Penis Health Q & A

[00:00:01] Speaker A: Welcome to Gay Men Going Deeper podcast by the Gay Men's Brotherhood that showcases raw and real conversations about personal development, mental health and sexuality from an unapologetically gay perspective. I'm your host, Matt Lansadal, and joining me today is Dr. Joshua Gonzalez. Welcome.

[00:00:19] Speaker B: Hi, how are you?

[00:00:20] Speaker A: Good. Good to have you here. Dr. Gonzalez is a board certified urologist who is fellowship trained in sexual medicine and specializes in the management of male and female sexual dysfunctions. He is co founder of Popstar Labs, a sexual wellness brand focused on promoting the importance of sexual health for all. Dr. Gonzalez completed his medical education at Columbia University and his urological residency at the Mount Sinai Medical Center. Throughout his career, Dr. Gonzalez has focused on advocating for sexual health and providing improved healthcare to the LGBTQ community. He serves as an official sexual health advisor for Astroglide Lubricants. He has served on the board of directors for International Society for the Study of Women's Sexual Health. He has appeared on doctors television show, has been featured in Vogue magazine and is a medical contributor to Men's Health, Cosmopolitan and Oprah magazines. He continues to build a robust following on his Instagram and TikTok where he uses social media to educate the public on sexual health. So you're very qualified.

[00:01:21] Speaker B: Thank you. I appreciate that.

[00:01:23] Speaker A: Yeah, yeah. When I was seeking somebody out, you're the first person that came up in the searches and I was like, yeah, I gotta connect with this guy. So nice.

[00:01:30] Speaker B: Yeah, I'm glad you reached out.

[00:01:32] Speaker A: Yeah, yeah, me too. So the community knows I reached out to you guys. I asked you what you wanted to know about penis. Everything cock related. And today we're going to be answering all your questions that you had asked. I've broken them down into multiple categories and we're going to try our best to break through them all. And we're going to start with probably the most polarizing one.

Just dive right into the deep end.

[00:01:53] Speaker B: Yeah, let's get into it.

[00:01:54] Speaker A: Yeah. So about circumcision, we've had a lot of people on our YouTube channel ask for, you know, information on this, like, why is this happening? You know, the medical reasons behind it. So I've broken it down into a few questions. I just want to get your general opinion of circumcision. As a urologist, what's your thoughts on it?

[00:02:11] Speaker B: Yeah, I mean, I think I don't have like a strong, like, ethical or moral stance on circumcision. I will say from a medical standpoint, you know, I don't treat kids. So when we are performing circumcisions on adult men. It's usually for a medical reason, and it is not something that I would encourage an adult person to pursue strictly for, say, cosmetic or aesthetic reasons. And the reality is I don't. I don't see a lot of men requesting that. I'm sure that that happens, but they just don't happen to be seeing me for those. Those concerns. So I think that there is a time and a place and often a medical reason why some men would need to have a circumcision done as an adult. There are other socio cultural reasons that young boys are circumcised that varies depending on the culture and the location in the world. And, you know, that often involves certain religious beliefs. But I don't typically get involved in that just because I don't treat children. And I would say from a practical standpoint, I try to discourage men from pursuing that unless there's a real medical need for it.

[00:03:18] Speaker A: Yeah, well said. Do you know why it's even became a medical practice? I know there's religious aspects to it, but I know in the States and even in Canada, like, it's. Even without the religious component to it, it's still happening. I know in Canada there's now like, before it used to be a free medical service, and now they can charge you 500 bucks if you want to get your son circumcised at birth. Why? Why is this a thing?

[00:03:41] Speaker B: So the one thing that being circumcised has been shown to do is reduce your risk of urinary tract infections. Urinary tract inf. When you are a child, like a baby, can be dangerous, but being uncircumcised doesn't necessarily mean that you're gonna develop urinary tract infection. So I don't. I don't know the history as to why culturally, outside of religion, countries like America and Canada have favored circumcision versus keeping their boys uncircumcised. But that is, I would say, one of the few benefits to sort of a neonatal circumcision is that it reduces the risk of. Of urinary tract infections. There's some data looking at the reduction of HIV transmission and sexually transmitted infection in populations outside of the U.S. but there's not a ton of strong data to support that in US Populations. So, yeah, I mean, I think it's just something that grew up in the medical culture in the States or in North America specifically. But I think similar to what you're kind of describing in Canada, I think that there is the Pendulum kind of swings in different directions depending on what era you're talking about. But there seems to, at least right now, be people kind of favoring more leaving their boys uncircumcised.

[00:04:54] Speaker A: Yeah. What. Like, I, I heard you talk about some of the, the benefits of it. What would be the, the complications or, like, the downsides to circumcision?

[00:05:03] Speaker B: The downsides to circumcision? I mean, when it's done in the neonatal period, like in a newborn, essentially, there's not really much downside. I mean, obviously it's a medical procedure. There's things that can go wrong, but it's a pretty straightforward procedure. And these things are done so frequently that the risks associated with them are pretty low. Sometimes if too much skin is removed, it can cause, like, a webbing of the scrotal skin. It can kind of pull up on the scrotal skin so that it attaches on the shaft of the penis kind of higher up than it would otherwise normally attach. That doesn't necessarily cause an issue, but it can be. In some men, in, later in life, they. They sometimes will choose to have that fixed for aesthetic reasons, but it, it rarely causes a functional problem. There are other extremely rare complications that would require additional surgical interventions, but those are pretty uncommon. So it's, you know, as things go, it's a pretty straightforward procedure.

[00:05:57] Speaker A: Okay. Yeah. And what about. So the things that I've heard, and maybe you can just, like, say whether or not you hear validity to these. But the first one being, like, obviously the foreskin is meant to protect the glands of the penis. So can the glands of the penis become, like, calloused or desensitized from being exposed?

[00:06:13] Speaker B: So I guess we should clarify, like, what population we're talking about. Right. Because again, I don't really treat kids. If we want to talk about adult circumcision specifically, which is, I'm assuming, what many of your listeners are interested in. No, the head of the penis does not become callous or irritated. It can, for a short period after someone is circumcised, be a little bit hypersensitive because it's now exposed to air and things like clothing for the first time. But typically that wears off after a few weeks to a couple months, but it doesn't lead to any damage to the skin of the glands of the penis at all.

