Posts Tagged ‘ED’

The Penis Pump (Vacuum Erection Device): What You Need To Know

April 8, 2017

Andrew Siegel MD  4/8/17

The vacuum erection device (VED) is an effective means of inducing a penile erection suitable for sexual intercourse–even in difficult to treat men who have diabetes, spinal cord injury, or after radical prostatectomy for prostate cancer.  The device is also useful in the post-operative period following radical prostatectomy to maintain penile length and girth. It has some utility in Peyronie’s disease patients in order to improve curvature, pain and maintain penile dimensions. It can be used prior to penile prosthesis surgery in order to enhance penile length and facilitate the placement of the largest possible implant.  


Image Above: Vacuum Erection Device (obtainable via–use promo code UROLOGY 10 for 10% discount and free shipping)


Tissue expansion is local tissue enlargement in response to a force that can be internal or external.  Internal tissue expansion occurs naturally with pregnancy, weight gain and the presence of slow growing tumors. Plastic surgeons commonly tap into this principle by using implantable tissue expanders prior to breast reconstructive surgery.

The VED uses the principle of external tissue expansion by using negative pressures applied to the penis to stretch the smooth muscle and sinuses of the penile erectile chambers. The resultant influx of blood increases tissue oxygenation, activates tissue nutrient factors, mobilizes stem cells, helps prevent tissue scarring and cellular death and, importantly, induces an erection.

There are many commercially available VEDs on the market, which share in common a cylinder chamber with one end closed off, a vacuum pump and a constriction ring.  The penis is inserted into the cylinder chamber and an erection is induced by virtue of a vacuum that creates negative pressures and literally sucks blood into the erectile chambers of the penis. To maintain the erection after the vacuum is released, a constriction ring is applied to the base of the penis.  The end result is a rigid penis capable of penetrative intercourse.

Interesting factoid: Similarly designed vacuum suction devices are available for purposes of nipple and clitoral stimulation.

Brief History of VED

In 1874, an American physician named  John King came up with the concept of using a glass exhauster to induce a penile erection. The problem with the device was the loss of the erection as soon as the penis was withdrawn from the exhauster. In 1917 Otto Lederer introduced the first vacuum suction device.  After many years of quiescence, the VED was popularized by Geddins Osbon and named “the Erecaid device.” Currently, the VED is a popular mechanical means of inducing an erection that does not utilize medications or surgery.

Nuts and Bolts of VED Use

The VED is prepared by placing a constriction ring over the open end of the cylinder. A water-soluble lubricant is applied to the base of the penis to achieve a tight seal when the penis is placed into the cylinder.  Either a manual or automatic pump is used to generate negative pressures within the cylinder, which pulls blood into the penis, causing fullness and ultimately rigidity. Once full rigidity is achieved, the constriction ring is pushed off the cylinder onto the base of the penis. Importantly, the ring should never be left on for more than 30 minutes to minimize the likelihood of problems. After the sexual act is completed, the constriction ring must be removed.

Interesting Factoid: The VED can be used alone or in combination with other forms of treatment for ED, including pills (Viagra, Levitra and Cialis), penile injection therapy and penile prostheses.

Pluses and Minuses of the VED

A distinct advantage of the VED is that it is a simple mechanical treatment that does not require drugs or surgery.  Disadvantages are the need for preparation time, which impairs spontaneity.  Another disadvantage is the necessity for wearing the constriction device, which can be uncomfortable and can cause “hinging” at the site of application of the constriction ring resulting in a floppy penis (because of lack of rigidity of the deep roots of the penis) as well as impairing ejaculation. Other potential issues are temporary discomfort or pain, coolness, numbness, altered sensation, engorgement of the penile head, and black and blue areas.

VED After Radical Prostatectomy

Erectile function can be adversely affected by radical prostatectomy with recovery taking months to years. The VED can be used to enhance the speed and extent of sexual recovery after surgery, minimize the decrease in penile length and girth that can occur, and enable achievement of a rigid erection suitable for sexual intercourse.  Clinical studies have clearly demonstrated that VED use after prostatectomy helps maintain existing penile length and prevents loss of length.

Bottom Line:  The VED is one of the oldest treatments for ED that remains in contemporary use.  It works by creating negative pressures that cause an influx of blood into the penile erectile chambers resulting in penile expansion and erection.  Although effective even in difficult to treat populations, the attrition rate is high, perhaps because of the cumbersome nature of the device and the preparation regimen and time involved. However, the VED is an important part of the “erection recovery program” (penile rehabilitation) after prostatectomy, second only to oral ED pills in use for this purpose. It is particularly vital in the preservation and restoration of penile anatomy and size.  It also is useful in ED related to other radical pelvic surgical procedures including colectomy for colon cancer. It remains a viable alternative in men not interested or responsive to ED pills or penile injections and those not interested in surgery.

There are many different VED systems on the market. The Urology Health Store ( has a nice selection of VEDs (use promo code UROLOGY 10 for 10% discount and free shipping).

** The Urology Health Store  is offering live video VED instructional classes via Skype, Go-To-Meeting or FaceTime.  These classes are available by appointment from 1PM-3PM, U.S. Eastern Time, Monday-Friday.  Call 301-378-8433 for appointment.  No purchase is necessary to take the class.

Excellent resource: External Mechanical Devices and Vascular Surgery for Erectile Dysfunction.  L Trost, R Munarriz, R Wang, A Morey and L Levine: J Sex Med 2016; 13:1579-1617

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health

Viagra, Levitra, Cialis or Stendra: Which ED Med Is Right For You?

July 1, 2016

Andrew Siegel MD  7/1/2016


Cartoon by my patient/artist Ben Blank given to me shortly after  Viagra became available in 1998.  It says it all!

There are lots of options available if you are having erection problems. In my humble opinion, healthy lifestyle measures should always be considered first-line: weight management, healthy eating, exercise (including cardio, strength, core and pelvic floor), sufficient sleep, avoidance of tobacco, excessive alcohol and excessive stress, etc. With respect to ED medications, there are now many choices. Today’s entry will discuss which of the ED meds is best for you.

How the Penis Erects

In an erotic situation, nerves to the penis release nitric oxide that then causes the release of cGMP, resulting in blood flooding into the erectile chambers of the penis, the basis of an erection. As the erection gets fuller, penile veins become compressed, limiting the exit of blood and ultimately the pelvic floor/perineal muscles engage to cause maximal erectile rigidity.

How the Penis Becomes Flaccid

After ejaculation, the enzyme PDE-5 (phosphodiesterase) is released, the chemical mediator of flaccidity. It results in decreased levels of cGMP, resulting in a loss of the erection and a return to flaccid status.

ED Meds

The ED medications include Viagra, Cialis, Levitra and Stendra. They work by inhibiting PDE-5 and are known as PDE-5 inhibitors. Effective for many men with ED, they result in enhanced erectile function, sexual satisfaction and quality of life.

