Archive for June, 2014

Mind Over Bladder-Stress Reduction Used To Treat Overactive Bladder*

June 28, 2014

Overactive bladder (OAB) or when you gotta go, you gotta go affects millions of American men and women. OAB is a condition that significantly impacts the quality of life of those who suffer from this problem.

Now there is evidence that relaxing the mind may be helpful when it comes to reducing bladder urge issues, according to a new study completed at the University of Utah. Thirty women participated in an eight-week study and were followed for one year comparing the impact of mindfulness-based stress reduction (MBSR) with yoga on urinary urge incontinence, a challenge faced by as many as 26 percent of women in the United States.

Those affected may experience large, unpredictable leakage of urine which can be psychologically and socially devastating.

Older women are often the ones experiencing this incontinence, though it’s not clear why. Weaker muscles and neurological elements are likely the culprit. Medications are effective initially but not long-term and can have bothersome side effects.

Twelve months after participating in the study, the women who studied mindfulness-based stress reduction had 66.7 percent fewer urinary urge incontinence episodes compared with the control group, which saw only 16.7 percent reduction at that time. It may help to help calm the mind so the emotional area of the brain is not activated and thus allows the person to learn to reframe the normal urge sensations from their bladder.

More study is needed and the next step for researchers is to secure a National Institutes of Health grant to conduct the study on a larger group of women in the next several years.

Bottom Line: Learning techniques of stress reduction may be helpful for those who suffer from overactive bladder.

*this blog was inspired by an article in WebMD which appeared at: http://www.webmd.com/urinary-incontinence-oab/news/20090508/mind-over-bladder-may-lessen-leaks

Can Treatment For ED Cause Skin Cancer

June 21, 2014

A recent study has implicated Viagra as a cause of skin cancer. A study found that men who used the erection-enhancing drug sildenafil (Viagra) were 84% more likely to develop melanoma, a very significant skin cancer. That’s especially important for older men, who are at greater risk for developing melanoma and also at greater risk for dying from it. An estimated 76,000 Americans (more than half of them men) will be diagnosed with melanoma this year, and almost 10,000 will die from it.

Here are two truths about this work that you need to know. 1) This study does not show that Viagra causes skin cancer. Instead, it shows that in a large group of men, those who said they used Viagra ended up being diagnosed more often with melanoma than those who didn’t use this drug. The study shows a connection, but not a cause. 2). Even if Viagra does promote melanoma, the absolute increase is small.

The study grew out of laboratory research on how Viagra acts on cell-to-cell signaling pathways. This work demonstrated that the drug mimics key parts of a process that lets melanoma cells spread to other parts of the body. Skin cancer that spreads (metastasizes) is hard to control and can end in death.

Over the next decade, among the 29,929 men who said they had never used Viagra, 128 developed melanoma. Among the 1,618 Viagra users, 14 developed melanoma. In other words, 4.3 of every 1,000 who didn’t take Viagra developed melanoma compared to 8.6 of every 1,000 men who took Viagra.

After statistical adjustments, the increase from 4.3 to 8.6 is the 84% increase in risk that many news reports focused on. Researchers call that the relative risk (one group compared to another). The absolute increase, 4.3 cases per 1,000 men, represents an increase of 0.43%.

Whether a similar connection might exist between other erectile dysfunction drugs and melanoma isn’t known.
The raw numbers suggest that the risk for melanoma associated with Viagra is small. It’s even smaller than what was reported in the study because not all of the 14 cancers in the Viagra group can be attributed to the drug. Many factors affect a man’s risk of melanoma—the most important of which are age and cumulative exposure to ultraviolet (UV) radiation.
Should men who use Viagra worry about getting melanoma? Right now, no one can say. The relationship could be pure coincidence.
My advice to men: Protect your skin from too much sun and have routine skin checks to identify melanoma and other types of skin cancer early, while they are still treatable.

Bottom Line: In short, be afraid—but not of Viagra. Be concerned about getting too much sun and pay attention to weird-looking moles that could turn into metastatic cancer. Cover up when you go outside, and use a broad-spectrum sunscreen liberally when you do go out into the sun to work and play.

