Good evening and welcome to Doctors on Call back on our we're back on our 45th season at this time.

I'm Dr.

Ray Christensen, faculty member from the department of family medicine and biobehavioral health at the University of Minnesota Medical School Duth campus.

I'm also a family physician at Gateway Family Health Clinic in Moose Lake.

I am your host for our show tonight on men's health and prostate cancer.

Remember, the success of this program is very dependent upon you, the viewer.

So, please call in with your questions tonight and send or send them in ahead of time to our email address askpbsnorth.org.

The telephone numbers can be found at the bottom of your screen.

Our panelists this evening include Dr.

Ryan Harden, family medicine physician with Gateway Family Health Clinic in Moose Lake and Sandstone, Dr.

Benjamin Marsh, a urologist with Essentia Health, and Dr.

Paul Tonkan, a urologist with Tamarack Health.

Our medical students answering the phones tonight are Justine Acasta from Blaine, Minnesota, Lucas Selnus Brown from Grant, Minnesota, and Justine Joyel from North Branch, Minnesota.

And now on to tonight's program, men's health and prostate cancer.

Dr.

Harden, welcome.

It's good to be here.

Want to tell us a little bit about your practice?

So, I do family medicine in Moose Lake and Sansone, Minnesota at Gateway Family Health Clinic.

and I also teach up at the medical school.

Dr.

Marsh.

Yeah, I'm a general urologist at Essentia Health.

I'm the section chair as well.

I've been there for about seven years.

Um, I have a general urology practice.

So, a lot of kidney stones, BPH or enlarged prostates, vasectomies, and then a lot of urologic cancer, kidney, bladder, and prostate.

Dr.

Tonka, welcome.

Thank you.

Uh, nice to be back.

Nice to see you again.

Uh I have more of a rural focused practice.

I work for Tamarack Health.

Uh and I see patients in Hayward, Wisconsin, Ashlin, Wisconsin, and Superior, Wisconsin.

Uh practice similar to Dr.

Marsh.

Um with the exception that Dr.

Marsh does a lot of robotic surgery and uh that is no longer a part of my practice.

Um what's somewhat unique about my practice is that there is more of a blend uh between primary care and the surgical specialties uh based on the fact that we serve a very uh large geographic area um where there's not a lot of access to specialists um and so I would just say that our practice is certainly focused on kind of the whole patient uh as well as preventive care.

Great.

Dr.

Harden, I'll let you start it off.

Can you give me a just a brief summary of what men's health is?

So men's health is the subset of medicine that deals primarily with the male genital urinary and reproductive tract.

So I suspect that callers tonight will have some questions about prostate health, prostate cancer screening, uh low testosterone, erectile dysfunction, things like that.

Dr.

Marsh, we're probably going to focus first on the prostate.

uh you you do a lot of work with it.

That's do you want to tell us a little bit about the things that you see?

Yeah, so there's two kind of main issues that we deal with in the in the prostate.

One of them is like I mentioned BPH, which stands for benign prostatic hyperlasia, which essentially refers to an enlarged prostate that causes urinary troubles, weak stream, frequent urination, getting up a lot at night, things like that.

Um, the other main issue we deal with is prostate cancer.

Um, and of course the different treatments that go along with that.

Dr.

Tonkan, what is BPH?

Well, it's an enlarged prostate.

And this is a very common condition.

So, between 40 and 50% of men in their 50s would would have some evidence of an enlarged prostate.

And as men get older, this becomes incredibly common.

Um, and so, you know, one of the lines I say to my patients is once you get to be that age, your prostate really has no function other than to put my kids through college.

So, um, uh, you know, it's just a very common to having a large prostate and and if the prostate gets too big, very very common to develop urinary obstruction.

Um, and you know, Ben and I certainly treat patients with with medicines and and dietary changes when appropriate, but um, quite frequently um, some sort of surgical intervention is indicated.

So, Dr.

Harden, you're on that front line.

Someone comes in, what kind of complaints do they usually have when they have prostate difficulties and how do you evaluate?

Well, it's it's a common complaint in primary care prostate issues usually, uh, BPH, benign prosthetic hyperlasia or hypertrophy, um, where patients will they'll feel like they have to urinate frequently and when they urinate, they'll have they'll feel like they have a slow stream and it takes them longer to urinate and they'll have difficulty emptying their bladder.

