good evening and welcome to doctors on call I'm Dr Ray Christensen faculty member from the Department of Family Medicine and biobehavioral health at the University of Minnesota medical school in duth I'm also family doc at Gateway Family Health Clinic of Moose Lake I am your host for our program tonight on men's health prostate kidney and bladder problems remember the success of this program is very dependent on you the viewer so please call in your questions tonight or send them in ahead of time to our email address ask pbsn north.org the telephone numbers can be found at the bottom of your screen our panelists this evening include Dr Rebecca Beach a urologist ol with Aspirus at St Luke's Clinic Dr Nathan Hoffman a urologist with essential health and Dr Addie vorio a family medicine physician with aspir St Luke's Clinic our medical students answering the phones tonight are Riley Berg from bigi Minnesota Alex Higgins from Stewartville Minnesota and Wyatt windhorst from Alexandria Minnesota and now on to tonight's program on men's health prostate kidney and bladder problems Dr vitorio yeah welcome back you were just here last week good to see you U you want to tell us a little bit about your practice yeah um I've been in practice 15 years and it's all been with Aspirus St Luke's um I've wandered around from Clinic to Clinic um I see a full spectrum of outpatient practice so that means I see people in the office only um I do see primarily women but I I will tell you that women have spouses and I see a lot of men you know as well um at the of their disposes so that's usually how they get in yeah exactly Dr Hoffman uh I'm a urologist at St Luke's uh seeing basically the gamut of anything Urologic so lots of prod a lot of prostate issues bladder issues kidney issues as were previously discussed see lots of different types of cancer see different types of urination issues so just a a broad range of what we would call general urology Dr to beach I'm also a urologist at uh SP St Luke's and I see full spectrum adult Urology with men and women's bladder kidney cancers prostate cancers as well as benign things like urinary incontinence and Stones as well so Addie just because you have these men coming to see you yeah let's talk a little bit about men's health because that's part of this show tonight uh what kind of things do you do to for a male that comes in pick your age group if you want to to work with them in their health and make them better yeah and I will tell you do we see men in their 20s and 30s yes but it's typically for acute issues there's not a lot of men in their 20s coming in for a physical at that point um they're usually having an issue or we're talking about STD prevention testing um or not you know doing dumb things to harm yourself at that point um so the men I see who are in the 302 75y old range come in for physicals um come in for visits and I say whoa you're blood pressure looks really high we've got to start working on some stuff can we you know can we check your labs and along with that what do we do well we we check blood pressure that's a screening test we look at cholesterol values and the risk of heart disease um we make sure shots are up to date um we check things like a PSA when indicated and I'm sure we'll talk about that in a little bit um and then we you know do the typical things we do with the counter sex which is colonoscopies and immunizations and then talking about wrist gratification so what that means is you know what is going to be your biggest health risk at that point in your life um and so as men age we know that heart disease and cancer kind of become bigger issues that's great and how do we get more men to come in and do that there the next question well I mean my biggest thing is if you have health insurance come in for your annual visit use it use that very low co-pay or often free visit as a chance to talk to your doctor and troubleshoot and and really figure out am I missing something am I covering something I need to am I doing all I can to stay healthy in the future so Nathan tell us about the prostate so uh in terms of the prostate there's it's a joke that it helps you have kids when you're younger and then it helps to keep me employed when you're older because uh you know it it actually does not have that much of a a physiologic function much past your your 30s but it does tend to cause problems it gives you cancer it gives you issues with urination um um and so that's generally what we see people for we don't actually see a lot of you know General Health and I'm guessing Dr Beach either we do see a lot of people for um as I said urination issues prostate cancer screening specifically the PSA um which has been poo pooed over the last few years but it's still an excellent screening tool that we think is still a um does a great job of screening people for prostate cancer and we also see people acutely for kidney stones and then we work on kidney stone prevention uh in terms of their health and their diet and making some medication Chang sometimes as well Dr Beach maybe give us a little background on the bladder and kidneys too that's a part of our charge tonight yeah of course I think that you know there's a few things that uh I think that everybody should know are reasons to see your doctor if you ever