Bladder vs Prostate: How to Prevent Bladder Complications of BPH

[Dr. Jose Silva]:
I'm sure you see those patients that say, "Hey, I'll be fine." Then you go in and the detrusor, they have severe trabeculations. Even though the PBR is low, but still, you have a big prostate, 60, 80 grams, kissing lobes, but they say, "I'll be fine. Why am I going to do a surgery?" Then that UroCuff will give you the information or the transition to, "Hey, we need to do something before that bladder goes to stage five." Wayne, can you go over the five stages of their function or bladder damage, sorry?

[Dr. Wayne Kuang]:
The five stages of bladder health, that's really fun. For folks who want to learn more, feel free to go to manvsprostate.com, it's a free download, as well as the Italian Brigade of Defenders of the Detrusor led by Defender Luca Cindolo. He really picked up on this and really has put his academic wisdom on the five stages of bladder health and you can get that in the journal of Nature of Prostate Cancer and Prostatic Diseases and that's with that–

Go to www.manvsprostate.com. Really insightful comments from him from a very nicely academic perspective. The five stages of bladder health, amazingly, has really taken off, at least on LinkedIn to the point it's been inspirational for urologists around the world. There's Defender Sonny Schlein of Schlein Catheters and Prostalone. He actually did a painting. If you get a chance to see it, it's amazing. I couldn't believe it.

[Dr. Jose Silva]:
I saw your post of the catheter, but no, I haven't seen the painting.

[Dr. Wayne Kuang]:
I'll have to put that back out again, but it's got the saintly bladder being attacked by these five demons representing the five stages of bladder health. We have to recognize the bladder is being victimized by the villainous prostate as that prostate is getting bigger and growing tighter. The five stages of bladder health, as I said, is really the talk track that allows us to guide patients to make the best decision as well as to pierce the armor of masculinity that allows them to lower their defenses and to reach for something greater for themselves, which is a life well-lived, catheter-free and chemical-free. It's a verbal map like we talked about.

The reason why, if we're going to talk about, take for example, cancer, we talk about late stage prostate cancer, nobody wants that. Same thing with BPH. We talk about prostate cancer affecting one in eight men. We should be at least as concerned about BPH, which is affecting eight to nine of ten men and preventing late stage BPH. To say that, we need to have the stages. The five stages are predicated on the fact that it has to have relatable terms. We're talking about the prostate is the size of a golf ball and the shape of a mini donut. We express a sense of gravity that, yes, the bladder is only one of two organs that cannot be transplanted, the brain and the bladder.

We've reinforced that, "Hey, Mr. Smith, this is a problem when the IPSS score is eight and above. Then we need to make an analogy where people can relate to, as you and I know, really the perfect [unintelligible 00:20:00] for the heart is valvular heart disease or aortic stenosis. If we got into valvular heart disease with our patients, we'd never get out of that room. Luckily, we have ischemic heart disease, and people can understand that. As a result, I created the five stages of bladder health. As that prostate is getting bigger, the donut hole is getting tighter. Mr. Smith, we talked about the heart is a muscle that pumps blood, the bladder is a muscle that pumps urine through that prostate. As that donut hole gets tighter, stage one, things are going to slow down.

Then stage two, if we don't take care of that problem, the bladder now over 5 years, 10 years, 15, 20 years, is going to be overworking, struggling, quivering, becoming overactive, causing those symptoms, Mr. Smith, of urgency, frequency, getting up in the middle of the night. Then stage three, I think is one of the most important. "Mr. Smith, if you don't take care of this, your bladder will start to act out like a rebellious child, and it'll squeeze without your permission, cause you to leak down your leg." Why is that important? Because it's not even covered. Urge urinary incontinence is not covered in the IPSS.

I will say, at least from my experience, and Jose, you may or may not feel the same, but that's the most embarrassing and shameful. I've had guys who stopped leaving the house because they were leaking down and smelling funny and embarrassed to be in the shopping mall. Then stage four, Mr. Smith, just like the heart can have a heart attack, the bladder can all of a sudden stop working, you choke in the emergency room, needing a catheter. Then stage five, just like your heart can go into heart failure, your bladder can go into bladder failure and you may need a catheter for the rest of your life.

The one difference is, Mr. Smith, is if your heart went into heart failure, you can still get a heart transplant. With the bladder, that's it, game over. You're living with that situation and that's not okay. That story, that verbal roadmap that we're guiding them down, activates them to make the best decisions for themselves. I'm not telling them what to do, but they're self-activating to take action about their situation because they don't want to be that guy that gets a late stage BPH.