They are taken orally, require some time to get absorbed and necessitate sexual stimulation to work effectively. Although they can result in some increase in penile fullness (tumescence) without sexual stimulation, sexual stimulation is a must in order to induce a fully rigid erection.

Although effective for many men, they will not work for everyone.  If there is significant nerve or vascular compromise to the penis, they will likely be ineffective. It is important to know that the same ED drug at the same dose may work variably depending on the particular time and situation, sometimes more effectively than at other times since there are so many factors that determine erectile rigidity.

Men who are taking nitrates of any kind should never use the ED meds or serious consequences may result, including a dramatic drop in blood pressure (Remember Jack Nicholson in “Something’s Gotta Give”?). All of these ED drugs are metabolized in the liver for breakdown by the body.

Viagra (Sildenefil) This was the first of the group, released in 1998. Dosed at 25, 50 or 100 mg, the half-life (the amount of time it takes for the blood level of the drug to drop by 50%) is about 4 hours. It is taken on demand and kicks in in 15-60 minutes and remains active for 4 or more hours.

Viagra trivia:  Viagra was discovered by chance. Pfizer scientists conducted a clinical trial with an experimental medicine that causes blood vessels to dilate in an effort to treat high blood pressure and chest pain. The medication did not work particularly well for the intended purposes, but had a side effect in that it dramatically improved erections. When the study ended, the participants were profoundly disturbed that the drug was no longer available. The rest is history.

More Viagra trivia: The name Viagra was born as a fusion of the words “vigor” (physical strength) and “Niagara” (the most powerful waterfall in North America).

Even more Viagra trivia: Viagra is not only used for ED. A 20 mg dose is effective for children with pulmonary hypertension, a condition in which the blood vessels in the lungs have abnormally high blood pressures.

The most common side effects of Viagra are headache, facial flushing, upset stomach, and nasal stuffiness. Less frequent side effects are temporary changes in color vision, sensitivity to light, and blurry vision.

Levitra (Vardenefil) This drug came to market in 2003 and is very similar to Viagra, available in 10 mg and 20 mg doses. The effectiveness and side effect profile is similar to Viagra; however, there are no reports of visual distortions as side effects. It is taken on demand and has an onset of about 25 minutes and has a half-life of about 4 hours and remains active for 4 or more hours.

Levitra trivia: The name Levitra derives from “elevate”; in French “le” indicates masculinity and “vitra” suggests vitality.

More Levitra trivia: Levitra is also formulated in a minty, dissolves-in-your-mouth 10mg formulation called Staxyn.

Cialis (Tadalafil) This was FDA approved in 2003 and is available in 2.5, 5, 10, and 20 mg doses. The effectiveness and side effect profile is similar to Viagra. Uniquely, Cialis has a long duration of action that has earned it the nickname “the weekender” as it can be taken on Friday evening and remain effective for the remainder of the weekend without the need for an additional dose. This affords a considerable advantage in terms of spontaneity. Cialis is either taken on demand (usually 10 or 20 mg, although 5 mg can be effective as well) or on a daily basis (2.5 or 5 mg) and has an onset of 15-45 minutes and remains active for 36 or more hours.

Cialis trivia: Cialis is also approved to treat children with pulmonary hypertension.

In 2012, daily Cialis (2.5 and 5 mg) was FDA approved for the management of urinary symptoms due to benign prostate enlargement.

Cialis, on occasion, can cause backaches and other muscle aches. Cialis is not affected by eating fatty meals, which can slow the absorption of the alternative ED meds.

Stendra (Avanafril) This was FDA approved in 2012. Available in 50, 100 and 200 mg doses, it has the advantage of a rapid onset of action. It is taken on demand and has an onset of about 10 minutes and remains active for 6 or more hours. It seems to have lower rates of hypotension when nitrates are co-administered.

Stendra trivia:  The name Stendra probably is a derivative of the word “extends.”

My Take

I have been in urology practice since 1988 and have plenty of clinical experience managing ED with these meds. In my opinion, Viagra 100 mg is the most potent of the group, but will also incur the most side effects, particularly facial flushing and potentially a nasty headache. Levitra is very similar in most respects to Viagra. Cialis is overall the best of the bunch because of its long duration, the spontaneity factor, the ability to take it with a fatty meal and its dual utility of helping urination as well as sexual function. The downside to Cialis is the occasional muscle aches. Stendra’s rapid onset gives it a small advantage.

Many men are capable of functioning satisfactorily without any of these medications, but find that taking a “recreational dose” of Cialis 5 mg enhances erectile capability and takes 20 years or more off the functional age of the penis. It is particularly useful for those with performance anxiety.


These drugs have gradually increased in price to the point where they are ridiculously expensive, unaffordable for many. None of the ED meds are yet generic. They typically retail for $40 or more per pill.

Tip of the Day: Viagra 20 mg (for pulmonary hypertension in children) is now generic and significantly less expensive than the branded variety and can be used for ED (taking up to 5 pills) at significant savings.

Bottom Line: The arrival of this class of medication in 1998 revolutionized the management of erectile dysfunction. Each of the available ED medications in this class is effective in improving erectile dysfunction issues for most men. There are subtle differences among the four that provide potential advantages and disadvantages. Trial and error will determine what works best for your needs.

Wishing you the best of health and a wonderful Independence Day weekend,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health– and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo; paperback edition available at

Author page on Amazon:

Apple iBook:

Trailer for The Kegel Fix: 

Co-creator of Private Gym and PelvicRx: comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: or Amazon.  In the works is the female PelvicRx pelvic floor muscle training DVD. 

Pelvic Rx can be obtained at, an online store home to quality urology products for men and women. Use promo code “UROLOGY10” at checkout for 10% discount. 

Limping Along

November 14, 2015

Andrew Siegel MD   11/14/15


(Above image courtesy of: staff. “Blausen gallery 2014“. Wikiversity Journal of MedicineDOI:10.15347/wjm/2014.010ISSN 20018762.)

This  entry is intended to be unisex, since both genders are equally susceptibility to clogged arteries and impaired blood flow to muscles and other vital organs (a.k.a., ischemia).  Although sexual dysfunction resulting from compromised pelvic blood flow is outwardly more obvious in the male with the inability to achieve an erection or difficulty in obtaining or maintaining an erection, females as well can suffer with sexual consequences to a similar degree with impaired arousal, lubrication and climax.

Male sexual response is so evident, conspicuous and literally palpable, a binary system with a digital “one” or “zero” response, whereas female sexuality is to all appearances so much less obvious and so much more subtle and nuanced. However, this framing of human sexual response is off target as the female sexual response results in genital anatomical changes as profound as those that occur in males, just less apparent. Under normal circumstances, the vagina is no more “primed” for sex than is a flaccid penis, the un-stimulated vagina being merely a potential space with the vaginal roof and floor in direct contact. However, when stimulated, the vaginal walls lubricate and the vagina expands, lengthens and widens in order to accommodate an erect penis, changes that are as dramatic as the transition of a flaccid penis to an erect penis.  

