TODAY'S GUEST: Josh Gonzalez, urologist and doctor of sexual medicine

I'm extremely happy to welcome Dr. Josh Gonzalez to Hard Conversations!

Joshua Gonzalez, MD, is a board-certified urologist who is fellowship-trained in Sexual Medicine and specializes in the management of male and female sexual dysfunctions.

These include issues surrounding hormone deficiency, menopause, sexual arousal, orgasm, ejaculation, libido/desire, sexual pain, penile curvature, and erectile function. Dr. Gonzalez also treats a variety of common urological conditions including benign prostatic disease, voiding dysfunction, and male infertility.

Throughout his career, Dr. Gonzalez has focused on advocating for sexual health and providing improved healthcare to the LGBTQ community.

• WEBSITE:

  https://joshuagonzalezmd.com/

YOU'LL LEARN

• How doctors become sexual health specialists

• What happens when you visit a urologist to explore erectile dysfunction

• The various treatments for medical erectile dysfunction

• The majority of erectile dysfunction has some psychological components

• All about testosterone

• The main reasons men experience erectile dysfunction

• All about how endocrine systems can affect erections

• About penile implants and penile implant surgery

• All about penile injections

• Prostatitis and pelvic pain affects a lot of men

• And more!

THANK YOU FOR LISTENING to my male sexuality and sex therapy podcast!

To get more hard conversations sent directly to your device as episodes become available, you can subscribe on iTunes or Stitcher!

Also, reviews on iTunes are extremely helpful and greatly appreciated! I read each and every one of them, and feel free to share your URL there so I can contact you later on and say thanks!

And lastly, if you have any questions (or would like answers to previously submitted voicemail questions!), head on over to Tim’s website.

About the Show

Introducing Hard Conversations, a podcast about male sexuality, and all things erectile, from the latest natural erectile dysfunction treatment to the best ed medical treatment. Therapist Tim Norton expands the conversation about male sexuality, adds context to why we struggle as a society to have hard conversations and breaks down how in a sex-positive environment there really is no room for taboos, judgment, or shame when it comes to penises.

YOUR online sex therapy and couple’s therapy HOST:

Tim Norton is a sex positive sex therapist working in private practice. He offers online therapy, online sex therapy, online sex coaching, and therapy and coaching for somatic symptom disorder.

Tim obtained his bachelor’s and master’s degrees from the University of Southern California. Tim is a proud member of American Association of Sex Counselors, Educators, and Therapists (AASECT), the Los Angeles Sexological Association, and works part-time with the Pain Psychology Center in Beverly Hills.

hard conversations podcast transcript

Tim Norton: Hello, and welcome to hard conversations. Today's guest Joshua Gonzalez MD is fellowship trained in sexual medicine and specializes in the management of male and female sexual dysfunctions. These include issues surrounding hormone deficiency, menopause, sexual arousal, orgasm ejaculation, the Beto desire, sexual pain, penile curvature, and erectile function.

Dr. Gonzalez also treats a variety of common neurological conditions, including benign prosthetic disease, voiding dysfunction, and male infertility throughout his career. [00:01:00] Dr. Gonzalez has focused on advocating for sexual health and providing improved healthcare to the LGBTQ community. Thank you, Dr.

Gonzalez for this today. I really appreciate it. Yeah. Thanks for having 

me. 

Tim Norton: Yes. Does your, does your bio.  leave anything out. You said you were born in Los Angeles. You're from Los Angeles originally. 

Dr. Gonzalez: Yup. Yeah, I was born and raised here. Didn't leave here until I got into medical school than I did my medical school training and residency in New York.

So I lived there for 10 years in New York. Yes. 

Tim Norton: Columbia medical school, Columbia 

Dr. Gonzalez: medical school. Yeah. 

Tim Norton: And were you able to learn about sexual medicine over there? 

Dr. Gonzalez: No. So I think that's a disservice,  in the medical education, the way that we do medical education in this country, it's, it's really not an emphasis.

And I think people who are drawn to sexual health as a career, kind of have to seek it out themselves. And so, you know, medical education is very much about exposing students to just the basics of [00:02:00] physiology and pathophysiology and kind of introducing them to the different fields of medicine and then allowing them to choose their career path based on that.

 but sexual health can be sort of approached from,  several different sort of traditional areas of medicine,  if you're interested, but you kind of have to,  be motivated to do that on your own. And you were initially,  not, I didn't really know what that it was a F fields really. I mean,  I, so I, initially, the way I got into this was basically I in medical school was drawn to sort of surgical subspecialties, which we were made to rotate through during our third year of medical school.

So we got to kind of be exposed to all the different surgical subspecialties. And I just really liked urology. I thought that the,  people that go into the field of urology just tended to be. Which is kinda cool.  a lot of surgeons, you know, don't have the best reputations of being personable or humble.

 but a urologists didn't seem to [00:03:00] really fit that mold and kind of did seem more genuine to me. And I don't know if that has to do with the fact that we kind of deal with. Private parts,  and therefore have to have a certain sense of humor and kind of not take ourselves too seriously, but I just was really drawn to the people.

So I decided to go into urology. And then once I got into urology, just kind of looked at the different potential subspecialties within that field. And really liked the men's health space.  and so I, when I was getting towards the end of my residency, kind of looked at fellowships that I could focus on mental health and kind of stumbled upon,  sexual medicine as a field, which involved not just male sexual health, but female sexual health, and,  ended up doing fellowship in San Diego.

Doing just that. I mean, focusing on,  treating male and female sexual dysfunctions, so. Okay, great. 

Tim Norton: And so, I'm curious about this program and San Diego, [00:04:00] this fellowship, how many fellowships are there like that in the country? 

Dr. Gonzalez: So that one in particular is pretty unique. Meaning I don't think that there's any other fellowships like that in the country, in the country.

 primarily because it does focus on both men and women. Okay. So the other fellowships that I applied to. You know, simultaneously we're more focused traditionally on male sexual health. So they kind of were a combination of men's health issues and,  male and fertility. So,  the, the fellowship I did in San Diego is pretty 

Tim Norton: unique.

