Understanding Your Well-Being Screening: What Questions Doctors Ask Those Over the Age of 65 and Why

Americans live longer today than ever before. More than one in every seven adults in the U.S. is 65 or older—and the average person can now expect to celebrate their 78th birthday.

Prevention is the key to enjoying your golden years. In May, during Older Americans Month, we highlight important health and wellness topics that specifically affect our older population.

A yearly preventive/wellness visit or Annual Wellness Visit (AWV) with your primary care provider lays the foundation for a lifetime of well-being, even if you are visiting your doctor throughout the year for other reasons. This check-up is an opportunity for you and your doctor to discuss ways you can stay healthy and prevent disease. Patients who have annual preventive/wellness visits are in better overall health and have more control of their chronic conditions.

If you came in recently for an AWV, you may have noticed our well-being screening postcards. These postcards serve as a reminder of important topics to discuss during your visit such as mental health, medication costs, fall risk, bladder control, and activities of daily living – topics that you may not have been thinking about, or maybe have been but feel a bit uncomfortable bringing up. Our doctors have seen and heard the full spectrum of issues, but they can only help you with what you tell them about. Therefore, it’s important to have an open, ongoing dialogue.

While we like to remind you to bring up your concerns, your doctor will be asking you some specific questions. Learn why we ask these questions, how this knowledge can improve your overall wellness and quality of life, and the various ways our teams can help.

Questions Doctors Ask and Why

Topic 1: Improving Bladder Control

Expert advice from Philip J. Dorsey, MD, a urologist at New Jersey Urology, a Summit Health Company.

Questions we ask: Do you experience leaking urine? Does it interfere with your daily life?

Why we ask them: Dr. Dorsey: Urinary incontinence, or leaking urine, affects between 15 and 33 percent of older adults in the community. Urinary symptoms like leaking and increased frequency or urgency negatively affect both physical and mental health. Unfortunately, many urinary conditions are undiagnosed and undertreated. It is common for patients to be ashamed of these symptoms, become isolated at home, and believe there is nothing that can be done to help them.

Patients typically will not volunteer that they have bothersome urinary symptoms. We hope these questions will jumpstart conversations about a very common condition that has a profound impact on quality of life.

How we can help: Dr. Dorsey: Fortunately, there are many ways we can help patients with urinary leakage. Some patients experience improvement with changes to their diet or routine and simple pelvic exercises, while others may benefit from medications or minor surgical procedures.

In any case, the only way we can help is if all information is disclosed to us. So, the first step in improving symptoms is to bring them to the attention of the provider.

Topic 2: Mental Health

Expert advice from James Korman, PsyD,  Service Line Chief of Behavioral Health at Summit Health and Dr. John Wang, Psychiatrist at Westmed Medical Group.

Questions we ask: Do you have concerns about your emotional health? Does anxiety or depression interfere with your daily life?

Why we ask them: Dr. Korman: A significant number of patients sitting in the primary care waiting room suffer from anxiety and depression. Many may not even realize it. Physical symptoms like aches and pains can be caused by underlying stress, anxiety, and depression.

Anxiety and depression can impact many areas of life, including work and occupational functioning, socialization, the ability to enjoy activities, sleep patterns, as well as diet and nutrition.

Dr. John Wang: Patients are often unaware or reluctant to bring up behavioral health issues and symptoms. Our goal is to identify these individuals and make appropriate interventions so they can function normally and enjoy their lives.

How we can help: Dr. Korman: There are many ways we can relieve some of this personal distress. When appropriate, we integrate mental, behavioral, and physical care during patients visits to their physicians. But not everyone needs therapy or medication. Minor adjustments, such as not being socially isolated or re-engaging in activities, can make a big difference.

We have numerous specialists who can help, including psychologists, psychiatrists, social workers, nutritionists, and physical therapists. We encourage the patient to continue working with their primary care provider to identify the proper course of treatment.

Dr. John Wang: With our older patients, often they and their families struggle with access to services and how to get assistance. Connecting them with resources can be an important first step. Additionally, encouraging them to address end of life issues with their primary care provider is a critical part of helping them achieve orderly care. With the transition away from nursing home placement, family members are often acting as home health aides and utilizing visiting nurse services and/or hospice. With proper planning, senior aging can be a smoother transition than facing the unpredictable unprepared.

Topic 3: Physical Health/Activity

Expert advice from Bankim Shah, MD, an internal medicine physician at Summit Health.

Question we ask: Does your physical health interfere with your daily activities like bathing, getting dressed, and completing household tasks?

Why we ask it: Dr. Shah: Discussing activities of daily living with a patient allows us to understand their limitations. They may bring up issues like pain, limited range of motion, balance concerns, or organizational and cognitive problems. Gathering information about their home environment, such as access to caregivers, helps us understand their living situation and evaluate their safety and independence.

How we can help: Dr. Shah: We connect patients with occupational, physical, and speech therapy, as needed. In addition, we offer resources for patients who need assistance in or out of the home such as outpatient nursing, home health aides, or social work management. Caregivers are included in the conversation to ensure the patient has the proper social support.

Topic 4: Reducing Risk of Falling

Expert advice from Ian Stein, MD, a neurologist at Summit Health and Cordelia Schwarz, MD, Chair of Neurology at Westmed Medical Group.

Question we ask: Have you fallen or had trouble with balance or walking?

Why we ask it: Dr. Stein: If a patient has fallen once, it is likely they will fall again in the future. We ask this question to help identify the reason why they fall and help reduce future risk of falls and injuries. It could be an issue affecting their strength, balance, or sleep, as well as a problem with the home environment such as having too many stairs or rugs in the house.

Dr. Schwarz: More than one in four people aged 65 and older have had at least one documented fall. Some of these falls cause injuries, loss of independence, and in some cases, death. Many falls can be prevented by identifying and modifying risk factors.

How we can help: Dr. Stein: If we identify risks for falls such as medication, vision issues, or dizziness, we can work to eliminate the risk. If imbalance is the issue, the most important way we can intervene is to get a physical therapist to see the patient. These specialists play a critical role in fall prevention by helping to improve their gait, or how they walk. We can also suggest modifications to the patient’s home, such as grab bars and hand railings, or removing tripping hazards to help prevent slips and falls.

Dr. Schwarz: We can reduce falls by reviewing medications and suggesting ways to make a person’s home safer. Installation of grab bars and removal of tripping hazards is a great way to start. But oftentimes, we’ll prescribe physical therapy or suggest various balance exercises. We may also recommend having the eyes and feet checked and have a discussion on proper footwear.

Topic 5: Medication Cost

Expert advice from Gwen Egloff-Du, PharmD, BCPS, a pharmacist at Summit Health.

Question we ask: Do you have any concerns about the costs of your medications?

Why we ask it: Dr. Egloff-Du: When patients are unable to afford their medication, they often skip doses or fail to fill their medication altogether. By encouraging patients to discuss the cost of medications, we can address their concerns, increase adherence to their course of treatment, and improve overall health outcomes.

How we can help: Dr. Egloff-Du: The best way to lower costs is to prescribe a generic medication that is equally as effective as a more expensive brand medication. Your provider can help you investigate if there is an alternative that would be more cost-friendly.

