A Candid Conversation About Men’s Health with Dr. Ryan Berglund

Podcast Transcript

Nada Youssef:   Hi, thank you for joining us. I'm your host, Nada Youssef, and today we have with us Cleveland Clinic Urologist, Dr. Ryan Berglund, to address some common or uncommon questions that men may ask or may be even reluctant to ask their doctors when it comes to below the belt. So thank you so much for being here today.

Ryan Berglund: Thanks for having me on.

Nada Youssef:   I want to give you a few moments to just introduce yourself to our viewers.

Ryan Berglund: My name's Ryan Berglund. I'm on the staff of the Glickman Urologic and Kidney Institute at the Cleveland Clinic. And I also do a radio segment where I address men's questions about kind of embarrassing health questions they may have. So that's-

Nada Youssef:   And what is that called again?

Ryan Berglund: Is It Red?

Nada Youssef:   Is It Red? Okay, great. Well, thank you so much for being here, and for the viewers, if you have any questions, you can type them in the comment section below. We'll try to get them here in the second half of the broadcast. And before we begin, please remember, this is for informational purposes only and it's not intended to replace your own physician's advice.

Nada Youssef:   So I want to talk a little bit about the MENtion It survey and some of the results that we got out of it. So two online surveys were conducted amongst a total of approximately 2,000 U.S. Americans, 18 years or older living in the U.S. The MENtion It survey was conducted in order to get insights into the behaviors and attitudes of men related to their health, including their go-to sources to discuss health and their health concerns.

Nada Youssef:   So some key findings that I wanted to mention. So, many men keep health changes to themselves. Obviously, we know that. So 43% of men would not discuss frequent erectile dysfunction they're experiencing with their partner, and 41% of men would not discuss painful erections with their partner. But then when it comes to more stronger issues, they might bring it up, so like 67% of American men would see a doctor right away for blood in their urine, and 46% of men would see a doctor promptly for painful erections. So I want to talk about that a little bit. Why do you think that is, and do women play a role?

Ryan Berglund: Well, you know, this is the third year of our survey. So MENtion it, so M-E-N, T-I-O-N. MENtion it. Mention if you have a problem. And so the first couple of years were looking at men and why they don't seek healthcare, and we all kind of sort of know these things, but the fact is that men, as our past surveys proved, they don't want to bother people. It's considered not manly to talk about health problems, and as some of the issues that you discussed, talking about erectile dysfunction. It's embarrassing. People don't like to admit that they have it. They don't like ... It's kind of a taboo subject.

Ryan Berglund: So this year we wanted to look at the role that women play in that decision making process because we know that ... I mean, I can tell you in my own personal relationship, my wife hassles me about going to see the doctor, and I'm not the best about it, I'll admit it. We're trying to figure out why men don't go and then what role women can play in the process. Over 80% of women tell us that they have pressured in some way their male significant other to go see the doctor. And then we look at the men, a third of them say they're too healthy to go see the doctor, which we know is completely incorrect, and then over half of them admit to not seeing the doctor regularly, even when they know that they have a problem.

Ryan Berglund: So one of the questions I get is, how do we fix this problem? And I think that that is a question which I don't necessarily have all the answers to.

Nada Youssef:   Right, right. All we could do is educate, right?

Ryan Berglund: Yeah. You know, that's it, and one of the things that comes up is that oftentimes men don't go to see a doctor until they really have a problem, until they're having chest pain or there's slurring of the speech or there's blood in the urine, et cetera. So one of the things we're encouraging men to do is to be more comfortable establishing a relationship with a primary care physician, someone who can be the quarterback of their care.

So I'll very frequently have a man show up with a significant medical problem, and they don't have a primary care physician. I have no primary care physician to send a letter to, et cetera. So the primary care physician may not be able to manage the kind of complicated urologic problem, but they would be the one to determine there's a problem and then send you in the right directions.

Nada Youssef:   Sure, sure. Great. Well, I wanted to talk about one of our Cleveland Clinic Health Essentials posts. You mentioned some questions that men are afraid to ask their doctors, so I kind of wanted to go over some of these. So first question, can a man break his penis?

Ryan Berglund: The answer is yes, it's called a penile fracture. We have a funny photograph that kind of circulates ... And it's on the Internet too. If you Google it, you'll find it ... that's an X-ray that shows a ... You can kind of see a penis in silhouette and then a broken bone in the middle of it. And just to be clear, there is no bone in the-

Nada Youssef:   I was going to say. Yeah.