Because the primary driver of the human sexual response is BLOOD FLOW, females can be as susceptible as males to compromised circulation and can “limp” in the bedroom just as much as males can. It’s just not as ovvious and apparent. Furthermore, both genders are susceptible to limping in the street. 

In terms of ambulation, many people limp instead of walk because of peripheral arterial disease (PAD), a medical condition in which the arteries in the legs clog due to a buildup of fatty plaque. This impairs blood flow and the delivery of oxygen and nutrients to muscles and other tissues, giving rise to pain when exercise increases the muscle’s demand for oxygen.

PAD commonly occurs on the basis of poor lifestyle–obesity, diabetes, an unhealthy diet, a sedentary existence and often the use of tobacco. When muscles are denied the increased blood flow required with the demands of movements such as walking or exercisizing, pain and limping result, known as claudication, from the Latin “claudeo,” meaning “to limp.”

Claudication often does not demonstrate itself until there is significant blockage–usually about a 70% restriction– to arterial flow. It occurs because of insufficient oxygen to the leg muscles causing the buildup of lactic acid, which causes discomfort and pain. Claudication typically responds to stopping movement, which resolves the pain.

Claudication is by no means limited to the leg muscles, but can happen to any muscle in the body. “Claudication” of the heart muscle—which occurs when the coronary arteries are compromised—is known as angina. “Claudication” of the brain—which occurs when the carotid arteries are compromised—can give rise to mini-strokes or transient ischemic attacks (TIA). “Claudication” of the penis—which occurs when the penile arteries are clogged with years of accumulation of fatty plaque—is known as erectile dysfunction (ED), a.k.a., when the penis limps along.

Sexual dysfunction in either gender can be a warning sign that an underlying medical problem exists, the quality of sexual response serving as a barometer of cardiovascular health. When it comes to men, the presence of rigid and durable erections is an indicator of overall cardiovascular health, and conversely, the presence of ED can be a clue to poor cardiovascular health. For this reason, men with ED should consider undergoing a basic medical evaluation seeking arterial disease elsewhere in the body (heart, brain, aorta, and peripheral blood vessels). Since the penile arteries are generally rather small—1 to 2 millimeters in diameter—and the coronary (heart) arteries are about 4 millimeters in diameter, it stands to reason that if vascular disease is affecting the tiny penile arteries, it may well be soon affecting the larger coronary arteries as well. The presence or absence of erections may thus be considered a genital “stress test.”  The same applies to females who are limping in the bedroom.

The presence of ED is as much of a predictor of cardiovascular disease as is a strong family history of cardiac problems, tobacco smoking, or elevated cholesterol. The British cardiologist Graham Jackson expanded the meaning of the initials ED to: Endothelial Dysfunction (endothelial cells being the type of cells that line the insides of arteries); Early Detection (of cardiovascular disease); and Early Death (if missed).

Bottom Line: Heart-healthy and blood vessel-healthy is sexual-healthy (and vice versa). If you do not care to limp when you walk or be limp in the bedroom, commit to a healthy lifestyle. Minimizing the buildup of fatty arterial plaque will prevent claudication everywhere in the body. To do so requires weight management, healthy eating, regular exercise, avoiding tobacco, etc. And if you are already limping (whether it is on the sidewalk or the bedroom), a lifestyle “angioplasty”—cleaning up your unhealthy lifestyle habits—can help reverse the problem.  This applies equally to both men and women. 

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: or Amazon.

Is There A Better Way To Manage Erectile Dysfunction Than “Doping”?

October 3, 2015

Andrew Siegel, MD    10/3/15


(My patient Ben Blank, a talented artist and cartoonist, gave me the cartoon shown above in 1998 when Viagra first became available.  It is hanging in one of my exam rooms)

Erectile dysfunction is usually caused by a combination of many factors, including lifestyle, medical issues, medications, impaired blood flow, nerve damage, pelvic muscle weakness, stress and psychological conditions.

Managing any medical problem should employ a sensible strategy trying the simplest, safest, and least expensive alternatives first. If unsuccessful, more aggressive, complicated and invasive options can be entertained.

For example, when a patient presents with arthritis, he or she is not offered a total knee replacement from the get-go (at least I hope not!). In accordance with the aforementioned strategy, managing knee arthritis should start with rest and anti-inflammatory medications and proceed, if necessary, down the pathway of exercise/physical therapy, arthroscopy, endoscopic knee surgery, and ultimately if all else fails, under the proper circumstances, to prosthetic joint replacement.

A Sensible and Practical Approach To Erectile Dysfunction

A similar approach should be applied to managing erectile dysfunction. Unfortunately, however, many patients and physicians alike seek the “quick fix” and ignore many treatments that can help prevent or reverse the condition.

I like to adhere to the following principles to manage sexual dysfunction:

  1. Provide education (verbal and in writing) so informed decisions can be made.
  2. Try simple and conservative solutions before complex and aggressive ones.
  3. If it isn’t broken, don’t fix it: “First do no harm.”
  4. Healthy lifestyle is crucial: “Genes load the gun, but lifestyle pulls the trigger.” Lifestyle improvement measures are of paramount importance.

“Doping” is common among athletes, who use illicit drugs to enhance their athletic performance. In my urology practice, many of my patients “dope”—with legal drugs—in an effort to improve their sexual performance. Is there not a better and more natural way than starting with performance-enhancing drugs from the get-go?

Don’t get me wrong, the oral meds for ED (Viagra, Levitra, Cialis and Stendra) are “revolutionary” additions to the limited resources we once had to treat ED. Although far from perfect—expensive, contraindicated with certain cardiac conditions and for those on nitrate medications, associated with some annoying side effects, and not effective in everyone—nonetheless, for many men they are highly effective in creating a “penetrable” erection.

These drugs are commonly used as the first-line approach to ED. As useful as they are, I contend that “doping” should not be first-line treatment, but should be reserved for situations in which the simple and natural first-line interventions fail to work.

Since erections are nerve/blood vessel/erectile smooth muscle/pelvic skeletal muscle events, optimizing erection capability involves doing what you can to have healthy nerves, blood vessels and muscles. How does one keep their tissues and organs healthy? The first-line approach is commonsense—getting in the best physical (and emotional) shape possible. This might mean a lifestyle makeover to get down to “fighting” weight, adopting a heart-healthy (and penis-healthy diet), exercising regularly, drinking alcohol moderately, avoiding tobacco, minimizing stress, getting enough sleep, etc.—measures that will improve all aspects of health in general and blood vessel health in particular.

Focused pelvic floor muscle exercises improve the strength and endurance of the male “rigidity” muscles that surround the deep roots of the penis.

