A humanizing force: The book in my white coat

“Doctor, could you speak to me in plain English, please?!”

I rarely hear this in my men’s health practice. It’s likely because I am aware that Medspeak, or the language of medicine, is a second tongue, and a very foreign one to boot.

The Language of Medicine

There are 750 muscles, 206 bones, 428 named nerves and 60,000 miles of named and unnamed arteries and veins in the adult human body. Add to this all known body organs and physiological and molecular pathways and it becomes clear that the first two years of medical school involves learning 20,000 new vocabulary words, the equivalent of an entirely new language. Suddenly, sweating becomes diaphoresis, vomiting becomes emesis and red becomes erythematous. Throw in normal physiology and disease states in the second two years of medical school, and you have another 20,000 word vocabulary lesson. For some reason, patients now ambulate, visualize, articulate and masticate when the rest of us walk, see, talk and chew. That’s two whole languages to be learned in 4 years.

The Beauty of Medspeak

The vocabulary of medicine can be elegant, efficient and sound oh-so beautiful with all those Latin words. There is something poetic and mellifluous about the word “vestigial” which is a leftover structure with no current function, like the appendix. Another example: I recently hurt my thumb after my 7-year old daughter’s ace tetherball serve. Presenting my black and blue thumb to my favorite orthopedic surgeon, he said: “A minor bruise to your flexor pollicis longus and brevis muscles.” Just sort of rolls off your tongue. Felt better already.

The Vagaries of Medspeak

But Medspeak can also dehumanize. In the field of men’s health, I hear the words “idiopathic epididymitis” all the time. That’s eleven syllables of Medspeak in just 2 words. Sounds impressive but what does it really mean? How’s this: “unexplained scrotal pain that is not due to cancer or other badness.” When put in front of another word, “essential” also means unexplained. Admittedly, Medspeak can make even the vague and unknown sound official.

When commenting on written Medspeak, the late author-doctor Michael Crichton wrote: “I don’t agree… that medical writing is inept. I argue that it is actually a highly skilled, calculated attempt to confuse the reader.” Agreed. When used excessively or carelessly, it is dehumanizing and can change the moment and direction of a patient’s life.

While I was a resident at the University of Pennsylvania years ago, a college friend who trained with me gave me a small book of poems to carry around. I opened it during those rare, quiet moments that can happen while on call. The book was by William Carlos Williams, a noted doctor-poet. Dr. Williams fully understood the two edged sword of Medspeak when he noted: “It is not what you say that matters but the manner in which you say it; there lies the secret of the ages.”

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Kokopelli, the ancient fertility symbol.

“I’ve been told that my cancer is now cured… how do I get my fertility back?

Patients ask me this question weekly all the time and I am glad to help. Some of the most satisfying medical moments I’ve had are associated with these patients.

But when I hear this call for help, it also reminds me how medicine has been remiss in preventing the infertility in the first place. We can do better and we can do it right now.

The topic of fertility preservation is the substance of my recent lecture at the annual meeting of the American Society of Reproductive Medicine (ASRM) in Orlando, Florida. This well-attended course focused on the prevention, treatment and restoration of male fertility in the setting of sterilizing treatments typical of cancer therapy.

The goal of my lecture was to review and update providers on current and future strategies for the preservation and restoration of male fertility. Here are some of the ideas discussed. I’ve also included a link to the lecture slides if you are so inclined.

Preserving Male Infertility

• Sperm banking. A 200-year old technique that is the purest form of preventative medicine, it is vastly underutilized, not covered by insurance, and not routinely offered to many cancer patients before treatment. What gives? Here is where we need to do the most work in this field.
• Sperm Harvest. For 15 years, it has been possible, nay routine, to harvest sperm from men who want children after having a vasectomy without reversing the vasectomy. This same technology is easily applied to men before, during and after sterilizing cancer treatments. One very successful example of this in my practice is fine needle aspiration “mapping” of testicles for sperm in cancer survivors. Indeed, no-touch, metabolic imaging for sperm may be the ultimate iteration of this concept.
• Electroejaculation. Based on decades of successful use in spinal cord injured men, artificial stimulation of ejaculation can be a very effective way to bank sperm or restore fertility in men or post pubertal teens who have had nerve damage to reproductive organs from cancer surgery.
• Shielding Sperm Production. Physical shields are routinely used to block the effects of aberrant X-rays from hurting sperm production during treatment. In animal models, hormonally induced shut down of sperm production can protect the testicle during the storm of chemotherapy as well.