Ryan Berglund: ... human penis. And interestingly, there are species that do have bones in their penis. So the whale, the walrus, the raccoon, the dog, but we in fact do not have a bone in our penis. So the question is, well, what are you breaking? And there's actually a layer of tissue called the tunica albuginea, very strong layer, which is what allows for the erection to become rigid, that during certain types of kind of vigorous intercourse can break. And when that happens, we tend to see something that's called the eggplant sign. You can imagine what that means. The penis looks like a big eggplant. Because when that layer ruptures, the-

Nada Youssef:   Swelling and-

Ryan Berglund: You bleed into the subcut tissues, and the penis swells up and kind of looks like an eggplant, and that is a surgical emergency. It needs to be repaired, so that is a reason to come in and seek help. Now, people will frequently talk about I heard a snapping or a popping during intercourse. Without seeing that kind of effect, it's probably just something else that caused that noise, but it wasn't a fracture.

Nada Youssef:   And I would imagine it would be extremely painful if you actually break it.

Ryan Berglund: Extremely. It is painful. And-

Nada Youssef:   Okay. So you would know if it's just a noise and-

Ryan Berglund: It's not subtle. It's not subtle when it happens.

Nada Youssef:   Okay.

Ryan Berglund: Sometimes after intercourse they'll notice some blood in the urine as well. That could mean that the fracture involved the urethra.

Nada Youssef:   Okay. And jumping onto the next question, erectile dysfunction in young men, is it normal?

Ryan Berglund: So, erectile dysfunction itself is actually very common, and your chance of having some degree of erectile dysfunction is roughly equivalent to your decade of life. So men in their 50s, about 50% of them will have some degree of erectile dysfunction, but what we're talking about is profound erectile dysfunction. And by erectile dysfunction, there are a lot of things that we call sexual dysfunction, but erectile dysfunction is specifically referring to the inability to obtain and maintain an erection sufficient for intercourse. So men under the age of 50, in men under the age of 50, it's uncommon to have profound erectile dysfunction, and there's a high correlation between erectile dysfunction and cardiovascular disease.

Ryan Berglund: So over half of patients that are getting bypass surgery for heart disease have erectile dysfunction. Two thirds of patients that have a heart attack have a coexisting erectile dysfunction. So ED can be a sign of heart disease, and a young man that has ED, in addition to the fact that it can be embarrassing, it can cause problems with relationships, it can also be a sign of cardiovascular disease. That's when you need to see your primary care physician. Dietary screening, family history, blood pressure, checking all of these things that can potentially be managed.

Nada Youssef:   Sure, and then what about if a penis has acne or spots on it, and I know we talked earlier and you said that was one of the most popular questions that maybe you're getting in your practice, so maybe we can talk about that.

Ryan Berglund: So everybody has spots and bumps on their penis, and that's, in most cases, normal. The question is, when are these abnormal? I see patients all the time. Nine times out of 10 they're normal, but what should we be concerned about? All sort of lesions are a concern. So anything that is eroding the skin, so painful erosions. That can be anything from ... It can be a sexually transmitted disease like herpes. Non-painful can also be sexually transmitted disease. The classic example there would be syphilis. And then of course truly erosive lesions can represent penile cancer.

Ryan Berglund: Now, in everybody that comes in with something on their penis, the first thing they'll worry about is, do I have penile cancer? And let me be very clear about a couple of things with penile cancer. Penile cancer is uncommon in the United States. It's actually uncommon in countries that have high rates of neonatal circumcision. It is exceedingly rare, almost unheard of. Let's just put it at exceedingly rare for an individual that has neonatal circumcision to develop penile cancer.

Ryan Berglund: Interestingly, having a circumcision later in life is not protective against penile cancer, but penile cancer is very unusual in the United States. It can happen. It tends to be an erosive lesion, something that is causing destruction to the surrounding tissue. Now, some early stages can present more as kind of reddish rashes, a little bit of weeping rashes, et cetera. It's always good to have a professional take a look at it, but in the third world, actually, penile cancer is actually fairly common.

Nada Youssef:   Common?

Ryan Berglund: Yeah.

Nada Youssef:   So how about testicular cancer, and how old should a man be to get tested?

Ryan Berglund: So there's no argument that women should do a monthly breast exam, and it's tricky because someone who's not an expert in doing a breast exam may not be able to find a subtle nodule, but women should conduct a monthly breast exam. We do recommend that men conduct a monthly testicular self-exam, and the population that we're most concerned about is the age from 15 to 45. Testicular cancer is the most common cancer in men from 15 to 45, and it tends to present as a painless mass in the testicle. Now, there are exceptions. Some people can have painful masses, and there's always a question about whether or not it's inside the testicle. You will feel masses and other things outside the testicles. Some of those are normal structures like the epididymis. Sometimes you can have cysts, et cetera, that are in some of the surrounding tissue, but you should not have a mass in the testicle.

