Posts Tagged ‘testicles’

What You Don’t Know About Testosterone Treatment…and Perhaps A Better Option

January 10, 2015

Andrew Siegel MD  1/10/15

shutterstock_orange gu tract

The Magic Of T

You probably have heard a great deal about T (testosterone) and its extraordinary properties and indeed, for the symptomatic man who has low levels of T, boosting levels of this hormone can result in a remarkable improvement of energy, sexuality (sex drive, erections, ejaculation), masculinity, mood, body composition (muscle and bone mass), mental focus and other parameters. However, men considering T treatment need to understand that T is not a cure-all and must only be used under the circumstances of symptoms of low T and laboratory testing that shows low T. Most certainly, T has been over-marketed, over-prescribed and certain side effects have been understated. It is vital to understand the side effects of T before committing to treatment.

Some Necessary Science

Most T is made by the testicles. Its secretion is governed by the release of LH (luteinizing hormone) from the pituitary, the master gland within your brain. Some of T is converted to E (estradiol). E is the primary hormone involved in the regulation of the pituitary gland. Under the circumstance of adequate levels of T, E feeds back to the pituitary to turn off LH production. This feedback loop is similar to the way a thermostat regulates the temperature of a room in order to maintain a relatively constant temperature, shutting the heat off when a certain temperature is achieved, and turning it on when the temperature drops.

The Effects of Being on Long-Term Testosterone Replacement

So what happens when you have been on long-term T? This exogenous (external source) T, whether it is in the form of gels, patches, injections, pellets, etc., shuts off the pituitary LH by the feedback system described above so that the testes stop manufacturing natural T. Additionally, the testes production of sperm is stifled, problematic for men wishing to remain fertile. In other words, exogenous T is a contraceptive! Nearly all men will have some level of suppression of sperm production while on T replacement, less so with the gels vs. the injections or implantable pellets.

Thus, using T results in the testes shutting down production of natural T and sperm and after long-term T use, the testes can actually shrivel, becoming ghosts of their former functional selves. And if you stop the T after long-term use, natural function does not resume anytime quickly.  Although recovery of natural testosterone and sperm production after stopping T replacement usually occurs within 6 months or so, it may take several years and permanent detrimental effects are possible.  So, at the time that you are receiving the benefits of exogenous T, your natural T is shut off and you can end up infertile, with smaller testicles (testicular atrophy, in urology parlance)!

Is there an alternative for the symptomatic male with low T? Can you boost levels of T without shutting down your testes and developing shrunken, poorly functional gonads?

The answer is an affirmative YES, and one that Big Pharma does not want you to know. There has been such a medication around for quite some time. It has been FDA approved for infertility issues in both sexes and is available on a generic basis. In urology we have used it for many years for men with low sperm counts. But here is a little secret: this medication also raises T levels nicely, and does so by triggering the testes to secrete natural T. It works by stimulating the testes to make its own T rather than shutting them down. No marble-sized testes that have their function turned to the “off” mode, but respectable family jewels. The other good news is that treatment does not necessarily need to be indefinite. The testes can be “kicked” back into normal function, and at some point a trial off the medication is warranted.

The medication is clomiphene citrate, a.k.a, Clomid, and I will refer to it as CC. CC is an oral pill often used in females to stimulate ovulation and in males to stimulate sperm production. CC is a selective estrogen receptor modulator (SERM) and works by increasing the pituitary hormones that trigger the testes to produce sperm and testosterone. CC blocks E at the pituitary, so the pituitary sees less E and makes more LH and thus more T, whereas giving external T does the opposite, increasing E and thus the pituitary makes less LH and the testes stop making T.

Works Like A Charm

CCis usually effective in increasing T levels and maintaining sperm production, testes anatomy (size) and function. Its safety and effectiveness profile has been well established and minor side effects occur in proportion to dose and may include (in a small percentage of men): flushes, abdominal discomfort, nausea and vomiting, headache, and rarely visual symptoms. In general, those with the highest LH levels have the poorest response to CC, probably because they already have maximal stimulation of the testes by the LH.

Not FDA Approved For Low T

One issue is that CC is not FDA approved for low T, only for infertility. Many physicians are reluctant to use a medication that is not FDA approved for a specific purpose. It needs to be used “off label,” even though it is effective and less expensive than most of the other overpriced T products on the market.

