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 physician at the Gateway Family Health Clinic in Moose Lake I am your host for our program tonight on men's health and kidney stones remember the success of our show is very dependent on you the viewer so please call in your questions tonight or email them to ask ask at wdse.org the telephone numbers can be found at the bottom of your screen our panelists this evening include Dr Josh Ingles Jared an urologist at the Essentia Health System Dr Nick Johnson a urologist with Saint Luke's Urology Associates and Dr Paul Sanford an internal medicine specialist with St Luke's Internal Medicine Associates our medical students answering the phones tonight are Michael Gutman from Marshall Minnesota Alexis code from Redwood Falls Minnesota and Kylie schulke from Dawson Minnesota and now on to tonight's program from on men's health and kidney stones gentlemen I'd like to take you just a moment to introduce yourselves Dr Sanford can you tell us a little bit about your practice and sure what you do oh absolutely I'm a general medicine Internal Medicine physician just do primary care for adults started in 1991 at what's now Essentia to Duluth clinic and joined my parents and they were already practicing up here so good bread and butter Primary Care Dr Johnson uh yeah I am a general urologist here in Duluth at St Luke's serology Associates I've been here for about 10 years a little bit longer I do a little bit of everything in urology from stones to bigger surgeries to smaller procedures and Dr Ingles Jared uh yeah I'm uh Dr Josh Ingles Jr and I practice at Essentia Health I also do sort of general urology a little bit of everything but I do have a bit of a special interest in robotic surgery and and cancer surgery thank you welcome gentlemen Dr Sanford in your office with your general medicine office what are the common things you see from a Urologic standpoint oh the most common is I have to get up every two hours at night to urinate in in we're just talking about men right now aren't we yeah so that's a a big one you know people can be concerned that they don't have the flow that they used to they can't write their names in the snow anymore sorry mom um and uh those are the the two biggest ones so Nick as we look at that we're looking at the prostate I would say it and the discussion goes to the prostate tell us a little bit about the prostate gland why it's there and where the problems come and you can jump in too if you need to yeah um prostate is a funny bit of anatomy and probably one of the creators poor a bit of planning so it's a gland that sole job is to support sperm on its journey to help with fertilization and it makes secretions and it sits right at the base of the bladder where the bladder funnels down and takes off to the urethra and unfortunately for reasons which aren't clear most men's prostates tend to get bigger over time and sometimes that enlargement results in obstruction which makes it more difficult to urinate or contributes to a host of symptoms that Dr Sanford was talking about it isn't always a equals B in other words just because you have a big prostate doesn't mean you have a hard time peeing but the two do often go together and so as Dr Sanford was saying it's a big part of community Urology a lot of men come to see us for urinary issues which probably are in the end related to their prostate in some way Dr Ingles Jared how do you evaluate the prostate that's a good question so um if a patient comes to my office for example and and was complaining of a weak stream or feeling like they had to urinate more often than they used to typically the the workup begins with them answering a questionnaire that gives me a little bit of an idea of all of the symptoms that they're having so it tells me how often they're urinating if they feel like their stream is weak how often they're getting up in the middle of the night to name a few things sometimes we will have them urinate for us into a device that can calculate how well their stream is and then oftentimes we will also calculate something called their post void residual volume which is how much urine is Left Behind in their bladder after they feel that they have emptied their bladder those are kind of the first things that we usually check out when they come and missus Dr Sanford in your office what do you do oh the the questions by far is 90 of the diagnosis and then in as part of the general exam I always want to do a rectal digital rectal exam because there's not always a correlation between prostate cancer PSA and what you feel so but it's 95 of the diagnosis is just in talking to people the digital rectal exam the correct the finger wave if you will and then the PSA have been around for some time I remember when the PSA emerged on the scene we've been around a long time Paul uh and we've used it a lot where are we at the present time with digital rectal exams um and Nick I'm throwing this one at you digital rectal exams and the PSA are we using them as much as we used to there was a period it seemed like we backed off and now we're I think we're back again yeah that's a really good way to put it it's uh it's a long history and there's a lot of details but I would I would say this as you're asking the question um did the thing that came to my mind is that it does seem like things tend to Wax and Wane and For Better or For Worse we still don't have a better tool for finding prostate cancer early than PSA and PSA is still a big part of the