PSA Screening 101: What You Should Know

20 Oct 2020 Blog

Prostate-specific antigen, or PSA, is a chemical produced by the prostate gland. PSA functions to liquefy semen following ejaculation, aiding the transit of sperm to the egg. A small amount of PSA filters from the prostate into the blood circulation and can be measured by a simple blood test. In general, the larger the prostate size, the higher the PSA level, since larger prostates produce more PSA. As a man ages, his PSA rises based upon the typical enlarging prostate that occurs with growing older.

How is PSA used to screen for prostate cancer?

Using PSA testing, about 90% of men have a normal PSA. Of the 10% of men with an elevated PSA, about 30% will have prostate cancer. In a recent study of 350,000 men with an average age of 55, median PSA was 1.0. Those with a PSA greater than 1.5 had a 0.5% risk of developing prostate cancer, those between 1.5-4.0 had about an 8% risk, and those greater than 4.0 had more than a 10% risk.

Although it is an imperfect screening test, PSA remains the best tool currently available for detecting prostate cancer. It should not be thought of as a stand-alone test, but rather as part of a comprehensive approach to early prostate cancer detection. Baseline PSA testing for men in their 40s is useful for predicting the future potential for prostate cancer. The most informative use of PSA screening is when it is obtained serially, with comparison on a year-to-year basis providing much more meaningful information than a single, out-of-context PSA.

Is there any truth that the PSA test is worthless?

A major backlash against screening occurred a few years ago with the United States Preventive Services Task Force (USPSTF) grade “D” recommendation against PSA screening and their call for total abandonment of the test. This organization counseled against the use of PSA testing in healthy men, postulating that the test does not save lives and leads to more tests and treatments that needlessly cause pain, incontinence and erectile dysfunction. Please note, there was not a single urologist on the committee. The same organization had previously advised that women in their 40s not undergo routine mammography, setting off another blaze of controversy. Uncertainty in the lay press prompted both patients and physicians to question PSA testing and recommendations for prostate biopsy.

Is there really any harm in screening? Although there are potential side effects from prostate biopsy (although they are few and far between) and there certainly are potential side effects with treatment, there are no side effects from drawing a small amount of blood. The bottom line is that when interpreted appropriately, the PSA test provides valuable information in the diagnosis, pre-treatment staging, risk assessment and monitoring of prostate cancer patients. Dismissing this important test does a great disservice to patients who may benefit from early prostate cancer detection.

Why should I get screened for prostate cancer?

Excluding skin cancer, prostate cancer is the most common cancer in men (1 in 9 lifetime risk), accounting for one-quarter of newly diagnosed cancers in males. Prostate cancer causes absolutely no symptoms in its earliest stages and the diagnosis is made by prostate biopsy done on the basis of abnormalities in PSA levels and/or digital rectal examination. An elevated or accelerated PSA that leads to prostate biopsy and a cancer diagnosis most often detects prostate cancer in its earliest and most curable stage. Early and timely intervention for those men with aggressive cancer results in high cure rates and avoids the potential for cancer progression and consequences that include painful cancer spread and death.

The upside of screening is the detection of potentially aggressive prostate cancers that can be treated and cured. The downside is the over-detection of unaggressive prostate cancers 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 cancers, with adverse consequences from necessary treatment not being given.

Why is PSA elevated in the presence of prostate cancer?

Prostate cancer cells do not make more PSA than normal prostate cells. The elevated PSA occurs because of a disruption of the cellular structure of the prostate cells. The loss of this structural barrier allows accelerated seepage of PSA from the prostate into the blood circulation.

Does an elevated PSA always mean one has prostate cancer?

Not all PSA elevations imply the presence of prostate cancer. PSA is prostate organ-specific but not prostate cancer-specific. Other processes aside from cancer can cause enhanced seepage of PSA from disrupted prostate cells. These include prostatitis (inflammation of the prostate), benign prostatic hyperplasia (BPH, an enlargement of the prostate gland), prostate manipulation (e.g., a vigorous prostate examination, prostate biopsy, prolonged bike ride, ejaculation, etc.).

Why is PSA an imperfect screening test?

PSA screening is imperfect because of false negatives (presence of prostate cancer in men with low PSA) and false positives (absence of prostate cancer in men with high PSA). Despite its limitations, PSA testing has substantially reduced both the incidence of metastatic disease and the death rate from prostate cancer.

Who should be screened for prostate cancer?

Men age 40 and older who have a life expectancy of 10 years or greater are excellent candidates for PSA screening. Most urologists do not believe in screening or treating men who have a life expectancy of less than 10 years. This is because prostate cancer rarely causes death in the first decade after diagnosis and other competing medical issues often will do so before the prostate cancer has a chance to. Prostate cancer is generally a slow-growing process and early detection and treatment is directed at extending life well beyond the decade following diagnosis.

The age at which to stop screening needs to be individualized, since “functional” age trumps “chronological” age and there are men 75 years old and older who are in phenomenal shape, have a greater than 10-year life expectancy and should be offered screening. This population of older men may certainly benefit from the early diagnosis of aggressive prostate cancer that has the potential to destroy quantity and quality of life. However, if a man is elderly and has medical issues and a life expectancy of less than 10 years, there is little sense in screening. Another important factor is individual preference since the decision to screen should be a collaborative decision between a patient and their physician.

PSA screening detects prostate cancer in its earliest and most curable stages, before it has a chance to spread and potentially become incurable. PSA screening has unequivocally reduced metastases and prostate cancer death and it is recommended that it be obtained annually starting at age 40 in men who have a greater than a 10-year life expectancy. PSA testing in men who have been diagnosed with prostate cancer provides valuable information about pretreatment staging, risk assessment and monitoring after treatment. Although PSA has many shortcomings, when used intelligently and appropriately, it will continue to save lives.

