SPEAKER_01: 0:01

Welcome to the Healthy Matters Podcast with Dr. David Hilden, primary care physician and acute care hospitalist at Hennepin Healthcare in downtown Minneapolis, where we cover the latest in health, health care, and what matters to you. And now here's our host, Dr. David Hilden.

SPEAKER_03: 0:18

Hey, welcome to episode six of the podcast. I am your host, Dr. David Hilden, and today we're talking about men's sexual and urologic health. You know, one of the great things about the podcast medium is you can learn about things you might not feel comfortable talking about. And if you're listening today, and maybe you're thinking, I've wondered about this but never said it out loud, just know you're not alone. Erectile dysfunction, testosterone issues, urinary leakage, these are incredibly common, and yet they're some of the hardest things for men to talk about. The good news is these are medical issues, they're treatable, and they're often connected to overall health in important ways. To help us walk through what's normal, what's not, and what to do about it, I'm joined once again by urologic surgeon Dr. Travis Paliara. Travis, welcome back to the podcast. Thank you, Dr. Hilton. It's great to have you here. Um, maybe you could frame the conversation for us. We're talking mostly about men's urologic health today, but many men and their partners feel uncomfortable discussing sexual health. Why is having this conversation so important?

SPEAKER_02: 1:22

So I think there's a couple ways you could approach it. First, you could look at it from the physical side. Obviously, men care about sex, uh, they care about their own urinary health, but they might be uncomfortable talking to their partner. But there's actually studies that show that they want their doctor to ask them about it. It's like you may be ashamed about it, you may be afraid to talk about it, but you want to be asked. So if it's a doctor listening to us today, ask your patient, you'll have higher satisfaction scores. And if you're the patient, don't be too afraid to bring it up because the doctor is there for you. Even if they don't know the answer, they know who to refer you to. These conditions, they're gonna cause stress in your marriage. They're gonna cause stress internally. There's signs of depression that are associated with all sorts of things we're gonna talk about today, uh, from incontinence, from erectile dysfunction, from low testosterone, decreases in quality of life and actual physical manifestations of these problems that can lead to a shortening of your life, even.

SPEAKER_03: 2:15

What a great way to frame it. And I've already have a take-home point. I am a doctor. I am sitting there with a lot of men in a clinic room, and I have to remember to ask. They really do want to want to talk about it.

SPEAKER_02: 2:25

No, absolutely. If they feel like, you know, I'm at a place where I should feel safe. And if they feel like their doctor can ask them this question with that little bit of confidence of look, I'm asking you this for good reasons, they feel like, wow, this person really wants to help me. Nice, nice.

SPEAKER_03: 2:39

Okay, so let's normalize the topic by talking about how common are these issues.

SPEAKER_02: 2:44

Okay, sure. Uh we have a couple different topics. So, I mean, uh, to let's touch on it first with incontinence. It's pretty rare in men. Okay. Um, it's most common though, after having prostate cancer treatment, surgery or radiation. In those men, 10% of men who have had treatment for prostate cancer will end up having some form of incontinence. Most common is stress incontinence, meaning the type that you get when you cough, sneeze, laugh, shovel snow, that sort of stuff. Well, considering we treat about 60 to 150,000 men a year, I mean, that there's a lot of men out there who have this problem. Uh, when we talk about erectile dysfunction, now the numbers start to really, really climb. Really common. Really common. If you look at some studies, they say men over 40, 50% of men have experienced it. Now it starts to increase. It's not like all men in their 40s, but it starts to increase dramatically, exponentially, by the decade. So every 10 years you go up, those numbers are going to increase. I've seen a study that said 80% of men at 80 years old have erectile dysfunction. So it really does climb rapidly. And then for hypogonadism, we're still trying to gather the numbers on this. There's uh hypothood? Hypogonad, you're right, exactly. Low testosterone, low T.

SPEAKER_03: 3:54

Low T, as you maybe have heard out there in the community. Hypogonadism. That's the medical term.

SPEAKER_02: 3:59

That's the medical term for low testosterone, which we're all being targeted with ads nowadays. I mean, I don't think I can, and it's probably because of my profession and what I do, but I swear that the ads on the internet target me and tell me and talk to me about low T every day, right? And I'm sure a lot of men out there in their 50s and 60s are getting those same targeted ads. The number of prescriptions for testosterone for people with prescriptions in the past few years has more than tripled. I mean, talking about a huge increase. Now, not everybody's following the proper guidelines with those, but the numbers are really staggering. You can read all sorts of different options in terms of answers, but it's 15 to 25%, up to 50%. I've read studies all over the board.

SPEAKER_03: 4:40

So you're a urologist. Before we get into these topics in individually, what the heck do you do? Yeah. What is a urologist? Great. So uh I think I know, but help us out.