Don’t be shy when it comes to your well-being. While your providers may ask specific questions related to these issues, you should certainly bring them up at your visit. Don’t be embarrassed. Your provider is happy to discuss these concerns and help you stay well and feel good.

Prostate Cancer: What Men Need to Know

Found only in males, the prostate is a walnut-sized gland that is part of the reproductive system located below the bladder and in front of the rectum. Cancer can develop when cells in the prostate begin to grow out of control. While there are a few rare forms of prostate cancer (i.e., sarcomas, neuroendocrine tumors), almost all are diagnosed as adenocarcinomas that develop from gland cells.

Why It’s So Important to Be Aware of Prostate Cancer

Prostate cancer is the second most common form of cancer that occurs in men in the US. According to the American Cancer Society, approximately 268,490 men will be diagnosed with prostate cancer in 2022, and an estimated 34,500 deaths will occur from prostate cancer this year.

While 1 in 8 men will be diagnosed with prostate cancer at some point in their life, the rate of diagnosis goes up with age. For example, 1 in 451 males under the age of 50 will be diagnosed, 1 in 55 between the ages of 50-59, and 1 in 20 for ages 60-69. Men over the age of 65 will represent close to 60% of the diagnoses.

Prostate cancer is typically detected when the cancer is confined to the prostate and localized areas. For men diagnosed in the early stage of prostate cancer, the 5-year survival rate is greater than 99%. Despite the high percentage of positive outcomes, it’s important to recognize that it is still a deadly disease for some men and it’s important to know the signs and symptoms to catch and treat the cancer as soon as possible.

Early Signs and Symptoms of Prostate Cancer

Most men with prostate cancer will experience no symptoms at all, hence the importance of screening.  When symptoms do occur, it often indicates locally advance or advance prostate cancer.  When symptoms do occur, they may include the following:

  • Difficulty starting or holding back urination
  • Frequent urination especially at night
  • Pain or burning during urination
  • Blood or urine in semen
  • Painful ejaculation or decrease in amount of semen ejaculated
  • Incessant pain or stiffness in low back, hips, pelvis and/or thighs

Keep in mind that these symptoms may indicate conditions other than prostate cancer which may also require medical evaluation. This is why it’s so important to see a urologist if you are having any of the symptoms above, and especially if you are seeing a combination of these symptoms.

Risk Factors for Prostate Cancer

All males have some level of risk for prostate cancer, but there are contributing factors that may increase the risk of developing this disease that include:

  • Increased age – especially if you’re 65 or older
  • Having a family history of prostate cancer
  • Ethnicity – African American men are 1.7 times more likely to be diagnosed with prostate cancer.
  • Unhealthy lifestyle- being overweight or obese

There are also existing studies suggesting that a history of breast cancer in the family may increase the risk for a man to develop prostate cancer.

Prostate Cancer Screening to Determine if Treatment is Necessary

If you are at a high risk for prostate cancer, and/or are showing early signs of prostate cancer, you will want to make an appointment with a urologist for screening. Screening for prostate cancer is something to be discussed with your doctor who will review your personal risk factors, the benefits and harms of screening including the pros and cons of other tests and treatment, and if you have other medical conditions that may make it difficult to treat prostate cancer (find a urologist near you here).

If the decision is made to have a prostate screening there are two main ways in which to screen for prostate cancer.

Prostate Specific Antigen (PSA) Test

PSA is a substance made in the prostate. A blood test called a PSA test measures the levels of PSA in the blood. High levels of PSA may indicate prostate cancer or other conditions that affect the prostate.

Digital Rectal Exam (DRE)

The DRE exam is when your doctor carefully inserts a lubricated, gloved finger into your rectum to determine if your prostate feels enlarged or if a nodule, lump, asymmetry, or other irregularity is felt that may indicate an underlying prostate cancer. This procedure may feel uncomfortable but it isn’t painful.

Diagnosing Prostate Cancer

If your prostate screening detects an abnormality, your doctor may suggest more testing to determine if you have prostate cancer, including:

  • Ultrasound which uses sound waves to create an image of the prostate.
  • Magnetic Resonance Imaging (MRI) scan to get a more detailed image of the prostate.
  • Prostate biopsy to collect prostate tissue cells that are analyzed in a lab to determine if cancer cells are present.

Treatment Options for Prostate Cancer

If prostate cancer is diagnosed, you and your doctor will discuss one or more treatment options depending on certain factors such as stage of the cancer, age, PSA test results, type of cancer, urinary symptoms, medical co-morbidities and other important considerations. Some treatment options consist of the following:

Active Surveillance

Certain prostate cancers can be slow growing, and if localized (hasn’t grown outside the prostate), it may not be a significant threat. In this case, the doctor may discuss ‘active surveillance’ as an option.

You will be regularly tested and closely monitored to see if the cancer progresses. Rather than going directly into treatment, active surveillance may avoid treatment-related side effects.

Prostatectomy

A prostatectomy is a surgical procedure to remove the prostate and surrounding tissue. The vast majority of prostatectomies for prostate cancer are done using a robotic-assisted laparoscopic technique.

Hormone Therapy

Hormone therapy treatments stop the body from creating the male hormone testosterone. Cutting off the supply of testosterone may cause cancer cells to die or to grow more slowly.

Medication

There are a variety of different medications available at the urologist’s disposal to help fight prostate cancer.

Radiation Therapy

Radiation therapy uses high-powered beams of intense energy to kill cancer cells.

Freezing or Heating the Prostate

Cryotherapy or cryoablation is the repeated cycle of using very cold gas to freeze and then thaw prostate tissue which kills cancer cells and some surrounding tissue.

Heating the prostate tissue uses concentrated ultrasound energy called high-intensity focused ultrasound (HIFU) to cause the prostate tissue to die.

Chemotherapy

Chemotherapy is an option for treating prostate cancer that has spread to other areas of the body. It uses drugs to target cells that grow and divide quickly such as cancer cells.

Immunotherapy

Immunotherapy is used to stimulate or boost a person’s own natural immune system defenses.

Make an Appointment with a Urologist

If you find yourself experiencing any signs or symptoms of concern, or think your symptoms warrant a more in-depth evaluation, contact one of our urology specialists.

 

Written by Dr. Andrew Siegel

10 Treatment Options for Menopause

More than 50 million women in the United States will are over the age of 51, the average age that menopause occurs. Yet in some ways, menopause is the last taboo subject among women, many of whom are hesitant to talk about hot flashes, hormone imbalances, and a type of thinning hair that’s different from that of women in their 20s and 30s. But times are changing.

Menopause is defined as having gone 12 months without a menstrual period. The years leading up to that time may include irregular periods which may or may not be quite heavy, moodiness, fatigue, and weight gain. Most of these changes occur because of changes to the body’s production of both estrogen and progesterone, both of which are produced by the ovaries. In addition, many begin to suffer with urinary incontinence, which, while being common, is not a normal part of aging.

Fortunately, there are a multitude of effective treatment options that are both hormonal and non-hormonal. However, only about 10% of women seek medical advice during the menopausal period. Many women require no treatment, however, if symptoms are affecting a woman’s daily life she should see her doctor. The treatment options available will depend on the symptoms, medical history, and preferences of the patient.

