In this article, I’m speaking with Dr. Aaron Spitz. He’s not only a urologist, he’s also the author of The Penis Book. If you have a penis or know someone who has a penis, this is the interview for you.
Dr. Aimee: Hi, Aaron. How are you? Would you tell us about yourself?
Dr. Aaron Spitz: I specialize in male sexual function. I’ve been in practice for about 20 years. I’ve had a lot of great opportunities to share expertise in this area with a large audience through appearances on television and also most recently in the documentary The Game Changers. I also have a book out called The Penis Book, surprisingly. I really enjoy the opportunity to get the word out on this rather hidden topic.
Dr. Aimee: Why did you write The Penis Book?
Dr. Aaron Spitz: After having gone on television for several years and sharing information about relatively taboo topics in a way that was demystifying but also in a way that was really accessible, I was approached with the suggestion of putting a book together on the topic. After a very nice dinner meeting with an agent and further discussion, we realized that we really had a great opportunity here.
It was really born over a dinner conversation. It was something I had been toying around but didn’t really have a lot of solid direction on, but then the timing was right. I think there’s sort of a season for everything, and this was the season for me to put this book together.
Dr. Aimee: My first question is what makes an erection happen?
Dr. Aaron Spitz: An erection is kind of a convergence of a lot of complex body systems. You have to have the brain, you have to have the heart, you have to have the circulatory system, hormones, all of these different things come into play. But it can be simplified down as what I would call a hydraulic event. Hydraulic meaning fluid moving in or out of something, and in this case the fluid is blood.
Blood rushes into the penis and then it gets trapped there, and that’s an erection. An erection is when the blood can no longer expand the penis, it can just make it stiffer and stiffer, and then at some point no more can go in and it can’t get out. The reason that all happens begins with a signal from nerves. That signal is usually initiated by the brain, some stimulating senses — sight, sound, and touch — cause a message to go down the spine, and then the nerves from the spine go to the penis and they release a signal, nitric oxide, which then triggers all of those blood vessels in the penis to open up and allow lots of blood to rush in.
The blood rushes in to the point where it actually opens the blood vessels and squishes them against the walls of the chambers of the penis so much so that the veins that would normally drain the blood back out get pinched off. When we don’t have an erection, blood is flowing in and out down there, but it’s going in and out, it’s not a high flow state. When you have this signal that makes everything open up and fill and engorge, you have the erection.
Then after climax, after ejaculation, a different signal, adrenaline, is released. That makes all of the blood vessels squeeze tight and squeeze the blood out, kind of like a sponge squeezing itself dry. Now the veins aren’t pinched off anymore and the blood can drain out and the penis goes soft.
Dr. Aimee: What are the most common causes of erectile dysfunction, and how do you fix them?
Dr. Aaron Spitz: Erectile dysfunction has a few different very common causes that really vary a lot of on age and other associated conditions.
For young guys, the most common cause is what we would call behavioral or psychological. What that really boils down to is releasing too much adrenaline. Stress, worry, or other behavioral or psychological concerns have a common denominator in that they cause us to release adrenaline. Adrenaline is the molecule our body releases when we’re under stress.
Looking at this from an evolutionary standpoint, eons ago the stress that men faced was environmental. That is to say severe weather or a predator bearing down on them, or some other guy attacking them. To deal with that, to physically survive, their body released adrenaline, which caused all the blood to shunt inward to the vital organs, the heart, the lungs, the liver, and the brain, and away from the less vital structures like the fingers, toes, and the penis.
Now in our modern day, we have very few environmental stressors because we’ve pretty much controlled our environment, but we have a lot of psychological stressors. Our physical bodies still release adrenaline even though the threat is no longer one where we might lose a finger, a toe, an arm, but nonetheless our blood gets shunted away from those appendages. If we are faced with stress, we will go limp or have trouble getting an erection.
So, for most young guys, it’s a pretty simple scenario. They’re having an off night, maybe they have cold or maybe they were partying too hard or they were up late studying, whatever it was, and they just didn’t perform. But it’s very alarming to them, and the next time they go to have a sexual encounter they think this stressful thought of, “What if that happens again? What if something is wrong with me?”
Just that thought causes their body to release adrenaline the same way as if they were having the thought, “Oh my god, there’s a tiger about to attack me.” Same adrenaline. They will have trouble getting it up or keeping it up. Now, the third time they go to have sex, it’s a pattern, “Oh my gosh.” Then what happens is it becomes a vicious loop and the body keeps releasing adrenaline with even less trigger.
