Mens Health Concerns with Dr James Ulchaker

Podcast Transcript

Nada Youssef:  Hi, thank you for joining us. I'm Nada Youssef, your host for today, and today we are taking your questions regarding men's health issues, in honor of Prostate Health Awareness Month. Make sure you leave your questions down below in the comments section, and we'll read them live. September is Men's Health Awareness Month at Cleveland Clinic. Our goal is to have men put sports talk on hold, and get them talking about their health. In a recent Cleveland Clinic survey, we found that only 61% of men visit the doctor's office when a problem or symptom arise, and about 32% of these men don't talk to their families about their health because they don't want to worry them. Our goal is to help men open up about these matters, which are their health. So join the conversation today with our discussion, with a hashtag #MENtionit, and today we have Dr. James Ulchaker, professor and vice chairman of urology of the Cleveland Clinic to answer your questions. But before we get started, again please remember, this is for informational purposes use only, and this is not to replace your own physician's advice.

Thank you so much for coming in today.

James Ulchaker: Thank you for having me.

Nada Youssef:  Do you want to go ahead and just introduce yourself to our viewers?

James Ulchaker:  Sure. Good afternoon. As you can see, we have a beautiful mid-September here in Cleveland, OH, which we are very thankful for. My name is Jim Ulchaker, I have been here on staff at the Cleveland Clinic now for 21 years. The areas that I concentrate on mostly in my care for patients is in prostate cancer, bladder cancer, and I'm in charge of male voiding disfunction here at the clinic. I welcome to, again, answer questions or concerns, here as a resource for you. Let's get started.

Nada Youssef:  Awesome, thank you. Well, let's get started with Henry's question. What are some of the food or supplements to help my prostate health?

James Ulchaker:  Ah, that's a good question. There are many over-the-counter supplements which are available, but understand that because they're supplements, none of them need to go under FDA approval or studies, and so there's very little data on many of these. Saw palmetto is probably the most common, and the most common dosage that saw palmetto is used is, it usually comes in 116 mg or so capsules or tablets, and 320 mg a day is the most common dosage. It may help in some mild voiding dysfunction, again, but some of the studies from Europe don't show that there is a lot of benefit to it.

Nada Youssef:  Sure.

James Ulchaker:  There have been many studies that looked at zinc. Zinc has kind of fallen out of favor, doesn't really do a whole heck of a lot.

Nada Youssef:  Mm-hmm (affirmative)

James Ulchaker:  One time it was felt that lycopenes, which is a substance that's released in cooked tomato products, may lead to potentially less prostate cancer and potentially even some voiding benefits. That's been refuted.

Nada Youssef:  Okay.

James Ulchaker:  At one time, vitamin E was thought to be of benefit. That's also been refuted. In fact, we now know that vitamin E actually can cause some increased cardiovascular negative effects, so we definitely do not recommend excess vitamin E. Again, some of the other prostate supplements, I'm not going to name any particular ones by name, but again, understand they maybe have some mild benefit, but in many men, it will be of not very much benefit whatsoever.

Nada Youssef:  Okay, great. I have Brian, "I've had prostate cancer that was successfully treated, with a combination of Lupron and radiation therapy that ended in February 2016. I had my last shot in May. Is it possible to receive testosterone to offset the side-effects of Lupron?"

James Ulchaker:  Well, Brian, good luck. I'm glad that your treatments have gone well, and you think that they have been successful. Brian, I'll be honest with you, with the information that I have, I can't really tell you whether or not it's going to be safe or not to do that, to go on testosterone. One, normally a man is on a combination of LHRH agonists, Lupron being one of those, which for those of you who may not know, Lupron is actually designed to decrease the amount of testosterone in the system. It's used normally in higher-grade prostate cancer treatments, along with external-beam radiation.