Available treatment options include:

  1. Herbal Remedies – Soy, Black Cohosh, Relizen. These are non-estrogen compounds that while have not been specifically FDA-approved for the treatment of peri-menopausal symptoms, research studies suggest an improvement in symptoms with minimal side-effects.
  2. Paroxetine (Brisdelle) – This is the only non-hormonal FDA approved treatment for peri-menopausal symptoms.
  3. Hormone Replacement Therapy (HRT) – This is considered to be the most effective treatment to treat the above symptoms. Hormone therapy can be received by a simple patch on the skin that releases estrogen and progestin. In addition to treating many troublesome menopausal symptoms, HRT also helps to prevent osteoporosis, and lowers colorectal cancer risk. While most formulations of HRT are safe, some may raise the risk of breast, ovarian or uterine cancer, as well as raise the risk of coronary heart disease, stroke, and memory loss.
  4. Low-dose Antidepressants – Effexor, Prozac, Paxil, Celexa or Zoloft.
  5. Omega 3s – May ease psychological distress and depressive symptoms often suffered by menopausal and peri-menopausal women.
  6. Gabapentin (Neurontin) – This is effective in treating hot flashes. It is commonly used for treating seizures.
  7. Vaginal Estrogen – Vaginal estrogen may be applied locally using a tablet, ring or cream. This medication effectively treats vaginal dryness, discomfort during intercourse, as well as some urinary problems. A small amount of estrogen is released and absorbed by the vaginal tissue.
  8. Ristela – A novel herbal therapy functions to increase nitric oxide concentrations in the vagina. This leads to the increased blood supply to the vagina which results in increased libido and improved sexual function.
  9. Exercise.
  10. Hypnosis and Acupuncture – May prove effective for the treatment of hot flashes. Researchers reported in the Journal of Menopause, in October 2012, that hypnosis can reduce the symptoms of menopausal hot flashes by up to 74%.

Written by Dr. Paul Littman

Dr. Littman became the first urogynecologist to practice in Sussex, Warren, and Morris counties. He has brought a multitude of novel, minimally-invasive outpatient procedures to northwestern New Jersey including single-incision vaginal approaches to correct both urinary incontinence and pelvic organ prolapse, robotic surgery, sacral neuromodulation, botox-injections, and acupuncture-based treatments.

Underactive Bladder: What You Should Know

Overactive bladder (OAB) is a condition in which the bladder churns and contracts uncontrollably, causing urinary urgency, frequency and sometimes incontinence. OAB has received a great deal of attention and clinical research.  However, its younger sibling, underactive bladder, is an ailment that most people have not heard of and is a condition that is largely neglected with respect to clinical and scientific research. Here’s what you should know about this disorder in which the bladder muscle is weak and incapable of contracting sufficiently to empty the bladder properly.

What is Underactive Bladder?

The medical term for the bladder muscle is the detrusor and the term for underactive bladder is detrusor underactivity. It is technically defined as “a bladder that contracts with reduced strength and/or duration, resulting in prolonged bladder emptying and/or failure to achieve complete bladder emptying within a normal time span.”

What are the Symptoms of Underactive Bladder?

There is a significant overlap of symptoms of the conditions of underactive bladder, overactive bladder, and bladder outlet obstruction (an obstruction to the flow of urine, often from prostate enlargement, urethral scar tissue, or dropped bladder in females). The bladder is “an unreliable witness” since lower urinary tract symptoms often do not accurately reflect the underlying condition.

Someone with an underactive bladder will typically experience incomplete emptying and their bladder will remain partially full at all times. In addition to experiencing obstructive symptoms (because of the weak bladder “motor”), they will also commonly experience irritative lower urinary tract symptoms including urgency and frequency and sometimes incontinence, similar to those with overactive bladder.

What Causes Underactive Bladder?

Causes of underactive bladder include:

  • Neurological diseases that adversely affect the bladder. For example: diabetes, multiple sclerosis, or spinal cord injury.
  • Aging can affect bladder contractility adversely and may give rise to underactive bladder.
  • Longstanding bladder outlet obstruction, classically from benign prostate growth, can ultimately cause bladder decompensation and underactive bladder.
  • Ischemic bladder dysfunction on the basis of impaired blood flow to the bladder is another cause of underactive bladder.

Tests to Evaluate Underactive Bladder

  • Uroflowmetry:  This is a simple, non-invasive test in which one urinates into a flow meter that measures flow rate and generates a flow curve.
  • Post-void residual urine volume: This is a simple ultrasound scan that determines the quantity of urine left behind in the bladder after urinating.
  • Urodynamics: These are sophisticated tests of bladder function that evaluate the storage and emptying phases of urination and can help distinguish between overactive bladder, underactive bladder, and bladder outlet obstruction.

The Faucet and Hose Analogy

Just as the “bladder is an unreliable witness,” so the flow out of a garden hose is not a good indicator of an underlying problem. If you have an outdoor faucet that is functioning well and gushes when it is turned on, when you attach a hose to it your expectation is a powerful flow of water through the hose. If the flow is meager, then there is obviously a kink (obstruction) in the hose. If you have an outdoor faucet that is functioning poorly and when it is turned on only generates minimal water pressure, when you attach a hose to it there will also be a meager flow through it. The conclusion is that poor flow through a hose can be caused by either a faucet functioning well that is obstructed or, alternatively, a poorly functioning faucet in the absence of obstruction. And so it is with the human bladder. A weak urinary flow can be caused by a perfectly functioning bladder that is obstructed, or alternatively, by a poorly functioning, underactive bladder.

Urodynamics measures the bladder contractility simultaneously with the flow and can make the distinction between the two entities.  Obstruction is defined as excellent bladder contractility (high pressures) with poor flows, versus underactive bladder that is defined as poor bladder contractility (poor pressures) with poor flows. The only way to know what is going on with the bladder “faucet” is to measure its pressure at the time of voiding.

How to Manage Underactive Bladder

Because underactive bladder gives rise to incomplete emptying and residual urine remaining after voiding, it’s important to make every effort to empty the bladder as completely as possible. This will minimize the occurrence of irritative lower urinary tract symptoms and urinary infections that may occur with incomplete bladder emptying. The following measures can facilitate emptying the bladder that does not have the muscle power to empty fully on its own:

  • Relaxation: In order to empty the bladder efficiently, the bladder muscle must contract synchronously with relaxation of the sphincter muscles. The sphincter muscles can be adversely affected by anxiety and nervous states. Sit to urinate, bring a magazine, take some deep breaths, try to assume a relaxed frame of mind and patiently empty your bladder.
  • Double and triple voiding: When seemingly finished voiding, give it a second and even a third try.
  • Valsalva maneuver: This is the medical term for straining the abdominal muscles. Bearing down and squeezing generates increased pressure external to the bladder that may facilitate emptying.
  • Crede maneuver: This is the medical term for applying external pressure to the lower abdomen in an effort to better empty one’s bladder. It can be thought of as CPR for the bladder.  It’s best performed with both hands placed on the lower abdomen between navel and pubic bone while leaning forward, pressing down firmly while trying to urinate.
  • Suprapubic tapping: This involves tapping rhythmically over the region between navel and pubic bone in an effort to trigger a nerve reflex that will trigger urination. This is not effective in everyone, but worth a try.
  • Medication: Unfortunately, there is no effective medication to increase bladder contractility; however, there are medications that decrease sphincter resistance and this class of medication (alpha-blockers) may be worthwhile on a trial basis.
  • Self-catheterization: This is the mainstay of effective treatment for underactive bladder. Self-catheterization involves learning to pass a disposable catheter into the urinary bladder at least four times daily in order to empty it completely. Self-catheterization serves to empty the bladder completely and provides an opportunity to urinate spontaneously prior to each catheterization, and enable measuring the voided (urinated) and residual (what remains in the bladder after a voiding attempt) volumes that will be indicative of improvement/resolution of the problem.
  • Neuromodulation: Interstim device is a battery-powered neuro-stimulator (bladder “pacemaker”) that provides electrical impulses carried by a small lead wire to stimulate selected sacral nerves that affect bladder function. This can be considered in select cases of underactive bladder.

