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The Real Prostate Cancer Second Opinion-Illustrated “Factors to consider” in your  treatment decision-making process.

I had my biopsy done by a partner during lunch. I took an antibiotic and  nothing for pain. My partner did attempt a prostate block but  it did not work. He took about 16 samples and it lasted about 20 minutes. It was very uncomfortable. My biopsy experience. I am trying to think if I under tell patients about the pain involved.

I give each patient a sedative and a pain pill prescription (such as an ativan and a percocet) that they take an hour before the procedure and I also perform the prostate block which is guided by the ultrasound. (For any of you that are interested, that is a space easily identified on ultrasound just lateral to the seminal vesicles at the posterio-superior aspect of the prostate. That’s where the nerves that enervate the prostate run and responsible for the pain.)

There are about three kinds of pain associated with the biopsy and my little protocol, and I would be surprised if most urologists don’t do something similar, limits all of them. First there is the pressure pain associated with the ultrasound probe itself, this is like a rectal exam done by large thumb and is five inches long-a generalized pressure pain. Then there is the irritation the rigid instrument has on the prostate and the prostatic urethra. (Any one reading this and trying to determine what type of treatment you are planning to pursue needs to understand the prostatic urethra and how it is affected by all the treatments. This is about a good a tip I could ever give you. I’ll put something today into the ” Decision Process” section of this blog.) The pressure on prostate gives you an intense sensation that you need to urinate, so be sure to empty your bladder before the procedure. And then of course, there is the actual biopsy itself. We all use a spring-loaded biopsy gun now, so you’ll hear a clicking sound before each biopsy and it feels like a bee sting. (A patient told me one time, ” Hell doc, that ain’t no bee sting, that’s a Texas wasp.) By the way, I went up to the river yesterday and while I was looking for a stick to throw into the river for Penelope, I got stung by two or three wasps on my ear….right on the lobe of it. Man oh man… I hate those things.

The blood that is referred to in the piece below is hematospermia and this does get your attention but is harmless. It doesn’t hurt anyone and usually goes away in a week or so, but not always. When there becomes a brownish tint to the fluid, you are almost done with it. It can last for weeks however.  After the biopsy-from ” The Decision.”

As urologists we worry most about a fever or difficulty voiding after a biopsy. This type of stuff occurs about 3% of the time and is why  we give an antibiotic before and after, usually Cipro, and tell the patient and family to call if any voiding issues.  If you are already on a drug to help you urinate or are having difficulties now, you are more at risk for problems voiding and this is something you should make known to your urologist. I do about 100 biopsies a year and in my 24 year career I have had to admit someone for a biopsy complication probably about 5 times.

I feel that I am fairly discerning about the pain. I ask my nurse to watch the patient’s expression and that will often tell you if there is undue discomfort. If we sense it, we stop and do something else… redo the block or consider giving something I.V. This is a recent post of a patient that did impersonations during his biopsy, if that tells you how he did pain wise during the procedure.

The other component to the piece that follows has to do about men and how much they will talk about pain and their medical condition.  I think its fine and appropriate to say to the urologist at the time of the scheduling, like I do with a Dentist, ” I don’t like pain. Can you give me something?” If the urologist says no and you want medicine…get another urologist.  It is really that simple, I doubt many will say no however.

More about men and what they will disclose. If you know someone who had robotic removal, most likely they will almost brag about having had it removed that way. It is almost as if they think they were cutting edge or ” informed.” But… if you ask them how are they doing, particularly with continence and potency, then that’s different story. I mention this to be careful to separate out from the conversation ” the procedure ” and the ” aftermath.” That’s a world of difference and you’ll have to really dig and persist to find out how they are ” really doing.” You might ask, ” Why would persist into something that is personal?” Well, my friend you are trying to make a decision about what to do and if you make it based on how the procedure went but not how things ended up ” functionally” then you have made a decision in error. Robotic and Brachytherapy are similar in this aspect. Patients often make the decision based on the procedure attributes  and not on a full understanding on how they will ” end up.”

As my mother said, ” Don’t value short-term gratification over long-term gain.”

From Chuck Gallagher’s Blog

Urologists Take Note – The Real Truth About A Prostate Biopsy!

At first I thought I was just a “wimp.” At the urging of my family doctor I went to a urologist for a prostate check. She (my family doctor) said my PSA was a bit high for my age – 4.58 PSA and I was 47 years old.

Now let me state…I didn’t even know what a PSA was until she forced the test when I was having routine blood work done. Something I hated as I had a fear of needles.

