Ask The Urologist Anything (Dr Michael Rotman)

[DrRotman]

Dr Rotman,

What's your view and experience with testicular pain/discomfort being related to TRT? Ive been on TRT pellets for 5 months and about 2 months ago having some pain and discomfort on and off. In describing the situation, many online folks think it must be atrophy and I should take HCG. However, I've seen 2 Urologists and 1 Endo in person, and all 3 think it's more likely due to either back misalignment caused by working out, or just that somehow that area has become inflamed and often times it takes time to return to normal --prescribed Daypro for 30 days. Prostate normal 0.46, urine culture normal, testicular ultrasound normal. Do you come across testicular pain much in your practice and if so, does HCG cure it, or is it more often related to something other than atrophy from TRT?

i do sometimes see pain during TRT without hcg , sometimes caused by testicular shrinkage and other times for unknow reasons. I rarely if ever see it in patients on both T and HCG.

 

[D Race]

Is there such a thing as testicle implants? I've been on TRT long enough that my previously small nuts are now even smaller. I'd like to at least look normal.

 

[DrRotman]

Is there such a thing as testicle implants? I've been on TRT long enough that my previously small nuts are now even smaller. I'd like to at least look normal.

Yes there are, but are used primarily in patients having an orchiectomy at a young age for reasons such as testicular cancer, and are used to simulate appearance of a testicle in the scrotum. I would not implant one along side a small testicle just for cosmetic appearance. And you certainly wouldn't want to remove a small testicle as it still has biological function .

 

[Bud Black]

TRT for 7 months, still dealing with e2 swings, PSA was .3 then 5 weeks later 6.1 ( no issues, bleeding, pain or otherwise) however e2 ultrasensitive was 80 at the time of BW. met a referred urologist and he wanted to biopsy immediately. (i declined). I have a hunch its BPH from high e2. In 7 months i have been higher than lower. I have always been e2 sensitive.

BTW I am meeting a new Dr. in 6 weeks (endo). latest BW should be here tomorrow.
I have tried Arimidex but can never seem to get dosage. which Ai is easier to dial in?

 

[DrRotman]

TRT for 7 months, still dealing with e2 swings, PSA was .3 then 5 weeks later 6.1 ( no issues, bleeding, pain or otherwise) however e2 ultrasensitive was 80 at the time of BW. met a referred urologist and he wanted to biopsy immediately. (i declined). I have a hunch its BPH from high e2. In 7 months i have been higher than lower. I have always been e2 sensitive.

BTW I am meeting a new Dr. in 6 weeks (endo). latest BW should be here tomorrow.
I have tried Arimidex but can never seem to get dosage. which Ai is easier to dial in?

Hi Bud, how old are you roughly if you don't mind my asking? What protocol are you on now ? Were you using the anastrazole under medical guidance?

 

[Bud Black]

Dr. Rotman, 52 my GP told me to lower my test cyp to .2 e3d. which is what I did the time of the high PSA. My TRT Dr. I have pretty much fired simply from lack of communication and guidance. My 1st script on the dex had me at .5mg e3d. which i did and drove my e2 into single digits. The 80 e2 reading was lowered to 17 in 1 month with just trial and error simply because theres no TRT Dr. near me that seem to know a lot about real TRT. when my hemaocrit is 51 and my body starts bloating and I feel dizzy and brainfog I take /25 of dex. I am at a loss till I find a Dr. that knows his stuff.

Sad thing is I am a business owner and I pay big $$ for insurance. Trying to find an online dr is tough the takes insurance. Thanks for reaching out Dr Rotman

 

[ALMSGT502]

DR Rotman , Do you know when generic or otc Cialis is coming to a local pharmacy
thanks

 

[DrRotman]

Dr. Rotman, 52 my GP told me to lower my test cyp to .2 e3d. which is what I did the time of the high PSA. My TRT Dr. I have pretty much fired simply from lack of communication and guidance. My 1st script on the dex had me at .5mg e3d. which i did and drove my e2 into single digits. The 80 e2 reading was lowered to 17 in 1 month with just trial and error simply because theres no TRT Dr. near me that seem to know a lot about real TRT. when my hemaocrit is 51 and my body starts bloating and I feel dizzy and brainfog I take /25 of dex. I am at a loss till I find a Dr. that knows his stuff.


As a urologist I would first start by discontinuing your medications for TRT for a few weeks (you wont crash in a few weeks) and recheck PSA to obtain another level and see where your baseline lives. Once you see that the elevation was an error you can then resume the TRT at a slow gradual pace.

 

[DrRotman]

DR Rotman , Do you know when generic or otc Cialis is coming to a local pharmacy
thanks

Fall 2017 is what I hear.

