Joey Wahler (Host): It's a key part of a man's health journey, so we're discussing enlarged prostate and prostate cancer. Our guest is Dr. Matthew Karlovsky, a urologist and urogynecologist, as well as Chair of the Surgery Department at Wickenburg Community Hospital and Clinics.

This is WickCare Talks, the podcast from Wickenburg Community Hospitals and Clinics dedicated to helping our community lead healthier, more active lives. In each episode, we connect you with trusted health experts, sharing valuable insights on a wide range of topics, from managing chronic conditions to simple tips for everyday wellness. We're here to provide practical information to support you on your health journey. So, be sure to follow us so you never miss an episode. Thanks for joining us this time. I'm Joey Wahler. Hi, Doctor. Welcome.

Matthew E. Karlovsky, MD, FACS: Hi. Thank you. Good morning.

Host: Good morning. So first, what is an enlarged prostate? Many of us have heard the term, of course. What does it mean when a prostate is enlarged and how does that differ from, God forbid, prostate cancer?

Matthew E. Karlovsky, MD, FACS: Sure. An enlarged prostate certainly is very different from prostate cancer. Now, occasionally, the signs or symptoms of them can cross over or mimic each other. And so, that's why seeing a urologist to figure out the difference between the two is important.

But an enlarged prostate is something which naturally occurs with time as men get older. The prostate sits right in front of the bladder and it acts like a little tunnel or channel through which the urine has to exit through to get out. And it produces some of the fluid in semen or the ejaculate. So, it has a purpose. It's not just there to annoy men as they get older.

But as the prostate grows, as it gets older, it can act a little bit like a vice and squeeze around the channel. That's the easiest way to describe it. And the bladder is going to do its best to try to do its job, which is to get the urine to push through. So if the prostate is acting in an obstructive way or it's squeezing on the channel, the bladder can respond by trying to work harder to get the flow to come through. So, the signs sometimes of enlarged prostate is frequency of urination. The bladder wants to do its job. Urgency, it's getting filled, but it feels like it may not be able to empty. And sometimes the stream is weak because the channel is more narrow, or the channel is getting to a point where it's very narrow, you feel that you can't empty. And men can have a combination of these types of different urinary symptoms or getting up at night.

So, an enlarged prostate is just a growing prostate. Now, a lot of times it can grow and you get to 60, 70, 80 and it doesn't really bother you that much. Well, even if you have an "enlarged prostate," it doesn't necessarily mean you have a condition or something which has to be treated.

So by saying enlarged prostate, it confers an idea that something is happening, but not all the time is it bothersome, not all the time is it significant. And maybe your enlarged prostate symptoms of urgency, frequency is maybe you're drinking too much coffee. And so, to make sure that somebody actually has a diagnosis of an enlarged prostate, what do we need to do? We need to look at their medical history. What medications are they taking? Do they have diabetes? Are they overweight? Are there other things which can cause the bladder to misbehave? It's not really the bladder's fault, it's just responding to a prostate, which is growing over time.

Conversely, on occasion, prostate cancer can cause urinary trouble. Most times prostate cancer is silent. And we pick it up with a blood test and the physical exam, PSA test and doing a prostate exam. But on occasion, prostate cancer can grow and cause urinary trouble, and we don't want to be too dismissive of urinary problems and call it enlarged prostate. Because when you go to the urologist, it's very easy to determine and distinguish between the two by doing an exam, checking the PSA, doing an ultrasound of the bladder and the prostate. And that way, we can discern between something which is more of a nuisance or benign medical problem, which is enlarged prostate versus prostate cancer, which usually-- but not all the time-- but usually is something significant.

Host: Having said that, how can someone typically distinguish between normal aging prostate symptoms, which you've described-- frequency, weak stream, et cetera-- and signs that they should see a doctor. Where's the line between what we might be able to live with and when it needs to be checked out?

