Male Health Issues Discussion with Dr. Carey of Spotsylvania Regional Medical Center

(slow instrumental music) – Yeah, my name’s Peter
Carey, I’m a urologist, been here at Fredericksburg for 24 years. I’m from New England but
I was in Charlottesville, trained in all my training
in Charlottesville from ’79 to ’89. Married a woman from Fredericksburg in ’82 and then after I finished my
residency, came back here. First I joined Dr. Beaman, who many of you may have heard of. He and Dr. Gray were
the first two urologists and I worked on Princess Ann
Street, right next to Carls. Did about four or five years there. Then we moved into the
Thompkins Martin Building, next to Mary Wash. Did probably 14 years there and
and then we built a building behind, kind of up off Cowan Boulevard. There’s three or four
doctor’s offices up there. So we moved into that office. I’ve got seven partners. So we’ve expanded quite a bit. Two years ago we opened
our office down here to service Spotsylvania Regional Hospital and we’re in the building
kind of right across 95 from Spotsylvania Hospital and that’s where I’ve
been this week working. It’s been busy, it’s been fun. So that’s who I am. I’m a urologist. One of the more common
things we treat in urology– We treat a lot of stuff, a
lot of people ask you why you’d go into urology,
it’s a surgical field but it’s kind of… It’s enjoyable. I treat a lot of kidney stones,
a lot of prostate issues. There’s a lot of female urology. Women with pelvic
prolapse and incontinence and things like that. A lot of cancer surgery, kidney cancer, bladder cancer, prostate cancer. It’s an enjoyable surgical field. It’s a little different
from general surgery, which deals more with the
liver and the intestines and the appendix and the
gallbladder and that type of stuff. But far and away the most
common patients we see are middle aged men and above
who have male health issues, as this talk is called. Most of them pertain to the prostate. I had a couple of topics
that I wanted to cover and then I’ll just let
anyone ask questions. Three of the more common
prostate problems we deal with are prostatitis, which is an
inflammation of the prostate, primarily younger guys,
and prostate enlargement. That’s BPH, we call it,
benign prostate hyperplasia. That’s the actual physical
growth of the gland as we get older, as men get older. Then finally, prostate cancer, which is a completely
separate item and two or three of these conditions can coexist. A man can have BPH and prostatitis or he could have BPH and prostate cancer. So it’s not mutually exclusive. Men can have mixes of
those three conditions. Let me just remind
everyone of the anatomy. It’s a little gland, it’s part
of the reproductive tract. It makes a fluid, it’s a
gland that makes a fluid, just like the salivary
gland or the pancreas. It makes a fluid that is a
major component of semen, which is an important part of
you know, male reproduction. Beyond that, it’s a cause
of a lot of troubles for men during their lifetime. But it does have that
important physiologic role. It’s a reproductive organ. The urethra runs right
through the middle of it. So for a man to urinate the
bladder has to contract. There’s a sphincter muscle that’s called, which is right in the, runs
right through the prostate. That has to relax in order for
the man to empty his bladder. So that explains a lot of the symptoms. The urethra, down below,
has no muscular function. It’s just kind of a dumb
tube that just allows the urine to pass through. But as men age, the prostate,
for reasons that aren’t really well understood,
the prostate enlarges. When a guy is, let’s say, 25 years old, his prostate is 20 grams, roughly, which is about the size of a walnut. It’s a very small organ in a 20 year old. It can double, triple, quadruple in size so that by the time we
see a lot of our patients when they’re in their
60’s, 50’s, 60’s and 70’s, it’s 40, 50, 60, 80 grams in size. So that’s quite a bit of
growth if you think about it. It’s a similar kind of
disease as women’s fibroids. Women in their uterus will get
these kind of rubbery tumors of the uterus called fibroids. BPH, the enlargement of a
prostate in men as men get older, is a very similar process. If you think of those rubbery
kind of muscular nodules that women can get on their uterus, picture the same occurrence
happening in the middle of the prostate gland here. What it does, as you can
guess, because of its location, is it pinches the urethra. It makes it, the prostate’s growing out, but it’s also squeezing the
urethra here so it’s harder for that urethra to relax and
harder for men to urinate. As men get older and as
this disease we call BPH, as it progresses, the bladder
symptoms start to bother the man more and more and more. Those symptoms are, as
everyone knows from television, you know getting up at night more, the more frequency during the daytime, slower stream because
you’ve got, you know, this compressing effect on the urethra, and what’s called urgency,
which means when you feel like you have to go you
gotta go very quickly or else you may not make