Written by Dr. Andrew Siegel

Do I Have Low Testosterone? 24 Questions Answered By A Urologist

Written by Dr. Andrew Siegel

There has been an “epidemic” of a clinical syndrome based on low testosterone levels. There is no subject rife with more confusion and misinformation than testosterone deficiency and its treatment. Hopefully, the following 24 questions and answers, pulled from those commonly asked by my patients at office visits, will help enlighten and inform you and clarify misconceptions and falsehoods.

Before we get started, here are some common abbreviations I’ll be using throughout this blog post:

  • T = Testosterone (the key male sex hormone)
  • TD = Testosterone Deficiency
  • TRT = Testosterone Replacement Therapy
  • E = Estrogen (the key female sex hormone)

Q: What exactly is testosterone?

A: Testosterone is an “anabolic” hormone, a chemical messenger that promotes growth via protein synthesis, which drives the building of muscle and bone mass as well as strength. Testosterone is equally an “androgenic” hormone, causing masculinization. T is made from cholesterol with most produced in the testes, with a small amount made in the adrenal glands (organs that sit above kidneys). Healthy men produce 6-8 mg testosterone daily, in a rhythmic pattern with a peak in the early morning and a lag in the later afternoon. If you find that you are most amorous in the early morning, now you have a good biochemical explanation.

Q: When does testosterone kick in and what does it do?

A: Testosterone surges around age 12-14 and drives puberty, causing the following:

  • Penis enlargement
  • Development of an interest in sex
  • Increased erections
  • Pubic, underarm, facial, chest and leg hair
  • Decrease in body fat
  • Increase in muscle and bone mass, growth, and strength
  • Deepened voice and prominence of the Adam’s apple
  • Sperm production
  • Bone and cartilage changes, including: growth of jaw, brow, chin, nose and ears (aka: the transition from “cute” baby face to “angular” adult face)

Q: Is testosterone important after puberty?

A: Throughout adulthood, T helps maintain libido, masculinity, sexuality, and youthful vigor and vitality. Additionally, T contributes to mood, red blood cell count, energy, and general “mojo.”

Q: What is Testosterone Deficiency and why does it occur?

A: Testosterone Deficiency (TD) is a clinical and biochemical syndrome characterized by relevant symptoms and signs in conjunction with a deficiency of T or T action. Symptomatic TD occurs in 2-6% of men.  There is approximately a 1% decline in T level each year after age 30. Most commonly it is an impaired testicular production of T. It can also happen because of a pituitary issue in which there is not enough production of luteinizing hormone (LH), the hormone that drives the testes to manufacture T. Furthermore, it can happen under circumstances of normal T levels when there are elevated levels of the hormone that strongly binds T (SHBG), reducing the amounts of T available for action. It is important to distinguish TD on the basis of testes impairment vs. pituitary impairment, as the management is different.                                                                                                          

Q: Is testosterone going to help my erections, which are not quite what they used to be?  

A: Maybe. Although testosterone is important for sexual function and for maintaining the health and vitality of the penis, one does not need high or even normal levels of T to obtain an erection. A good example is a pre-pubertal boy who gets erections all the time, but has no interest in sex. The more compelling role of T is in driving libido.

Q: Testosterone seems like such a vital hormone for men…is it for me?

A: ONLY under the circumstances of a testicular or pituitary problem causing the characteristic symptoms of TD coupled with a blood test that proves that low T levels is it worth pursuing a trial of TRT. It is only beneficial continuing the TRT if it is providing meaningful symptom improvement in the face of a normalized T level.

Q: How does testosterone get to the body tissues where it works?

A: Since T is a hormone – a chemical messenger that is made in one locale but works elsewhere – it needs to be transported to get to those cells where it acts. T circulates in the bloodstream. 60% is inactive as it is tightly bound to SHBG (sex hormone binding globulin), 38% is weakly bound to albumin, and 2% is free. The albumin-bound and free T are the biologically “active” forms of T.

Q: How does testosterone work?

A: Much of T is converted to dihydrotestosterone (DHT), a more potent form, which couples with a special receptor enabling it to move into the nucleus of cells and bind to DNA, where it provides the blueprint for protein synthesis. Some T does so without being converted to DHT and some T is converted to E, the main female hormone.

Q: What about the female hormone estrogen…is it important for men?

A: Yes! More than 80% of  estrogen (E) in males is derived from T. When levels of T are low, a decline in E levels will occur. E deficiency is important in terms of osteopenia (bone thinning) in men. As commonly happens with abdominal obesity, E levels become too high as abdominal fat is an active endocrine organ that converts T to E, causing:

  • Low T
  • High E
  • Breast development
  • The appearance of a smaller penis and general emasculation.

Q: Why have testosterone levels been dropping over the years?

A: Unhealthy lifestyle and the use of alcohol, steroids (for asthma, arthritis, connective tissue disorders and inflammatory bowel diseases) and opiate pain medications (methadone, tramadol, etc.) are risk factors.

Obesity has played a huge role. Diabetes and metabolic syndrome have contributed to the low T epidemic as well. Physical and psychological stress affect pituitary hormone synthesis, which can give rise to low T levels. Sleep apnea can contribute to TD. Environmental factors such as phthalates, commonly used in plastic products, as well as many other environmental exposures, are associated with low T levels.

Q: How important of a factor is obesity in causing testosterone deficiency?

A: Obesity is the single most common cause of testosterone deficiency in the developed world. More than half of men with TD are overweight or obese. The good news is that it is potentially reversible with weight loss.

Q: What is the issue with diagnosing low T based upon the established ADAM (androgen deficiency in the aging male) screening test?

