EP 585: Is Peeing Pissing You Off? Learn About BPH and Bladder vs. Prostate Treatments

Today, Dr. Mistry and Donna Lee are joined by NAU Urology Specialists' partner, Dr. Lucas Jacomides, to discuss BPH and all things bladder and prostate. While many men suffer from an enlarged prostate (particularly as they age), every man is different. Our urologists work with each individual patient to determine the best course of treatment for his urinary symptoms. And as Dr. Mistry and Dr. Jacomides explain, it can be tricky to distinguish between symptoms caused by the bladder vs. the kidneys. Whether you have urinary frequency, urgency, or difficulty emptying your bladder all the way, we can present you with treatment options that fit your preferences and lifestyle so that you're peeing happily...not pissed off!

Voted top Men's Health Podcast, Sex Therapy Podcast, and Prostate Cancer Podcast by FeedSpot

Dr. Mistry is a board-certified urologist and has been treating patients in the Austin and Greater Williamson County area since he started his private practice in 2007.

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Transcript

Speaker 1: 0:07

Welcome to the Armor Men's Health Hour with Dr. Mistry and Donna Lee.

Dr. Mistry: 0:19

Hello and welcome to the Armor Men's Health Hour. I'm Dr. Mistry, your host, here with my co-host, the professional comedienne and effervescent office manager, Donna Lee.

Donna Lee: 0:30

I'm also a professional office manager.

Dr. Mistry: 0:32

You know, Donna, people call here asking for you for some reason.

Donna Lee: 0:35

Because I'm awesome.

Dr. Mistry: 0:38

Well, there you are. I'm a board certified urologist. This is a men's health show. This show is brought to you by NAU Urology Specialists. We are experts in the field of male and female urologic health, which can include kidney stones, kidney cancer, bladder cancer, bladder stones, prostate cancer, prostate stones. I guess it's kind of a theme.

Donna Lee: 0:58

You've said that before. I can tell you've practiced.

Dr. Mistry: 1:01

We also do a number of things that are really specific for men's health, like testosterone replacement therapy, erectile dysfunction. We also do advanced surgery for erectile dysfunction, including the infamous FLP.

Donna Lee: 1:14

Funny looking pee pee.

Dr. Mistry: 1:16

FLP doesn't work when you say ding-a-ling. We have quite a large practice, although we started in 2007 with just one physician provider, little old me. And then we are now up to seven physician providers, four PA and nurse practitioners. We have inhouse sex therapy in house nutrition, counseling in house pelvic floor physical therapy, in house sleep apnea testing, and what I think is a really holistic whole-person approach to male health.

Donna Lee: 1:41

One day though, we're gonna talk about female health.

Dr. Mistry: 1:44

We talk about it all the time.

Donna Lee: 1:46

Not enough. Not enough.

Dr. Mistry: 1:47

That's right. Yes. Women know how to hurt us, so we have to talk about their health, too. Today. We are joined by one of our partners here, Dr. Lucas Jacomides. Hello, Lucas.

Dr. Jacomides: 1:56

Hello. Thank you. Thank you everybody. I appreciate the love.

Dr. Mistry: 1:59

I will tell you that no other person demonstrates the impact that a microphone will have on your voice more than Dr. Jacomides.

Dr. Jacomides: 2:06

Why, thank you so much. Very kind.

Dr. Mistry: 2:09

When you come to see him as a patient, you'll find him to be very similar in voice to a 16 year old prepubescent boy, but somehow here he has become very white.

Dr. Jacomides: 2:19

This is where I grow. This is where I, where I drop the octaves down, and then I'm normally at a Mariah Carey level, really. Yeah.

Dr. Mistry: 2:28

Lucas, you trained at UT Southwestern.

Dr. Jacomides: 2:30

Correct.

Dr. Mistry: 2:31

I trained at Baylor, of course, College of Medicine in Houston. If you haven't heard of it.

Dr. Jacomides: 2:34

I grew up in there, I grew up there.

Dr. Mistry: 2:36

It's the finest medical institution ever.

Dr. Jacomides: 2:38

Spent some time there. A great place.

Dr. Mistry: 2:40

That's right. That's right. They let you in? That's weird. But...

Dr. Jacomides: 2:43

Research.

Dr. Mistry: 2:45

We both trained in urologic surgery. We have quite a bit of an experience. I think between the two of us, we probably have nearly 30 years of urologic experience.

Dr. Jacomides: 2:53

God, when you put it that way, I just want to get into my wheelchair and move over. I don't know. It's just unbelievable, really.

Dr. Mistry: 3:01

It's unbelievable. And just the, a number of things that we've learned and how much has changed just in urology in our short time, really on this urologic earth has been amazing, and really no field has altered more than that for the treatment of an enlarged prostate.

