Mar 8, 2022

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Scot: Welcome to "Who Cares About Men's Health." It's a Men's Health Essentials episode. A weak stream, is that something that you should have a doctor look at? That's what we're going to talk about.

My name is Scot Singpiel. I am the manager of thescoperadio.com. I provide the BS. That's what I do. The MD to my BS is Dr. Troy Madsen.

Troy: Hey, Scot. It's me, and I have to say I am so excited to be joining you today on the number two rated podcast in the world.

Scot: What?

Troy: Men's health podcast. Let me clarify that. The number two rated men's health podcast in the world. It's my honor to be here.

Scot: Tell me about that. We're number two?

Troy: We are number two. I did a search. I just searched on Google "top men's health podcast." The first site that came up ranks them by multiple factors. We are number two, behind "Men's Health" magazine's podcast. It's pretty cool.

Scot: All right. Wow.

Troy: We'll take it.

Scot: Yeah, I don't know if . . .

Mitch: We will take it.

Scot: . . . that's cool or that's more pressure. And joining us as always, Producer Mitch is in the mix.

Mitch: Hey, there.

Scot: And going to help us with our weak streams if any of us have weak streams . . . I think I might have a weak stream. I don't know. We're going to find out. Urologist Dr. John Smith, welcome.

Dr. Smith: Hey, thank you.

Scot: So weak stream. Hey, Troy or Mitch, how is your stream? Everything okay with the stream? You feeling pretty good about it?

Troy: The problem with a question about the stream, Scot, is I don't know what to compare it to. Should I be looking at guys in the airport in the urinals without the barrier there and just look at their stream? I don't know. I think my stream is good.

Scot: Yeah, or sometimes you listen, and it's like, "Oh, my gosh, what's that? About a gallon a minute coming out of there?"

Troy: Oh, yeah. Some guys are just like, "Wow." Yeah, it's something else. I feel like I've got a good strong stream, but I don't know.

Scot: All right. Mitch, do you want to comment or do you want to abstain?

Mitch: No. I know for a fact that I have an average or above-average stream because I've actually talked to a urologist.

Scot: Oh, you have?

Mitch: Yes, I have, about this very concern.

Troy: And you've measured it?

Mitch: They measured it. It's not like I measured it myself. There was a science to it that I'm sure Dr. Smith will be able to tell us all about.

Dr. Smith: So you objectively know you've got a good stream, it sounds like.

Mitch: I'm going to see if I can't pull up the graph. You guys might find that interesting, or gross. I don't know. Hold on. Keep going.

Scot: Dr. Smith, that's what we're here to talk about. I feel like perhaps as I've aged, maybe I've lost a little stream power. Maybe. I don't know. It varies. Some days I'm like, "Huh, this isn't coming out very fast." And then other days, things seem to be fine. So we're going to get into all of that. First of all, is stream something that we should be worried about as guys?

Dr. Smith: I think you should be at some point. I usually ask gentlemen about their stream and I ask them, "Do you hit the back of the bowl, the middle of the bowl, the front of the bowl, or your shoes?" But I think if you're a front of the bowl or shoes guy, we definitely should be having a conversation.

Scot: Okay. Has that been proven by research, that little method that you just told us about?

Dr. Smith: It's anecdotal, but it gives me a lot of information right up front without having to put them on a machine like Mitch.

Scot: Okay. All right.

Troy: So you're saying that for some men, full force, they're hitting their shoes?

Dr. Smith: Well, they shouldn't hit their shoes. That usually means they've got a problem.

Troy: Yeah.

Scot: And is this they're trying to actually actively push out, or should the urine just be coming out? Is that how you would measure the ideal stream measurement?

Dr. Smith: I'll answer that with talking about Mitch's machine. So we do have a machine. It's called the uroflowtometer. It sounds really, really cool. We shorten it to uroflow just to make things easier.

And they actually have one of these that you can get at home now. There's a company where you can get one of these at home. It's called the Stream Dx, and your doctor could actually send one home with you.

What this machine does is when you urinate, it takes the amount of urine that you're putting out over time, and then it'll also show us if you're actually straining to urinate and you're using your abdominal muscles to urinate, because you really shouldn't need to do that. You should be able to just open things up and let things go.