A: The ADAM screening questions are very general and involve decreased libido, diminished erections, lack of energy, decrease in strength/endurance, loss of height, decreased joy, the presence of sadness or grumpiness, deterioration in sports performance, falling asleep after dinner and deterioration in work performance. These symptoms have an enormous overlap with changes that accompany normal aging, insufficient or poor quality sleep, overworking and/or an unhealthy lifestyle.

For example: a professional athlete of your choice who is at peak performance in his early 20’s. Fast-forward 30 years…how many of the aforementioned questions do you think will be answered positively? Is it low T? Possibly, but certainly not probably.

Q: What are the symptoms that indicate the possibility of testosterone deficiency?

A: 5 domains may be affected by TD: physicalsexualcognitiveaffect and sleep.

  1. Physical changes are reduced muscle mass and strength, increased body fat and abnormal lipid profiles, frailty, breast development, loss of body hair and central obesity.
  2. Sexual changes include decreased desire, diminished erection quality and weakened ejaculation and orgasm.
  3. Cognitive changes that may occur are impaired concentration, diminished verbal memory and altered visual-spatial awareness.
  4. Changes in affect can be a reduced sense of general wellbeing, decreased energy and motivation, anxiety, depression and irritability.
  5. Sleep issues include fatigue, tendency to sleep during the day and difficulties falling and staying asleep.

Q: How is testosterone deficiency diagnosed with lab testing?

A: The diagnosis of TD is made via a blood test for total T and free T as well as for the pituitary hormones LH and prolactin. In cases of obese or elderly men, SHBG can be useful. It is important to know that T levels can vary depending on the particular lab and can fluctuate on a day-to-day basis as well as depending on what time of day it is drawn, as T has circadian biorhythms. T can be temporarily suppressed by illness, nutritional deficiency and certain medications. Fasting T levels are generally higher than T levels after a meal. The bottom line is that T should be checked on at least two occasions.

Q: What is the first-line approach to treating testosterone deficiency?

A: Lifestyle improvement measures including:

  • Weight reduction
  • Exercising regularly
  • Management of sleep apnea
  • Stopping the use of opioids

Q: When should Testosterone Replacement Therapy (TRT) be used?

A: When TD fails to respond to first-line approaches in a man with characteristic symptoms and laboratory documentation of TD.

Q: What is the goal of TRT?

A: To restore T levels to the mid-normal range of levels observed for healthy men and alleviate the signs and symptoms of TD without causing significant side effects or safety issues.

Q: What are some of the testicular side effects of TRT?

A: Because TRT is an external source of T, it suppresses testes function, resulting in diminished sperm count, decreased fertility and the possibility of testes atrophy (shrinkage) with long-term use. Men who wish to retain fertility should not be put on TRT, but should consider the use of an oral medication that stimulates the testes to produce natural testosterone without suppressing sperm count.

Q: What are some of the other side effects of TRT?

A: Acne, oily skin, breast development, worsening of sleep apnea, hair loss, fluid retention, elevated blood count and aggression.

Q: How is TRT administered?

A: There are many different preparations: buccal (applied to the gums); transdermal (patches and gels); nasal gelinjections; and pellet implants. Each has advantages and disadvantages.

Q: What about treating TD without TRT?

A: Since TRT impairs sperm development and fertility and may result in testes atrophy, an alternative to TRT, called clomiphene citrate, works by stimulating the testes to produce natural T. It is approved by the FDA for both male and female fertility, but not for TD, so must be prescribed “off-label” for TD.

Q: Do men with TD on TRT need follow up?

A: Yes, regular follow up is imperative to ensure that the TRT is effective, adverse effects are minimal, and T blood levels are in-range. Periodic digital rectal exams are important to check the prostate for enlargement and irregularities, and, in addition to T levels, other blood tests are important including a blood count to check for increased hematocrit (thicker, richer blood) and PSA (Prostate Specific Antigen). With the commonly used gel products, absorption rates vary considerably from person to person depending on skin thickness, body hair, preparation, application site, degree of sweating, etc., so dose adjustments need to be made depending on T levels that are periodically checked.

Q: What about TRT in men with cardiac disease or prostate cancer?

A: To quote a review article from the Journal of Sexual Medicine (Dean et al: The ISSM’s Process of Care for the Assessment an Management of TD in Adult Men, 2015;12:1660-1686): “TRT use has been complicated by controversies regarding prostate cancer and cardiovascular risks. Although the absence of large-scale, long-term controlled studies with TRT limits the ability to make definitive conclusions regarding these risks, the weight of evidence fails to support either concern.”

Q: How about testosterone supplements or boosters that can be bought online?

A: The Internet is overrun with male “sexual enhancement” products. They capitalize on male insecurity, which has created a huge market, with hordes of men willing to pay top dollar for products that have misleading claims and are often mislabeled, contaminated and falsely advertised. Unfortunately, such supplements are exempt from the stringent regulatory oversight applied to prescription drugs, which requires reviews of a product’s safety and effectiveness before it goes to market. Do not waste your money!

Bottom Line: Testosterone deficiency (or low T) is a very real entity, but not as common as it’s been made out to be. The symptoms can be devastating, and when accompanied by lab testing confirming the suspected clinical diagnosis, testosterone replacement therapy can be magical. I had one patient who eloquently described his “world of black and white turning into a world of color” after his testosterone level was normalized. For many others with the syndrome, the beneficial effects of TRT are far more subtle. If your T level is normal, it is highly unlikely that your symptoms are on the basis of low T and TRT should not be a consideration.


Kidney Stones 101: Symptoms, Treatment and Prevention

Kidney stones are a common problem that I treat daily. Kidney stones are often related to our dietary habits, the amount of fluids that we drink, and our weight.

If you have ever suffered with a kidney stone, you know what excruciating pain is. Many women who have experienced both passage of a kidney stone and natural childbirth without any anesthesia will report that the childbirth was the less painful of the two!

