How Often Should You Pee and Other Urination Explanations

29:03And all of a sudden you have kind of a jack-in-the - beanstalk phenomenon going on. You be careful what you wish for, right? But the truth is, it is all hormonally mediated, Jordan. And we don't know exactly why it's important to keep those DHT receptors on as we age. Really no known understanding of that, except for that, thankfully, we do have medications that can block that, albeit with side effects. But that is still considered a first line agent is blocking those receptors so that the testosterone that gets converted into DHT and therefore the prostate growth, the magic dust that makes the prostate grow can stop turning off.

29:43And then actually it does involute or it does actually shrink the prostate, which is pretty cool. And that was a pretty amazing discovery 30 odd years ago. I mean, I keep thinking back to what you're saying earlier about the key of the door phenomenon, which is something, you know, I'll have a 45 minute commute or something and I'll be completely fine until I'm walking up the stairs to my apartment. That's right. Yeah. Commuters have this thing. I mean, I, when I asked guys and I screen them, you know, about their urinary symptoms, I say, well, you know, how often are you driving? And, you know, LA is famous for our freeways and famous for our congested freeways in the West side of town where I live in practice.

30:20It's the 405, which is obviously made it into Saturday night live lore is how to avoid the 405 at certain times a day, right? I take the 10 or the 110. The 405 sign is also a very hyper-local way of saying, well, when do you get that urge to pull off the 405 because you just can't hold it anymore? Or have you ever pulled off and just found an old Gatorade bottle or something and just let her rip into that? And the guys will say, oh yeah, that's happened. And that to me is pathologic urgency. And to the point where there are guys that actually don't leave their house or take surface trees because they don't want to get caught on the 405 or whatever your local equivalent of the 405 is, the LIE.

31:04And so I think, I mean, it wasn't good for Harry Chapin. It's not good for the commuter sometimes. It's too soon. Wow, yeah, I was going to say, that's a deep cut music lore reference. Yeah, when you're coming home, Dad, no time soon. Oh, God. I'd blast some taxi later for him. Oh, God, man, we could go on and on. So, yeah, but that's it. You know, those are the signs that you're in trouble. And so those are pathologic in themselves. But also, I mean, I have to say, as we get older, and we talked a lot about frailty, and we talked a lot about the importance of testosterone in men as we age, and we had that whole episode with Admiral Christine talking about the importance of testosterone.

31:48and frailty, which means, you know, when your muscles get weak and your bones get weak and you get a little unstable, that can kill you urologically as well. I mean, if you, the number of guys that end up in the emergency room, because they get up at night to pee and they stub their toe and they fall over and they break a hip or they break a back or something like that is not zero. And, and once you break a bone and you're older and you're kind of frail, it did, it's a kind of a time clock in terms of the number of guys that recover and the number of guys that need long-term rehabilitation and then the number of people that I can actually die from complications from hip fracture, spine fracture.

32:25And so it does become more than a urologic issue getting up at night to pee. So some of the pointers, especially for our guys, our older guys out there is, yes, make sure you have a little nightlight in your bathroom so it doesn't affect your sleep, but give yourself a little runway so that you know how to get to the restroom and night make sure that you don't have you know your clothes or your dog or something on the floor between you and the night room and that you have a clear pathway because that's the worst thing in the world and and i'll tell you one other crazy little pearl is that that the most common medicines that we prescribe for men to to help them pee is the what i said it is the alpha blockers and there's non-specific and there's specific alpha blockers and then the specific alpha blockers or things like Tamsulosin is kind of the most common psyllidocins, another one Alfusacin, actually that's all three of them, not trying to show off or anything.

33:17And they all are a little bit less guilty of causing what we call orthostatic hypotension, where when you get up too fast, it can make you a little woozy and you can fall. The non-selective ones, which are old, old, old school, they all have a much higher rate of that where, you know, can you imagine if your doctor gives you a drug, says, hey, I I want you to pee better. I want you to sleep through the night. And, oh, yeah, one of the side effects is it can make you kind of dizzy and make you kind of unstable when you first get up. And in the middle of the night, the first time you're on, you're like, oh, this is great.

