In this episode of Solo, Peter McGraw and his co-host speak to a urologist. They learn why a urologist isn’t just for men. They discuss the non-linear effects of testosterone, why you shouldn’t get a vasectomy if you are considering freezing your sperm, and what to do if you or a partner has a crooked penis. In the bonus episode, Peter tells a story about his casting call for a Cialis commercial.
Listen to Episode #6 here
Vasectomies, Prostates, And Crooked Penises
In this episode, my co-host and I speak to a urologist. We learned why a urologist isn’t just for men. We discussed the nonlinear effects of testosterone, why you shouldn’t get a vasectomy if you’re considering freezing your sperm, what to do if you or a partner has a crooked penis. In a bonus episode, I tell a fun story about my casting call for a Cialis commercial.
Our guest is Dr. Stephen Siegel. Stephen is a board-certified urologist. He graduated with honors from Duke and received his medical degree from Vanderbilt. Before moving to Boulder, he was in private practice in Georgia and Connecticut and he’s living a solo life while he waits for his family to join him here. Welcome, Stephen.
Thanks for having me.
We’re joined by a special guest co-host, Kym Terribile. Kym is a writer, Reiki practitioner and certified yoga teacher. She’s a graduate of the University of Hawaii with a degree in English Literature. She’s 36 or she likes to say, “30 sex.” She’s single and lives in Boulder, Colorado with her two dogs. Welcome, Kym. Thanks for helping out.
Peter, thanks for having me.
What do urologists do?
Urologists have anything that has to do with the urinary tract.
That means it’s not men only.
30% to 40% of our patients are female. A lot of people think that we’re the male version of a gynecologist.
Do most men have a urologist like most women have a gynecologist? Is this someone you see on the regular or is it a special occasion trip?
Most men do anything they can to avoid seeing a urologist. I also think that men in general are not trained to go to the doctor. Women have it a lot rougher. In the list of medical woes, the women are far ahead of us. Most guys have avoided going to the doctors all these years while the women start getting embarrassing exams from a young age. Most men do not have urologists. Most men end up with urologists when they’re older, but not in the under 50 range for sure.
In full disclosure, I met Stephen because I went for the first time in my life to a urologist.
Was it for a check-up? What brought you there, Peter?
I went because I was curious about getting a vasectomy. It was a consult. I didn’t even drop my pants. It was quite a comfortable, positive experience.
Is it most men who walk in there for a consultation and don’t ever come back or they don’t go through with the procedure?
I don’t know the numbers on that. It depends on why they’re thinking about getting a vasectomy because a lot of guys are coerced in there by their wives. Those guys end up showing up again because the wives have the power when it comes to that. Some guys start to feel guilty that their wives have gone through so much in terms of birth control and having babies and all that. They’re like, “It’s my turn to step up to the plate.” There’s a large percentage of guys who don’t end up scheduling vasectomy. There are guys who I’ll consult and then a year later they’ll go, “I need to schedule that.” My nurse will come to me and go, “Do you need to talk to him again or can we schedule this?” I don’t know the exact breakdown, but my sense is that most guys who come talk to me end up getting a vasectomy.
You’re a doctor who specializes in the urinary tract for men or women. What does that mean exactly? What can go wrong with a urinary tract?
It’s anything from the kidneys to the bladder, to the prostate and then sexual functions. I see lots of folks who come to see me for a kidney stone. It has nothing to do with transsexual stuff or urinary stuff, they just have a stone. My niche while at my practice was in Connecticut, I did a lot of prostate cancer work and I still think that what most urologists do relates to the prostate.
Will my prostate kill me or try to kill me?
Not likely, but it’s possible. Prostate cancer is the number two cancer in all men behind skin cancer. In the news, if you read it, they talk about it not being a significant cancer being slow-growing. It’s still the number two killer of men behind lung cancer. It is a potentially significant cancer.
My understanding of it is that if you live long enough as a man, you’re likely to have an issue with your prostate.
Certainly, you’re going to have an issue with your prostate. If you want me to go deep into prostate cancer studies there was a crazy study where a pathologist looked at men who died from car accidents, shootings, stabbings and took out their prostate and look for cancer cells. By decade, that was the percentage chance of you having some prostate cancer cells. A 70-year-old man had a 70% chance of having some prostate cancer cells. We don’t diagnose that in 70% of men. They’re in our cells that don’t go on to cause true disease, but it’s terrifying at the amount that’s there.
What exactly is a prostate?
The prostate is a gland that lies underneath the bladder, the urethra, the urinary tube runs right through the middle of it. That’s why it causes many problems for men. As they get older, the prostate gets bigger, compresses the urethra, urine has to go through there. That’s the urinary issues. The function of the prostate is to provide nutrition to sperm. Once you’re done making babies, the prostate doesn’t do anything but get in the way.
I have a checkup coming up. I do a yearly checkup with the doctor here in town. Jill Siegfried, I’m sure you’ve met her. As far as doctors go, it’s the longest I’ve had since like my childhood doctor, Dr. Ringold. He’s not around anymore, but he used to smoke in the office. I remember when I was turning 45, I went into my checkup and she comes in and I say, “Doc, I’m 45. Are you doing something special for this checkup?” She’s like, “Like what for example?” I point at this tray next to the table that I’m sitting on and there’s a rubber glove. This beat-up bottle of lubricant. It’s been used a lot. It’s all crinkled. She goes, “No.” I think she said that’s 50. I can’t remember exactly, but it’s not now. She puts it away. “You might want to send the nurse in here again and do my blood pressure reading, it might be a little bit high.” She looked at the charts and she goes, “Yes, it is. We will do that.” This prostate can go haywire. It’s more likely to the older you get. There’s a lot of new literature about checking this.
