skewed, because by the time a lot of these guys get to me, they've already had it checked with their primary doctor who's not going to treat them unless they're outside of the normal range. And then when they are, they get referred to our office. A lot of primary care doctors don't love treating testosterone patients and they know that that's kind of what we do.

And so I get a skewed percentage. Most of the people who come in and are looking for testosterone have already kind of been pre-screened, so they are low. I would say a vast majority, at least three-quarters of the people that I see, already have testosterone levels that come back and are low and they're there to talk about therapy as a referral from their primary doctor.

Troy: Interesting. Yeah, I just wondered if it's one of these things that it's just something else for us to worry about. And if a lot of us are getting tested and it's a small percentage, or maybe it is, like you said, over 45% . . . I think you mentioned 45% of men have levels under 300. So maybe more of us should be getting tested at some point and we're just not getting tested.

Dr. Smith: Yeah. It's around 40% over the age of 45, you'll see low testosterone levels. And again, it's one of those things where you tend to hit that middle age, people tend to not necessarily be as active, and things like that as well. So there are a lot of things that go into it.

But if we're looking at the actual testosterone itself . . . Let's say you come in, you're low or you're low normal, and you want to try testosterone. There are a lot of things you need to have a discussion with the patients about. Are you interested in having children in the future or any more children if you already have children? What are your goals as far as that goes?

There are multiple different ways to treat testosterone these days or to treat low testosterone, I should say. And kind of having that full disclosure discussion with the patient goes a long way, because there are multiple different modalities of treating it from oral medications to topical medications, to injections, to long-term injectables, to subcutaneous pellets. I mean, there's a myriad of different treatment options that we can discuss.

Scot: And of your patients that you start on therapy, you mentioned that the symptoms can be very broad and caused by a lot of different things. Maybe you're not getting enough sleep. Maybe you've got too much stress in your life. That's why you're low energy. Maybe you're not eating the right foods or exercising. That's why you don't feel good. How many after they get testosterone that come in that have low testosterone actually go, "Yeah, that made a difference," versus, "I'm about the same"?

Dr. Smith: Majority of them. But that also varies via the root that they get testosterone. So I'll talk kind of a little bit about each modality. Oral options is . . . there's a medication called Clomid. A lot of people know it as a fertility medication. Women use it for fertility purposes. But what the medication does is it stimulates your body to produce more testosterone and more sperm. This is a very gradual improvement in testosterone. And a lot of times people don't feel that robust boom, that jolt of energy and things, because it's kind of a low-key slow rise of the testosterone back into the normal range. They don't have that big boost.

And most of the time, when people have that boost, it's from the injection because they're injecting a bolus of testosterone that then is being absorbed into the body and they have their levels shoot outside the normal range. So they feel like Superman. It gives them that rush of testosterone, which you don't get with topicals, the lotions, and you don't get with the oral because it's doing what your body normally did before you didn't create enough testosterone. And so you don't get those super highs that you would have before.

So a lot of patients know, "Oh, man, I do have more energy. I do feel good." The ones who do injections tend to come back and have more of a, "Man, that's great. This stuff is great," because they get that boom, that rush, that spike of testosterone very quickly.

Troy: And then how long until that wears off?

Dr. Smith: So usually people inject on a weekly basis, sometimes every other week, depending on their injection tolerance. And I do have a few patients who inject multiple times per week of low doses because they don't like that roller coaster effect. You do really get a high of testosterone and then it kind of fades out over the course until you do your next injection.

And so that's what they notice. They're like, "Man, I just get this high, and I feel it for about two to three days, and then it kind of wears down and I feel pretty good. And then when I do my next injection, I get that high again." I see that a lot more frequently with people who inject testosterone rather than take oral medications or do topical gels.

Scot: And what about side effects or downsides to testosterone therapy?

Dr. Smith: Man, it's almost like you wrote a script for that or something.

Troy: Talked about the good stuff. Let's talk about the bad stuff.

Dr. Smith: I'm going to make you feel like Superman. And now I'm going to tell you the downside.

Scot: Kryptonite is no good for you.

Dr. Smith: Exactly. You really have to monitor things with testosterone. So testosterone can cause an increase in red blood cell mass, and that in and of itself isn't necessarily a bad thing as long as it doesn't get outside of the normal range too far. That puts you at an increased risk of a cardiovascular event, like a heart attack or stroke.

Now, those incidents are rare, but it's something that we definitely keep an eye on. And that's a reason why we follow these folks with labs regardless of the type of replacement that we do.

Other things that we follow is your estrogen levels can rise because testosterone is a precursor to estrogen. There is a molecule called aromatase that actually converts testosterone to estrogen. Their chemical formula is very, very similar.

Your body likes to keep a ratio of about 10-to-1 testosterone to estrogen, and so the higher your testosterone goes, the higher your estrogen level goes.

And some people will develop breast sensitivity, nipple tenderness, or breast growth from elevated estrogen if their bodies are over-converting to estrogen. And so we watch that closely because that can be bothersome to folks.

And then a couple of the other things, we always monitor PSA in folks that are over the age of 40, or at least I do in my practice because . . . There's not an increased risk of prostate cancer, but if you were to develop prostate cancer, testosterone would feed the prostate cancer.

It's kind of like if you have a match and it's lit, nothing happens. But if you have a match and you pour a gasoline on it, you have a problem on your hands. And so the prostate cancer would represent the match and the testosterone would represent the gasoline. It would help it to kind of progress faster in a way.

And those are the things that we really kind of keep an eye on, especially people with family history or people who have had prostate cancer that we're treating with testosterone, which yes, we do that quite frequently.

Troy: So now that we've talked about the risks of taking the testosterone supplement, let's just say someone is like, "Okay, I've had my testosterone level checked. It's low. I don't want to assume those risks." What's the downside of that?

Dr. Smith: So the downside is you can develop osteoporosis with time. There are some studies that . . . initially some studies came out with testosterone that said testosterone supplementation caused cardiovascular issues, and now it's become the opposite. That's been debunked, and there is some literature out there, I don't know that it's super robust, that said low testosterone can increase your risk of cardiovascular events. So those are the big things of not having enough.

Long term, it's really difficult to assess a lot of those risks, but those are the risks. if you were to just have low testosterone.

Scot: Do you have anybody ever come in that you just are like, "No, it's not a good idea for you"?

Dr. Smith: Yeah. I mean, people who come in with a testosterone level of 600 from their primary care doctor. It's a bad idea.

Scot: Yeah. But I mean low testosterone. Is there ever a time where it's just like, "No, probably not. The risks are too big"?

Dr. Smith: So I think the one thing that I didn't get to with the risks is testosterone replacement will cause sterilization. It will stop you from being able to have children. When you supplement testosterone . . . not all methods of supplementation will hurt fertility, but injections will. Anything that's injectable topical or the long-term injectables or pellets all will cause sterility to a point. And so those things are things that you've got to have those conversations.

So if someone comes into my office and they have low testosterone and they don't want to take the pill like Clomid and they're like, "I just want to do injections, but I still want to have kids in six months," I would say, "Let's hold off until you're done having kids or until your wife gets pregnant, or go donate some sperm so that you can have children if that's your goal, before we start therapy."

Scot: Mitch, given the information that you just got today, are you going to go in? You're going to get some T?

Mitch: I don't know. I'm in a place where I think that after this conversation, I would like to go talk to a men's health specialist, especially if there is a hesitation from primary care physicians to just be like, "Oh, you're in the normal range. You're good." There is a curiosity there. There is an interest there, knowing where I'm sitting at on the levels, if they think it would be something that could help with some of the situations that I'm dealing with right now.

Scot: I guess I'm afraid that it just sounds like another pill. I don't mean that as I don't want to take drugs. I just mean we're all looking for the quick fix, right? So yeah, maybe I'm a little tired. Would I like to lose some fat? Sure. Would I like to have a little bit more muscle mass? Yeah. If I'm in that normal range and on the low end, I don't know. It just feels like I'm expecting too much. I'm going in for the wrong reasons. Does that make sense to anybody?

Dr. Smith: And I don't think you can necessarily . . . I mean, again, I'm not trying to sell testosterone here. I just think that . . .

Scot: No, that's not the point of this. We're just trying to get some information, for sure.

Dr. Smith: Right. But I think that if you want to feel your best and be able to do your thing to the healthiest you can be, I don't think it's a bad thing to come in with the desire to be healthier, to feel better, to have more energy. Again, when you start testosterone therapy, you do have a change in lean muscle mass by about five kilograms switch over from body fat to lean muscle.

Scot: Hold on a second. Hey, Siri, convert five kilograms to pounds.

Dr. Smith: Right. Exactly.

Troy: That's a lot of pounds.

Dr. Smith: It's 2.2 pounds per kilogram.

Scot: It's 11 pounds there. All right.

Dr. Smith: Actually, I said that incorrectly. It's five pounds of fat or two and a half kilograms. My apologies.

Troy: That's still a lot.

Dr. Smith: But still, a five-pound change in your body mass, it can be substantial. It can really help. And again, those are just the numbers that we have from the literature that's out there. And so it can be beneficial.

I don't think there's a wrong reason to come in to look for it. Most patients aren't coming in to be like, "Hey, man, I saw this magazine with this guy Schwarzenegger on it and he was pretty big. I kind of want to get there. Can you help me?" Those aren't the patients that I see.

People come in, they're like, "I'm really fatigued. I feel tired at night. My libido is down. I want to feel better. And I want to see if testosterone may be helpful in that regard." And they're not looking necessarily as a magic bullet or trying to use it as a substance of abuse where they can go and just change their whole body composition. But I think it is very beneficial for a lot of people.

Scot: Troy, where do you stand on it?

Troy: As we talk about this, I just feel like there are so many other things I need to address. That's way down the list. We talk about energy and everything there. I feel like, wow, I'm still trying to figure out how to sleep and those kinds of things. So I'm kind of hung up on that still. We've talked about this and if we talk about it today, I am still kind of curious about it, but I don't think I will be getting tested any time soon. I'll say that.

Scot: I noticed a parallel from another show that we did. You're talking about using testosterone treatments to kind of get over that hump, right? Let's say that you would like to exercise more, but you don't have the energy and you do find you do have a low testosterone. That was almost kind of like using medication for mental health. If you're having challenges with your mental health, it can be really hard to become motivated to exercise or eat well, or maybe you don't even sleep well. So you can take medications for a short period of time until you kind of get those things working. We talk about that Core Four, how they all interact with each other. And then possibly come off of it. Am I understanding that correctly?