33:48I only got up once tonight, not four times. But that one time you get up, you get dizzy, you fall over, you hit your head, you break your hip. You know, unfortunately, that doctor didn't do you any good. And so it becomes its own side effect that is, you know, that you're trying to, you're treating something, but you could cause an entire additional pathologic process with that. So no free lunch, man. No free lunch in the pharmaceutical industry. Now, this is kind of a broad question, but what are some everyday factors that can worsen urinary symptoms? Caffeine, alcohol consumption, antihistamines, decongestants.

34:25Oh, man. Holding it too long. I mean, are there any things that you really want to give a general PSA about, the warm people of? Hell yeah. In fact, it was actually funny. The guy, one of my guys I was telling you about that I just saw, again, for totally different urologic issues, Peronis of all things that we just talked about. He was a guy that got stuck somewhere between New York and Paris with urinary retention. And I said, well, did you do anything different? You know, I mean, we knew he had some prostate enlargement issues other than the whole plane ride. He said, no, I, I, um, this is the craziest little medical, you know, Dr.

35:03House moment, but he changed, uh, underarm deodorant. Cause he went to like a long acting when he's like, I'm going to be in Paris. It's going to be hot. So we went to this new deodorant and that set off allergies and cause all this, uh, rhinitis and stuff he knows. And so he doubled his allergy medications to combat the deodorant that he changed to so he could go to Paris and not stink up on Le Metro with 100-degree weather Paris. And that was probably enough to put him over the edge, that and a long time flight. So yeah, antihistamines and especially the cold medication, Sudephedrin, they're actually what we call alpha agonists.

35:40So they work exactly opposite of the alpha blockers we just talked about, Tamsulosin, Solidosin, Alfusacin. They can cause the muscles in the prostate to contract, to basically cause those two big oak doors that the prostate act on your bladder to slam shut. And they work exactly opposite what happens in the nasal turbinate. So you take those to open up the nasal turbinates and let more airflow in. And by letting more flow in the nose, the same receptors cause that prostate to contract to the point where it's harder to pee. And antihistamines have a little bit less but still a known side effect of that.

36:19they can actually cause the bladder to have what we call a cholinergic effect where basically the bladder muscle doesn't contract as much so you don't get that push you need. And so if you combine that with a little extra prostate tissue that causes a little extra outlet obstruction and the bladder is not working as hard, that can cause urinary retention as well. So it's kind of nutty. It's really amazing how quickly the cascade can set off. Caffeine, yeah, it can definitely increase temporarily you need to pee. Now, caffeine in general has a half-life of about six hours for most people. And so definitely, you know, you don't want to be drinking coffee too late in the day for both, obviously the reasons for, you know, can affect your sleep, but it can cause you to pee a lot more frequently.

37:06And alcohol has that same, it has that same hormone effect of, or diuretic hormone effect of causing you to want to pee a little bit more. And so more than just the volume of alcohol. Now, you know, if you're drinking beer, not whiskey, you know, one ounce to 12 ounces, then obviously there's going to be some volume effect of drinking a dilute source of alcohol. So both of those very well-known effect. And yeah, I mean, again, it's the same thing. You know, you want to limit your alcohol intake before bed. It's not good for your sleep. It messes up your sleep cycle, as Dr. Ishkari told us a long time ago on our podcast, and it also can mess up your urinary habits just because it causes so much more urine to be made.

37:47So those are two things. And in general, yeah, the whole idea of sleep hygiene is important, meaning that if you have a problem getting up at night to pee, then trying to limit your fluid intake right before bed is important. And there's no good rule of thumb, but generally, if you can really hold, even if you have to take medicines right before bed, just a little sip of water. but if you can give yourself a couple hours, you know, so if you go to bed at 10, yeah, just take that last sip of water around eight. It's amazing how little things like that actually can help. And then if that doesn't, then again, go in and see your doc because there could be something else going on that she could help you with if you have sort of a good global perspective about what's going on, making sure you don't have diabetes, making sure your heart's ticking away just fine and then getting into your logic sources.

