The first of these potential causes is trauma. If the penis bends in an awkward position or undergoes direct trauma the tunica albuginia which is the covering of the corpora cavernosum gets torn. This leads to the production of collagen during the process of wound healing. This excess of collagen reduces the normal elasticity of the penis and can cause painful erections, penile curvature and deformity. Mostly this is thought to happen on a microscopic level. Indirectly, it has been theorized that this repeated micro-trauma to the tissue of the penis may trigger an immune response to try and heal the injury but the body is improperly acting by the production of excess fibrous tissue. An overt tear of the corpora is called a penile fracture. This is usually seen during intercourse where the penis is forcefully bent at an odd angle, literally breaking the corpora, causing immediate and severe pain as well as immediate detumescence. A penile fracture is a urologic surgical emergency and is beyond the scope of this discussion.

There are certain medications which have been implicated in Peyronies disease because they have been reported to cause fibrotic tissue disorders. Beta blockers which are common medications for hypertension or cardiac arrhythmia may be a potential cause of the problem. Phenytoin, which is an anti-seizure medication, as well as supplements such as glucosamine and chondroiton have also been implicated. Finally large doses of Vitamin C may also promote the production of excess collage.

There is also the line of thinking that there is a genetic predisposition to Peyronies disease. It appears to be related to other fibrotic type disorders such as Dupuytren’s disease which is a buildup of fibrotic tissue in the palm of the hand which causes pain and palmar contractures. Similarly plantar fibrosis in which the buildup of plaque is in the foot is thought also to possibly be related.

Finally, there are other conditions which may have an association with Peyronies disease such as diabetes, gout and heart disease. As you can see, we have a ton of theories on why Peyronie’s disease happens. Unfortunately, we have no real definitive answers to the etiology of Peyronies disease. When you see this in medicine, it should tell you something. That something is that we just don’t have enough information. Also, it is likely that the etiology of the problem is multi-factorial.

Next time we will discuss available treatments for Peyronie’s disease. They range from watchful waiting, to medications and finally to surgical repair. Each has its benefits and drawbacks, and like everything else in medicine one size does not fit all.

Nice win by the Ravens this week. This was a game that we needed to win and do so convincingly. It was as they say, just what the doctor ordered. Although they gave up more yards than typical, the defensive backfield represented well. They will need to continue their hard work as they go to New England and face one of the best quarterbacks in the game. I think this is a winnable game. I see the Patriots as a carbon copy of the Broncos. Neither team has an effective running game and the Patriots just traded away their home run receiver. In addition, their defense is just not what it used to be. I am looking for the Ravens to steal a hard fought win in a difficult venue in which to play. If they do so, it is home to Baltimore to play the hapless Buffalo Bills and go into the bye potentially with a league leading 6-1 record. Let’s hope it happens. It will make all the fans in Ravenland very happy. Have a great week.

Peyronies disease (PD) was written about as early as 1678, but was first described by Francois Gigot de la Peyronie. in 1743. He was the personal surgeon to King Louis XIV of France. Peyronies is a benign disorder of wound healing.

It is characterized by the presence of excess collagen laid down in the corpora cavernosum which are the erectile bodies of the penis. The penis when cut in cross section is a series of three tubular structures. The two on the top are the corpora cavernosum which when filled with blood become rigid giving the man an erection. The third tubular structure is the urethra and lies essentially in the groove on the underside of the two corporal bodies. The covering of the corporal bodies (tunica albuginia) are extremely dense but distensible coats covering the vascular tissue which fills with blood to give men erections. In men with PD there is the presence of excess collagen woven into certain areas of the corporal bodies often leaving palpable dense fibrotic areas often called plaques.

The most common presenting symptoms of PD are penile curvature and painful erections. PD was originally thought to be very rare, but a recent questionnaire of 8000 men found that the prevalence of the condition was 1.5% for men in their 30’s, 3% for men between 40 and 60, 4% for men in their 60’s, and 6.5% for men over the age of 70. These numbers are likely an under representation of the problem because many men do not seek diagnosis and treatment especially if they are not sexually active. A study reported in the Journal of Urology some years ago looked at men at autopsy and found that 22% had some degree of PD.

