Prostate cancer is a significant health-care problem in the United States due to its high incidence. It is the most common cancer in men affecting approximately 189,000 American men each year with approximately 32,000 of these men dying each year. Prostate cancer is different from most cancers in that a large percentage of men may have a silent form of this cancer – it does not cause symptoms or progress beyond the prostate gland. Sometimes this cancer can be small, slow growing and present limited risk to the patient. Clinically important prostate cancers can be defined as those that threaten the well-being or life span of a man.

What are the causes and risks associated with prostate cancer?

What causes prostate cancer is a subject of intensive research. It is likely that prostate cancer occurs due to many reasons. Predominately a disease of elderly men, the diagnosis of prostate cancer is rare before age 40 but increases dramatically thereafter. In the United States , it is estimated that one in 55 men between the ages of 40 and 59 will develop prostate cancer. This incidence climbs almost to one in seven for men between ages 60 and 79. This association is also reflected in mortality as prostate cancer accounts for 10.8 percent of cancer-related deaths in men between the ages of 60 and 79 and 24.6 percent in those over the age of 80.

Worldwide, prostate cancer ranks third in cancer incidence and sixth in cancer mortality among men. There is, however, a notable variability in incidence and mortality among world regions. The incidence is low in Japan and intermediate in regions of Central America and Western Africa . The incidence is higher in North America and Northern Europe . Although some of these differences may be accounted for by differences in screening for prostate cancer and the risk of other diseases among world regions, it is likely that they can be accounted for, in part, by genetic predisposition as well as diet.

There are also ethnic determinants of risk. Blacks are in the highest risk group, with an incidence of 224.3 cases per 100,000 black men. The incidence in Caucasian and Asian men is considerably lower at 150.3 and 82.2 (per 100,000), respectively. In addition, blacks tend to present with more advanced disease and have poorer overall prognosis than Caucasian or Asian men.

Men with a family history of prostate cancer are at an increased risk of developing the disease. The risk correlates with the number of first-degree relatives (father, brother or uncle) affected by prostate cancer and the age at onset. Men with a family history of disease may have a risk of developing prostate cancer two to 11 times greater than men without a family history of prostate cancer.

There is also considerable evidence showing that prostate cancer is more common in men with a high intake of fat in their diets. The worldwide difference in prostate cancer incidence may be associated with dietary intake of soy proteins. In Asian countries such as Japan and the Republic of Korea where prostate cancer incidence and mortality are just a fraction of that in North America, soy consumption in the form of tofu, soy milk and miso is up to 90 times higher than that consumed in the United States. In a study of more than 40 nations, researchers found soy, on a per calorie basis, to be the most protective dietary factor. This protective role may be associated with two of soy’s components, genistein and daidzein that may act as weak estrogens. Estrogens are female hormones that inhibit prostate cancer growth. Some experts have suggested that the worldwide differences in prostate cancer incidence may also be explained by the high intake of green tea by residents of Asia.

The intake of other certain dietary factors may also reduce the risk of developing prostate cancer. Such substances include lycopene, selenium and vitamin E. Cooked tomatoes are rich sources of the carotenoid lycopene. Lycopenes are antioxidants that may protect cells from becoming cancerous. Several studies have shown that the likelihood of developing prostate cancer is reduced by high intake of lycopene. Researchers found that men ingesting two or more servings of tomato sauce per week had a 36 percent reduction in cancer risk compared to those who did not. Selenium intake has also been reported to lower prostate cancer risk. In a clinical trial designed to determine if selenium could lower skin cancer recurrences, men who took selenium had a 63 percent reduction in prostate cancer incidence compared to those who took a sugar pill (placebo). Attention has also focused on vitamin D’s effect on the prostate. Epidemiologic evidence shows an inverse relationship between prostate cancer risk and ultraviolet radiation, the primary source for vitamin D production. This observation has led some to suggest that higher rates of prostate cancer in the elderly may be partly due to decreased sun exposure or a decline in the body’s ability to make vitamin D with aging.

Finally, the correlation of vasectomy and prostate cancer risk remains controversial. Although some studies have suggested that men who have undergone a vasectomy are at an increased risk of developing prostate cancer, many other studies have failed to show such a correlation.

What are the symptoms of prostate cancer?

In its early stages, prostate cancer often causes no symptoms. When symptoms do occur, they may include any of the following: dull pain in the lower pelvic area; frequent urination; problems with urination such as the inability, pain, burning, weakened urine flow; blood in the urine or semen; painful ejaculation; general pain in the lower back, hips or upper thighs; loss of appetite and/or weight; and persistent bone pain.

How is prostate cancer diagnosed?

Currently, digital rectal examination (DRE) and PSA tests are used for prostate cancer detection. The age at which time screening for prostate cancer should begin is not known with certainty. However, most experts agree that healthy men over the age of 50 should consider prostate cancer screening with a DRE and PSA test. Screening should occur earlier, at age 45, in those who are at a higher risk of prostate cancer such as black men or those with a family history of prostate cancer.

DRE: Is performed with the man either bending over, lying on his side or with his knees drawn up to his chest on the examining table. The physician inserts a gloved finger into the rectum and examines the prostate gland, noting any abnormalities in size, contour or consistency. DRE is inexpensive, easy to perform and allows the physician to note other abnormalities such as blood in the stool, which might allow for the early detection of rectal or colon cancer. However, DRE is not the most effective way to catch an early cancer so it should be combined with a PSA test.

PSA test: Is usually performed in addition to DRE and increases the likelihood of prostate cancer detection. The test measures the level of PSA, a substance produced only by the prostate, in the bloodstream. Very little PSA escapes from a healthy prostate into the bloodstream, but certain prostatic conditions can cause larger amounts of PSA to leak into the blood. One possible cause of a high PSA level is benign (non-cancerous) enlargement of the prostate, otherwise known as BPH. Prostate cancer is another possible cause of an elevated PSA level. The frequency of PSA testing remains a matter of some debate. The American Urological Association (AUA) encourages men to have annual PSA testing starting at age 50. The AUA also recommends annual PSA testing for men over the age of 40 who are African-American or have a family history of the disease (for example, a father or brother who was diagnosed with prostate cancer). Some experts have suggested that men with an initial normal DRE and PSA level of less than 2.5 ng/ml can have PSA testing performed every two years. Recently, several refinements have been made in the PSA blood test in an attempt to determine more accurately who has prostate cancer and who has false-positive PSA elevations caused by other conditions like BPH. These refinements include PSA density, PSA velocity, PSA age-specific reference ranges and use of total-to-free PSA ratios. Such refinements may allow for improved increased ability to detect cancer.

