Archive for June, 2012

A Kegel A Day Keeps the Depends (TM) Away

June 30, 2012

Urinary incontinence is a devastating problem affecting millions of American women. For women with mild to moderate loss of urine with coughing and sneezing, Kegel exercises can M)improve urinary control and decrease the use of absorbent pads and even the use of Depends.

Kegel exercises strengthen the pelvic floor muscles, which support the uterus, bladder and bowel. You can do Kegel exercises discreetly just about anytime, whether you’re driving in your car, sitting at your desk or relaxing on the couch.
Many factors can weaken your pelvic floor muscles, from pregnancy and childbirth to aging, which is associated with estrogen deficiency and being overweight. This may allow your pelvic organs to descend and bulge into your vagina — a condition known as pelvic organ prolapse. Kegel exercises can help delay or even prevent pelvic organ prolapse and the related symptoms.
Another huge benefit of Kegel exercises includes assistance for women who have persistent problems reaching orgasm. I am not sure how this works but I have heard so many anecdotal success stories that I am convinced that Kegel exercises are effective.

I have recommended a device, the Laselle by Intimina (http://www.intimina.com/en/kegel-exercisers-laselle.php), for women with incontinence issues.

Laselle spheres

Laselle Spheres For Kegel Exercises

There is documented evidence that has concluded that pelvic exercises should be included in first-line conservative management programs for women with urinary incontinence. The Laselle Kegel exercisers are elegantly crafted spheres with an attached string for easy insertion and removal that helps women gain objective evidence that they are doing the exercises correctly.

These weighted spheres, which if worn discreetly inside the vagina during daily activities, give women the most complete intimate workout, helping women to locate their pelvic floor muscles and providing a solid object for women to flex around for more effective strengthening. Within each sphere is a weighted ball that responds to your body’s movements, causing gentle kinetic vibrations to help prompt your pelvic floor muscles to contract and relax as you walk around.

Laselle Kegel exercisers are available in three different weights. These three different weights provide different levels of resistance and can be combined and adapted to your routine as your pelvic floor becomes stronger, helping you to unlock the full potential that this muscle set offers.

Correct performance of Kegel exercises
1. Contract your pelvic floor muscles, lift the exerciser(s) upwards
2. Hold the contraction for 2-10 seconds, while taking deep breaths
3. Release the contraction
4. Rest & relax for a minimum of your hold time, or for as long as you need before repeating the exercise
Repeat 10 times for a Kegel set, if this is challenging, reduce your repetitions to an amount that is comfortable for you.
For an efficient workout, perform a Kegel set 3 times a week on alternative weekdays
Correct Kegels do not involve tensing the abdomen, squeezing the buttocks, or straining and pushing down when contracting.

Correct Performance of Kegel Exercises

Performing Kegel Exercises Correctly

Bottom Line: Incontinence is a common problem affecting millions of American women. Kegel exercises are an effective method of solving the problem. Laselle spheres by Intimina are an easy way to get started.

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PSA Rise After Treatment for prostate cancer

June 23, 2012

Nearly 20-30% of men who have a radical prostatectomy or radiation therapy for prostate cancer will have a rise in their PSA after treatment.  There are multiple options for managing the PSA elevation but they all seem to depend on the answers to three questions:

How long after treatment did the PSA start rising?

How fast does the PSA rise?

What is the Gleason score of the cancer?

If there is a low Gleason score or there is a long delay between the treatment and the first elevation of the PSA and the doubling time of the PSA is greater than one year, then there is not going to be an urgency for manging the rise in PSA.  However, for those men who have a high Gleason score, a PSA that starts to increase in less than three years after treatment and whose doubling time of their PSA is less than 3 months, then this is more worrisome and the men are at high risk of increased morbidity and mortality and needs more immediate management. 

Options.

Radiation can be used after prostate surgery if there is a local recurrence in the prostate gland.  This helps a small number of men but is also associated with side effects.  Men will have the best response if the radiation begins before the PSA is greater than 1.0ng\ml.