screening protocol so if you really want to do up-to-date prostate cancer screening PSA almost has to be a part of it and of the two between the prostate exam and the and the lab test the lab test is by far the more valuable of the two in terms of detecting prostate cancer so you can still get a lot of information from the digital rectal exam and if someone's new to my office whether or not they come in for a PSA questioned or urinary symptom question I still almost always do the exam just to get a little bit more Baseline information about what I think is going on but specifically for cancer detection the PSA for better or worse is still our best tool for detecting prostate cancer early Josh it's been a while since I've been really really active in practice I'm still to some extent but not every day like it used to be what I remember is that prostate cancer I kind of think of it as there's you can get it early on there's the they all look alike and how do you determine what you can watch what needs to be worked on uh like I keep thinking there's three different basically three different types do you want to help help me separate that a little bit Yeah so um in the workup for an elevated PSA typically the only the only way to to truly diagnose prostate cancer is to do a prostate biopsy nowadays oftentimes before we do a biopsy we're getting an MRI of the prostate which gives us a really detailed view of the prostate and can show us if there's any concerning lesions for prostate cancer and that can actually help us do a more accurate prostate biopsy called an MRI Fusion biopsy which can essentially allow us to biopsy the lesion as well as do the systematic biopsies throughout the prostate and if if those biopsies do diagnose prostate cancer um it's basically based on on what the pathologist sees Under the microscope when they look at those biopsies and they give it a score called a prostate grade group score that goes from one to five with five being kind of considered the most aggressive most concerning type of cancer and a one being very unaggressive and oftentimes when it is a one wheat we don't even consider doing a form of Curative treatment and we know it's safe to watch it so that's probably what you're thinking of is that score the great group score that's moved on since I last looked at that that's great uh Nick I assume you do prostate surgery and cancer surgery and so on so if you've got some of the prostate cancer can you talk about that a little bit and how you would handle those and Josh you may want to jump in on this too and Paul you can like probably slightly sit back and listen for a minute well uh I think Josh had a great entry to the question because the first part about figuring out you know prostate cancer surgery is who actually need surgery there are multiple Forks in the decision-making Road and as Josh talked about the first Fork is figuring out if this is a person that needs to be treated up front or is is this someone that could be watched safely and then if you do determine treatment the next question is is this a person that would benefit from localized treatment in other words surgery to remove the prostate or radiation directed at the prostate or has the cancer Advanced beyond the prostate in which case you're thinking more of systemic treatment in order to choose between surgery and radiation there are multiple other Forks but the biggest one is honestly patient preference if you look at the data from cancer outcome surgery and radiation are more or less equivalent and they're they're both well tolerated the surgery has to be on the right person there's some criteria that we use to select who's a good candidate or who is safe for surgery but ultimately you're looking for an outcome where by surgery you're going to get rid of the cancer and we do that now robotically and it's it's the wrong term to say it's standard of care but functionally it is the standard of care because virtually every high volume Surgery Center Urologic Urologic Surgery Center in the country does this robotically I assume you both do a robotic yeah so the what age what age should we start looking at people for prostate it's one of the questions that's here when when do you start um I I have a couple of ways I look at it I mean the auas are kind of governing uh guidelines uh want us to start at 55 but I think that's in most cases that's probably a little bit uh too old especially if there's any family history and if you if you press most men there's a family history and so this is not guidelines supported but in my ideal World I'd love to see a PSA by age 45 and if it's within normal limits then maybe two or three years later just to establish a Baseline and if I've got any concerns because of health history then I'll start doing one every year at 50.

