Your Urology Questions - Answered!
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Show notes:
How much did you learn about urology in school? If your answer was “not a whole lot,” welcome. Most Nurse Practitioner programs do not cover urology concerns in great depth, which can contribute to a real lack of clarity once you start practicing.
You May Double Or Triple Your Knowledge Of Common Urology Concerns Today
Urology has a fair amount of overlap with other specialties, which can blur the lines. Does a kidney stone go to urology or nephrology? Is erectile dysfunction best managed in primary care or urology? Are recurrent urinary tract infections best suited to primary care, gynecology, or urology?
This week, we talk with Dr. Joseph Acquaye, who answers all of the questions that you submitted about urology. In this interview, we talk about:
When to refer your patient to urology, and what happens when you do
Urinary incontinence
Testosterone replacement
PSA screening – how to interpret, and when to stop screening
Imaging – should you order it before sending your patient to urology?
Not every patient that is referred to urology will be managed by urology indefinitely; in this interview, we also cover when it is appropriate for the patient to be sent back to primary care for ongoing care. The relationship between urology and primary care can be a dynamic one, and works well for the patient when both sides have a good understanding of what the other can do for the patient.
Dr. Joseph Acquayesays that his favorite part of working in urology is the wide variety of topics that he encounters on a daily basis. Whether performing a procedure, working with a couple to understand and address the impact of erectile dysfunction on them, or coming up with an approach to treat the tricky interstitial cystitis, there is always something different waiting in the urology office.
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Hey there, welcome to the Real World NP podcast. I'm Liz Rohr, family nurse practitioner, educator,
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and founder of Real World NP, an educational company for nurse practitioners in primary
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care. I'm on a mission to equip and guide new nurse practitioners so that they can
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feel confident, capable, and take the best care of their patients. If you're looking for clinical
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pearls and practice tips without the fluff, you're in the right place. Make sure you subscribe and
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leave a review so you won't miss an episode. Plus you'll find links to all the episodes with
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extra goodies over at realworldnp.com slash podcast. In this week's episode, I interviewed
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Dr. Joseph Akwai. He is a urologist, and we sourced questions from the Real World NP community
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about urology. The general theme being what you wish primary care providers knew, and then what
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we would like to ask you. So we talked about things like microscopic hematuria, BPH, incontinence,
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and erectile dysfunction, so many, so many different things and things that he wishes we
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knew, and pet peeves, and it was just, it was so much fun. So I can't wait for you to watch or
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listen to this episode. If you haven't already, please do grab the ultimate resource guide for
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the new NP. Head over to realworldnp.com slash guide. You'll get these episodes sent straight
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to your inbox every week with notes from me, patient stories, and bonuses I really just
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don't share anywhere else. Without further ado, here is my interview. Thank you so much for
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being here. Can you introduce yourself?
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All right, thank you for having me. First of all, my name is Dr. Joseph Akwai. I'm a urologist
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with WellSTAR at the Douglasville, Georgia location. And yeah, I'm looking forward to this
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opportunity to discuss some of the common urologic issues that probably come up on the
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primary care landscape and, you know, talk about some do's and don'ts and, you know,
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recommendations for things that we get consulted on pretty routinely.
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Awesome, awesome. I'm so, so, so happy you're here. So the first question I have, which
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is kind of the theme of this full interview is like, maybe a place to start is like,
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what do you wish primary care providers knew in the context of urology?
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Okay, so I think there's like three general categories where there might be some
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knowledge gap, but something that would make it a little more streamlined in terms
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of what gets sent to urology. So the three areas are renal masses, microscopic
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hematuria, and PSA screening. Okay, so I think I'll start with renal masses. So
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we get a lot of consults on renal masses, you know, a lot of times are
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incidentally discovered, let's say somebody gets in a car accident, or gets
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imaging for something else, and a renal mass shows up on their CT scan or
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their ultrasound. And I get sent those patients a lot. And a lot of times, I
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think that, you know, a lot of the private providers who are sending those
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patients over, haven't looked at the patients prior imaging to realize that
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renal mass that we're being consulted on has been there for like 10 years. So
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when I get this consult, it's like, oh, yeah, you mean that one that you
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had back in 2009? Yeah, it's the same size, nothing to do. So I think
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that's, that's, that's a common one. And I think that's an easy fix. You
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know, anytime you get imaging, especially with a new mass, you know,
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just make sure it's actually new. Take a look at the previous imaging and
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make sure it's stable. You know, we don't really get excited about renal
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masses until they hit three or four centimeters. And if it's been stable
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for years, then it's probably benign. So really nothing to do on that
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regard. So I do think that's a good, easy thing to think about whenever you
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get a consult for renal masses. And on the same vein, I guess I could
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also talk about kidney stones.
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Yes. Oh, yes, I forgot to mention that. There's so many questions about
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kidney stones. All the gems and pearls, please.
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Yeah, so I think a basic principle about kidney stones is that of course,
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you can have kidney stones that are actually just in the kidney, not
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obstructing, just kind of sitting there. And you can have kidney
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stones in the ureter, which are obstructing and obviously going to
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cause some symptoms. So I get a lot of consults on not obstructing
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kidney stones. And if a person has a kidney stone that's just been
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sitting in their kidney, and the same principle, it may have been there
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for years and years, and it's just hanging out, no reason to consult.
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It gets a little more nuanced when the stone is large, let's say it's
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bigger than one centimeter, then it's more reasonable to send a
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consult over. The reason is because a lot of times they're going to
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require some treatment for that stone, potentially in the future,
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because they're more likely to become symptomatic, or be a
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nidus for recurrence infections. So that's one thing to kind of
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think about. But if it's like a three millimeters, not obstructing
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stone, it's just been sitting there, it came up incidentally on
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imaging, no reason to send it to urology, because we're going to
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send it right back.
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That'll be $300, please. No, but really nothing to do there.
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With those stones, though, I could get some of the rationale
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behind sending them. Because when you do a urinalysis, one
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person with a rusting stone, there's usually going to be
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blood there, some microscopic hematuria. But yeah, I guess
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that's a good segue to the next thing, microscopic
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hematuria.
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Yes, 100%.
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Microscopic hematuria, of course, depending on how you're
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measuring it, they have a dipstick, it'll say one plus,
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two plus, three plus, or trace. We usually don't really get
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excited, anything below two plus. So if it's trace or
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one plus, that says something, you say, hey, let's retest it in
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like, six weeks and see if the UA shows anything. If it's
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persistently positive, or it's increased, then of course, I
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think it's reasonable to send over a console. But if it's
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very trace amounts, no reason to send that. Especially if
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it's in the setting of an infection, or you're on
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platelet-started plavix, or there's a clear etiology for
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what could cause the microscopic hematuria, you can
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lay that console and just repeat a UA in like, six
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weeks. And if it's still positive, then yeah, send it
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over, you know, we'll do the workup. For microscopic
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hematuria, the workup entails some type of upper tract
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imaging, so typically a CT, a Urogram, and it also
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entails cystoscopy, you know, and then a lot of times
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we'll do the workup, it's negative, and we'll send them
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back. And they may have persisted hematuria, but you
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know, I wouldn't get too excited about it. But let's say
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two years down the road after the negative workup, if they
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still have it, then it's reasonable to say, okay,
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maybe you should talk to the urologist again. And sometimes
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we'll do a repeat workup. And then sometimes we're like,
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yeah, there's nothing, it's probably a renal cause. Because
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a lot of it can be a renal cause, and some people are
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just going to have microscopic hematuria. Yeah,
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I'd say first things first, make sure it is not another
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plausible explanation. And if it's trace or one plus, just
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repeat the UA in a couple of weeks, to make sure that
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really have, you know, nothing's going on.
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Yeah, I was gonna say I so appreciate that. Because I
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think like, I think, and I don't know if you
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experienced this as a newer physician, but I remember
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especially as a newer grad, I'd be like, there's
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microscopic hematuria, like, I need to like deal with
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this right now. And especially like in the
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context of like BPH, because that's pretty common, right? If
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BPH, you can have that hematuria, especially with small
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amounts, and be like, well, what do I do? Should I send?
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Should I send them even though they have BPH? What if
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they have bladder cancer on top of it? Like, I just got
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really in my head about it. So it's like helpful to hear
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that from from your perspective of like, it
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really is that time based thing. Is there and I had a
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lot of questions about the workup before sending for
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hematuria. Because it sounds like imaging is a really big
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part of it. But also, do you recommend like, anything
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aside from your analysis? Do you do your in cytologies?
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Like, what is your what are your thoughts about that?
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Yeah, the most updated guidelines do not recommend
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cytology from microscopic hematuria. If they have
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growth, then yeah, you go full tilt, which is the
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cytology, the CTU, and then referring for
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cystoscopy. So you know, different practices work
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differently. So I know a lot of people refer and they
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don't want to do the CTU before they refer, because
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they want the urology and everything. But you know,
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some people will do the CTU before they send them to
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urology. That way, once they see the urologist, we
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just say, okay, we looked at your upper tract imaging,
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and we'll go with cystoscopy. Now sometimes,
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obviously, the upper tract imaging shows something
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really obvious, like a bladder mass or a huge stone
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or a bladder stone. So in those cases, it kind of
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streamlines the process because we're not going to
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do a cystoscopy on somebody who has a clear cause, we
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might just schedule them for example.
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I'm sorry, what did you do? You scheduled them for
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what?
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Oh, for the OR.
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Yeah.
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We'll just go straight to OR, we're not going to
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go through the whole thing. But yeah, the big
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delineation is microscopic hematuria is just imaging
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and cystoscopy. Gross hematuria is imaging,
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cystoscopy, and a cytology. That's the big difference.
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That's so helpful. Thank you so much. Yeah. And I think
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there's a ton of questions, with most specialties, too, of
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like, what imaging do we get first? Because I like just for
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context for newer clinician listeners and viewers, like,
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like, that's one of the discomforts people have is
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like, should I order this test that I don't really know
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how to interpret? Because I'm like, I don't do it all the
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time, versus is it much more helpful to have the imaging, you
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go to the appointment, and then they've saved so much time.
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And that's my personal philosophy of practice, like,
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even like in primary care, it's like, you're, you have
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to know all the specialties a little bit, right? And so
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that's my philosophy, typically, with patients is
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like, hey, we're going to do this imaging, we'll see
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what the results are. But like, this is on like, this
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is to help the urologist once we get there.
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Yeah, yeah. And I think, you know, I have, I'm not
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bothered either way. I know, I practice this work
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differently, and people have different comfort levels.
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But yeah, as long as consult is indicated, yeah, if we
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have to order the imaging or the imaging, it's not too
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much of a burden there. But yeah, I think this is just
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a matter of, of how you're going to do it, how you're
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going to approach it.
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Yeah, yeah. And I have a question. Do you have any
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pet peeves of primary care providers? You can also
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take a pass if you don't want to answer, we're not
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going to come for you.
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My second going to the next one, which is PSA screen.
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Oh, yes, yes, yes, yes, yes. Yes, I sorry. Would you
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get to the third one? Okay. Go ahead.
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I, I would say that's part of my pet peeve about
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consult. So I know that's, you know, the
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guidelines are kind of fluctuating. But generally,
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the guidelines say start PSA screening at 50, or at
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age of 10 years before the first degree relative
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had it. So for example, if their dad had it at 50,
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then the person will start screening at 40. And
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then the consensus is to stop at 70. Or, you
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know, sometimes you have the discussion with the
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patient if they want to continue screening. So
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my pet peeve is when I get the 85 year old
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patient who just has a PSA, and the PSA is like
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sky high. And now we have to have this weird
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discussion with this screening in the first
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place. And of course, they're nervous, you
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know, because they have a PSA, they might have a
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PSA of 20 something. And now it's like, what do
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you want to do? Are we going to biopsy you?
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Are we going to go that route, that route? You're
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going to need surgery, you're going to need
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radiation. And a lot of times, you know, you
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can convince them that, hey, you're 85, like
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prostate cancer is slow growing, it's probably
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not going to have any clinical significance for
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10 years. A lot of times they don't want to
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hear that, like, oh, I need to do something.
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And you know, these workups we do for
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prostate cancer, not benign, like prostate
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biopsy, you know, the side effects or the
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outcomes can be pretty deadly, especially if
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they get like an infection, for example,
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prostate infection is not a small thing. And
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especially with an older person who has less
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of a reserve. So I think that I always
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encourage PCPs to just stick to the guidelines
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and from the PSA screening. I know it's
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obviously a little hard because, you know, a
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lot of times it's part of a big panel. So
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they're just doing a yearly physical and it's
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just a checklist. One of the checklists is a
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PSA. But unless they're like a really healthy
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70, you know, you have 70 year olds who are
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like super healthy, no comorbidity. Yeah.
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You know, it's reasonable to keep screening
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them. But if it's like a guy with a
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thousand comorbidities and he probably is
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not going to have prostate cancer, probably
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low on the things that's probably going to
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kill him. I would not continue to screen
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them because it does basically start this
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whole cascade of events that continue for
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the rest of their life when they could have
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just avoided that altogether.
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Totally. People had questions also about
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thresholds for PSA referrals. Do you
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have like any thoughts about that of like
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any abnormals come to see you? Or do we
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do a trend over time? Like, I feel like
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it's been so contentious with PSA back and
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forth over the years.
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No, I think it's reasonable just as long
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as it's elevated, you know, above four.
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Because when you set it over, we have the
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discussion for the subsequent discussion.
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We say, hey, your PSA is mildly elevated.
