Ask The Urologist Anything (Dr Michael Rotman)

[jfullam]

Dr. Rotman,
I have a question about Prostate and urine flow.

Some background: I am 51 years old, I have been on TRT for the last 18 months or so. I was lucky enough to get dialed in very quickly under Defy Medical, my current protocol is 120mg/week Test Cyp (60mg Sun/Wed subq). Also HCG, 250 iu 3x per week (Tues/Thurs/Sat, also subq). I feel fantastic. Been maintaining around 776 total and 20.3 free. E2 is a bit high at 52.2 but Doc is not worried as I am not showing any symptoms. My PSA has been consistently good, with last result 2.1 ng/mL.

Over the last 5 years, I have been increasingly getting up nightly (now at least 2x per night) to urinate and my flow is noticeably restricted. My annual physical exams, my doc did the typical rectal exam and has never been concerned with the size or feel of my prostate. He most recently tried a new test, a Bladderscan, and 2 tests done in Sept and Dec show urine volume at 231ml and 193ml respectively. My primary doc put me on Flomax and after taking it daily for 5+ weeks, I felt zero improvement in flow or nightly urination. My doc then decided to double my dosage (1 pill in morning and and 1 pill at night), but that dosage quickly made me light headed (I have fairly low blood pressure generally) so we stopped the Flomax. Now I am scheduled to see a urologist to discuss 2 possible options: an alternate drug to Flomax (which I am told is a Testosterone blocker) or a Turp surgery (which sounds significant).

I am concerned the urologist might recommend changing or ceasing my TRT, which I feel would be a big step backwards for me. Do you have advice for someone in my situation? I assume that when I see the urologist, he will do other tests and perhaps there is more to the story than we know now. Any insight you can provide would be helpful.

 

[DrRotman]

Dr. Rotman,
I have a question about Prostate and urine flow.

Some background: I am 51 years old, I have been on TRT for the last 18 months or so. I was lucky enough to get dialed in very quickly under Defy Medical, my current protocol is 120mg/week Test Cyp (60mg Sun/Wed subq). Also HCG, 250 iu 3x per week (Tues/Thurs/Sat, also subq). I feel fantastic. Been maintaining around 776 total and 20.3 free. E2 is a bit high at 52.2 but Doc is not worried as I am not showing any symptoms. My PSA has been consistently good, with last result 2.1 ng/mL.

Over the last 5 years, I have been increasingly getting up nightly (now at least 2x per night) to urinate and my flow is noticeably restricted. My annual physical exams, my doc did the typical rectal exam and has never been concerned with the size or feel of my prostate. He most recently tried a new test, a Bladderscan, and 2 tests done in Sept and Dec show urine volume at 231ml and 193ml respectively. My primary doc put me on Flomax and after taking it daily for 5+ weeks, I felt zero improvement in flow or nightly urination. My doc then decided to double my dosage (1 pill in morning and and 1 pill at night), but that dosage quickly made me light headed (I have fairly low blood pressure generally) so we stopped the Flomax. Now I am scheduled to see a urologist to discuss 2 possible options: an alternate drug to Flomax (which I am told is a Testosterone blocker) or a Turp surgery (which sounds significant).

I am concerned the urologist might recommend changing or ceasing my TRT, which I feel would be a big step backwards for me. Do you have advice for someone in my situation? I assume that when I see the urologist, he will do other tests and perhaps there is more to the story than we know now. Any insight you can provide would be helpful.

Hi,

It's not quite clear yet how much of an effect TRT has on ones BPH symptoms. Certainly you appeared to have symptoms prior to starting TRT. The elevated residuals on bladder scan in addition to your symptoms and failing medications would indicate you may need intervention. A Turp or transurehral prostate resection is not your only option. There are many minimally invasive non surgical options including Urolift , Rezum, Prostiva etc. which I and many other urologists offer. I doubt just discontinuing TRT would resolve your symptoms. Good luck with your appointment and if your urologist doesn't present you with all options, obtain another opinion from a board certified urologist.

 

[jfullam]

Hi,

It's not quite clear yet how much of an effect TRT has on ones BPH symptoms. Certainly you appeared to have symptoms prior to starting TRT. The elevated residuals on bladder scan in addition to your symptoms and failing medications would indicate you may need intervention. A Turp or transurehral prostate resection is not your only option. There are many minimally invasive non surgical options including Urolift , Rezum, Prostiva etc. which I and many other urologists offer. I doubt just discontinuing TRT would resolve your symptoms. Good luck with your appointment and if your urologist doesn't present you with all options, obtain another opinion from a board certified urologist.

