The Armor Men's Health Show

EP 657: Where There's A Will(y), There's a Way: Dr. Mistry on ED and How Anyone Can Achieve an Erection with the Right ED Treatment

• Dr. Sandeep Mistry and Donna Lee

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In this segment, Dr. Mistry and Donna Lee answer listener question about ED after TURP (TransUrethral Resection of the Prostate) procedures and ED treatments including TriMix injections, the vacuum erection device, and inflatable penile prostheses. Our team at NAU Urology Specialists are experts in these and other cutting edge treatments. The vacuum erection device is a non-surgical treatment that uses suction to achieve an erection maintained with a penile constriction ring. The silicon prosthesis is entirely concealed within the body and inflated using a pump implanted into the scrotum, producing a rigid and satisfying erection that appears natural and soft when not in use. Dr. Mistry explains that the penile prosthesis is an excellent option for addressing a variety of patient concerns from end stage ED to nerve damage from diabetes or neurologic issues. Importantly, he points out that long-term ED actually diminishes the length of the penis over time, so the penile implant can actually help those struggling to achieve erections--no matter the reason--to maintain their size. If you or someone you love would like to learn more about treatment options for ED, please give us a call today!
 
Voted top Men's Health Podcast, Sex Therapy Podcast, and Prostate Cancer Podcast by FeedSpot

Dr. Mistry is a board-certified urologist and has been treating patients in the Austin and Greater Williamson County area since he started his private practice in 2007.

We enjoy hearing from you! Email us at armormenshealth@gmail.com and we’ll answer your question in an upcoming episode.

Phone: (512) 238-0762

Email: Armormenshealth@gmail.com

Website: Armormenshealth.com

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 Round Rock, TX 78681

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Dripping Springs Office
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 Dripping Springs, TX 78620

Speaker 1:

<silence> Welcome to the Armor Men's Health Show with Dr. Mystery and Donna Lee.

Speaker 2:

Hello and welcome to the Armor Men's Health Show. This is Dr. Mystery , your ever humble host. Joined as always by my even more humble co-host, Donna Lee. That's

Speaker 3:

Right . Super humble over here. Looking really cute.

Speaker 2:

We love this show. We love the opportunity of doing this information gathering and transmitting service for the citizens of Austin, greater Austin area and the entire world.

Speaker 3:

I was gonna say just Austin . No, the entire world we're so humble.

Speaker 2:

The other day I was going to the operating room and I was helping one of my partners , uh, take out part of a kidney. And the husband was like, you're not gonna have Donna Lee back there, are you <laugh>? And I thought that was pretty funny. And

Speaker 3:

I was in the back scrubbing that <laugh>. That's right.

Speaker 2:

Little do they know. That's

Speaker 3:

Right. When I pop that glove, all those guys get excited.

Speaker 2:

Dr. Donna's not just a joke.

Speaker 3:

That's right . <laugh>.

Speaker 2:

This is a men's health show. This is brought to you by the practice that I started in 2007 NAU Urology specialist. Gosh,

Speaker 3:

You're old. We

Speaker 2:

Are old now. Uh, we have seven physicians that are a part of our practice.

Speaker 3:

Isn't that crazy?

Speaker 2:

We have six mid-level providers, two pelvic board physical therapists, a sex therapist, a health coach, 14 providers in all.

Speaker 3:

Wow.

Speaker 2:

We have availability even as early as today or tomorrow to see a patient, which is something you won't get always in a urology practice. No.

Speaker 3:

And recently it was like a three month wait. So you're welcome. Community.

Speaker 2:

This last week, 93% of our phone calls were answered.

Speaker 3:

Shut up.

Speaker 2:

That's a pretty big number.

Speaker 3:

Wow. I mean , that's weird for Austin 'cause nobody's answering their phones anymore.

Speaker 2:

So when it comes to taking good care of you and giving you service, we believe in the three A's . Availability is the big one .

Speaker 3:

I always forget the a's you

Speaker 2:

Do

Speaker 3:

Affability , that

Speaker 2:

Means being nice.

Speaker 3:

Accountability.

Speaker 2:

No ability ,

Speaker 3:

Ability to answer

Speaker 2:

The

Speaker 3:

phone .

