9/18/2014 Men’s Health at the University of Iowa Department of Urology September 24, 2014 Dr. Karl Kreder Dr. Chad Tracy Dr. Brad Erickson Mens Health Survey http://www.uihealthcare.org/men/ 319-356-2421 Appointment Scheduling Urinary Incontinence 1 9/18/2014 Types of Incontinence • Stress Urinary Incontinence (SUI) – Leaking during a physical activity like lifting, exercising, sneezing and coughing – Most common following prostate cancer surgery • Urge Incontinence – Leakage associated with an overwhelming need to urinate … Gotta go, gotta go!!! • Overflow Incontinence – Leaking when your bladder never completely empties • Total Incontinence – Leaking when the urinary sphincter muscle is completely deficient What causes incontinence? • Prostate cancer surgery: radical prostatectomy or TURP • Conditions such as diabetes, multiple sclerosis, Parkinson disease or stroke • Pelvic trauma • Birth defects Behavioral Modification and Medication • • • • Decrease fluid intake Urinate frequently Avoid caffeine, alcohol Avoid activity that increases intra-abdominal pressure • Pelvic floor muscle strengthening exercises • No FDA approved medication for stress incontinence in men 2 9/18/2014 Absorbent Products: Pads, Diapers • • • • • Is this a satisfactory solution for you? Are these the best solution? How often do you need to change them? Do you have skin irritations and rashes? Are they inconvenient? Devices: Clamps Cunningham Clamp, C3 Clamps Some Advantages • • • • Non-medical, non-surgical Easy to use Functional Inexpensive Some Disadvantages • • • • Bulky Scarring Painful Skin and tissue problems Devices: Catheters External vs. Internal Some Advantages • Functional Some Disadvantages • Attached to a bag • Increased risk of infection 3 9/18/2014 Periurethral Injections • Macroplastique • Success rate is 26% at 6 months Surgical Options • AdVance male sling • Artificial urinary sphincter AdVance Male Sling: Benefits • Outpatient surgery • May be performed under spinal or general anesthesia • Often no catheter necessary upon discharge • No device activation required • Immediate improvement • Restored dignity and quality of life 4 9/18/2014 AdVance Male Sling • AdVance is not for people with: – Urinary tract infections – Blood coagulation disorders – Compromised immune systems or any other condition that would compromise healing – Renal insufficiency and urinary tract obstruction Artificial Urinary Sphincter • The gold standard for treatment of moderate to severe incontinence • A cuff wraps around urethra and inflated (closed) at rest • A pump in the scrotum deflates (opens) the sphincter and allows urination Artificial Urinary Sphincter • Outpatient procedure • Effectively gives most men the ability to achieve continence • 92% of patients would have the device placed again • 96% of patients would recommend it to a friend • Device is placed completely inside the body, providing simple, discreet urinary control • Published clinical data shows long-term effective results 5 9/18/2014 AMS 800 Artificial Urinary Sphincter • The AMS 800 is not for men who: – are not good candidates for surgical procedures with spinal or general anesthesia – have an irreversibly blocked lower urinary tract – have unresolvable detrusor hyperreflexia or bladder instability – have a known allergy or sensitivity to rifampin, minocycline or other tetracyclines Sleep Apnea Obstructive Sleep Apnea • Affects 4-5% of all middle-aged men • Hypopnea or apnea events caused by a hypotonia of the upper airway during sleep and followed by arousal reactions, defined as a 3second or greater shift in electroencephalographic frequency measured at C3, C4, O1 or O2 • Apnea and hypopnea are defined as breathing arrest of a minimum of 10 seconds between two subsequent breaths or a flow reduction of 50%, respectively, as well as blood oxygen desaturation of 4% or more 6 9/18/2014 Obstructive Sleep Apnea Risk Factors • Obesity • Male • Old age • Brain injury • Decreased muscle tone (caused by drugs, alcohol, neurological problems) • Increased soft tissue around the airway (due to obesity) • Anatomical pathologies: adenotonsillar hyperplasia, nasal septum deviation, shortening of the mandible and/or maxila • Hypothyroidism and acromegaly Obstructive Sleep Apnea • Upper airway muscles normally relax during sleep • With OSA, the muscles no longer relax when you take a breath • Your airway is sucked in and closed when you try to take a breath Normal Snoring Sleep Apnea Obstructive Sleep Apnea Symptoms Nighttime • • • • • • • • • Snoring Someone tells you that you stopped breathing Waking up during the night Waking up choking or gasping for air Not feeling rested in the morning Restless sleep Waking up to go to the bathroom Dry mouth Decreased libido 7 9/18/2014 Obstructive Sleep Apnea Symptoms Daytime • Early morning headaches • Feeling tired • Daytime sleepiness • Poor memory, concentration or motivation • Unproductive at work • Falling asleep while driving • Depression Obstructive Sleep Apnea and Cardiovascular Disease • Uncontrolled hypertension (high blood pressure) – 83% have obstructive sleep apnea • Acute coronary syndrome – 40-50% have obstructive sleep