They don't want to be that guy that was warned about it and chose to do nothing and then ended up with a dead bladder. It's the fear of catheters, the fear of emergency room visits, retention, leaking on themselves, and that vision, that dream for themselves to live their best lives, the best version of themselves, chemical-free and catheter-free, that is going to have them want you to get the data to find out what's going on.

[Dr. Jose Silva]:
Exactly. You mentioned the fear, but also, unfortunately, some patients think that it's normal part of aging, that it's just, "Hey, I'm getting old, it's normal." Maybe their parents had it. The father had it, so they're used to it. No, there's treatment. There's treatment. Like you mentioned, there's things that we can do so that you have a better life. You mentioned earlier during the segment, education. Do you go and talk to PCPs about this and start talking more about bladder health instead of just the prostate?

[Dr. Wayne Kuang]:
Absolutely. For us, the vision for ManVsProstate, it's a garage-grown, grassroots crusade for us to redefine the BPH care pathway. It's going to take all of us. It's going to take a village. I will tell you, at least here in the Americas, primary care docs are overwhelmed. I just worked with a primary care doc on Saturday, and he's like, "I don't have time. I need help. I've got 15 other problems I got to take care of in 15 minutes. How am I going to really dive into that?" That's why it's going to take a collaborative effort on all of our parts. Primary care physicians, specialists, mid-levels, urologists, industry, academics. We're going to all have to work together.

Yes, the primary care docs need to be enlightened. We need to help them, I think, with mobile apps or online education, having a campaign that goes a national shout out to Defender Austin Slaves, who did some research and reached out to our company. It's going to cost us about $247,000 to try and launch a national campaign. Obviously, grassroots, we're not there yet, but how do we get the message out directly to the patients so the patients are coming in pre-educated for the primary care doc, pre-educated about the issues, the late stage BPH, when they meet with the urologist.

One of our playful hashtags that we really want to get out to patients is hashtag, hey, what about my bladder? We want them pushing the dialogue, and we can do that through collaboration to build communities, whether it's within industry, within online amongst patients, whether it's within academics, with the AUA, the EAU, and the NICE, building communities, consistently sharing that message.

For example, healthcare industry representatives, there's a Defender Trey Dorman from NeoTract asked, "Hey, what do we do?" A very simple thing is start collaborating with other industry companies within diagnostics, and work with devices to share this message. Also in our marketing, we need to be very consistent in showing the bladder being beat up with trabeculations. A great one is when OptiLume came out on the front cover of Journal of Urology. I was like, "Yes." If you look at the picture, the bladder has trabeculations. On the academic side, AUA, EAU, NICE, you need to put good pictures of normal bladders versus trabeculated bladders that all urologists can download and put on the websites.

Every time a patient comes to a website from a urology practice, they're seeing a beat up bladder, we're consistently sending the same message that, "Hey, bladder health is what is really a priority, the preservation of bladder health." Then the second thing is internally and externally, we need to challenge the orthodoxy. Medications, and this is a very important point. Folks ask me, "Hey, are you anti-medications?" No, we're pro-data and we're pro-education. Part of that education is medications, yes, have their role, but not as therapeutic measures. They need to be relegated and reassigned to a category of temporizing measures, similar to a Foley catheter.

Guy comes in with stage four retention. In the emergency, we temporize the situation with a Foley catheter. A man comes in with symptoms, stage two or stage three, overactive bladder, [unintelligible 00:26:34]. We temporize the situation with medications, "Hey, but Mr. Smith, there's a bigger problem going on here." We need data to figure out what needs to happen.

That's a really important challenge to the orthodoxy, that medications are not a therapeutic measure, but a temporizing measure. Another one is just the use of language. We talk about benign prostatic hyperplasia in our guidelines, but that's a histology. We need to really get back. Words matter. If we use the word obstruction, that word affect our thought, affects our actions and affects our habits, because obstruction means there must be a solution that means de-obstruction, and chemicals don't de-obstruct.

[Dr. Jose Silva]:
I remember in residency, there were only four real indications for treatment. It was urine retention, persistent hematuria, I think renal failure, and I don't remember if it was recurrent UTIs or bladder stones. By that time, you're already probably stage four, stage five, and that's when you do a treatment and you're not going to get him back to a baseline. You're going to try to alleviate some of the symptoms, but really, maybe you're not going to do nothing outrageous in terms of quality of life.