A lot of it has been negative. At the United States Department of Human and Health Services, they came out a few years ago and said, “Screening for prostate cancer was a mistake and could cause more harm than good.” The urologic community was not happy with that report. If you read the report, one of the risks that they include in getting your prostate screen, which included the exam you were referring to, plus a blood test, was that you potentially could end up with a bruise from having your blood drawn. The official recommendation is 50 if you don’t have a family history, but 40 if you do. I was 43 when my father was diagnosed with prostate cancer. I was sitting in the waiting room while he was having the surgery being on the other side of the door. I went, “I went from not needing my prostate check for seven years to I’m three years too late. I should be doing this.”
This is a hacked joke but I’m going to ask it anyway. As urologists, can you check your own prostate?
I have not tried but I have been doing yoga. It might be more possible than it used to be, but I have not tried. I went for my check-up and the practitioner looked at me and asked me, “Do you do it? Do you have one of your partners do it?” I’m like, “No, you’re doing it. Sorry, you can’t get out of this.”
For those of us who have not had this check-up, can I ask what it entails?
[bctt tweet=”Most men do anything they can to avoid seeing a urologist. ” via=”no”]
It’s still much simpler than what you do. It’s a rectal exam. Take a feel of the prostate. That’s it. You’re feeling lumps or bumps. It takes all of five seconds to do and guys make a much bigger deal about it than it is.
Kidney stones, that’s what you started with. That’s common. I’ve been lucky enough to avoid having a kidney stone. I drink lots of water, does that help?
That absolutely helps. It’s one of the things that I’ve noticed in moving to Colorado. The people here, their stones are much bigger than what I’m used to. I have no idea what that is. I look at this community as a pretty good water drinker.
At times, you’re more dehydrated. For people who don’t know where Boulder is at, we’re a mile high and then it’s dry. Humidity in the summer will be 10% or 15%. You get dried out.
I’m not seeing a lot of kidney stones, but big stones.
What exactly is a kidney stone?
It’s exactly what it sounds like. It’s a little rock that forms in the kidney. If it’s sitting in the kidney, it doesn’t cause problems other than occasional blood in the urine. If it tries to move and it goes between the kidney and the bladder, it can get stuck and cause significant pain.
Are men or women more at risk?
It’s about equivalent.
Do you treat it differently for men or women?
No, it’s exactly the same. The only thing that would be different is if it’s a young woman of childbearing age. We try not to do the shockwave treatment that could potentially affect their ovaries. Outside of that, it’s exactly the same thing.
You break these things up with shockwave?
This is why it was great to play video games as a kid. We have lasers that they get to break stones up with. We have ultrasonic waves. It’s a video game.
As an aside, is this a concern that robots will do that job? Robots can read X-rays now and things like that. Is that coming?
Not that I’m aware of. We do robotic surgery and patients sometimes get confused that robots are doing the surgery, but it is a tool that we’re using. You can go through a scanner and you could be found to have a stone, but you still have to have the consultation with the patient about how to treat that stone.
I was imagining, you’re like, “You’re going to have this machine do this thing for you at some point in life.” Kidney stones, prostate cancer and other prostate issues. Are there other issues besides cancer? That involves treating it and then removal sometimes. Before we get to the juicy stuff, will you do something called brachytherapy?
That’s a different treatment for prostate cancer. That radioactive seed and plantation. It’s not that exciting to talk about. We see a lot of women with bladder dysfunction, urinary frequency and racing them to the bathroom and leaking with coughing, sneezing and laughing. The other main thing we do is erectile dysfunction. I do a lot of treatment of Peyronie’s disease, which is the curvature of the penis with erections.
That’s a disease?
That’s what I say to patients. I hate the word ‘disease’ in that. When you say the word ‘disease’, it makes it sound like it’s something you caught, it’s something you’re going to give. All it is a scar formation in the erectile tissue.
Can you correct that?
I can, yes.
There are many guys out there who have no idea that this is a thing.
There’s a medication out there starting to advertise. A lot of the old-time docs didn’t like the direct to consumer advertising and medication. It’s great in terms of letting patients learn exactly what’s out there. I can’t imagine there are many guys who have curvature of their penis with erection that go up to another guy and go, “Mine is curved, is yours straight? I think something’s wrong.” That’s something that’s a conversation that guys want to have.
That’s their scar tissue.
The erectile tissue is a sponge that gets filled with blood and that’s what causes it to get the wider, longer and harder. If you have a scar on one side and that side can’t expand, then it’s going to curve towards that side.
How do you treat that?
That’s a medication that’s injected directly into the scar to try to break the scar down.
What’s the percentage of men in the population who have this issue?
Because guys don’t talk about it, we will probably don’t know the real answer. It’s estimated to be somewhere between 8% and 12%. It’s also how curved is curved.
Is there a percentage that then counts?
In order to get a guy qualified for this medication, I have to give a guy an injection in the office to give him an erection then measure with a little protractor to measure the degree of curvature.
That must become a comfortable interaction. Do you use a drape? Does he not see what you’re doing?
What do you inject into a penis to give it an erection?
There’s a medication that will do exactly what happens physiologically to create the erection. It dilates the arteries to bring more blood in there. It constricts the veins to trap the blood there.
Who was the person who invented that there?
There is a great story. I don’t know his name but at the American Neurological Association meeting, the story goes, this is back before I was in practice. He injected himself and got an erection in this meeting and walked up and down the aisles to show the urologist his erection that he created with this injection. Folklore has it that the urologists were reaching out and pinching it to feel how firm it got.
You couldn’t get away with that now.
I don’t know but urologists are an interesting group.
What is a urology conference like? Is it a big party scene? Are urologists more outgoing, extroverted, comfortable types of doctors?
There’s a general belief that urologists are the nice guy surgeons.
There are no God complexes in the urology world.
No, I don’t think that goes on.
They’re fine, but they’re nice and fun.
They’re meant to be educational.
Why urology for you? What was the drive there?