have blood in your urine for any reason if you can see blood in your urine you should be seen by your doctor if um it always should be evaluated I think if you're having troubles with recurrent infections or things like that that or if you're having um you know leakage of urine which is tend tends to be more like a quality of life issue but it can still uh there's still many things that we can do to help make things better and improve your quality of life as well very good um the questions are going right to prostate and we kind of suspect that they might do that uh the first question I have is what what do I what can I do to prevent prostate cancer and are there any screening recommendations so you kind of lit into that a little bit yeah I mean the the the there was as I said a time when PSAs kind of got poo pooed but there are many cancers that would love to have a test that is as quote unquote flawed as PSAs it's still an excellent screening tool yes a PSA that's elevated does not always mean cancer but it means that one of us should get involved in that in that story and in general the things that are hard healthy that you've heard for years keeping your blood pressure low exercising eating right is in gener considered prostate cancer healthy as well so the things you've heard for years to take care of yourself generally takes care of your prostate too when should a man start having his PSA checked I would say that really depends on family history we know that prostate cancers can run in families so for patients that have a first-degree relative so a brother or a their dad um that has prostate cancer they should probably start screening a little bit earlier um I usually start screening those patients about I usually do a baseline about 40 um and if it's less than one then I do another one at 45 and then I start you know usually annual screening about age 50 to 55 depending again on their risk factors the average patient I still think should have maybe have a baseline PSA at 40 and if that's less than one then I start really doing screening about 50 to 505 annually and I usually stop screening about age 70 but it really just depends on what other health issues they have as well and and this can vary between practitioners because a lot of primary doctors will screen with a PSA every 3 to five years you know based it's you need to with your doctor what your risk factors are and what your comfort is with the level of screening you're getting so as a family doc what about rectal exams well I can tell you that our older docs who kind of trained in the you know 80s and '90s still do rectal exams um and PSAs together um what rectal exams actually pick up are anatomical abnormalities of the prostate um in my training um in the 2000s we were taught that that wasn't very specific and it wasn't absolutely necessary as a screening tool but that doesn't mean that when you come into your doctor and you say I'm waking up six times a night to pee or you know I'm having trouble emptying my urine um that you don't need a prostate again those are reasons where you need a doctor to examine you in that area and do the rectile exam yeah I think the thing to remember is is that there's not one size bits all pun intended for prostate issues you know people's prostates size varies their PSA levels vary their family history varies all that stuff and that we as practitioners we all build that into how we screen people and so people who come in with like an absolute hard and fast rule is you know is not always what's needed but again the kind of the cut offs are 40s if you have a family history and then 50s if you know if you're you know asymptomatic and normal without a family history Rebecca what are the best treatments for BPH that is again another very nuanced question but for most patients that present to me with BPH symptoms or having difficulty emptying their bladder I usually start with medications usually start with medication like Flomax or tamsulosin it's a medication it's usually pretty well tolerated you take it once a day um sometimes and it's cheap yeah I mean it's it's been around forever um there are you know other medications that can help uh something called finasteride that can help shrink the prostate but that's not for everyone that has tends to have some other side effects that we would talk about but I do use it pretty often and then there's a number of surgical options for helping with BPH um and really depending on the age of the patient their overall health what their you know sexual activity is or sexual expectations are that all goes into determining what is the maybe a surgical option that might be helpful for them the goals of longevity how long they want the treatment to last and how much they want to do to get it to last that long is generally the the process by which you select them the more invasive the longer they last but the more side effects you have is the general rule and we used to be like we wanted to do one procedure that was going to make it so they never had to be treated again for their BPH symptoms and now we have less invasive things that might get them 5 to 10 years without taking medications have less sexual side effects for when they're younger but then you know when they are a little bit further along or you know depending