Category: News

A message from Dr. Wallen regarding your Erectile Dysfunction

YOU & WEE UROLOGIC SURGERY & WELLNESS

 

DR. JARED J. WALLEN, MD

 

 

A message from Dr. Wallen regarding your Erectile Dysfunction:

A diagnosis of erectile dysfunction (ED) can be difficult to deal with. Together we can navigate treatment options and restore your function so that you may be able to participate in sexual activity again should you so choose. The process of an erection and ultimate sexual intercourse, orgasm, and de-tumescence (becoming flaccid again) require a highly coordinated response from the neurologic, vascular, psychologic, and sensory systems. The penis should be thought of as an inflatable rod and the cardiovascular system (the heart and blood vessels) is the pump and tubing that inflates the rod. You need good blood flow in to fill up the rod and you need the little valves in the veins to close and trap it there. This process normally happens for on average 3-6 mins of penetrative intercourse before normal ejaculation and orgasm occur and shut the system down. If the blood vessels in your heart are not functioning well, it is likely that blood vessels in your penis are not functioning well. In fact, ED is proven to be a 3 to 5 year indicator of potential heart problems for the simple reason that the blood vessels in the Penis are 1/2 the size of the blood vessels in the Heart and become clogged or blocked sooner, even with less severe disease. Among many causes of erectile dysfunction are things like coronary artery disease, neural compromise from spinal problems or trauma, diabetes, smoking, pelvic surgery, drug use including alcohol and marijuana, etc.

If you are safe for sexual activity, this means that you can walk up 2 flights of stairs without getting winded, short of breath or chest pain then the 1st treatment option is lifestyle modifications. This includes things like following a Plant-Based Diet and avoiding all animal proteins, eating plenty of antioxidant rich foods like fruits and vegetables, ensuring 40-45 mins of cardiovascular activity (walking, swimming, biking, running, etc) 5 days or more a week, avoiding Drugs, Alcohol or smoking usage, following a low salt diet, Pelvic Floor Muscle Exercises, and managing medical conditions such as low testosterone, diabetes, high blood pressure, obesity, and many others.

The 2nd treatment option is Oral Medications. These common medications are: Viagra, Levitra, Cialis, Stendra, etc. You must be careful taking these
medications with other medications for blood pressure or
specifically alpha blockers for BPH or lower urinary tract symptoms. If you take these medications discuss with Dr. Wallen as you can other-wise experience an unsafe drop in blood pressure. These medications can be taken daily or on demand prior to sexual activity. However, it should be noted that manual or visual stimulation is required for an erection. These pills are safe when used in coordination with your doctor however sometimes specific side effects should be noted: Blurry vision, change in color vision, diplopia, hypotension, myalgias, headache, nasal congestion, etc. These pills should never be taken in combination with nitrates for chest pain without specific consultation with a doctor.

The 3rd treatment option is a Vacuum Erection Device (VED). This is a plastic tube that is fit over the penis and pressed against the base of the penis and pubis. It then uses suction via a hand pump or battery- operated suction to pull blood into the phallus and cause engorgement. This is often used in conjunction with a restriction band that fits around the base of the penis to trap the blood in. This cannot be used with the band for more than 30 minutes at a time. Patients have reported in the past that this causes a floppy penile base where the band is and can limit the effectiveness of activity. Further patient feedback is such that the manual hand pump VED device may be gentler on you to use as you can pump as slow or fast as is comfortable. Discuss with your doctor if you take anticoagulation medications (Coumadin, aspirin, Plavix, warfarin, Lovenox, etc).

How to USE the VED:

  1. Place the penile ring Around the Cylinder of the VED (no ring required for Penile Rehab)
  2. Use Vaseline or Lubrication on the skin at the base of the penis to ensure a good seal
  3. Slide the Cylinder of the VED over the shaft and glans penis
  4. Press Firmly into the skin to ensure a good seal
  5. Press the button to create suction in the VED (Or squeeze the pump if your device is manual)
  6. Continue suctioning until the penis is fully engorged
  7. Slide the Restriction Band off the VED to the base of the penis
  8. Participate in activity, but Remember to Remove the band within 30 minutes after placement.

