[Music] 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 duluth campus and a family medicine physician at gateway family health clinic moose lake minnesota i'm your host for our program tonight on men's health and kidney stones please remember the success of this program is very dependent on you the veer viewer so be sure that you call in your questions or email them to ask at wdsc.org the number on the telephone numbers can be found at the bottom of your screen our panelists this evening include dr toga hanhan a family medicine physician with st luke's lakeview medical clinic two harbors and dr benjamin marsh urologist with essentia health our medical students answering the phones tonight are melissa edgar from castle minnesota michael goodman from marshall minnesota and shane johansen from austin minnesota and now on to tonight's program men's health and kidney stones well good evening toga tell us a little bit about your practice i'm a family medicine doctor up at lakeview in two harbors minnesota it's pretty broad spectrum we have a small community hospital up there and a clinic as well but it's uh fairly typical i think for a lot of rural minnesota communities and dr marsh you practice already sencha can you tell us a little bit about your practice and what you do sure i'm a urologist at essentia i practice general urology so it's a little bit of everything i treat men women and even some children most common conditions i treat are kidney stones enlarged prostate a lot of urologic cancers such as prostate cancer bladder cancer kidney cancer do you basically stay in duluth or do you visit some of your outstates i do outreach in moose lake actually good for you yep twice a month very good toga we talked a little earlier i think we should start out maybe just discussing what's men's health and what at your office what do you tell me if i come in for a preventive exam or whatever those exams are uh what would you tell a man about men's health yeah well i think uh when we think about men's health we'll get into the specifics of things that are unique to men today but what is good for women is also good for men and the number one killer of men's continues to be cardiovascular problems heart attack etc in heart disease and so uh when i think about men's health first and foremost uh it all comes back to living healthy so exercise good healthy diet and trying to avoid some preventable conditions such as diabetes etc dr marsh from a urologist standpoint do you want to weigh in on this also sure so from my perspective probably the most common things that i'm talking to men about in this topic would be making sure they're updated on the recommended screening tests such as psa screening prostate exams and also just talking about their voiding habits and erectile function and things like that topics that men oftentimes need a little coaxing to discuss i would say so you opened it up psa and rectal exams we've been going through kind of a lot of whipsawing back and forth as to what we should do as physicians what's the current status and what are your recommendations yeah as you mentioned this is kind of a controversial topic and for a while there there was a recommendation to stop screening for prostate cancer with psa testing but that decision was reversed in recent years and i that's how i practice as well so i do recommend that my patients get an annual psa screening as well as a rectal exam to check their prostate um yeah toga do you kind of follow those same kind guidelines and in your practice yeah uh we started thinking about prostate health i think in the in your 50s the current recommendation is to consider screening between ages 55 and and 70. and so yeah we'll talk about uh risks and benefits of screening most men would like a psa test it's non-invasive it's a blood study and and if there's a high grade prostate cancer typically it's going to show up in the blood what are the usual complaints of men in your office when they come in specific now we're talking kidneys and men's health so prostate bladder genitalia what are the things that usually they complain about yeah most men uh if they're gonna complain about conditions unique to to being a man uh would include some urinary uh complaints uh as we age many of us get a larger prostate and so what happens there well uh prostate is uh an organ uh which is in the outlet of our urinary tract uh it affects the outlet of our urinary tract so urine can get backed up so when that happens you might feel like you have to urinate more often you might feel like you don't empty your bladder very well some of my patients with large prostates will tell me in social situations one of the first things they do is find the bathroom because they want to know where it is because they have to get there quickly dr marsh your thoughts on this yeah as tolga mentioned the common things that i hear are weak stream frequent urination getting up a lot at night i often tell guys that the prostate kind of sits at the base of the bladder like an orange with a straw through it and as they get older the pulp of that orange continues to grow and kind of pushes in on the straw cause obstruction which leads to all these symptoms that toga mentioned there's a question here we we talked earlier about going to kidney stones and talking about kidney stones a little bit toga and you and i talked briefly before what are kidney stones and you want to give us a little