Dr. Jacomides: 3:15

I think you said it well. I, I was thinking about all the things that I do now, how few I actually did in residency. I mean, I do kidney stones the same, but prostates? I mean, there were almost nothing that I do now, actually, nothing I do now I did in residency.

Dr. Mistry: 3:29

That, it's fascinating because you, you know, when you're in training, you think that you're gonna come out fully formed like a completely made nice cake. When in fact you're just, you know, jello going into the refrigerator. It's time to harden up over time and learn more of your skills. You learn on the analogies later and you get better and better at making, making examples of, of how you're gonna develop as an individual. When it comes to BPH surgery on the radio, I feel like it's always been a mantra of ours that this is kind of the longest time you're gonna get with a urologist, you know, this one hour you get a week. How do you describe what BPH is to a patient? And when do you try to convince a patient that surgical intervention is gonna be superior to medical intervention?

Dr. Jacomides: 4:09

You know, I trained under the great Claus Roehrborn in Dallas, who's probablyone of the world's most famous benign prosthetic hyperplasia, or BPH, experts. And if, if you really want to know, nobody cares if you're a famous urologist, you know? You're still just a urologist. But for those of out there who know in the community, and it was always fascinating to see how class would, would talk to people. And I think BPH of all the things that we do single-handedly exemplifies why I think a lot of us went into urology. Because, you know, we give people options. You say,"Look, we can try this medication. You can be on this for the rest of your life, if you don't mind. If you don't want surgery, if you don't want procedures or, you know, we can go straight to an operation or we can go somewhere in between." So just giving people the, the opportunity to have lots of choices, and I think it's just empowering them with knowledge. And even in the things I've learned about trying to decide, when is it time to do one or the other?

Dr. Mistry: 4:55

One of the interesting differences between what it's like to practice as a doctor and what it was like to educate as a doctor is that when you're learning about medicine, every patient is just kind of the same. Patient A is a 55 year old man who has slow flow, urgency, an enlarged prostate. What do you do? And the answer is medicine. But in real life, it's different. Every man's different. Some guys don't tolerate the medicine well. Not everybody responds to the medicine that well. Some guys are gung-ho to, to operate right away. Some guys are very, very averse to operating. Some people are based upon people's their, their neighbor's experience or their father's experience. Some people just wanna avoid medication at all, at, at all costs. And fortunately, today, now we can really kind of tailor your approach for BPH to really exactly what you want.

Dr. Jacomides: 5:41

Right. And I think it's reading the patient in front of you. I was thinking about a patient you said that I saw yesterday who really should not be playing around with medications anymore. This man has had kidney failure, has had catheters, multiple times had hospitalizations for infections. It's time to get to work on this guy where he potentially could end up, you know, we call it benign prosthetic hyperplasia versus malignant and cancer, but benign prosthetic hyperplasia can have serious side effects of kidney failure. Not just one kidney, but you kill both kidneys if you don't empty your bladder well. So I think, you know, telling people,"No, it's time to do something more about this and not everybody fits in that perfect box, you know, you need something done."

Dr. Mistry: 6:16

And the number of people that are on medications like Flomax are also known as Tamsulosin for BPH and are really not completely satisfied with their treatment is staggeringly high. It's probably the minority of patient that comes in and says,"No, no. That medicine works perfect. I don't want anything else."

Dr. Jacomides: 6:31

My dad is very much, he's on Uroxatral, and I said, well, he's miserable, and he says,"What can I do, son?" He's like,"Well, you need to go see about getting a surgery.""Oh, I don't wanna do surgery.""Well, then stick with your meds.""Well, I don't wanna do meds." You know, and this just kind of goes back and forth. And he's, he's in Greece right now, so he can't hear this podcast, I don't think. So we can make fun of him all we want. No, I love you dad, but...

Dr. Mistry: 6:49

There's no internet in Greece?

Dr. Jacomides: 6:50

No, that's, it's, it's, it's a, it's very, very poor, very poor country. We, you know, it's COVID is really hitting it. But seriously, I think, yes, there's no reason to be a martyr and suffer if the pills aren't doing it for you, or even why bother starting with meds sometimes, you know? That's, that's certainly a, a switch that I've made over the years.

Dr. Mistry: 7:10

So we've talked about several different treatments on this show before, and if you get a hold of the podcast or ever want to come talk to us for a second opinion, we do GreenLight laser, standard TURP. We do vaporizations of the prostate using the laser. Some of us do HoLEPs or whole gland enucleations of the prostate. We do in-office procedure called Rezum, which uses hot steam therapy. Prostate artery embolization is a relatively newer addition to our armamentarium, as well as the in-office Urolift. Lucas, what kind of treatment intervention do you feel has gotten the most recent improvement in your mind and what have you had success with?