So are there a lot of those around, I'm just 

Dr. Gonzalez: trying to get a lay of the land there. I mean, there's less than. 15. I think when I applied, I applied to 10 different programs.  they're kind of spread out all over the country and you know, it's a fairly small community. I mean, when we have sexual medicine, national meetings, it's the same core group of like 200 to 300 people globally that comes so globally.

[00:05:00]  who, yeah. Who are considered specialists in sexual medicine. So, and 

then 

Tim Norton: globally, do you get the sense that. Like which countries are more cutting edge or kind of on top of it or is it, can you really say that's 

Dr. Gonzalez: no, the T it's hard to say.  I mean, I think that in terms of publications in the sexual medicine space, a majority of those are probably coming out of the U S but there's, you know,  a large interest in sexual medicine in Asia, China, Japan,  Europe, certainly.

 we have some colleagues in,  in South America.  there's a lot of people,  that come out of Brazil,  who attend the meeting. So there, there there's, there is really a global interest.  but I would say, you know, in terms of publications in sexual medicine, my guess would be most of them come at it, the U S okay.

Tim Norton: All right, outstanding. So I'm a sex therapist and [00:06:00] if I'm. Doing my job, every guy that comes in and wants to talk about erectile issues. My first question is, have you talked to a doctor? Have you talked to a medical doctor? Yeah, most of the time they say, Oh, I've talked to for the last thing I wanted to do is talk to you.

Talk to me, talk to talk about the, you know, what's going on in the bedroom and everything like that, that this could be some form of anxiety. So I, and I actually. Heard of your name a while ago, and you've got a good reputation in this town. Oh yeah. I am a bit genuinely. I always say that about my guests, but it's always true.

I am excited about this interview. I appreciate,  what happens when they come here? 

Dr. Gonzalez: So, I mean, I think that one of the,  strengths that I have in terms of treating patients with these issues is that,  a lot of them come to see me and I am the fifth or six doctor that they've seen because I think men, especially, you know, if they happen to.

Be on the younger side, [00:07:00] get,  dismissed. And that's after, you know, months to years of shame that they have had about this issue.  if we're talking about erection specifically where they haven't sought help, so then they finally get the courage to seek help and,  You know, if you get a,  unqualified provider who doesn't really understand the nuances of how to sort of formally work up erectile dysfunction, then they just either throw pills at these patients, which may or may not be appropriate depending on their problem.

Or they tell them that it's, they. You know, are unhappy in their relationship or it's all in their head. And,  that's not helpful for patients,  because they still are. They walk away, not fully understanding why they have this problem. And so I spend a good amount of time in their first visit.  just educating them on the various causes of erectile dysfunction and basically tell them.

You know, as their physician, I'm going to focus on primarily the physical causes or potential physical factors that are [00:08:00] contributing to their issue.  give them solutions to address those problems and,  just educate them on, on,  all of the factors that come into play when you're talking about,  erectile dysfunction and, you know, I'm, I'm, I'm pretty upfront with them in that first visit.

I tell them that,  That anxiety and certain psychological factors can definitely play a role. And, you know, I try to make them feel better and say that, you know, in my experience, a majority of men have some psychological component and, and it makes sense because if you're a man who is in a relationship and you enjoy having sex and you want to have sex and you can't, then it's going to cause anxiety and,  Then you're going to carry that anxiety onto future encounters.

And it's always going to be something that you're thinking about and,  could potentially contribute or,   make worse any physical issues that are going on. So, right. Yeah. Yeah. I 

Tim Norton: think the unfortunate thing is when the doctor who says whatever, it's all in your head, [00:09:00] or this might be stress there, it would be great if they had a.

A psychologist next door. Right. You can say, well, go talk to this person today. And I don't, we still haven't really bridged that. Yeah, sure.  maybe I'll get an office in this suite, but I think we're really, we always talk about mind, body. And are you getting the sense that there's, we're gonna be able to reach across the 

Dr. Gonzalez: aisle?

Well, so the, where I did my fellowship,   in San Diego, the, my mentor, who's sort of like the guru of sexual medicine. I mean, he's been in the field for 40 years.  really,  his practice is integrated, so he has onsite,  himself. He has,  Physician extenders. He has like a nurse practitioner and a physician assistant,  who help him,  with the medical side of stuff.

And then,  in the same office, he also has a sex therapist and the pelvic floor, physical therapist. So [00:10:00] each new patient who comes to see him,  his men has to see all three. Clinicians. So,  they are all seeing him as the physician. They're seeing the sex therapist and they're seeing the public for physical therapist,  for at least an initial evaluation.

Now, not all those patients need to see, continue to see those providers, but,  because it is often such an integrated problem. Yeah.  it's a really great model. I think the problem is, is that it's,  he is a fee for service practice, so he can, he has the sort of freedom to do that. I think when you're talking about,  Integrating providers,  and trying to work in the sort of Western medicine model, it becomes a little challenging, but I do think it's a, it's a very valuable way of sort of treating these patients because they don't even have a choice like that first visit.

They're seeing all three providers, even if they think like, no, I don't have anxiety about this. It's all a physical problem.  they're still getting sort of screened to make sure [00:11:00] that there's not, you know, See significant non-physical issues. It 

Tim Norton: sounds like utopia. Yeah. No, no, that sounds great. Yeah. Have you heard among, you know, if you went to a conference, like when you're talking about anybody else talking about doing things 

Dr. Gonzalez: like that, I think people are, they see value in sort of an integrated approach.

I mean, yeah. People talk all the time about like a bio-psycho-social model. And so I think there are centers that are. Being created.  it's interesting. Cause I think a lot of it is happening in the female sexual health space where you're seeing pelvic floor, physical therapists working alongside kind of colleges who are interested in sexual health,  and maybe psychologist or sex therapist or what,  I don't see it a ton in the male sexual health space.

