Urology

Meet Our Specialists

FDRAbout Urology

Our urologist expertise includes stone disease, enlarged prostate, cancer surgery (kidney, bladder, prostate), men’s health, and sexual dysfunction. Dr. Dhir is now a Urolift Center of Excellence. Click here to keep reading…

We connect with patients, build solid relationships, and improve outcomes. By taking a personal approach to treatment, our physician provides the type of individualized care you need. Compassion and understanding is at the forefront of our medical philosophy. HTX Urology strives for excellence in medical care and patient satisfaction. Dr. Dhir is a 2019 and 2020 Three Best Rated Award-Winning Urologist!

FDRWe Provide Expertise in:
Procedures
What’s New in Urology: Minimally Invasive Treatment for BPH

The UroLift® procedure is a short clinic or outpatient procedure that offers rapid relief from symptoms of enlarged prostate. There is minimal downtime and absolutely no sexual dysfunction, unlike major surgery.

The Rezum treatment, or Water Vapor Therapy, is a short clinic or outpatient procedure that can treat BPH effectively and prevent progression of disease over time.

What's Happening in Urology - Recent Blog Posts

As any busy urologist in Houston knows, the summer months are truly #stoneszn.  Kidney stones makes up a large part of my clinical practice, but the emergency room calls for patients hospitalized with stone disease really increases once it’s hot outside.  Unfortunately, in Houston this can seem like half the year.

The old adage is definitely true: passing a kidney stone can be worse than childbirth!  To make things worse, stone rates are actually increasing in prevalence.  New data suggest more than 10% of the US population will suffer from at least one kidney stone in their lifetime, and half of these patients will have multiple stones, or what we call chronic stone formers.

New patients in my clinic understand I have two goals: to treat their current stones and to then prevent stones in the future.  The less they have to see me the better.  Since prevention is key, I wanted to share my stone prevention tips and tricks with you.

Tips for Kidney Stone Prevention:

  1. Hydration, Hydration, Hydration. Summer is stone season for the simple reason that we sweat and our urine becomes more concentrated than in cooler times.  Spending more time outside and exercising in the heat dehydrates us.  When urine volume decreases, the urine minerals tend to concentrate, and a stone is born.  Thus, hydration is the easy solution.  Focus on drinking at least 2L (64 oz) daily with a goal of 3L (100 oz) if you are a chronic stone former.  Simple dilution of stone-forming minerals is simple and effective.
  1. Decrease Your Salt Intake. This tip is a bit tricky, as we all enjoy salty treats like potato chips, pretzels, deli meat, and mixed nuts to name a few.  Salt is even present in our cereal and sodas so it can be difficult to avoid.  Stone formers should make a diligent effort to decrease their salt loads, as high salt diets lead to high calcium levels in the urine.  Avoiding fast food and planning more meals at home are some simple ways to better control the amount of salt in our diets.  Most people will also benefit from a low salt diet from a heart health standpoint, as this helps lower blood pressure – think of a low salt diet as a “twofer” for your wellness goals.
  1. Moderate Your Animal Protein. For many Texans, including myself, this is the hardest lifestyle change.  Too much protein from animal sources – including red meat, fish, chicken, eggs, and seafood – can not only decrease citrate in the urine (which prevents stones) but also increase our urinary uric acid levels.  This makes us much more likely to make stones.  Now this does not mean abandon meat entirely, but it does indicate we must curb our “meatatarian” ways.  If you have animal protein in multiple daily meals, try your best to limit this to just once a day, perhaps for dinner.
  1. When Life Hands You Lemon, Make Lemonade. Citrate supplementation is the name of the game in stone prevention.  Many of my patients are prescribed large horse pills called potassium citrate, as their metabolic workups show they are deficient in this mineral.  An alternative is to naturally supplement your diet with citrate.  Lemons, limes, and other fruit juices are high in natural citrate.  For a low-sugar method, squeeze fresh lemons into a jar and pour a small amount in your water regularly.  Diet lemonade preparations like crystal light packets also work great.  If the acidity hurts your stomach, try a gentler version by drinking coconut water.

By modifying your lifestyle via the tips above, most stone formers can significantly decrease risks of future stone attacks.  Of course, there are many more stone prevention recommendations that may need to be discussed given a patient’s specific metabolic issues.

If you are suffering from recurrent stone disease, I highly recommend scheduling an in-office consultation.  An extensive metabolic workup is always recommended for anyone that has made a kidney stone more than once in their life.

Good luck during #stoneszn and keep those water bottles close by!