SPEAKER_02: 4:49

You know, I could uh I have two kids, and uh my seven-year-old knows of me as a bladder doctor, which is almost great. I more like uh colloquially would say that I'm a surgeon of anything that touches or makes pee. That's another way to put it.

SPEAKER_03: 5:04

Did you grow up thinking that that's what I want to do? I want to be a surgeon for the naughty bits.

SPEAKER_02: 5:08

Yeah. The stream team. That's right. No, there's there's a whole lot of names. I never thought I would be, but here I am. Um, and I love it. So the really, if you think about it, we are the surgeons who did a surgical residency, meaning five more years uh of specialized training on the kidneys, the tubes that connect the kidneys to the bladder, the bladder, and then the genitalia. So anything in that area, we're we're kind of the surgeons, the specialist of it.

SPEAKER_03: 5:33

Got it, got it. So, Travis, talk us through like a typical man comes in with you and and how do they frame these issues? Uh, do they usually say, I'm I'm having trouble with my sex life, I'm having trouble with my urinary life? Um, how does that usually present to you?

SPEAKER_02: 5:47

Good one. Uh so we have uh a couple different options. You know, sometimes we get patients referred to us because we are more of a specialty center and there's a lot less urologists than there are internal medicine doctors. So a lot of it's a referral basis. So they come to us with a problem in mind. They might have an elevated PSA, which is the screening number for prostate cancer. And then while they're there, we check on all their issues. And, you know, we happen to say, you know what, we're dealing with that prostate cancer stuff. But at the same time, you know, do you have any issues with erectile dysfunction? Do you have any issues with incontinence? And then sometimes people are a little shy around and beat around the bush a little bit, and they might say, you know what, me and my partner are having some issues. And that's the you know my key. You know, I think what you learn in from doing years of clinic in urology is all you want them, if they just open the door the littlest bit, you're like, I got it from here. Yeah, you know where you know where this is. I know how to take you down the journey of this conversation. We're gonna be fine, you know? And then you can just make them feel comfortable because they're the thing they're most nervous about is that I'm gonna be awkward. So I think when I can look them in the eye and talk to them directly and say, like, hey, look, yeah, you're having ED. It happens. It happens to this many men. And they are like, what? That many people have this?

SPEAKER_03: 6:50

Yeah, you're not alone in this.

SPEAKER_02: 6:51

Don't worry.

SPEAKER_03: 6:51

And it is a little bit of a window into men's overall health. They might come with you with a erectile dysfunction, you find out about a whole bunch of stuff going on in their life, or they're they're urinary incontinence and they're worried about cancer. So there's a lot of overlap with all that.

SPEAKER_02: 7:04

And just to even take that a step further and put something concrete to it, so the arteries that give you erections, they're a third the size of the arteries in your heart. So if someone has atherosclerosis, that they have diseases of their blood vessels that we get from high lipids, you know, we get from having diabetes, the general things we think about causing heart disease, well, guess what? They affect the penis on average five years before they're ever going to affect the heart. So we used to call erectile dysfunction the canary in the coal mine of heart disease. Of heart disease. Oh, that's fascinating. And there's tons of data, especially in the diabetic community where it was really well studied, that before having a heart attack, ED predates it by five years. So really, you can save a life. There's actually, there was a great article in the 90s that somebody wrote and said how to save a life in a urology visit for ED.

SPEAKER_03: 7:56

Just look into the erectile dysfunction before they're having their heart attack.

SPEAKER_02: 8:00

Yeah. And we have more we can talk about this with the low testosterone, too. So wait to bring it up.

SPEAKER_03: 8:05

Okay. So although we did a whole episode on erectile dysfunction uh uh 18 months ago or something, and listeners, I do encourage you to go back through the archives, find the one for Dr. Paliara and I where we talk about ED. But we're gonna touch on it briefly here today, if we could. How do you define erectile dysfunction? When is it a problem?

SPEAKER_02: 8:21

Yeah, I the funny thing is it's a vague d definition of whenever it's a problem for you. Exactly. That's what I was gonna say.

SPEAKER_03: 8:27

That's pretty subjective, isn't it?

SPEAKER_02: 8:28

It is, it is, absolutely. So if it's a problem for you, we're happy to make it our problem too and help you work through it. Sometimes that is just psychologically, you're like reframing what's normal and maybe this shouldn't be a problem for you. And other times it's yeah, you actually do have a problem, and we need to address it and you know, give you the whole litany of the options that we talked about last time for fixing it.

SPEAKER_03: 8:45

Yeah, because you said it's very common in men over 40 and then even gets more as 50. And then you mentioned 80-year-olds. So uh a lot of people are probably going, Well, yeah, you're getting older. That's what to expect. So is it normal? I mean, I as you age, it's common as you age, but is it normal? When's it a pathology?

