BY BRIAN JONES
COLUMBUS – Dr. Joshua Griffin and Dr. Ben Woodson of the Columbus Urology Group spoke to the Columbus Exchange Club Dec. 8. They talked about common urological ailments and new treatments.
Griffin covered prostate screening, overactive bladder and urinary incontinence.
“Urologists are not just plumbers,” he said. “We do a lot more than ‘why does it sting when I pee, doctor?’ We deal with kidneys, bladder, prostate disease, urinary incontinence, fertility, urinary tract infections, cancers of the urinary tract. We also cover men’s health, when it comes to erectile dysfunction and low testosterone and those kind of things. Urology is not men-specific. A lot of people think that urology is a man’s doctor, and that’s true, but we treat a lot of women as well.”
Griffin began with prostate problems.
“All men have a prostate,” he said. “Initially, anyway, unless you see one of us. It’s basically the size of a walnut, and is at the base of the bladder. It’s around the urethra. It is a gland that produces fluid that is transported into the sperm during ejaculation. It’s important for fertility and that’s about it.
“Some of the things that we see very commonly is problems with it being enlarged or having chronic infections,” he said. “We also see prostate cancer. It is a natural thing as men age. The prostate gland grows as men get older. About 90 percent of men by age 80 have an enlarged prostate. About 38 million men are dealing with symptoms of enlarged prostate, and they are significant. They can really cause a disruption in your lifestyle.
“The prostate can become enlarged to the point where it affects urination,” he said. “It gets larger and it presses the urethra, which is the tube that urine passes through. Over time the bladder becomes a lot thicker, and over time, just like with people with heart failure, that thickening causes problems which can eventually lead to significant issues.
“Things we see include going to the bathroom frequently,” he said. “Men getting up frequently in the night, and not getting good sleep; straining to get urine out; incomplete emptying. When people come in to see us we do a prostate exam, to see how big the prostate is, and we try to get an idea of the symptoms and how serious they are. Ultimately we make a decision if the symptoms are bothersome enough to get some type of medical treatment. Some men it’s not bothersome to them. The treatment really caters to the patient and the severity of the symptoms.”
The condition can be treated with medication or with a procedure, he said.
“The medications are used once a day, and are helpful,” he said. “Before we had medications, people had surgery. Some people may have heard it referred to as the ‘roto rooter’ surgery. Basically we would go in and remove prostate tissue. Now we have medications that are very effective for many men, but they do have some side effects that can sometimes be an issue. Surgery is usually the second line, with a few exceptions. Historically we would just go in with a scope and remove that tissue to open up that channel so you could urinate more effectively. That has been a very durable treatment for many, many years, but it does involve anesthesia, there is bleeding, you have to stay in the hospital.
“Over time there has been a lot of new treatments developed involving lasers,” he said. “That does shorten your hospital stay, and a lot of times people can go home. They don’t have to stay in the hospital, but it is still a procedure with anesthesia. There is new treatment called UroLift. This has been done for several years in Europe and Australia, and they got good results. The FDA has approved it in the United States. It is a much more minimally invasive procedure. We used to say you had to go in and take out this blocking tissue, but this goes in and pulls the tissue apart and puts in a very small suture. We tension it, and it basically opens that up. It’s almost like opening up a curtain. It opens up the channel and then you can urinate more effectively.”
Urinary incontinence affects both men and women, he said.
“It’s more commonly seen in women, but what we’re talking about is involuntary leakage or urine,” he said, “if you’re sitting here right now and you suddenly just can’t hold it, or if coughing or exercise or straining of any kind results in leakage. It’s very common in women. One in three women deal with some kind of urinary incontinence.
“Normally the bladder fills with urine and a sphincter muscle at the bottom prevents anything from coming out during normal situations,” he said. “When you want to urinate, the muscle relaxes, the bladder squeezes, and as it squeezes the urine is removed. What happens with urinary incontinence the bladder is over-squeezing and it’s too strong for that obstruction to resist, or, in some cases, stress on the bladder just pushes the urine out. Leakage when you cough or strain is something that is very common in women.”
There are very effective treatments for the leakage, he said.
“When we evaluate in the office, we do a physical exam and find out how severe the leakage is,” he said. “This can be very problematic for women. They’re wearing pads, they’re avoiding certain activities. It can have a big impact. But there are several options. The first thing is behavioral therapy, where we alter diet and urination patterns, making sure they are emptying their bladder in a timed fashion, every couple of hours. There are medications for it, but they’re not very effective. There are also some devices that can be worn to help. Ultimately most people don’t find the results they want with this, and we move on to more aggressive treatment.