Dr. Smith: Yeah. And I think if that's your plan, you've got to look at a way to keep the testicles producing while you do that. If you went to an injectable or a topical testosterone that's going to shut down the body's production . . .

So let me nerd out a little bit with the physiology of this. Your body has these precursor hormones called FSH and LH. And those are the two hormones. They are in both men and women. In women, they regulate the menstrual cycle, and in men, they stimulate the testicles to make testosterone and sperm.

And when you give testosterone, it's a negative feedback loop. And so your body sees there's enough testosterone in the bloodstream and stops sending FSH and LH to stimulate the testicles. And so you've got to do something to keep those testicles producing if you're going to be on testosterone in the short term. That's where other drugs come in.

There's an injectable called HCG that we use to help stimulate. It's an LH analog, meaning it's not LH, but it will stimulate the LH receptor on the testicle. And it will continue to have the testicle continue to produce at a lower level, even though you're giving yourself exogenous testosterone.

And then if you decide to come off after six months or a year or whatever, after you've gotten in shape and you've gotten that motivation, then you don't have this complete drop-off of testosterone where your body has to start making it again where it hasn't for the last year.

Scot: But it would. If you're using a topical solution that's telling your body then not to produce more testosterone, does that mean you're dedicated to that for the rest of your life?

Dr. Smith: You can. Now, you can come off of it. And the thing I tell people is if your body was already not producing enough and you haven't done a darn thing to change that, your body is not likely going to go back to producing more than it was before you started the drug. But then there's always that kind of window where your body has to catch up and it's not producing hardly anything at all and you just feel like garbage.

Troy: But it would come back over time?

Dr. Smith: Yes. And that's the part where the HCG comes in to help it, where you don't have as big of a drop-off. Scot: All right. So now I need to ask the question that I think everybody is wondering. I've heard that if you're on testosterone treatments, your testicles get smaller. Is that true?

Dr. Smith: Absolutely.

Scot: Okay. How small are we talking? Yeah.

Troy: What are we talking here? Yeah. Like raisin-size?

Scot: I mean, for running marathons, Troy, that might not be a terrible deal. Right?

Troy: Thanks, Scot. Much less chafing. Yeah.

Dr. Smith: He's looking out for you, Troy. He's looking out for you.

Troy: Exactly. It'd just be nice smooth surface down there.

Dr. Smith: You'll shave minutes off your time.

Troy: Exactly. All that extra weight.

Dr. Smith: Yeah, you won't have the metronome like you've got now, but it'll work out.

Troy: That's right.

Dr. Smith: But they do shrink, and over time you'll notice that testicular size loss happens the longer you're on testosterone. So people who've been on, say, long-term injectable testosterone, they'll shrink down and be very, very small when you get down to it, almost to raisin-like size that you'll see, which is something that I always talk to people about. And again, that's where HCG can come in if you want to preserve testicular size.

And to some people, that's important. And to other people, I say, "If you're not looking to have kids and it doesn't really matter to you . . ." I've never, ever in my experience of having this had someone come in with their spouse and had them saying, "Man, you know what? I just wish Troy's balls were bigger."

So I don't know how much it really matters, but I think a lot of times it is kind of the vanity side of it, of, "This is what I know, this is what I've had my whole life, and I don't want it to change."

Troy: Well, I will tell you, John, hearing that, I'm reassured that your patients are not talking about the size of my testicles.

Dr. Smith: Nor their wives, for that matter.

Troy: That's good.

Scot: John, let's wrap this up. I think we all know your bottom line. I think I've got your bottom line on testosterone treatments. If you're experiencing these symptoms and you get a test and you're in that low range or below, it could be a very good option to help you get some energy back, to help you with your sexual function, with few downsides, really.

Dr. Smith: Yeah. The downsides are minimal. If you're one of those people who overproduces red blood cells or something like that, we keep an eye on it, but yeah, that is the bottom line. If you feel like it's going to make a difference for you, there's a lot of good that can come from it. And it doesn't necessarily have to be a long-term thing. However, most of my patients that are on it are long term.

And I think if you do have questions, go talk to someone that knows what they're talking about. I'm happy to sit down with people. Most of my new hypogonadism patients/low testosterone folks, I like to spend time going over the benefits, the risks, and everything that is involved is involved so that they have a clear picture of what options they have.

And I do have plenty of people who come in and say, "You know what, doc? I think I am going to try to lose 25 pounds and recheck my testosterone." And then I have others who say, "You know what, doc? I just know myself and I'm not going to do that. And so I'm going to take the testosterone and try to do it that way." I think there's merit both ways. Absolutely.

Scot: John, thank you very much for having this conversation with us about testosterone. Hopefully, this will be helpful to a lot of guys. And bottom line, it sounds like perhaps guys who have talked to primary care physicians, haven't gotten a lot of conversation, it sounds like if you do go to a men's health expert, you've got a little bit more time to discuss through some of these issues and really come up with the right choice for each individual guy.

Dr. Smith: Absolutely. I'd be happy to see anybody in our men's health department at The U. I think we do a great job at taking care of folks and making sure that we go over the options and making sure that we help you make the right decision for you.

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

Dr. Smith: Gents, thanks for having me. It's always a pleasure.

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.

Scot: Welcome to "Who Cares About Men's Health." It's a Men's Health Essentials episode. A weak stream, is that something that you should have a doctor look at? That's what we're going to talk about.

My name is Scot Singpiel. I am the manager of thescoperadio.com. I provide the BS. That's what I do. The MD to my BS is Dr. Troy Madsen.

Troy: Hey, Scot. It's me, and I have to say I am so excited to be joining you today on the number two rated podcast in the world.

Scot: What?

Troy: Men's health podcast. Let me clarify that. The number two rated men's health podcast in the world. It's my honor to be here.

Scot: Tell me about that. We're number two?

Troy: We are number two. I did a search. I just searched on Google "top men's health podcast." The first site that came up ranks them by multiple factors. We are number two, behind "Men's Health" magazine's podcast. It's pretty cool.

Scot: All right. Wow.

Troy: We'll take it.

Scot: Yeah, I don't know if . . .

Mitch: We will take it.

Scot: . . . that's cool or that's more pressure. And joining us as always, Producer Mitch is in the mix.

Mitch: Hey, there.

Scot: And going to help us with our weak streams if any of us have weak streams . . . I think I might have a weak stream. I don't know. We're going to find out. Urologist Dr. John Smith, welcome.

Dr. Smith: Hey, thank you.

Scot: So weak stream. Hey, Troy or Mitch, how is your stream? Everything okay with the stream? You feeling pretty good about it?

Troy: The problem with a question about the stream, Scot, is I don't know what to compare it to. Should I be looking at guys in the airport in the urinals without the barrier there and just look at their stream? I don't know. I think my stream is good.

Scot: Yeah, or sometimes you listen, and it's like, "Oh, my gosh, what's that? About a gallon a minute coming out of there?"

Troy: Oh, yeah. Some guys are just like, "Wow." Yeah, it's something else. I feel like I've got a good strong stream, but I don't know.

Scot: All right. Mitch, do you want to comment or do you want to abstain?

Mitch: No. I know for a fact that I have an average or above-average stream because I've actually talked to a urologist.

Scot: Oh, you have?

Mitch: Yes, I have, about this very concern.

Troy: And you've measured it?

Mitch: They measured it. It's not like I measured it myself. There was a science to it that I'm sure Dr. Smith will be able to tell us all about.

Dr. Smith: So you objectively know you've got a good stream, it sounds like.

Mitch: I'm going to see if I can't pull up the graph. You guys might find that interesting, or gross. I don't know. Hold on. Keep going.

Scot: Dr. Smith, that's what we're here to talk about. I feel like perhaps as I've aged, maybe I've lost a little stream power. Maybe. I don't know. It varies. Some days I'm like, "Huh, this isn't coming out very fast." And then other days, things seem to be fine. So we're going to get into all of that. First of all, is stream something that we should be worried about as guys?

Dr. Smith: I think you should be at some point. I usually ask gentlemen about their stream and I ask them, "Do you hit the back of the bowl, the middle of the bowl, the front of the bowl, or your shoes?" But I think if you're a front of the bowl or shoes guy, we definitely should be having a conversation.

Scot: Okay. Has that been proven by research, that little method that you just told us about?

Dr. Smith: It's anecdotal, but it gives me a lot of information right up front without having to put them on a machine like Mitch.

Scot: Okay. All right.

Troy: So you're saying that for some men, full force, they're hitting their shoes?

Dr. Smith: Well, they shouldn't hit their shoes. That usually means they've got a problem.

Troy: Yeah.

Scot: And is this they're trying to actually actively push out, or should the urine just be coming out? Is that how you would measure the ideal stream measurement?

Dr. Smith: I'll answer that with talking about Mitch's machine. So we do have a machine. It's called the uroflowtometer. It sounds really, really cool. We shorten it to uroflow just to make things easier.

And they actually have one of these that you can get at home now. There's a company where you can get one of these at home. It's called the Stream Dx, and your doctor could actually send one home with you.

What this machine does is when you urinate, it takes the amount of urine that you're putting out over time, and then it'll also show us if you're actually straining to urinate and you're using your abdominal muscles to urinate, because you really shouldn't need to do that. You should be able to just open things up and let things go.

And some men notice as they age, they have to push a little bit more. The urine stream is not as strong as it used to be. Some younger men may notice that they had an abrupt change in their stream. And those can both be issues that need a little bit of attention.

Scot: Is it normally an abrupt change, or is it over time, or is it both really?

Dr. Smith: So, depending on what's going on, the thing that is the problem depends on whether it's more of a sudden thing.

So an abrupt change in stream is something where you want to get it checked out because it could be a narrowing of the urine channel or the urethra, anywhere from the bladder all the way down. That usually happens in a rather quick fashion, and that's something that can cause a problem.

A urethral stricture is usually the most common thing that we see in younger men who come in with an abrupt change in their stream. And that's a narrowing in the urine channel as a result of a traumatic event, or even just sometimes what we call idiopathic, meaning it happened and we have no idea why.

Troy: You talked about the abrupt change, suddenly something happens, but it sounds like probably what you see more commonly would be stuff that just gradually decreases over time.