Currently, it is recommended that both a DRE and PSA test be used for the early detection of prostate cancer. It is important to realize that in most cases an abnormality in either test is not due to cancer but to benign conditions, the most common being BPH. For instance, it has been shown that only 18 to 30 percent of men with serum PSA values between four and 10 ng/ml have prostate cancer. This number rises to approximately 42 to 70 percent for those men whose PSA values exceeding 10 ng/ml.

Biopsy: Prostate biopsy is best performed under transrectal ultrasound guidance using a spring-loaded biopsy device coupled to the transrectal probe, which is placed in the rectum. Patients are positioned on their side for this procedure. The physician will first image the prostate using ultrasound noting the prostate gland’s size and shape and whether or not any other abnormalities exist, the most common of which are shadows which might signify the presence of prostate cancer. However, not all prostate cancers are visible. Using the spring-loaded biopsy device attached to the ultrasound probe, the physician will perform multiple biopsies of the prostate gland. Generally, six to 14 biopsies will be performed. Recently, many investigators have shown that performing more than six biopsies, especially in certain regions of the prostate gland, will improve the ability to detect prostate cancer. Each biopsy will remove a cylinder of prostate tissue approximately 3/4 inch in length and 1/16 inch in width. The entire procedure will take 20 to 30 minutes. The biopsy tissue taken will then be examined by a pathologist (a physician who specializes in examining human tissue to determine whether it is normal or diseased). The pathologist will be able to confirm if cancer is present in the biopsy tissue. If cancer is present, the pathologist will also be able to grade the tumor. The grade indicates the tumor’s “aggression level” – how quickly it is likely to grow and spread. The most popular prostate cancer grading system is the Gleason score system and is designated between two and 10. Scores of two to four designate low aggressiveness, five to six mildly aggressive, seven moderately aggressive and scores of eight to 10 highly aggressive.

Although transrectal ultrasound guided prostate biopsy is usually very well tolerated, approximately 20 to 25 percent of those undergoing the procedure may find it painful. Injecting local anesthetics into the area before biopsy may minimize this discomfort. Blood in the ejaculate (hematospermia) and blood in the urine (hematuria) are common, occurring in approximately 40 to 50 percent of patients. High fever is rare, occurring in only 3 to 4 percent of patients. Antibiotics and enemas are usually given at the time of the procedure to prevent infection.

Why is prostate cancer staged?

Once prostate cancer has been diagnosed by a prostate biopsy, the physician seeks to stage the disease; that is, to determine the extent of the cancer (i.e., the “T” stage) and whether it has spread to the lymph nodes and/or the bones. The T stage is determined mainly by the DRE and can be divided into the following categories:

• T1: Doctor is unable to feel the tumor or see it with imaging (e.g., transrectal ultrasound)
• T1a: Cancer is found incidentally during a transurethral resection (TURP) for benign prostatic enlargement. Cancer is present in less than 5% of the tissue removed
• T1b: Cancer is found after TURP but is present in more than 5% of the tissue removed
• T1c: Cancer is found by needle biopsy that was done because of an elevated PSA
• T2: Doctor can feel the tumor when a digital rectal exam (DRE) is performed but the tumor still appears to be confined to the prostate
• T2a: Cancer is found in one half or less of only one side (left or right) of the prostate
• T2b: Cancer is found in more than half of only one side (left or right) of the prostate
• T2c: Cancer is found in both sides of the prostate
• T3: Cancer has begun to spread outside the prostate and may involve the seminal vesicles
• T3a: Cancer extends outside the prostate but not to the seminal vesicles
• T3b: Cancer has spread to the seminal vesicles
• T4: Cancer has spread to tissues next to the prostate (other than the seminal vesicles), such as the sphincter, rectum and/or wall of the pelvis

To determine if the cancer has spread to the lymph nodes or bones, the physician may order a CT scan of the pelvis or a bone scan. This is only done when the physician deems the cancer to be very serious.

Prostate cancer represents a spectrum of disease. Although some cancers may grow so slowly that treatment may not be needed, others can represent a threat to life. Determining the need for treatment can be a complex decision. Initially, the need for treatment should be based on the stage and grade of the cancer as well as the age and health of the patient. Many physicians have sought to devise risk assessment schemes that predict the likelihood of disease recurrence if patients are treated and progression or significant growth of their cancer if they undergo initial surveillance or watchful waiting. By combining many types of information (i.e., serum PSA level and cancer grade, stage and volume), patients can be advised of the aggressiveness of their cancer and the need for and types of treatment available. Certain imaging tests, such as a radionuclide bone scan, CT scan or MRI, may need to be done to better assess whether the cancer is still confined to the prostate or has spread elsewhere in the body. When prostate cancer spreads (metastasizes) it is usually to the lymph nodes or bones. Not all men with prostate cancer need to undergo imaging tests as the risk of spread to other organs can be estimated on the basis of serum PSA levels and cancer grade. It is reasonable to omit the bone scan in patients with newly diagnosed, untreated prostate cancer, who have no symptoms from their cancer and have serum PSA concentrations less than 20 ng/ml and certainly in those with serum PSA concentrations less than15 ng/ml. Similarly, a pelvic CT scan or MRI may not be necessary in men with lower grade cancers, cancers still confined to the prostate and serum PSA values less than 25 ng/ml.

Frequently Asked Questions:

• Can prostate cancer be prevented?

  No. However, you can take measures to reduce the risk by maintaining your health in general – healthy diet, being physically active and visiting the doctor on a regular basis. Clinical studies are ongoing which are testing the ability of some agents like vitamin E and selenium to prevent prostate cancer.

