good evening tonight show we have a special guest dr tim wiring will be with you shortly  good evening tonight's guest dr tim tim's a board certified urologist him i've had the pleasure of nine for at least twenty five years tim welcome to the show thank you jan thank you for having me tim it's there's been a huge amount of urologic controversy amongst us as your ologists we still continue to get the test however there have been a variety of panels that have said they are not necessary the take a message for us as ologists is that we still warder them we do believe in their merit invalidity however as in all testing just as you do in your general surgery practice you have to take the context of the p on the basis of the patient in the room it's not an absolute test that determines a biopsy surveillance or any mode dalla t but you use that in conjunction with other things in the room the family's urologic history the physiologic age which is how healthy are they at their chronological age their overall urologic hell symptoms their digital rectal examination so what that does gene for us is your ologist is it gives us more information to help determine if indeed any further testing or treatment it's to be done so again at p s a is an absolute number to determine an absolute test is not necessary but it does help along with many things we do help determine a patient's urologic health and what we should do so i still believe in him i get them right and i still believe in their validity in their appropriate testing  else you know does it cover my colon you know if i get this test and i particularly get this if we are following a patient with k prostate cancer you know my ok with everything else p s a again as you indicated prostate specific it's doesn't indicate anything else within the body ok when i look back at the c b s news article i find that the piano this task force yes was headed by a family physician well you know and they did look and if you read that study and look at the data they did look at a large group of numbers and subsequently p s a testing and did it make an impact on the overall population but again if you look at the american cancer society statistics the death rate of prostate cancer is decreasing the reason is one primarily the p s a to along with that more effective  carry less morbidity and mortality so we are making impact but the primary reason is due to p s a test ok again i agree with the panel's thinking and data in that if everybody with an elevated p were to get a biopsy based on attempting to rule out cancer right that we are doing too many biopsy ok the majority of men that walk into my office with an elevated p s a once we discuss everything do not get a biopsy we follow them but when you look at all of that data and you look at the patient in the room when the door close most of them don't need a biopsy so i have a tendency to disagree with that panel on a general men or the women tell them and they should come and see well in general guidelines a strong family history of prostate cancer dad goals brothers particularly a father beginning at the age of forty ok after american gentleman if i get this correct if you're having any symptoms you're logically come see ten but i and i think we as your ologist always do p s a's because again we're looking at it in the context of the entire urologic patient and all the after mentioned things from before their health their history their symptoms their exam but we believe it helps add information to make correct clinical judgment decision so if you're out there  v land and you get an elevated p s a what are the odds you have cancer versus something else great question if you look at the standard value with normal being less than four we have a couple of areas we have what's called on we typically look at a p s a between four and ten statistical risks on general is about twenty to twenty five percent so when you counsel somebody in the office that means they have about a seventy five to eighty percent chance that they don't have cancer above ten to say ten to twenty that increase is to say forty percent once you start hitting thirty in above your likelihood is greater than indeed you do have cancer but those are general things that we look perfect and as you said i think it's important the p s a you have to take a history of physical we have to see a german tim or somebody in the field because you have symptoms with your logic voiding anything like that and it's and again it's like you do in general surgery you have to take everything in the context of what's in the room you have to look at the entire patient and what's the best options to treat that patient and not everyone with an elevated p s a based on what i said the majority don't have cancer and in the majority of patients they don't need a biopsy we do follow them with periodic blood test and evaluations we might modify that depending on how they change either clinically their exam or how their p s a changes we really look at p velocity but the majority of men don't necessarily come to a biopsy or any of your logic problems ok in the outside world is there anything that men are doing eating drinking that can elevate their p s a falsely well that's it that's another great question everyone ask when they come in the office well what can i do for my p s a medication wise there are numbers that will lower the  basically medicines that trink the prostate but i always believe you don't take a medicine just to lower number were the number has no impact on your health so i'm not a big advocate of that in general their health of their prostate is no different than you were cardio logic or internal medicine colleagues you know proper diet watch your farber watch your excessive fat you know what i'm saying is that there's no magical die other than the diet that we all preset ok profess to be healthy so in other words  sexual function particularly as we age becomes very proud once some men don't want