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

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?

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

 

Genetic Testing for Prostate Cancer

Genetic Testing for Prostate Cancer

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 by one’s exposure to environmental toxins 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.

The last few years have witnessed a dramatic increase in our understanding of inherited mutations (“germline” mutations) as important predisposing causes of aggressive prostate cancer. About 10% of prostate cancers are on the basis of inherited germline mutations. “Germline” mutations are DNA mutations that are inherited from one’s mother, father, or both parents. These inherited mutations have been present in every cell in the body since birth. This is as opposed to “somatic” mutations that are mutations that have occurred 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 vs Somatic Mutation illustration

Germline mutations play a key role in many breast and ovarian cancers and some inherited germline mutations that increase the risk of these cancers in females—BRCA (BReast CAncer) mutations—do the same in terms of 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 levels or activity) and 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 BRAC2.

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 of prostate cancer, high-risk or very high-risk (aggressive) prostate cancer, regional spread or metastatic prostate cancer, in patients with multiple cancers that include 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 in patients with intraductal 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, patients 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.

HOW IT WORKS

Genetic testing and how it works illustration

BENEFITS OF GENETIC TESTING

There are numerous advantages of finding out if one has a genetic mutation linked to prostate cancer. It can prompt 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 can prompt genetic testing of female family members, since this mutation, if present, will greatly increase the risk for breast and ovarian cancer and will mandate intensified screening. Germline 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.

 

Written by Dr. Andrew Siegel


What is a PSA? Why Men Should Get Screened for Prostate Cancer

What is PSA?

PSA (prostate specific antigen) is a chemical produced by the prostate gland. It functions to liquefy semen following ejaculation, aiding the transit of sperm to the egg. A small amount of PSA filtrates 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. As a man ages, his PSA rises based upon the typical enlarging prostate that occurs with growing older.

Why screen for prostate cancer?

1 in 8 men will be diagnosed with prostate cancer

 

Excluding skin cancer, prostate cancer is the most common cancer in men (1 in 8 lifetime risk), accounting for about 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 state. Early and timely intervention for 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 cancer 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.

How is PSA used to screen for prostate cancer?
Although it’s an imperfect screening test, PSA remains the best tool currently available for detecting prostate cancer. It shouldn’t 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.

Upon PSA testing, about 90% of men are found to have a normal PSA. Of the 10% of men with an elevated PSA, 30% or so 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 < 1.5 had a 0.5% risk of developing prostate cancer, those between 1.5-4.0 had about an 8% risk, and those > 4.0 had greater than a 10% risk.

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.

There is no letter C (for cancer) in PSA

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 not a perfect 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.

How is PSA used in men diagnosed and treated for prostate cancer?

PSA is unquestionably the best marker to gauge prostate cancer status in the follow-up of men who have been treated for prostate cancer by any means. After surgical removal of the prostate gland for cancer, the PSA should be undetectable and after radiation therapy the PSA should decline substantially to a reading of usually less than 1.0. Rising PSA levels after treatment may be the first sign of cancer recurrence. Such a “biochemical” relapse typically precedes a “clinical” relapse by months or years.

How is PSA best used to screen for prostate cancer?

The most informative use of PSA screening is when it’s obtained serially, with comparison on a year-to-year basis providing much more meaningful information than a single, out-of-context PSA. Because PSA values can fluctuate from lab to lab, it’s always a good idea to try to use the same laboratory for the testing.

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’s little sense in screening. Another important factor is individual preference since the decision to screen should be a collaborative decision between patient and physician.

What are refinements in PSA testing?

PSA Velocity – Comparing the PSA values year to year is most informative. Generally, PSA will increase by only a small increment, reflecting benign prostate growth. If PSA accelerates at a greater rate than anticipated—a condition known as accelerated PSA velocity—further evaluation is indicated.

An isolated PSA (out of context) is not particularly helpful. What is meaningful is comparing PSA on a year-to-year basis and observing for any acceleration above and beyond the expected annual incremental change associated with aging and benign prostate growth. Many labs use a PSA of 4.0 as a cutoff for abnormal, so it is possible that one can be falsely lulled into the impression that their PSA is normal. For example, if the PSA is 1.0 and a year later it is 3.0, it is still considered a “normal” PSA (because it is less than 4.0) even though it has tripled (highly suspicious for a problem) and mandates further investigation.

PSA Density – PSA density (PSA divided by prostate volume) is the PSA level corrected to the size of the prostate. The prostate volume can be determined by imaging studies including ultrasound or MRI. PSA elevations are less worrisome under the circumstance of an enlarged prostate. A PSA density > 0.15 is concerning for prostate cancer.