Since intact and functioning nerves are fundamental to the erectile process, activation of the nerves via penile vibratory stimulation can be an effective means of resurrecting erectile function.

The vacuum suction device—a.k.a., the penis pump—is a means of drawing blood into the penis to obtain an erection and enable penetration.

Second-line treatments are the well-established oral medications for ED. Although Viagra, Levitra, Cialis and Stendra all have the same mechanism of action, there are nuanced differences in potency, time to onset, duration of action, side effects, etc., so it may take some trial and error to find out which works best for you. Cialis uniquely is approved for both ED and prostate issues, so can be an excellent choice if you have both sexual and urinary issues.

Third-line alternatives include urethral suppositories and penile injection therapy. Suppositories are absorbable pellets that are placed in the urethra that act to increase penile blood flow. Injections do the same, but are injected directly into the penile erectile chambers.

Fourth-line treatment is the prosthetic penile implant. One variety is a semi-rigid non-inflatable device and another is a hydraulic inflatable device. They are implanted surgically within the erectile chambers and can be deployed on demand to enable sexual intercourse. For the right man, under the right circumstances, the penile implant is a life changer—as magical as a total knee replacement can be—converting a penile “cripple” into a functional male. However, it is vital to understand that the implant is a fourth-line approach, and less invasive options should be exhausted before its consideration.

Bottom Line: Sadly, our medical culture and patient population often prefer the quick fix of medications or surgery rather than the slow fix of lifestyle measures. A sensible approach to most medical issues—including ED—should be the following:

  • Get educated about all treatment options.
  • Explore the simplest, safest, and least expensive alternatives first.
  • Before considering medications to improve performance, think about committing to a healthy lifestyle and getting into optimal physical shape, including exercising the rigidity muscles of the penis and using vibratory nerve stimulation.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: or Amazon.

Pelvic “Trauma” From Cycling And Other Saddle Sports: What To Do

May 2, 2015

Andrew Siegel, MD  5/2/15


(Nude cyclist 1995 Fremont Solstice Parade…thank you Wikipedia Commons)

 When sitting on a saddle—whether a bike seat, motorcycle seat, horse, etc.—one places a great deal of body weight on the perineum (area between genitals and anus), putting anatomy that is usually protected into a vulnerable position. Prolonged time in the saddle can compress vital genital nerves and arteries and traumatize the pelvic floor muscles (PFMs) that are essential for erectile and clitoral rigidity. The scrotum and the inner aspect of the penis (penile roots anchored to the pelvic bones) as well as the labia and inner aspect of the clitoris can be compressed as well. Over time, with repeated stress to the pudendal nerve and artery, PFMs and penile root, damage may lead to sexual dysfunction.

Cycling, in particular, has the potential for wreaking pelvic havoc. The downward force of the cyclist’s weight while tilting forward on the saddle generates extreme pressure on the perineum that pinches the pudendal nerve and artery against the pubic arch. Both the duration and the magnitude of compression are factors in determining the degree of trauma. Moreover, many cyclists are lean and their limited body fat does not provide padding that could potentially offer some relief from saddle pressure. Cycling-related sexual dysfunction has multiple factors involved including the geometry and hardness of the saddle, the anatomical variations of the individual, the amount of time spent in the saddle, the cyclist’s weight, the intensity of the effort, and the style of sitting, which is nuanced and variable.

Wide Enough, Flat Enough, Firm Enough

The saddle nose is the part of the bike seat that is especially dangerous. Greater saddle width and the absence of a saddle nose have been the most important factors in preventing compression. If the saddle is not wide enough to support the ischial tuberosities (sit bones), body weight is borne by the perineum. It is important for a saddle to be flat enough because if there is too much curvature, the center of the saddle can push up into the perineum and cause compression. Additionally, it is important that a saddle is firm enough. Gel saddles actually cause more trauma than unpadded saddles by virtue of the body sinking into the soft padding. The reduced surface area of saddles with a narrow cutout can actually increase the extent of the pressure (on the edges of the cutout); however, for those cyclists who find that if they have a saddle that is sufficiently wide, flat and firm yet remains uncomfortable, they may need a cutout to help relieve some of the discomfort.

Numerous factors influence compression. A horizontal or downward-pointing saddle position causes less pressure. Heavier riders exert more pressure on their saddles than lighter riders. Lower handlebars may worsen the situation by forcing the rider to lean forward, putting more body weight on the perineum. As a cyclist goes from sitting upright to the bent over aerodynamic position, the torso and pelvis rotate forward and the sit bones are lifted off the saddle surface, shifting more weight onto the perineum. This is clearly a superior position for racing, but inferior for one’s genital health!
 On the other extreme, when standing on the pedals, there is no pressure. Mountain bikes cause a greater degree of sexual dysfunction than road bikes, likely because of the additional hammering and vibrational trauma from cycling over rough terrain; however, this is balanced to some extent by the use of suspension mechanisms, the increased time spent out of the saddle and more frequent dismounts.

Kegels For Your Pelvic Health: Resuscitate Your Genitals

Dr. Arnold Kegel popularized PFM exercises to improve female sexual and urinary health after childbirth. His legacy lives on with the exercises that bear his name—Kegel exercises. Men have the same PFM as do women and an equivalent capacity for exercising them, with parallel benefits to urinary and sexual health. Saddle sport participants can tap into their PFMs to pump some “life” back into their compromised genitals after a long ride.

Similar to using a bike pump to inflate tires so that they are well pressurized, with each contraction of the PFM, blood pumps into the genital tissues to help “resuscitate” them.

PFM training can be valuable to help lessen pelvic trauma from saddle sports. PFM training increases the strength, tone, and endurance of the PFMs and can ease saddle compression. Aside from committing to an exercise regimen, the practical application is to actively squeeze the PFMs for 1-2 seconds repeated 3-5 times, before, during and after cycling. Most cyclists will periodically take a break from sitting in the saddle by standing up and this provides a perfect opportunity to take the pressure off the perineum and to do a few PFM contractions to restore genital blood flow.

Keys To Reducing Risk Of Sexual Dysfunction

  1. Wear well-padded shorts. 

  2. Shift from sitting to standing every 10 minutes or so, and if numbness and tingling occur, shift position or stand more often. 

Sit back firmly on your sit bones and not on your perineum: as you shimmy from nose towards rear saddle, you can feel the proper engagement. 

  4. Invest in an ergonomic saddle tailored to your anatomy—make sure it is wide enough to support your sit bones, firm enough so that your perineum doesn’t sink and flat enough so that you don’t slide and that it doesn’t wedge up under your perineum.