So yeah, I mean, I definitely think there's a need for it. Okay. 

Tim Norton: So maybe briefly, I don't know if there are a lot of different reasons, but there maybe hundreds [00:12:00] maybe, but when it's physical and then it's very clear like that you wouldn't have to have any kind of an anxious response or in any elevated cortisol levels.

What are the most typical 100% physical erectile dysfunction? 

Dr. Gonzalez:  so if you're just talking about physical, I mean, you can break it down. Into like three basic causes. So you can have a hormonal issue,  in which, you know, your testosterone, as an example may be low. And,  we know that, you know, men's erections tend to function better when.

They have healthier levels of testosterone. So that's something that's pretty easy to screen for it. Just do some blood work,  on their initial visit. I also pause,  when I am talking to patients about this particular,  type of, of ed, because a lot of them have had testosterone levels checked and they might fall into the normal range.

And so that's a point at which they are often dismissed because their doctor's like, listen, we checked her testosterone. It's normal. This is not [00:13:00] our physical problem.  the truth is, is that, you know, they could be in the normal range, but that normal range is pretty wide.  because it's meant to encompass men from adolescents until death.

So, you know, if you're a 35 year old guy and you're on the very low end of normal, that's probably not going to be an optimal level for you being a 35 year old guy who is having issues with his erections or. You know,  symptom of, of having low testosterone. So I think a little bit more liberally about that.

And I explained to patients like I'm not looking for normal or abnormal, I'm looking for are your levels optimal for what we're trying to accomplish. So,  that's why,  you know, one physical area that we investigate,  blood flow is obviously huge. I mean, for our erections to work,  the blood flow to the erection has to, has to function normally.

 but what, what I think some people don't appreciate regarding. Blood flow is it's not enough to just deliver enough blood into your penis for an erection. You also, we have the, the ability, [00:14:00]  to trap the blood in the penis. And so that's a unique thing to the penis,  because most of the time blood.

Enters tissue drops off. Oxygen picks up waste and immediately circulates out. But when you have an erection, blood does not leave the system. At least it shouldn't in a normally functioning erection.  and so a lot of guys think like, Oh, well I can get an erection. I just have trouble keeping it so that doesn't qualify as erectile dysfunction, but that's actually not true so that we have a way of investigating that.

By doing an ultrasound to actually look at their blood flow in real time, when they have interaction and figure out which potential vascular issue they may have, are they not delivering enough blood there or are they not trapping the blood there? And those two things are really important because it's going to sort of predict how they respond to certain medical treatments.

If you're trying to give them a solution for the,  blood flow issue.  lastly, you can have a neurological issue. So a problem of the nerves, we see that in people who have had long standing diabetes, people who have. [00:15:00] Spinal cord injury, people who have,  certain neurological diseases.  so those are the, the sort of broad categories of physical causes.

Tim Norton: So I want to ask about neuro neurological issues and the trapping. So what is the basic mechanism that traps the blood in 

Dr. Gonzalez: there? So,  It would be nice if I could,  illustrate this. But 

Tim Norton: the first thing I thought of was a cock ring, 

Dr. Gonzalez: right? So Cochran does basically what you should be able to do on your own by physically constricting the blood and not letting it leave there.

But basically,  we have veins that take blood. Out of the penis that exists on the periphery or on the edge of the chamber, the erection chamber that has the spongy tissue that gets that expands. When you get blood into your penis during arousal, in an ideal situation, the erection chamber rapidly expands as it fills with blood, your penis gets bigger and it gets harder.

And as that erection chamber expands, it compresses the [00:16:00] veins that exist at the periphery.  but there are certain conditions,  where men can develop scarring in the, in their erection tissue. And so those areas of scarring don't allow for rapid expansion or sometimes incomplete expansion of that particular area.

And so at that. Periphery,  you have veins that remain partially open. So,  you're kind of leaking blood,  back into your systemic circulation,  when you don't want it to, I mean, you want the blood to, to stay there. So,  that's primarily how it's called venous leak, erectile dysfunction,  how that happens.

And then, you know, you try to overcome that using a ring by,  externally compressing,  the blood in the penis, 

Tim Norton:  thumbs up, thumbs down. Cock ranks. What, what is,  I always wanted to ask for 

Dr. Gonzalez: a urologist function, both.  I mean, I think that they're fine,  [00:17:00] for,  play, which certainly,  I think you need, I counsel patients that they just need to be careful of what kind of conquering they use.

 because obviously when your penis becomes gorgeous, it's bigger than.  it was when you put the cock ring on.  so I have in residency had to cut cock rings off. So I usually,  tell patients to steer clear of metal cock rings because those,  are difficult to remove. And the last thing you want is an electric saw down there trying to cut through to do that.

Yeah. Oh my God. Yeah.  the fire department was involved, but yes, I was there.  but you know, rubber, a rubber cock rings, I think are fine.  and then in terms of function, it just really depends on the problem. So I mean, if, if a man has really mild venous leak, I'm using Cochran's in combination with pills or sometimes even injections,  can be helpful.

 some guys will use vacuum erection devices, also in conjunction with those. But, you know, I mean, I've had patients who [00:18:00] have more moderate or severe venous leak who asks. If the, if I think it'll be helpful and in, in those guys, it really isn't.  it just,  it's not strong enough to sort of overcome them their issue.

Tim Norton: And so what 

Dr. Gonzalez: do you do for them? So, so for guys who have pretty serious venous leak,  the gold standard of treatment is really a penile implant. So surgery. Yeah. 

Tim Norton: And do you, you don't do those, are you? Yeah. Oh, you do. Okay. 

Dr. Gonzalez:  It's like my favorite surgery. It's your favorite 

Tim Norton: surgery? Yeah. What do you like about doing penile implant surgery?