Matthew E. Karlovsky, MD, FACS: Sure. Most people will come to the conclusion that if they drink wine or if they have a beer in the evening, or they have a nightcap, or if they're drinking a lot of coffee or they're eating a lot of spicy foods, they'll notice that they have to get up at night to urinate more frequently because they're drinking closer to bedtime and alcohol or caffeine can promote urinary production and irritation of the bladder. So, they'll say, "Oh, maybe I'll stop drinking at six or seven o'clock in the evening." And if you go to bed at three or four hours later, they notice they can impact their nighttime bladder habits. And if they feel that that is improvement for them, no reason to come to the doctor. They've kind of taken care of it themselves.

Same thing with spicy foods. People notice, "Oh, I can't have hot sauce any longer," or onions or something that's bothering them, hot pepper, chili pepper, and they stop eating that. Oh, now the bladder is not as crazy. Maybe it's not an enlarged prostate, maybe it's not overactive bladder. And so, they take care of it on their own.

If they feel like they're doing a lot of diet adjustment, fluid management, and they're still not getting anywhere and it's becoming frustrating or what I like to call the trigger word-- it's bothering them or bothersome, then you come into the urologist. We ask you your five to ten questions. We do an exam, bladder ultrasound, PSA test, and we figure it out. What is going on here? Is it prostate issues? Is it general medical health issues? Or is it infection or is it even prostate cancer in the background? So, urology visits are not that complicated in terms of the workup and trying to figure it out.

Host: Speaking of which, when you talk about a urology visit and a workup, what are the most effective ways that you use to diagnose either an enlarged prostate or possibly prostate cancer? And how accurate are they? Because it's really a multi-pronged approach that you can use, right?

Matthew E. Karlovsky, MD, FACS: Right. Well, I'll say this, a lot of people are nervous or they're scared to come to urologist. Uh-oh, they're going to get the one-finger treatment with the glove. But at the end of the day, even if a prostate exam takes two or three seconds, the things that we do in the office usually will answer 99% of the questions, what are they? Asking questions, getting answers about your habits, what's going on with your prostate, your bladder, your family history, looking at your medication, prior surgeries, right? Looking at your blood work.

Number two is doing an exam, a groin exam, checking for hernias, doing a prostate exam. Number three, a PSA blood test, and looking at other blood tests. Again, looking at your general health. Is it cholesterol? Any issues, is it a contributing heart disease? Do we have thyroid problems causing health changes, which can contribute to over or underactive bladder?

And then, finally, you can do a urinalysis in the office. Is there blood in the urine? Do you have infection? You want to make sure that that's okay. Doing a ultrasound of your bladder and prostate, totally noninvasive. It takes just a couple minutes. We can measure the size of the prostate. We can measure how well your bladder is emptying. And if all that kind of fits into a sequence of answers, which can help a patient improve their prostate or bladder health, then great, you don't really need to go further than that. There are herbals. There are medications. And there are other tests which can be done if there's really a concern about prostate cancer.

And then, there are other tests that you can do if your prostate enlargement, urinary symptoms are getting too significant and too bothersome, and then what to do about that. Usually, we start with herbs and medications. And then, if it gets beyond that, then there's other tests to do to figure out what can you do next.

So, there's an entire panoply of things which can be done. However, we do them in an orderly fashion, and it's very logical. And we don't try to jump too many spots at once. Most people want to do the non or lesser invasive things first. That's what's reasonable. That's what makes sense to people.

Host: Talk to us, please, about how crucial regular screenings can be in making the difference to determine prostate issues early and what age does that start. Because the age has changed recently, right?

Matthew E. Karlovsky, MD, FACS: Right. Most prostate cancer screenings really initially are done by the primary care doctor. They do all the blood work, they do a PSA. Most primary care doctors will order a PSA, some don't. So if you're not sure, you should ask, because there is this older notion that doing a PSA test to screen for prostate cancer is useless. It doesn't amount to much. It's overscreening, it's overtreatment.

Over the arc of 35 to 40 years, we see that checking your PSA does reduce the death from prostate cancer. It takes a while to achieve that conclusion because it does take prostate cancer so long to develop. And even once somebody has it, it's not extremely lethal in that moment of time. By example, lung cancer, very lethal, not a lot of options. Prostate cancer can be lethal, but because it does grow slowly and there are types of cancer which are lower grade, you may not die of prostate cancer for a decade or so. And so, to prove that the PSA test is actually worthy and useful, it has taken decades to show that. But always be careful to screen, you throw it in with the rest of the blood work.

