260 ‒ Men’s Sexual Health: why it matters, what can go wrong, and how to fix it

The expert views daily Cialis not just as a treatment but as a preventative measure. He explains that while on-demand PDE5 inhibitors only cover ED for a night, daily use can actually improve the underlying physiology by causing hypertrophy of the smooth muscle in the penis and improving systemic endothelial function. Studies have shown persistent improvements in endothelial function even after stopping daily Cialis. He notes that 5mg daily is also FDA-approved for benign prostatic hyperplasia (BPH) and pulmonary hypertension, offering additional benefits. The cost of generic Cialis has become very low, making it accessible.

The expert explains that injections were historically a 'second-line' therapy but are now offered as an option in shared decision-making. The medication is injected at the 2 or 10 o'clock position at the base of the penis. The dose is carefully titrated to avoid priapism, which is a medical emergency. He notes that partners often learn to administer the injection. While effective, ED is a progressive disease, so men may need increasing doses or stronger solutions over time. He advises varying injection sites to mitigate trauma to the corpus cavernosum.

The expert describes the penile prosthesis as a 'phenomenal treatment option' that has been around for 50 years. The surgery takes about 45 minutes under general anesthesia. He emphasizes the importance of choosing a surgeon who performs many of these procedures (at least 50-60 per year) to minimize risks. The infection rate is low (around 1%) but can be catastrophic, often requiring removal of the device. Prophylactic antibiotics and strict sterile techniques are used to mitigate this risk. A key benefit is that the erection can be maintained after ejaculation, which some men find very favorable.

The expert strongly favors injectable testosterone, particularly subcutaneous cypionate or enanthate, due to its affordability ($25/month cash price from compounding pharmacies) and ability to maintain more stable, physiological levels. He recommends twice-weekly injections (e.g., 50mg each) to avoid the peaks and troughs associated with less frequent dosing, which can lead to higher rates of erythrocytosis. He differentiates between cypionate (more anabolic, more sodium retention, for younger patients) and enanthate (for older patients). He also discusses protocols for fertility preservation, such as co-administering HCG, which helps protect testicular function and spermatogenesis, even when exogenous testosterone is suppressing LH/FSH.

The expert notes that while pellets are effective and liked by many patients for their convenience, they have a pharmacokinetic profile where testosterone levels peak within 72 hours and then decline sharply by the third or fourth month. This can lead to patients feeling great for a few months and then 'lousy' before their next implantation. The interval can be shortened to three months to mitigate this. The procedure involves a small incision, and he uses a 'stacking' technique to implant the pellets like a column to reduce the risk of expulsion. Patients need to avoid strenuous activity for 72 hours post-procedure.

The expert discusses the recent FDA approval of several oral testosterone formulations (Jatenzo, Tlando, Kyzatrex) in the US, noting that similar drugs have been available globally for decades. The key innovation is their lymphatic absorption, which avoids the hepatotoxicity associated with older oral testosterones. He emphasizes the importance of taking them with food, as fasting leads to no absorption. He suggests dosing at breakfast and lunch (off-label) to superimpose the pharmacokinetic curves and achieve more stable levels throughout the day, mimicking natural diurnal variation. While convenient, they are generally more expensive than generic injectables and may not achieve the same high levels as injectables.

The expert highlights that while the official position of the American Urological Association doesn't explicitly acknowledge PFS, the drug's package insert does mention prolonged side effects. He believes a significant subset of patients experience these issues, including permanent ED, loss of libido, depression, and suicidal ideation. He points out that the drug's mechanism is more complex than just blocking testosterone to DHT conversion; it also affects other steroids and their conversion into neurosteroids, particularly allopregnanolone, which is crucial for mood and cognition. The persistence of symptoms after stopping the drug suggests an epigenetic mechanism, such as DNA methylation of the 5-alpha reductase gene.

The expert details how the initial concern originated from a single patient study in 1941. He cites the American Urological Association's 2018 guidelines, which state there's no association between testosterone and prostate cancer. He then discusses 'bipolar androgen therapy' (BAT), where high doses of testosterone are given to men with metastatic prostate cancer, often after initial androgen deprivation. This unconventional approach, pioneered by the Hopkins group, has shown remarkable results, including a 50% reduction in PSA and radiographic disease, and even improved overall survival compared to standard treatments like enzalutamide, at a fraction of the cost. His own lab research on prostate cancer cells and mice supports an 'inverted U' model, where very low or very high testosterone levels are protective, while hypogonadal levels are dangerous.

The expert explains that ED is a progressive disease, and on-demand PDE5 inhibitors only mask the symptoms. Daily Cialis, however, has been shown to cause hypertrophy of the cavernosal smooth muscle, keeping the penile tissue healthy. Studies have also demonstrated that daily Cialis significantly improves systemic endothelial dysfunction, with benefits persisting even after stopping the medication. This suggests a broader cardiovascular health benefit beyond just erectile function. He recommends starting daily Cialis at the first signs of mild ED, not just for treatment but for prevention.

The expert initially dismissed LISWT but was convinced by the underlying science: inducing microtrauma to stimulate neoangiogenesis and recruit stem cells, thereby improving nitric oxide synthesis. However, the market is flooded with 'radial shock' machines, which are pneumatic, have significantly lower pressure and penetration, and are essentially ineffective. These 'Class Type 1' devices are low-risk and can be bought by anyone, leading to widespread, expensive, and often useless treatments. He highlights the vulnerability of ED patients and the high placebo response rate, which further fuels the proliferation of these ineffective clinics. He emphasizes that only 'Class Type 3' electrohydraulic or electromagnetic machines are effective, but even these are investigational and require more studies, especially for mild to moderate ED.