Written by Dr. Andrew Siegel 

When the doctor becomes the patient: Urologist visiting the urologist

When the Doctor Becomes the Patient: Urologist Visiting the Urologist

Urinary problems are not a result of aging, but of prostate enlargement as men age.

As a maturing man who is approaching 50 years old, I personally have had time to truly empathize with many of my patients. Most men confuse the onset of urinary symptoms and worsening lower urinary tract symptoms as the normal aging process.

The good news is that what many men consider a part of aging can be reversed. For example, it is not part of the normal aging process for men to get up during sleep and need to urinate. Having a hard time starting the stream (hesitancy), a weak stream, and feeling like the bladder isn’t empty are also not part of the normal aging process.

WHAT IS NORMAL

Male urinary anatomyThe urinary process starts from the kidneys, the pump that makes the urine, filtering the blood and releasing urine, which is composed of water and electrolytes and waste products from the body.

The urine passes from the kidneys to the bladder by small tubes called ureters. The bladder has the main function of storing the urine until we are ready to eliminate it.

When a person wants to urinate, the bladder will squeeze and the urinary muscles will relax. If the urinary tract outlet, which we call the bladder outlet, is normal, the urine will start right away and the flow will be quick; the bladder will empty, and the flow will stop quickly as the bladder empties.

WHAT HAPPENS WITH AGING

Men can develop trouble emptying the bladder for many reasons, but the majority of the time the problem is the prostate. The prostate is a donut-shaped organ that connects the bladder with the urethra. Its opening is called the prostatic urethra and is the main cause of blockage for the aging male. As the prostate enlarges (also known as BPH or Benign Prostate Hyperplasia), it can become larger on the outside, which does not affect urination that much, but more importantly can grow on the inside, which causes blockage and forces the bladder to squeeze and work harder to pass urine.

normal prostate vs enlarged prostate gland

THE BLOCKAGE (OBSTRUCTIVE SYMPTOMS)

The first signs of problems for men are often obstructive symptoms. The symptoms include a hard time starting urinary flow, the stream being slower than it used to be, and a feeling of not being completely empty after finishing to urinate. This usually starts slowly and it can take years before it becomes a problem. For me, I first started to notice the slowing of the stream when occasionally I awakened in the middle of the night. As time went by, this became more obvious, and when I first urinated in the morning, the stream was at its slowest compared to other times of the day.

THE BLADDER RESPONSE (IRRITATIVE SYMPTOMS)

The bladder usually can compensate by working harder and increasing its pressure so the urinary flow is maintained. While this is a good thing to maintain a normal urinary life, the bladder works harder and the muscle gets thicker and it becomes overactive. Men then develop the urge to urinate much sooner than they should, since the bladder is irritated and wants to empty before it has reached its normal size. This urgency leads to frequency of urination, having to urinate more frequently than one did before. When this happens at night, we develop nocturia, the need to urinate more at night, which becomes a problem since we are unable to sleep as well as we should. Also see, “7 Symptoms of Enlarged Prostate (BPH).”

THE GOOD, THE BAD, AND THE UGLY

The Good News

The good news is that the process of urinary dysfunction is not really normal or a sign of aging, but the effects of aging which lead to an enlarged prostate. As I am nearing 50 and seeing my primary care doctor for a referral for a colonoscopy, which I thought was more than enough for now, I also plan to visit my colleague Dr. Opell, but not in the usual way.

The Bad News

This is not really bad news, but it is important for men as they get older to make sure that any urinary symptoms are not due to prostate cancer, which can also cause a blockage. This will require an examination and blood work for a PSA.

The Ugly

People are born with one bladder and if we let urinary problems progress, this can lead to a poorly functioning bladder, the worst case being that the bladder does not function anymore. Letting the bladder reach higher pressure than it should can lead to problems with the kidneys draining. This can also lead to swelling of the kidneys, which was relatively common many years ago when men were not evaluated for urinary problems as frequently as they are now, but now is rarely seen.

THE GREAT NEWS

Urologists have many ways they can improve urinary function in men. Supplements or medications can often help and usually are a lifelong necessity. As the prostate enlarges, most men will still have further symptoms; however, Urologists also have multiple procedures that can be performed to reverse the effects of an enlarged prostate and leave men with normal urinary function as they get older.

Genetics of Prostate Cancer

Genetics of Prostate Cancer and Breast Cancer

21 Oct 2021 Blog

October Breast Cancer AwarenessThis month is breast cancer awareness month. Interestingly, breast cancer and prostate cancer have so much in common. Excepting skin cancer, breast cancer is the most common cancer in women; prostate cancer is the most common cancer in men. Breast and prostate are dependent upon the sex hormones estrogen and testosterone, respectively, and one mode of treatment for both cancers is suppression of these hormones with medications.

leading causes of cancer and death 2021

The incidence of both breast and prostate cancer increase with aging. Breast and prostate cancer are often detected during screening examinations before symptoms have developed: breast cancer is often picked up via screening mammography, whereas prostate cancer is often identified via an elevated or accelerated PSA blood test. Alternatively, breast and prostate cancer are detected when an abnormal lump is found on breast exam or digital rectal exam of the prostate, respectively. Both breast and prostate cells may develop a non-invasive form of cancer known as carcinoma-in-situ—ductal carcinoma-in-situ (DCIS) and high-grade prostate intraepithelial neoplasia (HGPIN), respectively—non-invasive forms in which the abnormal cells have not grown beyond the layer of cells where they originated, often predating invasive cancer by years.

brca mutation cancer

Family history and genetics is relevant to both breast and prostate cancer. Women who inherit BRCA1 and BRCA2 abnormal genes have an increased risk of breast and ovarian cancer; men who inherit the BRCA1 and BRCA2 abnormal genes have an increased risk for prostate cancer. Imaging tests used in the diagnosis and evaluation of both breast and prostate cancers are similar with ultrasonography and MRI commonly used. Surgery, radiotherapy, chemotherapy and hormone therapy are important treatment modalities for both breast and prostate cancer.

How Normal Cells Break Bad into Cancer Cells

Normal cells become cancer cells (malignant cells) when mutations in the DNA (deoxyribonucleic acid) sequence of a gene transform cells into a growing and destructive version of their former selves. These abnormal cells can then divide and multiply without control. Although DNA mutations can be inherited, it is much more common for DNA mutations to occur from environmental toxin exposure or from random cellular events. Under normal circumstances the body repairs damaged DNA, but with cancer cells the damaged DNA is unable to be repaired.