Stones are a common condition that have occurred in humans since ancient times — kidney stones have even been found in an Egyptian mummy dated 7000 years old. The good news is that most of them will pass spontaneously without the necessity for surgical intervention. If surgery is required, it is minimally invasive (open surgery for kidney stones has virtually gone by the wayside).

How do kidney stones form?

Kidney stones form when minerals that are normally dissolved in the urine precipitate out of their dissolved state to form solid crystals. This crystal formation often occurs after meals or during periods of dehydration. Most kidney stones manifest themselves during sleep, at a time of maximal dehydration.

Dehydration is also why kidney stones occur much more commonly during hot summer days than during the winter. Anything that promotes dehydration can help bring upon a stone, including exercise, saunas, hot yoga, diarrhea, vomiting, being on bowel prep for colonoscopy, etc.

In addition to dehydration, another factor that can contribute to kidney stone formation is excessive intake of certain vitamins. The biggest culprit is Vitamin C, also known as ascorbic acid. When metabolized by the body, vitamin C is converted into oxalate, one of the components of calcium oxalate stones, the most common type of stone. The problem is that vitamin C is a water-soluble vitamin, so any excessive intake is not stored in the body but appears in the urine in the form of oxalate.

Additionally, excessive dietary protein intake, fat intake, and sodium are all associated with an increased risk for kidney stones. Having inflammatory bowel disease or previous intestinal surgery can also increase the risk for stones. Urinary infections with certain bacteria can promote stone formation. Having a parathyroid issue and high circulating calcium levels is another cause of kidney stones. Obesity is also a risk factor for kidney stones. Some stones have a genetic basis, with a tendency to affect many family members.

A kidney stone starts out as a tiny sand particle that grows as the “grain” is bathed in urine that contains minerals. These minerals are deposited and coalesce around the grain. They can grow to a very variable extent so that when they start causing symptoms they may range from being only a few millimeters in diameter to filling the entire kidney.

What are the symptoms?

Some stones are “silent” because they cause no symptoms and are discovered when imaging studies are done for other reasons. However, most stones cause severe pain known as colic. Colicky pain is often intermittent, originating in the flank area and radiating down towards the groin.  It often causes an inability to get comfortable in any position, and is associated with sweating, nausea, and vomiting. Kidney stones can also cause blood in the urine, sometimes visible and, at other times, only on a microscopic basis.

When a stone moves into the ureter (the tube running from the kidney to the bladder), it can become impacted and block the flow of urine. Stones can sometimes cause lower urinary tract symptoms such as urgency and frequency, particularly when the stone approaches the very terminal part of the ureter that is actually tunneled through the wall of the bladder.

How are they diagnosed?

Kidney stones are usually easily diagnosed, based upon their rather classical presentation. However, on occasion, a stone causes no symptoms whatsoever and is picked up incidentally on an imaging study such as an ultrasound, a CAT scan, or an MRI. The imaging study of choice for evaluating a kidney stone is an unenhanced CAT scan (without contrast). A plain x-ray of the abdomen is very useful for stones that contain calcium, and thus are readily visible on an x-ray.

How are they treated?

Most stones will pass spontaneously without intervention given enough time. Conservative management involves hydration, analgesics and the use of a class of medications known as alpha-blockers that can help facilitate stone passage by relaxing the ureteral smooth muscle. As long as the pain is manageable and there is progressive movement of the stone seen on imaging studies, conservative management can continue to be an option.

Intervention is mandated under the following circumstances: intolerable pain; refractory nausea and vomiting with dehydration; larger stones that are not likely to pass; failure of a stone to pass after a reasonable amount of time; significant obstruction of the kidney; a high fever from a kidney infection that does not respond to antibiotics; a solitary kidney; and certain occupations that cannot risk impaired functions such as an airline pilot.

There are a number of minimally invasive means of treating kidney stones depending upon the size of the stone, its location, and the degree of obstruction of the urinary tract. Gone are the days when treating a kidney stone required a painful incision and a prolonged stay in the hospital. Shockwave lithotripsy is commonly used to treat stones in the kidney or upper ureter. Typically done under intravenous sedation, shockwave lithotripsy uses shock waves directed at the kidney stone via x-ray guidance to fragment the stones into pieces that are small enough so that they then can then pass down the ureter, into the bladder and out the urethra with the act of urinating.

Another means of managing stones, particularly amenable to stones in the lower ureter but also applicable to any stone, is ureteroscopy and laser lithotripsy. This procedure is done under general anesthesia. A narrow lighted instrument known as a ureteroscope is passed up the ureter to visualize the stone under direct vision.  A laser fiber is then utilized to break the stone into tiny particles. The largest fragments are removed using a special basket. A ureteral stent is often left in place after this procedure to allow the ureter to heal as well as to prevent obstruction of the kidney.

What are the risk factors?

You are at high risk for kidney stones if you:

  • Don’t drink enough fluids
  • Have an occupation that requires working in hot environments
  • Exercise strenuously without maintaining adequate hydration
  • Are a male, since the male to female ratio of kidney stone incidence is 3:1
  • Had a previous kidney stone, since about 50% of people who have a stone will experience a recurrence
  • Have a family history of kidney stones
  • Have a urinary tract obstruction
  • Have an excessive intake of oxalate, calcium, salt, protein and fat
  • Take excessive amounts of vitamin C, A, and D
  • Have an intestinal malabsorption
  • Have gout
  • Have parathyroid disease

Can kidney stones be prevented?

The key to preventing kidney stones is to stay well hydrated, particularly when exposed to hot environments or when exercising for prolonged periods of time. It is also important to avoid overdoing it with certain vitamins—particularly vitamin C. The two biggest risk factors for kidney stones are, in fact, dehydration and excessive intake of vitamin C. Chances are that if you have a healthy diet, you have more than adequate intake of vitamin C and any extra is potentially dangerous. A good sign of adequate hydration is the color of your urine: the urine of a well-hydrated person will look light in color like lemonade, whereas the urine of a dehydrated person will look like apple juice.