The bone scan can help determine if there is spread to the bones.  This test is not useful if the PSA is less than 10ng\ml.

Another form of management is hormone therapy using drugs that shut down the production of testosterone from the testicles.  The options of using hormone therapy incude continuous hormone therapy and intermittent hormone therapy where the drugs are used until the PSA decreases and then follow up with PSA testing every month or two then starting hormone therapy again when the PSA rises.  Intermittent hormone therapy has the advantage of less side effects from the treatment.  The other option is to wait until the PSA significantly rises or that the man becomes symptomatic and then start hormone therapy.  At the present time there is no study or consensus of when to start hormone therapy in men with a rising PSA.  However, if there is a rapid rise in PSA or a doubling time less than three months, these men need treatment sooner. 

Bottom Line: Men have several options for managing the rising PSA after treatment for prostate cancer.  There is no one treatment that works for everybody.  You need to have a discussion with your urologist or your oncologist. 

If They Love You, They Will Tell Others-Generating Testimonials From Your Satisfied Patients

June 19, 2012

Every day we are told how terrific we are and how delighted our patients are with our care. Those are words that we need to capture and, with the patients’ permission, share those kind words with our existing patients or potential new patients. You can toot your own horn, but when others do the tooting, there’s more music and harmony to be made. An effective testimonial can be incorporated into your website (see http://www.neilbaum.com), your brochure, or even a scrap book of your collected testimonial placed in your reception area. Trust me, it will be the most looked at book(s) by patients in waiting in your reception area.

While most physicians are uncomfortable asking for a testimonial, you can ask patients who have said nice things about your or have provided you with one of the many compliments you receive on a daily basis to put their spoken words into written words that will be shared with other patients. Most of those patients who provide you with accolades will be willing to share their thoughts with others. When patients read from the scrapbook in the reception area, they will even ask, what do I need to do to get into that book?
I emphasize that you must get the patients’ permission before using the testimonial. When the patient offers a testimonial, I tell them it may appear on my website and will ask them to sign a waiver giving me permission. (See example below from my practice)

Testimonials

Testimonial Authorization

Another use of testimonials is to share them with your office staff at staff meetings. This lets everyone know about the quality of the care that you provide your patients and raises the bar for patient satisfaction with the entire staff.

Bottom Line: Testimonials are a great way to get the word out. It’s equivalent to the ol’ time word of mouth marketing. Remember what the good book says, “Ask and you shall receive.” The same applies to requesting and sharing testimonials.

Diabetes Drug Linked to Bladder Cancer

June 19, 2012

Attached is a blog submitted by Elizabeth Carrollton who wants to alert us to the relationship of a diabetes drug, Actos, and bladder cancer.

When diet and exercise aren’t enough, medical professionals turn to trusted medications to help type 2 diabetes patients live longer and healthier lives. But many of the medicines that are aimed at improving diabetes can have the opposite effect on other bodily functions.
One of the most popular type 2 diabetes drugs on the market, Actos (pioglitazone), is also one that comes with the biggest dangers. Studies have linked this popular once-daily pill to an increased risk of bladder cancer, congestive heart failure (CHF), edema and other life-threatening conditions.
Worldwide, drug regulators have put the brakes on Actos. But in the United States, drug regulators have allowed Takeda Pharmaceuticals to continue its prolonged study into its drug while sales continue. The U.S. Food and Drug Administration (FDA) has done little to protect vulnerable Actos patients.

Evidence in Scientific Studies
Since Actos belongs to the thiazolidinedione drug family, medical professionals have had their doubts about the drug. The two other drugs in this family, both of which were also used in diabetes patients, have been pulled from pharmacy shelves because of serious medical dangers.
Even before Actos was mass marketed in 1999, clinical trials indicated problems. Studies showed links between Actos and bladder cancer, CHF, bone fractures, edema and blindness. Instead of holding the drug back for more research, Takeda launched a 10-year study into bladder cancer risks while sales of the drug skyrocketed. When the drug’s link to CHF was pinpointed, the FDA gave the drug a black-box warning instead of taking it off the market. (The black box is the strongest type of warning the FDA can require.)