The urologist did the “bend over boy” routine finding nothing with his “DRE” – Digital Rectal Exam. Now I have to be honest, that wasn’t the most exciting exam, but all in all it didn’t cause me any great pain. But, as the urologist said, “Better to be safe than sorry. Let’s schedule you for a biopsy.”

Now let me be frank…I had no clue what to expect other than what my doctor told me. He said there wouldistock_000002146611small be some minor discomfort but mostly I would be annoyed by the sound of the instrument when the sample was taken. “Other than that,” he commented, “most men don’t really feel much.” I do recall asking if there was pain, and again, my urologist stated, “Most men feel very little. Nothing to be concerned with.”

I have been interviewing men from all around the English speaking world who have been diagnosed with prostate cancer. With few exceptions everyone reports the same thing. The damn biopsy hurts! When they report this, I ask a follow up question: “Did you tell you doctor this?” Their response – “Well, no, I just took it like a man.”

GUYS…WHAT A CROCK!

In Dr. Sheldon Marks book, “Prostate and Cancer” he describes the biopsy as follows:

In a biopsy of the prostate, multiple tiny sliver-like ppeces of tissue are obtained for microscopic analysis to see if cancer is present. These pieces are obtained through a long but very thin needle, specially designed to open inside the prostate, take the sample and then close.

For most men, biopsies can be done as an outpatient office procedure without anesthesia and with usually only temporary discomfort. Now we can get a good representative sampling of the entire gland with minimal trauma to the gland.

He is right…it is done outpatient most of the time. Where I beg to differ is on the pain issue. Thus far, well over 70% of the men I have talked with have reported that their urologist misled them when it came to what to expect and the pain. All but two men interviewed would, in retrospect, have desired pain medication before the biopsy. One man reported that had he known it would have hurt as bad as it did…he would never had submitted to the test. (Although the test might have saved his life).

Several men stated that they felt that ALL UROLOGISTS should have a biopsy on their prostate so that they would know exactly what their patient was going through. In that way, the urologist might be willing to volunteer provide some local anesthesia to reduce the pain and trauma.

Urologists…do you get the picture. What is reported to you is inaccurate (men don’t want to admit to their pain) and it (the biopsy) freekin…hurts – SO GIVE US SOMETHING TO TAKE THE EDGE OFF.

WHAT ABOUT AFTER THE BIOPSY? For most men normal functions – exercise, work, activity will all resume as normal either the next day or day after that. Now, when I say normal functions…that also includes sex.

I’ve scoured the Internet and seldom do I see PRACTICAL ADVICE that men need to know – so here’s some. A few days after your biopsy you may engage in sexual activity. Be prepared! When you achieve orgasm your ejaculation will be bloody. Guys I don’t mean a trace of blood, but bright red bloody. And, gentlemen, if you are unprepared for that, it can cause alarm. That alarm may be to you and/or to your partner. Nothing can change the mood of an intimate evening of sexual play than to achieve an orgasm and find that you look like you just hemorrhaged.

GUYS… The biopsy is necessary so in no way take this entry as anything other than solid information. Have it done, and more than once if necessary. My personal advice is – request pain medication.

Chuck Gallagher is a business ethics and fraud prevention speaker and author. Having been diagnosed with Prostate Cancer, he spends time working to help educate men and their families about the practical aspects of Prostate Cancer and how to survive.

This entry was posted on Monday, November 10th, 2008 at 5:12 am

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where there is a will...i want to be in it- a paraprosdokian

So who do you believe-the folks that say the PSA doesn’t save lives or the ones that say it does. You want to know the answer-simply view it as if you or someone you love has been diagnosed late and has disease too late to cure and you didn’t do the screen stuff because you saw on t.v. that it was not helpful and so you did not get tested. Now how do you feel? Which statistics mean the most to you now? Are you the “vast majority” or are you the one that goes unmentioned, the “very small percentage that it helps.”

If the odds are one in a hundred and you are that one then it’s 100%

I’d love to agree with you but we’d both be wrong…

I love these things….paraprostdokians

Etymology

“Paraprosdokian” comes from Greek “παρά“, meaning “against” and “προσδοκία“, meaning “expectation”. Canadian linguist and etymology author William Gordon Casselman argues that, while the word is now in wide circulation, “paraprosdokian” (or “paraprosdokia”) is not a term of classical (or medieval) Greek or Latin rhetoric, but a late 20th century neologism.[2][3] However, it occurs—with the same meaning—in Greek rhetorical writers of the 1st century BCE and the 1st and 2nd centuries CE.[4][5][6][7]

