Male Fountain of Youth in a Pill

July 14, 2018

Andrew Siegel MD 7/14/2018

fountain-of-youth-sign-st-augustine

Thank you http://www.goodfreephotos.com for the image above

I only believe in prescribing (and taking) medications when absolutely necessary,  after simpler measures have been tried (usually lifestyle modification) and have failed to improve the issue and when advantages outweigh disadvantages.  That stated, there is one medication in particular that can lop off a number of years in terms of its positive effect on male form and function.  Requirements for any medication are twofold—safety and effectiveness.  Recent studies conducted over the course of twenty years confirm the safety and effectiveness of this medication. The chief investigator presented his long-term findings at the 2018 American Urological meeting in San Francisco and called the findings of the study “transformational.”

Aging can be unkind and Father Time is responsible for a host of changes that occur with the aging process. The aging male often suffers with an enlarging prostate gland that can cause annoying urinary symptoms as the enlargement crimps the flow of urine. Aging is also a key risk factor for the occurrence of prostate cancer. As we know all too well, aging also often causes the loss of one’s youthful full head of hair, leaving a balding and shiny scalp subject to sunburn and often managed by combovers or shaving one’s head.

What if I told you that there is a drug that can shrink the prostate and often alleviate the symptoms of prostate enlargement?  That would be considered a good drug.  What if I told you that it could also reduce the risk of prostate cancer?  Now we’re talking excellent drug.  Finally, what if I told you that it could reverse male pattern baldness?  Now we are talking exceptional drug.  This drug not only exists, but also is generic, inexpensive and yours truly is proof of its success!

Prostate Cancer Prevention Trial

The Prostate Cancer Prevention Trial was a clinical experiment that tested whether the drug finasteride (brand name Proscar) could prevent prostate cancer. The medicine works by blocking the activation of testosterone to DHT (dihydrotestosterone).

This trial was based on two facts:

  1. Prostate cancer does not occur in the absence of testosterone
  2. Men born without the enzyme that converts testosterone to its activated form DHT do not develop benign or malignant prostate growth (nor hair loss, for that matter).

This 7-year study enrolled almost 20,000 men who were randomly assigned to finasteride or placebo. The study was terminated early because men in the finasteride arm of the study were found to have a 25% risk reduction for prostate cancer.  The original study in the 1990s also demonstrated a slight increase in aggressive prostate cancer in the finasteride arm.  This negative finding resulted in a “black box” warning from the FDA, as a result of which many men were frightened about the prospect of using the drug.

Recent follow-up on the original clinical trial (median follow-up > 18 years) presented at the 2018 American Urological Association meeting found 42 deaths from prostate cancer in the finasteride arm and 56 in the placebo arm. The study concluded that finasteride clearly reduces the occurrence of prostate cancer and that the initial concerns regarding high grade prostate cancer were unfounded.

Prostates in those treated with finasteride were 25% smaller at the end of the study as opposed to the prostates in the placebo group. Finasteride (and other medications in its class) lower prostate specific antigen (PSA) by 50%, so any man on this class of medications will need to have his PSA doubled to estimate what the PSA would be if not taking the medication.

proscar-tablet.jpg

When my thinning hair progressed to the point that I had a sunburn on my crown, I started using Propecia (a.k.a. finasteride). In a matter of a few years I had a full regrowth of hair. After the Prostate Cancer Prevention Trial report revealed a 25% risk reduction for prostate cancer with finasteride use, I was strongly motivated to continue using the drug, particularly since my father had been diagnosed with prostate cancer at age 65 (he is thriving over two decades later).

The 2 photos are proof of my fine head of hair, thank you finasteride

 IMG_7168

 

IMG_7169 

 The bottom line is that finasteride (Proscar and Propecia) and dutasteride (Avodart) can help prevent prostate cancer, shrink the prostate gland, improve lower urinary tract symptoms due to prostate enlargement, help prevent the need for prostate surgery and grow hair on one’s scalp… a fountain of youth dispensed in a pill form if ever there was one!

For more information on the fascinating tale of how this drug was developed–one of the most interesting backstories on drug development–see my entry: Girl at Birth, Boy At Puberty…and A Blockbuster Drug.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

New video on female pelvic floor exercises:  Learn about your pelvic floor

On the topic of “fountain of youth,” my first foray into writing was Finding Your Own Fountain of Youth: The Essential Guide to Health, Wellness, Fitness & Longevity.  If you see me as a patient and ask for a copy, it’s yours for free.  Alternatively, if you would like to download a free copy in PDF format, visit www.AndrewSiegelMD.com and click on “books.”

 

 

 

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5 Reasons Your Penis May Be Shrinking

July 7, 2018

Andrew Siegel MD   7/7/18

Today’s entry is not about the moment-to-moment changes in penis size based upon ambient temperature and level of arousal, but to permanent alterations in penile length and girth that can occur for a variety of physical reasons. The preservation of penile dimensions is contingent upon having healthy, well-oxygenated, supple and elastic penile tissues that are used on a regular basis for the purposes nature intended.

 sculpture emasculated Reykjavik

Above photo I recently shot in Reykjavik, Iceland

Penis size is a curiosity and fascination to men and women alike. An ample endowment is often associated with virility, vigor, and sexual prowess.   There is good reason that the words “cocky” and “cocksure” mean possessing confidence.

What’s normal?

With all biological parameters, there is a bell curve with a wide range of variance, with most clustered in the middle and outliers at either end. The penis is no exception, with some men phallically endowed, some phallically challenged, but most somewhere in the middle. Alfred Kinsey studied 3500 penises and found that the average flaccid length was 8.8 centimeters (3.5 inches), the average erect length ranged between 12.9 -15 centimeters (5-6 inches) and the average circumference of the erect penis was 12.3 centimeters (4.75 inches).

Who cares?

Interestingly, 85% or so of women are perfectly satisfied with their partner’s penile size, while only 55% of men are satisfied with their own penis size.

5 Reasons for a Shrunken Penis

  1. Weight gain: Big pannus/small penis

The ravages of poor lifestyle habits wreak havoc on penile anatomy and function.  The big pannus (“apron” of abdominal fat) that accompanies weight gain and especially obesity cause a shorter appearing penis.  In actuality, most of the time penile length is intact, with the penis merely buried in the fat pad.  It is estimated that for every 35 lbs of weight gain, there is a one-inch loss in apparent penile length.

The shorter appearing and more internal penis can be difficult to find, which causes less precision of the urinary stream that sprays and dribbles, often requiring the need to sit to urinate. Additionally, the weight gain and poor lifestyle give rise to difficulty achieving and maintaining erections.  This shorter and less functional penis and the need to sit to urinate is downright emasculating.

Solution: Lose the fat and presto…the penis reappears and urinary and sexual function improve.

  1. Disuse atrophy: Use it or lose it

Like any other organ in the body, the penis needs to be used on a regular basis, as nature intended.  If one goes too long without an erection, collagen, smooth muscle, elastin and other erectile tissues may become compromised, resulting in a loss of penile length and girth and limiting one’s ability to achieve an erection. In a vicious cycle, loss of sexual function can lead to further progression of the problem as poor genital blood flow causes low oxygen levels in the genital tissues, that, in turn, can induce scarring, which further compounds the problem.

Solution: Exercise your penis by being sexual active on a regular basis, just as you maintain your general fitness by going to the gym or participating in sports.