So drink up, particularly on hot days…and squeeze some citrus fruit into your water instead of popping a vitamin C supplement…your kidneys will thank you!

Written by Dr. Andrew Siegel


The Prostate Gland: Man’s Center of Gravity

The prostate gland is a mysterious male reproductive organ that can be a source of curiosity, anxiety, fear and potential trouble. Since this gland is a midline organ nestled deep within the pelvis, I like to think of it as man’s “center of gravity.”

Where exactly is the prostate gland?

The prostate gland is located behind the pubic bone and is attached to the bladder (above) and the urethra (below). The rectum is directly behind the prostate (which permits access for prostate exam). The prostate is situated at the crossroads of the urinary and reproductive tracts and completely surrounds the urethra, allowing its many ducts to drain into the urethra. The relationship between the prostate and the urethra can potentially be the source of problems for the older male. When a man ages, the prostate gland gradually enlarges. This prostate enlargement can constrict and block the urethra, giving rise to bothersome urinary symptoms.

What is the prostate, what purpose does it serve, and how does it function?

The prostate is a male reproductive gland that produces prostate fluid, a nutrient and energy vehicle for sperm. The prostate consists of glandular and fibro-muscular tissue enclosed by a capsule of collagen, elastin and smooth muscle. The glandular tissue contains the secretory cells that produce the prostate fluid.

Semen is a “cocktail” composed of prostate fluid mixed with secretions from the seminal vesicles and sperm from the epididymis. The seminal vesicle fluid forms the bulk of the semen. The seminal vesicles and vas deferens (tubes that conduct sperm from testes to prostate) unite to form the ejaculatory ducts.

At the time of sexual climax, prostate smooth muscle contractions squeeze the prostate fluid through prostate ducts at the same time as the seminal vesicles and vas deferens contractions squeeze seminal fluid and sperm through the ejaculatory ducts. These pooled secretions empty into the urethra (channel that runs from the bladder to the tip of the penis). Rhythmic contractions of the superficial pelvic floor muscles result in the ejaculation of the semen.

What are the zones of the prostate gland?

The prostate gland is comprised of different anatomical zones. Most cancers originate in the “peripheral zone” at the back of the prostate, which can be accessed via digital rectal exam. The “transition zone” surrounds the urethra and is where benign enlargement of the prostate occurs. The “central zone” surrounds the ejaculatory ducts, which run from the seminal vesicles to the urethra.

Curious facts about the prostate:

  • The prostate functions to produce a milky fluid that serves as a nutritional vehicle for sperm.
  • Prostate “massage” is sometimes done by urologists to “milk” the prostate to obtain a specimen for laboratory analysis.
  • The prostate undergoes an initial growth spurt at puberty and a second one starting at age 40 or so.
  • A young man’s prostate is about the size of a walnut, but under the influence of aging, genetics and testosterone, the prostate gland often enlarges and constricts the urethra, which can cause annoying urinary symptoms.
  • In the absence of testosterone, the prostate never develops.
  • The prostate consists of 70% glands and 30% muscle. Prostate muscle fibers contract at sexual climax to squeeze prostate fluid into the urethra. Excessive prostate muscle tone, often stress-related, can give rise to the same urinary symptoms that are caused by age-related benign enlargement of the prostate.
  • Women have a female version of the prostate, known as the Skene’s glands.

Written by Dr. Andrew Siegel


4 Common Causes of Urinary Incontinence in Men

17 Feb 2020 Blog

Urinary incontinence is the accidental leakage of urine that you can’t control. Anywhere from 5% to 15% of men over the age of 60 are affected.

Urinary incontinence is not just a medical problem – it often becomes an emotional and social problem that interferes with people’s everyday lives. Often targeting the cause of urinary problems can help you and your doctor find the best treatment option to reduce bladder leakage and restore daily function.

Common Causes of Urinary Incontinence in Men:

  1. Prostate problems. Prostate problems, especially as men age, can result in problems with urinary incontinence. If the prostate is enlarged, it may affect the flow of urine and cause a weak stream, frequent urination, or leaking. When the prostate is removed for cancer treatment, it is common to have stress incontinence, meaning coughing or sneezing can trigger leakage.
  2. Conditions that cause nerve damage. Because muscles and nerves must work together to control the bladder, any condition that damages the nerves can create urinary problems. Conditions may include Parkinson’s, a stroke, diabetes, or multiple sclerosis. Injuries of the spinal cord can also result in urinary incontinence.
  3. What you drink. Certain types of beverages can put stress on the urinary system. Limiting the amount of alcohol, caffeine, or carbonated beverages that you drink can help reduce bladder leakage. Staying hydrated is important, but it is not necessary to drink a certain amount of water during the day.
  4. Being overweight. Being overweight can cause or worsen male incontinence because extra weight weakens the muscles that help with bladder function. Obesity may affect female incontinence more than in men, but it can still be a factor of male incontinence.

Treating Male Urinary Incontinence

There are many ways to ease the symptoms of male urinary incontinence, including behavioral treatments, medication, and surgery. Speak with a urologist about your treatment options.


5 Signs of Bladder Cancer: What Women Should Know

Bladder cancer may not be on your radar even if you’re vigilant about getting routine GYN care. After all, it’s far more common among men than women, and the majority of cases affect patients over age 65. However, don’t let those stats keep you from learning to spot the symptoms.

More than 17,000 women are diagnosed with bladder cancer every year in the United States. The Bladder Cancer Advocacy Network reports that women are more likely to be diagnosed with bladder cancer at an advanced stage because they may not be on the lookout for early signs.