Speaker 2:

Being able no to do , to do what's right for you medically. <laugh> , oh, there's that <laugh> . Donna, why don't you tell people about our offices and , uh, how to get ahold of us. That's

Speaker 3:

Right. You can call us and we'll answer the phones at (512) 238-0762. We are located all over central Texas, round Rock, north Austin, south Austin and Dripping Springs where we're in more often these days. So we used to be there like every now and again, like once a week or so. But we're there like a lot now. So if you're in Dripping Springs three days

Speaker 2:

A week . That's right.

Speaker 3:

And you got a little peepee or p poop problem. Just peepee. We'll , we'll help

Speaker 2:

Nipples to the knees. Nipples to the knees . Stick to the stick to the message.

Speaker 3:

Sorry. Nipples to the knees. Dripping springs. You

Speaker 2:

Got a question for us today, Donna?

Speaker 3:

You know, I do. Are you ready?

Speaker 2:

Go ahead.

Speaker 3:

This gentleman is so patient. He said, Dr . Mystery , my prostate was removed with robotics and now I have full-time ed, which is also a recile dysfunction. Viagra doesn't work and pumps did not work. So what is my alternative without surgery? I'm 78 and in good health condition.

Speaker 2:

So this gentleman is experiencing a relatively unfortunate and common problem, which is severe erectile dysfunction after a radical prostatectomy.

Speaker 3:

Hmm .

Speaker 2:

The first thing I want to do is explain to the patient and to similar patients in his situation where you don't want to go. What, what avenues you don't want to pursue if the medications are not working at all and you're getting zero erection at all. Mm-Hmm .

Speaker 3:

<affirmative> with

Speaker 2:

Medications, then doing something like shockwave therapy where we use low intensity shockwave or ultrasound waves to help regenerate the penis is not going to work.

Speaker 3:

Right.

Speaker 2:

I've had countless patients that have spent thousands of dollars unnecessarily and uselessly , uh, on this technology. And I feel that the providers that give this option to these types of patients are doing a disservice and are doing something wrong because the nerves aren't there anymore. You're not going to help regenerate them. And using this technology is not something that works well. The second thing I'll say is the second statement that he made, he said that pumps do not work. Mm-Hmm . And what he's referring to is the vacuum erection device. Right . VED , we sell them from our office. There's a manual one. If you have good hand dexterity or an electronic one or a electric one, if you don't , uh, have great hand dexterity and if it doesn't work, then you are not using it. Right. It's that simple.

Speaker 3:

Really every time. It ,

Speaker 2:

It works every time,

Speaker 3:

Huh ?

Speaker 2:

Because it's as simple of a mechanical device as it you , you know, it's just, it's just Right . Something sucking your penis hard. Wow . That's all it is .

Speaker 3:

That is exciting. And

Speaker 2:

So if it's not sucking it properly, then it could be that the skin of your scrotum is coming into it. It could be, you're not seeding it correctly on your skin. It could be that you're not giving a good enough vacuum seal to get the, you know, the air pumped out of it. Or it means that the ring that you're using, because you have to use a ring and a lot of patients don't know this, it doesn't just like, like allow the blood to go into it and you pop it off and everything's fine. You actually have to keep that blood in the penis with a constrictive ring.

Speaker 3:

It comes with it, right?

Speaker 2:

It does. But the three that it comes with small, medium, and large. I mean, not all rings are made for all men,

Speaker 3:

Not all penises. Small, medium and large.

Speaker 2:

Yeah. I

Speaker 3:

Thought that they were , and

Speaker 2:

Actually there's no small, it's, it's like, it's like large, extra large and double extra large. Like Yeah . <laugh> , our men can't take that kind of

Speaker 3:

White, black and Indian. Is that what you're trying to

Speaker 2:

Say <laugh>? There's not, yeah, there's no tie. You know what I'm saying? There's , there's no tie , there's no tie size. Aw . So, so you have , um, you have to recognize that if the vacuum erection device isn't working, then you may have the wrong constriction ring and there are thousands of rings. Thousands, literally.

Speaker 3:

Mm-Hmm . <affirmative> .

Speaker 2:

So you have to be kind of inventive and curious and, you know, exploratory to find the right ring for your penis size.

Speaker 3:

What if you, what do you do if if it's not in the box, it comes with the v eed . You just go online.

Speaker 2:

They make 'em online. We like a company called Eddie by Giddy. You'll see them on your Facebook page and may think that they're just kind of spam, but Right.

