2. The Satisfying Solution for You and Your Partner October 6, 2009 BELLEVUE UROLOGY PRESENTS: Mens Health Talk Effective Treatment Solutions for BPH, Urinary Incontinence and Erectile Dysfunction

3. The Satisfying Solution for You and Your Partner Urologists from Bellevue Urology will present information on BPH, urinary incontinence, and ED, its causes and treatments Galen & Linda Bird, patient advocates will share their story of their struggle with ED & urinary incontinence. Question & Answer session Appointment cards are available for you to make an appointment tonight Tonight'sAgenda Tonight's Agenda

4. The Satisfying Solution for You and Your Partner Benign Prostatic Obstruction Replaces the term Benign Prostatic Hypertrophy ( B.P.H. ) which is a histological description of pathological tissue. Represents the most common etiology of Bladder Outlet Obstruction ( B.O.O. ) Bladder Outlet Obstruction represents one etiology of Lower Urinary Tract Symptoms ( L.U.T.S. )

5. The Satisfying Solution for You and Your Partner Lower Urinary Tract Symptoms Storage Symptoms Voiding Symptoms Bladder Sensation Symptoms Postmicturition Symptoms

6. The Satisfying Solution for You and Your Partner Storage Symptoms Increased Daytime Frequency Nocturia OVERACTIVE Urgency BLADDER Urinary Incontinence - Urge Incontinence –Stress Incontinence - Mixed Incontinence - Enuresis – Continuous Urinary Incontinence

7. The Satisfying Solution for You and Your Partner Voiding Symptoms Urinary Hesitancy Straining to Void Slow Urinary Stream Intermittent Stream Terminal Dribbling Splitting or Spraying of the Urinary Stream

8. The Satisfying Solution for You and Your Partner Lower Urinary Tract Symptoms Most Common Symptoms were all of the Voiding Type Most Bothersome Symptoms were of the Storage Type Not all symptoms are Bothersome

9. The Satisfying Solution for You and Your Partner Lower Urinary Tract Symptoms The coexistence of Benign Prostatic Enlargement and Bladder Outlet Obstruction can be termed Benign Prostatic Obstruction

10. The Satisfying Solution for You and Your Partner Lower Urinary Tract Symptoms Not all voiding symptoms are related to obstruction Bladder Outlet Obstruction may be a component of L.U.T.S. Benign Prostatic Enlargement is one form of Bladder Outlet Obstruction B.P.H. is a Histological Dx.

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14. L.U.T.S. caused by Benign Prostatic Obstruction Need to document that BPO is the cause of Bladder Outlet Obstruction (B.O.O.) History Physical Examination Routine Labs and Studies Specialist Investigations

15. The Satisfying Solution for You and Your Partner LUTS- History AUA or International Symptom Score Voiding Diary / Frequency Volume Chart Medical History

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17. LUTS - Physical Exam Palpation of the Abdomen Examination of the Genitalia ( note any meatal stenosis ) Digital Rectal Exam to note size, contour, consistency, and symmetry of the Prostate. Rule out any rectal mass Focused neurological examination

18. The Satisfying Solution for You and Your Partner LUTS/ Bladder Outlet Obstruction- Lab Urinalysis Creatinine PSA

19. The Satisfying Solution for You and Your Partner LUTS/Bladder Outlet Obstruction- Therapy Moderate/ Severe Symptom Score. Low Bother Score, Negligible Post Void Residual- Expectant Therapy Moderate/ Severe Symptom Score. Low Bother Score- Significant Post Void Residual- Alpha Blocker Therapy Moderate/ Severe Symptom Score. High Bother Score/ Negligible or Significant Post Void Residual- Alpha Blocker Therapy or Intervention ( Thermal Therapy or TURP )

20. The Satisfying Solution for You and Your Partner Goals of Therapy for BPH Successful treatment of BPH is measured by: Decreased symptoms (IPSS/AUA) Decreased bother (bother score) and interference with daily activities Decrease in prostate size or arrest of further growth Increase in peak flow rate Improvement in obstruction Prevention of long-term outcomes/complications Acceptable adverse events profile US Agency for Health Care Policy and Research. AHCPR publication 94-0582; OLeary MP. Urology. 2000;56(suppl 5A):7-11.

21. The Satisfying Solution for You and Your Partner Treatment Options Watchful waiting Medical therapy Phytotherapy Pharmacologic therapy Alpha-adrenergic blockers 5-Alpha-reductase inhibitors Anti-muscarinic/Anti- Cholinergic medications Combination therapy Minimally invasive surgery TUMT TUNA Less invasive surgery VLAP ILC TUVP Major surgery TURP (gold standard) TUIP PVP Green Light Laser Open surgery (prostatectomy) Chatelain C et al. In: Chatelain C et al, eds. Benign Prostatic Hyperplasia. Plymouth, UK: Health Publication Ltd; 2001;519-534; DeBruyne FMJ et al. In: Chatelain C et al, eds. Benign Prostatic Hyperplasia. Plymouth, UK: Health Publication Ltd; 2001;397-421; AUA Practice Guidelines Committee. J Urol. 2003;170(2):530-547.