Fortunately, it is reversible, but it is a real physical effect on the penis. It’s not that you can think your way through it. You have to not release the adrenaline. Once you release adrenaline, it’s a chemical reaction and it takes its toll.
So, that’s the most common cause for young guys. Just understanding that helps a lot of the young guys who come in to see me, because they’re relieved that they don’t have a really bad physical problem. They kind of have an a-ha moment like, “Yes, exactly. That’s what happens to me.”
For the vast majority of guys for whom we call it psychological or behavioral, it’s not some deep dark psycho-sexual abnormality that’s deeply buried in the brain. It’s just that simple, “Gosh, I wonder if I’m going to have trouble having an erection,” adrenaline gets released, boo, problem, self-fulfilling prophecy.
As you get up in the years towards guys my age, I’m 53, in their 50s and beyond, 60s and 70s, it’s very common for guys to start having erectile dysfunction that is not behavioral, that is physical. It’s just the arteries, the blood vessels to the penis, are aging, so they don’t provide as much blood flow. That hydraulic event of opening them up, letting the blood flow in, pinching off and keeping the blood trapped in there doesn’t work as well because those blood vessels are aging, they’re stiffer, and they’re narrower.
Now, that’s not true for all guys at all ages. Some do much better than others. Some can live their whole lives with no problem. Others start to have problems in their 40s. It’s worse if you have other conditions that are also undermining your blood vessels in addition to age, such as diabetes, for example. Type II diabetes is super common in our population, along with the metabolic syndrome, the overweight, the obesity, the hypertension. All of that stuff is undermining the blood vessels to the penis, setting guys up for erectile dysfunction.
Guys in their later decades of life coupled with high blood pressure, diabetes, obesity, is a perfect set up for erectile dysfunction that is physical. Certainly, there can be a psychological reaction to that, add some adrenaline in there, too, but the underlying problem is physical.
Then you have the less common cases, like nerve injuries. A spinal cord injured patient, a young guy in a diving accident or car accident, paraplegic or quadriplegic, they’re not going to have that brain nerve signal connection that they need to release the signal to have an erection under normal circumstances. Fortunately, the vast majority of cases — psychological, neurological, vascular, metabolic — can be improved or cured.
Dr. Aimee: As I’m driving to work, almost every morning, I feel like I hear these commercials for what’s feeling like consumer direct Viagra or Cialis. What do you think about that, is that kind of stuff safe? For people who are trying to conceive, is that safe for them to be taking as well?
Dr. Aaron Spitz: Fortunately, for people who are trying to conceive, these medications like Viagra, Cialis, the generic equivalents, have no negative effect on sperm. In fact, I will often use them for my couples that are trying to conceive where the stress of infertility is causing erectile dysfunction. The guy is called upon to perform at specific times according to the ovulation cycle and that can be very stressful. Plus, just the concern about how much longer will this infertility issue go on.
In some cases, couples are having difficulty getting pregnant because they’re not able to complete sexual intercourse because of the erectile dysfunction issue, so these pills can be helpful in allowing these couples more at bats, if you will.
With regards to direct to consumer advertising, this is really a shortcut when it comes to healthcare. Ultimately, there will be cases where it really is inadequate and, in some cases, potentially dangerous. That can be true for a variety of different health ailments. A variety of conditions are direct to consumer marketed, including prostate problems or feminine problems as well.
We all know as physicians that a lot of stuff is simple and can be remedied by simple remedies, that if these remedies were over-the-counter and you could go pick them up in a drugstore on your own, you would likely do okay. But there’s going to be conditions where these are actually indicators of much more serious conditions that you’re not going to know about as a consumer, and these products aren’t even going to begin to address them.
I think that the direct to consumer marketing of erectile dysfunction medications is not dangerous for many of the guys, maybe even most of the guys, who take advantage of it. But it is going to be insufficient for some key guys. It’s really interesting, but because the penis is all about blood flow, it is an early warning sign for cardiovascular disease or stroke. For guys who have erectile dysfunction, that may be the very first indicator that they have an underlying serious problem with the blood vessels in their heart or brain.
If they’re evaluated by a doctor in a comprehensive way, that will be picked. Their erectile dysfunction may even save their life. If they simply rely on direct to consumer access to these pills, never knowing this will happen, they might restore their erection only to die of sudden death a few years later. The erection problems lead the heart problems by a few years, because those arteries in the penis are several times smaller and narrower than the arteries in the heart and the brain, so it takes a few more years for them to finally clog up and give you trouble.