Examples

  • “If I am reading this graph correctly — I’d be very surprised.” —Stephen Colbert[8]
  • “You can always count on the Americans to do the right thing—after they have tried everything else.” —Winston Churchill[8]
  • “I’ve had a perfectly wonderful evening, but this wasn’t it.” —Groucho Marx[10]
  • “A modest man, who has much to be modest about.” —supposedly Winston Churchill, about Clement Attlee[10]
  • “She looks as though she’s been poured into her clothes, and forgot to say ‘when’.” —P. G. Wodehouse[10]
  • “I like going to the park and watching the children run around because they don’t know I’m using blanks.” —Emo Philips[10]
  • “If I could just say a few words… I’d be a better public speaker.” —Homer Simpson[11]
  • “I haven’t slept for ten days, because that would be too long.” —Mitch Hedberg[3]
  • “I sleep eight hours a day and at least ten at night.” —Bill Hicks[3]

So I bet at least five people from patients to a guy in the operating room show me the article from a magazine like American Scientific saying that the PSA was not helpful in the diagnosis of prostate cancer and resulted in too many this and that…and bla bla bla.

“Whada ya think about this article doc,” the orderly asked as my patient was being put to sleep in the operating room.

On the cover it said something like this…”In most cases prostate cancer is slow-growing and in the vast majority of patients death will be the result of something other than prostate cancer.”

I say to the well-meaning orderly, ” let’s say this is your father we are talking about and you are there and I am there and he has just been diagnosed with prostate cancer and you show me this article.”

“I’ll ask you if it matters to you and your dad that the articles says that “most” are slow-growing and that the “vast majority” of patients will die of something other than prostate cancer. What will you want for your dad. If  “most” or “vast majority” is good enough for you then don’t have your prostate cancer treated. If it ain’t enough then I’d have your prostate cancer treated.”

I then asked, ” who would you be in this scenario.”

The twenty something orderly with no knowledge of prostate cancer replied, ” I’d want my father to be treated.”

“Well then that is the right answer…for you.”

Now this from Australia….80% of men never tested? What the hell?

Oh the statistics and the paraprosdokians….just thought it sounded good. I was going to link the two together in a clever fashion but now I am bored with this….so down to the cove with the four dogs above and see if I can catch just one for more pictures on my iphone.

Study: Prostate Blood Test Reduces Cancer Deaths

By: Daryl Nelson  |  Yesterday  |  TheCheckup.com

Thinkstock

A new study suggests men screened for cancer using the prostate specific antigen (PSA) blood test reduces the number of prostate cancer deaths.

The report from the Prostate Cancer Foundation of Australia found men who were given the PSA test showed a 21 percent drop in prostate cancer deaths after being re-examined 11 years later. The study involved more than 162,000 in eight European countries.

“Importantly the prostate cancer mortality difference between men who  were screened and men who weren’t became wider the longer they were  followed up after screening began,” a statement from the foundation  said.

Researchers at the foundation found that 80 percent of Australian men between the ages of 45 to 74 did not get a PSA test and 3,300 died annually from prostate cancer. With the PSA test about 700 lives would be saved, the foundation president said.

In conflicting results, U.S. researchers found no decline in prostate cancer deaths among men who were regularly screened, however, Dr. Lowe believes the seven year U.S. study wasn’t long enough to draw a complete conclusions.

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if you can keep your head up when all about you are losing theirs and blaming it on you...kipling

Limbaugh on the NFL’s Pink and Breast Cancer Awareness. His theory does explain the question about why no Prostate cancer blue month  in the NFL.

My interest in this “Pink stuff” is more about how it is affecting performance of the athletes. If you have ever played or are a big fan of sports you know very well the importance of rituals and superstitions and doing everything exactly the way that has worked. Again, it is breathtaking to think you’d have a kicker change a shoe, regardless of color, I mean just changing the shoe is risky. Mickey Mantle had “his” bat made for him by a  particular company and a particular cut of wood. ( Tarred just right.) In time there will be a discussion of this and it will be fun to  watch.

Ever noticed that pitchers when they walk off the field make a point not to step on the chalk line on the way back to the dugout? Hmmmmmmmmm?

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chattahoochee red-eyed shoal bass

The rectal refusal syndrom in the male.  A cartoon.

A primer on the prostate and prostate cancer and a cartoon demonstration of why prostate cancer is often diagnosed too late to cure. It’s a ” male ” thing!

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somebody wants in

I had my biopsy done by a partner during lunch. I took an antibiotic and  nothing for pain. My partner did attempt a prostate block but  it did not work. He took about 16 samples and it lasted about 20 minutes. It was very uncomfortable. My biopsy experience. I am trying to think if I under tell patients about the pain involved.

