Penile fibrosis after long time without morning erections?

[Simbarn]

If a reasonable dose of TRT is treating mental conditions that would otherwise require SSRI and anti-anxiety medications I think it would be irresponsible to suggest he stop the TRT. Those drugs are only effective short-term and then contribute to the continuation and exacerbation of the very conditions they are prescribed for. They also impair your ability to fully experience life in ways that can be difficult to appreciate for those who haven't taken them.

Some might disagree but in my assessment there is less harm in responsible TRT than psychiatric drug use.

Some might disagree but in my assessment there is less harm in responsible TRT than psychiatric drug use.

If someone has very low testosterone and their depression is attributed to this hormone dysfunction, then I would agree wholeheartedly with your opinion.

I do not agree that there is less harm with giving TRT to someone who is eugonadal (has very healthy testosterone levels) to treat depression. Many times the drugs used to treat depression can be withdrawn after a period of time with the help of cognitive therapy and the patient does not have great issue doing this. Withdrawing a patient from hormone therapy can be a very different matter if they are on the therapy for a number of years. The drugs you mention are short acting for good reason.

 

[Simbarn]

"They did. I always did bloodwork at least 6-8 weeks after every pct attempt and test levels fluctuated from 600 to 800. I meant that i dont know if after every isomer of clomid cleared my system, would the levels remain or drop."

I thought the doctors must have. You have not been very clear in previous posts with regard to what has actually occurred.
As I understand this, after 6-8 weeks of little to no SERMS in your system you had a very good level of Testosterone: between 600-800. Given this, an experienced Endocrinologist prescribed TRT for you to fix your sexual dysfunction? I do find this hard to believe.

Good medical practice IMO should have evaluated how your natural hormone levels maintained after the period of 6-8 weeks, before putting you onto hormone replacement. I cannot see how hormone replacement was warranted when it had not been determined that your hormones needed replacing! This almost qualifies as a misuse of testosterone.

"i took multiple breaks from serms and if it takes more than 4-5 months for the function to restore on its own (doubtful) then its not worth it. Most people recover at the end of pct or a month later at most. Besides if bloodwork shows everything on point whats left to be restored. Doesnt make sense"

But you didn’t have 4-5 months off SERMS, only two maximum from what you have just said. After 2 months when your penis was still having issues, you would just hop back onto Clomid again, causing more issues with your sexual function. After 2 years of doing this whereby your sexual function never regained normality, you instigated TRT above the normal 100mgs per week starting point, in excess of what your body produces and then continued to increase the dose.

Having your natural production in place with a very healthy level of 600 and waiting over 6 months to see if sexual function finds some normality again is not worth it?
From what you have said your erectile function has still not recovered after a year on TRT! Even Cialis at your age of 33 is not enabling you to have a full erection.
“Most people recover at the end of a month”?! Sounds like you frequent those bodybuilding forums full of misinformation. Playing around with your HPTA is fraught with danger full stop. There is always a risk that something will not come back quite so fast as you say for “most people”. You are a unique biochemical factory, every one of us is. How you recover can be quite different to another individual.

The AAS you used was testosterone. It is considered the strongest of all the anabolic steroids available. It is also considered to be the one which can cause the most problems with discontinuing and androgenic side effects. Some people do not want to risk using large doses of this steroid given the possibility that their HPTA may not return to normal function or other post sexual dysfunctions. You should have considered that it may take much longer for certain functions in your body to find homeostasis again after using such a powerful steroid, most good doctors know this. In my opinion you were fortunate that your natural T levels returned to where they were and appeared to stay that way!

The statement “if bloodwork shows everything on point whats left to be restored” tells me you have a way to go with understanding how complex our bodies actually are. There is so much we do not understand yet and it’s the unknown that good doctors fully appreciate.