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Here are your options. We can do a biopsy
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and just go aggressive. We can do an MRI
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if you want to skip that and see if
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there's any lesions that are potentially
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amenable to biopsy. Or we can just watch
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your PSA and repeat it again in like
256
00:14:44.200 --> 00:14:46.760
six months. And a lot of patients will
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opt for one of the three. So we can
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have that discussion. I don't mind having
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that discussion with the patient because
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it is a more nuanced urology discussion.
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But sending them over is fine. I think
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you just use a lot of thresholds, you
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know. If it's four, then yeah, use four
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as your threshold. And above four, just
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send them over. Sometimes, though, you
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have to also, it can be prudent
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because let's say they've been like
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zero, zero point one, zero point three,
269
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and all of a sudden they have a PSA of
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20, you know. And then you got, okay,
271
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did you do something different or
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something going on? Or is there a
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lab error? For example, patients who
274
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take up bike riding and they have
275
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perineal pressure, their PSA will be
276
00:15:24.940 --> 00:15:27.220
falsely elevated. Or if they recently
277
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have it replaced, or if they recently
278
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had an infection, all of these can
279
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falsely elevate PSA. So sometimes I'll
280
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get these crazy consults and it's like,
281
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oh yes, PSA just jumped to 20. I
282
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think he's got metastatic prostate
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cancer and I'll just repeat the PSA
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and it's zero again. Because, so if
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there's a weird outlier, you know,
286
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I'll be like, okay, that's kind of
287
00:15:47.740 --> 00:15:49.760
weird. I'll check it again in three
288
00:15:49.760 --> 00:15:52.580
months or something, just to make sure
289
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it's not anything, or not like,
290
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it's like six weeks. And I mean, you
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know, if you send those, that's fine,
292
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but that's just something to keep in
293
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mind, especially if it's not making
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sense in your head as to why this PSA
295
00:16:04.780 --> 00:16:06.680
trend is off. But no, I think it's
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reasonable just to send the consult
297
00:16:08.580 --> 00:16:10.960
over and we'll have that discussion
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00:16:10.960 --> 00:16:12.220
what they want to do next.
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I so appreciate you sharing that
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because like I think that I really
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want to highlight, especially for
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00:16:17.940 --> 00:16:19.740
newer clinicians, adjusting that like
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we don't have to do it all and we
304
00:16:22.360 --> 00:16:23.980
don't in fact have the time and we
305
00:16:23.980 --> 00:16:25.100
don't have the nuanced knowledge to
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have those conversations, whether it's
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00:16:27.060 --> 00:16:29.360
NP or MD in primary care. And I
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00:16:29.360 --> 00:16:30.740
think that it's just really helpful
309
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to hear, like what's on the other
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side? Like I think I'm just, I'm such
311
00:16:34.600 --> 00:16:36.560
a nosy curious person to begin with
312
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that I just like want to hang out in
313
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all the specialties and like what
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00:16:39.220 --> 00:16:40.960
happens, you know, so the fact that
315
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like that's what's going to happen
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00:16:41.920 --> 00:16:43.200
when you get there, when the patients
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00:16:43.200 --> 00:16:45.280
get there, like I can explain to
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them, like this is the process to
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00:16:46.700 --> 00:16:48.840
expect, even if I don't have the
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nuanced conversation about PSA, so
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it's cool. So I have some other
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questions from people. So you
323
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kind of touched about stones. So
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you primarily, when it comes to
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kidney stones, I guess the
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question is people want to know
327
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about urology versus nephrology
328
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because I know there's bladder
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stones, there's ureter stones,
330
00:17:12.579 --> 00:17:13.560
there's kidney stones, like what are
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your thoughts about urology and
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00:17:15.220 --> 00:17:16.980
nephrology from that perspective?
333
00:17:18.119 --> 00:17:19.980
Yeah, so nephrology is not going to
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do anything for your kidney stones.
335
00:17:24.359 --> 00:17:26.420
So just to clear up that myth there,
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just because it's in the kidneys,
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they don't own it.
338
00:17:29.620 --> 00:17:32.000
Okay, so they're just going to send
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00:17:32.000 --> 00:17:34.840
it to urology. Yes, like I said, I
340
00:17:34.840 --> 00:17:36.620
think the major delineation you
341
00:17:36.620 --> 00:17:38.140
have to be concerned about is this
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00:17:38.140 --> 00:17:39.920
an obstructing stone? And of course,
343
00:17:40.000 --> 00:17:41.600
if it is, the patient will know
344
00:17:41.600 --> 00:17:43.340
and that's something you send to
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00:17:43.920 --> 00:17:45.640
urology, right? If it's a
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00:17:45.640 --> 00:17:47.060
non-obstructing stone that's just
347
00:17:47.060 --> 00:17:49.080
in the kidney, once again, the same
348
00:17:49.080 --> 00:17:51.080
principle with renal masses, see if
349
00:17:51.080 --> 00:17:52.800
you can see any evidence of this
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00:17:52.800 --> 00:17:54.860
stone on previous imaging, if it's
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00:17:54.860 --> 00:17:57.860
available. If you are going to do
352
00:17:57.860 --> 00:17:59.300
any type of stone work, if you
353
00:17:59.300 --> 00:18:00.640
have a question about a stone, don't
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00:18:00.640 --> 00:18:01.820
order an ultrasound, I don't know
355
00:18:01.820 --> 00:18:02.860
how to read those for stones,
356
00:18:02.920 --> 00:18:03.820
they're not really helpful.
357
00:18:05.040 --> 00:18:07.160
A CT non-contrast is good.
358
00:18:07.860 --> 00:18:09.500
That's another pet peeve when people
359
00:18:09.500 --> 00:18:11.120
order ultrasounds for stones because
360
00:18:11.120 --> 00:18:12.540
I always have to order a CT
361
00:18:12.540 --> 00:18:15.920
because I will say, yeah, maybe you
362
00:18:15.920 --> 00:18:18.180
can see a stone, recommend CT.
363
00:18:18.520 --> 00:18:19.720
So it's like you're just having,
364
00:18:19.900 --> 00:18:21.720
you're just doing imaging for no
365
00:18:21.720 --> 00:18:25.500
reason. But yeah, I think with
366
00:18:25.500 --> 00:18:27.420
kidney stones, they're under
367
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urology's purview and if they're
368
00:18:29.340 --> 00:18:30.640
obstructing or if they're really
369
00:18:30.640 --> 00:18:32.040
big, like I said, over one
370
00:18:32.040 --> 00:18:33.900
centimeter, reasonable to send it
371
00:18:33.900 --> 00:18:35.040
over. If it's a small little
372
00:18:35.040 --> 00:18:37.080
punctate stone and even if they're
373
00:18:37.080 --> 00:18:39.080
bilateral and they're not having any
374
00:18:39.080 --> 00:18:41.520
symptoms, no reason to send that
375
00:18:41.520 --> 00:18:42.400
because we're not going to do
376
00:18:42.400 --> 00:18:43.220
anything about it.
377
00:18:43.560 --> 00:18:45.460
There's no indication to go and
378
00:18:45.460 --> 00:18:46.600
clear out the stones in the
379
00:18:46.600 --> 00:18:48.720
kidney because oftentimes you'll
380
00:18:48.720 --> 00:18:50.400
do more harm than benefit.
381
00:18:50.920 --> 00:18:53.200
The only would be after having
382
00:18:53.200 --> 00:18:54.540
recurrence infections, for
383
00:18:54.540 --> 00:18:56.000
example, or after having a lot
384
00:18:56.000 --> 00:18:57.880
of pain because there are people
385
00:18:57.880 --> 00:18:59.340
who will have flank pain without
386
00:18:59.340 --> 00:19:02.300
an obstructing stone when the
387
00:19:02.300 --> 00:19:04.000
stones are big. And sometimes
388
00:19:04.000 --> 00:19:05.960
it's like, okay, I've worked
389
00:19:05.960 --> 00:19:08.060
this person up and let's just
390
00:19:08.060 --> 00:19:09.460
send them to urology. They're
391
00:19:09.460 --> 00:19:10.540
annoying consults, but we
392
00:19:10.540 --> 00:19:12.960
understand that you're really
393
00:19:12.960 --> 00:19:14.120
kind of pushed to that point.
394
00:19:14.860 --> 00:19:16.520
Yeah, totally. Do you have any
395
00:19:16.520 --> 00:19:17.920
guidance also about ordering the
396
00:19:17.920 --> 00:19:19.120
CT Urogram?
397
00:19:20.440 --> 00:19:23.960
Yeah, so usually imaging centers
398
00:19:23.960 --> 00:19:25.360
have a protocol, so as long as
399
00:19:25.360 --> 00:19:28.660
you put CT Urogram or you put
400
00:19:28.660 --> 00:19:31.220
it in the, because it's with
401
00:19:31.220 --> 00:19:32.880
IV contrast, so let's say you
402
00:19:32.880 --> 00:19:35.040
don't have CT Urogram, you
403
00:19:35.040 --> 00:19:36.500
can just put CT with IV
404
00:19:36.500 --> 00:19:38.360
contrast and then the comments
405
00:19:38.360 --> 00:19:40.940
write Urogram. The imaging
406
00:19:40.940 --> 00:19:41.860
center should know what that
407
00:19:41.860 --> 00:19:45.460
entails. A CT Urogram would only
408
00:19:45.460 --> 00:19:47.900
be for hematuria workup. If
409
00:19:47.900 --> 00:19:49.120
it's a stone, you can simply
410
00:19:49.120 --> 00:19:51.000
just put a CT non-continue.
411
00:19:51.000 --> 00:19:54.340
Yeah, that's awesome. I'm
412
00:19:54.340 --> 00:19:55.200
trying to think of the other
413
00:19:55.200 --> 00:19:57.040
questions we had. I think a
414
00:19:57.040 --> 00:19:59.720
really big one is about, I
415
00:19:59.720 --> 00:20:01.620
think three big ones, and we
416
00:20:01.620 --> 00:20:02.440
can pick and choose depending
417
00:20:02.440 --> 00:20:05.060
on time, but I think there's
418
00:20:06.900 --> 00:20:10.820
erectile dysfunction, BPH, and
419
00:20:10.820 --> 00:20:12.320
incontinence. I think there's a
420
00:20:12.320 --> 00:20:13.580
lot of questions. The main
421
00:20:13.580 --> 00:20:15.760
thing is there's resources to
422
00:20:15.760 --> 00:20:17.180
consult about how to best
423
00:20:17.180 --> 00:20:19.340
manage those, but then I think
424
00:20:19.340 --> 00:20:20.360
there's questions a lot of
425
00:20:20.360 --> 00:20:21.400
people have with those,
426
00:20:21.400 --> 00:20:22.600
especially those conditions of
427
00:20:22.600 --> 00:20:25.400
like at what point, yeah,
428
00:20:25.460 --> 00:20:26.500
like at what point when you
429
00:20:26.500 --> 00:20:27.780
find an enlarged prostate, if
430
00:20:27.780 --> 00:20:30.240
it's like a first diagnosis, is
431
00:20:30.240 --> 00:20:31.260
that something that the
432
00:20:31.260 --> 00:20:32.640
primary care provider should be
433
00:20:32.640 --> 00:20:34.120
managing versus do you refer
434
00:20:34.120 --> 00:20:36.660
urology right away? Yeah, like
435
00:20:36.660 --> 00:20:38.000
I said, let's start with maybe
436
00:20:38.000 --> 00:20:40.040
enlarged prostate to start and
437
00:20:40.040 --> 00:20:40.920
then we'll talk about the
438
00:20:40.920 --> 00:20:41.560
other topics.
439
00:20:42.120 --> 00:20:43.280
Yeah, so I think it depends on
440
00:20:43.280 --> 00:20:44.620
the initial presentation. So
441
00:20:44.620 --> 00:20:45.880
right, there's a guy with
442
00:20:45.880 --> 00:20:47.200
enlarged prostate who's like,
443
00:20:47.200 --> 00:20:48.280
yeah, I'm having a little
444
00:20:48.280 --> 00:20:50.300
trouble with peeing and my
445
00:20:50.300 --> 00:20:51.060
stream is a little bit
446
00:20:51.060 --> 00:20:52.140
weaker. And then there's a guy
447
00:20:52.140 --> 00:20:53.680
who comes in with urinary
448
00:20:53.680 --> 00:20:54.960
retention and he's got like
449
00:20:54.960 --> 00:20:55.940
a thousand liters in his
450
00:20:55.940 --> 00:20:57.600
bladder. So obviously that
451
00:20:57.600 --> 00:20:59.680
second guy, that should be an
452
00:20:59.680 --> 00:21:01.360
immediate referral to urology
453
00:21:01.820 --> 00:21:03.280
because his retention is going
454
00:21:03.280 --> 00:21:04.400
to need something more than
455
00:21:04.400 --> 00:21:05.700
just medical treatment. You
456
00:21:05.700 --> 00:21:07.260
can initiate medical treatment,
457
00:21:07.380 --> 00:21:08.320
but that person's going to
458
00:21:08.320 --> 00:21:10.240
need to see my urology. The
459
00:21:10.240 --> 00:21:11.960
other guy who's like, yeah,
460
00:21:12.040 --> 00:21:13.860
I'm a little trouble peeing and
461
00:21:13.860 --> 00:21:14.780
you know, I want to try
462
00:21:14.780 --> 00:21:16.140
something. It's reasonable to
463
00:21:16.140 --> 00:21:19.460
start Flomax. It's the most
464
00:21:19.460 --> 00:21:21.060
side effect profile. You
465
00:21:21.060 --> 00:21:21.880
know, you basically just have
466
00:21:21.880 --> 00:21:22.760
to tell them, hey, take it
467
00:21:22.760 --> 00:21:23.640
at nighttime because it's
468
00:21:23.640 --> 00:21:24.480
going to make you kind of
469
00:21:25.140 --> 00:21:27.060
drowsy potentially. And then
470
00:21:27.060 --> 00:21:28.300
you always have to let the
471
00:21:28.300 --> 00:21:29.660
men know about the retrograde
472
00:21:29.660 --> 00:21:30.900
ejaculation because it's
473
00:21:30.900 --> 00:21:31.960
always a number one thing.
