For Men Only; how does my prostate grow?

Of our many organs, the prostate gland seems to offer the most annoyance to men as we age. The prostate produces most of the fluid that carries semen and so is critical to reproduction. It is located near the bladder outlet and in young men is about the size of a walnut. As men age, the prostate grows. Unlike heart disease, there is nothing one can do with diet or healthy habits that impacts the prostate.

The two major problems that impact men’s health are prostate cancer and blockage of urine flow from a growing gland.

Growth of the prostate, called benign prostatic hypertrophy (BPH), is a normal part of aging, and occurs in essentially all men. Because of the location of the gland, it can impede flow of urine out of the bladder. It is a good rule that a 60-year-old man, however healthy, should not expect the urine flow of a 20-year-old.

What one does about BPH is entirely based on symptoms. The hallmark of BPH is incomplete emptying of the bladder. You may finish urinating and then feel you need to go again. Most older men will get up at night to void. It may cause urgency – the feeling that if you do not get to the bathroom you are going to lose control.

If these symptoms are mild, no treatment is needed. If they are more severe, medication can help. One class is alpha-blockers, that make it easier to void, that were originally developed to treat high blood pressure. They are generally easy to take, though may be a problem if you tend to have low blood pressure.

The more definitive treatment is to take a testosterone-blocker. Finasteride in low dose is used to treat male-pattern baldness (Propecia) and in high dose to shrink the prostate. It has been shown to reduce the need for surgery and the likelihood of complete urinary blockage. The downside is reduced sexual drive and erectile dysfunction (ED).

ED drugs like tadalafil help urinary flow and may be a good option to improve flow while also treating erectile dysfunction. Your insurance may not pay for this, as most still ration these drugs.

If medicines fail, surgery will usually work.

Prostate cancer occurs in the same organ, but otherwise is unrelated. Cancer occurs in small glands and huge ones equally. As men age, prostate cancer occurs more often and at the same time becomes less aggressive. If a 50-year-old has prostate cancer, unless it is surgically cured, he will probably die of this cancer. If an 80-year-old has prostate cancer, he will almost certainly die of something else, with his cancer but not due to his cancer.

I must also note that African-American men have almost twice the risk of white men.

While prostate cancer can be detected on a rectal exam, by this time it is usually advanced. Early detection is done with a blood test, the PSA (prostate-specific antigen). To say that PSA testing is controversial is an understatement; arguments for and against have raged in the medical literature for years.

I can best sum up the thousands of pages written by saying that screening men with regular PSA testing modestly reduces death from prostate cancer but has minimal effects on overall death rates. There is also consensus that PSA testing should stop at advanced age, though exactly when is debated. I would suggest 75.

If the PSA is elevated, in 2025 the best next step is an MRI of the prostate to detect and quantify any cancer. In low-risk patients, “watchful waiting” is a very viable option. In high-risk men, complete removal of the prostate offers the best chance for cure, with radiation therapy an acceptable alternative. Both treatments have significant side-effects, including bowel and/or urinary incontinence and loss of erection, hence the idea that not all cancers should be treated.

Prostate disorders are clearly conditions in which dialogue between the patient and doctor are key and second opinions critical. Do not accept the first option offered.


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It's a matter of balance

Falls can have very serious consequences as we age. Every year more than 25 percent of adults 65 or older have a fall, and 3 million are treated in emergency departments for fall injuries, according to the CDC.

Several things increase your risk of falling. Blood pressure that falls when you get up is a common culprit, and this in turn can be due to medication you take. If you feel light-headed when getting up, have your BP checked sitting and standing and if there is a fall of more than 10 points, discuss this with your doctor.

Poor vision, particularly when combined with poor light, can lead to a fall. Be sure that you have adequate light in your bedroom if you get up to go to the bathroom.

Be wary of electric cords that are everywhere and can easily trip you. Tape them down or to the wall.

Inadequate leg strength and poor sensation in the feet can lead to falls, as can vertigo from inner ear problems.

What can you do to reduce your risk of falling in addition to the above suggestions?

