Armor Men's Health Show

EP 677: Pissed About Urinary Incontinence? Dr. Jacomides on Strengthening Your Pelvic Floor

• Dr. Sandeep Mistry and Donna Lee

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In this segment, Dr. Mistry and Donna Lee are joined by NAU Urology Specialists' own Dr. Lucas Jacomides. Today, Dr. Jacomides and Dr. Mistry discuss the diagnosis and treatment of everything from incontinence to prostate cancer to erectile dysfunction. As a holistic practice, the doctors at NAU Urology Specialists treat the whole patient and look for the underlying causes of urinary symptoms. One of the best and most effective holistic modalities we offer is pelvic floor physical therapy--stretches/exercises to strengthen the "basket" of muscles holding up our bladder, prostate, and other internal organs. Support structures like urethral slings can provide additional support where PT  alone isn't enough. Dr. Jacomides and Dr. Mistry also discuss the pros/cons of prostate cancer treatments like high intensity focused ultrasound and radical prostatectomies. To learn more about pelvic floor and prostate health, or to schedule your consultation, call or visit us online today! 

Voted top Men's Health Podcast, Sex Therapy Podcast, and Prostate Cancer Podcast by FeedSpot

Dr. Mistry is a board-certified urologist and has been treating patients in the Austin and Greater Williamson County area since he started his private practice in 2007.

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Speaker 1:

Welcome to the Armor Men's Health Show with Dr. Mystery and Donna Lee.

Speaker 2:

Hello and welcome to the Armor Men's Health Show. I'm Dr. Mystery . Your host joined us always by my co-host Donnel Lee . Hey

Speaker 3:

Everybody, welcome to the show. Thank you for listening.

Speaker 2:

We've been delivering this show and wonderful content for a good number of years, and you can get it on the radio as well as on our podcast. How do people search for our podcast, especially with the spelling? Well,

Speaker 3:

They can Oh, that's right. You spelled armor incorrectly. It's A-R-M-O-R, but it's armor men's health.com. That's our website. Or you can listen to our show live on KLBJ News Radio , KLBJ at 3:00 PM in central Texas.

Speaker 2:

And so , uh, we've been delivering this show we love , uh, all the content, all the guests , um, and all of your questions. How do people send us questions or visit us as patients?

Speaker 3:

You can reach out to our website for your questions that will answer anonymously every time on this show. It's armor men's health.com. There's a little button at the top right that says, submit your question here. And you can see Dr. Mystery and my smiling little sweet faces right there. And then you can also see us as patients in Round Rock, north Austin, south Austin, or Dripping Springs, Texas, y'all.

Speaker 2:

So although we started that practice, you know , uh, I come from an era in which a practice is really like a family. Mm-Hmm. <affirmative> . And , uh, every person that joins becomes like, you know, a cousin or

Speaker 3:

Like a brother from another mother

Speaker 2:

Or a brother. And so I have a brother from another mother joining us today. That's right. Dr. Lucas Jedis . Lucas, thank you so much for joining us today. Thank

Speaker 4:

You. My brother,

Speaker 2:

<laugh> <laugh> . Dr. Jedis is a board certified urologist. He is , uh, the fo the , the , the fourth person to join our practice , uh, as a urologist. Mm-Hmm . He's been in practice for a great number of years. Uh , Dr. Jacquees , why don't you give us a little background on your education and , uh, kind of your , uh, your career

Speaker 4:

Route? Well, it all started out in a little hamlet called Houston, Texas. Mm-Hmm . <laugh> where I was born and raised and educated at Rice University. And I went up to the , uh,

Speaker 2:

Valedictorian at Bel Air , first of all. Uh ,

Speaker 4:

And then you tied for first there was a bunch of us. There you go . But that's okay . Go . There you go . Wow . Yeah. That's how I roll <laugh> .

Speaker 2:

I was never tied for

Speaker 4:

First <laugh> . It was , it's all gone downhill from there . But no, it's , uh, it was a great school. Bel Air High School fighting Cardinals. Mm-Hmm . <affirmative> , then went to Rice University. Our football team was okay. Not too bad. And then up to Dallas for a University of Texas Southwestern Medical School.

Speaker 2:

And you went there for a residency as well, and

Speaker 4:

Residency as well. So Dallas

Speaker 2:

Decade . And so you spent, you spent six years or five years there.