Another use for a Vacuum Erection Device is for what is called “Penile Rehab.” This is done to maintain penile length in the face of increasingly severe erectile dysfunction. This is certainly used for patients who have had prior prostate procedures or other radical pelvic surgery, but also any patient who has erectile dysfunction and especially if you are no longer having nighttime erections. In this setting, the vacuum erection device is used 3-5 times per week for approximately 30 minutes at a time with NO restriction band. This is to cause engorgement in and stretching of the phallus. This is thought to be helpful because typically men with increasingly severe erectile dysfunction lose their nocturnal erections which would otherwise stretch out the penis and bring in new blood flow to the tissues daily. So, using the VED will bring engorgement and nutrient rich blood to the tissues. Caution again should be advised for patients taking anticoagulant medications.

The 4th treatment option would be the delivery of a combination of medications locally to the penis. This can be done via an intraurethral suppository (MUSE) or gel, or via an injection into the penis with a tiny needle.

These treatments can be a combination of anywhere from 1- 4 medications. Some of these medications can result in scar tissue formation (corporal fibrosis) from prolonged use. This can cause or worsen deformity or curvature of the penis. To help prevent this it is recommended to alternate sides of the shaft and to travel up and down the length of the shaft for each new injection. In short, do not always inject in the same spot repeatedly. You should also never inject at the 12 or 6 o’clock positions on the top or bottom of the shaft of the penis as the nerves and blood vessels are on top and the urethra is on the bottom. It should be noted that patient to take MAO inhibitors (a type of Anxiety and Depression medications) should not use this treatment, if you are taking these medications please discuss this with your doctor prior to use. This is also the one main treatment form that can cause a Priapism (an erection lasting longer than 4-6 hours). There is only about a 10% chance however this is an emergency and you should call your doctor immediately or seek care at the nearest Emergency Room.

How to perform an Injection:

  1. Draw up medication
  2. Wipe down the skin surface with an alcohol wipe
  3. Insert the tiny needle approximately 1-2cm into the side of the shaft of the penis at the 3 or 9 o’clock position and inject instructed dosage
  4. Remove Needle
  5. Apply pressure with alcohol wipe to the site of injection for 2-3 mins to stop any minor bleeding
  6. Wait 15-20 minutes as this will give the penis all the signals necessary for an erection to occu

The 5th option includes doing an outpatient surgery to place either an inflatable or semi-rigid penile implant. These devices are a permanent prosthetic implant to provide an erectile function to the penis and unless malfunction or infection occurs typically last up to 10-15 years. In fact, satisfaction is very high as greater than 90% of patients and their partners are satisfied after this procedure is performed. These devices are non-visible after surgical placement. These surgeries do require that you stop any anticoagulation medications and have appropriate medical optimization or clearance.

This procedure typically lasts 45 mins and is done in an outpatient fashion. The patient typically goes home with a surgical drain and a jockstrap with a dressing. Follow up in the office typically occurs 3 days after your procedure. There are 3 typical incisions that can be used to place a penile implant. The Infrapubic (just above the base of the penis), Penoscrotal (in the junction of the bottom of the penis and scrotum), or Subcoronal (behind the head of the penis similar to a circumcision incision). I can perform all of these and choose based on many individual factors with each patient. If all things are equal, I believe the Infrapubic approach to be the best as it offers the quickest and easiest recovery for patients. Typical recovery periods range from 3-6 weeks prior to being able to participate in activities.

As with any surgery, there are risks involved including
bleeding, infection, erosion of the implant, device
malfunction, need for revision surgery, pain, cosmetic dissatisfaction, perforation of the urethra, injury to any surrounding structure, as well as the risks of anesthesia including but not limited to heart attack, stroke, and death. However upwards of 60-80% of devices are still functional 15-20 years after surgery. It should be noted that these
devices provide erectile function, but this function is somewhat different than normal erection given that there is a prosthetic in place. The inflatable devices tend to be more common as they offer both the erect and flaccid state of a normal erection. Furthermore, the transition between the flaccid and erect state is operator dependent by a manual pump in the scrotum. Look forward to future innovation that will allow this transition from flaccid to erect to be operated by your blue tooth device or a fab style switch. It also should be noted that in the flaccid state you may be able to see a fold or outline of the device through the outside of the skin but should not see the actual device. The semi-rigid device tends to be a better option for a man that is desiring erectile function but has poor manual dexterity. However, many patients report this to be more difficult to conceal as it is basically semi-solid rods that are implanted into the corpora cavernosa which are the chambers that typically fill with blood causing an erection. These rods are then bent UP and Down for activity as compared to the inflatable device where the cylinders are inflated and delated by sterile saline that is sealed in the device once it is placed surgically. This intervention should correct your erectile dysfunction without changing your ability to ejaculate, achieve orgasm, or change or sensation in the penis.

