Monday, July 7, 2014

Stone Prevention Reminder

With the Summer heat in full effect in middle Tennessee, we have seen an uptick in stones at our practice.  Remember to stay hydrated this Summer as dehydration is the #1 cause of kidney stones.  Some other general pointers include (as written in Urology Times):



Water intake. Such interventions include inexpensive and well-proven treatments as simple as increased water intake to effect up to 2.5 liters of urinary output daily. Although there is much debate about the intake of fluids other than water, it has been demonstrated that higher consumption of sugar-sweetened sodas and punch is associated with an increased risk of kidney stones (Clin J Am Soc Nephrol 2013; 8:1389-95).

Diet. Similarly, lower ingestion of salt, specifically a sodium target of ≤2,000 mg/day, should also be recommended. This may have a dual effect in the management of elevated blood pressure and decreased levels of hypercalciuria.

Exercise.  Incidental stones were reduced up to 31% in patients undergoing moderate to high physical activity (J Am Soc Nephrol 2014; 25: 362–9). Although these results pertain to postmenopausal women specifically, one could extrapolate the same results to premenopausal women or males. 



Water intake. Such interventions include inexpensive and well-proven treatments as simple as increased water intake to effect up to 2.5 liters of urinary output daily. Although there is much debate about the intake of fluids other than water, it has been demonstrated that higher consumption of sugar-sweetened sodas and punch is associated with an increased risk of kidney stones (Clin J Am Soc Nephrol 2013; 8:1389-95). Restriction of such fluids should be highly encouraged in patients with both conditions, as consumption of beverages with higher contents of sugar and fructose also may worsen visceral obesity, fasting glucose, and triglyceride levels (all part of the metabolic syndrome), and higher refined carbohydrate diets have also been associated with increased urinary calcium excretion.
Diet. Similarly, lower ingestion of salt, specifically a sodium target of ≤2,000 mg/day, should also be recommended. This may have a dual effect in the management of elevated blood pressure and decreased levels of hypercalciuria, the latter being the most common abnormal metabolic risk factor encountered in patients with kidney stones. The DASH (Dietary Approaches to Stop Hypertension)-style diet, which is high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein, has been shown to decrease the risk for kidney stones despite the theoretical increase in foods with higher oxalate content (J Am Soc Nephrol 2009; 20:2253–9). The DASH diet has also been shown to lower blood pressure.
Exercise. One overlooked aspect of counseling in patients with both conditions is exercise. Although scarce data is available to show the beneficial effects of regular exercise in patients with kidney stones, recent data from a large, prospective, longitudinal multicenter study in postmenopausal women help confirm these beneficial effects. Incident stones were reduced up to 31% in patients undergoing moderate to high physical activity (J Am Soc Nephrol 2014; 25: 362–9). Although these results pertain to postmenopausal women specifically, one could extrapolate the same results to premenopausal women or males. Even if this is not a currently proven fact, the effects in all other aspects of the metabolic syndrome should be good enough to reinforce this intervention to all patients.
When a metabolic evaluation is performed, it is reasonable to ask whether a patient with metabolic syndrome will comply with dietary recommendations. Our group recently evaluated this question in a study of 214 patients, 29% of whom were obese and 12% of whom were morbidly obese. At a mean follow-up of 10 months, obese stone formers were as successful as those with normal body mass index at improving their diet to optimize their urinary risks (figure), and these changes also led to a decrease in BMI in those who were obese (J Endourol 2014; 28:248-51).
- See more at: http://urologytimes.modernmedicine.com/urology-times/news/how-prevent-stone-formation-patients-metabolic-syndrome?page=0,1#sthash.Xsn5CKaG.dpuf
Water intake. Such interventions include inexpensive and well-proven treatments as simple as increased water intake to effect up to 2.5 liters of urinary output daily. Although there is much debate about the intake of fluids other than water, it has been demonstrated that higher consumption of sugar-sweetened sodas and punch is associated with an increased risk of kidney stones (Clin J Am Soc Nephrol 2013; 8:1389-95). Restriction of such fluids should be highly encouraged in patients with both conditions, as consumption of beverages with higher contents of sugar and fructose also may worsen visceral obesity, fasting glucose, and triglyceride levels (all part of the metabolic syndrome), and higher refined carbohydrate diets have also been associated with increased urinary calcium excretion.
Diet. Similarly, lower ingestion of salt, specifically a sodium target of ≤2,000 mg/day, should also be recommended. This may have a dual effect in the management of elevated blood pressure and decreased levels of hypercalciuria, the latter being the most common abnormal metabolic risk factor encountered in patients with kidney stones. The DASH (Dietary Approaches to Stop Hypertension)-style diet, which is high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein, has been shown to decrease the risk for kidney stones despite the theoretical increase in foods with higher oxalate content (J Am Soc Nephrol 2009; 20:2253–9). The DASH diet has also been shown to lower blood pressure.
Exercise. One overlooked aspect of counseling in patients with both conditions is exercise. Although scarce data is available to show the beneficial effects of regular exercise in patients with kidney stones, recent data from a large, prospective, longitudinal multicenter study in postmenopausal women help confirm these beneficial effects. Incident stones were reduced up to 31% in patients undergoing moderate to high physical activity (J Am Soc Nephrol 2014; 25: 362–9). Although these results pertain to postmenopausal women specifically, one could extrapolate the same results to premenopausal women or males. Even if this is not a currently proven fact, the effects in all other aspects of the metabolic syndrome should be good enough to reinforce this intervention to all patients.
When a metabolic evaluation is performed, it is reasonable to ask whether a patient with metabolic syndrome will comply with dietary recommendations. Our group recently evaluated this question in a study of 214 patients, 29% of whom were obese and 12% of whom were morbidly obese. At a mean follow-up of 10 months, obese stone formers were as successful as those with normal body mass index at improving their diet to optimize their urinary risks (figure), and these changes also led to a decrease in BMI in those who were obese (J Endourol 2014; 28:248-51).
- See more at: http://urologytimes.modernmedicine.com/urology-times/news/how-prevent-stone-formation-patients-metabolic-syndrome?page=0,1#sthash.Xsn5CKaG.dpuf