Banned in Europe; Whistleblowing in the U.S.
Even after the initial results of Takeda’s bladder cancer study revealed that Actos patients taking the drug for longer than a year had a 40 percent increased chance of getting the disease, the FDA did little to regulate it. Instead, in 2011, the FDA added yet another warning to the drug’s label. At the same time, France, Germany and Canada took steps to restrict or remove the drug from the market.
Adding to the skepticism about Takeda’s truthfulness regarding Actos, a former medical reviewer for the company filed a federal whistleblower lawsuit. Dr. Helen Ge said that Takeda repeatedly lied to the FDA about the drug’s safety record.

Doctors Make Other Choices
While the FDA waits for Takeda to finish and publish its final bladder cancer study results in 2013 — and as the whistleblower’s Actos lawsuit makes its way through the court system — Actos continues to be readily available. However, many medical professionals have been opting to instead prescribe type 2 diabetes drugs with better safety records.
Bottom Line (by Neil Baum): Patients taking ACTOS should see their doctor and obtain a urine test and a urine cytology. If either of these tests are abnormal, then a cystoscopy is in order. This is a test to look into the bladder with a small, lighted tube to be sure no bladder tumors are present.

Elizabeth Carrollton writes about defective medical devices and dangerous drugs for Drugwatch.com.

Vitamin D May Reduce Your Risk Of Prostate Cancer

June 15, 2012

A new study suggests that vitamin D may protect against prostate cancer. Men around age 65 who had a positive biopsy for prostate cancer who took 4000 IU/day of Vitamin D for a full year had a 55% decrease in the number of follow up positive prostate biopsies. Men who did not take vitamin D, 2\3 had progression compared to only 1\3 who took vitamin D.

Bottom Line; This is a report of a small study and certainly the results are encouraging but preliminary and more testing needs to be done. But as my wise Jewish mother would say, “It may not help, but it voidn’t hoit!”

PCA3 Test For Prostate Cancer-It’s The New Kid On the Prostate Cancer Block

June 15, 2012

Many American men have heard that a recent task force advised against PSA testing for ALL men. I have weighed in on this advice in a previous blog and suggest that all men over the age of 50 and all men at increased risk for prostate cancer which include African-American men and men with a close relative with prostate cancer have a discussion with their doctor about PSA testing.

Now there is a new test, PCA3 which is more sensitive than the standard PSA test and can be helpful 1) for men who have an elevated PSA make a decision regarding a biopsy, 2) for men who have had a negative biopsy but there is a suspicion that prostate cancer is present, or 3) for men with a positive biopsy for prostate cancer and to know how aggressive is the prostate cancer which may help suggest if treatment is indicated or if watchful waiting is the appropriate form of management.

The PCA3 test a gene-based test to aid in the diagnosis of prostate cancer. The test consists of a urine sample collected after a digital rectal examination. The doctor will receive the results as a numerical value between 4-125. The higher the PCA3 score the more likely the biopsy will be positive. The lower the PCA3 score the more likely the biopsy will be positive. Keep in mind that the decision to perform a biopsy is also dependent on other factors such as your age, family history of prostate cancer, and the results of the digital rectal exam, prostate size and PSA value. If you and your doctor decide not to perform a biopsy, you may repeat the PCA3 test after 3-6 months. In the absence of prostate cancer, the PCA3 score will remain the same or vary only slightly over time. If the PCA3 increases significantly, a biopsy may be indicated.

Bottom Line: the digital rectal examination and the PSA test are still good screening tests for prostate cancer. The PCA3 test is a refinement of the other two tests and help make the diagnosis of prostate cancer and help decide upon the treatment or help with the monitoring of patients who decide to follow their cancer with watchful waiting.