The other complicating factor here is your depression. When did this start, how long have you had a history of this, was it present before the AAS use, did the use of AAS and subsequent use of Clomid worsen the depression post coming of steroids?
These are important questions for a doctor to answer as depression can play havoc with ED and sexual function. This on its own could have slowed down your recovery post AAS use.

"I agree that the more dugs the more problems BUT downregulation of androgen receptor isnt proved that it happens whatsoever. Brosciense. And if it did happen it would affect more aspects than just sexual function. My gains, muscularity, vascularity, hair growth are all inceased."

Correct, it has not been proven that the AR is downregulated in muscle tissue. The jury is still out on this and if it may do this in other tissues, specifically in smooth muscle. I am not surprised that all the things you mention have increased, you are virtually on a “bodybuilding” dose of testosterone.

"Possible insulin resistanse because of a couple of bloodworks that showed blood sugar slightly above 100? LOL. The appropriate medical care for my condition are high doses of ssri according to multiple psychiatrists. But i try to find alternatives. I am already 2 years clean from alcohol so i dont think i need professional help for that at the moment."

I congratulate you on the milestone of being off alcohol for 2 years. This cannot be underestimated as being a great achievement for anyone with a problem with alcohol. I am sorry, but I still fear that the high levels of testosterone you are on is just masking the depression. A good psychiatrist will most probably understand this too. If you had very low levels of testosterone before TRT, your depression could be attributed to that. Subsequent replacement would then be warranted in order to treat said depression.

It was you that mentioned a possible blood sugar issue. It is estimated that there is a substantial cohort of the population that is in a pre-diabetic condition and they can be like this for many years, even decades before actually getting diabetes later on in life. I think anything over 100 puts you in that category. It’s very good that you have seen this now and can alter your lifestyle and diet to reduce the risk that it could turn into diabetes later on. Testosterone does appear to improve insulin sensitivity, and low testosterone is connected with metabolic syndrome, but the causal relationships here are still be studied.

"My trough doesnt have big difference from my peak cause i inject M/W/F"

Correct, it most probably doesn’t in this case. You injected this way right from the beginning? Your endocrinologist suggested this?

"i also inject hcg so the upstream hormones are not the issue."

Not only are you injecting 200 mgs per week of testosterone, but you are also taking HCG, which will be producing even more testosterone as your testes seem very capable of producing adequate T.
In the past I have known some guys who would use 200-250mgs per week for what was termed as a beginner’s AAS cycle. Dosage’s such as these are not HRT.

Do you believe that HCG substitutes for all of your upstream hormones? It’s a perfect replica of LH, FSH and the pulsatile release of these hormones? For a start it has very little FSH action, if any.
What about the diurnal rhythm of these hormones and testosterone? Do you think this happens for no reason? Do you think completely changing this diurnal rhythm will not have consequences for some if not all of us?

"I have already done a doppler ultrasound that came back normal and again no proof that high doses of T damages erectile tissue."

I am not implying that you have damaged your penis. I used the word IF. The title of your thread is about possible fibrosis. It was your original concern that fibrosis has developed due to the loss of nocturnal erections. Let’s discuss this for a moment. It is mentioned in many papers I have read that the loss of nocturnal erections may cause hypoxic conditions in the erectile tissues. This sets of processes that increase the effects of oxidative stress and tissue remodelling, endothelial dysfunction and the subsequent reduction in NO activity. The early stages of this is the loss of some of our smooth muscle content and possible availability of NO. The early effects this has on performance is erections become more difficult to achieve and maintain. Doppler ultrasound may not show this in the early stages due to the very strong erection producing drugs that are used to generate an erection during the test.

Dopplers do not show all the issues that a male can have with ED. I have a friend in NY who had many of them and they all came back normal. He has had ED since being a teenager, to cut a very long story short after years of consultations with many specialists in the US, some of the best urologists the US has to offer, he eventually did a CT Cavernosogram, just before they were about to operate on him: performing an embolization procedure of the pudendal veins in and behind his penis. They found a large venous leak that none of the dopplers had shown. He had spent years trying to find out why he had ED and large sums of money. This didn’t explain why he had CVOD, just that blood was seen to be escaping from the corpus cavernosum through the pudendal veins. But at least he had confirmation of a physiological problem.