Speaker 3:

But,

Speaker 2:

But we use that all the time. We don't get paid by them, unfortunately here on the show. But we should <laugh> , but we do use them. Um, and trying to find the right, the right ring is key to making the vacuum work. Mm-Hmm .

Speaker 3:

<affirmative>

Speaker 2:

There are things that we do. In fact, sometimes the scrotum can be real high riding , uh, and it can get sucked into the device.

Speaker 3:

There

Speaker 2:

Are patients that will do what's called a scroop plasty on, it'll give them a longer appearing penis. It'll keep the scrotum further away from the base of the penis and give them a much longer , uh, erection for them to be able to have intercourse. I actually have a couple scheduled , uh, this , uh, month alone scroop plasty for improved use of the vacuum erection.

Speaker 3:

Is that like scrotum where they put the Botox in the scrotal area ?

Speaker 2:

No, that's a , that's scrotox

Speaker 3:

Scrotox. Sorry.

Speaker 2:

Scrotox scrotum. Scro otoplasty.

Speaker 3:

Scroop plasty is different. You've

Speaker 2:

Now said it four times.

Speaker 3:

I know .

Speaker 2:

Relax.

Speaker 3:

So excited about this .

Speaker 2:

The next thing that we have are injections that you deliver into the penis right before intercourse. And this is about one of the most successful, unique, strange things that we would ask a man to do, which is to inject his, you know, I mean , uh, it's not a filler, so it's not gonna just stay up. It stays up for about an hour or two, is kind of what our goal is. Mm . Uh , 30 minutes a outta time. That's a poor <laugh> . Donna's like, what are we gonna read for the next hour and a half?

Speaker 3:

Do you have one that lasts for two minutes, <laugh> or less?

Speaker 2:

So the Trimix injection , uh, is what we do. There used to be a medicine with just one of the components called Alprostadil that was called Caverject. And that's still available, but that costs about $40 a dose. The trimix injection costs about $3 a dose, but it's a little finicky. So if you're out there and you've been using the trimix injection, and sometimes it works and sometimes it doesn't work and this, that, the other, and you're not sure why, please come and see us. It's a finicky medication because one of the components degrades quickly outside of the freezer. And so a lot of patients, they take it in and out of the freezer thinking that it will stay longer when it won't. Once you take it outta the freezer the first time you have 30 days to use it. Oh, and that's it.

Speaker 3:

Okay.

Speaker 2:

So if you're not having sex 10 times in 30 days and you have a 10 dose vial, then you're gonna waste half of it. So you either have to have more sex or the vials have to be smaller. And that's what we work with you. So if you're having sex 10 times a month, then I get you a 10 dose vial. If you're having sex once a month, then I get you a one dose vial. There

Speaker 3:

We go. So

Speaker 2:

You're not wasting the medication. I

Speaker 3:

Like that up .

Speaker 2:

But if your doctor doesn't understand your sexual patterns, then they're not going to modify their dosage to your particular personalized needs.

Speaker 3:

How often do people lie? They're like, I'm having sex a hundred times a month. And they're

Speaker 2:

Like , men never lie about how much sex they're having. We're trying to brag. Oh, well

Speaker 3:

That's lying sometimes with the wife's standing behind 'em and going , shaking her head.

Speaker 2:

Yeah , no, please don't half of that, half of that. No, no, no. That men don't try to brag to their urologist.

Speaker 3:

No,

Speaker 2:

No, I'm not, I'm not their golf buddy. <laugh> . You know, so they're usually pretty accurate, especially when it comes to, to money. How many of these pills do you need? Eh , if you just give me two, I'll probably last the whole year. <laugh> Michael. And , and , and so when it comes to the final option, which he already said he doesn't want, he said he does not want surgery. And surgery would be the inflatable penile prosthesis. It is a three piece silicone device that we place completely internally that you pump up and get an erection. And what I would say to that man is this, you're 78 years old, how many more years do you think you're gonna have on this planet where you get to actually have intercourse with somebody? Mm-Hmm . <affirmative> . Because you have to have a willing partner, which is actually the hardest part. And then you have to take intercourse. Like seriously. The longer you wait after your radical prostatectomy to visit a doctor like us that can do a prosthetic implant, the less likely you are to actually enjoy intercourse later into your years and relationships, coupling behavior. Let's say you're single, but you think that you, you know, wanna help out the young ladies of Sun City , uh, with your personality. If , if you go too far from the getting out of the habit of having sex, you will never get back into it. I've just seen it too many times. The inflatable penile prosthesis is paid for by your insurance, which is so strange most of

Speaker 3:

The time .

