Online Health Chat with Daniel A. Shoskes, MD, MSc, FRCS(C)

April 22, 2015


Do you suffer from a men’s health condition such as low testosterone, erectile dysfunction, chronic testicular pain, benign prostatic enlargement (BPH) or chronic prostatitis? If so, you’re not alone. These conditions are very common and many treatment options are available.

Low testosterone (also known as androgen deficiency), erectile dysfunction, chronic testicular pain, benign prostatic enlargement (BPH) and chronic prostatitis are some of the common health concerns for men. If you suffer from one of these conditions, know that you’re not alone and effective therapy is available. During this private, live web chat, Dr. Shoskes will answer your questions about common men’s health concerns. Dr. Shoskes is a board-certified urologist in the Glickman Urological & Kidney Institute at Cleveland Clinic's main campus. Dr. Shoskes' specialty interests are renal transplantation, chronic prostatitis, chronic pelvic pain syndrome, interstitial cystitis, benign prostatic hypertrophy, erectile dysfunction and low testosterone in the aging male. He is also Professor of Surgery, Cleveland Lerner College of Medicine and Case Western Reserve University.

About the Speakers

Daniel A. Shoskes, MD, MSc, FRCS(C), earned his medical degree from the University of Toronto Faculty of Medicine in 1985. He had previously completed his undergraduate studies at the University of Toronto, graduating in 1981. He served a comprehensive surgery internship at Toronto's Wellesley Hospital and a residency in urology at the University of Toronto. He was a research fellow at the University of Alberta in 1988 and 1989, where he earned an MSc in experimental surgery. Dr. Shoskes also served a research fellowship at the Nuffield Department of Surgery, Oxford, England, and was a fellow in renal transplantation and renovascular surgery at Cleveland Clinic.

Dr. Shoskes held academic positions at the University of Oxford, where he was a clinical lecturer in surgery; at the University of California, Los Angeles, as an assistant and then associate professor in the Department of Urology; as vice chair of the Regional Organ Procurement Agency in Los Angeles; and at Nova Southeastern University, Fort Lauderdale, FL. While in Florida, he was also chair of the Department of Renal Transplantation at Cleveland Clinic Florida. He joined the staff of Cleveland Clinic in Ohio in 2005.

Dr. Shoskes has received a number of research grants, published numerous articles and is a frequent presenter. He is board-certified in urology from the Royal College of Physicians and Surgeons of Canada.

Let’s Chat About Men’s Health Concerns

Moderator: Welcome to our chat about Men’s Health Concernswith Cleveland Clinic urology specialist Dr. Daniel Shoskes. Thank you, Dr. Shoskes, for taking the time to be with us to share your expertise and answer our questions.

Let’s get started with our questions.

Battling BPH

jercleclin: I am 81 with an enlarged prostate since 1993 with PSA readings for the past 20 years from 1.2 in 1993 to 3.4 in November 2012 (well in the normal range). In November 2013, it "spiked" to 4.1; in November 2014, it "spiked" to 4.8; and recently, in February 2015, it again "spiked" to 5.3. My former doctor put me on alfuzosin 10 mgs., which I have been on for about a year now, and my present doctor added finasteride 5 mgs. in February 2015, saying it should help shrink the prostrate, lower the PSA and reduce my nightly trips to the bathroom, which are three to four times nightly. I am taking both now. No biopsy has yet been performed. Are these two drugs consistent with each other? What is the best method that is non-invasive to reduce nocturnal trips to the bathroom? When I take ibuprofen before bedtime, my visits to the bathroom are reduced to one to two times. Is this harmful if not taken too often? Should I be concerned about my latest PSA reading?
Daniel_A._Shoskes,_MD,_MSc,_FRCS(C): All guidelines recommend against doing routine screening PSA measurements in men above the age of 75. Having said that, six months of treatment should reduce the PSA by 50 percent. At age 81, you have an 80 percent chance of having prostate cancer (as do ALL 81-year-old men), but a low chance of having an aggressive cancer that would shorten your life. It is routine to combine finasteride with an alpha blocker such as alfuzosin for urinary symptoms from an enlarged prostate. Getting up to urinate at night is often caused by multiple medical issues and may not be due to your prostate. Ibuprofen is not a therapy for voiding issues and is not without risk.

paulo: Would you explain BPH and discuss how to lower the risk?