I knew I wanted to be a surgeon. I wanted to go that route. I looked at different fields and I liked the variety of ailments that we treat. I liked having the longevity of having a patient with me. Not like, “You have appendicitis, you need your appendix out. I took your appendix out. I never need to see you again.” I get to follow these patients. I get to treat cancers that are curable. I don’t have to have a lot of bad conversations. There are fewer emergencies. It’s not that good, it’s not bad either, but I get to sleep.
What emergencies do you see?
Kidney stones are the most common. Late-night calls in a lot of pain, but those can be treated with pain medication overnight. They’re not urgent surgery. The only true emergency I take care of is testicular torsion, where the testicle twists. He got about 6 hours to untwist it or the guy could lose the testicle.
How does he twist it up?
One of those things that happen. It’s not a sports injury. The testicle is a ball on a string. The cord has a blood supply. If the testicle twists, it twists the blood supply and cuts it off.
I assume you know once it’s been twisted.
The patient knows. It hurts. It’s not difficult to make that diagnosis.
Does that happen most of the time like walking down the street or are they having interaction? What’s going on when this happened?
There are supposedly increased incidents with masturbation but I don’t think guys normally admit to that. They say it just happened.
I played lacrosse for 25 years and I played defense. I religiously wear a cup, an athletic supporter and protector because people were often shooting the ball at high velocity at the goal and sometimes you’re in front of the goal. You’d rather the ball hit you then score. I’ve been hit on by square on the cup before and had some swelling. I didn’t have twisting, but I had some swelling and it was bad. I didn’t go to the doctor because everything was intact.
Unless you ruptured the testicle, there’s nothing to do. It just hurts.
[bctt tweet=”Once you’re done making babies, the prostate doesn’t do anything but get in the way. ” via=”no”]
We’re going to get some of the good stuff, kidney stones, prostate cancer and incontinence. What causes incontinence?
In women, it’s having babies and in having hysterectomy and changes in hormones as they get older.
Is that because of muscular? It’s sphincter-type stuff?
Not necessarily sphincter. That’s less common, but the pelvic floor gets weakened. The bladder doesn’t have the same support it once had.
I have a question about the pelvic floor. Coming into my mid-30s, I keep hearing everyone talking about these Yoni Eggs, like in weights. Is this inappropriate? It’s a weight that you insert into your vagina and you’re supposed to go about your morning routine, trying to hold onto it like you brush your teeth, you drink your coffee, walk around your house. It’s to keep the muscles.
It’s a vaginal workout.
Yes. That’s supposed to help with future bladder issues, especially in women who have had babies is what I’ve heard.
How big is this thing? How much does it weigh?
I’m not an expert. I don’t have one. I’ve been searching for one. They’re about a size less small than my ChapStick. They’re made of different things like jade, rose quartz, I’m sure there are non-crystal ones for the non-bolder people. I was in Pharmaca and I saw some of them there. There’s different heaviness is that you can use.
Is this a real thing or is this snake oil?
I’ve never prescribed those, but it does make some sense. If you’re trying to work a muscle out, there is a pelvic girdle of muscles. If you’re contracting those and keeping them strong, that’s going to be helpful.
It’s good to know.
I didn’t know that there were rose quartz ones. That’s even better than stainless steel.
As you get stronger, do you start to up the weight?
I think that’s what’s supposed to happen. Now, you can prescribe vaginal weightlifting to your patients.
People in Boulder are super competitive when it comes to their fitness-type stuff. I can be like, “I’m at 3 kilos now.” You said from the kidney all the way down.
I’ve talked to a lot of guys about erectile dysfunction.
In your opinion, what percentage of erectile dysfunction is physical-physiological versus psychological-emotional?
It used to be believed that it was all in the guy’s head. That thinking has turned around completely and thought to be much always physical. I would argue that whether it’s physical or not, it ends up being psychological because a guy wants to perform and perform well. If he’s having a little physical issue and it’s affecting him and it’s an important date and the guy’s like, “This time I got to have a good erection.” At that point that the guy is starting to think about it and worry about it and go, “I hope tonight, I perform well.” It’s a physical issue. It’s a loss of blood flow to the penis. In order to get an erection, you have to increase the blood flow to the penis, six-fold. There is no other part of your body that needs an increase in blood flow. If you have a little bit of disease, it’s going to show up in the penis first. Those guys are all in their heads.
The penis is like the thermometer of the body?
You have the guys that are in the amazing physical shape that dropped dead of a heart attack. There’s a belief that the heart disease went undetected. Guys that are younger that have erectile dysfunction are showing the first signs. A guy like that should have a cardiac workup to make sure there’s nothing going on in the heart because they’re too young to be having erectile dysfunction.
The physical part of it is you think about as men get older, this is more likely to happen. That would be suggestive that it’s not psychological that it’s physiological or physical in some way. You’re saying it’s mostly there’s something impeding that blood flow.
Your cholesterol is high and is blocking some of the blood vessels. One of my more interesting jobs as a urologist is I do become a psychologist for guys. I do see young guys with erectile dysfunction and a lot of the times it’s guys who are recently single. Getting into a new relationship or they’re out in the dating scene and they’re dating a lot of different women and they want to be able to perform well as the real masculine way of impressing a woman. Those guys will come into me and say, “You have a 24-year-old who says he can’t get an erection. You get down into it.” You’re like, “I had been dating this girl for a while and we broke up.” You start talking about it. It’s one of the things to the guys having in their heads that they need to impress somebody. If you’re in a long-term relationship and you’re having troubles with erections, you can talk with your partner but if you’re meeting someone on an app, you want to be able to perform and not have to have that conversation.