“We have injections that we can put in around the opening of the bladder, where the leakage occurs,” he said. “These are called bulking agents, and there are several on the market. They are very effective for a short period of time, and they don’t typically hold up over time but they are very minimally invasive. The most effective treatment for this is a sling. It is an outpatient procedure. We make a small incision in the vaginal wall, and then the sling is placed through a couple of puncture sites. The best way to think about it is a hammock that supports that area whenever you’re coughing or straining of lifting.”
These slings are not the ones you see on TV that are being recalled, he said.
“Those are really a different kind of pelvic surgery that was done for pelvic organ prolapse,” he said. “The FDA has said clearly that the safety of these has been well-established.”
Woodson talked about overactive bladder, kidney stones and prostate cancer.
“When we talk about overactive bladder, we’re talking about urinary frequency, running to the bathroom all the time,” he said. “Risk factors include history of childbirth, post-menopausal women, aging, weight gain, diabetes, and it seems to afflict depressed females as well. It’s a big burden on medical expenditure – it costs about $9 billion to $12 billion a year to treat. It affects about 20 percent of women. Men can also suffer from this, but it’s less often. It is often one of the most common reasons for nursing home admission, and it increases the fall risk and fracture risk among the elderly.
“When we treat this, we tend to use drugs, and they are fairly effective,” he said. “The biggest side effects in about 10 percent of women are dry mouth and constipation. Topical estrogen is sometimes used, and a procedure called neuromodulation is used, which is stimulation of the sacral nerve. It is basically a retraining of the bladder to alter the reflex and the overactivity.”
Botox can also be used, he said, although the effects wear off in about four months.
Kidney stones are become more common, he said.
“That’s primarily due to diet,” he said. “We are typically gaining weight as a nation, and that’s a factor. The risk of recurrence in five years once you have a stone is 30-50 percent. Once you have two stones, it’s even higher. The cost to the health care system is over $2 billion a year. Once you have a stone is that you need to be drinking enough water to produce at least three liters of urine a day. A lot of people drink three liters of water a day, but there’s a big difference between drinking three liters and producing three liters. The second recommendation is for a low sodium diet. The recommendation is to get about two grams of salt intake a day, and the average American gets around 15.”
Symptoms of a stone are “the classic, stabbing flank pain,” and sometimes blood in the urine. It is often accompanied by nausea and vomiting.
CT scans are the most reliable way to diagnose a stone, he said.
“If the stone is five millimeters or less you have a pretty reasonable chance of passing it,” he said. “Often we put on FloMax, which is actually a prostate drug, but it does dilate the urethra and increase the chance of passing the stone by about 30 percent.”
There are several treatment options, he said.
“The first is to drive a scope up there and grab the stone,” he said. “Oftentimes we will use a laser to break it up into smaller pieces that can easily be removed. We just slide a basket up through the scope and grab the pieces and pull them out. A stent can be put in to allow the kidney to drain afterwards. Most people find the stent to be a nuisance, because it can itself cause some frequency issues and some blood in the urine. It is temporary, and most people get it out after four or five days.”
Sound waves can also be used to break up stones, he said.
“We barely even touch you,” he said. “You basically lie on a bid and sound waves travel through your body and converge on the stone. The technology has been around since the 1980s, and it delivers 2,500 to 3,000 shocks to the stone. It is very effective. Recovery from that is very easy. Some people will have a bruise on the side the next day, but other than that it’s very well tolerated.”
Woodson also briefly talked about prostate cancer screening.
“It is the second most common cancer in men,” he said. “It’s more common than colorectal cancer, lung cancer, more deaths per year than colon cancer. One in six males will be diagnosed with prostate cancer in their lifetime. Of those who are diagnosed very few will die of prostate cancer. The old saying is that you die with prostate cancer, not of prostate cancer.
“The US government came out in 2012 and recommended against prostate cancer screening,” he said. “That spread a lot of confusion, among the general public and among physicians who had been screening people for years. This task force that came up with this recommendation was composed of a lot of pediatricians, OB-GYNs, internal medicine doctors, there was not a single urologist on that task force. Death rates by prostate cancer have declined by about 40 percent over the last 20 years, despite relatively stable incidences of the disease. I guess the beef is that we’re picking up too many men who have prostate cancer that may never even affect them. Having said that, 20 years ago getting diagnosed with prostate cancer was tantamount to a death sentence because it would be so far gone at the time of diagnosis. It shows you what a good job the medical community has done in diagnosing it early and treating it.
“At the very least you need to have a discussion with your physician if you are a male between 55 and 70,” he said.