Dr. Gonzalez: you know what, I think it's the most satisfying. No. Well, first of all, it's the most satisfying for patients. I mean, the satisfaction rate with penile implants like 90, 95%,  it's higher than any medical treatment we have for ed.  and I think, I think for a physician it's very satisfying because you take guys who have probably been.

Impotent for the lack of a better word. I don't really like that word, but,  [00:19:00] non-functional sexually for years. A lot of the times,  sometimes decades. I mean, it's it's and, and, and then you give them the ability to be.  as functional as they want to be. And so the peanut and plant, it takes a guy who probably couldn't get an erection or at the very least couldn't maintain his erection.

Now he has the ability to activate the device, have sex and basically stay hard until he chooses to not be hard anymore. And so it's really satisfying.  and can be life-changing. I mean, I've had patients tell me that. You know, saved their marriage and it completely changed their life. I've had patients who were depressed for years because they couldn't have satisfying sex who, you know, got off medications.

I mean, because they were the source of their depression was no longer there, so. Wow. Yeah. 

Tim Norton:  On the off chance that the listener out there isn't binge listening all my episodes and doesn't know exactly what a penile implant surgery is. Could you kind [00:20:00] of tell us what happens? We did talk about it in another episode, but 

Dr. Gonzalez: yeah, so basically what we do is,  implant a device that,  how do you get it in there?

 well, there's different types of incisions you can make. I mean,  we typically choose to do like a scrotal incision. Because,  you can sort of approach all of the things that you need to get access to through that incision. But some men will, or some physicians will make like a called an Infor pubic incision, which is basically just at the base of the penis.

Okay.  either one,  Works.  but basically through one incision, we kind of implant a multi-component device. That's composed of two cylinders that are placed where your erection tissue is currently,  a pump that goes into the scrotum and a reservoir that holds fluid that gets circulated over and over again.

And so,  what you do. You know, what, what a man does basically when he wants to have sex is reaches down [00:21:00] into his scrot pumps up the device and it draws fluid out of the reservoir, into the erection,  sorry into the,  the cylinders,  until you get fully hard. So it provides the rigidity that you, you can't, you can no longer do naturally.

Tim Norton: And it literally stays hard until they. Yeah. 

Dr. Gonzalez: So at least hard, I mean, you basically become like the world's greatest lover because you stay hard until you deactivate the device. And so on the, on the top of the pump, there's a button that you press that basically reverses the whole process. So it's a hydraulic system that basically just reuses, salient fluid over and over again.

 but yeah, I mean, it it's,  I remember when I was a fellow, one of the,  male patients that we had said that he,  His comment was, he felt like he could have sex, like a woman after the surgery. And my, my,  mentor said, well, what do you mean by that? And he said, well, w I can literally lay there. And [00:22:00] my wife can, you know, go to town basically.

And I'm just, you know, until she's done, I'm just, you know, I can just. Read a book. If I, you know, basically was saying he doesn't have to be present if he doesn't want it.  you know, and for years that he was probably really concentrating, trying to like maintain his erection. But,  so yeah, he was actually really happy about that.

So the partner satisfaction rate is also really great too, because especially for people who are in couples,  because it's such a big part of, you know, Being in a couple, and if you can't have sex, now you have the ability to, so it can be really sort of life-changing for both people. 

Tim Norton: And do, does anybody say that after a certain amount of time it's uncomfortable to leave?

Was 

Dr. Gonzalez: it hard or, yeah, I mean, you definitely don't want to leave it hard for like hours and hours and hours, but,  cause you, you know, you can have complications from that, certainly.  but you know, most people are. Not leaving it hard for, for longer than a couple of hours [00:23:00] I would imagine. Yeah. Yeah. 

Tim Norton: And so what, what can go wrong with it?

What, what do people come back 

Dr. Gonzalez: for? Well, it's a mechanical device, so I, you know, everybody gets counseled on at some point, this is going to fail. So it just really depends on the patient's age.  the average, you know, life expectancy for one of these devices is 10 to 15 years. Okay.  so if you have an older gentleman, you know, he may just need one surgery and then,  That's it, that's it.

If you have a younger patient,  you know, if they have, if they have a device failure, at some point they would have to have surgery to have it explanted planted and have a new one put in.  so that's just something that all patients get counseled on prior to surgery.  but you know, th th that life expectancy's pretty good.

Okay. Yeah. And 

Tim Norton: then they just come in and get it replaced, correct? Yeah, that's fine. Yeah. All right. So you also said neurological issues. Yes. Can you test for those? 

Dr. Gonzalez: So there are ways of testing,  [00:24:00] someone's   sensitivity. It's usually done through . So basically what you would do is use different modalities to test how sensitive they are.

 and we usually use the finger as sort of a comparative point. So,  when I was a fellow, we would often do vibratory testing.  we would test,  hot and cold and basically put it on, you know, put the, the,  T test their finger first and then,  test the head of their penis and then both sides of the shaft to, to assess both of the different erection chambers and see if there was a discrepancy between how sensitive their finger was versus how sensitive their penis was.

 should they be the same, roughly? Yeah. Yeah.  the. The only problem with that is [00:25:00] that we don't have,  traditionally there have not been ways to. Change that. So if you find that,  someone is not as sensitive as they should be, there's not really a way to fix that. Now, my mentor is doing a lot of investigating of neurological causes of erectile dysfunction.

It's been primarily focusing on the spine. So, I, I don't know how many patients,  they have in their series, but, you know, he's reported on a few instances of patients with, you know, various sexual dysfunctions that are, you know, genital specific,  where they've found spinal pathology, they do spine surgery to fix whatever spine issue there is.

And some of those patients have gotten better, but that's sort of. Avant-garde kind of stuff. And he's really the only one that's doing it at this point. So, but he, as I mentioned is sort of the guru in this field. And I think if anyone is gonna push us,  to the next frontier in sexual medicine, it's going to be him.

[00:26:00] And what's his name?  Erwin golden Ali. 

Tim Norton: Yeah. Okay. So you've narrowed down to one of those three broad categories. Yeah. And. Let's say, let's say it's blood flow.  and let's say, it's not that bad. Yeah.  what are, what are their options or what do you, what, what, what are you sending them home saying?

Okay, this is what you need to do more of. 

Dr. Gonzalez: So, I mean, you can talk to people about,  you know, lifestyle, behavioral things that they can do to help improve their, their issue. I mean, certainly if they're a smoker, you know, you wouldn't want to counsel them on quitting smoking, that's going to not only affect their erectile health, but their general cardiovascular, you know, if they're obese maybe, maybe yeah.

Have like some hormonal issue you can talk to them about, well, if you lost some weight, your hormones. Parameters would likely improve.  so those are the two big things, you know, regular cardiovascular exercise,  healthy diet. I mean, there's the, [00:27:00] there's a sort of saying in sexual medicine than what's like good for your heart's good for your penis.

So, you know, people were always asking me, well, what can I do in terms of diet or whatever,  to improve things. And I tell them just that, you know, what your doctor tells you, that the diet that your doctor tells you. To,  you know, help your heart or help your cardiovascular health is exactly what you need to do to help your erectile health too.

And that's again, because it's all about blood flow, right? So if you're, if you are in the beginning stages of developing atherosclerosis, then you know, the things that your doctor would talk to you about in terms of trying to reverse that or prevent it from getting worse, it's exactly what you would need to do to help.

With your erections and help the blood flow to your erections. Are there 

Tim Norton: any magical foods out there that you endorse these days? 

Dr. Gonzalez: Not really. I mean, unfortunately none of it's like, there's, there's not a ton of science driven data out there looking at,  at that kind of stuff.  but patients like, you know, a lot of patients like to feel like they're doing something other than just taking medicine for these issues.

So I think giving them [00:28:00] advice on, on how to eat healthier,  heart healthier is something that they. They can use as motivation to try to help with this issue. 

Tim Norton: I've been wondering, how do I know when to go to a urologist versus a cardiologist? Or do you sometimes send 

Dr. Gonzalez: guys to cardiologist? Yeah, so there's actually a,  a fair amount of data that's been published in the last like decade or so, that has shown,  correlations between erectile dysfunction and cardiovascular health.

 primarily that men. We'll often present with ed before they would present with other symptoms of underlying cardiovascular disease. So it's, it's been called the soul sort of Canary in the coal mine in terms of predicting underlying cardiovascular disease. That wasn't. Yeah. Previously detected. So there are, and I have sent,  patients to,  cardiologists to be screened for, you know,  other effects of [00:29:00] cardiovascular disease.

 if their initial complaint is ed and we find that they actually have a vascular problem. Okay. Yeah. 

Tim Norton: Now you said to me before off camera, you said to me that you only see on a, on a busy day, 10 to 12, 13 patients in a day. And I think, you know, there's a larger narrative in our culture right now about how all these doctors are seeing 40 people in a day.

And,  w what's the difference between you and them and, and why? 

Dr. Gonzalez:  well, I think. To work in this space and to try to help address these issues. Like it just, it's impossible to see many patients. There's a lot of education that I have to do. So, you know, my initial consultations tend to be longer than, than a doctor who's, you know, Treating primary care health issues.

There's a lot of, you know, like I said, these patients have been sort of circulating [00:30:00] through the healthcare system for years a lot of times. And so they, if we got, if they didn't already have neurotic tendencies, they've developed those because they've been dealing with this issue for a while and it's not been addressed.

 and no one believes them and they feel dismissed. And so I'm sort of, I have to then unpack a lot of that. So for me, it just doesn't, it, it would not. Be possible to see that number of patients. And I think that's where patients and even providers who refer to me find my practice, especially helpful is that, you know, patients walk out of here understanding exactly why they have their problem and how we're going to sort of fix it or address it as best we can.

Not everything is reversible, but I can usually offer some sort of strategy to at least address whatever problems we find. 

Tim Norton: Okay. So do those initial consults get pretty Frank and graphic about the sex that they're having? 

Dr. Gonzalez:  not necessarily in the specifics, but [00:31:00] I just basically try to assess from them what their goals are.

I mean, if you're talking about a gay man, for instance, like I will ask them, you know, on their first visit, do they have a preference in terms of topping or bottoming? What is their goal?  because. To top someone and to have eight, you know, anal sex, you have to be pretty rigid. And so if that's not a priority to them, then, you know, that's, that's important for me to know, or if that's an absolute priority to them, I definitely need to know that because we have to figure out a way to get them the rigidity that's necessary to top.

So I ask those kinds of questions more from a, how can we get you? Do your functional goal. I don't get into the specifics about what kind of, sort of day-to-day sex they're having or what their sort of sexual preferences are outside of that kind of stuff. Okay. Yeah. I mean, 

Tim Norton: do they ever start to just really open up about that stuff?

Dr. Gonzalez: Sometimes people I get both. Spectr some people walk in here and blush and say, they can't believe they're talking to me about this.  I've had other patients who [00:32:00] are very Frank about what kinds of sex they're having, and they're going to, you know, a sex party this weekend and they need to figure out how they're going to be able to stay hard the whole time.

And,  So, yeah, I mean, I, I just, I tell them, you know, at the end of the day I need, I want them to be as honest and open as possible because that's just going to help me be a better doctor to them and provide them the best care, because then I know where they're coming from and what their goals are.

Okay. 

Tim Norton: So how does somebody stay hard for an entire weekend? 

Dr. Gonzalez: Well, I don't, I wouldn't advise doing that attempting.  that's something called priapism and it can be a major, major problem.  but you know, I have patients who use injection therapy. A lot of times they need it. They actually have real vascular issues.

 but they enjoy using it for sometimes, you know, group sex situations. And,  I think I am. I don't want to say unique. And I learned, definitely learned this from my mentor, but a lot of my patients who use injection therapy, who, you know, potentially could be at risk for [00:33:00] developing priapism, like getting an erection that lasts longer than four hours that you hear about on the commercials all the time.

 which actually is a V is, you know, a medical emergency.  but you know, when guys use injections, they are at real risk of developing that. So I. Again, spend a little extra time trying to prescribe an upper, you know, the appropriate strength of injections that they're using.  try to counsel them on what I think is inappropriate dose, and then also teach them how to administer the anecdote.

So it's the same stuff we administer in the ER, if someone comes in,  with this problem,  and, and essentially reverses the erection,  and just tell them, listen, if you have an erection that doesn't go away after three hours. I would advise you to use this reversal. And then the next time you inject, you know, that that dose that you use the last time, it's probably too much.

 so, you know, I tell them they have to do a little bit of dose adjustment at home on their own, the goal being that they get an erection that lasts however [00:34:00] long they need it to last. But if you're getting to that three hour, Mark, you know, you want to, you want the erection to resolve spontaneously on its own and not have to use the reversal, but they have, they have the tools with them.

Should they need to use it? 

Tim Norton: And I did talk about injections on, on the same prior episode. Remind everybody what's in these injections. Is it just a fluid of Viagra of sildenafil or what's what's in 

Dr. Gonzalez: there? They're vasodilating,  medications. I mean, I do kind of describe them to patients as sort of like a supervi Agra that you're going to inject directly into your penis.

 so they work much more powerfully than Viagra and Cialis and the other pills,  because they're not absorbed systemically. I mean, they're literally. Being injected right where you want it to work. So, but they, the injections come as a single, a single medication. They come as compounds of either two or three medications, sometimes four, but they all basically function to maximally dilate the,  [00:35:00] cavernosal artery so that you sort of bring as much blood into the penis as possible.

Tim Norton: Was that what they were designed for. I know how Viagra was originally intended to be just a heart 

Dr. Gonzalez: medication. Right. You know, I don't know the history specifically of injections, but interestingly, the injections have been around longer than Viagra and Cialis. So part of the reason that those medications have become so prevalent and successful is that.

For years, like through, through the eighties and most of the nineties, the only medication that was available was an injection. And it's, you know, not the easiest thing in the world to get a guy to be excited about injecting himself when he wants to have sex.  so I, yeah, I don't know how they were initially studied.

 but,  they'd been around for a while since you know, the seventies 

Tim Norton: and do people when I get them also. Typically get the antidote or 

Dr. Gonzalez: no. So most patients don't. So, [00:36:00] you know, we see, see patients all the time coming into the emergency room saying that they used injections and they've had an erection for 24 hours and it's a, it's a big problem.

And it, depending on what needs to be done to make the erection go away, I mean, it can, it can lead to worsening ed or sometimes. Medication refractory erectile dysfunction. So it's a big issue.  so, you know, I teach all my patients how to safely inject themselves with the reversal medication.  so that, that doesn't happen because there's a lot of shame, you know, depending on what kind of sex they were having at the time of their priapism.

There's, it's not uncommon for men to just not seek help and to wait. You know, the whole weekend. And then they come in on a Sunday night or they come in Monday morning to their doctor and they've had an erection for 48 hours.  that's a major, major problem, and they're probably going to end up having to be operated on to, to fix this issue.

And then they sometimes are, you know, end up with permanent ed. Oh man. Yeah. 

Tim Norton: But then they get a penal implant, then they could get a penile implant. Okay. Good. So, one thing I was going to ask [00:37:00] is,  when I met you, I introduced myself to you. It was at a pelvic pain talk. So is this a significant part of your practice as well?

Working with male pelvic 

Dr. Gonzalez: pain? It is. Yeah. So I,  am pretty,  pretty close relationship with several sort of pelvic floor. Physical therapists in LA. And so they refer a lot of patients to me,  to,  act as sort of like the medical adjunct to whatever,  you know, myofascial or muscle issues that these patients have.

 so I do, I'm sort of becoming, you know, without even really trying sort of,  the. Prostititus pelvic pain specialists in this area.  so yeah, it is, it's a pretty significant,  number of patients that I see, 

Tim Norton: what I noticed out in, in, in life is that a lot of people don't know that. Men get pelvic pain, right?

What are some [00:38:00] of the more common forms of male pelvic pain you're seeing? 

Dr. Gonzalez: So it can present. I mean, that's where it becomes.  it can become challenging. And again, this is a space in which men are often dismissed and told that they're crazy or which is really unfortunate because a lot of these patients get.

Better with sort of minimal medical treatment and physical therapy, but it can present in a myriad of ways. So men will often report,  pain with erection pain, with a jacket, elation, lower abdominal pain, testicular pain, pain in their parents, Niamh.  sometimes, you know, burning when they pee, they think they have a UTI or some sort of STD,  So it can present in lots of different ways.

And sometimes it's even been not, you know, benign symptoms, like just I'm going to the bathroom more frequently than I used to, or my stream is weaker than it used to be. And so they often will, you know, see urologists or know sometimes just their primary care doctor and would be given just sort of [00:39:00] thrown medication at them or just, you know, told that it's.

It's nothing, you know, they get checked for a urinary tract infection and it's not a UTI so that they get dismissed as, you know, you're just straight or, you know, whatever it is. But yeah, it can present in lots of different ways, which I think is why it's challenging for a lot of providers who don't treat it a lot because, because they don't believe the symptoms or they don't see how pain in the testicle can be, you know, a pelvic floor issue or, you know, sort of, it's sort of a.

One symptom of a pelvic pain disorder basically. 

Tim Norton: Right. And so when I meet those guys too, I find that a lot of them have gotten an automatic prescription of some kind of,  either a steroid or, or some kind of,  like a penicillin, like an antibiotic. Yeah. Yeah.  And it does nothing. 

Dr. Gonzalez: Right, right. Right.

Well, because I mean, most of these patients don't have an infection, so, but, you know, [00:40:00] historically I think that providers, you know, want to feel like they are doing something. And so they just put people in sort of blindly on, you know, broad spectrum antibiotics. And some, some of those patients do get better symptomatically.

The reason that, that, that is usually the case is not because there's an actual bacteria that's being killed and that they're getting better.  and.  in that regard, but you know, a lot of antibiotics are really strong anti-inflammatories and a lot of this issue is more inflammatory related. And so often, you know, the patients that do get better with antibiotics,  that is the mechanism by which they're getting better.

Not because there's some, you know, bacteria that's causing their problem and it's being treated by the antibiotic. 

Tim Norton: You said historically in your studies, in, in, in your fellowship and everything. What is the history of male pelvic pain? It doesn't go back very far. Do you remember? 

Dr. Gonzalez: Or, I mean, it's basically just taught us prostititus yeah.

In medical [00:41:00] education, which is like a horrible name, because it implies that there's some sort of, again, infection in the prostate and sometimes there is, but most of these patients have. You know, these chronic forms of pelvic pain, it's not like an acute bacterial prostititus where they're getting fevers.

And, you know, sometimes I have to be hospitalized and that's, that is a real infection, but most of these patients have been dealing with this for six months, three years, you know?  and it's a chronic condition, but it all kind of gets lumped in at least in medical education and the prostititus category.

And so the treatment has been the same. Everyone gets, like you said, antibiotics,  And there's a big gap in terms of understanding the importance of the pelvic floor and incorporating that into their treatment plan. So I tell patients all the time, who I see, you know, that they have a condition called chronic prostititus chronic pelvic pain syndrome.

And the first thing I say to them, I'm like, it's a horrible name and I don't want you to freak out. Number one, chronic sounds scary to patients and you know, prostititus is a bit of a misnomer. And I basically [00:42:00] say your problem is primarily a function of. Your muscles and connective tissue in your pelvis, and maybe some inflammation on top of that.

And so medically we'll all help treat the inflammation.  but you know, if, if they didn't, if they didn't already come to me from a physical therapist, they're getting a referral at the end of their first visit for sure. 

Tim Norton: Okay. It's just, it's weird when so many people haven't heard of it, you know, 

Dr. Gonzalez: so, and I, you know, especially like what I tell patients is, you know, some things that can cause flaring of symptoms is like prolonged sitting,  stress, anxiety, right?

Those, those all cause us to sort of tense. Tents are pelvic floors. And like, we live in Los Angeles, so everyone is always sitting in their car or then they go to work and they sit at their desk all day. We're all constantly stressed out and anxious. And so it's like a perf you know, of course here, and I'm sure it's true in most, you know, large urban centers.

 yeah, a lot of people miss problem. [00:43:00] Yeah. So that's 

Tim Norton: very common. Yeah. You, you you'll always have plenty of business or for awhile, right.  porn. Yeah. Guys, ask you about that. Yeah. Trying to cover everything.  guys, come in then do they say is my EDD because I watch too 

Dr. Gonzalez: much porn?  yeah. Yeah. I think it depends on how they got to me.

Some people have like read online themselves and they've convinced themselves that they have like a porn addiction. Other people have, have already been seeing a therapist and maybe they've had that conversation with their therapist.  So it just depends, you know, but, but the truth is, is that I've had patients who have believed that about themselves and have sort of cut back on porn and it doesn't always help.

So, you know, I, I try to discourage patients from thinking black and white regarding porn and that it's not, it shouldn't necessarily be thought of as a bad thing in terms of how it relates to their sexual function. Certainly it can, you know, Be a helpful thing and in some situations, but [00:44:00] like with anything, if all you're doing all day is watching porn and you're masturbating five times a day and then you have opportunity to have sex with another person and you can't be physically or mentally stimulated in the same way as you can with plans.

And then yeah, maybe it's probably causing an issue and yeah. That's where I think sex therapists and therapists in general can be helpful.  sort of retraining that sort of behavior. Mm. 

Tim Norton: Any other times we can help all the time. No, I'm just kidding. But yeah. When do you typically refer or say, what do you see that you're just like, you 

Dr. Gonzalez: need a Dakota?

Well, I mean, certainly if we do the sort of physical workup and there's no problem,  which is pretty rare,  honestly, so that's obviously where I would refer to,  a therapist. Anytime. I feel like there's like a significant relationship problem.  not like the PR the relationship itself is problematic, but this larger sexual issue has caused [00:45:00] distance or, you know,  the partner now, you know, doesn't want to have sex because for years, you know, my patient couldn't.

Perform. And now I've given him the ability to perform. And now the partners sort of, you know, like, well for, I was, I had to deal with this for years, and now I'm not interested in having sex with you. So there's, there's lots of sort of relationship issues that can come up. Patients who have, who are younger.

I think it can be really helpful for, because if they've never had normal. Or satisfying sex.  then they have a lot of anxiety about how to, how the, how is that going to look going forward now that you've, you know, we've addressed these issues and you've given me the tools. I think that the therapy can be really helpful in those situations too.

 and I think just, you know, if you have a generally anxious person who is, you know, Fluctuating, you know, they have a good day and they're doing great, but if they have one, you know, they wake up one morning and there are penises and erect and they, they call freaking out like, well, for the last [00:46:00] five days I had morning would, but now I don't, what does this mean?

And they start spinning out those patients. I think, you know,   definitely are, can be helped with therapy for sure, because, you know, I can only do so much in terms of giving them solutions for their physical issues.  but if their anxiety is going to keep creeping in and, and, and. It's sort of counteract what I'm doing then I think it's really helpful.

Tim Norton: And I think that's probably a good thing for guys to hear that the occasional, non mourning 

Dr. Gonzalez: wood. I mean, I don't get morning. You never get morning with no, I know I do. I just don't get it every day. Not every morning. Right. No man gets it. Right.  or necessarily wakes up with it. I'd have it in your sleep.

A lot of guys get it, get it in their sleep and they just don't know. And then they wake up.  but yeah, I mean, I have a lot of patients who like perse Everett on that, you know? Well, I had like a. You know, two weeks and it was great every day and then they have one bad day. It's just like life, right? So it's just about keeping perspective.

And, and sometimes that's easier for the [00:47:00] therapist to do, because I can't see a patient in the office every week to reassure them. But I think that's where therapy can be helpful, you know, while we're treating whatever physical issues that are, 

Tim Norton: I have developed kind of a saying that I. I mentioned in sessions and I haven't even actually run this by anybody, but you deal with women too.

So sometimes I say something along the lines of, we don't freak out when a woman isn't as lubricated one night as she was the prior night. Right. And is that a good analogy? Like, is it, do men sometimes just focus way too much on it and then there's less that we can do about it, whereas it's a lot easier to just use some lubricant.

Dr. Gonzalez: Right, right, exactly. I think it just depends on the guy, you know,  I think if you have a baseline anxious person,  and, and they have,  sort of a fixation with their penis then, I mean, I, I get guys in here all the time that are asking me about this little [00:48:00] spot and that little spot and what I think yesterday, my erection was harder than it was the day before.

And, you know, at the end of the day, it,  I try to keep it.  give them perspective and say, well, you had sex both of those nights and you were able to complete intercourse. So you're just because your assessment of how hard you were happens to fluctuate from one night to another. It doesn't at the end of the day, really mean anything or try to reassure them that your penis looks completely normal.

And I've had to tell patients, like, stop looking at your penis, right. You're not allowed to look at it anymore. Yeah. Or don't go online and read about, you know, all the things that it could be on web MD or on Reddit or whatever, because you know, people can really go down like dark wormholes about this kind of stuff.

My 

Tim Norton: social media, person's been asking me to,  Get get sound bites. I think that's the one stop looking at your piece. Yeah, right there. 

Dr. Gonzalez: Yeah. Sometimes I use the more,  [00:49:00] colloquial terms. I don't always say penis, but yeah. Okay. 

Tim Norton: That, that,  I can only imagine. So what are, what are some things that are just super normal?

Nothing to worry about. A little spots here and there a little, what, what,  what are the things that just guys 

Dr. Gonzalez: can. Oh, penis sizes. Huge. Yeah, no, I mean, no pun intended. Yeah. So,  people there, there's also,  a huge discrepancy in how men perceive how big their men perceive their penis to be. Especially if you're talking about a guy who's had ed for years, like he will imagine that he used to be like eight and a half, nine inches, and then we'll do a penile implant surgery for instance, or whatever in his penis is now.

Seven inches. And he's swears that from the surgery, he lost two and a half inches. And the truth is, is that there probably is some shrinkage, but the reason behind that is that for 10 years, he hasn't been getting great erections. So the blood flow to that [00:50:00] tissue is not been great. And you get atrophy just like you would, you know, your bicep would get smaller if you're not working out, your biceps is going to shrink.

So does your penis, so,  People always imagine how they were when they were 18. And now that they're 65, they think that they're going to be there once they get it, you know, give them a treatment for their ed.  but you know, again, that's sort of playing with,  expectations and, and helping people have realistic expectations about what qualifies as normal and, you 

Tim Norton: know, Yeah, and I I'm sure guys will come in worried that their penises 

Dr. Gonzalez: are too right.

Yeah. What do you tell them?  it's pretty rare that you see somebody who has a penis that's so small that it would, you know, make them make it difficult for them to function at the end of the day. Like, you know, I try to reiterate to patients like most partners don't care how big your penis is Pat, you know, above a certain [00:51:00] size, which.

99% of men are.  they just care that it gets hard, like at the end of the day, right. If you can't get hard, that's going to be a problem for your partner.  and so if you can get, if your penis is on the smaller side, but you can get rock hard and you're going to please somebody. 

Tim Norton: Yeah. Yeah. Okay. Because my understanding of anatomy is that everything that they're trying to reach is within reach, 

Dr. Gonzalez: right.

Exactly. G-spot 

Tim Norton: yup. Prostate. You're going to hit it. Yeah.  yeah, with,  something on the smaller end of the spectrum and that's, that's what everybody wants. Exactly.  okay, well, that's good. So this has been 

Dr. Gonzalez: great. 

Tim Norton: Yeah.  what, you know, I haven't been asking anybody this, but I was wondering why you said yes to this interview.

Like what, what is it that, what do, what do you think.  the world needs to know. And, and, and why, why should we be having conversations about erectile issues? 

Dr. Gonzalez: And,  I just think it's time that like we stopped having [00:52:00] shame and about these issues. I mean, as men in general, but you know, women as well. I mean, there's, there's a lot of shame that, that women experience too, in seeking out help,  for their own sexual issues.

But, you know, I think,  it's my goal to kind of help. The larger community, even beyond my own practice, understand that, that it's okay to talk about these things. Oftentimes it is not strictly a psychological problem. It's not all in your head.  and F whatever physical things are going on that could potentially be causing problems.

There are solutions for, so, I mean, every guy that comes into my office for ed, I tell them at the, like, on their first visit, like one way or another, we're going to get you. And erection, like whether that be a pill that we prescribe, whether we put you on a hormone program, whether we give you injections or you end up having surgery, I tell them if you are willing to listen to my American recommendations, once we kind of do the whole workup, we'll get you an erection one way or another.

So, [00:53:00]  you know, there are solutions for, for all of the stuff that we find out, find out there. I 

Tim Norton: felt that when you said what a nice message that must be to hear. Yeah.  Looking someone in the eye got your and your doctor's office and everything. I bet. That's really powerful. 

Dr. Gonzalez: Yeah, I think so. Because a lot of patients think that they're, they feel hopeless a lot of times.

Yeah. Yeah. 

Shout outs to the sex positive community, including sex educators, sex therapists, sex coaches, and other fellow sex podcasters, sex surrogates, academics, sexual health, medical community, sex workers, the tantric community, and everybody else involved with having hard conversations. Bye-bye.