When You Have A Tack In Your Sack-Chronic Testicular Pain

June 15, 2012
When It Hurts Down There

Chronic Testicular Pain

Chronic testicular pain is a common malady causing havoc in men with this problem. The pain can be so debilitating that men lose productivity in the work place, have sexual problems and even depression that requires treatment. Men often have anxiety about cancer. Chronic testicular pain is also called orchialgia, orchidynia, chronic pelvic pain syndrome, or chronic scrotal pain syndrome. These are all terms used to describe intermittent or constant testicular pain.

Chronic testicular pain occurs at any age but the majority of the patients are in their mid to late thirties. The pain can involve one or both testicles. The pain can remain localized in the scrotum or radiate to the groin, perineum, back or legs. On clinical examination the testis may be tender but in the majority of men is otherwise unremarkable.

Causes of orchialgia include infection, tumor, testicular torsion, varicocele, hydrocele, spermatocele, trauma and previous surgical procedures such as a vasectomy.

Any organ that shares the same nerve pathway with the scrotal contents can present with pain in this region. Pain arising in the kidney, hip, prostate gland or back pain caused by a herniated disc can present as testicular pain. Injury to nerves following a hernia repair can cause chronic testicular pain. Chronic testicular pain has been recognized as a feature of diabetic. Some men attribute the start of their chronic testicular pain to some form of blunt injury to the testicles. Unfortunately in a large proportion of patients the cause of their pain remains unknown.

Post vasectomy chronic pain syndrome
It is not common but there is a possibility that following a vasectomy an obstruction or congestion of the vas or in the epididymis may be the cause of the pain.
If the man has an injection of local anesthetic, such as xylocaine, prior to cutting the vas, this may reduce both immediate and long term post vasectomy pain.

The formation of spermatic granuloma following a vasectomy has been well documented but its protective or causative role as been controversial.

Testing
Scrotal ultrasonography is usually part of the evaluation of patients with scrotal pain. However, in the absence of significant clinical findings during physical examination and in the presence of negative urinalysis, the only real benefit of scrotal ultrasound is reassurance to the patient worried about cancer

Treatment
Surgery is to be avoided if possible. Even if infection has not been identified a small number of patients may respond to a combination of antibiotics and non-steroidal anti-inflammatory drugs. Tricyclic antidepressants, such as imipramine, sometimes relieve the pain. Those with intractable symptoms may benefit from a multidisciplinary team approach involving a urologist and a pain clinic specialist including a psychologist. Transcutaneous electrical stimulation or TENS analgesia often have favorable results. This works on the principle that transcutaneous electrical stimulation causes release of endorphins in the nerves of the spinal cord that supply the scrotum.

A spermatic cord block with a local anesthetic such as xylocaine can be done in the doctor’s office. The procedure, if successful, can be repeated in regular intervals.

For patients who fail to respond to conservative management and wish to avoid the surgical options that are available in treating chronic orchialgia, a trial with an alpha blocker might be an option.

For patients in whom all medical treatments have failed and testicular pain continues to impair their quality of life, surgical intervention may be indicated as a last resort. A number of surgical strategies have been described.

Microsurgical denervation of the spermatic cord may provide relief of chronic testicular pain. Another technique is to divide the ilioinguinal nerve and its branches.

Removal of the epididmymis or epididymectomy should be performed only if the patient had been counselled regarding the likelihood of poor results.

Vasectomy reversal
Putting the vas back together or a vas reversal has helped a number of men with chronic testicular pain.

Unfortunately a small number of patients who fail to respond to medical or more invasive treatment will ultimately undergo removal of the entire testicle for pain relief. This procedure must be the last resort.

Bottom Line:
Chronic testicular pain remains a challenge to doctor as well as the patient.
Help is usually available with medication, nerve stimulation with TENS, and only surgery as a last resort.

A Burn In the Urine-Managing Urinary Tract Infections (UTI)

June 15, 2012

One of the most common afflictions affecting most women and many men are urinary tract infections. UTIs are eight times more common in women than men. Initial symptoms typically include burning at the time of urination, frequent and intense urge to urinate, with discoloration of the urine ranging from cloudy to even bloody.

