210: The Annual Urology Checklist for Men

Scot: Guys, my stream might not be as strong as it should be.

Mitch: Is that what you're starting the year discussion with?

Dr. Smith: I like where this is headed.

Mitch: I know you do.

Scot: I don't know, though. So my stream might not be as strong as it should be. I think I should see someone. It's been kind of hanging out in my mind for the past couple years that maybe I should, but I'm not sure. Do you have anything like that, Mitch? Do you have anything that's been kind of hanging out?

Mitch: Yes. I let my testosterone stuff lapse, so I'm trying to hurry really hard to get back into urology to get my levels back.

Scot: All right. John, you're a urologist, so probably nothing like this has ever happened to you because I'm sure as soon as something arises, you go see one of your colleagues or you self-diagnose, right?

Dr. Smith: Always self-diagnose.

Scot: By the way, side quest. Is that something doctors should do? Do they talk about this in med school? Because I'd heard that you shouldn't self-diagnose, that that's a bad idea.

Dr. Smith: I agree. I mean, I can tell you some instances that are probably good and some of those that are bad. So I think it depends on the person. Someone who is a true hypochondriac probably should just leave it to other people, but people who are legitimate and honest with themselves probably could do a nice job.

Scot: All right. Well, the point of this conversation is many men will wait until something feels kind of urgent before seeing a urologist. I think my stream would have to stop before I would probably be sure to make that appointment. But today we want to make the case that urology isn't just about crisis care, it's about managing function, comfort, and long-term health.

This is "Who Cares About Men's Health" with information, inspiration, and a different interpretation of men's health. My name is Scot. I bring the BS. The MD to my BS, urologist Dr. John Smith, and the star of the show today.

Dr. Smith: Oh, you're too kind.

Scot: And Producer Mitch is our "Who Cares About Men's Health" convert.

Mitch: Hey, there.

Scot: All right. So, Dr. Smith, we're going to give the show to you today and we're going to just ask the questions. Looking for some common reasons men should consider seeing a urologist maybe sooner than later. These are everyday issues that oftentimes go unaddressed even though the effective treatment and guidance are available. There are guys like Dr. Smith that can help you. We're going to explore the types of concerns men tend to overlook, what makes sense to get checked, and also why earlier attention maybe could make a meaningful difference.

So, John, let's go. Where are we starting this thing? Things that guys should take a look at from a urological standpoint sooner than later.

Dr. Smith: We'll start with you, Scot, and your weak stream, if you will.

Scot: That was on your list, huh?

Dr. Smith: Well, that's actually probably the top one on my list. Now, the thing is, is kind of decades, right? As you go through life, things change. You notice you wake up one morning when you turn 35 and you're like, "My back has never hurt like this before. I think I can't see myself in the mirror anymore because it's blurry." All those things start to happen, right? You feel like everything is falling apart.

But I think when you mentioned the slowing down of the urinary flow, that's one that a lot of guys will kind of put off. And I usually tell people the sooner you get in and start getting things kind of dialed in on that front, the better off you are.

We call those lower urinary tract symptoms. Some people will call it early-onset enlargement of the prostate, or BPH is a common thing that you hear. And that's one of the things that starts.

Now, the prostate in every man grows with age, and so these symptoms tend to get worse with age. And so if they start early for you, getting in and seeing someone and talking about possible medications or other things that can be done can be important. While it's not curing cancer, so to speak, it can make a huge quality of life difference for you down the road.

And so that's the number one thing that I actually had on my list, is don't just let those little nagging urinary things . . . whether it's increased urinary frequency, having more urgency throughout the day, you might start waking up at night.

Now, once you hit your 50s, waking up once at night is normal. If you're in your 30s, 40s, 50s, and you're waking up two, three, four times at night, then you're going to want to check that.

Scot: You said every man's prostate is going to get bigger with age? That's just something that's going to happen to all of us?

Dr. Smith: Yep. Nose, ears, and prostate. Those are the three that are always going to grow. So yeah, that would be the number one thing.