Because PD is a disorder of wound healing, it is thought that there are a couple of stages after onset of the disease that are common to each case. The first is the acute inflammatory reaction phase which typically lasts about a year, but can be anywhere from six to eighteen months. This is the period of time in which pain is most common and along with penile curvature is the reason that most men seek medical attention. The chronic or stable phase follows in which the disease reaches its most severe state, stabilizes and then typically goes through a period of improvement which often is minimal.

As stated before, the plaque of PD forms in the tunica albuginia which is the dense covering of the erectile bodies. It is most often easily felt under the skin of the shaft of the penis. The plaque is a scar in the covering of the erectile body and reduces the elasticity of the tunica albuginia. Think of a long balloon that when inflated is bent because in the center of the balloon is scar like area that just won’t expand. This plaque or scar in the erectile body results in penile curvature, indentations in the penile shaft, erectile dysfunction, erectile pain and potentially loss of length or girth of the penis.

Any change in erectile function in men not only is physically debilitating, but in many men it is emotionally debilitating as well. Questionnaires used in the study of PD patients found that 77% suffered from psychological effects of the disease and 65% of these patients stated that the problem concerned them frequently.

Today we have covered the definition and the symptoms associated with PD. Our next installment of Men’s Health Matters will address the known causes and treatment options for PD. And while this is a disease of which not too much is known, it is much more common than originally thought and there are treatments which have shown significant promise.

It’s Steelers week for the Ravens. In my opinion the Ravens and Steelers have the best rivalry in football. The games are typically hard hitting, intense battles which typically are close scoring affairs. Even though it is very early in the season, this is an extremely important game for the Ravens. Having already lost to the Bengals the Ravens can ill afford to drop another divisional game. A loss here puts the Steelers up two games over the Ravens. A win, which would be HUGE, likely puts the AFCN into a three way tie. I have been very disappointed in our fan base this year. To hear people booing Flacco and the offense after the first series of the first home game was more than annoying. While Joe hasn’t been distinguished in his games against the top tier of NFL teams, the reality is that he wins much more than he loses. Keep in mind, Joe Flacco came from a D2 school and is still a work in progress. He and the Ravens need our support. It’s time for Joe and the offense to step up. And certainly, there would be no better place to do so than in Pittsburgh against the hated Steelers.  Go Ravens.

Sexual dysfunction can occur along the age spectrum from the beginning of sexual activity as a teenager all the way until the end of active sexual as an octogenarian or even later. Each of the various diagnoses tends to have an age group in which is more prevalent, but as always in medicine there are no hard and fast rules.

We spent our last few blogs discussing andropause which is a hormonal issue. Over the next series of weeks, we will move from the male hormonal axis to structural issues such as Peyronies disease, sensitivity issues such as premature ejaculation, vascular issues such as organic impotence and the psychologic issues of psychogenic impotence.

In general, treatment of these problems is focused on restoring the ability to complete satisfactory sexual interludes. For many men this means penetrative intercourse. As the man ages, it is not uncommon for this to mean the ability of the man to give pleasure to his spouse or partner by any number of methods.

As with prostate cancer, the internet is filled with bad information. Show me someone who has never seen an ad for “soft viagra”, whatever that is, and I will show you someone without an email address. Advertisements in the newspaper for companies promising to restore your potency are more common than ads for free kittens. Each of these venerable companies promises to tailor your treatment to your specific problem. I will tell you that I have seen dozens of men who have spent thousands of dollars with these companies all who are given the same cookbook evaluation and therapy. And oh by the way, you have to buy the medications and injections from the company which is a la carte in cost. You will see ads for hospitals sponsoring seminars on impotence where some urologist will tell you the advantages of penile prosthetics. Not that I have anything against a good penile prosthesis, but no one will argue that it is primary therapy for the treatment of impotence in this day and age.

I guess what I am trying to say is caveat emptor otherwise known as buyer beware. It is unfortunate, but there are a number of people out there who prey on men with sexual dysfunction. Sexual dysfunction goes to the core of “maleness,” and many men will spend thousands of dollars trying to deal with the issue without letting their spouse or partner know what is happening. It is a setup for a ripoff. If this blog does anything positive, I would hope that it would be to convince the guy reading today that the issues of sexual dysfunction are common, treatable, and not stigmatizing.

We will start our discussion of the treatment of sexual dysfunction next time with a talk about Peyronies disease. It is one of the more frustrating diagnoses in urology and there isn’t all that much known about the disease. This will lead us into the other issues we outlined earlier.