it to the restroom in time. All of those symptoms are what
we call obstructive symptoms and they’re from BPH, as
the prostate gets bigger, that’s what happens to men. We can diagnose it with a history. You talk to the man and he’ll tell you what his problems are. You have to do a rectal exam
and you can feel the prostate is enlarged. As I said, the 20 year old’s
prostate is very small. It’s about two finger
breadths, so boom boom. You can feel it’s that tiny. But as a man gets BPH, I mean, the gland may be literally that wide. You know, almost like a small
tangerine or a small lemon. It becomes physically quite enlarged. So physical exam helps. Sometimes we do a test called a flow rate, which we quantitate a man’s urinary flow and if it’s low, then that
supports the diagnosis that the man’s obstructed
and that he needs some help for treating his BPH. As far as treatment goes,
you know, up until probably ’79 or ’80, we had no medical
treatment whatsoever for BPH. Then starting in the 80’s we
started to use these drugs called Alpha-blockers,
which are drugs like Hytrin and Doxazosin and Flomax,
which is tamsulocin. Then also back in the 80’s
another group of drugs came up that would actually shrink the gland. The alpha-blockers don’t shrink it. What they do is they relax
that little tube right there and make it easier for the
bladder to empty itself. The other drugs, like
Finasteride and Avadart, actually shrink the gland. They’re more of a hormone type. They effect the hormone
metabolism of the gland. So we have two weapons now that we can use as opposed to surgery. Up until about the early
80’s all we had to offer was surgery, what’s
called the roto rooter, men call it that. We call it a TURP, a T-U-R-P, which is not a fun operation. It’s a very successful
operation, but it’s not a fun operation for men to
have unless they need it. It’s a fairly bloody operation. You have to have a catheter
in for several days. If a medicine will solve the
problem and avoid the surgery, well then obviously men
will flock to that medicine rather than have the surgery done. It’s you know, similar to women. If women, if there’s a way
to avoid a woman having a hysterectomy, then obviously
women are gonna flock to that non-surgical treatment. Everyone wants to avoid
surgery wherever possible. The treatment, the
primary treatment for BPH for this benign prostate
enlargement that I’ve been describing is medical now. That’s always our first
step is a drug like Flomax or Avadart to try to shrink the gland, relax the gland and the men will, I’d say, 80% of the time will respond
and they’ll have improved flow. They’ll get up less at night. They’ll feel better, they’re happy. If it doesn’t work though,
then we do offer them these new laser TURPs they’re called, where we anesthetize the man, obviously. We put him to sleep and
then pass a scope up here and hollow out the prostate
just like you’re coring an apple with a laser. It doesn’t bleed as much
as the old way of doing it. So that’s highly effective
if the pills don’t work. So that’s BPH. The next I wanted to
touch on is prostatitis. Prostatitis tends to be in younger guys, guys in their 20’s, 30’s, 40’s. It tends to cause pain more. BPH, what I’ve just been talking about, doesn’t cause any pain. It may be a pain in the neck
because you gotta get up at night and go more often, but it doesn’t actually hurt down here. With prostatitis it’s a little different. With prostatitis men tend to
get achiness in the testicles, achiness down their
thighs, their low back, their pelvic region here. They just don’t feel right. They tend to have some sexual disfunction, some ejaculatory disfunction,
some frequency of urination. So some of the symptoms
do overlap with BPH. They will have more urination
at night, a weaker stream, similar to the BPH, but the
problem is not that the gland has doubled or triples
in size like in BPH. The problem is that there’s an
inflammation in the prostate which is causing all of these symptoms. That inflammation can
be due to a bacteria, which is why we often give
antibiotics for prostatitis. Sometimes it’s not due to a bacteria. We don’t know why the gland is inflamed. We see it, for example,
in guys that do you know, they get on a fitness craze
and they’ll do 500 sit ups or crunches in a day. You know, anything that
you’re constantly pushing with abdominal pressure
on the prostate gland or heavy lifting, things of that nature. That can cause the
prostate to become inflamed and irritated and painful as well. But the diagnosis is generally
by history and physical exam. There’s no blood test that proves it. There’s no x-ray that proves it. The treatment, as I
said, is usually due to, usually with antibiotics and
anti-inflammatory medicines like Advil, basically. Drugs like Celebrex or Advil or Motrin or things of that nature. So that’s prostatitis. The final one I wanted to
talk about is prostate cancer. Prostate cancer you know,
is a big item in the news over the last 20 years. It’s extremely common. It’s the number two most
common cancer in men. But the good news is is it’s
