Originally published in The Ottawa Citizen September 20, 2004
Original Title: The Testes of Time

Young men rarely see their family doctor (if they have one). There is a tendency to think that nothing can really go wrong in your late teens or 20s.

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Originally published in The Ottawa Citizen August 5, 2003
Original Title: BPH, PRCa, PSA:What’s the deal?

CJOH anchor Max Keeping’s selfless revelation about his prostate cancer has renewed interest in prostate disease and PSA testing. His announcement came the day after a group called Early Prostate Cancer Diagnosis launched a campaign geared at getting OHIP to pay for an the early screening called the prostate-specific antigen (PSA) blood test for all men over 40.

As it stands, the province will fund PSA tests for men who have already been diagnosed with prostate cancer and those who already have symptoms.

But diagnosing prostate cancer is sometimes no simple matter, even with the PSA test. Is it worthwhile to find the $25 in your own pocket for the peace of mind?

One thing that make prostate cancer hard to diagnose is that it has symptoms similar to those of other conditions, including benign prostatic hypertrophy (BPH), which usually starts after the age of 50.

This enlargement of the prostate gland can cause significant discomfort and potential bladder damage. The prostate increases in size in eight per cent of men aged 31 to 40, in 40 to 50 per cent of men aged 51 to 60, and over 80 per cent of men older than 80 years of age.

If you are a man and live to a ripe old age, chances are good you will get prostate cancer. You’re also very likely to survive it.

Autopsy studies show 10 per cent of men over 50 had prostate cancer, while 70 per cent of men over 80 had it. Ten per cent of prostate cancer is inherited. One in nine Canadian men will get prostate cancer and one in 29 will die of it.

The symptoms of BPH and prostate cancer slowly develop over years. The signs include getting up more frequently at night to urinate, needing to void after urinating, waiting longer for urinary flow to begin, dribbling after urination, urinating more often during the day and a slower, less forceful and sputtering urinary stream.

BPH and prostate cancer have the potential to obstruct the bladder’s efforts to empty. Urine accumulates and distends the bladder walls, which can permanently damage bladder function. It loses the ability to contract and expel the urine.

But other disorders can also be at fault, including a narrowing of the urethra (the tube running from the bladder to the tip of the penis) or the bladder outlet, bladder cancer, bladder stones, urinary tract and prostate infections, or poor nervous system control of the bladder.

A thorough medical history of urinary difficulties, nerve damage or disease, bloody urine, trauma to the urethra and medication use helps point the way to a specific diagnosis.

Rectal examinations will help assess prostate size and consistency among other characteristics and differentiate between benign versus malignant disease.

Several other tests will complement the evaluation, ranging from a simple urine test for blood and infection to more invasive procedures.

A common imaging test, a transrectal prostatic ultrasound, will determine the size of the gland, its consistency and if there are suspicious areas for prostate cancer.

Other tests will measure how well the bladder functions. If there is a clinical suspicion of prostate cancer, a prostate biopsy would be the next step.

BPH treatment involves lifelong medical therapy and, depending upon the clinical situation, surgery to remove part or all of the gland.

Prostate cancer treatment includes a combination of chemotherapy, surgery and radiation therapy. Early detection is essential.

There is contradictory and confusing information about the PSA test. Still, it remains a valuable tool especially for certain clinical conditions, race and age groups.

PSA is a protein produced by the prostate gland. Most of it is attached to other blood proteins, but some floats freely in the blood stream, not bound to other substances.

This unbound type, “free” PSA, is low in men with prostate cancer and high in men with BPH. The serum PSA test adds the bound and free PSA levels together.

PSA levels increase with gland enlargement. The test can be used as a cancer-screening tool for men between 50 and 69 years of age because of the predictable slow and steady growth of the gland and PSA values.

However, the PSA test has limitations, in part because of other influences on the prostate gland. Irritation, ejaculation, infection, obstruction of the urethra and direct pressure (from a rectal exam or anal intercourse) will pump more PSA into the bloodstream, artificially elevating the result.

Men over the age of 69 tend to have more rapid enlargement of the prostate and increasing PSA levels. The results must be interpreted according to age and race-based normal values. Failure to do so could lead to false positive or negative results.

The widely used cut-off serum PSA value of four nanograms per millilitre, an indicator for the suspicion of prostate cancer, remains controversial.

Recent evidence indicates lesser values being associated with cancer. In three studies of men aged 50 and older, 148 of 597 men without prostate cancer (25 per cent) had a PSA value of four or higher. And 136 of 319 men with prostate cancer (43 per cent) had values below four.