Dr. Dhir’s guide to sorting through the many options of treating enlarged prostate, and why he feels The UroLift System is the best combination of symptom relief and preservation of Bladder Health. 

For some clinical context, I’d like you all to know that I have been treating Benign Prostatic Hyperplasia (BPH), otherwise known as enlarged prostate, for over 10 years.  There are many technologies that have come and gone, and personally I feel it is quite confusing for patients suffering from BPH to know what actions need to be taken.  Hopefully this post will provide men with some clarity.

 

Should I Take Medications?

Medical therapy for BPH is usually started when bothersome urinary symptoms are mentioned to a primary care doctor.  This includes symptoms such as weak urine flow, urinating frequently during the day or night, and an urgency to urinate often. 

There are three classes of drugs used for BPH:

  1. Alpha-blockers: these are usually the medications of choice due to quick onset of symptom-relief. These medications include tamsulosin (Flomax), silodosin (Rapaflo), terazosin (Hytrin), and alfuzosin (Uroxatral).  A-blockers work to decrease the muscle tone of the prostate and relax compression on the urinary channel; unfortunately, these medications must be continued for life.  If you forget a dose or want to stop an a-blocker, your symptoms will return.  These medications commonly cause dizziness or nasal congestion; there are also new studies indicating a possible association of long-term use with early dementia.
  2. 5-Alpha Reductase Inhibitors (5-ARIs): these include finasteride (Proscar) and dutasteride (Avodart).  These medications work to shrink the size of the prostate.  Despite good intentions, makers of finasteride and dutasteride are now involved in class action lawsuits due to harmful long-term side effects seen in those experiencing post-finasteride syndrome.  I never prescribe these medications for healthy men looking for BPH solutions; in fact, I commonly remove these medications during consultation.
  3. Anticholinergics / B3-agonists: these drugs help with storage urinary symptoms like urgency, involuntary leakage of urine, and going frequently to the bathroom. Anticholinergics (like Vesicare and Detrol) and B3-agonists (Myrbetriq) can cause side effects such as dry mouth, constipation, blurry vision, elevations in blood pressure, and more.  Anticholinergics in particular can be very dangerous to use in the elderly and should be avoided.

When I see patients in the office, they are usually on an a-blocker and/or 5-ARI; some are even on a third medication to calm the bladder down as mentioned above.  3 medications for a problem of prostate obstruction?  That is truly ridiculous in my opinion.  Most men do not want to even take 1 much less 3 medications for anything!  The analogy that comes to mind is that your sink is clogged, so every week you pour Drano to fix the problem for the rest of your life.  Does that make sense?

The fact of the matter is that medications are simply band-aids for symptom-relief, they carry harmful side effects, they can be expensive, and they do not fix the actual problem.  As the prostate blockage inevitably progresses over time, medications become less helpful and Bladder Health can deteriorate.

 

What is Bladder Health?

In my office, I make every attempt to explain the concept of Bladder Health to my patients.  The bladder is like any other muscle in the body.  It squeezes to drain urine when we go to the bathroom.  If the prostate is enlarged and blocking urine flow, the bladder muscle over time will thicken, or hypertrophy.  The consequences of this are a decreased ability to hold urine and the inability for the bladder muscle to mount sufficient pressure to completely empty.  This leads to the well-known BPH symptoms of weak stream, urgency, and frequency of urination that typically will worsen as men age.

My analogy for Bladder Health is that the bladder is like a pump, and if this pump is straining for years it will eventually give out.  We want to remove the obstruction before the pump, or your bladder, permanently deteriorates.  If BPH is left unaddressed, the bladder can fail and a catheter will be needed to drain urine.  There is a reason there are so many catheter commercials on late-night TV: BPH affects most men and often these symptoms are being ignored.

As previously reviewed, the medications listed above may offer some symptom relief, but it is not relieving the strain on the bladder.  Bladder Health is still deteriorating since the obstruction has not been treated.  Medications, to use the previous analogy, are acting like Drano.  They are a temporary measure but not the solution.

 

What are Procedural Treatments to BPH? 

In-office and surgical procedures to treat BPH are plentiful, but all are not created equal.

Options include minimally-invasive procedures like UroLift or Rezum; more invasive day-procedures like GreenLight Laser Therapy or Plasma Button Vaporization; and finally, the most invasive “gold standard”: Transurethral Resection of the Prostate (TURP).