474
00:21:31.960 --> 00:21:34.600
Oh, I'm not, I was not aware
475
00:21:34.600 --> 00:21:35.780
of. Thank you for telling us.
476
00:21:36.720 --> 00:21:38.840
So that one, basically because
477
00:21:38.840 --> 00:21:41.120
it relaxes the muscle of the
478
00:21:41.120 --> 00:21:42.180
prostate, that's what the
479
00:21:42.180 --> 00:21:43.740
ejaculatory ducts are as well.
480
00:21:43.820 --> 00:21:44.720
So some of the ejaculation
481
00:21:44.720 --> 00:21:45.600
is actually just going to
482
00:21:45.600 --> 00:21:47.280
dribble out and some will go
483
00:21:47.280 --> 00:21:48.440
back to the bladder and then
484
00:21:48.440 --> 00:21:49.400
suddenly like, hey, what's
485
00:21:49.400 --> 00:21:50.340
going on? And so you just
486
00:21:50.340 --> 00:21:51.740
let them know that's a
487
00:21:51.740 --> 00:21:52.800
potential side effect. But
488
00:21:52.800 --> 00:21:53.580
aside from that, it's a
489
00:21:53.580 --> 00:21:54.640
pretty minimal side effect
490
00:21:54.640 --> 00:21:56.820
profile. So I always just
491
00:21:56.820 --> 00:21:57.720
start them and have them
492
00:21:57.720 --> 00:21:59.460
follow up in three months. And
493
00:21:59.460 --> 00:22:01.180
then at three months, like,
494
00:22:01.180 --> 00:22:02.560
what's great. I'm like, all
495
00:22:02.560 --> 00:22:04.240
right, see you in a year with
496
00:22:04.240 --> 00:22:06.640
regards to the issue. You know,
497
00:22:06.820 --> 00:22:08.400
now there is the guy who,
498
00:22:08.580 --> 00:22:10.060
let's say you have a patient
499
00:22:10.060 --> 00:22:10.960
who's already been on flow
500
00:22:10.960 --> 00:22:11.980
max, he's been on it for
501
00:22:11.980 --> 00:22:13.340
years and he's like, yeah,
502
00:22:13.340 --> 00:22:14.240
I was working before and
503
00:22:14.240 --> 00:22:15.340
now it's not working too
504
00:22:15.340 --> 00:22:18.200
much. You know, it's not
505
00:22:18.200 --> 00:22:19.400
necessarily FDA guidelines,
506
00:22:19.460 --> 00:22:20.460
but sometimes people just
507
00:22:20.460 --> 00:22:21.820
double up the dose. So you
508
00:22:21.820 --> 00:22:23.260
can go some point, point
509
00:22:23.260 --> 00:22:24.980
eight, but sometimes you
510
00:22:24.980 --> 00:22:26.200
can also just send them to
511
00:22:26.200 --> 00:22:27.540
urology because at that
512
00:22:27.540 --> 00:22:28.840
point we're going to have
513
00:22:28.840 --> 00:22:30.260
the discussion about, okay,
514
00:22:30.260 --> 00:22:32.220
we can start you on enough,
515
00:22:32.280 --> 00:22:33.540
we can increase your dose,
516
00:22:34.160 --> 00:22:36.000
we can add finasteride,
517
00:22:36.100 --> 00:22:37.560
or we can talk about
518
00:22:37.560 --> 00:22:38.920
minimally invasive treatment
519
00:22:38.920 --> 00:22:40.450
options. Because of course,
520
00:22:41.200 --> 00:22:42.160
people know about the
521
00:22:42.160 --> 00:22:42.820
TURP, which is the
522
00:22:42.820 --> 00:22:44.100
traditional way of relieving
523
00:22:44.100 --> 00:22:45.040
obstruction. But now
524
00:22:45.040 --> 00:22:46.030
there's so much more
525
00:22:47.400 --> 00:22:49.180
lessened procedures that
526
00:22:49.180 --> 00:22:50.440
patients can take and
527
00:22:50.440 --> 00:22:51.460
they're catered towards
528
00:22:51.460 --> 00:22:52.640
these patients who are on
529
00:22:52.640 --> 00:22:54.000
medications, but still not
530
00:22:54.000 --> 00:22:54.860
happy with where their
531
00:22:54.860 --> 00:22:57.340
symptoms are at. And
532
00:22:57.340 --> 00:22:58.260
especially with the younger
533
00:22:58.260 --> 00:22:59.280
guys, they don't want to
534
00:22:59.280 --> 00:23:00.540
be put on finasteride,
535
00:23:00.560 --> 00:23:01.660
which is the other agent,
536
00:23:01.960 --> 00:23:02.600
because of the
537
00:23:02.600 --> 00:23:03.600
hormonal side effects,
538
00:23:03.700 --> 00:23:05.280
decreased libido, erectile
539
00:23:05.280 --> 00:23:06.500
dysfunction, things like
540
00:23:06.500 --> 00:23:09.000
that. All those guys,
541
00:23:09.500 --> 00:23:10.180
I'll see them like,
542
00:23:10.320 --> 00:23:11.040
yeah, I've been on
543
00:23:11.040 --> 00:23:12.380
Flomax for years and
544
00:23:12.380 --> 00:23:13.340
it's not really working.
545
00:23:14.100 --> 00:23:15.000
And, you know, I tried
546
00:23:15.000 --> 00:23:16.600
doubling up and still not
547
00:23:16.600 --> 00:23:17.680
really working. So I'll
548
00:23:17.680 --> 00:23:18.640
talk to those guys and
549
00:23:18.640 --> 00:23:19.400
say, okay, well, listen,
550
00:23:19.420 --> 00:23:20.580
we can give you surgery
551
00:23:20.580 --> 00:23:21.600
and that might actually
552
00:23:21.600 --> 00:23:22.620
get your medications
553
00:23:22.620 --> 00:23:24.280
all together. And we have
554
00:23:24.280 --> 00:23:25.180
all these options
555
00:23:25.180 --> 00:23:26.500
available in addition to
556
00:23:26.500 --> 00:23:27.540
the traditional TURP, which
557
00:23:27.540 --> 00:23:28.200
is still the gold
558
00:23:28.200 --> 00:23:30.200
standard. Yeah. Yeah.
559
00:23:30.200 --> 00:23:30.680
And I guess I have a
560
00:23:30.680 --> 00:23:31.640
question about that, too.
561
00:23:31.680 --> 00:23:32.820
Like, when should we
562
00:23:32.820 --> 00:23:34.480
be more concerned about
563
00:23:34.480 --> 00:23:35.440
some sort of underlying
564
00:23:35.440 --> 00:23:36.660
prostate cancer when
565
00:23:36.660 --> 00:23:37.660
somebody is coming in
566
00:23:37.660 --> 00:23:39.400
for enlarged prostate?
567
00:23:40.760 --> 00:23:43.000
So it's very uncommon
568
00:23:43.000 --> 00:23:44.100
to actually see that
569
00:23:44.100 --> 00:23:45.200
as a presentation,
570
00:23:46.180 --> 00:23:47.440
because if you have
571
00:23:47.440 --> 00:23:48.640
an enlarged prostate
572
00:23:48.640 --> 00:23:49.900
and it's secondary to
573
00:23:49.900 --> 00:23:50.700
cancer, that means your
574
00:23:50.700 --> 00:23:51.920
cancer is like very
575
00:23:51.920 --> 00:23:53.700
locally advanced and
576
00:23:53.700 --> 00:23:54.380
they would typically
577
00:23:54.380 --> 00:23:55.640
have the back pain
578
00:23:55.640 --> 00:23:56.960
and their PSA would
579
00:23:56.960 --> 00:23:58.920
be sky high. But part
580
00:23:58.920 --> 00:24:00.320
of the initial workup for
581
00:24:00.320 --> 00:24:02.620
BPH is always to get a PSA.
582
00:24:03.340 --> 00:24:05.000
So if you get a PSA
583
00:24:05.000 --> 00:24:05.780
that's super high,
584
00:24:05.920 --> 00:24:06.380
then you're like,
585
00:24:06.660 --> 00:24:07.240
well, I'm sending it
586
00:24:07.240 --> 00:24:08.220
to urology because there
587
00:24:08.220 --> 00:24:09.220
might be something else
588
00:24:09.220 --> 00:24:10.200
underlying this.
589
00:24:10.760 --> 00:24:11.380
But if they come
590
00:24:11.380 --> 00:24:12.100
for the first time
591
00:24:12.100 --> 00:24:12.860
and they have
592
00:24:12.860 --> 00:24:13.520
an enlarged prostate
593
00:24:13.520 --> 00:24:14.420
with a PSA with
594
00:24:14.420 --> 00:24:15.220
the normal limits,
595
00:24:15.240 --> 00:24:15.840
then it's fine.
596
00:24:16.260 --> 00:24:17.160
Cool. Cool.
597
00:24:17.180 --> 00:24:17.820
That's awesome.
598
00:24:18.240 --> 00:24:19.140
Yeah. And so I think
599
00:24:19.140 --> 00:24:20.140
there's a similar question
600
00:24:20.140 --> 00:24:21.360
about erectile dysfunction
601
00:24:21.360 --> 00:24:23.520
in terms of workup
602
00:24:23.520 --> 00:24:25.040
versus treatment in
603
00:24:25.040 --> 00:24:25.840
primary care versus
604
00:24:25.840 --> 00:24:26.880
sending to urology.
605
00:24:26.880 --> 00:24:28.020
What are your thoughts about that?
606
00:24:28.900 --> 00:24:29.660
Yeah. So I think
607
00:24:29.660 --> 00:24:31.780
there's a lot of
608
00:24:31.780 --> 00:24:33.260
different philosophies
609
00:24:33.260 --> 00:24:34.020
because like some
610
00:24:34.020 --> 00:24:34.740
clinics just work
611
00:24:34.740 --> 00:24:35.680
different, some clinics
612
00:24:35.680 --> 00:24:36.140
are existing.
613
00:24:36.360 --> 00:24:37.160
I don't have time to do
614
00:24:37.160 --> 00:24:38.000
EDs. I'm going to
615
00:24:38.000 --> 00:24:38.820
send you over.
616
00:24:39.860 --> 00:24:40.300
But, you know,
617
00:24:40.400 --> 00:24:41.420
symbol, I mean, like I said,
618
00:24:41.560 --> 00:24:43.020
similar Vagrancialis,
619
00:24:43.080 --> 00:24:44.360
they both have a similar
620
00:24:44.940 --> 00:24:46.080
relatively mild side
621
00:24:46.080 --> 00:24:46.720
effect profile.
622
00:24:46.860 --> 00:24:47.820
You know, the headaches,
623
00:24:48.120 --> 00:24:48.780
the congestion,
624
00:24:48.960 --> 00:24:49.920
some of the color vision
625
00:24:50.340 --> 00:24:50.740
abnormalities,
626
00:24:51.060 --> 00:24:52.020
those are all trans
627
00:24:52.020 --> 00:24:53.880
and usually they resolve
628
00:24:53.880 --> 00:24:54.880
or patients, you know,
629
00:24:54.880 --> 00:24:55.800
are not doing any of this.
630
00:24:55.880 --> 00:24:56.860
I think it does kind of
631
00:24:56.860 --> 00:24:58.440
operate on the principle of,
632
00:24:58.540 --> 00:24:59.740
listen, I'm going to start you on
633
00:24:59.740 --> 00:25:01.040
the middle dose of two pills
634
00:25:01.040 --> 00:25:02.160
and you can go up to four
635
00:25:02.760 --> 00:25:03.460
or not.
636
00:25:03.520 --> 00:25:05.240
And then you can go both ways.
637
00:25:05.340 --> 00:25:06.620
I mean, I get some patients
638
00:25:06.620 --> 00:25:08.600
who are coming for new ED
639
00:25:08.600 --> 00:25:09.200
a lot.
640
00:25:09.600 --> 00:25:10.000
It's like, whatever,
641
00:25:10.160 --> 00:25:10.520
I'll see them.
642
00:25:10.840 --> 00:25:12.860
But it's not wrong
643
00:25:12.860 --> 00:25:14.420
with seeing them in primary care.
644
00:25:15.380 --> 00:25:16.700
The part do definitely
645
00:25:16.700 --> 00:25:17.840
refer to them as if
646
00:25:17.840 --> 00:25:19.700
they've tried oral therapies
647
00:25:19.700 --> 00:25:21.180
already and they're like,
648
00:25:21.180 --> 00:25:22.140
hey, this is working.
649
00:25:22.500 --> 00:25:23.080
And then, of course,
650
00:25:23.100 --> 00:25:24.220
we'll talk to them about
651
00:25:25.320 --> 00:25:26.700
escalating medical therapies
652
00:25:26.700 --> 00:25:30.040
things like ICI,
653
00:25:30.040 --> 00:25:31.620
intra-cavernousal injections.
