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?

Excluding skin cancer, prostate cancer is the most common cancer in men (1 in 7 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


6 Ways to Reduce Your Risk of Prostate Cancer

Wouldn’t it be wonderful if we could prevent prostate cancer? Unfortunately, we’re not there yet—but we do have an understanding of what measures can be taken to help reduce your risk of developing prostate cancer.

Precancerous lesions are commonly seen on prostate biopsy many years before the onset of prostate cancer. We also know that there’s an increased prevalence of prostate cancer with aging. These facts suggest that the process of developing prostate cancer takes place over a long period of time—often more than a decade—from the initial prostate cell mutation to the time when prostate cancer manifests with either a PSA elevation, an acceleration in PSA, or an abnormal digital rectal examination. This means that there’s an opportunity for intervention before prostate cancer is established.

Here are six ways to reduce your risk of prostate cancer (and reduce risk of progression for men on active surveillance):

  1. Maintain a healthy weight, since obesity has been correlated with an increased prostate cancer incidence.
  2. “Eat food. Not too much. Mostly plants.” The smart advice from Michael Pollan. A healthy diet consists of abundant fruits and vegetables (full of antioxidants, vitamins, minerals and fiber) and real food, as opposed to processed and refined foods. Eat plenty of red vegetables and fruits including tomato products (rich in lycopene). Legumes (beans, nuts, peas, lentils, etc.) have an anti-inflammatory effect. Consume animal fats and dairy in moderation. Eat fatty fish containing omega-3 fatty acids such as salmon, tuna, sardines, trout and mackerel.
  3. Avoid tobacco and excessive alcohol intake.
  4. Staying active and exercising on a regular basis can reduce your risk for prostate cancer. If you do develop prostate cancer, you will be in tip-top physical shape and will heal that much better from any intervention necessary to treat the prostate cancer.
  5. Get checked out! Be proactive by seeing your doctor annually for a digital rectal exam of the prostate and a PSA blood test. Abnormal findings on these screening tests are what prompt prostate biopsies, the definitive means of diagnosing prostate cancer. The most common scenario that leads to a diagnosis of prostate cancer is a PSA acceleration, an elevation above the expected incremental annual PSA rise based upon the aging process.

It’s important to mention that 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 you can be falsely lulled into the impression that your PSA is normal.  For example, if your PSA is 1.0 and a year later it is 3.0, it is still considered a “normal” PSA even though it has tripled (highly suspicious for a problem) and mandates further investigation.

A healthy lifestyle, including a wholesome and nutritious diet, maintaining proper weight, exercising regularly and avoiding tobacco and excessive alcohol can lessen one’s risk of all chronic diseases, including prostate cancer. Be proactive by getting a 15-second digital exam of the prostate and PSA blood test annually. Prevention and early detection are key to maintaining both quantity and quality of life.

Written by Dr. Andrew Siegel


Prostate Cancer: Risk Factors and Treatment Options

After a prostate cancer diagnosis, there can be a lot of information to take in. The path you and your doctor decide to take for treatment depends on certain factors including the stage of the cancer, your age, and your prostate-specific antigen (PSA) test results, among others.

Risk Factors for Prostate Cancer

You may have a higher risk of developing prostate cancer if you:

  • Are over 65 years old
  • Have a family history of prostate cancer
  • Are African American

Treatment Options for Prostate Cancer

There may be more than one treatment necessary and recommended by your doctor. Common prostate cancer treatments include:

  • Radiation therapy – Radiation therapy is often used after surgery when the cancer hasn’t spread outside of the prostate. This treatment requires radioactive seeds to be placed inside the prostate gland and is often done when the cancer is found early.
  • Hormonal therapy – These types of treatments block the effect or creation of testosterone. Because prostate tumors need testosterone to grow, hormonal therapy can prevent further growth of the cancer. This treatment does not cure the cancer.
  • Medication – Medication is given to help the body’s immune system fight cancer.
  • Prostatectomy – A surgical procedure to remove the prostate and surrounding tissue.