A “free” PSA test — a variant of the PSA test — might improve cancer-screening evaluation. This test measures the individual concentration of the total PSA and free PSA. The total PSA level must be more than four in order for this test, combined with the patient’s age, to differentiate BPH from prostate cancer.

To date, the evidence indicates a combination of digital rectal examination and serum PSA testing is the best available means to exclude prostate cancer. The recommendation is to start screening for prostate cancer by age 50 with a rectal exam and PSA.

Family history might result in earlier testing, say, at around age 40. Given the evidence that this is the best we have so far, it stands to reason to give men any opportunity to prevent the disease.

Every other test we have that is covered by OHIP has no age restriction. I do not think PSA should be subjected to this rule. The decision for the test is based on clinical interpretation of the facts and in the best interest of the patient. There must be consistency in the system.

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Originally published in The Ottawa Citizen July 29, 2003
Original Title: The Stones Wrong Address Part III; Sand and water are more fun on the beach

Part 1
Part 2

During my residency at the Jewish General Hospital in Montreal, I watched a groaning patient in tremendous pain hobble into the emergency room, clutching his lower back and side.

The ER staff physician, his back to the ER entrance and writing his notes, said without the slightest hesitation: “Kidney stones. That groan is unmistakable.”

Passing a kidney stone ranks as one of the most painful events in a person’s life. Twelve per cent of white men and five per cent of white women will experience this by the time they’re 70.

Younger adults are more prone to stones than the elderly. Whites are more likely to develop stones than Asians and blacks. Kidney stones occur more frequently in hot, dry regions of the world.

Although many assume the kidneys are located in the lower back area, their true location is behind and below the rib cage in the middle back.

Millions of microscopic tubes within the kidney collect and filter blood and create urine. These tubes drain into larger collecting areas, the calyces, which lead to a large central region called the renal pelvis. Urine flows through from the renal pelvis into the ureter, the tube connecting the kidney to the bladder.

The anatomy of the kidney lends itself to the process of stone formation. Greater than normal concentrations of certain substances in the urine will crystallize and adhere to the collecting system of the kidney. These microcrystals gradually increase in size, forming stones ranging from the size of a grain of sand to as large as a golf ball.

Stone fragments can travel down the urinary system, either passing completely through or lodging within the ureter and obstructing the urinary flow.

Dietary habits pose a significant risk factor. Eighty per cent of stones contain calcium compounds, primarily calcium oxalate (and calcium phosphate to a lesser extent). Oxalate-containing foods include spinach, rhubarb, beets, strawberries, wheat bran, nuts and nut butters.

Bowel surgery, chronic diarrhea and short-bowel syndrome are among the medical conditions that increase the absorption of oxalate from the bowel. Dehydration will concentrate the urine, increasing the risk of stone formation.

Drinking a litre a week of soft drinks acidified with phosphoric acid can mildly increase the risk of stones.

Uric acid, a breakdown product of protein metabolism, is responsible for gout and can cause kidney stones. Eating red meat and drinking alcoholic beverages can increase blood uric acid levels.

Certain bacterial strains found in urinary tract infections can directly influence the production of struvite stones (magnesium ammonium phosphate).

People with high blood pressure have twice the risk of developing stones. There’s also a higher risk if you have a family member with a history of having stones. The chance of forming another stone after one year is 15 per cent, 35 to 40 per cent at five years and about 80 per cent at ten years.

The pain associated with renal colic, from hardly noticeable to excruciating, depends on how far the stone travels within the ureter. Spasms of severe pain can last 20 to 60 minutes. A stone found in the upper ureter/pelvis will cause flank pain in the area between the ribs and the hip. As the stone descends, the pain intensifies, radiating to the lower front part of the abdomen and groin.

Nausea and vomiting may accompany the attack. Some people may have painful urination and feel an urgent need to urinate. Blood in the urine is a common sign. Grains of sand or gravel may be present. Others may have less typical symptoms such as vague or sudden abdominal pain or penile or testicular pain.

Major complications include obstruction of the ureter and severe infections. The urine backflow due to complete obstruction can lead to damage of the delicate filtering structures within the kidney.

The diagnoses of a kidney stone are based on symptoms, urine tests, X-ray with special dye, ultrasound and CT scan imaging. Many people, unaware they have kidney stones, do not have symptoms. Discovering the stone commonly occurs when an X-ray or ultrasound of the abdomen is performed in the course of investigating a different medical condition.

For some, the treatment consists of pain control while waiting for the stone to come out. Stones greater than seven millimetres may need sound shock waves (extracorporeal shock wave lithotripsy) to shatter them into smaller pieces. Others may require a small fibre-optic tube with a snare at its end inserted through the urethra into the bladder and ureter to grab the stone.

