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Men’s Health Talk Dr. Kenneth R Thomas, August 28, 2012.

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Presentation on theme: "Men’s Health Talk Dr. Kenneth R Thomas, August 28, 2012."— Presentation transcript:

1 Men’s Health Talk Dr. Kenneth R Thomas, August 28, 2012

2 Background – Dr. Thomas Grew up in backwoods Mississippi High school at MSMS Chemical Engineering undergrad at MSU Medical school at UMMC Urology training at University of Virginia Married with 4 children In this community to serve

3 Men’s Health Talk What should we cover? Erectile Dysfunction Incontinence Low Testosterone Difficulty Voiding

4 Men’s Health Talk Contact Info 302 Hospital Road, Starkville MS 39759 662-615-3756

5 Satisfying Solutions Erectile Restoration

6 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 1 Over 30 million American men 2 Over 150 million men worldwide 2 Causes: 90% physical, 10% psychogenic 3 1. Selvin E, Burnett A, Platz E. Prevalence and risk factors for erectile dysfunction in the US. Am Jour of Med 2007(120) 151-157 2. 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. 2005 Nov;174(5):1948-52 3. Mulligan T, Teitelman, J. Geriatric sexual dysfunction. Va Med Q. 1991 Spring;118(2):97-9

7 Main Physical Causes of ED 4 Vascular Diabetes Medication Pelvic Surgery, Radiation or Trauma Neurological Causes Endocrine Problems Other 4. Goldstein I. Male sexual circuitry. Working Group for the study of central mechanisms in erectile dysfunction. Sci Am., Aug 2000;283(2):70-75 Vascular Diabetes Medication Vascular

8 Degree of ED by Age 5 5. Data on file at AMS; Dymedex Market Research Prevalence of ED by Age and Severity (%) Severe Moderate Mild or Mild/Moderate 100% 80% 60% 40% 20% 0%

9 Nearly every man can be successfully treated. Do you have to live with ED? NO!

10 Treatment Options For Erectile Dysfunction

11 Oral Medications Not effective in approximately 30% of cases 6 Work only in response to sexual stimulation 7,8 Must take at least ½ hour to one hour before anticipated sexual activity 7 Viagra ® can remain effective for up to 4 hours 7, Cialis ® can be effective up to 36 hours 8 High fat meals can affect absorption of Viagra 7 Estimated cost per pill: $15-$30 9A 6. Goldstein I, Lue TF, Padma-Nathan H, Rosen RC, Steers WD, Wicker PF, for the Sildenafil Study Group. Oral sildenafil in the treatment of erectile dysfunction. N Engl J Med. 1998 May 14;338(20):1397-404 7.; downloaded 7/21/11 8.; downloaded 7/21/11 9A.; downloaded 3/3/11 VIAGRA® is a registered trademark of Pfizer Inc. CIALIS® is a registered trademark of Eli Lilly and Company Corporation.

12 Oral Medications Common side effects 7,8 Headache, Facial Flushing, Stuffy Nose, Upset Stomach Some Cautions Cannot take with NITRATES 7,8 Precautions with alpha-blockers; medications for high blood pressure and for prostate problems 7,8 Tell Your Doctor if You: Have ever had any heart problems, stroke or low or high blood pressure 7 Have ever had liver or kidney problems 7 7.; downloaded 7/21/11 8.; downloaded 7/21/11

13 Vacuum Erection Device Some Advantages 10 Non-invasive Drug free Cost effective 9B. Levine L, Dimitrious R. Vacuum constriction and external erection devices in erectile dysfunction. Urologic Clinics of North America 2001 May (28) No. 2, 335-341 10. Yuan J., et al. Vacuum therapy in erectile dysfunction – science and clinical evidence. International Journal of Impotence Research. 2010; 12: 211-219 11. The Process of Care Consensus Panel. The process of care model for evaluation and treatment of erectile dysfunction. Int J Impot Res. 1999;11:59-70. Position Paper 12. Miner M.M., Kuritzky L. Erectile Dysfunction: A sentinel marker for cardiovascular disease in primary care. Cleveland Clinic Journal of Medicine. 2007 May; 74 (3); 30-37 Some Disadvantages Cumbersome 12 Unnatural erection 12 Erection is not warm to the touch 12 Bruising/burst blood vessels 9B, 11 Penile pain/discomfort 11 Numbness 11 Delayed ejaculation 11