Daniel_A._Shoskes,_MD,_MSc,_FRCS(C): : BPH refers to the increased size of the prostate, which commonly occurs with aging. It may or may not cause symptoms. Some men with huge prostates have no symptoms; some with minimal enlargement have many symptoms. These symptoms can also come from the bladder muscle. There is not much solid data on lowering risk for symptomatic BPH. A low-fat diet may help. The prostate shrinking drugs finasteride and dutasteride lower the risk of the prostate growing and lower the lifetime risk of needing surgery for prostate enlargement.

Jack_in_Florida: As a 70-year-old male with BPH, I've noticed the urge to urinate has become very strong in the last six months. Prior to that, I did not experience this urgency. Is the size of the prostate the issue or could there be other factors here?

Daniel_A._Shoskes,_MD,_MSc,_FRCS(C): : Urgency to urinate can happen because the bladder is overfull (never completely empties) or if the bladder muscle thickens and becomes "twitchy." It basically sends a signal to the brain that it is full when it isn't. A simple painless ultrasound test can tell if the bladder is not emptying properly. There are treatments for both scenarios.

jercleclin: Why do I, who has BPH, urinate every two or so hours during bedtime while during awake hours I don't get the urge for many hours, like before I had BPH?

Daniel_A._Shoskes,_MD,_MSc,_FRCS(C): : There are many reasons why men urinate during the night. These can include fluid intake, diet, heart disease and kidney disease, sensitivity to foods and caffeine, and obstructive sleep apnea. It may not even be due to BPH. The problem can be addressed starting with a full history, physical exam and ultrasound of the bladder to assess emptying.

Penile Problems

irish1311: I am just wondering. When I have an erection, my foreskin doesn't pull back by itself. I can pull it back myself. Should I leave it pulled back or not?

Daniel_A._Shoskes,_MD,_MSc,_FRCS(C): As long as the foreskin otherwise can pull back easily, return forward easily and doesn’t have any trauma during sex, it is a personal preference.

mariop: I'm having a problem with my penis. It has been going on for about a year.
My penis has a reddish spot at the very tip where the urine exits. My family doctor surmises that it is an irritation. She gave me a prescription for clotrimazole and betamethasone dipropionate, which provide some relief. My local urologist believes that circumcision might help. I'm 70 years old and have never had a problem. My wife and I haven't been sexually active for about five years. Would I get better answers if I saw you or some other urologist at Cleveland Clinic? The only tests performed were standard urine tests (urinating in a plastic container).

Daniel_A._Shoskes,_MD,_MSc,_FRCS(C): For a persistent rash or irritation, we typically refer to a dermatologist. Circumcision won’t help with an irritation, but can help if persistent wetness causes recurrent fungal infections

cdamewood: Recently, I've had infrequent but really bothersome and sometimes painful episodes whereby my penis seems to be shrunk to the point of being nearly inverted. Sometimes, the skin is completely covering the head of what's remaining visible of the penis, and it is painful to retract it. Having excess foreskin is not typical for me and has never been a problem. Sometimes, during these episodes, it seems that I am experiencing something like an overload of adrenaline or something similar. However, my heart is not pounding, I'm not sweating and cannot think of any apparent reason for such a "fight or flight" feeling. This is not always present when the penis practically disappears as described. This situation makes it very difficult to urinate standing or even to hold the penis once the foreskin is finally pulled back. My penis remains less than half its normal size in length and especially girth. I'm 63 and have fibromyalgia, coronary artery disease and have had a pacemaker implanted.