to talk about it i've met a lot of men do want to discuss that which we do a lot of as as in the urologic community when a guy comes in and we address this we look at risk factors things like a smoking history a lot of men are surprised to find out that fifty percent of the men that smoke have some degree of erectile dysfunction excessive alcohol in diabetes is a huge contributing factor hypertension vascular disease some medications and unfortunately one i have to remind men of that is a general risk factor for e d and now it's aging no matter how well we take care of ourselves guys hate for me to say this we're not eighteen any so with that what you do your logically is you assess their risk factors and counsel them on options that are available the beautiful part of that in this day and age are the new what are called p d e five inhibitors or the blue pill the magical vi agora cialis which is both as needed in daily and livy train stacks and which are the same drug in different forms but there are wonderful drugs save revolutionised our ability to continue or sexual performance seemed either in men to their seventy's or eighty's now unfortunately as in all disease processes if we want to call it a disease is there are people in the spectrum of that disease from mild to severe unfortunately the medicines don't cure everybody but there are modalities that go beyond those simple things which include vacuum devices supposed to tory's injections and even still implants that can create a scenario where men are still able to function sexually what i do counsel men on is that the  higher up you go on the aggressiveness if you would of the my dalla these you carry a little more of what i call a hassle factor a little bit more of an effort the good news is we can do things for gentleman and it doesn't always necessarily mean doc which of these work the balance to my classic or is response is whatever they perceive that works better and so typically a lot of times i'll give them all three and again the key element of that is their perception of efficacy because a lot of what works different in everybody the side effect profile can work different and everybody so the classic line to answer questions that might be out in the audience is they have to figure that out ok so i'm not s do two things one they protests produce testosterone which is basically our male engine they produce sperm as well to start for and drives all of our secondary male sexual characteristics when we hit puberty the test large we produce testosterone we get facial hair body hair we get increased muscle mass growth and develop sexual function and interest testosterone can decrease as we age almost if excuse me one is a into a shot basically you know given on a variety of anywhere from one to four weeks interim muscular there is no world replacement yet so unfortunately a lot of the medicines quote that are advertised on t v for oral testosterone on pay per view channels in infomercials really although i'm not saying they're not efficacious really are not testosterone replacement there because we haven't come up with a w effect of deliver testosterone not to sound doctors but because of the past history of the liver degrading so we haven't been able to do that now in my typical sarcastic way that you've grown to know me over the years a lot of guys will querrey me on testosterone replacement and give me symptom suggestive that they may not have that problem for our public you know decrease libido less center g more fatigue generally not feeling great there's no doubt there's a percentage of those men with indeed low testosterone levels however a lot of times in those gentlemen you will check testosterone levels and their normal and the question doc how calm and i'll go welcome to life age stress kids college and all of those things are actually driving their symptoms and not necessarily a low testosterone although the symptoms are mimicking each other a great question i get in the office is if i have a low but normal level or now normal level can i still do the therapy there's not a lot of literature on nab i have no problem with that what i try to counsel my patients on are of some very key elements for testosterone place reese placement therapy to be cover from a pharmaceutical standpoint with your coverage the vast majority of third party payers require you to have two documented low levels you do not have to fast they do have to be before ten am if not they will not cover the medication so if they want to proceed with replacement without documented levels low levels i'm sorry they have to cover that cost the other which is probably not in so you go for it so it can be rather pricey because there are no generic form surveils ok there is injection therapy which is a good modality but you still have to see what i'm saying is it's an out of pocket expense a recent physician was indicted then i believe that's currently on trial for in a bowl of steroids and so that the public is not confuse could you clear because they're trying to improve their quality of life in a man you're still trying to do the same thing you're trying to supplement a low level to improve libido and argy muscle and they feel better and there's no doubt there is a great segment of population that respond well to the therapy you are not who you passed out you want to keep on keeping with that said what happens is in replacing the therapy they feel better you are not giving them excessive steroids so you don't get the horror stories of the old law allows say doe's and those patients that have significant risk factors with excess anabolic performance they're worried therapy so you're the risk of those is actually very little if any we follow their prostates we follow their bloodwork you do have to follow blood counts but we follow those patients and t date we haven't had any significant reactions we've had a modify some dosages ok but it's a totally different thing other than the thing