The embolisation procedure has improved his issue considerably thus far for him. At 35 he can now have a successful erection with minimal PDE5i assistance. We spent years talking with each other and from a great amount of research he decided to try the above embolization performed by a specialist doing an updated version of this procedure. Most doctors he saw had no firm idea why he had ED. Many claimed it was psychological in origin.

I feel that a level of testosterone that is too high for an individual can create and imbalance over time with the inhibitive mechanisms which keep the penis flaccid. That is increasing the expression or sensitivity of the NE neurons and their receptors in the erectile tissues, thus making this pathway stronger or more dominant. There is also evidence that excessive testosterone could elevate oxidative stress, this has been shown in the animal model. We constantly deal with the effects of oxidative stress in our bodies with antioxidants, maintaining a fine balance of these processes in our cells. We need a certain amount of oxidative stress, however when this becomes elevated due to increased production of reactive oxygen species (ROS), processes begin which can cause cell apoptosis. Our ability to deal with the increase of free radicals becomes compromised. It has been suggested that both an insufficient and an excess of testosterone may exacerbate these processes.

The penis is very sensitive to cumulative damage within its vascular system. Excessive oxidative stress is considered one of the major players in the degradation of the endothelium and therefore results in inadequate bioavailability of nitric oxide (NO) and smooth muscle apoptosis. This is what sets of tissue changes in these vital areas of the penis which result in ED. The correct amounts of testosterone could be beneficial in ways that may combat some of the effects of oxidative stress also, but an excessive amount may do the opposite. It has been shown that supraphysiological levels of testosterone induce vascular dysfunction via mROS generation and NLRP3 inflammasome activation. Events such as these may increase cardiovascular risk too. The penis is generally an early warning indicator of dysfunctions in our vascular system, that is it begins to show signs of malfunction quite early as erectile function is very sensitive to the health of the endothelium in the corpus cavernosum and smooth muscle content.

I think you need to understand that an excess of testosterone could be just as bad if not worse than not enough.

I will quote some text from the book “Handbook of substance misuse and addictions”:

“Testosterone and other androgens, mainly at supraphysiological levels, affect every single body tissue or system, including the cardiovascular system. Testosterone increases cardiovascular disease risk, causes myocardial infarction, stroke, high blood pressure, blood clots, and heart failure. Among the potential mechanisms whereby testosterone affects the cardiovascular system, both indirect and direct actions have been reported. Indirect actions of testosterone on the cardiovascular system include changes in the lipid profile, insulin sensitivity, and haemostatic mechanisms, modulation of the sympathetic nervous system and renin-angiotensin-aldosterone system. Direct actions of testosterone in the cardiovascular system involves activation of pro-inflammatory and redox processes, decreased nitric oxide (NO) bioavailability, and stimulation of vasoconstrictor signalling pathways.”

I find the stimulation that testosterone can have on the vasoconstrictor signalling pathways to be of great interest when it comes to ED. The penis is very sensitive to this owing to the fact that these pathways are always working to keep the penis in a flaccid state. Any exacerbation in the activation of these pathways could make erectile function quite temperamental.

The renin-angiotensin system (RAS) is one of those pathways and is of interest when it comes to the subject of erectile dysfunction being related to testosterone excess. The RAS has been shown to play an active role in the erectile tissues.
The RAS is also a regulator of the cardiovascular system. There is compelling evidence that this system is an essential modulator of the erectile process. There are higher levels of angiotensin (ANG) II (the main part of RAS) in the corpus cavernosum, when compared to systemic plasma. Physiologically, Ang II mediates (one of the pathways concerned with this) the tonic contraction of the smooth muscle in the corpus cavernosum. It is the tonic contraction of smooth muscle that keeps the penis flaccid.