I had a disclosure alert. This is a long time ago. I’m in my 30s. I had a serious relationship. This is someone I thought I was going to marry. This is back when I thought I would get married. My goal wasn’t to get married, but with this person, I thought that would happen. I wasn’t seeking it out, but I stumbled on it. The relationship ended in a spectacular fashion. I remember the first time I was with a new partner after that and had exactly that experience in part because that was the moment in time where I was like, “This is over. This is clearly done.” It was all in my head. Fortunately, I had known the woman prior to that for a while and I was like, “Sorry, I freaked out a little bit here.” She was understanding and quite compassionate about that experience. I could see how that side of it can mess with you. When there’s nothing physically, I was in my early 30s at that time. What about fatigue, alcohol?
All of those will play a role, for sure.
What is the course of action for dealing with erectile dysfunction? If somebody comes into your office and they’re having trouble performing with their new partner or their partner for a long time, what do you do? Is there medication? Do you refer them to someone?
I am that someone. They’ve been referred to me.
What I meant is a mental health professional.
Most guys are having a hard time going to urologists. They have to talk to a psychologist about it. Most of the time, if they can talk to me about it and I can tell them they’re okay and that’s normal and that I’ve heard this a thousand times before. That helps some guys. I also use Viagra, Cialis, Levitra, all the erectile dysfunction drugs. They started to go generic and they’ve come out in low doses. You can tell a guy, “It’s okay to use a crutch for a little while and let’s get you some confidence and get out of your head. If it’s an important date and then here’s some medication that’s going to help you. It’s going to work because there’s nothing wrong with you physically.” The crazy thing about erectile dysfunction is even if I work up that guy and find something physically wrong with him, the treatment is the same. Try these medications and see if it works. I’ll tell a guy to a low dose. They’re happy and they don’t come back.
I usually make jokes and I’m cheeky in general, but you start talking about dick stuff. There’s more opportunity, there’s a reason that the dick joke is popular in hack comedy. You say the treatment is the same, but what about general health? Let’s suppose you’re having some of these issues, shouldn’t the guy start eating better, exercising more, taking better care of himself? Can that potentially have an impact?
If it seems more physical then, absolutely, I’d get them back to their regular family doctor. Those are the guys I was mentioning before that may benefit from having some cardiac workup to make sure that there’s nothing more significant going on. If you’re having trouble getting an erection, there’s plenty of stuff that we can do as urologist to get you an erection. Their overall health is more important and there are lots of reasons to eat well and exercise well.
There’s a difference between erectile dysfunction and sex drive. You also do work with men who are low deficient in testosterone. Do you do anything with guys who are too high?
There’s not a whole lot you can do about that. When I was talking to before about consumer marketing from these drug companies when all of a sudden there are all these medications that came out for testosterone replacement. We started checking testosterone like never before. When I first got into practice, we weren’t checking that many guys testosterone. It got in the forefront of everyone’s brain. I’m checking a lot of testosterone these days.
Disclosure alert. Dr. Siegfried was doing the annual checkup and everything and she asks questions about your sex life and protection and this and that. I was saying that I had been less amorous than I normally would be. I had a partner at that time. I was like, “Is there something wrong with me? Is this normal? What’s happening?” She said, “What do you think it is?” My answer was stress, “I’m stressed out and when I get stressed out, that seems to be an outcome of that.” She said, “Let’s check your testosterone just in case.” Around the same time, I have a colleague, he’s in Australia but he was a professor during my PhD. He does research on testosterone and its effect on things like risk-taking.
They do a simple test of testosterone, which is, it’s the digit difference. It’s the difference between your index finger and middle finger or something like that. It’s an indicator evidently of prenatal testosterone, which is correlated with testosterone in general, it’s a weak test. Nonetheless, you can still detect differences. I’m on the phone with him and I’m like, “It looks like mine’s pretty.” He interrupted me, he goes, “Pete, you have high testosterone. I know it from knowing you for fifteen years.” My doctor, she comes back and she’s flipping through the chart. She goes, “It’s not your testosterone. I had never had it checked.” As a guy, it’s an interesting test because this idea of testosterone, masculinity, manhood, all these things rarely as a man do you have a number that you can put next to how much of a man you are. It seems like testosterone is that number.
There are guys who are hoping it’s low so they will give them testosterone.
I thought there would be guys that are like, “You’re average,” and they are like, “Crap.”
There’s a big range of what’s considered normal blood tests. Guys are a little competitive with themselves about how normal they are. It’s in the normal range, but shouldn’t it be higher?
My understanding of testosterone is higher is not necessarily better. It’s the sweet spot.
Once the receptors are filled then the rest of the testosterone is floating around doing nothing.
If you see two guys walking down the street, can you gauge physical characteristics to figure out which one has higher testosterone?
Besides their digit, no, but behaviorally, you can. It’s a weak predictor, but things like competitiveness and stuff like that can be known. This is also in women because women have testosterone also.
The guys that are more aggressive. The guys who live in gyms and work out and engage their masculinity by how big their bicep is. Those are the guys who are more interested in getting their testosterone to the highest amount. I’ve seen some of these guys who’ve come to me, wanting testosterone whose muscles are so big that they can’t turn their head. The guy swears up and down, he’s not getting testosterone from the locker room in the gym and you check their levels.
How is testosterone measured?
The normal range is 280 to 800. One of these guys that I’m thinking of in particular, his level is 12,000. I confronted him with that and he said, “Doc, I swear, I’m not using anything.” I said, “Whatever. You’re not using, you need to stop that.” Once it’s over 400, you’re done. There’s no difference between having testosterone at 550 and 750.
It’s like the diminishing marginal returns fertility. The jump between 280 to 400 is huge. What are the benefits of testosterone for a man?
It’s supposed to be good for strength. It’s supposed to be good for the heart. It’s supposed to be good to get rid of belly fat. It’s supposed to be good for energy level, for sexual desire. It’s good for the brain. Having normal testosterone is good.
Is that the same case for women too? When you get the same benefit because women have much less testosterone.