Speaker 2:

Many times. Yeah . Especially when you're 78 years old. Yeah. And it's a simple operation that takes us about an hour and a half the recovery's a few days, and then you get to use that thing in six weeks. We would love to see you. And although you may not want surgery, I don't want surgery. Well, if you're not, you know, you really have to assume that I'm not holding back some magic treatment from you.

Speaker 3:

Right.

Speaker 2:

Because I think that's what patients think. Well, are you sure? You have nothing else? I'm like, I'm here to help you have sex. I really am. And so we would like to help you have sex, Donna . How do people get ahold of us and come and see us.

Speaker 3:

Call us to have sex at 5 1 2 2 3 8 0 7 6 2 and visit our website, armor men's health.com for

Speaker 2:

A good time. Hello and welcome to the Armor Men's Health Show. This is Dr. Mystery , your host. Join my, my very funny co-host Donnel Lee .

Speaker 3:

Hi everybody. Welcome to the show and happy day to you.

Speaker 2:

You may wonder , uh, how we have such a great repertoire. It's really because of me, but Donna is also a professional comedian and she was voted what ,

Speaker 3:

Uh , seventh funniest mom in America by Nick at night , like 105 years ago. But it still counts because I'm still alive.

Speaker 2:

That's right. It still counts. It still counts. And I've met a lot of funny mothers. Uh , no I haven't. Whoa . So it's actually a small group of people that you're a part of, so that's great.

Speaker 3:

Nice. Well, you know, I was in a restaurant the other day with my husband and somebody in the back. It was an Asian restaurant and no offense to my people, but they were fighting, the cooks were fighting in the back. It was hysterical because they didn't know how to say a proper slang English word. Mother effer .

Speaker 2:

Yes. So

Speaker 3:

He just kept saying, you are effing your mother. You are effing your mother. And I was like, we are in the wrong place right now.

Speaker 2:

He was actually the guy's dad. He was really upset.

Speaker 3:

He was correct.

Speaker 2:

He was correct. He was correct. He was doing it . If you are a Sun City resident, we have a treat for you , uh, on November 15th from two to four in your activity center. We are coming to do our go with the flow event.

Speaker 3:

Mm . Where

Speaker 2:

We show you all the ways that we can help make America pee again.

Speaker 3:

Mm .

Speaker 2:

<laugh> we have , uh, it's like the prostate carnival, but it's also for women. We're gonna talk about Mm-Hmm . <affirmative> stress incontinence and urgent incontinence options that we have for women. We'll talk about fecal incontinence in case that little streak in your underwear is getting a little bit bigger than you had hoped that your age. We're gonna talk about enlarged prostate and overactive bladder in men. Everything from medications to all 10 of the surgical options that we have for you. Wow. And so if you have some kind of treatment that you heard about in the locker room or on the golf course or anywhere else, you get your medical advice , uh, and you wanna learn more about it, don't be limited by who your urologist is. Come and learn about all the different things. And you get to spend two hours with me and Donna Lee. That's

Speaker 3:

Right. Those Sun City people know how to party. I've been to their health fairs. They they got it going on there.

Speaker 2:

I mean, it ends by five 30, but they're all drunk by five 30.

Speaker 3:

You know what, we , we older people in life can do things at noon that young people do at midnight.

Speaker 2:

Yes. Isn't that, isn't that funny?

Speaker 3:

It's, it's a , it's a passage July .

Speaker 2:

I look forward to going to bed at eight o'clock. <laugh> <laugh> . That is November 15th from two to four in your activity center in

Speaker 3:

The Florence room.

Speaker 2:

So , um, being a urologist and this show has given me a lot of good feelings, A lot of , uh, great karma from, from our audience and from the patients that see us. Mm-Hmm. <affirmative> . So I really appreciate , uh, everybody that , that pays attention to us. Donna, how do people get ahold of us and where are our offices? Send

Speaker 3:

Us your good juju and karma to 5 1 2 2 3 8 0 7 6 2. That's our number that you wanna share it with. And then if you wanna send us a message because you love us so much, it's armor men's health.com. We're in Round Rock, north Austin. South Austin in Dripping Springs, Texas. I have questions.