Ryan Berglund: Testicular cancer is a true success story in cancer treatment in the United States. Well over 90% of patients who develop testicular cancer will end up being cured of their disease, and so early detection and treatment can save lives. And so a monthly testicular self-exam is advised, and the easiest way to do it is do it in the shower once a month.

Nada Youssef:   Yeah, just like women, just like you mentioned.

Ryan Berglund: Exactly.

Nada Youssef:   But you're saying for men to start at 15?

Ryan Berglund: It is the most common cancer in men for 15 to 45.

Nada Youssef:   Wow. That's very young.

Ryan Berglund: It's uncommon ... It's certainly possible, but it's uncommon in the pre-pubescent male, and it is uncommon in the older male, but we can see cases in both groups. So I'm not saying that those groups don't need to examine themselves, but that 15 to 45 age range is kind of the sweet spot of where testis cancer occurs.

Nada Youssef:   Okay. What about if a woman can transmit a UTI to a man during sexual intercourse? That was a question-

Ryan Berglund: I get asked this-

Nada Youssef:   ... that I saw that a lot.

Ryan Berglund: I get asked that all the time.

Nada Youssef:   Yeah.

Ryan Berglund: Women have a greater propensity to getting urinary tract infections because number one, the vaginal flora includes bacteria that lead to infection, number one. Number two, the female urethra is very shortened, and so it's easier for bacteria to track via the urethra up into the bladder. The male urethra is much longer. It's harder for bacteria to get into the bladder, and frankly, urinary tract infections in men tend to represent other disorders. So for instance, obstructive urination from an enlarged prostate.

Ryan Berglund: But transmitting E. coli from a female urinary track infection to a male, it's not really ... That's not the way it works. Now, women and men can transmit sexually transmitted diseases to each other. So not urinary tract infections, but let's look at sexually transmitted diseases like urethritis, so gonorrhea, chlamydia. Those are easily transmittable between men and women, but that's not going to be your standard urinary tract infection.

Nada Youssef:   Sure. Now, if someone is worried about that, how often ... or how fast do you go get checked out if you think you have a sexually transmitted disease, because I know some show later. I heard in your radio show.

Ryan Berglund: It's a problem. It's a problem. Latency.

Nada Youssef:   Right.

Ryan Berglund: Latency. So a number of the tests that we have for different sexually transmitted diseases include tests that test for an immune response to the bacteria or virus, or test for the presence of the virus or the bacteria first, and with the initial infection, you may not actually see sufficient numbers of the bacteria or virus to be able to get a positive result or you may not have enough time to see an immune response.

Ryan Berglund: So if you have a high risk exposure, number one, you should avoid ... Just maintain some type of barrier protection until you've had time to get tested, and then testing really a minimum of a month or two after the exposure.

Nada Youssef:   Okay.

Ryan Berglund: So that's a good question.

Nada Youssef:   Now, I am getting some live questions, so I'm going to get some questions before I keep going on here. I have Marie. Can you discuss frequency of urination for prostate cancer patients with a secondary disease of diabetes?

Ryan Berglund: Oh, that's great question. Fantastic question. One of the interesting things about prostate cancer is that, in general, by the time you have symptoms from it, it's usually too late. So if you look at the pre-PSA or ... PSA is the screening test for prostate cancer. It's been called the male mammogram, but if you look at the pre-PSA era, most of our patients being diagnosed with prostate cancer were being diagnosed with symptomatic disease, and it was incurable at that point. So the prostate cancer that we're trying to diagnose these days, we're usually not having urinary symptoms. Urinary symptoms from prostate cancer would be a late phase of disease, and oftentimes, you have other symptoms. Pelvic pain, bony pain, something else like that.

Ryan Berglund: So I would not look at urinary symptoms as being a sign of prostate cancer so much as either as a sign of prostatic problems, prostatic enlargement, which is usually benign, or in this case with diabetes, diabetics can develop a diabetic bladder, or essentially neurologic and muscle related problems that the diabetes itself is causing on the bladder.

Nada Youssef:   Now, how about blood in urine? Does that mean then something's too late too?

Ryan Berglund: Great, great question. So blood in the urine is the most common presenting symptom of bladder cancer, and visible blood in the urine, roughly 20% of patients that have visible blood in the urine will end up having a bladder cancer. So certainly seeing blood in the urine should be worked up for bladder cancer. Now, interestingly, most of the time we see a patient with visible blood in the urine, we can't find the cause of the blood in urine. So the point of the workup is to make sure that you don't have a bladder cancer.

