Men's Health: Expert Interview with Dr. Wagner

Dr. Tobias Wagner, M.D., is a board-certified urologist and a member of the renowned Center for Urology, which offers comprehensive urological care at its locations in Wiesloch, Walldorf, and Sinsheim. With his many years of experience and expertise, Dr. Wagner is a key member of the specialized medical team, which is distinguished by its first-rate professional competence and a holistic approach to the treatment of urological conditions. The Center for Urology is known for its state-of-the-art diagnostics and therapies, particularly in the fields of men’s health and urological oncology. Dr. Wagner plays a key role in the treatment of patients with urological cancers and precancerous conditions.

Through close collaboration with renowned institutions such as the Charité in Berlin and the use of state-of-the-art diagnostic techniques such as fusion biopsy and Rezum treatment of the prostate, he ensures precise and modern care. Of particular note is Dr. Wagner’s dedication to treating sexual dysfunction and erectile dysfunction, for which he offers a wide range of innovative treatment options, including medication and shockwave therapy. He also provides excellent diagnostic services and therapeutic support in the fields of andrology and infertility treatment. Dr. Wagner is also active in preventive care and the treatment of urinary incontinence—two areas that affect both men and women and require nuanced, empathetic care.

Patients benefit from his in-depth expertise and his ability to develop individualized treatment approaches tailored to their specific needs. As a member of the Center for Urology, Dr. Wagner provides excellent medical care within a network that has gained nationwide recognition, particularly in the field of outpatient surgery. Through the use of modern techniques and his empathetic patient care, Dr. Wagner contributes significantly to the high quality of urological care.

The editorial team of the Leading Medicine Guide had the opportunity to speak with Dr. Wagner about men’s health.

Men’s health is a central aspect of modern medicine that is often overlooked, even though many men face specific health issues over the course of their lives. Particularly in middle and older age, conditions related to the prostate and erectile dysfunction frequently occur. The prostate is a vital organ of the male reproductive system, and conditions affecting it—such as benign prostatic hyperplasia or prostate cancer—can cause both physical and psychological distress. In addition, many men suffer from erectile dysfunction, which can significantly impair sexual well-being. Both issues are often associated with shame and reluctance to seek help, which can lead men to delay seeking medical care. However, early diagnosis and a personalized treatment approach are crucial for maintaining quality of life and preventing long-term health consequences.

“Prostate cancer screening for early detection is highly recommended, even for patients without symptoms. If the tumor is detected at an early stage—when it is confined to the prostate—the patient can be completely cured of the disease. Early treatment not only improves life expectancy but also functional outcomes and, consequently, long-term quality of life. Therefore, all men aged 45 and older should undergo regular screening. However, men often avoid seeing a doctor, for various reasons. On the one hand, many men feel embarrassed to discuss the topic; on the other hand, there are often misconceptions about screening exams, which are frequently anticipated as unpleasant and rejected even before they take place. Furthermore, preventive care is not yet as well established among men as it is among women. For women, regular visits to the gynecologist are part of routine care. We men need to catch up in this regard. Patients often begin their visit by saying, ‘My wife sent me; otherwise, I wouldn’t have come.’ That’s why I’m always pleased to see so many women attending information sessions and patient events,” Dr. Wagner explains at the start of our conversation.

Benign prostate enlargement (benign prostatic hyperplasia, or BPH for short) and malignant changes such as prostate cancer differ in their development, progression, and health consequences. 

BPH is a widespread, age-related condition that occurs in many men starting in middle age. It is caused by hormonal changes, particularly a shift in the testosterone/dihydrotestosterone balance, and leads to an increase in prostate tissue, usually in the inner part of the gland. This tissue growth can constrict the urethra and cause typical symptoms during urination.

“The danger of malignant changes is that they usually do not cause any symptoms at first. Symptoms often do not appear until a prostate tumor has locally advanced or has already metastasized. That is why screening is so important. In contrast, benign prostate enlargement (benign prostatic hyperplasia) is a common condition, and patients usually visit the doctor because of symptoms. Typically, patients report a weakened urine stream, more frequent and urgent urination, nighttime urination, dribbling after urination, and a sensation of incomplete bladder emptying. Men should take these symptoms seriously and see a urologist. In later stages, irreversible changes often occur; symptoms worsen, and complications such as infections, bleeding, stone formation, and ultimately even urinary retention and kidney failure can result. Early screening and treatment are therefore very important,” Dr. Wagner emphasizes.

Today, a range of modern and proven methods is available for the reliable diagnosis of prostate diseases, which can be effectively combined depending on the suspected diagnosis and individual risk profile. 

“It is important to distinguish between the diagnostic approaches for BPH and those for prostate cancer. In the case of BPH, a detailed medical history is first taken. Diagnostic tools include ultrasound, urine flow rate measurement, transrectal digital rectal examination, and standardized questionnaires. The most reliable way to determine prostate size is through transrectal ultrasound. To detect prostate cancer, the digital rectal exam is currently the most commonly performed test in Germany. This is primarily because it is the only screening test currently covered by statutory health insurance. In my view, however, this is not sufficient. Using the PSA level, which is determined through a blood test, along with other diagnostic procedures, it is possible to detect a significantly higher rate of prostate cancer. In particular, the combination of PSA, digital rectal examination, and transrectal ultrasound is a sensitive form of early detection. This assessment is also consistent with the current changes in the guidelines. “The trend is increasingly moving toward PSA-, ultrasound-, and MRI-based early detection,” explains Dr. Wagner, adding:

“If changes are detected in the PSA level, digital rectal exam, or ultrasound, a multiparametric prostate MRI can be performed for further diagnosis. Unfortunately, despite its high diagnostic potential and the central role that MRI now plays in the German prostate cancer guidelines, statutory health insurance plans do not cover the costs—a situation that, in my view, is difficult to understand and understandably often leads to frustration among my patients. However, this does not detract from the significant benefits this examination provides. In some cases, the MRI may even spare the patient a prostate biopsy if an experienced radiologist finds the prostate to be normal. If a biopsy is nevertheless necessary, it should—in accordance with the latest medical standards—be performed only after a prostate MRI has been conducted, specifically as a so-called “fusion biopsy” of the prostate. In this modern form of biopsy, MRI and ultrasound images can be superimposed in real time to precisely target areas of concern identified on the MRI. “Both for MRI and for fusion biopsy, there are now well-established and very helpful AI systems to support diagnostics and procedures.”

