Ask The Urologist Anything (Dr Michael Rotman)

[DrRotman]

Dr. Rotman - What is your opinion on gels for TRT?

Inconsistent results and don't acquire levels most people are seeking. In addition they are messy and expose people around you.

 

[tim0]

Hello Doc,
Do you think Enclomiphene holds any promise for people with lowT? Also any information on its effect on libido and erections?
I have used clomid (25 mg EOD). It improves my blood work but completely kills libido and erections.

 

[wrldzfstst]

Doctor,

What are your thoughts on the recent guidance from Dr. Crisler and others who feel that therapeutic phlebotomy is not necessary for TRT patients with higher HCT (and no other confounding factors)? I will check with my local doc but wanted your opinion on what seems to be a new trend in treatment.

Thanks!

 

[DrRotman]

Doctor,

What are your thoughts on the recent guidance from Dr. Crisler and others who feel that therapeutic phlebotomy is not necessary for TRT patients with higher HCT (and no other confounding factors)? I will check with my local doc but wanted your opinion on what seems to be a new trend in treatment.



Thanks!

I saw some of the data presented in Nov 2016 but I need to consult my local hematologists to see what the consensus is and what possible ramifications might be. Great question.

 

[Lmholmes11]

Hello Doctor thank you for taking the time to help us all out here on excelmale. I am 30 years old and have been dealing with weak (and sometimes dissapearing erections) for a few years now. A little less than a year ago I finally went to a Urologist (who didnt really know what he was doing I later found out after posting on excelmale). My testosterone level was at 394, he prescribed 1ml of Cypionate 200mg per month, but i injected .5ml once every other week. Needless to say I stopped that protocol soon after and have kind of been in limbo ever since, trying to improve my lifestyle. I am 30 years old, I would rather not HAVE to be on test injections for the rest of my life, since the only reason I would take it, is for my erection quality. My mood is fine, my energy level is fine, etc. I recently quit using chewing tobacco, started lifting weights at the gym again, cut out caffeine and also started eating better. Would any of those things I changed be enough to impact my ED? Also, how do I find out if my poor erection quality is because of my low T, or blood flow related? I do, and have always had really good blood pressure. And why the heck is my testosterone that low to begin with?

Sorry this is so long, but having this problem at the age of 30 is really wearing me down. Thanks again for the help

 

[DrRotman]

Hello Doctor thank you for taking the time to help us all out here on excelmale. I am 30 years old and have been dealing with weak (and sometimes dissapearing erections) for a few years now. A little less than a year ago I finally went to a Urologist (who didnt really know what he was doing I later found out after posting on excelmale). My testosterone level was at 394, he prescribed 1ml of Cypionate 200mg per month, but i injected .5ml once every other week. Needless to say I stopped that protocol soon after and have kind of been in limbo ever since, trying to improve my lifestyle. I am 30 years old, I would rather not HAVE to be on test injections for the rest of my life, since the only reason I would take it, is for my erection quality. My mood is fine, my energy level is fine, etc. I recently quit using chewing tobacco, started lifting weights at the gym again and also started eating better. Would any of those things I changed be enough to impact my ED? Also, how do I find out if my poor erection quality is because of my low T, or blood flow related? I do, and have always had really good blood pressure.

Sorry this is so long, but having this problem at the age of 30 is really wearing me down. Thanks again for the help

Hello sir,

Firstly, what the range for normal for your Testosterone test? Did you do any other studies including bioavailable, estradiol, vitamin D? Testosterone is only one component of erectile function. Many other variables including blood flow. I would seek out another urologist and also obtain a full physical exam to evaluate any other variables.

 

[crazyhaha]

I'm 41 and started TRT a few months ago. In the past year I saw three urologists. One did a prostate exam and said I had a slightly enlarged prostate. The others said an exam wasn't even necessary because of my age. A bit confused by the differences in approach and what if any prostate check-ups should be done while on TRT.

Thanks!

 

[Lmholmes11]

Hello sir,

Firstly, what the range for normal for your Testosterone test? Did you do any other studies including bioavailable, estradiol, vitamin D? Testosterone is only one component of erectile function. Many other variables including blood flow. I would seek out another urologist and also obtain a full physical exam to evaluate any other variables.

Thanks for the reply. The reference range for my Testosterone level is (241-827). At the time, my Vitamin D was very low. It was 14.8 ng/ml (Reference was 30-100), however ever since the lab I have been on 2,000 iu of Vit. D daily and the erection problem still persists. (I am getting re tested next week). It says my 'Free T-4' was 1.14 ng/dl (Range is .89-1.76), but im assuming that does not mean 'Free Testosterone'. My TSH was 1.9 uiu/ml ( .5 - 6.2 )


Now, during that protocol I described above, my T level was at 563 (240 – 950), and free testosterone was 14.6 (4.85 – 19.0)

 

[DrRotman]

Thanks for the reply. The reference range for my Testosterone level is (241-827). At the time, my Vitamin D was very low. It was 14.8 ng/ml (Reference was 30-100), however ever since the lab I have been on 2,000 iu of Vit. D daily and the erection problem still persists. (I am getting re tested next week). It says my 'Free T-4' was 1.14 ng/dl (Range is .89-1.76), but im assuming that does not mean 'Free Testosterone'. My TSH was 1.9 uiu/ml ( .5 - 6.2 )


Now, during that protocol I described above, my T level was at 563 (240 – 950), and free testosterone was 14.6 (4.85 – 19.0)

You definitely need Vitamin D retested and up your dose to 5000 units daily. It appears your levels are within normal limits albeit maybe on low end for age but it alone wouldn't be responsible for your ED.