Dr. Jacomides: 7:48

Well, I think it's all again about the target. I mean, I I've had great successes with Urolifts, but even that gentleman, I told you earlier, he came to me with another physician elsewhere telling him that he should have a Urolift. And I sort of thought,"No. You probably need a full resection of the prostate with the PlasmaButton." I've been very pleased with the PlasmaButton over the last eight years or so that I've switched to it from the GreenLights. I think everybody's got their own favorite arrow in their quiver. It's just good to have options. And I think among the, the four of us that operate in this clinic, I think it's, it's good that we all have kind of a relative one that we like better than others. And then, you know, you've mentioned also about even robotic simple prostatectomies. We don't do'em very often, but I think honestly, that's what a lot of people do need sometimes. So I've been very pleased with the PlasmaButton TURPs. I've been pleased with the Rezums. I've been pleased, very pleased with the Urolifts. We haven't done, I haven't personally done any PAs or had patients with it, but I'm interested about it. So I think it's a matter of if patients are ready to jump to a bigger procedure versus maybe do something in between, and if it doesn't work, then do more. You can always do more. You can't usually do less once you've done the bigger case.

Dr. Mistry: 8:53

That's right. I mean, the, the idea of this iterative stepwise process through, you know, more and more invasive type procedures may appeal to some."I'd like to do the least that you can, to me with the lowest complications and then proceed." BPH surgery is very much a, a cost versus reward kind of trade off. The more likely something is to work, the more likely you are to have some potential complication. But just for our listeners, none of these procedures are likely to cause impotence. None of them are really likely to cause any incontinence. They may not work, and some of them have varying levels of discomfort in terms of how long you have to wear a catheter. But if you're interested in getting a second opinion on your BPH, if you've kind of been going to the same urologist for years and years or primary care doctor for years and years, and that doctor doesn't seem to be adding anything new to your options, call us for a quick phone call. We'd love to do a telemedicine visit with you and talk to you more in depth about, uh, options for your BPH. What's really great about us talking together on the show is to kind of showcase differences in how we deal with certain conditions. Really talk about those areas of urology, that, that we've had a lot of experience with, less experience with, and how powerful it is to be part of a group like ours that takes such a, a holistic approach to urology. And so I thought I'd talk a little bit about urgency and frequency in men. When I was in training, we really only learned that men had one condition. That was an enlarged prostate, and that was like the mother of all the urinary symptoms, and that was it. But certainly in practice and, and just kind of biologically, as we've learned as a profession, we know that there's lots of nuances there in what can cause a man to have urinary symptoms. So when a man comes to you predominantly with nighttime peeing and daytime urgency and frequency, what's some of that little speech that you give him?

Dr. Jacomides: 10:44

Yeah, that's a great question. I mean, I think it's very important to get to the bottom of that pretty quickly. And you know, the counterintuitive explanation I try to give them is,"I'm gonna do something to possibly make your frequency and urgency a little worse to start with. And that is that I'm gonna help you urinate better in some form or fashion." Because it, it isn't count, it is very counterintuitive if you think about it. Like,"Well, I'm going in a bathroom every hour." Like,"Great. Let's do a, a, a surgery or medication's gonna make you go even better, but even quicker." The reason I think we, we stress the prostate and the bladder outlet first is because, historically, I'm concerned,"Am I gonna make this guy worse?" If I give him a pill to slow him down, to make him go less often, well, he'll be in the ER later that night with a urinary retention and a fully catheter placed. So I think that it right away, we do things in the office that we can try to ascertain if they truly empty their bladder. That's a very important question. So personally, I like them to come in with a full tank or comfortably full bladder, get back in there and get a flow rate on them and see how fast they can go into a little cylinder, and then measure how much they leave behind. And then subjectively try to get to the bottom of what is their bigger problem, as far as the urgency, the frequency, the stream. Is it getting started getting empty is the harder part, or is it more the over-activity?

Dr. Mistry: 11:55

You really hit on it is, is that when men come in for urinary problems, trying to distinguish those symptoms that are obstructive, such as difficulty getting started, slow flow, and I put post-void dribbling in there as well, versus irritative, which is nighttime peeing, urgency, and frequency, can really give me an idea of whether or not I think the prostate's the primary problem or their bladder's the problem. How does age play a role?

Dr. Jacomides: 12:20

We warn more about as patients age, and especially they've had a lot of years of obstruction that perhaps they're gonna develop a dead bladder in contractility issues. So then they become a really high risk for retention as you place it. I think about medications, about constipation. There's a lot that goes to that. You know? You start to say, you know, this person has trouble elimination. They're gonna end up higher with retention, I think, and also medication side effects. I also think about polyuria, which we really don't talk about, or I personally, I admit, I, I need to get more into that conversation and find out that for some reason, I noticed that, at the older we get, we almost flip our circadian rhythms to where we actually make more urine at night than we used to. So I tell'em if you're ever in the hospital, see what your nighttime shift, your 12 hour shift, 7P to 7A is versus your 7A to 7P. And if you're making a lot more urine at night, you have nocturnal polyuria.