  1. Peyronie’s disease: Scar in a bad place

Peyronie’s disease is scarring of the covering sheaths of the erectile chambers. It is thought to be due to the cumulative effects of chronic penile micro-trauma.  The scar tissue is hard and inelastic and prevents proper expansion of the erectile chambers, resulting in penile shortening, deformity, angulation and pain. In the early acute phase—that can evolve and change over time—most men notice a painful lump or hardness in the penis when they have an erection as well as a bent or angulated erect penis. In its more mature chronic phase, the pain disappears, but the hardness and angulation persist, often accompanied by penile shortening and narrowing where the scar tissue is that gives the appearance of a “waistband.”  Many men as a result of Peyronies will have difficulty obtaining and maintaining an erection.

Peyronies can also occur as a consequence of a penile fracture, an acute traumatic injury of the covering sheath of the erectile chamber.  This most commonly happens from a pelvic thrusting miss-stroke during sexual intercourse when the erect penis strikes the female perineum or pubis and ruptures.  This is an emergency that requires surgical repair to prevent the potential for Peyronie’s disease.

Solution: If you notice a painful lump, a bend, shortening and deformity, see a urologist for management as the Peyronies is treatable once the acute phase is over and the scarring stabilizes.  If you experience a penile fracture after a miss-stroke—marked by an audible pop, acute pain, swelling and bruising—head to the emergency room ASAP.

  1. Pelvic surgery

After surgical removal of the prostate, bladder or colon for management of cancer, it is not uncommon to experience a decrease in penile length and girth.  This occurs due to damage to the nerves and blood vessels to the penis that run in the gutter between the prostate gland and the colon. The nerve and blood vessel damage can cause erectile dysfunction, which leads to disuse atrophy, scarring and penile shrinkage.

In particular, radical prostatectomy—the surgical removal of the entire prostate gland as a treatment for prostate cancer—can cause penile shortening. The shortening is likely based on several factors. The gap in the urethra (because of the removed prostate) is bridged by sewing the bladder neck to the urethral stump, with a consequent loss of length from a telescoping phenomenon.  Traumatized and impaired nerves and blood vessels vital for erections give rise to erectile dysfunction. The lack of regular erections results in less oxygen delivery to penile smooth muscle and elastic fibers with subsequent scarring and shortening, a situation discussed above (disuse atrophy).

Solution: Resuming sexual activity as soon as possible after radical pelvic surgery will help “rehabilitate” the penis and prevent disuse atrophy. There are a number of effective penile rehabilitation strategies to get “back in the saddle” to help prevent disuse atrophy.

  1. Anti-testosterone treatment

“Androgen deprivation therapy” is a common means of suppressing the male hormone testosterone, used as a form of treatment for prostate cancer. Because testosterone is an important hormone for maintaining the health and the integrity of the penis, the low testosterone levels resulting from such therapy can result in penile atrophy and shrinkage.

Solution: This is a tough one.  Because of the resulting low testosterone levels, most men have a diminished sex drive and simply lose interest in sex and “use it or lose it” becomes challenging. Furthermore, many men on this therapy have already had a radical prostatectomy and or pelvic radiation therapy, so often have compromised erections even before using androgen deprivation therapy. Anecdotally, I have had a few patients who have managed to pursue an active sex life and maintain penile stature with the use of Viagra or other medications in its class. 

Wishing you the best of health!

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

 

 

Ladies, If You Leak When You Exercise

June 30, 2018

Andrew Siegel MD  6/30/18

Exercise is of vital importance to physical and psychological health, reduces risk for diabetes, cardiovascular disease and cancer, is a great stress reducer and improves muscle strength, endurance, coordination and balance. It is an important factor in maintaining a healthy weight, decreasing body fat, increasing longevity and decreasing mortality. All good!girl-woman-sport-photographer-train-recreation-1165198-pxhere.com (1).jpg

image above, Creative Commons

Urinary incontinence is an annoying condition that women experience much more commonly than do men.  One of the main types is leakage with physical activities and exercise, a.k.a. stress urinary incontinence (SUI). When a woman suffers from SUI it often acts as a barrier to exercising because no one wants to be put in the embarrassing and inconvenient situation of wetting themselves every time they jump, bounce or move vigorously. Some women adapt by modifying the types of exercise that they participate in, while others give up completely on exercising, an omission that can contribute to poor physical and psychological health, a greater risk for medical issues, weight gain, etc.

What physical activities cause leakage?

The most common exercises that provoke SUI are high impact, vertical deceleration activities in which there is repeated contact with a hard surface with both feet simultaneously, e.g. skipping, trampoline, jumping jacks, jumping rope, running and jogging.

Other physical activities that commonly provoke SUI are exercises that combine dynamic abdominal and pelvic movements, e.g., burpees, squats, sit ups and weight bearing exercises, e.g., weighted squats, overhead kettle bell swings, etc.  The classic weight lifting style exercises are occasional triggers of SUI.

Activities that cause SUI (in order of those most likely to provoke the SUI)

  1. Skipping
  2. Trampoline
  3. Jumping jacks
  4. Running
  5. Jogging
  6. Box jumps
  7. Burpees
  8. Squats
  9. Sit ups
  10. Weighted squats
  11. Kettle bell swings
  12. Dead lifts
  13. Push ups
  14. Wall balls
  15. Shoulder press
  16. Clean and jerk
  17. Snatch
  18. Bench press
  19. Rowing

 So, what to do?

Many women figure out the means to improve or diminish the problem.  Common sense measures include urinating immediately before exercising and if possible taking washroom breaks during the activity (not always possible and inconvenient).  Even so, most women do not empty the bladder 100%, so if 1-2 ounces remain after emptying, there is still plenty of urine to potentially leak.  Other adaptive measures are fluid restriction (not particularly healthy before vigorous activity, risking dehydration).  Wearing a protective pad or incontinence tampon is certainly a way around the problem (although not ideal).  Another strategy is to modify one’s exercise program, such as reducing the duration, frequency or intensity of the activity.  Avoiding high impact exercises entirely and substituting them with activities that involve less impact is another possibility. However, these are adaptive and coping mechanisms and not real solutions.

There is a better solution

Urologists–particularly those like myself who have expertise in female pelvic medicine–can help manage the condition of stress urinary incontinence.  First line treatment is  Kegel pelvic floor exercises that—when done properly (as they are often not) with the right program—can often significantly improve the situation.

New video on pelvic floor exercises.

If a concerted effort at a Kegel program fails to sufficiently improve the situation, a 30-minute outpatient procedure called a mid-urethral sling is a highly effective means of treating the exercise incontinence.

Bottom Line: Physical activities most likely to induce urinary leakage are high impact exercises including skipping, trampoline, jumping jacks, jump rope and jogging.  Coping mechanisms and adaptive behaviors include fluid restriction (not healthy before exercise), urinating before activities (reasonable), taking breaks from exercise to urinate (inconvenient), pads (ugh), dialing down the intensity of exercising, modifying type of exercise or complete avoidance of exercising (undesirable).  If coping and adaptive behaviors are not effective, consider seeing a urologist who focuses on incontinence.  The goal of treatment is to be able to return to the physical activities that you enjoy without the fear of urinary leakage.   

Excellent resource: Urinary leakage during exercise: problematic activities, adaptive behaviors, and interest in treatment for physically active Canadian women: E Brennand, E Ruiz-Mirazo, S Tang, S Kim-Fine, Int Urogynecol J (2018)29: 497-503

Wishing you the best of health and a happy 4th of July holiday!

