Local medical experts focus on issues like vaginal prolapse, incontinence, kidney stones, and how to make treatment decisions about prostate cancer. They’re common problems, but often have uncommon solutions.
[approaches to prostate cancer]
Dr. Michael Mastromichalis, urologist, SS M-St. Clare Health Center:
A prostate cancer nomogram is a prediction tool that identifies the likelihood that a man’s cancer will metastasize, or stay confined within the prostate. Think of them as online calculators where you plug in personalized information about your prostate cancer–your PSA number, your Gleeson score and the stage of your prostate cancer at the time of diagnosis. Prostate cancer nomograms are tools patients can access, but they’re not a substitute for medical advice.
Nomograms were designed for men who are considering prostate cancer surgery. They’re based on years of data accumulated by high-volume cancer programs—such as those at Johns Hopkins, Memorial-Sloan Kettering and Duke University—that have performed thousands of prostatectomies. Nomograms indicate the likelihood, by percentage, that one’s prostate cancer will spread to adjacent organs. They are used in determining treatment decisions. For instance, if a nomogram indicates that your chance of cancer spread is 50 percent, you might be under-treating it if you pursue only prostate organ removal. You may require additional therapy before surgery or you may require post-operative radiation therapy. Nomograms are valuable tools when used during pre-treatment counseling.
Dr. Gerald Andriole, chief of urology, Washington University & Barnes-Jewish Hospital:
The majority of men who are diagnosed with prostate cancer from PSA screenings are not destined to die from the disease, but most of them get treated—and treatment has side effects that can reduce the quality of their lives. All too often doctors don’t consider other relevant factors beyond age in predicting a man’s life expectancy. Consequently, there are some men getting over-treated for a condition that’s not destined to kill them, especially if they have other co-morbidities such as obesity, diabetes or bad heart disease.
There are a couple of things men should consider. Biopsies don’t accurately characterize how big or how aggressive a cancer is. They sometimes underestimate those features. Men contemplating treatment should consider an MRI scan of the prostate, preferably with one that has a 3-tesla magnet, which is stronger than 90 percent of the magnets available. It allows us to see the cancer better. They should also consider genetic testing. There are now two genetic markers that can predict the future aggressiveness of a man’s prostate cancer. The combination of this information can help determine if a man should seek active surveillance or have surgery or radiation.
[that sinking feeling]
Dr. Fareesa Khan, urogynecologist, Center for Urogynecology:
Pelvic organ prolapse occurs when the muscles and ligaments supporting the pelvic region become weak or lax. This allows one or more of the surrounding pelvic organs to slip out of position and sag. Vaginal prolapse occurs when vaginal walls collapse inward and downward, causing surrounding structures, such as the uterus or bladder, to fall. Vaginal prolapse is a consequence of childbirth and/or age. It can be hereditary. It can also occur because of a chronic increase in weight, or in intra-abdominal pressure caused by long-term coughing and straining.
There are three common treatment choices: do nothing and ignore it, use a ring pessary — it pushes everything back — or surgery. Surgical approaches are done through the abdomen, laparoscopically, and through the vagina. Not all surgeries require the use of vaginal mesh. Data suggests that the laparoscopic and abdominal methods are more durable than the vaginal approach. Surgery depends on the patient, her age and the severity of her prolapse.
Dr. Jodie Rai, obstetrician-gynecologist, Women’s Healthcare Consultants:
Regular exercise, weight loss, smoking cessation and the avoidance of heavy lifting and straining are all part of the first step in treating mild vaginal prolapse. Diet changes, such as reducing caffeine intake and increasing natural fiber, also can help. I counsel patients on doing Kegel exercises, which help strengthen the pelvic floor. The next step in treatment is medication for symptom relief. After that, I refer patients to a qualified, pelvicfloor physical therapist. Most obtain enough symptom relief after a course of physical therapy that they don’t need additional treatment. A small number of patients may be fitted for a vaginal pessary. Pessaries come in various shapes and sizes and are devices inserted into the vagina, generally by the patient, to provide support. However, some patients still require surgery. The type of surgery depends on the nature of the vaginal prolapse. Urine incontinence is commonly treated with a sling procedure, whereas uterine prolapse, which occurs when the womb falls into the vagina, may be treated with a vaginal hysterectomy. Fortunately, most women don’t need surgery.