Paul what are your thoughts exactly the same I get a baseline sometimes at age 40 depending you know people with family histories of malignancy Lynch syndrome any type of malignant syndrome Lynch syndrome is a unusual genetic based propensity to cancer usually ovary breast pancreas prostate is not high up on the on the Lynch list but you know anything that I believe puts people at higher risk of malignancy you know first of all just asking if their urinary symptoms have changed when in doubt check a urine for microscopic blood or microscopic hematuria and well my job is to look at at every patient as if they've probably got some horrible cancer in them and make sure I'm wrong and that's just how I'm trained with the surgery side effects of the surgery in the past there was a lot of incontinence and uh sterility or inability to ejaculate and to have sex with the robotic surgery our outcomes better these days one of the questions is is does this affect the possibility of having children yeah so um in terms of ability to have children it will essentially when we do the surgery we're doing a vasectomy which is um transecting the vas deferens which is what carries sperm so it would make it so that in the traditional sense you wouldn't be able to have children you're you would still produce sperm but it would have to be retrieved in a different way if you wanted to have children after having a prostatectomy um the most common side effects after prostatectomy are urinary incontinence or leakage of urine as well as erectile dysfunction um I I have not done prostatectomies prior to robotics all of my training was in robotics but I would think that the symptoms are less severe doing it robotically compared to the open approach the beauty of doing it robotically is we have basically a 3D um enhanced view that is giving us the most detail possible to be able to see all of the anatomy when we do the surgery which allows us to really preserve the muscles that are important to regain continence after surgery it also allows us to perform surgery doing a what's called a nerve sparing technique the nerves that are important for erections wrap right around the prostate and so we're we're able to basically sweep those nerves off of the prostate when we do the surgery with the idea of leaving them behind so that they can recover and then allow men to have erections afterwards and it's surgery that's deep in the pelvis which is very tight and complex and yes and I think you said that very well the other one that comes up in the past I don't know what's happening these days as far as radiation therapy but it used to be radiation damage to the colon and those type of things are are we still using radiation for this too yes so um in a certain population a patients radiation is a is a better option if we feel that they would not be able to handle the anesthesia for surgery or they have certain conditions that would not allow us to hold the blood thinner for example and in those patients radiation still is a good option we do have sort of a new technique that allows us to protect the colon called space or I don't know if you guys are doing that but essentially puts a little bit of space between the rectum and the prostate so when they when they give radiation to the prostate the rectum is spared from any radiation side effects Paul um oh I lost I lost my question here um with the with prostate cancer is this a familial disease and if someone in the family has it so my dad had it and everyone is this something I need to worry about well I try to encourage people never to worry period that's just praying for suffering but like in my family history positive for prostate cancer I've had prostatectomy the old-fashioned way so I think I don't know the exact genetic loci mgh6 is that generally the Gene and but anyway um I always assume there'll be a propensity if there's a family history of ovarian breast or prostate cancer so to finish this one up any one of you can answer this what do you do to prevent prostate cancer prevent BPH is there anything that a person can do or just live your life and enjoy it enjoy yeah I bet you every 90 year old man alcohol and things like that are those factors or not I still have never been never proven direct I mean I I assume none of them help low selfish cheeseburgers help yeah yeah but for for risk factors there's only three known one is being over 50 one is having a family history and one is being African-American and so African-American males should consider earlier PSA screening because of that and family history means close relatives so father Brothers uncle Josh because this falls into some of the things that you enjoy doing or you're doing tell me a little bit about bladder cancer uh yes so um bladder cancer now that is something that is seen more often and we know that smoking is a basically the biggest risk factor to to develop bladder cancer um you may have your primary care doctor check your urine in the office for signs of blood in the urine or if you notice that you have blood that you can see when you urinate that is one of the sign potential signs of bladder cancer and would be a reason for you to get referred to a urologist for further evaluation Paul what causes kidney stones oh my goodness you've got the most common one we're going to kidney stones yeah oh that's good gravel is needed to keep the roads non-slippery but yeah calcium oxalate probably the most common uric acid the second most common and then struvite these really cool little coffin shaped stones are the least common but it's just where the concentrated urine is allowed things to go from being a solute into a crystal so that's why you always want to be drinking gobs of water other thoughts gentlemen as far as how do dietary with dietary carefulness or whatever can you do anything to avoid kidney stones so oxalates and fluids and what else well uh kidney stones are complicated there's multiple different kinds uh Paul listed some of the most common kinds but the the reality is this you and I might drink and eat the exact same things I might get stones and you might not and there's just some metabolic risk factors that some humans have some of it is probably a good familial risk