Speaker 4:

It was six years of residency after four years of medical school.

Speaker 2:

That's right. So back then, that's when, you know, men were men and urologists spent six years doing <laugh> doing , doing urology residency. It's a little shorter now. Thankfully. Your was six too, right ? That's right. And then , and then you went to work, and then you spent a , the majority of your career at Baylor Scott and White . Correct. And , uh, then decided to come into private practice. And , um, you know, you see probably the most number of new patients of anybody in in , in our, in our clinical practice. Uh , what are some of the common things that you see people coming to a urologist for that , um, that, that you treat?

Speaker 4:

Well, I think , um, people do think as a rule that we see more men than women. And I think there's some truth to that. Men coming in for erectile dysfunction, it's always interesting to see how they call us and schedule an appointment. They don't exactly wanna tell their whole problems on the person answering the phone and say, Hey, here's what I'm coming in to see.

Speaker 2:

Right. Because it's a pri you know, they want to be private about, about what that is. And I think that when, if you're calling and really don't want to tell us what you're coming in for, you know, an annual checkup is a great, a great way to kind of put that on the, on the list. Uh, obviously offering online scheduling opportunities gives you a little bit more, I, I don't know , you don't feel as embarrassed saying it , uh, but we do it day in and day out. So Ed to us is, you know, as common as a ingrown toenail would be to a podiatrist

Speaker 4:

And possibly the source. Yeah. Um, you know, guys have urinary problems. Of course, women get urinary tract infections and actually a slightly increased preposition to stones, as you know. So we do see a fair amount of women as well, and certainly incontinence.

Speaker 2:

Now, when it comes to urinary incontinence, you've been treating it for , uh, a large number of years, and stress incontinence in particular is something that you've had a special expertise that you've developed. Well , well , why don't you tell us why women develop stress incontinence and what are the symptoms and how is that different from early

Speaker 4:

Incontinence? It's so nice to talk about women on this show. I was gonna say, you know , the

Speaker 2:

Change,

Speaker 4:

Nice change , those was born women at birth. You know, it's fantastic. <laugh> <laugh> . But , uh, I , for women, I mean, just to , just as a paint a broad brush , um, you know, we classically think of incontinence as urge incontinence and stress incontinence. Whereas urge incontinence, we think, okay, maybe just an overactive bladder. You try medications. And now we have exonics , uh, in our office as well. Um, and then stress incontinence and slinging something that , you know, when you cough or sneeze and laugh, and that's when the leakage happens. And

Speaker 2:

That's a big difference. I mean, pathophysiologically, what's happening in the body leaking when you're coughing and sneezing is different than leaking when you can't get to the bathroom fast

Speaker 4:

Enough. Correct. And I think women have a component of both, honestly. So you have to kind of tell 'em ahead of time, Hey, we're gonna treat, this sounds like it's more of an urgency picture. Let's go this route. Versus let's start talking about stress incontinence and surgeries or even pelvic floor therapy as we offer too.

Speaker 2:

So when it comes to stress incontinence, what, what are some of the risk factors that you see the most common , uh, to cause stress incontinence?

Speaker 4:

Well, clearly childbirth. I mean , um, you know, when you have three or four kids all weighing nine pounds a piece , you know, that's just a matter of time. And I think that some of that runs hereditary. I think women who leak will begat children. Is that right? Begat beget . Mm-Hmm . Um, make babies that also leak

Speaker 2:

In the future. And , and , and what , what's happening physically is when the uterus enlarges and the baby gets into the pelvis, all of those muscles and nerves get stretched. And this is the support structure that's keeping all these organs up. And when these support structures get weak is when they descend or drop when you cough and sneeze and leak. That's right. And so , um, we offer pelvic floor physical therapy. Uh , how , how do you explain to patients what pelvic floor physical therapy is and why it helps, helps?

Speaker 4:

Well, I think a lot of , uh, years ago, I think women had a concern, and rightfully so. There were a lot of bad slings, bad mesh out there, and a lot of the, you know, lawyers on TV advertising it. Uh , and I, I don't think that's true. I think there are some bad products out there, but certainly we would never willingly put them in people. So I think when people look at us and say, Hey, we, what can I do that doesn't involve me going to surgery, then, you know, pelvic floor therapy certainly sounds good. And I don't think it takes away the need for it. I just saw a patient that I, I did a , a bulk mid procedure or something that's not quite as aggressive as a sling, and she had a little bit of leakage afterwards. And then she did pelvic floor therapy. Um, and I think it really helped her out, just something as an adjunct to what we do. Just basically like you're going to the gym except down there.