I'll call it almost like the Mohammed Ali theory of prostate cancer treatment. The hormone therapy is kind of like a constant jab, jab, jab, jab, and then the hormone therapy is like the right cross to try to knock out the prostate cancer, but again that's normally only for higher grade prostate cancers, and we normally don't want to start people on testosterone really right away after, because again, testosterone kind of serves like fertilizer for prostate cancer. We don't want that actively growing. So, that's one I would tell you, you probably want to wait a little longer till your PSAs are lower. That's something maybe you can consider a few years out, but that's one I think I would discuss with your urologist and your radiation therapist, and get their opinion really on that.

Nada Youssef:  Awesome. Jumping from prostate to bladder, I have Mimi with a question here. "When is it appropriate to treat stage three bladder cancer with chemo before bladder removal?"

James Ulchaker:  That's a good question. It's called neoadjuvant, or before definitive treatment chemotherapies. That was really the standard of care in Europe for many years before, and there are studies which show that for certain types of bladder cancers, that there may be of some benefit to it. Where you may have a longer disease-free survival, if you get the chemotherapy up front and then the surgery. If there's any small, microscopic areas of spread, the chemotherapy tries to take care of that area first, and then kind of like a clean-up is what the surgical management then is.

The problem, or the difficulty with it, depending on how healthy or what other comorbid conditions an individual may have -- that one's not just for a man, because women get bladder cancer as well. That is, that you gotta be able to receive all of the doses of the chemotherapy up front, and still be healthy enough to have the bladder removed. What we call your performance status, or how healthy you are at the time of diagnosis and in the early treatment may dictate the different type of cancer. For transition cell stage-three bladder cancer, there may definitely be a role for the chemotherapy up-front, but there are some varieties of bladder cancer, some different cell types of bladder cancer where, again, that may not necessarily be the optimal option. That as well, you're going to want to discuss with your medical oncologist as well as your urologist, because those are the two individuals that are gonna be really dictating and evolved, or giving you your best options for your care. That's a great question.

Nada Youssef:  Thank you for that. We have Ryan, "It takes me a long time to pee, and it takes a while to start. Should I be worried?"

James Ulchaker:  That's again, falling right in the area of what the majority of my practice is. We call that hesitancy, where you have the feeling to go to the bathroom, and you try to go to the bathroom, and you're just not able to really get it started. That's a bigger issue as well if we find out that you're not emptying your bladder. Again, if you're not emptying your bladder, one of the concerns or the risks or the sequellae of what we call urinary retention. Those sequellae may be bladder stones, those sequellae may be infections, and eventually one of the big things we try to make sure is that there's no significant back-up of urine in your kidneys that develops where it can lead to potential renal, acute kidney injury or chronic kidney injury, and subsequent dialysis, in severe forms. Now, I'm not saying that that's necessarily your case, but I'm just giving you what the potential sequellae may be. If it takes you a long time to pee, the question then becomes, is it because your prostate is too big and is block the stream, or is it that your bladder may not be pushing as well and contracting as well to drive the urine out.

Again, if it becomes a major issue in your life and is bad enough, I would seek some help from a healthcare professional. Maybe your primary care doctor first, who may be able to check a residual value or ... It's called a bladder scan, a small little device that is handheld that will tell us how much is left in your bladder. Again, if it becomes severe enough or your symptoms are bothersome enough, you may want to see your urologist, depending. There are both medical options and procedural, surgical options which may be of benefit to you.

Nada Youssef:  Great. Jim has actually, a question about dripping after you pee. "How do I make it stop, and is it something to worry about?"

James Ulchaker:  Again, one of the questions is, Jim, are you emptying your bladder or are you not? Again, we don't know. A couple of things that you may want to consider doing. Number one is, many men may have what's called a post-micturition or a post-void bladder contraction, where the bladder wants to contract even though you don't necessarily want it to after you're done urinating. One of the things that we tell guys often, if this is the case, is that you may just want to wait twenty or thirty seconds after you're done urinating, see if you have one of those to try to avoid that, so the urine comes out in the toilet before you put yourself away and it comes out in your underwear. The other thing that you may want to consider, is actually you can milk the prostate, and that's the area where the perineum is, between the scrotum and the rectum, and if there's any trapped urine there and milk it forward, that may decrease some of the post-void residual. You still gotta make sure whether or not you're actually emptying your bladder adequately or not.