https://www.coloplastmenshealth.com/treatments/erectile-dysfunction-treatment/penile-implants/

https://www.bostonscientific.com/en-US/products/penile-prosthesis/ams-700-inflatable-penile-prosthesis.html

The 6th option that exists is experimental studies. They are currently 2 new interventions that we know about to treat erectile dysfunction but are currently undergoing experimental study. The 1st is an injection into the penis of stem cells or platelet rich plasma (PRP). The 2nd is low intensity extra corporal shockwave lithotripsy to the penis. These studies are ongoing, however, would likely require you to travel to a different location for therapy. If you are interested in these options please discuss with Dr. Wallen.

Sincerely,
Dr. Jared J. Walllen

 

A message from Dr. Wallen regarding your Lower Urinary Tract Symptoms (LUTS) or BPH:

YOU & WEE UROLOGIC SURGERY and WELLNESS

Jared J. Wallen, MD

 

 

Experiencing lower urinary tract symptoms is very common as we age, it however can be a very life-altering problem for a man. Many causes exist for symptoms such as urgency or frequency of urination, slow stream, a stream that stops and starts, urinating frequently at night, etc. Here we will specifically discuss lower urinary tract symptoms secondary to BPH (benign prostate hypertrophy). BPH is one of the most common diagnoses in men over the age of 40. In fact, approximately 50% of men over this age will have some urinary symptoms. The main indications for treatment are due to quality of life issues (getting up a lot at night to urinate and losing sleep, bothered by your ability to urinate, etc.) urinary retention, recurrent urinary tract infections, bladder stones, or evidence of damage to the kidneys thought to be due related to poor emptying.

This is a plumbing problem for a man, to void he requires that his brain and spinal cord coordinate relaxation of his external sphincter and bladder neck (this keeps him dry when not voiding), while also coordinating bladder contraction or squeezing to expel urine. This is exactly the opposite of when not trying to urinate. Many different pathologies can contribute to lower urinary tract symptoms including but not limited to prior surgery, kidney stones, tumors, prior traumatic
injury, social habits including alcohol/smoking/drug use, prior radiation, medication or supplement use, caffeine, old age, etc. Please discuss with your doctor if you feel any of these may be contributing to your symptoms.

As seen in the picture to the right the bladder sits on
top of the prostate and the urethra (the tube that drains the bladder) runs directly through the middle of the prostate. As men age, we see that the prostate continues to grow. In fact, based on autopsy data for each decade after 50 the percentage of men with BPH increases to that percentile: So for instance, 70% of men over the age of 70 have BPH. The problem with this is that there is an outer shell or capsule and the bones of the pelvis around the prostate tissue so instead of growing outward, as the tissue grows it grows inward and this decreases the size of the tube or upward and causes a “ball valve” similar to a one-way flap valve in plumbing terms called a “median lobe” of the prostate to grow. This decreased size equals more difficulty and more pressure required to empty the bladder. What we try to achieve with treatment is opening the size of the lumen of the tube or removing the flap valve and making it easier for men to urinate with fewer symptoms.

 

1st treatment option is oral medications:

  1. Alpha Blockers (Flomax, Uroxatral, Rapaflo) which work by relaxing the bladder neck and
    prostatic urethra. These medications are little less than half as effective as having a procedure or surgery done in terms of symptom scores for patient’s before and after surgery. Most current literature suggests that these medications change the patient’s AUA or IPSS symptom score by about 4-6 points. Previous literature suggests that a change in at least 4 points is considered a significant quality of life change. These medications do have some side effects including low blood pressure, lightheadedness, dizziness, retrograde ejaculation (movement of the semen into
    the bladder during ejaculation instead of out the end of the urethra; this is not harmful), etc it should be noted.
  2. 5 Alpha Reductase Inhibitors (Finasteride, Proscar) which worked to inhibit the production of the most potent form of testosterone. This acts to limit the growth of the prostate. Previous research has shown that the combination of alpha blockers and 5 alpha reductase inhibitors for prostate over 40 g help prevent patients from the need to have surgery or having a catheter placed due to retention. These medications are associated with side effects like low testosterone or hypogonadal males with changes in mental clarity, libido, central obesity, glucose tolerance, muscle mass, erectile function, etc.
  3. Anticholinergic Agonists (Ditropan, Trospium, Toviaz, VESIcare) these medications are typically reserved for patients who have more irritative symptoms like urgency frequency urgency incontinence related to irritation of the bladder from an enlarged prostate or from procedures performed as a treatment for enlarged prostate. Some patients also benefit from limiting dietary exposure to caffeine, alcohol, spicy foods, nicotine.