SPEAKER_02: 9:02

Yeah, that's a good question. And I think it depends on what the underlying problem is. So, like when people come in for it, I always screen them and tell them, you know, hey, we're gonna check your testosterone level and we'll get into that. We're gonna check to see if you have high lipids and send that to your primary care doctor to make sure they're addressing it. We're gonna screen you with an A1C, which is a test for diabetes, and find out if you had undiagnosed diabetes. I found people who have diabetes because they came to me for ED. They didn't have good primary care follow-up, but I was like, hey, look at that. We might have just saved your life.

SPEAKER_03: 9:32

Yeah, exactly. So can you talk to us just briefly? What are the causes of erectile dysfunction? I guess that might actually mean tell us what causes our normal erection and then what can go wrong. Absolutely.

SPEAKER_02: 9:43

So uh it's way more complicated than people think. I always tell people, my patients, that erections start in the brain. Okay. So you have to be in the right head space. And that leads to the first area, the first category of problems, which is psychogenic erectile dysfunction, meaning you're just nervous. It's between your ears. It's between your ears, all right? Supratentorial. It's up in your head. You just have a problem where you're thinking about work, you're nervous. Are you going to be able to perform? You're with somebody new, all those things that can cause stressors. That's the number one cause of ED for people under 40. So when somebody walks into my clinic and they're 25 years old, I that's exactly what I'm focusing on. I'm saying, like, look, this is tell me about your stressors in your life. You start a new job, do you get fired? You got a new girlfriend, new boyfriend? What's going on? You know? So we go down that pathway. Beyond the brain, it has to travel a signal via nerves. So you can have a nervous issue. That can be a source of problems. From there, it has to hit the arteries, which open up and bring more blood flow in. And then you can think about an arterial problem. The other source, though, up high is uh in the brain, would be like your libido. So that's where low T can kick in. If you do have low, low T, low energy levels, it could be a cause of erectile dysfunction as well. So, what's normally supposed to happen? Kind of that pathway, you know, brain, nerves, blood flow.

SPEAKER_03: 11:00

But if it doesn't, any of those deaths are a number of places things could go haywire. So let's talk about what I do want to focus on in this episode a little bit is testosterone and its role in men's sexual health. So start us out, frame that. What is testosterone? How when's it a problem? Let's just let's get into that.

SPEAKER_02: 11:18

Absolutely. I think uh I'm waiting to see a good summary, but testosterone research has been probably one of the most quickly expanding areas in urology in the past 10 to 15 years.

SPEAKER_03: 11:31

20 years ago it was barely talked about, and now it's everywhere. I gotta be honest, in med school, I think we had about a half hour lecture on it that's it, right? 25 years ago. I don't think there was tons on it.

SPEAKER_02: 11:42

Right. But now you'll see that there's 10 more ED or T clinics popping up around the Twin Cities, and they they all frame themselves as men's health clinics. They're all really focusing on checking testosterone levels. So, what is testosterone? It's the male hormone. It's only produced by one thing in your body, and that's your testicles. And your testicles really only have two jobs they make testosterone and they make semen. That's it. If one goes wrong, they usually both go wrong. So if you're having problems with infertility, you probably have low testosterone too. If you have low testosterone, you're probably infertile too. There's a good chance at least. But the way we find out if you have an abnormal testosterone level is a blood test. Now it has to be drawn in the morning because where we determined what normal was was all based on curves of thousands of people based on morning tests. And it's interesting, like this molecule is fascinating. So in our bodies, we see this peak of it in the morning, and then it starts to decline around noon and it goes down. And then you get a very small second peak in the afternoon.

SPEAKER_03: 12:38

I was wondering why this is. Yeah. Because I see patients often in the afternoon, and they and if we're talking about test house, I go, Oh, sorry, buddy, it's three in the afternoon. It's not a great time to check it. I'm supposed to check it at 8 a.m. Why is there a variation during the day?

SPEAKER_02: 12:51

But you know, think about it back to the day of like hunters and gatherers. This is what I like to do. I like to go back to this idea of all right, what drove us to get out of the caves and go hunt? It's testosterone, right? What what got us up and moving?

SPEAKER_03: 13:02

I got up really early this morning to shovel snow. I wonder if that was pretty good. Your testosterone's great. Oh, yeah, it's so good. Oh, good to know. It's really good.

SPEAKER_02: 13:10

No, but real, I think that there's something to this that goes, we could go back to the, we could anthropomorphize it all the way back to the various stone age, but really, this is what we know is it's high in the morning, and that's when we have what is our normal level. So that's what we have to base it on. So if your doctor says, Oh, I can't check it now because it's 12 or 3 o'clock, they're doing it for good reason. They're not just trying to push it and you know, kick the can down the road. They're saying, look, you need to have this check before 11, because if I check you at noon or one, everyone's gonna look low. And we're not gonna have a good thing.