Well, it’s Ravens season again. I would like to thank Buck Showalter for making the Orioles interesting enough to keep my attention until the start of football season. Watching the Ravens beat the Jets in their new stadium on Monday Night Football was a great treat. As much as I loved Rex Ryan as our defensive coordinator, his loud mouth and boorish ways were exactly why I didn’t want to see him as our head coach. I am sure Harbs wanted to win that game to prove the Ravens right in their choice of him as the head coach. I am just as sure Rex wanted to win to prove the Ravens wrong. Sorry Rex. This was not your night. You may have a great defense. But your quarterback you call “Sanchize,” just isn’t ready for prime time and your offense is as challenged as the Ravens were in Kyle Boller era. Now it’s on to Cincy. Time to make Carson Palmer pay for all of the beatings he has given us in the past few years. Go Ravens.

On Friday morning, I awoke early before going to shul and went into her room. It was its typical mess and there she was stretched sideways across her bed just like when she was a little girl. I stroked her hair, told her how much I loved her and started crying like the day she was born. She awoke, which was miraculous, considering it takes a nuclear weapon or an act of G-d to wake her from sleeping. She saw me crying, hugged me and told me that it was “ok” and that she would be fine in Israel. I thought I was supposed to be the one giving the reassurance.

For the past week she has been packing, unpacking, repacking, and weighing her bags. El Al is brutal about weights and measures. Must have all had good Torah educations.

Shabbos went by too fast. After Havdalah, I pulled out my dog-tags from when I was deployed to Operation Desert Storm, otherwise known as the first gulf war. I put my dog-tags around her neck and told her that they got me home from the Middle East and I prayed that they would do the same for her. This time it was her turn to cry.

Today was the big day. What a miserable drive from Baltimore to JFK. The road was packed. The drivers around me were moronic miscreants who learned to drive by Braille and all I could think about was sending my little girl on an airplane all by herself to be away from the family that raised her. We got there, B’H”, with time to spare and got her checked into El Al. Within 20 minutes there were literally a hundred girls all going to different seminaries descending upon the same area. Double parked, and waiting to be ticketed, I hugged my not so little girl, blessed her with success and joy, managed not to cry and went back to the car. That gave Mom and her brother HB a chance to run in and say goodbye as well. The drive home was five hours in rain and traffic and I didn’t have time to think.

It’s now 11:26 PM. I just read a six page email from her seminary telling me that the plane took off and detailing the intricacies of the security arrangements that they adhere to in order to keep our children safe. And now, my child is somewhere over the ocean going to do something that I never had the opportunity to do. And guess what? I am sitting here at the computer, blogging and crying at the same time.

It is kind of funny. My parents, may they both rest in peace, never told me how painful and pleasurable it could be as a parent. Especially at the same time.

So today, I write about heart pain. My only daughter is flying to Israel and I am crying at my computer. May the Holy One, Blessed is He, watch over Cassidy and keep her safe. May He give her a wonderful year of growth and learning. May she come home a year from now, happy that she took this year between high school and college to really learn about what it means to be a Jewish woman. But most of all, please Hashem return my daughter to me so that these tears of sadness I have shed today at her departure, can be turned into tears of joy at her return.

Another method of treatment coming to fore is replacement by using a buccal patch. The one available in this country is called Striant and it is a patch placed on the inner cheek and replaced every 12 hours. There have been some studies which show that it is a superior delivery system, but frankly I have no experience in the use of the medication and I have been quite satisfied with the results achieved by either Testim or Androgel which are once per day rather than twice per day medications.

Within a week or two most men will notice the changes associated with testosterone replacement. I start men at one tube per day of the Testim or one packet (4 pumps) of Androgel which is available in packets or a pump bottle. I seem most men back 4 to 6 weeks later and check a random testosterone level. If they are eugonadal (normal level) I leave them on the dose. If needed dose adjustment can be made at that time.

The most common finding I see with testosterone placement is an improvement in the general feelings of mood, affect and sense of well being. Improvement in libido is the next most common finding in my experience.  Improved quality of erections or a better response to the oral medications such as Viagra, Levitra, or Cialis is also frequently seen. Long term I will often see change in body characteristics by improvement of muscle mass especially in the men who exercise.

In terms of side effects, skin irritation is also seen with the gels but not as commonly seen as with the patches. The biggest complaint that I hear is that the dose does not seem to be “enough.” Some men will talk about temper flares and this needs to be monitored closely.