It would be different for women. You should have normal testosterone, but you don’t want to have supernormal testosterone. The problem is once you start using testosterone, the body stops making it on its own because it’s going, “You’re getting it from somewhere else. We don’t need to do this anymore.”
Is this an injection?
There are injections, there are no pills. There are injections but a lot of guys are using gels. If you remember Barry Bonds and the clear gel. It was used by the bicycle racers because one of its side effects is it increases the red blood cell count. The red blood cells carry oxygen. If you have more red blood cells around, then you have more oxygen in your bloodstream so you can compete better. That’s why testosterone is an illegal drug for cyclists. Barry Bond wanted it so he could hit more home runs and be stronger. Cyclists want it so they can go further faster.
People have talked about lifting heavy weights as a way to help stimulate testosterone.
You may be able to increase it a little bit, but you’re not going to take a guy who needs testosterone replacement and fix that.
I’ve heard people talk about dead-lifting. Is there also a state versus trait element to testosterone? Does it increase and decrease through the course of a day or through the course of a week or a month?
No, there’s definitely a cycle to these two testosterones. It definitely moves up and down throughout the day. In fact, if you’re going to get your blood drawn, you have to do it before 10:00 in the morning for it to be an accurate result.
I’m learning so much. I’m like, “I know all about erectile dysfunction and testosterone.” This is great.
This is the point of the podcast is to tackle topics that people don’t normally talk about. You might not even anticipate that you need to know at some point. The goal of this is designed for single people. Even more than for single people, but to try to help them live in a better life. Some of the topics are clearly geared towards the opportunities that single people have and so on. What brought me to you and what gave me the idea to do this, and what gave me the idea to invite Kym is the notion of having a vasectomy. If you decide you’re going to be single or you don’t want to have children, as a man, why wouldn’t a vasectomy beyond the table? What’s interesting is most of your patients are folks who are married.
Yes, and guys who have gotten to a divorce. They’re going to go out and start dating again. They don’t want to have an accidental pregnancy.
[bctt tweet=”As a urologist, you end up becoming like a psychologist for guys. ” via=”no”]
Those guys would fit this solo life. Divorced men that are single and so on. If you were to break those percentages down, the percentage of guys never married, don’t want to have kids, guys who are married who have had kids but don’t want more divorce guys.
It’s heavily biased towards married men who’ve had children. That’s 80% of the guys that I see. There are some guys who are married that choose not to have children. The rest are the single guys and a lot of them have reached that age where they go, “Even if I decide that now is a time that I’m going to stop being single and I’m going to find a life partner, I’m at the age now where I don’t want kids.”
What age is that usually?
It’s different for different guys. Once a guy gets into their early to mid-40s, they start thinking about mortality and doing the math in their head of like, “How old will I be when the kid graduates from high school, if I had one tomorrow.” They go, “I’m not doing that.”
It’d be 70 with a kid in college.
Sometimes I get guys who come in that are in their late 20s that want a vasectomy. You’re like, “Wow, that’s pretty early.” They go, “I have four children.” I’m like, “All right.”
Describe what the procedure is for a vasectomy.
Vasectomy is by far the simplest form of permanent birth control. No question. Easier than anything that can be done for or to a woman. The vas deference is the tube that goes from the testicle to the ejaculatory duct. Its only function is carrying sperm. Vasectomy is cutting in some manner that tube to prevent sperm from getting into the ejaculate. It’s a simple procedure I do in my office. I happen to do the least invasive procedure that’s called a no-needle, no-scalpel vasectomy. Guys who are not used to going to the doctor like the idea that we’re not going to use a needle to inject their scrotum. I have a spray gun that’ll spray lidocaine through the skin to numb everything.
We make a small puncture to get to the tube. There are two of them, one from each side, but I manipulate the second one to the same puncture site. You have the one hole. It isn’t that big of a deal. I tell guys I need to go home and pretend like it’s a big deal, so they get some sympathy. It’s not that big of a deal. I put little titanium clips onto the tube and then I also remove a segment. I occlude the tubes and then I separate them. One of the long-term risk theoretical in my mind is that the tubes can grow back together. The way I do it, I don’t think it’s possible. I’ve done over 3,000 of these things and as far as I know, it’s never happened that it’s grown back together.
Are they reversible?
They are reversible. I have reversed them. The problem with the reversal is insurance doesn’t cover that. It’s an expensive procedure. What takes me 10 or 15 minutes to do in my office and it takes me about two and a half hours to do in a microscope in the operating room to sew the vas back together. I tell guys to think of it as a permanent thing. If you wait too long to try to reverse it, then the testicle does stop making functional sperm. Even if you can reattach it, the likelihood of pregnancy is quite low and it’s expensive.
How many consultations do you do before you schedule the appointment?
It’s just one visit.
Do you have to wait for some period of time?
You’re not immediately sterile when you get a vasectomy.
You don’t get home early and be like, “Hey, honey.”
You can, but that’s where you say that you still need to use protection, but because there can be sperm on the far side of where we cut, you do need to have a bunch of ejaculates in order to try to clear out the tubing. Four to six weeks later, we get a patient to go for a semen analysis to make sure there’s no sperm there.
I know someone who had it and he was upset. For some reason, his wife can’t use birth control. He’s like, “I have to use condoms with my wife for the next six weeks.”
What was he doing before that?
That’s what they were having to do. He thought he would be like free and clear.
Are the guys in a lot of pain after the procedure?
They’re sore. I used to provide pain medication, a prescription for narcotics after this. Honestly, with the whole opioid scare in the news, most guys now don’t want pain medication afterward. Most guys are going home and taking Tylenol and Motrin and I never hear from them. I haven’t gotten many calls about, “I’m in so much pain, I need pain medication.” Back to your story about lacrosse and getting hit in the balls with the rubber ball. It’s not the sensation of getting hit. It’s 4 or 5 minutes later where it’s still sore, but you can see again. That’s the sensation. Guys go home and put an ice bag or frozen peas and sit on the couch and they’re okay.