SPEAKER_03: 13:38

And the reference values were done at 8 a.m. Right. That's basically what is. So tell me about symptoms. Okay. What symptoms? Now, here's what I'm gonna tell you, Travis, what I often see. Uh, I have a guy who's about 55 years old and he comes in, I'm tired. Yeah. He doesn't even get so far into the erectile issues yet. Is that a symptom, or what are the common symptoms of low testosterone?

SPEAKER_02: 13:58

Right. There's the good, there's a there's actually a questionnaire out there called the Adam Questionnaire, and you can look it up. But in general, things like, yes, I'm tired. Uh I just feel like I have no pep in my step, no energy levels. That's probably the most vague of them all.

SPEAKER_03: 14:12

Because as you know, it is kind of vague because there's like 38 other causes of that, too. Exactly.

SPEAKER_02: 14:16

Right, right. But this is the one that I think is the most often overlooked. You know, this is one where people just say, Well, your thyroid was normal and uh I don't have anything else. And you know, you don't even think that's a good thing. That's a true statement.

SPEAKER_03: 14:25

We check thyroids all the time when people are tired.

SPEAKER_02: 14:28

Right, exactly. But this one can be that hidden one that you haven't checked. So they're tired, they have a low libido, they just feel like I don't even want to have any sex anymore. I just don't even have any drive at all. Uh, you're falling asleep right after you're eating is an example of a symptom. Why that is, don't exactly know. But like really. Yeah, like literally, you have dinner and you're like, yeah, I'm just zonked. I fall right to sleep immediately. It's one of the like list of the questions that we ask people for.

SPEAKER_03: 14:52

Could have been the two glasses of wine that would that you had with that. That could definitely do it too.

SPEAKER_02: 14:56

Yeah, that could also do it. Yeah. Your meat sweats and your exhaustion, right? But after eating, okay, the exhaustion after eating. Um pathologic fractures. So people have loss of bone density. If you know you're like breaking a bone and you're like, well, I've never broken a bone before. That's odd. You know, that's one thing to check. Loss of height is a weird one. I haven't actually seen anybody come in for that, but it's another sim sign of it. People who have chronic disease states, so people who are chronically uh HIV positive, people who are diabetics, people who are morbidly obese, it's actually now indicated just to check them automatically because the chronic disease state of inflammation can suppress your testosterone levels. Aside from that, ED is another one. Uh, heart disease is another one. Um, and this is one of those really fascinating factors. If you look into the idea of testosterone replacement, you're gonna see all these things pop up on the internet about oh, increases in heart disease and heart attacks and prostate cancer. In truth, that we have very large studies that have meta-analyses where they look at all the papers that are out there, right? And they try to summarize what's the actual answer? What is the truth of this? And they found no correlation between the risk with prostate cancer, no risk with the heart attacks. But what they have now found is that low testosterone is an independent risk factor for heart disease. So the reason why this is tricky, like it's hard to study will people get heart attacks on testosterone replacement because of the age group.

SPEAKER_03: 16:21

Yeah, because they're because that's so common they're gonna you might get it anyway for a number of reasons. Exactly. You have other risk factors.

SPEAKER_02: 16:26

Yeah, the most common age that men are gonna be put on testosterone replacement is in their late 50s and 60s, even 70s. Yeah, right when heart disease starts showing up in men. Right. So that's why these studies are really faulty. They're never able to prove, like you look at one study, it says men on testosterone get heart attacks. You look at another, it says it decreases the risk. So they looked at it differently and they just found out all right, men who are on testosterone and men who weren't, who has the higher incidence of heart disease, like theatrical arosclerosis, looking at calcium scans and all that other stuff. And they found it is an independent risk factor. So having it low. Having it low is actually dangerous. Low.

SPEAKER_03: 16:58

Low testosterone is dangerous. So you you mentioned all these signs and symptoms for why you might have or where your doctor should look into low testosterone, but isn't it just normal as you age that it drops? Or is this are are these things, did it start at birth, or is did something happen later in life, or is it just a continuous drop as we age?

SPEAKER_02: 17:19

Now, good, good point. There are, of course, anomalies and genetic things, uh chromosomal changes, things that you're born with, right? That can cause you to have low T forever. They usually present in their 20s and we're trying to figure out why they've had infertility issues. That's usually they show up. They show up. And they're like, actually, you don't have any sperm and you don't have any testosterone. And they may have never known. They might have been acting like gone through puberty even in a pretty normal way. There's all sorts of things. But for most men, it's not supposed to just dramatically decline. Really, the testosterone level should stay above 300 even as we age. So when testosterone, and this is what our National American Urologic Association guidelines tell us is that as long as it's above 300, you don't need replacement. But when it gets below, it's pathologic, meaning if it's throughout your life? Throughout your life. Yeah. Yeah. We, I mean, here's the thing. If somebody comes in and they're 70 years old and they tell me I've had this change, I feel different. I don't have drive, I don't have energy. And they come in and their testosterone 250. You know, you wouldn't just do it to treat the number alone. What we do is treat the symptom and the number. And then they tell me they've got all these symptoms and their number matches, I'd say, fine, let's treat you if you want to, understanding the risks and the benefits.