Nada Youssef:  Excellent. I have Aaron, "What is the best treatment for low bladder pressure?"

James Ulchaker:  That's a great question, Aaron. We have a lot of great drugs that are designed for high bladder pressures. We have drugs that help the bladder, called anticholinergics, that help the bladder to stop some of the contractions of the bladder. The biggest problem with those, is that those side effects are dry mouth and constipation, and some men find -- and women, to -- find that to be worse than the symptom they had. There's also another class of drugs called the beta-3 agonists, which actively relax the bladder, and they don't have quite the same negative side effects. There are some, a little bit of side effect that they may have, but much lower percentages and people tolerate those drugs. Unfortunately, we don't have any great drugs to help the bladder to contract better. There were some drugs at one time that were in development, but it hasn't been made specific enough for the bladder, so it made the bowels contract differently and people got cramps. It could make the heart or the lungs contract differently, and make it more difficult to breathe. There's too many cross-reactivity organs that it affects, so I don't have any drugs to make it contract better.

Oftentimes, for very weak bladders, one of the things we try to do is to try to -- through procedures or at times, medicines, but more often procedures --- to decrease the outlet resistance, that the prostate may offer. So it may take less bladder pressure to try to drive the urine out. It's a plumbing issue, but I don't have any meds to help. There are some older meds, but they just don't work very well. I don't have any great drug that helps the bladder contract better.

Nada Youssef:  Great. We're jumping on to Matt's, "I've been getting up a lot during the night. Is that something to worry about?"

James Ulchaker:  Again, Matt, I don't know what a lot is. I can tell you this, that it's normal for a sixty-year-old man to get up once, a seventy-year-old man to get up twice, an eighty-year-old man to get up three times. That's what we kind of consider the norms. Understand, nighttime frequency, I say that it's multifactorial There's a lot of things that contribute to men getting up at night, it isn't necessarily just urologic or prostate. For example, we know that men who have sleep apnea oftentimes will get up more times at night. It's not really their urination that's getting them up, they get up for other reasons and then go urinate. Two, we actually make more urine at night than we do during the day. That's because, especially as we get older, more fluid, because our veins just aren't as... Well, they don't work quite as well. They leak a little more fluid, and there's more fluid that may pool in our lower extremities during the day. At night, when you lie down at night, that fluid gets back in circulation, your heart and your kidneys say, boy, I got too much fluid, I'm bored, let's get rid of some of this fluid. Subsequently, you make more urine.

Again, there can be cardiovascular reasons why you retain some of that fluid. Some of the easy things you may want to do is watch your fluid intake after dinner. What goes in, has still got to come out. Number two is you may want to watch your caffeine and your alcohol intake, in the evening hours especially. We know that caffeine is the number one bladder irritant that exists, so you are going to go more urgently and more frequently with caffeine. Caffeine mostly is in coffee, tea, iced tea, soda pops, and then alcohol. Alcohol works a little bit differently. The kidneys aren't able to reabsorb water the same way with alcohol, so you're going to make more urine when you have alcohol. I'm not telling anybody, not necessary to have coffee or alcohol, what I'm saying is A, if it's bothering you and you're having some of the negative side effects from it, that may be a lifestyle modification you may want to make to lessen those, especially in the evening hours.

Nada Youssef:  Now, if Matt is under sixty years old, going more than once a night is abnormal?

James Ulchaker:  Well, I don't get upset too much if somebody's getting up once a night. Again, if you're going more often, whatever ... Some men are able to fall right back asleep, so it's not necessarily a big issue or big problem. One of the things that you consider is, a, are you emptying your bladder well or not? If you have a cup and you're only able to urinate half the cup, it doesn't take you as long to fill back up again to want to go to the restroom. Another reason why a man may want to seek some medical guidance, if it's a problem in his life.

