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Prakash Chandran (Host): As men grow older, some start to experience low testosterone, as well as getting up more often in the middle of the night to urinate our urologist, Dr. and Dr. Saba wall. We'll discuss some causes and treatment for these issues and encouragement to talk to their doctor and not accept them as just a part of getting older.

This is AMITA HealthCast, the podcast from AMITA Health. I'm your host Prakash Chandran. So, Dr. Boniquit and Dr. Sabharwal, thank you so much for joining us today. We really appreciate your time. Let's first talk about low testosterone. Dr. Boniquit, what exactly is low T or low testosterone? And how prevalent is it?

Christopher Boniquit, MD (Guest): So, low T which T stands for testosterone, is something that we see in actually many men these days that, sorry, the man's hormone production, which is testosterone over time, can diminish. Now, there are different reasons for that, but as a result, it can cause different symptoms, which of course can affect a man's sexual function or daily activities. In terms of prevalence, it's quite common, I believe. We see quite a few men in our clinic with these issues. But because of how popular low T is currently, some tests do need to be done to actually prove that's the case.

Host: And Dr. Boniquit, just wanted to ask a clarification. What is considered a low testosterone level?

Dr. Boniquit: So, low testosterone levels vary on a man's age. Unfortunately in many men who have had these tests done, can attest, the range of quote unquote normal can go from anywhere from 200 to a thousand. The reason that this has done is that as young as 18 and men, as old, as you know, in their 90s, kind of are lumped in the same group.

So, a level that may cause a man who is 30 to be symptomatic, may be different than a man who's 70. In our practice, we like to use 300 as, or I prefer to use a 300 as a cutoff. So, if your level is below 300 and you're having symptoms of low testosterone, then that's something that we can evaluate.

Host: So, Dr. Sabharwal, I'd like to ask you a question. What exactly causes testosterone levels to drop in the first place?

Vibha Sabharwal, MD (Guest): There's two really main types of hypogonadism, which is low testosterone. One is found like in younger men and they have if it's before puberty, they actually have signs of, you know, smaller testicles and don't manifest all the features of, you know, body hair, et cetera, that male pattern body hair, et cetera.

That's a different problem. And that has to be treated differently. But the more common one that we see is in you know, middle-aged men and older men where the decline occurs gradually. In a large number of elderly men, there is a normal decline in testosterone with age, just like in women, when they go through menopause, there's going to be a decline in estrogen. We don't necessarily focus on treating the normal decline in testosterone, which occurs in most men as they age. You would look for specific symptoms. If a man presents with symptoms of decreased libido, they're not having the early morning erections that they used to have, decreased energy. Those are more symptoms associated with low testosterone. Decreased muscle mass as well as hot flashes, but other features, the men sometimes come complaining of such as erectile dysfunction or mood swings, depression. Those don't necessarily relate to just low testosterone. There's a variety of diseases that can cause those symptoms. So, we need to evaluate the patient specifically for low testosterone, if they manifest the specific symptoms.

Host: Okay, that makes sense. Dr. Boniquit are there natural ways to boost one's testosterone?

Dr. Boniquit: Yeah. You know, men ask us all the time, what they can do to help themselves. Usually it's a healthy lifestyle that can kind of help supplement your own testosterone production. So, by that, I mean, you know, you want to increase your cardiovascular workouts, your exercise levels, get good sleep, eat well, plenty of water.

We always say, what's, you know, what's good for the heart is good for kind of all other systems in the body. And so those kinds of things, and we've had young men who of course are maybe borderline low, but are not interested in any kind of medical treatment. These are things that they focus on especially when the weather is nice, springtime, summertime.

A lot of the symptoms that they may have had per se going into the fall months or the winter months seem to improve. So, you know, to a point you can boost your own levels. If you're very low, however, the likelihood is that it won't increase it significantly. But we do see some improvement in with men's just improving their overall lifestyle.

Host: So, Dr. Sabharwal, I've actually seen a lot of over the counter testosterone boosters and supplements when I'm out shopping. Are these safe to use?

Dr. Sabharwal: We really don't know what's in, what the content of those over the counter herbals is. And they're not FDA regulated. So, normally I would say there's a pretty good chance either A, you're wasting your money because it's not going to work or B, you're taking something you probably shouldn't.

One of the issues is oral testosterone, you know. Up until now, until recently a new medication that bypasses liver metabolism became available, oral testosterone was actually dangerous because it's metabolized in the liver and can cause cancer. So, no, I wouldn't recommend over the counter testosterone supplements.