14 Urethral Suppository: MUSE ® MUSE is a trademark of VIVUS, Inc. 13. downloaded 11/12/10 14., downloaded 2/15/11 15. Shabsigh R, Lue T.F. A Clinician’s Guide to ED Management. MPR Urologist 2006; 76-77 Some Disadvantages Penile Pain & Burning 13 Inadequate penile ridigity 14 Must be refrigerated 13 Cost is approximately $25 per application 14 Patients with poor manual dexterity/vision or severe obesity may find administration difficult 15 Some Advantages No needles or injections Erection within 10 to 15 minutes 13

15 Penile Injection Therapy Some Advantages Effective 17 On-set of erection within 5-20 minutes 16 Some Disadvantages Risk of erection lasting 4 hours or more (priapism) 16 Possible bleeding at injection site 16 Possible pain at injection site 16 Requires training 16 Cavernosal fibrosis 16 Poor long-term tolerability 17 Fear of sticking needle in penis 17 16.; downloaded 7/21/11 17. 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

16 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 18 High patient and partner satisfaction 19,20 18. "Penile Prosthesis." The Sexual Medicine Web Site. 2008. European Society for Sexual Medicine. 23 Jan 2009; downloaded 1/8/09 19. 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 20. Montorsi F et al. AMS three-piece inflatable implants for erectile dysfunction; a long-term multi- institution study in 200 consecutive patients. Eur Urol. 2000; 37:50-55

17 Penile Implant Versus Other Treatment Options 17. 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 Overall Patient Satisfaction with ED Treatments 17 Percentage Satisfied n=22 n=31 n=32

18 Three-Piece Inflatable Penile Implant Some Advantages Totally concealed in body 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

19 Implants are Highly Recommended 19 19. 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 These recommendations pertain to the AMS Two-piece inflatable prosthesis

20 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 19 Does not interfere with ejaculation or orgasm Benefits 19. 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

21 Possible Risks Will make latent natural or spontaneous erections as well as other interventional 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 (typically associated with healing process)

22 As with any medical procedure, there are risks involved and not all patients are candidates for a penile implant. Discuss the risks and benefits of this procedure in more detail with your urologist.

23 Insurance Coverage Is a penile implant covered by insurance or Medicare?

24 Insurance Coverage Is a penile implant covered by insurance or Medicare? YES! –Most insurance carriers cover the cost of implant surgery

25 Summary ED is a common problem Nearly every man can be successfully treated for ED Penile implants offer a long-term solution Talk to your partner, talk to your Urologist

26 Brief Summary – AMS 700 and Ambicor The AMS 700 ® Series Inflatable Penile Prosthesis and the AMS Ambicor ® Penile Prosthesis are intended for use in the treatment of chronic, organic, male erectile dysfunction (impotence). These devices are contraindicated in patients who have active urogenital infections or active skin infections in the region of surgery or (for the AMS 700 with InhibiZone®) have a known sensitivity or allergy to rifampin, minocycline, or other tetracyclines. Implantation will make latent natural or spontaneous erections, as well as other interventional treatment options, impossible. Men with diabetes, spinal cord injuries or open sores may have an increased risk of infection. Failure to evaluate and treat device erosion may result in infection and loss of tissue. Implantation may result in penile shortening, curvature, or scarring. Possible adverse events include, but are not limited to, urogenital pain (usually associated with healing), urogenital edema, urogenital ecchymosis, urogenital erythema, reservoir encapsulation, patient dissatisfaction, auto- inflation, mechanical malfunction, impaired urination, penile curvature, or sensation change. Prior to using these devices, please review the Instructions for Use for a complete listing of indications, contraindications, warnings, precautions and potential adverse events. Rx Only

27 Questions on ED?

28 Satisfying Solutions Understanding Male Continence

29 What is Incontinence? Male urinary incontinence is usually caused by a damaged sphincter, the circular muscle that controls the flow of urine out of the bladder. When damaged, often the unavoidable result of prostate cancer surgery, the muscle cannot squeeze and close off the urethra. This causes urine to leak. “My plumbing has a faulty washer”

30 Types of Incontinence Stress Urinary Incontinence (SUI) Leakage 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 Leakage when your bladder never completely empties Total Incontinence Leakage when the urinary sphincter muscle is completely deficient.