Dr. Aimee: You can say either my penis saved my life, or my penis almost killed me.
Dr. Aaron Spitz: Well, ignoring your penis can kill you and paying attention to your penis can save your life. We used to be told that our penises were going to get us in trouble, but if you don’t pay attention to your penis, you’re going to get in trouble too.
Dr. Aimee: I have another question along the lines of the size of the penis. What is the average size of a penis, and how do you measure it?
Dr. Aaron Spitz: The average size of a penis is actually just a little under five-and-a-half inches. That’s the average, so that means the normal penis is about two standard deviations larger or about two standard deviations smaller. The normal range of penis size is about four-and-one-quarter inches to about six-and-three-quarter inches, with average being a little under five-and-a-half.
How do you measure? Great question. We talked about adrenaline release, and nothing will make you release adrenaline like a gray-haired scientist brandishing a ruler at your erection. What we do instead is we measure the stretched flaccid penis. When the penis is soft, if you grab it by the head and pull it out as far as it will go, it actually is very similar in length to when it is erect. It doesn’t mimic the girth, but it does mimic the length pretty closely. A ruler is placed at the base of the penis and measured out to the tip while it’s fully stretched out.
Some of the measurements are going to be varying by how fat the guy is. If you have a lot of fat pad above the penis, it’s going to make your penis measure smaller. Functionally, your penis will actually work larger, because during sex that fat will be kind of pushed back out of the way.
But, that is how the penis is measured for the scientific studies that bother to measure the penis.
Dr. Aimee: Are there any supplements or devices that can make the penis longer or bigger, if someone is interested in that?
Dr. Aaron Spitz: The answer is pretty much no. There are definitely no supplements that will make the penis bigger, but a lot of supplements over the years have been marketed as doing just that.
The way they got away with that was that the penis would get bigger as it was becoming erect. Of course it does. When the soft penis becomes erect, it gets bigger. That was the increase in size that they could hide behind, they could say that’s all they really meant. No pills make your erection become a bigger erection.
As far as devices go, the vacuum erection pumps and penile stretching devices have been marketed to make the penis bigger, but they rarely do. When you look at the studies, what you’ll find is on average, first of all, the vacuum devices really are not effective, but the penis stretching devices have some effect, but it’s really what I would call a long run for a short slide. When you look at the data, if you use the penis traction device for hours a day, for months and months, the average gain is one centimeter. You can gain a lot more than that by just losing weight. They’re really not a way to do it.
The good news is that most guys who are seeking out methods to increase the size of their penis don’t realize that their penis is completely normal in size. They are under this misinformation that their penis is inadequately sized, so they are searching for this remedy when they don’t need it, if they would just realize it.
So, although there is not a way to make your penis bigger, in the vast majority of cases there is no rationale to make your penis bigger.
Dr. Aimee: Right. I hear those commercials as well, for how to make your penis bigger, on Sirius XM as I drive to work every morning.
Dr. Aaron Spitz: What station are you listening to exactly?
Dr. Aimee: I swear, I’m not making this up. What about guys with low libido? Do medications like testosterone help? What about Arimidex, HCG, Clomid? What do you think about that, and their impact on fertility as well?
Dr. Aaron Spitz: There are many men who suffer from low testosterone. It tends to be age related, but it is not always. In the population of infertile couples, guys who are infertile, who have low sperm counts, more often than in the general population can also have low testosterone, because the testicles make the testosterone and the sperm. If they have a condition that is lowering their sperm count, they may also have a condition lowering their testosterone production.
When the testosterone levels are low, they can suffer from low libido. Libido is the desire to have sex, and it really is largely influenced by testosterone. There are other things, other behavioral and psychological issues that can suppress a guy’s desire or turn him off, but if the testosterone level isn’t normal, he’s really not going to have the desire at a foundational level.
I see couples like that and I need to help those guys restore their testosterone to a normal level so they can restore their desire level, so they can have intercourse so they can try to have a baby. Not to mention, the many other important health factors that testosterone plays a role in.
For young guys who are trying to be fertile, if they go on testosterone shots, gels, or pellets, it will definitely boost their testosterone, but it shuts off their sperm production. Therefore, in guys who are trying to preserve fertility, we use alternatives, which you mentioned, Arimidex, Clomid, HCG. These all work by stimulating the testicles’ own production of testosterone.