on their Anatomy then we might do something a little bit more aggressive so now I feel like we're approaching it surgically more in a staged fashion instead of being a oneandone type of situation right the surgeries were dangerous and so therefore you didn't want to do it more than once but now we've got such easy things that we can do we can say all right this is going to get you through your 50s when you're tending to be more sexually active and want the fewest sexual side effects than the fewest time off of work a lot of them have time off work you know but then you're in your 70s the sexual interest is generally less not always um but then also in your 70s you can have more time and you can go through a little bit more to have it be kind of more of a a longer lasting procedure you kind of bring back memories of the 70s I'm this one here and a Gentleman surgeon who used to work at enena who would take a chips every so often he never rendered anyone in continent and it worked really well on a periodic basis just to go ahead and open up yeah Addie what can be done to prevent BPH um you know a lot of that is genetic or hormonally influenced so um you know if your father had issues with BPH or your brother does you are very likely to start having issues you know around the same time frame um we do want men to be physically active and live a healthy life and you not not smoke not drink excessively all those things affect different aspects of how the urine drains um in addition to the prostate so so if you have you know issues where you you know have an alcohol problem we will see urinary retention because of some of the neural receptors that are kind of in the area so it's not the BPH but it's other factors affecting that as well this person's already had a EUR old lift M and that's new and I thought I knew it was but I don't remember so you're going to tell us uh and he's on Flomax but still have to take uh or still have trouble initiating urination a weak stream what else can be done well unfortunately you know the eurolift is another way to basically all these procedures that we've been talking about open up the hole in the prostate wider to allow urine flow better um so that is one potential issues to why someone can't initiate their stream the other one is the bladder actually has to push the urine out and so we're really good making the hole in the prostate wider we're not as good at telling the platter what to do and actually squeeze harder so it would depend on you know is you know but like we said before the eurolift is some one of the ones that's one of the more lesser invasive procedures that doesn't tend to last as long and so as a result this person may need to have someone evaluate them to look at um you know do they need to go to one of the more aggressive procedures to try to open them up even more aggressively or is a situation where the bladder can't squeeze hard enough in which case that's a little bit trickier to fix prostate cancer tell us take us down that road a little bit sure so prostate cancer is a very common cancer in men it affects about onethird of men um in this country um and it the the big thing about prostate cancer is it can be either very benign um or it can be very aggressive and it really um every man's prostate cancer story can be very different so when we typically patients are diagnosed with prostate cancer based on their PSA um or an abnormal exam and then based on that we do a biopsy the biopsy will tell us how aggressive the prostate cancer is and what we should do to treat it so if they have something like glein 6 prostate cancer which is the lowest risk prostate cancer most of the time we will do something called active surveillance or we won't actually treat them but we will monitor them to make sure it does not become something that we need to be more worried about then there's intermediate risk prostate cancer so those are the guys that we usually recommend treatment for either with surgery or radiation and then there's the high-risk prostate cancers that we usually recommend you know treatment if it hasn't spread then still with surgery and radiation but sometimes if it's already spread to other parts of the body then we need to think about chemotherapy hormone therapy other uh multimodal um treatments to help treat or cure that prostate cancer are the Nathan this is probably for you or E either one of you are there uh treatments for cancer that spare the ability for sexual activity yeah I mean uh in radiation and in surgery both ejaculatory preservation is very difficult but erection preservation is generally is generally fairly easy to achieve um and so um it depends on what you define as sexual function ejaculatory preservation and general anytime you mess with the prostate in aggressive way either radiation or surgery that will be difficult but erection preservation we we have many many tools to get erections back um anywhere from just medications that you take as pill form you can do injections of medication and there is actually in a a prosthetic device you can have inserted to basically recreate erections that works really well so I mean uh in terms of treatment it is not a death sense to your sexual activity by your such the imagination Edie I don't want to keep ignoring you sitting over there