Dr. Smith: Yeah. So the decrease over time thing generally happens with men as they age, and that tends to be more of a prostate-related issue. And that's the slowing down of the stream where you go to the restroom in the airport, or you go to the Jazz game, or you go somewhere and you're standing next to somebody and you go, "Man, that doesn't sound like what I've got over here."

And so that can be due to age-related changes in the prostate. The prostate is like your ears and your nose. It continues to grow until the day that you die.

Scot: I feel like this is a stupid question. What about kidney stones? Could that result in a reduced stream?

Dr. Smith: It can if it's lodged within the urethra. Usually, kidney stones that are in the tubes coming down the ureters from the kidney to the bladder don't usually slow your flow down. They just cause pain and make you miserable.

Mitch: You'll know if you have a kidney stone, and that's what's blocking things, right?

Dr. Smith: Usually, if you know you're passing a kidney stone and then you have a urinary flow change, you could have it stuck in the urethra, but it's less likely to happen because the tube coming from the kidney down to the bladder is very, very small. And compared to the urethra, that's very, very large in comparison. It'd be like taking a coffee straw and then a Boba straw.

Scot: Good reference.

Mitch: All right. Okay.

Scot: You're very topical, aren't you? So is it really only two things that might cause a weak stream, the narrowing of the urethra or a prostate issue?

Dr. Smith: No. There are other things too, but those are the most common things that I see in younger and older age groups.

Another thing that I see commonly across all age groups is something called pelvic floor dysfunction. There's also dietary things that can make urination more difficult. The big three that I always talk to folks about are caffeine, alcohol, and spicy foods, three things that can definitely make urination more difficult or problematic.

Scot: Back to that machine that measures stream pressure, do I have to stand up when I do that, or is that a sit-down deal?

Dr. Smith: Either one. So usually, you can stand up to do it if you're comfortable that way, but you can also sit down.

It's kind of a crude measurement. It pretty much measures the urine as far as a volume . . . actually, excuse me, as a weight of urine as it comes out. It measures how much weight is being added to this scale over time. And so initially, you're going to be adding less weight, the weight of the urine to this flowtometer. And as you build up speed and you reach your maximum flow, you're putting that weight in at a rate and then it graphs that in a curve.

And the normal curve looks like a bell curve that you would have in school when they would grade you and give half the kids Fs that are on that one end, and the other kids get As and everybody else is in the middle. That's what the uroflow, a normal one, would look like.

Scot: Hey, in the chat, click on . . . Mitch sent us this. Is this what we're talking about here?

Mitch: Yeah. Those are two examples of the machines.

Scot: The very first one?

Dr. Smith: I don't know how to get into the chat. Let me check and see.

Mitch: Yeah. I had something similar to the first one.

Dr. Smith: Yeah. That's exactly what it is. Did you order one of those on Alibaba?

Mitch: We are $500 away from knowing exactly how everyone's flow is going.

Scot: I know.

Dr. Smith: It's less than that if you just get your doctor to prescribe you a Stream Dx.

Mitch: You could probably DIY this. It looks like you could maybe do a bucket, a funnel, and . . .

Dr. Smith: One hundred percent you could DIY this.

Troy: It's just a funnel and some sort of measuring . . . Yeah.

Mitch: A scale.

Troy: A scale. That's right.

Dr. Smith: It really is. Then you've just got to be able to graph it over time and have that amount of stuff come in. But yeah, those are the normal graphs. If you look at that flow curve, you'll see what we see. That normal bell curve is pretty normal. And then the guy that has multiple different curves, they have an interrupted flow, that start, stop, start, stop that a lot of guys will talk about that have a slow flow.

Scot: What's up with this dysfunctional voiding curve? It goes way up and way down.

Dr. Smith: So usually, that's due . . . When they say a detrusor overactivity, the detrusor is the muscle that's in the bladder wall. And when that muscle is overactive, it has a spasm and just pushes with a high amount of pressure, and that's why you see the flow and the pressure go up.

Troy: Interesting.

Mitch: So you completely void the bladder in the first few seconds. That's why we're seeing such a high curve. I'm trying to make sure for listeners who can't see graphs . . .

Dr. Smith: Yes.

Mitch: Yes. Okay. Interesting.

Troy: I guess as I'm hearing this, though . . . I don't know if I have a weak stream. Maybe you go to a Jazz game or a sporting event or something, you hear other guys and it sounds like they just opened up a garden hose over there or something. I don't know. But the question is, does it matter? Do I need to buy the uroflowmeter and check out my flow, or what's the downside of having a weak stream?

Dr. Smith: So to a certain extent, it's not an issue. It can be and it is as people age. The big thing you want to make sure of is that you're emptying your bladder.

Now, the thing I always tell my patients is the urinary system, the bladder on out, is meant to be a low-pressure system. The sphincter that keeps the urine in your bladder and out of your pants opens up, your bladder squeezes, the urine goes out into the toilet, and nobody is the wiser. And that's supposed to be done in a low-pressure setting.

As we age, the prostate gets bigger and closes down the opening of the prostatic portion of the urethra, making it a higher-pressure system. Now, that's not a problem until it becomes a problem.

I know that's very specific, and so what I usually tell people is there's a certain point where that pressure builds up and the bladder can't keep up with it and you start to have residual amounts of urine where your body is not emptying the bladder completely. That can cause a problem, increase your risk for infection.

But also, as your bladder increases the pressure, it can also push pressure back up the ureters towards the kidneys, and long-term can cause kidney damage. And so that's the reason where if you think there's a problem, you should probably have somebody take a peek at it.

Troy: Would you have other signs also that would maybe suggest that there was an issue there?

Dr. Smith: Yeah. So normally, we call these lower urinary tract symptoms. Some doctors will just say LUTS. That's the lazy way to say it. But it's pretty much a non-specific group of things like going to the bathroom more frequently, having increased urgency to get to the bathroom. When you have to go, you have to go now. I call it the "gotta-gos." You can have urinary hesitancy, difficulty getting things started. You can have nocturia, which is waking up multiple times at night to go to the restroom.

Those are all considered lower urinary tract symptoms. And there are a few others that are involved there that make the rounds.

And so again, those are the things that you may also experience in addition to a slowed urinary flow. People may also say, "I don't feel like I'm emptying. I just feel like after I'm done, there's more there."

Scot: You probably already explained this, but I just want to be clear. So first of all, I thought a weak stream was indicative of maybe some health problem. But other than the fact that you might not be getting all the urine out and over time that can cause an issue, a weak stream in of itself isn't necessarily a bad thing.

Dr. Smith: Not necessarily. It does depend on how weak the stream is and what's going on upstream. Some people have intermittent weak stream, like you were saying. Some days, it seems like it's weaker than others. Usually, that's due to caffeine, alcohol, spicy foods, things like that, where people notice, "Oh, if I drink four cups of coffee, I tend to go more frequently and have urgency and may not feel like I empty well," or whatnot that way.

Mitch: So the reason I got tested was I was urinating a lot more frequently last year, and it was enough that I was worried to go to the doctor. They had me use the uroflow, test everything out, and then come to find out I was just drinking a pot of coffee a day because of the two jobs I was working. So it was a whole thing.

Dr. Smith: Yeah, you're not uncommon. A lot of times when people come in, I usually check for lifestyle things. Guys that go to Buffalo Wild Wings and they have a couple of beers and then they go home and they notice that their urinary system or their urinary function is more frequent, less frequent, those types of things, I tell them, "If you know that's happening to you, then it's self-inflicted and you know how to change it."

Or the guy that drinks a pot of coffee and I say, "Hey, you just need to drink less caffeine or no caffeine to make your life easier and make your urinary system better."

Troy: I guess hearing this, too, it makes me wonder, and hearing Mitch's experience, do you find that people think their stream is too weak and they overreact and so you see a lot of these cases where, "Hey, your stream is fine"? Or do you find that a lot of guys just put this off and ignore it and then come in when they have a really weak stream?

Dr. Mitch: So I see both ends of that spectrum. I have the guys who when something seems to go wrong from the waist to the knees, they immediately are in your office, and the other guys that don't think it's a problem and come in once their bladder is no longer functioning and they have a liter and a half of urine in their bladder and don't know it.

So those are kind of the extremes, but I do see both angles where people are very worried about their current urinary flow, and then others that are like, "Oh, yeah. It's been like this for 15 years," and they don't do anything about it.

Troy: Yeah. See, John, I'm just worried I'm going to be the guy with a liter and a half in my bladder. I'm going to finally show up and be like, "Something is wrong here."

But again, it's hard to tell. Now that we're talking about all this stuff, I'm thinking, "Yeah, I do get up two or three times a night," and, "Yeah, sometimes I really have to go." So it makes me wonder. I don't know. Maybe I need to get checked out.

Dr. Smith: Well, Troy, I'm not going to age you at all, but I'll just give what I tell people. Over the age of 50 to 55, everybody, both men and women, gets up once a night. It's pretty normal. So once a night is not a huge issue.

When you start getting up two and three times a night, that tends to be a little bit more pathological where you may want to even just get it checked out.

Troy: I might need to. I do drink a lot of water. We've talked about that before. So I don't know if that's part of it. Hearing Mitch's experience, it sounds like there was a lot of coffee consumption going on and a lot of caffeine. I just drink a ton of water. So I've always chalked it up to that, but I don't know. Yeah, it sounds like maybe I should get checked out.

Dr. Smith: Well, some homework you could do too is if you cut the liquids off a couple hours before you go to bed and then you notice that you don't wake up as much.

I have plenty of patients who come in and they're like, "Yeah, I drink two glasses of water before I go to bed and I wake up two or three times." I said, "Yeah, go figure."

Mitch: That's how I felt after we had done all this testing and everything and he's like, "You're drinking how much coffee a day?" And I'm like, "Yeah, it's about a pot of coffee a day. Of course, I'm urinating more. No duh."

Troy: Exactly.

Dr. Smith: You're putting eight cups of a diuretic into your system and then drinking a liter and a half water. You're going to be going to the bathroom. And the same thing, if you drink 32 ounces of water before you go to bed, you're going to wake up to go to the bathroom.

Troy: Yeah. That is true.

Scot: I feel like this conversation has expanded beyond weak stream. We're talking about going often or going in the middle of the night. Is it all really related?