  5. Adjust seat and handle bar height and angle to minimize compression. 

  6. Do PFM contractions periodically while cycling and PFM exercises when not cycling. 

  7. If you start having sexual issues, seek help! 

Bottom Line: Cycling and other saddle sports may contribute to both male and female sexual dysfunction, especially for serious participants who spend prolonged time in the saddle. Pay careful attention to your perineum, a most valuable piece of human real estate.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in your email in box go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback:  

Co-creator of Private Gym pelvic floor muscle training program for men: 

The Private Gym is a comprehensive, interactive, follow-along exercise program that provides the resources to strengthen the pelvic floor muscles that are vital to sexual and urinary health. The program builds upon the foundational work of Dr. Arnold Kegel, who popularized exercises for women to increase pelvic muscle strength and tone. This FDA registered program is effective, safe and easy-to-use. The “Basic Training” program strengthens the pelvic floor muscles with a series of progressive “Kegel” exercises and the “Complete Program” provides maximal opportunity for gains through its patented resistance equipment.

5 Things You Can Do To Cure Post-Void Dribbling (PVD)

March 20, 2015

Andrew Siegel MD 3/21/15

“No matter how much you shake and dance,

The last few drops end up in your pants.


PVD is “after-dribbling” of urine that is more annoying and embarrassing than serious. Although it commonly occurs after age forty, it can happen to men at any age.  Immediately or shortly after completing urination, urine that remains pooled in the urethra (tubular channel that conducts urine) drips out, aided by gravity and movement.

One specific pelvic floor muscle (PFM) is responsible for ejecting the contents of the urethra, whether it is urine after completing urination or semen at the time of sexual climax. With aging and loss of PFM strength and tone, both PVD and ejaculatory dysfunction may occur. The specific muscle responsible for ejecting the contents of the urethra is the bulbocavernosus muscle, which compresses the deep, inner portion of the urethra to function as the “urethral stripper.” In fact, the 1909 Gray’s Anatomy textbook referred to this muscle as the “ejaculator urine.”

Factoid: Dr. Grace Dorey published the landmark article in the British Journal of Urology that proved the effectiveness of PFM exercises for erectile dysfunction (ED), but also demonstrated an association between the occurrence of ED and PVD. She essentially showed that ED and PVD are linked and parallel issues, one sexual and the other urinary—both manifestations of PFM weakness, and both treatable by PFM exercises.

Factoid: Dr. Grace Dorey wrote the foreword to my book, Male Pelvic Fitness: Optimizing Sexual and Urinary Health. She also serves as a board member at Private Gym and helped design the Private Gym male pelvic floor training program for men.

What To Do About PVD?

  • PFM training has been proven to be an effective remedy for PVD, with the premise that a more powerful BC muscle will help the process of ejecting the contents of the urethra. Not only will PFM training optimize emptying the urethra, but it also has collateral benefits of improving erections and ejaculation.
  • Try not to rush urination. Urologists interpret “Haste makes waste” as “Haste makes PVD.”
  • When you are finished urinating, vigorously contract your PFMs to displace the inner urethra’s contents. By actively squeezing the PFM by using the Private Gym “rapid flex” technique—3-5 quick pulsations—the last few drops will be directed into the toilet and not your pants.
  • If necessary, PFM contractions can be supplemented with manually compressing and stripping the urethra, but this is usually unnecessary since the PFM—particularly when conditioned—are eminently capable of expelling the urethral contents. To strip the urethra, starting where the penis meets the scrotum, compress the urethra between your thumb on top of the penis and index and middle fingers on the undersurface and draw your fingers towards the penile tip, “milking” out any remaining urine.
  • Gently shake the penis until no more urine drips from the urethra. Apply a tissue to the tip of the penis to soak up any residual urine.

Wishing you the best of health,

2014-04-23 20:16:29


A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Kindle, iBooks, Nook, Kobo) and paperback:

Co-creator of Private Gym pelvic floor muscle training program for men Gym-available on Amazon as well as Private Gym website

The Private Gym is a comprehensive, interactive, follow-along exercise program that provides the resources to strengthen the pelvic floor muscles that are vital to sexual and urinary health. The program builds upon the foundational work of Dr. Arnold Kegel, who popularized exercises for women to increase pelvic strength and tone. This FDA registered program is effective, safe and easy-to-use: The “Basic Training” program strengthens the pelvic floor muscles with a series of progressive “Kegel” exercises and the “Complete Program” provides maximum opportunity for gains through its patented resistance equipment.

Are You Cocky (Cock-y)?

December 20, 2014

Andrew Siegel, MD  12/20/14

shutterstock_side view manjpeg

On Cockiness

The word cocky (derivatives cockily and cockiness) is defined as “conceited or arrogant, especially in a bold or impudent way.” Cocksure (derivatives cocksurely and cocksureness) is defined as “presumptuously or arrogantly confident.”

Being able to function well sexually contributes to your masculine identity and behavior and is responsible for a “swagger” that permeates positively into all areas of your life. Body confidence promotes mind confidence just as mind confidence promotes body confidence. There is good reason that the words “cocky” and “cocksure” mean possessing a great deal of confidence.

 Slang Terms For The Penis

There are an abundance of slang terms for the penis. Some are vulgar, others less so. The most popular are “dick” and “cock.” The “w” words “wang,” “wiener,” and “willy” are popular. There are the descriptive words: “manhood,” “member,” “package,” “tool,” “unit,” “prick,” “pecker,” and “dong.” Let’s not forget the name words “Johnson” and “Peter.” There is the medical term pudendum” and its derivative “pud.” There are the Yiddish slang terms, “schlong” (slang for snake) and “putz,” often used in a derogatory sense. On the international scene, “lad” is Irish, “todger” is Australian/UK origin, and “schwanz” is German, literally meaning tail. When I was a urology resident, we used the term schwanz quite often, although I’m not sure quite why, it just sounded like an appropriate term, and was subtler and smoother than the harsher terms “dick” and “cock.”

Slang Terms For Erections

There is no scarcity of slang words for an erection. The most popular are the descriptive terms “hard-on” and “boner,” but “chubby,” “stiffy” and “Mr. Happy” are reasonably popular as well. Then there are the metaphors: “wood,” “rod,” “joystick,” “pony” and “pitching a tent.”

Constriction Devices

Cock rings—a.k.a. constriction devices, tension rings and erection rings—are tourniquet variants that are placed around the circumference of the base of the erect penis with the intention of providing constrictive pressure to stop the exit of blood to help maintain erectile rigidity.

Constrictive devices are sometimes used to treat ED, particularly when the underlying cause is veno-occlusive disease, the ability to obtain a rigid erection, but its premature loss because of failure of blood to be trapped appropriately. As a urologist I have often prescribed the Actis adjustable loop for patients with venous-occlusive disease or “venous leak.” Additionally, constrictive devices are often used in conjunction with vacuum suction devices, to trap the blood pulled into the penis by virtue of the vacuum.

Cock rings are also used recreationally to enhance the rigidity of erections or at times as a sex toy. Caution must always be taken when using a device that chokes off blood flow. Although they can enhance rigidity and sexual pleasure, they can also cause discomfort, a cold and dusky penis, an unstable (floppy) erection because of failure of the device to create rigidity of the deep roots of the penis, and can make ejaculation impossible. One of the biggest issues with  rings is that they provide constrictive pressure that affects only the pendulous outer half of the penis without compressing the inner penile roots, which are “where the money is” in terms of providing erectile rigidity.