Restoring Male Infertility

• Stem cell transplantation. Currently possible in animal models, this involves taking the delicate testicle stem cells from either pre- or post-pubertal boys or men and freezing the cells before cancer treatment. Subsequently, the stem cells are thawed and replaced back into the testicle to restore sperm production after the cancer is cured.
• Sperm Maturation in a Dish. A variant of the above, also demonstrated in animal models, this technique involves maturing stem cells harvested from the testicle before cancer treatment in the laboratory all the way to their final form: a sperm with a tail.
•  Sperm from Stem Cells. Yet another variant of the above that has been demonstrated in animals, this involves growing usable sperm from early, pluripotent stem cells such as embryonic or adult pluripotent stem cells. One example would be to take a skin biopsy from a sterile man, coercing them to become adult stem cells and then push those cells to sperm in a dish. Truly, a fantastic outcome of America’s investment in stem cell technology.

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Testosterone: a molecule for life

I see a lot of patients who think that their testosterone levels should be higher for various reasons. I would like to set the record straight.

Even I have been heard to say that it is the “elixir of a man’s life.” Indeed, testosterone is one seriously important molecule throughout men’s lives. In the womb, it determines anatomic maleness. And during puberty, when another splash of testosterone hits boys and sticks for good, I don’t have to tell you what it does: feeds the growth spurt, cracks the voice, encourages hair growth, acne, stronger muscles and is the ultimate governor of teenage thought and action.

Testosterone in Adults

Testosterone in men is essential for health and well-being. First isolated in 1935, it is an anabolic hormone in that it generally induces growth. And it does this all over the body.  In the brain, it influences sex drive, assertiveness, mood, energy and some aspects of thinking and verbal memory. In the heart, it helps dilate the arteries, which is good. Testosterone increases muscle strength and maintains normal bone density.  It also reduces belly fat. In the kidney, it stimulates a hormone called erythropoietin that keeps blood counts normal. It also strengthens the immune system and helps blood to clot. In the male sexual organs, normal testosterone levels are important for erections and sperm production. So, it’s about as close to an “elixir” as any single circulating molecule in our bodies.

A List of What Testosterone Isn’t

Testosterone is not as vital to us as oxygen. For the record, here is what testosterone isn’t or doesn’t do:

• It is not a common reason for erectile dysfunction (<6% of cases).
• It is not a common cause for low sex drive.
• It will not help you get more dates or make you a sex machine.
• It will not magically make you a muscle man.
• It will not magically cause weight loss or reduce fat. This requires a diet and exercise program.
• It will not help you live forever; it falls with age.
• It does not cause prostate cancer or liver cancer.
• It is not higher during periods of stress; in fact, stress lowers testosterone levels.
• It is generally lower in athletes than non-athletes.
• It does not by itself cause baldness. Baldness is mainly genetic.
• It does not get lower the more you masturbate.
• It will not make you taller or your hands bigger as an adult.
• More testosterone will not solve all of your problems.

What’s absolutely key to testosterone management is that there are symptoms present in association with low levels. In such cases, the benefits of treatment are clear. Think of testosterone as oil in your car: it helps everything work better, but when a problem occurs, it is usually something else that has gone wrong.

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This white paper is red hot.

It has been said that we, like many other living creatures, were put on this good earth to eat, sleep and reproduce. In a minimalist, animalistic and mechanistic way, everything else is we do to make the world a better place is icing on the cake. Of course, we have free will and we can choose not to do any or all of these organic functions. However, I personally have not met anyone who has successfully avoided all three.

The Problem with Reproduction

In the big picture, what exactly does it mean if we try to reproduce and are unable to? With women, age is a clear determinant of fertility. They are born with all the eggs they will ever have, and when they run out fertility is no longer possible.

However, with men, the system is entirely different. The healthy adult human male makes 1200 sperm/heartbeat right up until andropause (7^th to 8^th decade) with new sperm produced constantly. So, when young men can’t reproduce because sperm production has ground to a halt, one has to wonder why such an important organic function is compromised. And this has led to boatloads of research over the last several decades into its causes and treatments, to the benefit of both patients and science.

The White Paper on Reproduction

A white paper is an authoritative report that helps solve a problem. White papers try to educate readers and help people make decisions. And I am delighted to announce that a white paper has recently been produced by the NIH regarding the issues surrounding infertility. As you may recall from prior posts, we met several months back in the middle of winter at the NIH headquarters in Washington DC, with the charge of identifying key opportunities in science that will define way we examine reproductive health over the next decade. At this meeting, I led a session on how infertility relates to overall health in men and women. Well, ta da, we now have the official White Paper from this meeting for your review at: www.NICHD.NIH.gov/vision.