And some men notice as they age, they have to push a little bit more. The urine stream is not as strong as it used to be. Some younger men may notice that they had an abrupt change in their stream. And those can both be issues that need a little bit of attention.

Scot: Is it normally an abrupt change, or is it over time, or is it both really?

Dr. Smith: So, depending on what's going on, the thing that is the problem depends on whether it's more of a sudden thing.

So an abrupt change in stream is something where you want to get it checked out because it could be a narrowing of the urine channel or the urethra, anywhere from the bladder all the way down. That usually happens in a rather quick fashion, and that's something that can cause a problem.

A urethral stricture is usually the most common thing that we see in younger men who come in with an abrupt change in their stream. And that's a narrowing in the urine channel as a result of a traumatic event, or even just sometimes what we call idiopathic, meaning it happened and we have no idea why.

Troy: You talked about the abrupt change, suddenly something happens, but it sounds like probably what you see more commonly would be stuff that just gradually decreases over time.

Dr. Smith: Yeah. So the decrease over time thing generally happens with men as they age, and that tends to be more of a prostate-related issue. And that's the slowing down of the stream where you go to the restroom in the airport, or you go to the Jazz game, or you go somewhere and you're standing next to somebody and you go, "Man, that doesn't sound like what I've got over here."

And so that can be due to age-related changes in the prostate. The prostate is like your ears and your nose. It continues to grow until the day that you die.

Scot: I feel like this is a stupid question. What about kidney stones? Could that result in a reduced stream?

Dr. Smith: It can if it's lodged within the urethra. Usually, kidney stones that are in the tubes coming down the ureters from the kidney to the bladder don't usually slow your flow down. They just cause pain and make you miserable.

Mitch: You'll know if you have a kidney stone, and that's what's blocking things, right?

Dr. Smith: Usually, if you know you're passing a kidney stone and then you have a urinary flow change, you could have it stuck in the urethra, but it's less likely to happen because the tube coming from the kidney down to the bladder is very, very small. And compared to the urethra, that's very, very large in comparison. It'd be like taking a coffee straw and then a Boba straw.

Scot: Good reference.

Mitch: All right. Okay.

Scot: You're very topical, aren't you? So is it really only two things that might cause a weak stream, the narrowing of the urethra or a prostate issue?

Dr. Smith: No. There are other things too, but those are the most common things that I see in younger and older age groups.

Another thing that I see commonly across all age groups is something called pelvic floor dysfunction. There's also dietary things that can make urination more difficult. The big three that I always talk to folks about are caffeine, alcohol, and spicy foods, three things that can definitely make urination more difficult or problematic.

Scot: Back to that machine that measures stream pressure, do I have to stand up when I do that, or is that a sit-down deal?

Dr. Smith: Either one. So usually, you can stand up to do it if you're comfortable that way, but you can also sit down.

It's kind of a crude measurement. It pretty much measures the urine as far as a volume . . . actually, excuse me, as a weight of urine as it comes out. It measures how much weight is being added to this scale over time. And so initially, you're going to be adding less weight, the weight of the urine to this flowtometer. And as you build up speed and you reach your maximum flow, you're putting that weight in at a rate and then it graphs that in a curve.

And the normal curve looks like a bell curve that you would have in school when they would grade you and give half the kids Fs that are on that one end, and the other kids get As and everybody else is in the middle. That's what the uroflow, a normal one, would look like.

Scot: Hey, in the chat, click on . . . Mitch sent us this. Is this what we're talking about here?

Mitch: Yeah. Those are two examples of the machines.

Scot: The very first one?

Dr. Smith: I don't know how to get into the chat. Let me check and see.

Mitch: Yeah. I had something similar to the first one.

Dr. Smith: Yeah. That's exactly what it is. Did you order one of those on Alibaba?

Mitch: We are $500 away from knowing exactly how everyone's flow is going.

Scot: I know.

Dr. Smith: It's less than that if you just get your doctor to prescribe you a Stream Dx.

Mitch: You could probably DIY this. It looks like you could maybe do a bucket, a funnel, and . . .

Dr. Smith: One hundred percent you could DIY this.

Troy: It's just a funnel and some sort of measuring . . . Yeah.

Mitch: A scale.

Troy: A scale. That's right.

