Dr. Prakash Maniam with the Urology Wellness Center in Oviedo shares answers to the top ten urology questions. Topics covered include bedwetting, kidney …
– Good evening everyone,
my name is Prakash Maniam.
I'm a urologist here at
Oviedo Medical Center.
And tonight I'm gonna be talking to you
about a smorgasbord of topics in urology.
I've put together the top questions
that we get from patients
and audiences as we go
through our lecture series
here at Oviedo Medical Center.
and I've summarized all them
to try to hit all the topics.
A little bit about myself.
My name is Prakash Maniam.
I'm a urologist here,
and I grew up in Ohio.
I went to medical school
at Ohio State University
and did my residency
training in Cleveland, Ohio
at the Case Western Reserve University.
And I've been here in Florida
for about 2.5 to three years.
So let's get started.
And I'm gonna try and summarize everything
in about 30 minutes.
So we'll flip through the topics here,
and in the interest of time I'm gonna skip
the pediatric topics and
go to the adult topics.
Probably the most common
topic that we treat
or problem that we treat in
urology is kidney stones.
Most people will have a kidney stone
at some point in their life.
And some people will have
a number of kidney stones.
So I want to talk to you
about what causes stones
and why they're as painful as they are.
The symptoms of kidney stones
are most characterized by pain,
and the pain can be one side or the other,
usually in the flank area.
And it usually will
radiate around the side
sometimes into the groin
and the genital area.
And the stones are produced up here
in the periphery of the kidney.
And as they develop,
they are released from
the papilla of the kidney,
and they work their way
down the collecting system
or the drainage tract of the kidney.
And the drainage tract
consists of a long, narrow tube
called the ureter which
then leads to the bladder.
Now if the stone is small enough,
it'll pass through the ureter
and work its way down to the bladder.
However, if it's large enough,
then it'll try to get down to the ureter
but it will get stuck.
And when it obstructs that ureter,
the kidney then swells
because of the back pressure,
and that pressure that
develops within the kidney
is what gives the pain, and the nausea,
and all the characteristic signs
and symptoms of kidney stones.
And again, the typical symptoms
are pain in the back area
radiating into the groin
usually associated with nausea,
vomiting, and often visible
blood in the urine as well.
If it's near the bladder,
you may sometimes experience
urgency and frequency to urinate,
in other words bladder symptoms.
The best way to prevent kidney stones
is by diluting the urine
because these stones form
because certain chemicals
are in too high a concentration
in the urine so they precipitate.
And when they precipitate,
they form crystals,
and those crystals then
aggregate to form stones.
So one of the best ways to prevent stones
is by increasing your water intake
and essentially you're
diluting your urine that way.
And by diluting your urine,
it's less concentrated,
less likely to have those crystals join,
bind together and form the stones.
So often a common question
is well, how much water
do I need to drink?
Generally speaking, you need to put out
at least two liters of urine per day
is what the recommendation is.
So in order to do that,
you have to take in that much more
because as you can imagine
especially here in Florida
in the heat you're gonna be perspiring,
and you're losing fluid just from the heat
and just from normal daily activity.
So water intake of at least 2.5 liters
per day is recommended.
The other dietary
recommendation is sodium.
You wanna avoid excess sodium.
You wanna keep your dietary
sodium to a minimum.
A recommended allowance would
be about three grams per day.
As your body's having
to metabolize the sodium
as the kidneys are excreting that sodium,
they will eliminate calcium as well.
So if that calcium then…
The concentration builds up in the urine,
as you can imagine that's
how the stones form.
Finally, dietary citrate is important.
And dietary citrate consists
of things like lemon juice,
or lemonade, or orange juice as well.
Citrate is important because
it's a stone inhibitor.
So the more citric you
can take in, the better.
And one good recommendation
would be to take
an ounce of lemon juice,
put it in the water that you're
gonna be drinking all day.
And so you get the benefit of the water
and the citrate as well.
In some people, there are stones
that you can't get enough
citrate in your diet,
and we have to supplement
it through a medication.
But most people can get enough
citrate through their diet.
People often ask about calcium
and what's the role of
calcium in stone formation?
Dietary calcium does not
need to be restricted.
In fact, it's actually beneficial
to maintain calcium in your diet
because that calcium
then binds with things
like oxalate which is another
stone-forming component.
And that bound product then is eliminated
through the GI tract.
So actually cleansing your body
of stone-forming components.
So if you don't have enough calcium,
those are absorbed individually
and then made up in the
kidney in your urine,
and then the stones will form.