And probably the most common symptom is nocturia which means at when they go to sleep they end up getting up at night frequently to go to the bathroom which can be quite bothersome.

So Dr.

Marsh that with with the symptomatology what kind of studies would you do?

Yeah.

Uh one of them is called a euroflow test.

So basically urinating into a funnel that measures the velocity of your urine stream and there are different cutoffs which might indicate obstruction from the prostate versus non-obstructed.

Um we also typically get a symptom score questionnaire that just measures kind of the degree of bother with something like that.

Um and then sometimes we'll do what's called a cystoscopy.

So taking a small camera and actually looking directly at the prostate to get a better feel for the size of it and and kind of what things look like on the inside.

What kind of blood studies would you do, Paul?

So I was going to add that to what Dr.

Marsh had mentioned.

So um there is some controversy in our field about you know when is it appropriate to get a PSA screening test for prostate cancer.

Um, I would just like to make the point that when a man has urinary symptoms, uh, I would certainly argue that we're no longer talking about screening.

We're talking about you're trying to make a diagnosis and is it possible that a man may have a prostate cancer, potentially a serious prostate cancer that is now causing symptoms.

So, one one key point I would just like to make is, you know, when you're having symptoms, um, I think checking a PSA is almost always indicated.

Um and and PSA, you know, will never be accused of being a perfect test or a great test, but it it is oftenimes helpful.

Um and we're now, you know, in 2026, our imaging studies have gotten so much better.

Um that prostate MRI technology has become incredibly helpful in trying to distinguish between is there really a prostate cancer risk and if so, how serious or is this just straight up BPH and enlarged prostate?

So in there I didn't hear when you think people should just automatically start getting checked.

Dr.

Marsh V. Yeah.

So the again different guidelines from different organizations.

The American Neurologic Association or AUA guidelines would tell us to that every man aed 50 to 69 should consider starting regular PSA screening.

Um there are some recommendations to start a little earlier than that, especially you've got a if you've got a family history of prostate cancer.

um as early as 45 or even 40 sometimes to get a first PSA checked.

Um beyond age 70, things get a little bit more controversial about what the benefits are to continuing screening at that age.

But yeah, that 50 to 69 is kind of the prime time to get PSA screened.

I think one of the reasons it's so controversial is when I was in medical school it was recommended to get a PSA every year and then I think like 2012 they decided that it didn't decrease mortality so they said well you shouldn't get a prostate PSA screening test every year and then in 2018 the pendulum kind of swung back in the other direction and they said well you should talk with your doctor about your goals and values and whether or not you should get a PSA test so yeah it's it's been confusing to patients like what what should they do?

But I agree the recommendation now is you know talk with your doctor about it.

Some people benefit from screening for prostate cancer and can I ask you about that just because um you know it when there's not too many tests we're getting without talking to the patient about things like that.

Right.

So right is that actually much different than just any other test that we're getting?

No.

No it's not.

And a lot of times patients will call into my practice and they'll say that they want to get their labs before their physical exam.

Sure.

and I'll say, "Well, PSA is one that I feel really uncomfortable ordering because it's kind of dependent on the patients values, you know, their family history, whether they've had a PSA test before and stuff."

And it's it's a there's a clinical element to whether or not you should get a PSA done.

Sure.

What are the risk factors for prostate cancer?

Um, well, we know there's a genetic component of it.

If you've got a family history of prostate cancer, you're much more likely to develop it yourself.

Um, there are some genes that are now being identified as being specific risk factors.

Uh, smoking is another one.

Um, agent orange exposure has been shown to cause risk of prostate cancer.

I'm not sure if there's any other age is a big one.

So, certainly the older a patient gets, the more likely are to get prostate cancer.

It's also probably true you're less likely to die from it.

Um and so, you know, one of the things we try to talk about is just, you know, prostate cancer just comes in, you know, different different kind of flavors and and different grades and levels of severity.

Um so, fortunately for the patients that Ben and I diagnosed with prostate cancer, uh the the most common type is a very low-grade cancer, a grade group one cancer, which really has an extremely low lethality, you know, 1 2 3%.

And so really, it's been it's been our norm for more than a decade to to really watch those cancers.

And so I think as time uh goes on, what's going to happen, I think, is that we're going to better understand which cancers are serious and pose real risk and which ones can be watched safely.