Want To Know A Little Secret?

You actually have a natural, built-in ring that you can tap into at will and use in lieu of a constriction device!

Two of the pelvic floor muscles are compressor muscles that function to impede the exit of blood from the penis and maintain erectile rigidity and high penile inflation pressures. The two important pelvic floor muscles involved with rigidity are the bulbocavernosus (BC) and ischiocavernosus (IC) muscles, located in the perineum, the area between the scrotum and the anus. The BC and IC muscles cover, support and compress the inner aspects of the erection chambers of the penis and when engaged during sex stabilize the erect penis and decrease the return of blood to help maintain penile rigidity, extraordinary penile blood pressures and a skyward-pointing erection. At the time of climax, they contract rhythmically and are responsible not only for maximal erectile rigidity at the time of ejaculation but also provide the muscle power behind ejaculation. The classic 1909 Gray’s Anatomy textbook aptly labeled the IC the “erector penis.”

How To Optimize Function Of Your Natural Ring?

Pelvic floor muscle exercises to improve the strength, tone and endurance of the pelvic floor muscles will maximize erectile rigidity and durability. If you want to be confident (cocky) in the bedroom, you might consider preparing, just as you would for any other athletic event. The preliminary results from our ongoing clinical trial with the Private Gym male pelvic floor muscle training program have shown that not only does the program improve erectile dysfunction, but also optimizes function in those men who do not have erectile dysfunction, with “confidence” being the one parameter that was most consistently reported as improved.

Wishing you the best of health and a wondeful holiday,

2014-04-23 20:16:29


A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Kindle, iBooks, Nook, Kobo) and paperback:

Private Gym: -available on Amazon as well as Private Gym website

The Private Gym is a comprehensive, interactive, follow-along exercise program that provides the resources to properly strengthen the pelvic floor muscles that are vital to sexual and urinary health. The program builds upon the foundational work of Dr. Arnold Kegel, who popularized exercises for women to increase pelvic strength and tone. This FDA registered program is effective, safe and easy-to-use: The “Basic Training” program strengthens the pelvic floor muscles with a series of progressive “Kegel” exercises and the “Complete Program” provides maximum opportunity for gains through its patented resistance equipment.

Nature’s Brilliant Design: Erection Hydraulics

December 6, 2014

Andrew Siegel, MD  12/6/14

shutterstock_side view manjpeg


Humans are hardwired for two basic functions: survival and reproduction. Nature’s forces have made the reproductive process a pleasurable one, and by so doing have ensured the greatest likelihood of reproduction being successful. What a clever bait and switch scheme in which in the seeming pursuit of a feel-good activity—determined by this evolutionary sleight of hand—we have been hoodwinked into reproducing!

The goal of reproduction is the fusion of DNA from two individuals to perpetuate the species. The penis functions as a “pistol” to inject the DNA into the female’s reproductive tract. A flaccid penis is unable to complete this task, as the process demands penetration.

Many mammals—including the gorilla and chimpanzee—have a bone in the penis (the baculum), which functions to keep the penis hard enough for vaginal penetration and injection of the DNA. (There is also a bone in the clitoris called the os clitoridis.) However, the human penis is boneless (as is the human clitoris). While we can debate whether or not this is a good thing, it certainly helps to keep the penis hidden during the workday!

Creating a “Bone” Where One Doesn’t Exist

So what did nature do to overcome this challenging design problem: how do you create bone-like rigidity in a boneless organ?

The answer lies in hydraulics—using blood as a hydraulic mechanism—not the typical use of blood, which is for the transportation of oxygen, carbon dioxide, hormones, nutrients, and wastes to and from our organs. This use of blood as a hydraulic mechanism for erections—both penile erections in men and clitoral erections in women—is nothing short of brilliant…our bodies having evolved to use blood the way a tire uses air, to inflate deflated organs to allow them to function!

Another example of an animal that uses hydraulic action is the jumping spider, which uses blood forced into the legs to straighten them out to facilitate powerful jumps, avoiding the need for muscular legs that are bulky and clearly not spider-like.

Erection hydraulics requires a special means of regulating flow. To do so, the inflow needs to turn on like a gushing faucet and the outflow needs to shut off like a plugged drain in a sink. This is not the usual state of affairs for blood flow to an organ, which typically requires a relatively small amount of inflow to meet basic metabolic needs and an equal amount of outflow, creating a dynamic state of equilibrium. An erection demands that the arteries of the penis function as high-pressure faucets (inflow increasing many times over baseline) and the penile veins to close off completely.

So how has our body evolved this capacity?

The penis is a marvel of design and engineering, capable of increasing its blood flow by a factor of 40-50 times over baseline! This surge happens within seconds and is accomplished by relaxation of the smooth muscle within the arteries supplying the erection chambers and within the erectile sinuses of the erectile chambers. This is not the case of non-genital organs, in which blood flow can be increased upon demand (for example, to our muscles when exercising), but not anywhere to this extent.

Now for a little deviation off course for some interesting trivia:

  1. The spongy tissue in the erectile chambers is virtually identical to the spongy tissue in our facial sinuses. (My pathologist buddy claims that he can’t tell the difference under a microscope.)
  2. When this spongy tissue in the penis or clitoris becomes congested with blood, an erection occurs; when it happens in ours facial sinuses it is known as sinus congestion or a stuffed nose.
  3. The spongy tissue in the erectile chambers is surrounded by connective tissue known as the tunica albuginea, the second toughest connective tissue in our bodies, the toughest being the dura mater that surrounds our brains and spinal cords.
  4. A side effect of the ED meds like Viagra is nasal congestion…now you understand why.
  5. Prolonged erections (priapism) are often treated with the same medications used to treat a stuffed nose, e.g., phenylephrine.

The Important Role of the Pelvic Muscles

So, under the right circumstances the penis becomes swollen (tumescent) with blood. How has our body evolved the capacity to trap the blood so it does not return to the circulation? How does the penis go from swollen to rock-hard rigid?

First, as the sinuses within the erectile chambers fill with blood, they pinch off the veins, which traps blood in the penis. Second, nature—in its typical brilliant way—has designed a means of increasing the blood pressure in the erectile chambers to sky-high levels by means of a “muscular tourniquet” that not only chokes off the exit of blood, but with each squeeze of this specialized muscle, causes a surge of blood with increased filling of the erectile chambers, the end result being bone-like rigidity.

What are the names of these specialized muscles and what muscle group are they part of?

These are the ischiocavernosus and bulbocavernosus muscles (man’s best friends, but equally helpful to the ladies out there) that are part of the group of muscles known as the pelvic floor muscles, which form the floor of the important group of muscles known as the “core” muscles.