Another common topic that
we deal with in urology
is blood in the urine,
the medical term is hematuria.
And it comes in either in visible
or gross hematuria, or
microscopic hematuria.
And obviously, with microscopic hematuria,
you're not going to see it,
but you're physician,
usually your primary doctor
on a routine urinalysis may pick it up.
And it shouldn't be ignored
because it can be a sign
of significant problems.
So we can classify it in different ways.
There's microscopic blood in the urine,
or what may be more significant
is if you actually see
the blood in the urine.
In other words, gross hematuria.
We also wanna know whether it's
painless or if it's painful.
And to see why you would
have blood in the urine,
you have to understand the
anatomy of the kidneys.
And so going back to the
kidney stone section,
if the kidneys are here
in the back of your body,
the urine is made out in
the periphery of the kidney,
and then it's transported
down into the bladder.
So the various causes of
blood in the urine can range
from anything from kidney
disease like glomerulonephritis,
to a kidney stone as we just talked about,
or cancers of the urinary tract
which can be anywhere from the kidney
all the way to the bladder or beyond.
And bladder cancer can occur
in the bladder obviously.
In some men, you can
develop a bladder stone
which will give the blood.
Cystitis refers to a
urinary tract infection.
So if an infection is bad enough,
it'll give blood in the urine
because the lining of the bladder,
or kidney, whatever the case may be,
it will be so inflamed that that blood
will then be released.
Prostate enlargement can often
lead to blood in the urine
in men of older age.
Other cancers like kidney cancer
and kidney infections can
also give blood in the urine.
There are also situations
where it may be not pathologic at all.
It may be a normal thing to notice
is to have blood in the urine.
Some women of reproductive
age may have blood
in the urine microscopically,
and it's not of any concern.
But if it's there persistently
and especially if it's visible blood,
it should be checked out.
Another common problem that we see
in general urology practice is
frequent bladder infections.
This often happens in women,
and there's a sort of
a bimodal distribution.
You can see it oftentimes in younger women
that are sexually active,
and you can also see
it at a high frequency,
a prevalence of it in older women
especially postmenopausal
women for different reasons.
Bladder infections are fairly
straightforward to understand.
Bacteria enters through the urethra.
In women, they can enter
through the vaginal
canal, enter the urethra,
and they'll usually set
up in the bladder lining.
The bacteria will adhere to receptors
on the lining of the bladder.
For example, E. coli
bacteria binds to receptors
on the bladder's epithelial
lining or mucosa.
And once they adhere to these receptors,
then the infection begins,
and then they work their way
or ascend from the
bladder up to the kidney.
As I said, there's two groups of women
that are most prone to
urinary tract infections,
young women in the 20s and 30s
and then the postmenopausal women.
Other factors that are involved
in urinary tract infections
are fluid intake or lack of food intake,
constipation because it's
often the bowel flora
that ascends into the trans-
Locates into the vaginal canal and urethra
that can then develop
into these infections.
Sexual activity has a role as well.
Ways to prevent urinary tract infections
are number one, fluid intake.
Keep the water in your
body, keep things moving.
You don't want stasis.
You want everything to keep moving.
Avoid constipation because
again the bowel bacteria are…
For example, E. coli are
oftentimes the culprits
of these urinary tract infections.
So good bowel habits are very important.
Post-coital prophylaxis
is something that a doctor
will often recommend if
you can correlate the onset
of the urinary tract
infections to sexual activity.
So there's a strategy
that can be worked out
to prevent the infections rather
than wait for them to come
and then treat them afterwards.
There's also continuous
prophylaxis which we tend to avoid,
but in some cases you can't avoid,
and that's a daily dose of a very…
A daily, but a low dose
of a common antibiotic
again, to help prevent the infection
rather than wait for it to
come about and then treat it.
There are some other…
Excuse me,
some other things that can help as well.
Everybody knows about
cranberry juice or tablets.
There's been some conflicting data
about the beneficial effect of cranberry,
but you can take it in
either the juice form
or the tablet form.
And the chemical within the cranberry
is thought to be beneficial
by preventing the binding
of the bacteria to the
urinary tract lining.
And by preventing that binding,
you never get the bacteria to adhere,
and it never ascends, and
you never get the infection.
There are a couple of
other things as well.
Probiotics is often helpful.
Probiotics is as the name
implies is good bacteria.
So for example, in women who have stopped
producing estrogen and are
in the postmenopausal years
don't have the estrogen production,
and that leads to changes
in pH in the vaginal area,
and you lose the good,
normal bacterial flora.
And so then the bad bacteria
can then enter and cause infection.