Host: So, Dr. Boniquit, one of the things that you alluded to earlier was that healthy lifestyle, right? And so let's say I'm doing everything right, and I'm still getting low testosterone results during my annual physical. Since these over the counter supplements aren't necessarily safe to use, or we just don't know enough about them, what exactly are my treatment options?

Dr. Boniquit: So, based on our testing, if you are truly hypogonadic and you have symptoms that are consistent with having low T, there are different options that we can provide. Now, one of the questions I usually ask just to touch base or return on the boosters and supplements is some men have taken either steroids or some sort of testosterone derivative in the past, whether it was for, you know, whether it was athletes in their past, who are trying to maintain for their sport.

But what ended up happening is external testosterone use can actually decrease a man's natural production. So, if the testing does prove that somebody is hypogonadic and the symptoms are consistent, testosterone replacement therapy is something we can discuss. Now replacement can be done in different ways. Dr. Sabharwal alluded to one, which is an oral option, which is new. Topical testosterone has been used in the form of gels. Injectable testosterone has also been used and the dosing is, is it varies depending on the the option that you choose. There's also a implantable pellets that could be used, which is a slower release form. But the goal is to increase one's levels through the replacement and see if the clinical symptoms improve.

Host: So, Dr. Sabharwal, at this point in the conversation, I wanted to move on to talking about prostates and enlarged prostates. If someone is having symptoms where they're waking up every night and urinating frequently, is that normal?

Dr. Sabharwal: So, the question comes down to whether. So, the first thing you ask them is how much does this bother you? Because some people don't sleep. They have other reasons for why they wake up at night. They have, 30% of people wake up at night because they have sleep apnea. And they end up, you know, obstructing their airway, wake up. And then the first thing you think of when you wake up is, oh, I got to go pee. So, you really need to figure out why they're getting up. If they truly have to go urinate, if they got up for other reasons, you need to figure out if they're producing more urine at night versus during the daytime, you need to find out if they have leg swelling, how their stream is during the day and nighttime, if they have a difficult time initiating the stream, whether they have a sensation of empty and completely, all those questions come into play.

And you also want to know if they're diabetic, if their sugars are well controlled, because diabetics will wake up very frequently to urinate at night as well, if they're poorly controlled,

Host: So, Dr. Sabharwal, just expanding on that a little bit. If it does end up disturbing a patient to where they're not comfortable with the amount of times that they're urinating during the evening, how can they stop it?

Dr. Sabharwal: Well, there's a multitude of treatments, but the treatments depend on figuring out what the cause is first. So, when the patient is seen for this problem, you know, sometimes we ask them to keep a voiding diary. Sometimes it's based on the questions we ask them about their stream and how, you know, how long it takes to empty out.

How, you know, do they have dribbling afterwards. Do they have the sensation of incomplete emptying. We'll check a bladder scan, which tells us how much urine is in the bladder after urination. Normally, you know, we should be able to empty out maybe at the most have 10 or 15 cc's left over, but if it's due to a blockage, due to BPH, enlarged prostate, they may have more than that.

So, you have to look at all the signs that the patient presents to you and then decide what the treatment would be. What type of medication or behavioral modification, you know, cutting off your fluids four hours before bedtime. If they have a lot of leg swelling, you want them to do something to control the leg swelling. It might be due to eating too much salt or cardiac problems. They may need to wear compression stockings, et cetera.

Host: So, Dr. Boniquit, Dr. Sabharwal touched on this briefly, but I'm curious as to your opinion on when it's actually worth seeing a doctor about frequent urination.

Dr. Boniquit: You know, I would recommend if it's becoming so bothersome that you really don't have any solutions that you can think of at home to help, then come see us. Again, the workup can be fairly extensive and you know, the first thing we tell our folks is if you are taking in a lot of fluid in the evenings, you want to try to limit that. You know, if your sugars are uncontrolled, you want to control that. The, you know, patients on their own can try a few things. However, you know, determining what the cause is important, because if you're not really sure of why you're getting up so many times at night, it's very difficult for a patient on their own to try to improve that.

Host: So, one of the things I would love for each of you to comment on is the fact that sometimes it takes a while for men to actually get these issues addressed. So, what in your experience usually keeps guys from getting treatment and Dr. Sabharwal will start you.

Dr. Sabharwal: They think it's a normal part of aging. They're embarrassed to talk about it. A lot of times it's their wife, that'll say, yeah, he's in the bathroom for a real long time when he goes, which gives you kind of an indication. And sometimes you just get used to it. Cause it's develops very, enlarged prostate symptoms can sometimes develop very insidiously where they come on gradually and you get so used to it that you don't notice. And sometimes we'll see people that come in that can't pee and they were, you know, in their mind they were urinating last week. I'm not peeing today, but it was something that developed gradually that they just chose not to acknowledge to themselves.