 

The 2nd treatment option is an in-office procedure called Rezum.

This is a water vapor based procedure in which a camera and a small needle are used to deliver treatments to the inner 30% of the prostate. This can be performed in approximately 10 minutes in the office. This will require a catheter be placed for approximately 2-3 days after the procedure, and a 2nd internal catheter to be placed for 2-3 weeks while you heal if your prostate is greater than 80-100 cc in size or you had retention prior to the procedure. This is the least invasive procedure to have on the prostatic urethra to attempt to clean the pipes so to speak, that is to clear any obstruction and form a nice clean tube to drain the bladder through. There are some side effects that include bleeding, infection, pain, burning, the urgency of urination, frequency of urination, need for a prolonged catheter, need for a repeat procedure, retrograde ejaculation, erectile dysfunction, etc.

The beauty of this revolutionary and new technique is that given its minimal invasiveness, the sexual side effects including retrograde ejaculation, and erectile dysfunction are minimized compared to all of the other treatments on the market today. This would typically be performed in the office with oral sedation and local anesthetic. In comparison to medications, a change in symptoms cores is approximately 12-14 points or expected about 50% reduction in symptom score. The newest literature that was recently published suggests a durable result of rezume at least 5 years. Some limitations include the size of the prostate and use of anticoagulation medications, please discuss these with your doctor.

http://www.rezum.com/

 

The 3rd option includes a product called Urolift.

This is a surgically implantable device that works to “open the curtains” of the lateral lobes of the prostate. If we look at the diagram to the right, we can see the differences in an open prostatic urethra, middle lobe hypertrophy, bilateral lateral lobe hypertrophy, and triple lobe hypertrophy. These are the 3 most common configurations we can see of benign prostatic growth. Your doctor would be able to diagnose your configuration based on a cystoscopic examination. Again, the goal is to achieve a free-flowing pipe for urine to easily pass through. If we look at the bilateral lateral lobe hypertrophy example on the bottom to the left, this is the most appropriate setting for Urolift. Essentially this procedure can be seen as tacking the lateral lobes of the prostate back toward the sidewalls to allow for free-flowing of urine. Typically, if you have median lobe hypertrophy we should avoid Urolift as a potential treatment option. This is a safe and effective treatment that has less sexual side effects than surgical options below, and also has good but lower symptom score reduction than rezum at 5 years post-procedure. There was also at least 14.5% of patients that need a second procedure prior to 5 years for further symptoms, and another 10% that restarted medications.

http://www.urolift.com

 

The 4th option includes doing an outpatient surgery with either a GreenLight laser or a TURP (transurethral resection of the prostate).

These are used similar to the Rezum but are a surgeon dependent way to core out the inner portion of the prostate. This is typically done to remove a larger percentage of the inner portion of the prostate. This does require general anesthesia. Similar side effects can be found with these surgical procedures as with the office-based Rezum procedure above. Similar changes in symptoms course can be found as with Rezum and these results have been shown
to be durable beyond 5-7 years. In particular for very large prostates 100-120 g and above or patients that are on anticoagulation medications and cannot stop them, the GreenLight laser can be a useful tool to safely perform surgery in this setting. There is typically a 75% or greater risk of retrograde ejaculation with these procedures and minimal but not unheard of 5-15% of erectile dysfunction risk. Again, as the amount of tissue removed increases the risk to the structures outside of the prostate gland and the chance that some changes in function occur increases as well. Typically GreenLight Laser is preferred in my hands because it offers an outpatient procedure, less blood loss, and a decreased catheter time compared to TURP. This procedure can be an effective outpatient procedure, even for prostates as big as 286 grams in size.

https://www.treatmybph.com/bph-patient-us/treatment-options/laser-therapy-with-greenlight.html

 

The 5th option that exists is an inpatient robotic or open simple prostatectomy.