Types of Prostatectomy

There are four main types of prostatectomy:

  • Retropubic Surgery – requires an incision below the belly button to remove the prostate gland, causing as little damage to the nerves and blood vessels as possible.
  • Perineal Surgery – a cut is made between the anus and base of the scrotum. This is a smaller incision than the retropubic technique, but it is harder to spare nerves or remove lymph nodes.
  • Laparoscopic Surgery is when the surgeon makes several small cuts and uses long tools and a video camera to see inside during the procedure.
  • Robotic-assisted da Vinci® Surgery – the da Vinci® surgical system can be used to perform a prostatectomy. This technology allows your surgeon to make several small incisions as opposed to one larger incision, and the surgeon has a 3D view inside your body. The robotic-assisted surgical device can bend and rotate more than the human hand for better precision and control during the procedure.

What to Expect After Adult Circumcision

What is a circumcision?

Circumcision is the surgical removal of the foreskin. The procedure takes about thirty minutes and is performed under general anesthesia. The entire foreskin is removed using an incision just behind the head of the penis. This leaves the head of the penis completely exposed. Local anesthesia will be used to relieve discomfort after the operation.

Why is circumcision performed?

Circumcision is usually performed on newborns for medical, social, or cultural purposes. According to the CDC, more than 58% of newborns in the United States are circumcised. However, people with an uncircumcised penis may choose to become circumcised later in life for many reasons, including:

  • Phimosis (tight foreskin cannot be retracted to expose head of penis)
  • Paraphimosis (retracted foreskin cannot be brought back to cover head of penis)
  • Balanitis (inflammation of head of penis)
  • Posthitis (inflammation of the foreskin—pronounced pos-THI-tis)
  • Cosmetic or personal reasons
  • Tearing of the penile skin when sexually active

Although circumcision is a simple procedure, it’s a larger surgery for adults than it is for newborns.

What can I expect afterwards?

You will be sent home with a compression dressing that can be removed in 48 hours. If it falls off sooner than that it’s not a problem. Absorbable stitches are used that do not require removal. After the dressing is removed, petroleum jelly can be applied to the stitch line to prevent the penis from sticking to your underwear.

You will likely experience pain for a few days that can be managed with analgesics that will be prescribed. Anti-inflammatories such as Advil and Ibuprofen are preferred to the narcotics as they are equally effective and have less side effects. You should not drive a car or operate machinery if you are using a narcotic for pain relief.

Activities need to be restricted for a few days. Sexual activity cannot be pursued for at least six weeks to allow full healing. You may experience pain with spontaneous erections.

When do I need to follow-up in the office?

You will need to be checked back in the office a week or two after the circumcision, and at the six-week point.

Written by Dr. Andrew Siegel


What to Expect: Botox Injection for Overactive Bladder (OAB)

You’ve probably heard of Botox being used to improve the cosmetic appearance of facial wrinkles. However, botox has many medical uses that go beyond improving one’s appearance. For example, botox is commonly used to improve internal body functions. In the field of urology, it can be injected into the bladder muscle to improve symptoms of overactive bladder (OAB).

What is botox?

Botox is derived from the most poisonous substance known to man—botulinum toxin. This neurotoxin is produced by the Clostridium bacterium, responsible for botulism. Botulism is a rare but serious illness that can result in paralysis. Botulinum toxinwhen used in minute quantities in a derivative known as botox, is a magically effective and powerful potion.

How does botox work?

Botox is a neuromuscular blocking agent that weakens or paralyzes muscles. Beyond cosmetics, it can be beneficial for a variety of medical conditions that have some form of localized muscle overactivity. Botox is generally used to improve conditions with muscle spasticity, involuntary muscle contractions, excessive sweating and eyelid or eye muscle spasm.