Same Day Medical Appointment-Just What the Patient Ordered

June 20, 2014

No one knows for certain what the future holds for American Medicine. What we do know is that reimbursements are going to decrease in the near future. We are challenged to find ways to increase the volume of patients we see in our practices. An even greater way to maintain our incomes is to increase the volume of patients seen but also to increase the income per patient that is seen in our offices. On of the best ways to accomplish both goals is to see more new patients. We all know that seeing a patient in the 90-day global period is not as productive as seeing a new patient who is likely to need a work up, evaluation, and perhaps a surgical procedure. Remember there is no income generated by suture removal! After reading this article you will understand the concept of same day appointments and how to consider implementing this in your practice.

Why are same day appointments important?
SDA is what our patients want. Every patient with menometrorrhagia experiences anxiety about her condition and wants to be seen as soon as possible. Most patients do not wish to wait weeks or months for an appointment regardless of the fame and reputation of the doctor. That medical doctors are in a service industry and it behooves us to cater to our patients needs. If we are honest with ourselves, doctors who have long waiting times from weeks to months to see a new patient are merely stoking their egos.

However, this philosophy and this practice of making patients wait to receive an appointment will not enhance patient satisfaction nor improve a practice’s performance. Patient satisfaction is vital in order to build and maintain a successful practice. You can be the most talented robotic surgeon and have a reputation for doing a laparoscopic hysterectomy in less than one hour with no blood loss, and less than 24 hours hospital stay, but if your patients are not satisfied with your care before and after their surgery you may find large gaps and openings in your schedule and a decrease in the number of surgical procedures you perform.

I see up to 35-40 patients/day, which may include 6-8 new patients! How do I do it? I suggest having a sufficient number of the right staffers with the right attitudes while providing them with the appropriate tools to do their job and accomplish their goals. I am solo practitioner and have 6 FTE employees. This is nearly twice the national average of 3 FTE/provider. However, a robust staff allows me to accommodate SDA in addition to seeing follow-up appointments and performing office procedure. I have motivated my employees to know that accommodating SDA is expected and I am willing to provide them with adequate staff and tools to see the extra patients. My ability to accommodate SDA is assisted by having a highly integrated practice management and electronic medical records system, which I fully exploit, makes my practice truly chartless.

Being able to offer SDA requires the proper attitude, which includes a positive, can-do spirit by the doctor. It starts at the top, i.e., with the doctor. It begins with the doctor arriving and ready to see patients on time. If the patients are to be seen at 9:00, that means patients are placed in the room and the doctor is ready to begin seeing patients at 9:00 and not 9:15 or later. If the doctor is late, you can be sure that the day will contain significant delays and the ability to accommodate SDA will not be possible.

I recommend that physicians leverage technology whenever possible to optimize your workflow. Using his electronic medical records system, he is able to see in real-time which patient has arrived, who has been roomed, and if the patients are running on time. He can see this information anywhere in the office by using his tablet computer. He can better “pace” himself when such information is available.

I suggest that you qualify patients when they call for a new appointment by making certain payer information and appropriate authorizations have been obtained, and that patients know in advance what the estimated cost and co-pay will be and that the fee is going to be collected prior to the visit. This requires a well-coordinated effort by the
front desk and the billing office, as well as having the necessary electronic and web-based resources to accomplish this complex task.

Physicians should not assume the liability of providing care without being compensated. It is a good idea for the demographic information and health questionnaire be completed before patients arrive in the office so as not to delay their visit. The patients are also informed to be on time as they will be seen within a few minutes of their arrival. Before
the patient is placed in the exam room, all the reports, supplies, and equipment needed to see the patient is in the room or already available in the electronic health record/chart.
It is a good idea to anticipate how many additional slots he will need by leaving openings to accommodate new patients. This takes minimal analysis of patient appointment demand patterns. For example, leaving additional slots on Monday afternoons as a few patients seen in the ER will likely be calling Monday morning for follow up appointments.

In the next blog I will describe how to accomplish same day appointments and how you can be the darling of your patients.

Prostate Gland Enlargement-A New Minimally Invasive FDA Approved Treatment

June 18, 2014

Most men experience benign enlargement of the prostate gland that causes symptoms of difficulty with urination, dribbling after urination and getting up multiple times at night to urinate. All of these symptoms can impact a man’s quality of life.
Enlargement of the prostate gland occurs naturally as men age. Unfortunately, this process can press on the urethra and result in some frustrating side effects including urination and bladder problems. The good news is that an enlarged prostate is benign (not cancerous) nor will it increase your risk of prostate cancer; for these reasons it is often referred to as benign prostatic hyperplasia (BPH) or benign prostatic hypertrophy.