Dr. Smith: Yes. When it comes down to a lot of that, a lot of times people come in and once you ask them those more probing questions, "Do you have increased frequency, urgency, your stream is weak? Do you feel like you're emptying well? Do you have hesitancy? Do you start and stop your flow?" those types of things, usually it's not just, "Oh, I thought my flow was weak," and that's it. There's usually a yes to multiple of those other questions.

Scot: Okay. And then how do you avoid being the person that's in your office when anything goes wrong between the pelvis and the knees, you said?

Dr. Smith: Yeah, the waist and the knees.

Scot: Yeah, and being the person that should have been there two years ago. How does a guy that's listening figure that out? I think a lot of us guys don't go to the doctor because we're like, "Oh, it's probably nothing," or we don't want to be a bother, or it can be a hassle, or whatever. So how does a guy figure that out?

Dr. Smith: I think you use your best judgment if you think it's slowed down enough that you want to get it checked out. But other things you can do are just lifestyle modifications. Mitch could have probably cut the coffee down before he went into the urologist and seen if there was a difference. Troy can cut water off before he goes to bed, and see if that makes a difference.

You can do lifestyle modifications where you decrease the amount of caffeine you intake, alcohol, spicy foods, see if there's anything dietary related. Then you can also watch your intake before bed. Make sure that you're putting yourself in the best position possible to see how your urinary system functions without any of those additives that may make your life worse.

Troy: And what about the person who's listening right now, just like me listening to this, and just thinking, "I've wondered if there's an issue"? Would it be a simple test to just say, "Okay. I've got to go urinate right now"? You go and you urinate, and your stream is hitting the back of the bowl without a lot of effort. Are you good?

Dr. Smith: That's the reason that I ask that question, because it lets me know how worried I should be about those folks.

The other thing is to go ask those questions to . . . If you've got a significant other, that's my favorite when the patient comes in with their spouse.

Scot: Oh, no.

Dr. Smith: I go, "Is your stream weak?" He's like, "No. It's good." And you just look over their shoulder and their significant other that's with them is just shaking their head like, "He's totally lying."

Scot: Is that because they're the one that cleans the toilet? Is that what's going on there?

Dr. Smith: Guaranteed. Yeah. Or washes the shoes.

Troy: You're just a poor aim, or what?

Dr. Smith: But you'll see a lot of them like, "Oh, do you wake up much at night to go to the bathroom?" They're like, "No. I maybe wake up once," and their partner looks over at them like, "No, he wakes up like four times at night." So they'll keep you honest a lot of times.

Scot: Yeah. It sounds like that's something to watch out for as a guy, is just that sometimes maybe we disillusion ourselves a little bit. We need to take an honest look at these types of things.

Dr. Smith: Absolutely.

Troy: Again, just for my own peace of mind, it sounds like if you do go to the bathroom and you are hitting the back of the bowl without a lot of effort, you're probably okay.

Dr. Smith: Yes. I would say that's a pretty good idea. If you're not forcing the urine out and your flow is coming out pretty robustly, you're okay.

Now, if you have any questions, Troy, you just give me a buzz. We'll get you into the office.

Troy: Okay. I'm a little nervous now because the whole night thing, that's got me thinking, "Maybe I need to get things checked out." Anyway, I'm feeling okay about things.

Scot: But there are not other symptoms, though, really. Are there?

Troy: Sometimes, like John said, the whole gotta-gos things, sometimes I'm just like, "I've got to go." But again, I've always just attributed it to I drink a lot of water. So maybe I'll cut back on the water a little and see what happens.

Scot: Hey, if you guys want . . . Hey, Dr. Smith, can you write us a prescription for that thing? Do you guys want to have a little competition?

Mitch: There's no need to make this a competition.

Dr. Smith: I'm sure we could figure that out. Not that we need to make this a competition, but I think we could probably figure that out.

Mitch: I'm worried this is going to be like the pushup competition where it's going to be a recorded thing and John is going to be the referee watching and like, "Okay. Go for it, Mitch. Let's see what you can score."

Dr. Smith: Well, I don't have to watch. I have the machine give me a printout, so it makes it much less awkward.

Troy: That's good.

Scot: And then that's a little souvenir for all of us. We can each have our own little printout when we're done. So that'll be fun. Put that up in the office next to the diploma or whatever.

Mitch: Man.

Troy: Yeah. Exactly.

Dr. Smith: You can do that live on . . . not a podcast. You can make a vlog and throw that up.

Troy: Yeah, just like, "Here we go." This is University of Utah Health at its finest.

Scot: Any final thoughts, Dr. Smith? Anything that you feel compelled to say? Anything we should have hit or should have mentioned, or a wrap-up that you'd like to give a guy?

Dr. Smith: No. I think if you're worried about your stream and you do have any questions or concerns, getting in sooner rather than later is definitely better for you. So if you do have concerns, just pick up the phone, make a phone call. It's a pretty easy visit. It's nothing to be overly concerned about. You can check things out pretty quick and get some good objective answers and give yourself a lot of peace of mind.

Scot: And is that a urologist you're going to go to, or would your primary care physician have this equipment to do this?

Dr. Smith: If your primary care has this equipment, I would be very, very surprised. You want to call a specialist like a urologist, yeah.

Scot: Okay. Great. Well, Dr. Smith, as always, it's great having you on the show. Thanks for being a part of it, and thanks for caring about men's health.

Dr. Smith: Hey, pleasure is mine, guys. Thanks for having me. It's always great to be with you.

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

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.

Dr. Smith: Yeah, I got rid of all of our dogs, and we just have six kids now. So it's a little different.

Scot: Traded in dogs for kids.

Dr. Smith: It's the same amount of urine on the floor, though.

Scot: Welcome to "Who Cares About Men's Health." Today's show is part of our Men's Health Essentials series. These are conditions that impact men. Today, we're talking about something called Peyronie's disease.

First, the introductions. My name is Scot. I'm 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. I am a urologist at the University of Utah, and I definitely care about men's health.

Scot: Peyronie's disease, from what I understand it's a condition where scar tissue can cause the penis to curve or lose length or girth. It's painful, and it can impact a man's physical and emotional health. And from what I understand, a lot of men suffer in silence about it. They don't think that there are any treatments, or they don't want to talk about it, but there are treatments.

Troy: And help me understand a little bit more what this is. Is this something that people are born with? Is this something that develops over time? What exactly are we talking about here?

Dr. Smith: So one of the things is some men have a natural curvature to their penis and it's not necessarily a problem. Whenever I'm talking with patients who have Peyronie's disease, our goal is to get them functionally straight. What that means is they're never going to be straight as one of Robin Hood's arrows that he's going to shoot out of his bow, but they'll definitely be able to perform sexually and comfortably. That's one of the reasons that a lot of men will come in, is they have difficulty being able to have sexual intercourse in a way that's not uncomfortable for them or their partner.

Scot: What kind of curve are we talking? Because I would imagine, all guys can be a little different. One guy is going to point off to one way, and the other the other way, but what is a Peyronie's curve?

Dr. Smith: So Peyronie's disease, the definition is a curvature of the penis that occurs and makes it difficult for someone to have normal sexual function or even urinary function. So if you're curved, it can range anywhere from a few degrees all the way up to 90 degrees. I've got a picture here in one of the textbooks when I was just going over some of this stuff you might be able to see here, but it's literally bent almost 170 degrees. And so that's a very aggressive curve.

Scot: That's curving up. Am I seeing that right? That's curving up?

Dr. Smith: Yeah, it's curving back on itself.

Scot: Is that common? Is it up, or is it to the side, or is it all directions it can bend?

Dr. Smith: It's all directions. It just depends. And sometimes it's multi-directional. Sometimes it can be up and to the left, down and to the right. It really just depends on the patient. So those are the things that . . . we deal with each case individually to come to a conclusion on what the best treatment is.

Troy: And does that kind of thing happen from an injury, or is this a penile fracture that wasn't treated, or is it just something that develops with some fibrous tissue over time or a combination?

Dr. Smith: So it's usually fibrous tissue that happens over time. If you have a penile fracture, those are generally very detrimental to the erectile function. Most of the time, these Peyronie's curves start off and they just worsen over time. You get patients who will say, "Well, over the last six or eight months, I've noticed a big increase in this curvature."

And Peyronie's disease, we don't really know what causes it. The theory behind it is that there's some micro-trauma there that then causes a scarring between the two corpora cavernosa. Anatomically, there are three chambers to the penis, two on the top and one on the bottom. The two on the top are called the corpora cavernosa. The one on the bottom is called the corpus spongiosum. And it also incorporates the urethra.

So in between those two chambers on the top, the corpora cavernosa, there can be some scarring. And if there's scarring on one side or the other, that will pull the penis to that side and cause curvature and shortening of the penis.

Scot: And just to be clear, when you're flaccid, you don't notice this, right? It's only erect penises that you get that curve. You're shaking your head no.

Dr. Smith: Correct. So you can feel the Peyronie's plaque in a flaccid penis. That doesn't necessarily mean that it's curved, but you sometimes can feel a very distinct area on the penis where that plaque and that curvature begins. And so you can get an idea when they're flaccid, but you won't see the curvature until the penis is erect.

Troy: So this raises an interesting question. If you're diagnosing this in a clinic, do you have to require that a man is erect to be able to determine what's going on, and how does this affect a guy's willingness to come into a clinic?

Dr. Smith: Right. So a lot of gentlemen who come in, they're ready to talk about this because they've been unable to function sexually or they've been peeing into the wall or something like that, where their curvature is bad enough where they want to do something about it.

Most men who come in . . . I guess I shouldn't say most. But some of them will have taken photographs that they'll bring in to show.

But as part of the workup, we offer them what's called a penile duplex ultrasound where we bring the patient into the clinic and we do a special ultrasound where we inject the penis with a special medication called TriMix. It helps to give an artificial erection to the patient.

We measure the penis. Once it's erect, we measure the curvature with a goniometer, the same thing you would measure angles with when you were doing trigonometry in school. We measure the curvature of the penis so that we know exactly what the curvature is, and we also measure what directions the curvature is in, whether it's up, down, left, right.

Scot: Before we get to the treatments, is this something that just gradually starts showing up? You just gradually start noticing and it gets worse and worse? Does it come on pretty quickly? And then the follow-up to that, the sooner you treat it, the better?

Dr. Smith: So I think you could say yes to all the above. So sometimes it comes on quick. Sometimes it's longer lasting. Oftentimes, men will report that there was a little bit of pain and irritation of the penis, and they noted the curvature worsening. And there is a maturation of that area of the scar over the course of three to six months where that pain dissipates, goes away. And that's where the curvature settles into what it's going to be long term without any treatment. For some folks, that lasts a little shorter. For some folks, that lasts a little longer.

