Posts Tagged ‘prostate biopsy’

Medical “Urban” Myths in Urology

December 1, 2018

Andrew Siegel MD  12/1/2018

I am pleased to announce that with this entry I have surpassed 400 blogs composed over the past seven years.

Myth:  a widely held but false belief or idea; a misrepresentation of the truth; a fictitious or imaginary thing; exaggerated or idealized conception

thank you Pixabay for image above

Part I of today’s entry confronts widely held but false medical concepts that run rampant in the general population. Part II addresses widely held but false medical concepts that run rampant within the medical field. The medical mythology I attempt to debunk is largely urological in nature.

General population medical myths: Some myths are perpetuated by the general (non-medical) community, consisting of erroneous beliefs and inaccurate presumptions. These falsehoods often require a great deal of physician time in an effort to disabuse patients of them. 

Medical community medical myths: Some aspects of the practice of medicine are on the basis of customs perpetuated by medical personnel (most often not physicians) that seem logical or justified and ultimately become accepted dogma. However, they often do not hold muster, crumble under scientific scrutiny and can be categorized as medical myths.   

GENERAL POPULATION MEDICAL MYTHS

“A vaccine caused my child’s autism.”

(This is a non-urological myth, but nonetheless needs to be addressed.)

Myth: Vaccines, particularly MMR (measles, mumps, rubella) cause neurological injuries including autism spectrum disorder.

Reality: Scientific evidence overwhelmingly shows no correlation between vaccines in general, MMR vaccine in specific, and thimerosal (a mercury-based preservative) in vaccines with autism spectrum disorders or other neuro-developmental issues. 

We have come a long way on the immunization and vaccination front, wiping out a significant number of diseases completely.  In children, vaccines have been among our most effective interventions to protect individual as well as public health. What a great means of reducing  risk for certain infections that are potentially lethal, if not capable of incurring significant morbidity.  Vaccinations are now available for hepatitis A and B, diphtheria, tetanus, pertusis, polio, hemophilus, measles, mumps, rubella, varicella, meningitis, cervical cancer/human papilloma virus, influenza and pneumococcal pneumonia and herpes zoster (shingles).

“Doing a prostate biopsy will spread any cancer that may be present.”

Myth: Using a needle to obtain tissue samples of the prostate allows cancer cells to seed and implant along the needle track, or alternatively, into blood or lymphatic vessels. 

Reality: Although this is a theoretical consideration, the truth of the matter is that based upon millions of prostate biopsies performed annually in the USA, the incidence of seeding is virtually non-existent and the potential risk can be thought of as being negligible at best.

“Cancer spreads when exposed to oxygen.”

Myth: When a body is opened up and exposed to oxygen any cancer present can readily spread.

Reality: There is no scientific evidence that supports cancer advancing because of exposure to air/oxygen.  At times, upon doing an exploratory surgery, more cancer is discovered than was anticipated based upon imaging studies. This has nothing to do with the surgical incision nor exposure to air/oxygen, but is simply on the basis of cancer that did not show up on the diagnostic evaluation.

“All prostate cancer is slow growing and can be ignored.”

Myth: Prostate cancer grows so slowly that it can be disregarded. 

Reality:  Every case of prostate cancer is unique and has a variable biological behavior.

Yes, some are so unaggressive that no cure is necessary and can be managed with surveillance; however, others are so aggressive that no treatment is curative, and many are in between these two extremes, being moderately aggressive and highly curable. A major advance in the last few decades is the vast improvement in the ability to predict which prostate cancers need to be actively treated and which can be watched, a nuanced and individualized approach.

Those who feel that prostate cancer should not be sought out and treated should be attentive to the fact that it is the second leading cause of cancer death, with an estimated 30,000 deaths in 2018, and furthermore, that death from prostate cancer is typically an unpleasant one

MEDICAL COMMUNITY MEDICAL MYTHS

“Drink lots of fluids to flush out kidney stones.”

Myth: Drinking copiously will help promote passage of kidney and ureteral stones. The rationale of this advice is that by hydrating massively, a head of pressure will be created to help passage of a stone present in the kidney or ureter.

Reality: The presence of a stone often causes urinary tract obstruction.  Over-hydration in the presence of obstruction will further distend the already bloated and inflated portion of the urinary collecting system located above the stone. This increased distension can exacerbate pain and nausea that are often symptoms of colic. The collecting system of the kidney and the ureter have natural peristalsis—similar to that of the intestine—and over-hydration has no physiological basis in terms of helping this process along, being pointless and perhaps even dangerous.  Drinking moderately in the face of a kidney or ureteral stone is sound advice.