• What is the outlook for prostate cancer?

  The number of men diagnosed with prostate cancer remains high. However, survival rates are improving. It is estimated that 89 percent of men diagnosed with the disease will survive at least five years, while 63 percent will survive 10 years or longer.

Where can I get more information?

• AUA Guidelines Patient Guides: Prostate Cancer Awareness for Men
• American Cancer Society
• CancerLinks
• National Cancer Institute
• National Comprehensive Cancer Network
• Agency for Healthcare Research Quality
• National Alliance of State Prostate Cancer Coalitions
• Men’s Health Network
• Prostate Cancer Foundation

Urinary incontinence is a very common problem affecting as many as 13 million people in the United States . Many of these people suffer in silence unnecessarily, since incontinence can be managed or treated. Discuss this condition with your urologist to find out what treatments are available to you.

What is urinary incontinence?

Urinary incontinence is the involuntary loss of urine and is not necessarily a part of aging. It is a common condition experienced by men and women of all ages.

What are the different types of urinary incontinence?

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  Incontinence / Overactive Bladder – Urological Health Topics – Tracy and Manteca

  Stress urinary incontinence: Stress incontinence is leakage that occurs when there is an increase in abdominal pressure caused by physical activities like coughing, laughing, sneezing, lifting, straining, getting out of a chair or bending over. The major risk factor for stress incontinence is damage to pelvic muscles that may occur during pregnancy and childbirth.

• Urge urinary incontinence: Also referred to as “overactive bladder,” this type of incontinence is usually accompanied by a sudden, strong urge to urinate and an inability to get to the toilet fast enough. Frequently, some patients with urge incontinence may leak urine with no warning. Risk factors for urge incontinence include aging, obstruction of urine flow, inconsistent emptying of the bladder and a diet high in bladder irritants (such as coffee, tea, colas, chocolate and acidic fruit juices).
• Mixed urinary incontinence: Mixed incontinence is a combination of urge and stress incontinence.
• Overflow urinary incontinence: Overflow incontinence occurs when the bladder does not empty properly and the amount of urine produced exceeds the capacity of the bladder. It is characterized by frequent urination and dribbling. Poor bladder emptying occurs if there is an obstruction to flow or if the bladder muscle cannot contract effectively.

What is minimally invasive management of urinary incontinence?

Some of the causes of incontinence are temporary and easily reversible. Reversible causes include urinary tract infection, vaginal infection or irritation, medication, constipation and restricted mobility. However, in some cases, further medical intervention is necessary. Minimally invasive treatment options are those treatments that do not involve surgery and should be the first line of treatment for patients. However, they may also be used in conjunction with surgical therapy.

• Fluid management: This option consists of instructing a patient to increase or reduce their fluid intake. Incontinent patients may need to reduce the amount of caffeine or other dietary irritants (such as acidic fruit juices, colas, coffee and tea), while at the same time increasing water intake to produce an adequate amount of non-irritating, non-concentrated urine. A recommended water intake is six to eight glasses per day.
• Bladder training: A diary is the starting point for bladder training. Patients are instructed to record fluid intake, urination times and when their urinary accidents occur. The diary allows the patient to see how often they actually urinate and when incontinence occurs. The diary is also used to set time intervals for urination. Patients who urinate infrequently are instructed to do “timed urination” where they urinate by the clock every one to two hours during waking hours. By achieving regular bladder emptying they should have fewer incontinent episodes. Timed urination may be effective in patients with both urge and stress incontinence.
• Bladder retraining: Bladder retraining is used for patients with urinary frequency. The goal of retraining is to increase the amount of urine that the patient can hold within their bladder. Patients are instructed to keep a diary to determine their urination interval. Patients are then instructed to gradually increase their urination interval by 15 to 30 minutes per week. The goal is to have patients urinating every two to four hours while awake with less urgency and less incontinence.
• Pelvic floor exercises: Also known as Kegel exercises, this type of minimally invasive treatment focuses on strengthening the external sphincter muscle and the pelvic muscles. Patients who are able to contract and relax their pelvic floor muscles can improve their strength by doing the exercises regularly. Other patients require help from a health-care professional to learn how to contract those muscles. Biofeedback and electrical stimulation can be used to aid patients in doing pelvic floor exercises. During electrical stimulation, a small amount of stimulation from a sensor placed in the vagina or rectum is delivered to the muscles of the pelvic floor. Like any exercise program, the patient must continue to do the exercises to maintain the benefit. Patients with stress incontinence benefit from pelvic floor exercises by increasing resistance at the urethra and by increasing the strength of the voluntary pelvic floor muscles. Patients can also be taught to compensate by contracting the pelvic muscles with certain activities like coughing.
   
  Pelvic floor muscle exercises are effective for urge incontinence, since a contraction of the pelvic floor can interrupt a contraction of the bladder smooth muscle and stop or delay an accident.
• Medicinal treatment: Stress incontinence may be treated with drugs that tighten the bladder neck, such as pseudoephedrine or imipramine. Just as pseudoephedrine causes constriction of the blood vessels in the nose, it also causes the muscles at the bladder neck to contract. Because of its effect on the smooth muscle in blood vessels, it should not be used in patients with a history of hypertension. Imipramine is a tricyclic antidepressant. In addition to causing the bladder muscle to relax, it also causes the smooth muscles at the bladder neck to contract. Urge incontinence is also treated with drugs that have anticholinergic properties. Anticholinergics allow for relaxation of the bladder smooth muscle. A commonly used anticholinergic is oxybutynin chloride. This drug works well to treat urge incontinence but has side effects including dry mouth, confusion, constipation, blurred vision and an inability to urinate. New drugs or new formulations of older drugs have been developed in an effort to reduce side effects. Oxybutynin is now formulated in a slow-release tablet taken once daily. The slow release of this new drug allows for a steady level of the drug and fewer side effects. Tolterodine tartrate is another new anticholinergic that is different than the older ones in that it has less effect on the salivary glands and therefore causes less dry mouth. It is also available in a slow-release, one-a-day form. Postmenopausal women with incontinence may benefit from hormone treatment. Normally the bladder neck and the urethra are closed at rest. With loss of estrogen, the tissues become weakened or dried and normal closure is lost. Hormone replacement improves the health of these tissues and allows for closure to be regained through increased tone and improved blood supply.