ranks probably 9th or 10th in terms of cause of cancer death. Now what does that mean? That means a lot of men
die with their cancer, prostate cancer, rather than
from their prostate cancer. We’ve known that for many, many years. It’s a very slow growing
cancer that often times is not lethal. However, back in about 1980,
we found this blood test called prostate-specific antigen. Someone discovered that in
men with prostate cancer this protein, which by the
way, PSA is a protein made by the prostate gland, okay. If you collect prostate fluid,
let’s say from a man’s semen, it’s got huge amounts of PSA in it. Well, a little bit of it
leeches into the blood stream. So if I draw blood from a
patient there’ll be a tiny amount of PSA, prostate-specific
antigen, it’s a protein, in the blood stream that
came from his prostate gland. It was discovered back in
the early 80’s that men with prostate cancer leak a little
more of this PSA substance into their blood stream. So instead of having a PSA of one or two, they have a PSA of five or six or seven. But it’s not specific for cancer, that’s the problem with it. It can be high in men with BPH. It can be high in men with prostatitis. But it was using starting
in about the 90’s as a screening tool of prostate cancer. It’s highly effective at
finding prostate cancer. The problem where you’re hearing
about in the press nowadays is that we kind of got too good
at finding prostate cancer. We found a lot of prostate
cancers using PSA screening in men who were never gonna get sick from their prostate cancer,
who don’t need to be treated for their prostate cancer. So the estimates are that in our country, that we were kind of over
treating almost half, 40%, of the men who we diagnosed
with prostate cancer, don’t need to be treated
for their prostate cancer. But what we’re finding now is that the younger guys especially,
should be screened. Guys in their 40’s and guys
who have a family history of prostate cancer. If your father had prostate cancer or if you’re African American or as I said, men over 40, we
recommend a PSA as a baseline and then every couple of years thereafter. We probably shouldn’t be
screening men in their late 70’s and 80’s because and why is that? Because some men in their 80’s
come in and I try to explain to this to them and they get very angry. They say well, my life
is worth just as much as a 45 year old man’s life. And that’s absolutely true. But we don’t want to find,
as I describe it to men, we don’t want to find in an 80 year old, we don’t want to find a little
speck of prostate cancer that big and that’s what
PSA allows us to do. We can find tiny little cancers in men. Well, if we found that in an 81 year old, who like Warren Buffet,
this was in the news. Warren Buffet was just diagnosed
with a prostate cancer. He’s 83 or 84. Then you’re gonna be tempted to treat that little small cancer. The problem with that is the treatment, the studies have shown, the
treatment of prostate cancer in men in their 80’s is
usually worse than leaving the cancer alone because you can get side, terrible side effects from the radiation or from surgery or from
things of that nature. So the experts worldwide on
prostate cancer are trying to move the, shift the
emphasis to guys in their 40’s and 50’s as far as cancer screening goes. Prostate cancer doesn’t
typically cause symptoms. In other words, it’s just a
little speck of cells that big sitting in a man’s prostate. He’s not gonna feel
that he has this growth unless it gets really advanced, which doesn’t happen very often. Usually we’re finding
prostate cancers much more now from PSA screening at this
very small, early stage before it causes any symptoms. It’s similar to women who get
screened for breast cancer with mammograms. Okay yes, we want women to do self exams, but basically, if you’re a
woman, you want to find your breast cancer before you can feel it. You want it found as a
tiny spot on a mammogram that gets biopsied and then
you get your lumpectomy and your radiation. If you wait until you can feel a hard spot in a woman’s breast, then it becomes a harder cancer to cure. Well, it’s the same
principle of prostate cancer. You want to find the cancer
when it’s just a small speck with PSA screening in
younger guys especially. You don’t want to wait
until you feel a hard nodule this big in the prostate or
until it’s causing symptoms because if you wait until that happens, often times it’s too late to cure. You wind up having to
look to other treatments. For patients that are
diagnosed with prostate cancer, you know the most common
treatments are you either radiate it or you remove it. I won’t go into the details
about which is better and which isn’t better, but they’re both highly
effective treatments. Some men decide to get
their prostate removed. Some men decide to get
their prostate radiated. They both have kind of unique side effects that we can’t go into here. So anyway, I’ve described
the three common things that we see in urology
for men’s health issues. The three most common are BPH, which is the benign prostate