Botox to treat Overactive Bladder (OAB)

Overactive Bladder (OAB) syndrome can be described by the symptoms of urinary urgency (the sudden desire to urinate), with or without urgency incontinence (urinary leakage associated with urgency). It’s usually accompanied by frequent urination during both day and night hours. OAB has been described as the “bladder squeezing without your permission to do so.”

When botox is injected into the bladder muscle, it treats the thick muscle bands, known as trabeculation. These are typically present in conditions that cause obstruction to the outflow of urine or bladder overactivity. By temporarily paralyzing a portion of the bladder muscle, OAB symptoms can improve dramatically.

The goal of botox in the bladder is to effectively treat persistent and disabling urinary urgency, frequency and urgency incontinence. Botox can be used to treat OAB for both males and females. It’s usually a plan B treatment for those who haven’t responded well or have been intolerant to bladder relaxant medications. Botox is FDA approved in the USA in a 100-unit-dose for OAB and 200-unit-dose for OAB associated with neurological conditions.

What to expect during a bladder botox injection

Bladder botox injection is a brief office procedure usually done under light sedation. It involves placing a cystoscope into the bladder and injecting botox into numerous sites in the bladder via a needle that fits through the cystoscope. The entire procedure takes about 10 minutes.

How to prepare for your bladder botox injection, and what to expect after the procedure:

  1. Stop blood thinner medications one week before botox injection
  2. Start antibiotics 2 days before and continue for 2 days after
  3. You may experience blood-tinged urine, burning with urination and pelvic pain for a day or so after the procedure.
  4. You may experience difficulty urinating and feel that you are not emptying completely. If so, you may require a catheter or learn how to temporarily do self-catheterization.
  5. It may take 1 -2 weeks to notice improvement. Although botox is highly effective, it’s not so in everyone.
  6. A follow up appointment with urinalysis and check of the post-void residual volume (how much urine is left in the bladder after voiding) will be scheduled for two weeks.
  7. Botox should last 6-9 months or so. After the improvement wears off, the injection can be repeated. If ineffective or only partially effective, the botox dosage can be increased.

Visit our locations page to find a urologist near you.

Written by Dr. Andrew Siegel


6 Reflexes That are Vital to Your Pelvic Health

12 Aug 2019 Blog

A reflex is an automatic response to a stimulus, an action that occurs without conscious thought. Many of us are familiar with the knee jerk reflex, in which the knee straightens as a result of the quadriceps muscle contracting in response to the tendon of our kneecap being tapped with a reflex hammer.

Here are six reflexes that you probably aren’t aware of, but are vital to your urinary and sexual health:

  1.  Guarding Reflex. The sphincter muscles guard the entrance to the urinary bladder. The voluntary sphincter muscle—the one that you have control of and are capable of contracting at will—is largely composed of the deep pelvic floor muscles (PFMs). The deep PFMs are your friends, helping you store urine while the bladder fills up. Even when you are not actively squeezing the PFMs, they have a baseline tone, working to provide resistance that keeps you from leaking urine as the bladder becomes fuller. They only relax completely when you urinate. The guarding reflex is the increase in the contraction strength of these “guarding” PFMs as the bladder gets fuller and fuller, with stronger PFM tone as the volume of urine in the urinary bladder increases.
  2. Cough Reflex. This reflex increases the contraction of the PFMs when you cough—above and beyond their resting tone—preventing you from leaking urine. This is nature’s way of protecting you from leaking urine when there is a sudden increase in your abdominal pressure, as occurs with a cough. This protects against cough-related stress urinary incontinence.
  3. Pelvic Floor Muscle-Bladder Reflex (PFM-BR). The PFM-BR is a unique reflex that you are capable of engaging voluntarily, resulting in the relaxation of a muscle as opposed to its contraction.  Anyone who has ever experienced an urgent desire to urinate or move their bowels will find it of great practical use. When the reflex is deployed, it will result in relaxation of both the urinary bladder and rectum and a quieting of the urgency. It works when you feel the sudden and urgent desire to urinate—pulse the pelvic floor muscles (PFMs) five times—brief but intense contractions.  When the PFMs are so deployed, the bladder muscle reflexively relaxes and the feeling of intense urgency disappears. Likewise, when the PFMs are deployed, the rectum relaxes and the feeling of intense bowel urgency should diminish. This reflex is a keeper when you are stuck in traffic and have no access to a toilet!
  4. BulboCavernosus Reflex (BCR). The BCR is a contraction of the bulbocavernosus and its mates, the ischiocavernosus (IC) muscles when the glans (head) of the penis in a male or the clitoris in a female is squeezed. This reflex is important for maintaining erectile rigidity, since with each contraction of the BC and IC muscles there is a surge of blood flow to the penis/clitoris, maintaining the high blood pressures within the erectile chambers necessary for engorgement of these organs. Sexual stimulation can be thought of as a chain of linked BCRs.
  5. Double reflex. Did you ever experience an urgent desire to urinate and find relief by squeezing the head of the penis?  If so, you have discovered the linkage of two reflexes—the BCR coupled with the PF-MBR. Here’s what happens: A strong urge to urinate occurs and is managed by squeezing the head of the penis, which makes the urgency dissipate. What’s actually happening is that the squeeze of the penis triggers a PFM contraction via the BCR. In turn, the PFM contraction relaxes the bladder muscle via the PFM-BR and makes the urgency either improve or disappear. Reflex magic!
  6. Cremasteric reflex. The cremaster muscle surrounds the spermatic cord (the cord-like structure that contains the testicular blood supply, nerves, etc.). The cremasteric reflex occurs when the inner thigh is stroked and the testicle pulls up towards the groin via a contraction of the cremaster muscle. This is a brisk reflex in boys and tends to become less active with aging. It is a natural protective reflex that helps us avoid testicular injury when danger approaches, like a turtle pulling its head into its protective shell.

The reflexes described above are vital to your sexual and urinary health. Being aware of them, and knowing how to tap into them can be used to your advantage!

Written by Dr. Andrew Siegel 

Is Active Surveillance the Best Treatment for My Prostate Cancer?

5 Aug 2019 Blog

Prostate cancer is the second leading cause of cancer death in men. There are 240,000 new prostate cancer cases diagnosed annually, and it accounts for 30,000 deaths per year. However, unlike many other cancers, prostate cancer is often not a fatal disease and may never need to be treated.

Patients with slow-growing, early stage prostate cancer as well as older men with other health issues may be put on active surveillance, also known as watchful waiting, as opposed to traditional treatment with surgery or radiation.

The problem is that not all prostate cancer cases are slow-growing and early stage. The challenge is predicting the future behavior of the cancer so it can be treated appropriately – offering cure to those with aggressive cancer, but sparing the side effects of treatment in those who have non-aggressive cancer.

What is active surveillance?

About 1 in 6 men will be diagnosed with prostate cancer during his lifetime, yet only 1 in 40 men will die from it. These statistics point out that many men with prostate cancer have a slow growing cancer. Because of this fact, an alternative strategy to aggressive management of prostate cancer is active surveillance, which includes careful follow-up with strict monitoring and immediate intervention should signs of progression develop.

The goal of active surveillance is to allow men with low risk prostate cancer to avoid radical treatment with its associated morbidity and/or delay definitive treatment until signs of progression occur. This involves two things:

  1. Vigilant monitoring
  2. A compliant patient who is compulsive about follow-up

Which patients are good candidates for active surveillance?

Being a candidate for this approach is based upon the results of the PSA blood test, findings on the digital rectal exam, and the details of the prostate biopsy. General eligibility criteria for active surveillance include all of the following:

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

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

Note that these are basic guidelines and need to be modified in accordance with patient age and general health— certainly if one has a life expectancy of less than 10 years, he would be a good candidate for active surveillance, regardless of the above.