I have extensive experience with all the modalities listed above.  I have performed hundreds of TURPs in my career, which is a very effective procedure when done in expert hands.  TURP, despite not involving any incisions, is still major surgery with a 6-week recovery time.  During recovery, you cannot take aspirin or blood thinners, you cannot lift anything over 10 pounds, and you cannot participate in any strenuous exercising.  The surgery includes a night in the hospital to monitor bleeding with a large catheter which can be quite uncomfortable.  TURP often leads to worsening of erectile dysfunction, and dry orgasms (retrograde ejaculation) are inevitable.  TURP is appropriate in more severe BPH cases and has a significant period of recovery with multiple sexual side effects.  Symptom improvements are often not seen for months after this procedure.  For most men, this is simply not the procedure of choice.

Alternatives to TURP are quicker day-procedures like GreenLight Laser Therapy or Plasma Button Vaporization.  These two options are preferred by patients to TURP as there is no hospitalization time after the procedure, and bleeding risks are minimal.  Disadvantages include significant irritative symptoms (urgency, frequency, burning with urination) that can persist for weeks to months after the procedure.  Urinary catheters are still necessary for a period of time.  Finally, the procedures carry extra risk of scar tissue development at the bladder neck and in the urethra.  This common complication can lead to repeat surgeries in the future to incise scar tissue.

 

UroLift to the Rescue?

The UroLift System has been performed for over 15 years, but recently in 2018 the American Urological Association (AUA) added this procedure as an effective option in its BPH Surgical Management Guidelines.  I consider myself fairly conservative in adopting new technology as patient safety is of the utmost importance.  Once the UroLift System became validated by the AUA, based on their extensive research and experience with the technology, I began to perfect my technique.

I have performed roughly 100 UroLifts with great results.  In the past, the majority of my surgeries for BPH were TURPs or Plasma Button Vaporizations.  Now, the amount of TURPs I perform has dramatically reduced in favor of UroLift.  Why?  Because UroLift combines the strong outcomes of TURP, minimizes recovery time, and eliminates the threat of sexual side effects.  It also takes about 5 minutes in comparison with the other procedures that take 1-2 hours under general anesthesia.  UroLift is a the first real “game changer” I have encountered in Urology.

The UroLift System can be performed in the office or while under twilight sedation in the hospital or surgery center.  Developed my MIT engineers, it uses small implants to push the blocked prostate tissue away from the urinary channel in a very short procedure time.  What is remarkable is that there is usually no need for a urinary catheter, no significant bleeding, no post-operative pain, and the recovery time is measured in days not weeks.

When faced with a decision to either ignore the symptoms, take medications, or fix the issue, my answer would personally to be treat BPH with UroLift.  All things equal, it is the quickest and most effective solution with the least amount of post-operative complications, and most importantly no sexual side effects.

To learn more about UroLift do not hesitate to schedule a consultation with me in office to see if you are a candidate for this optimal treatment technique.  The UroLift procedure is fully covered by Medicare and all major commercial insurers.

 

Dr. Dhir has no financial investment or paid partnership with the makers of the UroLift System.

HTX Urology is now pleased to offer ProNox, a Nitrous Oxide delivery system for patient comfort during in-office procedures. ProNox is a great idea for those that experience anxiety in a doctor’s office, or for those with low pain tolerances.

ProNoxä can be used for a variety of office procedures, including cystoscopy, prostate biopsy, vasectomy, intravesical botox, bio-identical testosterone pelleting, and UroLift.

How does ProNoxä Work?

ProNoxä is a fixed mixture of 50% Nitrous Oxide and 50% Oxygen that is delivered by a specially designed on-demand valve. Gases are only delivered to the patient when valve is used. This is patient-managed, meaning you control how long to use and it when to use it during the procedure. ProNoxä works in a way that the patient can recognize when the dosing is appropriate and remove the mouthpiece when the desired effect has been achieved.

Does ProNox have Side Effects?

Some patients may experience short-lived nausea. Usually taking several breaths away from the mouthpiece will resolve this feeling. Make sure to speak with Dr. Dhir if you have COPD or recent thoracic or abdominal surgery, as this is a contraindication to ProNox use.

Is ProNox safe?

Yes. Nitrous Oxide has been used for decades around the world. It is very short-acting, not addictive, and has been shown to minimize the need for narcotic pain medications after procedures and surgery. Patients can use ProNox and even drive themselves home from the clinic as long as they wait 15 minutes after their last inhalation.

What is finasteride?

Finasteride, along with its cousin Dutasteride, is a medication Urologists have been describing for decades.  Some of you may also know these medications by the names Proscar, Avodart, and Propecia.