What can be expected from minimally invasive treatment for urinary incontinence?

Minimally invasive therapies can lead to improvement in incontinence but not necessarily a cure. Improvement generally does not occur overnight. Patients need time to adapt to behavioral changes. Results with pelvic floor exercises may take three to six months. Some patients may notice an immediate effect with medical therapy, whereas in others an effect may not be seen for approximately four weeks. Incontinence may also recur after treatment. Continuing behavioral techniques or continuing or resuming pharmacologic treatment as well as practicing preventive strategies may prevent such recurrence. Incontinence may also be prevented by good toileting habits including regular urination, pelvic floor exercises, avoidance of constipation, avoidance of bladder irritants and adequate water intake.

Frequently Asked Questions:

• What should I do if I suffer from incontinence?

  Talk to your health-care provider. Incontinence can sometimes be treated by a primary care physician or it may be necessary for you to see a urologist who specializes in treating incontinence. You can help your doctor by bringing a list of your medications to your appointment. Prior to the appointment, you might want to record for two to four days the amount and type of liquids that you consume, the number of times you urinate and the number of accidents you have.

• What can I do about my incontinence prior to being seen by a health-care provider?

  You can urinate every two to three hours during the day, drink six to eight glasses of water, avoid bladder irritants (e.g., coffee, tea, colas, chocolate and acidic fluid juices), avoid constipation and do pelvic floor exercises.

• What foods or drinks are irritating to the bladder?

  Caffeine is a common bladder irritant but there are other substances that can also cause bladder irritation. Not all incontinent patients are bothered by certain foods or drinks. The only way to know if diet is a factor is to eliminate possible irritants and see if continence is improved. Some of the most common bladder irritants are: alcohol, carbonated beverages (with and without caffeine), coffee or tea (with and without caffeine), chocolate, citrus fruits, tomatoes and acidic fruit juices.

• How do I know if I am doing pelvic floor exercises properly?

  When you do pelvic floor exercises only the pelvic floor should move. The pelvic floor muscles are tightened as if you wanted to stop urinating midstream or stop the passage of gas. The abdominal, buttock or leg muscles should not be tightened. By doing the exercises in front of a mirror or by placing a hand on the abdominal or buttock muscles you will be able to tell if you are contracting any of the wrong muscles. If the exercises are done properly, they can be done anywhere. There are written instructions available from support groups or from your health-care provider.

• Could any of my medications be causing my incontinence?

  Certain types of medications can cause or exacerbate incontinence. These medications include diuretics, sedatives, narcotics, antidepressants, antihistamines, calcium channel-blockers and alpha-blockers.

• Will my incontinence get worse as I continue to get older?

  Your urinary incontinence will not necessarily get worse, but it also will not improve without treatment.

• I have a small amount of incontinence very infrequently that doesn’t bother me. Is this abnormal and do I need to be treated?

  Any leakage of urine is abnormal. You should consider treatment if your incontinence prevents you from doing the activities that you want to do. Although pads or diapers may prevent embarrassing accidents, there are other treatment options currently available that can eliminate your need to wear such protection.

Erectile dysfunction (ED) is a medical term that describes the inability to achieve and or maintain an erect penis adequate for sexual function. This condition is one of the most common sexual problems for men and the number of men suffering from ED increases with age. Approximately 25 million American men suffer from ED, although not all men are equally distressed by the problem.

What are some causes of ED?

By far, the most important cause of the development of ED is the presence of illnesses like high blood pressure, diabetes mellitus, high cholesterol levels and cardiovascular disease. These processes, acting over time, can lead to a degeneration of the penile blood vessels, leading to restriction of blood inflow through the arteries and also to leakage of blood through the veins during erection.

The choices we make in life can lead to degeneration of the erectile tissue and the development of ED. Smoking, drug or alcohol abuse, particularly over a long period of time, will compromise the blood vessels of the penis. Lack of exercise and a sedentary lifestyle will contribute to the development of ED. Correction of these conditions will contribute to overall health and may in some individuals correct mild ED. Treatment of many medical conditions can interfere with normal erections. Drugs used to treat these risk factors listed above may also lead to or worsen ED. Patients undergoing surgery or radiation therapy for cancer of the prostate, bladder, colon or rectum are at high risk for the development of ED.

How is ED diagnosed?

For most patients, the diagnosis will require a simple medical history, physical examination and a few routine blood tests. Most patients do not require extensive testing before beginning treatment. The choice of testing and treatment depends on the goals of the individual. If erection returns with simple treatment like oral medication and the patient is satisfied, no further diagnosis and treatment are necessary. If the initial treatment response is inadequate or the patient is not satisfied, then further steps may be taken. In general, as more invasive treatment options are chosen, testing may be more complex.

What are some non-surgical treatments?

The first line of therapy for uncomplicated ED is use of oral medications known as phosphodiesterase-5 inhibitors (PDE-5) — sildenafil citrate, vardenafil HCl or tadalafil. Men with ED take these pills before beginning sexual activity and the drugs boost the natural signals that are generated during sex, thereby improving and prolonging the erection itself. These medications are safe and fairly effective, with improvement in erection in nearly 80 percent of patients using these drugs. Early concerns about possible bad effects on the heart have not proven true; after extensive testing and five years of use, sildenafil citrate can be used safely by all heart patients except those using medications called nitrates because of an interaction between these two classes of drugs. The side effects of PDE-5 inhibitors are mild and usually transient, decreasing in intensity with continued use. The most common side effects are headache, stuffy nose, flushing and muscle aches. In rare cases, sildenafil can cause blue-green shading of vision due to high blood levels of sildenafil exerting a brief effect on the retina of the eye. This is of no long-term risk and is gone within a short time as the amount of sildenafil in the blood decreases. It is important to follow the instructions for using these medications in order to get the best results. Tests have shown that 40 percent of men who do not respond to sildenafil will respond when they receive proper instruction on medication use.