How is prostate cancer grade determined?

Prostate cancer grade is often the most reliable indicator of the potential for growth and spread. The Gleason Score provides one of the best guides to the prognosis and treatment of prostate cancer and is based on a pathologist’s microscopic examination of prostate tissue. This score can predict the aggressiveness and behavior of the cancer.

To determine a Gleason Score, a pathologist assigns a separate numerical grade to the two most predominant architectural patterns of the cancer cells. The numbers range from 1 (the cells look nearly normal) to 5 (the cells have the most cancerous appearance). The sum of the two grades is the Gleason Score. The lowest possible score is 2, which rarely occurs; the highest is 10. High scores tend to suggest a worse prognosis than lower scores because the more deranged and mutated cells usually grow faster than more normal-appearing ones.

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

What is involved in active surveillance?

The active surveillance monitoring schedule is typically:

  • PSA and DRE every 3-6 months for several years, then annually
  • Prostate biopsies: once a year after initial diagnosis, then periodically until age 80 (this depends on the patient)

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

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

Written by Dr. Andrew Siegel

How Much Water Do You Really Need To Drink?

29 Jul 2019 Blog

Many sources of information say that humans need 8-12 glasses of water daily to stay hydrated and thrive. Some people take that rule literally and end up in a urologist’s office complaining of urinary urgency, frequency and leakage. Clearly, the 8-12 rule is not appropriate for everyone!

Why do humans need so much water?

Water is a vitally important part of our bodies that promotes optimal organ and cellular function. It also regulates temperature, transports nutrients and waste, provides joint lubrication, and facilitates thousands of chemical reactions that occur within our bodies.

More than half (60%) of our body weight is water. Two-thirds of which is within our cells, and one-third of which is in the blood and tissues between cells. For a 165-lb. man, that translates to 100 lb. of water weight. For a 125-lb. woman, that translates to 75 lb. of water weight.

Water intake comes from beverages AND food.

Many foods have a high water content and can be a significant source of water intake. In general, the healthier the diet (the more the fruit and veggie intake) the higher amount of dietary water. For example, melons, citrus fruit, peaches, strawberries and raspberries are about 90% water, with most fruits over 80% water. The same is true for vegetables, with lettuce, tomatoes, cucumbers, celery, radishes and zucchini comprised of about 95% of water, with most veggies over 85% water.

Our body needs water “equilibrium,” with water intake balancing water losses. Most people need a total of 65-80 ounces daily, although this can vary greatly depending upon one’s size, the ambient temperature and level of physical activity. Water losses are both “sensible,” consisting of water in the urine and stool, and “insensible,” from skin (evaporation and sweating) and lungs (moisture exhaled).

Again, water intake comes from beverages and foods consumed, with many foods containing a great deal of water (particularly fruits and vegetables, as mentioned). So the 65-80 ounces includes both beverage and food sources.

However, caffeinated beverages (such as coffee, tea, colas, energy and sports drinks and other sodas) as well as alcohol both have diuretic effects, causing you to urinate more volume than you take in. So, if you consume caffeine or alcohol, you will need additional hydration to maintain equilibrium.

How much water do I really need?

The formula that doctors use for figuring out daily fluid requirements is 1500 cc (50 ounces) for the first 20 kg (44 lb.) of weight, and an additional 200 cc (7 ounces) for each additional 10 kg (22 lb.) of weight.

So for a 125-lb. woman, the daily fluid requirement is 2250 cc (75 ounces). For a 165 lb. man, the daily requirement is 2600 cc (87 ounces). It’s important to remember that these fluid requirements include both beverages and food. If one has a very healthy diet with lots of fruits and vegetables, there will be less need for drinking water and other beverages.

The other important factors with respect to water needs are ambient temperature and activity level. If you are reading or doing other sedentary activities in a cool room, your water requirements are significantly less than someone exercising vigorously in 90-degree temperatures.