Speaker 2:

And it may not sound like , uh, it makes complete sense, but this pelvic floor muscle is like a, like a basket that holds all of your organs up. Men and women both have them, and they both cause a lot of dysfunction. Women have several holes in this pelvic floor, one they poop from, one they pee from, and then one that goes around the vaginal canal. And so when that muscle gets weak , uh, around the urethra, you can certainly start seeing a lot more incontinence with stress, cough, sneeze, and pelvic floor physical therapy, which we offer in our office can be very helpful. You, you mentioned bulk amid . Bulk amid , and so that's B-U-L-K-A-M-I-D. So , uh, maybe explain to our listeners what is bulk amid who is the right patient and what can you expect from the procedure?

Speaker 4:

Um, I , I think when people look for , when women look for an option , it's still only available for women right now. Uh , they're getting , um, indications for men in the right scopes for it. But basically the best way I describe it is you're creating a damning effect. You know, so you're injecting this product in , in the , uh, walls of the urethra just to make the hole a little bit less big so when the gushing happens, you have a little bit more of a control over it. And I try to explain to them that this is not something that necessarily will work forever, although I've been very impressed with the longevity of it compared to its predecessor. Some other products that were like it. Um, so I , you're looking at a 10, 15 minute surgery, and in fact you can probably do it in the office. I haven't done bulk mid specifically in the office, but it really doesn't take much to do that. And so I think when women are looking for an option that's not quite something permanently implanted, a sling, a mesh, you know, these conceptions that it's terrible and then that's a perfectly good option.

Speaker 2:

Yeah. I think that for, for me, this , uh, bulk of mid option is good for women who are leaking, maybe a precautionary pat or one pat or less a day , um, mainly when coughing or sneezing and , and are looking to avoid kind of a bigger operation, like a sling. But we do slings, we do slings, we do slings. And so, and the midurethral sling still remains the mainstay and gold standard for treatment, for stress urinary incontinence in women. Um , what sling do you do? Well,

Speaker 4:

I like to brag that I did the first midurethral sling in the city of Austin. Nice. That's true. You know what? Most people don't know that. And , uh, she did great. Um , and I guess 'cause I never heard from her again, or she's out there yelling about how terribly leaking she still is, but that was like 14 years ago. And , um, I, it basically, the way I describe it, it's like a little hammock, you know? So if you cough and sneeze and bear weight, you're looking for some support. Now we have a little camera, so I can make the little hammock noise <laugh> . But something to give a little bit of support underneath that urethra to create a back resistance so that you give yourself a little bit time to catch it and get to the bathroom in time. And , um, I , I do it and it takes me about 20 minutes to do it.

Speaker 2:

Uh , I do , uh, the transvaginal tape sling with that involves three incisions, one in the vagina and two in the super pubic region. I think that for me, that works out better. There are slings that come out through the thighs, the trans Tator tape, and there are some that are just single incisions that get pinned into the muscle. Which one do you use? Well,

Speaker 4:

Yeah, you're right. Let me preface that. The Midurethral sling , I , the first one that was done in Austin was the single incision right in the , uh, vagina, no other incisions. I remember having one lady that I've been thigh incisions, and she ended up with a huge thigh bruise. I'm saying, why am I making these big incisions on their thighs? And that's nowhere near where I need to go. Uh, but , um, I've used , uh, solic sling, the , uh, the Alta sling. You know, they're, they're all fine products. Before that, it was a mini arc , uh, you know, very good products overall, they've never been recalled

Speaker 2:

On this. Uh, you know, on this show we frequently talk about how the bias of your surgeon will significantly impact the bias of the treatment you get. So if you go to a urologist that doesn't do slings , uh, you're gonna be, you know, non-operatively treated for the entirety of your disease process. So make sure you try to find a surgeon that specializes or at least has an interest in the disease process that you're going to them for. Don't assume that all surgeons are the same, because , uh, they certainly are not. Lucas, thank you so much for joining us. He is a partner at , uh, NAU Urology Specialist. Donna, how does, how do people make an appointment with Dr. Giacometti and get on our schedule? You

Speaker 3:

Call us at (512) 238-0762 or visit our website, armor men's health.com. Thank you, Dr. edis . Thank you.