And then, again, the sooner that you come in . . . if you come in during that acute phase, where there's still change happening to the curvature, oftentimes we won't recommend treatment for that because we don't know where the curvature is going to finally end up and we'd like to let that plaque mature. There is some debate on that nowadays. Some people are treating these earlier. But as a rule, generally, we'll let that mature so that we know what kind of curvature that we're trying to correct.

Troy: And it's interesting, though, that you say this just all happens. It all of a sudden really gets worse over six months. Is there a certain age where it seems to happen?

Dr. Smith: So it usually happens in older men, but it can happen at any time. We have men who come into the clinic in their 30s, 40s, 50s, 60s, all the way on up. I would say a majority of folks that come in are over the age of 45, but it can happen at any age.

Again, we don't really have a good reason for it a lot of times. Sometimes people can pinpoint it to maybe a sexual encounter where they noticed that there was a bend to the erection that then afterwards they noted some curvature, or they had an injury some other way that they started to notice pain and curvature of the penis afterwards. But most of the time, it's just an insidious onset where they can't really pinpoint anything where they had an issue.

Scot: I've got a couple of things I found on Reddit here I just want to throw out quickly before we get to the cure. So there were a couple of things that said it can be an injury during sex. And I even found this on a couple of what I would consider legit medical sites. You said we're not too sure if that's what's causing it or not. What's your take on that?

Dr. Smith: So that is the theory, that there is some micro-trauma happening at some point. And the time when the penis would be under the most stress would be during sexual intercourse. So that's oftentimes the theory that's put behind it. However, no one really knows for sure.

Like I said, some patients come in and they can pinpoint a sexual encounter where they did notice a bending of the penis that was painful and then the curvature started after that. But however the micro-trauma happens, it definitely can be. And so a lot of times we do look for a time when the patient may have had a sexual encounter where there may have been a bending or an abnormal bending of the penis that may have caused some of this damage.

Scot: On Reddit, I also saw that some people thought medications cause it. A lot of people would say, "Yeah, I was on such and such medication, and that's when it happened." Is there any truth to that?

Dr. Smith: So, again, I think that there can be some truth to that. There's not really good evidence to guarantee any of that. But again, you can't say yes or no 100% about anything. There are some medications that can cause fibrosis and things like that that people have pointed to. "Well, I didn't have any of these issues before I took these medications." So that definitely could be the case.

Troy: I guess with all this in mind then, what's someone going to do about this? Obviously, the answer, it sounds like, is come talk to you. And then if I come there, and there's clearly an issue, what should I expect next?

Dr. Smith: So you come in and you see us. We're going to recommend doing the ultrasound to measure the curvature because looking at how much curvature you have can really make a difference.

Some men just want some reassurance. They're functionally straight, they're not having difficulty with urination or sexual function, and they just want reassurance that it's not something that's going to be a huge deal. And if that's the case, then maybe we do nothing for those folks.

But again, looking at it, if it is something where it is problematic, there are treatment options. We'll talk about it from least invasive to most invasive. So there are no real good oral therapies. I know some people will say, "Oh, you can take this oral therapy to straighten things out." None of those have been shown to be effective.

Scot: Name a couple of those because I did actually look . . .

Troy: Yeah, you piqued my interest. I'm curious. Are we talking ginseng or . . .

Dr. Smith: You'll see things like coenzyme Q10, vitamin E, POTABA, colchicine, different things. Some people say Omega-3 fatty acids. People will say, "Well, if you just take Viagra, it'll help you straighten out." None of those things have been shown to really do anything to help with the curvature of the penis.

The three things that we generally offer folks in the office . . . the ultrasound to evaluate their curvature properly. Generally, the photos that they bring will let us know that they do have curvature, but they're not really accurate as far as getting measurements. So we want to know how much curvature they have because that can really dictate treatment options.

And there are three treatment options that we generally offer our patients. One is a penile straightening device. These devices are worn on the penis for a duration of time to help straighten out that curvature. They're generally worn for a few to several months at a time. Some of them range between two sessions of 30 minutes a day all the way up to nine hours a day and monitor the curvature to see improvement.

Scot: So that's something you can wear under your clothes if it's nine hours a day. Or is it at night?

Dr. Smith: Not usually. It's pretty bulky. They're not really able to be worn . . . they don't want you to sleep with them. So it's very prohibitive for a lot of people. I think with COVID where people are staying home a little bit more, it may have been a little bit easier of an option for some folks. But again, you're not going to put that on and go to the office with it.

Troy: That sounds like it would work for a Zoom meeting.

Dr. Smith: Right. It would. Yep, you could have your button-up shirt on the top and your basketball shorts on the bottom.

Scot: All right. So that's Option 1. What are the other two options that you offer? And how many people take that option, by the way?

Dr. Smith: It depends on the patient. A lot of people actually say, "Well, I'd rather try that than do the other two options." And you may understand that once I talk about the other two options.

Scot: It's not going to get better, huh?

Troy: What's next?

Dr. Smith: Well, this is the least invasive option. This doesn't require any other needles or any other surgical intervention on the penis other than the ultrasound where we do inject the medicine during the ultrasound.

And so the second option that we offer is an injection that goes directly into that scarred area of the penis. We call it the Peyronie's plaque. And that Peyronie's plaque is injected with the collagenases material. And this is done by injecting that site with a series of injections, and then allowing the patient to go home and do what they call modeling of the penis for a duration afterward before repeating a series of injections. No sexual intercourse for four weeks after that injection series because you don't want to risk any rupture of the penis causing a penile fracture.

And so that's Option 2 that we offer, and that can be done in multiple cycles. Three or four cycles can be done to improve the curvature of the penis.

The caveat to that one is you have to have at least a 30-degree curvature of the penis before that's even an option. That's what the research was done on it, that you have to have at least 30 degrees of curvature for that to be an option for treatment.

So number three is a surgical intervention. It's called a penile plication. They go in, they induce an artificial erection in the penis while you're undergoing surgery, and they place sutures to straighten the penis out. This is obviously the most invasive, and at the end of the surgical procedure, they try to get it as straight as they can and then allow for healing.

This does cause some shortening of the penis because sutures are generally placed opposite of where the scarring is, which causes that shortening of the penis that you had to be permanent. You do lose some length with that. So a lot of patients are a little skeptical when they hear that. But this is the quickest route to get you back to straight because it's a surgical intervention. It's a one-and-done.

Reviews are mixed if you ask different urologists what they think. Some of them are very . . . they like plication. Some of them think that it's not the greatest option and they would avoid it if they could. But it is an option and sometimes it is the option that's best for some men.

Troy: So what would you choose if you were doing this?

Dr. Smith: It depends on what my curvature looked like. I think if I had a moderate curvature, I would likely try a penile traction device because it is the least invasive. I would probably try that first if my curvature wasn't severe.

Scot: Any last thoughts or concerns that men have when they talk to you about this sort of issue that you'd like to get out there in the world?

Dr. Smith: I think a lot of times just having conversations with folks to just know that there is something that you can do. If it is something that's bothering you, at least having that conversation to have an understanding.

I think there are some misconceptions out there. I've had men come in and think that they had penile cancer when really they just had a very mild curvature of their penis, and to give them reassurance is helpful.

But if you know that this isn't something that's going to hurt you, it's not going to shorten your lifespan, it's something that is treatable . . . I think a lot of men just want that hope of being able to function appropriately again. And I think that would be my lasting thing. There is something we can do.

Scot: Thanks for joining us for our Men's Health Essentials series on Peyronie's disease.

Hey, check out some of our other episodes too where we talk about diet and nutrition and exercise and sleep and managing your stress, those things that we need to do to stay healthy now and be healthy in the future. We give you some tips and talk to some experts about that sort of thing.

If you have any questions, you can reach out to us at hello@thescoperadio.com, you can call us on our listener line 601-55SCOPE, or you can go to facebook.com/whocaresmenshealth. That's where you'll find the community of men that were trying to build that do care about their health.

Thinking about health in a different way, this is "Who Cares About Men's Health." Thanks for listening. Catch you next time.

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.

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.

Scot: Here we go. Did I maintain? Troy, are you still there?

Troy: I'm here.

Scot: Dr. John Smith, you there?

Dr. Smith: I am here.

Scot: Did you hear John, Troy?

Troy: What?

Scot: Did you hear John, Troy?

Troy: Yes.

Scot: Troy, did you hear John? John, did you hear Troy?

Dr. Smith: I hear everything.

Troy: I think we're good, Scot.

Scot: Okay. Here we go. The podcast is called "Who Cares About Men's Health," providing information, inspiration, and motivation to understand and engage in your health so you feel better today and in the future. My name is Scot Singpiel. 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 non-surgical urologist at the University of Utah, and I care about men's health.

Scot: Second time we've had Dr. Smith on the show. The first time, Troy, it took a little warming up to Dr. Smith, but finally at the end of the episode, gave him some applause. So we've become fast friends. It's great to have you back on the show, Dr. Smith. Sure do appreciate you coming on and talking about some urology, urological sort of issues.

Dr. Smith: Thanks for having me back.

Scot: Quick question before we get to the topic, and today we're going to talk about erectile dysfunction because Dr. Smith was telling me that that's a reason, one of the reasons, one of the big things that he sees on a daily basis is guys coming in with some sort of an issue. So we're going to talk about that. We're going to give you the real information. So it's not like you're getting it from the friends on the playground. That's the internet, by the way, in case you're not catching my reference there. You're going to get it actually from the doctor's mouth. So that's going to be awesome.

Troy, I have a question for you. So at one point, you talked about how in the ER, you call urologists sometimes to do some procedures.

Troy: We do.

Scot: What are some of the reasons that you have urologists come to the ER? One time you said that if you're having difficulty inserting a catheter, you might have to have a urologist come and then do that for you. What other reasons?

Troy: Sometimes we call them for kidney stones. That's probably one of the more common reasons. If it's a very large stone that's just likely not going to pass on its own or an infected stone where the patient has a big kidney stone, or even a smaller kidney stone and a bladder infection, kidney infection, along with it. We do call them for trauma-related injuries, whether that's a tear of the urethra or sometimes even a penile fracture. Scot, you may hear that and say, "Wait, is there a bone in the penis that gets fractured?"