You can have an erection right away or do you recommend taking some time off?
I tell guys to take a few days off from sex. You’ll know when it’s okay. When things aren’t hurting, then you can go back to doing it. Having an erection, it’s not going to have any effect on what I did.
I thought about one of the more fascinating things that you said. I don’t know if you volunteered it or I asked, but the notion of, in the same way, that women will freeze their eggs so that they can get pregnant after. It’s not easy to get pregnant anymore. A guy might freeze the sperm and then have a vasectomy. You said something that I thought was interesting. Do you remember what it was?
What I’ve said to a lot of guys is, if you’re thinking about doing that, they don’t have the vasectomy. You need to think of this as a permanent event. There’s a finite amount of sperm that you can freeze. It’s expensive. I did look it up for one patient. It’s not as expensive as I thought to freeze sperm. If you’re at the mentality of that, “I need to freeze it,” then you’re not ready to make a decision to do a permanent procedure.
That’s a useful piece of advice. If someone is like they want to do it but they’re not sure. That’s where I am. You can help with this idea. I know I don’t want to have children. It seems a no brainer to do this and yet I find myself reluctant to do it.
There are all the what-ifs. Somebody might change your mind. There are people out there that go, “What if I need this 25-year-old that the only way that she’s going to be with me is if I at least have the ability and that if I tell her I had a vasectomy.” When you get right down to the basic biology of humans, the only function of man is to procreate. Once you’ve taken away that ability, you’re useless.
Is there any correlation between loss of erectile function and vasectomy? Is that a risk?
Are there any risks?
To separate and then sew it together.
There has to be a psychological risk. If a guy believes that now he’s less of a man.
Honestly, I haven’t heard that. Guys are a little concerned about it initially, but once I explained the anatomy that all we’re doing is taking a tube that carries sperm and occluding it. That’s it. That tube has nothing to do with erections. The only thing that changes sexually for a guy is there’s less ejaculate because there’s no sperm in it. Sperm only makes up about 10% of fluids so 90% still comes out. Most guys can’t tell the difference between losing that 10% of the fluid.
Does it come out with the same force? I’m wondering if it’s like a dripping leaking faucet.
That should not be an issue. That’s an issue for guys as they get older in general, but not the vasectomy part of. The actual emission comes from the squeezing of the prostate and the seminal vesicles. That’s further upstream. All of that still good.
As a woman, that’s an enjoyable part of sex is the force of the ejaculation. Does anyone ever walk into your office where you’re like, “Do not do this.”
You talked about your old practice.
It used to be that we had a consent form. There was a spot for the partner or the spouse to also sign and we were getting consent from the wife. That never made sense to me. He’s a grown man. He can make his own decisions. If he does it and she didn’t want him to do, that’s between the two of them and they can have that conversation outside of my office. To me, vasectomy is a medical procedure and if you went and got a tattoo, you don’t need your wife’s permission. I never understood that.
This is back East.
Yes, but we stopped doing that. That never made sense and I couldn’t understand. Getting someone to sign a consent form, it’s a legal document. If a person of majority age makes the decision to have a medical procedure, I don’t think their spouse or their mother should be able to come in and say, “No, you can’t do it.”
Were there ever people you knew weren’t telling their partners that they were getting this done?
Not for a vasectomy but I had one guy who I did surgery to put in a penile prosthesis surgery to cause an erection. He didn’t want me to tell his wife. That one I never understood. I’m like, “She going to find out at some point.” I haven’t had that problem with vasectomies. Viagra doesn’t work and this is the surgically implanted.
They get pumps up, right?
Yes, like the old Reebok Pump.
Some guys have this because they’ve had testicular cancer or there are some other more profound physical reasons that you might have done.
These are guys who don’t respond to the Viagras of the world. Bad diabetics or something like that. If you’re a 50-year-old guy and you’ve had juvenile diabetes, the likelihood of you having erectile dysfunction that doesn’t respond to Viagra is high. Those are those guys.
Has there ever been an instance where there’s a guy who comes into your office for maybe not a vasectomy initially and you’re like, “This guy should not have kids. It is my duty to stop this man from reproducing.” Let me see if I can talk him into this.
In my practice back in Connecticut, I did have the opportunity to take care of a lot of federal prisoners. Some of those guys that came in with sexual deviancy as their crime. Those guys, I contemplated wanting to do something but no.
First of all, thank you for doing this. This is super informative. There are a few other things that I want to do and Kym, you should keep the questions coming. This is a skill that takes some developing. Getting back to this idea of a single life. We’ve been a little more focused on men than women. Let’s say this, in general, what advice do you have for people given your expertise in terms of preventive medicine or things that they should be aware of and thinking about? Is there anything in particular that you think is important for a single person? As you’re saying, the idea of a vasectomy is a no brainer because of its permanence. If you know that you certainly don’t want that but beyond those.
When it comes to single folks, to me, it comes down to the sexual conversations that I have with guys. Having the capability of going to a physician, if you’re having some issues and you’re not performing the way that you think you should, It’s not a sign of weakness. There’s a lot of guys out there, if you think back about the original Viagra commercials when they first started, they had Bob Dole as their spokesman. They had some old dude around. Now, if you look at the commercials, everyone’s maybe it’s because I’m getting older, but everyone seems to be in their 40s and 50s. That’s done for a purpose. It’s because it has become more acceptable to talk about erectile dysfunction.
This is how we started the conversation that guys are reluctant to go to the physician. They feel like they’re going to tell me something that I’ve never heard before. I can’t remember the last time I had a patient telling me something I had never heard before because we hear it all. It’s a safe environment to come to talk to us about the problems that they’re having. If it helps them be a more successful single and have the confidence to be out there, it’s easy to do. There’s no horrible testing that we’re going to do to you. It’s just a conversation.