Speaker 2:

Let's do it.

Speaker 3:

Alright from this gentleman. I am a 67 year old type two diabetic and I've struggled with Ed for years. I used pills years ago and they progressively got less effective. I tried shockwave therapy and had absolutely zero success with that. Get that quite a bit, don't we? I then went to the trimix injections, which worked, but is almost impossible to orgasm with trimix in inject injection . The erections don't seem to be as firm as they once were. My family doctor has me on one CCC of testosterone every two weeks. With all that said, I'm now thinking about a penile implant. I know there are pros and cons with this procedure, but the satisfaction rate is very high from what I read. I guess my question is, is the next logical step in our request for satisfying sex life, the penile injection? He said implant.

Speaker 2:

It's a great question and it really dovetails well on kind of the, the end of our last conversation. Right ? So let's talk about what a penile implant is, what it isn't. But I first wanna talk about lack of orgasm , uh, in patients. So if you are on any type of treatment and you are having a delayed or difficult time orgasming, there are treatments available to you in our clinic. We will do something called pelvic floor physical therapy that does help relax the pelvic floor musculature and allow that reflex of an orgasm to occur.

Speaker 3:

Wait, I need to interject. A lot of the patients that I talk to that do pelvic floor physical therapy at our office or some other office are absolutely amazed with the results and they had no idea it was an option for them. And

Speaker 2:

A lot of pelvic floor physical therapists do not have a , uh, a lot of experience with men.

Speaker 3:

Yep .

Speaker 2:

And that's what makes our place so unique when it comes to our, our program here.

Speaker 3:

Mm-Hmm. <affirmative> .

Speaker 2:

We also use a herbal extract very frequently called yohi bean . We use one that's compounded, so it's not one that you're buying from a nutrition store or wherever, and it's a much higher dose yohi bean . It is a medicine that does have some side effects potentially with high doses. So that's why taking it with our care is something important. I would caution people against every two week testosterone. I think that weekly, the more frequently you do it, the less you have ups and downs. Uh oh . And there can also be more side effects like hypoestrogenism and elevated red blood cell counts.

Speaker 3:

Okay.

Speaker 2:

So we do self-injection teaching here for weekly testosterone. And some of our patients are even doing it a couple times a week just so that they don't have the highs and lows

Speaker 3:

And it's really inexpensive.

Speaker 2:

That's right. Very inexpensive. So if you are on trimix injections and you are having difficulty orgasming, the first question is whether you're on any medicines that could be preventing you from orgasm. Second is we want to make sure that you're not confusing orgasm from. Orgasm is the feeling you get. is the fluid that comes out of you. And sometimes diabetics, especially severe diabetics, will not have any fluid that comes outta them anymore just because of their medical condition.

Speaker 3:

And it really feels the same though if they have a retrograde.

Speaker 2:

We say it does,

Speaker 3:

But you don't know.

Speaker 2:

But I don't know. But our patients, and , and maybe it's because they, the old guys didn't complain and the young guys now complain. I don't know.

Speaker 3:

Hmm .

Speaker 2:

You know this, you know, the boomers could handle anything. My generation, we complain about everything Dan ,

Speaker 3:

Millennials,

Speaker 2:

<laugh> , I think I'm Gen X ,

Speaker 3:

You're Gen X , but I'm talking about the millennial patients or like,

Speaker 2:

So then you have moving on to this. So if you are on trimix and you can or orgasm with a flacid penis but can't after the trimix, then we just need to adjust your dosing. You might need to be on a different type of medication. You're all pros may be too high. And then we have this awesome cream that you can put on the , on the very head of your penis called trimix gel. Or it can be something called a capsaicin gel. And both of them can help improve the sensitivity of the head of your penis and make it easier to orgasm

Speaker 3:

Are directions to rub vigorously for five minutes . That's ,

Speaker 2:

That's my , that's my favorite <laugh> . That there was a medicine for female sexual dysfunction called zest. And it was an ointment that you rubbed vigorously into the clitoris for 15 minutes prior to intercourse.

Speaker 3:

Vigorously was work , which you just love it.