So by taking in probiotics,
you regenerate or repopulate the area
with the good bacteria,
and that prevents the entry of
the bad or harmful bacteria.
Other things that is often
used that's been some data
for recently is D-Mannose.
It's a naturally occurring sugar
that mimics the receptors on the bladder
so the bacteria adhere to the D-Mannose,
and they render themselves ineffective
and then prevents the infection.
Another common problem that
we deal with in urology
is having accidents or
urinary incontinence.
And there are a number of
reasons for incontinence
because there are a number of causes-
There's a number of types of incontinence.
We generally classify incontinence
in one of two categories.
There is stress incontinence.
Stress referring to
pressure on the bladder
and not so much psychological stress,
but stress on the bladder.
So if the bladder is…
The bladder is normally
supported by the pelvic floor
which is sort of like a bowl,
a muscle that forms the
floor of the pelvis.
If there's weakness in
that floor of muscles,
then the bladder and
urethra can then descend,
and they move more than
they normally should.
So if the pelvic floor muscles are strong,
then the urethra is held up tightly.
As we get older,
things start to sag as we all know, right?
So that includes the pelvic floor muscles.
So as the pelvic floor
muscles sag or weaken,
the urethra itself can weaken as well,
and then so it descends.
So when there's pressure
placed on the bladder,
there's nothing to tighten
up and hold the urine in,
so that urine will then leak out.
So it's kind of like having
a balloon full of water.
And if you have that
balloon full of water,
and you pinch the end of the balloon,
and you press on the
balloon, what happens?
The balloon changes shape,
but nothing leaks out.
So if you take that and
not pinch it so much
and then you press on the
bladder, what'll happen?
It'll leak right out.
So that's what's happening
in stress incontinence.
So if you have a full bladder,
and you increase the
pressure on the bladder,
and there's nothing to hold
it back, then it's gonna leak.
So that's called stress incontinence.
The other type of incontinence
is called urge incontinence.
Urge incontinence refers
to that got-to-go sensation
where you have the urge to
go and you can't control it.
You can't hold it.
It starts to come about
even before you can get to the bathroom.
Under normal circumstances,
there's a gradual progression
of filling of the bladder.
And that sends signals to
the central nervous system
in your brain that tells you
okay, I think I've got to go right now.
And then gradually progresses to
well, we got to go right now.
But in people with overactive
bladder or urge incontinence,
they don't have that gradual progression.
Even the slightest amount of bladder urine
tells them they have to go on right now.
And the bladder will start to leak
if they're not at the bathroom.
So again, there's different
types of incontinence,
so each type has different treatments.
We always wanna start with
the simplest treatments first.
Things like dietary management
is often beneficial.
Things that can worsen
urinary incontinence
are things like caffeine, sodas, alcohol,
anything that stimulates or
overstimulates the bladder.
So by moderating those dietary factors,
you can often keep the urinary
incontinence under control.
For example, caffeine is a diuretic,
so it'll lead you to
urinate more frequently.
So if you can moderate the caffeine,
that's often a big factor.
Sodas similarly.
Behavioral factor, so there's
something called timed voiding.
Timed voiding simply just
means that you hit the bathroom
at a very regimented schedule.
So for example, if you know
that when you have to go,
you've got to go,
then you set your schedule
every two hours for example
and empty your bladder regularly
so that you never reach
that threshold point
where you have to go
so urgently that it's gonna leak on you.
So that's an example
of behavioral therapy.
And also Kegel exercises.
Kegel exercises are those
exercises that women
are taught after childbirth
to tighten the pelvic floor muscles.
When you tighten those
pelvic floor muscles,
that can often turn off the urge
in urge incontinence patients.
It also strengthens the
pelvic floor muscles
in stress incontinence patients.
And so in addition to stress and urge,
there's also some people
have a little bit of both,
and we call that mixed
urinary incontinence.
Hormonal factors are also involved.
Again, going back to the
postmenopausal years,
women don't make the
female hormone estrogen,
and that causes changes
in the vaginal canal
and the urethral anatomy.
So that makes the urethra more irritated
and can lead to urgency
and urge incontinence.
There are some medications
that can help in this regard.
They often work by reducing
the reflexive contraction of the bladder.
So it allows the bladder to hold more
so the frequency is not there.
So the more you can hold,
the longer intervals you have
in between the bathroom trips.
There are also medications
that actually work
on the muscle to prevent the contraction
of the muscle like Botox.
Botox injections are often
used for urge incontinence.
And then there are surgical
treatments as well.