factors but what we generally do to to really answer that question correctly if you have stones and you've been treated or you've had multiple sewn events we try to get a piece of the stone to have it analyzed and then we often have our patients complete What's called the lithol anchor a 24-hour urine test which is actually looking at your specific metabolic risk factors for why you might be forming Stones so you can take the composition and you can take the results of that 24-hour test and you can come up with the very specific reason hopefully why you're at risk performing stones and then our therapies are our Target is as opposed to generic so if you have a Josh if you have a stone in the kidney how do you handle that so uh and I'm suggesting a larger Stone that's not going to drop okay so if it's a stone that we feel like isn't going to drop or if it were to drop it was going it would cause you know significant discomfort and have have difficulty passing um there's a couple ways that we can approach it depending on the size the most common way that stones are typically treated is with a procedure called ureteroscopy where we use a small camera scope that we insert through the urethra and are able to to Traverse up into the kidney itself which allows us to visualize the stone and then we can use a laser fiber to basically break up the stone into small pieces pull all those pieces out using a small basket to clear the stone out of the kidney and then in the bladder usually you can ride those out so if a stone gets into the bladder oftentimes it will won't cause problems anymore that'll be the point where you'll be able to urinate the stone out and it'll pass on its own now there are situations where stones are too big and they won't pass on their own and that's often seen in men that have BPH who aren't urinating well not emptying their bladder well and in those situations we sometimes have to go in and use a laser to break up the stone in the bladder this is a question that came in this person's doctor once told him that he wanted to use needles on the prostate to reduce the size of the prostate is this a common practice uh it's if I'm understanding the question it was a fairly common practice but hasn't been oh it was yeah I don't remember that yeah uh yeah but it's been uh not since I've practiced yeah but I might maybe were because there might be might be reference saying a newer uh intervention as well so it's I'm not exactly clear they could be referencing a procedure called resume therapy um where you go in with a camera scope into the urethra where the prostate is and needles are placed into the prostate and then um basically Aqua therapy is used to cause the prostate tissue to necross and then that tissue then kind of slips away to open up the channel to allow them to urinate better I I bet that's what they're yeah there's an old the tuna the transverse needle oblation and I don't know if that's what they're talking about but probably at Aqua ablation if this has come up recently yeah I've never heard of it well thank God I haven't Paul what do you tell your patients that so you've got a gentleman that's older and is having incontinence and so on what kind of things can you do to help him in the office we've talked to surgical procedures but there's a whole lot more that can be done oh yeah no behavioral things are so important when people find themselves after watching six Innings of a baseball game find themselves all of a sudden getting up to urinate and then cannot make to the bathroom I try to remind them first of all have scheduled times every hour just go to the bathroom even if you don't have a big raging emptying it's still worthwhile just to move around good for your heart number two and no it's probably not not as strict as before but try to avoid caffeine and chocolate the chemical group and the class methazanthines in the old days were believed to cause increased prostate swelling increased resistance and then with that increased retention of urine you feel like you have to urinate out of court you urinate out a pint you still got that pint in there so I don't know what you guys think about methazanthines in the diet like caffeine and chocolate contributing but usually I tell people to get off their Duff and go out and walk around and urinate any one of you want to discuss Sexual Health as relates to the advancing age and the problems that men have uh sure any specific question or um well my understanding is it's important to continue it and that being sexually active is not a bad thing as far as taking care of the organs of men as they get older yeah I think I think I understand what you're asking so uh one question I get asked Josh I don't know if you probably have the equivalent but uh a patient will come in with sexual health questions or urinary issues or or what have you and then there's always the tagline is that normal and I and I think that's a a common perception among uh men who are getting older is that there must be some natural decline or this is just part of it and this is all normal um and I just usually start by I have to call it oh sorry about that great job just getting to the best yeah I really want to thank our panelists Dr Josh Ingles Jared Dr Nick Johnson and Dr Paul Sanford and our medical student volunteers Michael Goodman Alexis codette and Kylie schulke next week please join host Mary Morehouse for a special on Mental Health on a show on Grief and loss thank you for watching and good night thank you foreign