[00:06:47] Speaker A: What expose. What about if you were circumcised as, like a, as a baby, but then you go into your adulthood, right. And you don't have a foreskin to protect the Penis throughout life. Like, I know because I. For myself, I'm circumcised. And I was circumcised as an infant, and I was circumcised very tight, like what you described. So I didn't really have a lot of slack. And I actually did like a. Like, I've done so much research on this and in this space. And because of that, so I ended up doing like a foreskin restoration period of like two years just so I could get like, enough slack back that I wouldn't be able. That I don't have to use, like, lubes. I could, like, have a bit of foreskin to be able to, you know, go over the glands of, you know, the head of my penis. So things like wearing boxers as, like a guy who's uncircum or who's circumcised, like, the penis can, like, rub on, like, the boxers and like, it's very sensitive. Right. So, like, for me, like, I wear briefs so that it kind of keeps everything together. So things like that. I've never. I haven't really had much of an issue with desensitization. Like, my. The head of my penis is like, quite sensitive. So I don't know if that's, you know, for me that's not the case. But from some men, I've heard that their circumcision has led to that callousing and like, the nerve endings of the penis head get like, of the glands get desensitized.

[00:07:59] Speaker B: Yeah. I mean, I think the problem with this conversation is there's really not any good data looking at this kind of stuff. Right. And when you talk about anecdotal reports of somebody saying, oh my, you know, newborn circumcision led to the head of my penis being desensitized, that's one story. You know what I mean? But I think what they have shown is that there is no effect on sexual function in men who are circumcised at birth.

[00:08:26] Speaker A: Yeah.

[00:08:26] Speaker B: So men who are circumcised later who lose their foreskin as they're after they're in adolescents and adults can see a reduction in sensitivity. But because the brain is still developing at the time of a newborn circumcision, there doesn't seem to be a clear negative effect on sexual function.

[00:08:44] Speaker A: So.

[00:08:45] Speaker B: So these reports of people saying that they have, like, they feel like their penis is less sensitive than it otherwise would have been had they had a foreskin intact are just, you know, anecdotal. Like, I don't think that we can draw any conclusions based on that.

[00:08:59] Speaker A: And will I never have anything to compare it to either? Like, I react, but it's like to have a foreskin, so I'm not compare it to anything. But I do think the conversation needs to be had more. And I wish there was more, you know, these anecdotal stories taken into account and become qualitative research, because it would be. But I think shame, like, a lot of men don't want to talk about this because of shame. And I think, yeah. In our community, I've heard so many stories of men who are circumcised and men who are intact both carrying so much shame. Right. Because I think men that have foreskins, when they grow up in like, say, the states and everyone doesn't, they get shamed. And then guys who don't have their foreskin maybe feel like a part of their body was taken from them at a young age. So it's just a very, like you said, polarizing topic. And it's. It can harbor a lot of shame, in my opinion.

[00:09:44] Speaker B: Yeah, I would definitely agree with that for sure. Yeah.

[00:09:47] Speaker A: Yeah. Is there any key, like. I think you already answered that. The key differences of the impact of adult circumcision versus infant circumcision. Um, is there anything to add to that?

[00:09:56] Speaker B: Just to say that, you know, again, if you're treating somebody with an adult circumcision, hopefully it's for a real medical issue. And so we should talk about what those medical issues are. Right. So men can have recurrent infections related to having a foreskin because the head of the penis being covered can sometimes create an inflammatory response in the body. It can lead to something called balinitis, which is like a recurrent infection, sometimes fungal, sometimes just inflammatory changes that happen to the skin. You know, that's one reason that sometimes we do the. Do a circumcision, something called phimosis, where the head. I'm sorry, the horse can actually get stuck over the head of the penis and can't fully be retracted. That can cause problems that can lead to infections. It can cause problems that result in pain when somebody gets an erection. Right. You can imagine if your penis gets bigger when you're aroused and that that skin can't fully come back, it starts to pull. It can even tear if it's really tight in some men. And that can certainly negatively impact their sexual function. So, you know, if you're doing this procedure in men like that, then I think in those cases, the benefits of that procedure outweigh the potential Risks and any potential change or decrease in sensitivity that they may develop as a result of the procedure.

[00:11:10] Speaker A: Yeah.

[00:11:10] Speaker B: Because most of those men already have a negative impact on their sexual function. And when you do the procedure, you fix that for them.

[00:11:18] Speaker A: Yeah, I've been with guys like that where they've had that tight foreskin and it's like almost painful for them and it can cause ripping and sorts of complications. So.

[00:11:26] Speaker B: Yeah.

[00:11:27] Speaker A: Yeah.

[00:11:27] Speaker B: And as a. If you are with somebody like that and you don't know, and you're, you know, just jerking them off or something, and you don't know, you could pull too hard and it could be really, really, really painful for them. So. And then each time you develop a tear, there's a scar that forms. Right. That makes it even tighter in that area. So it just like predisposes you to additional injuries in the future.

[00:11:47] Speaker A: Okay. And then in your practice specifically, do you notice any trends of sexual dysfunction between circumcised and intact men? Is there any correlation at all that you see?

[00:11:57] Speaker B: Not really. Like I said, you know, the foreskin obviously has a lot of nerve endings in it and theoretically losing those nerve endings could make sex less enjoyable. But again, in most of these cases, at least in my practice. Right. We're doing it for a real medical reason that's already usually having a negative impact on their sexual function. So I haven't really seen people complaining of like a detrimental effect on their sexual function. I'm sure it does happen. I just don't get. It's not something that I hear reported a lot.

[00:12:27] Speaker A: Okay, yeah, fair enough. And then how to care for a circumcised penis. Are there any products that are good for moisturizing or repairing the dick or, you know, for the callusing, if anything like that? Is there anything that comes to mind?

[00:12:39] Speaker B: I mean, in general, I don't recommend that people put really anything on, on their penis. If you felt like the skin was dry on the head or something like that, then applying like a, like an aquaphor, something that's going to be really benign and not irritating to the skin. The skin on the genitals in general is pretty sensitive. So you want to use like stuff that, if you are going to put something on there, you want to make sure it's like fragrance free and like going to be not as hypoallergenic and minimally irritating as possible.

[00:13:05] Speaker A: Yeah. And like I said, for me, I wear briefs because it keeps everything snug and then my, my dick isn't dangling and like rubbing on, on The. The fabrics of the.

[00:13:15] Speaker B: Yeah, yeah.

[00:13:16] Speaker A: Do you have any thoughts on foreskin restoration at all?

[00:13:19] Speaker B: No. Again, like, no. No moral or ethical judgment on that practice. What I would caution people is that, and I have seen this, people sometimes who engage in that practice can actually cause trauma or injury to themselves.

[00:13:36] Speaker A: Yeah.