How will I know if I’m well-hydrated?

Humans are extraordinarily sophisticated and well-engineered “machines.” Your body lets you know when you are hungry, ill, tired and thirsty. Paying attention to your thirst is one of the best ways of maintaining good hydration status.

Another great method is to pay attention to your urine color. Depending on your 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.

Advantages of staying well-hydrated include:

  • Avoids dehydration and all its consequences (this is pretty obvious)
  • Dilution of urine helps prevent kidney stones
  • Dilution of urine helps prevent urinary infections
  • Helps bowel regularity
  • Maintains hydrated and supple, less wrinkled skin
  • Helps keep weight down because of the filling effect of drinking; also, thirst can be confused with hunger and some people end up eating when they should be hydrating

The only disadvantage to staying well-hydrated is that you may urinate a lot, which is not good for those with overactive bladder symptoms.

Written by Dr. Andrew Siegel

Nocturia: 7 Ways to Improve Frequent Nighttime Urination

22 Jul 2019 Blog

Nocturia is the medical term for the need to awaken from sleep to urinate. Getting up once to relieve your bladder during sleep hours is usually not particularly troublesome. However, when it happens two or more times it can negatively impact one’s quality of life because of sleep disruption, leading to an increased risk of fall-related nighttime injuries, daytime fatigue and an increased risk of fatigue-related accidents.

How many times is normal to urinate at night?

Not everyone is the same, and there are factors that determine what is “normal” for most people. For example, nighttime urination is more common if you have something to drink right before bed, and is also more common in older adults. Most people without nocturia can sleep for 6 to 8 hours without having to urinate, but getting up to go to the bathroom once during the night is still within the realm of normal. If you have to use the restroom two or more times per night, it is a good idea to talk to your urologist about nocturia.

What causes nocturia?

Nocturia correlates with aging and the associated decline in kidney function and decreased ability to concentrate urine. Although having an enlarged prostate may contribute to nocturia, it’s much more complicated than that since women do not have prostates and nocturia is equally prevalent in men and women.

Nocturia is based on multiple factors that require careful evaluation in order to sort out and treat appropriately. As a urologist, my goal is to distinguish between urological and non-urological causes for nighttime urinating. It often comes down to one of three factors:

  1. Nighttime urine production by the kidneys
  2. Urinary bladder capacity
  3. Sleep status.

In the elderly population, excessive nighttime urine production is a factor almost 90% of the time.
Nocturia can be classified into 5 categories:

  • Global polyuria (making too much urine, day and night)
  • Nocturnal polyuria (making too much urine at night)
  • Sleep disorders
  • Reduced bladder capacity
  • Overactive bladder

Global polyuria can result from excessive fluid intake or from dehydration from poorly controlled diabetes mellitus. The pituitary gland produces an important hormone responsible for water regulation — ADH (anti-diuretic hormone) — and it works by giving the message to the kidneys to concentrate urine. Diabetes insipidus is a disease of either kidney origin in which the kidneys do not respond to ADH, or pituitary origin in which there is deficient secretion of ADH. In either case, lots of urine will be made, resulting in frequent urination, both daytime and nighttime. Medications including diuretics, SSRIs (selective serotonin reuptake inhibitors), calcium blockers, tetracycline and lithium may induce global polyuria.

Nocturnal polyuria may be on the basis of excessive fluid intake, especially diuretic beverages including caffeine and alcohol. It may also occur because of a nocturnal defect in the secretion of ADH or an unresponsiveness of the kidneys to the action of ADH. Congestive heart failure, sleep apnea and kidney insufficiency also may play a contributory role. Certain conditions result in accumulation of fluids in the tissues of the body, particularly the legs (peripheral edema); when lying down to sleep, the fluid is no longer under the same pressures as determined by gravity, and returns to the intravascular (within the blood vessels) compartment. It is then subject to being released from the kidneys as urine. Such conditions include heart, kidney and liver impairment, nephrotic syndrome, malnutrition and venous stasis.