White Paper Themes

Here are some of the overall themes of the white paper. What is very satisfying for me is the fact that several of my initiatives were carried through to the white paper:

• Overall health affects reproductive health, and reproductive health affects overall health.
• Reproductive and sexual health is essential to our wellbeing and serves as a window to overall health in males and females
• Reproductive research is the cornerstone of stem cell research and is central to the field of regenerative medicine
• Fundamental and applied contraceptive research is critical to this initiative as half of pregnancies in the US are currently unintended and unwanted
• A better understanding of human development is necessary to reduce the incidence of adult male and female infertility
• The effects of infertility on quality of life should be examined more thoroughly in future studies
• We need to develop a national database of prospectively collected reproductive health data (e.g., an NIH social health network).

Now it’s your turn. Do your country and me a favor and take a couple of minutes and glance at the white paper. Tell us if it’s on or off the mark. Send your comments to NICHDvision@mail.nih.gov. We need your opinion to help direct this science over the next decade.

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Mirror, mirror on the wall…

They called again and want to talk. Similar to a strict parent who gives you little clue as to where they stand, the National Institutes of Health (NIH) wants to have a conversation. I said: “Yes, absolutely.”

The NIH is nation’s power player in healthcare research. In 2010 it spent $32 billion or about $100 per American citizen forging new research paths, describing and curing disease, informing and transforming health care and keeping academic centers financially afloat. It is a model of healthcare research worldwide.

They want me to lead a think tank session next week in Washington D.C. at the NICHD headquarters. In the dead of winter, they are crystallizing plans to roll out a comprehensive new vision for reproductive health in America. This vision will lead to a white paper statement and guide the government’s research agenda for years to come. I am honored to attend.

Leading a session of experts from around the country, I will guide discussion of how reproductive health is a window to overall health, a topic upon which I have often reflected both here and in the published literature.

In preparation for this innovative meeting, I made a list of all of the medical conditions or illnesses that have been linked to male infertility or erectile dysfunction, either causally or by association. I also included conditions linked to having a past history of either of these sexual health disorders. What frightened me is that the list is 40 conditions long! Everything from diabetes to dyslipidemia, hypertension to heart disease, from tobacco use to sexually transmitted disease, and from chromosomal disorders to cancer. This list is extensive, sobering and reaffirms my deeply held belief that sexual health is a “window” into men’s overall health. Not only do male sexual health disorders coexist with many other medical conditions, but they also predict the future occurrence of even more.

So I will be showing up in Washington with my sleeves rolled up and ready to clean the sullied panes of the looking-glass, and hoping to clarify a new vision of men’s health.

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A walk among giants…

As President of the Northern California Urology Society, I held an interesting event in my office this week. I post it here because what I learned from it could apply to all of us in some small way.

It was an event meant to highlight the idea of mentors in our lives. Titled “Inside the Minds of Great Urologists,” it was modeled after the show called “Inside the Actor’s Studio” hosted by James Lipton on Bravo TV. Three internationally known, highly successful, academic urologists (Drs. Jack McAninch, Fuad Freiha and Ralph de Vere White) were featured and I acted as James Lipton and interviewed them. I asked them how they got where they are, what were their major influences and traits as they started and along the way, and what advice do they have for others. Quite a unique and modern venue for an old academic urology society.

What was incredible, though, was how revealing and educational the session was. The stories were short and full of meaty tidbits of advice from a blue ribbon panel of doctors. Most interesting were the answers to the questions that centered on how they got where they are, what they considered to be the secret sauce to becoming an “expert”. The major points are worthwhile summarizing here.

1. Enjoy what you do. If you have a passion, pursue it, as it will keep you smiling.
2. Don’t be jealous of others. Talent differs greatly from individual to individual.
3. Mentors help greatly in finding and pursuing your passion. Find and treasure them.
4. Stay focused. Stick-to-it-tiveness matters. “Be like a postage stamp. Stick to something until you get there.” (Josh Billings).
5. An expert involves many things, but importantly, the desire and capacity to constantly change and improve.
6. Be true to yourself and to others.
7. Make a difference if you can.