[00:13:37] Speaker B: So, you know, if you are going to engage in that kind of activity, just be careful, you know what I mean? Like, the last thing you want to do is cause a nerd injury or cause injury to the tissue itself. That can result in problems with your erections or pain with sex, that kind of stuff. Just be careful.

[00:13:54] Speaker A: Yeah, yeah. It's a long process. It took me like two years just to get like a bit of slack back. And yeah, it was. It was a lot. It was a lot to deal with. I'm glad I did it because it's like, it's allowed me to have a bit of, you know, slack, like I said. And I think the other thing too, to answer the question, like, just from my own anecdotal thing, is. Yeah, you know, like the masturbation style of a guy that is circumcised, I think will play into that as well. Because if you're constantly rubbing over the glands, I think that can, you know, some guys, like, I watch them, like, jerk off and they'll like, kind of rub to the gland and then come back down and go to the gland. So they're not actually rubbing over the gland with like, their more calloused hand skin. And that tends to be fine. But if you're like a guy that goes over the glands with your hands, like, make sure your hands are, you know, moisturized and you don't have like. Yeah, because that can cause being more rough with, you know, with that. And that can probably lead to callusing, in my opinion. Yeah, yeah.

[00:14:47] Speaker B: I mean, that's true for any part of the penis. Right. Like, I mean, in general, you're going to want to use some sort of lubricant even when you're. When you're masturbating, because any kind of skin on skin friction. Right. Is. Is going to potentially break down that skin, especially with something like masturbation. Right. Because you're often moving your hand very quickly. You're often gripping pretty tightly. And so you want to make sure there's like a layer of something that allows, you know, the skin to skin contact to kind of slide back and forth easily. Otherwise you can develop like an abrasion or like you're saying, like, over time to callusing.

[00:15:20] Speaker A: Yeah, yeah. Yeah, I love lube, too. Like, even with a guy that's, like, uncut, I love lube. I just think it's like, there's something so hot about it. So.

[00:15:28] Speaker B: Yeah, and there's so many different, you know, lube options, and depending on what kind of activity you're participating in, like, you know, there's a lot of. A lot out there.

[00:15:36] Speaker A: Yes, exactly. Exactly. Um, okay, so that puts a cap on circumcision. Now let's talk just a bit about foreskin. So I'm curious, what causes the odor that can come from, like, an unclean foreskin?

[00:15:48] Speaker B: So, I mean, it's usually assuming it's not from an infection. It's usually just from, like, dead skin cells. Right. So if that area is. Stays covered and you're not doing a good job of retracting your foreskin and cleaning underneath there, then you just get an accumulation of, you know, the oils that are secreted by the skin, the dead skin cells that slough off over time. And that can just, you know, if it stays trapped underneath, the skin can just start to smell. People may have heard of something called smegma, which is essentially just that. Right. It's a. It's the sloughed off cells. Skin cells and the sort of natural oils that your skin makes combining into like a. Almost like a. I was gonna say exudate, but it's sort of like a. Looks like a paste.

[00:16:32] Speaker A: Yeah, like, almost kind of. Yeah. Mm. Okay, so what's the best way to clean foreskin? Cause I've heard guys that are intact say that soap, like, stings. It's not good for that. Like, what's. What's the best cleaning practice for somebody with foreskin?

[00:16:45] Speaker B: Just water, honestly. Yeah. And. Or whatever you're using to clean your body in the shower. You know, you don't ne need to aggressively scrub that area or put the soap directly on that area. In fact, you know, as you just alluded to, that's. And as we talked about a second ago, that skin is pretty sensitive. But just retracting your foreskin in the shower while you're cleaning the rest of your body and letting the kind of soap and water run over that area is usually more. More than adequate to keep it clean.

[00:17:12] Speaker A: Okay.

[00:17:13] Speaker B: I think part of the issue with cleanliness and hygiene related to foreskin is that that process, that practice needs to start when you're a kid, and at least in the States, because, again, more boys are circumcised than not. We don't do a great job of teaching Parents how to help their boys manage a foreskin. And so they're not often pulling back aggressively enough when their sons are, you know, infants and toddlers. To make sure that it doesn't get stuck and to make sure that there is kind of laxity and, and movement of that skin over the head of the penis.

[00:17:49] Speaker A: Okay, yeah. Good to know. Is there anything that you would share with somebody that does have an intact penis listening, like, on how to take care of it, like, is there anything other than cleanliness, like what you just shared? Is there any other things that are important to know?

[00:18:02] Speaker B: Yeah, I mean, I think a lot of them we already kind of covered. So just like, you know, daily hygiene, as if along with all the other areas of your body that you clean. Right. Like you're cleaning your armpits, you're cleaning your crotch, you know, you're cleaning your bum, like all of that, like, same thing. You should just. It should be another part of your body that you focus on when you're cleaning yourself in the shower. If you feel like your foreskin is on the tighter side. What I usually recommend that patients do is, is practice daily retraction in the shower. When their, their skin is wet and more pliable, it's more easily stretchable. So kind of pulling back on that skin to keep it back. And over time, stretching that skin out will help it kind of move easier. And then like we just spoke about a minute ago, when masturbating, it's not necessary to use lubricant, but I encourage patients to always use lubricant because of that, you know, that skin to skin contact that you want to avoid, which can lead to breakdown of the skin.

[00:18:58] Speaker A: Yeah, it's interesting just even these two of these two topics, and I know there's people listening who are probably circumcised. There's people listening that are uncircumcised or intact. And I think it's important that we don't compare ourselves to each other and we don't shame each other. We don't call somebody who's circumcised mutilated. We don't call somebody who's got a foreskin unclean or dirty. Like, I just think it's really important to like, own. Own any shame that we might have and not project it onto. Onto one another. Yeah, really important. All right, let's start moving into conversations around, like, dysfunction because I know this is your, this is your specialization and I know there's just so much suffering out in the world within men around Things like erectile dysfunction, premature ejaculation, stuff like this. So right off the top, like, people talk about erectile dysfunction a lot, like, what is normal erectile function? If we're going to create a baseline.