[Dr. Wayne Kuang]:
That's a challenge right there. That's perfect. Challenging the orthodoxy, what's an indication? Then just redefining, like, "Hey, how do we find the right patient with the right prostate to intervene at the right time within the window of curability?" Some folks have said, "Hey, Wayne, are you an advocate for just early surgery for every guy?" No, we're an advocate for finding the right time in that shared decision-making process that fits both the surgeon and the patient when warranted. I think that's really important, is that the right timing.

[Dr. Jose Silva]:
Wayne, why do you think we don't talk more or when we did residency, and I don't know if currently there's talk about detrusor, but why we don't talk about detrusor enough? It's like after residency now that you have the Defender of the Detrusor. You're doing the LinkedIn, all the agenda. Why do you think we don't talk about this more?

[Dr. Wayne Kuang]:
It's a fantastic question. The conversation about earlier intervention within the window of curability to preserve bladder health has been around for 20 years. Defender Andrea Tubero from Italy published a great paper in 2001 talking, early intervention is needed to protect the bladder. It's been around for 20 years, but that was a different time. We did not have many tools on our tool belts. We had monopolar TURP, and we had open simple prostatectomy with incredible morbidity and mortality. As a result, medications came along with a perceived more favorable benefit to risk profile.

Then we had industry dollars pushing pharmaceuticals. Think of all Flomax, all Hytrin, Cardura, et cetera, et cetera, 5-alpha reductase inhibitors, OAB medications, and the device industry and pharmaceutical industry really started putting a lot of money into that. I think it just distracted us a little bit, also because we didn't have many good other options. At that time as well, we weren't feeling the full impact of late stage BPH. We are now feeling the full extent of men living longer with all these problems.

Because of that, I think that was a big part of it, and then on top of that operationally, it's just not that easy to get guys to do a cysto or to do pressure flow studies. It takes work, but things are changing. We live in this golden age of BPH. Where pressure flow studies, whether it's Urocuff or [unintelligible 00:30:25], things are getting easier with AI and so forth, with the operational efficiency of cystoscopy. Now there's disposable cystoscopes. You don't have to worry about trying to get that prepped and ready and worry about sterilization. I think we're starting to break the habit. In the past it was just too easy to prescribe and refill.

That was compounded by the fact that men had the armor of masculinity and I'm fine syndrome. It's just easier to refill it because they said they're fine. What we need to get back to, once again, we are not anti-medications. We're pro-data. Put the cards on the table. We have never had a better time to get data to put in front of men and say, "Hey, this is who you are. This is your bladder function. This is your prostate situation. These are your options." Now we have just a plethora of surgical de-obstructing technologies in all the surgical categories of least invasive surgical therapies, minimally invasive, invasive, and most invasive. This is a great time for us to really tackle this problem and stem the tide because there's a tsunami coming of late stage BPH.

[Dr. Jose Silva]:
At the level of the AUA, even in the guidelines, they revise it all the time, but really they don't talk about detrusor. It's very vague in terms of the options, but they do mention a lot of the pills. How can we change that language in terms of the AUA guidelines or the AUA being a force to help bring that information to the patients and all urologists about, we need to change the paradigm and focus on the detrusor.

[Dr. Wayne Kuang]:
Once again, it's going to take a village. It's going to take healthcare industry reps. We need you to be evangelists. I need you going out there and challenging doctors, challenging practices. Ask them that question, "Hey, what happened in the emergency room when that guy came in four [unintelligible 00:32:16]? Why did that happen?" Then obviously, you can introduce what your technology does to help facilitate that BPH care pathway to prevent late stage BPH because that's a shared common goal. ManVsProstate is really working at the grassroots level trying to direct a patient.

We're going to try and launch BPH 360 in the spring equinox to really directly get the good information to understand that there's three things that we talk about. The three Ps, prioritizing the preservation of bladder health, putting an end to the polypharmacy epidemic, and preventing late stage BPH. Then on top of that, we're coming out, the EAU incontinence commission just put out a manifesto that they submitted and they had key opinion readers sign it. We're doing the same thing, just saying, hey, this is what we think we get and I get it too. Please understand. I recognize who I am and who I am not. I am just a small community doc in the desert.

[Dr. Jose Silva]:
You're more than that, man.

[Dr. Wayne Kuang]:
That's the truth. I do not have the academic experience and expertise of all the literature. We need everybody to chip in, but also really focusing on the patients. I do believe that, hashtag, hey, what about my bladder? If patients are pounding, "Hey, what about my bladder?" I know you're talking about my prostate, but what about my bladder? It's going to drive that change on multiple levels.