Ryan Berglund: Now, the next question there though is what about microscopic blood in the urine? Microscopic blood in the urine has a much lower rate of having bladder cancer, about three to five percent, but we still do recommend a workup because bladder cancer, like prostate cancer, if it's diagnosed early, is much easier to intervene and successfully treat.

Nada Youssef:   Sure. Now you said 20%, they would be getting bladder cancer. What about the 80%?

Ryan Berglund: So 80%, sometimes we'll find another cause. We see bleeding from the prostate or we see a little blood ... People can have a proverbial bloody nose of the bladder. So a little blood vessels, a stone, something else that's caused it, but most of the time we don't find the cause the blood in the urine. We're just trying to make sure it's not a bad cause, not a bladder cancer.

Nada Youssef:   All right, and then I have Felicia. What can be done for enlarged prostate?

Ryan Berglund: The answer is a lot, and that field has really grown. It's a very, very common problem. The prostate tends to ... The prostate is located at the outlet of the bladder, and growth of the prostate tissue can block the flow of urine outside the bladder. And so this obstruction can lead to symptoms like frequent urination at night, weak stream, difficulty emptying the bladder, and at some point can ultimately lead to the complete inability to empty the bladder.

Ryan Berglund: The first thing we do is we try behavioral modifications, limiting fluid intake at night, limiting bladder irritants, so spicy foods, caffeine, et cetera, but if those don't work, and they frequently don't, we then go to medications, and we have two broad categories of medications that can help. Alpha blockers, which will relax the muscle tissue that's in the prostate to relieve some of that obstructive effect of the prostate, and then 5-alpha-reductase inhibitors that shrink the prostate over time.

Ryan Berglund: If those don't work, we can actually go forward with interventions. We actually have minimally invasive techniques and larger surgical techniques that we can use to either reduce the size or even completely remove the obstructing prostate tissue to allow emptying the bladder.

Nada Youssef:   Great. And then Steve says, "I saw a commercial about smoking causing ED. Is that true?"

Ryan Berglund: Absolutely.

Nada Youssef:   Smoking causes everything, so I was like ... But yeah, so that's one big risk factor.

Ryan Berglund: Steve, that's a great question. I'm glad you brought it up. Smokers frequently experience ED for the same reasons that they have a higher rate of having heart disease and stroke. It causes disease of the small blood vessels that lead to the penis, which lead to erectile dysfunction, just like they lead ... just like smoking leads to the disease that narrows the artery in our heart or can narrow the arteries that go to our brain.

Nada Youssef:   Okay. And then Christopher. I have a dribble after I pee. Is that normal? What causes it and what should I do?

Ryan Berglund: So that's frequently called terminal dribble. That is a very common sign of an enlarged prostate. So if that's your only presenting sign, some people will say, "Ah, you know, just stand at the toilet a little bit longer," and they're okay with that, but some people it gets really significant to the point that it's causing some hygiene problems or getting urine in the underwear, and that would be a reason that people would proceed with treatment for BPH and treatments or medications, with the possibility of a procedure down the road.

Nada Youssef:   All right. I'm going back to some of my questions here. So is it Peyronie's disease?

Ryan Berglund: Peyronie's, yes.

Nada Youssef:   Peyronie's. So what is that and why is it a concern?

Ryan Berglund: Peyronie's disease, and very frequently I'll have patients with Peyronie's disease present in my clinic concerned they have penile cancer, and the first thing that we notice about Peyronie's disease is Peyronie's disease is a lump or bump that is inside the penis that is not on the outside, it's not an erosive lesion or an ulcerative lesion, and it's essentially a plaque of that tunica albuginea, that strength layer over the penis that allows us to have erections, the part of the penis that can get fractured with a penile fracture.

Ryan Berglund: When you develop this scar tissue, normally this tunica albuginea is very strong, but it's also very elastic, which allows for the characteristics of a normal erection. When you develop a scar tissue, it is not very elastic. It's strong, but not very elastic, and it can lead to curvature of the penis, pain with intercourse, narrowing of the penis, and an erectile dysfunction.

Ryan Berglund: So it can be treated, but the question is, do you have a problem that needs to be treated? So there are a number of treatments available, surgical and also now a treatment that can break down the scar tissue, but all these treatments have risks, so we tend to treat patients that have significant curvature that's caused by the Peyronie's and curvature that leads to an inability to engage in satisfactory intercourse. So-

Nada Youssef:   Does that include surgery or ...