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

 

 

Noctiva: A New Treatment for Annoying Nighttime Peeing

June 23, 2018

Andrew Siegel MD    6/23/18

bottles-8MM[1]There is compelling medical evidence that a good night’s sleep is of vital importance for one’s health. We recognize this intuitively when we compare how we feel after a night of sleeping well as opposed to a night of sleep deprivation, but it goes way beyond mere fatigue.  Sleeping well is a key component to cognitive and physical fitness as well as overall health, equally important to diet and exercise. Aside from daytime fatigue, weight gain because of altered eating patterns, and increased risk of traffic accidents and fall-related nighttime injuries, sleep deprivation has been associated with an assortment of medical problems that negatively affect quality and quantity of life.  

Although there are many reasons for failing to obtain sufficient sleep, one such cause is interrupted sleep from the need to frequently empty one’s bladder. This can be disruptive to achieving a good night’s sleep, with many nighttime voiders unable to get back to sleep after urinating. Today’s entry reviews a new medication that can help sleep-disruptive nighttime urinating when it is caused by overproduction of urine, a causal factor in over 80% of cases of nighttime urination.

Nighttime urination—nocturia in medical speak—is a complex condition that aside from affecting quality of sleep and quality of life can be a symptom of underlying medical issues, e.g., diabetes, obstructive sleep apnea and cardiovascular issues. It is common in both women and men, tends to increase with aging, and its underlying basis is often multifactorial.  If it occurs once or twice a night and is not too bothersome and one can readily get back to sleep, it is no big deal.  However, if it occurs more than twice a night and is sleep-disruptive, it may be time to consider a means of improving the situation. Importantly, although nocturia is typically a complaint that drives patients to urologists, most of the time the nocturia is NOT urological in origin.

A simple test to help assess nocturia is a 24-hour voiding diary, which requires a pen and paper, a watch or clock and a measuring cup. The time at which urination occurs and the volume of each urination are recorded. Typical bladder capacity is 10–12 ounces with 4–6 urinations per 24 hours. Such a diary will help differentiate between those with a reduced bladder capacity, those who produce lots of urine only while sleeping, and those who produce lots of urine both day and night.

Reduced bladder capacity is often a sign of urological issues including overactive bladder, benign prostate enlargement, neurological diseases affecting the bladder, and loss of elasticity of the bladder as may occur with pelvic radiation.

Those who produce lots of urine only while sleeping are commonly found to have the following causes: increased fluid intake in the evening, obstructive sleep apnea, edematous states such as congestive heart failure, and failure to produce sufficient quantity of a hormone that regulates urine production.

Drinking a few cups of coffee or tea after dinner or a few beers before bedtime will cause nighttime urination and has an obvious solution. Obstructive sleep apnea is a under-appreciated and common cause of full-volume nighttime urination that when treated with CPAP (continuous positive airway pressure) or other means will significantly reduce the nocturia. Edema is fluid within the tissues–-typically the ankles and legs–that tends to accumulate aided by gravity over the course of the day. Upon assuming the lying-down position when sleeping, the legs are relatively elevated as opposed to standing and this tissue fluid returns into circulation, causing the kidneys to increase urine production. In general, those with peripheral edema go to sleep with ankles and legs engorged with edema fluid and wake up with thinner legs, as the return of some of the fluid to the circulation and the subsequent increased urination rids them of this. Another possibility is an abnormality in the nocturnal secretion of anti-diuretic hormoneThis pituitary hormone causes the kidneys to concentrate urine and pull water back into the circulation; nocturia may occur because of an age associated decline in its secretion while sleeping.

Those who produce lots of urine both day and night often have overzealous fluid intake, diabetes mellitus or diabetes insipidus, or are on certain medications (e.g., lithium) that can cause the problem.

Noctiva (Desmopressin) to treat nocturnal excessive urine production

One of the most common reasons for nocturia is excessive nighttime urine production, defined as nighttime urine volume exceeding 1/3 of the 24-hour urine production.  If this is demonstrated on the voiding diary, you may be a candidate for this anti-diuretic medication that works by decreasing nocturnal urinary production.

Desmopressin is a synthetic version of anti-diuretic hormone. The function of this hormone is to put the “brakes” on the kidneys so that the kidneys do not allow excessive loss of body water, which could be detrimental to one’s health and lead to severe dehydration. For years, desmopressin has been used for children who are bed wetters.

Noctiva (Desmopressin) nasal spray is a new formulation of intranasal desmopressin for those who have full-bladder volume nocturia two or more times.  It is a modification of desmopressin that is designed to enhance absorption from the nasal lining, available in doses of 0.83 and 1.66 microgram.  One spray in either nostril is used about 30 minutes prior to sleep.

The absorption of this product is enhanced as compared to that of the oral version (8% vs. 0.3%), which means more consistent dosing and rapid absorption and elimination allowing more rapid onset and less prolonged drug activity.  It is well tolerated with the most common side effect low levels of sodium and other side effects including nasal irritation, nasal congestion, nosebleeds, sneezing, and high blood pressure.  The drug cannot be used in the face of excessive fluid intake, low serum sodium, steroids or loop diuretic use, heart failure, uncontrolled high blood pressure, poor kidney function, and with illnesses causing fluid and electrolyte imbalances. Sodium levels need to be monitored periodically.

Bottom Line: Nocturnal urinary frequency should be investigated to determine its cause, which may in fact be related to conditions other than urinary tract issues.  Nighttime urination is not only bothersome but may also pose real health risks as chronically disturbed sleep can lead to a host of collateral wellness issues. Noctiva is a new addition to the armamentarium to combat nighttime urination when it is due to excessive nocturnal urinary production.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

New video on female pelvic floor exercises:  Learn about your pelvic floor

Blood in the Urine in Patients on Anticoagulants

June 16, 2018

Andrew Siegel MD  6/16/2018

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TY, Pixabay, for image above

Many people take blood thinners to prevent clotting complications that may occur as a result of cardiac arrhythmias—particularly atrial fibrillation, cardiac valvular disease; cardiomyopathy, mechanical heart valves, as well as for treatment or prevention of venous clotting and pulmonary embolism. Visible urinary bleeding is not uncommon in patients on anticoagulants, especially under the circumstance of being “over”-anti-coagulated.  Anticoagulants per se do not usually cause urinary bleeding, but if there is an underlying urinary tract abnormality they can provoke and perpetuate the bleeding.  Thus the importance of doing an evaluation to search for an underlying cause of the urinary tract bleeding.

Commonly used anticoagulants (blood thinners)

  • Fragmin (dalteparin)
  • Lovenox (enoxaparin)
  • Heparin
  • Coumadin (warfarin)
  • Eliquis (apixaban)
  • Pradaxa (dabigatran)
  • Xarelto (rivaroxaban)
  • Plavix (clopidogrel)
  • Brilinta (ticagrelor)

Hematuria

Medical speak for blood in the urine is hematuria.  When blood can be seen it is called gross hematuria, although I prefer the term visible hematuria. Visible hematuria may cause red urine if the bleeding is fresh or tea or cola-colored urine if the bleeding is old. Sometimes hematuria is accompanied by blood clots. At times hematuria is only evident by seeing bloodstains on one’s underwear or appearing on toilet tissue after wiping.

Most hematuria is painless. When there is pain associated with hematuria, it is often a symptom of a kidney stone or urinary infection. Like a nosebleed, hematuria can be a non-significant problem due to a ruptured blood vessel, or alternatively, it can be due to a serious issue that mandates treatment, such as a kidney or bladder cancer, which are  two of the most serious causes of hematuria. Those who use or who have used tobacco and have hematuria have a much higher risk of bladder  and kidney cancer than non-tobacco users. The most common cause of hematuria in men is benign prostate enlargement (as the prostate grows, so does the blood supply) and the most common cause in women is a urinary infection.