 

[Weasel]

Doc,

I've been lacking libido and/or ability sexually for nearly 3 years and believe it has to be neurotransmitter related. How do you approach these instances where labs show almost perfect or perfect labs but yet libido and or ability are still lacking?

I was offered Cabergoline for slightly elevated prolactin (14.1 range: 3-7-17.9) , but to be honest DAWS scares the crap out of me as i believe i experienced it after quitting ropinerole when using it for restless legs syndrome. Caber is just that much more powerful of a drug.

Thanks Dr. Rotman!

 

[DrRotman]

Doc,

I've been lacking libido and/or ability sexually for nearly 3 years and believe it has to be neurotransmitter related. How do you approach these instances where labs show almost perfect or perfect labs but yet libido and or ability are still lacking?

I was offered Cabergoline for slightly elevated prolactin (14.1 range: 3-7-17.9) , but to be honest DAWS scares the crap out of me as i believe i experienced it after quitting ropinerole when using it for restless legs syndrome. Caber is just that much more powerful of a drug.

Thanks Dr. Rotman!

Hi,

I do occasionally come across a case like yours where the symptoms do not correlate with the numbers. I do not believe cabergoline is indicated in your clinical situation. In cases like yours, I will use a multidisciplinary approach and involve other specialists to address the patients situation. I wish you luck with finding a solution.

 

[Someguy]

Earlier you mentioned penile vasculature testing. Assuming that problems are found with penile vasculature what (if anything) can be done to correct them? What does the prognosis generally look like?

 

[DrRotman]

Earlier you mentioned penile vasculature testing. Assuming that problems are found with penile vasculature what (if anything) can be done to correct them? What does the prognosis generally look like?

Poor penile arterial flow or venous leak do indicate a more serious form of ED that could require stronger therapy than PDRS inhibitors such as trimix and various doses of Trimix. I can't quantify prognosis as it is different in each sscenario. I can tell you I have had patients on injections for many years with success and some patients have had to go on to have penile pumps placed. In general if someone is motivated enough, we can treat their ED successfully. We can't fix arteries and veins as that has been not effective but certainly can accentuate blood flow/rigidity.

 

[MikeXL]

Dr Rotman,
Let me ask a similar question. If you know that amount of bioavailable testosterone, is there any value in knowing the total testosterone level? If so, why?

i don't really use free T much in practice anymore and have completely adopted bioavailable T which is a much more accurate measure.

 

[DrRotman]

Dr Rotman,
Let me ask a similar question. If you know that amount of bioavailable testosterone, is there any value in knowing the total testosterone level? If so, why?

Yes , to calculate the Bioavaialble T. Also, insurance companies require it to approve treaments. Won't accept the other variables. I didn't make the rules, but have to follow them even when I disagree.

 

[1Draw]

Dr. Rotman:

Do you know of a way to lower SHBG for guys who are genetically predisposed with high SHBG? I've been on TRT for 2 1/2 years now and am fighting this problem. I need very high T levels to lower the SHBG which in turn creates problems with hematocrit being too high. My SHBG runs mid 80's to 100. All of us at EM really appreciate your valuable views and thanks!

 

[Tiago]

Hi, dr Rotman. Which HCG protocol do you think is better while on TRT( SQ Testoviron 80mg 2 times/week) to preserve fertility? Is there any advantage to take clomid too? At what dosis? With HCG do i need anastrozole? I am 38 yo right now. Thanks, dr.

 

[DrRotman]

Dr. Rotman:

Do you know of a way to lower SHBG for guys who are genetically predisposed with high SHBG? I've been on TRT for 2 1/2 years now and am fighting this problem. I need very high T levels to lower the SHBG which in turn creates problems with hematocrit being too high. My SHBG runs mid 80's to 100. All of us at EM really appreciate your valuable views and thanks!

Other maintaining a healthy diet and avoiding dietary associated diseases, there is no other evidence i am aware of to lower SHBG. I will look into it though.

 

[DrRotman]

Hi, dr Rotman. Which HCG protocol do you think is better while on TRT( SQ Testoviron 80mg 2 times/week) to preserve fertility? Is there any advantage to take clomid too? At what dosis? With HCG do i need anastrozole? I am 38 yo right now. Thanks, dr.

As of now there is no evidence based medicine to show what is safe to preserve fertility. There are some restrospective studies to support hcg every other day with Testosterone weekly as being sage. There are some people using clomid daily as well with success. Important to monitor semen analysis at baseline and then a few months after initiating treatment to see effect.

 

[MikeXL]

Dr Rotman,
while you are looking into possibly lowering SHBG, I would like your view on a related matter. 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. Moreover, Dr Crisler claims 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 ?