Thanks for the reply, Dr.Rotman.
I have noticed some other posts on this forum mentioning that a low daily dose of Cialis was effective at treating BPH symptoms. Any opinion on that as an option? I had not heard of some of the other options you noted (Urolift, Rezum, Prostiva) but I will research. Thanks again.

 

[DrRotman]

Thanks for the reply, Dr.Rotman.
I have noticed some other posts on this forum mentioning that a low daily dose of Cialis was effective at treating BPH symptoms. Any opinion on that as an option? I had not heard of some of the other options you noted (Urolift, Rezum, Prostiva) but I will research. Thanks again.

It would not be effective in your case where your symptoms are predominantly obstructive. You could try cialis 5 mg and a daily flomax and see if that improves your symptoms but I don't think that will work in yiur case.

 

[buggies100]

Dr Rotman,
i have been struggling with high hct, at threaputic phlebotomy today at red cross, she said my hgb was 20.7. Yes i a, o. Test Cyp, 40mg twice a week. Question I have is could the 4 cysts on the outside of my left kidney lead to increase of red blood cell production? I have been trsted for iron and ferretin levels to rule out polycthemia vera. Just a thought baout kidney cyst

 

[DrRotman]

Dr Rotman,
i have been struggling with high hct, at threaputic phlebotomy today at red cross, she said my hgb was 20.7. Yes i a, o. Test Cyp, 40mg twice a week. Question I have is could the 4 cysts on the outside of my left kidney lead to increase of red blood cell production? I have been trsted for iron and ferretin levels to rule out polycthemia vera. Just a thought baout kidney cyst

No, simple cysts on the kidneys do not cause elevated RBCs. Hopefully you are under care of a good hematologist.

 

[pm3405]

Bud, what is "dex"?

 

[pm3405]

Dr Rotman, Can you explain "bio-available" Testosterone vs total and free? (I hadn't heard of it till your recent post)

Thanks for your time and effort, we appreciate you very much!

 

[tthomas922]

Hey Dr. Rotman,
Nelson directed me your way. I will try to make this short if I can. I have been on TRT for several years and never abused it. My normal dose was .5ml once week for years and just a few months ago increased it to .5ml one week and the next week 1.0 ml. I went to primary physician 2 days ago because of problems being able to finish urinating, gaining and maintaining an erection and sever pain in the rectum and groin area. Prostate exam showed enlarged or inflamed prostate so was given levaquin in case there is infection. I just came back from visitng a urologist who is putting me on avodart to shrink the prostate and told me to get off testosterone. One week ago I started Cialis 5mg daily and am on flomax once a day. I was told I could increase flomax to twice a day and that 10mg cialis daily could help also. I am 60 years old, am a competitive powerlifter, never done steroids. I can live with pain but I can't live not being able to have sex with my wife which has been increasingly difficult lately. Can you offer any suggestions.

 

[Gene Devine]

Dr Rotman, Can you explain "bio-available" Testosterone vs total and free? (I hadn't heard of it till your recent post)

Thanks for your time and effort, we appreciate you very much!

Basics:

1. Total Testosterone is the serum concentration levels for:

* Testoterone bound to SHBG
* Testosterone bound to albumin
* Testosterone not bound (Free)

2. Bio Available Testoterone

* Testosterone bound to albumin and what is not bound

3. Free Testosterone

* Testosterone not bound to SHBG or albumin

The bond to SHBG is very strong and as such may never become available for recpetor acivation. The bond to albumin is somewhat weak and there is a school of thought that it will become available for receptor activation in time. Free is just that, the testoerone in serum that is available for receptor activation.

 

[DrRotman]

Bud, what is "dex"?