SPEAKER_03: 18:34

That makes sense. Um, before we get off the like signs and symptoms and the the levels of testosterone, what about um is there a correlation between mourning erections and testosterone? Many men might know this since you were nine or 12 or 14 and throughout your life. Uh, about is that a real thing? And if someone is in their 20s, they're having trouble conceiving a child with their partner, would they have known, would they have had any clue based on things such as that?

SPEAKER_02: 19:03

Absolutely. That is another sign. If somebody comes in and they say, you know, I'm not getting erections naturally in the morning, I'm not getting them at nighttime. That's absolutely like we ask, do you get nocturnal erections? And there are tests for that. But then also, are you getting them in the morning when you wake up? And if they're not, it is a sign that they could have low tea as well.

SPEAKER_03: 19:21

Great. We're gonna take a quick break now. We are talking with Travis Paliari. He is a urologic surgeon, and we are talking about men's sexual health. When we come back, we're gonna talk a little bit about urinary incontinence and then about treatment options, particularly for low testosterone. Stay with us, we will be right back.

SPEAKER_00: 19:39

When Hennepin Healthcare says we're here for life, they mean here for you, your life, and all that it brings. Hennepin Healthcare as a hospital, HCMC, a network of clinics in the metro area, and an integrative health clinic in downtown Minneapolis. They provide all of the primary and specialty care you'd expect to find, as well as services. Like acupuncture and chiropractic care. Learn more at hennepinhealthcare.org. Hennepin Healthcare is here for you and here for life.

SPEAKER_03: 20:16

And we're back talking about men's sexual health. So, Travis, let's touch a little bit if we could about urinary incontinence in men. How common is that?

SPEAKER_02: 20:23

Well, um, like we said before the break, it's mainly in men who are gonna have a result of treatment for prostate cancer or for big prostates, BPH. Primarily, though, it's gonna be after prostate cancer. So to touch on those real quick, men either get radiation or they get surgery to remove or try to destroy the prostate tissue that has cancer in it. And as a result, about 10% of men after one year are gonna have permanent incontinence. And that means that they leak and have to wear pads or diapers, at least a pad a day, sometimes many diapers a day, every time they cough, sneeze, or just do anything that involves a stress.

SPEAKER_03: 20:58

So that's a bummer. Do men know that before they're because you treat prostate cancer too. Right. They is this conversation usually had with men that there's at least a chance.

SPEAKER_02: 21:08

Yes, and it absolutely should be in every informed consent discussion about treatment. Because uh to say it when I said it happens at a year, well, that whole year beforehand it's much, much worse. So almost everybody leaks for the first few months, and we're talking after their treatment. After their treatment. And so they have to wear these sorts of absorbent products, and then it starts to get better as you regain strength and you learn to kind of coordinate your muscles around the area to hold it back better.

SPEAKER_03: 21:32

Why is this? And I think it's something to do with the anatomy of where the prostate is.

SPEAKER_02: 21:36

Totally, absolutely. So it's one of two things it's either like destruction of the nerves or the actual tissues themselves. So there are two sphincters. Sphincters are like your mouth, it's a circular muscle, right? There's one at the top of the prostate where it meets the bladder, and there's one at the bottom of the prostate. That's the one that, you know, for the guys listening, if you were standing at the urinal and you wanted to stop peeing without using your hands, you'd squeeze that muscle. Yep. You know, women would call it kind of like a kegel exercise, also. You squeeze that pelvic floor. Well, when you have prostate surgery to remove your prostate, the nerves get shocked, the muscles themselves can get damaged, and so you can no longer make that sort of squeeze. And by doing so, without that ability, you start to leak. So you lose the little lizard brain sphincter that we have. That's the one inside of the bladder neck. Our body actually just keeps that tight all the time. And that one gets destroyed by the surgery because we have to disconnect the prostate from the bladder and then sew the urethra back to the bladder. Um, and the other one just loses uh some control and gets kind of shocked after surgery.

SPEAKER_03: 22:33

So that's relatively common. One in tens relatively common, a 10% chance of some urinary incontinence, and it's mostly after prostate cancer treatment. Okay, let's talk about some treatment options, mostly for low T. Low testosterone is what we're talking about now. First of all, before we get into treatment, I guess I should ask you how do you get tested? Well, you said it's a morning blood, is it just a blood test?