People who have had one stone should increase their fluid intake to three litres per day. This will increase urine flow and help prevent the formation of microcrystals within the kidney.

Calcium restriction is not a requirement because oxalate is the main culprit. Restrict oxalate-containing foods instead. Avoid megadoses of vitamins C and D and reduce red meat if you have uric acid stones.

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Originally published in The Ottawa Citizen September 25, 2001

Ladies, you have borne your children and have been responsible for contraception. Now, when the time finally arrives to decide who will be the one to undergo sterilization your guy will be making himself scarce. In my office it is usually wives that ask about vasectomies on behalf of their husbands. They all have similar stories. Their husbands are concerned about prostate cancer, decreased libido, bleeding and grapefruit size swelling of the scrotum. As someone who recently has undergone this simple procedure, stand your ground ladies! Vasectomy has a lower failure rate than tubal ligation (getting your tubes tied). Aside from the potential of minor bleeding the other side effects just do not stand up to the facts.

Vasectomies are done in a doctor’s office in as little as 10 minutes. It is painless with few side effects and should be considered irreversible. Dr. Ron Weiss, an Ottawa family doctor introduced the No- Scalpel Vasectomy (NSV) technique to Canada in 1992. To date he has performed over 9000 in his career. He states that the infection rate and post operative bleeding (hematomas) into the scrotum are four per 1000 procedures. This compares to 32 per 1000 for the original surgical technique wherein a scalpel is used to cut through the scrotal skin.

In Dr. Weiss’ practice the failure rate is one in 9000. He states that published data reports one to three per 1000. He stresses that his data is specific to his practice.

The goal of vasectomy is to cut the tubes (Vas Deferens) which transport sperm from the testicles to specialized structures within the prostate gland. All patients are asked to purchase a soft athletic supporter and wear it on the day of the procedure. You must also shave the scrotal area. Some men are anxious and offered the option of an anti-anxiety medication like Valium to be taken prior to the NSV. Dr. Weiss escorted me to his consultation room where he described the procedure, the above mentioned risks and failure rates. With consent given we proceeded to the procedure room.

Your pants, underwear and athletic supporter are pulled down to your ankles. A loose elastic band is placed around the head of the penis. The band is clamped to a drape that rests upon the abdomen thereby lifting the penis up and away from the scrotum. A liberal amount of warm iodine disinfectant solution is applied over the scrotum which can tickle. Sterile drapes are placed over the area. A small needle is used to inject local anesthetic to freeze the skin. It feels like a small pinch or mosquito bite. The rest of the NSV is pain free.

The Vas deferens is located by palpating the skin. A specialized tool is used to poke a hole in the skin and grab the tube. The vas is then pulled out through the hole. A centimeter portion is cut and removed. The ends are cauterized and sealed with a tiny titanium clip. Only one hole is necessary to retrieve both tubes.

The average time to complete healing is about one month. There can be slight bruising but nothing of consequence. I was able to return to work the next day without pain. After the first week sporting activities and physical work can be resumed albeit slowly. If there is any pain, back off and go slow.

Avoid sexual activity for one week after vasectomy because intercourse may increase the risk of failure. There is no pain with the first ejaculation after the NSV. It takes about 15 to 20 ejaculations to achieve a zero sperm count for 80% of men. A sperm count should be done three months after the vasectomy to ensure it has been successful. An alternate method of birth control should be used until the count is proven to be zero.

Humour is a welcome part of the human condition. When I tell this story to my patients it serves to humanize the procedure for them. On one occasion, Dr. Weiss’ assistant was prepping a patient for the NSV. While she was applying the iodine solution the elastic band that held the penis snapped. The resulting slingshot effect forced the penis downward into the solution of iodine splashing the hapless assistant on her clothes and face. Needless to say she was startled and screamed. Dr. Weiss, in another exam room, ran over to the commotion, not knowing what was going on. The poor patient was ashen-faced and looked like a man seeking a rock to hide under. Any effect the valium had prior to this turn of events was long gone. After profuse apologies on the part of Dr. Weiss and his assistant, the poor man went ahead with the procedure. He did very well and was able to laugh about what happened afterwards.

Stories like these are rare. But it does serve its purpose. The laughter breaks the ice. Rarely do men decide against vasectomy once they are aware of the facts. Although there has been a run on heavy duty elastic bands at Home Depot!

Info sites:
http://vasectomy.ca

http://www.plannedparenthood.org/BIRTH-CONTROL/allaboutvas.htm

http://www.aafp.org/afp/990700ap/990700b.html

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