Hematuria can occur after vigorous exercise, particularly in people who have bladder stones or an underlying structural abnormality of the urinary tract. Hematuria can be a side effect occurring many years following pelvic radiation to treat cancers of the bladder, prostate, rectum, uterus, cervix, etc.

What to do If you experience urinary tract bleeding while anti-coagulated:

  1. Inform your doctor who prescribed the anticoagulant and  ensure that you are on the appropriate dosage.
  2. If the bleeding is severe enough, it may be necessary to temporarily halt the use of the anticoagulant. Make sure this decision is discussed with the doctor who prescribed the anticoagulant.
  3. Restrict exertional activities and straining with bowel movements and any other activity that may exacerbate the bleeding.
  4. Step up your fluid intake to dilute the urine and promote passage of blood clots.
  5. See your urologist to be properly evaluated.

How hematuria is evaluated

Urine Cytology:  Pap smear of a specimen of urine that looks for abnormal cells.

Urine Culture: Lab test to see if a urinary infection is present.

Imaging Tests: Ultrasound, computerized tomography (CT), magnetic resonance imaging (MRI) and cystoscopy with contrast injected into the ureters to image the inner aspects of the upper urinary tract (retrograde studies) are all possibilities.

Cystoscopy: A visual inspection of the bladder with a narrow, flexible instrument performed on a video monitor with magnification.

Bottom Line:  Regardless of whether or not you are anti-coagulated, never ignore blood in urine, whether visible or microscopic (seen on a urinalysis test).  It may be “nothing” (not a sign of a serious illness) or may be “something” (a warning sign of a potentially life-threatening illness), so it is always beneficial to seek proper evaluation.  If you experience hematuria while anti-coagulated, do not assume that it is an expected consequence of the medication, since there may be serious underlying problems that are “provoked” or “unmasked” by the anticoagulant. Do not panic since the cause can usually be readily determined and treatment initiated; even if the precise cause cannot be pinpointed, serious underlying causes can be excluded.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

 

Try This First Before Seeing A Urologist

June 9, 2018

Andrew Siegel MD  6/9/2018

Picture1

Many suffer with urinary urgency and frequency, requiring repeated trips to the bathroom.  Although not serious or life-threatening, it is annoying and inconvenient.  After happening repeatedly, it can be become an ingrained habit that is difficult to break.  Concerns surface about sitting in traffic, traveling, seeing a Broadway show, getting the right seat on an airplane, etc.

 If you are dealing with an urgency/frequency issue, you may benefit from “bladder retraining.”  It is relatively simple, requires neither medication nor surgery, and can help you control when you urinate, how often you urinate and allow you to delay urinating. 

What happens under normal circumstances

As the bladder gradually fills, most people ignore the initial sense of urgency, continuing to go about their life and carrying on with their activities.  As the bladder continues to fill, they continue to tune out the sense of urgency until the point that it becomes compelling enough so that they are motivated to leave their activity and go to the bathroom to empty their bladder.

What happens to the frequent urinator

For one reason or another, the frequent urinator often becomes “hyper-vigilant” about their sense of urinary urgency.  For him or her, the bladder is “front burner” and not “back burner.”  This may be based on a previous physical bladder problem that gave rise to the hyper-focus, commonly a urinary infection. The frequent urinator often responds to the initial sense of urgency by acting upon it and heading to the bathroom to empty their bladder.  When this behavior is habitually repeated, it becomes a dysfunctional ingrained habit—the “new normal,” and again, a habit that is tough to break. The bottom line is that when there is excessive focus on the sensations arising from the bladder (or for that matter, any part of the body), one will be hyper-acutely aware of sensations that they normally are not cognizant of.

As another example of this, if you focus on the weight of your watch on your wrist or your ring on your finger, within a matter of minutes, their presence will start annoying you.  No good comes of when background becomes foreground!

A 24-hour bladder diary (log of urination recording time of urinating and the volume of each urination) is a simple but helpful tool in sorting out the different causes of urgency/frequency.  Since normal bladder capacity is about 12 ounces, if the diary shows frequent voids of full volumes, the problem is most likely related to excessive fluid intake (or rarely a kidney or hormonal problem that can cause excessive urinary production).  However, if the diary shows frequent voids of small volumes (e.g., 4 ounces), the problem can often be improved with bladder retraining. If the diary shows frequent voids of small volumes during the day, but full volume voids while sleeping or no voids while sleeping, it points to frequency on a psychological basis and also can often be improved with bladder retraining. It is important to know that frequent voiding of smaller volumes is not always a dysfunctional habit and may be on the basis of prostate or bladder issues that might require the services of your friendly urologist.  However, no harm can come from an initial attempt at bladder retraining.

Fixing it

The goal of bladder retraining is to break the dysfunctional habit and restore normal—or at least better—bladder functioning.  Bladder retraining can be challenging, yet rewarding, and requires a positive attitude and being willing, informed and engaged.

  1. FLUID AND CAFFEINE IN MODERATION

Urgency will often not occur until a “critical” urinary volume is reached, and by limiting fluid intake, it will take a longer time to achieve this volume. Try to sensibly restrict your fluid intake (without causing dehydration) in order to decrease the volume of urinary output. Caffeine (present in tea, coffee, colas, some energy drinks and chocolate) can increase urinary output and is a urinary irritant, so it is best to limit intake of these beverages/foods.  Additionally, many foods—particularly fruits and vegetables—have hidden water content, so moderation applies here as well.  It is important to try to consume most of your fluid intake before 7:00 PM to improve nighttime frequency.

  1. ASSESS MEDICATIONS

Diuretic medications (water pills) can contribute to frequency by design. If you are on a diuretic, it may be worthwhile to check with your medical doctor to see if it is possible to change to an alternative, non-diuretic medication. This will not always be feasible, but if it is, may substantially improve your frequency.

  1. AVOID BLADDER IRRITANTS

Irritants of the urinary bladder may be responsible for worsening your symptoms.  Consider eliminating or reducing one or more of the following irritants and then assessing whether your frequency improves:

Tobacco

Alcoholic beverages

Caffeinated beverages: coffee, tea, colas and other sodas and certain sport and energy drinks

Chocolate

Carbonated beverages

Tomatoes and tomato products

Citrus and citrus products: lemons, limes, oranges, grapefruits

Spicy foods

Sugar and artificial sweeteners

Vinegar

Acidic fruits: cantaloupe, cranberries, grapes, guava, peaches, pineapple, plums, strawberries

Dairy products

  1. URGENCY INHIBITION

The act of reacting to the first sense of urgency by running to the bathroom needs to be modified.  Stop in your tracks, sit, relax and breathe deeply. Pulse your pelvic floor muscles rhythmically to deploy your own natural reflex to resist and suppress urinary urgency (more about this below).

  1. INTERVAL TRAINING

Imposing a gradually increasing interval between urinations will help establish a more normal pattern of urination. If you are urinating small volumes on a frequent basis, your own sense of urgency is not providing you with accurate information about the status of your bladder fullness.  Urinating by the “clock” and not by your own sense of urgency will keep your voided volumes more appropriate. Voiding on a two-hour basis is usually effective as a starting point, although the specific timetable has to be tailored, based upon the bladder diary.  A gradual and progressive increase in the interval between voiding can be achieved by consciously delaying urinating.  A goal of an increase in the voiding interval by 15-30 minutes per week is desirable.  Eventually, a return to more acceptable voiding intervals is possible. The urgency inhibiting techniques mentioned above are helpful with this process.