This can be thought of as removing the entire inner portion of the prostate leaving only the capsule. Like removing the entire inner portion of an avocado. Obviously, this is a more invasive procedure and it has higher risks. This is typically done for extremely large prostates greater than 130-150 g. This requires general anesthesia and typically a 1-2 night stay in the hospital for recovery prior to discharge home. Patients will typically have to have a catheter for approximately 10 days. The risks of this surgery include bleeding, infection, pain, DVT, PE, heart attack, stroke, death, need for blood transfusion, need for 2nd procedure, erectile dysfunction, ejaculatory dysfunction, bowel injury, need for colostomy, etc. As this is a much longer procedure than any of the above this also requires medical or cardiac clearance.

 

The 6th option is experimental studies.

There is currently a study with embolization of the prostatic arteries as a treatment for enlarged prostate. This procedure is not performed by myself, and would likely require consultation with interventional radiologists for the risks, benefits, and applicability to your clinical situation.

 

If you are interested in any of these options please discuss it with Dr. Wallen.

Sincerely,
Dr. Jared J. Wallen

A message from Dr. Wallen regarding your Elevated PSA exam:

YOU & WEE UROLOGIC SURGERY and WELLNESS

Jared J. Wallen, MD

 

 

A message from Dr. Wallen regarding your Elevated PSA exam:

 

A diagnosis of elevated PSA can be anxiety provoking. Together we can navigate the next step. There can be multiple reasons that a PSA blood test may be elevated:

 

  • An enlarged prostate (BPH)
  • An infection in the prostate or urine
  • Prostate cancer
  • Inflammation in the prostate or prostatitis
  • A recent prostate biopsy or massage
  • Bicycling or motorcycle riding
  • Recent sexual activity or ejaculation

 

Sometimes an elevated PSA can be associated with lower urinary tract symptoms such as urgency, frequency, burning or dysuria, urinary retention, incomplete emptying, slow stream, etc and these can be indications that this may be related to an enlarged prostate. The above symptoms in addition to pelvic pain or rectal pain can be indicative of prostatitis. If you know you had a recent infection in the urine or have had any of the above symptoms within 1-2 weeks of your blood test please inform your doctor. Also, always ensure 3-4 days of abstinence prior to your blood test. (No sex or masturbation)

 

What we know about the PSA is that it, in combination with a yearly digital rectal exam (DRE) is the only way to “catch” prostate cancer prior to very advanced stages of the disease. For high-risk groups, the American Urologic Association recommends shared decision making regarding early screening starting at age 40-45. High-risk groups are anyone who is of African American descent or has a positive family history of prostate cancer. For everyone else who does not fall into the category shared decision-making is made regarding screening with a yearly PSA and DRE exam from the age of 55-70 years or in any situation where the patient has >10-year life expectancy and understands the risks of screening.

If you fall into a category of patients where your elevated PSA is thought to be possibly due to prostate cancer, then you will be recommended to have a Prostate MRI or a Template Prostate Biopsy. We used to go straight to Template Biopsy as in the picture to the picture above. This procedure is essentially 12 small needle pokes through the anterior rectal wall and into the prostate to sample specified areas of the prostate and attempt to understand if any potential cancer is present. There is however approximately a 15-20% chance we miss something with this approach. This can be thought of as a “Blind Biopsy,” and similar if you did 12 needle pokes in a template fashion to an apple, you may find or miss any potential “bad spots” present within the apple.

 

The potential to miss a small tumor increases with increasing size of the prostate due to the increased size or volume of prostate tissue and thus a smaller percentage of overall tissue sampled with our 12- core template needle biopsy.  More commonly nowadays a Prostate MRI is performed first prior to any biopsy. This allows us to “visualize” any potential concerning lesions in the prostate prior to biopsy.