Speaker 2:

Hello and welcome back to the Armor Men's Health Show. I'm Dr. Mystery , your host, join as always with my co-host, Donnel Lee .

Speaker 3:

Hey, everybody, thank you so much for listening to the show and sharing it with all of your friends. Yeah,

Speaker 2:

We would appreciate you sharing it with your friends. Mm-Hmm. <affirmative> , when we have listeners that come into the office, they are well primed to understand what holistic urology is all about. Mm-Hmm. <affirmative> , they understand that they're going to be offered not just surgical options, but also non-surgical, sometimes some holistic options. You're gonna be offered counseling on dietary and supplement , uh, alterations that we want you to make. You're gonna be given the latest and greatest and regenerative options and really a , uh, a real aim to care for the whole person, not just the things between the nipples and the knees. That's

Speaker 3:

Right. I think holistic urology too is such an interesting buzz phrase that we've created because I've interviewed lots of urologists around the country and they're like, what in the world does that mean? Yes,

Speaker 2:

Because you surgery can make this job, you can make this job very trained monkey or you can make it elegant trained monkey. That's right . One of the two.

Speaker 3:

You like elegant trained monkeys.

Speaker 2:

How do people become our patient ?

Speaker 3:

You can call us and learn all about the elegant trained monkeys at 5 1 2 2 3 8 0 7 6 2 . Our website, as you well know, is armor men's health.com. And we are in Round Rock, north Austin, south Austin, and Dripping Springs, Texas. Y'all . So be sure to reach out to us. We're here to help.

Speaker 2:

So , uh, once again, we're joined by one of the partners at NAU Urology Specialists, my brother from another mother, Dr. Lucas Eds , thanks a lot for joining us, Lucas.

Speaker 4:

Thank Youo <laugh>.

Speaker 2:

So when it comes to our, you know, mutual treatment of patients , uh, we, you know, we , we certainly , uh, do a lot of things the same. We do some things differently , uh, but I kind of wanted to explore your treatment algorithm and how you counsel patients that have been diagnosed with prostate cancer that we know has been , uh, localized to the prostate. So you're diagnosed with prostate cancer. What are some of the things that you think about and talk about when you're discussing treatment with a patient? Yeah ,

Speaker 4:

It's a good question. I, I usually see about one or two di new diagnosed prostate cancers a week. And in a perfect world, I'd like to see them at the end of the morning or the end of the day. And, you know, sometimes it's just not feasible or practical to do, but then sometimes I just reas realign my whole schedule because I don't think it's a quick, easy, yeah, you've got a kidney stone, let's go get it out kind of conversation. It is complicated. A lot of the cancers that we see are pretty straightforward. You say you got a kidney tumor, you gotta take it out, or the whole kidney, or you got a bladder cancer, take it out. Or the whole bladder a testicle cancer, you take it out right away. But a prostate cancer has lots of flavors. So, you know, about 15 years ago, we were all challenged by the lay press to say, we are doing way too much prostate cancer, diagnosing and treating, and we're mutilating men and we should never ever check PSA,

Speaker 2:

Because the idea here is that most men that are diagnosed with prostate cancer, we'll never die from it. But some men with prostate cancer That's right . Do die from it. And it's our job as the gatekeepers to try to figure out who those people are and then advise our patients as best as we can.

Speaker 4:

That's right. And what I tell them, you'll never know if you need, if which one of those you're gonna be unless you get a biopsy. And you never know if you're gonna need a biopsy, if you never check your PSA. And so these are very easy tests to do, and I like to think that I let people make the choice after I tell 'em, Hey, here's your pros and cons of doing something. So when I get that diagnosis, I think it's important to say, okay, standard biopsy, maybe 12 cores. We take 12 little pieces of the prostate out one by one. And you know, how many of those were came back positive for cancer? And then how aggressive they look on a microscope,

Speaker 2:

Because that's what you can tell, not just whether you have cancer, but how much, where is it and how aggressive it looks like. And if you do an MRI beforehand, we can even get a more targeted biopsy with an m MRI guided biopsy.