Daniel_A._Shoskes,_MD,_MSc,_FRCS(C): : I can't tell what is happening based on your description. As a first step, you would need a thorough urologic physical exam.

Ejaculation Issues

gm3: After open surgery a year and a half ago for abdominal aortic aneurysm repair I have not experienced erection problems; however, the ejaculation force of semen is not as strong, and the amount of semen ejaculated has decreased. Could nerves have been cut or damaged during the surgery that relate to this reduction problem? If nerves have been cut during surgery, will they self-repair or redevelop?

Daniel_A._Shoskes,_MD,_MSc,: Seminal emission is controlled by the sympathetic nerves that travel along the front of the aorta. It is possible to damage them unavoidably during abdominal aortic aneurysm repair. It is unlikely the nerves will repair or redevelop.

AG: I am in my 30s and experiencing night emissions (wet dreams) usually twice a week. What could be the explanation?

Daniel_A._Shoskes,_MD,_MSc,_FRCS(C): Wet dreams are uncommon past adolescence unless you are completely celibate (meaning no sex or masturbation). If this is not the case, you may wish to consult a physician locally for a physical examination.

Tom G: I had a prostatectomy in 2002 and, of course, was no longer able to achieve an erection. However, as of recently, I'm able to actually ejaculate what appears to look and smell like semen. Is it possible for the prostate to regrow, or why am I able to achieve ejaculation of fluid?

Daniel_A._Shoskes,_MD,_MSc,_FRCS(C): It is not possible for the prostate to regrow following a radical prostatectomy for cancer. If done for benign disease, normal prostate is left behind. Fluid may be produced by glands in the urethra that has the appearance of seminal fluid.

Common Conditions

3392*p: What is prostatitis? Who does it affect? What are the symptoms? What treatment options are available? Also, is it considered acute (short-lived) or chronic (long-term)?

Moderator: Prostatitis is a condition of the prostate that is either caused by an infection (bacterial or viral) or inflammation (swelling) of the prostate gland with no signs of infection. Prostatitis may have symptoms such as changes in urination (frequent or difficult or painful urination); fever, chills; pain with ejaculation or sexual intercourse. Depending on the cause there are treatment options available. For more detailed information, here is a link to a Cleveland Clinic document about Prostatitis.

bb21gh: What causes testicular pain?

Daniel_A._Shoskes,_MD,_MSc,_FRCS(C): : There are many causes of acute and chronic testicular pain. Cause may include infection, trauma, cancer, nerve damage from prior surgery, etc. Chronic pain (for more than six months with no identifiable cause) is often related to nerve or muscle problems.

Moderator: Additional information about testicular pain may be found at the following links:

Testicular Torsion    

Testicular Pain

MK1967: I was treated for prostatitis last summer with Cipro®, which did shrink the prostate back to normal. I am still having very frequent urination and some lower back pain. My questions are: 1. How often should the prostate be examined? Is quercetin effective and safe for treating prostatitis? My age is 48 if that is relevant.
Daniel_A._Shoskes,_MD,_MSc,_FRCS(C): : Without symptoms, the prostate should be examined once a year with a digital rectal exam. Quercetin is effective for many men who have category III prostatitis, the type that is not caused by a bacterial infection. We typically use it at 500 mg. two to three times per day. If it doesn't help after six weeks, there is no point to continue.

Low T Treatments

belson: I have been on AndroGel® for two months now. I started with two pumps, then for the last three weeks, I have been on three pumps. My doctor said if my T count doesn’t improve by my next appointment, he wants me to start taking hormone shots. Would that be every day? I'm not too enthusiastic about taking shots. Should he give it more time on the gel, maybe increase it to four pumps? Please advise.

Daniel_A._Shoskes,_MD,_MSc,_FRCS(C): : The typical starting dose for AndroGel (testosterone gel for low T) is two pumps per day. If target testosterone levels are not reached (400-600), then the dose can be increased to three or four pumps per day. There are many other options for treating low testosterone. The hormone shots are every two to three weeks. TESTOPEL® pellets may also be implanted under the skin and can last four to five months.