When a man has a rigid erection, contracting these muscles will lift up the erection and point it majestically towards the heavens, thank you pelvic floor muscles. You knew that your core muscles were important, but did you realize that the “boner” that you take for granted is based upon well-functioning core muscles?  Ditto for the firm clitoris in the female.

Maintaining & Strengthening Your Pelvic Muscles

So, take good care of your pelvic floor muscles and they will take care of you! Keep them fit, just as you do your other muscles. With aging and lack of physical activity the pelvic muscles become lax, so by increasing the strength, tone, power, and endurance of the pelvic muscles through exercise, you will optimize your erectile rigidity. Moreover, the pelvic muscles assist in delaying ejaculation. Weak pelvic floor muscles can impair the ability to delay ejaculation and voluntary contraction of the pelvic floor muscles can help control ejaculation. When flexed, the pelvic muscles assist in short-circuiting premature ejaculation. Learn more about how you can strengthen and maintain these critical muscles at

Enough of my prose…time to finish with a poem I have written for the occasion:

The Muscles Of Love

Limber hip rotators,

A powerful cardio-core,

But forget not

The oft-neglected pelvic floor


Wishing you the best of health,

2014-04-23 20:16:29


A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health:

Private Gym: – now available on Amazon as well as Private Gym website

Man’s Motivation for Medical Ministration: His Penis

October 18, 2014

Andrew Siegel MD


shutterstock_side view manjpeg


You—as a man—are a master of denial, who, through a combination of nature and nurture, often play the stoic, tough guy, independent, cool as a cucumber, stubborn, non-demonstrative, too-proud-to-ask-directions act. You typically serve the role of provider, protector, hunter, and warrior as opposed to your nurturing and more emotional female gender mate. Furthermore, you are literally “tainted” by testosterone levels that can biochemically impair your ability to think rationally. Truth is that deep inside, most men are actually weak-kneed milquetoasts who are put to shame by women when it comes to true bravado. Regarding seeking help in the form of medical care, men are much more reluctant to do so than women, particularly preventive health care, and medical care is often not sought until after a problem develops, establishes itself and worsens.

Men’s Health: Facts

  • Men live 6 years less than women on average
  • 36% of men seek medical care only when they become really ill
  • 30% of men defer seeking medical help as long as they can
  • 90 million men have a usual place of medical care, as opposed to 106 million women
  • 30 million men reported no office visits with a physician in the past year, as opposed to 16 million women
  • Men have higher rates of inactivity, poor nutrition, and excessive alcohol consumption than women
  • More than 50% of premature death in men in the USA are result of chronic, but preventable medical conditions

One of the challenges of being a physician is to persuade men to pursue preventive health services. Over the years, however, getting the male patient into the office has actually become much easier, thanks to the emerging field of sexual medicine, the availability of Viagra and other ED drugs, and Big Pharma’s extensive direct-to-consumer advertising.

Viagra was the initial drug in its class that addressed a previously unmet medical need with the collateral effect of being the “carrot” that enticed men to see their doctor. The direct-to-consumer advertising effort has resulted in a change in name of the pejorative term “impotence” into the more euphemistic term “erectile dysfunction,” de-stigmatizing sexual dysfunction, resulting in patients more readily making appointments. Big Pharma has also made the word “testosterone,” previously the domain of endocrinologists and urologists, into a commonly used household word, and numerous patients now appear in the office requesting to know what their “T” is.

Men may be stoic when it comes to their general health but when it comes to their genital health it is a different story. To many, their penis is literally their GPS, and when its function goes south, they become immediately motivated to find medical help! Never mind that they are having chest pain that gets dismissed as indigestion—an episode or two of failure to launch an erection is all it takes for an “emergency” appointment! There is some real truth to the concept that men think with their penises.

What most men do not realize is that they actually have a “canary in their trousers,” analogous to the “canary in the coal mine” carried by mine workers into the mines, the death of which would indicate the presence of dangerous gases. Since the penile arteries are generally rather small (diameter of 1 to 2 millimeters) and the coronary (heart) arteries larger (4 millimeters), it stands to reason that if vascular disease is affecting the tiny penile arteries, it may soon affect the larger coronary arteries as well—if not now, then at some time in the future. In other words, the fatty plaque that compromises blood flow to the smaller vessels of the penis may also do so to the larger vessels of the heart and thus ED may be considered a genital “stress test.” 

In fact, the presence of ED is as much of a predictor of cardiovascular disease as is a strong family history of cardiac problems, tobacco smoking, or elevated cholesterol. The British cardiologist Graham Jackson expanded the initials ED to mean: Endothelial Dysfunction (endothelial cells being the type of cells that line the insides of arteries); Early Detection (of cardiovascular disease); and Early Death (if missed).

Bottom Line: Because many men have an “obsession”—if not a “fascination,” with their penises—a dysfunction in this department is often the motivating factor that drives them to seek medical help, which often uncovers other medical issues. The pharmaceutical companies have developed excellent medications to treat ED and are credited with the name “ED” and for de-stigmatizing sexual issues are also responsible for getting the stoic gender into the physician’s office. So man’s peno-centric focus and Big Pharma are actually beneficial for men’s health.


Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health:

Private Gym:

Testosterone: Not Just For Men; Estrogen: Not Just For Women

October 5, 2013

Andrew Siegel MD Blog # 122

What’s going on with the unrelenting direct–to-consumer television advertising for medications?  On television and radio we are bombarded with ads for drugs for the “ABC” diseases—ED (erectile dysfunction), OAB (overactive bladder), low T (testosterone).  What’s all this hubbub about T (testosterone) anyway?  Why is T suddenly so special, so hot and trendy, the hormone de jour, the “new” Viagra?  Is this for real or mere media hype?

Medicine is truly in its “infancy” with respect to its understanding of the male and female sex hormones, testosterone (T) and estrogen (E), respectively. Not too long ago it was dogma that T was solely the male hormone and that E was solely the female hormone.  As is often the case in science, “dogma” turns to “dog crap” with time, research, and progressive understanding.

Dr. Joel Finkelstein, in the September 13, 2013 New England Journal of Medicine, disrupted the endocrine status quo and provided the scientific basis for the major importance of both T and E for male health and wellness (and there is little doubt that both E and T are also equally crucial for female health and wellness). His study clearly demonstrated that muscle size and strength are controlled by T; fat accumulation is primarily regulated by E; and sexual function is determined by both T and E.

Some basics about T:

In the life of the male embryo, T is first produced during the mid-first trimester, and this hormonal surge causes the male external genitalia (penis and scrotum) and internal genitalia (prostate, seminal vesicles, etc.) to develop. In the absence of T, the fetus becomes a female, making the female gender the “default” sex. Dihydrotestosterone (DHT) is the activated form of T required by the fetus to initiate the development of male physical characteristics. In the absence of DHT, male genitalia do not develop.  DHT is far more potent than T and is the hormone that also gives rise—much later in life—to male pattern baldness and the condition of benign prostate enlargement.