These medications are FDA-approved to treat benign prostatic hyperplasia (BPH, enlarged prostate) as well as androgenic alopecia (male-pattern baldness).  Recently, these medications have gained some popularity as you can order these medications shipped to your door through companies like Roman and Hims.

How does finasteride work?

Finasteride and dutasteride block Testosterone’s conversion to DHT (dihydrotestosterone) by inhibiting many cell receptors in the body.  DHT is very potent, and contributes to prostate enlargement, male pattern balding, facial hair growth, and acne.  DHT receptors are located in the prostate, testes, brain, skin, and in many other human tissues.

By blocking the receptors, men on finasteride have less DHT which shrinks an enlarged prostate and helps slow hair loss.  50% of men will suffer from BPH once over age 50 and 50% of men will lose hair by age 40 – it is easy to understand why so many men take these medications.

What are the risks?

Post-Finasteride Syndrome (PFS) encompasses a constellation of adverse symptoms that can affect a man physically, neurologically, psychiatrically, and sexually when taking finasteride.  These symptoms include:

  • Erectile dysfunction (ED)
  • Decreased desire for sex
  • Chronic fatigue
  • Atrophy (tissue breakdown) of genitals
  • Muscle wasting
  • Increased fat deposits
  • Breast tissue growth
  • Anxiety & “Brainfog”
  • Blunted affect or emotional sensitivity

Obviously, this is a very long list of side effects and there are others reported as well.  PFS can start shortly after starting the medication and can possibly last months to years after stopping.  Decreasing the dosage strength is unlikely to reduce the risk of PFS.  Patients considering using these medications should be very careful and speak to a Urologist in person about risks, benefits, and indications of treatment.

I take finasteride, what should I do?

There is much to still learn about PFS, and more long-term studies are needed before we decide to stop prescribing these medications entirely.  For now, my recommendation if you are taking finasteride is to schedule an appointment with me to discuss alternatives to medication for enlarged prostate.

It is important to note that edications like finasteride typically only mask the symptoms of BPH but do not offer a cure for symptoms of enlarged prostate.  Definitive treatment is becoming the key to preserving bladder health and avoiding harmful side-effects of medication as mentioned above.

For example, the UroLift System can get men off medication and cure BPH symptoms in an office procedure in under 10 minutes.  If the prostate is significantly enlarged, a TURP may be needed which can be performed under anesthesia without incisions or need for post-operative pain medication.

For more information on PFS, please visit the PFS Foundation website.

What is Movember?

Some of you may have already heard of a campaign called “Movember”.  Perhaps your friend or family member was growing some ridiculous moustache last November and you may not have really understood why.

Movember, or “Moustache November”, is far more than a gag to look like a dashing young Tom Selleck.  It is a cause to support the men in our lives.  It promotes awareness of issues that can be quite difficult for many men to discuss.  This includes tackling tough issues like Prostate Cancer, Testicular Cancer, Mental Health, and Suicide Prevention.

Can Prostate Cancer be Prevented?

Yes!  Unlike many other aggressive cancers, prostate cancer can be screened, treated, and cured as long as men get yearly visits to their primary doctor or Urologist.  Starting at age 50, it is important for men to get a PSA blood draw and a digital rectal exam yearly until age 70.  If over 70, talk with your doctor to see if screening is still in your best interests.  If you have a brother or father with prostate cancer, or are African American, then the age of yearly screening should start at age 45 as you are at higher risk.

At HTX Urology, many of my new patient referrals are from primary doctors identifying an elevated PSA level or a nodule on the prostate during exam.  In these cases, typically a prostate biopsy in the office is the next step.  In under 10 minutes with some light sedation and local nerve block, tissue samples can be analyzed for cancer cells.  Bleeding risk is negligible if you are not on blood thinners, and infection rate is under 1%.

What about Testicular Cancer?

Testicular cancer typically affects men in their 20s and 30s.  In fact, it is the most common cancer in males from age 15 to 35.  Risks factors can include race (white men), previous family history, or having an undescended testicle as a child.

It is important for young men to perform a self-exam in the shower each month.  If you feel an abnormal lump or growth, it is important to make an appointment with a urologist.  A scrotal ultrasound can also help assist with diagnosis.  If found early, testicular cancer, much like prostate cancer, is highly treatable even if cancer cells have spread beyond the testicle.

How do I support Movember?