[00:19:49] Speaker B: So I'm going to flip that a little bit and say, what is what classifies as erectile dysfunction? Right. Because there's not really like a baseline that we say, like, you have to be this or the. Otherwise you have ed. So erectile dysfunction is the consistent inability to get or maintain an erection long enough to complete sexual activity. The classic definition used a penis, a penovaginal model. Right. It was. It's all like most of the metrics in sexual function in sexual medicine. It's based on a heterosexual model. So the classic definition is an inability to get or maintain an erection long enough to complete vaginal intercourse. But we can take that narrow definition and expand it to all types of sex. Right. And just say if you have trouble getting hard or you have trouble staying hard, or if you have trouble with both long enough to complete whatever kind of sexual activity you are engaging in, then that is erectile dysfunction. Generally, with any kind of dysfunction, it shouldn't be something that just happens once or twice and then, you know, it goes back to normal. It should be a consistent issue that you're dealing with in a variety of situations.

[00:20:52] Speaker A: So.

[00:20:52] Speaker B: And that helps inform how we think about a particular individual's function. Right. So if it's a situational problem, for instance, let's say it's only a problem when they're having sex with a partner. But when they masturbate, their erections are totally fine. They get nighttime erections or wake up with morning erections. But whenever they try to have sex with a partner, they have trouble performing. That sometimes can indicate that that problem may be more psychologically driven and less. Have less to do with like a physiological issue. Not always. I mean, it's. It's more complicated than that. But that would be one clue that that could be what's going on. But that's sort of the classic definition is just the inability to get or maintain an erection.

[00:21:31] Speaker A: Okay, so what are the causes from your perspective? What do you see? And I know you're obviously operating within the medical model, and I think that's what we're wanting from you today. But I can maybe even add some things in from my own research and stuff like that, but. Yeah, what are the main causes of ed?

[00:21:45] Speaker B: So the main physiological reasons that men have erectile dysfunction. Well, the, the things that we evaluate from a Physiological standpoint are hormonal issues that can come up, right? So like, testosterone is an important hormone in the male body. You could argue that it's the most important hormone for erectile function. And for a number of reasons, Men can have testosterone deficiency or decline over time in their testosterone levels that can cause them problems with their erections. So age related testosterone declines are something that basically all men will deal with at some point in their life. Which is why one of the reasons why we see a decline in erectile function with age. So we oftentimes, when we see patients with ED in our office, we'll do an initial hormonal evaluation to look at their testosterone levels as well as other hormone levels that can kind of interact with testosterone production and how it's used by the body to see if there's any anything that can be optimized from a hormonal standpoint to improve their erections. The second big category would be vascular issues. So obviously your penis is a vascular organ like all the other organs in our body. And to get an erection, you have to have normal blood flow. And what that means is you have to have an adequate amount of blood going into the penis when you are aroused, and you have to be able to trap the blood in the penis to maintain that erection. And that is a property that is unique to the penis. For instance, if you think about your finger, right? Like when you have blood go into your finger through the artery, it drops off oxygen to the tissues, right? It immediately circulates through the venous system, taking away all the waste from that. This is getting back to, like basic biology from high school. But the artery drops off oxygen through the capillary system. The capillaries then pick up the waste products and then go out of that tissue through a vein and take it back to the heart. And the whole process gets cycled over again, right? So there's this constant circulation of blood that happens in our tissues. When you are having sex and you get an erection, you get blood into the penis and the blood stays there, or it should stay there, right? And that's how you maintain an erection and stay hard. That happens because the tissue, the erectile tissue, as blood goes into it, expands rapidly. And that expansion of the tissue causes a compression of the veins. So it essentially shuts off the venous system so that blood stays in the erectile tissue. Men can have problems with inflow, meaning maybe their delivery of the blood is abnormal, but they can also have a trapping problem. So they maybe the blood going in is fine, but for whatever reason, those veins are not completely compressed, and some of the veins stay open and they leak blood out of their penis. And a lot of those men will report trouble maintaining their erection. So. And that's a really important distinction because a lot of men, you know, who are not educated on erectile dysfunction and the endovascular things that have to happen for you to have a normal erection, just think it's about, like, blood getting in there, then if it gets in there, it should be fine. And don't appreciate that the maintaining part is possible because you're shutting down one whole side of the cardiovascular system, right? You're completely shutting down the venous system for that time while you're erect. So we do vascular assessments in my office. So we do something called a penile Doppler to look at people's blood flow flow to diagnose whether or not they have an inflow problem, a trapping problem, or both.

[00:25:08] Speaker A: Okay? And that's an ultrasound.

[00:25:10] Speaker B: So it's usually related to some kind of scar tissue in the erection, in the erectile tissue itself. So again, for the system to work normally, you get blood into the tissue, it rapidly expands, and then that expansion shuts off the venous system. You have scar tissue in the erectile tissue to begin with, then that expansion at certain points is restricted. And so there are some parts where you don't fully expand the tissue, and that allows for the veins in that area to remain open. Sometimes the scar tissue is visible on an ultrasound, and sometimes it is not. Sometimes it is related to some prior recognized injury, and sometimes it is not. So I've seen venous leak in somebody as young as, like, 21. It's not a common problem for younger men, but it certainly can happen. It does increase. The risk of having venous leak does increase with age. Again, because it's a function of the health of your erectile tissue. There are some risk factors. Things like, you know, longstanding hypertension and diabetes can predispose you to having problems with your erectile tissue that can lead to venous leak. But there are plenty of cases that we call idiopathic where someone develops a venous leak for no recognizable reason.

[00:26:22] Speaker A: Do you think maybe psychosomatics would come into play there? Like, it could be, like, fear, excessive fight or flight, high cortisol levels or adrenaline levels for long periods of time. Like, say, somebody who has trauma. Right. And they could develop dysfunction in that?

[00:26:35] Speaker B: I don't think that would lead to venous leak because it's. It's a property inherent to the Quality of the tissue, which is not something that psychologically I think you could induce, but you could cause problems with inflow. Right. Like the inflow of the blood happens because you get vasodilation. But there are plenty of psychological things that could be going on. Anxiety, trauma that can allow your brain to turn off that system or dampen that system so that your inflow is not consistently good. And sometimes people can have problems maintaining without venous leak. So if you have interrupting your blood going in, you can also have problems maintaining your erection. So that's where I see more of the psychological factors play a role. Is. Is sort of interrupting normal inflow.

[00:27:24] Speaker A: Okay. So we have almost like, kind of like two streams, what I'm hearing. So you have like, the hormonal side of things, then you have the vascular side. That's what you're saying. How do you discern, like. I know you said you have the penile doppler, which is like, what you're using to determine the venous leak and flow kind of thing. Do you do, like, testing for testosterone or how does that work? Yeah, yeah.

[00:27:46] Speaker B: So everybody. Well, I don't say every. Most people who are coming with erectile dysfunction on their first visit with us are getting blood work done to look at their testosterone levels and also some of those other hormones that interact with testosterone to make sure that there's nothing wrong and to assess whether or not anything can be optimized to improve their sexual function.