22. The Satisfying Solution for You and Your Partner 5 Alpha - reductase inhibitors Appropriate and effective treatment for patients with LUTS associated with demonstrable prostatic enlargement * Not appropriate for men with LUTS who do not have prostatic enlargement * May prevent progression of disease Currently represented by finasteride and dutasteride *AUA Guideline on BPH

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25. Alpha - adrenergic blocker therapy Appropriate treatment options for patients with LUTS secondary to BPH* Currently represented by Alfuzosin, Doxazosin, Tamsulosin, and Terazosin *AUA Guidelines for BPH

26. The Satisfying Solution for You and Your Partner Combination Medical Therapy The combination of an alpha – adrenergic receptor blocker and a 5 alpha reductase inhibitor ( combination therapy ) is an appropriate and effective treatment for patients with LUTS associated with demonstrable prostatic enlargement * * AUA Guidelines on the management of BPH

27. The Satisfying Solution for You and Your Partner What is ED? The inability to maintain an erection firm enough to have sexual intercourse

28. The Satisfying Solution for You and Your Partner How Common is It? 1 in 10 men Over 30 million American men 90% physical, 10% psychological Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts male aging study. J Urol Jan 1994; 151: 54-61. Sun P, Seftel A, Swindle R, Ye W, Pohl G. The costs of caring for erectile dysfunction in a managed care setting: evidence from a large national claims database. J Urol Nov 2005; 174: 1948-1952. Mulligan T, Teitelman J. Geriatric Sexual dysfunction. VA Med Q Apr/Jun 1991; 118(2): 97-9.

29. The Satisfying Solution for You and Your Partner Physical Causes of ED Diabetes Heart disease Surgery (Prostate, Bladder, Colon, Rectal) Medications Spinal injury Hormone imbalance

30. The Satisfying Solution for You and Your Partner Do I Have To Live With ED? NO! Nearly every man can be successfully treated

31. The Satisfying Solution for You and Your Partner Treatment Options Oral Medications (Viagra®, Levitra®, Cialis®) Vacuum Erection Devices Injection Therapy Urethral Suppositories Penile Implants Viagra is a trademark of Pfizer Inc., Levitra is a trademark of Bayer and GlaxoSmithKline and Cialis is a trademark of Lilly ICOS.

32. The Satisfying Solution for You and Your Partner Oral Therapies: Work only in response to sexual stimulation Must take Viagra and Levitra at least ½ hour before anticipated sexual activity. They remains effective for up to 4 hours after are they taken Cialis can last as long as 36 hours

33. The Satisfying Solution for You and Your Partner Vacuum Erection Devices

34. The Satisfying Solution for You and Your Partner Vacuum Erection Device: Externally applied device mechanically increases penile blood engorgement Cylinder/pump placed over penis creates closed chamber; pump creates vacuum, drawing blood into corpora cavernosa Constrictive elastic ring then placed at base of penis to restrict flow of suctioned blood Levine LA, Dimitriou RJ. Urol Clin North Am. 2001;28:335-341. Montague DK, et al, for the AUA Clinical Guidelines Panel on Erectile Dysfunction. J Urol. 1996;156:2007-2011.

35. The Satisfying Solution for You and Your Partner Vacuum Erection Devices Advantages Not a medication Minimally invasive Disadvantages Discomfort 35% Satisfaction Rate

36. The Satisfying Solution for You and Your Partner Urethral Suppositories MUSE (Prostaglandin E1) Small medicated pellet placed in the tip of the penis Advantages Relatively easy Fast Disadvantages 30-65% effective Side effects include pain

37. The Satisfying Solution for You and Your Partner Transurethral Medication: MUSE

38. The Satisfying Solution for You and Your Partner Injection Therapy Diabetic needle and syringe 5-15 minute response time 30 minute to 2 hour duration Possible side effects Pain on administration Prolonged erections Scarring

39. The Satisfying Solution for You and Your Partner Injection Therapies Single agent and mixed agents Direct injection of medication into the penis Advantages Fast Minimally invasive Disadvantages 61-73% Effective Side effects Needles

40. The Satisfying Solution for You and Your Partner Some Are More Satisfying Than Others Oral Medications: not effective in 30% of cases 1 Vacuum Erection Devices: cumbersome, unromantic Injection Therapy: needles, expensive, may cause burning sensation, long term scarring Urethral Suppositories: expensive, may cause burning sensation 1 Goldstein I, Lue TF, Padma-Nathan H, Rosen RC, Steers WD, Wicker PA; Sildenafil Study Group. Oral sildenafil in the treatment of erectile dysfunction. 1998. J Urol. 2002 Feb;167(2 Pt 2):1197-203; discussion 1204

41. The Satisfying Solution for You and Your Partner Penile Implants vs. Other Treatment Options Overall Patient Satisfaction with ED Treatments 1 0%20%40%60%80%100% Percentage Satisfied Penile Implant Oral Medication Penile Injection 51% 93% 40% 1 Rajpurkar A, Dhabuwala CB. Comparison of satisfaction rates and erectile function in patients treated with sildenafil, intracavernous prostaglandin E1 and penile implant surgery for erectile dysfunction in urology practice. J Urol Jul 2003 v.170(1)p.159-63.