Dr. Smith: It really is. Then you've just got to be able to graph it over time and have that amount of stuff come in. But yeah, those are the normal graphs. If you look at that flow curve, you'll see what we see. That normal bell curve is pretty normal. And then the guy that has multiple different curves, they have an interrupted flow, that start, stop, start, stop that a lot of guys will talk about that have a slow flow.

Scot: What's up with this dysfunctional voiding curve? It goes way up and way down.

Dr. Smith: So usually, that's due . . . When they say a detrusor overactivity, the detrusor is the muscle that's in the bladder wall. And when that muscle is overactive, it has a spasm and just pushes with a high amount of pressure, and that's why you see the flow and the pressure go up.

Troy: Interesting.

Mitch: So you completely void the bladder in the first few seconds. That's why we're seeing such a high curve. I'm trying to make sure for listeners who can't see graphs . . .

Dr. Smith: Yes.

Mitch: Yes. Okay. Interesting.

Troy: I guess as I'm hearing this, though . . . I don't know if I have a weak stream. Maybe you go to a Jazz game or a sporting event or something, you hear other guys and it sounds like they just opened up a garden hose over there or something. I don't know. But the question is, does it matter? Do I need to buy the uroflowmeter and check out my flow, or what's the downside of having a weak stream?

Dr. Smith: So to a certain extent, it's not an issue. It can be and it is as people age. The big thing you want to make sure of is that you're emptying your bladder.

Now, the thing I always tell my patients is the urinary system, the bladder on out, is meant to be a low-pressure system. The sphincter that keeps the urine in your bladder and out of your pants opens up, your bladder squeezes, the urine goes out into the toilet, and nobody is the wiser. And that's supposed to be done in a low-pressure setting.

As we age, the prostate gets bigger and closes down the opening of the prostatic portion of the urethra, making it a higher-pressure system. Now, that's not a problem until it becomes a problem.

I know that's very specific, and so what I usually tell people is there's a certain point where that pressure builds up and the bladder can't keep up with it and you start to have residual amounts of urine where your body is not emptying the bladder completely. That can cause a problem, increase your risk for infection.

But also, as your bladder increases the pressure, it can also push pressure back up the ureters towards the kidneys, and long-term can cause kidney damage. And so that's the reason where if you think there's a problem, you should probably have somebody take a peek at it.

Troy: Would you have other signs also that would maybe suggest that there was an issue there?

Dr. Smith: Yeah. So normally, we call these lower urinary tract symptoms. Some doctors will just say LUTS. That's the lazy way to say it. But it's pretty much a non-specific group of things like going to the bathroom more frequently, having increased urgency to get to the bathroom. When you have to go, you have to go now. I call it the "gotta-gos." You can have urinary hesitancy, difficulty getting things started. You can have nocturia, which is waking up multiple times at night to go to the restroom.

Those are all considered lower urinary tract symptoms. And there are a few others that are involved there that make the rounds.

And so again, those are the things that you may also experience in addition to a slowed urinary flow. People may also say, "I don't feel like I'm emptying. I just feel like after I'm done, there's more there."

Scot: You probably already explained this, but I just want to be clear. So first of all, I thought a weak stream was indicative of maybe some health problem. But other than the fact that you might not be getting all the urine out and over time that can cause an issue, a weak stream in of itself isn't necessarily a bad thing.

Dr. Smith: Not necessarily. It does depend on how weak the stream is and what's going on upstream. Some people have intermittent weak stream, like you were saying. Some days, it seems like it's weaker than others. Usually, that's due to caffeine, alcohol, spicy foods, things like that, where people notice, "Oh, if I drink four cups of coffee, I tend to go more frequently and have urgency and may not feel like I empty well," or whatnot that way.

Mitch: So the reason I got tested was I was urinating a lot more frequently last year, and it was enough that I was worried to go to the doctor. They had me use the uroflow, test everything out, and then come to find out I was just drinking a pot of coffee a day because of the two jobs I was working. So it was a whole thing.

Dr. Smith: Yeah, you're not uncommon. A lot of times when people come in, I usually check for lifestyle things. Guys that go to Buffalo Wild Wings and they have a couple of beers and then they go home and they notice that their urinary system or their urinary function is more frequent, less frequent, those types of things, I tell them, "If you know that's happening to you, then it's self-inflicted and you know how to change it."