At least that's how we're hoping to get there. The ManVsProstate manifesto, direct to patient education. Really having us talk about, just like here today on your podcast and other podcasts, how do we get there? Also, the publication that came out in the Journal of Nature, Prostate Cancer and Prostatic Diseases, that was huge, really, to just give it a little bit of meat and authority that, hey, there's something here that we need to talk about.

That's what we're hoping, just changing the conversation, challenging the orthodoxy and being willing to have that conversation. Oh, the other thing is I want to bring up burnout and moral injury within urology. It's because we got away from being who we are. We're solution-finding surgeons. BPH is 30% of most practices' workload, but only 6% of their revenue. It's also not fulfilling. We're not fixing problems. We need to get back to what brings us joy as surgeons. I think all those things, we start thinking about it, talking about that, feeling it, and listening to what I would call cognitive dissonance and resonance, what feels right, and letting that be our guide.

[Dr. Wayne Kuang]:
As you know or folks may or may not know, I was on faculty part-time at the University of New Mexico doing male fertility. I had a combined position with a large urology group of practice in the community which I was with for eight years. Then about 2010, I started the Southwest Fertility Center for Men where I could really focus on male fertility, vasectomy reversals. Then in 2014, I opened up a solo practice called MD for Men. It was really an experiment or adventure into understanding how do we create a place that is the go-to place for men's wellness?

I chose it specifically not the number one place, but the go-to place, a place where men will tell another man, "Hey, that's the place you need to go to." We're building community. With that, it was the mission that how do we empower men with the guest experience to evolve fearlessly into the best versions of themselves? Part of that, so vasectomies, testosterone, Peyronie's, erectile dysfunction, BPH. They're all really part of men answering a simple thing, which is, what am I scared of? We have to help men face, embrace, and move through their fear so that they can become the best version 2.0, the best fathers, the best sons, the best colleagues, the best bosses.

That was how we started out. I wanted every pathway within the practice to be simple, safe, effective, efficient, and personalized. When I came to BPH Care Pathway, I, over the first 10 years, there was a cognitive dissonance. There was something that wasn't quite right. Jose, you and I trained for years to be solution-finding surgeons. Yet I found myself being a pill-pushing physician. Instead of helping men be the best version of themselves in the operating room for BPH, I was mostly taking care of them in the office. I'm guilty of doing the prescriptions and the refills.

Where else was I taking care of them? In the emergency room. When they came in with stage four, late-stage BPH retention, coaching for other physicians and other groups, the number one thing when I asked is, "Hey, when was the last time you were called from the emergency room for a guy in retention?" For you, Jose, what's the largest volume you've been called about?

[Dr. Jose Silva]:
5,000.

[Dr. Wayne Kuang]:
Exactly. Three, four, five liters. Then if I asked a secondary question, what percent of those guys are on BPH medication?

[Dr. Jose Silva]:
Probably all of them.

[Dr. Wayne Kuang]:
80%? 90%?

[Dr. Jose Silva]:
At least on Flomax, yes.

[Dr. Wayne Kuang]:
Exactly. Treats as cognitive dissonance. What am I doing wrong? Here we have all these guys showing up, and I am following the guidelines. There's a disconnect. There's a cognitive dissonance. There's something wrong with the system. I was part of that problem. I recognized that I was just trying to be a great urologist. How was I doing? I was towing the party line. I was following the AUA guidelines. It was not happening. The healing and the curing wasn't happening in the operating room. Like I said, it was in the office with prescriptions and in the emergency room with Foley catheters with guys with late-stage BPH.

I had become something that I wasn't comfortable with, which was a pill-pushing physician instead of a solution-finding surgeon. What I realized is that, and this is over a whole decade, is I was straying too far from our Hippocratic Oath. I think I became so fearful that I was going to harm someone by doing something that I should not have done, like a surgery prematurely, potentially, that I forgot that you can equally harm someone by not doing something that you should have done, like intervening soon enough within the window of curability to save a bladder, to prevent that late-stage BPH.

Really understanding that and recognizing that, in my world, if I wanted to create a pathway that's simple, safe, personalized, effective, and efficient-- effective, right? It's doing the right thing. I recognize that just managing symptoms with the AUA guidelines, we could elevate that. We could do better. For us, it was prioritizing the preservation of bladder health. That is a higher calling that we all can share and believe in. Then to be efficient, I needed to recognize that it's not just in the treatment and the post-treatment phase of the care pathway, but actually in the pre-treatment phase, what are we doing before we treat to optimize how we make that decision with our patients about the right timing to intervene for a mechanical problem that deserves a mechanical solution.