And the most important thing to know about screening for prostate cancer with the PSA test is the trend of the PSA over time. If the PSA was 1, and then now it's three, that may still fit into the normal bracket on the lab paper, the lab result. But for you, that may not be normal because that trend is too high. So, regular screening for men who don't have any risk factors, 50, if somebody is a black race or they have family history of prostate cancer, they need to start even as early as 40 years old, and that also includes a prostate exam. Most primary care doctors don't do prostate exams anymore. If they feel there's a concern about the PSA, they'll send you to the urologist, and the urologist should do the prostate exam. Now, you don't have to have a prostate exam each and every visit. You should have one at the beginning. And then, if the PSA changes, you should have one too, because what does that PSA change represent? Something benign or something that needs to be paid attention to. So, set the fear aside. "I'm getting a prostate exam." It only takes a couple seconds and get your PSA done. And usually, most of the questions can be answered.

Host: So, can you describe for us, please, the latest treatment options, first, for an enlarged prostate?

Matthew E. Karlovsky, MD, FACS: Okay. So, treatment options, let's say you've already done lifestyle modification. You're controlling your diabetes, you're controlling your blood pressure, it has nothing to do with that or the medication you're taking. Let's say you've eliminated all of that. Some people will try herbals. It's very common to try saw palmetto. I'm not endorsing any one type of herbal right now. But there's a lot of herbals out there. Pumpkin seed, there's African plum. There's all kinds of things and remedies that you can pick up. And there's really very little harm to trying that for a month or two, a couple times a day, and see if that impacts your urination.

All things being equal, you've moderated your coffee, you've moderated your lifestyle, and all of that, most enlarged prostate symptoms when you get to a certain point and all of that doesn't help, you try medication. Everybody knows the drug tamsulosin and there are a lot of other medications like that, and that helps to open the prostate and improve urination significantly. It doesn't change how the prostate develops and grows over time. There are other medications, which do shrink the prostate.

But let's say even you've maxed out on medications and even the medications don't help you any longer, there are a lot of very minimally invasive, non-Roto-Rooter surgeries, which can help the prostate. I'll Just mention a few in no particular order, and I'm not endorsing one over the other. A very common one that's seen on commercials is called UroLift. It's essentially done through a scope. And in layman's terms, it's essentially pushing out the prostate tissue with little staples or little sutures. You're not cutting or burning anything. And many people find that that's useful. It can be done in an office setting or in a surgery center.

There's another one called Rezūm, where you inject steam into the prostate. And it actually bends the arc of the prostate growth. It actually causes the prostate to shrink. And a lot of people like these two types of procedures in lieu of doing a TURP, transurethral resection of the prostate, which is the classic Roto-Rooter surgery, which shaves out-- you can think of coring out an apple, opens up the channel to pee better. So, Eurolift opens the channel. Rezūm opens a channel.

There are types of tubular metal stents. I don't love those personally only because they may have trouble removing them. There are different iterations of them. There are things you can see on Instagram. I wouldn't highly recommend somebody promoting something on Instagram. But there's even something non-surgical called prostate artery embolization where the blood flow to the prostate is reduced. And by doing that, you get the prostate to shrink, and sometimes it could be very dramatic shrinkage by 50% or more. And that's without having to do anything with a scope or through the penis. There's a very new popular technique called Aquablation where you're basically injecting hot water, making a little water explosion kind of inside the prostate. It's managed and done through ultrasound guidance. But that's kind of like a TURP in a way, and sometimes you have to cauterize afterwards.

There's also laser. A lot of people are familiar with something called GreenLight laser. There's also something called Holmium laser where you can use the laser to kind of core out some of the tissue. There's so many things that can be done for an enlarged prostate. It is always worthy to read up on it on the patient side. Go on the internet, go on Google, go on chat, go on AI, and read about the differences. Because then when you come in, then you can ask more pointed questions to the urologist. And then, you'll find out from the urologist what in their hands works the best. If the urologist says, "Hey, I've done a thousand GreenLights," or "I've done a thousand TURPs," or "I've done a thousand Rezūms" or a thousand UroLifts," then you know that that is going to be usually a good quality procedure. Or you ask the urologist what they think their opinion is based on the differences that they've seen.