[00:28:06] Speaker A: Yeah. Though. Yeah.

[00:28:06] Speaker B: In general, what we're doing, you know, initial visit, they're getting blood work done. We usually have to have them come back to do the ultrasound, but it's usually like a week or two later. And then we review all of that information. We review the findings of the ultrasound, we review the results of the lab work on that second visit and kind of come up with a treatment plan based on those things. Assuming that we find something wrong. Some. We don't always find something wrong with the. Those two factors, but those are the two primary things that we're assessing for. There is sort of a couple other physiological issues or factors that can play a role in. In erectile dysfunction. One would be pelvic floor dysfunction, which I see a lot of. So the muscles that are in our pelvis control all of the actions that happen in our pelvis. Right. So that includes erection, ejaculation, urination, defecation, and they act. Well, they're supposed to act in a coordinated fashion. Right. The problem is, is that those muscles are under poor voluntary control. Right. Like, think about all of those things I just mentioned, all of those things happen without you really having to think about them. Right? So most people don't have good conscious control of those activities because they don't have good control of those muscles. For a variety of reasons, men can develop pelvic floor muscle dysfunction, and that can affect their ability to get blood into their penis. It can make it more difficult to maintain an erection. And so if we suspect that may be going on, and there's some clues in people's histories and on physical exam where we might suspect that if we think they are, have some degree of pelvic floor dysfunction, we will often refer them to a pelvic floor physical therapist to have a formal evaluation and work with them to get that fixed. Another category that can lead to erectile dysfunction would be some sort of neurological factor. Right? So spinal cord injury patients. Right. Will have erectile dysfunction. The nerve contribution to erectile function is that the nerves tell the. The blood vessels when to turn on and turn off. Right. So you get aroused, the brain sends a signal to the periphery, and those nerves tell the blood vessels to dilate to get blood into your penis. If you have some sort of nerve injury peripherally or even centrally in the spine, you can interrupt that normal process and it could cause problems with your erections as well. There's not a ton of great, like, testing that can be done for that. Sometimes we will do like a, an MRI of someone's, like, lumbar spine if, especially if they report like a history of, you know, back issues or pelvic pain or something else that would kind of clue us into some sort of spinal pathology. We'll sometimes get an MRI to assess for that. But the problem is, so many people have incidental findings on these kinds of studies, like herniated discs. It's hard to know who has a problem related to that minor disc herniation or if that's just something that was. Has been there for a long time.

[00:30:59] Speaker A: Okay, so three streams. Hormones, vascular and pelvic. Pelvic health. This musculature, essentially, is what you're saying?

[00:31:06] Speaker B: Sure.

[00:31:06] Speaker A: Okay.

[00:31:07] Speaker B: Yeah.

[00:31:07] Speaker A: Okay. So that's good. That's good to have a kind of a breakdown in upstreams. What are some of the treatment modalities for each of. Maybe let's start with. I'm assuming it's hrt, right. Hormone replacement therapy. Is that.

[00:31:17] Speaker B: Yeah, yeah. So, I mean, if we use testosterone, everything. As an example, if testosterone is deficient in somebody, we will discuss with them treatments that can raise their, their testosterone Level, sometimes that's testosterone replacement therapy. If it's a younger person or somebody that wants to preserve their fertility, we have to sometimes use other medications that try to stimulate their body to make more testosterone rather than provide an exogenous form of that hormone. I don't know if your listeners are familiar with this, but testosterone replacement therapy will often suppress the testicular function, which includes testosterone production, but also sperm production. So men who are on TRT often are producing very low amounts or no sperm at all. So it's an important thing to consider. I have a lot of gay male patients who unfortunately aren't counseled on this risk. I think, because a lot of people assume they don't want children because they are gay and sometimes will come to me on trt, I have this conversation with them. They have been, you know, uninformed up until that point, and then we have to kind of try to undo that so that we can get them, their body to start producing sperm again. So there are different methods. Right. There are what we call testicular preserving treatments that stimulate the body to produce more. More testosterone, and then there's traditional testosterone replacement therapy. So those would be the main ways that we address the. The hormonal issue that, that we find. There's some other hormone problems that can come up. You know, things like hyperprolactinemia, thyroid dysfunction that require other types of treatments. But I would say, you know, the testosterone pathway is, is the. The main one that we kind of go down.

[00:32:52] Speaker A: Okay, yeah. And also, like a symptom of low testosterone is depression. Right. Low energy, depression, sorts of things. So, yeah, it's important for us as we age, as men, to get tested our hormones tested for sure. Yeah.

[00:33:04] Speaker B: I mean, there's no, like in. At least in the US I don't know how. What it is in Canada, but there's not like an age at which we recommend that all men get tested for testosterone. I hope that will change at some point. I think there's a lot of stigma around. Around testosterone replacement therapy, which to me is kind of silly. But I think there are a lot more men coming to the doctor asking for this kind of testing because they read about it online or listen to podcasts like this and understand how important it is not just for sexual function, but for things like mood and energy and muscle, you know, maintenance and cognitive function, all these sorts of things, and find that they may be experiencing problems in these areas and are then seeking help for it. But right now, there's no age cutoff at which we tell people that they should be getting tested. I would say, if you wanted to be proactive, getting tested, like in your mid-30s makes sense because most men are seeing a decline in their testosterone levels around age 40. Sometimes they're earlier.

[00:34:01] Speaker A: So that's the. The hormone side. So I'm curious now about vascularity. Like, what are some treatments that can be done for this venous leak? Inflow, outflow.

[00:34:10] Speaker B: So all of the treatment, medical treatments that we have for vasculogenic erectile dysfunction all have to do with the inflow. There are no medications that fix venous leak. So let's start with the medicines first. So many people are familiar with medications like Viagra or Cialis, right? Um, they've been around for more than 20 years now. Those medicines work to dilate the arteries that supply the blood into the penis during an erection. So if you get vasodilation, that means more inflow of blood, better erection. These medications are systemically absorbed, so you take them by mouth, they get absorbed through the stomach, filtered through the. Or metabolized, excuse me, through the liver, and then cause vasodilation during arousal. It can lead to side effects because they are systemically absorbed but are generally well tolerated. But some of the more common side effects that men experience would be facial flushing, sometimes headache, lightheadedness, changes in vision, blurry vision, double vision, sometimes even like a blue hue to their visual fields.

[00:35:14] Speaker A: Are these permanent or these just when you're.