Scot: When it comes to the stream, though . . . and I think we had a separate episode on this. Maybe I should go back and listen to our own episodes. That's a hard thing to judge, though. Is it really getting slower? I don't know, because it probably tends to slow down over time.

Dr. Smith: Yeah, it does. And a lot of it is kind of an insidious thing, and you kind of notice it after time. The other thing is sometimes you'll hear it from your friends or your spouse or whatever, where they're like, "Scot, you are in the bathroom so much longer than you used to be," or, "It takes you so much longer to empty your bladder now."

Guys will come in and they're like, "Yeah, my wife's been on me to get in here," or my buddies that I golf with say, "I'm going to the bathroom way more frequently during our 18 holes," or whatever.

Mitch: So, John, I guess as someone who in the past has been a guy who puts things off, because maybe I'm a little spooked, maybe I'm asking for a friend on this podcast. One, are there treatments available that it's not life or death? And then secondly, what happens if you don't go and get it checked?

Dr. Smith: Yeah. So none of this stuff is life or death that I put together today. These are just things to think about. So I think that's great.

But long-term consequences are tough because with this being kind of a slow onset, for some people, they can have it for years and years and years and they just have a slow flow and they may not empty their bladder as well as they used to.

For some men over time, it can actually cause damage to their bladder where they actually have a decrease in the function of their bladder and they retain urine. They're not able to empty their bladder all the way.

And ultimately, some men, their bladder stops working and they end up needing a catheter or other things.

A lot of men will catch it long before that. They'll come in and they'll get on medications, or they'll have a surgery to kind of debulk the prostate and open up that urinary channel.

Those are the mainstays of what we do. There are usually two ways we treat an enlarging prostate. One is with medication, and the other one is if surgery is indicated. Those are conversations that you have down the road, but if you're starting to know those things are coming on, that would be kind of the reason to get in and do something earlier rather than later.

Scot: Is medication usually the first line of treatment?

Dr. Smith: Yeah.

Scot: Okay. I mean, I didn't think about this until you were just talking about it. I guess I assumed that there was going to be surgery involved, so that's good to know.

Dr. Smith: Yeah, medicines usually are the first line and you can try them. Now, some people have side effects to the medications, and so they don't tolerate them well. But overall, majority of people tolerate the medications very well and it's a great place to start.

Scot: I think I noticed it more, and I'm afraid . . . So here's my big fear. I'm afraid that it's other things, because I know that if you eat spicy food or drink alcohol, sometimes that can slow the stream.

I tend to really notice it when I'm on long road trips and I put off going to the bathroom longer than I should, and when I finally pull over, it seems like it takes forever and it doesn't seem like it's coming out as fast as I'd like it. Then I also get that feeling of the bladder is not emptying all the way.

Does that sound crazy or does that sound right in line with what you hear?

Dr. Smith: That's all the things that I hear from everybody, 100%. I mean, you're giving me all of the classic cues. "When I have some beer and hot wings, I go to the bathroom all night," or, "When I get out of the car after a long road trip, I have a hard time getting started." All those things.

Another one is cold medicine. That's one that I see during the wintertime. Some of the Sudafeds, things like that, these cold medications can actually get the prostate tightened up and guys that didn't have a problem before are like, "Yeah, man, I started taking cold medicine, and man, I just am really having a hard time using the restroom."

So those are all the common things that you see when people come in and you hear those same things over and over again.

Mitch: It's funny that you say that because on the other side of it, I'm being, I think, on the spectrum of "wait until it's way too bad," and I'm a little more towards that hypochondriac side.

But I was having some flow issues a couple of years ago, and I went in, I saw the magic weight bucket and everything. I was like, "Oh, man. Dude, what can we do? What is going on?" And I was told that I was probably drinking too much coffee. And so as soon as I cut down on the pot-a-day habit, go figure. But at the same time, I'm glad I went and actually got it checked.

Scot: What changed in your life that made you go? Is it just the fact that now it's not an issue and you don't have to worry about the hypochondriac?

Mitch: Yeah.