Inherited Mutations Predisposing to Prostate Cancer

Our understanding of “germline” mutations (DNA mutations inherited from one’s mother, father, or both parents) as an important predisposing cause of aggressive prostate cancer has increased dramatically over the past few years. About 10% of prostate cancers are due to inherited germline mutations that have been present in every cell in the body since birth. This is as opposed to “somatic” mutations that occur after birth and are not passed on to children. 90% of prostate cancer is thought to be due to non-inherited, acquired somatic mutations.

Germline mutations play a key role in many breast and ovarian cancers. Inherited germline mutations that increase the risk of these cancers in females—BRCA (BReast CAncer) mutations—also increase the risk for prostate cancer in men. BRCA1 mutations double the risk of metastatic castrate resistant prostate cancer (prostate cancer that has spread and is resistant to treatments that decrease testosterone); BRCA2 mutations increase the risk of metastatic castrate resistant prostate cancer by a factor of 4-6, with earlier onset, higher grade at diagnosis and shorter survival. More than 20% of men with metastatic castrate resistant prostate cancers are found to have germline mutations, most commonly BRCA2.

germline vs somatic mutation

Genetic and Genomic Testing

Germline mutation assessment (genetic testing) helps assess one’s risk for prostate cancer. Somatic mutation assessment (genomic testing) examines the genes in a prostate cancer specimen and helps with decisions regarding treatment. Genomic testing can help predict how aggressively a prostate cancer might behave and how likely it is to advance and metastasize.

Genetic testing for prostate cancer is indicated in the following circumstances: early onset prostate cancer, aggressive prostate cancer, regional spread or metastatic prostate cancer, multiple cancers including prostate cancer (e.g. prostate cancer and male breast cancer), in prostate cancer patients who have family members with prostate, breast, ovarian, colorectal or pancreatic cancer, and intra-ductal prostate cancer histology.

The most common mutations found in prostate cancer are the BRCA2 mutation, which accounts for about 50% of hereditary prostate cancer mutations, and Lynch syndrome mutation. Lynch syndrome (hereditary non-polyposis colorectal cancer) is an inherited cancer syndrome causing mutations in DNA repair genes called MMR genes (MisMatch Repair). Because of this predisposition to mutation resulting from impaired DNA repair, those with Lynch syndrome have increased risk not only of colorectal cancers, but a host of other cancers including prostate cancer.

New Jersey Urology currently uses Myriad’s multigene panel for germline testing to determine the presence of 10 genetic mutations commonly implicated in inherited prostate cancer. Specimens are obtained either through a saliva or blood sample and results are typically available in 2-3 weeks. This panel includes the following genes: BRCA1, BRCA2, MLH1, MSH2, MSH6, PMS2, EPCAM, TP53, NBN, and HOXB13.

There are numerous advantages of finding if one has a genetic mutation linked to prostate cancer. It prompts genetic testing of other family members and, if they test positive, they may wish to undergo prostate cancer screening starting at an earlier age than men with no family history. Depending upon the particular mutation, they may also wish to undergo screening for other cancers as well. If the BRCA mutation is discovered, it prompts genetic testing of female family members, since the presence of this mutation will greatly increase the risk for breast and ovarian cancer and mandates intensified screening.

Genetic testing has given rise to the exciting field of precision medicine, individualized and customized treatment strategies with specific medications targeted against the specific mutations, a treatment based upon cancer biology and no longer only cancer histology.

For more information about cancer treatment at New Jersey Urology, please see our Cancer Treatment Centers or Contact Us for an appointment.

Written by Dr. Andrew Siegel

What is Urologic Care and When Do I Need One?

What is Urologic Care?

“Urology” (uro—urinary tract; logos—study of) is the branch of medicine that diagnoses and treats diseases of the urinary tract in males and females and the reproductive tract in males. The urinary organs under the “domain” of urology include the kidneys, the ureters (tubes connecting kidneys to the urinary bladder), the urinary bladder, and the urethra (channel that conducts urine from the bladder out). These body parts are responsible for the production, storage and release of urine. The male reproductive organs that a urologist cares for are the testes, epididymis (structures above and behind the testicle where sperm mature and are stored), vas deferens (sperm duct), seminal vesicles (structures that produce the bulk of semen), prostate gland and the scrotum and penis. These body parts are responsible for the production, storage, and release of reproductive fluids. The reproductive and urinary tracts are closely connected, and disorders of one oftentimes affect the other…thus urologists are referred to as “genitourinary” specialists.

Urology is a balanced specialty – urologists treat men and women young and old, from pediatric to geriatric. Whereas most physicians are either medical doctors or surgeons, a urologist is both, with time divided between a busy office practice and the operating room. Although most urologists are men, more and more women are entering the urological workforce.

It takes extensive training to become a urologist. My pathway to urology was 4 years of college, 4 years of medical school, 2 years of general surgery residency, 4 years of urology residency and 1 year of specialty fellowship training in pelvic medicine and reconstructive urology. I started practicing at age 33.

The American Board of Urology logo

Board certification is the equivalent of a lawyer passing the bar exam. There are three board certifications in urology: general urology, pediatric urology, and female pelvic medicine and reconstructive surgery. Thereafter, one must maintain board certification by participating in continuing medical education and pass a recertification exam every ten years. Every urologist at New Jersey Urology is either board-certified or board-eligible (the younger urologists who have not yet sat for the board exam). Some, like myself, are double board-certified.

A Comprehensive Team Approach

Although urology is a unique and niche specialty, there is some overlap with other medical and surgical disciplines, including nephrology (specialists in medical diseases of the kidney); oncology (medical cancer specialist); radiation oncologist (radiation cancer specialists); radiology (imaging specialists); gynecology (female specialists); endocrinology (hormone specialists); and infectious disease (infection specialists).

The NJU Urology Team

When Does One Need Urologic Care?
Although many of our patients are sent over by their primary care physicians, many others directly seek our care. Urologists are the male counterparts to gynecologists and the go-to physicians when it comes to expertise in male pelvic health. Although gynecologists treat only females, urologists care for both genders. Providing healthcare to females is a routine part of urology and commonly treated female issues include recurrent urinary infections, urinary incontinence and pelvic organ prolapse.

When to see a urologist checklistCommon reasons for a referral or visit to a urologist include:

  • Blood in the urine or semen (whether visible or found on a urine test)
  • Elevated PSA (Prostate Specific Antigen)
  • Prostate enlargement
  • Irregularities of the prostate on digital rectal examination (DRE)
  • Pelvic organ prolapse
  • Urinary disease:
    • Urinary leakage or control issues
    • Inability to urinate (urinary retention)
    • Urinary frequency
    • Urinary infections
  • Kidney Stones
  • Urologic Cancers

Sexual dysfunction is a common condition managed by the urologist—erectile dysfunction, ejaculation problems, and testosterone issues. Urologists treat not only male infertility, but also create male infertility when it is desired by performing voluntary male sterilization (vasectomy). Testicular pain and swelling are also the domain of urologists.