42. The Satisfying Solution for You and Your Partner Penile Implants Ideal for men who have tried other treatments without success On the market for over 30 years 25,000 penile implants per year Over 300,000 implants to date High patient and partner satisfaction

43. The Satisfying Solution for You and Your Partner Types of Penile Implants One-piece non-inflatable Two-piece inflatable Three-piece inflatable

44. The Satisfying Solution for You and Your Partner One - Piece Non-Inflatable Penile Implant Advantages Easy for you or your partner to activate Good option for men with limited dexterity Totally concealed in body The simplest surgical procedure Least expensive prosthesis Disadvantages Stays firm when not in erect position May show through clothing

45. The Satisfying Solution for You and Your Partner Two – Piece Inflatable Penile Implant Advantages Simple to use Fast and simple one-step deflation Totally concealed in body Natural flaccidity compared to non-inflatable implants Disadvantages Requires some manual dexterity Possibility of leakage or malfunction Flaccidity not as natural appearing as the 3-piece

46. The Satisfying Solution for You and Your Partner Three – Piece Inflatable Penile Implant Advantages: same advantages as the two - piece plus Acts and feels more like a natural erection Expands the girth of the penis More firm and full than other implants Feels softer and more flaccid when deflated Disadvantages Requires some manual dexterity Possibility of leakage or malfunction Possibility of unintentional erections

47. The Satisfying Solution for You and Your Partner Proven Benefits Achieve an erection easily and maintain it Erection hard enough for penetration and allows you to complete sexual intercourse Feels natural to you and your partner Easy to use Dependable, works every time Usually outpatient procedure

48. The Satisfying Solution for You and Your Partner In addition, penile implants Requires surgery Risk of surgical complications which may include infection Cost may be prohibitive Possible discomfort or pain from use Non-reversible In rare cases, there may be mechanical failures which may require revision surgery

49. The Satisfying Solution for You and Your Partner Implants are Highly Recommended Levine LA, Estrada CR, Morgentaler A. Mechanical reliability and safety of, and patient satisfaction with the Ambicor inflatable penile prosthesis; results of a 2 center study. J Urol. 2001 Sep; 166 (3) :932-7 100% 95% 90% 85% 80% 92% would recommend to others 3 90% partners would recommend to other couples 4

50. The Satisfying Solution for You and Your Partner Summary ED is a common problem Nearly every man can be successfully treated Penile implants offer a dependable, long-term solution Talk to your partner, talk to your Urologist

51. The Satisfying Solution for You and Your Partner Incontinence is another problem that affects some ED patients.

52. The Satisfying Solution for You and Your Partner The objective demonstration of involuntary loss of urine consequent to bladder and/or sphincter dysfunction. The International Continence Society Ballanger P et al. Female Urinary Incontinence. Eur Urol 1999; 36:165-174. What is urinary incontinence?

53. The Satisfying Solution for You and Your Partner What is urinary incontinence? My plumbing has a faulty washer

54. The Satisfying Solution for You and Your Partner Types of incontinence Stress Incontinence Leakage during physical activity that increases intraabdominal pressure, i.e. lifting, exercising, sneezing, and coughing Urge Incontinence Leakage associated with an overwhelming need to urinate Gotta go, gotta go! Mixed Incontinence Combination of the above Hunskaar et al. One hundred and fifty men with urinary incontinence. Scand J Prim Health Care 1993; 11:193-196.

55. The Satisfying Solution for You and Your Partner How does the process work? Bladder collects urine The sphincter - a circular muscle at the level of the prostate - controls the flow of urine The sphincter muscle wraps around the urethra A healthy sphincter stays closed until one relaxes it to urinate

56. The Satisfying Solution for You and Your Partner Am I the only one with incontinence? 2 million men in the world suffer from loss of urinary control Rate of incontinence ranges between 1-31% after prostate surgery AMS 2003 Annual Report Campbells Urology 2002 8 th Edition NO!