[kidney stones: between a rock & a hard place]
Dr. Thomas Scully, urologist, Metropolitan Urological Specialists:
Insufficient fluid intake is the No. 1 risk factor for kidney stone development from a dietary standpoint. When fluid intake is inadequate, urine becomes concentrated. The more concentrated urine becomes, the higher the risk for stone development, particularly calcium-formed stones. You need to drink at least one gallon of liquid a day. This helps prevent positively charged calcium ions and other negatively charged ions from connecting and developing into a crystal, which can grow into a stone.
About 80 percent of kidney stones contain some form of calcium. In order to develop calcium-formed stones you need calcium in your urine. Calcium does not dissolve in water. The amount of calcium you consume is controlled by your diet, but the amount of calcium you absorb is controlled by your body. Your body always absorbs a little more calcium than what’s needed. The excess is excreted by the urinary system. But if urine is concentrated and the calcium level is elevated, stones start to form.
Dr. Sameer Siddiqui, SLUCare urologist and director of urology, Saint Louis University School of Medicine:
There are a couple of misconceptions about kidney stones. One is that they occur only in people who don’t drink enough water. About 20 percent of the U.S. population has a familial predisposition to forming kidney stones. Another misconception is that, given enough time, stones will pass. That’s occasionally true for small stones, but not for large stones. Another misconception is that if you drink enough water, the kidney stone will dissolve. But most kidney stones cannot dissolve with any type of oral treatment.
There are three major ways to treat kidney stones. Shock wave treatment is the least invasive. In this technique, we use sound waves to break the stone. Another treatment is called ureteroscopy, which is a minimally invasive procedure. We slip a tiny camera through a scope into the ureter and then use a laser beam to break the stone into tiny pieces. The third treatment is surgery called nephrolithotomy, where we make an incision on the back and lower a big camerascope inside the kidney to break the stone up. A tiny basket lifts out larger debris.
[fecal incontinence]
Fecal incontinence occurs primarily in women and is often caused by obstetrical issues, says Dr. Ralph Silverman, surgeon, Colorectal Specialists. “Childbirth often damages the anal sphincter muscles or their nerves,” he says. “It’s unusual to find fecal incontinence in a woman who hasn’t delivered vaginally.” What may start with a small muscle tear can become a big problem decades later. “And it’s difficult to get women to seek help—they don’t want to admit something’s wrong, even to their physician. They think they’re the only one who has the problem.” But surveys indicate that this uncomfortable condition affects between 2 and 7 percent of the general population, perhaps more.
Fecal incontinence progresses in steps, Silverman says. “Initially, patients have problems with flatulence. Then they develop liquid stools. Last, they lose control of formed stools.” Treatment options include a device called the InterStim. “It’s a little pacemaker for the sphincter muscles,” he explains. “It sends impulses to strengthen the nerves that control the sphincter.” The device is implanted under the skin in the upper buttock and is invisible to the eye. “It’s become the first line of therapy for surgical intervention.”
[urinary incontinence]
Is urinary incontinence occurring at earlier ages? T&S put that question to Dr. Travis Bullock, Urology Consultants, Ltd. “It’s hard to say whether it’s occurring in younger women or whether more women simply are aware of the problem.” But Bullock referenced the National Overactive Bladder Evaluation (NOBLE) study, designed to determine the prevalence of overactive bladder (OAB). Most urinary incontinence is either OAB or stress incontinence. Stress incontinence occurs with coughing, sneezing and lifting. OAB is characterized by urgency, frequency and nocturia (having to urinate during the night). “The NOBLE study found that 12 percent of women, age 18 to 30 who did not bear children, experienced OAB, and that 17 to 20 percent of women under age 40 had experienced OAB at some point in their life.” Most women experience both types of incontinence, with one being dominant. While urinary incontinence is more common with age, it’s not a normal consequence of aging. So when is it a problem? “When it bothers you,” Bullock says. Treatments abound, from pelvic-floor strengthening exercises, physical therapy, medication, Botox and InterStim, a pacemaker-like device for bowel or urinary incontinence.
[u•rol•o•gist]
n. Urologists diagnose, treat and monitor disorders of the urinary tract and the external genital organs, which can include kidney, ureter, urethra, bladder and prostate issues. They also conduct related surgery, like procedures performed on the adrenal glands (which sit on top of your kidneys).
By Mary Konroy
