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DEAR DR ROACH: I have uncomfortable bladder stones, and I'm on a low-oxalate diet to help prevent more stones. I also have osteoporosis, and my blood work shows high calcium. My doctor suggests Prolia, which I question since I am a 95-year-old female and exercise daily. I have switched my calcium citrate to calcium with magnesium and stopped taking Tums for heartburn. I'm asking for any additional suggestions about my calcium intake and Prolia. -- T.G.

ANSWER: You have a dilemma. Calcium supplements are often used in people with osteoporosis because the medicines that treat osteoporosis need calcium to work. The studies that have shown them to be effective all used supplemental calcium.

On the other hand, calcium supplements -- whether they are Tums (calcium carbonate) or calcium citrate, or they include magnesium -- all clearly increase the risk of kidney and bladder stones in people who make calcium oxalate stones.

In my opinion, the best way out of this dilemma is to increase dietary calcium, while avoiding or minimizing calcium supplements. Getting calcium through the diet reduces the risk of stone formation, so it'll be your best way to help with stones.

It's possible to get the recommended amount of calcium for osteoporosis through diet alone, but it does require planning. Working with a registered nutritionist can help you plan a meal program that can get you the calcium you require. By getting most of your calcium through food, this will help prevent stones.

Finally, women with osteoporosis in their 90s are at a very high risk for fractures, and denosumab (Prolia) is one of several reasonable treatments to reduce fracture risk.

DEAR DR. ROACH: I'm 75 years old and currently taking tamsulosin to manage benign prostatic hyperplasia (BPH). I'm looking into surgical solutions for an enlarged prostate, preferably noninvasive, and I saw an article on prostate artery embolization (PAE). Could you enlighten me on the benefits and potential medical problems/side effects of this procedure? -- S.L.N.

ANSWER: Before considering surgical solutions like PAE, you should consider a second medication along with tamsulosin, such as dutasteride or finasteride. These medicines shrink the prostate slowly over time and work well with tamsulosin and other similar medicines.

They also reduce the risk of prostate cancer; however, they can cause sexual difficulties in men at a rate of about 5%, although they usually (but not always) diminish over time. Rarely, the reactions persist even after the medicine is stopped.

PAE involves identifying the artery to the prostate radiographically and injecting materials that block part of the blood flow, which causes the prostate to shrink. A recent review evaluated 11 different surgical therapies, including less-invasive procedures like PAE. PAE has less effectiveness than standard surgery, and retreatment rates are higher than with other treatments. However, sexual side effects are very low with this treatment. Side effects immediately after the procedure include difficulty urinating, nausea and vomiting.

I recommend finding an experienced urologist and discussing other options like standard surgery, laser surgery, a prostate lift, transurethral microwave thermotherapy, water vapor therapy, and more. A surgeon who knows your particular anatomy and your concerns for side effects can help you decide the best option.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.

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