Speaker 4:

Right. And I think it's important also to get a general picture of the , uh, guy's health. Um, you know, also ask him , how old were your parents when they died? You know, I , I'll never forget telling, asking a patient that, and he came to me 80 years of old, and he had a 30-year-old wife and a 5-year-old son. And , and I said, how old are your parents when they died ? And he says, they're in the waiting room, they're alive, <laugh> , they're 105 . So you just , you never want to be ages people, you know , if you got about a 10 , wow .

Speaker 2:

That's right . Having an age related cutoff doesn't make any sense in a society that's both aging and getting healthier as they get

Speaker 4:

Older. It , it's something that , to look at the person and say, is this person gonna be around in 10 to 15 years? And if so, could this prostate cancer kill them? And, and I think that's when you kind of make the decisions about how to go down the road, what to do about it.

Speaker 2:

So traditionally we've offered people radical prostatectomy, which we do robotically. Then there are a number of different options that can be done from a, a radiation standpoint. And we've talked about both of those , uh, on the show at, at great length. Why don't we talk a little bit about active surveillance, watchful waiting and molecular testing. What, what , what do these words mean and and what's their role?

Speaker 4:

Well, active surveillance, watchful waiting a lot of times are used interchangeably. But

Speaker 2:

I had a patient that hated when I said watchful waiting. He was like, no, I went to a doctor that's doing active surveillance. Really? I was like, oh man. Same thing. It's it's , it's

Speaker 4:

Longer words .

Speaker 2:

It's the same word. It's just the same thing. <laugh> , I don't like you Dr . Mystery. I wanted active surveillance, not watchful waiting. <laugh> ,

Speaker 4:

You're right. But I've always thought there was a little bit of a difference to No , think I'm just a little bit, and maybe I'm gonna do more biopsies to you.

Speaker 2:

I'll definitely do more biopsies, so don't worry. That's right. I have definitely am an active surveillance guy. I'm very active. So,

Speaker 4:

You know, to the point is , uh, you know, for a lot of times if you're, let's say a 75, 80-year-old and you have one positive biopsy and it's the least aggressive Gleason score, three plus three equals six that you'll see, typically, that's a , that's a guy who can probably watch it. You know, that's the kind of guy you don't want to say it's like killing a fly with a bazooka gun. You know, we're just gonna see what this thing does, and if it starts to turn ugly, then we re-biopsy you and see if now you have a Gleason eight, you know, or something much more aggressive and all your biopsies are positive. So, so that's what I look at as far as active surveillance. And I, I, I think every patient's different, to be honest with you. I don't know if you have a different , uh, criteria how you watch these guys. For

Speaker 2:

Every one , I usually do a PSA every six months, and I do a repeat biopsy at a year in everyone . Um, and , uh, I guess that's just the kind of way that I develop.

Speaker 4:

Yeah, I think six months is standard. I think , um, a lot of times I'll look for the trigger to get me to then say, okay, we missed your, we didn't see any cancer the first time. Now you got a PSA, that's a couple points higher, now let's do an MRI again, see if anything changed . And then re-biopsy, anything that looks suspicious, a lot of times that's the direction I'll go.

Speaker 2:

And there are , uh, not only MRIs, but now we have molecular genetic tests that we can do on the biopsy specimens to tell us, not only is it objectively look dangerous to the pathologist, but on a molecular level, do the genes look like there , this is gonna be a more active cancer. And that can help me decide who's a good active surveillance candidate as well. Yeah .

Speaker 4:

There are three , uh, companies at least that offer this. Um, I'm curious what your algorithm is, if there's someone that you say look at, but basically we're trying to say not just a Gleason score. How many bio are positive? What is your, I mean, let's face it, it's , I tell, it's like having covid , we're all gonna get covid, just don't die of it. So as a men , you know, we're gonna get prostate cancer, just find out which one's gonna

Speaker 2:

Kill you. And I would say conventional wisdom tells me that I think our patients out there think that we actually do more tests than we actually do. Meaning that they expect us to have a lot more innate knowledge of their disease process than sometimes we're given with a simple pathology report. And I think that we are entering that, that era of molecular medicine where we're gonna have that. So both of us do HIFU or high intensity focused ultrasound, which is a fourth way to address cancer. So, you know, watchful waiting, radical prostatectomy, radiation therapy, and then now this FU therapy and not, not very many urologists in the country do this. You and I probably are in a, in a field of about a hundred urologists in this country that offered this procedure. What has been your experience with high intensity focus ultrasound for prostate cancer?

