Mid-twenties Never had morning wood and my genitals look lik

Patient

Q: Mid-twenties. Never had morning wood and my genitals look like that of a child. Bloodwork shows that t(total: 579ng/dl free: 1ng/dl) levels are normal, dht levels are low but normal(total:18ng/dl free:1.70pg/ml). Took clomid and anastrazole to further up them(t total: 1047ng/dl free: 35.8pg/ml; dht total: 75ng/dl free: 15.20pg/ml), still no morning wood. I can have an erection consciously and my body looks like that of a man with a beard. What could I be missing here?

Doctor

A:   Hello,
Thanks for the query to ATD for an opinion,
I can see hear that absence of morning wood in your case, you have associated it being a probable cause for child like genitals and possible low testosterone levels. Hence you have got your testosterone levels done. I would like to assure you that your testosterone levels are normal and as you have no erectile dysfunction issue or an ejaculatory issue, the prime concern of not achieving a morning wood is primarily sleep related and not hormone related in your case.

The physiology is such:-
In addition to the vivid movie-like dreams that are characteristic of REM sleep, the penis also becomes erect and engorged with blood during these periods. This is due to activity of the parasympathetic nervous system affecting the sacral nerve. This is technically called penile tumescence. When this occurs in the morning, the stiffened penis may be referred to in slang terms as "morning wood" or "morning glory."
Therefore, morning erections are secondary to the timing of REM sleep and the natural physiological processes that are associated with this sleep state in men. It seems that the body is testing systems during sleep, and this is a normal and healthy phenomenon in men. It may even be noted in young children.
So, if you are not achieving morning wood, its nothing abnormal , but possibly your sleep cycle has be disturbed due to increased daily life stress levels which can be physical , emotional , psychological, professional or any. So it is advisable to check stress and opt for de-stressing modalities for a week and observe for yourself. I am sure you shall see the change.

I hope i have answered your query in detail,
Wishing you good health,
Regards

Comments / Follow Ups

Patient: Thanks for your answer. I have two follow-up questions/comments:
1. I do have dreams before waking up(not wet dreams), so I'm assuming i do go through the REM cycle. Is it normal to still have never had a morning erection despite having dreams?

2. My primary concern is really not the morning erections, but the child like genitals...I was only thinking the two might be related. With seemingly normal hormonal levels, what could possibly prevent a male's genitals moving from boyhood to manhood? I have very male-like features (beard, mustache etc), so I'm assuming I'm not androgen insensitive. My urologist ordered a Y-chromosome microdeletion, and the results show that I am negative for deletions in the AZF regions of the Y chromosome. Aside checking hormonal levels...where else should I be looking?
Doctor: 1. Morning erections may not always be associated with dreams or REM, the circadian rhythm which regulates the increased testosterone production by midnight -early morning and also regulates the growth hormone release by pituitary can affect the erection in the morning.
2. once androgen insensitivity and Y microdeletion is ruled out then the only possible cause seems to be left is poor growth hormone release and likely disturbed circadian rhythm.
Patient: Thanks for your answer. I did bloodwork for IGF-1 LC/MS, and my results were normal at 255ng/ml with a z-score of 0.8. I guess that rules out poor growth hormone release leaving possible androgen insensitivity(I doubt I have this, but have done no lab tests to confirm this yet) and possible undiscovered genetic abnormalities.
I have one last question:
1. When I was a child until I was 13, I always used to press and massage my balls(looking back, I'm not sure why I did this, but I started very young and only stopped when I realized my genitals were not growing during puberty at 13).
Also, someone kneed me in the genitals when I was about 10.
Is there any possibility any of these events contributed to my current issue? Could they have messed up some growth structures or something along those lines, and how do I go about detecting(lab tests? scans?) if they did.
I really appreciate your help.
Doctor: I Don't think injury to scrotum or squeezing habit of yours would have caused decreased testicular growth, because it would have caused hydrocele to develop instead. As the growth hormone is also normal and all secondary sexual characters are present with normal testosterone levels , it can be deduced that the present size is natural for you and no real treatment is actually required.

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