And so I think once we better understand that with our diagnostic tools, uh I I think the screening and the watching that we partner with our primary care colleagues is going to really be shown to have some benefit.

So the PSA we talked about Ben how do you diagnose prostate cancer?

What's how do you how do you make that diagnosis?

One is tissue I suppose but what kind of pro what process do you follow?

Yeah.

Um so the really only way to diagnose it is a a biopsy of the prostate.

Um typically that and that pathway has changed.

So now a patient will come to see me with an elevated PSA level or an abnormal PSA.

Um, typically an MR an MRI of the prostate is the first test that we're getting um to evaluate more of what's going on on the inside of the prostate as well as the nearby lymph nodes.

And then if that suggests that there's something abnormal or a cancer there, then a biopsy is the next step.

From there, depending on the grade of the cancer, how aggressive it looks, sometimes we talk about doing additional imaging tests to to make sure the cancer has not spread outside of the prostate yet.

Henry, if I can just add to that, um, uh, what's different, uh, now versus when I started my career, um, you know, going back 20 years, I guess, um, is that when we used to do biopsies, it was done blindly, meaning that we could kind of have a general sense of where the prostate was.

Um, and we tried to get some samples from the right, some from the left, and and now we're using very highly sophisticated computer software that links with our biopsy machinery.

And I actually brought with um one of our grids.

Um, and this this is, you know, fine-tuned down to the millimeter.

And and really our computer software programs help us find these high index lesions.

And so I'm sure Ben and I practice the same way.

We can actually specifically target a lesion as small as a few millimeters uh which from what we see in MRI target that lesion get a few more samples from the other gland but we end up going to any sort of process intervention with a really pretty good understanding of where the cancer is and how serious it is.

How do you treat it?

So there's two main options in this country.

Uh one is surgical removal of the entire prostate.

uh and that's primarily being done robotically uh or in a more minimally invasive fashion.

Uh the other one is radiation treatment to kind of zap the cancer from outside the body with radiation beams.

And they both have their pros and cons and and one may be a good fit for one type of patient and a bad fit for another.

Um but those have been the main stays of treatment for a long time.

Uh there are some newer options that are still considered experimental where instead of treating the entire prostate gland, you're treating just portions of it.

Um and so Amy really trying to be more precise with the cancer treatment to avoid side effects from from treatment overall.

But again, those are still pretty early stage type treatments.

Dr.

Harden, can you live without the prostate?

Absolutely.

Yeah.

So in in your practice if one of your patient this is a question from two or three people if somebody's diagnosis diagnosed with prostate cancer should their brothers go in and get checked and other family members.

Well I I mean I think probably one out of eight men is going to be diagnosed with prostate cancer in their lifetime.

So I would say if somebody has one or two relatives with prostate cancer, I wouldn't be as concerned as I would be if you know multiple family members have prostate cancer or metastic prostate cancer or mo multiple cancers run in the family because there are some genes you can inherit that can increase your risk for other cancers in addition to prostate cancer.

And and another thing about prostate cancer is if somebody is diagnosed with prostate cancer, other treatments could be just watchful waiting where the PSA is tracked over time and if it changes and the and the prostate is examined either through imaging or through a digital rectal exam in the office to see if there's changes that would be worrisome that would suggest the prostate cancer is becoming more clinically significant.

But to answer your question, the people who have family members who have prostate cancer, I think they're in the same boat as everybody else where they should just talk with their physician about their values.

Um, you know, their other risk factors and whether or not they would benefit from prostate cancer screening and and one of the real one important things is they need to know what's going to happen if they have a high PSA.

You know, that's right.

They're going to see it probably end up being referred to urologist.

they might have some additional imaging and there's a lot of anxiety and cost and travel associated with that.

So, um I mean it really is a conversation for everybody whether or not they want to have a PSA test done and there's a lot of discussion on those little one.

Somebody asked about a PSA of 33.

I think probably you need to move on that one.

anytime a PSA is over 20, we start to worry that, you know, not only is it cancer, could be a serious cancer, it's a cancer that may be in the process of spreading.

So, I would certainly recommend uh, you know, working that up.

You know, one of the nice things about what's happened with our prostate cancer diagnostics is, you know, I would I would just make the point that if you have an elevated PSA uh because you and your family doc decided to screen or get one because you're having symptoms, it doesn't necessarily mean you're going to automatically get a biopsy.