Transrectal ultrasound (TRUS) is another method frequently used as part of a biopsy or to assess prostate size; however, on its own, it often does not provide sufficient information about the nature of a lesion. When prostate cancer is suspected, histological confirmation via a tissue sample—that is, a biopsy—remains crucial for diagnosis and treatment planning.

Lifestyle factors play a significant role in the development and progression of prostate diseases as well as in the development of erectile dysfunction. A balanced diet, regular exercise, and stress reduction can significantly lower the risk of both health problems and positively impact quality of life.

“Erectile dysfunction, in particular, is significantly influenced by our lifestyle. Cardiovascular diseases and diabetes are very common conditions associated with an unhealthy diet, stress, lack of exercise, and obesity. These conditions, in particular, very often lead to organically caused erectile dysfunction. Likewise, stress, worries, and pressure to perform can significantly affect mental health, which can then also lead to the onset of erectile dysfunction. Accordingly, the first steps also include a recommendation to change one’s lifestyle habits. In digital health applications, for example, this is facilitated through a guided program lasting several months, as the importance of sports, exercise, and mindfulness in relation to erectile dysfunction has been recognized. “While these factors play a lesser role in prostate diseases than in erectile dysfunction, a healthy lifestyle still offers protective benefits here as well,” recommends Dr. Wagner.

Studies have shown that a diet rich in fruits, vegetables, fiber, and healthy fats (such as omega-3 fatty acids) can reduce the risk of prostate diseases. On the other hand, a high-fat diet with a high proportion of red meat and processed meat can increase the risk. Foods such as tomatoes, which contain lycopene, and green leafy vegetables, which provide antioxidants, have been shown in some studies to be beneficial in reducing the risk of prostate diseases. Adequate intake of vitamin D and zinc is also associated with better prostate health.

Erectile dysfunction (ED) can be caused by a variety of medical, psychological, or hormonal factors. 

“As already mentioned, comorbidities such as diabetes, high blood pressure, and cardiovascular disease are major contributors to the development of erectile dysfunction. However, psychological stress can also have a significant impact on erectile function. In many cases, a combination of both factors is present. Furthermore, low testosterone levels can lead to erectile dysfunction as well as a loss of libido and other symptoms. Any patient who is affected by or burdened by these symptoms should consult a urologist. However, even if there is no subjective impairment due to erectile dysfunction, a patient with this condition should seek an internal medicine evaluation. “Erectile dysfunction is often the first symptom of an undiagnosed cardiovascular disease,” says Dr. Wagner.

If erectile dysfunction occurs regularly or suddenly appears for no apparent reason, a urologist or specialist should be consulted. This is especially true if ED is accompanied by other health problems such as chest pain, shortness of breath, or hormonal imbalances. A medical examination is also necessary if symptoms do not improve despite lifestyle changes or if other sexual dysfunctions, such as a decreased libido or ejaculation problems, occur. Seeking medical attention early is crucial for identifying potential underlying conditions such as diabetes or high blood pressure and finding the appropriate treatment. 

Modern treatment approaches for erectile dysfunction (ED) and benign prostatic hyperplasia include a variety of treatment options that are tailored to the individual based on the cause and severity of the condition. 

Dr. Wagner explains: “For erectile dysfunction, the most common form of treatment is medication, specifically so-called phosphodiesterase-5 inhibitors (PDE5 inhibitors). These are now available in a wide variety of types and mechanisms of action, mostly at affordable prices for patients. Unfortunately, however, these medications often cannot be safely prescribed due to existing cardiovascular diseases. This makes the situation more difficult, and alternatives must be considered. Fortunately, there are also effective alternatives for patients with heart disease, such as ESWT (extracorporeal shock wave therapy) for the corpora cavernosa, or PRP therapy, in which the patient’s own plasma—which has been processed beforehand—is injected into the corpora cavernosa. The digital health applications mentioned earlier are also available. The appropriate therapy can and must be selected and tailored to the patient’s pre-existing conditions and the underlying issue. For benign prostatic hyperplasia, there are now also a wide variety of treatment options, particularly in the surgical field. The days when patients had to undergo open surgery are long gone. A wide range of gentle and minimally invasive procedures—performed endoscopically, that is, using a camera inserted through the urethra—is available for treatment. For large prostate volumes, laser-based surgical methods have become established and are effective even for extremely large prostate volumes. These procedures are also becoming increasingly gentle and minimally invasive. With the Rezum method, for example, steam is injected into the prostate, thereby reducing its volume without the need for an incision or laser treatment. The procedure is so minimally invasive that it can be performed on an outpatient basis, eliminating the need for a hospital stay. Treatment options are thus becoming increasingly modern and less invasive, and can be tailored individually to each patient’s clinical presentation and personal situation.”

Thank you very much, Dr. Wagner, for this important and helpful information!

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The Center for Urology has a total of six physicians available at three locations.

On average, the following surgeries and treatments are performed annually:

Rezum: 52 procedures

Vasectomies: 288 surgeries

Fusion biopsies: 62 patients

ESWT: 234 patients

PRP: 72 patients

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