So there you have it. Straight from pretty reputable sources in my field. And from this, it seems to me that the secret sauce to being a successful urologist in America is probably quite similar to that of any other profession.

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How damaged is your genetic sheet metal?

Imaging parking your car at home after work and all the nicks and scratches are removed while you sleep, before heading to work the next day. All shiny and new, polished even, while you sleep. Believe it or not, this is normally what happens to your genes and chromosomes on a minute-to-minute basis. DNA mismatch repair is a constant and vigilant process, occurring in all cells of the body. Why the biologic vigilance?  Well, It keeps us whole, healthy and cancer free.

About 11 years ago, we published a paper showing for the first time that infertile men can’t repair the errors normally encountered in their DNA as well as normal men. This was startling news in part because it implied that infertile men may be more likely to develop other problems later in life, including cancer. Why cancer? Because the development of cancer has been associated with the inability to normally repair the frequent daily errors that occur to one’s DNA as the body’s cells divide and renew.

Today, however, we know much more. We know that testis cancer is 3-fold more likely to occur in previously infertile men than in fertile men as they age. And our latest research has shown that prostate cancer, thought to be a disease exclusive to older men, occurs more seriously and more commonly in previously infertile men.

So what does this mean? Is male infertility the first sign of a larger problem in our species? It is the ultimate medical problem of a species trying to reproduce?  Well, honestly it isn’t entirely clear. However, to me it indicates that male infertility should certainly be considered an insurable and real medical condition that should be taken as seriously as a heart attack. Even more worrisome is the issue of whether the use of sperm from severely infertile men is putting their offspring at even higher risk of medical issues than that experienced by their fathers.

So do not ignore the infertility issue when it strikes and get that male partner evaluated by a specialist. Teach him to perform testicular self-examination, a simple maneuver performed once monthly in the shower that has far more potential to extend his life than even exercising or weight control. Educate him about prostate cancer so that he does not ignore the powerful screening tools available to find it early. The age of innocence is over. The warning signs are now clear; get men the care that they deserve.

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A stem cell in a dish is worth a hundred different therapies.

Not all stem cells are alike. News to you? Maybe not, but it has hit researchers pretty hard over the past several weeks. As you may have garnered from prior essays on this blog, stem cells are potentially capable of morphing into many different tissues, such nerves, heart or liver, and are the next wave in medical therapy for all kinds of diseases affecting both the young and the old. The medical treatment that they will bring to the table is called “personalized, cell based therapy.”

One huge problem is that the best kind of stem cell, the one that can do the most, is created from embryos. The embryonic stem cell has many “issues” though: derived from embryos, retrieval ethics, not patient specific, created by cloning, inefficient to produce and the like. Because of this, research has focused on alternatives like transformed adult stem cells or our very own untransformed testicular stem cells. The news today concerns the quality of adult-type stem cells that are “reprogrammed” and transformed into embryonic-like stem cells, also termed induced pluripotency stem (iPS) cells.

Well, there appear to be growing pains for the iPS cell, an embryonic stem cell alternative. Developed in 2006 from adult skin cells, researchers genetically manipulated a specialized adult cell, transforming it back to an unspecialized state. Since then, hundreds of labs have leaped into the burgeoning adult stem cell field.

The ideal stem cell is like a blank slate. It is capable of becoming any other tissue, and is immortal. True embryonic stem cells are like this, but, according to several recent publications, many iPS cell lines are not really blank slates. Also, it appears that nerve and blood cells made from iPS cells grow poorly and age quickly and may even “remember” what cell from whence they came. Some even conclude that iPS cells may not even be considered a practical choice for cell-based therapy down the line.

The realization that iPS cells are not exactly like the gold standard embryonic stem cells has slowed the field down a bit, but it is an important observation. Like people or even wine, stem cells are a bit different from one another, each with their own personality, temperament and potential. Some do this better than that, and others do that better than this. It suggests that stem cell-based therapy may eventually involve tapping into a mixture of different stem cells to cure the problem. Now that’s an old fashioned idea: a little of this and a little of that…

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Can we be DNA barcoded like a soup can in a grocery store?

How many of you would take a blood test to learn exactly how long you will live? How about whether or not you will become demented? Since the Human Genome Project ended, the genes and mutations associated with a vast array of diseases are being discovered daily and it is pretty easy to just put them on “chip” and make them available to the public.