“Everyone must drink 8-12 glasses of water a day.”

Myth: Many sources of information (mostly non-medical and of dubious reliability) dogmatically assert that humans need 8-12 glasses of water daily to stay well hydrated and thrive.

Reality: Many people take the 8-12 glass/day rule literally and as a result end up in urologists’ offices with urinary urgency, frequency and often urinary leakage. The truth of the matter is that although some urinary issues are brought on or worsened by insufficient fluid intake–including kidney stones and urinary infections–other urinary woes are brought on or worsened by excessive fluid intake, including the aforementioned “overactive bladder” symptoms.  Water requirements are based upon ambient temperature and activity level. If you are sedentary and in a cool environment, your water requirements are significantly less than when exercising vigorously in 90-degree temperatures.

Humans are extraordinarily sophisticated and well-engineered “machines” and your body lets you know when you are hungry, ill, sleepy, thirsty, etc.  Heeding your thirst is one of the best ways of maintaining good hydration status, in other words, drinking when thirsty and not otherwise. Another method of maintaining good hydration status is to pay attention to your urine color.  Urine color can vary from deep amber to as clear as water.  If your urine is dark amber, you need to drink more as a lighter color is ideal and indicative of satisfactory hydration

“When a patient needs to have a catheter placed because he or she is unable to urinate, clamp the catheter intermittently to allow for gradual drainage instead of allowing it to drain at once.”

Myth: Rapid bladder decompression with a catheter can cause problems including bleeding that may require intervention, kidney failure and circulatory collapse. 

Reality: Science has clearly shown that concerns for kidney failure and circulatory collapse due to rapid bladder decompression are untruths.  Yes, on occasion some bleeding can occur (with or without) rapid decompression, but it is usually self-limited and inconsequential.

“A patient is experiencing leakage around a urinary catheter, so it must be too small and replaced with a larger one.”

Myth: A catheter that leaks needs to be replaced with a larger bore catheter so as to provide a better seal and reduce the leakage. This practice is commonly applied in nursing homes where many patients have long-term indwelling catheters for a variety of reasons.

Reality:  Leakage of urine around indwelling catheters is a common scenario. Although it can be due to a blocked catheter, most often the cause is bladder spasms induced by the catheter or catheter balloon irritating the bladder. The sensible management is to irrigate the catheter to ensure no obstruction, deflate the balloon to some extent, and thereafter consider the use of a bladder relaxant medication to minimize the bladder spasms.  The best practice is always to use the smallest catheter that is effective and remove it as soon as feasible. The longer a catheter stays in, the greater the chance for infections and long-term catheters that are upsized are clearly associated with urethral erosion and urethral stricture (scarring).

“If a patient has bacteria in the urine they must have a urinary infection that needs to be treated.”

Myth: There are bacteria present in the urine on urinalysis, so there must be an underlying infection that demands antibiotic treatment.  This is one of the medical myths perpetuated by internists and general practitioners.

Reality: The thought process that the presence of bacteria in the urine without symptoms means an infection is erroneous. It is vital to distinguish a symptomatic urinary infection from asymptomatic bacteriuria. Asymptomatic bacteriuria, common in elderly and diabetics, is the presence of bacteria within the bladder without causing an infection. This does not require treatment, which is futile and promotes selection of resistant bacteria.  Asymptomatic bacteriuria should be treated only in select circumstances:  pregnant women; in patients undergoing urological-gynecological surgical procedures; and in those undergoing prosthetic surgery (total knee replacement, etc.).

An extension of this myth is that bacteria in the urine in the face of an indwelling catheter is an infection that must be treated. The reality is that in the vast amount of cases, this is bacterial colonization without infection.

Bottom Line: Lay and even medical populations are subject to medical myths—mistaken beliefs that are often passed down like memes with little to no basis in fact. These myths have no place in the art and craft of medicine and need to be challenged with real science.  

“What is dogma today is dog crap tomorrow.”

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

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Must My Prostate Cancer Be Treated?

January 4, 2014

Blog # 135

“To do nothing, that’s something.”

Samuel Shem, The House of God

Prostate cancer needs to be accorded respect as there are 240,000 new cases diagnosed annually and it accounts for 30,000 deaths per year, being the second leading cause of cancer death in men, only behind lung cancer.

Unlike many other malignancies, prostate cancer is often not a lethal disease and may never need to be treated. Shocking, right…a cancer that does not necessarily need to be cut out or managed in any way! Patients with slow-growing, early stage cancer as well as older men with other health issues may be put on surveillance, aka watchful waiting, as opposed to traditional treatment with surgery or radiation.