T is produced mostly in the testes, although the adrenal glands also manufacture a small amount. T has a critical role in male development and physical characteristics. It promotes tissue growth via protein synthesis, having “anabolic” effects including building of muscle mass, bone mass and strength, and “androgenic” (masculinizing) effects at the time of puberty.  With the T surge at puberty many changes occur: penis enlargement; development of an interest in sex; increased frequency of erections; pubic, axillary, facial, chest and leg hair; decrease in body fat and increase in muscle and bone mass, growth and strength; deepened voice and prominence of the Adam’s apple; occurrence of fertility; and bone and cartilage changes including growth of jaw, brow, chin, nose and ears and transition from “cute” baby face to “angular” adult face.  Throughout adulthood, T helps maintain libido, masculinity, sexuality, and youthful vigor and vitality. Additionally, T contributes to mood, red blood cell count, energy, and general “mojo.

Thanks to the advertising of Big Pharma, patients now come to the office requesting—if not demanding—to know what their T levels are. Prescriptions for T have increased exponentially over the last five years, creating a $2 billion industry with numerous pharmaceutical companies competing for a piece of the lucrative T pie, as the cost of the product is minimal and the markup is prodigious.  Little did Butenandt and Hanisch—who earned the Nobel Prize in chemistry for their synthesis of testosterone from cholesterol way back in 1939—know of what their discovery would lead to 70 years later!

Who Knew? Humans manufacture T using cholesterol as a precursor, so don’t be under the delusion that all cholesterol is bad. However, don’t get carried away consuming cholesterol-laden foods reasoning that the Big Mac with cheese will raise your T.

T can bind to specialized receptors that are present in many cells in the body and exert numerous anabolic and androgenic effects; alternatively, T can be converted to 5-DHT  (the active form of T) or can be converted to estradiol—a form of E—by the chemical process of aromatization. More than 80% of E in men is derived from T as a source. When levels of T are low, there is a decline in E levels. E deficiency is important in terms of osteopenia (bone thinning) in both men and women.

Dr. Finkelstein’s study was really a more sophisticated and quantitative take on the original study by organic chemist Professor Fred Koch at the University of Chicago in 1927, this time using humans instead of animals, and quantitating the effect of the T replacement as opposed to a qualitative assessment. Professor Koch used capons—roosters castrated surgically (having their testes removed) at a young age.  He then injected them with a substance obtained from bull testicles—readily available from the Chicago stockyards—which essentially was T.   After injecting the capons with this extraction, the capons crowed like roosters, a feat that capons are incapable of.  When the study was repeated in castrated pigs and rats, the substance was found to re-masculinize them as well.  Unlike Professor Koch, who used surgically castrated animals, Dr. Finkelstein used humans who were temporarily “castrated” via a reversible medication.

In Dr. Finkelstein’s study, as reported in the NEJM, there were 2 groupings of 5 populations of men. Both groupings had their T production blocked chemically. One population was given no replacement T, another 1.25 grams T daily, another 2.5 grams T daily, another 5 grams T daily, and the last group 10 grams T daily. The average serum T and E levels of each population were the following: no testosterone replacement: 44/3.6; 1.25 grams: 191/7.9; 2.5 grams: 337/11.9; 5 grams: 470/18.2; 10 grams 805/33. The second grouping of 5 populations had their E blocked as well.  Testing was done to see the effects of T and E levels on lean mass, muscle size and strength, fat mass, and sexual function.

By looking at the aforementioned numbers, one can see a direct relationship between T dose and serum level of both T and E.  The higher the T dose, the greater is the serum T and E.  The study concluded that lean mass, muscle size and strength were T dose-dependent, meaning the higher the T, the more the lean mass, muscle size and strength.  Additionally, fat mass was seen to be E dose-dependent and sexual function was both T and E responsive.

Dr. Finkelstein concluded that E deficiency in men is a manifestation of severe T deficiency and is remediable by T replacement. Fat accumulation seems to occur with a mild T deficiency (T measurements in the 300-350 range); muscle mass and muscle strength are preserved until a more marked T deficiency (T <200) occurs.   E was shown to have a fundamentally important role in the regulation of body fat and sexual function and evidence from previous studies demonstrated a crucial role for E in bone metabolism. Therefore, low T is not just about low T, but is also about E deficiency, which is responsible for some of the key consequences of T deficiency. Measuring levels of E are helpful in assessing sexual dysfunction, bone loss, and fat accumulation in men with low T.

The amount of T made is regulated by the hypothalamus-pituitary-testicular axis, which acts like a thermostat to regulate the levels of T.  Healthy men produce 6-8 mg testosterone daily, in a rhythmic pattern with a peak in the early morning and a lag in the later afternoon. T levels can be low based upon testicular problems or hypothalamus/pituitary problems, although the problem most commonly is due to the aging testicle’s inability to manufacture sufficient levels of T.  T levels gradually decline—approximately a 1% decline each year after age 30—sometimes giving rise to symptoms.  These symptoms may include the following: fatigue; irritability; decreased cognitive abilities; depression; decreased libido; ED; ejaculatory dysfunction; decreased energy and sense of well-being; loss of muscle and bone mass; increased body fat; and abnormal lipid profile. A simple way to think about the effect of low T is that it accelerates the aging process.

T is commonly prescribed for T deficiency when it becomes symptomatic. There are many means of testosterone replacement therapy (TRT).  Oral replacement is not used because of erratic absorption and liver toxicity. Injections are not the first-line means of TRT because of wide fluctuations in testosterone levels and injection site reactions. There are a number of testosterone gel formulations that are commonly used. There are also skin patches, pellets that are injected into the fatty tissue of the buttocks, and a formulation that is placed in the inner cheek or gum. Currently in the works is a long-acting injection.

Men on replacement T need to be followed carefully to ensure that the TRT is effective, adverse effects are minimal, and blood levels are in-range. Periodic digital rectal exams are important to check the prostate for enlargement and irregularities, and, in addition to T levels, other blood tests are obtained including a blood count and PSA (Prostate Specific Antigen).  Potential complications of TRT include acne and oily skin, increased hematocrit (thicker, richer blood), worsening of sleep apnea, hair loss, and suppression of fertility.

Bottom Line: T and E levels are of vital importance to men (as well as women), greatly impacting physical development, sexuality, mood, energy levels, etc. So while T advertisements may be annoying and confusing, it is wise nonetheless to assess and monitor T levels, particularly if one is experiencing any of the myriad of symptoms associated with low T.

Reference: “Gonadal Steroids and Body Composition, Strength, and Sexual Function in Men by Joel Finkelstein, M.D., et al:  ”The New England Journal of Medicine (September 12, 2013)

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food:

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health;  book is in press and will be available in e-book and paperback formats in November 2013.

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