[00:35:16] Speaker B: No, for. No, no, no. Most of the time it's just related to the use of the medication and they wear off. But I would say, as medications go, they're generally pretty safe and well tolerated. Some men don't respond to those medications. Like, for instance, if they have pretty significant vascular disease, then they may not respond well to them. Also, men who have large psychological components to their erectile dysfunction can override the efficacy of these medications. So I've seen some patients who are, you know, in their mid-20s who have ED, who we treat with these medications sometimes even when they don't have a vascular problem, and they still report finding the medications unreliable. And that's because you can override the effectiveness of these medications, especially if you have, you know, a lot of performance anxiety. So when men don't respond to those medications, there are injectable medications that can be administered, and those go directly into the penis. So men inject their penis with a medication that cause vasodilation, again, draw blood into the penis, and work oftentimes more effectively than the pills because they are acting locally and are not systemically absorbed. That has pros and cons. Right. So the pro would be you're injecting it right where you want it to work so there are less systemic side effects so you don't have to worry about the headaches and the facial flushing and any of that stuff. The downside is that they are also a lot stronger than the pills and can sometimes lead to something called priapism, where you have a prolonged erection, which, while that sounds exciting, you know, is not a safe thing to go on for too long, because if you are not allowing that blood to recirculate, then you are not getting new oxygen to your tissue. And over time, you can have death to that tissue because your nose just need oxygen to survive. Right. But that can be pretty easily managed. Like, for instance, in our practice, we do these injections in the office, first with patients, first to assess their response to it, and secondly to make sure they can safely administer these injections. And we also have all of our patients who use these medications learn how to dose the reversal or the antidote. Should they develop priapism, they can give themselves a shot at home that reverses the first medication so that they don't end up in an emergency room and having to have their penis, like, drained of blood. So, you know, if you're going to someone who works in this space as an expert in sexual health and knows what they're doing in terms of prescribing these medications. The priapism thing is a risk, but can be managed if you, you know, figure out what's an appropriate dose and strength of these medications for the right person.

[00:37:49] Speaker A: Okay, can I ask you.

[00:37:50] Speaker B: Those are questions? Yeah. Yeah.

[00:37:52] Speaker A: You need arousal for them to work?

[00:37:54] Speaker B: Yes. They're all vasodilators, so you need to have the brain component. You need to be aroused for them to be maximally effective. Now, the injections work pretty, you know, they're pretty strong, so you may need less stimulation than you would with something like a pill. But in general, yes, the brain component of arousal needs to be present for you to have the maximum response to any of these medications. And the same is true for Viagra and Cialis. Like, a lot of people who've never tried these medications sometimes ask me, like, if I pop this medication, am I gonna, like, walk around hard all the time? And the answer is no. Right. You're not gonna just be in the supermarket and get a random erection. I mean, you could. If you see somebody that you find attractive and your brain starts to get stimulated, but you're not going to walk around, like, hard all the time. And the same is true for these injections. Like, you are going to need to be in a. In a sexual situation and be aroused to. For them to. To work the way they should.

[00:38:51] Speaker A: Yeah, yeah. This is. I have an interesting story about this because I'm a demisexual, but just like probably six years ago, morphed into a demisexual. For those of you who don't know what that means, it's somebody who requires emotional connection for sexual arousal. And I thought my dick was broken for the longest time. I'm like, why am I not getting aroused? Because I was doing what I've always did in my 20s, which was hookups. So I went to the doctor, get some Cialis. Take it. It's not working. I'm like, what the heck is going on? I literally, for a whole year, thought my dick was broken. And. But what I realized is that I need a connection. When I have a connection, I have a strong connection with somebody, whether it's intellectual or emotional connection. My erections are good, so I actually call my erections heart bonds. Because I get like. When my heart is.

[00:39:35] Speaker B: I like that.

[00:39:36] Speaker A: I've never.

[00:39:36] Speaker B: I've never heard that before.

[00:39:37] Speaker A: I get an erection. Right. So. And I just want to say that because I know there's a lot of guys out there that might be listening, that might struggle with this, and they might carry a lot of shame around this, but when you find the right connection, your dick might work better. It's just been my experience.

[00:39:50] Speaker B: Yeah, I've seen that firsthand. Well, I have a question. Why do you think you developed into that? Because you said that you have not always been that way. Right.

[00:39:57] Speaker A: I think around that time, it was probably like six or seven years ago, like, there was an intersection between my spirituality and my sexuality. And I think I started to, like, open my heart and develop more consciousness around because in my 20s, I was very hypersexual. I was using drugs. I was always drinking alcohol to have sex. And I was almost like dissociating. And I think as I got older, I started to do a lot of work. I started to open up my heart and wanting to connect more. And I think I might have always been a demisexual. I'm pretty sensitive guy. I'm very, you know, I. I want heart connection, but I think I just was forcing myself into, you know, hookup culture because it. That's really. Yeah. New, right? So.

[00:40:33] Speaker B: Yeah. Yeah, yeah, yeah, yeah. Interesting. Those are like the primary medical treatments that we Have. There are some other stuff. Like sometimes there are gels that men can squeeze into their urethra. I don't know if they have this in Canada, but there's like a little pellet that can be inserted in the urethra. Those are vasodilators as well. I don't use a ton of them because you can imagine putting something in your urethra doesn't always feel good. It can burn. It can. I wouldn't want to do anything like that. I wouldn't want to put anything in my urethra. So we don't get a lot of patients asking for those. I, I think it's much easier to administer a shot with a very, very tiny syringe into the side of your penis than it is to put something into your urethra and deal with like a burning sensation. Yeah. But they're technically out there. And if your listeners, your listeners may have been read about them or tried them themselves. But intraurethral gels, intraurethral suppositories are other forms of vasodilators that improve blood flow. We in our office do regenerative therapies. So shockwave therapy is something that we do. It's an in office treatment where we use a probe that delivers a specific type of sound wave energy into the penis that promotes neovascularization, New blood flow to the area and over time can lead to improved erectile function. So that's sort of like a non, non medication treatment option that can improve blood flow.

[00:41:52] Speaker A: Is that good for the scarring?

[00:41:53] Speaker B: Yeah, it can help with scarring. So and I want to touch on treatments for venous leak because a lot of patients are like, well, what can I do if I have venous leak? The gold standard for that has always been penile implant surgery because again, it's a problem inherent to the erectile tissue itself. Right. We don't have any medical medications that fix that problem with shockwave. In recent years, we've been able to improve the quality of that tissue for some men such that they become more responsive to some of the medical therapies that we have available. And, you know, while penile implant surgery is still the gold standard and is a very, very good option for people especially with more moderate to severe venous leak conditions, not everybody wants to have surgery. And so it's nice that we have this, this new treatment option that, you know, may work well enough to allow someone to respond to injections or oral medications. Usually they'll have to use like a cock ring. With them or something again, to try to trap the blood as best as they can. Yeah, but for some people, that's, that's enough. And then, then they can avoid surgery altogether.