  1. BOWEL REGULARITY

A rectum full of gas or fecal material can contribute to urinary difficulties. Because of the proximity of the rectum and bladder, a full rectum can put internal pressure on the bladder, resulting in worsening of urgency and frequency.

  1. PELVIC FLOOR MUSCLE TRAINING (PFMT)

The pelvic floor muscles (PFM) play a VITAL role in inhibiting urgency and frequency.  Voluntary rhythmic pulsing of the PFM can inhibit urgency and frequency and PFMT hones the inhibitory reflexes between the pelvic floor muscles and the bladder.

Initially, one must develop an awareness of the presence, location, and nature of the PFM and then train these muscles to increase their strength and tone.  These are not the muscles of the abdominal wall, thighs or buttocks.  A simple means of recognizing the PFM for a female is to insert a finger inside her vagina and squeeze the PFM until the vagina tightens around her finger.  Another means of identifying the PFM for either gender is to start urinating and when about half completed, to abruptly stop the stream. It is the PFM that allows one to do so.  When feeling the urge to urinate, rhythmic pulsing of the PFM–“snapping” the PFM several times—can diminish the urgency and delay a trip to the bathroom.

  1. LIFESTYLE MEASURES: HEALTHY WEIGHT, EXERCISE, TOBACCO CESSATION

The burden of excess pounds can worsen frequency by putting pressure on the urinary bladder, similar to the effect that excessive weight has on your knees. Even a modest weight loss may improve the situation.  Pursuing physical activities can help maintain general fitness and improve frequency. Lower impact exercises–yoga, Pilates, cycling, swimming, etc.–can best help alleviate pressure on the urinary bladder by boosting core muscle strength and tone and improving posture and alignment. The chemical constituents of tobacco constrict blood vessels, impair blood flow, decrease tissue oxygenation and promote inflammation, compromising the bladder, urethra and pelvic muscles.  By eliminating tobacco, symptoms can be improved.

Bottom Line: Bladder retraining can be an effective means of whipping your bladder (and your mind) into shape to help convert dysfunctional habits into more normal and appropriate voiding patterns.  This has the potential of helping many people. However, if the aforementioned strategies fail to improve your situation, you should have a basic urological evaluation, including a urinalysis (dipstick exam of the urine), a urine culture (test for urinary infection) if indicated, and determination of how much urine remains in your bladder immediately after emptying.  At times, tests such as cystoscopy (a visual inspection of the urethra and bladder with a narrow, flexible instrument) and urodynamics (sophisticated tests of bladder function) will need to be done as well. Urologists have the wherewithal to improve this situation and your quality of life.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD: PelvicRx

Female version in the works: Female PelvicRx

Little Tumors in the Kidney: Challenges and Solutions

June 2, 2018

Andrew Siegel MD    6/2/18

Years ago–prior to the advent of advanced means of imaging the abdomen–malignant growths of the kidney would manifest with symptoms.  The “classic triad” of symptoms and signs were pain, blood in the urine and a mass that could be felt on examination.  Nowadays, the vast majority of renal masses are asymptomatic, incidental (unexpected) findings picked up on imaging studies done for other issues. The widespread and liberal use of ultrasound, computerized tomography (CT) and magnetic resonance imaging (MRI) done for a variety of reasons not uncommonly result in the incidental finding of a small mass in the kidney, known as a small renal mass (SRM).  Urologists are the go-to doctors who manage renal masses, including SRMs, which can present challenges in term of how best to manage it.

small-kidney-tumor-right

SRM of right kidney on CT

 Evaluation

So, what to do when one is found to have a small mass in the kidney, often less than one inch (2.5 cm) in diameter?

A CT or MRI imaging study without and with contrast is recommended for the assessment of renal masses. The premise is that when a mass takes up contrast, it has a blood supply and is usually not a simple benign cyst containing fluid, but a solid mass that is considered malignant until proven otherwise.  Although these studies are capable of diagnosing and evaluating solid renal masses and distinguishing them from fluid-filled cysts, neither study is capable of distinguishing benign from malignant.

One possibility to address the shortcomings of CT and MRI is a CT-guided kidney biopsy.  It is an outpatient procedure performed by an interventional radiologist who obtains a tiny biopsy of the area of concern using CT guidance.  The biopsy is microscopically studied by a pathologist.  This can distinguish benign from malignant as well as provide tumor type and grade.  Such a biopsy can reduce unnecessary surgery for benign lesions and guide the selection of patients appropriate for monitoring and those who need to be treated.

Fact: About 20% of SRMs are potentially aggressive kidney cancers, 50% exhibit slow growth and are unlikely to ever be a problem, and 30% are benign.

Prognostic factors

Size is of significance, as larger masses have a higher risk of being malignant.  Mass size also predicts the possibility of spread, with a 2.4% risk in tumors under 3 cm versus 8.4% for tumors 3 – 4 cm. Another important factor is tumor growth rate, the average being 0.1 – 0.4 cm/year. Rapidly growing masses are at higher risk for progression and spread.

To treat or not

Active surveillance—careful interval imaging and follow-up with consideration for intervention if the situation merits a change—is a prudent means of management of the SRM in elderly patients, in those with significant medical problems who have a limited life expectancy, and those at high risk for surgery and surgical complications. Active surveillance is also an excellent option in patients who have a solitary kidney or significant kidney disease. Clinical studies have shown that management of SRMs with initial surveillance and delayed intervention does not compromise the success of the surgery or increase the risk of local spread or metastases.

On the other hand, a young, healthy patient with a long life expectancy merits definitive treatment. Typical treatment options are partial nephrectomy versus tumor ablation.  Partial nephrectomy is most often done via laparoscopy with robotic assistance and removes the mass with a margin of normal tissue, sparing the bulk of the kidney. An ultrasound probe is used to help the surgeon precisely image the tumor and its margins.

An alternative option is tumor ablation– the application of heat (radio-frequency) or cold (cryosurgery) directly into the SRM–in an effort to destroy the tumor while leaving the remaining kidney intact.  This can be performed percutaneously (using a needle placed through the skin without an incision) via CT imaging.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (the female version is in the works): PelvicRx

 

Testosterone Treatment and Tiny Testicles: There is a Better Option

May 25, 2018

Andrew Siegel MD  5/25/18

“If a man is prescribed Food and Drug Administration approved testosterone for androgen deficiency, his overall health improves but his sperm production declines and his testes shrink. If he is prescribed off-label clomiphene citrate, his health improves and his sperm production is preserved, as does the size of his testicles.  This selective receptor estrogen modulator for male reproductive endocrine therapy must be a great new discovery, right? Wrong. It has been around for 50 years.”

Dr. Craig Niederberger, Department Head of Urology, University of Illinois School of Medicine

The Magic of Testosterone (T)

For the symptomatic man who has low levels of T, boosting levels of this male  “rocket fuel” hormone can result in a remarkable improvement of energy, sexuality (sex drive, erections, ejaculation), masculinity, mood, body composition (muscle and bone mass), mental focus and other parameters. However, men considering T treatment must understand that T is not a cure-all and must only be used under the circumstances of symptoms of low T and laboratory testing that shows low T.  Most certainly, T has been over-marketed, over-prescribed and certain side effects have been understated. It is vital to understand the side effects of T before committing to treatment.