Or the guy that drinks a pot of coffee and I say, "Hey, you just need to drink less caffeine or no caffeine to make your life easier and make your urinary system better."

Troy: I guess hearing this, too, it makes me wonder, and hearing Mitch's experience, do you find that people think their stream is too weak and they overreact and so you see a lot of these cases where, "Hey, your stream is fine"? Or do you find that a lot of guys just put this off and ignore it and then come in when they have a really weak stream?

Dr. Mitch: So I see both ends of that spectrum. I have the guys who when something seems to go wrong from the waist to the knees, they immediately are in your office, and the other guys that don't think it's a problem and come in once their bladder is no longer functioning and they have a liter and a half of urine in their bladder and don't know it.

So those are kind of the extremes, but I do see both angles where people are very worried about their current urinary flow, and then others that are like, "Oh, yeah. It's been like this for 15 years," and they don't do anything about it.

Troy: Yeah. See, John, I'm just worried I'm going to be the guy with a liter and a half in my bladder. I'm going to finally show up and be like, "Something is wrong here."

But again, it's hard to tell. Now that we're talking about all this stuff, I'm thinking, "Yeah, I do get up two or three times a night," and, "Yeah, sometimes I really have to go." So it makes me wonder. I don't know. Maybe I need to get checked out.

Dr. Smith: Well, Troy, I'm not going to age you at all, but I'll just give what I tell people. Over the age of 50 to 55, everybody, both men and women, gets up once a night. It's pretty normal. So once a night is not a huge issue.

When you start getting up two and three times a night, that tends to be a little bit more pathological where you may want to even just get it checked out.

Troy: I might need to. I do drink a lot of water. We've talked about that before. So I don't know if that's part of it. Hearing Mitch's experience, it sounds like there was a lot of coffee consumption going on and a lot of caffeine. I just drink a ton of water. So I've always chalked it up to that, but I don't know. Yeah, it sounds like maybe I should get checked out.

Dr. Smith: Well, some homework you could do too is if you cut the liquids off a couple hours before you go to bed and then you notice that you don't wake up as much.

I have plenty of patients who come in and they're like, "Yeah, I drink two glasses of water before I go to bed and I wake up two or three times." I said, "Yeah, go figure."

Mitch: That's how I felt after we had done all this testing and everything and he's like, "You're drinking how much coffee a day?" And I'm like, "Yeah, it's about a pot of coffee a day. Of course, I'm urinating more. No duh."

Troy: Exactly.

Dr. Smith: You're putting eight cups of a diuretic into your system and then drinking a liter and a half water. You're going to be going to the bathroom. And the same thing, if you drink 32 ounces of water before you go to bed, you're going to wake up to go to the bathroom.

Troy: Yeah. That is true.

Scot: I feel like this conversation has expanded beyond weak stream. We're talking about going often or going in the middle of the night. Is it all really related?

Dr. Smith: Yes. When it comes down to a lot of that, a lot of times people come in and once you ask them those more probing questions, "Do you have increased frequency, urgency, your stream is weak? Do you feel like you're emptying well? Do you have hesitancy? Do you start and stop your flow?" those types of things, usually it's not just, "Oh, I thought my flow was weak," and that's it. There's usually a yes to multiple of those other questions.

Scot: Okay. And then how do you avoid being the person that's in your office when anything goes wrong between the pelvis and the knees, you said?

Dr. Smith: Yeah, the waist and the knees.

Scot: Yeah, and being the person that should have been there two years ago. How does a guy that's listening figure that out? I think a lot of us guys don't go to the doctor because we're like, "Oh, it's probably nothing," or we don't want to be a bother, or it can be a hassle, or whatever. So how does a guy figure that out?

Dr. Smith: I think you use your best judgment if you think it's slowed down enough that you want to get it checked out. But other things you can do are just lifestyle modifications. Mitch could have probably cut the coffee down before he went into the urologist and seen if there was a difference. Troy can cut water off before he goes to bed, and see if that makes a difference.

You can do lifestyle modifications where you decrease the amount of caffeine you intake, alcohol, spicy foods, see if there's anything dietary related. Then you can also watch your intake before bed. Make sure that you're putting yourself in the best position possible to see how your urinary system functions without any of those additives that may make your life worse.