Whereas when you go on testosterone shots, you’re putting the testosterone into your bloodstream, and you can put very good levels in your bloodstream that are great for your whole body, except for your sperm. When the testosterone is made naturally in the testicle, it starts in the testicle and then it gets into the bloodstream and then it circulates all around. But guess what? The levels in the bloodstream are way lower than the levels where it’s made in the testicles where the sperm is.
The sperm is used to levels of testosterone that are 100 times higher than what you measure in your blood. You can’t give that by injection. But if you give HCG, what that does is it stimulates the cells in the testicles that make testosterone to make more. If you give Clomid or Arimidex, it stimulates the center in the brain, the pituitary gland, that sends the signal to the testicles to make testosterone to ramp up that signal.
With these different strategies, we boost the testicles’ level of testosterone, giving the sperm that 100-fold higher level, resulting in blood levels that are normal and higher than where the guy was before.
For guys who aren’t trying to preserve their sperm function, testosterone injections and gels work very well. By and large, they’re quite safe, as long as guys are monitored properly.
Dr. Aimee: What about any natural supplements? Is there anything natural that a guy can do, or foods that he can eat to improve erections and libido?
Dr. Aaron Spitz: Let’s separate erections and libido into two categories. They work together, but let’s talk about libido as a testosterone effect and then let’s talk about erections as this vascular hydraulic effect.
For the testosterone, there’s really not food that boosts testosterone. There are a couple of supplements that may boost testosterone in some guys, but not in others. I’ve tried these on guys and measured their blood levels, and they’re very inconsistent. Tribulus is one, Chrysin is another. Tribulus works to stimulate testosterone production. Chrysin works to block the conversion of testosterone to estradiol, the same way Arimidex works that we mentioned. But they are really erratic in how to predict if they’re going to work. If you wanted to try it, you would have your doctor monitor your levels before and after to see if it’s working or not.
However, testosterone can be improved in men who are overweight or obese, because the excess fat does convert testosterone to estrogen and therefore lowers the testosterone level. Getting lean is a natural way to improve testosterone that’s not related to a particular kind of food but related to the amount of food one is consuming.
Now let’s talk about supplements, food, and erections, that blood flow event. I mentioned earlier that the signal that the nerves release into the penis to get the blood flowing is nitric oxide. Nitric oxide can be derived from food. Our bodies produce nitric oxide, but once we hit 30, we start making less and less on our own, so it’s good to try to find another source. The best source of nitric oxide from food is from vegetables, particular green leafy vegetables, cruciferous vegetables, and beets.
Nitric oxide is actually a gas, it only lasts very briefly, but it can be derived from nitrate. Nitric oxide is NO, nitrate is NO3-. When we eat these vegetables, what happens is the nitrate gets converted to NO2- (nitrite) by these bacteria in the back of our tongues. So, you don’t want to use mouthwash that is bactericidal, like Listerine. You want those bacteria to be there, you need them to get the nitric oxide out of your food. They convert it and it goes down to the stomach, some of it goes into the blood, and then it gets converted to nitric oxide in hemoglobin molecules in the blood cells.
Then what’s interesting is some of it gets excreted out in the urine and the kidneys, and then about a quarter of it gets hyper-concentrated in your saliva and that salivary glands, and it gets concentrated to be 20 times higher of a level. The next time you go to eat a vegetable, when you’re chewing, that nitrate gets excreted out onto those bacteria that then convert it. You have this turbo drive system between the bacteria in your tongue, the salivary glands, and the vegetables, and it’s designed to hyper-reinforce your ability to get nitric oxide from plants.
There are supplements that can boost nitric oxide as well. Ginger stimulates the nitric oxide production enzymes in the blood vessels. When you drill down to other particular good foods, on the fruit side, because vegetables are great but fruits are more fun sometimes for desserts and whatnot, blueberries are really potent. Blueberries have a lot of great antioxidants, as do many fruits and vegetables.
The antioxidants serve a really important role, because although the nitric oxide stimulates the blood flow to the penis, a lot of what we eat — animal products and processed foods — create these free radicals in our blood, these are toxins in our blood that are going to counteract the blood flow and make our blood vessels worse. Antioxidants, which are found in fruits and vegetables, neutralize those bad chemicals. They play defense and allow the blood vessels to work better and enjoy the effects of the nitric oxide.
That’s how food works for erections and for testosterone.
Dr. Aimee: You just heard all of the tips of what you should pack your for snacks, lunch, and dinner leading up to your big day, whether it’s your IUI day or egg retrieval day. People ask me all the time what they can eat, what they can do, and those are great tips.