background of why they form sure kidney stones can form anywhere basically in the urinary tract they well they tend to form in the kidney itself but but they can be found anywhere in the urinary tract they tend to be most of them uh some numbers i've seen is about 80 percent of them are made of a component called calcium oxalate and uh they do print you know it's uh very pertinent to men's health as well because it is predominant in men there's about a 1.3 to one ratio of men versus women but women of course can get kidney stones as well and then as you might imagine uh as a stone gets caught in your urinary tract the it can be quite painful the smooth muscles of the urinary system can contract and cause a lot of pain and uh and some people are very prone to them uh and uh and um sometimes they get so big they have to be removed by urologists so dr marsh are there is there a diet or is what can i do to avoid getting them yeah so the most common thing that i tell my patients is that stones tend to form in more concentrated urine and that if you're going to do one thing making your urine more dilute by increasing your fluid intake and urine volume is the one thing the biggest thing that you can do so i tell my patients to shoot for about two and a half liters of urine output per day so to make that much urine you have to drink at least that much fluid so i tell them to think about like a two liter bottle of soda hopefully drinking water or something a little bit healthier than soda but so come on guys you this you've got this little old man that's having trouble emptying his bladder now how does this work uh yeah i'm i'm sympathetic uh we also have occupational risk for kidney stones as well for people can't urinate uh very frequently if you're a cab driver uh that's very difficult surgeons surgeons yeah classroom teachers are all that can be tough that can be a big ask to drink that much water there's some other smaller things that you can do avoiding salt uh uh it also helps you're less likely to put calcium in your in your urine there's a list of oxalate rich foods that you can try to avoid although if you look at the list it's pretty there's a lot of delicious stuff on there a lot of nuts a lot of chocolate a lot of actually healthy foods and so i do tell my patients know that list but if you're going to eat something from it wash it down with some calcium dietary calcium is generally considered a good thing and if you can get that calcium to attach that oxalate in the in the gi tract it's less likely to happen in your urinary tract does alcohol help funnily enough the the research shows that almost any type of fluid you drink including wine beer and liquor is going to increase your urine volume and decrease incidence of kidney stones i i generally don't recommend that to my patients but if i'm being honest yeah it does might make passing the stone a little better too i don't know why it has to hurt so bad uh if someone gets a kidney stone what are the chances they're going to get another very good unfortunately so i think the latest data i saw that says that the general population there's about a 10 incidence of kidney stones in the general population actually that's the old data that number has been increasing i think it's now up to 15 or maybe higher and and i think it's about a 50 chance that if you have one stone you're going to get another one down the line well what size what size can the kid what size kidney stone no will no longer pass on its own i'll get the question right here yeah so um we i do a simple calculation typically which is the size of the stone measured in millimeters maybe i'm getting too complicated so basically a 10 millimeter stone has about a zero percent chance of passing a nine millimeter stone has a ten percent chance of passing down to a a five millimeter stone is a fifty 50 chance of passing so um and you can extrapolate that up and down and once it passes through the ureter it's still got to come out through the urethra too right actually i usually tell my patients that when the stone is up in the kidney you generally don't feel it and the same thing is true when it gets to the bladder when it's in the ureter that's where all the pain comes into play and once it gets into the bladder you're home free it's actually the the diameter of the urethra is so much larger than the ureter that most patients don't even realize that they're passing the stone once it gets into the bladder so if we have a stone that's lodged up in the kidney what do you do is there do you do we need to get the stone out can you live with the stone that's a good question so depending on the size of the stone and if the patient has other issues like some stones can be colonized with bacteria resulting in urinary tract infections as long as something like that isn't present yeah you can live with a stone oftentimes i'll have patients come back on a yearly basis with something like an x-ray to make sure the stone isn't growing if that was the case then we might attack it sooner rather than later i definitely have some patients though that either for personal reasons or even professional reasons such as airline pilots aren't allowed to fly if they have stones in their kidneys so they might want to again go after these stones sooner rather than later and i missed do you can you go up and grab them or do you lithotripsy or what kind of things do you do that's the most common way they're