For men who do not respond to oral medications another drug, alprostadil, is approved for use in men with ED. This drug comes in two forms: injections that the patient places directly into the side of the penis and a transurethral suppository. Success rates with self-injection can reach 85 percent. Modifying alprostadil to allow transurethral delivery avoids the need for a shot, but reduces the effectiveness of the agent to 40 percent. The most common adverse effects of alprostadil use are a burning sensation in the penis and the risk of over correcting the problem, resulting in a prolonged erection lasting over four hours and requiring medical intervention to reverse the erection.

For men who cannot or do not wish to use drug therapy, an external vacuum device may be acceptable. This device combines a plastic cylinder or tube that slips over the penis, making a seal with the skin of the body. A pump on the opposite end of the cylinder creates a low-pressure vacuum around the erectile tissue, which results in an erection. To keep the erection once the plastic cylinder is removed a rubber constriction band goes around the base of the penis, which maintains the erection. With proper instruction 75 percent of men can achieve a functional erection using a vacuum erection device.

There are some men who have severe degeneration in the tissues of the penis, which makes them unable to respond to any of the treatments listed above. While this is a small number of men, they usually have the most severe forms of ED. Patients most likely to fall into this group are men with advanced diabetes, men who suffered from ED before undergoing surgical or radiation treatment for prostate or bladder cancer and men with deformities of the penis called Peyronie’s disease. For these patients reconstructive prosthetic surgery (placement of a penile prosthesis or “implant”) will restore erection, with patient satisfaction rates approaching 90 percent. Surgical prosthetic placement normally can be performed in an outpatient setting or with one night of hospital observation. Possible adverse effects include infection of the prosthesis or mechanical failure of the device.

What can be expected after treatment?

All of the treatments above, with the exception of prosthetic reconstructive surgery, are temporary and meant for use on demand. The treatments compensate for but do not correct the underlying problem in the penis. So it is important to follow-up with your doctor and report on the success of the therapy. If your goals are not reached, if your erection is not of sufficient quality or duration and you are still distressed, you should explore the alternatives with your doctor. Because the medications used are not correcting the problems leading to ED, your response over time may not be what it once was. If such should occur again, have a repeat discussion with your physician about the remaining treatment options.

Frequently Asked Questions:

• How do I know my ED is not in my head?

  Many years ago most men with ED were thought to have psychological problems. This was the result of our ignorance of the normal mechanism of erection and the causes of ED. We now realize that most men have underlying physical causes.

• If I worry about my ability to get an erection can I make a bad condition worse?

  Nothing happens in the body without the brain; worrying about your ability to get an erection can itself interfere with the process. This condition is called performance anxiety and can be overcome with education and treatment.

• Can I combine treatment options?

  This is often done but because of the risk of prolonged erections with drug therapy it should only be performed under physician supervision. Ask your doctor for proper instructions.

• I was fine until I began taking this new drug; what should I do?

  Many drugs can cause ED, but some cannot be changed because the benefits outweigh the adverse effects. If you are fairly certain that a specific drug has caused the problem, discuss the possibility of a medication change with your doctor. If you must remain on the specific medication causing the problem, the treatment options outlined above can still be used in most cases.

Kidney stones are among the most painful and prevalent of urologic disorders. More than a million kidney stone cases are diagnosed each year, with an estimated 10 percent of Americans destined to suffer at some point in their lives.

Fortunately, most stones pass out of the body without any intervention. If you are not so lucky, the following information should help you and your doctor address the causes, symptoms and possible complications created by your kidney stone disease.

What is a kidney stone?

A stone forms in the kidney when there is an imbalance between certain urinary components -chemicals such as calcium, oxalate and phosphate – that promote crystallization and others that inhibit it.

Most common stones contain calcium in combination with oxalate and/or phosphate.

A less common type of stone is caused by infection in the urinary tract. This type of stone is called a struvite or infection stone. Much less common are the pure uric acid stones. Much rarer is the hereditary type of stones called cystine stones. Even more rare are those linked to hereditary disorders.

Who forms kidney stones?

For unknown reasons, the number of people in the United States with kidney stones has been increasing over the past 20 years. Caucasians are more prone to develop kidney stones than African Americans. Although stones occur more frequently in men, the number of women who get them has been increasing over the past 10 years, causing the ratio to change. Kidney stones strike most typically between the ages of 20 and 40. If a person forms a stone, there is a 50 percent chance they will develop another stone.

What causes a stone to form?

Scientists do not always know what makes stones form. While certain foods may promote stones in susceptible people, researchers do not believe that eating a specific item will cause stones in people who are not vulnerable. Yet they are confident that factors – such as a family or personal history of kidney stones and other urinary infections or diseases – have a definite connection to this problem. Climate and water intake may also play a role in stone formation.

Stones can also form because of obstruction to urinary passage like in prostate enlargement or stricture disease. Stone formation has also been linked to hyperparathyroidism, an endocrine disorder that results in more calcium in your urine. Susceptibility can also be raised if you are among the 70 percent of people with rare hereditary disorders such as cystinuria or primary hyperoxaluria who develop kidney stones because of excesses of the amino acid, cystine or the oxalate in your urine.

Another condition that can cause stones to form is absorptive hypercalciuria, a surplus of calcium in the urine that occurs when the body absorbs too much from food. The high levels result in calcium oxalate or phosphate crystals forming in the kidneys or urinary tract. Similarly, hyperuricosuria, excess uric acid tied to gout or the excessive consumption of meat products, may also trigger kidney stones.

Consumption of calcium pills by a person who is at risk to form stones, certain diuretics or calcium-based antacids may increase the risk of forming stones by increasing the amount of calcium in the urine. Calcium oxalate stones may also form in people who have chronic inflammation of the bowel or who have had an intestinal bypass operation or ostomy. This is because of loss of more water from the body as well as absorption of oxalate from the intestine.

What are the symptoms of a kidney stone?

Usually, the symptom of a kidney stone is extreme pain that has been described as being worse than child labor pains. The pain often begins suddenly as the stone moves in the urinary tract, causing irritation and blockage. Typically, a person feels a sharp, cramping pain in the back and in the side of the area of the kidney or in the lower abdomen, which may spread to the groin. Also, sometimes a person will complain of blood in the urine, nausea and/or vomiting.