There are some conditions that some guys might have, and I’ve seen them clinically in patients of mine as well. What is Peyronie’s disease, or bent penis, and how do you treat it? Sometimes it can be harder to get pregnant if you have that. Can you tell us a little bit about it?
Dr. Aaron Spitz: Sure. Peyronie’s disease is a pretty fancy name for an erection that becomes bent or deformed in some way, it takes a severe angle, to the right, to the left, down, twisty, corkscrew, all variations. It’s called Peyronie’s disease, but fortunately it’s not truly a disease in the sense that we think of a disease as something that can hurt you, spread in your body, and maybe even kill you.
It’s an area on the chambers that fill up with blood in the shaft of the penis that becomes disorganized and won’t stretch, expand, and lengthen the same as the rest of those chambers. There are two chambers that are side by side in the shaft of the penis that fill with blood, they expand and they lengthen, and that makes the erection. They’re lined with a really interesting material that is a weave of collagen and elastin. Collagen is strong, elastin is stretchy. It’s kind of like the waistband in your underwear, it’s strong but it’s stretchy. That’s what this material that makes these two chambers is like.
What happens is there’s an overgrowth in a disorganized way of the collagen and it won’t stretch anymore. Sometimes you can even feel a little lump there where it’s happening. It can also be painful initially. Because that spot won’t expand like the rest, the penis will kink and bend right at that spot. For some, it can be so severe that they cannot have intercourse, the bend is too severe.
That’s what Peyronie’s disease is. It c an come on just out of the blue, or it can come on after some damage to the penis during sex, like if it got bent a little bit too much, or it can even come on after some blunt trauma, like from a baseball or something like that. Most of the time, it comes on out of the blue.
It can be a genetic thing. Some guys who have Dupuytren’s contractures, which are thickening and contractures in the palms, are more prone to get this as well.
It typically happens in the 40s and later, but I’ve seen it sometimes in younger guys. It can make the erections weaker, too, because it doesn’t allow the blood to get trapped as well, because that lining doesn’t pinch off the blood vessels as well. Anyway, it’s a mechanical issue. It doesn’t spread. It doesn’t lead to cancer.
The treatment for it is mechanical. The idea is you have to break down that patch that is thick and won’t stretch, you have to make it more stretchy. You can do that that penis traction device that you wear for about 30 minutes twice a day that pulls and stretches. You combine that with injections of special medication that goes into that thick area and gradually breaks it down. Or you can do surgery to correct it, cutting out that patch and putting in a graft, or cinching up the other side to straighten out the curve.
It’s a condition that affects probably 10–12% of men. It’s just not been talked about very much. When guys come in with it, they’re amazed that there are so many other guys that have it. They think they’re the only guy in the world and they can’t imagine how something so crazy and so devastating is happening to them. The good news is that we have a lot of success treating it now.
Dr. Aimee: You mentioned that sometimes it can happen with sex, and I just thought of something. Can you actually break a penis?
Dr. Aaron Spitz: In fact, you can. It’s uncommon, but I’ve treated several over the course of my career. We call it a boner, but it’s not really a bone. How do you break something that’s not a bone? It’s really a rupture.
I talked about the two chambers. They’re like a long balloon, if you will, that expands and then at some point won’t expand anymore. What can happen is that lining, if you bend it too hard, the pressure gets so intense that it will actually burst open like a balloon, and then the blood comes rushing out. Of course, there’s still the skin around it, which traps it, so that blood rushes out of the chamber, but it gets trapped by the skin and it just makes the penis swell and swell until it looks, literally, like an eggplant. In urology we call it the eggplant sign. It’s kind of funny that eggplant is the emoji for penis in texting, but in urology it’s the sign for a fractured penis, that’s what we call it.
But, it’s not a bone, it’s the lining that contains the blood that ruptured. The correction of it is not a cast or a splint. It’s surgery to go find that tear and sew it shut.
Dr. Aimee: Just another penis question before I forget. How does sleep affect the penis?
Dr. Aaron Spitz: Sleep is very important for the penis. For one thing, guys have erections all through the night, whether they’re having a sexual dream or not. This happens every night in men with healthy sexual function. Why does that happen when the guy is unconscious? Well, we don’t know for sure. We do know that when it’s happening, it’s increasing the oxygenation of the tissues, it’s forcing blood flow into those tissues in a way that is very healthy for the tissues and that keeps the tissues younger and more elastic.