T Science

Most T is made by the testicles. Its secretion is governed by the release of luteinizing hormone (LH) from the pituitary, the master gland in the brain. Some of T is converted to the female hormone estradiol (E). E is the primary hormone involved in the regulation of the pituitary gland. Under the circumstance of adequate levels of T, E feeds back to the pituitary to turn off LH production. This feedback loop is similar to the way a thermostat regulates the temperature of a room in order to maintain a relatively constant temperature, shutting the heat off when a certain temperature is achieved, and turning it on when the temperature drops.

The Effect of Long-Term T Replacement

So, what happens when you have been on long-term T? This externally sourced T, whether it is in the form of gels, patches, injections, pellets, etc., shuts off the pituitary LH by the feedback system described above so that the testes stop manufacturing natural T. Additionally, the testes production of sperm is stifled, problematic for men wishing to remain fertile. In other words, external T is a contraceptive! Nearly all men will have suppression of sperm production while on T replacement, less so with the gels vs. the injections or implantable pellets.

Thus, using T results in the testes shutting down production of sperm and natural T and after long-term T use, the testes can actually shrivel, becoming ghosts of their former functional selves. “Use it or lose it” is relevant to every organ in the body and external T essential puts the testes into hibernation and dormancy.

If you stop the T after long-term use, natural function does not resume anytime quickly. Although recovery usually occurs within 6 months or so, it may take several years and permanent detrimental effects are possible.

The bottom line is that at the time you are receiving the benefits of T, your natural T is shut off and you can end up infertile, with smaller testicles (testicular atrophy, in urology parlance)!

Is there an alternative for the symptomatic male with low T?  Can you boost levels of T without shutting down your testes and developing shrunken, poorly functional gonads? 

The answer is an affirmative YES, and one that Big Pharma does not want you to know. There has been such a medication around for 50 years. It has been FDA approved for infertility issues in both sexes and is available on a generic basis. In urology we have used it for many years for men with low sperm counts. Here is a little secret: this medication also raises T levels nicely, and does so by stimulating the testes to secrete natural T rather than shutting them down.  No marble-sized testes that have their function turned to the “off” mode, but respectable family jewels.  The other really good news is that treatment does not necessarily need to be indefinite. The testes can be “kicked” back into normal function, and at some point a trial off the medication is warranted.

The medication is clomiphene citrate, a.k.a Clomid, and I will refer to it as CC. CC is an oral pill commonly used in females to stimulate ovulation and in males to stimulate sperm production. CC is a selective estrogen receptor modulator (SERM) and works by increasing the pituitary hormones that trigger the testes to produce sperm and testosterone. CC blocks E at the pituitary, so the pituitary sees less E and makes more LH and thus more T, whereas giving external T does the opposite, increasing E and thus the pituitary makes less LH and the testes stop making T.

clomiphene-citrate-tablets

Works Like A Charm

CC usually works like a charm in increasing T levels and maintaining sperm production, testes anatomy (size) and function. Its safety and effectiveness profile has been well established and minor side effects occur in proportion to dose and may include (in a small percentage of men): flushes, abdominal discomfort, nausea and vomiting, headache, and rarely visual symptoms.  In general, those with the highest LH levels have the poorest response to CC, probably because they already have maximal stimulation of the testes by the LH.

Not FDA Approved For Low T

One issue is that CC is not FDA approved for low T, only for infertility.  Many physicians are reluctant to use a medication that is not FDA approved for a specific purpose. It needs to be used “off label,” even though it is effective and less expensive than most of the other overpriced T products on the market.

Bottom Line: Treatment to boost T levels should only be done when one has genuine symptoms of low T and a low T level documented on laboratory testing. Using externally-sourced T to boost T successfully raises T and often resolves the symptoms of low T but shuts down the testes and nullifies whatever natural T was being produced as well as sperm production. Clomid is an oral, less expensive alternative that stimulates natural T production and the oral pill formulation is an easier and more discreet delivery system than sloppy gels, injections and pellets.

A study from Journal of Urology (Testosterone Supplementation Versus Clomiphene Citrate: An Age Matched Comparison of Satisfaction and Efficiency. R. Ramasamy, JM Scovell, JR Kovac, LI Lipshultz in J Urol 2014;192:875-9) compared T injections, T gels, CC and no treatment.  T increased from 247 to 504, 224 to 1104 and 230 to 412 ng/dL, respectively, for CC, T injections and gels. Men in all of the 3 treatment arms experienced similar satisfaction. The authors concluded that CC is equally effective as T gels with respect to T level and improvement in T deficiency-related clinical symptoms and because CC is much less expensive than T gels and does not harm testes size or sperm production, physicians should much more often consider CC, particularly in younger men with low T levels.

Wishing you the best of health and a wonderful Memorial Day weekend,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

60 Minutes Disses Boston Scientific Meshes: WTF?

May 18, 2018

Andrew Siegel MD  5/18/2018

60 Minutes Trashes Boston Scientific and Pelvic Meshes

Last Sunday, a piece aired on the CBS weekly 60 Minutes concerning Boston Scientific meshes that are used in the field of female urology. The segment was spun in such a way that many viewers were likely to get the wrong impression about Boston Scientific products that are used for two common pelvic floor issues–stress urinary incontinence and pelvic organ prolapse.  These meshes are composed of polypropylene, a synthetic material that is commonly used inside the human body for many purposes, including  hernia repairs as well as a suture material.   I cannot speak for the provenance of the raw materials used for Boston Scientific meshes, although the issue has apparently been addressed by Boston Scientific as well as the FDA, but I can certainly vouch for the safety and effectiveness of their slings and meshes.  After watching the 60 Minutes piece, one might wrongly conclude that Boston Scientific meshes specifically, and all polypropylene meshes generally, are downright dangerous and should never be used in humans.

Au contraire!  Boston Scientific is a reputable company dedicated to both female and male pelvic health and their mesh products (Obtryx mid-urethral sling for stress urinary incontinence and the Uphold Lite for anterior and apical pelvic organ prolapse) are well-designed and clinically effective. I have implanted these products successfully in hundreds of women with stress incontinence and pelvic organ prolapse over the course of many years and will continue to use them.  Furthermore, I have always found the Boston Scientific “reps” to be knowledgeable, available and helpful and the company always willing to provide ample educational opportunities for physicians.  With respect to meshes used for pelvic reconstructive surgery, polypropylene has been the “gold standard” for many years.  Many clinical publications support the safety and effectiveness of polypropylene pelvic floor meshes and numerous medical societies and regulatory bodies have endorsed the utility of polypropylene pelvic meshes for pelvic floor dysfunction.

Proper Repair of a Dropped Bladder (Cystocele)

Not every cystocele is the same, differing in type, extent, symptoms, and degree of bother. The central type (top image below) is a central weakness of the support tissues of the bladder that can cause a pronounced degree of prolapse. The lateral type (bottom image below) is a detachment of the bladder support from the pelvic sidewalls, usually causing only a modest degree of prolapse. Most women have a combination of these two, a combined central-lateral type.

CD

lat defect

 

In my opinion, the classic “plication” repair (sewing together of native tissues)— a.k.a. colporrhaphy—is best suited to a central cystocele in which satisfactory native tissues are present.  However, this will not adequately address a lateral defect cystocele or a combined cystocele. Thus, it is important to determine the type of cystocele in terms of repairing it with native tissues. One of the advantages of a mesh repair is that it addresses all three types of cystocele. Additionally, instead of using native tissue that has already failed in terms of providing adequate structural support, mesh repairs use a strong and durable material to provide support.