Speaker 4:

I , I've been very happy with it. We've been doing it now for about five years. I just remember the very first day I did them, I did two. The second guy I did that day went home and ran a , a 10 K the following week after surgery and, you know, ran a personal best . So, you know, he, he's a little picture he sent me and we published it in a running magazine because just to tell people you can get back on your feet in no time. So it's a lot , it's very useful for those who really just are nervous about watchful waiting after surveillance, whatever you want to call it .

Speaker 2:

And that's where I use it. I actually have very few patients on watchful waiting, you know, because we can offer a treatment that is minimally invasive very quick, has very little downtime, and has very low side effect profile. So risks of impotence and incontinence are very low with high intensity focused ultrasound, especially if it's kind of tailored. And , uh, and I've been very pleased with it. More and more insurances are, are paying for it. Our cash pay price is the lowest in the country at 13,500. And , uh, although not everybody's a candidate, many people are good candidates for high intensity focused ultrasound.

Speaker 4:

Well, people do push the envelope. I , my, I think my third patient was a Gleason eight cancer that had a surgery scheduled with another urologist. And, and I said, you need to get your prostate out . I agree with him. He goes, oh no, I'm not getting my prostate out. Yes .

Speaker 2:

Because ultimately the patient's decision, if they don't want to have it done, they're not gonna have it done .

Speaker 4:

This , this guy was classic though . He went to a urologist and said, do , would you do a Gleason eight fu? And he goes, not only would I do it, I had Gleason eight cancer and I had it done on me. This patient is now also about five years out with no evidence of disease. So he's, he , and then he sends me his Gleason nine brother and I go, look, we're pushing our luck here , <laugh> . So yeah, you have to be careful. Not everyone's a candidate, but you know, you'd be surprised.

Speaker 2:

You'd be surprised at how many are, and we are just about to embark upon a new era in this city. We are , we have the fanciest most , uh, most technologically advanced machine. We have the , the new focal one haifu machine that's coming to town. It has MRI guidance capabilities. It is state of the art . This coming week, I'll be doing my first case , uh, on a , uh, on a doctor's dad who has an a , you know, an MRI seen lesion and we're gonna, you know, we're gonna take care of it and ablate it using this haifu. I'm, I'm very excited.

Speaker 4:

Oh, I'm very excited to hear it too. I mean, it sounds amazing.

Speaker 2:

And from a recovery standpoint, what are you telling patients on how long it takes to recovery and, and what are some common postoperative symptoms? I,

Speaker 4:

I tell them if I have to treat the whole prostate, I'm probably gonna recommend to do a , a resection or aqua ablation. Something that's gonna open up the inside to minimize their risk of having trouble urinating afterwards. You know, you have to respect that some prostates are big and if you, you know , do it all at once, they're gonna have trouble going and you don't wanna do surgery if you can avoid it after the a fu ablation. Uh, if I do one side, a lot of times I tell 'em, we don't have to, you know, if you don't have any symptoms, we don't have to. But I, we do send 'em home with a catheter, usually for about five to seven days just to make sure that they're gonna be fine afterwards. And then, like I said, you're not gonna necessarily run a 10 K and get a PR from it. But I tell 'em , you can probably be out there, go

Speaker 2:

Back to work, and you're gonna be

Speaker 4:

Just fine. Absolutely . You can go to work next week. I mean, the , the day surgery, no admission. I mean, you know , just have to tell 'em that. Yeah , it's a catheter, but it's not two weeks.

Speaker 2:

Like we , and , and , and we, we love second opinions, second opinion, mystery. They call me. Mm-Hmm . <affirmative> . And , uh, and I'll give you a third and fourth one if you really want it. Mm-Hmm. <affirmative> . Uh, but , uh, coming to us to a visit with Dr. edis about your prostate cancer di uh , diagnosis is their first step to get a high food . Donna, how did they get ahold of us? Call

Speaker 3:

Us at (512) 238-0762.

Speaker 1:

The Armor Men's Health Show is brought to you by NAU Urology Specialist. For questions or to schedule an appointment, please call 5 1 2 2 3 8 0 7 6 2 or online at armor men's health.com.