Knowing the signs and symptoms can help you get diagnosed sooner, which may improve your prognosis. Here are five warning signs to watch for:

  1. Blood in the urine. This is the most common early symptom of bladder cancer. It’s easy for women to overlook because it’s typically painless and can go weeks or even months between occurrences. Many women ignore this symptom because they attribute it to menstruation or menopause.
  2. UTI-like symptoms. Bladder cancer can be mistaken for a Urinary Tract Infection (UTI) because many of the symptoms overlap. Patients may experience increased frequency and urgency of urination, pain with urination, or urinary incontinence. If you’ve noticed any urinary problems—you have to go all the time, or you feel like you have to go but can’t, or you have a hard time emptying your bladder—or if antibiotics don’t seem to be helping your UTI symptoms, talk to your doctor.
  3. Unexplained pain. More advanced bladder cancers are often associated with pain. Pain can occur in the flank area, abdomen, or pelvis. Patients can also develop pain in their bones if the cancer has spread to their bones. If you’re having aches and pains in those areas, tell your doctor—especially if you’ve also had the aforementioned spotting or UTI symptoms.
  4. Decreased appetite. Appetite loss is a common cancer symptom, and bladder cancer is no exception. If the cancer has grown or spread, you might experience weight loss or feel tired and weak. Of course, there are plenty of other things that can mess with your appetite, so don’t automatically assume the worst—but do talk to your doctor about it if it persists.
  5. Smoking. According to the National Institutes of Health, about 50% of women diagnosed with bladder cancer are smokers. Smoking is the biggest risk factor for bladder cancer. If you notice any of the above symptoms and you smoke, let your doctor know as soon as possible.

Bladder cancer may be overlooked in women because it’s easy to chalk up symptoms to a stubborn UTI or normal vaginal spotting. Unfortunately, this means women are often diagnosed after the cancer has spread and it’s harder to treat. So if you’re worried, don’t just write off your symptoms. Call your doctor to determine if it’s a minor infection or something more serious. If it is bladder cancer, it’s easier to treat if you catch it early.

Written by Dr. Paul Littman


Male Sexual Dysfunction: A Predictor of Heart Disease

Erectile Dysfunction (ED) serves as a good proxy for cardiac and general health. The presence of ED is as much of a predictor of heart disease as is a strong family history, tobacco smoking, or elevated cholesterol!

All fat is not created equal.

Having some fat on our bodies is not a bad thing. Fat serves a number of useful purposes, such as cushioning internal organs, providing insulation to conserve heat, and storing energy and fat-soluble vitamins. Fat is also part of the structure of the brain and cell membranes and is used in the manufacturing process of several hormones.

However, not all fat is the same. It’s important to distinguish between visceral fat and subcutaneous fat. Visceral fat– also referred to as a “beer belly” – is internal fat located deep within the abdominal cavity. Subcutaneous fat – also known as “love handles” – is superficial fat located between the skin and the abdominal wall.

In addition to the physical distribution of the fat being different, so is the nature of the fat. Although neither type is particularly attractive, visceral fat is much more hazardous to one’s health than subcutaneous fat. Visceral fat increases the risk of heart disease, diabetes and metabolic disturbances. Subcutaneous fat is inactive, relatively harmless, and generally does not contribute to health problems.

Visceral fat is essentially a metabolically active endocrine “organ” that does way more than just create an unsightly protrusion from our abdomens. It produces numerous hormones and other chemical mediators that have many detrimental effects on all systems of our body, including risk of diabetes, cardiovascular disease, low testosterone, erectile dysfunction (ED) and premature death.

So how can erectile dysfunction predict heart disease?

Visceral fat and metabolic syndrome are highly associated with low testosterone and poor erection and ejaculation function. The fatty tissue present in obese abdomens contains abundant amounts of the enzyme aromatase which converts testosterone to estrogen, literally emasculating obese men. So, visceral fat can steal away our masculinity, male athletic form and body composition, mojo, strength, and the ability to obtain and maintain a good quality erection.

This is why ED serves as a good proxy for cardiac and general health. The presence of ED is as much of a predictor of heart disease as is a strong family history, tobacco smoking, or elevated cholesterol.

FactoidThe penis can function as a “canary in the trousers.” Since the penile arteries are generally rather small (diameter of 1- 2 mm) and the coronary (heart) arteries larger (4 mm), it stands to reason that if vascular disease is affecting the tiny penile arteries and causing ED, it may affect the larger coronary arteries as well — if not now, then at some time in the future. In other words, the fatty plaque that compromises blood flow to the smaller vessels of the penis may also do so to the larger vessels of the heart and thus ED may be considered a genital “stress test.”

What does this all mean?

  • Visceral fat is a bad, metabolically-active form of fat that is highly correlated with metabolic syndrome, diabetes, heart disease and sexual dysfunction.
  • ED often occurs in the presence of “silent” heart disease (no symptoms) and serves as a marker for increased risk for heart disease (as well as stroke, peripheral artery disease and death). ED will often occur 3-5 years before heart disease manifests. Early detection of ED provides an opportunity to decrease the risk of heart disease and the other forms of blood vessel disease. ED has a similar or greater predictive value for heart disease as do traditional factors including family history, prior heart attack, tobacco use and elevated cholesterol. The greater the severity of the ED, the greater the risk and extent of heart disease and blood vessel disease.

What can I do?

Lifestyle intervention has the potential for reversing visceral obesity, metabolic syndrome and sexual dysfunction. This lifestyle intervention involves achieving a healthy weight, losing the belly fat, eating healthy, exercising regularly, quitting smoking, limiting alcohol intake, and managing stress.

Written by Dr. Andrew Siegel


Urine Color and Odor – What Does It Mean?