you look so peaceful yeah is there a difference between PP BPH and prostate cancer absolutely um and the word see you know cancer is the the difference but we don't know um because often times we will have a person come in with an ated PSA and it'll be really bad BPH or it'll be urinary issues with BPH um and so that's the time when you need to meet with your doctor and get an exam as well as speak with one of these um people about you know whether that needs to be evaluated and what is evaluation it's you know if there is a mass found on an ultrasound um which is done over the actual gland then biopsies are taken to either prove or disprove that that's a cancer so very different things one is benign one is potentially dangerous she brings up Imaging MH do one of you want to go down that road and help myself so one of the latest advents I would say probably in the last 10 years is was this idea of using MRI to guide prostate cancer screening um it has been a way to try to determine who in the list has BPH and who in the list has prostate cancer um there's variety of ways um it basically looks at very simply prostate is mostly water and then if you if you have a lot of cells in one place that generally tends to be cancerous and so that's the reason why that area lights up on the MRI and that's the area we direct our biopsies into um and that has improved a lot the people it used to be basically anybody who's at an elevated PSA you you got a biopsy and now we can actually stratify them into okay you have an elevated PSA but it's just because your prosty it's 200 grams or now you have a you have uh you have it an elevated PSA but it's actually because you have this spot in here that's very likely cancerous is that prostate biopsy a office procedure or do you do it in the hospital I do most of my prostate biopsies in the office I think that they're fairly well tolerated um and certainly if anybody's very uncomfortable we would just stop and we can always schedule it for something to be done under anesthesia there are there's a different type of prostate biopsy called the transanal biopsy where you go through the skin underneath the scrotum that tends to be a little bit more uncomfortable those patients usually do get sedated for that procedure mhm as long as we're chatting here are there any new medications we've kind of been through this but just to finish it off yeah are there any new medications or advancements in treating prostate cancer and I think we've finished that but there are some things sitting on the horizon too yeah the the biggest thing that we've learned was the idea that prostate cancer makes its own testosterone it used to be we would you know in in late stage prostate cancer we'd assume that you know we had this thing that turned off testosterone and testosterone is basically food for prostate cancer and so we'd give them that and then that would quit working and we assumed that it learned to grow without testosterone but actually what had happened was is that the Prancer learned to build its own testosterone and then we learned ways for the testosterone to be block at the prostate cancer cell level and that was probably the biggest advance in terms of medications at least and also just the idea that chemo could work we used to assume that chemo could not work for late stage prostate cancer and now there is chemo for it which there wasn't before so both those things have ex you know it used to be you had pric answer you had a year left go to the beach and have a good time because that's all you got and now I got people 5 10 15 years on these medicines that are doing fine or they're dying of their other cancers right exactly mean other problems I mean I think that that has been a huge shift especially in the last eight years that I've been in practice is more use of chemotherapy and all these different antigen receptors that we're being able to interfere with with actually pretty good tolerance um and patients are living a lot longer than they used to did you want to jump in I thought well I think oncology care in general has advanced just because of the the development of antibodies um to use as chemotherapy instead of um just you know cell killing drugs that we give people so there's a lot of Truth to be told about oncology advancing dramatically over the past 15 years across medicine been a lot teaching the immune system to kill it rather than us having to kill it has been a huge step forward can you take Flomax and Viagra together I say yes I would say that I would say if if you're a patient if you're a patient that tends to have low blood pressure at Baseline then I would say you know take your take them 12 hours apart I think is what our my usual recommendation is but most of my patients do not suffer from low blood pressure and I think it's it's fairly safe to take both at the same time now you should never take your n nitroglycerin and your Viagra together yeah that's the only absolute indication if you if you've taken Viagra and you have chest and you have nitroglycerin in your pocket you have to go to the ER and your first words out of your mouth have to be I have chest pain and I've taken Viagra because they'll give you nitroglycerin there too and it's still bad Addie what are the benefits of sap Helo does it help with ED