Nada Youssef:  Great. Sergio, I think we kind of touched on this a little bit, but Sergio's asking, "Sometimes it feels like I have to go pee really bad, but then when I go only a couple drops come out."

James Ulchaker:  One of the questions is, Sergio, I have no idea how well you're emptying your bladder. Again, if you're just emptying to take the pressure off but you're still retaining a significant amount of urine, that's something you may want to see a healthcare professional about.

Nada Youssef:  I have Said, "What are the most common tests or treatments for erectile dysfunction, ED?"

James Ulchaker:  So, Said, a lot of times there isn't a whole lot of tests or testing that is actually done before some treatments. By far, the most common way that ED is treated in this country is by oral medications. There are medications which are out there that are designed to give you better, longer-lasting erections. One of the big reasons why some of these drugs actually don't work is, a, the timing and how they're taken by patients. So in the majority of them, you want to take them about sixty to ninety minutes before you want to have an erection, on an empty stomach, with no alcohol. That's how these medications work the best. We know as well that some of these medications may not work as well in diabetic males, as well.

Sometimes we have to go to second-line therapies. The majority of the second-line therapies will consist of, we call it a vacuum-erection device, which is a pump system, so to speak, that you put over the penis. It creates negative pressure in the chamber that allows more blood flow into the penis, and a constriction band is placed at the bottom to maintain the blood in the penis. There is injection therapies, where you're able to inject a small amount of specific medications into the shaft of the penis. That actually gives a very good erection as well. Lastly, and in more severe forms -- or when the other therapies don't work -- there's what is called a penile prosthesis, which is a silicon device which is surgically placed, and then men are able to achieve an erection in that fashion. Those are the most common ways that erectile dysfunction is treated in the United States.

Nada Youssef:  Great. Awesome. I have Jim, "Does what I eat matter when it comes to ED?"

James Ulchaker:  Does what you eat matter when it comes to ED? I mean, it can, but it's more what you drink may affect erectile dysfunction.

Nada Youssef:  Okay, good to know.

James Ulchaker:   We know that alcohol is a big thing, and so that's really one of the biggest that we ingest ourselves. I normally tell my guys, do it the opposite way of what we normally do socially, and I'll say, take your erectile medication at 4:30, have some fun at six o'clock, then have a drink and go out to dinner. Societal-wise, we'll often have a drink, go out to dinner, and then come home and have intercourse, and again, if you're going to take the medicines, it doesn't work as well with alcohol, it doesn't work as well on a full stomach. So that's one.

In terms of actual foods, we do know there's a significant correlation with our metabolic index and what I'll say, and erections. When a man is in the optimal health that they can be in, so a heart-healthy diet is a prostate- and a penile-healthy diet, because again, if we have blockages in our coronary arteries, etc., and we know that high-fat diets and -- again, I'm not a dietitian expert -- that those substances, such as fat, some animal fats, can clog the coronary arteries, they can also decrease the size of our iliac and our various other arteries that supply blood flow to the prostate. Proper exercise, get yourself in good shape. We know that some medications as well, diuretics are big things that decrease erectile abilities. That, you'll want to check with your healthcare provider as to whether some of those medications you're ingesting as well may be leading to some of your erectile dysfunction.

Nada Youssef:  To piggyback off of that, I know we're taking about physical fitness but what about psychological effects? Could that affect...?

James Ulchaker:  Absolutely. We know that it's a continuum, both erections and ejaculations, of a physical effect, a psychologic effect. If a man is under extreme stress, whether it's work issues, whether it's home or family issues, whether it's anything -- a big exam, a change in their job, whatever it may be. Absolutely, even that psychogenic stress can definitely lead to some ... You have to be able to relax in order to be able to achieve a good erection.