I think to Ben's point, prep high likely to get an MRI um of the prostate, but I think as our imaging gets better and I do think there's going to be a role for artificial intelligence to help our radiologists, you know, look at these images um more seriously and and have better agreement between radiologists about what's serious and what needs to be investigated.

I am hoping that the fear of looking for some of these things will be mitigated.

Um because really uh the idea that PSA, elevated PSA equals a painful biopsy in the office setting, I I think those days are uh coming to an end uh sometime soon.

Yeah, I would agree.

And and one more thing I'll say, if somebody has a high PSA, um I mean 30 is relatively high, but if somebody has an elevated PSA, uh it there's other things that can elevate your PSA.

If somebody has BPH, that you know causes a PSA to be chronically elevated.

But if somebody has an infection in their prostate or prostate trauma, um that can elevate the PSA.

So if somebody has an elevated PSA, unless it's really high, I would say they should probably just get it rechecked before they get referred to a urologist.

Sure.

Yeah.

Uh the lab the lab would tell us a cutoff of four is it kind of sends alert signals that that that's considered elevated.

that's kind of an arbitrary cut off.

Um, and so something that Paul and I will often look at is just the patient's age because the actual cut off for what is normal or not is absolutely affected by your age.

I am a lot less concerned about a PSA of four in a 75 year old man than I am in a 50-year-old man.

That's right.

And earlier, Ben, you brought up checking a PSA in in your 40s.

And you're like, "Wow, 40s, 55 to 70 is usually when we check it."

If you have a PSA level in your 40s, the benefit of that is if you have a high PSA in your 50s or 60s, you have something to compare it to.

Sure.

Because it gradually and slowly increases over time.

But if you see a spike in that level of PSA, that's typically more concerning.

So definitely if somebody has a PSA of four when they're 60, but their PSA was 3.8 when they were 40, that's quite reassuring.

Sure.

if you have p high PSA numbers and are symptomatic, should you get tested for prostate cancer?

And I think the answer is yes from my standpoint.

Yeah.

The the odd thing is that there's a question.

Well, a lot of people uh think, well, could I really have prostate cancer?

I don't have any urinary problems.

That's right.

And the fact is that the vast majority of the prostate cancer you're dealing with when it's localized, when it hasn't spread, does not cause any urinary symptoms.

it's growing in a different part of the prostate that doesn't typically cause those.

So, if somebody has urinary symptoms that may be from something entirely other than what's causing the elevated PSA as well.

Should I have my testosterone levels checked at the doctor, Ryan?

Again, a conversation with your physician.

There's typical symptoms that can be associated with low testosterone.

Um, over time our testosterone levels gradually go down as we age.

Whether a low testosterone is causing symptoms that a patient might be complaining of, low libido, fatigue, um, is a conversation with your physician as to whether or not you would want to have that tested and if you know, you want to be ready to treat it if you're going to test for it.

So, I would want to have a conversation with patient about the treatment before we test for it.

Ryan brought up the idea of gain a baseline PSA early in life and I would make the point that there probably is also a role for a early baseline testosterone.

Certainly if you're a 35 year old man feeling good and and you get your testosterone checked and it's low normal.

Okay, fine.

It's just it's just a data point in your chart.

You know, 20 years later now all of a sudden you put on weight, you're lethargic, sex life isn't what it once was.

You get your testosterone checked.

It's low normal.

to Ryan's point earlier, uh probably not testosterone because it's actually similar to what it was, you know, uh 10 20 years earlier.

Um those symptoms that I described are somewhat generic and and certainly depression um and low thyroid and other things can can masquerade as low testosterone.

So, uh I I do see some real value in in in you know, young men gaining a testosterone just to know kind of what their normal was when they were feeling good.

It's a it's a tough one because I mean if you ask your patients uh hey do you sometimes feel tired like are you ever I don't think any anybody's never going to be yeah sometimes I'm really tired.

So the symptoms are ve widely variable but absolutely some of them can be associated.

Yeah.

How important is iodine for your prostate and what is the recommended dose?

I think I think Ryan Harden is a great is a great person to answer that question.

Iodine for the prostate.

This is textbook really textbook.

This is your I think nail it right here.

I It's more important for your thyroid.

Yeah.

Than for your prostate gland.

Um so I think that's what the caller is thinking about.