Bottom Line: Treatment to boost T levels should only be done when one has genuine symptoms of low T and a low T level documented on lab testing. It is imperative to monitor those on such treatment on a regular basis. Using T to boost T can result in shutting down the testes and the possibility of atrophied, non-functional testes that do not produce sperm or natural testosterone. CC is an oral, less expensive alternative that stimulates natural T production.

A study from Journal of Urology (Testosterone Supplementation Versus Clomiphene Citrate: An Age Matched Comparison of Satisfaction and Efficiency. R. Ramasamy, JM Scovell, JR Kovac, LI Lipshultz in J Urol 2014;192:875-9) compared T injections, T gels, CC and no treatment. T increased from 247 to 504, 224 to 1104 and 230 to 412 ng/dL, respectively, for CC, T injections and gels. Men in all of the 3 treatment arms experienced similar satisfaction. The authors concluded that CC is equally effective as T gels with respect to T level and improvement in T deficiency-related clinical symptoms and because CC is much less expensive than T gels and does not harm testes size or sperm production, physicians should much more often consider CC, particularly in younger men with low T levels.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

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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”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: http://www.MalePelvicFitness.com

Co-creator of Private Gym pelvic floor muscle training program for menhttp://www.PrivateGym.com

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10 Ways To Know That You Are Doing Your Man Kegel Exercises Properly

July 19, 2014

Andrew Siegel, MD   Blog # 163

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There has been a great deal of hubbub on the topic of pelvic floor exercises for men this past week, with the publication of a review article in the Gold Journal of Urology reviewing the benefits of pelvic floor muscle training in males:

http://www.ncbi.nlm.nih.gov/pubmed/24821468

and with Tuesday’s New York Times article entitled Pelvic Exercises For Men, Too.

http://well.blogs.nytimes.com/2014/07/14/pelvic-exercises-for-men-too/?_php=true&_type=blogs&_r=0

and with the launch this week of the first comprehensive, interactive, follow-along exercise program that helps men strengthen the muscles that support sexual and urinary health www.PrivateGym.com.

The story was carried in the NY Daily News

http://www.nydailynews.com/life-style/health/men-kegels-new-device-article-1.1869335

as well as the San Francisco Chronicle, the Atlanta Journal Constitution, the Tampa Bay Times and many other media outlets, including Live With Kelly and Michael and Doctor Radio.

There has been some misinformation regarding the proper technique of pelvic floor muscle exercises, and I would like to set the record straight. On one of the radio shows I listened to, it was stated that kegel exercises are akin to “pushing down, grunting and doing the Valsalva maneuver (medical term for pushing and straining).”  The truth of the matter is that kegel exercises involve pulling in and up without grunting, just the opposite of straining. One strains to move their bowels, whereas when one kegels they accomplish the opposite—tightening up the sphincters to NOT move their bowels; in fact, doing kegels is a means of suppressing bowel as well as urinary urgency.

In the 1940’s, gynecologist Dr. Arnold Kegel popularized pelvic floor muscle exercises for females—particularly for women who had recently given birth—in order to improve urinary and sexual health. But Kegel exercises are NOT just for the ladies. Men have the same pelvic floor muscles as do women and they are equally vital for sexual and urinary health. The pelvic floor muscles form the floor of the all-important “core” group of muscles and contribute strongly to men’s ability to have control of their bladders and colons and are play a crucial role in erections and ejaculation. The pelvic floor muscles are what allow the blood pressure in the penis at the time of erection to be sky high—way above systolic blood pressure—allowing for bone-like rigidity. These muscles are also the “motor” of ejaculation.

Doing Kegel exercises properly is fundamental to reaping the benefits derived from getting your pelvic floor muscles in tip-top shape. So how do you know if you are contracting the pelvic floor muscles properly?