The exact cause of BPH is unknown; however, a common hypothesis points to changes in the balance of the sex hormones during the aging process. The testicles may also play an important role in prostate growth: for example, men who have had their testicles removed (i.e. as a result of testicular cancer) do not develop BPH. Furthermore, men who have their testicles removed after having developed BPH will experience a decrease in prostate size.
Medications

Prescription drugs are typically the first line of treatment for BPH. Alpha blockers are typically associated with high blood pressure, but in the case of BPH, act by relaxing the muscles in both the bladder neck and prostate, resulting in effortless urination. The effects of alpha blockers are typically seen very quickly (in about a day or two). Some well-known examples are drugs like Rapaflo or Flomax.

Another set of medications, 5 alpha reductase inhibitors, reduce the size of the prostate, thus reducing the pressure on the urethra. Examples of these are Avodart or Proscar. Often, improvements are not seen for a couple of weeks or even months. Common side effects include decreased sex drive and erectile dysfuction. Combination therapy of alpha blockers and 5 alpha reductase inhibitors can be more effective than either drug alone. Antibiotics may also be prescribed to treat prostatitis (prostate inflammation) which can accompany BPH.

Minimally Invasive Procedures
GreenLight Laser uses a high-powered laser combined with fiber optics to vaporize the overgrowth of prostate cells quickly and accurately. The heat of the laser also cauterizes blood vessels, resulting in minimal bleeding. It is an out-patient procedure that involves catheterization for about two days. Stents can be placed in the urethra to help keep it open and allow urine to flow easier. These stents must be replaced every four to six weeks, and as such, are not considered a long term treatment option.

Now a new treatment, the Urolift, has been approved by the FDA and is a minimally invasive treatment that can be done in the doctor’s office under a local anesthetic with immediate results after a 20-30 minute procedure. The procedure consists of inserting two to four implants that opens the urethra directly by retracting the obstructing prostatic lobes without cutting, heating, or removing prostate tissue. The implants pushes aside the obstructive prostate lobes like opening window curtains. Small permanent UroLift implants are deployed, holding the lobes in the retracted position, and thus opening the urethra while leaving the prostate intact. Patients report marked improvement in symptoms immediately after the procedure. There is no problems with erections after the procedure.

Prostate, shown in yellow, with blockage of the urethra

Prostate, shown in yellow, with blockage of the urethra


4 pins in the prostate open the gland and allow improvement in urinary symptoms

4 pins in the prostate open the gland and allow improvement in urinary symptoms

Surgical Procedures
If medications are not effective, or if your prostate is too large, surgical intervention may be necessary. Transurethral resection of the prostate (TURP), or the modified Button TURP, involves the removal of portions of prostate which block urine flow. Hospital stay is typically one day with a two-day catheterization. Reserved for those with unbearable BPH symptoms and extremely large prostates, prostatectomy is the complete removal of the prostate gland. It is more invasive than either TURP or GreenLight Laser, and usually has a higher risk of complications and side effects and requires a longer catheterization. For these reasons, prostatectomies are typically not recommended for those with BPH, but rather the go to surgical intervention for men diagnosed with prostate cancer.
Bottom Line: Prostate enlargement affects nearly 14 million American men mostly after age 50. There are many treatment options available for BPH: medications, minimally-invasive procedures and surgery. Which treatment option is best for you depends on your overall treatment goals, the size of your prostate, your symptoms, your age, and your overall health. Make sure you speak with your doctor about the different treatment options; your doctor will recommend treatments based on your symptoms and treatment goals.

A Balloon In The Bladder-A New Treatment For Incontinence

June 18, 2014

Laughter is the best medicine; but not for overactive bladder! This is a common condition affecting 15 million American men and women. Now a new novel treatment that does not require surgery is currently undergoing clinical studies in the United States in order to achieve FDA approval.

Stress urinary incontinence or loss of urine with coughing, sneezing, laughing, or even bending over to tie your shoes is the most prevalent form of incontinence among women, affects an estimated 140 million women worldwide. SUI is defined as the inability of the bladder to store urine during normal everyday physical activities without sudden increases in bladder pressure.