27 Jan 2020 Blog

Everyone has probably noticed at one time or another that the color and odor of their urine can change. While the difference may just be something you ate, the color and odor of your urine can also be indicative of a possible health condition. As such, it’s important to take notice of any changes in your urine and what these changes may mean – and to know when to contact a doctor for medical attention.

Urine Color

Urine color can range from pale yellow to deep amber, and there are many factors that can affect urine color including fluid balance, diet, medicine, and disease.

What Color Urine Is Best?

Your urine color will likely be different in the morning than at night. Because urine is more concentrated in the morning, it will optimally be a pale straw color if you’re well hydrated and healthy. At night, look for a pale yellow color, or closer to clear like water. If you are seeing a slightly more “concentrated” yellow color, it is likely a sign that you simply should be drinking more water.

Light Yellow or Dark Yellow Urine

How light or dark the color of your urine is depends on how much water you drink. Water and other fluids dilute the yellow pigments in urine, so the more you drink, the clearer your urine will be. In cases of dehydration, the urine can become a dark amber color. In general, very light (clear) colored urine is a good sign that you are drinking enough water. If you find yourself asking “why is my urine dark yellow?” there’s a good chance you need to drink more water (related: “How much water do I really need to drink?”). If your urine is reddish-brown, it may be more cause for concern.

Reddish-Brown Urine

Some foods, such as blackberries, beets or rhubarb – can turn urine a reddish-brown. More significantly, having blood in your urine can also make it appear reddish-brown, so it’s important to observe and take note of these subtle signs and symptoms.

Bright Yellow Urine

Some vitamins and supplements – such as Vitamin B – can turn urine bright yellow. Generally speaking, vitamin toxicity and overdose rarely leads to serious illness. If your urine color is causing concern, you can also contact us for further evaluation.

Light Green Urine

Light green urine is typically caused by dyes in food, though it could also be caused by medications such as antidepressants and drugs containing phenol. It is typically not a cause for concern, but be sure to keep watch and contact your urologist if you have accompanying conditions.

Urine Odor

Some foods (such as asparagus), vitamins, and antibiotics (such as penicillin) can cause urine to have a different odor. In most cases, urine odor is not a strong concern. However, there are a few scenarios where urine odor is a cause for concern and you should contact your doctor for further evaluation.

Sweet, Fruity Urine Odor

This may be caused by uncontrolled diabetes. If you have been diagnosed with diabetes, it is important to contact your physician to evaluate your current course of treatment. If you have not been diagnosed with diabetes, this urine odor could be an indication of an issue, and it is important to consult your doctor for testing.

Foul Urine Odor

Foul smelling urine is often a sign of a Urinary Tract Infection (UTI), as the presence of bacteria in the urine affects the odor. This is also often accompanied by cloudy or bloody urine.

When to See a Doctor

Sometimes, symptoms can be very vague or subtle which makes it very difficult to figure out what the problem is. If you are dehydrated your urine will be more concentrated and urinating may cause discomfort. Drink enough fluids to keep your urine light yellow or clear, this will help decrease discomfort.
Visible blood in the urine is often a sign of a urinary tract infection or kidney stone. Dark or orange urine may be a sign of liver malfunction. You should notify your doctor if you experience any of these symptoms.

If you have more questions about your urine color, and would like to consult a physician, please use our locations page to find a urologist near you, or simply contact us through our main contact form.


10 Ways to Get A Good Night’s Sleep

20 Jan 2020 Blog

In addition to exercise and healthy eating as the key pieces to a healthy lifestyle, modern science supports quality sleep as a third piece of equal importance. According to the CDC, more than one third of Americans are not getting enough sleep on a regular basis. 

How Much Sleep Do I Need?

Getting enough good quality sleep is important for our well-being and daily functioning. We’ve all enjoyed the joyous experience of a great night’s sleep, waking up well-rested, energetic and optimistic. On the other hand, we’ve all also experienced a poor night’s sleep, awakening feeling physically exhausted, mentally spent, and often in a disassociated “zombie” state.

The amount of sleep each person needs is biologically determined and different for everyone. Some can make do with five hours of sleep while others require ten hours. As a general rule, seven to eight hours of sleep is recommended. Regardless, sleeping has a restorative function as our brains and bodies require this important down time for peak performance.

Why Do I Need So Much Sleep?

Good quality sleep is an important component of overall health, wellness, and fitness. Sleep deprivation can have a negative impact on numerous bodily functions, including:

  • Cognitive
  • Endocrine
  • Metabolic
  • Cardiovascular
  • Gastrointestinal
  • Immunity

While sleeping, there is an increased rate of anabolism (cellular growth and synthesis) and a decreased rate of catabolism (cellular breakdown). These processes are disrupted by sleep deprivation. Chronic sleep issues can result in making one feel ill and appearing much older than they are.

Sleep disruption results in decreased levels of leptin (a chemical appetite suppressant), increased ghrelin levels (a chemical appetite stimulant), increased corticosteroids (stress hormones) and increased glucose levels (higher amounts of sugar in the bloodstream). As a result, chronic sleep deprivation commonly gives rise to increased appetite, increased caloric intake and the disassociated “zombie” state – resulting in dysfunctional eating patterns, consumption of unhealthy foods, and weight gain. In addition, chronic fatigue impairs one’s ability to exercise properly, if at all.

Chronic sleep deprivation also results in irritability, impaired cognitive function and poor judgment. The inability to be attentive and focused interferes with work and school performance, causes increased injuries (such as falls), and motor vehicle accidents.