My first reaction to that is it is useful for both men and women to hear that when you have a new partner, things might not go smoothly. That some level of comfort often enhances the experience.
The ability to talk to the partner that when you are struggling a little bit and when it’s a brand new experience and you can’t have that conversation because it’s the wrong time in the relationship. That’s when guys struggle the most.
That the same for women.
They did study whether or not Viagra would be beneficial with women because the clitoris is analogous to the penis in terms of that’s where it came. That’s the same anatomical start. Viagra will increase the blood flow, but there’s no way of measuring a woman’s sexual function. Whereas a guy, if they’re erect or they’re not. A guy can see it, the partner can see it and understand it. With a woman, you don’t know whether increasing that blood flow is going to make a difference.
There are ways to measure orgasms, but you’d have to do that study. I don’t know if those studies well.
Orgasm is something nobody understood. That happens somewhere else.
[bctt tweet=”Once you start using testosterone, the body stops making it on its own. ” via=”no”]
I know this because I haven’t an ex who is a sex scientist so she does research on these things. That’s a long story. You can measure orgasms, but you measure it with a butt plug. It measures the force.
There is no evidence that Viagra would benefit that.
I don’t think there is evidence that it does. Theoretically, there’s no evidence. There’s not a theoretical reason to believe that it was. I don’t know if it has. This is for male or female. Is there something you should be looking for in a urologist?
In choosing the right urologist, I’m a big believer in having complete comfort with that physician. Whatever advice they give you, if you’re comfortable with that physician, then you’re going to be more accepting of that advice and be more able to follow that advice. Guys are reluctant to go to physicians. They may want to get in and get out and get something quick and never go back. From patients that are willing to go to different doctors, I’ve heard lots of stories about things that you shake your head that the urologists have said to patients.
You’re seeking comfort.
Someone you feel like you can talk to. We’re people, we have experiences. If I can understand and relate to you that the doctor-patient relationship is a better one.
Are most urologists men?
I saw the numbers. Nine percent of urologists are women. I work with one other urologist and she’s a woman. She’s perfectly happy and able to take care of all the same things that I take care of. Those are great jobs.
Before we wrap up, I want to ask you. You’re living the solo life right now. You’re living the bachelor life and have been for quite some time, a few months now. You’ve been married and married again and you have kids but you haven’t been single for a while.
I’ve had a great relationship with my wife. We’ve been married for a few years and we were together for a couple of years prior to that.
How is it? How are you enjoying being single?
It’s not fair because I’m in Boulder and she’s stuck in the winters of Connecticut and she’s packing up a house and taking care of kids and taking care of a dog. I’m reading books and taking classes. She has it worse now than I do. Although I’m solo and although she still has all of our stuff in Connecticut. My house that we’re going to be moving into is completely empty. I have a mattress and four barstools and that’s it. I can’t complain because I still get to do what I want to do. A lot of my responsibilities have shrunk. I did laugh at myself when I moved into the house. I’m all excited and went to the grocery store and said, “I can do some shopping and fill some stuff up because we’re going to be here forever.” I bought my cereal, my milk and I was all excited. I’m like, “I’m going to have cereal before I go to work in the morning.” I got my cereal out and my milk and then realized I didn’t have any bowls.
You’re a musician. I thought it was cool when you sent me your bio. You do the School of Rock which is cool.
I play guitar and I love music. I’ve been going to concerts for my whole life. That is something that came out of my solo life because I was going through a divorce and realized that I was going to have a lot of time alone and that 50% of the time my children weren’t going to be with me. I thought that this is a time where I need to find a good, healthy hobby because that’s a good time for a guy who has too much time on his hands to pick up bad habits. I started playing guitar. My wife has become our biggest groupie and it’s tons of fun. I get to play in bars and be the rock star that I always imagined I wanted to be.
Do you have a band?
At the School of Rock, we are a band.
With that, I want to say Kym, thank you very much for being the co-host. I would ask you to do it again if we have an opportunity.
Stephen, you have what it takes to be a great urologist. Not only that you’re steady with your hands, but you’re easy to talk to and a likable guy. I appreciate the time. Thank you.
It’s my pleasure.
Kym and Stephen are still here. I had said that I have a Cialis story. I’ve given away a little bit of the punch line, but I want to describe this event because it is a crazy story for me. Feel free to interrupt with questions, you two. A few summers ago, this was a few years ago. I was going to be in Los Angeles. I decided I was going to spend some of my summer in Los Angeles. I was there for 3.5 weeks. I rented Airbnb in Silver Lake which is the serious hipster part of town. I was going about doing my normal writing. I was working on papers and so on. I was living a little more LA lifestyle. I got invited to this Alt Comedy show. On Wednesday nights for many years, the Alt Comedy Show in Los Angeles was this comic bookstore on sunset in Hollywood in the NerdMelt theater. It was in a little cramp theater in the back, but it was a who’s who of comics. My good friend, Shane Mauss, who is appearing on this show at some point was doing a show and he invited me to it.
I was like, “Yes, I’m definitely coming.” It’s a Wednesday night and I brought a date. This was a woman I had been out with one time before and we had had coffee or met for a drink at happy hour. We go to the show. It’s a great show. It’s fun because there’s one of my good mates up there on stage performing. After the show, we walked down the street to a pub called The Pikey on Sunset. Unlike living in Boulder, at 10:30 on a Wednesday night, we walk into this place and it’s jam-packed. It’s tough to find a place open at 10:30 in Boulder. That’s exciting and fun. On the other hand, there’s three of us, we want to sit down and talk. I say, “I’ll get us drinks.” I go to the bar and there’s an open seat at the bar. I stand at that open seat. I ordered the drinks and I looked to my left and I looked to my right. There are two couples on either side of me. I’m like, “Wouldn’t it be great if one of those couples gets up and leaves?” I’m waiting. This guy directly to my right a little bit older is in deep conversation with this young woman.