The Solace Bladder Control System is a non-surgical alternative to involuntary urinary leakage. The Solace Bladder Control Balloon is a small, lightweight device that floats within the urinary bladder. The balloon is designed to eliminate or reduce involuntary urinary leakage. It acts as a “shock absorber” to reduce the temporary pressure changes in the bladder that cause urinary leakage.

The Solace Bladder Control Balloon procedure is performed in the physician’s office. No medication or preparation is required before the procedure. The physician places the Solace Bladder Control Balloon into the bladder through a small tube inserted into the bladder under a local anesthetic. Pressure reduction is immediate. The balloon can be removed at any time.

For more information on the Bladder Control Balloon go to http://www.stopsui.com.

Bottom Line: Incontinence is a common condition that affects millions of American men and women. At the present time there is no medication to treat this problem. The Bladder Control Balloon may be a treatment option.

Aveed – New Long Acting Injection Treatment For Low Testosterone

June 13, 2014

Aveed – New Treatment For Low Testosterone

Many of you may have heard about a “new” long acting form of injectable testosterone that is available in the U.S.A. and the U.K. Known as Aveed in the U.S.A. Both Aveed and Nebido are oily injections that contain 1000mg of testosterone undecanoate. These pharmaceuticals are the first preparations that allow the individual to drastically reduce the number of injections to approximately four per year, once testosterone levels are stabilized.
Previously the only other option for long lasting testosterone delivery was the implant, otherwise known as “pellets”. This is a procedure where local anesthetic is generally applied to an area of skin, usually on the abdomen or buttock, where the pellets will be placed. A number of small “pellets” are then placed under the skin. These are expected to last four to six months. It has been estimated that approximately 2-3 percent of the pellets inserted force themselves to the surface of the skin.
Many of you, who are not using implants, are using the injectable forms of testosterone marketed as testosterone cypionate and testosterone enanthate. These are also both oily injections that are generally injected every ten days to three weeks depending on your current dosage and testosterone levels.
As with all medications however, there are side-effects. Many of you would be aware of the patient leaflet supplied with all vials of testosterone that indicate possible side-effects. Aveed is no different. These include diarrhea, leg pain, dizziness/headache, breathing problems, acne, itching, and breast-pain and enlargement. Some of the other effects known to occur in this preparation included weight gain, muscle cramps, nervousness, hostility, depression, sleep apnea, water retention, skin conditions and balding. A rare complication is a lung embolus of the oil causing shortness of breadth and chest pain. These symptoms are usually transient and dissipate after just a few minutes.
This, of course, does not mean that these symptoms will occur in all individuals who use the preparation. It is, however, always wise to weigh up the options available to you. It is most important to inform your doctor of any medical issues or concerns you may have so that the most suitable preparation can be chosen for you.

Curves Belong on Baseballs Not On Penises

June 3, 2014

Peyroine’s disease affects millions of American men. The problem consists of curvature of the penis that can make erections difficult or even painful to the man and his partner. Now there is a new FDA approved treatment for this common urologic condition.

Peyronie’s Disease is a local connective tissue disorder characterized by a change (scar formation) in the collagen composition of the tunica albuginea of the penis.

The two corpora cavernosa and corpus spongiosum of the penis are composed of an elastic covering within the tunica on top of the erectile-spongy tissue inside. During an erection, blood is trapped in all three corporal bodies leading to dissension of the corpora and an erection occurs. Peyronie’s plaque, which is composed predominately of collagen, although calcium deposits may occur, replaces the normal elastic tissue. This results in penile deformity, primarily a curvature (I have seen up to 120 degree bends!); along with penile narrowing, indentation and shortening of the penis.

Causes of Peyroine’s Disease

Microvascular trauma resulting from excessive bending or injury to the penis (possibly during sexual activity) is thought to be an important trigger for the inflammatory response and plaque development. Genetic pre-disposition and autoimmunity may also play a role in the development.
• Sexual intercourse: As one can imagine, the deformity can result in inability to penetrate or function properly. If the deformity is severe enough, pain to the partner as a result of the penile glans pushing on the vaginal vault side wall can occur.