Troy: And what about the person who's listening right now, just like me listening to this, and just thinking, "I've wondered if there's an issue"? Would it be a simple test to just say, "Okay. I've got to go urinate right now"? You go and you urinate, and your stream is hitting the back of the bowl without a lot of effort. Are you good?

Dr. Smith: That's the reason that I ask that question, because it lets me know how worried I should be about those folks.

The other thing is to go ask those questions to . . . If you've got a significant other, that's my favorite when the patient comes in with their spouse.

Scot: Oh, no.

Dr. Smith: I go, "Is your stream weak?" He's like, "No. It's good." And you just look over their shoulder and their significant other that's with them is just shaking their head like, "He's totally lying."

Scot: Is that because they're the one that cleans the toilet? Is that what's going on there?

Dr. Smith: Guaranteed. Yeah. Or washes the shoes.

Troy: You're just a poor aim, or what?

Dr. Smith: But you'll see a lot of them like, "Oh, do you wake up much at night to go to the bathroom?" They're like, "No. I maybe wake up once," and their partner looks over at them like, "No, he wakes up like four times at night." So they'll keep you honest a lot of times.

Scot: Yeah. It sounds like that's something to watch out for as a guy, is just that sometimes maybe we disillusion ourselves a little bit. We need to take an honest look at these types of things.

Dr. Smith: Absolutely.

Troy: Again, just for my own peace of mind, it sounds like if you do go to the bathroom and you are hitting the back of the bowl without a lot of effort, you're probably okay.

Dr. Smith: Yes. I would say that's a pretty good idea. If you're not forcing the urine out and your flow is coming out pretty robustly, you're okay.

Now, if you have any questions, Troy, you just give me a buzz. We'll get you into the office.

Troy: Okay. I'm a little nervous now because the whole night thing, that's got me thinking, "Maybe I need to get things checked out." Anyway, I'm feeling okay about things.

Scot: But there are not other symptoms, though, really. Are there?

Troy: Sometimes, like John said, the whole gotta-gos things, sometimes I'm just like, "I've got to go." But again, I've always just attributed it to I drink a lot of water. So maybe I'll cut back on the water a little and see what happens.

Scot: Hey, if you guys want . . . Hey, Dr. Smith, can you write us a prescription for that thing? Do you guys want to have a little competition?

Mitch: There's no need to make this a competition.

Dr. Smith: I'm sure we could figure that out. Not that we need to make this a competition, but I think we could probably figure that out.

Mitch: I'm worried this is going to be like the pushup competition where it's going to be a recorded thing and John is going to be the referee watching and like, "Okay. Go for it, Mitch. Let's see what you can score."

Dr. Smith: Well, I don't have to watch. I have the machine give me a printout, so it makes it much less awkward.

Troy: That's good.

Scot: And then that's a little souvenir for all of us. We can each have our own little printout when we're done. So that'll be fun. Put that up in the office next to the diploma or whatever.

Mitch: Man.

Troy: Yeah. Exactly.

Dr. Smith: You can do that live on . . . not a podcast. You can make a vlog and throw that up.

Troy: Yeah, just like, "Here we go." This is University of Utah Health at its finest.

Scot: Any final thoughts, Dr. Smith? Anything that you feel compelled to say? Anything we should have hit or should have mentioned, or a wrap-up that you'd like to give a guy?

Dr. Smith: No. I think if you're worried about your stream and you do have any questions or concerns, getting in sooner rather than later is definitely better for you. So if you do have concerns, just pick up the phone, make a phone call. It's a pretty easy visit. It's nothing to be overly concerned about. You can check things out pretty quick and get some good objective answers and give yourself a lot of peace of mind.

Scot: And is that a urologist you're going to go to, or would your primary care physician have this equipment to do this?

Dr. Smith: If your primary care has this equipment, I would be very, very surprised. You want to call a specialist like a urologist, yeah.

Scot: Okay. Great. Well, Dr. Smith, as always, it's great having you on the show. Thanks for being a part of it, and thanks for caring about men's health.

Dr. Smith: Hey, pleasure is mine, guys. Thanks for having me. It's always great to be with you.


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