How To Get a Good Night’s Sleep

The good news is that sleep deprivation can be alleviated. Here are ten ways to get a good night’s sleep:

  1. Lead an active lifestyle with lots of exercise and stimulation.
  2. Whether you are an early riser or a night owl, try to be consistent with wake-up and bedtimes on both weekdays and weekends. If these times vary greatly, you’re setting yourself up for sleep problems by disturbing your body’s internal clock.
  3. Maintain a comfortable sleeping environment with a good quality supportive bed, comfortable pillows, a dark room, cool temperature and, if you like, “white noise” (I find that the monotonous sound of the sea produced by a sound machine, coupled with the gentle whirring of an overhead fan, is an instant relaxer).
  4. Avoid caffeine (coffee, tea, cola, etc.) particularly after 6 p.m. Herbal teas (like chamomile) can be soothing and relaxing.
  5. Avoid eating a large dinner or eating very late at night.
  6. Don’t drink too much alcohol.
  7. Avoid exercising late in the evening.
  8. Reduce the stress in your life as much as you can. Engage in a de-stressing activity immediately before sleep, such as reading, watching a movie or television show, or doing crossword puzzle.
  9. Try to minimize evening exposure to the bright light (“blue light”) of cell phones, tablets and computers that inhibits production of the sleep-promoting hormone melatonin. Under normal circumstances, melatonin levels rise with darkness. If possible, dim the light settings on electronic devices that are used at night.
  10. Supplemental melatonin seems to help some people, but is ineffective for many others (including myself), but may be worth a try.

Written by Dr. Andrew Siegel


10 Easy Food Substitutions for a Healthy Eating Lifestyle

Today’s entry is about a healthy eating lifestyle—as opposed to a diet—that works for me and I promise will help you improve your body shape and shed excess pounds. I want to emphasize that this is not a fad diet. It’s a style of eating that can be easily incorporated to replace the typical calorie-rich, nutrient-poor Western diet that is overloaded with highly processed foods that contribute to chronic health problems. As opposed to many weight loss programs that are gimmicky, unbalanced, unhealthy, and unsustainable, this approach is a no-nonsense, intelligent one—clean, lean, with plenty of green—that will stave off your hunger and hold caloric intake in balance with expenditure, making it effective and durable.

The Bialy Diet

First, I will introduce the bialy diet. It is sensible and nutritious eating, replacing unhealthy, high-calorie foods with healthy, low-calorie alternatives. For example, eating bialys instead of bagels. A bialy diet does not imply eating a bialy at every meal, but is simply code for substituting healthier choices for unhealthier ones!

bialy | bēˈälē | noun (plural bialys) US a flat bread roll topped with chopped onions

Who doesn’t love a fresh, warm NY bagel with a smear of cream cheese? Sadly, the answer is our bodies and our health. The 360-calorie bagel with two tablespoons of cream cheese (100 calories) is 460 calories of mostly refined carbs and fat. A great alternative is a bialy, a delicious flat bread roll that contains no hole and has a depressed middle that is flavored with cooked onions and poppy seeds. The 180-calorie toasted bialy with a teaspoon of light butter with canola oil (20 calories) is only 200 calories, tastes delicious, and doesn’t leave you feeling bloated. This with a mug of strong black coffee and half a grapefruit with a few strawberries or blueberries thrown on top is my typical breakfast. Sometimes on the weekends I will have an egg white omelet on a bialy with a slices of NJ tomato and avocado!

The Mediterranean Diet

Mediterranean style eating emphasizes less meat and more fish, an abundance of vegetables and fruits (rich in biologically active compounds including antioxidants, vitamins, minerals and fiber), whole (unrefined) grains, legumes and healthy vegetable fats from olives, avocados, nuts and seeds. Herbs and spices are used to flavor food, rather than salt. Dairy products are eaten in moderation.

The 80/20 Strategy

Another element of a healthy eating lifestyle is the 80/20 strategy. This means that 80% of the time you adhere to a healthy eating style, but 20% of the time you give yourself a break, jump off the wagon and indulge in limited amounts of whatever temptation indulgence you would like. This avoids deprivation and, in my opinion, is “an inoculation to prevent the disease.” On the limited list are sweets including cookies, cakes, donuts, candy and liquid carbohydrates such as sugary drinks including soda, ice tea, lemonade, sports drinks and fruit juices. The only liquid carbohydrate I consume is alcohol in moderation, wine being a component of Mediterranean-style eating.

Here are 10 easy substitutions that incorporate the above mentioned healthy-eating lifestyles:

  1. Bialys instead of bagels
  2. Seafood and lean poultry instead of red meat (if you do eat red meat, consume only the leanest cuts and opt for grass-fed instead of corn-fed)
  3. Vegetable protein (legumes such as peas, soybeans and lentils) instead of animal protein
  4. Olive oil instead of butter
  5. Real fruit instead of dried fruit or fruit juice
  6. Whole grains (wheat, brown rice, quinoa, couscous, barley) instead of refined grain products
  7. Flavored seltzers or sparkling water instead of soda
  8. Plain Greek yogurt instead of sour cream
  9. Soy, rice, almond or other nut-based milks instead of dairy
  10. Low-fat or non-fat dairy products instead of whole milk products

Other Nuggets of Advice:

  • The pathway to a healthy weight is slow and steady, demanding patience and time
  • Eat slowly, deliberately and mindfully
  • Get enough good quality sleep to help keep the pounds off
  • Avoid late night meals and excessive snacking
  • Stay well hydrated as it is easy to confuse hunger with thirst
  • Do not skip meals
  • Keep healthy foods accessible
  • Avoid foods that contain unfamiliar, unpronounceable, or numerous ingredients
  • Organic does not imply healthy or low-calorie
  • Let the last thing you eat before sleep be healthy, natural and wholesome (e.g., a piece of fruit)—you will feel good about yourself when you get into bed and even better in the morning

A lifestyle of healthy eating can improve your overall wellness, both physical and mental. Here’s to a happy, healthy new year!

Written by Dr. Andrew Siegel


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