I I'm not aware that iodine I'm not I'm not aware of a relationship a player in pro.

That's why I tripped it to you.

You guys aren't doing iodine treatments, right?

longer is the I mean it's the first I've heard of it.

The radiation the source of radiation for prostate that's not iodine.

The the seeds that they used to plant.

No.

No.

Those are made of gold.

Yeah.

Yeah.

I'm not aware of any relationship between iodine and prostate health, but uh maybe we'll hear some for the next 5 10 years.

What diet and lifestyle changes will help my erectile dysfunction?

Doctor.

Well, the the diet and lifestyle changes that will help erectile dysfunction are the same ones that will help your heart, that will help your prostate health.

And I would say a regular or a healthy well- balanced diet high in fruits and vegetables, a healthy weight, regular exercise, good sleep habits, um avoiding smoking, and uh avoiding alcohol.

Yeah, I I would say there's there's incredible value in in high quality deep sleep, you know, both for sexual function but also urinary function.

One one of the things that my team diagnoses probably a dozen two time dozen times a year is undiagnosed sleep apnnea for people who present um with uh urinary symptoms.

Um and so we've gotten quite good at distinguishing patients who have minimal urinary symptoms during the day but at night are being tortured by urinary symptoms.

uh that can be an atypical presentation of sleep apnnea.

And if you meet someone with sleep apnnea, you'll also realize probably low testosterone, you know, low libido, probably some sexual dysfunction.

Uh sleep apnea puts you at high risk for stroke and heart attack.

So, um just one of those things that I think uh our listeners should be aware of.

So, getting up frequently at night disturbs sleep.

How how does this affect your deep sleep and your sleep pattern?

Is there a problem here?

There is a problem if you have interrupted sleep.

I mean, we need continuous sleep to be feel rested during the day, not fall asleep when we're driving or watching TV or something like that.

That could be a cause or an effect of prostate enlargement.

And sleep apnnea also, of course, can cause interrupted sleep.

So, Ben, what diet should I avoid if I have kidney stones?

That's a great question.

Um, so I think the the most bang for your buck at preventing kidney stones is going to be fluid intake.

Um, we I tell my patients to shoot for two to three liters of intake a day to try to shoot for about 2 to three liters of urine production.

Um, beyond that, I tell my patients to watch for high oxalate containing foods.

So that's nuts, peanuts, peanut butter, spinach, rhubarb, uh all good things, but unfortunately a lot a lot of oxalate there.

Um and then there are some other dietary recommendations, but those are kind of the the big ones that I tell everyone with recurrent kidney stones.

Nothing to add.

Okay.

Hydrate.

Hydrate.

Hydrate.

I don't know much about euro, but there's a question here about Eurolifts.

What are the long-term effects of a euro procedure?

It's from Grand Rapids.

So, Eurolyft is a procedure that's used for BPH or enlarged prostate.

Um, essentially most of the surgical procedures for enlarged prostate are designed to get rid of the obstructing component while leaving the other important parts intact.

And so, Uralifty is a way to kind of pin open the walls of the prostate.

Is that how you'd describe it?

Yeah, I I think a lot of our procedures and surgeries for enlarged prostate involve removing tissue.

Uft is one of the rare ones that doesn't remove tissue.

It compresses tissue.

Uh and there are permanent implants that are left in place.

Um it is important to you know pick a surgeon who's got a lot of experience with this procedure.

Uh because certainly when you're talking about a permanent implant if that goes in the wrong location that can certainly cause uh you know lifelong issues.

So it's certainly on the list of things.

I'm sure Ben I choose for some of our patients.

Uh probably not one of the more common ones.

I would I would assume I have seen a few patients I don't I don't do a whole lot of euro lift myself, but I've seen some patients that have like Paul was saying implants put in the wrong area and that can cause some chronic pain issues sometimes.

Um so I'm going to have to bring us to a close.

Oh, okay.

Thank you gentlemen.

Great show tonight.

I want to thank our panelists, Dr.

Ryan Harden, Dr.

Ben Marsh and Dr.

Paul Tonkan and our medical student volunteers Justine Acasta, Lucas Selnus Brown, and Justine Joyel.

Please join Dr.

Mary Owen next week for a program on cancer prevention and diagnosis when our panelists will be Dr.

Brett Friday and Dr.

Sandy Stove.

Thank you for watching and have a great night.