Don’t get me wrong; gene testing already has already improved our lives. Such tests can clarify a diagnosis and better direct care, while others allow families to avoid having children with life-threatening or disabling conditions. They can be used to prevent disease before it happens, as with monitoring and removal of colon growths among those who have a gene for familial polyposis, and can diagnose common iron-storage diseases early enough to treat them and prevent them from becoming fatal. They can also help to positively identify murderers two decades after the crime.

One real problem is that many commercialized gene tests are targeted to healthy people who might be at high risk because of a strong family medical history for a disorder. Unfortunately, because of how complex we are as biological organisms, the tests give only a “probability” for developing the disorder. That means that some people who carry a mutation may never develop the disease. Another limitation is the possibility of laboratory errors. What this means is that the tests are not perfect and could be wrong.

And what happens to your job prospects and health (or life) insurance rates when it is learned through genetic testing that you might develop a significant disease? Well…nothing. Because of the federal GINA Law (Genetic Information Nondiscrimination Act) passed in May 2008, insurance companies and employers cannot discriminate on the basis of information derived from genetic tests. So, genetics has now been added to the list of characteristics first embodied by the Civil Rights Act of 1964, that states that U.S. employers cannot discriminate according to race, color, national origin, sex, or religion. And this is good.

So, go ahead and take the “23 and Me” “DeCode” or “Navigenics” genomic screens if you so desire. Get to know your DNA barcode. Maybe you will get an idea of what may be around the corner for you. And maybe, just maybe, you will take better care of yourself knowing more about your genes. Just understand that many in the medical community feel that uncertainties surrounding test results, the current lack of available treatment options, the tests’ potential for provoking anxiety and social stigmatization could outweigh the benefits of testing. You know the saying: “Too much information…”

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One famous fountain: the mannequin pis in Belgium

As a man ages, he is more likely to look at travel experiences as a series of restroom stops. He might begin navigating his way to the grocery store, the gas station or to a friend’s house for poker based on whether or not there’s a restroom conveniently located nearby. This may sound like the end of the world, but it’s not. It may be the end of long road trips. It is also the start of the realization that, similar to needing reading glasses, he is not immortal but actually a simple human being.

The prostate is a gland the size of a walnut at the base of the penis. It wraps around the urethra (the tube that urine comes from). A prostate is essential for normal male fertility, as it is responsible for making fluid that protects and nourishes sperm. Everything is shipshape until a man gets older, when two problems can arise. One is benign prostatic hypertrophy (BPH), which is a fancy way of saying enlargement of the prostate. This occurs in about half of all men in their sixties. For reasons still unclear, the prostate continues to grow as a man gets older. It is usually symptomatic – men have urinary urgency, dribbling, weak stream and may have to get up at night to urinate. The other problem is prostate cancer. Most commonly, cancer has no symptoms.

BPH is not preventable, but prostate cancer may be. Following a heart-healthy, low-fat, low carbohydrate diet is key to the prevention strategy, as are exercise, weight management and stress reduction. Concentrate on fruits and vegetables, which are high in antioxidants that protect the cells of your body from becoming cancerous. Soy and green tea may also protect the prostate. Sugar intake should also be limited, as it often ends up stored in your body as fat, and obesity is linked to prostate cancer.

That said it may surprise you to know that prostate cancer doesn’t always kill. Cancer is no one’s friend, but prostate cancer is not as deadly as lung cancer, colon cancer or breast cancer. It is much more slow-growing than these other cancers, doubling in size every 2-3 years instead of every 4-6 months. As such, a man is eight to ten times more likely to die of heart disease than prostate cancer. Even more interesting, some believe that prostate cancer is really a disease of age in men, as the likelihood of having small amounts of cancer in the prostate goes up with age. That means that about 80% of 90 year old men will have prostate cancer, and may never know it. They will likely die of unrelated causes. It also means that there are many prostate cancers occurring in men that are “clinically insignificant,” a rare term in cancer medicine. So, many prostate “cancers” actually don’t act as such.

Although diseases of the prostate are rarely lethal, they can affect your quality of life…and your road trips. Men over forty should start to have the prostate checked regularly, although most men would rather spend quality time with the dentist’s drill than go in for that exam. Blood tests for a substance called PSA, can also help detect cancer. The symptoms of prostatic enlargement can treated with pills; if these don’t work, various, safe but indescribable procedures can remove the symptom-causing prostatic tissue. Some of the FDA approved pills to treat BPH also prevent prostate cancer. Now that’s a pill that men might want to swallow. So, for all kinds of reasons, don’t ignore the prostate. Try to attend to it before it disrupts the flow of your daily life.

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