  1. You know you are doing your Man Kegels properly when you see the base of your penis retract inwards towards the pubic bone as you contract your pelvic floor muscles.
  1. You know you are doing your Man Kegels properly when you see the testicles rise up towards the groin as you contract your pelvic floor muscles.
  1. You know you are doing your Man Kegels properly when you place your index and middle fingers in the midline between the scrotum and anus and contract your pelvic floor muscles and you feel the contractions of the bulbocavernosus muscle near the scrotum and the pubococcygeus muscle towards the anus.
  1. You know you are doing your Man Kegels properly when you can pucker your anus (not the gluteal muscles) as you contract your pelvic floor muscles. As you do so, you feel the anus tighten and pull up and in.
  1. You know you are doing your Man Kegels properly when you get the same feeling as you do when you are ejaculating as you contract your pelvic floor muscles.
  1. You know you are doing your Man Kegels properly when you touch your erect penis and feel the erectile cylinders surge with blood as you contract your pelvic floor muscles.
  1. You know you are doing your Man Kegels properly when you can make the penis lift up as you contract your pelvic floor muscles when you are in the standing position.
  1. You know you are doing your Man Kegels properly if you can stop your urinary stream completely when you contract your pelvic floor muscles.
  2. You know you are doing your Man Kegels properly if you can push out the last few drops of urine that remain after completing urination when you contract your pelvic floor muscles
  3. You know you are doing your Man Kegels properly ifafter doing a pelvic floor muscle training regimen you start noticing improvements in erectile rigidity and durability as well as better quality ejaculations, ejaculatory control and improvement in urinary control.

Andrew Siegel, M.D.

http://www.AndrewSiegelMD.com

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”:

www.healthdoc13.wordpress.com

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

www.MalePelvicFitness.com

Private Gym website where pelvic floor instructional DVD and resistance training equipment are now available:

www.PrivateGym.com

 

 

 

What The Heck is Urology?

August 24, 2013

Andrew Siegel, MD  Blog #116

“Urology” (uro—urinary tract and logos—study of) is a medical specialty concerned with the study, diagnosis, and treatment of diseases of the urinary tract in females and of the genitourinary tract in males. The organs under the “domain” of urology include the adrenal glands, kidneys, the ureters (tubes connecting the kidneys to the urinary bladder), the urinary bladder and the urethra (the channel that conducts urine from the bladder to the outside).  The male reproductive organs include the testes (i.e., testicles), epididymis (structures above and behind the testicle where sperm mature and are stored), vas deferens (sperm duct), seminal vesicles (the structure that produces the bulk of semen), prostate gland and, of course, the scrotum and penis.  The reproductive and urinary tracts are closely connected, and disorders of one oftentimes affect the other…thus urologists are referred to as  “genitourinary” specialists. Urology involves both medical and surgical strategies to approach a variety of conditions.

Urology has always been on the cutting edge of surgical advancements (no pun intended) and urologists employ minimally invasive technologies including fiber-optic scopes to be able to view the entire inside aspect of the urinary tract, as well as ultrasound, lasers, laparoscopy and robotics.  There is a great deal of overlap in what urologists do with other medical and surgical disciplines, including nephrology (doctors who specialize in medical diseases of the kidney); oncology (cancer specialists); radiation oncologists (radiation cancer specialists); radiology (imaging); gynecology (female specialists); and endocrinology (hormone specialists).

Urologists are the male counterparts to gynecologists and the go-to physicians when it comes to expertise in male pelvic health.  Urologists, in addition to being physicians, are also surgeons who care for serious and potentially life-threatening illnesses, particularly cancers of the genital and urinary tracts.  In terms of new cancer cases per year in American men, prostate cancer is number one accounting for almost 30% of cases; bladder cancer is number four accounting for 6% of cases; and cancer of the kidney and renal pelvis (the inner part of the kidney that collects the urine) are number six accounting for 5% of cases.  Urologists are also the specialists who treat testicular cancer.  Urologists also treat women with kidney and bladder cancer, although the prevalence of these cancers is much less so than in males. 

Very common reasons for a referral to a urologist are the following: blood in the urine, whether it is visible or picked up on a urinalysis done as part of an annual physical; an elevated PSA (Prostate Specific Antigen) or an accelerated increase of PSA over time; prostate enlargement; irregularities of the prostate on examination; urinary difficulties ranging the gamut from urinary incontinence to the inability to urinate (urinary retention).

Urologists manage a variety of non-cancer issues. Kidney stones, which can be extraordinarily painful, keep us very busy, especially in the hot summer months when dehydration (a major risk factor) is more prevalent. Infections are a large part of our practice and can involve the bladder, kidneys, prostate, or the testicles and epididymis.  Urinary infections is one problem that is much more prevalent in women than in men.  Sexual dysfunction is a very prevalent condition that occupies much of the time of the urologist—under this category are problems of erectile dysfunction, problems of ejaculation, and testosterone issues. Urologists treat not only male infertility, but create male infertility when it is desired by performing voluntary male sterilization (vasectomy).   Urologists are responsible for caring for scrotal issues including testicular pain and swelling.   Many referrals are made to urologists for blood in the semen.