Scot: There's not.

Troy: Was that your thought?

Scot: I mean, I know there's not though. I mean, sixth grade Scot would have thought that.

Troy: Sixth grade Scot.

Dr. Smith: Seventh grade Scot knew better.

Troy: He wised up quickly.

Scot: He did.

Troy: It's referred to as a penile fracture. It's a tear in . . . John can describe it in more detail, but a tear in the . . .

Scot: Or not.

Troy: It's an incredibly painful thing. I will say that. Having seen men with penile fractures, it looks incredibly painful. So we will call them for that as well.

I will say along the lines of erectile dysfunction, I was working a night shift once and a man came in at 6 a.m. and he said, "My woman said, 'You leave the house and you go to the ER and you don't come back until you get that fixed.'" We did not call urology for that. We didn't do that to them. But I have seen "erectile dysfunction" emergencies, at least in the mind of the individual in the ER, as well. So again, I did not call urology and push that on them, but it would have been funny.

Scot: Dr. Smith, you would actually handle some of that stuff though, even though you don't necessarily go into the ER. But don't they use . . . for kidney stones, don't they use sound waves now for a lot of that sort of thing?

Dr. Smith: So they can. There are multiple different ways to treat kidney stones. We could probably do a show on that, but . . .

Scot: Well, let's do that.

Dr. Smith: Fair enough. I'll come back.

Scot: Not right now, but yeah, someday. We've got more pressing topics to get to.

Dr. Smith: That's fair. But yeah, there is something called a lithotripsy. and they use a machine where they put a little bag of . . . it feels like a bag of water, like a gel bag, against your back and they find the stone with an X-ray and then they send shockwaves in to break it up.

Scot: Wow. That's pretty cool. Technology is awesome. So let's talk about erectile dysfunction, one of the main reasons guys come and see you. Just want to break it on down. So help us kind of understand what's going on, what you as a urologist do to help men solve their problem, and I think, in general, makes men that are struggling with this feel that it's okay because it is okay.

Dr. Smith: It is okay.

Scot: Yeah, so where should we even start this conversation? I'm not good with sensitive conversations.

Dr. Smith: You just start by digging in. There's no way to just waltz around this thing and hope that it comes to you. I would say a lot of men come in with erectile dysfunction. It can be a . . . well, there are multiple different reasons, but overall erectile dysfunction, the definition of it is the inability to achieve or maintain an erection that's adequate for sexual function.

And so it's estimated that about 18 million men in the United States have erectile dysfunction. So guys, you're not alone. That's a pretty sizable number. Some of them seek treatment, some don't. This condition can affect people in a lot of different ways in their relationships. So it's one of those things where you might as well come in and have a conversation.

Scot: So it's not just about erectile dysfunction. It can cause psychological issues. Are there other health issues that men should be aware of?

Dr. Smith: Sure. So it can be a harbinger of cardiovascular problems, other things like that. Folks with longstanding diabetes often have erectile issues. There are multiple health problems that can cause or precipitate erectile dysfunction. And so those are good reasons to come in as well.

Scot: So my ability to not get or maintain an erection is not because I've become less of a man. It could actually be a medical symptom to a bigger problem, or it could just be mental. What are some of the other causes?

Dr. Smith: Absolutely. So it could be psychogenic, which means that . . . guys like to think if it doesn't work once, it's never going to work again. And so that brings in some gentlemen. Again, diabetes can be a problem, people with known vascular problems, people who've had prostate cancer and had surgery or radiation oftentimes have a decreased quality of erections.

And then sometimes we don't know. We call it idiopathic. There's not a reason for you to have erectile dysfunction but you do. It's not necessarily an age thing, but as men age, generally, the quality of their erection declines some.

But those are kind of the things that we kind of overview with folks when they come in to have a chitchat.

Troy: John, it sounds like there are a lot of different things that maybe could cause it. But how do you really determine if someone has erectile dysfunction? What do you use just to say, "Yeah, it sounds like this is definitely an erectile dysfunction," versus, "Maybe you don't have a problem"?

Dr. Smith: So, generally, I ask a few questions. "Do you have a decreased ability to attain or maintain an erection?" Oftentimes, it's not one or the other. It's both for folks. I ask them how rigid their erection is compared to an erection that they had when they were having quality erections. And one of the big ones for most people is, "Is it adequate for sexual function?" And so if it's not, that's a good indication that it's erectile dysfunction. That's true erectile dysfunction.

Scot: And when a guy comes in and you ask him the questions, how often is the next word out of his mouth or the first word actually when he even walks into your office, "Yeah, I have a problem and I need some pills"? I mean, is that kind of the first thing that you get asked?

Dr. Smith: Not always. Some men come in and that's kind of what they want, and in a way, that's not a bad way to look at it because the pills generally work for all comers of erectile dysfunction. It doesn't matter why you have it. Seventy percent to 80% of patients with erectile dysfunction are treated adequately with medication. So again, that's not a bad way to go, but it does warrant a little bit of investigation at times.

Scot: So there are two different types, it sounds like, getting and maintaining, and then maybe even a third, having the quality of an erection that is adequate enough for sex. You give the man the pills, and then you send him on his way. Is that that, or are there other potential treatments that you might have to look at?

Dr. Smith: If you're going to come to me, I'll generally do a workup for you. The American Urologic Association has guidelines that they put out for everything, and I tend to try to follow those guidelines. One of them is to make sure that there's not a hormonal issue. I'll check a hypogonadism panel, make sure that everything's working as far as testosterone, hormones, things like that.

If I feel like after getting a history from you that there's maybe a cardiac issue, or you're a diabetic that may struggle with controlling your diabetes, I may refer you back to other folks before we get you started on medications, things like that.

But generally, looking at all those reasons, it's not just as simple as saying, "Here are some pills. Go and let me know how it works out." But in certain cases where we do the workup and we don't really find a reason and they do well with pills, it's not a bad way to treat them as long as we work it up and look at it the right way.

Troy: Speaking of pills, John, and the workup you mentioned, I'm sure we've all seen the ads on TV. You're seeing them more and more now, especially if you watch sports, for some of these online things where you basically, it sounds like, probably chat online with someone and then get medication for erectile dysfunction. What's your thought on that? Is that a reasonable route to go for someone who's maybe embarrassed to go into see a physician or any insight into that?

Dr. Smith: I think those companies have a place. One of the companies, I think one of the guys that started it actually had a cardiac issue and that's why he had erectile dysfunction. So they kind of mention that in some of their advertising where it makes sense to maybe talk to your primary doctor as well.

The big thing for me is making sure that people are taken care of the right way. If you were my dad or my brother, how would I want you treated? And I think that sometimes those guys may miss some steps. I've never used them to know a 100%, but I think looking at everything as a whole and making sure that there's not some underlying problem is important.

However, if it's impacting your relationship or there are different reasons, I could see a reason why you would utilize those services. No question.

Scot: You said the pills take care of a majority of men's problems. In the instance that pills don't work, what do you start looking at, at that point?

Dr. Smith: So in general, the algorithm that I use is if oral medication isn't effective, I'll generally refer you to have an ultrasound done, a penile Doppler ultrasound where I'll look for a possible cause of your erectile dysfunction at that point.

And the reason that I don't do that first is it requires us . . . we usually do it with a medication called Trimix, which is three medications that will produce an artificial erection. And most men aren't jumping to get a needle put into their penis. Granted it's a small needle, it's like a diabetic needle that you would use, but most men aren't interested in trying that first.

So I'll generally look at that next and see if I can come up with the actual reason that they may have an issue, and see if there's a blood flow problem and different things like that. And then after that, the options that we have for treatment are, again, if that medication works well to give an artificial erection, you can continue to use that. And then there are other surgical options that are out there as well.

Troy: John, I guess getting back at treatment, obviously medication, injections, surgical options, what if someone comes to you and just says, "Hey, I just don't like taking medications. Is there anything else I can do?" Is there anything you recommend in that situation, or do you just say, "Probably want to try some pills first"?

Dr. Smith: So there are always things you can do. Diet and exercise has been shown to be effective in helping mild erectile dysfunction, to improve the quality of an erection. It's not as effective as medication, as the Viagra/Cialis/Levitra medications, but it has been shown to provide some benefit to improving the quality of erection.

And I think the whole purpose of this podcast is "Who Cares About Men's Health" and you guys often speak about taking care of yourself. And I think if we're all smart about that and we take care of ourselves and take care of our diet, different things like that, make sure that we're healthy, it does improve the quality of your sexual function.

Scot: Does the pill also help in the instances of maintaining or can that be other things?

Dr. Smith: Absolutely. So for some folks who have difficulty maintaining, sometimes a constriction band . . . the layman's term that everyone uses is a cock ring. You can utilize that to help maintain an erection if you have a venous leak where more outflow of blood is coming out of the penis than the inflow can support. And that can be very effective for men with that issue. I would say that's a lower percentage of the patients that you see with erectile dysfunction, but when it works, it works really well for folks.

Troy: Too many stories from the ER with the cock ring, too many. We won't go there. Like things gone wrong, but we won't go there.

Dr. Smith: I'll give you a two-second story that you can edit out.

Troy: Or not.

Dr. Smith: We took a family vacation when I was in residency, out to Hersheypark. I was in New York, so it was a close drive. And we stayed in a hotel, went to Hersheypark the next day. We were going for two days, which if you ever go, don't go for two days. You only need one.

Troy: Been there.

Dr. Smith: But I wake up in the morning, we're getting ready to go to the park, and my kid comes over and she goes, "Dad, look at this ring I found in the drawer." And it's this silicone, spiky little ring. And my wife's jaw just drops. I look over and I go, "Drop it and go wash your hands immediately, child."

Troy: Our department chair in residency was doing teaching rounds. And they had a patient whose complaint was he had a cock ring on, he couldn't get it off, and the department chair did not know what a cock ring was. All the residents there were just totally silent, did not say a word to try and tell him, "This is what it is." He says, "So we'll just look this up," and goes over to the computer and types in and all these images just start coming up. And it's like, "Oh, okay. Let's shut this down." Anyway, yeah, we've seen some crazy things.

Scot: I feel a little left out. I'm the only one without a story.

Troy: Scot, you can make one up. You could just tell one.

Scot: I haven't lived apparently because I don't have a story to share. Both of you sound like you've got even more of them and I have none.

Troy: Unfortunately, yes. But we won't go there.