38:39Now, you talked earlier about incomplete voiding, I think is the polite term. Yes, or incomplete emptying. Yeah, but that could actually be both. That could be front side, backside, I guess both. So yeah, we'll start with the front side. Empty. What are some sort of hazards of that? What happens when urine repeatedly remains in the bladder? Can that damage the bladder, the kidneys, increase risk of infection? Yeah, yeah. So, so that, that's sort of, we got back to, I got on that, that prehistoric, almost tangent about Galen and Hippocrates, but the, but right. I mean, so the most common thing that happens is that the bladder, if it doesn't empty every time you pee, so say that you have 250 milliliters in your bladder and every time you go, you get down to 50.

39:27That's pretty good. You know, that's what we call a post void residual of 50 milliliters. We don't get worried about it, But if that 50 turns into 100, if that 100 turns into 200, then two things are starting to happen. One is your bladder is insidiously capacitating more to the point where instead of getting that urge to pee when you have a can of soda in there, so that, you know, 300 milliliters or so, then you will all of a sudden say, hey, you know what? My bladder is getting stronger. That's a good thing. I can hold it better. the most common professions I worry about are, you know, Buckingham Palace guards, or I mean, I don't know, but I imagine they stay standard, they stay straight for what, eight hours at a time, you know, unless they have a catheter or diaper, you know, I worry about those guys, military policemen in our armed services, uh, generally, you know, just police detectives on stakeouts, firefighters, people that, that can't have immediate access to, to restrooms because of occupational hazards.

40:22I mean, there's a term of, of almost respect and a thought of, of, of the, of the term nurse's bladder in veteran nurses where they're like, I can hold it for a whole shift. You know, that's almost like, yeah, I'm, I'm stronger than the other nurses. I'm like, no, you're not. It's really bad for you. Like, it's great that you're so dedicated to your patients or surgeons that do 12 hour cases. I mean, there's sometimes we're scrubbed in for 12 hours without a break. You know, if you do that once a week and then the rest of the time, you're actually living a relatively normal urinary existence, okay, you can get away with it.

40:57But other than that, it's not cool, you know, to not void on the regular. But so that's one thing is your bladder can go into what we call myotonic failure where it capacitates to the point where those muscle fibers are so far apart that they can't contract. And I always use the analogy that if you try to do a bicep, curl with your arms straight out, it's really, really hard because your fibers are already at their most extended. And so any amount of weight is going to be tough to pull in. But if you pull that bicep closer into your, closer into your body, and you're at about 90 degrees instead of 180, yeah, man, then you can curl for days.

41:32Well, it's the same thing. If your bladder is so extended, then it's hard for those muscles to actually form the cross links they need to do their job, which is to contract and push urine out. And so that's myogenic failure. The second thing is that that concentrated urine will start to accumulate solids that normally you pee out, calcium, magnesium are the two big ones, phosphate, oxalate, all of these things that can form bladder stones. And you will get a chemistry environment within the bladder where you will have more of the dissolved material than the bladder or the urinary or the water that is in the bladder and that material will form into stones.

42:16And sometimes bladder stones can be as big as your bladder. They can completely cause the bladder to have no storage capacity and you're making the new urine that's coming in is just going to be surrounded as a shell around this giant fist-sized stone. And that's where you can get in trouble and those stones can become infected. So yeah, basically those are the three horsemen of the bladder apocalypse, which is myotonic failure, bladder stones, and infection, and myotonic, and all three of those things can lead to the fourth horseman, which will kill you, and that's renal failure. And so one of the ways that if your bladder has that myotonic failure, those pressures will get transmitted up to the kidney, and the kidney doesn't really love high-pressure systems, and high-pressure systems will cause either from blood pressure problems, which is one of the biggest causes of need for dialysis and kidney failures, high blood pressure, high bladder pressure also can kill the kidney and lead you to renal failure.

43:16And that's, you know, that's ridiculous in this day and age. Unfortunately, it still happens with guys that have poor access to medical care that they can get to the point where they go into renal failure from, from bladder obstruction. But, you know, I've seen it multiple times in my career. And again, I'm not, I'm not avoiding specialist anymore, really, even though I'm a urologist, my career is so specialized and yet I still see it on call. I still see it in some of my guys that are coming for me for other things. And so, yeah, that's a huge PSA right there. So, yeah, you got to go on the regular, man.