Free PSA – PSA circulates in the blood in two forms: a “free” form in which the PSA is unbound, and a “complex” PSA in which the PSA is bound to a protein. The free PSA/total PSA ratio can offer a predictive value (similar to how HDL cholesterol/total cholesterol can be helpful in a person with an elevated cholesterol level). The higher the free to total PSA ratio, the greater the chance that benign enlargement of the prostate is the underlying source of the PSA elevation. In men with a PSA between 4 and 10, the probability of cancer is 9-16% if the free/total PSA ratio is greater than 25%; 18-30% if the ratio is 19-25%; 27-41% if the ratio is 11-18%, and the probability of cancer increases to 49-65% if the ratio is less than 10%.

4Kscore test – The 4Kscore Test is a refinement that measures the blood content of four different prostate-derived proteins: total PSA, free PSA, intact PSA and human kallikrein 2. Levels of these biomarkers are combined with a patient’s age, DRE status (abnormal DRE vs. normal DRE), and history of prior biopsy status (prior prostate biopsy vs. no prior prostate biopsy). These factors are processed using an algorithm to calculate the risk of finding a Gleason score 7 or higher (aggressive) prostate cancer if a prostate biopsy were to be performed. The test can increase the accuracy of prostate cancer diagnosis, particularly in its most aggressive forms. (It cannot be used if a patient has received a DRE in the previous 4 days, nor can it be used if one has been on Avodart or Proscar within the previous six months. Additionally, it cannot be used in patients that have within the previous six months undergone any procedure to treat symptomatic prostate enlargement or any invasive urologic procedure that may be associated with a PSA elevation.)

What is prostate MRI?

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

PI-RADS Classification & Definition:
I – Most probably benign
II – Probably benign
III – Indeterminate
IV – Probable cancer
V – Most probably cancer

What is the definitive test for prostate cancer?

Prostate biopsy (ultrasound guided) is the definitive and conclusive test for prostate cancer. An elevated or accelerated PSA, abnormal digital rectal exam and suspicious MRI are all helpful, but “the buck stops here” with prostate biopsy, the conclusive test for prostate cancer.

Bottom Line: PSA testing provides valuable information in the diagnosis, pre-treatment staging, risk assessment and monitoring of prostate cancer patients. PSA screening has resulted in detecting 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 metastatic prostate cancer and death from prostate cancer and it is recommended that the test be obtained annually starting at age 40 in men who have greater than a 10 year life expectancy.

Written by Dr. Andrew Siegel


Rezūm Therapy for BPH

14 Jul 2021 Blog, BPH

What is Resūm Therapy?

Rezūm Therapy is a safe and effective first-of-its-kind minimally invasive treatment to treat BPH — an enlarged prostate. It has been shown to relieve symptoms by reducing excess prostate tissue, which is the cause of BPH, with the use of water vapor therapy.

Prior to Rezūm, options for treating BPH were medications or surgery.  However, for men who choose not to utilize those methods, Rezūm offers an alternative.

The Rezūm System is included in The American Urological Association’s BPH treatment guidelines. In early 2019, a four-year study determined patients who had undergone Rezūm therapy continued to experience significant and sustained improvement in symptoms of BPH and in quality of life over the period of the study.

Understanding Benign Prostatic Hyperplasia (BPH)

Benign prostatic hyperplasia (BPH) — an enlargement of the prostate — is a common condition as men get older. It is caused when the cells of the prostate gland begin to multiply, causing the prostate gland to swell. This swelling compresses the urethra and thus limits the urine flow.

BPH does not increase cancer risk, nor is it the same as prostate cancer. However, its symptoms can be bothersome and impact quality of life for many men.

Typical BPH symptoms include:

  • A weak or interrupted urinary stream
  • Sudden urgency to urinate
  • Frequent urination, especially at night
  • Trouble starting the flow of urine
  • Inability to completely empty the bladder
  • Leaking or dribbling after urination

Common BPH treatment methods include prostate medications—such as medications to relax the muscles around the bladder and in the urethra; medication that impacts testosterone in order to reduce the prostate’s size; and several non-invasive therapies as well as minimally invasive therapies (such as Rezūm).

Surgical options include transurethral resection of the prostate (TURP) in order to ease the flow of urine, Greenlight laser photovaporization of the prostate, and rarely, suprapubic prostatectomy.

Those with minimal symptoms may desire to choose active surveillance, in which BPH symptoms are monitored in regular appointments with a urologist for evaluation and/or the need for intervention.