treated nowadays is ureteroscopically which basically means with the patient asleep in the operating room going in with a small camera through the urethra into the bladder and up into the kidney and using a laser to break up the stone and take the pieces out shockwave lithotripsy is another option so using shock waves to break up the stone from outside the patient's body that's becoming i would say less common as our technology with ureteroscopes gets better and better and smaller and smaller i haven't seen the lithotripsy for a long time toga are there certain ethnic groups that are at higher risk for developing kidney stones i don't know where they answer that question do you know not to my knowledge actually i'm not sure it's it is based a lot on diet and so there may be some ethnic groups that their diet contributes to a larger incidence of stone formation but i'm not sure i'll stop my head at what age should men begin to have their prostate exams we didn't go there we just talked about men's health but at what age would you start doing prostate exams then how often so toga in your practice yeah my practice uh is a different patient population than dr marsh's of course uh he sees a lot probably more people with prostate problems i i start uh checking prostates when people have started having complaints and for most people that's probably in their 50s uh and then as part of cancer screening it can be considered as well i think for a while actually it was pretty common as a way to kind of screen for cancers but and now that the blood studies are so good i i don't think that there that is done routinely quite as much yeah toga mentioned 55 as being a common age to start screening there's also a recommendation to start as early as 45 if you have a family history of prostate cancer or if you're african-american so you just brought up another topic so we got the psa and we got the digital rectal exam are they both important or is it just the psa we should worry about uh i i think the psa is a little bit more what we would call sensitive um and uh i i think uh rectal exams can vary amongst the experience of even the doctor of of how many they're doing for example and uh this is an interesting question how often would a prostate cancer show up with a negative psa yeah it's it's very rare so i put a lot more stock into the psa personally the rectal exam is probably more important for something such as staging for getting a feel for if there is an obvious prostate cancer present is it invasive into neighboring structures like the rectum but in terms of just detecting a prostate cancer it's it's very rare like one to two percent would be found on a rectal exam alone but not but have a normal psa level so then the other question that comes with this is you're you're doing a rectal exam for bph benign prostatic hypertrophy big prostate um do the does the size of the prostate on rectal exam equate with the symptoms uh oftentimes yes but not necessarily is the hedging answer there that there can definitely be patients who have a very enlarged prostate on imaging tests or on rectal exam but have very minimal to no symptoms whatsoever and i think it has to do with more the configuration of the gland itself and whether the gland is more obstructing or not rather than just absolute size ben do you want to talk a little bit about sponge kidneys i don't know anything about sponge kidneys i so medullary sponge kidney is a condition that can be associated with kidney stones and specifically a condition called nephrocalcinosis basically where the patient makes a large volume of stones frequently and these are usually calcium phosphate stones and so basically it's a it's a congenital condition so they're born with it and for whatever reason the the metabolics of that type of kidney predispose them to making more stones and it gets kind of complex but yeah oftentimes these patients can have recurrent stones over many many years and that was a female patient that called um thank you it brings back i remember now a little more thank you toga this is kind of down your line a little bit so should someone in their 60s see an internist rather than primary care provider for their yearly exam so you want to correct what all is going on with that yeah so uh the word internist essentially refers to a specialty of medicine called internal medicine and uh internal medicine is essentially medicine for adults and non-pregnant women and family medicine which is my specialty is also for adults but we also see kids as well and some family medicine doctors will deliver babies and such and so i think uh in terms of the question if your provider is comfortable giving care to an adult i think that's great they'll be aware of these recommendations and an internist is a primary care physician also that's right yep so yep um are there any drawbacks to taking ferociomite or other diuretics for blood pressure and i'm thinking kidneys and so i'm bringing into the kidney from my perspective oftentimes i see patients who are on lasix or furosemide and specifically that can increase their urine volume quite a bit so if they do have existing prostate or bladder problems that can exacerbate them quite a bit but in terms of management of blood pressure other issues that's a little bit of my realm of expertise yeah hydrochlorothiazide actually can prevent kidney stones uh i mean there's drawbacks to any medication and one of them is