654
00:25:32.400 --> 00:25:34.480
Obviously, more invasive side,
655
00:25:34.580 --> 00:25:35.780
we can talk about surgeries
656
00:25:35.780 --> 00:25:37.020
like penile prosthesis
657
00:25:37.640 --> 00:25:39.840
and we can adjunct tools
658
00:25:39.840 --> 00:25:41.100
like penile pumps
659
00:25:41.100 --> 00:25:43.200
or things like that.
660
00:25:43.520 --> 00:25:44.860
Yeah, yeah, definitely.
661
00:25:46.160 --> 00:25:47.560
And I should have preface
662
00:25:47.560 --> 00:25:48.620
before we started recording
663
00:25:48.620 --> 00:25:50.240
that I also like using
664
00:25:50.240 --> 00:25:51.180
interviews to ask
665
00:25:51.180 --> 00:25:52.580
and also the whole channel
666
00:25:52.580 --> 00:25:53.300
to ask questions
667
00:25:53.300 --> 00:25:54.520
that I feel dumb asking.
668
00:25:54.580 --> 00:25:55.520
But if I feel dumb,
669
00:25:55.600 --> 00:25:56.440
then other people probably
670
00:25:56.440 --> 00:25:57.240
feel dumb too.
671
00:25:57.620 --> 00:25:59.420
So I have a, well,
672
00:25:59.540 --> 00:26:00.420
it's not necessarily a dumb question,
673
00:26:00.460 --> 00:26:01.200
but it's been a while
674
00:26:01.200 --> 00:26:01.960
since I've worked up
675
00:26:01.960 --> 00:26:02.740
erectile dysfunction.
676
00:26:03.200 --> 00:26:04.220
Do you, and also,
677
00:26:04.240 --> 00:26:05.120
there's a lot of questions
678
00:26:05.120 --> 00:26:06.760
about using testosterone,
679
00:26:07.960 --> 00:26:08.900
like check for low testosterone
680
00:26:08.900 --> 00:26:09.820
and managing that.
681
00:26:10.060 --> 00:26:11.160
Is that something that is,
682
00:26:11.200 --> 00:26:12.740
like I know endocrine manages that.
683
00:26:12.800 --> 00:26:13.460
Is that something that
684
00:26:13.460 --> 00:26:14.460
you also manage
685
00:26:14.460 --> 00:26:15.800
in terms of the hormonal?
686
00:26:16.720 --> 00:26:18.260
Yeah, so urology
687
00:26:18.260 --> 00:26:19.920
or endocrine can manage
688
00:26:19.920 --> 00:26:21.260
like hypogonadism.
689
00:26:22.120 --> 00:26:22.600
Because typically,
690
00:26:23.100 --> 00:26:24.240
testosterone can be part
691
00:26:24.240 --> 00:26:25.900
of the original erectile
692
00:26:25.900 --> 00:26:26.980
dysfunctional workup.
693
00:26:27.660 --> 00:26:29.540
When you go back low,
694
00:26:30.000 --> 00:26:31.020
you tell the patient,
695
00:26:31.020 --> 00:26:31.980
so just one reading,
696
00:26:32.160 --> 00:26:33.240
like the full test
697
00:26:33.240 --> 00:26:34.580
hypogonadism workup
698
00:26:34.580 --> 00:26:36.480
entails two testosterone.
699
00:26:37.100 --> 00:26:38.300
And you also test
700
00:26:38.300 --> 00:26:40.060
for some like central labs
701
00:26:40.060 --> 00:26:42.900
like FSHLH, prolactin, estrogen.
702
00:26:42.900 --> 00:26:43.580
Right, right.
703
00:26:44.960 --> 00:26:46.220
To see if you can delineate
704
00:26:46.220 --> 00:26:47.000
where the source
705
00:26:47.000 --> 00:26:48.620
of the hypogonadism is.
706
00:26:49.500 --> 00:26:50.760
But yeah, I think that,
707
00:26:51.340 --> 00:26:52.340
you know, if you're going
708
00:26:52.340 --> 00:26:53.060
to do a workup,
709
00:26:53.160 --> 00:26:54.000
the basic workup
710
00:26:54.000 --> 00:26:55.180
is just getting a testosterone.
711
00:26:55.180 --> 00:26:57.720
And that's like at least
712
00:26:58.300 --> 00:26:59.100
basic thing.
713
00:26:59.240 --> 00:27:00.340
But yeah, if they're going to be
714
00:27:00.340 --> 00:27:01.560
on testosterone replacement,
715
00:27:02.580 --> 00:27:03.920
there's kind of two scenarios I see.
716
00:27:04.000 --> 00:27:05.360
So one scenario is that
717
00:27:05.360 --> 00:27:06.980
patient gets a testosterone drawn.
718
00:27:07.240 --> 00:27:07.780
It's low.
719
00:27:08.080 --> 00:27:09.620
After the initial low testosterone,
720
00:27:09.860 --> 00:27:10.800
they're sent to me
721
00:27:10.800 --> 00:27:12.020
and I basically take over.
722
00:27:12.380 --> 00:27:14.680
And then there's
723
00:27:14.680 --> 00:27:16.100
the other scenario where
724
00:27:16.100 --> 00:27:18.400
patient gets initial low testosterone.
725
00:27:18.680 --> 00:27:19.580
They come to me.
726
00:27:20.120 --> 00:27:21.900
I do the additional workup.
727
00:27:22.160 --> 00:27:22.900
They get started
728
00:27:22.900 --> 00:27:24.320
on testosterone replacement.
729
00:27:24.320 --> 00:27:25.560
And then they want to go back
730
00:27:25.560 --> 00:27:26.540
to their primary care
731
00:27:26.540 --> 00:27:27.500
because they're like,
732
00:27:27.500 --> 00:27:28.980
hey, I don't do the injections
733
00:27:28.980 --> 00:27:31.200
if they go that route myself.
734
00:27:31.400 --> 00:27:32.760
But it's also a lot of work
735
00:27:32.760 --> 00:27:33.940
to come to here.
736
00:27:34.200 --> 00:27:36.300
So can my major do them?
737
00:27:36.520 --> 00:27:37.680
And it's basically just a standard.
738
00:27:38.020 --> 00:27:39.100
Those patients do it at home,
739
00:27:39.120 --> 00:27:40.940
but some patients don't want to do it.
740
00:27:40.980 --> 00:27:41.740
So in that scenario,
741
00:27:41.940 --> 00:27:42.920
they end up back there.
742
00:27:43.120 --> 00:27:44.500
And if they end up back there,
743
00:27:44.540 --> 00:27:46.320
then it's just a matter of
744
00:27:46.320 --> 00:27:47.720
monitoring the testosterone.
745
00:27:48.320 --> 00:27:48.860
And pretty much,
746
00:27:48.860 --> 00:27:49.680
you know, it's pretty simple.
747
00:27:49.820 --> 00:27:50.860
You just want the testosterone
748
00:27:50.860 --> 00:27:52.160
to be above 300.
749
00:27:52.660 --> 00:27:54.200
You don't want to overshoot
750
00:27:54.200 --> 00:27:54.820
too much.
751
00:27:54.980 --> 00:27:56.520
So if you're going in the thousands,
752
00:27:56.620 --> 00:27:57.900
you should probably just cut down
753
00:27:57.900 --> 00:27:59.340
their dose to the next lowest.
754
00:28:00.220 --> 00:28:01.220
And you know,
755
00:28:01.320 --> 00:28:02.000
in the hermetic grip
756
00:28:02.000 --> 00:28:03.340
to make sure it doesn't get too high
757
00:28:03.340 --> 00:28:04.760
because if it does get too high,
758
00:28:04.920 --> 00:28:06.640
then they'll need to donate blood
759
00:28:06.640 --> 00:28:08.880
or phlebotomy or something like that.
760
00:28:09.240 --> 00:28:10.200
Just to get some.
761
00:28:11.460 --> 00:28:12.500
So yeah, you know,
762
00:28:12.500 --> 00:28:13.840
I think it all depends
763
00:28:13.840 --> 00:28:15.080
on how your practice is structured.
764
00:28:15.200 --> 00:28:16.000
A lot of patients,
765
00:28:16.160 --> 00:28:17.200
they'll just stick with us
766
00:28:17.200 --> 00:28:18.420
for the testosterone replacement.
767
00:28:19.020 --> 00:28:19.620
Some will stick
768
00:28:19.620 --> 00:28:20.580
with their primary care
769
00:28:20.580 --> 00:28:21.820
and others still will go
770
00:28:21.820 --> 00:28:22.780
with endocrine.
771
00:28:22.880 --> 00:28:23.320
Totally.
772
00:28:23.320 --> 00:28:24.120
That's helpful.
773
00:28:24.220 --> 00:28:24.920
That's super helpful.
774
00:28:25.320 --> 00:28:26.660
Is there a cutoff for you?
775
00:28:27.620 --> 00:28:28.260
And again, like,
776
00:28:28.280 --> 00:28:29.360
it's been such a long time
777
00:28:29.360 --> 00:28:30.240
with testosterone,
778
00:28:30.300 --> 00:28:31.600
low testosterone treatment for me
779
00:28:31.600 --> 00:28:32.580
and not many people.
780
00:28:33.020 --> 00:28:34.420
But what is the cutoff?
781
00:28:34.600 --> 00:28:35.780
Is there a guideline cutoff
782
00:28:35.780 --> 00:28:37.060
or a personal kind of like
783
00:28:37.060 --> 00:28:37.860
anecdotal cutoff
784
00:28:37.860 --> 00:28:39.820
for the hermetic grip elevations?
785
00:28:40.880 --> 00:28:42.600
The guideline cutoff is 300
786
00:28:42.600 --> 00:28:44.480
and it's total testosterone.
787
00:28:44.940 --> 00:28:46.220
Just not so, you know,
788
00:28:46.220 --> 00:28:47.760
there's free testosterone,
789
00:28:48.040 --> 00:28:49.240
there's binded testosterone.
790
00:28:49.360 --> 00:28:50.340
All those don't matter.
791
00:28:50.540 --> 00:28:51.600
Just the total testosterone
792
00:28:51.600 --> 00:28:54.160
is what you use and 300 is enough.
793
00:28:54.240 --> 00:28:55.460
And they basically standardize
794
00:28:55.460 --> 00:28:56.820
it to simplify things.
795
00:28:57.860 --> 00:28:59.080
Oh, the hermetic grip though,
796
00:28:59.140 --> 00:29:00.580
like the hermetic grip and hemoglobin.
797
00:29:00.660 --> 00:29:01.960
Is there a cutoff for that one?
798
00:29:02.800 --> 00:29:05.540
As long as it's not like above 55,
799
00:29:05.680 --> 00:29:06.980
I'd say, you know,
800
00:29:07.020 --> 00:29:08.580
because the upper limit
801
00:29:08.580 --> 00:29:09.800
is like 54 or something.
802
00:29:10.040 --> 00:29:11.580
So yeah, anything about 55,
803
00:29:12.020 --> 00:29:12.960
you know, it's getting a little bit
804
00:29:12.960 --> 00:29:14.600
and you just want to let them know,
805
00:29:14.740 --> 00:29:16.040
hey, you might need to
806
00:29:16.040 --> 00:29:16.920
go donate some blood
807
00:29:16.920 --> 00:29:18.020
or something like that.
808
00:29:19.200 --> 00:29:20.900
That's a pretty easy way to do it.
809
00:29:20.900 --> 00:29:22.880
If they're eligible, absolutely.
810
00:29:26.440 --> 00:29:27.080
Sorry, go ahead.
811
00:29:28.120 --> 00:29:28.540
I was just saying,
812
00:29:28.620 --> 00:29:29.520
it's not going to cost you money
813
00:29:29.520 --> 00:29:30.660
and you're helping somebody else.
814
00:29:30.960 --> 00:29:31.180
So there you go.
815
00:29:32.200 --> 00:29:32.260
Totally.
816
00:29:33.200 --> 00:29:34.740
So I have a question about incontinence
817
00:29:35.940 --> 00:29:37.320
and urinary frequency,
818
00:29:37.500 --> 00:29:39.480
especially in cis female patients.
819
00:29:40.080 --> 00:29:41.840
Do you like any thoughts,
820
00:29:41.920 --> 00:29:43.440
pearls, all the things,
821
00:29:43.560 --> 00:29:44.380
anything you want to say,
822
00:29:44.380 --> 00:29:45.120
I welcome it.
823
00:29:45.240 --> 00:29:47.020
Urology, as you can maybe can tell,
824
00:29:47.140 --> 00:29:49.540
urology is not a strong area for me.
825
00:29:50.220 --> 00:29:51.540
All the questions.
826
00:29:52.820 --> 00:29:53.820
That's not what you're saying.
827
00:29:54.160 --> 00:29:55.060
Sometimes that's what's hard for me.
828
00:29:56.620 --> 00:29:58.900
But yeah, incontinence is a tough one
829
00:29:58.900 --> 00:30:00.100
because, you know, obviously,
830
00:30:00.460 --> 00:30:01.180
you know, at first of all,
831
00:30:01.280 --> 00:30:01.780
you have to delineate
832
00:30:01.780 --> 00:30:02.720
what type of incontinence
833
00:30:02.720 --> 00:30:03.520
you're dealing with.
834
00:30:03.620 --> 00:30:05.160
So is it stress incontinence?
835
00:30:05.280 --> 00:30:07.160
You know, obviously the people who cough
836
00:30:07.160 --> 00:30:08.980
and laugh and leak and things like that.
837
00:30:09.380 --> 00:30:11.600
Is it over, is it
838
00:30:11.600 --> 00:30:14.180
overactive bladder or urgent incontinence?