For followup, most recent recommendations suggest that laboratory monitoring of total testosterone, PSA and hematocrit be completed on a regular basis. PSA and DRE should be checked every 3 months for the first year and then annually thereafter. Any increase in PSA of > 0.5 ng/ml in the first six months of testosterone replacement therapy deserves further evaluation. A digital rectal examination of the prostate is mandatory in my mind as is PSA. While there is no evidence that replacing your body’s normal testosterone causes or predisposes men to prostate cancer, it can not be disputed that prostate cancer is in most cases hormonally active and therefore use of exogenous testosterone, while safe and effective, needs to be monitored closely by a physician comfortable with its use, side effects and complications.

Countdown to football season is official. Get on the bandwagon now. We are stocked at starters and backups. If this team can remain relatively healthy, we are going to the Superbowl. Go Ravens. Summertime is here and the blog is going on vacation for a couple of weeks. If anyone really has a yearning to talk Urology, I can be found just outside of Taos, New Mexico in a little town called Arroyo Hondo at about 6000 feet elevation. The pond is stocked with rainbow trout that are just waiting to be caught, but you’ve got to bring your own fishing poles, lures and worms. Identify yourself when you come out. Gun laws in the southwest are much less strict than in Maryland. Have a great couple of weeks and enjoy the Baltimore summer.

Once the diagnosis is made and a prolactin secreting tumor is excluded, treatment can be instituted. If we are dealing with straightforward hypogonadism, it is typically treated by the urologist or the primary care doctor. If there are other abnormalities in the hormonal profile, typically, I would refer the patient to an endocrinologist. The majority of the time, however, this is not necessary. Fortunately or unfortunately (depending upon which side of the knife you live on,) there is no surgical cure for the problem. There are however, excellent methods of restoring a proper hormonal balance.

If you go back over 10 years ago, the most common treatment for hypogonadism was intramuscular injections of testosterone in one form or another. The patient would come into the office about every four to 6 weeks and receive his injection. The major issue with this type of treatment is that it does not mimic the body’s typical daily production characteristics of testosterone. Intramuscular injections give a quick boost of hormone which is absorbed slowly by the body and dissipates over the course of time. And while the boost may be great, the whole process was not very physiologic and for many men somewhat painful. Many years ago, oral testosterone would be given. However, it has been found that this method of treatment is associated with significant liver toxicity and for the most part it is no longer in use.

The first attempt at finding a different vehicle to deliver testosterone was in the use of a scrotal patch called Testoderm. It required shaving the scrotal hair and caused a lot of scrotal irritation and itching. It was however an improvement on coming into the doctors office every three to four weeks to get a shot. The next generation of patches came with Androderm.  Androderm is a convenient, once daily skin patch, called a transdermal delivery system. Like Testoderm the vehicle is similar, the difference was that Androderm can be applied to the back, abdomen, thighs, or upper arms. The major issue with Androderm was again the problem of an inflammatory reaction at the site of the patch. In studies done by the company 38% of men reported itching at the site of the patch. In addition 12% of men had a blister like reaction and 7% of men developed redness or swelling. These were the most common side effects specifically of Androderm but seen in Testoderm as well. Use of steroid cream on the skin prior to application of the patch helped with the side effects but this caused issues with uptake of the medication. These medications represented a major improvement over intramuscular injections, but still were not optimal in how they delivered the medication or the panel of side effects that were commonly associated with their usage. The next generation of treatment options for andropause needed to be easier to use and cause less side effects while mimicking the body’s daily production of male hormone.

In the next blog, we will discuss the latest and greatest generation of medications designed to treat andropause. They have much less in the way of side effects and have really become the mainstay of treatment. They have taken hypogonadism out of the closet and made the condition easy to treat. More importantly, I believe that their development has made it easier for men to come forward and even discuss the problems associated with andropause.