 

Special Technology can then be used to merge these MRI Pictures with a “live” Ultrasound Image to specifically TARGET the lesion in question.  It is important to note that a Prostate MRI by itself cannot Diagnose cancer, and a Patient will still ultimately need a Biopsy to confirm the Tissue Diagnosis of Cancer. Further, Prostate MRI is also an imperfect test. There is about a 20-30% chance that we miss lesions that are very small (less than 1 cm). However, studies have shown that with MRI “vision” and a combined Targeted and Template Biopsy of the Prostate we are better at finding and or ruling out the presence of cancer. We do typically perform both a Targeted (4 biopsy of any lesions on MRI) and Template (as above) at the same time because we have had situations where the MRI lesions come back negative for cancer on Tissue Diagnosis and thus if we had not sampled the rest of the gland in standard template fashion, would be left wondering if there was a problem somewhere else in the gland.

 

In order to be prepared for your biopsy, please follow the following instructions:

 

  1. You should begin taking your antibiotics on the day prior to your test
  2. You should take an over the counter Fleet enema on the evening before your test at approximately 4-6:00 p.m.
  3. You should discuss with your doctor to stopping any anticoagulation medications (Coumadin, warfarin, aspirin, Plavix, etc.) you may be on.
  4. You should bring your filled prescription of Valium 10 mg to the office with you, and remember do not take prior to signing a consent form.

 

For the most part, patients do very well with biopsies and this is a relatively minor procedure with no major incisions or cuts. Some may have minor local symptoms for a few days. These include blood in the urine, blood in the stool, blood in the semen, burning with urination, soreness in the area of the prostate or with bowel movements, urgency or frequency of urination. There are 2 risks, albeit small in chance, that can require more immediate care… there is about a 3-5% chance of the need for a short-term Foley catheter due to swelling in large prostates that prevent men from urinating after the procedure, and finally, a very small 1-2% chance of severe infection called sepsis. Both of these issues can be rectified by seeking more care at your local Emergency Room. At home after your biopsy please take Tylenol/ ibuprofen for pain relief. You will also be getting an injection of numbing medication in the prostate area prior to the biopsy which will help with pain relief for approximately 48-72 hours. Otherwise, you should take it easy for approximately 3-5 days and no heavy lifting (greater than 10-15 lb.), sexual activity, or strenuous activity for 1-2 weeks. If you are otherwise doing well and can return to work with light-duty activities this can be as early as 3-5 days. I do hope this has helped you better understand the potential causes and standard workup for elevated PSA blood tests or an abnormal finding on Digital Rectal Exam by your Physician.

 

Rest assured OUR Team will do whatever we can to make this a gentle easy experience.

 

Sincerely,

Jared J. Wallen MD

Dr Wallen’s Tips for Your Best Life

11 Tips to be Healthier and Happier

  • 40 mins of cardiovascular activity 5 days a week
    • Walking, jogging, swimming, biking, etc
    • Yoga or stretching should be emphasized especially as we age
    • As we get older it can also be helpful to do pelvic strengthening exercises
  • Plant Based Diet
    • YES ALL FRUITS AND VEGGIES!!!
    • At the very least mostly plant based with fish and chicken as preferable sources of lean white meats
    • Organic meats and produce preferable
  • 8-10 bottles of water a day
    • More if you are in hot, dry climate
  • 4 oz of lemon juice in your water daily
    • 1 oz mixed in a glass of water
    • 4 (1) oz shots of lemon juice with water chaser
  • Low Salt and Sugar diet
  • Turmeric or Curcumin supplements OTC
  • +/- Multivitamin
  • Use Sunblock 30-50+ SPF and protective sun wear
  • Visit your Dentist every 6-12 months
  • Remove the NEGATIVE:
    • Alcohol, Tobacco, Marijuana, and other drugs
    • Gambling
    • Sex and Pornography addictions
  • Cancer screening for men:
    • Testicular Cancer:
      • 15-45 year old Men should be performing self-exams of the Testicles monthly in the shower and if they have questions they should see a Urologist.
    • Prostate Cancer:
      • Men whom have a (++) Family History or African American ancestry should have screening with a PSA blood test and DRE (finger exam of Prostate) once a year starting at age 40-45 years old until they are over age 70 or have less than a 10-15 year life expectancy.
      • Men who DO NOT have a family history or African American ancestry would start screening with a PSA blood test and a DRE once a year starting at age 55, then as above.
    • Colon Cancer:
      • Men age 45-50 depending on family history should have screening colonoscopy then further as directed by their Gastroenterologist.

Write down your goals. Chase them. Achieve them. Repeat.

Thanks,

Jared J. Wallen MD