57. The Satisfying Solution for You and Your Partner Why treat incontinence? Avoid negative feelings embarrassment, discomfort, isolation, anger and depression Return to usual lifestyle Regain dignity Resume intimacy Save money on protective garments Improve quality of life

58. The Satisfying Solution for You and Your Partner 150 men reported the practical inconveniences associated with incontinence: 52% Extra Laundry 37% Smell 17% Extra Expense 12% Skin Irritation 11% Disturbed Sleep Source: Hunskaar s, Sandvik H. one hundred and fifty men with urinary incontinence. Scand J Prim Health Care 1993 v. 11 p.193-196 Why treat incontinence?

59. The Satisfying Solution for You and Your Partner Management options Pads/diapers Medication Devices

60. The Satisfying Solution for You and Your Partner Devices Clamps Cunningham clamp, C3-clamp Advantages Non-medical, non-surgical Easy to use Works well Disadvantages Bulky Pressure necrosis Generally not a turn on

61. The Satisfying Solution for You and Your Partner Devices Catheters External vs internal Advantages Works Disadvantages Attached to a bag Increased risk of infection

62. The Satisfying Solution for You and Your Partner Treatment options Behavioral modification Biofeedback Injectables Surgery

63. The Satisfying Solution for You and Your Partner Behavioral modification Void frequently Avoid caffeine, alcohol Avoid activity that increases intraabdominal pressure

64. The Satisfying Solution for You and Your Partner Pelvic floor rehabilitation a.k.a. biofeedback Means of teaching Kegel exercises Objective way to measuring pelvic floor strength ? how much better than verbal instruction

65. The Satisfying Solution for You and Your Partner Surgical options for male stress incontinence AdVance Male Sling Artificial Urinary Sphincter

66. The Satisfying Solution for You and Your Partner AdVance Male Sling Sling restores urethra to its proper anatomical position for optimal sphincter function, restoring urinary control Procedure: –Spinal or general anesthesia can be used –Three small incisions: 1 under the scrotum, 2 over groin creases –Specially designed surgical tools are used to position the sling –Sling is gently tensioned –Incision closed

67. The Satisfying Solution for You and Your Partner Artificial Urinary Sphincter (AUS) Litwiller SE, et al. Post-prostatectomy incontinence and the artificial urinary sphincter; a long-term study of patient satisfaction and criteria for success. J of Urol 1996; 156:1975-1980. over 100,000 implanted since 1972 The Gold Standard for treatment of moderate to severe incontinence 60 minute outpatient procedure 92% of patients would have the device placed again 96% of patients would recommend it to a friend Device is placed completely in the body, providing simple, discreet control

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69. Male Incontinence Severity Level Guidelines Onur R, Rajpurkar A, Singla A. New perineal bone-anchored male sling; Lessons learned. Urology Jul 2004 v. 64 (1) p.58-61

70. The Satisfying Solution for You and Your Partner What should you do next? See your Urologist! Come prepared with questions Discuss your treatment options Your lifestyle and medical condition are important factors

71. The Satisfying Solution for You and Your Partner Summary Incontinence is a common problem Nearly every man can be successfully treated Some treatments are more effective than others Surgical treatment options offer proven, long-term solutions Talk to your Urologist – talk to your partner For more information on Incontinence, ask for the patient brochures, End Urinary Incontinence and The Satisfying Solution You can Live Life Dry!

72. The Satisfying Solution for You and Your Partner Galen Bird, DVM

73. The Satisfying Solution for You and Your Partner Urinary Incontinence

74. The Satisfying Solution for You and Your Partner Advance sling A small sling made of synthetic mesh is placed inside the body through three small incisions.

75. The Satisfying Solution for You and Your Partner Artificial Urinary Sphincter (AUS) Over 100,000 implanted since 1972 The Gold Standard for treatment of moderate to severe incontinence Minimally invasive 92% of patients would have the device placed again 96% of patients would recommend it to a friend Device is placed completely in the body, providing simple, discreet control Litwiller SE, et al. Post-prostatectomy incontinence and the artificial urinary sphincter; a long-term study of patient satisfaction and criteria for success. J of Urol 1996; 156:1975-1980.

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77. Three – Piece Inflatable Penile Implant Advantages Acts and feels more like a natural erection Expands the girth of the penis More firm and full than other implants Feels softer and more flaccid when deflated

78. The Satisfying Solution for You and Your Partner My Experience with a Penile Implant Totally concealed Easy to operate Feels natural A life-changing solution Regret waiting 2 years 2 CC Carson, JJ Mulcahy, FE Govier, Efficacy, safety and patient satisfaction outcomes of the AMS 700CX inflatable penile prosthesis: Results of a long-term multi-center study. AMS 700CX Study Group. J. Urol. 2000 Aug; 164 (2): 376-80.

79. The Satisfying Solution for You and Your Partner Talk To Your Partner! Talk about what you both want and need Discuss your treatment options together with your urologist Talk to others with the same problem

80. The Satisfying Solution for You and Your Partner Questions & Answers