A couple of sports and philosophical related comments to end the blog. I used to be a huge NBA fan. That changed after the retirements of Dr. J, Bird, Magic and Michael Jordan. Mostly, I find the NBA a bore. I was however fascinated by the whole LeBron James discussion. I guess if Carmelo Anthony who is from Baltimore played for our mythical NBA team and decided to leave after seven years to pursue what he felt was a better chance at winning titles, I would be really disappointed. But I don’t think I would burn his jersey or make some of the comments I have heard coming out of Cleveland and specifically from the owner of the team. Cleveland, the Cavs, and Dan Gilbert (who owns the team) made a boatload of money off of LeBron and his talent. Just how long does LeBron owe the city of Cleveland? He is a free man in a free market system. Why should he not be able to sell his services to anyplace willing to pay him his desired salary? However, the dog and pony show that he put on ESPN was in poor taste and should never have been done. He should have had his press conference in Miami and been done with it. By doing what he did, he made himself more important the game. It made him appear selfish and arrogant which by all accounts is not his personality. So I’ll tell Cleveland the same thing I said when the Browns left to come to Baltimore. Get over it and move on. It’s not like you have any other choice.

Finally, I come to the Reverends Jesse Jackson and Al Sharpton, two of the biggest parasites in the United States of America. There is almost no situation where they aren’t willing to play the race card. But for Jesse to say that Gilbert treated LeBron like a runaway slave is totally inappropriate and given his history not unexpected. I guess my real question to the two muckrakers is as follows: The Department of Justice, run by an African American under the guidance of the first African American President, declined to prosecute the New Black Panther Party for videotaped documented voter intimidation in Philadelphia during the last Presidential election. Is this whole imbroglio with LeBron James so much more important than the Civil Rights Voting Act that you felt it necessary to lend us your brilliant erudition while having no comment on documented voter intimidation at the pols? If the men of the NBPP were Caucasian, the event happened in the south, the defendants wore KKK hoods or had swastika tattoos, would you feel the same way? How quickly would we have seen protest marches and sit-ins? Why is one condonable but not the other? Is lady justice not supposed to be blind to race, creed, skin color or religious affiliation? Just thought I’d ask.

If you have a few of the complaints associated with hypogonadism, and you find them limiting to your lifestyle, you need to approach your family doctor or urologist and let them know. It is important to note that if the changes associated with andropause are not causing issues, then in my mind evaluation and treatment is less important. Many family doctors will check your testosterone level and if it is low refer you to either a urologist or less likely an endocrinologist. There are some family doctors quite comfortable treating hypogonadism and will prescribe therapy themselves. Very often a thyroid panel, cholesterol and other blood tests will accompany a check of your testosterone. It is important that if your testosterone is to be checked, that it be done so in the morning. It does not need to be done as a fasting blood test, but it is better if it is done in the morning.

If your testosterone is low or borderline and it was done in the morning, the next step will often be to check a more involved testosterone panel. In addition, it is important to check a prolactin level. There is a pituitary tumor that is easily treated whose first presentation is often as a low testosterone level. But in order to be diagnosed, a prolactin level needs to be ordered. This is something that is often not picked up by the primary doctor, but should be addressed by the urologist or endocrinologist. If the prolactin level is abnormal, an MRI of the pituitary gland is indicated and at that point typically the urologist will refer the patient to the endocrinologist who is expert in the area.

Ok…. We have now addressed the symptoms often seen when a man goes through andropause. We have discussed the evaluation of the man who presents with the symptoms. Normal testosterone levels don’t mean that the symptoms you are experiencing are psychologic. It just means that hypogonadism is not the prime cause. I would still encourage further evaluation by the family physician, but the problem itself is no longer “urologic.”

Next time we will discuss treatment options for male hypogonadism. We have come a long way from the days of my residency when men used to come in every few weeks for a shot of testosterone. But we will leave that discussion for next time.

I wouldn’t suggest buying playoff tickets yet, but has anyone noticed that the Orioles have won four games in a row?

Is your libido (sexual desire) lacking?
Do you feel like you are losing muscle mass?
Is your overall energy level just not where it used to be?
Is your sleep pattern disturbed?
Are your erections not quite what they used to be?
Have you been sad or grumpy lately?
Have you noticed a recent deterioration of your ability to play sports?
Are you falling asleep after dinner?
Has there been a recent deterioration in your work performance?
Have you lost height?

A positive answer to three or more of these questions could indicate low testosterone levels. Obviously these are general questions and there are a number of diagnoses which also are supported by these symptoms, however, hypogonadism (low testosterone levels) is much more common than you think.

It is estimated that up to one in three men over the age of 45 have a low testosterone level which means that somewhere around 13 million men may be affected by the problem. Because testosterone levels naturally decrease over time, the older you are, the more likely you are to have the problem. Between the ages of 45 to 74 almost 40% of men have testosterone levels that are considered to be low. The good news is that it is an easily treated problem that can have remarkable impact on quality of life once it is treated.