839
00:30:14.180 --> 00:30:15.560
Those are people who just get
840
00:30:15.560 --> 00:30:16.360
the urge out of nowhere,
841
00:30:16.420 --> 00:30:18.020
can't make it to the bathroom in time.
842
00:30:18.260 --> 00:30:19.440
Is it a little bit of both?
843
00:30:19.540 --> 00:30:21.380
You can have mixed incontinence.
844
00:30:21.880 --> 00:30:23.060
And then, of course, in the rare case,
845
00:30:23.200 --> 00:30:24.620
you can have overflowing incontinence
846
00:30:24.620 --> 00:30:26.020
where the person is in retention
847
00:30:26.020 --> 00:30:27.540
and they have so much in their bladder
848
00:30:27.540 --> 00:30:28.760
just leaking out.
849
00:30:29.720 --> 00:30:32.120
So I'd say obviously urgent incontinence
850
00:30:32.120 --> 00:30:33.180
and stress incontinence
851
00:30:33.180 --> 00:30:35.660
are mixed or what we see more commonly.
852
00:30:36.120 --> 00:30:36.960
And I think especially
853
00:30:36.960 --> 00:30:38.820
when you're trying to figure out
854
00:30:38.820 --> 00:30:39.900
or parse out the symptoms,
855
00:30:40.000 --> 00:30:41.400
you have to ask the patient straight up,
856
00:30:41.480 --> 00:30:42.080
like, hey, listen,
857
00:30:42.140 --> 00:30:42.980
I can't treat anything.
858
00:30:43.280 --> 00:30:44.400
What's bothering you the most?
859
00:30:44.480 --> 00:30:46.580
Is it the stress or is it the urge?
860
00:30:46.760 --> 00:30:47.780
That's what we're going to focus on.
861
00:30:48.120 --> 00:30:48.460
Yes.
862
00:30:48.460 --> 00:30:51.220
So that's one thing you want to delineate.
863
00:30:51.460 --> 00:30:52.360
So urge is the one
864
00:30:52.360 --> 00:30:54.520
that's a lot more common in women.
865
00:30:54.940 --> 00:30:55.860
And the first thing you do
866
00:30:55.860 --> 00:30:57.220
before thinking about all the
867
00:30:57.220 --> 00:30:59.720
pharmacological interventions is like,
868
00:30:59.880 --> 00:31:02.420
hey, what's your daily fluid intake?
869
00:31:02.880 --> 00:31:04.380
So do you drink a lot of caffeine?
870
00:31:05.160 --> 00:31:06.060
Do you drink a lot of
871
00:31:06.060 --> 00:31:06.940
carbonated beverages?
872
00:31:07.580 --> 00:31:09.560
Do you drink a lot of citrusy things?
873
00:31:10.080 --> 00:31:11.780
Do you eat a lot of dark chocolates?
874
00:31:13.880 --> 00:31:16.520
Do you eat a lot of spicy foods?
875
00:31:16.520 --> 00:31:19.160
These are all triggers for people
876
00:31:19.160 --> 00:31:20.300
who tend to have these
877
00:31:20.300 --> 00:31:21.360
overactive bladders.
878
00:31:21.500 --> 00:31:22.860
And you'll be surprised.
879
00:31:22.960 --> 00:31:23.900
You'll talk to a patient like,
880
00:31:23.980 --> 00:31:26.100
yeah, I drink like five cups of coffee a day.
881
00:31:26.100 --> 00:31:27.240
I drink two energy drinks.
882
00:31:27.240 --> 00:31:28.640
And I'm like, okay, stop.
883
00:31:28.860 --> 00:31:29.900
And I think you're going to
884
00:31:30.460 --> 00:31:30.780
know the improvement.
885
00:31:31.500 --> 00:31:33.300
And usually that's enough to be like,
886
00:31:33.380 --> 00:31:35.140
hey, yeah, I'm not urinating
887
00:31:35.140 --> 00:31:36.520
12 times a day anymore.
888
00:31:37.180 --> 00:31:39.080
I'm not throughout the night.
889
00:31:39.460 --> 00:31:40.900
Like, yeah, of course.
890
00:31:41.480 --> 00:31:42.880
The other thing is I always ask
891
00:31:42.880 --> 00:31:44.040
about their bowel habits.
892
00:31:44.780 --> 00:31:46.020
Because you analyze patients
893
00:31:46.020 --> 00:31:47.780
who are extremely constipated.
894
00:31:48.040 --> 00:31:50.220
And the rectum is in very close proximity
895
00:31:50.220 --> 00:31:51.560
to the bladder outlet.
896
00:31:51.920 --> 00:31:52.780
So if you're constipated,
897
00:31:52.820 --> 00:31:54.260
you're not into your bladder well.
898
00:31:54.700 --> 00:31:56.140
And if you're not into your bladder well,
899
00:31:56.240 --> 00:31:56.760
it's what it's going to feel like.
900
00:31:56.780 --> 00:31:58.140
You have to pee all the time.
901
00:31:58.300 --> 00:31:59.680
You'd be surprised about that.
902
00:31:59.920 --> 00:32:00.980
Oh, yeah, you know what?
903
00:32:01.080 --> 00:32:01.660
I don't actually,
904
00:32:01.860 --> 00:32:02.760
when you have a bowel movement
905
00:32:02.760 --> 00:32:04.180
every three or four days,
906
00:32:04.260 --> 00:32:06.320
I'm like, yeah, that's not good.
907
00:32:06.680 --> 00:32:09.080
So I usually just have them start
908
00:32:09.080 --> 00:32:10.640
on some kind of bowel regimen,
909
00:32:10.700 --> 00:32:12.460
like some Miralax and Colace.
910
00:32:13.020 --> 00:32:13.640
And yeah, a lot of times
911
00:32:13.640 --> 00:32:14.600
that helps as well.
912
00:32:15.040 --> 00:32:16.600
So once you always start
913
00:32:16.600 --> 00:32:17.900
with the behavioral stuff,
914
00:32:18.380 --> 00:32:20.060
give them like a month or, you know,
915
00:32:20.100 --> 00:32:21.640
some people do diaries and things
916
00:32:21.640 --> 00:32:22.280
and you can do those.
917
00:32:22.680 --> 00:32:24.480
But I just find patients generally
918
00:32:24.480 --> 00:32:25.780
tend not to do them.
919
00:32:25.960 --> 00:32:26.980
Unless it's like
920
00:32:26.980 --> 00:32:28.960
a very like studious patient,
921
00:32:29.160 --> 00:32:30.500
you know, let me like a case person
922
00:32:30.500 --> 00:32:31.180
going to do it.
923
00:32:31.180 --> 00:32:32.300
Otherwise, I'm just like,
924
00:32:32.400 --> 00:32:33.440
listen, just do this stuff.
925
00:32:33.720 --> 00:32:34.580
We'll check in in a month
926
00:32:34.580 --> 00:32:36.120
and see where you're at.
927
00:32:36.660 --> 00:32:38.320
Now, if after a month,
928
00:32:38.500 --> 00:32:39.720
you know, they've done all this stuff,
929
00:32:39.720 --> 00:32:41.300
they've actually like really done it
930
00:32:41.300 --> 00:32:43.120
and they're still having over activity.
931
00:32:43.640 --> 00:32:45.040
Then you can kind of, you know,
932
00:32:45.100 --> 00:32:46.320
you can say, listen,
933
00:32:46.320 --> 00:32:47.980
I'm going to send you to urology
934
00:32:48.420 --> 00:32:49.980
or listen, I'm going to start you
935
00:32:49.980 --> 00:32:51.800
on a basic anticholinergic
936
00:32:54.020 --> 00:32:54.900
or something.
937
00:32:56.120 --> 00:32:57.540
But that being said,
938
00:32:57.540 --> 00:32:58.720
you know, especially
939
00:32:58.720 --> 00:32:59.900
if you're an older patient,
940
00:33:00.220 --> 00:33:01.680
you can get kind of complicated
941
00:33:01.680 --> 00:33:03.480
trying to choose an anticholinergic
942
00:33:03.480 --> 00:33:04.800
because otherwise they'll fall risk.
943
00:33:05.280 --> 00:33:06.300
So if you have any,
944
00:33:06.560 --> 00:33:08.840
just send them over to urology
945
00:33:08.840 --> 00:33:10.580
kind of from there.
946
00:33:10.600 --> 00:33:11.640
Because at that point,
947
00:33:11.900 --> 00:33:12.860
we might say, okay,
948
00:33:12.860 --> 00:33:14.880
maybe you need some upper tract imaging
949
00:33:14.880 --> 00:33:16.960
or maybe you need a cystoscopy
950
00:33:16.960 --> 00:33:18.100
and we'll kind of delineate
951
00:33:18.100 --> 00:33:19.300
the symptoms a little bit more.
952
00:33:19.420 --> 00:33:20.000
And then be like, okay,
953
00:33:20.060 --> 00:33:20.660
while you're older,
954
00:33:20.780 --> 00:33:21.820
so we'll start you on this
955
00:33:22.860 --> 00:33:23.660
anticholinergic agents
956
00:33:23.660 --> 00:33:25.300
or this one at this dose.
957
00:33:25.860 --> 00:33:27.000
So if it gets there,
958
00:33:27.100 --> 00:33:28.320
then, you know, just send them over.
959
00:33:28.440 --> 00:33:29.820
But if it's like a younger person,
960
00:33:30.100 --> 00:33:31.440
you're not concerned about fall risk,
961
00:33:32.320 --> 00:33:33.660
oxybutin is always a reasonable
962
00:33:33.660 --> 00:33:35.200
first line to start with.
963
00:33:35.200 --> 00:33:36.720
And if that doesn't work,
964
00:33:36.740 --> 00:33:38.060
just send them over to urology.
965
00:33:39.480 --> 00:33:40.160
Go from there.
966
00:33:40.160 --> 00:33:41.240
And of course, you counsel them
967
00:33:41.240 --> 00:33:42.780
if you're going to do an anticholinergic.
968
00:33:42.780 --> 00:33:44.520
They're going to get dry eyes,
969
00:33:45.000 --> 00:33:46.940
dry mouth, potential constipation.
970
00:33:48.300 --> 00:33:49.480
And there's a fall risk.
971
00:33:49.580 --> 00:33:51.620
And there's also a small risk of retention
972
00:33:51.620 --> 00:33:53.000
that can work too well.
973
00:33:53.660 --> 00:33:54.120
I see.
974
00:33:54.200 --> 00:33:54.620
I see.
975
00:33:54.840 --> 00:33:55.100
Totally.
976
00:33:56.460 --> 00:33:58.080
And I was going to ask you
977
00:33:58.080 --> 00:33:59.920
how closely do you work with
978
00:33:59.920 --> 00:34:01.320
either urogynecology
979
00:34:01.320 --> 00:34:03.420
or pelvic floor therapists?
980
00:34:03.620 --> 00:34:06.080
Like, do you have much overlap with them
981
00:34:06.080 --> 00:34:07.760
or how does that work?
982
00:34:08.520 --> 00:34:09.800
Wouldn't say overlap.
983
00:34:09.980 --> 00:34:11.179
But let's say, for example,
984
00:34:11.179 --> 00:34:16.360
a person has incontinence or a bulge
985
00:34:16.360 --> 00:34:18.520
and they're diagnosed with prolapse.
986
00:34:19.600 --> 00:34:21.300
Then it's a urogynecologist
987
00:34:21.300 --> 00:34:22.920
because they don't do prolapse surgeries.
988
00:34:23.120 --> 00:34:24.340
There are some urologists
989
00:34:24.340 --> 00:34:25.560
who will take on them.
990
00:34:26.320 --> 00:34:27.820
Because a urologist is basically
991
00:34:27.820 --> 00:34:30.179
either a urologist who did that fellowship
992
00:34:30.179 --> 00:34:31.920
or a gynecologist who did that fellowship.
993
00:34:32.040 --> 00:34:33.719
So they do pairs.
994
00:34:34.420 --> 00:34:36.340
So that's when I kind of interact with them
995
00:34:36.340 --> 00:34:37.800
when a patient has a prolapse
996
00:34:37.800 --> 00:34:39.960
in the setting of strep incontinence.
997
00:34:42.000 --> 00:34:45.060
Conversely, with pelvic floor physical therapy,
998
00:34:45.440 --> 00:34:46.080
that's definitely for,
999
00:34:46.239 --> 00:34:47.840
I definitely have some patients there,
1000
00:34:47.880 --> 00:34:50.800
those patients who have dysfunctional voiding.
1001
00:34:51.120 --> 00:34:53.900
So those are patients who have a lot of this
1002
00:34:53.900 --> 00:34:55.440
pain during intercourse.
1003
00:34:55.960 --> 00:34:58.120
They can't seem to avoid.
1004
00:34:59.260 --> 00:35:01.740
And their symptoms are kind of like vague,
1005
00:35:02.120 --> 00:35:03.620
but it seems like
1006
00:35:03.620 --> 00:35:05.240
there's some tightness down there.
1007
00:35:05.400 --> 00:35:07.400
Those are people who have pelvic floor PT.
1008
00:35:07.960 --> 00:35:11.820
So I think it's never going to lose something
1009
00:35:11.820 --> 00:35:13.740
by sending something to pelvic floor PT.
1010
00:35:14.840 --> 00:35:17.260
You suspect that's what's going on.
1011
00:35:18.080 --> 00:35:18.140
Definitely.
1012
00:35:18.700 --> 00:35:18.920
Cool.
1013
00:35:19.380 --> 00:35:22.300
So I guess two last follow-up questions.