43:46I imagine that's something we'll touch more on on the kidney stones episode too. Yeah, stones are fascinating, fascinating things that can happen in our bodies. We're like oysters except for they're not quite as pretty when we pop out of pearl. But probably more expensive in the long run. Wow, well put. Yes, thanks to the American health care system. Yes.

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47:52So you didn't take her advice? I didn't take her advice. Are you still friends with that woman? No. She actually was kind of toxic. Neil deGrasse Tyson. I spent my whole life looking up. I was a geek kid. I had a telescope at age 12. And so... So you didn't have sex for a long time? Sherry Oteri. Were you a soap opera person? Young and restless. Okay. Well, first of all, you should know it's the young and the restless. I can't even believe you're mispronouncing the title. Some of us abbreviate it because we've been so weird for so many years. T.S. Madison. Are you into poly? No. No, I don't think so.

48:24No. I could have told you no on that. Girl, why are you not into Polly? Just based on what she's wearing and the way her hair is styled. She is not into Polly. Good try Polly. Anna Faris, Dave Franco, Madeline Klein, Hannah Gadsby, Adam Scott, Wanda Sykes, and more. Listen to Dear Chelsea on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

49:00my last question before we wrap up i know on an earlier episode you very beautifully discussed the the physiological ballet that occurs when men climax i wanted to ask you a a similar question for when we suddenly feel the urge to urinate what is actually happening what is the tipping point in the bladder i love that actually and there's a little bit of a correlation between in guise between climax and urination. So we'll hit it. So there is this cool part of the brain called the central pontine victorician complex. And I didn't even practice that. I just let her rip for the first time since I took my boards 20 years ago.

49:38I came out all right. But that is that urinary trigger where it sends a signal and it's probably pressure and hormonally based to the prefrontal cortex, which is the part of our brain that controls volitional behavior. and that's what potty training is right there is that you get an internal signal and if you're potty trained then you know you just let her rip in the diety right and then mom and dad clean it up and that happens until you know however old we are two three and then that prefrontal cortex takes over to the point where then you understand people are telling you that this is a socially appropriate time to urinate and it happens in all mammals right especially you know house trained mammals.

50:23So we do the same thing with our animals. We develop that prefrontal cortex to say, yeah, you can't pee on the floor. We got to get you outside. And eventually that socially appropriate trigger happens in mammals as well. I mean, in non-human mammals. And so that's the first part is the brain says, hey, dude, it's time to go. So then you say, cool, I'm going to go. And then because I am potty trained, I'm going to unzip, pull down, take off my jog shorts, whatever I got on that's blocking the socially appropriate flow of this golden liquid. And I'm going to stand over the toilet and then the relaxation phase happens.

50:59And so the first thing that should happen is your prefrontal cortex controls what we call your external urinary sphincter, which sits on guys just on the other side of the prostate. And when you let that skeletal muscle rip, which is down deep in the pelvis, in the kind of the very back part of the front of the urethra, if that makes sense at all. So right there in front of the prostate, that says, okay, cool, I'm going to let this sphincter open. And then you start to get that, the trucer contraction in the bladder, and the muscle just goes, and if you have no blockages, no strictures, and no big prostate, then it just empties all the way to the point where the urine is fully empty.

51:43And that sphincter, you don't have to really think about it, will just kind of close on its own because, you know, you're potty trained. So that's the urinary process in a nutshell. Wow. I really didn't consider the neurological, or I guess I should have more, or even just the psychological component of urination too. Well, right. And there is because a lot of times, I mean, you know, there are pediatric problems that are called dysfunctional voiding where some people will ignore that signal, but it's also kind of the same as, you know, as, as my truck drivers, my Buckingham palace guards of which I've seen zero in my practice, but obviously, you know, uh, don't, don't spend a lot of time over there, but, uh, but they, they can figure out how to potty train to the point where they ignore that signal.