The problem is that not all prostate cancers are slow-growing and early stage, and the challenge is how to predict the future behavior of the cancer so as to treat it appropriately—offering cure to those with aggressive cancer, but sparing the side effects of treatment in those who have non-aggressive cancer. The goal of active surveillance is to allow men with low risk prostate cancer to avoid radical treatment with its associated morbidity and/or delay definitive treatment until signs of progression occur. This involves two things—vigilant monitoring and a compliant patient who is compulsive about follow-up.

The ratio of 7:1 of the lifetime likelihood of diagnosis of prostate cancer (about 1 in 6 men) to death from prostate cancer (about 1 in 40 men) points out that many men with prostate cancer have an indolent (i.e., slow growing) cancer. Because of this fact, an alternative strategy to aggressive management of all men with prostate cancer is active surveillance, a structured means of careful follow-up with rigorous monitoring and immediate intervention should signs of progression develop. Being a candidate for this approach is based upon the results of the PSA blood test, findings on the digital rectal exam, and the details of the biopsy, which usually involves obtaining one dozen samples of prostate tissue.

General eligibility criteria for active surveillance include all of the following (Note that these are basic guidelines and need to be modified in accordance with patient age and general health— certainly if one has a life expectancy < 10 years, he would be a good candidate for active surveillance, regardless of the following):

  • PSA (Prostate Specific Antigen) less or equal to 10 (PSA is the blood test that when elevated or accelerated indicates the possibility of a problem with the prostate and is often followed by a prostate ultrasound/biopsy)
  • Gleason score 6 or less (possible score 2-10, more about this below)
  • Stage T1c-T2a

 (T1c = picked up by PSA with normal prostate on rectal exam; T2a = picked up by abnormal prostate on rectal exam, involving only one side of the prostate)
  • Less then 3 of 12 biopsy cores involved with cancer
  • Less then 50% of any one core involved with cancer

Prostate cancer grade is often the most reliable indicator of the potential for growth and spread. The Gleason score provides one of the best guides to the prognosis and treatment of prostate cancer and is based on a pathologist’s microscopic examination of prostate tissue. To determine a Gleason score, a pathologist assigns a separate numerical grade to the two most predominant architectural patterns of the cancer cells. The numbers range from 1 (the cells look nearly normal) to 5 (the cells have the most cancerous appearance). The sum of the two grades is the Gleason score. The lowest possible score is 2, which rarely occurs; the highest is 10. The Gleason score can predict the aggressiveness and behavior of the cancer. High scores tend to suggest a worse prognosis than lower scores because the more deranged and mutated cells usually grow faster than the more normal-appearing ones.

Prostate cancers can be “triaged” into one of three groupings based upon Gleason score. Scores of 2-4 are considered low grade; 5-7, intermediate grade; 8-10, high grade.

The active surveillance monitoring schedule is typically:

  • PSA and DRE every 3-6 months for several years, then annually
  • Prostate biopsies: one year after initial diagnosis, then periodically until age 80 or so (once again, a judgment call)

As long as the cancer remains low-risk, the surveillance protocol may be continued, sparing the patient the potential side effects of surgery or radiation.

Another meaningful way of predicting the behavior of prostate cancer is by using the PSA Doubling Time (PSADT)—defined as the amount of time it takes for the PSA to double. A short PSA doubling time is indicative of an aggressive, rapidly growing tumor, whereas a long PSA doubling time is indicative of an indolent, slow growing tumor. A PSADT of less than 3 years is clearly associated with the potential for progression of prostate cancer.

A change in plan from active surveillance to more active intervention needs to be instituted if any of the following occurs:

  • PSA doubling time is noted to be less then 3 years
  • Biopsy reveals grade progression to Gleason 7 or higher
  • Biopsy reveals increased prostate cancer volume

Approximately half of men on active surveillance remain free of progression at ten years, and definitive treatment is most often effective in those with progression. The absence of cancer on repeated prostate biopsy (because the cancer is of such low volume) identifies men who are unlikely to have progressive prostate cancer.

Bottom Line: Active surveillance is an effective means of minimizing over-treatment of indolent prostate cancer and avoiding the side effects of immediate treatment. Its disadvantages are the need for frequent and repeated testing and biopsy, the anxiety of living with untreated prostate cancer, and the possibility that delayed treatment may not be curative, although that is not usually the case.

Andrew Siegel, M.D.

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Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in  2014.

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