Scot: "Is this going to do long-term damage?" aspect.

Mitch: Yeah, there was a lot of that, some very dark WebMD searches. I should be better than that, but . . .

Scot: I do have one last question, though. Is this a urologist thing or is this a primary care?

Dr. Smith: So you can go to both, whoever you're more comfortable with. I do have a lot of folks who come in and see us, but a lot of people will start with their primary doctor, which I do appreciate because once you've got that relationship built with your primary doctor, a lot of them can start you on the medications. And then if they're not helping, you can always get over to see the urologist.

Scot: Perfect. I love that. All right. Number two, things guys might want to check out a little sooner than later, see that urologist sooner than later. What is number two?

Dr. Smith: So number two is getting in in your early 50s for a baseline PSA level. Now, this is controversial. Certain societies like family medicine societies and different things do not recommend getting a PSA. People say, "Well, what's a PSA?" and I say, "Great question. I'm really glad you asked."

Scot: I was going to ask that, so let's go.

Mitch: He's the journalist today.

Dr. Smith: It's almost like I've done that before. It's a prostate blood test. PSA stands for Prostate-Specific Antigen. It's a protein made by the prostate, and the only place that we've found where it's made is the prostate. And so it's a prostate-specific blood test and it's one that we use as a marker for monitoring for prostate cancer.

I tell people, "If you have a family history of anyone in your family who has prostate cancer, you should be the person who gets screened." Just like some of the screening tests where they'll tell women to go get a mammogram, things like that.

If you've got a family history, especially if you have a family history, get in and get a baseline PSA in your 50s. If you don't and you're concerned, you can go in and get one. It's a simple blood test.

Now, again, you can do this with your primary care doctor. However, some of the primary care doctors that you may run into may say, "Oh, you don't need that," or whatever. I'm a big proponent of people going and being an advocate for themselves, for their health. If you feel like it's something that you would want to do and have the knowledge base of, please get in and do it. I would recommend doing that from that standpoint.

Mitch: You're saying to just get a baseline? When we have talked about the PSA . . . So we don't have to do the manual digital test necessarily that everyone used to joke about. But the blood test, if the results come back negative, it's good for a couple years or something like that?

Dr. Smith: Exactly.

Mitch: It's a peace of mind for a long time?

Dr. Smith: So peace of mind. If it's in the normal range and you're young, we usually recommend checking it every one to two years. Now, some people, if they have a family history that's strong, they'll want to check it every year. If it comes back elevated, then you have a conversation of, "Hey, it's outside the normal range. This is kind of the next step." I usually always say, "Recheck it before you get too wild with anything."

Yeah, getting a baseline and really kind of following it, because the value of the PSA blood test isn't just the one value. It's actually what it's doing over time.

That's really the biggest thing that I tell a lot of my patients, is this PSA blood test, having one of them isn't super helpful, but if I have a PSA blood test from Scot when he turned 50 and then when he's 52, 54, 56, and then 57, 58, 59, he starts getting it every year, now if I have eight different records of a PSA and they're all very reassuring, it's very reassuring.

If you have someone whose PSA continues to rise and rise and rise, that gives you a little bit more concern of, "Hey, this is kind of raising and going up at a clip that I'm not super happy with. Let's dig a little deeper," or whatever.

Scot: So I love that you said advocate for yourself after you do the research, after you examine your own case. If your primary care provider is like, "No, I don't necessarily believe in that," and they're not willing to do it, go find a provider that can. Because there's not really a downside to doing it, is there?

Dr. Smith: No. I mean, some people will point to the cost of the system, things like that, but I think if it's something that you have a concern about and you want to have that conversation about and you want to stay on top of things, I don't think it's unreasonable to go and have those things checked.

Scot: Got it. And I should ask, I guess, the elephant in the room that I didn't ask, why is it controversial? Why do some not believe in it?

Dr. Smith: Well, the PSA blood test, like I say, is controversial because there are a handful of things that can make the PSA blood test elevated: infection of the prostate, inflammation of the prostate, things that stimulate the prostate.