apnea • Cardiac arrhythmias – usually atrial fibrillation • Heart failure • Sudden cardiac death • Stroke Obstructive Sleep Apnea and Diabetes Mellitus • Patients with severe sleep apnea are much more likely to have impaired glucose tolerance and diabetes 8 9/18/2014 Obstructive Sleep Apnea Continuous Positive Airway Pressure (CPAP) • A controlled air compressor generates an airstream at a constant pressure • Pressure is prescribed based on polysomnogram or titration • Surgical treatment to anatomically alter the airway is also available Low Testosterone Low Testosterone = Hypogonadism • Age-associated decrease in testosterone • ? Naturally occurring event or medical condition • “Andropause, ADAM, Low “T”, male menopause, late onset hypogonadism etc. • 364,000 websites 9 9/18/2014 From The Journal of Sexual Medicine http://onlinelibrary.wiley.com/doi/10.1111/j.1743-6109.2012.02783.x/full#f1 From The Journal of Sexual Medicine http://onlinelibrary.wiley.com/doi/10.1111/j.1743-6109.2012.02783.x/full#f2 Hypogonadism • Who is at risk? – Age – Metabolic syndrome • Large waistline, abnormal cholesterol, high blood pressure, high blood sugars – Obesity – Diabetes – Sleep apnea – Chronic kidney failure 10 9/18/2014 Hypogonadism • What are the symptoms? – – – – – Loss of sex drive (libido) Erectile dysfunction Depression Sense of well-being Difficulty concentrating ADAM questionnaire 1. Do you have a decrease in libido (sex drive)? 2. Do you have a lack of energy? 3. Do you have a decrease in strength and/or endurance? 4. Have you lost height? 5. Have you noticed a decreased "enjoyment of life"? 6. Are you sad and/or grumpy? 7. Are your erections less strong? 8. Have you noted a recent deterioration in your ability to play sports? 9. Are you falling asleep after dinner? 10. Has there been a recent deterioration in your work performance? If you answered "Yes" to question 1 or 7, or if you answered "Yes" to any 3 questions in total, you may wish to talk to your doctor about having a blood test to determine your testosterone level. Take this questionnaire to your doctor to help start the discussion. What is a “normal” testosterone level? • Levels change during the day – Peak levels in early AM • “normal” decreases with age – Likely from decreased stimulation from brain (hypothalamus) • Accuracy depends on quality of machines used to check the level 11 9/18/2014 What is a “normal” testosterone level? • Must be measured in the morning – When levels are highest • Confirmed on two separate occasions • Hypogonadism – testosterone less than 300 ng/mL Treatment? Hypogonadism: Treatment Effects • Bone Mineral Density – 8% increase • Improves anemia (low blood counts) • Muscle strength – No change • Increased fat-free body mass Health benefits and safety of TRT in asymptomatic patients are not supported by current data. 12 9/18/2014 Hypogonadism: Treatment Effects • Prostate Volume – 50% increase at 6 months – No change in urinary symptoms • PSA – Variable data – Does not appear to increase prostate cancer risk • Cholesterol – Variable data – Most show little change Hypogonadism: Treatment Effects • Sexual function – Only 6% of ED is hormonal – “more” is not usually better – Erection medications may work better in men with normal T Hypogonadism - Treatment • Testosterone injection – Dose every 1-3 weeks – Wide swings in levels – Least expensive 13 9/18/2014 Hypogonadism: Treatment • Transdermal – Patch • 5mg/day • 30% dermatitis – Gel • 5-10 gm/day • 5% dermatitis • Lack of absorption Hypogonadism: Follow-up • Three months after starting therapy – Testosterone levels – Blood counts – Liver studies – Prostate exam and PSA – Cholesterol Androgen Replacement: Risks • Most theoretical • May depend on dosage levels • Depends on previous health problems 14 9/18/2014 Androgen Replacement: Risks • Heart risk – 2 recent studies suggest TRT may be associated with a 2-3 fold increase in heart attack or stroke • Studies have many flaws and have been disputed by multiple professional organizations of doctors – Lower T levels may confer greater risk Androgen Replacement: Risks • Fertility – T supplements shut off production of T from testis – Decreased sperm production – Treatment of hypogonadism in men desiring fertility – different Testosterone Replacement Therapy: Summary • Low T in older men is associated with metabolic syndrome, type 2 diabetes mellitus, obesity, osteoporosis, renal failure, and anemia • TRT should be considered for men with abnormal serum T and symptoms of hypogonadism – Health benefits and safety of TRT in asymptomatic patients are not supported by current data • Diagnosis made from 2 morning blood tests for testosterone 15 9/18/2014 Satisfying Solutions: Erectile Dysfunction (ED) What is it? • The inability to maintain an erection firm enough to have sexual intercourse How prevalent is it? • 1 in 5 American men • Over 30 million American men • Over 150 million men worldwide • Causes: 90% physical, 10% psychogenic Main Physical Causes of ED 3% 1% Vascular 5% Diabetes 6% Medication Vascular 40% Medication 15% Pelvic Surgery, Radiation or Trauma Neurological Causes Diabetes 30% Endocrine Problems Other ED and