Another large component of urological practice is the management of infections that may involve the bladder, kidneys, prostate, testicles and epididymis. Kidney stones are another key issue that keeps urologists busy. To manage stones that fail to pass spontaneously, urologists have at their disposal minimally invasive, outpatient techniques with new generation shockwave devices and miniaturized fiberoptic telescopes with laser technology.

Urologic Cancers
Urological surgery involves operating on patients with potentially life-threatening illnesses, and cancers of the genital and urinary tracts are common and a major part of urological practice. These include prostate cancer, bladder cancer, and cancer of the kidney and renal pelvis (the inner part of the kidney that collects the urine).

Men age 40 and older who have a life expectancy of 10 years or greater should be screened for prostate cancer, the most common male cancer (aside from skin cancer), whether it is by their primary care physician or urologist. Screening is vital since prostate cancer does not cause symptoms until it progresses to advanced stages and screening aims to detect prostate cancer in its earliest and most curable states. Screening is as simple as an annual digital rectal examination and a PSA blood test.

Women with kidney and bladder cancer are also managed by urologists, although the prevalence of these cancers is much less in females. Urologists are the specialists who treat testicular, penile, and adrenal cancer. After definitive cancer care, patients will need follow-up for an indefinite period of time and it is urologists who provide this aftercare.

Cutting-Edge Surgical Advancement
Urology has always been on the cutting edge of surgical advancements (no pun intended) with continued evolution into improved and less invasive techniques. Urologists have at their disposal a host of minimally invasive technologies including fiber-optic scopes to view the entire inside of the urinary tract, as well as ultrasound, lasers, laparoscopy and robotics. As a result, many procedures that used to be done on an inpatient basis are now performed on an outpatient basis.

New Jersey Urology has been at the forefront of robotic-assisted laparoscopic surgery that has largely replaced open surgery. The urologist with a dedicated team of assistants harnesses the powers of the robot, an extraordinary example of human-machine symbiosis. It affords numerous advantages including high-quality 3D vision, motion scaling, and enhancement of surgeon dexterity, which translates to numerous benefits and advantages to the patient. New Jersey Urology has the largest experience in robotic urology procedures in New Jersey, particularly cancer and reconstructive urological surgery. Single-port access – even more minimally-invasive than the conventional multi-port robotic technology – is the latest iteration and evolution and New Jersey Urology has the largest clinical experience with this in the Northeastern United States.

Standard robotic laparoscopic surgeries require 5-6 small incisions, whereas the revolutionary single port robotic procedure combines them into one keyhole incision.

Clinical Research
Clinical research is a vital part of urology and New Jersey Urology has numerous ongoing clinical trials in prostate cancer, bladder cancer, benign prostate hypertrophy, and overactive bladder. Dr. Elan Diamond is the medical director of clinical research and the center for advanced prostate cancer therapeutics that offers many novel medications and immunotherapy. Genomic science has enabled the ability to determine the molecular blueprint of cancers, the key to assessing their biological potential. Determining a cancer’s unique genetic profile provides the potential for “precision medicine,” individualized and customized treatment strategies with agents targeted against the specific mutations, a treatment based upon cancer biology and no longer only cancer histology.

Bladder Cancer: What You Should Know

Bladder Cancer: What You Should Know

Bladder cancer comprises a large part of the practice of urology. The incidence of bladder cancer increases with age and is four times more common in men than women and twice as high in Caucasian men than African-American men. 80% of newly diagnosed individuals are 60 years of age or older. Excepting skin cancers, bladder cancers are the most frequently recurring cancer, with up to 70% of patients experiencing a recurrence. When the disease is diagnosed and treated in early stages, the chances of survival are excellent, highlighting the importance of a timely and accurate diagnosis.

Bladder Cancer: The Facts
Causes of Bladder Cancer

The highest prevalence of bladder cancer is in industrialized nations. Tobacco is the greatest risk factor for bladder cancer, accounting for half of all cases. Even if one stopped smoking years ago, the risk is related to the quantity of tobacco smoked over the years. Occupational exposure to cancer-causing chemicals (carcinogens) is another risk factor: dye, rubber, leather, aluminum, paint, and arsenic in drinking water. Occupations at higher risk for bladder cancer because chemical exposure include: hairdressers, painters, machinists, printers, and those who work with dyes, textiles, rubber, leather, and petrochemicals.

­The Relationship Between Tobacco and Bladder Cancer

Bladder cancer is second most common tobacco-related malignancy (#1 is lung cancer). Tobacco is the leading risk factor for bladder cancer and most newly diagnosed bladder cancer patients are smokers or former smokers. About 20% of newly diagnosed bladder cancer patients are current smokers. Carcinogens in tobacco (cancer causing chemicals) are absorbed through the lungs into the bloodstream, circulate throughout the body, filter through the kidneys into the urine and have prolonged contact time with the urinary bladder as urine is stored in the bladder. There is a long lag time between carcinogen exposure and the development of bladder cancer, often more than twenty years, similar to the relationship between sun exposure and skin cancer.

The health benefits of smoking cessation are considerable, decreasing chances of bladder cancer recurrence, progression and development of another tobacco-related cancer. Those smokers diagnosed with bladder cancer have a unique propensity to quit at the time of diagnosis, which seems to be a critical teachable moment, a window of opportunity where a lifestyle change can be leveraged. Continuing to smoke after diagnosis is associated with worse disease outcomes compared to those who quit.

Diagnosing Bladder Cancer

Bladder cancer typically presents with blood in the urine, either visible or microscopic (seen only under microscopic magnification). It may also cause irritative lower urinary tract symptoms including urgency, frequency, discomfort with urinating, and urinary leakage.

The evaluation of blood in the urine includes imaging, cytology, and cystoscopy. Imaging tests are means of visualizing the anatomy of the urinary tract, typically through ultrasound, computerized tomography (CT), or magnetic resonance imaging (MRI). Cytology is a microscopic inspection of a urine sample by a pathologist for the presence of abnormal or cancerous cells that slough off the lining of the bladder, similar to a Pap smear done to screen for cervical cancer. Cystoscopy is a visual inspection of the lower urinary tract (bladder and urethra) using a tiny, flexible, lighted instrument attached to a camera and monitor.

The Stages of Bladder Cancer

When a bladder tumor is identified on cystoscopy, attention is directed to the number of tumors present, their size, location within the bladder, and physical appearance. A papillary appearance consists of fronds (finger-like projections floating in the bladder) with a narrow attachment to the bladder lining versus a sessile appearance, in which the tumor appears solid and is widely attached to the bladder lining.

Once a bladder tumor is recognized, it needs to be removed and sent for pathological evaluation. This is performed under general or spinal anesthesia via cystoscopy, using an electric loop that is used to remove the area of concern as well as cauterize (use electricity to coagulate tissue) the underlying and adjacent tissue, both to stop bleeding and further destroy tumor cells.