Speaker 2:

I think that's just called foreplay. <laugh> <laugh>

Speaker 3:

No's pleasure.

Speaker 2:

So if you are interested in a penile implant, it is a three piece silicone device that's usually placed through one incision in our practice. It'll be a , a side to side incision right over the top of the penis. Mm-Hmm . Or a up and down incision right where the penis and the scrotum meet.

Speaker 3:

Mm-Hmm. <affirmative>

Speaker 2:

The surgery takes about an hour to an hour and a half. It is done in an outpatient setting in some, in some hands,

Speaker 3:

Really

Speaker 2:

In our hands. We usually keep you in overnight just so you can get some pain control and some extra antibiotics. You'll have to have a catheter overnight. All of this sounds terrible. It

Speaker 3:

Does.

Speaker 2:

But in the end, what you end up with

Speaker 3:

Is a big peepee

Speaker 2:

Is absolutely an amazing feat of engineering. And it was invented at Baylor College of Medicine where I trained of course the absolute mecca of urology. And so that surgery, all the components are inside you, so there's nothing that shows, and when it's deflated, you can't notice it.

Speaker 3:

Hmm . Satisfaction

Speaker 2:

Rates are very high, just as the listener noted, because these are people at the end of the rope. They're people that are desperate to maintain a sexual relationship or a capability and they're not satisfied with the options they've been given. Mm-Hmm.

Speaker 3:

<affirmative> . So

Speaker 2:

Satisfaction rates are over 90%.

Speaker 3:

Wow.

Speaker 2:

The healing is a couple of days, maybe a week of being a little bit of ginger ness because of your, you know, the, the swelling that can occur from the surgery. And then you have about five weeks after that where you can't use it. Please don't use it early. Okay.

Speaker 3:

<laugh> .

Speaker 2:

And then , then things tear and break and bruise. And then when you start using it, you'll pump up this little third ball in your scrotum and it gets you a hard erection and you get a really good experience. And because there's no drug circulating in the penile tissues , uh, you get full rigidity and you hopefully will maintain your ability to have satisfying orgasm.

Speaker 3:

Wow. When

Speaker 2:

You're a diabetic, the most important thing to recognize that your infection rates are higher if your blood sugar's uncontrolled. So depending on which surgeon you use within our clinic, there are different thresholds of your hemoglobin A one C or your diabetic control that are going to be important. The surgery can be done in a couple of different ways. You really want to go to somebody that does a few of them. You know , you don't want to go to somebody who's only one that year. Right.

Speaker 3:

And

Speaker 2:

We have two prosthetics surgeons within our practice. Doctors Yang and Dr. nw, both who are well trained on the penile prosthesis. Uh , they trained with really the masters in this country for this procedure. It's a very good solution for those of you with severe Peyronie's disease because the cylinders that are within the penis can be bent straight and that helps you maintain some of the length of your penis. That can be a concern that some men have. The cost of it usually is covered by insurance depending on your deductible. I have to be careful to say it's always covered because that doesn't always happen . We

Speaker 3:

Had a very put

Speaker 2:

Management

Speaker 3:

With , he had a weird insurance and it wasn't covered ,

Speaker 2:

But Medicare covers it. Mm-Hmm.

Speaker 3:

<affirmative> ,

Speaker 2:

Uh , your TRICARE covers it and oftentimes we can get your Tri West benefits to cover it. And your advantage plans your h hm o your , your Medicare advantage plans often will cover it. So if you are out there wondering about what you can do and, you know, erectile dysfunction can lead to a lot of psychological issues.

Speaker 3:

I'm sure.

Speaker 2:

Not just for the man.

Speaker 3:

Yeah.

Speaker 2:

A lot of women feel like their husbands are not attracted to them, but in fact it's a debilitating physical deficiency that doesn't allow us to have an erection. And so when you can't Interesting . You know, fill the bill sometimes your , how you become intimate with your partner changes. We're

Speaker 3:

Calling her bill now.

Speaker 2:

Okay. <laugh> Donna, how do people get more information from us? You

Speaker 3:

Can call us at (512) 238-0762. And you know it's not covered by insurance boobs.

Speaker 1:

The Armor Men's Health Show is brought to you by NAU Urology Specialist. For questions or to schedule an appointment, please call 5 1 2 2 3 8 0 7 6 2 or online at armor men's health.com.