Testosterone is a hormone produced by the testicles, and it plays an integral role in men’s health. The brain regulates testosterone production by sending chemical signals to the pituitary gland. The pituitary gland which is located in the center of the brain sends its own set of signals to the leydig cells within the testes driving them to make testosterone. Sexual health, physical health, and bone health are all dependent upon testosterone production. Failure in production of testosterone can have major impact upon these and other systems in the body.

Low testosterone comes with a wide range of symptoms including sexual and nonsexual issues. Some of the more common are:

Low sexual desire (low libido)
Weaker and fewer erections
Reduced sexual activity
Low energy or fatigue
Depressed mood or poor concentration
Reduced muscle mass/strength
Increased body fat

The problem is that low testosterone is widely under diagnosed because its symptoms are mistaken for just “getting older.” It is also commonly seen with other medical problems such as chronic opioid use (74%), obesity (53%), diabetes (50%), AIDs (50%), hypertension (42%), hyperlipidemia (40%) and erectile dysfunction (19%). Remember, erectile dysfunction is not synonymous with low testosterone level. It is possible to have one without the other and as you can see it is common to see both together especially in the presence of concurrent medical issues such as diabetes and hypertension.

In our next discussion we will talk about the evaluation and treatment of hypogonadism. But most important is to recognize the symptoms and have the courage to speak to your primary care doctor or urologist about the problem. One of the reasons that hypogonadism is under diagnosed is that many primary care doctors aren’t looking for the problem. But just as common is that the patient is not willing to discuss the symptoms. And while as doctors we would love to be able to read minds, that just isn’t reality. So if these symptoms are something that you are experiencing, and you are tired of watching it worsen, do something for yourself and seek attention from your primary care doctor or your urologist. I can tell you from the experience of so many of my patients, you will be very happy that you addressed the issue. It can make a world of difference in your quality of life

As noted before, Dr. Redwood is a graduate of Pikesville Sr. High School. He is well known in both the Jewish and African-American communities and has been at the forefront cutting edge technology in urology since finishing his residency. Last time we discussed his history and reasoning for making the move to a hospital doctor relationship. Today I wanted to more to the future of mens’ health and urology in Sinai and locally.

I asked Dr. Redwood why Sinai seemed to be his best match for him. He responded, “I have spent many of my formative training years in the Sinai system. I have seen it grown. I have personally heard the vision and mission of Lifebridge and Sinai from both Warren Green the CEO of Lifebridge and Neil Meltzer, the President of Sinai. My goals for developing the Department of Urology is in complete alignment with those goals.”

I asked what he saw as changes in urology in the next decade and what his focus would be as the Chief of Urology. “The health care climate is truly changing. With the aging population, urologic care will have to be an intimate part of care both acute, short and long term. Unfortunately, urology will be under a great deal of scrutiny due to the health care dollars involved. There will be a significant push for “Best Pathways” in care and Best Practices” in care. It is my goal to have Sinai and the Lifebridge System reconnect with the Jewish and African-American Communities. We would do this through education of the state of the art services offered and a sense of caring about patient issues.”

“I want to invite patients to have a conversation with their doctor and invite them to be more involved in the decisions about their urologic care. Finally I would like to integrate urology into not only acute and short term care, but long term care as well both inside the hospital as well as in outside institutions.”

Here Dr. Redwood and I are in total agreement. I believe that in today’s market the patient needs to drive decision making. The era of the paternalistic surgeon telling the patient what the plan was going to be is mostly gone. The patient needs to take ownership of his medical problem and the decision making that follows. I believe that it is the job of the physician to provide the appropriate education for the patient such that they are as well informed as possible in order to make decision that best serve their needs.

Medicine is changing, and it is doing so quickly. How the new heath care plan will affect that change is yet to be seen. It is my suspicion that many doctors will leave the field of medicine rather than be forced to accept some of these changes that they see as not in either theirs or their patients interests. There already is a shortage of physicians in general and a tremendous shortage of those in primary care. In the new health care legislation are provisions for the government to push to replace primary care physicians (family medicine, internal medicine) with physician extenders such as physician assistants (PA’s) and nurse practitioners (CRNP) because they can be trained more quickly. In addition there will likely be a relaxation of the regulations of physician oversight of these physician extenders. The real question is whether that will be in the best interest of the patient or the best interest of the government. Please don’t misunderstand, I know many outstanding PA’s and CRNP’s and would happily go to them for primary care, however they are not doctors and do not have the complete experience that most doctors have. These are only some of the changes coming down the road.