Cardiovascular Disease • Men with ED are 50% more likely to suffer a heart attack during their lives • ED can be the presenting symptom for hearth problems in many men – Schedule appt with your primary physician if you have not discussed your ED with them 16 9/18/2014 ED and Depression • 40-60% of men with depression complain of sexual problems – Medications – Cortisol levels – Loss of libido • Treatment of depression can improve erections • Treatment of erections can improve depression? ED and Smoking • Quitting smoking now can improve erections by in 30% of men by 1 year • Smoking is a leading cause of cardiovascular disease Degree of ED by Age Prevalence of ED by Age and Severity (%) 100% Severe 80% Moderate 60% Mild or Mild/Moderate 40% 20% 0% 20-29 30-39 40-49 50-59 60-69 70-79 80-89 17 9/18/2014 Do you have to live with ED? NO! Nearly every man can be successfully treated. Treatment Options for ED Erection Anatomy 18 9/18/2014 Oral Medications • Primary option for erectile dysfunction • VIAGRA: introduced in 1998 • Mechanism: promote arterial vasodilation (increased blood flow) to penis – Must take at least ½ hour to 1 hour before anticipated sexual activity – Viagra® can remain effective for up to 4 hours; Cialis® can be effective up to 36 hours – High fat meals can affect absorption of Viagra • Estimated cost per pill: $15-$30 Oral Medications • Introduced in 2003 • For ED: 10-20 mg as needed or 5 mg daily (2008) • For BPH + ED: 5 mg daily (2011) 19 9/18/2014 Oral Medications • • • • Which works better? No head-to-head trials Patient specific outcomes Doctor may alternate Oral Medications Common side effects • • • • • Headache Facial flushing Runny nose Upset stomach Body aches What to watch out for • Cannot take with NITRATES • Precautions with medications for prostate problems • If you have serious liver or kidney problems Vacuum Erection Device 20 9/18/2014 Vacuum Erection Device Some Advantages • • • • • • On-demand use Non-invasive Safe and effective Drug free Cost-effective Penile rehab?? Some Disadvantages • • • • • • • Cumbersome Unnatural erection Erection is not warm to the touch Bruising/burst blood vessels Penile pain/discomfort Numbness Delayed ejaculation Intraurethral Injections Urethral Suppository: MUSE® Small, medicated pellet placed in the tip of the penis; opens blood vessels to increase blood flow to the penis Some Advantages • No needles or injections • Erection within 10 to 15 minutes Some Disadvantages • • • • Penile pain and burning Inadequate penile rigidity Must be refrigerated Cost is approximately $25 per application • Patients with poor manual dexterity/vision or severe obesity may find administration difficult 21 9/18/2014 Cavernosal Injection Therapy • Introduced in early 1980s – Papaverine – Phentolamine – Alprostadil • Marketed – EDEX – TriMix Penile Injection Therapy Some Advantages • Effective • Onset of erection within 5-20 minutes Some Disadvantages • Risk of erection lasting 4 hours or more (priapism) • Possible bleeding at injection site • Requires training • Bruising, prolonged erection, cavernosal fibrosis • Can cause Peyronie’s disease • Poor long-term tolerability • Fear of sticking needle into penis What about surgery? • No operations to “improve blood flow” 22 9/18/2014 Penile Implants Ideal for men who have tried other treatments without success • On the market for over 30 years • Over 300,000 implants to date • High patient and partner satisfaction Penile Implant vs. Other Options: Satisfaction n=22 n=31 n=32 3-Piece Inflatable Penile Implant Some Advantages • Totally concealed in body • Like a natural erection • Device is inflated to provide rigidity and deflated for concealment • Erection longevity is controllable • When deflated, the cylinders are soft and flaccid • Expands in girth (all AMS 700® cylinders) and length (AMS 700 LGX™ and Ultrex™ cylinders) • AMS 700 with InhibiZone® is the only inflatable penile prosthesis with clinical evidence showing a significant reduction in the rate of revision due to infection 23 9/18/2014 Implants are Highly Recommended These recommendations pertain to the AMS two-piece inflatable prosthesis Benefits • Offers a long-term solution to ED • Provides the ability to have an erection anytime you choose • Allows for greater spontaneity – have sex when the mood strikes • Enables you to maintain an erection as long as you desire • Eliminates the need for costly pills or shots • Feels natural during intercourse • Does not interfere with ejaculation or orgasm Possible Risks • Will make latent natural or spontaneous erections as well as other treatment options impossible • If an infection occurs, the prosthesis may have to be removed • May cause the penis to become shorter, curved or scarred • There may be mechanical failures of the prosthesis • Pain 24 9/18/2014 Summary • ED is a common problem • Nearly every man can be successfully treated for ED • Penile implants offer a dependable, longterm solution • Talk to your partner • Talk to your urologist Thank you for attending! Mens Health Survey http://www.uihealthcare.org/men/ 319-356-2421 Appointment Scheduling 25
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