At some point, he looks over his left shoulder at me and he does a double-tick. He stops the conversation, turns around and says, “Excuse me, are you an actor?” I was like, “No man, I’ve got a face for radio. There’s no way I’m an actor, but I’m flattered.” He goes, “Too bad. I’m casting a commercial tomorrow and you would be perfect for it.” I’m like, “All right, I’ll bite. What’s the commercial for?” He said, “Cialis.” I start making boner jokes. I’m like, “It’s terrible. My penis works. I’ll pitch a tent in the middle of the commercial and all this stuff.” I swear he looks at me, he goes, “If you’re not interested.” He turns back to his conversation. I was, “Hold on. I’m definitely interested.” He gives me his card. He runs the casting agency. He owns the casting agency. It says it’s down the street. We’re going to be there from 10:30 to 1:45 for whatever, come by. I take the car, I go back to my friend and the date, I’m like, “You’re never going to believe what just happened here.”
The next morning, I wake up and I get out the card and I send him a text and say, “This is Peter. We met last night at The Pikey. Are you sure?” He’s like, “Yes, absolutely. You should come by.” I was like, “How do I dress for this? Is this casual okay?” He’s like, “That’s fine.” I get a car. It’s late morning, by the time I get over there, it’s 11:00 or 12:00. I get a car, I go over there and I go into this nondescript building. There’s a waiting room and it’s like in the movies. First of all, they were doing three spots, one for a white audience, one for a black audience and one for a Latin audience.
They were casting the white and black commercial that day. It was a multicultural group of people in the waiting room. People were anxiously looking at the notes or fixing their makeup. It’s quiet. I’m in there, I start talking to people. I started conversing with these different actors. I couldn’t help but tell them that I got invited to do this thing. They paired me up with this woman. She was like Russian or Eastern European in some way, she smelled like cigarettes. I remember I had distinctly. I was like, “How are you feeling about this?” she goes, “I need this commercial.” I was like, “We’re going to totally get it because I know the casting director.” We get called in and I walk. It’s a black box room. There’s a person at a camera, there’s a PA, a Production Assistant, and then there’s him. I walk right up to him and, “It’s good to see you again.” I shake his hand and all this stuff. We do the scene and the scene is it’s an auction. We’re bidding on a clawfoot tub. Stephen, why is that important?
That’s the trademark of Cialis. They have the tubs with the couple always in two separate tubs. It’s the most bizarre little trademark. That’s what Cialis does.
It’s a few lines. It’s all acting, looking happy. It’s like the desire is building through the scene. She’s stroking my arm. We finished. I know that it went terribly bad. I’m not an actor. It was terribly overreacted. I thank him, I leave and I’m thinking, “That was a fantastic experience.” I’m about to leave, but I’m lingering because I don’t want it to be over. One of the production assistants says, “We have an odd number of women. We need a guy to do it a second time.” Before she even gets to the second time, I’m like, “I’ll do it.” I’m thinking, now I know exactly what to expect. It’s got to go better. I get teamed up with another woman who I recognized from being an actor. She’s been on shows. Not famous-famous, but you would recognize her.
We go and do it again. I walk in, I’m like, “Good to see you again. I’m all warmed up.” I do it again, equally terrible again and then we leave. We walk out, we’re out on Sunset and I say, “It’s nice to meet you.” I said, “I have a confession to make. I’m not an actor. I hope it doesn’t hurt your chances at this commercial.” She goes, “Don’t worry about it. You should know if you get this commercial, it pays $40,000.” I was like, “What?” She’s like, “This is a union job so you could join the Screen Actors Guild. I’m a rep for this.” I’m like, “You are kind, but there’s no way in hell I’m getting this commercial.” We parted ways. I went home and I spent the rest of the day telling this story. Texting people, calling people, emailing, I spent the entire day on this thing. I waited for the call.
Did you have any problem with the idea of being in a commercial that was about erectile dysfunction?
Not really. Maybe a tiny bit, but I thought the upside was way higher than the downside. I’m a marketing professor and so I had this plan, there’s a Harvard Business case on Cialis that I don’t teach, but I was like, “I’ll start teaching it.” What I’ll do is I’ll say to my students, “Let’s look at a few commercials to see how Cialis is doing their branding.” I would show my commercial and I think that the students would go completely crazy. They would love that so much. I would get the highest evaluations I’ve ever received by that. That didn’t happen. If I had gotten the call, I would have done it. There’s no doubt.
It would have been a mistake if you hadn’t done it.
I am curious about what everyone else in that room looked like. What said, “Peter, you look like you have erectile dysfunction. People will buy you in this commercial.”
What Stephen was talking about was that the commercials have become more aspirational. The women have become hotter, the men have become younger and fitter. The guys in the room and the women in the room were young. The first woman, I bet you were 38 and the second woman I did the scene with was maybe 44. They were young and they looked fantastic.
They’re trying to normalize erectile dysfunction. It’s not a disease of old men. You’d take someone like Peter who’s a fit healthy guy and you say he’s taking it. He, the actor, is taking this. It’s okay for me the mid-40-year-old guy who’s healthy, who thinks something’s wrong with me that I can’t get an erection so it makes it okay.
You guys can see this, I started going great young. I was 45 at that time. I was great but still look youthful in that sense. I thought this would be a great story to add to the offerings. Thank you for reading that. Cheers.
- Dr. Stephen Siegel
About Dr. Stephen Seigel
Dr. Siegel is a diplomate of the American Board of Urology (board-certified). An honors graduate of Duke University and Vanderbilt University School of Medicine, he completed his general surgery training and urology residency at Yale-New Haven Hospital. Before coming to Boulder Medical Center, he was in private practice in Connecticut and Georgia.
Dr. Siegel is experienced with prostate cancer, brachytherapy and minimally invasive incontinence surgery along with all areas of adult urology including no-scalpel vasectomy.