Nada Youssef:  Excellent. Jumping onto bladder again, I have Amber, "My brother had his bladder removed because of cancer. Is there any way to reconstruct a bladder other than a peg?"

James Ulchaker:  Yes, absolutely. Let's first talk a little bit about bladder cancer in and of itself. We actually know that the number one cause of bladder cancer by far is cigarette smoking. It's actually one of the highest correlated cancers to cigarette smoking. I use an analogy of, if you're smoking a cigarette, your lungs see smoke for about eight minutes or however long it takes to smoke the cigarette, but many of the toxins that are inhaled and get into the bloodstream are actually filtered by the kidneys. Those toxins then get in the urine and constantly bathe the lining of the bladder of the urine. It's also very rare for a man or a woman to urinate completely, and even when you do, the urine fills back up slowly, so the bladder wall or the transitional cells are constantly seeing that toxin, twenty-four hours a day, seven days a week. That's why it's one of the highest correlated cancers to cigarettes.

For advanced cancers, invasive cancers, and certain high-grade cancers which have a very high probability of spreading, one of the treatment options is to have the bladder removed. But the urine has gotta go somewhere, and historically oftentimes, it went into what was called an ileal conduit, where we took a small piece of the ilium, which is the last segment of the small intestine, and plugged the ureters in here and made what was called a stoma -- I think that's what she's talking about -- that goes to the outside. Yes, in 2017, in many cases we have the ability where we're able to build a new bladder. Most commonly, it's called a Studer pouch, named after Earl Studer, a very prominent European urologist, very good man actually. In that particular procedure, you take out significantly more, about sixty centimeters rather than twenty, of the small intestine, and you do what's called detubularize it. You turn it from a tube and you make an incision, and it becomes a patch. You then fold the patch on itself to create a bigger patch, then you fold up the bigger patch to try to create a ball, and then hook the ball back up down to the bottom. In order to do that, you gotta make sure, a, there's no cancer on the bottom, or you take it off.

Two, a gentleman's gonna be -- or a lady -- is gonna be healthy enough to be able to have sixty centimeters of their intestine removed rather than twenty. It takes about an hour and a half to two hours long to do the procedure, and again, if you can't hook it up to the bottom, sometimes you're able to hook it up and you do what's called a catheterizable limb, and that's another way. Yes, we are able to build pouches now, so you don't necessarily have to wear a bag on the outside.

Nada Youssef:  Excellent. Time for just one more question. I have Aaron, "Can adult bed-wetting be cured by bladder therapy?"

James Ulchaker:  At times. Again, some of it can be improved by setting alarms, so you make yourself get up once or twice a night before your bladder gets too full, and you're able to avoid that. Two, maybe medications. We talked about some of the early medications, there's also medications such as Botox, such one called PTNS, peripheral tibial nerve stimulation, which is actually a procedure, not a medicine. There's another one, and a new form is coming out, it's basically DDAVP -- I'm not going to get into all the things -- but it basically stops urine from being made during that time. As well, watch your caffeine intake, watch your alcohol intake, sleep apnea, different things. Make sure you can do yourself, from a behavioral standpoint, the best you can. If after you make those changes, you're still suffering from some bedwetting, then seeking some care from a urological healthcare expert may make some sense.

Nada Youssef:  Excellent. This has been very interesting. Thank you. Is there anything, any last words that you would like to leave our viewers with?

James Ulchaker:  Again, guys, don't be afraid to come to the doctor. Remember, the number-one reason why many of our men come to the doctors is because their women or significant other in their lives tell them to go to the doctor.

Nada Youssef:  Making them do it, right.

James Ulchaker:  Don't be afraid, we're not going to bite you. We're only out for your best interest, and to try to both improve the quantity of your life and try to help the quality of your life. We're here if you need.

Nada Youssef:  Excellent. Thank you. For more health information, especially about men's health, visit clevelandclinic.org/mentionit, and join the discussion on social media using the hashtag #MENtionit. Thank you so much for watching us, and we'll see you next time.