Factors influencing me to do a mesh repair over a classic colporrhaphy are the following: poor tissues; risk factors for recurrence including chronic constipation, cough, obesity, and occupations that require manual labor; a relatively young patient who will need a durable repair; and those patients who have already failed a native tissue repair.

In the appropriately selected patient operated on with the proper surgical technique, the results of polypropylene mesh repairs have been extraordinarily gratifying. These procedures pass muster and the “MDSW” test—meaning I would readily encourage my mother, daughter, sister or wife to undergo the procedure if needed. When performed by a skilled pelvic surgeon, the likelihood for cure or vast improvement is great and the likelihood for complications is minimal. Meshes are strong, supple and durable and the procedure itself is relatively simple, minimally-invasive and amenable to outpatient surgery. When patients are seen years after a mesh repair, they are usually extremely satisfied and their pelvic exams typically reveal restored anatomy with remarkable preservation of vaginal length, axis, caliber and depth.

Meshes act as a scaffold for tissue in-growth and ultimately should become fully incorporated by the body. I think of a surgical mesh in a similar way to a backyard chain-link fence that has in-growth of ivy. Meshes examined microscopically years after implantation demonstrate a dense growth of blood vessels and collagen in and around the mesh.

As compared to the classic plication, when a mesh is used for bladder repair, there is rarely any need for trimming the vaginal wall, which makes for a more anatomical repair in terms of vaginal preservation. Another advantage of mesh repairs is that if the patient has a mild-moderate degree of uterine prolapse accompanying the cystocele, the base of the mesh can be anchored to the cervix and thus provide support to the uterus as well as the bladder, potentially avoiding a hysterectomy.

In my opinion, the keys to success are the following: estrogen cream preoperatively in the post-menopausal patient; intravenous and topical antibiotics; a small vaginal incision; good surgical exposure; careful technique making sure the mesh is anchored at the appropriate anatomical sites; trimming the mesh to use the least mesh load possible; avoiding mesh folding, redundancy and tension; and vaginal packing and oral antibiotics post-operatively.

The bottom line is that mesh repairs for pelvic organ prolapse have been revolutionary in terms of the quality and longevity of results—a true game changer. They represent a dramatic evolution in the field of female urology and urological gynecology, offering a vast improvement in comparison to the pre-mesh era. That said, they are not without complications, but the complication rates should be reasonably low under the circumstance of proper patient selection, a skilled and experienced surgeon performing the procedure, excellent surgical technique, utilization of the optimal mesh and patient preparation.

Mesh Integration

Three factors are integral to mesh integration, the process by which the mesh incorporates seamlessly into the body: mesh, patient, and surgeon factors. The goal is for the mesh to fully incorporate into the body so that it can serve its role in providing support to the urethra and/or bladder to cure/improve the stress incontinence and/or cystocele, respectively.

The “gold standard” mesh is large-pored, elastic, monofilament polypropylene. This has been the standard for sling surgery for stress urinary incontinence for over 20 years and for pelvic reconstructions for many years as well. This material is also the standard for mesh hernia repairs and also serves as a hardy suture used for closure of the abdominal wall.

Patient considerations are equally vital.  Risk factors for integration problems include: compromised or poor-quality vaginal tissues; radiated tissues; diabetes; patients on steroids; immune-compromised patients; and patients who use tobacco.

Foremost, a well-trained, experienced pelvic surgeon should be the person doing the mesh implantation. The surgeons most skilled and adept fake newsat this type of surgery are those who have undertaken fellowship training in female pelvic medicine and reconstructive surgery after completion of their urology or gynecology training. It is sensible to check if your surgeon is specialized, and if not, at least has significant clinical experience doing mesh implantation procedures. It is particularly important that the surgeon performing the mesh implant is capable of taking care of any complications that may arise.

The “Mesh-up”

Historically, many of the problems that occurred resulting from mesh implantations were not intrinsic to the mesh itself but were potentially avoidable issues that had to do with surgical technique and/or patient selection. Complications with integration such as mesh exposure—a situation where the mesh is “exposed” in the vagina and is not positioned in the correct surgical plane—can and do occur in a small percentage of patients (even when properly selected and when done by a well-trained pelvic surgeon).  When this situation occurs, it is generally quite manageable, although it will often involve revision surgery if it does not respond to conservative measures.

The crux of the “mesh-up” problem was that a few years ago several of the companies that sold mesh products–in an effort to amplify sales and profits–inappropriately and aggressively promoted their products to physicians who were not trained pelvic surgeons.  They offered “weekend training courses” to general gynecologists, many of whom started implanting pelvic meshes into patients after only a brief training period, often with disastrous results, with many patients sustaining incorporation issues.  This ultimately led to lawsuits and litigation and thereafter several of the mesh companies including Johnson and Johnson Gynecare and American Medical Systems pulled their mesh products off the market.  Fortunately for pelvic surgeons and patients alike, Boston Scientific remained in business, and it is their sling and mesh products that I most commonly implant for female pelvic surgical procedures.

This is not to say that there have not been bad mesh products on the market.  Historically, both the Mentor ObTape and the Tyco IVS sling were poorly designed mesh slings that did not have favorable incorporation features, had horrific results and were ultimately withdrawn from the market.

All of the slings and meshes that remain on the market that are used for pelvic floor surgery in the USA—including the Boston Scientific products–have favorable incorporation features and have been time-tested and have demonstrated their utility. Boston Scientific did not deserve a reaming on 60 Minutes, but I suppose it is irresponsible “spin” that makes for a story and commands advertising dollars.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

Artificial Urinary Sphincter (AUS): What You Need To Know

May 12, 2018

Andrew Siegel MD   5/12/2018

Severe involuntary leakage of urine following prostate surgery is a rare event, occurring in less than 5% of men following prostatectomy for prostate cancer, and in an even smaller percentage of men who have undergone prostate surgery for a benign process.  Following prostatectomy, it most often results from scarring of the bladder neck sphincter.  Severe incontinence can be devastating to one’s quality of life, affecting psychological, emotional, and sexual well-being and often causing loss of self-esteem, depression, and avoiding a healthy, productive, and active lifestyle.

Fortunately, for the small percentage of men rendered severely incontinent after prostatectomy, the AUS offers a great opportunity for cure and in significantly improving quality of life. It functions as a mechanical compression device of the urethra that is under the patient’s control, providing simple and discreet control over bladder storage and emptying.  Implanted entirely within the body, the device mimics the function of a healthy sphincter muscle by keeping the urethra closed until the patient desires to urinate.

The AUS prosthesis is a saline fluid-filled device composed of solid silicone elastomer consisting of three interconnected components: a cuff implanted around the urethra, a pressure-regulating balloon reservoir implanted behind the pubic bone, adjacent to the bladder, and a control pump implanted in the scrotum.  The cuff gently squeezes the urethra closed, preventing urine from passing.  When one wants to urinate, he simply squeezes and releases the control pump that is situated in the scrotum, temporarily transferring fluid from the cuff to the pressure regulating balloon.  The cuff opens, allowing urine to flow through the urethra.  Within several minutes, the pressure regulating balloon automatically returns the fluid to the cuff to once again pinch the urethra closed.

Blausen_0059_ArtificialUrinarySphincter

The AUS, first developed in 1972, has been used successfully for over 45 years and has been implanted in more than 150,000 men. Over the years, biomedical engineering refinements have further improved the AUS.  About two thirds of men will be completely continent after an AUS implant, and the other one third will experience only minor incontinence, requiring one or two small pads per day. The overall patient satisfaction rate exceeds 90%.