So it has been confirmed that there is a fundamental role of ANG II in the maintenance of the flaccid state. Interestingly Ang II levels in the human corpus cavernosum have been shown to be increased after an erection has ceased.

What has this to do with testosterone? Androgens are considered to be pro-angiogenic (increase angiotensin II production), which regulates vasoconstriction. The correct amount of testosterone may signal the right balance in the RAS system. Too much may cause another imbalance here. The penis may be particularly sensitive to this owing to its higher levels and sensitivity to ANG II via the AT1 receptor, which is said to be well expressed in cavernosal smooth muscle.

"I disagree. first of all if it takes 2 years to recover (which apparently doesnt happen to most people) whats the point. How could i follow that advice without any evidence that it could take that long but then recover."

The only advice you should follow is that of a competent doctor. I am only trying to make you think about what you are doing to yourself now, given what has occurred in the past. What I say to you is my opinion, nothing more.

As I mentioned above, what you consider “happens to most people” is a misconception. All sorts of complications occur from the use of AAS. I had a friend who died from complications of using AAS. I have seen all types of issues post use of these substances. You cannot make such simple generalisations with regard to how each of us will recover from the abuse of these drugs.

I know you will probably say to me: I have spoken to many of guys on forums and even in the gym where I train, that have said they have done multiple courses and recover each time and have no ED or other issues. My answer to that will be: lucky them and most probably, some of them are lying. Some will get away with it for a number of times, until their body turns around and says, that’s it I’ve had enough, I can’t cope with this interference anymore! Yours just did it somewhat earlier.
I worked in a gym for 10 years when I was young. I saw the reality of what they do and the lies the users tell themselves in order to make it all seem ok. I am a *** man, steroid use was and is almost endemic in our culture due to the unhealthy preoccupation of having the perfect body. I saw firsthand the damage it caused to young healthy men. I heard numerous times, accounts of young guys complaining of ED issues for months after stopping AAS use. This is not unusual. Your issue of ED post use of all these drugs is not unusual.

It is still my opinion, that you did not give your body enough time to recover, especially given your testosterone levels returned to normal and appeared to want to remain there.

"Ok but if you take what your body would produce and take hcg to keep upstream hormones in check what could be the issue? I mean we have entered the realm of guessing and brosciense."

I don’t think you have understood some of what I have said in my posts to you. You still seem to think that TRT can reproduce what our bodies do naturally? It doesn’t. Because of this, there will be shortcomings. I will say this again, HCG is not the same as our own gonadotropins. It is a crude attempt at filling in some of the missing components that comprise our HPTA. This is not guessing it is fact.

I wish you the best of luck with your TRT and trying to resolve your ED. ED can be a difficult condition to treat. I have spoken to guys from all over the world of different ages with varying etiologies. I can tell you from all that I have discovered, Testosterone does not seem to help it unless the guy is relatively young and suffers from very low T, even then it can be hit and miss.
If your ED has been caused by all the hormone disruption and manipulation caused firstly by AAS use and then the side effects that Clomid has caused (and there is no permanent damage caused to the physical structures in the penis) it was my thoughts, that the restoration of your natural hormonal milieu would be the most logical solution. However, I can see you are determined to stay on TRT, so you may need to accept that not all will be the same as it was pre AAS use. You may get much closer to a satisfactory outcome if you lower your T level considerably, with the help of a good doctor, experienced in sexual medicine.

 

[Mastodont]

Great read, one thing i will say is, some people taking large amounts of testosterone claim to need 500mg a week to achieve a rock hard erection. And they use these amounts as a constant, pretty sure they will pay for it at some point, but acutely it does not seem like a general rule that symphatetic activation due to massive t dose is detrimental to erection.

 

[madman]

Yeah I thought of that too but from what I read with venous leak you can't even get a semi erection.

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look over these thread from post #13

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