And I've done most of these procedures myself, and I can give you my personal opinion in an appointment, but it also depends on what the patient's goal is. How big is the prostate? How bad are their symptoms? So, sometimes a laser is not good for a person, because their prostate may be too big or maybe for UroLift, the prostate's too big and you can't do that. So, you have to tailor the procedure to the patient. And so, that's the job of the urologist.

And also, it's not an emergency. This is not something that has to be decided overnight. Go home and think about what you want, and you come back. And maybe surgery is not for you and you can continue medication. So, there's a lot of different options a patient can exercise, and most of it is non-emergency. You should not be pressured into doing something that you may think, "Oh, I don't know if I want to do that necessarily."

Host: And then, how about the latest in treating prostate cancer?

Matthew E. Karlovsky, MD, FACS: Sure. There's a lot of treatments emerging for prostate cancer. There's the classic treatments that most people know about, which is surgery. The standard of care these days for surgery is to do robotic surgery. Most urologists are trained in robotic surgery. If you're older, you may not be trained in robotic surgery. I was trained in the era before robotics came around. And there's also classic radiation. There's a lot of ways to administer radiation. External beam radiation, there's radioactive seeds, there's different ways to give external beam radiation, different styles. The number of treatments that you can give for radiation varies.

And then, based on the grade or how aggressive your prostate cancer is, you may need hormone treatment before you do radiation. In fact, if your prostate cancer is very aggressive, maybe surgery is not for you, maybe you do radiation instead. At the time of diagnosis of prostate cancer, you have to determine: is it local to the prostate, which could be amenable to surgery or radiation, or is it already outside the prostate? Or then, it wouldn't make sense to do surgery necessarily because why would you take out your prostate if your cancer, for example, potentially is in your bones or your lymph nodes. It doesn't necessarily gain you anything by doing surgery. Then, you do radiation or other treatments.

A lot of the emerging technology in prostate cancer now is doing focal treatment or non-surgical treatment. Again, I'm not promoting anything, but there's something called a HIFU, high-intensity focused ultrasound, ultrasound waves that kill prostate tissue. There's cryoablation where you can freeze the prostate. There's focal ablation where if the urologist knows exactly where in your prostate the cancer is, then you can burn or freeze just that portion.

There's even something called TULSA, which is magnetic-- you can call it magnetic heat of the prostate. They do with MRI guidance through a catheter. There's also so many types of emerging non-surgical procedure technologies for prostate cancer. And then, let's say unfortunately, maybe a person is diagnosed with later stage prostate cancer. There are next generation medications which can treat prostate cancer: hormone reduction medications, not just shots. But now, there are different pills, which have less effect on your bones, less metabolic problems, less risk of diabetes. There's numerous combinations of these medications, which are available.

And so, it's an ever-evolving specialty, which is very exciting. There's a lot of new technology. Unfortunately, prostate cancer is very common. But at the same time, it can be very commonly treated and very commonly cured. And in order to cure, like with most cancers, screening and catching it early is your best chance for catching it, and then being able to cure it if it is considered high grade or lethal or aggressive.

Host: Well, folks, we trust you are now more familiar with enlarged prostate and prostate cancer. Dr. Karlovsky, valuable information indeed. Thanks so much again.

Matthew E. Karlovsky, MD, FACS: Thank you so much. My pleasure.

Host: Same here. And for more information, please do visit wickhosp, W-I-C-K-H-O-S-P.com/wickcaretalks. We hope today's discussion is provided you with valuable insights to support your wellbeing. Remember, every step you take is a step toward a healthier life. To ensure you don't miss future episodes, please follow us on your favorite podcast platform and connect with us on social media. We appreciate you being part of our community. And thanks so much again for being part of WickCare Talks. Until next time, stay well.