Spread the word!  Join the cause and let your family and friends know on social media outlets like Facebook or Instagram that you think male cancer prevention is important.  Talk openly about these subjects as for far too long, men have unnecessarily suffered in silence and in embarrassment.  If you can, donate by visiting the top of the page and start growing those moustaches.

What is “Low T”?

Low Testosterone, commonly known as “Low T” or hypogonadism, refers to a decrease in a man’s testosterone levels causing unwanted symptoms. This can be attributed to problems with testicular production (primary hypogonadism) or with the pituitary gland (secondary hypogonadism). As men age, 1-2% of total testosterone is lost each year starting in the 3rd or 4th decade of life. Low T can lead to bothersome symptoms such as fatigue, weight gain, low sex drive, and erectile dysfunction (ED).

How Low T impacts Erectile Function

Erectile function is testosterone dependent. It is important to note, however, that not all men with ED suffer from Low T or vice versa. Furthermore, not all men with Low T and ED improve after replacement of testosterone to optimal levels.

Men may need to combine TRT with oral ED meds for optimal sexual function

Confused yet? I don’t blame you. With years of research, we now know there is a complex interplay between Low T and ED. Testosterone replacement therapy (TRT) for men with Low T will often improve ED, low sex drive, and other bothersome symptoms, however, if erectile function does not improve significantly, men may need to combine TRT with oral ED medications for optimal sexual function.

Causes of Low Testosterone

There are multiple possible causes of Low T including aging, stress, obesity, diabetes, sleep apnea, HIV/AIDS, testicular injury, infection, chemotherapy or radiation to the pelvis, and chromosomal abnormalities. Oftentimes, the cause is unknown.

TRT can dramatically improve quality of life

Regardless of cause, the symptoms of Low T can be quite debilitating. Testosterone replacement therapy can dramatically improve quality of life and can be used in a safe and effective manner. Improvements can be seen quickly, including strengthened bones, improved muscle mass, increased energy, improvements in erection quality, mental clarity, and fat loss. There is also new evidence that optimal testosterone levels can help prevent some chronic conditions such as hypertension, diabetes, and heart disease.

Low T Impacts Sex Drive

Low T almost always leads to a decrease in a man’s sex drive, or libido. A thorough history and physical exam from a physician who specializes in TRT, such as a Urologist, is essential to work through possible causes of a sudden loss of sex drive. Besides Low T, other conditions that could affect sex drive include thyroid disorders, sleep apnea, and (rarely) benign tumors of the pituitary gland.

Treatment Options for Low T

There are many forms of testosterone replacement available to men with Low T. Options include nasal sprays, topical creams or gels, intramuscular (IM) injections, and subcutaneous pellets.

Topical therapy is a simple way to replace testosterone daily without using needles or undergoing an in-office procedure. Care must be taken not to transfer the cream or gel after application via skin-to-skin contact to women or children.

Patients who are comfortable with needles are taught how to do the intramuscular injections in their physician’s office. The patient administers the treatments at home every 1-2 weeks depending on their doctor’s orders. There is no threat of transfer of the hormones to others with this treatment option.

Lastly, testosterone pellets are a longer-lasting injection therapy. Pellets are implanted under the skin in a quick office procedure. The therapy lasts for about 6 months and can minimize the roller coaster highs and lows some patients experience with IM injection therapy.

If You Want to Have Children

Talk with your physician if you are planning to have children. TRT causes infertility for a period of time, as exogenous testosterone suppresses your body’s ability to make viable sperm. Additionally, there is no guarantee fertility will be restored when you stop TRT. If you are of childbearing age, please speak with your physician about risks and benefits before starting any form of testosterone supplementation.

Men of childbearing age may be better suited to HCG and SERM

Human Chorionic Gonadotropin (HCG) and Selective Estrogen Receptor Modulators (SERM) are alternatives to TRT that can be prescribed to preserve fertility. An example of a SERM is the medication Clomid® (Clomiphene Citrate). Men of childbearing age with Low T may be better suited to these types of supplementation. After childbearing, a transition to TRT creams, injections, or pellets can then be made.

Side Effects

Possible side effects may include increased red blood cell count, worsening of urinary function, male-pattern balding, acne, and mood swings. There are also theoretical risks of cardiac issues or blood clots. If you have pre-existing cardiac risk factors, make sure to discuss this with your physician before starting TRT.

While on TRT, men must comply with a series of lab tests to ensure their testosterone level is on-target and other blood chemistries remain normal. Liver function tests, cholesterol panels, PSA for prostate cancer screening, and complete blood counts are closely monitored to help prevent any possible side effects of TRT.

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