The biopsied tissue is examined by a pathologist, who provides information regarding malignancy vs. benignity, tumor type, depth, and grade. The vast majority of bladder tumors are urothelial cancers, referring to the cells that line the bladder. A minority of bladder tumors are squamous cell cancers or adenocarcinomas. Depth refers to the degree that the cancer is growing into the bladder wall. Bladder cancers are broadly categorized into superficial and deep. Superficial tumors are largely confined to the bladder lining and superficial layers and do not penetrate the muscle layer of the bladder, whereas deep tumors have “roots” that penetrate the muscular wall of the bladder. Tumor grade refers to how much the microscopic appearance of the cancer deviates from the microscopic appearance of healthy bladder cells. Low-grade cancers are similar in cellular appearance to normal bladder cells and generally behave in an indolent (slow) fashion versus high-grade cancers that can often behave aggressively. Other factors of prognostic importance are the number of tumors present, the size of the tumors, and their physical characteristics.

In general, the best prognosis is for a solitary, small, superficial, low-grade papillary tumor and the worst prognosis is for multi-focal (originating from many different areas of the bladder), large, invasive (deep), sessile, high-grade tumors.

The biopsy information enables staging of the bladder cancer, a means of classifying the cancer, as follows:

  • Ta: Superficial cancer is found only in polyps (papillary) on the surface of the inner lining of the bladder.
  • Tis: Carcinoma-in-situ. Tumor is found only in flat lesions on the surface of the inner lining of the bladder.
  • T1: Tumor is found in the connective tissue below the lining of the bladder but has not spread to the bladder muscle.
  • T2: Tumor has spread to the muscle layer deep to the lining of the bladder.
  • T3a: Tumor has spread through the muscular wall of the bladder into the fatty tissue layer as identified under microscopic examination.
  • T3b: Tumor has spread through the muscular wall of the bladder into the fatty tissue layer and is capable of being identified without a microscope.
  • T4: Tumor has spread to the prostate in men and to the uterus or vagina in women, or to the pelvic or abdominal wall in either gender.

STAGES OF BLADDER CANCER

Stages of Bladder Cancer

The majority of patients with newly diagnosed bladder cancer have superficial cancer that involves the inner layers of the bladder wall, 20% have invasive disease that involves the deeper layers of the bladder wall, and 5% present with metastatic disease, defined as spread beyond the confines of the bladder.

Treating Bladder Cancer

Superficial cancers are managed with regular “surveillance” due to the high predilection for recurrence. Surveillance includes cystoscopy, urinary cytology, and upper urinary tract imaging on a scheduled basis.

Under certain circumstances, it is beneficial to use a medication that is instilled in the bladder to help prevent recurrences. This is especially the case when many tumors are present, in the presence of a high-grade tumor, or cancers that have recurred. It is particularly useful for carcinoma-in-situ (CIS), a variant of bladder cancer that is superficial, flat, yet high-grade. The medication of choice is often tuberculosis vaccine—BCG (bacillus Calmette Guerin), which is a live, attenuated (weakened) form of tuberculosis bacteria. There are also several chemotherapy alternatives to BCG that are used by bladder instillation.

Muscle-invasive cancers most often need to be treated with a surgical procedure involving either partial or complete removal of the urinary bladder. In the circumstance that the entire bladder needs to be removed, the ureters (tubes that conduct the urine from the kidneys to the bladder) need to be diverted to a piece of intestine that is either attached to the skin to a collection bag (ileal conduit) or attached to the urethra (neo-bladder or “reconstructed” bladder). At times, in lieu of surgery, chemo-radiation can be utilized (a combination of radiation therapy provided by the radiation oncologist and chemotherapy provided by the medical oncologist).

Bladder cancer often behaves as two separate types of diseases: one that typically presents as multiple, superficial papillary tumors, which tend to reoccur, but are not lethal (similar to many skin cancers), versus another more deadly form characterized by high-grade, non-papillary, muscle-invasive tumors that have a tendency to metastasize. Fortunately, the vast majority of bladder cancers are the superficial type.

What is Urologic Oncology? Urologic oncology is a urological subspecialty that diagnoses and treats cancers of the male and female urinary tract and the male reproductive organs.

What is Urologic Oncology?

Urologic oncology is a urological subspecialty that diagnoses and treats cancers of the male and female urinary tract and the male reproductive organs. Urologic cancers are extremely common and comprise a significant part of the medical and surgical practice of urologists, who treat many serious and potentially life-threatening cancers.

New Jersey Urology embraces a multi-disciplinary health care team approach to urologic cancers. In addition to urologists, radiation oncologists and medical oncologists are essential members of the team that treat urologic cancers. A radiation oncologist is a specialist in treating cancer with radiation therapy. A medical oncologist is a specialist in treating cancer with chemotherapy, advanced hormonal therapy, and immunotherapy. This trio – urologist, radiation oncologist, and medical oncologist – are the cancer team, a powerful management team with each member having a different expertise and contributing vitally to the decision-making and management process.

What Are the Most Prevalent Urologic Cancers?

In the United States, prostate cancer accounts for more than 26% of new cancer cases in men, bladder cancer for 7%, and cancer of the kidney and renal pelvis (the inner part of the kidney that collects urine) for 5%. Testicular cancer is relatively rare but is also under the treatment domain of urologists. Urologists treat women with kidney and bladder cancer, although the prevalence of these cancers is much less so in females.

Estimated New Cancer Cases in the United States
(by Gender)

US 2021 New Cancer Cases by Gender

In 2021, three urologic cancers are on the list of the top ten most prevalent cancers in men. Prostate cancer is number 1 (about 250,000 cases), urinary bladder cancer is number 4 (about 65,000 cases), and kidney and renal pelvic cancer is number 6 (about 49,000 cases). In females, kidney and renal pelvis cancer is number 9 on the list of the top ten most prevalent cancers in women. Other, but rarer cancers treated by urologists include penile cancer, urethral cancer and adrenal cancer.

2021 UROLOGIC CANCER STATS

2021 Urologic Cancer Stats

Prostate Cancer
Risk factors are aging, race (African and Caribbean ancestry have highest risk), family history/genetics, and lifestyle. The only modifiable risk factors are use of tobacco and excessive body weight, both of which may increase the risk of aggressive and potentially fatal disease.

Because prostate cancer is a leading cause of cancer death and causes no symptoms in its earliest stages, screening recommendation for men who have a life expectancy of at least ten years is an annual digital rectal exam of the prostate and a prostate specific antigen (PSA) blood test. Most prostate cancers are discovered after prostate biopsy based upon an elevated PSA or a PSA that has accelerated from previous and some on the basis of an abnormal prostate exam. The major management options for early stage prostate cancer are active surveillance, robotic prostatectomy, and radiation. Focal therapies including cryosurgery and high intensity focal ultrasound are alternative options. Late stage prostate cancer options include hormonal therapy, chemotherapy and immunotherapy.

Bladder Cancer
The incidence of bladder cancer is four times higher in men than women and two times higher in Caucasian men than African-American men. Tobacco is the greatest risk factor for bladder cancer, accounting for half of all cases. Occupational exposure to chemicals is another risk factor: dye, rubber, leather, aluminum, paint, and arsenic in drinking water. In the vast majority of cases, bladder cancer presents with blood in the urine, and less commonly with irritative lower urinary tract symptoms including urgency, frequency, and painful urination. Early stage disease is treated by removal of the cancer via the cystoscope, often followed by intravesical therapy (immunotherapy with BCG or chemotherapy instilled directly into the bladder). More advanced cancers may require bladder removal and urinary diversion. Late stage bladder cancer is treated with chemotherapy. Bladder cancers have a high predilection for recurrence and therefore careful follow-up is necessary.