People will say riding a bicycle can stimulate the prostate and elevate the PSA. Sexual function and ejaculation can elevate the PSA. And so we usually invite people to abstain from ejaculating for a few days before the test just to make sure that it doesn't get elevated for that reason. And so there is some controversy when it comes to that of, "Well, there are these other reasons that it could be elevated."

That's why I say look into it. If it's something that you think, "Hey, I really want to be on top of this," or, "Hey, I have three family members who have prostate cancer, and so I'm definitely going to be the guy that gets it checked," those are the things that . . . You've really got to take stock in your history.

Scot: Is it a worry of over-treatment? Other things could raise it, so then now it's, "Oh, boy, I got something wrong," or is it worrying your patient? What's the ultimate outcome?

Dr. Smith: I mean, you look at it, and let's say that it comes back and it's high, and there's not really cancer there. It's a false whatever. The biopsy has some morbidity associated with it, things like that, and then there's cost to the system if you got an MRI. There are all these different reasons that people can side of do or don't do.

And that's why advocating for yourself in that space of what's going to help you feel your healthiest and be your healthiest, you should totally give yourself at least the benefit.

At least have the conversation. If you talk to your doctor and he goes, "Hey, you're 45 years old. I don't think we need to check it yet. You don't have a family history, whatever," or, "Hey, you do have a family history and you're 50. I think this is a great time to start checking it," at least put yourself in a position to have that open dialogue.

Scot: Sounds good. Hey, I just added something to my list, Mitch, that I need to do now. I need to get a baseline PSA. I think I need to do a little bit more research and figure that out. I do have a family history of that sort of thing, so that would be good.

All right. John, number three on the list of things you should see your urologist for sooner than later, what is it?

Dr. Smith: So the third one is kind of two in one, more of a . . .

Scot: I love a two in one. That's great. Thank you.

Dr. Smith: It's a twofer.

Scot: That's a value-add.

Dr. Smith: This one usually comes to my clinic as a twofer, to be fair. It's hormones and sexual function. I'm going to put them together. Or sexual health, including hormones, because hormones can be in sexual health.

A lot of guys come in with issues with erectile function, performance with their partner, things like that, and they want to talk about that. But a lot of guys don't want to come in and have that conversation.

And so if that is something that's going on, there are definitely things that can be done. So get in and talk to somebody about it, because why wouldn't you? Why would you want to sit back and have that trepidation of, "Am I going to have an issue this time?" or all those things that run through your head? Get in, see somebody, have the conversation, and just be done with it.

Now, the hormones also play a role in that as well, because anybody that comes in with new-onset erectile dysfunction, I'll usually check hormones just to make sure that that's not one of the causes of that function loss. And so that's why I kind of tied those two together.

But then I also have a lot of guys who come in, and they say, "I have fatigue. I've noticed a decrease in my ability to recover. I've noticed a lot of these things that go along with low testosterone." And so checking those labs.

It's interesting, once we get comfortable in that conversation, a lot of them will say, "And I've noticed a decrease in the quality of my sexual function." And so I think those two go hand-in-hand quite a bit.

Once you're there and you have that comfort level with the provider that you're seeing, a lot of times those things become easier to talk about. And so that's why I gave that a twofer.

Mitch: Yeah. And one of the things that I want to . . . As someone who has had their testosterone levels checked and got their hormones kind of fixed, it was night and day, but it was something that I had put off for quite some time. I can only imagine how the quality of life could be with both, not only your hormones, but with your sexual function. That's a big thing that I kind of wish guys cared more about for themselves.

Scot: Why did you put it off? What was your reason?

Mitch: I was looking into a million other things and I had a primary doctor who multiple times said, "You're low, but you're not bad. And maybe we don't need to do this, maybe we don't need to do this." So I actually had to go and be a little bit of my own advocate to be like, "Hey, you're a specialist. Can we get this tested?" And sure enough, as soon as we got my levels back into the middle of the range, I felt a million times better.