A bacteria, E. Coli, is responsible for 75% to 90% cases of acute uncomplicated cystitis. UTIs can also be caused by sexually transmitted disease (STD) such as Chlamydia and Mycoplasma. Other possibilities of painful urination include pelvic inflammatory disease, radiation cystitis, and hemorrhagic cystitis.

Bacteria causing urinary tract infections

E. Coli bacteria – common cause of urinary tract infections

Your doctor can make a presumptive UTI diagnosis in symptomatic women if there is either burning with urination and frequency without vaginal symptoms. The diagnosis can be confirmed with urinalysis showing positive nitrite or positive leukocyte esterase. The ultimate diagnosis is based on urine culture which grows out the bacteria and tells the doctor the best drug or antibiotic for treating the infection.

Uncomplicated cystitis does not cause fever. If a patient has a fever the UTI may have spread to the kidneys. A bacterial infection of the kidney is referred to as pyelonephritis and the symptoms often include pain in the back or side below the ribs, nausea and vomiting.

Urinary tract infections in men are often the result of an obstruction or blockage of the urinary tract — for example, a urinary stone or enlarged prostate — or from a catheter used during a medical procedure.

Optimal empiric therapy for nonpregnant women with uncomplicated UTI is with trimethoprim-sulfamethoxazole (TMP-SMZ, Bactrim, Septra) 160 mg/800 mg orally b.i.d. for three days. Other antibiotic options include ciprofloxacin (Cipro), levofloxacin Levaquin), or nitrofurantoin (Macrodantin).

Cranbeery juice and supplements are thought to be a good alternative preventive treatment for recurrent UTIs. Rich in vitamins C and E, antioxidants and anthocyanins, cranberry may help prevent E. coli from attaching to the bladder wall as well as bladder stone formation, and provide symptom relief for cystitis.

Bottom Line: UTIs are common in both men and women and can be easily diagnosed with a history, physical exam, and examinatioin of the urine. Treatment is effective with antibiotics. If it burns when you urine, call your doctor.

Orchitis-A Royal Pain In the Nutt

June 13, 2012

Orchitis is a painful inflammation of the testicle usually caused by a bacterial or a viral infection.  The most common virus that causes orchitis is mumps. It most often occurs in boys after puberty. Orchitis usually develops 4 – 6 days after the mumps begins. Because of childhood vaccinations, mumps is now rare in the United States.

Orchitis may also occur along with infections of the prostate or epididymis, which is the gland behind the testicle that is responsible for sperm maturation.  Orchitis may be caused by sexually transmitted diseases (STD), such as gonorrhea or chlamydia. The rate of sexually transmitted orchitis or epididymitis is higher in men ages 19 – 35.

Risk factors for sexually transmitted orchitis include: High-risk sexual behaviors, multiple sexual partners, personal history of gonorrhea or another STD, having a sexual partner with a diagnosed STD or having a urinary tract infection. 

Risk factors for orchitis not due to an STD include: Being older than age 45, long-term use of a Foley catheter (a tube used to drain the urine from the bladder to the outside of the body), surgery of the urinary tract such as a prostate or bladder operation. 

Symptoms of orchitis

The symptoms of orchitis include: Blood in the semen, a clear or yellow discharge from penis, fever, groin pain, painful ejaculation, Pain with intercourse or ejaculation, pain with urination, scrotal swelling, tender, swollen groin area on affected side, tender, swollen, heavy feeling in the testicle, and testicle pain that is made worse by a bowel movement or straining.

Signs and tests

A physical examination may show: an enlarged or tender prostate gland, tender and enlarged lymph nodes in the groin (inguinal) area on the affected side, and usually a tender and enlarged testicle on the affected side.

Tests may include:  Complete blood count (CBC) which usually shows an elevated white blood cell count, a esticular ultrasound, tests to screen for STDs, and a urinalysis and a urine culture (clean catch).