Doing specific exercises regularly will help. Start with three simple ones:

1. Stand with your feet shoulder-width apart for 10 seconds, increasing this to 30 seconds

2. Next, stand with feet together for 10 increasing to 30 seconds

3. Stand on one leg then the other

If these are too easy, do them with your eyes closed. (Be sure there is a sturdy surface you can touch such as a kitchen counter available.)

Walk heel-to-toe near a wall that can offer support.

Sit on a sturdy chair; get up without using your hands if possible. Sit down. Repeat, aiming for 10 times.

Do these exercises twice a day.

When you are going up or down stairs, hold on to the railing!

Finally, three points of contact are much more secure than two. If you are concerned about falling, a walking stick can be a great safety device.


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Is there calcium in my coronary arteries?

For many decades, doctors have used the traditional coronary disease “risk factors” to predict an individual’s risk of developing heart attacks or other major coronary events. These include smoking, diabetes, high blood pressure and elevated cholesterol.

These factors can be plugged into various formulas to predict the likelihood of a coronary event occurring in the next 10 years, and are used to decide if a person should be started on lipid-lowering therapy.

If the calculated risk is very low or very high, no other information is needed. Many people, however, fall into an intermediate risk range. In some instances, even those with high risk of coronary disease may not want to start a statin drug because of feared side effects (which are uncommon).

Such situations suggest the use of a coronary artery calcium (CAC) score.

As plaque (cholesterol deposits) builds up in coronary arteries, calcium is also deposited. A low-dose CT scan can measure the amount of calcium. Ideally, you would have a score of 0, and the higher the score, the higher the risk of developing symptomatic coronary disease.

Who might benefit from this testing?

If your doctor has recommended you start a statin but you are hesitant, a zero score would allow you to postpone the drug while a score over 100 would strongly suggest you take it.

If your calculated risk is intermediate, a zero score would suggest you do not need to begin cholesterol-lowering therapy while a non-zero score would push you to do so.

If your cholesterol is not bad but you have other risk factors for coronary disease, a CAC score will give useful information. If several family members had early heart attacks, a non-zero CAC score suggests that even if your cholesterol is not high, a statin might be a good idea.

If you have not tolerated a prescribed statin and stopped it, a CAC score may help you to decide whether to try a different statin or one of the newer injectable cholesterol-lowering drugs.

Who should not get a CAC score done?

If you are under 40, a zero score is expected and will not impact decision-making; use the traditional risk factors to guide your thinking. If you are over 80, and not on a statin, the results are unlikely to change recommendations to begin.

If your risk for coronary disease based on the traditional risk factors is high, a CAC is a waste of money: take a statin. If you are on a statin and doing well, be happy and do not get a CAC test.

Finally, if your score is zero, repeating the test can wait at least 3 and probably 5 years.


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Oh, My Aching Back. Part 2: Chronic back pain

About 20% of adults 20-59 and even more people 60 and over suffer from chronic back pain, pain that lasts 3 months or more and bothers you most days. Chronic low back pain can interfere with your enjoyment of life and is the leading cause of disability world-wide.

Unfortunately for sufferers and their doctors, most of this pain has no clear cause and no great remedy available.

There are two specific causes of chronic back pain that have a defined cause and a potential surgical treatment: spinal stenosis and ruptured disk.

Lumbar spinal stenosis is rare in young people but gets more common with age. The symptoms are classically pain in the legs when standing or walking with almost immediate relief upon sitting down. If it is truly disabling, surgery is an option to consider.

A ruptured disk can put pressure on the nerve root coming out of the spine; the pain will run down the back of one leg, usually as far as the ankle. On examination, lifting the leg when you are lying on your back is very painful. Most acute disk ruptures will improve with time. Unless you have obvious leg weakness, you should NOT rush to surgery. In a minority of people, however, the pain persists.

What about the majority of sufferers, whose back pain has no clear cause?

There are numerous treatments available, their number and variety testify to the fact that most do not work well for most people.