Scot: Troy, actually I do want to ask you, do you have any advice if somebody is using one, based on what you've seen in the ER, that you want to avoid?

Troy: My advice . . .

Scot: Are we going to get into some argument here with Dr. Smith about you don't think they're safe and he says they are?

Troy: I don't think Dr. Smith will argue with this. My one piece of advice is if you use a cock ring, don't leave it on for three days. It's a bad idea.

Dr. Smith: That's a fact.

Troy: It's a bad idea. I think we're all on the same page there.

Dr. Smith: A hundred percent. Follow the directions.

Scot: Oh, they come with directions?

Troy: Read the directions.

Dr. Smith: Well, they should come with directions. If they don't, you should probably get one that does.

Scot: Have we covered the topic well enough? I mean, I don't know for sure. It seems like we've covered the important points that somebody might have. Did we leave anything out, Dr. Smith?

Dr. Smith: I talk about this all day, every day, so there's always plenty more to talk about, but I think that gets the ball rolling. If you haven't seen a urologist by that point, you probably should.

Scot: Sounds good. And if you have further specific questions, of course, you can reach out to us here at the "Who Cares About Men's Health" podcast. A lot of different ways to do it, which we will put in the links to the show notes, including hello@thescoperadio.com. You can call our scope line 601-55SCOPE. You can do Facebook direct messages, and you can use the name John Smith and just asking for a friend if you feel a little shy about the whole thing.

You know what? I'm proud of us. We really more or less got through this without making a lot of jokes. We've kept the jokes to a minimum, so that's good. Or is that bad? It could be bad.

Dr. Smith: I mean, it depends on the viewership, what they think. If they wanted more jokes, they should probably ask for them.

Scot: Do you find when a man comes in to talk to you about erectile dysfunction that they tend to have a little bit of a different personality? Do they tend to deal with it by joking a lot more than you think they might normally in real life? I mean, what's the demeanor of your average patient?

Dr. Smith: Average patient I would say comes in a little bit gun-shy. Most of them don't want to come in and talk about it, especially the older generation of men that I see in the office. The ones that are just "throw caution to the wind" don't care are generally the guys who've had prostate cancer, where they were told before they had their treatment that this is likely going to cause erectile dysfunction. So they come in and they're like, "Hey, I just had surgery. I have erectile dysfunction. What are you going to do?"

Scot: And it makes sense, because they've got a medical reason now. Getting back to this whole stigma about "Are you less of a man if you can't get it up?" and those sorts of things, there's not a stigma there anymore, right?

Dr. Smith: Right.

Scot: There was a medical procedure that was done beyond their control that caused this to happen.

Dr. Smith: Right. They've already been through a wild roller coaster of being diagnosed with cancer and the unknown there. And so a lot of times they're coming in and they're just like, "Hey, is there anything we can do? I hope so." But they're very happy to kind of be through that mental roller coaster.

Troy: John, along those lines, you mentioned our listenership. A large number of our listeners are women. How often do you have where people are coming in with their significant other, or they say they've been encouraged to come in? Is that something you see often?

Dr. Smith: Prior to the pandemic, yes. A lot of couples would come in together. And oftentimes, the spouse/partner is very supportive of the individual coming in because that intimacy is an important part of their relationship that they've kind of lost and they want it back. And so I did see quite a bit of that.

Now, with the visitor policies and things being different after the pandemic, I've even had a couple of patients say, "Hey, can we FaceTime or can we WhatsApp or whatever with my partner so that we can have this conversation together?" so they're all on the same page, which is great.

Scot: Dr. Smith, as we wrap this up, just kind of give us your final thought. I think you've given the men that listen to this show that might be suffering from this problem hopefully some good information to go seek help and know what to expect. But any kind of final thoughts on this for a guy that's on the fence?

Dr. Smith: There's just no reason to feel bad in any way about it. This is a normal thing. Like I said earlier, 18 million men in the United States have this issue, so you're one of a big group. And there's no reason to wait to feel better and improve your relationships and your confidence in that area.

Scot: Fine work. Thank you so much for being on the podcast, Dr. Smith, and thank you for caring about men's health.

Time for "Odds and Ends" on "Who Cares About Men's Health." We just have one item, and that is in reference to last week's episode about kettlebells. Possibly something you might want to do. A lot of people, their gyms are closed, or you don't want to go to the gym. That was certainly the situation I found myself in. I also used to do just traditional weight training, and I wanted to see if I can get more of a full body, natural movement sort of exercise routine going. So I wanted to do kettlebells, and Caleb helped get me started.

Troy, I'm happy to report that those kettlebells that I bought in that parking lot at the Walgreens in Bountiful, Utah, looked like some sort of a drug deal going down, but no, it was for kettlebells. I have started sniffing around them kind of like a dog sniffs around stuff. So I have started using them. I've started implementing some of the swings and the squats and the deadlifts that Caleb recommended.

And I'll tell you, I really like them. Now, I'm moving really slowly because it's a different type of exercise than I've done before. So I'm watching how heavy of a weight I'm using. I'm also just really not trying to do too many reps.

I've got a really light one up in my office. So I take little breaks while I'm working. I stand up, because you can sit for so long, and I'll do some exercises with that little light, 10-pound one. I've got an 18-pound one in the office. And then the big boys, those are out in the garage and I go outside and I do the swings and the cleans . . .

Troy: Your 35-pounders?

Scot: Yeah, and my full pood as they call it in Kettlebells. The 35 pounds is called a pood.

Troy: That's when you swing the pood in the garage.

Scot: Well, I do it out in the backyard. But I am really enjoying it, and I just wanted to update you that I'm really digging kettlebells. So if you haven't been doing some sort of strength training routine, and they say you should do 30 minutes at least three times a week of strength training, go back and listen to the last episode about kettlebells. Get some do's and don'ts, get a basic little routine, and check out that episode.

Troy: Well, I have not bought my kettlebells yet, but it was very convincing. I'm thinking about it. Like you said, supply and demand right now. Supply is not in our favor. Demand is definitely high. So it's a challenge getting kettlebells right now, but I would like to try them out.

Scot: I highly recommend it.

Troy: I would sing it, but I . . .

Scot: Na-na-na-na-na-na-na-na.

Troy: Thunder!

Scot: Troy, do the honors of singing, "You've been Thunder debunked!"

Troy: I can't do that, Scot. Come on.

Scot: Thunder debunked!

Troy: I kind of have to maintain some sense of dignity.

Scot: Thunder debunked!

Troy: I'm sorry. I can't. I think you already did it.

Scot: Eat this. Don't eat that. It can be really confusing out there when it comes to nutrition, and there's a lot of stuff on the internet. Is it true or is it false? Well, we're going to try to find out again with Thunder Jalili. He's our nutrition expert here on the "Who Cares About Men's Health" podcast. And this is a segment we call "Truth or Thunder Debunked?" So I'm going to give Thunder a statement here and I want him to tell us if it's truth or if he is going to Thunder Debunk it.

Frozen fruits and vegetables are less nutritious than fresh ones. Truth or Thunder Debunked?

Dr. Jalili: I'm going to have to go with Thunder Debunked on that one.

Troy: That surprises me.

Dr. Jalili: Depending on the context, it could be somewhat similar. Let me just give you a really quick background. So if we think about fresh fruits and vegetables that you buy in your grocery store, you've got to remember that product is not as fresh as you think. It was probably picked days or weeks before it found its way to the grocery store, and it was probably picked before it was ripe and it ripened during transit and delivery. So that means you're probably not getting the optimal nutrients in that in the first place.

Now, frozen fruits and vegetables, they're picked when they're actually ripe and then they're subjected to the freezing process. And so they may have a little better nutrient content. But of course, the process of freezing them and blanching them, that may degrade some of the nutrients.

So at the end of the day, when you look at both, they're about the same.

Now, the one exception for fresh is if you have a farmer's market close to you and you go there to buy fruits and vegetables, chances are you're buying something that was just picked in the last couple of days. In that case, that is the most nutritious version of the fruit or vegetable you can get because a ripe fruit has the peak nutrient content. And those were picked when they were ripe before they came to the farmer's market.

Scot: So the statement as it stands, frozen fruits and vegetables are less nutritious than fresh ones, again, Thunder Modified.

Troy: Thunder Modified. It sounds like if you've got the fruit tree in your backyard and you're picking it off the fruit tree and eating it, that's the best you can get. But otherwise . . .

Dr. Jalili: That's the best you can get. Or farmer's market. You've got to make a pitch for farmer's markets, especially when stuff is in season. That's really the highest quality produce you're going to find anywhere.

Scot: Fascinating, though, that frozen fruits and vegetables and fresh ones that you perhaps might get at the grocery store because they were picked and ripened on transit are essentially equal though.

Thunder, as always, thank you very much. We appreciate your participation on the "Who Cares About Men's Health" podcast with "Truth or Thunder Debunked?"

Time for "Just Going To Leave This Here" on "Who Cares About Men's Health." Could be something to do with health, might be something random. I'm going to start.

Just going to leave this here. I am going to encourage you, Troy and our listeners, to unleash your inner puppy. I want you to unleash your inner puppy.

So we have a brand-new puppy. His name is Murphy. I say puppy. He's in the body of an adult dog at this point. He's six months old. You look at him and it's hard to remember this is still a puppy. He behaves like an adult dog, but every once in a while you see the puppy in him. And the moment you see the puppy in him is like when we're outside and he will find a leaf and pick it up and throw it around and chase it and bite it and try to keep it away from you.

There are other little moments where he does puppy things, and that made me think back to times that we've talked about that for your own sanity and mental health, you should play.

And whether that's a hobby that you get into that flow state because you enjoy it so much, whether that's a sport that you like to play either by yourself or with other individuals, I think we forget to play. And we forget the benefits of playing on our mental health and our emotional health.

I've talked to psychiatrists who say that this can actually recharge you. We always talk about taking days off or vacations to recharge you, but it's also about what you do. So I'm encouraging you to release that inner puppy because it can help you unwind and be ready to take on what's going to happen the next day or the next week.

I can speak from personal experience that I find myself recharged after doing that. And maybe if you have kids, maybe that just means when you play with them, just get totally lost in it. Just get totally lost as a kid in it. And it can be hard because our adult brains kick in and we go, "Oh, I'm being silly. I'm being stupid." But just try it. Unleash your inner puppy.