[00:43:02] Speaker A: And then where would something like PRP come into play?

[00:43:05] Speaker B: Yeah, so PRP is another regenerative product that is basically a component of your blood. So PRP stands for platelet rich plasma. Plasma is just one component of your blood. So when patients have that treatment done, they get a blood draw in the office. You spin the blood down and it separates into serum and plasma. You extract the plasma, and then you inject it into the penis. It works also to kind of help regenerate tissue, improve blood flow to the area. We don't use a ton of PRP alone. There are other clinics that I know definitely offer that, you know, like one off PRP shots. I just haven't found it to be that effective. There's not really any clinical data to support that that works either. When we have used PRP in our practice, we typically combine it with shockwave and have found actually that the two work very nicely together. But I just haven't had much success in treating our patients with like one off PRP injections.

[00:44:00] Speaker A: And then some of the pelvic dysfunction. Right. Tight musculature trigger points, things like that. I know you said you refer to pelvic physio, and I'm sure they do like inner, like inner trigger point release and things like that. Where would something like Botox come into play? Like if, if someone does carry a lot of tension in their, in this pelvic musculature, does Botox a solution to start to maybe make the tension or the.

[00:44:22] Speaker B: Yeah.

[00:44:22] Speaker A: Take out the tension in the.

[00:44:23] Speaker B: Yeah.

So the way I think about Botox is more as like an adjunctive therapy to physical therapy. Right. Most people with pelvic floor muscle tension, if they work with a good physical therapist, can resolve that issue. Just doing, you know, regular PT for, you know, usually it'll start anywhere from like six to 12 weeks. It's really not that much time that required to like, fix that issue. But there are people that have refractory muscle tension, right. Like they go diligently, like we ask them to every week to see their pt, they get better. Like the muscle gets released during the treatment. They feel better for a short period of time after the treatment, but by the time they see them the next week, things are tight again. Those are the patients that I think benefit the most from from Botox. So I would never have someone get Botox you know, straight away, I always send them to physical therapist first, try to see how well they progress. And then for those people who seem to kind of plateau or get stuck with pt, those are the patients that we will typically recommend get Botox.

[00:45:25] Speaker A: Okay.

[00:45:26] Speaker B: And then, by the way, we get asked a lot about, well, like, Botox. I know in my forehead only works every for six months. Am I going to have to get this done every six months? There is some evidence to suggest that when someone gets pelvic floor Botox, assuming they are doing pt, which they absolutely should be doing before they get the treatment, that they may require additional treatments in the future. But it doesn't seem to be like they have to get it forever. So over time, you kind of train the muscle to stay in a more relaxed state. If you're combining both Botox with bt.

[00:45:58] Speaker A: So I know it's not. Probably wouldn't be venous leak, but, like, maybe outflow. Could tight pelvic musculature lead to outflow?

[00:46:05] Speaker B: Could it allow blood to escape? Is that what you're asking?

[00:46:07] Speaker A: Yeah, like, if the pelvic musculature is tight. Right. And it's not, it's not functioning properly. Because I'm assuming those muscles, they're, you know, like you said, they're part of ejaculation. They're part of these things. If the muscles are tight and taunt and they're not working properly, could that lead to things like outflow, you know, inability to maintain erection, or even like poor ejaculatory?

[00:46:27] Speaker B: I can't think of a case where I've seen venous leak or an outflow problem caused by pelvic floor dysfunction. I think it affects more the inflow issue because we have plenty of patients who do PT where, you know, it's not like their venous leak or outflow problem like, gets better if they do pt. But I have seen people who have abnormal inflow when we do that initial ultrasound, who go to PT and then their erections get better. And some of those patients, we end up imaging again and show either a resolution or at least an improvement in their inflow. So as it relates to erectile dysfunction, yes, it can certainly interfere with your ability to get and maintain an erection, but I think that has more to do with its effect on the blood going in. Not necessarily it interfering with your ability to trap the blood there. It definitely can have an effect on ejaculatory function. So men with pelvic floor dysfunction can have premature ejaculation. Some men will report a decrease in their ejaculatory force. Right. So a lot of guys, especially younger men who have more robust pelvic muscles, will often, you know, shoot farther than they will later in life. That's because those muscles, like all the muscles in our body, tend to atrophy over time. But there are some young guys who can develop that problem earlier before they experience atrophy because of dysfunction or poor coordination of those muscles. So, you know, there are some guys that see me for decrease in ejaculatory force, and sometimes I talk to them about the potential benefit of pelvic floor physical therapy, but it's. It's not something I ref. I would say I refer a lot to pt 4, where we refer a lot more to pt as it relates to ejaculatory function is with premature ejaculation. Right. So if men have spasticity in those muscles and they fire before they're supposed to, then men can ejaculate quicker than they would like. And there's published data showing improvements on ejaculatory control with pelvic floor physical therapy, even if you don't treat anything else.

[00:48:19] Speaker A: Okay, yeah, that's good to know. We're going to move into that shortly here. Have you read the book Headache in the Pelvis?

[00:48:25] Speaker B: That's a long time ago, but yes.

[00:48:27] Speaker A: Yeah, it's a great book. I've read it as well, and I recommend it to any viewer, listener. That's because it's a lot of information in there. It's very, you know, anatomical, but it also has a lot of good stuff in there just to understand the pelvis and how it works.

[00:48:38] Speaker B: And I was just on a panel last week actually related to a female pelvic pain, But I was talking about the benefits of pelvic floor physical therapy. And they said, what's one piece of advice that you would leave our listeners with today? And I said, go see a pelvic floor physical therapist. I think, like, every single person, this won't happen, but I think every single person could benefit from pelvic floor physical therapy. Again, going back to what I said earlier, like, we all have really no control over what's happening in our pelvis. And it's so vital to, like, all of the things that. That happen day in and day out. Right. And as it relates to sex, it's super, super important. And so if you don't understand kind of what's going on in that area, it can leave you feeling really confused and lost if you start to have problems with your sexual function either with erections or ejaculation.

[00:49:25] Speaker A: Right.