Renal Cell and Renal Pelvic Cancers
Renal cell cancers originate in the outer part of the kidney that produces urine, whereas renal pelvic cancers originate in the inner part of the kidney that collects the urine. 95% of kidney tumors are renal cell cancers. Risk factors include excess body weight, tobacco, and chronic renal failure. The vast majority of renal cell cancers are asymptomatic and picked up incidentally on imaging studies (ultrasound, computerized tomography, magnetic resonance imaging) done for other reasons, although on occasion they may cause blood in the urine, pain or a mass. Most renal pelvic cancers present with blood in the urine. The treatment options for a renal cell cancer include active surveillance, removal of the involved part of the kidney, removal of the entire kidney, or focal ablation by freezing or with heat. For advanced disease, immunotherapy and targeted therapies are the main treatment options.

5% of kidney tumors are renal pelvic cancers, which behave similarly to bladder cancer. Like bladder cancer, tobacco and occupational exposure to chemicals are the greatest risk factor for bladder cancer. Treatment options for renal pelvic cancers include endoscopic techniques, instillation of immunological or chemotherapeutic medications into the renal pelvis, and surgical removal of the kidney and ureter. For advanced disease, chemotherapy is the main treatment option.

Testes Cancer
Although cancer of the testicle is rare, it is the most common solid cancer in young men age 15-40, with the greatest incidence in the late 20s, striking men at the peak of life. Testes cancer is more prevalent in Caucasian men than African-American or Asian men and is occurs more commonly in men with undescended testes and Klinefelter’s syndrome. The great news is that testes cancer is a highly curable cancer, especially when picked up in its earliest stages, and also potentially curable even at advanced stages. Testes cancer typically causes a lump, irregularity, asymmetry, enlargement, heaviness or a dull ache of the testicle. It most often does not cause pain. Testes cancer can also present with a sudden fluid collection around the testes, breast enlargement and/or tenderness, back pain and rarely shortness of breath, coughing up of blood or a lump in the neck.

A careful physical examination is followed by an ultrasound of the scrotum. Tumor markers—alpha-feto protein (AFP), human chorionic gonadotropin (B-HCG) and lactate dehydrogenase (LDH) are routinely obtained. An outpatient surgical procedure removes the diseased testicle along with the spermatic cord that contains the blood and lymphatic supply of the testicle.
Depending on the final pathology report and staging studies, management options may include surgical removal of abdominal lymph nodes, chemotherapy or radiation therapy.

American Cancer Society logo

American Cancer Society Lifestyle Guidelines for Minimizing Risk for Cancers

  1. Maintain a healthy weight
  2. Stay physically active
  3. Limit sedentary behavior
  4. Make healthy eating choices
  5. Avoid alcohol
  6. Avoid tobacco

Written by Dr. Andrew Siegel


Painful Urination - When urination is painful

When Urination is Painful

Dysuria is the medical term for uncomfortable, burning or painful urination. It is a common symptom and a frequent reason for a consultation with a urologist. There are many underlying causes including infections, inflammatory conditions, trauma, injury, and pelvic floor dysfunction.

CAUSES OF PAINFUL URINATION

Painful urination often occurs due to infections of the lower urinary tract or genital structures (urethra, bladder, prostate and vagina). The most common reason for painful urination is a bladder infection, cystitis. Prostatitis, an infection of the prostate gland can be a cause in males and the parallel process in females, para-urethral gland infection (Skenitis) can also give rise to burning. Because of the close proximity of the female urethra to the vagina, yeast infections and other forms of bacterial vaginitis can secondarily involve the urethra and cause painful urination. Urethritis, an infection of the urethra, is a frequent cause of painful urination, most often on the basis of sexual transmitted infections (STI), particularly those caused by chlamydia, gonorrhea, and herpes.

Types of urinary infections

NON-INFECTIOUS CAUSES OF PAINFUL URINATION

There are also numerous non-infectious causes of painful urination. Urine contains waste products and if the urine concentration is too high because of insufficient hydration, one may experience burning. This happens particularly with the first urination of the day, when the urine is most concentrated because of the relative dehydration from the hours spent sleeping without consuming liquids. During the process of prostate radiation therapy as treatment for prostate cancer, radiation-induced inflammatory changes of the prostate may occur, resulting in irritative lower urinary tract symptoms and painful urination. On occasion, a long-term consequence of pelvic radiation therapy is radiation cystitis, that can manifest with bleeding, irritative lower urinary tract symptoms and painful urination. Interstitial cystitis, a painful inflammatory condition of the bladder that may severely impact one’s quality of life, causes painful urination, pelvic pain and urinary frequency.

Conditions that directly impacts the anatomy or function of the urethra can give rise to painful and difficult urination. These include the following: urethral stricture (scar tissue within the urethra), a urethral stone (lodged within the urethral channel), urethral diverticulum (an out-pouching from the urethra), atrophic urethritis (changes of the urethra that accompany menopause), and urethral trauma (following sexual intercourse, childbirth, straddle injuries and commonly from urinary catheters and following transurethral surgery). Pelvic floor dysfunction with hyper-tensioning of the pelvic floor muscles can cause painful urination as well as many other urinary, bowel, sexual and pelvic symptoms.

DIAGNOSING PAINFUL URINATION (DYSURIA)

Examination of the urethra, penis, testes and prostate in males and a pelvic exam in females, along with urinalysis and urine culture are imperative. If there is urethral discharge accompanying the painful urination and/or a history of unprotected sex, a STI screen is appropriate. Urinalysis and culture will rule out urinary infection. Depending on associated urinary symptoms, cystoscopy (visual inspection of the urethra and bladder with a tiny fiberoptic telescope) and imaging tests may be indicated.

PAINFUL URINATION TREATMENT

If the urine is hyper-concentrated, increasing fluid intake will improve the situation. Urinary infections are usually easily managed with a course of antibiotics. Urinary tract analgesics/antispasmodics are helpful for temporary relief of painful urination associated with infections. Prostatitis and Skenitis will generally require a more prolonged course of antibiotics. STIs are typically easily treated with the appropriate antibiotic or antiviral. Yeast infections are readily treated with anti-fungal medications. At times, a prostate relaxant medication can be helpful for the urinary difficulties associated with prostatitis, whether infectious or radiation induced. Anti-inflammatories are often useful as well. Interstitial cystitis is a complex situation with multiple potential treatment options. Atrophic urethritis can be addressed with topical estrogen. If a stone, stricture or diverticulum is found within the urethra, surgery is often indicated. For pelvic floor dysfunction, pelvic floor physical therapy can be extremely helpful to foster relaxation and “down-training” of the spastic pelvic muscles.

Painful urination treatment options

* Your urologist will determine the best course of treatment based on an individual diagnosis.

At times, despite substantial effort and testing, no source for the burning urination is found, a frustrating situation for patient and physician alike. This is often times labeled chronic urethritis and management may include including hot baths, anti-inflammatory analgesics, and the application of topical lidocaine jelly. However, in the vast majority of cases of painful urination, the diagnosis and treatment are straightforward.

 

Written by Dr. Andrew Siegel

 

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