regular lab monitoring for anybody on any type of diuretic you said it before i heard it but i want you to reset do men get kidney stones more than females and i think you gave a number uh they do uh the last numbers i looked at uh as uh men were about 30 percent more likely to get kidney stones i believe that figure used to be something like two to one in other words 50 more likely but women are sadly closing that gap i i don't think it's a gap that women want to close but their women are getting more and more kidney stones for reasons we don't understand gleason scores can you give us a primer on gleason's store gleason scores yeah so this is um used in the setting of prostate cancer specifically when patients have undergone a biopsy of their prostate we look at the tissue under the microscope and give it a score based on kind of how ugly the cells look the uglier being more aggressive and a higher gleason score it's named for a dr gleason who was a pathologist actually at the minneapolis va many many years ago and so this was the primary tool that we use in assigning prostate cancer to a different risk group such as low intermediate or high risk is mostly based on this gleason score speak a little bit about the lonely old foreskin uh just because i see quite a few older men that don't take proper care of things and we get into trouble with phimosis or tightness at the end any suggestions or thoughts i mean beyond basic hygiene and keeping things clean and there's not a whole lot i sometimes do see patients who are older and maybe have some issues like dementia and have trouble caring for themselves and that can be a problem sometimes but again beyond basic hygiene recommendations i wouldn't have a whole lot just a quick tour a little further up because we're on men's health somewhere between three and five percent of breast cancer is male right uh that's right i know it was less than five percent when should men be checked uh well uh i mean that's a good question i don't think there's a specific recommendation in terms of doing self checks uh anymore i tell that to men about their scrotums as well just know what your body feels like you know in the shower try not to obsess over it but if you notice a change you should definitely get seen just to add a little bit of something to that in terms of testicular self-exams i find that most my patients don't know actually aside from something abnormal what their what artistic testicular cancer actually feels like and so it actually feels kind of like a rock it's like if you feel your knuckle that's what a testicular cancer feels like that would just a little educational so as long as we're in that area are there any medical circumstances when a vasectomy should not be performed when it should not be performed i mean the only thing i can think of off top my head would be a patient who maybe was on a blood thinner that would be a situation might be too dangerous if they couldn't come off the blood thinner but other than that nothing's coming to mind can you think of anything no i think it's the only the only one i can remember is that i was unable to feel a vas in a person ah yeah so that can happen and it does um very rare um but in that situation oftentimes i'll recommend that the vasectomy be done in the operating room whereas probably 95 vasectomies that i do are in the clinic with the patient awake on the off chance that i need to do a little more digging so to speak so the one other thing that comes up a lot in men's health is overactive bladder bph and tell us a little bit about what overactive bladder is and is there a way of telling the difference it's it can be very difficult sometimes because an enlarged prostate so overactive bladder it tends to be what i think of as more kind of irritative symptoms frequency urgency even what we call urge incontinence or leaking urine and bph classically is thought of more of obstructive symptoms weak stream but enlarged prostate can lead to some of those irritative symptoms as well so it can be difficult to just differentiate the two certainly sometimes we'll do special tests in the clinic such as what's called a euro flow test where we'll have a patient urinate into a funnel and it'll give us the velocity of their urine stream to figure out if there's actually obstruction present or not and so that can sometimes be a way to look or distinguish between the two sometimes it's a matter of trying medications for one of the conditions or the other and see how they respond and how do the meds work so the most common we have a minute so oh okay so the most common medication that i'm prescribing for enlarged prostate is called flomax or tamsilosin which works to relax the muscle fibers in the prostate and the bladder neck kind of to open up well as i mentioned the pulp of that orange and there's also a medication called finasteride which can actually shrink the prostate down the overactive bladder medications are targeting more the the muscle fibers in the bladder itself to try to calm it down thank you very much this has been an interesting half hour i want to thank our panelists dr uh toga hanhan dr benjamin marsh and our medical student volunteers melissa edgar michael goodman and shane johansson please join host dina clabo of insight counseling next week for a special mental health episode on a program on the topic of holiday stress thank you for watching and good night [Music] [Music] [Music] you