Training to become a urologist involves attending 4 years of medical school after college and 1–2 years of general surgery training followed by 4 years of urology residency. Thereafter, many urologists like myself pursue additional sub-specialty training in the form of a fellowship that can last anywhere from 1–3 years.  Urology board certification can be achieved if one graduates from an accredited residency and passes a written exam and an oral exam and has an appropriate log of cases that are reviewed by the board committee.  One must thereafter maintain board certification by participating in continuing medical education and passing a recertification exam every ten years.  Becoming board certified is the equivalent of a lawyer passing the bar exam.

In addition to obtaining board certification in general urology, there are 2 sub-specialties within the scope of urology in which sub-specialty board certification can be obtained—pediatric urology, which is the practice of urology limited to children and female pelvic medicine and reconstructive surgery (FPMRS), which involves female urinary incontinence, pelvic organ prolapse, and other female uro-gynecological issues.  The FPMRS boards were offered for the very first time in June 2013, and I am pleased to announce that I am now board certified in both general urology and FPMRS.  There are approximately 100 or so urologists in the entire country who are board certified in the urology subspecialty of FPMRS.

In terms of the demographics of urology, although urology is largely a male specialty, women have been entering the urological workforce with increasing frequency.  This is because female students now comprise approximately 50% of United States medical school population. There are 10,000 practicing urologists in the USA, of which about 500 are women. Urologists have a median age of 53, so we are not a particularly young specialty. The aging population will demand more urological health services and the Affordable Care Act will result in the dramatic expansion of the number of American citizens with health insurance. These factors combined with the aging of the urological workforce and the contraction due to retirement, all in the face of growing demands, does not augur well for a balance of supply and demand in the forthcoming years.  Hopefully there will be enough of us to provide urological care to those in the population that need it.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health, in press and available in e-book and paperback formats in the Autumn 2013.

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.

Tainted By Testosterone: The Ultimate Double-Edged Sword

August 10, 2013

Andrew Siegel, MD  Blog #115

Many brilliant men have experienced their demise and downfall that can be explained in part— perhaps a large part—by a potent hormone known as testosterone, or more commonly as “T.” Bill Clinton, Elliott Spitzer, Anthony Weiner, John Edwards, Mark Sanford, Arnold Schwarzenegger and San Diego Mayor Bob Filner are all members of the “tainted by testosterone (TBT) club,” who have sustained career derailments partially attributed to the powerful effects of this chemical produced by the testicles and adrenal glands.  Aside from these well-known political celebrities, many a lesser-known man—just your average Joe—has similarly succumbed to the influence of T and joined the TBT club.

The nickname “T” has become very much in vogue these days. Many of my patients come into the office specifically asking for me to check their T levels—thank you, America Pharma.  The pharmaceutical industry is largely responsible for increasing grass-roots awareness of testosterone issues via direct-to-consumer advertising and promotion of testosterone replacement products. Once a subject that was primarily the domain of urologists and endocrinologists, T has gone mainstream.

What exactly is this powerful chemical that can have such a profound influence on a man’s behavior?  Many of us who enjoy the company of canine friends can attest to the dramatic change in behavior of our male pets after they are “fixed” by surgical castration. Man’s best friends become less aggressive, more docile, less alpha male, and less likely to hump your guest’s leg.  The term “fix” seem to imply that something was broken.  Extrapolate to human beings and one can understand how, when our brains are bathed in T, our thoughts, behaviors, and actions are influenced and modulated.

T—manufactured primarily in the testicles although a small percentage is made by the adrenal glands—is an all-important male sex hormone that goes way beyond male sexuality.  T is regarded as a key element in driving and maintaining men’s health. Current evidence suggests that a man’s testosterone level might serve as a very good indicator and marker of general health.  Aside from contributing to libido, masculinity and sexual function, T is responsible for all of the physical changes that occur at the time of puberty, including pubic, axillary and facial hair, deepening voice, prominent Adam’s apple and increased bone and muscle mass.  Additionally, T contributes to mood, bone and muscle strength, red blood cell count, energy, and general mojo.