that you mentioned for severe there ok so in other words the feds aren't going to come knocking on your door i hope not i don't  think they will because we're doing it for proper documented physiologic reasons ok when is it the same method when it's say that you know these muscle cars i don't know much about this one when these that carry a much greater anabolic muscle performance that what we're using we're basically using a load ok there now could you go crazy on those i think physiologically it would be very hard to do ok seems like your lecture may have a taken out one of our camera people that's ok should be ok ok all right if you're just tuning in completely and thoroughly bored with the c b s evening news telling you the same diatribe on an evening basis or coming over from n b c news which is telling you the same sense said tell since it's owned by g e and they will yes they will be covering any of the any of the senate hearings on been  very very and i'm not sure why this area but a good number of bladder cancers here's a couple key taken employed with bladder cancer although it is a malignancy by definition the vast majority of patients that present to our office have what's called a low grade superficial bladder cancer the good news of that is although we're diagnosing them with a form of malignant see they are typically diagnosed by a series of x rays but most importantly either in the office or as an outpatient what's called a cystoscopy which is a scope that's used to directly evaluate the lining of the bladder tumors  taken out under an anesthetic with a scope in a bladder so there's no quote incisions on them the basically the tumors are scraped out evaluated in for the therapy done depending on the grade and stage of the two is go say natural orifice therapy exactly something of that nature can somebody have if they have a dark urine is that something they should be concerned about great question the classic thing is dr doc might my urine is very dark yellow the majority of that is just they don't drink enough water the urine is concentrated the urine is very dark brown ros cherry colet bloody those are cancer is a lot of these are picked up on route routine evaluation by our colleagues with potentially just microscopic urine i e you don't see it but it shows up and it's abnormal amount of red blood cells in  believe beginning at forty or fifty people should get your early your analyses both what we call dipstick but even more importantly a microscopic about ok so we see seem to see this less and less in the preoperative stages but when you go to your we won't even go into that right now but stress as a physical next rassilon yes stress what we determine to stress incontinence as a cause is incontinence and these are primarily female related where picking up a couch doing scoffing sneezing stress exerts on to the bladder natally curan very common as women age and associated with childbearing my feeling in the office once we talk to these people i'm not think can substitute proper weight control because the heavy your are the more pressure placed on the bladder and what are called key goal exercises e g e l the gynecologist an obstetrician stressed to their ladies after intercourse the problem with stress incontinence and women typically again due to childbearing is they lose their support of hammock in the pelvis when they have stress the bladder drops a little when you're in follows the path of least resistance surgery is an option but i think you should try to keep that as a last option right please control your weight please do your kids go exercise and you can certainly google that find that i've got it's a very simple exercises and i agree urge incontinence as defined from the t v ads with direct patient advertising now when i gotta go i gotta go basically the bladder is a self sufficient organ and with that said that's why children leak urine is because it's they're able to go the bladder is designed to store and expel typically with aging with the ability of the urine the bladder to hold your own at same pressures gets worse and they can't hold it as well so the bladder is going i'm going whether you like dietary thing they have to understand that certain fluids can exacerbate or worse and that coffee's pops teas can worsen those symptoms keep that in mind there are medicines available if need be briefly a thank you we see a we see the plaintiff's attorneys always advertised if you had the sling or not great question i was that was there i was just recently brought up to me in the office by a lady talking about slings slinks or  basically substances that are designed by companies to do so to place support in pelvic organs and typically again in women and what they're attempting to do is provide support for what has failed due to childbearing you know age obesity and they work great ok the problem is you have to counsel the patient that they can erode any foreign substance placed in a body carries a certain risk from your hip replacement to your valve to whatever right erosion can occur i play slings and with no problems they work great but you have to really sit down with your doc in attempt to determine what you're trying to do why you're doing it and what your options are available i think they're they're very good modelling he's he does have to pick and choose as you and i do and writes in areas you have to pick and choose and counsel accordingly but the patient has to understand as you and i deal with surgically every day every procedure has a certain degree of risk associated no question and we can't fix what god does in designs as you know as you and i both know it's a it's you take a risk in your car and turn the exact clone on the  colleagues today and yes hopefully help her out but tim's a great guy if you have any questions on any one of a number of topics his office is available at the number below and you can certainly give him a call he's very well versed and as i said in all these