Scot: I think that that's an interesting point, John. Talk about that for a little bit. I've heard some providers say . . . and this is neither right or wrong, it's just a philosophy . . . "The symptoms that come with low testosterone could be related to a lot of other things: stress, overweight, not eating well enough, not getting enough sleep."

Dr. Smith: Oh, yeah.

Scot: Yeah. So I feel like maybe some guys might hesitate to go in because they're like, "Well, it's probably something else and this is something I can fix." Or like Mitch said, he had a lot of things going on, so maybe he was even making that assumption. Was that the assumption you were making, that it's probably something else?

Mitch: I went in and I was like, "Hey, I keep hearing all these ads about all these things that are happening with low T. I'd love to get these checked out." And he was like, "You know what? There are actually quite a few other things that could be causing this. Why don't we tackle those first?"

After doing that for six, seven months and still not really getting any relief, that's when I really found a second opinion and it was a big deal.

Scot: John, do you think that coming to a urologist and maybe addressing that first is a care decision that some providers might make differently? Talk about that.

Dr. Smith: So everybody has their comfort level of the things that they like to do and they do well. Some providers, too, have done this long enough where they're like, "Hey . . ."

And Mitch, you're a young guy too. That's the other thing. So I don't fault your provider at all for going, "Hey, man, let's check these other things first," because you're a young guy. Now, does it mean it doesn't happen to younger guys? No. It just means that I completely respect that level of, "Hey, let's make sure that these other things are in line."

Now, in the primary care space, those folks are going to see a lot of people who come in with similar symptoms to what we call hypogonadism, or low testosterone, that can be from thyroid issues, can be from vitamin deficiencies, can be from sleep issues, sleep apnea. There are a bunch of things that can cause a lot of these symptoms that are overlap.

And so I don't think there's a wrong place to start. I think if you can get into your primary doctor and have a conversation, great.

Now, some primary doctors are going to be very much open to saying, "Yeah, let's check your hormone levels. Let's get some good blood work. Let's check your thyroid. Let's check this. Let's check that. Let's get a sleep study. Let's really get to the bottom of this fatigue and things that you're having."

And some of them will say, "I just don't do a lot of the hormones. It's just not something I like to do." I am completely good with both of those things.

I tell all the residents and the fellows that I bring through my clinic, "If you don't want to be known as the guy that does that thing, then don't do that thing."

And so I completely respect all these docs in the primary care space that say, "I don't do that," because, again, that's the thing that I preach to all of these residents that are coming up that want to build their own practice. If you don't want to be the guy that's known for doing that thing, then don't do that thing. They have to be true to themselves, and so I don't fault them at all.

I know that's a tangent, but I really think in Mitch's case, for six, seven months, I don't mind the fact of them running through those things. Could they have gotten there quicker? Sure. Could Mitch have gotten a second opinion sooner? Sure. But I think as long as you know that your doc has your best interest in mind, I love sticking with them, letting them do the things to get you there.

And if they're like, "Hey, I'm not comfortable with XYZ," then go see the person who is, right? There's always going to be a urologist or an endocrinologist that's willing to look at your hormones, and that's okay.

Now, when you get in there, sometimes we do find that people's testosterone is normal, that it's in the middle of the range and they're still having symptoms. Well, that's when I lean on them and I say, "Have you had your thyroid checked? Have you had a sleep apnea test?"

Scot: Yeah. So then you come back around to the same stuff.

Dr. Smith: I go backwards because some of these folks do come to me first and they don't have low testosterone. They have a testosterone in the upper part of the normal range. I look at them and I go, "I really don't think this is testosterone-related because your testosterone is great." And they go, "Well, what else could it be?"

Now, Mitch did it the other way around where he saw his primary care and then made his way around to urology, whereas I get a lot of those folks who come in and I'm their first intake into that. And so it goes both ways.

Scot: I like how you describe that because it's interesting how you might get two different approaches to discovering that. Is one better than the other? I don't know. I think, ultimately, we just want to get better.