About the Rezūm Procedure

Rezūm Therapy works by using water vapor to kill prostate adenoma cells which cause the obstruction. With the extra prostate tissue removed, the urethra opens, alleviating the BPH symptoms. The body absorbs the treated tissue through the natural healing process, thus shrinking the prostate.

This one-time therapy is completed in a single session. While the entire appointment may take about two hours, the actual procedure takes only minutes. Thus far, Rezūm has been shown to have good outcomes for efficacy, safety and durability, with a potential for this outpatient-based treatment preserving sexual function.

What to Expect and Side Effects of Rezūm

Following the procedure, your doctor prescribes pain medication for your recovery. Most patients return to regular activities within a few days following treatment. The main precaution following the procedure is limiting strenuous activity until the catheter is removed.

In a majority of cases, individuals are able to fully recover from the procedure within a few days to a week. Improvement in BPH symptoms is often noted within a few weeks, and after three months, most individuals feel a complete relief from symptoms.

Rezūm has fewer side effects compared to surgical therapies. Potential side effects are similar to symptoms of BPH, such as frequent or painful urination, inability to urinate or to completely empty the bladder, and blood in the urine. However, most potential side effects are usually mild to moderate and typically resolve within several weeks following Rezūm. Your urologist will give instructions on how to prevent or manage any symptoms. If symptoms recur in the future, the treatment can be repeated.

Rezūm vs. UroLift and Prostate Medication

UroLift is a permanent implant and thus meant to be a permanent treatment. The implant device compresses the enlarged prostate tissue and holds it out of the way of the obstructed urethra, thereby opening the urethra. Like Rezūm, it has been shown to reduce symptoms and also to preserve sexual function.

A 2019 survey found that about half the men took medication to treat symptoms for their enlarged prostate; however, some were unhappy with the results. The survey also showed that while 50 percent of the respondents were aware of the availability of medications for their BPH, only six percent knew of minimally invasive procedures, such as UroLift and Rezūm.

The choice of UroLift or Rezūm, as well as other options for treating BPH, is based on individual cases and can be determined together with your urologist.

At NJU, We Can Help

There can be pros and cons of Rezūm Therapy. The decision to treat BPH with Rezūm may be right for some, but there are multiple options for BPH treatment. Your urologist can help to develop the best treatment plan for you. Contact NJU to set up an appointment to help get BPH under control.

Written by Dr. Andrew Siegel

12 Urology Misconceptions Debunked

Unfortunately, there is a lot of false information about urology circulating around the general population. To help you make sense of it, Dr. Andrew Siegel is helping to debunk twelve common misconceptions about urology.

1. Misconception: Urologists only treat men.

Reality: Although gynecologists treat only females, urologists care for both genders. Providing healthcare to females is a routine part of urology training. After a physician completes a urology residency, they may complete additional training that focuses exclusively on female issues, including pelvic organ prolapse and urinary incontinence.

2. Misconception: When you drink water it immediately goes to your kidneys and makes you want to urinate.

Reality: The pathway between drinking and peeing is the following: mouth–> esophagus–> stomach–> small intestine–> bloodstream–> heart–> aorta–> renal arteries–> kidneys–> ureters–> bladder. The likely reason you get a sudden urge to urinate when you drink water is that the presence of the water triggers a conditioned response that results in an involuntary bladder contraction.

3. Misconception: You must drink 8-12 glasses of water a day to maintain your health.

Reality: Many people take the 8-12 glass/day rule literally and as a result end up in urologists’ offices with urinary urgency, frequency and often urinary leakage. Water requirements are based upon the ambient temperature and your activity level. If you are sedentary and in a cool environment, your water requirements are significantly less than when exercising vigorously in 90-degree temperatures. Human systems are extraordinarily well-engineered and your body will let you know when you are dehydrated. Heeding thirst is one of the best ways of maintaining good hydration status. Another method is to pay attention to urine color. Depending on hydration status, urine color can vary from deep amber to as clear as water. If your urine is dark amber, you need to drink more as a lighter color is ideal and indicative of satisfactory hydration.

4. Misconception: You must flood yourself with fluids to help pass a kidney stone.

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

5. Misconception: The presence of bacteria in the urine is a urinary infection and always needs to be treated.

Reality: Asymptomatic bacteriuria, common in the elderly, diabetics, and particularly in nursing home residents, is the presence of bacteria within the bladder without the presence of infection. Asymptomatic bacteriuria only needs to be treated in certain situations: pregnancy, in patients undergoing urological-gynecological surgical procedures, and in those undergoing prosthetic surgery (total knee replacement, etc.). Screening or treatment of asymptomatic bacteriuria is futile, inappropriate, and should be strongly discouraged. Using antibiotics in this circumstance does not result in a decrease of symptomatic episodes, increases the occurrence of adverse drug effects, promotes the selection of resistant bacteria, and increases the cost of treatment. I really wish that internists would heed this advice!