If a guy when he’s conscious chooses to be celibate, let’s say he is a monk and he has taken a vow of celibacy, every night he will have erections while he is asleep. The penis will continue to get the nourishing blood flow it needs, whether the guy consciously chooses to allow sexual stimulation or not. So, getting a good night’s sleep allows the penis to have those series of erections that is good for it.
Secondly, sleep will affect a guy’s testosterone production. Testosterone is not only important for having the desire to have sex, it also nourishes the tissues of the penis and allows those blood vessels to remain stretchy and younger. When guys are sleep deprived, their testosterone production will drop by about 15%. That’s like aging 10 to 15 years. We might have a subtle drop in our testosterone by about 1% a year once we get past our prime. You can accelerate that dramatically by just not getting a good night’s sleep.
Not only that, if you have sleep apnea, which is a condition that a lot of guys have which interrupts their sleep, the sleep apnea causes your body to release adrenaline, because when you have sleep apnea you’re literally suffocating, you’re just not awake for it. Your body is awake for it, and to deal with that stress, that danger, it releases adrenaline. That adrenaline decreases the blood flow to your penis not only while you’re asleep, but also throughout the day there’s a higher level of adrenaline that just kind of persists, making it harder for your penis to get erect.
So, sleep is important for testosterone, to allow enough production of testosterone, to diminish the hyper-adrenaline effect, and to allow for erections at night while you’re asleep.
Dr. Aimee: Nice. Everyone, make sure you get your sleep as you’re leading up to your egg retrieval, your IUI, or your ovulation day. It’s super important. Eat your blueberries, get your ginger in, I love it.
Just some other questions that sometimes clinically I see in my office and I just want to run them by you to see what you think as well. What kind of advice do you have for a guy who, let’s say, can masturbate in the cup but he can’t ejaculate in his wife’s vagina, what can a guy do to fix that?
Dr. Aaron Spitz: That’s is fortunately an uncommon problem, but it is a real problem. This is typically more often a behavioral or psychological issue, but occasionally it can be physical. There are men who have had spinal cord injuries or partial injuries or with diabetes, where the degree of stimulation that their nerves need has just gotten to the point, because the nerves are blunted, that they need a more intense stimulation than can be achieved with vaginal intercourse.
For many, it’s a psychological behavioral situation. In some instances, it’s the result of the guy having developed a very idiosyncratic masturbation technique where he has really come to rely on a very specific rhythm and intensity of stimulation that’s not reproducible with vaginal intercourse. For those guys, working with a behavioral sexual medicine specialist, that can be unlearned. The guy can learn to allow his body to reach a climax with vaginal stimulation, but it is a process that a behavioral sexual medicine specialist would be most helpful with.
Dr. Aimee: What do you think about porn? Especially in cases where guys are having problems, and also if they’re trying to get pregnant, do you ever recommend that they bring porn into the bedroom?
Dr. Aaron Spitz: You would think that porn would just up the excitement, because certainly it’s very provocative and it’s very scintillating, but it turns out that porn can be actually detrimental to a guy’s sexual response. It becomes detrimental when it’s viewed very frequently. Occasional viewing of porn, there’s not much data to indicate that it’s harmful.
But many guys, because of the easy accessibility of pornography with broadband and our smartphones, are viewing porn frequently. By frequently I mean daily, and sometimes several times a day. What this does is actually remarkably shrinks the brain centers that are important for sexual response. It blunts them, it makes them smaller, as can be measured on MRI scans.
The very centers that porn is stimulating, it’s actually kind of overstimulating, kind of like a light that is too bright might impair your vision. These are stimulations that are coming in through our eyeballs and we think it’s an image, it’s psychological, it’s how we choose to react. No. They actually affect the very same centers of our brain that addictive drugs like cocaine and alcohol do. Those brain centers that allow us to become addicted to drugs also respond in the exact same way to pornography.
What happens over time is, as most people know with drug use, is the thrill gets less and less, and the person has to do more and more drugs just to feel normal. It’s the same with porn.
The excitement of the images of porn become less and less exciting and whoever is watching the porn has to look for harder and harder and more and more exotic or bizarre images to get excitement, often to the point where they are viewing images that they find repulsive but that they find necessary to get off. Again, this is in a very frequent porn viewer, daily or so. The centers of the brain that are important for modulating that signal that goes down to the penis to cause it to become erect start to shrink in size and they release less and less signal the more pornography is watched.
