Urology is the comprehensive care of the urologic system. It is one of the first surgical subspecialties and dates back to Egyptian times when bladder stones were found in mummies. Stones in the bladder have been treated by ancient Hindu surgeons and, throughout the ages, by the French and English. Urology was closely related to general surgery until the 19th century when the two fields began to split and subspecialize. Recognition of urology as a separate surgical subspecialty truly began in 1902 with the formation of the American Urologic Association and its Journal of Urology, which was formed later in 1917. The association and journal provided a format for the development of the field, with new surgical techniques and research used for many years to come.
A good topic to begin with is benign prostatic hyperplasia (BPH), which affects every man, to one degree or another, during his lifetime. BPH is the enlargement of the prostate that sits at the base of the bladder causing obstruction and urinary difficulties. Microscopically, 25 percent of 40-year-old men have BPH, while 75 percent of 70-year-old men suffer from it. Thirty percent of men will seek medical attention for this problem.
Though, not all urination problems stem from prostatic enlargement. Small prostates can also cause problems. In general, it is more likely that a man with a large prostate will have lower urinary tract symptoms (LUTS) than a man with a small prostate. BPH’s effects include urinary frequency, urgency, getting up at night, slow stream and loss of bladder control. It can also cause urinary incontinence, kidney dysfunction, bleeding, bladder stones and retention of urine.
The prostate gland is an accessory sexual organ giving fluid to the ejaculate for conception. It contains enzymes to help sperm for egg penetration and nutrients for sperm survival. The average size of the prostate is between 15 and 25 grams at the age of 40, and the size increases with age.
The normal examination for BPH includes a prostate exam, urine test, a prostate-specific antigen (PSA) test and a check for residual urine, along with a verbal history detailing urination problems. Other tests that may be included are urine flow rate, measurement of the size of the prostate by transrectal ultrasound, measurement of bladder function and a cystoscopy, which involves looking into the bladder with a small telescope.
Treatment for BPH can be broken down into behavior changes, such as consuming fewer fluids, herbal therapy (backed by limited scientific facts), medical therapy or surgery. Alpha blockers cause relaxation of the prostate capsule with enhanced opening of the urethra, which may also have some effects on the bladder floor. There can be side effects with alpha blockers, such as blood pressure changes, that must be monitored. Use of the 5-alphareductase inhibitors prevent the conversion of testosterone to dihydrotestosterone, which is active in the prostate and causes shrinkage of the gland. The prostate will shrink approximately 25 percent to 50 percent and the PSA will decrease by half. It takes several months to see the benefits; however, this treatment is generally well tolerated.
If medical therapy does not work, then surgical intervention may be necessary. There are multiple options available today, including minimally invasive outpatient treatment with laser therapy, heating the prostate and lowfrequency radio waves. These treatments are best suited for smaller glands and moderate symptoms. Investigational treatments also include ethanol and Botox injections into the prostate. The results of these are not yet known, but show some promise. The transurethral resection of the prostate (TURP), an open, simple prostate removal, is used for larger glands and, although more invasive, can carry with it better results that last longer. The effective treatment of BPH often includes all of the aforementioned medical and surgical interventions used in varying combinations to achieve the best results for each individual.
When screening for BPH, prostate cancer should also be a consideration. There are typically no symptoms associated with prostate cancer and early detection occurs with vigilance. A physical examination of the prostate and a PSA test are important. There are concerns regarding prostate cancer detection and screening, but several facts remain indisputable. More than 40,000 men will die of prostate cancer this year. It is the second-most common cancer in men, and since the institution of PSA testing and closer examination of the prostate, the death rate from prostate cancer has decreased and fewer men experience advanced cancer. This is not to say every man should be tested or treated. It is important to take lifespan into consideration in order to decide if treatment is the appropriate option. There are multiple treatments available, including observation, surgery, radiation by seed implant (brachytherapy), external beam radiation, cryoablation and hormonal manipulation. There are also new chemotherapies and genetic manipulations that show promise.
My area of particular interest and expertise is robot assisted laparoscopic prostatectomy (RALP). The da Vinci Surgical System by Intuitive Surgical, Inc. was first performed in Frankfort, Germany in 2000. In 2010, approximately 85 percent of all prostatectomies will be performed robotically. The benefits include less blood loss and pain, faster recovery and better cosmesis. This option, performed by experienced hands, may be superior to open surgery, but only time and clinical research will prove this. The important factor here is surgeon experience, and the more operations performed, the better.
Choosing an appropriate prostate cancer screening option remains a joint decision between a doctor and his patient. Many factors such as age and other health conditions, as well as expectations of the patient, must be considered in order to come to the right decision and treatment plan.
Impotence is defined as the consistent inability to sustain an erection sufficient for sexual intercourse, or the inability to achieve ejaculation, or both. Erectile dysfunction (ED) can vary in degree from total inability to partial; it can also resolve and reoccur. The risk of ED increases with age and is fourfold higher in men in their 60s. ED is linked to men with poor diets, less exercise and higher levels of alcohol consumption.
Diagnosing ED begins with a discussion about timing of onset and any medical or psychological factors. A physical examination, as well as basic testing of blood hemoglobin, testosterone, thyroid function and prolactin can be appropriate, but testing is decided on a case-by-case basis. Several common causes of ED are diabetes, hypertension, stress, depression, kidney failure, smoking, alcohol abuse and medication. Additionally, there can be other neurologic, vasculogenic, hormonal or psychogenic causes.
In order to achieve an erection, the basic physical ability must be present, but the appropriate psychological frame of mind must be present, as well. Very often, counseling is the best treatment for ED if other physical factors have been ruled out. If appropriate, medical therapy is possible with testosterone replacement or one of the Type 5 phosphodiesterase inhibitors such as Viagra, Levitra and Cialis. These medications work by potentiating a natural substance called cyclic guanosine monophosphate (cGMP) to cause vasodilatation and increase blood flow to the penis. Each therapy candidate should be carefully screened to rule out other health factors, and the risks of taking certain medications should be assessed. Other treatment options include a vacuum erection device or injections into the penis to cause increased blood flow and better erections. The final option would be a penile prosthesis, which is more interventional but also highly satisfying for the appropriate patient.
Sexual function is a very important aspect of a relationship and of maintaining an appropriate selfimage. The new onset of ED could indicate a health condition not previously recognized. Maintaining good health by exercising, watching your diet, getting adequate sleep and going for regular health maintenance exams will increase the longevity and enjoyment of life. Urology is no exception, and I have mentioned only a few of the fascinating areas of interest within this field.
Thank you again for allowing me to share some of my thoughts, and have a happy, healthy urologic year!