Dr. Mistry: 13:09

That's a great question. And so, or great point. So, so what I do is I give them a urinal at night and I have them pee at their last pee of the night in the toilet, then all the ones through the night in the urinal. And if you're making more than 800 milliliters of urine throughout the course of the night, I consider you to be someone who's making too much pee. Because if you're making 800, then you did need to get up twice to pee. But if you're only making 300, then that sensation to get up and pee at night was a false sensation. That may be treated better with medications. And I also feel like the younger you are, if you're under the age of 30 or under the age of 40, you probably don't have an enlarged prostate as the cause of your urinary urgency and frequency. And I'm looking for other things like overactive bladder and pelvic floor spasticity as the cause.

Dr. Jacomides: 13:52

And also some of the other non urologic things like sleep apnea or something that got you up or pain, chronic pain. I mean, the big question we always ask folks is when you feel the urge to wake up and go to the bathroom, the first thing you do is you wake up and go to the bathroom. You think that's what woke you up. But sometimes it's your dog, it's your wife kicking you, or it's the fact that you snore and woke yourself up and you suddenly you realize,"Oh, I need to go to the bathroom or I'm gonna wet this bed." Yeah, especially in the older patients, too. We gotta think about that as well.

Dr. Mistry: 14:18

So in somebody, let's say you got the quintessential 62 year old man coming into you with urgency, frequency, and a slow flow. Walk me through kind of the steps of what they would go through diagnostically and through medication.

Dr. Jacomides: 14:35

Well, I think you, you know, I see, I try to read what the patient is mostly interested in. Especially if they, if they've come to you with medications, it's probably time to start thinking, okay, they've maximized their meds. And a lot of them have. I mean, doubling to two Flomax pills instead of one isn't gonna help them in my opinion. So, so then I start to think diagnostically are, and do I need to look in their prostate? Especially if on exam, they don't have a big prostate, but it may be all caving in on the inside, and, and that may be their problem. Or maybe they have scar tissue or some reason to look inside their prostate. And then I also offer to also measure their prostate, to see if they're a candidate for a lesser invasive procedure. For some patients, they, the last thing they want to think about is a surgery and they come to you de novo, having never been on a single pill, and sometimes I'll give'em the option, say,"Okay, we'll try this for a month, see how you do. And let's see if it got better and then come back and see me and, and then decide,'You know, that really helped, but I really don't like to take the medications where I got these side effects.'"

Dr. Mistry: 15:27

I think what I find is that patients really like to know that you have a next step, if the first step doesn't work and that you're not just coming up with a brand new plan every time you see'em. And so for a patient like that, I will often put them on Tamsulosin or Flomax to start with, if they're not on it already. I'll have them come back and I'll look in their bladder with a camera to make sure nothing's blocking, and I'll measure their prostate with an ultrasound. And if that medicine doesn't work, then I'll flip it to medicines that work predominantly on the bladder. And then if I feel that person's gonna benefit from a surgical procedure, then I either try to go the line of overactive bladder or enlarged prostate, which to many of our listeners may sound like the same thing, but we know biologically and how we treat it are completely separate things.

Dr. Jacomides: 16:08

I think you lose an important point early on is that, you know, that men and women have overactive bladder at the same degree. It's not like somehow the extra Y chromosome denies us the need to have an overactive bladder. We still have overactive bladder as much as women do. It's important to probably treat that and at least set that expectation that you still may be getting up at night, just that you're gonna get to the bathroom and get more out of you. So I think, you know, certainly I saw a guy yesterday that I thought,"Oh, this guy just needs a procedure. I just needed to go in there. And I find it a look in, you can drive a truck through his prostate. He can knock the bark off a tree afterwards. Like you don't have a prostate problem. It's a bladder problem. Let's go after it."

Dr. Mistry: 16:42

Well, I think that's really great. And if you feel like you've been stuck into a one size fits all mentality of your urinary issues, we would love to see you as a second opinion. It's been one of the most powerful things that we've implored our listeners and our patients to do. We've done hundreds and hundreds and hundreds of second opinions for a variety of urologic conditions, predominantly surrounded around prostate cancer, predominantly around BPH, but we'll take care of questions about your low testosterone measurement or whatnot. And in this environment, doing telemedicine visits is, is, is very accessible, very easy, and very informative for you. So Donna, how do people get ahold of us?

Donna Lee: 17:19

You can call us at 512-238-0762. Our email address is armormenshealth@gmail.com and our website is armormenshealth.com. To go back to your bird analogy, we're gonna get the flock outta here.

Speaker 1: 17:31

The Armor Men's Health Hour is brought to you by Urology Specialists of Austin. For questions, or to schedule an appointment, please call 512-238-0762 or online at armormenshealth.com.