Jack_in_Florida: My lab results indicate the "normal" testosterone level between 350 and 1200 ng/dL. I had been diagnosed with low T in 2012 and was prescribed an AndroGel treatment, which is very expensive, poorly covered by insurance, etc. My levels actually then increased to 1400 and I stopped. Now, two years from my last treatment, I'm at the 400-600 range. My question is: do T levels fluctuate in normal men in their early 70s? Also, there have been some very negative articles on the gel rub in treatments with regard to side effects. What are your thoughts?

Daniel_A._Shoskes,_MD,_MSc,_FRCS(C): : T values do fluctuate. It's important to get the blood test done first thing in the morning. We typically don't treat if the morning total T is > 350. The latest press on T therapy includes concerns that it can increase the risk of heart attacks. This is almost certainly NOT true. The major published papers have significant flaws and contradict other studies done before and since.

Erectile Dysfunction

GNT: Is erectile dysfunction an early sign of coronary artery disease? Are there any medications to help those that do not respond to Viagra® and the other drugs currently on the market?
Daniel_A._Shoskes,_MD,_MSc,_FRCS(C): : Erectile dysfunction (ED), especially in younger men, can be an early sign of coronary artery disease (CAD) or heart disease. In one study, men arriving in an emergency room with a first heart attack were asked about ED. Eighty percent had new onset of ED within three years prior. There are multiple therapies for ED. Oral medications include Viagra, Cialis® and Levitra®. There is the vacuum erection device. There are medications that patients can self-inject into the penis, which are very popular and effective. There is also a penile implant/prosthesis that can be inserted in the operating room that is highly effective.

comm: At age 58, I am unable to attain an erection and ejaculate for intercourse. I usually have a couple of drinks daily and I am in a high stress career. This has been going on for a couple of years. What kind of tests do I need to determine a treatment plan? I am a bit embarrassed to discuss it with my physician.

Daniel_A._Shoskes,_MD,_MSc,_FRCS(C): : We start with a full history and physical exam. If you have fatigue and/or low libido, we would also check an early morning testosterone (and related labs) level. Most ED therapies can be offered without extensive testing. We do have tests available, however, that can help better identify the cause (for example, penile Doppler ultrasound). Don't be shy to speak with your physician. He or she has heard much worse!

General Information

jercleclin: What is the best procedure or method to reduce nightly visits to the bathroom?

Daniel_A._Shoskes,_MD,_MSc,_FRCS(C): The best approach is to start with a full history and physical and make a proper diagnosis as to why you are getting up at night. There are multiple possible causes for this, each with their own approach to therapy. In general, everyone can benefit from cutting back fluids between dinner and bedtime and cutting out caffeine at night.


That is all the time we have for questions today. Thank you, Daniel A. Shoskes, MD, MSc, FRCS(C), for taking time to increase our knowledge about men’s health concerns.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative.

For Appointments
To make an appointment with Daniel A. Shoskes, MD, MSc, FRCS(C), or any of the other urologic specialists in Cleveland Clinic’s Glickman Urological & Kidney Institute, please call 216.444.5600, toll-free at 800.223.2273 (extension 45600) or visit us at for more information. 

For More Information

Cleveland Clinic
The Department of Urology within the Glickman Urological & Kidney Institute is ranked No. 1 in the nation by U. S. News & World Report. Urologists in this institute are also recognized worldwide for excellence in patient care, teaching and research in all aspects of urology.

Cleveland Clinic Health Information
Learn more about symptoms, causes, diagnostic tests and treatments.

Benign Prostatic Enlargement (BPH)

Benign Prostatic Enlargement (BPH)

Erectile Dysfunction

Penile Disorders


Testicular Cancer & Self-Exam

Testicular Torsion

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Glickman Urological & Kidney Institute Treatment Guides
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