Treatment

Treatments may include:  Antibiotics — if the infection is caused by bacteria (in the case of gonorrhea or chlamydia, sexual partners must also be treated), anti-inflammatory medications such as ibuprofen, pain medications, and bed rest with the scrotum elevated and ice packs applied to the affected area.

Expectations (prognosis)

Getting the right diagnosis and treatment for orchitis caused by bacteria can usually preserve the normal testicle function.

If the testicle does not completely return to normal after treatment, further testing to rule out testicular cancer should be done.  Usually this can be done with the scrotal ultrasound. 

Mumps orchitis cannot be treated, and the outcome can vary. Men who have had mumps orchitis can become sterile if the condition affects both testicles.

Complications

Some boys who get orchitis caused by mumps will have shrinking of the testicles (testicular atrophy).  Orchitis may also cause infertility.  Other potential complications include:  Chronic epididymitis, death of testicle tissue (testicular infarction) and scrotal abscess.

Acute pain in the scrotum or testicles can be caused by twisting of the testicular blood vessels (torsion), which is a surgical emergency. If you have sudden pain in the scrotum or testicles, get immediate medical attention.

Calling your health care provider

All testicle abnormalities should be medically evaluated. Call your physician or go to the nearest emergency room if you experience sudden pain in the testicle.

Prevention

Getting vaccinated against mumps will prevent mumps-associated orchitis. Safer sex behaviors, such as having only one partner at a time (monogamy) and condom use, will decrease the chance of developing orchitis as a result of a sexually transmitted disease.

Bottom Line: Orchitis is usually caused by an infection and prompt treatment is required in order to save the testicle.  Call your physician or go to the emergency room for evaluation and treatment. 

Scrotal Pain-A Hydrococele Or Water In The Sack Down There

June 9, 2012

There are a number of conditions that can cause pain and swelling in the scrotum. A benign condition is a hydrococele, which is a common cause of pain and swelling and can be easily treated. A hydrocoele is a collection of fluid around the testicle.

Hydorcocele

Hydrococele demonstrating a fluid collection around the testicle

Most often these swellings are a painless swelling of the scrotum. Hydrocoeles can affect males of any age, but usually occur in men older than 40 years. They may affect one side of the scrotum or both sides. In many cases, no cause is found. Possible causes include: blunt trauma to the scrotum, infection (eg. epididymo-orchitis, rarely as a result of a testicular tumour or from a torsion of the testes where the testicle twists and compromises the blood supply to the testicle.

Symptoms of a hydrocoele:
The most common presentation of a hydrococle is a painless, enlargement of the scrotum. There may be a sensation of heaviness or dragging. Hydrocoele is not usually painful (pain may be an indication of an accompanying infection).


Investigations: A light shined through the scrotum will cause the hydrocoele to illuminate (transillumination).
Investigation is not usually required in children. For adults, an ultrasound of the testis may be required. 
Since testicular lumps could potentially be missed on physical examination (due to the collection of fluid preventing full examination of the testis), an ultrasound is often advised. An ultrasound of the scrotum will confirm the diagnosis of hydrocoele & also identify any abnormal testicular lumps. 


Treatment of hydrocoeles:
If the hydrocoele is small, no treatment is usually required and the hydrococele can be checked on an annual basis at the time of the physical examination. For larger hydrocoeles, drawing off of the fluid using a needle & syringe may be indicated. However, such needle aspiration is not therapeutic because the fluid usually reaccumulates quickly & is associated with a risk of infection. For larger hydrocoeles, or where there is a suspected underlying tumor, surgery may be required. Hydrocoeles can usually be cured with a relatively simple surgical operation.


Bottom Line: Most hydrocoeles occur with normal testes. Always see your doctor if you notice any change in the size and/or shape of your scrotum or testes.
For more information, please view my video on YouTube on hydrococele, http://www.youtube.com/watch?v=WRCVUbYqV4E