Occasionally stones do not produce any symptoms. But while they may be “silent,” they can be growing, even threatening irreversible damage to kidney function. More commonly, however, if a stone is not large enough to prompt major symptoms, it still can trigger a dull ache that is often confused with muscle or intestinal pain.

If the stone is too large to pass easily, pain continues as the muscles in the wall of the tiny ureter try to squeeze the stone along into the bladder. One may feel the need to urinate more often or feel a burning sensation during urination. In a man, pain may move down to the tip of the penis. If the stone is close to the lower end of the ureter at the opening into the bladder, a person will frequently feel like they have not fully completed urination.

Stones as small as 2 mm. have caused many symptoms while those as large as a pea have quietly passed. If fever or chills accompany any of these symptoms, then there may be an infection. You should contact your urologist immediately.

How are kidney stones diagnosed?

Sometimes “silent” stones – those that cause no symptoms – are found on X-rays taken during a general health examination. These stones would likely pass unnoticed. If they are large, then treatment should be offered. More often, kidney stones are found on an X-ray or sonogram taken on someone who complains of blood in the urine or sudden pain. These diagnostic images give the doctor valuable information about the stone’s size and location. Blood and urine tests also help detect any abnormal substance that might promote stone formation.

If your doctor suspects a stone but is unable to make a diagnosis from a simple X-ray, he/she may scan the urinary system with intravenous pyelography (IVP). It is an imaging technique that utilizes radiopaque injections of dye followed, during excretion by the kidneys, by abdominal X-rays. A kidney obstructed by a stone will not be able to excrete the dye as quickly and may also appear enlarged when compared to the normal organ. Since this technique requires prep, it has been replaced in many hospitals by an abdominal/pelvic CT scan, an extremely accurate diagnostic tool that can detect almost all types of kidney stones painlessly.

How are kidney stones treated?

Treating kidney stone disease depends largely on the size, position and number of stones in your system. Luckily, the majority of small stones (0.2 inch or 5 mm. in diameter) that are not causing infection, blockage or symptoms will pass if you simply drink plenty of fluids each day. Consuming two to three quarts of water increases urine production, which eventually washes kidney or other stones out of the system. Once they have passed, no other treatment is necessary. The doctor usually asks one to save the passed stone(s) for testing; a cup or tea strainer can be used for this purpose.

Also, renal colic, the sudden flank pain that occurs when small stones start down the ureter, can usually be treated with bed rest and analgesics or painkillers. Certain types of stones, such as those made or uric acid, can be broken up with medical therapy. The majority, however, are composed of calcium and are not responsive to medicine.

Surgery should be reserved as an option for cases where other approaches have failed or should not be tried. Surgery may be needed if a stone:

• does not pass after a reasonable period of time and causes constant pain
• is too large to pass on its own
• blocks the flow or urine
• causes ongoing urinary tract infection
• damages kidney tissue or causes constant bleeding
• has grown larger (as seen as follow-up X-ray studies)

Until recently, surgery to remove a stone was very painful and required a lengthy recovery time (four to six weeks). Today, treatment for these stones is greatly improved and many options do not require major surgery.

• Extracorporeal shock wave lithotripsy (ESWL®): This is the most frequently used procedure for eliminating kidney stones. It works by directing ultrasonic or shock waves, created outside your body through skin and tissue, until they hit the dense kidney stones. The stones break down into sand-like particles and are easily passed through the urinary tract in the urine. This method does not damage surrounding body tissues but breaks only the stone. The technology is only effective if the kidney is functioning well and there is no blockage to the passage of stone fragments.
   
  In the older devices, the patient used to recline in a water bath while the shock waves were transmitted. Today, the machines are more compact and have a soft cushion on which the patient lies. Most devices use either X-rays or ultrasound to help the surgeon pinpoint the stone during treatment. For most types of shock wave lithotripsy procedures, anesthesia is not needed. In most cases, shock wave lithotripsy is done on an outpatient basis and without anesthesia. Recovery time is short and most people can resume normal activities in a few days. If the stone is about one inch in size, then more than one sitting of shock wave lithotripsy will be needed.
   
  While shock wave lithotripsy is considered safe and effective, it can still cause complications. Most patients have blood in their urine for a few days after treatment. Bruising and minor discomfort in the back or abdomen from the shock waves are also common. To reduce the risk of complications, urologists usually tell their patients to avoid aspirin and other drugs that affect blood clotting for several weeks before treatment. Another complication may occur if the shattered stone particles cause discomfort as they pass through the urinary tract. In some cases, the urologist will insert a small tube called a stent through the bladder into the ureter to help the fragments pass.
• Percutaneous nephrolithotomy (PNL): This procedure is the treatment of choice for patients with kidney stones that are larger and are in a location that does not allow effective use of shock wave lithotripsy or cause a blockage so severe that they cannot be bypassed by using a stent.
   
  In this procedure, the surgeon makes a tiny cut in the flank area and then uses an instrument called a nephroscope to locate and remove the stone. For larger stones, a type of energy probe (ultrasonic, electrohydraulic or hydraulic) may be needed to break the stone into small pieces. All of this is done while the patient is sedated or under anesthesia.
   
  One advantage of this procedure over SWL is that the surgeon removes the stone fragments instead of relying on its natural passage from the ureters. Generally, patients stay in the hospital two to three days and may have a small catheter in the kidney during the healing process. Most patients can resume light activity in one to two weeks.
• Ureteroscopy (URS): Although some kidney stones in the ureters can be treated with shock wave lithotripsy, this procedure may be needed for mid and lower ureteral stones. In fact, this will be the preferred method in treating lower ureteral stones. Ureteroscopy involves the use of ureteroscopes, small flexible or semi-rigid telescopes that can be inserted up the urethra, through the bladder and into the ureter without an incision. These instruments allow the doctor to view a ureteral stone directly. They also have small working channels through which various devices can be passed to remove or fragment the stone. Anesthesia is generally used, and a stent is left in the ureter for a few days after treatment while healing takes place. Ureteroscopy was developed in the 1970s and came into wide use during the 1980s. Before then, a type of treatment called “blind basketing” was often used. A basket-like device was passed – blindly, with no viewing instrument – through the urethra and bladder and into the ureter to pull out the stone. This type of “blind” treatment risks injury to the ureter and is less effective than other methods used today. In particular, as ureteroscopy has advanced with continual instrument improvements, blind basketing is no longer a satisfactory treatment choice. The risks of ureteroscopy include perforation or stricture (scar tissue) forming, especially if the stone has been impacted or embedded within the wall of the ureter for longer than two months. The majority of ureteroscopic procedures can be performed as day surgery and that most individuals can return to work within one to two days following the procedure.