1014
00:35:23.040 --> 00:35:23.940
Two last questions rather.
1015
00:35:24.160 --> 00:35:27.800
So one is about recurrent UTIs.
1016
00:35:28.980 --> 00:35:32.120
So I recently just did an episode on the channel.
1017
00:35:32.680 --> 00:35:33.640
If people haven't seen it yet,
1018
00:35:33.740 --> 00:35:34.500
definitely you can check that out
1019
00:35:34.500 --> 00:35:36.720
of the foundational pieces about that.
1020
00:35:36.720 --> 00:35:39.660
But just generally speaking,
1021
00:35:39.820 --> 00:35:41.200
anything you want to share about that,
1022
00:35:41.300 --> 00:35:42.440
I think there was questions,
1023
00:35:42.660 --> 00:35:44.380
especially about recurrent UTIs
1024
00:35:44.380 --> 00:35:46.740
in post-menopausal cis female patients.
1025
00:35:47.200 --> 00:35:48.600
So what are your thoughts about that?
1026
00:35:49.900 --> 00:35:50.240
Yeah.
1027
00:35:50.440 --> 00:35:53.020
So I mean, you're kind of alluding to the fact
1028
00:35:53.020 --> 00:35:54.360
that after menopause,
1029
00:35:54.560 --> 00:35:56.880
it is more common for cis female patients
1030
00:35:56.880 --> 00:35:59.640
to get recurrent infections.
1031
00:35:59.660 --> 00:36:02.080
And if you think about the pathophysiology,
1032
00:36:02.160 --> 00:36:02.900
what's going on,
1033
00:36:03.980 --> 00:36:04.780
essentially, of course,
1034
00:36:04.780 --> 00:36:06.680
most infections are from E. coli
1035
00:36:06.680 --> 00:36:08.180
derived from the GI system.
1036
00:36:08.660 --> 00:36:10.900
And what happens is the GI system,
1037
00:36:10.900 --> 00:36:13.740
E. coli from there traverse the vagina
1038
00:36:13.740 --> 00:36:15.080
and make their way into the bladder,
1039
00:36:15.100 --> 00:36:16.300
and then it causes infections.
1040
00:36:16.680 --> 00:36:18.340
And normally that doesn't happen too frequently
1041
00:36:18.340 --> 00:36:20.560
because your vaginal lining is thick
1042
00:36:21.160 --> 00:36:23.300
and a natural barrier.
1043
00:36:23.840 --> 00:36:24.520
But of course,
1044
00:36:24.700 --> 00:36:26.720
with menopause and atrophic vaginitis,
1045
00:36:26.920 --> 00:36:28.240
that barrier gets very thin,
1046
00:36:28.600 --> 00:36:30.420
makes it easier for the bacteria to traverse.
1047
00:36:30.460 --> 00:36:31.940
And then after you start getting
1048
00:36:31.940 --> 00:36:33.720
into the cycle of recurrent infections.
1049
00:36:33.720 --> 00:36:38.220
So almost every post-menopausal cis female patient I see
1050
00:36:38.220 --> 00:36:40.240
gets started on vaginal estrogen.
1051
00:36:41.500 --> 00:36:43.900
Hey, here's vaginal estrogen.
1052
00:36:44.100 --> 00:36:45.300
Take a pea-sized amount.
1053
00:36:45.660 --> 00:36:48.140
Put it down in the vagina twice a week.
1054
00:36:48.980 --> 00:36:51.620
And then you'd be surprised that
1055
00:36:51.620 --> 00:36:54.370
that intervention alone definitely helps
1056
00:36:55.200 --> 00:36:56.620
decrease the frequency.
1057
00:36:57.220 --> 00:36:59.780
Sometimes it's a bit of trial and error.
1058
00:36:59.900 --> 00:37:02.320
So like I'll start them on vaginal estrogen first
1059
00:37:02.320 --> 00:37:04.960
and then after we might add cranberry pills.
1060
00:37:05.540 --> 00:37:06.600
You know, even though this is
1061
00:37:06.600 --> 00:37:08.140
a conclusive person in my practice,
1062
00:37:08.140 --> 00:37:10.240
I found that people get good results.
1063
00:37:10.600 --> 00:37:11.720
As you'll see a lot of patients be like,
1064
00:37:11.740 --> 00:37:13.060
yeah, I'm drinking a bunch of cranberry juice.
1065
00:37:13.140 --> 00:37:15.280
I'm like, yeah, that's all the added sugar.
1066
00:37:15.440 --> 00:37:16.100
I don't think it's worth it.
1067
00:37:16.180 --> 00:37:17.380
Why don't you just take a cranberry pill,
1068
00:37:17.380 --> 00:37:19.240
which is the equivalent of like 10 glasses
1069
00:37:19.240 --> 00:37:20.320
of cranberry juice.
1070
00:37:22.280 --> 00:37:27.020
And then sometimes they get started on other agents
1071
00:37:30.400 --> 00:37:33.240
like D-Manos, for example,
1072
00:37:33.780 --> 00:37:35.620
or sometimes rare cases,
1073
00:37:35.760 --> 00:37:38.160
I'll put them on low-dose prophylactic antibiotics.
1074
00:37:38.660 --> 00:37:40.980
But of course, I'm not a huge fan of that
1075
00:37:40.980 --> 00:37:43.340
because of the risk of resistance.
1076
00:37:43.840 --> 00:37:45.840
And then sometimes it can further work up,
1077
00:37:46.000 --> 00:37:47.780
especially let's say we've done all this stuff
1078
00:37:47.780 --> 00:37:49.740
and they're still having these recurrent infections.
1079
00:37:49.900 --> 00:37:51.280
We'll do some upper tract imaging.
1080
00:37:51.660 --> 00:37:53.100
Sometimes we'll do a system therapy.
1081
00:37:53.520 --> 00:37:54.580
And then rare cases,
1082
00:37:54.580 --> 00:37:56.680
we can find like a clear etiology.
1083
00:37:56.680 --> 00:37:59.560
But yeah, I'd say definitely in postmenopausal
1084
00:37:59.560 --> 00:38:00.440
cis-femal patients,
1085
00:38:02.760 --> 00:38:05.700
definitely vaginal estrogen is no harm.
1086
00:38:06.060 --> 00:38:08.800
Even if they have actually a breast cancer or something,
1087
00:38:09.040 --> 00:38:11.320
it's a very local thing.
1088
00:38:11.320 --> 00:38:13.080
So it's not going to cause systemic side effects.
1089
00:38:13.340 --> 00:38:14.760
But sometimes people get scared of that.
1090
00:38:15.160 --> 00:38:17.620
I have patients who have estrogen receptor
1091
00:38:17.620 --> 00:38:18.760
positive breast cancer
1092
00:38:18.760 --> 00:38:20.240
and they're still on vaginal estrogen.
1093
00:38:20.540 --> 00:38:21.420
And if you look at this,
1094
00:38:21.640 --> 00:38:23.380
there's not really a correlation there.
1095
00:38:23.380 --> 00:38:24.440
It's safe to use.
1096
00:38:25.160 --> 00:38:27.200
You just count the patient about that.
1097
00:38:27.760 --> 00:38:29.580
But otherwise, yeah, it's simple.
1098
00:38:30.040 --> 00:38:30.560
It's easy.
1099
00:38:30.700 --> 00:38:32.420
Twice a week, pea-sized amounts.
1100
00:38:33.640 --> 00:38:36.800
And patients are usually pretty adherent to it.
1101
00:38:37.320 --> 00:38:39.460
And then cranberry pills are available over the counter.
1102
00:38:39.900 --> 00:38:41.180
So it's like, yeah, it's easy.
1103
00:38:41.280 --> 00:38:42.060
You can add that.
1104
00:38:42.420 --> 00:38:45.140
And usually kind of a multimodal approach
1105
00:38:45.140 --> 00:38:47.220
kind of helps get the infections under control.
1106
00:38:47.700 --> 00:38:48.240
Totally.
1107
00:38:48.700 --> 00:38:51.180
And I guess from my understanding of like
1108
00:38:51.180 --> 00:38:53.980
the primary care part of recurrent UTIs,
1109
00:38:53.980 --> 00:38:56.940
it's like kind of this is in that episode,
1110
00:38:56.940 --> 00:38:57.900
it's kind of as a recap,
1111
00:38:58.000 --> 00:39:00.760
but like you're kind of we want to document
1112
00:39:00.760 --> 00:39:01.820
that it's actually an infection.
1113
00:39:02.080 --> 00:39:03.500
It's not dysuria of another cause.
1114
00:39:03.640 --> 00:39:07.560
And then we think about like if it's two or more
1115
00:39:07.560 --> 00:39:09.440
in six months or three or more in a year,
1116
00:39:09.560 --> 00:39:10.680
would you agree with that?
1117
00:39:10.780 --> 00:39:11.520
It's like appropriate.
1118
00:39:11.700 --> 00:39:11.960
Okay.
1119
00:39:12.180 --> 00:39:17.820
And then the other piece is like there's lifestyle
1120
00:39:18.380 --> 00:39:18.780
interventions.
1121
00:39:19.500 --> 00:39:22.120
Okay, I guess I talked about this in the thing,
1122
00:39:22.120 --> 00:39:23.400
but basically like as you already referenced,
1123
00:39:23.400 --> 00:39:24.980
cranberry juice is like not that effective.
1124
00:39:25.180 --> 00:39:25.920
This is my understanding.
1125
00:39:26.100 --> 00:39:26.820
So correct me where I'm wrong.
1126
00:39:27.180 --> 00:39:28.920
But cranberry juice is like plus or minus.
1127
00:39:29.040 --> 00:39:32.680
It's kind of anecdotal wiping front to back also anecdotal.
1128
00:39:35.340 --> 00:39:36.940
Intercourse frequency as well as spermicide.
1129
00:39:37.120 --> 00:39:39.280
Those are kind of like evidence-based potential causes.
1130
00:39:39.780 --> 00:39:43.620
But like if you've inter like intercourse frequency,
1131
00:39:43.760 --> 00:39:45.640
whatever, we're not going to intervene on that
1132
00:39:45.640 --> 00:39:47.980
unless it's like really uncomfortable for the patient.
1133
00:39:48.840 --> 00:39:49.880
And then spermicide use.
1134
00:39:49.940 --> 00:39:51.700
But in terms of other things,
1135
00:39:51.700 --> 00:39:55.200
before we get to the referral place or before we get to,
1136
00:39:56.740 --> 00:39:58.920
like where do we go from there in terms of like
1137
00:39:58.920 --> 00:40:01.240
the imaging really doesn't happen until we've tried
1138
00:40:01.240 --> 00:40:02.660
to intervene for a while, right?
1139
00:40:02.660 --> 00:40:04.600
Like we don't have to do imaging right away.
1140
00:40:04.800 --> 00:40:06.620
What is your threshold for kind of imaging?
1141
00:40:07.580 --> 00:40:09.040
Like how many, where's your?
1142
00:40:09.740 --> 00:40:11.400
Oh, based on their history as well.
1143
00:40:11.520 --> 00:40:13.060
So if they say, yeah, I've had the kidney stone
1144
00:40:13.060 --> 00:40:14.620
like every year blah, blah, blah.
1145
00:40:14.820 --> 00:40:16.780
Okay, maybe I'll just image.
1146
00:40:17.180 --> 00:40:17.780
Not gonna wait.
1147
00:40:18.200 --> 00:40:20.060
But if you're kind of taking the history
1148
00:40:20.060 --> 00:40:22.760
and there's nothing really that comes up as a red flag,
1149
00:40:23.300 --> 00:40:26.260
then I wouldn't image right away or anything like that.
1150
00:40:27.000 --> 00:40:30.660
You kind of focus on, yeah, like bowel habits,
1151
00:40:30.780 --> 00:40:32.420
once again, those are important.
1152
00:40:33.440 --> 00:40:35.400
And keeping a regular bowel movements
1153
00:40:35.400 --> 00:40:38.640
is because you sequester a bunch of stool in a rectum.
1154
00:40:38.640 --> 00:40:40.000
And of course, it's going to be easier
1155
00:40:40.000 --> 00:40:41.820
for it to make its migrate.
1156
00:40:42.920 --> 00:40:44.720
So that's always an important thing.
1157
00:40:45.100 --> 00:40:47.940
But yeah, I think and then hydration in general,
1158
00:40:47.940 --> 00:40:50.280
that's always a huge thing too.
1159
00:40:50.700 --> 00:40:53.340
But honestly, yeah, if there's no red flags that come up
1160
00:40:53.340 --> 00:40:56.460
and you've kind of done basic history and physical
1161
00:40:57.440 --> 00:40:59.620
and you've intervened where you can
1162
00:40:59.620 --> 00:41:00.980
in terms of behavioral stuff,
1163
00:41:01.140 --> 00:41:02.440
I think you just send them over
1164
00:41:02.440 --> 00:41:05.300
and then we can have that discussion.
1165
00:41:05.920 --> 00:41:08.340
But to your point, make sure it's actually recurrent UTIs.
1166
00:41:08.340 --> 00:41:09.660
Because there's so much patients who come in like,
1167
00:41:09.760 --> 00:41:11.660
yeah, I've had like 12 UTIs in a year
1168
00:41:12.240 --> 00:41:13.620
or the last six months.
1169
00:41:13.620 --> 00:41:14.680
And then we go and look
1170
00:41:14.680 --> 00:41:16.500
and there's not like a single positive culture.
1171
00:41:18.140 --> 00:41:20.980
And also culture-proven UTIs,
1172
00:41:21.820 --> 00:41:24.240
because otherwise it's persistent dysuria.