you know that one I don't know the exact we don't think it helps with Ed um we it's a version of a of a drug that we give the finasteride you already mentioned um it's basically a testosterone there's a more potent test testosterone that makes your prostate grow um and so when you when you take testosterone I mean when you have testosterone and it gets converted in this more potent form your prostate gets bigger Soom metal blocks that conversion with the finast that she mentioned earlier is is the other way to do it medically and and all the other ones you see the Super Beta Prostate those are other versions there of of the of what are called the plant steriles the the medicines that I mean sorry the herbs that block that conversion process I would say the studies are pretty mixed on how much it helps urologist the studies have not been consistent have not consistently shown that it's that beneficial that our medications actually work better correct and the other issue is the fact that those those are fairly unregulated in terms of what they actually get and so like they did this study one time where if you got the the you know the I forget I don't want to poooo any specific store but one store saal was like 99% soal and the other stores was like 2% and so those studies which are all have to be done in that fashion you just don't know what you're getting this is an adult male with surgery for an undescended testicle as a child will this have any effects on fertility or other long-term issues and go ahead yes I mean that undescended patients that have had an undescended testicle and have had surgery are at higher risk for um fertility issues um that testicle sometimes is is not very good depending on when the testicle then when that surgery was performed if it was done as a child it has a chance of being successful of producing testosterone and um sperm but there's a chance that it might not be as fertile as the other testicle as a normal testicle um especially depending on the age that that was performed it also is in um those patients also have an increased risk for testicular cancer and so they should be screening themselves with self exams um where if they have that history of an un a testicle and wear a cup and protection always wear protection yep protect protect the remaining boy yes so we've been dancing around testosterone the Fountain of Youth so there's a lot of this going on out out in the public now there's a lot of discussion about it uh advice I think people to see me to talk about testosterone always say I want it checked I it's got to be the cause of my fatigue of my lack of ability to get an erection of you know numerous things that are very common and that are very much associated with other more common things like obesity like smoking like other medications they take diabetes alcohol use drug use um or depression mental health issues so so when someone comes to my office am I willing to check a testosterone if they want it yes but by and far I can tell you most people are going to have a fairly normal level when we do check um when we do see an abnormally low testosterone especially in a younger person that's a reason for me to refer to my colleagues yeah and and in general I can say that in the number of I mean I do see a fair amount of blow testosterone there's a lot of argument as of what a quote unquote normal testosterone really is because You' assume that the testosterone of a 20-y old should be different than the testosterone of a 70y old but even using that what we used to there's a there's a paper that came out about the age adjusted testosterone even using that replace them to that age adjusted level not everybody feels better testosterone is not the elixir of life you know it's one part of a much larger Health picture than than just this one value Rebecca we're getting down in time but the question is kind of floating around Pyon disease uh is there any cure or procedure for Pyon disease maybe tell us what it is a little bit too so Pyon disease is one minute is angulation of the Tes or the the penis when you have an erection so sometimes usually it's painful when it's just starting we don't always know why it happened um treatment really just depends on how symptomatic you are if you have some curvature to your penis and you're still able to have intercourse the way you want to then we we we leave it alone um but if patients are having pain with penetration or can't have penetrative intercourse and that is what their goal is um then there is lots of treatment options out there um including injections um medications to help improve erections uh penal prosthesis or other surgeries to help straighten in the erections none of them are perfect um it's it's a it's a conversation that really just depends on the degree of bother and the um the goals real quick question Lutz what does that stand for lower urinary tract symptoms so meaning how your bladder functions how your urine gets outside your body I want to thank our panelists Dr Rebecca Beach Dr Nathan Hoffman and Dr Addie vitorio and our medical student volunteers Riley Berg Alex Higgins and Wyatt windhorst next week join Mary morouse for a program on Mental Health focusing on anxiety and its effects thank you so much for watching have a great night and panel thank you e