• Erectile dysfunction: An increase in incidence of erectile dysfunction has been associated with Peyronie’s Disease. With the use of PED5 inhibitors or 2nd/3rd tier treatments, a more rigid erection can result which can lead to an exacerbation of the penile deformities.

• Psychological: As one can imagine, the potential psychological effects to a man can be devastating. Recent studies showed that 48% of men with Peyronie’s Disease were found to have clinically meaningful depression.

Treatment Options

Antiquated treatments, including Vitamin E, Potaba, and anti-inflammatories, have been tried but have not been shown to be clinically effective. 

Penile injections of steroids and Interferon have been used with limited success. Probably the gold standard has been the use of Verapamil injections into the plaque. This has been reported, with and without the use of a vacuum erection device, to improve the deformity in some men. This requires a penile block followed by injection of 10-20 mg. of Verapamil every other week for a total of 12 treatments. Studies have reported a 30 degree improvement in the curvature in some men. 

The basis of the use of Verapamil is that it breaks up the collagen fibers leading to an improvement in the deformity. A number of compounding pharmacies have attempted to create a Verapamil cream to replace the intra-lesional injection of Verapamil with limited success. 

Surgical options include a simple procedure in which stitches are used to straighten the penis but this does result in some shortening of the erection (about an inch or so). The only other option is a penile prosthesis which for some men with associated ED is a viable treatment. However, placing implants with Peyronie’s is not necessarily an easy procedure. 



New Treatments


Xiaflex (collagenase clostridium) has been approved in the past for the treatment of Dupuytren’s contractions with significant success. The theory is that the collagenase breaks up the collagen fibers resulting in a relief and improvement in a deformity associated with this condition. 

Recently, Texas Urology participated in a clinical trial with use of Xiaflex for Peyronie’s Disease. Based on the results of two studies involving over 600 men, Xiaflex has been approved for the treatment of Peyronie’s Disease. In the two clinical trials, a 35% improvement was noted in men with a penile deformity of at least 30 degrees (placebo improvement approximately 20%). Additionally, there was an improvement in the Peyronie’s bother domain compared to placebo. 

Corpora rupture (penile fracture) was reported in 0.5% of men with Xiaflex. Additionally, greater than 25% of the men reported an incident greater than placebo of penile hematoma, penile swelling and penile pain.

In Xiaflex administration/home treatment, a solution of 0.25 cc of reconstituted collagenase is injected into the plaque at the point of maximum deformity (based on a pharmacological-induced erection). A second injection into the plaque is repeated 1-3 days later both in the office. The patient returns to the office 1-3 days later for penile modeling which involves stretching the penis in the flaccid state along with bending for approximately 30 seconds and then repeated twice with 30 second rest periods. The patient then proceeds for six weeks to perform penile modeling activities at home which include stretching the penis for 30 seconds, three times a day and penile straightening at least once a day for 30 seconds. The patient should abstain from sexual activity for at least two weeks. Up to four treatment cycles may be administered per plaque. 

The treatment should not be attempted for ventral plaques but only for dorsal plaques because of the urethral location ventrally. 




Xiaflex appears to be of benefit to men with significant penile deformities (greater than 30 degrees) who are interested in improving their curvature. The cost of Xiaflex per treatment cycle is $3,900 per treatment course cash price. Since it is a new medication insurance coverage will take time, but supposedly it is covered by Medicare. Remember it could take four courses! 

This could be a high price to pay in many ways, but for men with a significant problem it may be well worth it.

Bottom Line: Peyroine’s is a common urologic condition that can wreck havoc on man’s sexual performance. Now there are new and successful treatments for this condition. Speak to your urologist.