[00:49:25] Speaker B: Like, you don't understand how things are supposed to work and how some of it is. Is related to the muscle function down there. And so, yeah, I think books like that are great. And if you have time, you know, go see a public for physical therapist.

[00:49:38] Speaker A: Yeah, exactly. I think too, there's maybe a correlation psychosomatically with, like, you know, you look at the root chakra. The root chakra is at the base of the spine, which is where the pelvis is. And I think, you know, that root chakra is about security and fear. And I think a lot of us as gay men growing up have a lot of fear, a lot of hyper vigilance. Because we're gay, we have to hide the secret. We don't feel safe in the world. So I think fear can actually cause us to have to harbor things in our pelvis. So I know for me, when I did have pelvic physio, I remember crying, like in the office of this person, because, like, pushing on certain trigger points is like releasing emotions out of the body. It's very powerful, powerful practice. Yeah. Yeah.

[00:50:18] Speaker B: I've heard similar stories from my other patients that have been through the process.

[00:50:22] Speaker A: Yeah. Why are some men able to stay strongly erect for as long as they need while others lose an erection too quickly? Again, it's all these issues. It could be any of these issues combined.

[00:50:32] Speaker B: Yeah, I don't think there's one answer to that. I would say if you are someone who is struggling to maintain your erection, definitely, it's definitely worth having that evaluated by an expert to just see if there's, you know, is it a pelvic floor issue? Is it a vascular issue, Is it a hormonal problem? And, you know, we haven't really touched a lot on this because that's not my area of expertise. But looking at psychological factors too, you know, things like shame and sociocultural, religious beliefs, all these sorts of things that. That influence our ability to have good sex.

[00:51:02] Speaker A: Yeah. I did a whole video of that on my podcast or on my YouTube channel. So if you want to go, people can go look that up and maybe I'll link it in the show notes. Just my own journey with dealing with ED and performance anxiety. And, you know, I do a lot of research in the psychological area as well. So. Okay. Premature ejaculation. What are the main causes of pe?

[00:51:22] Speaker B: So PE is not well understood, unfortunately, even though it's incredibly common. So up to 30% of men experience premature ejaculation.

We think of it like in terms of how we treat it as like a, a phenomenon that happens both at the brain level and the periphery. Right. So I mentioned earlier about some spasticity that men can have in the muscles that control ejaculation. Physical therapy can be incredibly helpful with that. There are some men that are born with premature ejaculation and there are other men that it's an acquired phenomenon. So there's some period of normalcy where they have good ejaculatory control. Then they develop this problem later on in life. Historically, it's always been thought of as like a problem of like younger men, but it actually occurs throughout a man's life. It can occur at any age. And so when we talk about treatments, we kind of think about that sort of brain body connection. Physical therapy, as I mentioned, can be helpful, but the medications that we use tend to work more on the brain component. There are no FDA approved medications in the US for this condition. So we use medications off label with an understanding of how they work on the brain and how that those effects can disrupt this problem. Though the, the main one is a class of medications called SSRIs. Those are antidepressant medications. A main side effect of those medications is delayed ejaculation. So in this case we're using a known side effect to our benefit to help men with poor ejaculatory control prolong the time to ejaculation. So the medication that we use most is Paxil Paroxetine, which is taken every day. And that works, that has the most data supporting its, its efficacy of any other medication used for premature ejaculation. So it's something that we use especially in guys who have the congenital form, if your brain has always been hardwired this way. And then I have found Paxil to be most useful in that patient population. If you're somebody who has an acquired form, certainly we'll get those patients into physical therapy and talk to them about other medical treatments. The other primary medicine that I use in my practice is something called Tramadol, which is a pain medication. And we don't know why it works, but the, the explanation that I give my patients is that these medicines dampen the signal from the periphery to the brain. So you're sort of disrupting that excitatory stimulation so that it helps you to prolong the time to ejaculation and orgasm. Yeah, that is typically dosed sort of on demand. So we have patients use it about an hour, one to two hours prior to sexual activity. And sometimes we have to titrate up their dose. Like, they'll start at, like, the lowest possible dose and add onto that until they see the maximum benefit. The problem with that is that, you know, some people are sensitive to these types of pain medications. They can cause, like, nausea, feeling kind of drunk or woozy. In some patients, it can cause dizziness. So there is, like, some limiting factors in using these medications. And it's not always easy to take a pill that far in advance. Right. Like, you don't always know, I'm going to have sex in two hours, so now I got to take my medication. But for the right person, you know, if they're in a relationship in which maybe they're having sex planned more often than not, you know, it might. Might work perfectly well for them.

[00:54:49] Speaker A: What about numbing cream? I've heard of guys using numbing cream just to kind of take some.

[00:54:53] Speaker B: Yeah, I mean, that's the. That's like the. Those are over the counter. I mean, people, you can go to your local drugstore and probably find something on the shelf. I don't have a ton of success using those for a couple of reasons. Number one, people just don't like using them. They come as, like, numbing sprays. They come as a numbing cream. There's numbing wipes. And it's just like, not the sexiest thing to, you know, interrupt sexual activity and put this, you know, substance on your penis. That's number one. Number two, it can rub off on partners.

[00:55:23] Speaker A: Yeah.

[00:55:23] Speaker B: So sometimes you can cause your partner to become numb, which isn't fun for them. So those have been the biggest barriers for me and my patients with those kinds of products. But, yeah, I mean, they're certainly, you know, safe, and some people find them effective. And so I think those are reasonable options. There's some behavioral stuff like start stop technique, but not a ton of good data showing that, that those work. And again, you can imagine why that wouldn't work. If you're in the middle of having sex and you like, you know, all of a sudden you're like, I have to stop. It's not always easy to do that, and it's can be frustrating for not only the person, but their partner as well. So there's not a lot of success with those behavioral techniques either. So that's why we kind of typically will employ some of these medical options.

[00:56:08] Speaker A: Okay, great. Let's keep moving forward. We got. We only got 20 minutes. I know.

[00:56:12] Speaker B: We got a long list to go.

[00:56:14] Speaker A: Okay, so masturbation. What is a healthy amount of Masturbation was a question that one of the viewers asked.

[00:56:21] Speaker B: I would say whatever feels good to that individual. So there's no textbook or medical. Right answer to this. Masturbation is a healthy practice. It relieves stress, it feels good. So I encourage everybody who wants to. To masturbate. Yes. There are some cases in which it can be excessive. If you are causing injury to your penis. We talked about friction earlier.

[00:56:46] Speaker A: Right.

[00:56:47] Speaker B: If you are masturbating so frequently that you're getting cuts or abrasions that might indicate that y