Anti-inflammatories such as ibuprofen and naproxen have the best success rate. There is no good evidence supporting nerve ablation, epidural injections or intramuscular injections, and all of these have potentially serious side effects.

Unless there is strong clinical evidence for spinal stenosis or a nerve root compression, do not get imaging of your back. If you are over 50, there is a 60% likelihood imaging will show one or more abnormalities, and if you are over 70 this rises to almost 100%. This is true even if you have never had a backache in your life! Never allow anyone to operate on you based on imaging; imaging should confirm a clinical diagnosis, not substitute for one.

Finding arthritis in the spine will not change treatment.

What can you do?

Exercise helps, particularly exercises that strengthen the core. Heat and massage often help. Spinal manipulation by a physical therapist or a chiropractor may help.

Avoid narcotics. They may help initially but often must be taken in increasing doses and carry the risks of addiction and side-effects.

Proper use of pillows or other forms of back support are key when sitting or driving.

If surgery is recommended, ALWAYS get a second opinion.

Try to stay as active as possible. Exercise within your limits.


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Oh, my aching back. Part 1 - acute back pain

Most of us have (or will have) experienced an acute lower back pain. Sometimes the cause is obvious – you unloaded six bags of loam from the trunk of your car – while other times “I just bent over to pick up a pencil.” Our back muscles extend over a long distance and stretching them just the wrong way may be all it takes.

Whatever the cause, it can make for a very uncomfortable time. What should you do?

First, what you should not do is go to the emergency room. Unless you have one of the “red flags” I list below, you do not need X-rays or CT scans. What you need is pain relief and a short period of rest.

Pain relief for acute onset back pain takes many forms, no one of which works for everybody. Getting flat with your knees bent and some pillows under your knees may be all you need. Both heat and cold can be very helpful. For acute pain, I tend to start with ice rather than heat, but if you have found a heating pad works, stick with it.

Note that you should only spend an hour or two lying down. After that, gentle movement such as walking is fine.

Get some over-the-counter pain relievers: acetaminophen, ibuprofen or naproxen are equally likely to help but each of us has a favorite. If one anti-inflammatory does not work, try a different one.

When might you need an imaging test? If the pain extends down the back of one leg towards the ankle you might have a ruptured disk, a condition that can be suspected based on clinical exam and confirmed with a CT scan. If you have known osteoporosis or cancer, or have been on long-term cortisone-type medication or the pain comes after a serious fall, you may be dealing with a fracture of one or more vertebra. This can be proven with a plain X-ray.

Cancer, an unexplained fever, IV drug use or a depressed immune system raise worry about an infection near the spine and suggest you seek early medical attention.

Assuming none of these uncommon situations fits, your pain should subside within a day or two with rest, pain relievers and ice or heat. Don’t try to ignore it and push through or the pain will last longer.

Next week: what about back pain that does not go away?


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What price for "miracles," and who pays for them?

There are now five drugs on the market to treat genetic disorders that are each priced at over $2 million.

They have been approved by the FDA to treat illnesses that had no curative therapy. Some, such as spinal muscular atrophy, were fatal while others such as hemophilia and sickle cell anemia led to repeated crises and frequent hospitalizations.

Are these astronomical prices justified? The pharmaceutical companies justify the prices by citing two factors: the high cost of drug development and the long-term financial benefits.

The problem with using research costs as a justification for the prices is that much of the basic research is funded by NIH grants or academia rather than by industry.

In the case of Zolgensma, Novartis’ $2.1 million drug for spinal muscular atrophy, the bulk of the early funding came from a private charity founded by parents whose child had the disease. ProPublica documented how their efforts, both financial and emotional, were ignored when the commercial potential of the drug began to become apparent. They hoped for a cure for their daughter and others similarly afflicted, not a windfall for the executives of the start-up they helped fund. See: https://www.propublica.org/article/zolgensma-sma-novartis-drug-prices-gene-therapy-avexis

Research published in JAMA provided details of the sponsorship and funding of 341 trials of gene therapy. Fewer than half were industry-funded. Academic hospitals, universities and the NIH were more often the funders, and yet the financial rewards almost all go to the pharmaceutical industry.