This is such an insidious problem because not only is it affecting couples who are trying to conceive, if the guy is watching a lot of porn, it is affecting guys right out of the gate at the level of high school. Now we’re starting to see high school seniors report 25% instance of erectile dysfunction. That was unheard before the advent of streaming porn. In fact, the instance of erectile dysfunction in guys under 40 before streaming porn was under 4%. Now it’s 25% in 16-year-olds. It’s crazy.
Fortunately, it’s reversible. Studies have shown when guys go cold turkey and just stop viewing all together, after some months, not right away, their sexual responsiveness will return. Porn might be fun a little bit here and there, if that’s what you want to do, but it’s a slippery slope and it’s certainly a factor to take into account if you’re watching it very frequently.
Dr. Aimee: On to another question. I bet you get this a lot, too. How often should we have sex to get pregnant? What do you recommend?
Dr. Aaron Spitz: That’s a great question. There are all kinds of regimens out there. My recommendation is based on two scientific findings.
One scientific finding is that sperm will survive inside the woman’s uterus for several days. If you put sperm in a petri dish, under proper conditions it can survive for even a month. But the egg only survives for 24 hours once it’s released by the fallopian tube. With that in mind, you have to make sure you’re having sex on the day of ovulation. If you have sex the day after ovulation or two days after ovulation, it’s not going to do any good. But if you have sex a day before ovulation, two days before, three, four, five, six, seven day before ovulation, that sperm is surviving — at least some of it — until the egg arrives.
Now, we consider the fact that if you have sex every day in a row, you might be depleting your counts and have less and less by the time the egg drops down. The other scientific finding that I base my recommendations on is that when you do have sex every day in a row for six or seven days, even though there is less sperm in the semen on that last day, the quality of that sperm, as measured by a certain test called a DNA fragmentation test, is actually a lot better. So, although you have smaller numbers of sperm, you have higher quality sperm on that day.
If you take these two considerations together, that sperm will survive several days inside of the woman and that although the count is decreased, the quality increases, I instruct my guys to have sex every single day in a row for several days leading up to and including the day of ovulation, building up a welcoming party and increasing the quality of the sperm at the same time.
Dr. Aimee: I love that. I do say the same thing, but sometimes I get these big wide eyes, “Every day?” So, then I say, okay, every other day.
Dr. Aaron Spitz: That’s where Cialis and Viagra come in, or blueberries.
Dr. Aimee: That’s true. We hear about Kegels for women, as far as exercises that we can do. Are there any penis exercises that a guy can do? I know that sounds like a silly and probably totally stupid question. Is there anything like that for men?
Dr. Aaron Spitz: It turns out what’s good for the goose is good for the gander. It turns out that Kegel exercises also help erections and may also help with ejaculatory conditions, such as premature ejaculation. The Kegel exercise, as we know, is that squeeze we make when we’re trying to stop ourselves from peeing or pooping.
The muscles that constrict off the anus or constrict off the urethra also squeeze the base of the penis. When they do that, they make the trapped blood during an erection rise up in pressure even higher. When you have a party balloon and you squeeze the middle of it, the rest of it gets even more tense and even more full. That’s what these muscles do to an erection when the penis is full and then you do a Kegel squeeze, it makes the erection even firmer, or throb, if you will. Exercising those muscles on a regular basis can allow that kind of an effect to become even more accentuated or more sustainable.
Also, these are the same muscles that squeeze on the urethra of the penis to expel the semen when a guy ejaculates. If a guy has premature ejaculation, sometime working on Kegel exercises gets his body more in tune with those contractions, which are involuntary, but because his body is more in tune to it he can sense that inevitable contraction coming on and slow it down. It may even enhance the forcefulness of ejaculation for guys who are noting weak ejaculation.
Kegel exercises, when they’ve been studied and done in conjunction with biofeedback, in a very formalized way, have been shown to improve erections in men who had erectile dysfunction as good as Viagra in those studies.
Dr. Aimee: Wow. I bet a lot of people who are watching this did not know that. I have a feeling that maybe only like 5% of people knew that.
We have so many live questions that have been asked, but before I get into that, can you just share with us some of the most common penis myths out there for people to just know that they’re just myths?
Dr. Aaron Spitz: Sure. We’ve addressed some of them already. First of all, the myth that there is a pill that can make your penis bigger.
The myth that a normal penis is the kind you see in pornography. Those guys are way bigger than normal, that’s why they’re in porn. Lebron James is way taller and more athletic than normal, that’s why he’s a professional basketball player. Unfortunately, too many guys get their calibration of what normal is from pornography and then go off thinking they’re way too small. That’s a very pervasive myth.