Primary sleep disorders may also cause nocturia, including insomnia, restless leg syndrome, narcolepsy, and arousal disorders (sleepwalking, nightmares, etc.).

Reduced bladder capacity may be caused by numerous urological issues. Many processes can occur within the bladder that can irritate its delicate lining, causing a reduced “functional” capacity: bladder infections, bladder stones, bladder cancer, bacterial cystitis, radiation cystitis, and interstitial cystitis.

An overactive bladder—a bladder that “squeezes without its owner’s permission”—can give rise to nocturia. Some people have small “anatomical” bladder capacities on the basis of scarring, radiation, or other forms of damage. Prostate enlargement commonly gives rise to nocturia, as can many neurological diseases that often have profound effects on bladder function. Incomplete bladder emptying can give rise to frequent urination since the bladder is already starting out with the bias of being partially filled. Incomplete emptying is often seen with prostate enlargement, scar tissue in the urethra, neurologic issues, and bladder prolapse.

How is nocturia diagnosed?

The key diagnostic tool for nocturia is the frequency-volume chart (FVC), a simple test that can effectively guide diagnosis and treatment. This is a 24-hour record of the time of urination and volume of urination, requiring a clock, pencil, paper and measuring cup. Typical bladder capacity is 10–12 ounces with 4–6 urinations per day.

How is nocturia treated?

Nocturia is treated on a case-by-case basis under the direction of a physician. This treatment may contain lifestyle modifications, medication, or both.

Lifestyle modifications to improve nocturia include:

  1. Preemptive voiding before bedtime – Ensuring that there is as little urine in your bladder as possible right before bed can help eliminate the need to get up to urinate at night.
  2. Intentional nocturnal and late afternoon dehydration – Ensure that you are consuming enough fluids during the day, but limit them in the 2-4 hours before you go to bed.
  3. Salt restriction – In patients with a high salt intake, a reduction in salt has been clinically shown to reduce instances of nighttime urination (source)
  4. Dietary restriction of caffeine and alcohol – Caffeine increases bladder activity and therefore can cause nighttime urination, especially if consumed later in the day (note that even decaf coffee and tea do contain some caffeine). Alcohol can function as a bladder irritant and should be avoided as well.
  5. Adjustment of medication timing – Different medications, especially diuretic medications, can impact nighttime urine production. Note that it is extremely important to consult with your doctor before making any changes to your medication.
  6. Use of compression stockings with afternoon and evening leg elevation – Elevating the legs and use of compression stockings helps to prevent fluid build-up in the legs. This ensures the fluids are properly distributed throughout the bloodstream and helps reduce the need to urinate.
  7. Sleep medications – Sleep medications may be a part of lifestyle modification plan developed by your physician in order to maintain healthy sleep patterns when it is determined that there are no other potential harmful underlying conditions and sleeping through signals to urinate would not cause any additional issues.

Nocturia Medication

Urological issues may need to be managed with medications that vary based on the underlying causes of the condition. Medications that relax or shrink the prostate are typically used when the issue is prostate obstruction. In the instance of an overactive bladder, bladder relaxants may be of help. For nocturnal polyuria, synthetic ADH can be highly effective.

Questions Your Doctor Will Ask

If you decide to make an appointment to consult your urologist regarding nocturia, the doctor will likely have multiple questions for you in order to properly diagnose. Having the answers to the following questions ready will help you and your doctor quickly develop the right treatment plan:

  1. How many times do you wake up at night to urinate?
  2. When did your symptoms first start?
  3. What medications are you currently taking?
  4. How much is your bladder actually storing during the day and at night (is there a large or small amount of urine)?
  5. Are you typically a good sleeper?
  6. How much caffeine or alcohol do you drink each day? When?
  7. Has your diet changed recently?