If the stress incontinence
is from excessive movement
of the urethra or lack of
support of the urethra,
you can replicate that
support by a sling for example
which doesn't hold the urethra,
but it just gives it a backboard
so that if there is
pressure on the bladder
the urethra doesn't move much,
and you get that closure
that prevents leakage.
And often a topic that we see
here in urology is a vasectomy.
A vasectomy is a very effective
form of birth control.
And it has some…
It's been around for centuries.
And the reason is it's fairly simple.
And for a male, it's easier to perform
then having a sterilization in a woman.
So the way it's performed
is it's fairly simple,
it's done in the office,
and it's usually almost always
done under local anesthesia.
It takes about 15 minutes on each side.
So I would say about 30 minutes.
And because it's done
under local anesthesia,
the man can have the procedure.
And once it's done,
he can get dressed and go home.
Recovery period is usually
about two to three days.
So for example, if you had it on a Friday,
you could go back to work on Monday.
So the way it works is if you look
at the anatomy of the vas deferens,
the vas deferens is a
connection from the testicle
where the sperm is produced to the urethra
where the sperm then exits.
So during a vasectomy,
we separate that ductal tubule
called the vas deferens.
And so afterwards, the
sperm cannot make it out
from the testicle to cause pregnancy.
Again, it takes about
15 minutes on each side,
so it's about a 30 minute procedure.
Recovery time is fairly short,
and it's routinely done
in an office setting.
Now we often in the past
10, 15, 20 years are seeing
a large influx of patients
having low testosterone
because we're learning more
about the role of testosterone
and how we can replace it.
So low testosterone is
a routine blood test
that can be done.
That's usually done in the morning hours.
It doesn't have to be fasting,
but it has to be done in the morning hours
because the body
production of testosterone
has a pattern where it
peaks in the morning
and then levels off for
the rest of the day.
So the role of testosterone
is as most people know,
it's the male hormone.
It gives men vigor, it gives them libido.
And as men age usually in the late 40s,
it can start to decline.
So if you make the analogy to women,
they usually have a sudden drop off
of their female hormone
known as menopause.
But in men, it's more of a gradual decline
after about the late 40s, early 50s.
Level of testosterone peaks
during the morning hours,
so that's the time when you
wanna get the level drawn.
And the symptoms of low
testosterone are low energy,
being easily fatigued,
difficulty in concentration.
Libido is noticeably decreased.
A man may notice changes
in erection quality.
You may notice change in body
habitus with low muscle mass.
So testosterone has a role
in many symptoms in the body.
So the diagnosis of low
testosterone requires two things.
One is to have those symptoms
which is the primarily low energy level,
easily fatigued, low libido.
So that's symptom complex in addition
to a low serum level of testosterone
which the cutoff that
we usually use is 300.
So if a man meets both of those criteria,
there are ways to replace testosterone.
So the replacement of
testosterone can come in two ways.
There is an injection form that's given.
That's usually about once every two weeks
that the man can inject
themselves in the muscle.
Or if a man is trying
to preserve fertility,
wants to still have children,
then there is an oral form
which works by stimulating
the body's own natural
production of testosterone.
The injectable form,
because it's outside estrogen coming into-
Outside testosterone coming into the body,
the body senses that it
has enough testosterone
and it'll actually stop making its own.
And so when it stops making its own,
it also stops making sperm as well.
So that can render infertility.
So if a man is still interested
in maintaining his fertility,
then the oral form
or Clomifene would be
the best alternative.
Probably the most common thing that we see
especially in older male
population is prostate enlargement.
So enlarged prostate is a
naturally occurring phenomenon.
As men get older
and in fact all men as they get older
will have it we'll have it to some degree.
And to understand an enlarged prostate,
just you have to look at the anatomy here.
So this is the bladder here.
The prostate sits right below it.
And the bladder forms a
tube called the urethra,
and that urethra tube runs right
through the prostate gland.
So the prostate encircles it.
And so in normal situations,
the urine will pass right through
the prostate without difficulty.
However, in enlarged
prostate as you can see,
that urethra now is becoming constricted
because the prostate is growing,
and it then grows into the urethra.
So forms sort of a vice
grip on the urethra.
And that leads to the classic symptoms
of difficulty in emptying the bladder,
maybe having to push or strain to urinate,
or having to wait to
get the urine started.
Or after urinating, you still feel
like you have some urine in your bladder.
And that's because the bladder's not able
to push it out through that obstruction.
So again, here's the bladder.
This is the bladder neck area,
and the urine will then pass through here.
And this muscle here is
called the urethral sphincter.