I give each patient a sedative and a pain pill prescription (such as an ativan and a percocet) that they take an hour before the procedure and I also perform the prostate block which is guided by the ultrasound. (For any of you that are interested, that is a space easily identified on ultrasound just lateral to the seminal vesicles at the posterio-superior aspect of the prostate. That’s where the nerves that enervate the prostate run and responsible for the pain.)

There are about three kinds of pain associated with the biopsy and my little protocol, and I would be surprised if most urologists don’t do something similar, limits all of them. First there is the pressure pain associated with the ultrasound probe itself, this is like a rectal exam done by large thumb and is five inches long-a generalized pressure pain. Then there is the irritation the rigid instrument has on the prostate and the prostatic urethra. (Any one reading this and trying to determine what type of treatment you are planning to pursue needs to understand the prostatic urethra and how it is affected by all the treatments. This is about a good a tip I could ever give you. I’ll put something today into the ” Decision Process” section of this blog.) The pressure on prostate gives you an intense sensation that you need to urinate, so be sure to empty your bladder before the procedure. And then of course, there is the actual biopsy itself. We all use a spring-loaded biopsy gun now, so you’ll hear a clicking sound before each biopsy and it feels like a bee sting. (A patient told me one time, ” Hell doc, that ain’t no bee sting, that’s a Texas wasp.) By the way, I went up to the river yesterday and while I was looking for a stick to throw into the river for Penelope, I got stung by two or three wasps on my ear….right on the lobe of it. Man oh man… I hate those things.

The blood that is referred to in the piece below is hematospermia and this does get your attention but is harmless. It doesn’t hurt anyone and usually goes away in a week or so, but not always. When there becomes a brownish tint to the fluid, you are almost done with it. It can last for weeks however.  After the biopsy-from ” The Decision.”

As urologists we worry most about a fever or difficulty voiding after a biopsy. This type of stuff occurs about 3% of the time and is why  we give an antibiotic before and after, usually Cipro, and tell the patient and family to call if any voiding issues.  If you are already on a drug to help you urinate or are having difficulties now, you are more at risk for problems voiding and this is something you should make known to your urologist. I do about 100 biopsies a year and in my 24 year career I have had to admit someone for a biopsy complication probably about 5 times.

I feel that I am fairly discerning about the pain. I ask my nurse to watch the patient’s expression and that will often tell you if there is undue discomfort. If we sense it, we stop and do something else… redo the block or consider giving something I.V. This is a recent post of a patient that did impersonations during his biopsy, if that tells you how he did pain wise during the procedure.

The other component to the piece that follows has to do about men and how much they will talk about pain and their medical condition.  I think its fine and appropriate to say to the urologist at the time of the scheduling, like I do with a Dentist, ” I don’t like pain. Can you give me something?” If the urologist says no and you want medicine…get another urologist.  It is really that simple, I doubt many will say no however.

More about men and what they will disclose. If you know someone who had robotic removal, most likely they will almost brag about having had it removed that way. It is almost as if they think they were cutting edge or ” informed.” But… if you ask them how are they doing, particularly with continence and potency, then that’s different story. I mention this to be careful to separate out from the conversation ” the procedure ” and the ” aftermath.” That’s a world of difference and you’ll have to really dig and persist to find out how they are ” really doing.” You might ask, ” Why would persist into something that is personal?” Well, my friend you are trying to make a decision about what to do and if you make it based on how the procedure went but not how things ended up ” functionally” then you have made a decision in error. Robotic and Brachytherapy are similar in this aspect. Patients often make the decision based on the procedure attributes  and not on a full understanding on how they will ” end up.”

As my mother said, ” Don’t value short-term gratification over long-term gain.”

From Chuck Gallagher’s Blog

Urologists Take Note – The Real Truth About A Prostate Biopsy!

At first I thought I was just a “wimp.” At the urging of my family doctor I went to a urologist for a prostate check. She (my family doctor) said my PSA was a bit high for my age – 4.58 PSA and I was 47 years old.

Now let me state…I didn’t even know what a PSA was until she forced the test when I was having routine blood work done. Something I hated as I had a fear of needles.

The urologist did the “bend over boy” routine finding nothing with his “DRE” – Digital Rectal Exam. Now I have to be honest, that wasn’t the most exciting exam, but all in all it didn’t cause me any great pain. But, as the urologist said, “Better to be safe than sorry. Let’s schedule you for a biopsy.”

Now let me be frank…I had no clue what to expect other than what my doctor told me. He said there wouldistock_000002146611small be some minor discomfort but mostly I would be annoyed by the sound of the instrument when the sample was taken. “Other than that,” he commented, “most men don’t really feel much.” I do recall asking if there was pain, and again, my urologist stated, “Most men feel very little. Nothing to be concerned with.”