Host: Dr. Boniquit have anything to add to that?

Dr. Boniquit: Yeah, I would agree. I think a lot of men feel that it's normal with age. When in fact it doesn't necessarily have to do that much with age. You know, as men age, the prostate does tend to grow, albeit a slow process but you know, they feel like it's really not, not that different from their fathers, or not that different from their brothers.

The bother tends to kind of either have the patient mention something to their primary care physician and the primary care physician will start to initiate the conversation, then patients come see us. Sometimes it's just it's your urine. Some men just don't want to talk about their urine. They think it's not something that needs to be discussed. But, but yeah, it's a lot of different reasons that men decide not to. They want to ignore it or, you know, a lot of the worry sometimes is that okay, maybe, you know, prostate cancer is something that's fairly prevalent as well.

And if somebody has prostate cancer in the family per se, that may be something that's hindering an evaluation or the other way around. They may want to be evaluated because they know someone has had prostate cancer.

Host: So, Dr. Sabharwal, what exactly are the most effective ways to treat an enlarged prostate?

Dr. Sabharwal: Normally you would start out with medication because that's the least invasive method. And there's a first line medication and then a second line. And the first line is designed to relax the bladder neck so that when the person goes to urinate, the urine comes out easier. There are several different brands of that. If they've been on that for a while or can't tolerate it, the second line medication is designed to shrink the prostate. The patient is on it for up to six months, it can shrink the prostate by 25%. Let's say the person has been on both medications for a while and they're not working or the patient's still getting up a lot at night or they're retaining to much urine after voiding, then we would talk to them about either an office procedure to help open up their channel. That can act as a stepping stone before surgery or in lieu of surgery, or maybe sometimes people don't want to be on medication. If the office procedure is not an option or the patient has it and they fail, the next step is surgery. Surgery can entail a variety of options. The newest one is called aquablation. The goal of all the surgeries is to basically core out the inside of the prostate, kind of like a rotor rooter as we often call it. And you can scrape it out. You can take a laser to remove the inside, but the latest method is called aquablation and that's where we use high pressure water vapor and a robot to map out the prostate and ablate the tissue.

Host: So, the final question I'd love to end with is just talking about the fact that you both have a lot of experience as Urologists working with many male patients. What is one thing that, you know, to be true that you wish more men knew before they came to see you and Dr. Boniquit, let's go ahead and start with you.

Dr. Boniquit: Yeah. You know, I just I wish patients know and a lot may not, what we as Urologists can offer. Again, a lot of times if you're not very experienced with seeing physicians, you may not know that there are folks like us who can help whether it is for your enlarged prostate or stones, or low testosterone, erectile dysfunction.

You know, we cover a lot of different issues, both for men and women. Just to touch on other things, we deal with cancers, whether it's prostate cancer, bladder cancer, kidney cancers, whether it's folks who get recurrent urinary tract infections. If there are issues, whether it's incontinence, both men and women, whether it's stones, like I said, which is other common scenario. You know, we do cover a lot of various things that, you know, kind of solely focused on the urinary tract.

You know, don't be shy to ask for a urologist from your primary care physician. Because there may be something that we can do to help. But again, a lot of folks don't know what we do, what we can offer. We, you know, talk to your primary care physician. They can help as well in terms of answering some of those questions.

Host: Yeah. Great answer Dr. Sabharwal, what about you? Anything you would like to say just around that question?

Dr. Sabharwal: I think a lot of people don't come in to be seen for certain problems, such as incontinence or BPH or low testosterone, or even erectile dysfunction, because either they're embarrassed and don't want to talk to anyone about it, or they think it's a normal part of aging. And they think that there's no treatment available for it. Or it's just something you have to deal with. And I think I wish patients would realize that obviously they're not alone. That's why we have jobs, you know, because we take care of these problems and that's what we're here for. So, if there's something that really bothers you, don't be embarrassed to come in and talk about it because that's what we do.

Host: Well, I think that's the perfect place to end. Thank you both so much for your time today.

Dr. Sabharwal: Thank you.

Dr. Boniquit: Appreciate Appreciate it.

Host: That was Dr. Christopher Boniquit and Dr. Vibha Sabharwal, Urologists for AMITA Health. Thanks for listening to AMITA HealthCast, the podcast from AMITA Health. For more information, you can visit amitahealth.org. Click on find a service at the top of the page and select the letter U to find urology. I'm Prakash Chandran and thank you so much for listening.