Mitch: I still am with the same PCP. He's great. We have a really good relationship. And it was really kind of interesting these days where I'm like, "Hey, this problem, we can take it off my chart. We have it figured out," and he's excited about that. He's like, "I'm so glad that you went and got a second opinion. I'm so glad you whatever and we were able to find something out."

I think most of the doctors I've interacted, it's like they see themselves as on a team. It wasn't like, "Hey, I went and got a second thing and you're wrong." No. It's a good, healthy relationship that I did not fully understand is something that you could do and it's not taken personally.

Dr. Smith: Yeah, I love that you brought that up, because that was my point. As long as the people that you're working with on your medical team, you feel they have your best interest in mind, stick with those folks, man. If you know that they care about you . . .

And that's why you still have that good relationship. That person also wasn't offended, like, "Oh, no." It was like, "I'm so glad you figured that out. That's so great." That might not be their strong suit, and that's awesome that you're able to use that care team. That's what a medical care team should be.

In my world, that's where I think everybody kind of fits together in this puzzle. Your primary care doctor might not like doing hormones. Well, guess what? That's what I do and I'd be happy to help you out. And then I would lean on them for, "Hey, maybe you need to go ask them about this, because I checked the things that I would check for that problem and they looked normal for me, but they might have some other insights." And so I really liked that, Mitch.

Scot: Another little thing that I want to add there that's going through my mind is this idea that every treatment does have downsides.

So as I was listening to Mitch talk about your story, my first reaction was, "Oh, gosh, if they'd have just gotten to that first thing, the hormone replacement therapy, you could have saved so much time." But on the other hand, the other part of me is, "Hormone replacement therapy does come with some trade-offs. So if it's actually something else that's less invasive or that has less potential downsides, then let's pursue that first."

I think it's an interesting study in how a lot of human psychology might work. Busted on the person at first, and then after I considered it for a second, I'm like, "Well, maybe that was actually a smart approach."

And that's what being an advocate for yourself is, is doing that research, figuring out the pluses and the minuses and how you want to pursue things, sometimes knowing that it's just going to take a little time to get to the right solution. It's not "just show up at the doctor's office and problem solved."

Mitch: Not to just pat ourselves on the back a little bit, but in a related thing, I did not even think about being more of an advocate about this point until I talked to some people on this podcast.

Some people that listened to the podcast, I had conversations with them about their experience with getting their hormone levels in check, whether that's testosterone replacement or . . . I'm on Clomid, so it's a little different.

But it was those conversations. It was that being curious, it was that getting second opinions, etc. Having more information doesn't always hurt. Why not? Why not ask other guys in your life, people around you, etc., look online? I don't know.

Scot: It's a good list that you came up with, urologist Dr. John Smith. Two out of those three, I'm going to go ahead and take a look at. I'm not going to tell you which two out of the three. One I have got no issue with, so that's great. That's great news.

Dr. Smith: I love it.

Scot: Yeah. Any final thoughts before we leave?

Dr. Smith: I just appreciate you bringing me on to have that conversation, and I think the reminder of taking care of yourself. I want to tip my hat to Mitch for being an advocate for himself, and to you, Scot, for your new advocacy found in this episode.

Scot: Well, we'll see. I mean, I haven't made those appointments yet.

Dr. Smith: I know. I'm going to give you credit before you get there. I think those things are great. And I really think that these things, if they are something that you think will impact you, don't hesitate to get it done. I always say the sooner you get in, the better off for a lot of these things. So that's what I would say. Appreciate the opportunity and platform.

Scot: Perfect. Well, I understand that you had actually some more, so maybe there's a Part 2 coming up of things that you should talk to your urologist about sooner than later.

Dr. Smith: Sure.

Scot: So that'll be good.

If you are listening right now and any of this resonated with you and you'd like to comment, you can do so. Or is there a urological issue that you would like to know more about? Because the co-host here, Dr. John Smith, is a urologist, so we could really capitalize on having him on the show. Reach out at hello@thescoperadio.com.

Thanks for listening. Thanks for caring about men's health.