Dedication
This newsletter is dedicated to the memory of Dr. Alan Cashdan of blessed memory. Dr. Cashdan practiced urology in Phoenix for more than 20 years. He was loved by many of his patients who describe him as warm, caring, and compassionate. I had the distinct privilege of working with him and enjoyed the many times we worked together. His untimely death this past year deals us all a great loss. We truly miss him.

Female Incontinence Revisited
There are millions of women in the United State who are affected by urinary incontinence. This includes any women who have experienced dampness in their underwear or frank leakage of urine and wetting their clothing. The severity of the symptoms can be minimally irritating to almost totally incapacitating. Many women are subjected to staying in their home because of the sheer embarrassment and rarely get out, even to do grocery shopping. Frequently enjoyed life activities, such as walking, jogging, or exercising, may be given up because of this incontinence. It is, unfortunately, thought of as a normal aging process and many women do not seek treatment for it. The treatment for incontinence, as far as the use of pads and diapers, runs into the billions of dollars range per year in the United States. The age range for women may begin as early as the 30's. Childbirth can be related to the problem- women with multiple vaginal deliveries or prolonged labor tend to have more difficulty than others.

Incontinence in women is usually divided into either urge incontinence or stress incontinence, though many women may have both. Urge incontinence is loss of urine without warning, or wetting one's self when the urge to urinate hits without enough time to get to the bathroom. Stress incontinence refers to the less of urine with coughing, sneezing, laughing, exercise, or even going from a sitting or standing position. Both these kinds of incontinence can be very incapacitating and can limit one's activities and enjoyment in life.

These types of symptoms need to be brought to the Urologists for assessment and to determine the best treatment for the individual patient. Initially a thorough history must be obtained, including many of the details mentioned above. A very detailed examination should be performed as well, to determine if there are any problems within the bladder itself that may be causing the incontinence.

Urgency incontinence usually responds to medication, diet change, and sometimes even exercise. Stress incontinence is a difficulty which results from an anatomical change in the bladder position in relation to the pelvis. In other words, it will most likely need surgical correction. A relatively new procedure now being used, which is almost 100% successful in stopping stress incontinence, is the vaginal wall sling. The procedure uses the lining within the vagina to act as a sling, or buttress, to elevate and support the urethra and bladder in the correct position in the pelvis by anchoring it using special bone anchors into the pubic bone. The procedure can usually be performed within one hour, and involves either an outpatient procedure or one-night stay in the hospital. It is relatively painless and requires two very small incisions on the abdomen and a small incision in the vagina. In our practice, the procedure has been 95% effective in keeping patients completely dry so they are no longer wearing pads. Ninety-five percent of patients are happy with the procedure and would recommend it to their friends. Patients can be back to work within one week after undergoing the procedure, and after two to three weeks are essentially back to normal, except they are no longer wet.

For further information regarding this procedure, please contact our office for an evaluation. And please remember that incontinence is not a normal part of growing older.

Ask the Doctor...

Q. How common is prostatitis?
A. Prostatitis if the most common urological disease in men with 25-50% of all adult men experiencing prostatitis during their lifetime.

Q. How does one get prostatitis?
A. The urine can carry infectious or inflammatory agents into the ducts of the prostate gland. Stones can sometimes develop in the prostate which can cause blockage of secretions and trap bacteria in the prostate. If the infection is not treated adequately, chronic prostatitis may result in repeated bouts of infection.

Q. How many types of prostatitis are there?
A. There is generally thought to be three types of prostatitis: acute prostatitis, nonbacterial prostatitis, and prostatodynia. The bacterial prostatitis patients develop chills, fever, low back pain, and pelvis pain. These symptoms before the onset of frequent urination, burning with urination, and difficulty urinating. Nonbacterial prostatitis is the most common syndrome of prostatitis. This includes the same symptoms as bacterial prostatitis without fever or chills. It is referred to as nonbacterial prostatitis because of the difficulty in isolating bacteria from the prostate secretions. This may also be caused by inflammation, autoimmune diseases, or a backup of urine into the prostatic ducts. Prostatodynia is a syndrome in which the patient and symptoms as mentioned before, but without a history of bladder infection and no bacteria growing in the prostate secretions. The typical complaints are abnormal urinary flow, including slow stream and difficulty in starting the stream and dribbling after urinating, as well as pelvic pain, which can radiate to the groin, testicles, low back, penis, and urethra. The physical examination is usually normal.

Q. How do I know if I have prostatitis?
A. Your doctor should perform a complete physical exam and check the urine. Most patients will be treated with an antibiotic right away. The best test to assess prostatitis is collecting serial urine for culture and then massaging the prostate for secretions and sending a third urine specimen after the secretions. This will help identify where, if any, the infectious source is coming from.

Q. Does the blood test for prostate specific antigen (PSA) help is diagnosing prostatitis?
A. The PSA can be elevated in patients with prostate cancer. Patients with prostatitis may also have elevations in their PSA. If the PSA remains elevated after treatment for prostatitis, a biopsy may be warranted.

Q. What is the best way of treating prostatitis?
A. Recent studies have shown that a prolonged treatment with an antibiotic for about 12 weeks seems to have better results in symptom improvements compared to the four-week standard treatments. If the infection is not completely resolved, other treatments such as regular hot sitz baths and anti-inflammatory agents may be useful. Patients with large prostates may need to have resection (roto-rooter) of the prostate.

Q. What if the symptoms are not relieved by long-term antibiotics?
A. This may by the syndrome of prostatodynia. This syndrome may be related to pelvic floor tension or spasm of the bladder neck and the urethra. These patients may best be treated with an alphablocker, such as Prazosin or Terazosin. In other patients Valium, therapy, or exercise regiments may be helpful.

Q. Does having prostate infections increase my chances of getting prostate cancer?
A. There is no evidence that prostate infections will lead to prostate cancer. However, the American Cancer Society and the American Urological Association recommend that men over 50 have their PSA's checked and prostate examined yearly to catch prostate cancer in it's earlier curable stages.

Hot Flashes in Prostate Cancer Patients
In many patients, prostate cancer is not treated with surgery or radiation for varying reasons. Many of these patients are treated with hormone therapy to help control the spread of the cancer. This is accomplished with the use of injections of medicines which stop the body from producing testosterone, or by removal of the testicles, where most of the testosterone in the body is produced. A large number of patients who have been on hormone therapy for prostate cancer develop hot flashes, which can be very annoying. The patient develops facial flushing, sweating, and in general feels very hot. This is similar to women who undergo menopause after loss of their estrogen and develop these symptoms.

A female hormone, Depo-Provera has been found to be a safe, effective and economical treatment for hot flashes. In a recent study the use of Depo-Provera completely abolished hot flashes in 32 to 36 patients and in three other patients, the severity of the hot flashes as 9 to 10 patients who stopped treatment had no recurrence of hot flashes. Side effects noted were breast pain in two patients, which may have been also been cause by hormone treatment, and one patient developed a worsening of his congestive heart failure. It does not appear to affect the cancer itself and it seems to be safe in that regard. It is theorized that the area in the brain which sends the signal to make male hormone is very close to the area where temperature is regulated in the body. However, when that area is affected by the hormone treatment, the secondary area is also affected. The dosage use is 400mg injected monthly.