Tuesday, July 1, 2014

Lipscomb University Visits St. Thomas West

This past week St. Thomas had the honor of hosting the Lipscomb University Advanced Robotics Camp.  This wonderful camp, lead by Dr. Greg Nordstrom, focuses to expose students to the wonders of science and engineering.  We were please to be part of this program to show how, through technology developed by like-minded individuals, patients' lives can be changed.

I would like to thank all members of the St. Thomas Robotics Institute and Intuitive surgical for their involvement in this program, and to the Lipscomb University staff and students for their interest.  We look forward to future partnerships.





 

Monday, March 3, 2014

SELECT Study and Prostate Cancer

In 2001 the Selenium and Vitamin E Cancer Prevention Trial (SELECT) was initiated to determine if selenium or vitamin E would decrease the risk of prostate cancer.  In 2008, the study was stopped early (planned to cease in 2012) because the results demonstrated that there was no protective effect from selenium and suggested that vitamin E increased prostate cancer risk by 17%.

Vitamin E, found in vegetables, nuts, and eggs acts as an antioxidant.  Selenium does the same and is found in meat.  These are thought to prevent the effects of oxidation on fat cells, which are thought to increase mutations that can become malignant.

Currently, the evidence from the trial suggests the idea that the risk of prostate cancer may be increase by these supplements.  Currently, as published in the Journal of the National Cancer Institute, these supplements not only appear not provide protection, but may possibly increase the risks of prostate cancer.

In reality, patients looking to prevent prostate cancer should not start these medications, and then confer with their physicians prior to attempting any new dietary changes. 

"Men using these supplements should stop, period. Neither selenium nor vitamin E supplementation confer any known [health] benefits — only risks," said lead author Alan Kristal, DrPH, from the Fred Hutchinson Cancer Research Center in Seattle, in a press statement.

Tuesday, November 26, 2013

Shockwave Therapy for Erectile Dysfunction

In my practice I see both a high number of patients suffering from kidney stones and from erectile dysfunction.  Shockwave therapy, or ESWL, is a therapeutic method of fragmenting renal stones using ultrasound to initiate stone passage with decreased pain.

In a new study, a similar method of treating erectile dysfunction has been proposed.  ESWL has been shown to induce blood vessel formation and increased flow post-therapy.  In theory, using the same therapy to induce improved blood flow to the penis may correct erectile dysfunction.

While only a novel study at this time, over a several week course that involved two treatments per week, 15 men showed improved erectile function.  These participants were selected as they had cardiac-disease induced erectile dysfunction (ie. not related to surgery, etc.).  The same patients responded to the oral therapies currently on market for erectile dysfunction.

At 1 month of follow up the same men not only noted improved erectile function, but also no longer required the same medications for intercourse.  Furthermore, in 10 of the men, this effect was sustained for a year.

I find this therapy to be quite interesting, and should this hold up in further research, may be a groundbreaking improvement in treatment of this disease. 

Saturday, November 16, 2013

Stephen Colbert Prostate Exam

In honor of Movember and prostate cancer awareness, Stephen Colbert performed an on-air prostate exam.  Nashville band The Black Keys joined Stephen, John Lithgow, and Katie Couric during his exam last week.  Check out the link below for the video.

Stephen Colbert Prostate Exam

Wednesday, October 30, 2013

Chronic Testicle Pain

Orchialgia, commonly known as testicular pain, is a frustrating condition for both patients and urologists.  Present in all age groups, this condition can be quite limiting and can lower one's quality of life.

Common causes of this discomfort including recurrent urinary tract infections, epididymitis, and varicoceles. 

An initial evaluation should include a urine culture and a scrotal ultrasound to rule out other pathology.  In an infection is present, several weeks of antibiotics may be required to penetrate the tissue of the epididymis to cure infection.  Further therapy via conservative methods with sitz baths, scrotal support,  and nonsteroidal anti-inflammatory agents (ibuprofen, Aleve) are typically employed with success.

With post-vasectomy pain, orchialgia can be common.  This occurs in approximately 1 in 1000 men and is linked to pressure build up in the epididymis as sperm continues to be produced.  This pain can be dull with exacerbation from ejaculation.  The first treat should be the above conservative measures for 3 months.  Should these fail, vasectomy reversal or removal of the epididymis (epididymectomy) are considerations.

In men with pain post-hernia, the treatment can be more difficult.  Many times the ileoinguinal nerve will be entrapped post-hernia repair.  In this condition, conservative methods will allow for resolution.  If not, exploration and removal of any material may offer relief.

Finally, the most frustrating orchialgia is that of unknown etiology.  Without a specific cause, treatment can be quite difficult.  Again, conservative measures should be introduced for 3 months.  At the same time, consideration of alternative sources of discomfort (irritable bowel, ureteral stones, etc.) should be explored.  In these conditions, I have found success with addition of pelvic muscle physical therapy.  Finally, should all other measures fail, use of nerve blocks and microsurgical denervation of the genitofemoral nerve is considered.