In this episode of Pearls and Perspectives, host Amy Pearlman, MD, is joined by Joshua R. Gonzalez, MD—a board-certified urologist and sexual medicine specialist based in Los Angeles, California—for a candid, inclusive conversation on sexual health in men who have sex with men (MSM) and how urologists can better meet the needs of this often-overlooked patient population. Gonzalez shares how his fellowship under Irwin Goldstein, MD, helped him develop a broad, inclusive approach to sexual medicine, one that reflects the diversity of human experience across gender, orientation, and identity. Together, Pearlman and Gonzalez discuss how standard definitions of sexual dysfunction often rely on heteronormative models—especially around conditions like erectile dysfunction, premature ejaculation, and delayed ejaculation—and why a more nuanced clinical lens is necessary. They dive into Gonzalez’s work as co-founder of Popstar Labs, a sexual wellness company launched during the pandemic to meet real patient needs—starting with a supplement aimed at increasing ejaculatory volume. Gonzalez explains how this came directly from patient feedback, particularly from gay men, who described how volume contributed to pleasure, identity, and confidence. They also explore how this interest intersects with broader themes in men’s health—like sexual aging, performance expectations, and the underappreciated role of ejaculation in orgasmic satisfaction. The conversation covers practical, case-based strategies for counseling MSM patients: how to ask about types of sex in a culturally sensitive way, how anal sex or topping can influence erection requirements, and how tools like intracavernosal injections and at-home phenylephrine can be incorporated into individualized treatment plans. They also discuss delayed ejaculation, sounding, edging, pelvic floor dysfunction, and the use of physical therapy and Botox to address pain with bottoming. Later, they turn to procedural care—specifically penile girth enhancement using hyaluronic acid fillers—and how sexual practices may affect timing and technique. Gonzalez shares safety pearls on sounding, anal toys, and erection rings, emphasizing harm reduction over judgment, and urging clinicians to meet patients where they are. In his closing message, Gonzalez challenges urologists to move beyond assumptions and create space for patients of all identities to talk openly about their sex lives. “Meet people where they’re at,” he says, “and give them the tools to have better sex—safely and confidently.” Chapters 0:00 - Introducing Joshua R. Gonzalez, MD 5:00 - The Origins of PopStar Labs 13:42 - Addressing Ejaculatory Volume 18:19 - Talking with Patients About Sexual Activity 26:06 - Practicing Safe Sounding 38:09 - Treating Premature Ejaculation 50:43 - Penile Girth Enhancement

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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