52:32And instead of that, what we call first urge, where you're like, you know what, I got to pee. Uh, and guess what? There's a restroom right here. I'm going to let her rip to, you get that first urge when you're on the four Oh five and you're in an hour's worth of traffic you're like you know what i gotta pee i can't so i'm gonna ignore that urge and then you know an hour later you pull off and you find the nearest in and out and you go get a double double and you let her rip and then you get back in your car and you get back on the 405 and you're stuck in traffic for another hour to the next in and out or wherever you want to stop and in buckingham palace you know you do that at two hours you think i just started my shift i got six more hours of this and you just let her ignore and you ignore and you you can actually override to the point where you can go into urinary retention and get to that myotonic failure part because you ignore that.

53:15So it's not really a psychology as much as it's a trained behavior for sure. Back when I was in training and I don't even know if, I guess they have the switch these days, but we used to have a term called Nintendo bladder where kids were so fixed on playing their games that they absolutely would not pee until either they'd wet themselves or they'd get such severe bladder pain that they couldn't pee because they had ignored that urge. you know they learned so well when they were three and now they're seven or eight or 12 that that they wouldn't they wouldn't stop their game long enough to um to pee so so yeah there's a lot of condition responses in in the urinary process that cause it there's bashful voiding too or stage fright as we call it where you're you know you're at dodger stadium you're at the yankees game you're at the world cup and you're lined up for the trough and there's all these guys around you just letting her rip and you're like i don't know how well that translates audio wise but that was me wincing and trying to pee and couldn't.

54:09And, and that happens to, you know, where you can have bashful bladder and that's real. Wow, that is, I never considered that aspect of all this. That's so fascinating. I mean, it's a PhD worth of information in in 40 minutes. This is what we do here. No, the P, how do you spell that? P-E-E-H-D. Dude, you're the one with the jokes. I love this side of Jordan. I love this side of Jordan. No, we're good. I, you know, that was a primer, maybe, you know, with audience feedback, we'll revisit this in a lot more detail, because I think we touched on a lot of things. But, but yeah, I think these are super important little tidbits that guys should know that, yeah, you know, go on the regular, make it happen.

54:51If you're getting up too much at night to pee, go see somebody probably reasonable to start with your primary care doc, just to for them to do the workup to make sure it's not something more systemic than just a urinary issue or just the fact that you're not 30 anymore. But make sure you have at least an idea of who your good, friendly neighborhood urologist is to just take that diagnostic cascade home. That's it. And if you're in the LA area and you need to find a friendly neighborhood urologist, that's it. I think we know a guy. I know a guy. That's another whole tagline. Well, dude, that was fun.

55:26Thanks for hanging out with me. And a special shout out to Jordan, He really is literally calling in and we're doing this from his summer vacation. So God bless you, your dedication to the audience, to iHeart and all that you do, man. I got no jokes there. Just nothing but love and admiration. Right back at you. You every day are helping men, saving lives. My admiration is tenfold towards you. Thank you. Oh, come on. We could go on forever. All right, Long Transit. Get us out of here and we'll see you soon.

56:02Let's talk about it Let's talk about it Let's Talk About It

56:18Let's Talk About It

56:29It was executive produced by Jordan Runtog. It was edited, mixed, and mastered by Bahid Frazier. And the theme was provided by Long Transit. If you liked what you heard, please subscribe and leave a review. For more podcasts from iHeartRadio, check out the iHeartRadio app, Apple Podcasts, or wherever you listen to your favorite shows. This program is intended for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Consult your health care provider for any medical or other related questions or concerns. The views and discussions aired on this podcast are those of Dr.

57:09Mills and do not represent the official positions of UCLA or UCLA Health.

57:25the 90s is alive in podcast form. We're launching Podlandia AO Rewatch, our brand new podcast where we revisit every episode of Portlandia together, breaking down sketches, going deep on our iconic characters, and pulling back the curtain on how it all got made. And we'll also be joined by the people who helped bring it all to life. Guest stars, collaborators, and friends, including director Jonathan Kreisel, the mayor himself, Kyle McLaughlin, legendary musician Amy Mann, and many more. Kyle is going for it here. You fully improvised, not just words, but a song about it. Well, I thought you were all going to write a song.

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