What can be expected after treatment for kidney stones?

Although stone recurrence rates differ with individuals, in general you have a 50 percent chance of redeveloping stones within the next five years. So prevention is essential. Your urologist may follow up with several tests to determine which factors – e.g., medication or diet – should be changed to reduce your further risk.

Do not be surprised, if you are asked to collect urine for 24 hours after a stone has passed or been removed to measure volume and levels of acidity, calcium, sodium, uric acid, oxalate, citrate and creatinine. This information will be used to determine the cause of the stone. A second 24-hour urine collection will be needed on a restricted diet to determine the causes. A third 24-hour analysis may be used to find out the effectiveness of treatment.

Frequently Asked Questions:

• How can I prevent kidney stones?

  A good first step for prevention is to drink more liquids – water is the best. If you tend to form stones, you should try to drink enough liquids throughout the day to produce at least two quarts of urine in every 24-hour period. People who form calcium stones used to be told to avoid dairy products and other foods with high calcium content. However, recent studies have shown that foods high in calcium, including dairy foods, help prevent calcium stones. Taking calcium in pill form, however, may increase the risk of developing stones. Women taking vitamin D and calcium pills in the post-menopausal period to prevent osteoporosis, especially with a family history of kidney stones, need to be careful. If you are at risk for developing stones, your doctor may perform certain blood and urine tests to determine which factors can best be altered to reduce the risk. Some people will need medicines to prevent stones from forming.

• My stone has not passed, do I need surgery?

  In general, you are facing surgery if your stones are large enough to obstruct urine flow, if they are potentially harmful to your kidneys or if they are causing symptoms for which medication does not help.

• Will my children get kidney stones because I have them?

  Any person with a family history of kidney stones may be at higher risk for calculi. Stone disease in a first degree relative, such as a parent or sibling, can dramatically increase the probability for you. In addition, more than 70 percent of people with certain rare hereditary disorders are prone to the problem. Those conditions include cystinuria, an excess of the amino acid, cystine that does not dissolve in urine and instead forms stones of cystine; and primary hyperoxaluria, an excess production of the compound oxalate, which also does not dissolve in urine, forming stones of oxalate and calcium.

• Are gallstones and kidney stones related?

  No. There is no known link between gallstones and kidney stones. They are formed in different areas of the body. Also, if you have a gallstone, you are not necessarily more likely to develop kidney stones.

• What is a staghorn stone?

  Resembling the horns of a stag, these stones get their name from the shape they form by filling the pelvis or drainage system of the kidney (at the top of the ureter). Staghorn stones are linked to urinary tract infections. Despite the fact that they can grow large, they are often overlooked by patients because they cause minimal or even no pain. But a staghorn stone can lead to deterioration of kidney function, even without blocking the passage.

  Treating this condition can be challenging. In the past, urologists relied on conventional surgery to remove the offending stone. But today they employ a combination of shock wave lithotripsy and percutaneous surgical procedures, even though patients may still need a traditional operation. In any case, it is essential that once the stone is removed, you work diligently to prevent further ones from forming. Luckily, new drugs and the growing field of lithotripsy have greatly improved the treatment of all kidney calculi, including staghorn stones.

• Where can I get more information?

  AUA Guidelines Patient Guides: The Management of Ureteral Stones and The Management of Staghorn Kidney Stones

Benign prostatic hyperplasia is the medical term for a noncanerous enlarged prostate. BPH is very common and can occur in men over 40. When the prostate is enlarged it can obstruct the urethra – the tube that carries urine and semen through the penis. This can cause a decreased flow of urin and semen.

What are some of the symptoms associated with BPH?

Since the prostate surrounds the urethra just below the bladder, its enlargement can result in symptoms that irritate or obstruct the bladder. A common symptom is the need to frequently empty the bladder, sometimes as often as every two hours or more, especially at night. Other symptoms include the sensation that the bladder is not empty, even after a man is done urinating, or that a man cannot postpone urination once the urge to urinate arises. BPH can cause a weak urinary stream, dribbling of urine, or the need to stop and start urinating several times when the bladder is emptied. BPH can cause trouble in starting to urinate, often requiring a man to push or strain in order to urinate. In extreme cases, a man might not be able to urinate at all, which is an emergency that requires prompt attention.

How is BPH diagnosed?

In order to help assess the severity of such symptoms, the American Urological Association (AUA) BPH Symptom Score Index was developed. This diagnostic system includes a series of questions that ask how often the urinary symptoms identified above occur. This helps measure how severe the BPH is – ranging from mild to severe.

When a doctor evaluates someone for possible BPH, the evaluation will typically consist of a thorough medical history, a physical examination (including a digital rectal exam or DRE), and use of the AUA BPH Symptom Score Index. In addition, the doctor will generally do a urine test called a urinalysis. There are a series of other studies that may or may not be offered to a patient being evaluated for BPH depending on the clinical situation. These include:

1. Prostate specific antigen (PSA), a blood test to screen for prostate cancer
2. Urinary cytology, a urine test to screen for bladder cancer
3. A measurement of post-void residual volume (PVR), the amount of urine left in the bladder after urinating
4. Uroflowmetry, or urine flow study, a measure of how fast urine flows when a man urinates
5. Cystoscopy, a direct look in the urethra and/or bladder using a small flexible scope
6. Urodynamic pressure-flow study that tests the pressures inside the bladder during urination
7. Ultrasound of the kidney or the prostate

When should I see a doctor about BPH?