1173
00:41:24.600 --> 00:41:26.520
And maybe now you're treading water
1174
00:41:26.520 --> 00:41:29.580
into interstitial cystitis or something along those lines.
1175
00:41:30.320 --> 00:41:32.460
So if that's the case, I can still send them over.
1176
00:41:33.040 --> 00:41:35.640
But just make sure that the patient is aware
1177
00:41:35.640 --> 00:41:38.580
of the fact that, yeah, you don't have a UTI every time.
1178
00:41:40.880 --> 00:41:43.880
It's like not one culture
1179
00:41:43.880 --> 00:41:45.480
I can find that was actually positive.
1180
00:41:45.480 --> 00:41:47.780
It just kind of kept getting treated empirically
1181
00:41:47.780 --> 00:41:49.440
and then they get sent home.
1182
00:41:49.800 --> 00:41:49.960
Totally.
1183
00:41:50.120 --> 00:41:51.820
Yeah, I was going to say, because in real life,
1184
00:41:51.980 --> 00:41:54.160
like two to three infections in a year,
1185
00:41:54.380 --> 00:41:55.580
two in six months, three in a year,
1186
00:41:56.060 --> 00:41:58.160
most patients who come in with recurrent UTIs
1187
00:41:58.160 --> 00:41:59.600
are on that place of like 12.
1188
00:41:59.660 --> 00:42:00.420
And you're like, okay.
1189
00:42:01.180 --> 00:42:03.000
So I guess one pearl to take away for,
1190
00:42:03.060 --> 00:42:05.460
especially for newer clinicians is like,
1191
00:42:05.680 --> 00:42:07.800
because the IDSA guidelines, at least before,
1192
00:42:08.020 --> 00:42:10.080
were like that you could treat them empirically
1193
00:42:10.080 --> 00:42:12.200
without the culture if you had the evidence, right?
1194
00:42:12.440 --> 00:42:14.960
And then the next place is to get the culture.
1195
00:42:14.960 --> 00:42:18.820
But if like, yeah, culture, please, please add a culture.
1196
00:42:19.460 --> 00:42:22.660
It gets complicated, especially if they're just always
1197
00:42:22.660 --> 00:42:26.440
uncomfortable or always, you know, because it's like,
1198
00:42:26.440 --> 00:42:28.520
yeah, I don't know kind of what to do with this person
1199
00:42:28.520 --> 00:42:30.380
because I always, I can't treat them
1200
00:42:30.380 --> 00:42:31.580
and always saying that they have
1201
00:42:31.580 --> 00:42:33.060
some kind of baseline symptoms.
1202
00:42:33.500 --> 00:42:35.220
Yeah, it may be something deeper,
1203
00:42:35.580 --> 00:42:38.100
maybe like a social status or they may need further workup.
1204
00:42:38.140 --> 00:42:40.980
So those ones, kind of reasonable, you know,
1205
00:42:41.180 --> 00:42:43.240
even though it's like, okay, well, here we go.
1206
00:42:45.040 --> 00:42:46.360
Can I sneak in a question?
1207
00:42:46.700 --> 00:42:48.580
So I won't keep you for too much longer,
1208
00:42:49.040 --> 00:42:51.300
but sneak in a question about interstitials.
1209
00:42:51.640 --> 00:42:53.940
Just, you know what I'm trying to say?
1210
00:42:57.380 --> 00:42:58.260
Interstitial cystitis.
1211
00:43:00.440 --> 00:43:02.820
So like just my understanding of interstitial cystitis
1212
00:43:02.820 --> 00:43:04.840
is it's almost like a diagnosis of exclusion
1213
00:43:04.840 --> 00:43:07.180
and it's like considered like a general bladder,
1214
00:43:07.200 --> 00:43:08.940
irritation, pain, dysuria,
1215
00:43:09.260 --> 00:43:11.060
for not other causes that we can understand.
1216
00:43:11.980 --> 00:43:13.260
My understanding is at least we're trying
1217
00:43:13.260 --> 00:43:14.940
to reduce all those things that you were talking about
1218
00:43:14.940 --> 00:43:17.940
all the bladder irritants, like the dark chocolate
1219
00:43:17.940 --> 00:43:19.500
and the seltzers and stuff like that.
1220
00:43:19.680 --> 00:43:20.840
But do you have any other guidance?
1221
00:43:21.120 --> 00:43:23.940
Like it doesn't come up that often for me in primary care,
1222
00:43:23.940 --> 00:43:25.500
but I've seen it enough where patients
1223
00:43:25.500 --> 00:43:26.840
are just really uncomfortable.
1224
00:43:27.180 --> 00:43:28.320
And like I've even seen patients
1225
00:43:28.320 --> 00:43:30.240
where they're on pain medication for it,
1226
00:43:30.240 --> 00:43:32.120
like they're on like opiate pain medication for it.
1227
00:43:32.500 --> 00:43:34.180
So I don't know, what is your experience
1228
00:43:34.180 --> 00:43:35.360
with interstitial cystitis
1229
00:43:35.360 --> 00:43:37.360
or if you have any guidance for us in primary care?
1230
00:43:38.160 --> 00:43:40.840
It's like the toughest thing to treat in my opinion
1231
00:43:40.840 --> 00:43:42.040
because it's hard.
1232
00:43:42.600 --> 00:43:45.960
It's like, you know, so there's all sorts of things,
1233
00:43:46.000 --> 00:43:47.260
you know, some people do like
1234
00:43:50.340 --> 00:43:53.960
benzodiazepine depositories or opioid depositories
1235
00:43:53.960 --> 00:43:57.740
or, you know, all types of, you know,
1236
00:43:57.780 --> 00:43:59.700
people have done silver and nitrite treatments
1237
00:43:59.700 --> 00:44:01.600
in the past and things like that.
1238
00:44:01.820 --> 00:44:04.300
The most, you know, it's not really too much,
1239
00:44:04.300 --> 00:44:05.800
you know, because the thing is,
1240
00:44:06.380 --> 00:44:08.120
yeah, you can avoid the bladder irritants
1241
00:44:08.120 --> 00:44:09.180
and do all that.
1242
00:44:09.200 --> 00:44:11.180
And a lot of patients they find like
1243
00:44:11.180 --> 00:44:12.240
kind of happy medium.
1244
00:44:12.780 --> 00:44:16.200
I have some patients on things like D-manals or Urobel
1245
00:44:16.200 --> 00:44:18.800
and they seem that it works for them,
1246
00:44:19.100 --> 00:44:20.040
but there are other patients
1247
00:44:21.220 --> 00:44:23.120
more invasive management.
1248
00:44:24.760 --> 00:44:26.400
And a lot of times you can get
1249
00:44:26.400 --> 00:44:28.340
what's called an icy cocktail injection.
1250
00:44:28.660 --> 00:44:30.460
So we have like a cocktail difference.
1251
00:44:31.800 --> 00:44:33.860
They vary, but basically it's like
1252
00:44:33.860 --> 00:44:35.040
a couple of different things,
1253
00:44:35.240 --> 00:44:38.440
including lidocaine and patients
1254
00:44:38.440 --> 00:44:40.520
that are injected into the bladder
1255
00:44:40.520 --> 00:44:41.700
at regular intervals.
1256
00:44:42.100 --> 00:44:43.800
And sometimes that's what patients need
1257
00:44:43.800 --> 00:44:46.540
to kind of control the symptoms, you know.
1258
00:44:47.100 --> 00:44:49.840
Definitely, you know, at residency
1259
00:44:49.840 --> 00:44:50.760
I saw it much more.
1260
00:44:50.860 --> 00:44:51.840
I think that's definitely
1261
00:44:52.380 --> 00:44:54.160
the way to go for these patients.
1262
00:44:54.300 --> 00:44:55.420
There were like treatments
1263
00:44:55.420 --> 00:44:57.380
where they put some of the stuff
1264
00:44:57.380 --> 00:44:59.120
in the bladder and like shake it up
1265
00:44:59.120 --> 00:45:00.240
and let that come out.
1266
00:45:00.240 --> 00:45:01.500
Those don't really work.
1267
00:45:02.200 --> 00:45:03.260
There's, that's where they'd
1268
00:45:03.260 --> 00:45:04.580
hydrodestend the bladder.
1269
00:45:06.820 --> 00:45:09.700
So it's basically icy cocktail injections
1270
00:45:09.700 --> 00:45:11.720
and a lot of times your gynecologist
1271
00:45:11.720 --> 00:45:14.760
will do those types of treatments.
1272
00:45:15.000 --> 00:45:17.100
But yeah, those are tough to treat
1273
00:45:17.100 --> 00:45:18.960
and you know, all you do
1274
00:45:18.960 --> 00:45:20.780
as a primary care provider
1275
00:45:20.780 --> 00:45:22.200
is at least get them
1276
00:45:22.200 --> 00:45:23.760
to avoid the irritants
1277
00:45:23.760 --> 00:45:25.200
and see where they're at.
1278
00:45:25.360 --> 00:45:27.000
But if they're just for free,
1279
00:45:27.440 --> 00:45:29.060
yeah, just send them over
1280
00:45:29.060 --> 00:45:30.640
and then kind of take over
1281
00:45:30.640 --> 00:45:31.960
in terms of figuring out
1282
00:45:31.960 --> 00:45:32.780
what's the next step.
1283
00:45:33.240 --> 00:45:34.760
That's challenging when I still send
1284
00:45:34.760 --> 00:45:36.360
those patients out from time to time
1285
00:45:37.300 --> 00:45:39.080
to like more dedicated.
1286
00:45:39.080 --> 00:45:40.700
And I also refer to those patients,
1287
00:45:40.800 --> 00:45:41.980
you know, it's kind of,
1288
00:45:41.980 --> 00:45:43.000
it kind of sounds funny,
1289
00:45:43.560 --> 00:45:44.300
but I refer to,
1290
00:45:44.400 --> 00:45:46.880
there's like a big icy community
1291
00:45:46.880 --> 00:45:49.100
on TikTok and I've learned
1292
00:45:49.100 --> 00:45:51.260
tons of stuff about IC,
1293
00:45:52.180 --> 00:45:53.700
applied that and the patients
1294
00:45:53.700 --> 00:45:54.880
have benefited from it.
1295
00:45:54.900 --> 00:45:55.560
So it's like,
1296
00:45:55.700 --> 00:45:56.580
it's one of those conditions
1297
00:45:56.580 --> 00:46:00.840
that's chronic and it's multi-modal.
1298
00:46:00.960 --> 00:46:02.740
It's not just a particular medication
1299
00:46:02.740 --> 00:46:06.260
or having that support system
1300
00:46:06.260 --> 00:46:08.300
and talking about different ideas
1301
00:46:08.300 --> 00:46:09.880
and different ways of managing it.
1302
00:46:10.340 --> 00:46:10.820
Totally, totally.
1303
00:46:11.000 --> 00:46:12.060
Medical TikTok is wild.
1304
00:46:13.360 --> 00:46:14.860
Patients like coming in,
1305
00:46:14.860 --> 00:46:16.400
yeah, with all of the things.
1306
00:46:16.720 --> 00:46:18.360
So I don't spend too much time on TikTok,
1307
00:46:18.380 --> 00:46:19.380
but I feel like I should
1308
00:46:19.380 --> 00:46:20.300
based on all the things
1309
00:46:20.300 --> 00:46:22.300
that I keep hearing patients.
1310
00:46:22.300 --> 00:46:23.860
I just use it for,
1311
00:46:23.920 --> 00:46:25.060
that's probably the only
1312
00:46:26.260 --> 00:46:27.960
medical indication I use it for,
1313
00:46:28.180 --> 00:46:28.960
but that's it.
1314
00:46:29.560 --> 00:46:30.600
It's a little wild
1315
00:46:30.600 --> 00:46:31.700
and sometimes frustrating.
1316
00:46:32.660 --> 00:46:34.380
But there are, you know,
1317
00:46:34.420 --> 00:46:35.400
when you sift through
1318
00:46:35.400 --> 00:46:36.160
a lot of the garbage,
1319
00:46:36.300 --> 00:46:37.020
there's actually some really
1320
00:46:37.020 --> 00:46:38.060
good information there.
1321
00:46:38.560 --> 00:46:39.460
That's awesome.
1322
00:46:40.440 --> 00:46:41.700
So last two questions.
1323
00:46:42.600 --> 00:46:44.940
What is your favorite part
1324
00:46:44.940 --> 00:46:46.400
of being a urologist?
1325
00:46:48.500 --> 00:46:51.560
My favorite part of being a urologist is...
1326
00:46:51.560 --> 00:46:53.140
Or like why do you love urology too?
1327
00:46:53.220 --> 00:46:54.480
Like they could be the same.
1328
00:46:55.100 --> 00:46:56.940
I think it's just like,
1329
00:46:57.300 --> 00:46:58.960
you know, it's just wild.
1330
00:46:59.120 --> 00:47:01.260
I mean, you see kind of everything.
1331
00:47:01.360 --> 00:47:03.200
So I think I like the variety of it.
1332
00:47:03.200 --> 00:47:04.660
You might see a kidney stone
1333
00:47:04.660 --> 00:47:05.960
and do a stone surgery
1334
00:47:05.960 --> 00:47:07.340
and then the next day
1335
00:47:07.340 --> 00:47:09.300
you'll see a real mass
1336
00:47:09.300 --> 00:47:10.260
and do a nephrectomy
1337
00:47:10.260 --> 00:47:11.260
and the next day
1338
00:47:11.260 --> 00:47:14.100
you'll be doing relationship counseling
1339
00:47:14.100 --> 00:47:16.860
with a couple who are dealing
1340
00:47:16.860 --> 00:47:18.100
with the reptile dysfunction
1341
00:47:18.100 --> 00:47:18.860
and then the next day
1342
00:47:18.860 --> 00:47:19.440
you might be helping
1343
00:47:19.440 --> 00:47:20.860
fertility treatments
1344
00:47:20.860 --> 00:47:23.160
or things like that.