T is nothing short of being a drug with profound psychopharmacological effects. One can appreciate the potency of this powerful chemical simply by observing the physical, emotional, and libidinal changes that result in the transition from “little boy” pre-pubertal status to “big man” post-pubertal status. Not in any way to diminish the role of environmental factors that most certainly play a role, T is the difference between the little boy in the backyard playing with the toy soldier and a water pistol and the little girl on the porch playing with her dolls and jacks.  T is rocket fuel that can make a man all “piss and vinegar.”

T is most certainly a double-edged sword—on the one hand, it is essential for male health and masculinity, but at the same time it can drive our libido to the danger zone in which temptation and opportunity conspire, with potentially perilous results in terms of relationships, careers, lives, etc.  By no means am I implying that this hormone is solely responsible for man’s impulsiveness, improprieties and indiscretions, but it unquestionably plays a significant role.  Assuredly, “It wasn’t me, it was my T” would be an unsatisfactory justification of the behaviors of Clinton, Spitzer, Weiner, Edwards, Sanford, Schwarzenegger and Filner.  However, the role of T cannot be discounted and helps explain the biochemical basis of male behaviors.  If we treated the men of our species similarly to the way in which we treated our male canine pets by “fixing” them (I am not in any way suggesting this), then we most probably would not bear witness to the kind of career-slamming, self-destructive and life-disruptive indiscretions that have been such common occurrences.

Having a low T is clearly not a good thing.  We know this from observing two populations of men—those who have suffered the consequences of low T that has developed coincident with the aging process and those who are put on medications that purposefully lower T, usually for the management of prostate cancer. Most men will have an approximately 1% decline of T each year after age 30; however, this will not always be symptomatic.  40% of American men aged 45 or older have low or low range T.  Low T is associated with metabolic syndrome and diabetes, bone mineral loss, and altered sexual function.  Specifically, symptoms of low T may include one or more of the following:  fatigue; irritability; depression; decreased libido; erectile dysfunction; impaired orgasmic function; decreased energy and sense of well-being; loss of muscle and bone mass; increased body fat; abnormal lipid profiles; and more. Essentially, low T accelerates the aging process.

So, low T is bad and normal T can influence men to behave badly. Is it possible to find a balance between healthy masculinity and unhealthy philandering and other inappropriate male sexual behaviors?  I sure hope so.  For the record, I don’t really care what politicians do in their free time as long as they do their jobs well. Clearly, they face tremendous stresses and pressures and need outlets for release.  However, it certainly would be nice if they didn’t make such a public spectacle and so embarrass themselves and their families. One has to consider that the very potent chemical T plays a vital role in determining the powerful alpha-male personality that is so fundamental to political ambition and ascent. Unfortunately, it is the very same T that contributes to influencing men to behave badly and stupidly, ending up in sabotaging political intentions and, more importantly, causing their lives to spiral down into a freefall. As borne out by the activities and affairs of many politicians in power, T can be thought of as “fertilizer” for the penis and the very brain that governs and guides that penis.

For some men, T engenders a situation akin to walking around with a loaded shotgun that begs to be unloaded, and the longer it’s been since the weapon has been fired, the greater the need to unload.  T has undoubtedly played a major role and influence in terms of male aggressiveness, violence, homicides, destruction, power struggles, wars, and death that run rampant in our civilization.  Our male gender has been both blessed and cursed by this powerful chemical that is one of the drugs within our internal pharmacy.  The challenge is to use this drug responsibly.

Who Knew?  Many women claim that men think with their “little brains.” All joking aside, there is genuine scientific merit for this insofar as testosterone is a hormone that has many biochemical functions and effects.  Men’s brains are literally bathed in this hormone that can profoundly influence emotions, behavior and thoughts. As a Yiddish proverb from Phillip Roth’s ‘Portnoy’s Complaint’ stated: “Ven der putz shteht, ligt der sechel in drerd,” translated as “when the prick stands up, the brains get buried in the ground.”

Who Knew? The comedian Robin Williams famously said: “God gave every man a brain and a penis, but only enough blood to make one work at a time.”

Who Knew? Too many of us use our penises as our compasses, navigational instruments that give us “direction.”

Who Knew? The athletic “cup” is the device that provides protection to the male genitals for those participating in sports like baseball, hockey, soccer and boxing. The cup was devised years before the first protective helmet for one’s head was used.  This tells you where men’s priorities lie—big head/little head!

 

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

The Who Knew?  quips are from my forthcoming book, Male Pelvic Fitness: Optimizing Sexual and Urinary Health (in press).

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.