A man should see a doctor if he has any of the symptoms mentioned previously that are bothersome. In addition, he should see a doctor immediately if he has blood in the urine, pain with urination, burning with urination or is unable to urinate.

Treatments for BPH

1. Medications
2. Minimally invasive office treatments (MIT), and
3. Surgery (TURP, Greenlight Laser, Prostate Vaporization, etc.)

Frequently Asked Questions:

• Is BPH a rare condition?

  No, it is very common. It will affect approximately 50 percent of men between the ages of 51 and 60 and up to 90 percent of men over the age of 80.

• Does BPH lead to prostate cancer?

  No, BPH is not cancer and cannot lead to cancer, although both conditions can exist together. There are usually no symptoms during the early stages of prostate cancer, and so yearly physical examinations and PSA tests are highly recommended to eliminate cancer diagnosis.

• Which type of drugs are the best?

  To date, there is not enough research data to predict who will respond to medical therapy or which drug will be better for an individual patient.

• How do I know if oral medications are the best treatment for me?

  If you are diagnosed with BPH, you should discuss all treatment options with your urologist. Together, you can decide whether medication or surgical treatment is best for you.

• Where can I get more information?

  UrologyHealth.org AUA Guidelines Patient Guides: BPH: A Patient’s Guide and BPH: View the Webinar

An ultrasound examination, also commonly referred to as a sonogram, is a painless, diagnostic technique that makes use of the behavior of sound waves in the human body. When these sound waves are transmitted into the body, they are reflected in specific ways by specific tissues and organs. These reflected waves can be used to produce images of internal organs without the pain or exposure to radiation.

Depending on the reason for the study and the circumstances, ultrasound imaging may be performed in the urologist’s office, in the hospital or in an outpatient facility.

In most cases, very little preparation is needed for an ultrasound examination. Some examinations, such as a bladder scan for residual urine, require limited experience while others, such as ultrasound examinations of the kidneys, testicles or prostate, require more experience or expertise.

The patient will be asked to lie down on the examination table. A clear, water-based gel is applied to the skin over the area to be examined. This gel helps with the transmission of the sound waves. A transducer, which is a hand-held probe, is then moved over that area. Prostate ultrasound examinations are performed by placing a specially designed probe into the rectum.

There is no risk of radiation with this study and the patient can resume their daily activities immediately following this test.

Frequently Asked Questions:

• What can be expected with a Renal/Kidney ultrasound?

  The kidneys are fist-sized organs located in the retro peritoneum — the space behind the intestines and other abdominal organs. They are responsible for cleansing the blood of waste products and producing urine. They also balance electrolytes in the body, such as sodium and potassium, while providing hormones necessary to regulate blood pressure and red blood cell production.

  There may be many indications for a renal ultrasound examination. Renal ultrasound studies are useful for demonstrating the size and position of the kidneys and are helpful in identifying obstruction of the kidney, kidney stones or masses in the kidney.

  Renal ultrasound does not require fasting, bowel preparation or a full bladder. The test is performed with the patient lying on their back on the examination table and a conducting gel is placed on the skin to facilitate transmission of the sound waves. The right kidney is imaged by placing the transducer over the right upper abdomen and evaluation of the left kidney may require having the patient roll toward the right to expose the left flank.

• What can be expected with a bladder ultrasound?

  The bladder is an organ made of smooth muscle that stores urine until ready for release. The most common reason for bladder ultrasound is to assess bladder emptying by measuring residual urine after urination. Many conditions may result in disorders of bladder emptying and these include an enlarged prostate, urethral stricture or bladder dysfunction. Bladder ultrasound may also provide information about the bladder muscle, the presence of diverticula of the bladder, the size and shape of the prostate, the presence of stones or large tumors in the bladder. Bladder ultrasound as performed for urologic purposes usually does not assess the ovaries, uterus or colon.

  Bladder ultrasound does not require fasting or bowel preparation. The patient should not empty their bladder prior to arriving at the physician’s office for a full bladder is useful for the examination.

  The examination is performed with the patient lying on his/her back on the examination table. A conducting gel is placed on the skin to facilitate transmission of the sound waves. The transducer is placed on the lower abdomen between the umbilicus and the pubic bone. The image is viewed on a monitor and interpreted in real time.

• What can be expected with a scrotum ultrasound?

  The testicles (testes) are contained in a skin-covered muscular sac called the scrotum. The testicles manufacture sperm cells for reproduction and also produce testosterone. The primary indication for scrotal ultrasound is the evaluation of masses in the scrotum or in the testes themselves. The most common mass in the scrotum is a benign collection of fluid around the testis called a hydrocele. Another common condition is a collection of fluid in the epididymis called a spermatocele. Ultrasound studies are also very helpful in investigating solid masses within the testes, which may represent testicular cancer.

  A scrotal ultrasound examination does not require fasting, bowel preparation or a full bladder. The test is performed with the patient lying on his back. The scrotum is elevated on a towel and warm gel is applied to the scrotum to help conduct the sound waves.

• What are some additional uses of urologic ultrasound?

  • Evaluation of infertility: Under some circumstances, transrectal ultrasound may be useful in demonstrating the presence of abnormalities of the seminal vesicles and prostate. Examination of the testes may also be of value.
  • Evaluation of the female urethra: Transvaginal ultrasound may be useful in demonstrating a urethral diverticulum. A urethral diverticulum may be associated with urethral pain and recurrent urinary tract infection.
  • Pediatric urology: The painless and noninvasive nature of ultrasound and the immediacy of the results make it ideal for working with children. Ultrasound is particularly well suited to pediatric patients. Ultrasound provides excellent images of the kidneys and bladder. It is useful in the evaluation of congenital abnormalities of the urinary tract, the evaluation of problems with urination and the workup of recurrent urinary tract infections.
  • Evaluation of voiding dysfunction: Ultrasound may provide invaluable information about the function of the bladder neck and its relationship to urinary incontinence in men and women.
  • Evaluation of blood flow: A Doppler ultrasound may be used to determine blood flow in urologic organs especially the testes and kidneys.