Urinary Incontinence-You Don’t Have To Depend On Depends

June 3, 2014

Probably nothing is more depressing to a man or woman than losing control of their bladder. We tend to take for granted the act of urination and being able to urinate into a toilet when it is socially convenient. When any man or woman has to resort to pads, panty liners, or diapers, that is a very discouraging and often a depressing event in their lives. This can lead to the person restricting their social activities, becoming reclusive and even becoming depressed.
For a person who has lost control over her bladder life can be very difficult. It means he\she would lead a restricted life, think twice before stepping out of the house, and will be unable to undertake journeys. In short, he\she will lead a life that is far from normal.
It is a debilitating ailment that can make life immensely difficult. Urinary incontinence that results in sudden loss of bladder control is both embarrassing and distressing. A sudden, uncontrollable urge to urinate often leads to involuntary loss of urine in such people. However, lack of awareness and taboo associated with the problem often causes people to suffer in silence, when in fact, they should seek medical help.
Involuntary actions of the bladder muscles may be a result of damage to the nerves of the bladder, to the spinal cord and brain, or to the bladder muscles. Multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, stroke, and injury can also harm bladder nerves or muscles. While factors like injury, stroke, diabetes, and multiple sclerosis are common to both men and women, what makes the disorder twice as common in women than in men is the fact that they deliver babies and suffer menopause.
During pregnancy, when babies push down the bladder and urethra (the tube from the bladder to the outside of the body that transports urine from the bladder to the toilet), this weakens muscles of the pelvic floor and the bladder. Labor can weaken pelvic floor muscles and damage nerves that control the bladder. After menopause too, women experience problems with bladder control.
Urinary incontinence is of different types and a large number of women suffer from some or the other form of this problem. In some people with urinary incontinence exercises can be helpful. Kegel exercises performed several times a day can strengthen the muscles in the pelvis and helpf with the control of urination. Botulinum Toxin can be helpful in treating the symptoms and can give relief for up to 10 months. In fact, FDA has recently given a go ahead for the use of Botulinum Toxin for treating symptoms of urinary incontinence in certain neurological cases.

Bottom Line: Incontinence is not a natural consequence of aging. It is not something you have to live with. Help is available. You don’t have to depend on Depends!

Perhaps an Over the Counter Pill For ED (Erectile Dysfunction)

June 1, 2014

Eli Lilly , the manufactures of Cialis, are requesting permission to sell Cialis, the world’s top-selling impotence drug, without a prescription.
The drug in very small daily doses is also approved to treat enlarged prostate glands.
Lilly is requesting approval to sell Cialis over the counter in the United States, Europe, Canada and Australia. It remains to be seen, however, whether regulators will allow Cialis to be sold without a prescription, in view of possible side effects and contraindications such as in men using nitroglycerin for chest pain. Cialis can cause a dangerous fall in blood pressure if taken with nitroglycerin.
The U.S. Food and Drug Administration, needs to be sure patients are able to understand complex aspects of their disease, or exactly when to take the drug to ensure safe use.
Cialis will face competition from cheaper generics in the United States in 2017, when Viagra becomes a generic prescription.
Bottom Line: ED drugs are very expensive, $25-$35 a pill. Financial help may be on the ay if the drugs become generic making the treatment of ED more affordable.

At Last: Viagra For Women

June 1, 2014

Drug makers are testing new drugs that may be able to increase sexual desire in women.
A drug to boost female sex drive could be worth billions to the first company that manages to get it approved by the FDA. Recently, two new treatments have made strides towards that goal. But some are skeptical of the real value of such a drug to the women it’s supposed to help.
In late 2004, FDA approval of Intrinsa, a testosterone patch for low female sex drive, seemed imminent. News reports heralded Intrinsa as a “Viagra for her,” suggesting that it would revolutionize sexual health for women just as erectile dysfunction pills had for men.

Except an FDA advisory panel saw things differently. Finding numerous problems with the evidence for the drug’s effectiveness and safety, experts on the panel voted against approving it. Procter & Gamble, the company responsible for Intrinsa, withdrew its application. Now the frontrunner in the race to market the first prescription drug for low female sex drive is Boehringher-Ingelheim Pharmaceuticals. It has a drug called flibanserin in phase III clinical trials, the final phase of drug testing required for FDA approval. The company is a WebMD sponsor.
Flibanserin is a bit mysterious. It is a kind of antidepressant, but it hasn’t been approved previously for any use. Boehringher-Ingelheim is saying little publicly about the drug. At the moment we are not sure how the drug works or what is the mechanism of action of flibanserin.
Another drug, called bremelanotide, is in development for low female sex drive and male erectile dysfunction. Both potential uses are being tested in clinical trials, which are early studies to assess how well a drug works and how safe it is.
Bremelanotide is a new chemical created in the laboratory. It’s given in the form of a nasal spray, and it acts on the central nervous system.
Bottom Line: Stay tuned as a pill for women suffering from sexual dysfunction may be just around the corner at a pharmacy near you.