So when the prostate gets enlarged,
these two lobes then
grow closer to each other
and essentially form that obstruction.
So that's the anatomy of the prostate.
And if you understand how that works,
you can imagine what kind
of symptoms that would give.
So weak urinary stream
because of the obstruction,
difficulty starting it, same way.
And once the flow is started,
it can stop and start
because of that same obstruction.
So they're straining,
and there are changes
that occur in the muscle over time.
So that leads to urinary
frequency oftentimes at nighttime.
And because it affects the muscles,
that urgency to urinate as well.
Now as the prostate gets very large,
the veins on the surface
get larger as well,
and that can rupture and give
blood in the urine as well.
Now if the prostate's
enlarged to the point
that urine is not emptying
out of the bladder,
that urine that's sitting there
is then prone to infections.
So urinary tract infections
are one of the more late
signs of enlarged prostate.
Now we get a lot of questions in urology
about nutritional supplements
or herbal medications
because not everybody wants
to take prescription
medicines understandably.
And so the question arises
well, can I just take something
that's naturally occurring
and have all the same benefits?
One of the common…
Substances that we come across
is something called saw palmetto.
And I'm sure everybody
has come across marketing
for naturally occurring
herbal medications,
namely for the prostate
or sexual function.
And probably the most common thing
that we see is saw palmetto.
And there are many forms of it.
The most common one is saw palmetto,
but unfortunately there's not been
definite or strong evidence
that's saw palmetto really works.
There's some anecdotal evidence.
People who take it,
some people swear by it,
say that it really helps them.
But we don't have good solid evidence
that it's better than say tamsulosin
or some of the prescription medications
that we give for enlarged prostate.
So on the other hand,
it hasn't really shown
to be harmful either.
So if it works for a person
and so there's no problem
with taking the saw palmetto.
But you should understand that
there's no scientific basis
for the mechanism for saw palmetto.
The last topic we'll talk
about is prostate cancer,
and there's often questions
about screening for prostate cancer.
Do I need to get it now?
When do I need to get it?
When can I stop getting
screened for prostate cancer?
Does everybody need to get it?
Some people more so than others.
So generally speaking, the
screening for prostate cancer
consists of two things.
One is a prostate exam
which is the traditional
digital rectal exam.
And the other is the
blood test called the PSA.
Now PSA comes in several forms as well,
and it's a simple blood test,
and there has been some
recommendations that it not be done.
Some people say that it
should be done, but used judiciously.
And based on the American
Urological Association,
we urologist do continue to
order and use PSA screening.
We just use it in such a way
that we are very judicious
about who goes on-
What determines an abnormal PSA
and what you do about that abnormal PSA.
So there are definitely
benefits of screening
because you catch the disease
at an earlier stage in theory.
There are also harms in screening
because first of all,
there's cost involved.
There's some blood tests,
and it's a rectal exam.
And if you have to have a biopsy,
that's an invasive test
and that's not without its risks as well.
So we are very careful
about who gets screening
and what we do if we
find something abnormal.
So again two things, the PSA
and the digital rectal exam.
So we generally screen for
prostate cancer at about age 50.
There are people who
have a family history.
If you have a family history
and a first-degree relative
like your father, or uncle, or brothers,
then we started in earlier age.
We even screened in the 40s
at least to get a baseline PSA
and thereafter once a year
up to about the age 70.
We generally don't screen for PSA…
Screen for prostate cancer above age 70
because of life expectancy.
So the American Cancer
Society Screening Guidelines,
usually at age 50 with the
10-year life expectancy
should get a PSA and digital rectal exam.
There are groups that are higher risks
like people with family history
and African Americans
who have a higher risk
of prostate cancer and more
aggressive prostate cancers
that we start at an earlier age.
Again, the screening consists of a PSA
and digital rectal examination.
But again, it's very important to remember
there are pros and cons of screening,
and then biopsy is not without its risks.
Again, we as urologists
follow the American Cancer…
Follow the American Urologic Association
Screening Guidelines, and I
won't go through all of it.
But the bottom line is
we counsel the patients
on the pros and cons of screening,
why you should screen.
And ultimately, it's a
decision between the physician
and the patient as to whether
you continue screening or not.
There are some novel ways of
screening for prostate cancer
or detection of prostate
cancer I should say
with urine tests like XomeDX.
Decipher ways to kind of hone in
on who may have a positive biopsy
and who may not so we can
avoid unnecessary biopsies.
But the bottom line is it's a discussion
between the physician and the patient
as to whether to pursue a screening.
So with that, I'll take
any questions you may have.
Okay, thank you, and have a good evening.

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