Bonus misconception: The fact that plenty of people have bacteria in the urine debunks the myth that urine is always sterile.

6. Misconception: You’re not having pain, so there’s no way you could have prostate cancer.

Reality: Early prostate cancer causes NO symptoms whatsoever, including pain. As a general rule, if cancer is causing pain, that cancer is at a more advanced stage, either spread to structures adjacent to the site of the cancer, or remote from the site. Therein lies the importance of screening for prostate cancer with digital rectal exam (DRE) and PSA (prostate specific antigen) blood test.

7. Misconception: All prostate cancer is slow growing and can be ignored.

Reality: Each case of prostate cancer is unique and has variable biological behavior. It is true that some cases are so unaggressive that no cure is necessary and can be managed with active surveillance. However, others are so aggressive that no treatment is curative. Many cases are in between these two extremes: moderately aggressive and eminently curable.

A recent major advance is the improvement in the ability to predict which prostate cancers need to be actively treated and which can be watched, a nuanced and individualized approach. Those who feel that prostate cancer should not be sought out and treated should be attentive to the fact that it is the second leading cause of cancer death, with 33,330 deaths in 2020, and furthermore, that death from prostate cancer is typically an unpleasant one.

8. Misconception: A PSA blood test is a substitute for a digital rectal exam (DRE).

Reality: It is entirely possible to have prostate cancer with a normal PSA, the only clue being an abnormal DRE. The PSA blood test is NOT a substitute for the DRE. Both tests provide valuable and complementary information about prostate health and should be done. I really wish that internists would heed this advice!

9. Misconception: You had a colonoscopy, so you don’t need a DRE.

Reality: Same “foyer,” different rooms. (The foyer is the anal canal, the rooms are the prostate and the colon). Examination of the colon via colonoscopy does not in any way evaluate the prostate.

10. Misconception: Vasectomy causes prostate cancer.

Reality: Vasectomy does NOT cause prostate cancer; however, men who undergo vasectomies have relationships with urologists, the specialists who manage prostate issues, and therefore, men who undergo vasectomy are more likely to undergo prostate cancer screening with digital rectal exam and PSA blood testing than the average man who does not see a urologist. For example, every male patient above the age of 40 who I see for a vasectomy consult gets offered a digital rectal examination and a prostate specific antigen blood test that screens for prostate cancer. Few refuse!

11. Misconception: Ejaculation requires an erection.

Reality: You do not need an erection to ejaculate, as many men with erectile dysfunction discover, although an erection certainly enhances the process.

12. Misconception: If you lose your erection after ejaculation, you have erectile dysfunction.

Reality: It is normal (physiological) to lose your erection after climaxing. The refractory period is the time it takes to be able to get another erection, which can be highly variable depending upon age and other factors.


7 Symptoms of Enlarged Prostate (BPH)

Benign Prostatic Hyperplasia, or BPH, is the enlargement of the prostate gland. About half of men over age 75 will experience symptoms of BPH. BPH is a very minor condition and is not related to prostate cancer. However, symptoms can cause discomfort and be inconvenient.

What Is BPH and How Does It Affect Me?

The prostate gland surrounds the urethra and assists in reproduction. As a man ages, the prostate gets larger and begins to put pressure on the bladder and urethra, causing uncomfortable symptoms. It may be responsible for blocking the flow of urine out of the bladder, and can cause issues in the bladder, urinary tract, or kidneys.

How Do I Know if My Prostate is Enlarged? (Symptoms of BPH)

If your prostate is enlarged, it may not be a sign of cancer, but it is something that you should discuss with your doctor. Many of the symptoms of an enlarged prostate tend to relate to urination. If you are concerned about an enlarged prostate, here are 7 symptoms to look for:

  1. Difficulty starting urination. The enlarged prostate alters the pressure of your bladder to pass urine. This can have damaging effects on your kidneys.
  2. Weak urine stream. As the urethra becomes constrained, urine passes at a much slower rate.
  3. Urgent need to urinate. You may go from not needing to urinate to suddenly needing to go because of how the bladder gets constrained.
  4. Issues with sleeping. Pressure from the enlarged prostate can interfere with nerve signaling in the middle of the night. This leads to you thinking you have to urinate when you don’t.
  5. Feeling unable to completely empty your bladder. You may not be able to completely empty your bladder, which can lead to Urinary Tract Infections(UTI) and stone issues.
  6. Urinary tract infection. A UTI is caused by the urine that sits in your bladder which you can’t fully empty, creating an environment for bacteria to thrive.
  7. Bladder stones. The leftover urine in your bladder can also crystallize to create bladder stones.