One could make a case that the sky-high one-time cost of gene therapy pays for itself by preventing the numerous emergency room visits and hospitalizations that it will eliminate. The estimated lifetime cost of hemophilia is $20 million! This makes the one-time $3.5 million cost of Hemgenix seem a bargain.

The big if is that the only data we have is that the benefits last 3 years – hopeful, but only a short span in a life-long disease. If the benefits fade after 4-5 years will CSL Behring refund the cost?

Will health insurance companies be willing to pay for a drug that may benefit the patient for 50 years or more when they know that their average subscriber is probably going to change insurers in a few years?

We need a different way to pay for these “miracle” drugs. One option is to have them paid for on an annual basis, spreading the cost over the patient’s estimated lifespan, with payment to stop if the drug stops working. A plan must be devised soon, or scientific advances plus pharmaceutical greed will exceed society’s ability to pay.





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Osteoporosis: could I have it?

Osteoporosis, thin weak bones, is common in post-menopausal women and older men. While not fatal, it is a major risk for fractures and can severely impact your quality of life.

Estrogen in women and testosterone in men are needed to maintain healthy bones and the biggest risk factor for developing osteoporosis is aging. The precipitous drop in estrogen levels in women who go through “the change” accelerates bone loss, and some 80% of those with osteoporosis are female.

Other factors increasing your risk are smoking, alcohol consumption, poor intake of calcium and vitamin D, lack of weight-bearing exercise, taking cortisone-type drugs and being thin. (One of the few health benefits of obesity is that you are less likely to get osteoporosis.)

How do you know if you have it? Osteoporosis is a “silent disease,” with no symptoms until it is advanced, and may first be discovered when you suffer a fracture.

The best way to find it before a fracture is to have a modified X-ray called a DEXA scan, which measures the density of your bones at the hip, spine and/or wrist. This gives you two numbers, a T-score, which compares your bones to those of a young healthy adult, and a Z-score, which compares you to an average person of your age.

If your T-score is: (note that these numbers are a consensus, not “truth.”)

• –1 or higher, your bone is healthy.

• –1 to –2.5, you have osteopenia, a less severe form of low bone mineral density than osteoporosis.

• –2.5 or lower, you might have osteoporosis.

The risk of broken bones increases by 1.5 to 2 times with each 1-point drop in the T-score.

A DEXA should be done when a woman is 65, a man 75, unless they have many risk factors for osteoporosis. While there is no hard rule, it should be repeated in about 2 years. If the results are stable, you can probably wait 5 years before a third.

If you want a precise estimate of your risk of fractures, google “FRAX Score.” The first link that shows up (https://frax.shef.ac.uk/FRAX/tool.aspx?country=9) will take you to the validated tool developed at the University of Sheffield in England. In addition to your T score, it asks for information such as age, height and weight and will then tell you your risk of a major fracture in the coming decade.

How can you prevent osteoporosis? Don’t smoke; don’t drink much alcohol; do resistance exercise (weights); get adequate calcium in your diet (dairy, leafy greens, almonds) and get adequate Vitamin D. Note that dietary calcium is better than pills. We get D from sun exposure and fortified milk.

Since few adults are big milk drinkers, and most of us do not spend all day outdoors soaking up sun, a vitamin D supplement is a good idea, and the amount in a multivitamin is probably adequate for most.

If you are at high fracture risk, many different medicines are available that have been shown to reduce the likelihood of fractures – but are not a guarantee. The best-studied are the “bisphosphonates,” taken as a weekly or monthly pill, but there are many other classes of drugs highly marketed. All these remedies have the potential for serious side-effects, so the decision to start requires a careful dialog with your doctor.

There is also good evidence that taking a bisphosphonate for a couple of years and then stopping is a better idea than taking it forever.

Remember: prevention is better than treatment, so start early. The bones you preserve will be the ones to keep you upright and moving.



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