1345
00:47:23.220 --> 00:47:25.020
So it'll be by doing a vasectomy.
1346
00:47:25.600 --> 00:47:26.160
So, you know,
1347
00:47:27.360 --> 00:47:29.140
it's a spectrum of things
1348
00:47:29.140 --> 00:47:31.120
and the patients are really cool
1349
00:47:31.120 --> 00:47:33.240
and it's like all across the spectrum
1350
00:47:33.240 --> 00:47:35.360
and you can do all types of procedures
1351
00:47:35.360 --> 00:47:36.860
and you get clinic
1352
00:47:36.860 --> 00:47:38.060
and you get the inpatients
1353
00:47:38.060 --> 00:47:39.240
and you get the outpatients
1354
00:47:39.240 --> 00:47:39.880
and all of that.
1355
00:47:40.280 --> 00:47:41.620
So I think I like urology.
1356
00:47:42.900 --> 00:47:44.140
It's definitely the only place
1357
00:47:44.140 --> 00:47:45.100
you can get away with a lot
1358
00:47:45.100 --> 00:47:47.660
of inappropriate eggplant jokes.
1359
00:47:50.580 --> 00:47:52.460
It seems like a really fun place.
1360
00:47:52.680 --> 00:47:54.140
I feel like, yeah,
1361
00:47:54.140 --> 00:47:57.540
I just feel like every social media person,
1362
00:47:57.760 --> 00:47:59.060
medical social media person
1363
00:47:59.060 --> 00:48:00.320
that is like the most fun
1364
00:48:00.320 --> 00:48:01.400
is a urologist.
1365
00:48:01.580 --> 00:48:02.200
You know what I mean?
1366
00:48:04.020 --> 00:48:05.700
Yeah, I'd argue that's the same.
1367
00:48:05.700 --> 00:48:07.420
It's a very self-selecting specialty.
1368
00:48:09.420 --> 00:48:10.680
And I didn't know.
1369
00:48:10.760 --> 00:48:11.400
I had no idea.
1370
00:48:11.620 --> 00:48:12.940
The medicine is not my,
1371
00:48:13.000 --> 00:48:14.440
like renal is more my forte
1372
00:48:14.440 --> 00:48:17.420
in terms of my natural gravitation.
1373
00:48:17.440 --> 00:48:19.020
But I also just maybe don't,
1374
00:48:19.140 --> 00:48:21.040
I just haven't had the experience of urology.
1375
00:48:21.120 --> 00:48:22.000
Maybe that would be my thing.
1376
00:48:24.380 --> 00:48:26.560
But I'm so fun.
1377
00:48:27.380 --> 00:48:29.000
So I'm going to stop myself
1378
00:48:29.000 --> 00:48:30.020
from seeking more questions
1379
00:48:30.020 --> 00:48:31.100
so we can honor your time.
1380
00:48:31.320 --> 00:48:33.860
But my last question is about
1381
00:48:33.860 --> 00:48:36.980
where can people follow you online?
1382
00:48:38.500 --> 00:48:39.780
Well, would you like people
1383
00:48:39.780 --> 00:48:40.520
to follow you online?
1384
00:48:40.760 --> 00:48:41.420
I guess I should.
1385
00:48:42.460 --> 00:48:43.840
Yeah, I feel like, you know,
1386
00:48:44.040 --> 00:48:45.920
the number one place
1387
00:48:45.920 --> 00:48:47.000
I guess I'm most active
1388
00:48:47.000 --> 00:48:47.920
would be Instagram.
1389
00:48:48.660 --> 00:48:50.640
And you could definitely post my handle
1390
00:48:50.640 --> 00:48:52.560
and the links
1391
00:48:52.560 --> 00:48:56.280
in jacademic underscore md on Instagram.
1392
00:48:56.780 --> 00:48:58.420
And, you know, it's basically a lot
1393
00:48:58.420 --> 00:48:59.400
of my nonsense
1394
00:48:59.400 --> 00:49:01.020
with the occasional medical information
1395
00:49:01.020 --> 00:49:01.920
slipped in there.
1396
00:49:01.920 --> 00:49:03.560
But it's, you know,
1397
00:49:03.600 --> 00:49:04.340
I think I just,
1398
00:49:04.540 --> 00:49:05.140
it gives me a chance
1399
00:49:05.140 --> 00:49:07.120
to kind of interface with people.
1400
00:49:07.720 --> 00:49:09.200
And yeah, I like to actually, you know,
1401
00:49:09.240 --> 00:49:11.340
get some educational stuff in there
1402
00:49:11.340 --> 00:49:12.160
from time to time.
1403
00:49:12.180 --> 00:49:14.340
But that's probably the main place.
1404
00:49:14.360 --> 00:49:16.260
And then I am on TikTok,
1405
00:49:16.700 --> 00:49:18.440
which is slowly burgeoning.
1406
00:49:18.760 --> 00:49:20.560
It's, my TikTok is actually
1407
00:49:20.560 --> 00:49:21.920
dikdok underscore md.
1408
00:49:23.080 --> 00:49:25.700
So replace the T with the D.
1409
00:49:26.580 --> 00:49:29.400
Yeah, I love it.
1410
00:49:29.440 --> 00:49:31.420
You have one of my favorite
1411
00:49:31.420 --> 00:49:33.220
social media accounts for real,
1412
00:49:33.380 --> 00:49:34.180
for real, for real.
1413
00:49:34.880 --> 00:49:36.180
Like, I love it so much.
1414
00:49:36.180 --> 00:49:37.040
You're so funny.
1415
00:49:37.680 --> 00:49:39.100
Thank you so much for being here.
1416
00:49:39.120 --> 00:49:40.080
This is amazing.
1417
00:49:40.360 --> 00:49:42.440
And I hope you have a wonderful weekend.
1418
00:49:42.620 --> 00:49:43.540
But yeah, any, actually,
1419
00:49:44.060 --> 00:49:45.820
I didn't ask any other parting words
1420
00:49:45.820 --> 00:49:46.720
you would like to share.
1421
00:49:47.600 --> 00:49:48.160
Oh, yeah.
1422
00:49:49.420 --> 00:49:50.340
No, I think, you know,
1423
00:49:50.900 --> 00:49:53.180
it's really great to see that
1424
00:49:53.920 --> 00:49:57.780
you have APPs and PAs and MPs
1425
00:49:57.780 --> 00:50:00.120
kind of trying to bridge that gap
1426
00:50:00.120 --> 00:50:01.220
in terms, like you said.
1427
00:50:02.640 --> 00:50:03.600
School, clinic.
1428
00:50:03.880 --> 00:50:04.540
And I think that
1429
00:50:05.060 --> 00:50:06.120
it definitely makes it easier
1430
00:50:06.120 --> 00:50:07.140
for anybody involved
1431
00:50:07.140 --> 00:50:08.320
when you kind of know
1432
00:50:08.320 --> 00:50:09.300
when to refer,
1433
00:50:09.500 --> 00:50:11.580
when to try to accolade.
1434
00:50:11.800 --> 00:50:13.880
You know, I think there's no shame
1435
00:50:13.880 --> 00:50:15.480
in saying, hey, this is too much.
1436
00:50:15.560 --> 00:50:16.880
Let me just send it over
1437
00:50:17.980 --> 00:50:19.760
because that isn't the best
1438
00:50:19.760 --> 00:50:20.760
interest of the patient.
1439
00:50:20.920 --> 00:50:22.340
And I've definitely seen patients
1440
00:50:22.340 --> 00:50:24.100
who have suffered
1441
00:50:24.100 --> 00:50:25.100
to their detriment
1442
00:50:25.100 --> 00:50:27.300
over a primary care provider
1443
00:50:27.300 --> 00:50:29.060
just not wanting to refer.
1444
00:50:29.820 --> 00:50:30.260
Yeah.
1445
00:50:30.260 --> 00:50:32.360
So I think, or, you know,
1446
00:50:32.360 --> 00:50:34.240
sometimes there's the idea
1447
00:50:34.240 --> 00:50:35.140
that, hey, there's nothing more
1448
00:50:35.140 --> 00:50:36.200
that can be done for this.
1449
00:50:36.200 --> 00:50:37.500
And there definitely is, you know.
1450
00:50:37.800 --> 00:50:38.820
It's hard to keep abreast
1451
00:50:38.820 --> 00:50:40.140
with all the different specialties
1452
00:50:40.140 --> 00:50:41.360
and all the new advances
1453
00:50:41.360 --> 00:50:42.400
and things like that.
1454
00:50:42.420 --> 00:50:44.540
So just don't hesitate, you know,
1455
00:50:45.260 --> 00:50:46.860
especially if it's just, you know,
1456
00:50:46.980 --> 00:50:47.880
a patient's really frustrated
1457
00:50:47.880 --> 00:50:49.160
and they have a particular problem,
1458
00:50:49.180 --> 00:50:50.840
you know, it wouldn't hurt
1459
00:50:50.840 --> 00:50:52.980
to send a comment.
1460
00:50:53.220 --> 00:50:54.180
And yeah, you know,
1461
00:50:54.280 --> 00:50:55.680
sometimes we might gripe and moan,
1462
00:50:55.700 --> 00:50:56.640
but we'll see the patient.
1463
00:50:56.720 --> 00:50:58.060
And, you know, a lot of times
1464
00:50:58.060 --> 00:50:59.320
I would like, yeah, okay,
1465
00:50:59.560 --> 00:51:00.660
they actually have a legit problem
1466
00:51:00.660 --> 00:51:01.660
and take care of it.
1467
00:51:01.900 --> 00:51:02.920
Totally, totally.
1468
00:51:03.060 --> 00:51:03.700
Well, thank you so much
1469
00:51:03.700 --> 00:51:04.200
for saying that
1470
00:51:04.200 --> 00:51:05.260
because I think that,
1471
00:51:05.280 --> 00:51:06.620
I think everybody
1472
00:51:06.620 --> 00:51:08.080
in the real world MP community
1473
00:51:08.080 --> 00:51:10.180
is very patient first,
1474
00:51:10.500 --> 00:51:12.080
like excellent patient care.
1475
00:51:12.380 --> 00:51:13.780
And I think there is
1476
00:51:13.780 --> 00:51:15.100
so much imposter syndrome though
1477
00:51:15.100 --> 00:51:16.060
as newer clinicians
1478
00:51:16.060 --> 00:51:17.240
that it's like, oh my gosh,
1479
00:51:17.520 --> 00:51:18.280
they're going to like hate
1480
00:51:18.280 --> 00:51:19.240
me for sending this patient.
1481
00:51:19.260 --> 00:51:19.980
And it's like, you know what?
1482
00:51:19.980 --> 00:51:21.560
It really is about safety first, right?
1483
00:51:21.560 --> 00:51:22.460
Like it's about the patients,
1484
00:51:22.480 --> 00:51:23.360
about safety first.
1485
00:51:23.620 --> 00:51:24.520
It's all good.
1486
00:51:24.740 --> 00:51:26.340
So I appreciate you saying that.
1487
00:51:26.860 --> 00:51:27.620
All the imposters.
1488
00:51:27.620 --> 00:51:29.040
I sometimes wonder,
1489
00:51:29.380 --> 00:51:30.140
but you're all just.
1490
00:51:32.120 --> 00:51:33.160
It's so true.
1491
00:51:33.500 --> 00:51:34.500
Well, thank you so much.
1492
00:51:34.520 --> 00:51:35.540
This was so awesome.
1493
00:51:36.560 --> 00:51:37.540
No problem, no problem.
1494
00:51:37.620 --> 00:51:38.440
Thanks for having me.
1495
00:51:38.480 --> 00:51:39.600
I really appreciate it.
1496
00:51:48.840 --> 00:51:50.400
That's our episode for today.
1497
00:51:50.520 --> 00:51:52.280
Thank you so much for listening.
1498
00:51:52.560 --> 00:51:54.040
Make sure you subscribe,
1499
00:51:54.360 --> 00:51:55.020
leave a review
1500
00:51:55.020 --> 00:51:56.920
and tell all your MP friends
1501
00:51:56.920 --> 00:51:58.380
so together we can help
1502
00:51:58.380 --> 00:52:00.720
as many nurse practitioners as possible
1503
00:52:00.720 --> 00:52:02.660
give the best care to their patients.
1504
00:52:02.940 --> 00:52:04.540
If you haven't gotten your copy
1505
00:52:04.540 --> 00:52:06.000
of the ultimate resource guide
1506
00:52:06.000 --> 00:52:07.120
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1507
00:52:07.520 --> 00:52:09.760
head over to realworldnp.com
1508
00:52:09.760 --> 00:52:10.660
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1509
00:52:11.060 --> 00:52:12.400
You'll get these episodes
1510
00:52:12.400 --> 00:52:14.280
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1511
00:52:14.280 --> 00:52:15.720
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1512
00:52:16.060 --> 00:52:17.780
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1513
00:52:17.980 --> 00:52:19.920
I really just don't share anywhere else.
1514
00:52:20.320 --> 00:52:21.880
Thank you so much again for listening.
1515
00:52:22.020 --> 00:52:23.240
Take care and talk soon.
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