Arimidex or anastrazole

 

[DrRotman]

Hey Dr. Rotman,
Nelson directed me your way. I will try to make this short if I can. I have been on TRT for several years and never abused it. My normal dose was .5ml once week for years and just a few months ago increased it to .5ml one week and the next week 1.0 ml. I went to primary physician 2 days ago because of problems being able to finish urinating, gaining and maintaining an erection and sever pain in the rectum and groin area. Prostate exam showed enlarged or inflamed prostate so was given levaquin in case there is infection. I just came back from visitng a urologist who is putting me on avodart to shrink the prostate and told me to get off testosterone. One week ago I started Cialis 5mg daily and am on flomax once a day. I was told I could increase flomax to twice a day and that 10mg cialis daily could help also. I am 60 years old, am a competitive powerlifter, never done steroids. I can live with pain but I can't live not being able to have sex with my wife which has been increasingly difficult lately. Can you offer any suggestions.

Hi, there are two issues going on. Urination problems , which sound obstructive and erectile dysfunction. It has been shown that people with an enlarged prostate associated with obstructive symptoms do suffer from erectile dysfunction at a much higher rate. In your case I would address your urinary issues with one of the various BPH therapies out there and once it relieves your obstruction you can safely resume Testosterone and your ED will likely improve as well.

 

[tthomas922]

Thank yo for the reply. So do you recommend going ahead with the avodart and deal with the side effects?

 

[DrRotman]

Thank yo for the reply. So do you recommend going ahead with the avodart and deal with the side effects?

Not sure given your symptoms that Avodart would be answer. Would need to see variables such as your prostate size etc. ....Surgical options these days are much improved and can minimize side effects.

 

[FeelingLost]

Hello Dr Rotman, thank you so much for offering your time and expertise.

1) What are your thoughts on the "as seen on TV" Saw Palmetto Extracts/dietary supplements for general prostate health?

2) I am 63 and for the last 3 years I have gone to bed between 10 and 11 PM. Like clock work I am up at 2AM to urinate and again at 6AM. My urine stream is very weak like the muscle that contracts the bladder has atrophied. I have no pain other than the frequest desire to go pee. Is this just something that happens when you are in your 60's or can this be treated?

 

[DrRotman]

Hello Dr Rotman, thank you so much for offering your time and expertise.

1) What are your thoughts on the "as seen on TV" Saw Palmetto Extracts/dietary supplements for general prostate health?

2) I am 63 and for the last 3 years I have gone to bed between 10 and 11 PM. Like clock work I am up at 2AM to urinate and again at 6AM. My urine stream is very weak like the muscle that contracts the bladder has atrophied. I have no pain other than the frequest desire to go pee. Is this just something that happens when you are in your 60's or can this be treated?

1)One has to remember that vitamins/supplements are not subject to FDA regulations therefore their studies are not scrutinized and they can state false findings without facing any penalty. So buyer beware. That being said, Saw Palmetto dose help some people with their urinary symptoms. But if you purchasing TV brands you are paying a premium to subsidize their advertising fees.

2) Your prostate probably has increased in size causing pressure on the urethra thereby leading to hypertrophy of the bladder wall musculature. This changes the dynamics of the bladder and symptoms worsens as time goes on.

 

[Gamnc]

Question on Trimix: I have read (I think on this forum) that after a year of weekly use some men no longer need the injection. I also see where some after several years have to increase the injected amount. Was wondering if you had seen any research on these two statements. I like the thought of no use' but if not true still love my Trimix.

 

[Leesto]

Trimix and ED REhabilitation

Question on Trimix: I have read (I think on this forum) that after a year of weekly use some men no longer need the injection. I also see where some after several years have to increase the injected amount. Was wondering if you had seen any research on these two statements. I like the thought of no use' but if not true still love my Trimix.

My doctor told me the same thing and I have read elsewhere that trimix is sometimes used as rehabilitative therapy after prostate surgery. However there was a previous response in this forum which I have pasted below:

DrRotman: I am not aware of any evidence based medicine to support that notion. We do know injections can cause scarring and lead to fibrosis in some patients makin the ED non responsive to any local therapy aside from surgical pump placement. There is some data on PRP injection and stem cell therapy injections for improving ED but those are still experimental treatments and are quite costly.

 

[Cooper]

Dr. Rotman - What is your opinion on gels for TRT?

 

[DrRotman]

Question on Trimix: I have read (I think on this forum) that after a year of weekly use some men no longer need the injection. I also see where some after several years have to increase the injected amount. Was wondering if you had seen any research on these two statements. I like the thought of no use' but if not true still love my Trimix.

It my experience people who start injections with Trimix never get off and usually require titration to increase dose.