BPH can cause these symptoms, but having these symptoms doesn’t necessarily mean you have BPH. There are many reasons why you may have urinary issues. If you are at all concerned that you may have an enlarged prostate, you should consult a urologist.  You can find a list of locations near you here.

Treatment for BPH

Keep in mind, there is no permanent cure for BPH, but treatment options are meant to lessen the symptoms caused by BPH to help improve your quality of life. Your doctor may suggest lifestyle modifications, medication, or surgical options depending on the details of the individual case.

Lifestyle changes are typically recommended as the first option, especially in mild cases of BPH. Typical lifestyle changes that doctors recommend to help control BPH include:

  • Limiting intake of caffeine and alcohol
  • Exercises to strengthen pelvic floor muscles
  • Eating more fiber to help prevent constipation (which may worsen symptoms)
  • Diet and exercise to help reach and maintain a healthy weight
  • Limiting the consumption of fats and spicy foods

In moderate cases of BPH and cases in which lifestyle changes are not effective, a urologist may elect to prescribe medication.  Medication may be used to relax prostate and bladder muscles to relieve symptoms, shrink the prostate and prevent additional growth, or increase flow rate.

Beyond medication, there are minimally invasive procedures as well as surgical options to help with BPH. Minimally invasive procedures are preferred as they typically result in quicker recovery times and a less painful recovery.  In some situations, traditional surgical options are necessary based on the severity of the case and desired outcome.

For any treatment path, it is important to consult your urologist, discuss your options, and work together to determine the best treatment plan.

For More Information

You can learn more about men’s health services at New Jersey Urology through the link below.  If you would like to find a urologist near you or schedule an appointment, you can use the contact form on our contact us page or view our locations.


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 warning signs.

While bladder cancer isn’t one of the most common cancers in women, about 18,000 women are diagnosed with bladder cancer every year in the United States (Source: CDC – Bladder Cancer)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.

Facts About Bladder Cancer in Women

While bladder cancer typically hasn’t been associated with women, it is important to understand the unique way that bladder cancer does affect women, and why it’s critical that bladder cancer isn’t overlooked.

  • Approximately 50% of cases are diagnosed while the cancer is still in the bladder. However, that percentage is lower in women, because symptoms are often overlooked.
  • Women have a 1 in 89 chance of developing bladder cancer in their lifetime (Source: American Cancer Society – Key Statistics for Bladder Cancer). However, bladder cancer in women is on the rise.
  • Approximately 90% of bladder cancer cases are in individuals over 55 years old, so it is important to be extra vigilant of early signs of bladder cancer as you age.
  • Bladder cancer has a high recurrence rate. If you have been diagnosed with bladder cancer, it is important to continue to receive regular exams in order to handle any potential recurrence.

Early Signs of Bladder Cancer in Women

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 (hematuria). This is the most common early symptom of bladder cancer and typically the first sign of bladder cancer that is seen. 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. If you are unsure if there is an issue, your best bet is to consult a urologist
  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 noticed 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. Postmenopausal uterine bleeding. Any blood or spotting that you notice after menopause could be a symptom of bladder cancer or some other underlying issue. Similarly to blood in the urine, it may be easy to overlook, but it is recommended that you see your urologist to be safe.

Risk Factors of Bladder Cancer

By far, smoking is the biggest risk factor to be concerned about when it comes to bladder cancer. According to the National Institutes of Health, about 50% of women diagnosed with bladder cancer are smokers. Because the rate of occurrence is so much higher for smokers, if you notice any of the above symptoms and you smoke, let your doctor know as soon as possible.

Another major risk factor is previously having bladder cancer.  Bladder cancer has a 50-80% recurrence rate, which is among the highest of any form of cancer. This is why it is imperative to continue to see your physician and be on the lookout for any symptoms of bladder cancer if you’ve had it before.  When in doubt, get it checked out.

Age is another major factor. The average age of diagnosis in women is 73. Any woman over the age of 55 years old should keep an extra eye out for symptoms.

When to Make an Appointment with Your Urologist

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 become 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.

If you would like to talk to a urologist, you can see if we have a location near you or you can contact us to ask a question or make an appointment.

Written by Dr. Paul Littman


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