hyperplasia, the growth, the swelling of the gland
that occurs with aging. Then there’s prostatitis,
which we see in younger guys. Then there’s prostate cancer,
which we think men should be screened for starting at age 40. That was the majority of my talk. I can talk about any other
subjects that you guys want to talk about. I can talk about kidney stones, about ED as it’s called. I can talk about anything else
that people are interested in but thanks for listening. Yes sir? I don’t think so. I think BPH you see in all
races at roughly equivalent amounts but prostate cancer is
much higher in certain races and tends to present at a
later stage in certain races. There’s been a lot of work
done on diet, for example. Japanese males have a low
rate of prostate cancer. Is there something in the Japanese diet, you know with their rice consumption, their lack of certain foods
that they’re not eating that protects them from prostate cancer? There’s been a lot of research about that. But to answer your question, no, I think the increased risk of prostate
cancer in African Americans is not associated with
a higher risk of BPH or prostatitis, the other condition. There’s been books written
about that recently. It’s very difficult to prove that diet, as everyone knows, do cell
phones cause brain cancer? Well, one study says yes they
do and then two years later a study says no they don’t. For prostate cancer it’s quite similar. There’s every five years,
there’s a new diet element that is either touted as
a cause or a prevention for prostate cancer. But most of the emphasis
has recently been going on vitamin D as a protector
against prostate cancer, selenium in the diet, zinc in the diet, things of that nature. Saw palmetto. There is some rough evidence
that those can protect from prostate, protect a
man from prostate cancer. To answer your question,
they tend to run together, but there’s no cause and
effect between BPH and ED. For prostate cancer yes. For benign prostate enlargement,
this TURP that I described, the roto rooter that men call it, has been pretty much the
same operation for 80 years. Now we have new ways of doing it. We use lasers now. We don’t go in with a scope
anymore and trim away tissue or cut away tissue through the scope, which is what we did for 50 years. Now we pass a scope in
here and we hollow it out using a laser. So yes, that has reduced, primarily the bleeding
complications that used to occur. For prostate cancer, there’s 10 different ways to
remove the prostate for cancer. The more recently developed
techniques have decreased the side effects, if that’s
what you’re describing. What’s called the Da Vinci,
the robotic technique, has decreased blood
loss and decreased pain, so men go home quicker. Yes, there’s been
technological improvements, not only for treating
prostate cancer with surgery, but also for treating BPH with surgery. If you look at what kills men, it’s far and away high blood pressure, high cholesterol, overweight. Those are the three big killers of men that cause heart disease. So you need to go to your
internist or your family doctor and get your cholesterol
checked, your LDLs, your HDLs. Stop smoking if you smoke and
mostly, it’s blood pressure. Blood pressure is the big
killer in this country and has been, it’s been
recognized since the 1950’s. We have all these great drugs
now to control blood pressure. So far and away, that’s the most. As far as cancer screenings
go, the only ones that have been shown to be effective
really, is the main one, is colonoscopy, just as it is in women. – [Woman] What age do you start that? – I’m not a gastroenterologist,
so don’t quote me, but most people say unless
you have a history of some kind of familial,
there’s something called familial polyposis of the
colon, unless you have something like that, most people say
age 50 you should get your initial evaluation by a gastroenterologist and a screening colonoscopy. If that’s okay, now they’ve
become less stringent about follow up, which is good. They’ve stretched it out
to seven to 10 years now between colonoscopies. So that’s wonderful. For women, you would add
in obviously, mammography. But colonoscopy’s
important in women as well. But screening for lung
cancer has not panned out. There’s people that have
said, well should we get chest x-rays or cat scans every
few years on men and women? That hasn’t panned out. Pancreas cancer screening,
stomach cancer screening, none of it has been shown
to be cost effective and even prostate cancer
screening is up for debate. There’s people that feel PSA
screening for prostate cancer is unnecessary and doesn’t
save very many lives. In urology we disagree with that. We think the data in the
years ahead will clearly show that it does reduce mortality
just like mammograms reduce mortality for
women for breast cancer. But in urology we don’t
quite have the data. The data’s not quite mature yet. All right. – [Woman] This has been great! – Okay, yeah, I hope it
makes sense, some of it. (twinkly instrumental music)

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