Troy: Great advice. Well, since you have a new puppy, Scot, I'm going to share my puppy advice with you. We have Charlotte who you know. She's a pretty young dog. We guess she was probably maybe eight or nine months old when we got her. She had puppies herself, but we joked that she was like a teenage mom. She wanted nothing to do with her puppies. She'd feed them and then she would come up and play. She was a very young dog.

And Charlotte had a habit, and still has a habit, of eating our remote control for our TV. So what I do now is I keep a spare remote. The original remote I was trying to buy . . . I bought this stupid magic remote a couple of times that cost $50 after she ate it. And then I just said, "Forget it," and found some cheap $8 remote on Amazon.

So each time she eats the remote, I buy a new remote, and I then have a spare remote for when she eats the next remote. So then it takes us a week to get the next remote.

The good news is, I just looked, we've gone through three months now without her eating a remote. So I hope your puppy does not eat your remotes, but if you do, I can share my advice on stocking on remotes and making sure you have a steady supply so you can continue to watch your TV with your puppy.

Scot: Our dog does have a little bit of a chewing thing, but we've kept just chew toys around, and so far that has satiated his need to chew. So we'll see.

Troy: Good. That's great.

Scot: We'll see. But good advice on the remote.

Time to say the things that you say at the end of podcasts, because we are at the end of our podcast. Troy, kick it off with the how you can hear us. Of course, that's kind of redundant because somebody is hearing us right now. They already know.

Troy: Well, you can subscribe. Please subscribe anywhere you get your podcasts, whether it's Google Play, iTunes, Spotify, Stitcher, Pocket Casts. I'm going to mention Pocket Casts, Scot, because you don't like them but my sister uses Pocket Casts.

Scot: So does Producer Mitch.

Troy: So does Producer Mitch.

Scot: They're like the four people that . . . or two people. They're two of the four.

Troy: Two of the four who are still using . . . they probably still have Hotmail accounts as well. Actually, Hotmail doesn't even exist anymore I found out.

Scot: AOL accounts, they probably have.

Troy: Yeah, they have AOL accounts.

Scot: All right. And also then if you want to get in contact with us, there's a couple of ways to do that. And that entails if you have a question you want to ask about a health topic, a suggestion, anything of that nature, hello@thescoperadio.com. That's the email. The Facebook page is facebook.com/WhoCaresMensHealth. And there's also a phone number you can leave a recorded message, and that's 601-55SCOPE. That's 601-55SCOPE. Whatever you're comfortable with, we would love it if you'd reach out and say hi.

Thanks for listening and thanks for caring about men's health.

Interviewer: Erectile dysfunction can cause stress, self-confidence, and relationship problems, but making sure that you get the right treatment specific to your situation is important as well.

And that's why we've got Dr. John Smith, he's a urologist at University of Utah Health, on The Scope with us today. I wanted to talk to Dr. Smith about if a patient comes in with erectile dysfunction, what are some of the things that you do, what are some of the things you look at? But I think the first thing, Dr. Smith, that I do want to talk to you about is it seems like there's kind of this thought that maybe men are still embarrassed to go talk to their doctor about erectile dysfunction and any tips for overcoming that.

Dr. Smith: You know what, just it's okay. It happens. If you really look at it, I would say, in my practice doing men's health at the university, that's a majority of what I see. So you're in a majority, not a minority when you come to my clinic.

Interviewer: Yeah. I think another thing to keep in mind too is it's a lot of things that could cause erectile dysfunction, I mean, from physical to mental. So it's not necessarily like any sort of personal thing. It's not about you. It's a system. It's a complicated system, and that's one of the things that I want to get to today. So what are some of the causes?

Dr. Smith: So there's quite a few things. Some medical conditions can cause it. Diabetes is one that's well known. Gentlemen who've had prostate cancer and had treatment for that is another common one. Another probably less commonly known one is, you know, having stress in your life, whether it be at work, at home, relationship issues. The complexity of life can kind of get at you sometimes and wreak havoc on your body's libido and erections.

And sometimes its underlying medical conditions we don't know about. So we mentioned diabetes and prostate cancer that's been treated, but some folks with underlying, you know, cardiovascular problems that they don't know that they're there may also have a sudden onset of erectile dysfunction that could be kind of a harbinger of other things.

Interviewer: Yeah, that's interesting. So erectile dysfunction could be a symptom of, like you said, a lot of other just physical conditions we've all heard about before. So if somebody is experiencing erectile dysfunction and they come into your clinic, what does that visit look like? How do you try to figure out the best treatment for that individual?

Dr. Smith: So I bring folks in and we sit down and we start to have a conversation. I like to get a nice history of, you know, what's gone on, if they have past medical problems, and kind of also get kind of their social situation, what's going on relationship-wise and other things in their life, you know, work-wise, see and look at the whole individual and see, you know, kind of what could be causing this issue. And if we can put our finger on something specific, like they've been a diabetic for quite some time and this has been a long time coming, you know, that's one thing, or if they come in and it's just kind of a sudden onset thing, where stress, you know, went up in their life and they just noticed kind of a more sudden onset and kind of get a real feel for what brings them in and what kind of things we can do to help them. I like to get a testosterone on folks that come in to make sure that there isn't some kind of an endocrine issue going on as well as make sure, with my history and physical exam, that there may not be some other underlying condition that may be, you know, more problematic.

Interviewer: What's the next step in treatment? Obviously, if there's an underlying condition, the first goal would be to treat those underlying conditions. I'd imagine you want to make sure that those are taken care of. But what's the next step at that point?

Dr. Smith: For a lot of folks, you know, exercise can increase erections. You know, diet and exercise can be a great improvement for some folks who may have a few extra pounds and who may not be as active as they once were. That can help boost testosterone levels and also just kind of help them in general. If that's something that, you know, they're not really keen on or they're already doing and they're still having erectile dysfunction, you know, sometimes we'll trial medication to see how that can help them to have maybe a little bit more confidence or help their erections to be of a higher caliber or quality.

Interviewer: What types of medications are available? I mean, we've all heard of the one, right? Are there other types that do something different?

Dr. Smith: So in the class of drugs like the little blue pill that we've heard of so much, many of them have gone generic now. So the Viagra now is generic as sildenafil and Cialis is now generic as tadalafil. There's also Levitra, which was hot on the market for some time. That's also known as vardenafil. Those have all gone generic and have become quite inexpensive as treatment options. And there is some differences between those medications that we kind of go over with patients to make sure that we're getting them the right medication if that's the course that we go to.

Interviewer: Other than pills, are there things that you do for treatment options before you think surgery?

Dr. Smith: Of course, of course. There's multiple of different things we can do up until surgery. There's constrictive devices. The layman's term would be a cock ring. That can help people who are able to get an erection, but have difficulty maintaining it because that's part of the erectile pathway as well. If they have what we call venous leak, where their penis is letting out more blood than is coming in, you can lose that erection. And so sometimes those constrictive rings can really help during sexual intercourse. You can't leave that on for an elongated period of time. You use it during your sexual encounter, and then it's got to come off so it doesn't damage the tissue surrounding it because of the pressure. But that's one thing that we can do if we suspect a venous leak. That's why a thorough history and physical and understanding what's going on with a patient's erections, when they come in, can kind of lead us down a path to treat them with that rather than medicine.

Interviewer: What if the problem that is causing the erectile dysfunction is more of a mental issue? First of all, what types of mental issues kind of get in the way of that? And then what would you do to help somebody with that?

Dr. Smith: So one of the things is we call it psychogenic erectile dysfunction, where physiologically there's absolutely nothing wrong with the patient, but they're having difficulty with an erection. And I've seen this quite a bit with a few different types of patients. Someone who's been in a new relationship or had something like that, where they've had difficulty with their performance say, that can kind of ruin their psyche and kind of gets you down and then they have problems continuing. Another one that's fairly common is once people have started to try to conceive children, when sex kind of becomes a job at that point, sometimes I've seen men who kind of have difficulty with an erection because now it's not a spontaneous thing or it wasn't as fun as it used to be. Then I'll see them come in and say, "You know, I've had some trouble. We've been trying to have a kid for six months. It's been difficult, and I'm just, you know, a little short on the confidence thing, where this has kind of become more of a job than anything else."

Interviewer: And then ultimately, when a patient leaves, will they be coming back at some point then?

Dr. Smith: I generally say, "Here's the medication. We'll start with a dose." And I usually let them titrate the dose up or down depending on if they need additional medication within safe limits. And then I bring them back within, you know, a few months to make sure that that medication is effective, because if it's a not, I want them to know that we can look at other avenues and options to make sure that we can take care of their erectile dysfunction.

Interviewer: So the ultimate message is that if somebody is experiencing ED, that there is a solution for it. You can help in most cases.

Dr. Smith: Seven out of ten men will do well with just pills alone and, you know, beyond that, we can help them with other avenues as need be. So there is hope we can definitely help folks to get to their goals.

Interviewer: Are there times that you decide with a patient not to treat it because it just ultimately doesn't matter? Like they come there because they think that it is a problem, but ultimately, they're just kind of like, "Well, I really don't care."

Dr. Smith: Yeah. I've seen that, not too often. I mean, it's mostly older patients who may be like post-prostatectomy, who come in and they're not partnered anymore. They're, you know, either a widower or they're divorced. They don't have a partner. And it's like, "Why am I going to give you pills that may give you a headache or flushing, or, you know, those types of things when I don't really need an erection at this point?"

Interviewer: Yeah. Got you.

Dr. Smith: So those aren't as common. But I think some guys, when they come in, the younger guys as well, but they usually want a pill as kind of the ace in the hole to have in their back pocket so that it gives them a little confidence, to be honest.

Interviewer: Well, yeah. I mean, there's something to be said for that, right? They might not even never need to take it.

Dr. Smith: Oh, I've had tons of guys come in that are psychogenic erectile dysfunction, who come in, you know, in their 20s and 30s, who there's not a darn thing physiologically wrong with them. They have no underlying medical conditions. They go to the gym all the time. They're otherwise healthy. It's just they had that one sexual encounter and it didn't work, and now it's never going to work again.

Interviewer: But then you've got that pill. At least, you know that if worse comes to worse and that pill and you might not even need it.

Dr. Smith: Yeah. Well, and that pill potentiates things. I mean, once you get an erection, that pill will help you keep it. And that's the whole point of the pill. And so those guys totally, you know, it's total placebo, but not at the same time, if that makes sense.