 

[DrRotman]

I'm 41 and started TRT a few months ago. In the past year I saw three urologists. One did a prostate exam and said I had a slightly enlarged prostate. The others said an exam wasn't even necessary because of my age. A bit confused by the differences in approach and what if any prostate check-ups should be done while on TRT.

Thanks!

There is no consensus on how often prostate should be checked on a physical exam in a patient on TRT but in general I would check PSA yearly or even more often in a patient on TRT particularly if PSA rising or fluctuates. In general I was taught rectal exams should be done once yearly.

 

[Rus]

(Sorry for my english) Hello, Dr. Do you know of any cases or have you already treated individuals who have taken high doses of hcg (5000 IU or more per week) for more than a month ??


What would be the side effects of such a protocol?


Is it true that hcg causes aromatization inside the testicles and that the use of AI would be ineffective?

 

[Lmholmes11]

You definitely need Vitamin D retested and up your dose to 5000 units daily. It appears your levels are within normal limits albeit maybe on low end for age but it alone wouldn't be responsible for your ED.

Thank you for the reply. I will talk to my VA doctor about raising my Vit.D dosage. In a way I'm relieved that you don't think my problem is hormonal. Does Nicotine use constrict vessels enough for ED, or is there usually an underlying medical problem? Lastly, I mentioned I have always had perfect blood pressure. Does that not rule out ED resulting from a blood flow problem?

Thank you again

 

[BryanW]

Dr. Rotman,

Thank you for your time. Is it possible to have prostatitis without acute pain/discomfort? I'm 40, my PSA is > 4, and my urologist said I had a "small, smooth prostate". He prescribed 3 weeks of Bactrim DS. However I thought antibiotics would only treat bacterial prostatitis, which is supposedly very painful. I do not have pain. I have a very weak urine stream, frequent urination, and difficulty starting.

Thanks again for your time.

 

[DrRotman]

(Sorry for my english) Hello, Dr. Do you know of any cases or have you already treated individuals who have taken high doses of hcg (5000 IU or more per week) for more than a month ??


What would be the side effects of such a protocol?


Is it true that hcg causes aromatization inside the testicles and that the use of AI would be ineffective?

Hi, side effects include variable estradiol levels. I have very few patients on these high doses. And i don't believe the second statement is true.

 

[DrRotman]

Dr. Rotman,

Thank you for your time. Is it possible to have prostatitis without acute pain/discomfort? I'm 40, my PSA is > 4, and my urologist said I had a "small, smooth prostate". He prescribed 3 weeks of Bactrim DS. However I thought antibiotics would only treat bacterial prostatitis, which is supposedly very painful. I do not have pain. I have a very weak urine stream, frequent urination, and difficulty starting.

Thanks again for your time.

Many urologists will routinely prescribe antibiotics for a patient with an elevated psa as historically the psa would go down in cases of inflammation in the prostate and repeat PSA would be more reliable. That methodology is being discouraged now but many still do it.

 

[BryanW]

Many urologists will routinely prescribe antibiotics for a patient with an elevated psa as historically the psa would go down in cases of inflammation in the prostate and repeat PSA would be more reliable. That methodology is being discouraged now but many still do it.

Thanks. He said if my PSA doesn't drop below 2, a biopsy would be warranted. Does that seem reasonable?

 

[Vince Carter]

(Sorry for my english)
is it true that hcg causes aromatization inside the testicles and that the use of AI would be ineffective?

Not butting in to the good Dr's thread where he's graced us with his time and attention but I would like to say something on that point...The aromatisation that occurs in the testes, at what ever rate (there is aromatisation), an AI is less effective in the testicular environment. I would postulate that dosing that you speak of...5000iu/week is a VERY heavy dose.

 

[DrRotman]

Thanks. He said if my PSA doesn't drop below 2, a biopsy would be warranted. Does that seem reasonable?

2.5 has been used as a cutoff for people under the age of 60. That being said, it is not a universally accepted number . The choice to do a biopsy is made in a discussion between you and urologist so you can understand the risks , benefits and alternatives.

 

[MikeXL]

Dr Rotman
Thanks for you time on this board. Maybe you did not see my original question

Maybe it is something that you can research as well.

What is the hormonal ramifications of lowering SHBG besides increasing free T. If I understand correctly, SHBG also binds E2 and DHT. if that is the case, lowering SHBG would also increase free E2 and Free DHT. I have heard that SHBG has the greatest affinity to DHT then T and then E2. If that is the case, would lowering SHBG have a greater affect on freeing up E2, then T, then DHT? Or do I have that backwards? Or would it matter ?

 

[DrRotman]

Dr Rotman
Thanks for you time on this board. Maybe you did not see my original question

Maybe it is something that you can research as well.

What is the hormonal ramifications of lowering SHBG besides increasing free T. If I understand correctly, SHBG also binds E2 and DHT. if that is the case, lowering SHBG would also increase free E2 and Free DHT. I have heard that SHBG has the greatest affinity to DHT then T and then E2. If that is the case, would lowering SHBG have a greater affect on freeing up E2, then T, then DHT? Or do I have that backwards? Or would it matter ?

Thank you for your question. Honestly I don't think all this matters in the big picture. High SHBG is overcome with more testosterone but not sure there is way to manipulate SHBG except for controlling the diseased states that effect it.