I have been interviewing men from all around the English speaking world who have been diagnosed with prostate cancer. With few exceptions everyone reports the same thing. The damn biopsy hurts! When they report this, I ask a follow up question: “Did you tell you doctor this?” Their response – “Well, no, I just took it like a man.”

GUYS…WHAT A CROCK!

In Dr. Sheldon Marks book, “Prostate and Cancer” he describes the biopsy as follows:

In a biopsy of the prostate, multiple tiny sliver-like ppeces of tissue are obtained for microscopic analysis to see if cancer is present. These pieces are obtained through a long but very thin needle, specially designed to open inside the prostate, take the sample and then close.

For most men, biopsies can be done as an outpatient office procedure without anesthesia and with usually only temporary discomfort. Now we can get a good representative sampling of the entire gland with minimal trauma to the gland.

He is right…it is done outpatient most of the time. Where I beg to differ is on the pain issue. Thus far, well over 70% of the men I have talked with have reported that their urologist misled them when it came to what to expect and the pain. All but two men interviewed would, in retrospect, have desired pain medication before the biopsy. One man reported that had he known it would have hurt as bad as it did…he would never had submitted to the test. (Although the test might have saved his life).

Several men stated that they felt that ALL UROLOGISTS should have a biopsy on their prostate so that they would know exactly what their patient was going through. In that way, the urologist might be willing to volunteer provide some local anesthesia to reduce the pain and trauma.

Urologists…do you get the picture. What is reported to you is inaccurate (men don’t want to admit to their pain) and it (the biopsy) freekin…hurts – SO GIVE US SOMETHING TO TAKE THE EDGE OFF.

WHAT ABOUT AFTER THE BIOPSY? For most men normal functions – exercise, work, activity will all resume as normal either the next day or day after that. Now, when I say normal functions…that also includes sex.

I’ve scoured the Internet and seldom do I see PRACTICAL ADVICE that men need to know – so here’s some. A few days after your biopsy you may engage in sexual activity. Be prepared! When you achieve orgasm your ejaculation will be bloody. Guys I don’t mean a trace of blood, but bright red bloody. And, gentlemen, if you are unprepared for that, it can cause alarm. That alarm may be to you and/or to your partner. Nothing can change the mood of an intimate evening of sexual play than to achieve an orgasm and find that you look like you just hemorrhaged.

GUYS… The biopsy is necessary so in no way take this entry as anything other than solid information. Have it done, and more than once if necessary. My personal advice is – request pain medication.

Chuck Gallagher is a business ethics and fraud prevention speaker and author. Having been diagnosed with Prostate Cancer, he spends time working to help educate men and their families about the practical aspects of Prostate Cancer and how to survive.

This entry was posted on Monday, November 10th, 2008 at 5:12 am

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a left sided " throck-morton"

Do you know what a ” throck-morton” is in urology? Just for fun, those of you having to visit your urologist for prostate cancer concern, ask your urologist what it is? I bet he knows, it is well-known phrase in urologic circles.

A KUB x-ray (Kidney Ureter Bladder) is commonly done by urologists looking for kidney stones. More often than not at the very bottom of the x-ray, if it’s a male, a shadow of the males, well you know what I am suggesting , is seen. This particular organ is either positioned to the left or the right, never in the center. The fact that it is either left or right is the ” throck-morton” sign.

I have a thousand throck-morton signs that apply to all sorts of things, I may list them one day, all M.D.’s have them in their arsenal of conversation. We can say them and then all the other doc’s understand it and the situation to which it applies. ” 5% of the patients have 95% of the diseases” is one. “Call me if you need me but it’s a sign of weakness” comes to mind.

Okay. On the throck-morton. On a KUB x-ray, if the organ of record to which I refer hangs to the left… the pathology or in this case the kidney stone is on the left. If the “thing” hangs to the right the stone is on the right. The throck-morton is right 50% of the time.

If the organ is on the right and the stone is on the right that’s a ” positive throck-morton.” You get the drift.

Now in terms of the Pepsi up above. One might think that she is just tongue- dragging tired from chasing sticks in the river for three hours this past Sat afternoon. No, that is not it at all. I think that the tongue on the left tells me that she knows that I am going to throw the stick to the left.

Or, is she using some type of self fullfilling phrophsey and that she is actually guiding me to throw the stick in a particular way…….

I just thought the tongue reminded me of the T-M and I thought you might find that interesting and something you could talk to your urologist about. Try it… you might be surprised .. it just might open him or her up to a more personable conversation…. and that is important in all this also.

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