Ryan Berglund: Surgery is one approach. The most common treatment we have right now is to inject a collagenase, a drug into the plaque that breaks down the plaque. But I'll have patients come in who will ask me, "Well, why wouldn't I just treat it? I can feel that there's a plaque there." The problem is that that treatment can potentially lead to rupture, and so you don't want to take ... It's a low risk, but you don't want to take that kind of risk if you're already having satisfactory intercourse, so that's the whole idea there. It's also a fairly expensive treatment as well.

Nada Youssef:   All right. And then I want to talk about, is it normal to feel something in the testicles or scrotum, and what is normal and abnormal?

Ryan Berglund: And this goes back to, what are we really looking for? The biggest concern would be testicular cancer. Testicular cancer is a mass in the testicle. So if you feel the testicle, it resembles kind of like a little bit like a hard boiled egg. You shouldn't feel irregularity, a nodule, some kind of distinct hardness that is inside the testicle. But there are a lot of tissues that are outside the testicle that are totally normal. So for instance, the epididymis, which is the sac that collects the sperm that's produced by the testicle, and actually is the location where the sperm matures before it goes to the vas deferens and ultimately out to the ejaculate fluid. That's a normal structure to feel outside the testicles. So we'll have a lot of patients that come in and say, "Hey, I've got a mass in my testicle," and you actually feel it, and you feel the testicle and it's normal, but you feel the sac-like structure outside the testicle. That's normal.

Ryan Berglund: The epididymis, though, can develop cysts. They're very common. They're almost always benign. Very uncommonly we'll have a solid mass, and those, while rare to be cancerous, can potentially be cancerous, and occasionally we do need to, at a minimum, monitor, but sometimes remove them. You can develop masses outside of the complex of the testis and the epididymis in other areas of the core. Those can very easily be evaluated on physical examination and ultrasound, and rarely some of those masses will be solid and need to be removed. You can get rare, tumor-type sarcomas, et cetera, there, but most of those are going to be benign.

Nada Youssef:   Okay, great. Thank you. And then I have one more question. What about hemorrhage cystitis-

Ryan Berglund: Hemorrhagic cystitis, yes.

Nada Youssef:   Blood in the urine, yup. I'm not going to even know. Is it JCV-

Ryan Berglund: Oh, yeah. Virus. Viral.

Nada Youssef:   Yes, in an immune-suppressed patient. What is suggested?

Ryan Berglund: There are some antiviral agents that can be used in the immunocompromised patient. Hemorrhagic cystitis is essentially an inflamed bladder that's bleeding, so you could imagine an immuno-suppressed patient, they're susceptible to certain viruses because their immune system's not completely intact. Their immune system is being suppressed to protect their transplanted organ, so they're more susceptible to getting viral infections.

Ryan Berglund: So some of those patients do require antiviral treatment, but in the ... And that would be under the care of a transplant team and a transplant infectious disease specialist. You would want to make sure that there's no tumor there, that you have sufficient imaging and endoscopic evaluation. Make sure there's not a tumor present.

Nada Youssef:   Great. Well, we're running out of time, but I kind of wanted to give you the floor and kind of tell the men watching or listening, or the women that have men in their life that they are concerned about, what should a man do, when they should get tested. Is there an optimal diet, anti-inflammatory? Just whatever you think is-

Ryan Berglund: Really, first and foremost, have a relationship with a primary care physician. You don't need to ... Particularly in the younger years, you don't need to see them every year, but certainly in your 20s you do need to have some kind of risk assessment of cardiovascular disease. The critical time to start seeing your primary care physician on a regular basis, really in your 50s. Certainly for screening for prostate cancer, certainly for screening for colon cancer, and earlier in patients with a genetic predisposition.

Ryan Berglund: You know, guys, we're all guilty of this. I am too. We don't like to go see the doctor. We don't like to bother people with these problems. The problem of course, though, is if you're waiting until you're having symptoms from prostate cancer or colon cancer or heart disease or stroke, it usually is too late. So if you wait till you had your stroke to see the doctor, that is an irreversible phenomena in many cases. Same with a heart attack. If you're waiting until you have bone pain from prostate cancer, that usually is too late. And the fact is that, for instance, with prostate cancer, which I routinely treat, if caught early, it has very ... There are very high success rates and very low mortality rates, caught at an early stage.

Nada Youssef:   Sure, sure. That's good to know. Thank you so much for being here today.

Ryan Berglund: Thanks for having me on.

Nada Youssef:   Sure thing. And to explore tips from our experts and learn why you should confide in your doctor when you first notice symptoms, please visit our website at www.clevelandclinic.org/mentionit. And for the latest health news and information from Cleveland Clinic, make sure you're following us on Facebook, Twitter, Instagram, and Snapchat @clevelandclinic, one word. Thank you again. We'll see you next time.