In order to be an appropriate candidate for the AUS, incontinence needs to be on the basis of a weakened or damaged sphincter and not due to bladder over-activity.  Additionally,  bladder capacity needs to be adequate and urinary flow rate sufficient to empty the bladder. The incontinence should be present for a minimum of 6 months before considering the AUS, since spontaneous improvement occurs for some time after prostatectomy. One obviously need to be sufficiently motivated to receive an implant, and its use demands manual dexterity in order to operate the control pump.

Implantation of the Artificial Urinary Sphincter

Implantation of the AUS is a one hour or so outpatient surgical procedure done under anesthesia.  The conventional operation is performed with one’s legs in stirrups and requires one incision in the abdomen and the other in the perineum (area between scrotum and anus).  In 2003, Dr. Steve Wilson and I devised an innovative technique for AUS implantation via a single scrotal incision. The advantages of the scrotal technique are a single incision, the fact that it can be done supine (lying on one’s back versus legs up in stirrups), faster operative time, ease of doing the procedure and decreased patient discomfort.  In either case, the control pump is one-size fits all, but the cuff is precisely measured to your anatomy and the pressure-regulating balloon reservoir is usually chosen to be 61-70 cm water pressure.

It is important to know that the AUS will not be activated– and thus will not be functional– for about a 6-week period of time to allow for healing of tissues. Activation is a simple process that is done in the office, involving minimal discomfort.

It is advisable to order and wear a MedicAlert bracelet (www.medicalert.org) to inform health care personnel that you have an AUS implant in the event of a medical emergency. If you were rendered unconscious or unable to communicate, this bracelet will inform emergency medical staff that you have an AUS, because if there is ever a need for a urethral catheter, it is imperative that the AUS be deactivated prior to catheter placement in order to avoid damaging the urethra.

FAQ

Who manufactures the AUS?

American Medical Systems Men’s Health Division of Boston Scientific, Inc. http://www.BostonScientific.com

Will insurance cover the AUS?

Medicare has a coverage policy for incontinence control devices, which includes the AUS.  Most commercial health insurers also cover the AUS when deemed medically necessary for the patient.

How effective is the AUS?

More than 90% of patients with the AUS have greatly improved continence, many of whom achieve complete urinary control with no need for pads and the remainder of whom have occasional, minor stress incontinence with vigorous activities, typically requiring one or two small pads per day.  The 61-70 cm pressure regulating balloon provides 61-70 cm of pressure around the urethra, which is sufficient closure for most of the activities of daily living.

Does the AUS need to be measured to my body?

The control pump is “one size fits all”, but the cuff is sized to the circumference of your urethra to achieve a proper fit.  The reservoir comes in a variety of pressures.  The higher the pressure of the reservoir, the tighter the closure of the urethra. The tighter the closure of the urethra, the better is the continence, but also the greater the chance of urethral damage from the higher pressures. A balance must be achieved in order to achieve the necessary pressure to achieve continence while minimizing potential damage to the urethra. In practical terms, this translates into a 61-70 cm. pressure reservoir for most men.

Can I have an AUS if I underwent surgery followed by radiation therapy?

Yes, but radiation therapy increases the  potential risk for complications because of tissue damage, scarring, decreased blood flow and less optimal wound healing.

What are alternatives to the AUS, assuming that behavioral techniques and pelvic floor muscle exercises have failed?

  1. Absorbent pads and garments
  2. Penile compression clamps
  3. External collecting devices
  4. Urethral bulking agents
  5. The male sling

The first three are external, bulky, mechanical means of coping with–not treating–the problem.  Urethral bulking agents have fared poorly and the male sling is a possibility, although it is indicated for lesser degrees of incontinence and achieves results far inferior to those possible with the AUS.

Who should not have an AUS prosthesis?

The AUS is not appropriate for a man with an obstructed lower urinary tract. It also should not be used for those with bladder-related incontinence (overactive bladder or a small-capacity, scarred bladder) as it is indicated only for those with sphincter-related incontinence. It cannot be effectively used in those with compromised dexterity or mental acuity.

What are the potential risks and complications associated with AUS implantation?

Infection   As with any surgery, an infection can develop after an AUS implant.  Every step is taken to reduce the likelihood of an infection, including intravenous antibiotics, an antiseptic scrub of the surgical site on the operating table followed by the application of an chlorhexidine and alcohol skin antiseptic immediately prior to the operation, double-gloving, meticulous surgical technique with the procedure done as quickly as possible, topical antibiotics to flush the surgical site, and minimizing operating room traffic. Antibiotic ointment is placed on the surgical incision prior to placing the surgical dressing. Patients are sent home with oral antibiotics.

Two of the three components of the AUS–the cuff and pump–are coated with an antibiotic combination called InhibiZone, which consists of rifampin and minocycline.  If an infection occurs and does not respond to antibiotics, it may be necessary to remove the AUS, an extremely rare occurrence.

MH AMS 800 urinary sphincter product

Image above: AUS with inhibiZone coating of control pump and cuff

 

Erosion   This is a breakdown of the urethral tissues that lie beneath the cuff.   It is generally treated with cuff removal to allow for urethral healing prior to consideration for cuff replacement at a later date.  Erosion can occur when a catheter is placed into the urinary bladder by health care personnel uninformed that the AUS device is in place. The delicate urethra, pinched closed by the inflated cuff surrounding it, is traumatized and damaged by catheter placement.  This situation can be avoided by deactivating the AUS prior to catheterization.  This is one of the reasons that a MedicAlert card and bracelet are useful considerations. Erosion of the other AUS components can also occur on a rare basis. The control pump can potentially erode through the scrotal skin and the pressure-regulating balloon reservoir into the urinary bladder.

Mechanical Malfunction   The AUS is effective and reliable, but it is a mechanical device that can ultimately malfunction. It is not possible to predict how long an AUS will function in an individual patient.  As with any biomedical prosthesis, this device is subject to wear, component disconnection, component leakage, and other mechanical problems that may lead to the device not functioning as intended and may ultimately require additional surgery to replace the device. The median durability of the device is about 7.5 years, although I have patients who still have a functional AUS 20 years after implantation.

Urethral Tissue Atrophy   This can result from the long-term pressure effect of the cuff on the urethra.  Essentially, the urethra shrinks down from being squeezed by the cuff, resulting in worsening of urinary control.  When this happens, it generally requires repositioning of the cuff to a new urethral location or the use of a smaller cuff or, on rare occasion, placement of a second cuff (tandem cuff).

Pain    Discomfort in the groin, penis, and scrotum is expected immediately after surgery and during the period when the device is first used. It is very rare to experience chronic pain from an implantation of an AUS.

Migration and Extrusion  Migration is the movement or displacement of components within the body space in which they were originally implanted.  Extrusion occurs when a component moves to an abnormal location outside of the body.  These are both extremely rare occurrences

Bottom Line: The artificial urinary sphincter (AUS) is an effective, safe and reliable implantable medical prosthesis to restore urinary control in men with severe, refractory stress urinary incontinence.  Although there is no means of totally replacing our natural sphincter system, the AUS is the only device that simulates normal sphincter function by opening and closing the urethra at the will of the patient. It provides consistent results in the treatment of incontinence following prostatectomy and is considered to be the “gold standard” in the management of this problem. Many patients report that the AUS is nothing short of “life changing,” converting men who are bladder “cripples” back to normal function and restoring their quality of life. 

Wishing you the best of health,

2014-04-23 20:16:29

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx