Archive for February, 2015

Prostate Cancer Screening: What’s New?

February 28, 2015

Andrew Siegel MD 2/28/15

The Dilemma

The downside of screening is over-detection of low-risk prostate cancer that may never prove to be problematic, but may result in unnecessary treatment with adverse consequences. The downside of not screening is the under-detection of aggressive prostate cancer, with adverse consequences from necessary treatment not being given.

The Buck Stops Here

Prostate biopsy (ultrasound guided) is the definitive and conclusive test for prostate cancer. An elevated PSA (Prostate Specific Antigen) blood test or an abnormal DRE (digital rectal exam) are the findings that typically lead to the recommendation for prostate biopsy.

What’s New In Prostate Cancer Screening?

The following are refinements in the screening process that can help make the decision about whether or not to proceed with a prostate biopsy, potentially sparing some from the need to undergo the biopsy and clearly indicating the need for biopsy in others.

  • Free PSA
  • PSA Velocity
  • PSA Density
  • PCA-3
  • Prostate MRI
  • 4K Score

Free PSA

PSA circulates in the blood in a “free” form, which it is unbound and a “complex” form, in which it is bound to a protein. The free/total PSA can enhance the specificity of PSA testing. The greater the free/total PSA, the greater the chances that benign enlargement of the prostate is the cause of the PSA elevation. In men with a PSA between 4-10, the probability of cancer is less than 10% if the ratio is greater than 25% whereas the probability of cancer is almost 60% if the ratio is less than 10%.

PSA Velocity

It is extremely useful to compare the PSA values from year to year. Under normal circumstances, PSA increases by only a small increment, reflecting age-related benign prostate growth. PSA acceleration at a rate greater than anticipated is a red flag that may be indicative of prostate cancer and is one of the most common prompts for undergoing biopsy.

PSA Density

There is a direct relationship between prostate size and PSA, with larger prostates producing higher PSA levels. PSA density (PSA/prostate volume) is the relationship of the PSA level to the size of the prostate. PSA density > 0.15 is a red flag that may be indicative of prostate cancer.

PCA-3 (Prostate Cancer Antigen-3)

PCA-3 is a specific type of RNA (Ribonucleic Acid) that is released in high levels by prostate cancer cells. Its expression is 60-100x greater in prostate cancer cells than benign prostate cells, which makes this test much more specific for prostate cancer than PSA.  PCA-3 is a urine test. The prostate is gently “massaged” via DRE to “milk” prostate fluid into the urethra. The first ounce of urine voided immediately after massage is rich in prostatic fluid and cells and is collected and tested for the quantity of PCA-3 genetic material present. Urinary levels of PCA-3 are not affected by prostate enlargement or inflammation, as opposed to PSA levels. PCA-3 > 25 is suspicious for prostate cancer.

Prostate MRI (Magnetic Resonance Imaging)

MRI is a high-resolution imaging test that does not require the use of radiation and is capable of showing the prostate and surrounding tissues in multiple planes of view, identifying suspicious areas. MRI uses a powerful Tesla magnet and sophisticated software that performs image-analysis, assisting radiologists in interpreting and scoring MRI results. A validated scoring system known as PI-RADS (Prostate Imaging Reporting and Data System) is used. This scoring system helps urologists make decisions about whether to biopsy the prostate and if so, how to optimize the biopsy.

PI-RADS classification Definition
I Most probably benign
II Probably benign
III Indeterminate
IV Probable cancer
V Most probably cancer

4Kscore Test

The 4Kscore Test measures the blood content of four different prostate-derived proteins: Total PSA, Free PSA, Intact PSA and Human Kallikrein 2. Levels of these biomarkers are combined with a patient’s age, DRE status (abnormal DRE vs. normal DRE), and history of prior biopsy status (prior prostate biopsy vs. no prior prostate biopsy). These factors are processed using an algorithm to calculate the risk of finding a Gleason score 7 or higher (aggressive) prostate cancer if a prostate biopsy were to be performed. The test can increase the accuracy of prostate cancer diagnosis, particularly in its most aggressive forms.

(It cannot be used if a patient has received a DRE in the previous 4 days, nor can it be used if one has been on Avodart or Proscar within the previous six months. Additionally, it cannot be used in patients that have within the previous six months undergone any procedure to treat symptomatic prostate enlargement or any invasive urologic procedure that may be associated with a PSA elevation.)

As of now, the test is not covered by insurance and costs $395 from the lab that performs it.

Bottom Line: Excluding skin cancer, prostate cancer is the most common cancer in men (accounting for 26% of newly diagnosed cancers with men having a 1 in 7 lifetime risk). The median age of prostate cancer at diagnosis is the mid 60’s and there are 221,000 new cases per year, 27,500 deaths (the second most common form of cancer death, after lung cancer) and there are currently about 2.5 million prostate cancer survivors in the USA.  It is important to diagnose prostate cancer as early as possible in order to decide on the most appropriate form of management–surgery, radiation, or observation/monitoring (the most common treatment pathways, although there are other options as well).  These refinements in the screening process can help urologists make the decision about whether or not to proceed with a prostate biopsy.  

 

Wishing you the best in health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the inbox of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health:available in e-book (Amazon Kindle, Apple iBooks, B & N Nook, Kobo) and paperback: http://www.MalePelvicFitness.com

Private Gym Male Pelvic Floor Muscle Training  Program: http://www.PrivateGym.com -available on Amazon as well as Private Gym website

 

“I’m Almost There”: What You Need To Know About Delayed Ejaculation

February 21, 2015

Andrew Siegel, MD  2/21/15

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Male sexual problems go beyond difficulties with obtaining or maintaining a rigid erection.  Ejaculatory timing dysfunctions are commonplace, ranging from premature ejaculation on one extreme to delayed ejaculation on the other extreme. Premature ejaculation is one of the most prevalent male sexual disorders and seems to get all the attention, so today’s focus is on delayed ejaculation (DE). The condition of DE used to be referred to as “retarded” ejaculation, but because of the politically incorrect nature of the “R” word, this label has gone by the wayside, similar to “impotence,” which has been replaced by “ED” and “frigid,” which has been replaced by “anorgasmic.”

How Long Is Too Long?

A classic study of 500 couples across five countries measured time from penetration to ejaculation, with results ranging from 33 seconds to 44 minutes with the median being 5.4 minutes. It has been proposed that any time from penetration to ejaculation that exceeds 20-25 minutes that causes distress to the delayed ejaculator or partner meets the criteria for diagnosis of DE.

Ejaculation 101: A Few Words On The Science Of Ejaculation 

Ejaculation occurs after sufficient intensity and duration of sexual stimulation enables passing an ejaculatory threshold. Men with premature ejaculation are thought to have increased sensitivity and excitability of the penis, whereas men with delayed ejaculation are thought to have decreased sensitivity.

The ejaculatory center, located within the spine, integrates nerve input from the brain and the penis and coordinates the phases of emission and expulsion. Emission releases the secretions from the prostate, seminal vesicle and epididymis via the ejaculatory ducts and prostate ducts into the urethra. Expulsion propels the ejaculate through the urethra via rhythmic contractions of the pelvic floor muscles.

The spinal ejaculatory center is controlled mainly by the neurotransmitters serotonin and dopamine, although there others are involved as well. Serotonin inhibits ejaculation whereas dopamine facilitates it. One’s balance of neurotransmitters is determined by genetics and other considerations including age, stress, illness, medications and other factors.

Delayed Ejaculation

DE is a condition in which ejaculation occurs only after a prolonged period of time following penetration. Some men are unable to ejaculate at all, despite having a rigid and very durable erection.  Prolonged erection without ejaculation can result in testicular vaso-congestion, a.k.a. “blue balls.” With arousal and the increase in genital blood flow, the testicles can become swollen and a bluish tint can develop because of engorgement of veins. It can be painful, causing a tense, heavy, pressure-like discomfort in both testicles. The cure: ejaculation.

DE can be problematic for both the delayed ejaculator and his partner, resulting in frustration, exhaustion, soreness, if not pain.  The sexual partner often feels distress and responsibility because of the implication that the problem may be their fault and that they are inadequate in terms of attractiveness or having the facility to enable a climax. The combination of not being able to achieve sexual “closure,” the inability to enjoy the mutual intimacy of ejaculation, and denying the partner the gratification of knowing that they are capable of bringing their man to climax is a formula for relationship stress. As tempting as it is to think that DE is an asset in terms of pleasing your partner, in reality a marathon performance has major shortcomings.

Interestingly, some men with this condition can ejaculate in an appropriate amount of time with masturbation. As well, some men can ejaculate in a normal period of time with manual or oral stimulation from their partner although they cannot do so with intercourse. It is plausible that one’s masturbation technique can provide more sensory stimulation than can be duplicated by sex with a partner. The amount of sensory stimulation derived from intercourse is predicated upon partner skill, anatomy, pelvic floor tone, the quality of the “fit” and many other elements, both physical and emotional.

Physical Or Psychological?

There can be underlying medical conditions that factor into problems of ejaculation. For example, hypothyroidism is strongly associated with delayed ejaculation whereas hyperthyroidism is associated with premature ejaculation. Since serotonin and dopamine as well as oxytocin, prolactin, and other chemicals are involved with ejaculatory control, any drug that modifies the levels of these chemicals may affect ejaculation timing. The selective serotonin reuptake inhibitors (SSRIs) – the most widely prescribed medications for depression – are notorious for their effect on delaying ejaculation, and are in fact, used for the treatment of premature ejaculation. Various neurological conditions that disrupt the communication between the spinal ejaculatory center and the brain/penis can cause ejaculatory dysfunction. In general, as men age, they more commonly note DE that may be on the basis of declining function of nerves as well as changes in genital skin.

As with so many sexual dysfunctions, excessive focus on the problem instead of allowing oneself to be “in the moment” can create a self-fulfilling prophecy of doom.  In other words, if a man goes into a sexual situation mentally dwelling and consumed with the problem, it is likely that ejaculation will be prolonged.

One solution is to avoid ejaculation for a number of days prior to intercourse, the same line of reasoning used for managing premature ejaculation by masturbating immediately before intercourse. Although numerous medications have been tried to help improve DE, none are FDA approved and none have met with much success. This is as opposed to premature ejaculation, which can be managed with topical anesthetics, selective serotonin reuptake inhibitors, and pelvic floor training. Sexual counseling using sensate focus therapy has proven to be of benefit to some patients with DE. This is a series of specific exercises for couples originally developed by Masters and Johnson.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

6922

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Kindle, iBooks, Nook, Kobo) and paperback: http://www.MalePelvicFitness.com

Private Gym: http://www.PrivateGym.com -available on Amazon as well as Private Gym website

The Private Gym is a comprehensive, interactive, follow-along exercise program that provides the resources to properly strengthen the pelvic floor muscles that are vital to sexual and urinary health. The program builds upon the foundational work of Dr. Arnold Kegel, who popularized exercises for women to increase pelvic strength and tone. This FDA registered program is effective, safe and easy-to-use: The “Basic Training” program strengthens the pelvic floor muscles with a series of progressive “Kegel” exercises and the “Complete Program” provides maximum opportunity for gains through its patented resistance equipment.

Penile Attention Deficit Disorder (PADD)

February 14, 2015

Andrew Siegel MD  2/14/15

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(Thank you Pixabay for above image)

 

“It is like a firstborn son—you spend your life working for him, sacrificing everything for him, and at the moment of truth he does just as he pleases.”

 Gabriel Garcia Marquez

(from Love In The Time of Cholera)

 

“The penis does not obey the order of its master, who tries to erect or

shrink it at will. Instead, the penis erects freely while its master is asleep.

The penis must be said to have its own mind, by any stretch of the imagination.”

Leonardo da Vinci

PADD

In the vast range between flawless erectile functioning and defeated phallus syndrome, there are a variety of forms, dimensions and magnitudes of impairments in the working order of the penis.  You may be able to achieve a fabulous erection—a proud soldier standing tall at attention, saluting, noble, confident, majestic, and readily capable of penetration, but then, much to you and your partner’s bewilderment and dismay, it decides to display its short “attention” span and deflate before business is fully conducted. I like to refer to this as penile attention deficit disorder (PADD).

Erection Hydraulics

Our circulatory system consists of arteries that supply oxygenated blood to our organs and tissues and veins that return blood back to the heart. Since erections are all about blood filling the penis, being able to achieve proud soldier status infers that your inflow of blood is excellent and uncompromised, with blood surging into the penis through arterial vessels unclogged by the ravages of time and poor lifestyle. The attention deficit occurs when the blood that is stored in the erection chambers leaks, similar to air hissing out from a flat tire and slowly deflating. This often implies a venous leak, in which the veins are unable to close off effectively

Erections are a matter of simple hydraulics—maximizing inflow of blood while minimizing outflow. There are two stages of erectile hydraulics: tumescence and rigidity. In the tumescence stage the penis becomes plump and full; in the rigidity stage, the penis becomes rock hard. The penis consists of 3 erection chambers that fill with blood. The erection chambers are composed of sinuses—virtually identical to our nasal sinuses—and when the sinuses become congested with blood, an erection results. When you are in a sexually stimulating situation, blood surges into your erection chambers by virtue of smooth muscle relaxation in both the penile arteries and in the sinuses, permitting inflow. It is this ability for smooth muscle relaxation that is critical for the initial penile erection hydraulics. As the sinuses fill up with blood, they compress the penile veins to block the outflow of blood, resulting in a tumescent penis, plump and full, but not yet rigid.

Fact: To get a good quality erection, relaxation is key, as it is in so many other physical activities.

Role Of Pelvic Floor Muscle…From Tumescence To Rigidity

The pelvic floor muscles are critical in the transformation of your tumescent penis to a rigid penis. By compressing the deep, inner part of your penis (the root of the penis), the pelvic floor muscles foster rigidity by aiding closure of veins and by elevating the blood pressure within your penis to levels well above systolic blood pressure (an erect penis being a hypertensive penis…the only hypertension you desire!), causing bone-like rigidity. You can think of the role of the pelvic floor muscles in trapping blood within the penis like that of a tourniquet placed around your arm by a phlebotomist in order to block venous return to make your arm veins full and easy to draw blood from.

Effect Of Aging On Muscle

With aging, the smooth muscle of our arteries tends to become stiffer (less able to relax and permit inflow of blood), resulting in high blood pressure for many of us. Your penis is not spared, as the smooth muscle of your penile arteries and sinuses stiffens and becomes less able to relax. This muscle stiffness does NOT result in penile stiffness. No, unfortunately the consequence of stiff smooth muscle in the penis and the sinuses is less arterial inflow and poor venous trapping. Additionally, your pelvic floor muscles tend to weaken with age. With the smooth muscle stiffening and the weakened pelvic floor muscles, you have the perfect storm for your proud soldier to falter, causing weakened erections and not uncommonly PADD.

Fact: With aging, your arteries get stiffer and your penis gets less stiff.

So, What To Do?

How do you maintain proud soldier status? What can you do to keep the proud soldier from becoming a wounded warrior?

You must keep that soldier in tip-top shape, well fed, well exercised, and well utilized for the role for which he was intended. And don’t forget that for a soldier to stand tall and proud at attention, he needs to engage in training exercises and drills.

To reiterate, the pelvic floor muscles play a critical role during erections, activating and engaging to help maintain penile rigidity and a skyward angling erection. There is good reason that the 1909 Gray’s Anatomy labeled one of the key pelvic floor muscles the “erector penis.”  Numerous studies have shown the benefits of pelvic floor muscle exercises in the management of erectile dysfunction, with particular benefit to those with venous leakage. So, the first line of defense against the onset of PADD and other forms of erectile dysfunction is keeping your pelvic floor muscles fit.  Enhancing pelvic floor muscle strength, tone, durability and responsiveness results in stronger pelvic floor muscles and consequently more rigid and durable erections .

Fact: Exercising the pelvic floor muscles can help prevent or improve PADD and other forms of ED.

 

Wishing you the best of health and a wonderful, romantic and sexy Valentine’s Day,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

6922

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Kindle, iBooks, Nook, Kobo) and paperback: http://www.MalePelvicFitness.com

Private Gym: http://www.PrivateGym.com -available on Amazon as well as Private Gym website

The Private Gym is a comprehensive, interactive, follow-along exercise program that provides the resources to properly strengthen the pelvic floor muscles that are vital to sexual and urinary health. The program builds upon the foundational work of Dr. Arnold Kegel, who popularized exercises for women to increase pelvic strength and tone. This FDA registered program is effective, safe and easy-to-use.  The “Basic Training” program strengthens the pelvic floor muscles with a series of progressive “Kegel” exercises and the “Complete Program” provides maximum opportunity for gains through its patented resistance equipment.

5 Amazing Reflexes Vital To Your Pelvic Health

February 7, 2015

Andrew Siegel MD  2/07/15

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(Above image courtesy of Pixabay)

A reflex is an automatic response to a stimulus, an action that occurs without conscious thought. Many of us are familiar with the knee jerk reflex in which the knee straightens as a result of the quadriceps muscle contracting in response to the tendon of our kneecap being tapped with a reflex hammer.  There are 5 reflexes that you probably are not aware of, but are important to learn about since they are so vital to your urinary and sexual health.

Guarding Reflex

As the sphinx guards the entrance to the Great Pyramids, so the sphincter muscles guard the entrance to the urinary bladder. The voluntary sphincter muscle—the one that you have control of and are capable of contracting at will—is largely composed of the deep pelvic floor muscles (PFMs).

The deep PFMs are your friends, helping you store urine while the bladder fills up. Even when you are not actively squeezing the PFMs, they have a baseline tone, working to provide resistance that keeps you from leaking urine as the bladder becomes fuller. They only relax completely when you urinate.

The guarding reflex is the increase in the contraction strength of these “guarding” PFMs as the bladder gets fuller and fuller, with stronger PFM tone as the volume of urine in the urinary bladder increases.

Cough Reflex

This reflex is also your good buddy, one that increases the contraction of the PFMs when you cough—above and beyond their resting tone—preventing you from leaking urine. This is nature’s way of protecting you from leaking urine when there is a sudden increase in your abdominal pressure, as occurs with a cough. This protects against cough-related stress urinary incontinence.

Pelvic Floor Muscle-Bladder Reflex (PFM-BR)

This is a very useful and practical reflex that you can tap into. The PFM-BR is a unique reflex since you are capable of engaging this reflex voluntarily, resulting in the relaxation of a muscle as opposed to its contraction. Anyone who has ever experienced an urgent desire to urinate or move their bowels will find it of great practical use. When the reflex is deployed, it will result in relaxation of both the urinary bladder and rectum and a quieting of the urgency.

Here is how it works: When you feel the sudden and urgent desire to urinate, pulse the pelvic floor muscles (PFMs) five times—brief but intense contractions. When the PFM are so deployed, the bladder muscle reflexively relaxes and the feeling of intense urgency should disappear. Likewise, when the PFMs are so deployed, the rectum relaxes and the feeling of intense bowel urgency should diminish. This reflex is a keeper when you are stuck in traffic and have no access to a toilet!

Bulbocavernosus Reflex (BCR)

The bulbocavernosus muscle (BC) is one of the very important superficial PFMs. The BCR is a contraction of the bulbocavernosus and its mates, the ischiocavernosus (IC) muscles when the glans (head) of the penis in a male or the clitoris in a female is squeezed. This reflex is important for maintaining erectile rigidity, since with each contraction of the BC and IC muscles there is a surge of blood flow to the penis/clitoris, maintaining the high blood pressures within the erectile chambers necessary for engorgement of these organs. Sexual stimulation can be thought of as a chain of linked BCRs.

Double Reflex

Did you ever experience an urgent desire to urinate and find relief by squeezing the head of the penis? If so, you have discovered the linkage of two reflexes—the BCR coupled with the PF-MBR. Here is what happens: A strong urge to urinate occurs and is managed by squeezing the head of the penis, which makes the urgency dissipate. What is actually happening is that the squeeze of the penis triggers a PFM contraction via the BCR. In turn, the PFM contraction relaxes the bladder muscle via the PFM-BR and makes the urgency either improve or disappear. Reflex magic!

Cremasteric Reflex

The cremaster muscle surrounds the spermatic cord (the cord-like structure that contains the testicular blood supply, nerves, etc.). The cremasteric reflex occurs when the inner thigh is stroked and the testicle pulls up towards the groin via a contraction of the cremaster muscle. This is a brisk reflex in boys and tends to become less active with aging. It is a natural protective reflex that helps us avoid testicular injury when danger approaches, like a turtle pulling its head into its protective shell.

Bottom Line: The aforementioned reflexes are vital for your sexual and urinary health; knowing about them and how to tap into them can be to your advantage.

 

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

6922

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Kindle, iBooks, Nook, Kobo) and paperback: http://www.MalePelvicFitness.com

Co-founder of Private Gym: http://www.PrivateGym.com–available on Amazon and Private Gym website

The Private Gym is a comprehensive, interactive, follow-along exercise program that provides the resources to properly strengthen the pelvic floor muscles that are vital to sexual and urinary health. The program builds upon the foundational work of Dr. Arnold Kegel, who popularized exercises for women to increase pelvic strength and tone. This FDA registered program is effective, safe and easy-to-use: The “Basic Training” program strengthens the pelvic floor muscles with a series of progressive “Kegel” exercises and the “Complete Program” provides maximum opportunity for gains through its patented resistance equipment.