SPEAKER_02: 22:54

Yep. So to qualify, most insurance companies and then most guidelines, they want you to have two tests. So the first one we do is just a screening blood test, and it just has total and free testosterone. The reason we say total and free, okay? So total is the amount of testosterone in your body, but the free is what's actually active. And there are a lot of other molecules in our blood that bind up the testosterone. And so if it's really bound up, it doesn't do you any good. It kind of takes it out of active. Exactly. So you need to get both numbers. Then if that's low, then a week later, you can have a secondary test. And with that one, we add on a whole bunch of other hormones: FSH, LH, prolactin, estradiol, T T SH. We'll test all the other stuff. Yeah. Right. So we throw a bunch of other, you know, abbreviated hormones at you to try to get those tested to rule out everything and then make sure we don't have, you know, any really dangerous causes. Because there are some really rare things like tumors in the brain that can actually cause low testosterone. So we just want to rule those things out.

SPEAKER_03: 23:52

That's why we check what's called a prolactin. So the second, after the second set of tests, your doctor tells you your testosterone levels are low. What are your options? So um, now this is where you've probably seen lots of advertisements because the world is your oyster. You've probably seen on TV, if you're a TV watcher, low T, you've seen it in 89 point type on the TV sector. Absolutely, absolutely. Because they have a solution for you. So but there are a lot of really good ones, are there or not? Yeah, there are.

SPEAKER_02: 24:20

The world of the pharmacology of this has really changed just in the last five years. Like we didn't have an oral option really five years ago that was safe. And now we do. But yeah, all of these have a trade-off, okay? So we're gonna try to touch on these. We can start with just injectables in general. So longest acting injectable you have, we've placed these little pellets. They're made of testosterone out into the upper buttock fat. So out into your like hip sort of area. You come in, it's a five-minute procedure, almost no pain, and you have it and it stays in there for four to six months, just slowly dissolving in your body, always giving you that steady state. Okay, just it's all you'll always have the same amount of testosterone in you, and it's great. Next, you can say, Well, I don't want to have a procedure, or procedures are expensive, or I don't like needles. And is it like a little pellet gun? What is it? Is it like a staple gun?

SPEAKER_03: 25:08

I don't want to get too crude here, but how do you put them in there?

SPEAKER_02: 25:10

It's like a big needle, a really big needle that can you can pass the pellet through the needle. Whoa. But these are like even smaller than tic-tacks, they're pretty small. So, you know, it's it's really honestly, it I think it's probably what I would choose. It's so fast and easy. And then you don't have to take gels and pills. Four shots every week or day or every two weeks, exactly. Or remember to take pills.

SPEAKER_03: 25:29

And it's about every four to six months. It is right.

SPEAKER_02: 25:31

Okay, so pellets, that's option one. Option one. Then we have the shorter acting shots. So these are just liquid testosterone, which you can get done every 10 weeks if you have it done in a clinic. It's a little bit longer acting, but it has some special risk factors, so it has to be given by a nurse. Then there's really short acting, which is like two weeks. And so you just say, all right, every two weeks I give myself a shot. That's it. Some people prefer, though, the more natural rhythm of what your body would do. And so they try to copy that. And so they microdose testosterone. We call it micro, but it's not really. It's like it's just a lower dose, but they give it every morning. Every morning, just like your body would. Just like your body would. And you say, All right, but some people really hate shots, right? They just don't like the that seems like a wee bit of a commitment.

SPEAKER_03: 26:13

Yeah, right. To wake up every day. Every morning I'm gonna give my shot.

SPEAKER_02: 26:16

Yeah, but we say, hey, you know what? Diabetics do it every day. They do it many times a day. Yeah, if you want to do it, this is up to you. This is where I can't tell you it's better or worse. No one has been able to prove that these are better or worse than the other. What they can tell you about though is the roller coaster effect. So, for instance, in the two-week shots, let's say, you know, everybody's body's a little bit different, and we assume, well, two weeks is just the standard, but some people are gonna really drop off in that day 10 to 14 and they really just don't feel great. And they're like, man, I'm right back where I started. I hate this. And so then you're like, well, we can either shorten the the duration, increase the dose, but you know, that try to get you through to your next shot without having symptom recurrence. But you're gonna have more of that up and down. Every, you know, if you do daily shots, at the end of the day, you're gonna be really tired. You know, at the if you do the two-week shots, at the end of the two weeks, you're gonna feel really tired.

SPEAKER_03: 27:04

The longer acting ones sound better for all that. I like your pellet preference. Yeah. Do the pellets disappear or do they have to get taken out? They just dissolve after six months.

SPEAKER_02: 27:13

That's it. That's right.

SPEAKER_03: 27:14

Okay, I don't like shots at all, doc. Okay. So here we go. You're not putting a needle in me. You're not putting any pellets in. That's right.

SPEAKER_02: 27:20

What else you got up your sleeve? We've got two other options. So one is creams. I personally don't like these.

SPEAKER_03: 27:26

Aren't they messy?

SPEAKER_02: 27:27

They're messy. Uh, they can cause skin. Patients have told me they're messy. They can cause skin irritation. And the biggest risk is the risk of transference. So, what that means is hey, I wake up, I put my gel on, I forget to wash my hands really good. What if I go have my grandkids over that day? There are cases where this causes early precocious puberty.

SPEAKER_03: 27:46

Oh, transference to another person.

SPEAKER_02: 27:49

Yeah. Because otherwise on your hands. Right. You know, women weren't meant to have the same testosterone levels as men. So even if I just go and like hug my wife, you know, give her a gentle touch on the cheek. Yeah, with your testosterone on your too's hands.

SPEAKER_03: 28:02

Yeah, okay.

SPEAKER_02: 28:03

A couple weeks later, you know, wife's got a mustache and you're like, uh-oh, hold on. Does it does it wash off easily? It is supposed to. You know, I haven't actually read the instructions to see how well you're supposed to wash, but it's a risk. So where do you put it on your body? They have different options. Certain ones are say the inner thigh, and then other ones say the upper outer arm.

SPEAKER_03: 28:21

And it's just, is it like thick, creamy, like Vaseline petroleum jelly, or something?

SPEAKER_02: 28:25

It's not quite that thick, but it is, you know, it is. I have heard it's but it's messy, yeah. So I usually don't prescribe those. I have a couple patients who have been on them for 20 years and they don't want to change. And so it's good for them. It seems like it might be hard to dose too. Do you get the right amount? No, you're spot on. That's the thing. Some of them have like a pump actuator dispenser, but it's like maybe it's a little less some days and a little more other days. And maybe the absorption's a little bit different because I was at the beach yesterday and I was slattered with a sunscreen still. Right. So they've done plenty of studies to show that dosing is a lot more variable. And because of that, maybe your outcomes are a lot more variable.

SPEAKER_03: 28:57

So you have transdermal methods. That's right.

SPEAKER_02: 28:59

And then those pills now. There's now some pills. So the biggest hurdle we have with this is insurance coverage and then just uh remembering to take the pills. So again, you have to take these twice a day. And with that, you know, if you forget to take it because you're like, I don't know, I already have five other pills or I've just got a busy life, you know, you're gonna have that same roller coaster effect that's even worse. But yeah, if you don't want a shot, it's your option.

SPEAKER_03: 29:21

I don't think I've in my life prescribed pills because I've been doing this a little, I've done, I've sent people to you, right? And I have a couple of people on those gels. So that's why I know about that. I don't think I've done any pills yet. They really haven't been around long.

SPEAKER_02: 29:31

No, no, they really just in the past like two to three years, they've really finally gotten approval. There, there was an older oral version, but it had a lot of liver side effects. So we had to watch it a lot more closely and they recommend against those now.

SPEAKER_03: 29:42

But the new ones are safe. So, what can people expect about resolution or at least improvement of symptoms? Is it that afternoon, next week, a month later? And it can they expect erectile dysfunction will be better? Can they expect energy levels to be better? What can they expect about the response?

SPEAKER_02: 29:58

So usually it is pretty quick. I mean, people will really notice uh within a day. They say, wow, I've got more pep in my step, I feel more drive. The erectile dysfunction is it's a hit or miss. So we can't promise it's going to get better, but there are studies that say yes. There are some studies that say no, because again, you can have all those physiologic problems too, blood issues, blood flow issues, nerve issues. So there's a lot more of a complex issue. It's not just testosterone, as you mentioned earlier, but it could help.

SPEAKER_03: 30:24

It's possible.

SPEAKER_02: 30:25

Right. But like things like weight loss, they're going to take months. But I have seen tons of patients who've come into my clinic that get started on testosterone and they'll say, like, yeah, you know, I feel better. And I look at them, I'm like, Are you have you lost weight? And they're like, you know, like 30 to 50 pounds. I'm like, whoa. Yeah. Do we do we notice that all started right when we got on the testosterone and we were able to, you know, maybe, maybe they're not as, you know, uh surprised. They're like, I don't know. I didn't feel a huge difference. I'm like, look at your body. You're you're 30 pounds lighter right now.

SPEAKER_03: 30:53

Well, what about other um side effects? And side effects is a funny word we use. All medications cause a bunch of effects. Some of them we want, some of them perhaps we don't. You said the risk for prostate cancer isn't really as high as people thought.

SPEAKER_02: 31:06

No, in fact, we at all. It's really not been validated. You are required to check a PSA before and during treatment because you do want to follow it. Because, like we said, any man who's of this age group can get prostate cancer, specifically men over 50. But there is no data that says that prostate cancer gets worse while on testosterone. Okay. So that's important. Other side effects, though, that we do have to watch for. So we check people's liver enzymes, uh, especially because mostly because of that older um older formulations that did have more liver side effects. I've yet to see anybody have any liver issues yet. But one thing that is very common, but really not that dangerous, is an increase in their blood count. So if somebody came in and they actually had a low blood count and you put them on testosterone, you can expect that to go up. But if somebody was already at a pretty normal blood count, you might find that they become polycythemic. Their blood gets a little too thick.

SPEAKER_03: 31:57

I do have a guy whose hemoglobin is pretty high, abnormally high, and we think it's his testosterone. Yeah.

SPEAKER_02: 32:03

Well, you know what's interesting about it though? And this I've gotten into a debate about this with hematologists who are like blood doctors, right? So all the studies about the dangers of this high blood count, none of them are in patients on testosterone. They're only on patients who have had other blood counts.

SPEAKER_03: 32:16

We have high blood counts for other reasons. Right. Yeah.

SPEAKER_02: 32:19

So other issues. So there's a big debate, and like at the big, you know, urology conferences where we talk about it. Should we worry about it? Should we even worry about it? We kind of have to just because, you know, you want to protect patients and make sure nothing happens. And so it's as easy as this. If somebody has a hematocrit over 54, we just say, great, donate blood. And if you can't donate blood to the Red Cross, then we say, okay, we'll do flood body. Yeah, we'll just take the little bit. Drain it. That's right. We'll drain it. It's uh no biggie, no biggie. No biggie at all.

SPEAKER_03: 32:46

Um, we're not gonna talk about treatments for ED today because listeners, I'm gonna refer you back to that episode from a couple seasons ago. So we're not gonna get into that, but just know there's plenty of other treatments for that that we've talked about in more detail about erectile dysfunction. So before I let you go, I want to I want to do two more things. One, could you just briefly talk about a preventive health? Is there anything people should do to prevent um urologic problems in men, their sexual health, uh they're they're all of it?

SPEAKER_02: 33:12

Amazingly, I mean, and of course, like any good doctor's podcast, with all of these things, prostate cancer with low testosterone, you want to cut down the body's inflammation, you want to stay healthy. So you want to not become obese. So that means eat right, exercise, don't smoke, don't drink to excess. You know, all the things the doctors have been repeating to us over and over and over again. It's live a healthy lifestyle. That's really the main thing you can do. Another interesting thing, though, about testosterone is sleep. So sleep actually plays a 10% role in uh in about a normal testosterone. So you can actually take somebody who, for instance, works night shifts, and I've seen this, and it throws off their circadian rhythm, their testosterone's low. They can expect a 10% increase if they were to go back to getting a good eight hours of time.

SPEAKER_03: 33:57

Good night's sleep. That's really good tip. So the healthy living stuff. I just wanted to touch on that just so we make sure that that's always important. And you're right. We've been doing this podcast now for five plus years, and uh it comes up a lot. I've yet to hear any of my guests say, I recommend you start smoking. Nobody's ever said that yet. Okay. Um as I said at the beginning of this show, uh, this is a topic that maybe people find uh uncomfortable to talk about, but I hope you have realized by listening to this that it's actually a topic you can talk about, have a little fun with, and there's really good science, and there's really good things to be done, men, and your partners. So don't feel bad about talking about it. And doctors out there, make sure you ask your male patients about their sexual health. Okay, Travis, if you could leave us with a message, what would your take-home points for our listeners be?

SPEAKER_02: 34:45

Well, I would say kind of like what you just I re-emphasize what you just said, and that would be normalize men's health. Men should be more proactive, they should come to the doctor, get checked out, because you know, there's a reason that married men live longer. That's usually because their wives drive them to go get people?

SPEAKER_03: 35:05

That billboard, there's a billboard that says many men are gonna die of being stubborn, uh-huh. And then somebody had spray painted. No, we won't. Yeah. So men are a little bit stubborn. It is a that's a true statement. That's been validated that men seek out health care less. The average health care user of health care is a woman.

SPEAKER_02: 35:23

Right. And I think that it's just if we could normalize healthcare a little bit and we could make people feel comfortable coming to the doctor and asking the questions that they really have instead of the internet, you'll get true answers and you'll get reliable answers, and you'll get health. You'll get good health.

SPEAKER_03: 35:37

Go see Dr. Paliara, everybody. You don't have to get all your information from the internet. So, Travis, thanks for being on the show today. It's been a great episode. Thanks, Dave. Great to have Dr. Paliara back for his second round on the podcast. Listeners, thank you for joining us. You know, the holidays are the best medicine, so we are gonna take a break and we will see you again for our next episode in early 2026. Happy holidays and happy new year. And as always, be healthy and be well.

SPEAKER_01: 36:05

Thanks for listening to the Healthy Matters Podcast with Dr. David Hilden. To find out more about the Healthy Matters Podcast or browse the archive, visit healthymatters.org. Got a question or a comment for the show? Email us at healthymatters at hcmed.org. Or call 612-873-TALK. There's also a link in the show notes. The Healthy Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota, and engineered and produced by John Lucas at Highball. Executive producers are Jonathan Comito and Christine Hill. Please remember we can only give general medical advice during this program, and every case is unique. We urge you to consult with your physician if you have a more serious or pressing health concern. Until next time, be healthy and be well.