The more detail you have, the more helpful it is for the physician in making a diagnosis and finding the root cause of the issue.

Bottom Line: Nocturia should be investigated to determine its cause, which may often be related to conditions other than urinary tract issues. Nighttime urination is not only bothersome, but may also pose real health risks. Chronically disturbed sleep can lead to a host of collateral wellness issues.

If you are routinely waking up at night to urinate, especially if it is happening more than once per night, we recommend setting up an appointment with your urologist. To set up an appointment with one of our physicians or to see a list of our locations, please contact us.

Written by Dr. Andrew Siegel

How to Naturally Boost Your Testosterone Levels

15 Jul 2019 Blog

Testosterone has become a very in-vogue term. Many patients come into the office specifically asking for their testosterone levels to be checked.  The pharma industry has aggressively pursued direct-to-consumer advertising of testosterone replacement products, which has promoted a grass-roots awareness of testosterone issues, a topic that was previously the domain of urologists and endocrinologists.

So what is testosterone?

Testosterone (or T) is that all-important male hormone that goes way beyond male sexuality and is now regarded as a key factor in men’s health. Aside from contributing to libido, masculinity and sexual function, T is responsible for the physical changes that begin at puberty, including pubic, underarm and facial hair, deepening voice, prominent Adam’s apple and increased bone and muscle mass. Additionally, T contributes to your mood, bone and muscle strength, red blood cell count, energy, and general mojo.

What are the symptoms of low testosterone?

Most testosterone is manufactured in the testicles, although a small percentage is made by the adrenal glands.  There is a gradual decline in T that occurs with the aging process—approximately a 1% decline each year after age 30. This will occur in most men, but will not always be symptomatic. 40% of American men aged 45 or older have low or low range T.

Low T is associated with diabetes, bone mineral loss, and altered sexual function. Specifically, symptoms of low T may include one or more of the following:

  • fatigue
  • irritability
  • depression
  • decreased libido
  • erectile dysfunction
  • impaired orgasmic function
  • decreased energy and sense of well being
  • loss of muscle and bone mass
  • increased body fat
  • abnormal lipid profiles.

How obesity and lifestyle choices can affect testosterone levels

Obesity plays a pivotal role in the process leading to low T. Fat is not just fat—it is a metabolically active endocrine organ that does way more than just protrude from your abdomen. Fat has an abundance of the hormone aromatase, which functions to convert testosterone to the female sex hormone estrogen. The consequence of too much conversion of testosterone to estrogen is the potential for gynecomastia, (a.k.a. man boobs). Too much estrogen slows testosterone production, and with less testosterone, more abdominal obesity occurs and even more estrogen is made, a vicious cycle of emasculation.

The good news is that by losing abdominal fat, the unfortunate consequences of low T can often be reversed.

How to naturally boost your testosterone levels

  • A healthy lifestyle, including good eating habits, maintaining a healthy weight, engaging in exercise, obtaining adequate sleep, moderation with respect to alcohol intake, avoiding tobacco, and stress reduction are the initial approaches to treating low T. Insufficient sleep can lower T, and excessive alcohol increases the conversion of testosterone to estrogen. Maintaining an active sex life can help maintain T.
  • Lose the abdominal fat, with the caveat that a sufficient caloric intake of quality food and nutrients is necessary to prevent the body going into “starvation mode,” which can substantially decrease T production.
  • In terms of exercise, a healthy balance of aerobic, resistance, and core training is best. In particular, vigorous resistance exercise is crucial. This will help the flabby abdomen disappear and build lean muscle mass, which in turn will increase your metabolic rate.

Other treatment options for low testosterone

If lifestyle modifications fail to improve the symptoms of low T and levels remain measurably low via a simple blood test, a trial of T replacement under the supervision of your doctor can provide a meaningful improvement of your quality of life.

Written by Dr. Andrew Siegel

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