There’s also a myth about ejaculation. Again, pornography presented some extreme views on that as well. The average volume of ejaculate is anywhere from 2cc to about 6cc, so we’re talking about maybe a teaspoon full or more is normal.
Then I think another myth is that drugs and sex go hand in hand. It is true that we can feel more sexual or less inhibited with recreational drugs, but over time the recreational drugs can have a very negative impact on sexual function, whether it’s alcohol, meth, cocaine, very chronic marijuana usage, or what have you. That’s another really important factor.
Another big myth is centered around food. There’s this mythology that manly men eat beef, the bigger the steak the manlier the guy, and perhaps the harder the erection. It’s actually the exact opposite. It turns out that animal products are not so good for the circulation, and the erection is all about the circulation. Studies have shown that a predominantly plant-based diet results in improvements in erections and less erectile dysfunction in men than animal-based diets.
Dr. Aimee: Wow. That’s all great. I have a feeling that maybe people didn’t know any of that stuff. That’s super.
What are some signs and symptoms of a varicocele?
Dr. Aaron Spitz: A varicocele is a vein around the testicle that drain the blood away from the testicle that are larger than normal because the valves inside them that normally keep the blood flowing in one direction back to the heart are not working quite properly. Blood is flowing back to the heart, but a little bit of it is going backwards each time and it kind of stretches these veins out.
When they’re very prominent, you can see them through the skin of the scrotum and it looks like there’s this sort of squishy mass underneath the skin, bulging it out. People call it a bag of worms, because veins are like worms, they’re long tubular structures. When it’s medium size or small, you won’t really see it. However, a urologist can feel it based on how it feels through the skin.
For many men, varicoceles are just a normal variation. That’s just how they’re built, and it causes no problem whatsoever. For a small percentage of men, that excess blood around the testicle makes it get too hot. The testicles are supposed to be just a couple of degrees cooler than body temperature, that’s why they hang outside as opposed to ovaries which are inside. A couple degrees is very critical for sperm production and the varicocele makes it a little too hot and can lower sperm counts.
Also, in some guys it can be a source of pain, an achy feeling in the testicle that’s there. Sometimes more after activity, but often just with standing around. Pain and lower sperm count are the main symptoms of varicoceles that are affecting a guy. For other guys, like I said, there will be no effect whatsoever. In a small percentage of guys, varicoceles can even cause low testosterone.
This is something that is typically diagnosed by a doctor on a physical exam. Sometimes it will get confirmed on an ultrasound, and then it will be evaluated further by checking the guy’s sperm count, checking the guy’s hormone levels, or if the guy has pain and acknowledging that. Treating it is usually surgery to go in through the groin area, like where a hernia operation is done, not through the sac itself, to intercept all of those enlarged veins, close them off. Then what happens is the blood stops flowing through them, they shrink down, and everything goes to normal.
Dr. Aimee: Awesome. Thank you for that. Here’s another question. Do ED meds do anything to increase sperm count?
Dr. Aaron Spitz: The prescription medications do not affect sperm count one way or the other. Importantly, they don’t impair it.
Nutritional supplements contain antioxidants, and antioxidants are good for sperm as well. If it’s a nutritional blend that’s supposed to help the penis, sometimes it can have some overlap effect on sperm.
Nutritional supplements for sperm have mild beneficial effects, they’re not typically real profound. If a guy has no sperm in his semen, going on a nutritional supplement is not likely to fix that. But if he has some mild decrease in count or motility, it may well help.
Dr. Aimee: Great. A couple more questions and then we’ll say bye for tonight.
For patients going through IUI, would you recommend no abstinence to increase the quality of the sperm?
Dr. Aaron Spitz: As I mentioned, I would actually recommend ejaculating for four, five, six days in a row, up to and including the inseminations of the IUI. The only time I wouldn’t recommend that is if a guy’s count is pretty low to begin with and you’re kind of borderline numbers for the IUI. Then you might not want to take that approach. If the sperm count is normal, I think you’re getting the best of both worlds, as I pointed out.
Thank you for joining us tonight. We had so much fun talking about the penis and Dr. Aaron Spitz’s book, The Penis Book. I got to ask him all of my favorite questions I’ve had for him. We’ll be sure to have him back on the show very soon so he can answer more of your questions. Maybe we’ll just put a call out and you guys can send your questions in and we’ll have him back on to answer them for us.
Thank you for joining us. I hope you guys learned a lot.
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