Thanks to Dr. Redwood for taking the time to speak with me about all of the changes going on in his life and at Sinai Hospital. Next time we convene it will be to start the discussion regarding hypogonadism.

Only another month until the start of Raven’s training camp.

Today is the final topic. What do we do with the man presenting with metastatic disease? This is, in today’s world of medicine, a very unusual presentation. Back when I was a medical student and even very early in my residency many men presented to their doctors with voiding symptoms, back pain, hematuria and came away with a diagnosis of advanced prostate cancer. The use of PSA as a screening tool to identify early disease has made a profound impact in saving lives and diagnosing men at a point where the disease is more manageable. But there are still some men who present with metastatic disease.

The most common presentation will be a man who finally decided to see a primary care doctor at the age of 60 or 70. His family history may well be positive for prostate cancer. His internist checks a PSA and lo and behold it is astronomically high. I have seen presenting PSA’s of over 3000. Remember normal should be less than four. The panic call to the urologist comes in. The patient gets a biopsy and not surprisingly he has every core positive of high Gleason’s sum, high volume disease. The metastatic workup may show bone metastases and may well show lymphadenopathy on CT scan. A dynamic evaluation of the bladder might show significant bladder outlet obstruction.

The first line therapy for metastatic disease is total androgen blockade. We spoke before about Leupron and its side effects. Another option would be orchiectomy or removal of the testicles. In addition, we would start the patient on Casodex to block adrenal steroids. The men with significant bladder outlet obstruction will often get a transurethral resection of the prostate not as a treatment of the cancer, but to allow them return to normalized voiding function.

The results of total androgen blockade are often very good and durable. I have had men on Leupron for advanced prostate cancer for over 10 years and their PSA’s are still undetectable. There are, however, a number of men that after some period of time will see their PSA again begin to rise. A good rule of thumb for knowing how a man will respond long term to androgen blockade is to see how quickly their PSA drops to undetectable and if it stays that way for more than a year. If their PSA drops to undetectable and begins to rise again within a year that is a bad prognostic indicator.

For the men metastases to their bones the standard of care is to start them on intravenous Zometa. This is a medication that strengthens their bones, improves the bone pain caused by prostate cancer, and decreases their risk of what we call a “pathologic fracture,” which is a bone break through an area already overtaken by prostate cancer cells. And while Zometa does not improve survival from prostate cancer itself, it causes a major improvement in quality of life.

For the unfortunate man whose prostate cancer becomes refractory to hormonal treatment, the next step is referral to an oncologist. There are now a number of protocols available for hormone refractory prostate cancer and there are some promising results. I personally have a number of men on protocol at the oncology center at University of Maryland Medical Center. I have been very impressed with their compassion and their treatment of my patients. In addition, their communication back to the referring physician is excellent which is often problematic when you send a patient to a tertiary care center. The patient may get great care, but the home town doctor often has no idea of what happened or what becomes the overall plan of care.

It has been a long road getting through prostate cancer on this blog. I realize that for some people it may have become overly tedious. But prostate cancer is the number one cause of cancer and cancer death in men. It is a controversial topic because of the different camps of treatment vs watchful waiting, extirpate surgery vs radiation, cost containment vs impact on quality of life and quantity of life, and certainly PSA screening vs a non-screening approach. It has been very gratifying for me to do these set of blogs. I have had literally hundreds of men call my office to ask questions or just send a note and thank me for taking the time to do these detailed explanations. I’ll take this moment to thank Neil Rubin for allowing me the forum to discuss mens health issues. It was a leap of faith on his part and hopefully I have not caused him too many problems as the editor of the Jewish Times. Thanks also to my mentor, Phil Jacobs, who encouraged me to pursue my vision of writing a health column. Next time we will start discussing male menopause and hypogonadism. This is an under-diagnosed issue for many men often starting in the 40’s and moving on. Certainly it won’t take the time that prostate cancer did, but it is also a common men’s health issue that needs to be brought to light so it too can be treated appropriately.

Until next time…...