31 How Does the Process Work? In men, the urinary sphincter muscle is located below the prostate. The sphincter muscle surrounds the urethra. When the sphincter muscle tightens, it holds urine in the bladder. When it relaxes, the bladder contracts and the urethra opens, allowing urine to flow outside the body. When the sphincter muscle is damaged, it cannot close off the urethra.

32 What Causes Incontinence? Prostate Cancer Surgery (Radical Prostatectomy or TURP) Conditions such as diabetes, multiple sclerosis, Parkinson’s disease or stroke Pelvic Trauma Birth Defects

33 150 men reported the practical inconveniences associated with incontinence 21 : 52% Extra laundry 37% Smell 17% Extra expense 12% Skin irritation 11% Disturbed sleep 21. 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?

34 Am I the only one suffering from Incontinence? Worldwide, 55 million men suffer from incontinence 22. 5 million men in the United States suffer from incontinence 22. Rate of incontinence ranges between 2.5% up to 69% after prostate surgery 23. NO! 22. AMS Market Research on file 23. Tewari A. et al. Anatomic Restoration Technique of Continence Mechanism and Preservation of Puboprostatic Collar: A Novel Modification to Achieve Early Urinary Continence in Men Undergoing Robotic Prostatectomy. Urology. 2007; 69(4): 726-731

35 Can you Live Life Dry? Do you have to live with Incontinence? NO! YES!

36 Treatment Options for Stress Incontinence

37 Behavioral Modification and Medication Decrease fluid intake Urinate frequently Avoid caffeine, alcohol Avoid activity that increases intra-abdominal pressure No FDA approved medication for stress incontinence in men

38 Absorbent Products: Pads, Diapers Is this a satisfactory solution for you? Are these the best solution? How often are you changing them? Skin irritation and rashes Inconvenience

39 Cost is a factor… Absorbent Products: Pads, Diapers Cost Comparison of Wearing 5 Pads a Day for 10 Years Entrust Undergarments $0.99 each Active Style Pads $0.52 each Coveen Drip Collectors $1.05 each Depends Undergarments $0.52 each Cost/10 years 24 24. Brown J.A., Elliott D.S., Barrett D.M. Post prostatectomy Urinary Incontinence: A Comparison of the Cost of Conservative Versus Surgical Management. Adult Urology. 1998; 51(5): 715-720

40 Devices: Clamps 25 Cunningham Clamp, C3-clamp Some Advantages Non-medical, non-surgical Easy to use Functional Inexpensive Some Disadvantages Scarring Pain Skin and tissue problems 25.; downloaded 1/7/10

41 Devices: Catheters 26 External vs. Internal Some Advantages Functional Some Disadvantages Urinary tract infection Damage to the penis from friction with the condom Urethral blockage 26., downloaded 11/17/10

42 Collagen Injections Collagen, carbon beads, autologous fat Success rates for collagen ~ 17% after prostatectomy 27 27 Klingler HC et al. Incontinence after radical prostatectomy: surgical treatment options. Curr Opin Urol 2006; 16:60-64

43 AdVance ® Male Sling AMS 800 ® Urinary Control System Surgical Options

44 AdVance Male Sling: Benefits Outpatient surgery May be performed under spinal or general anesthesia Often no catheter necessary upon discharge No device activation required May begin to notice improvement following procedure 28 Restored dignity and quality of life 28. Rehder P., Gozzi C. Transobturator Sling Suspension for Male Urinary Incontinence Including Post- Radical Prostatectomy. Eur Urol 2007

45 AdVance Male Sling System 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 For a complete list of risks associated with AdVance, refer to device labeling at Rx Only

46 The Gold Standard for treatment of incontinence The cuff wraps around the urethra and is inflated/closed at rest Pump in the scrotum deflates/opens sphincter and allows urination The next slide will illustrate how this system works AMS 800 ® Urinary Control System Artificial Urinary Sphincter (AUS)

47 29. B. Kahlon, et al. Quality of life and patient satisfaction after artificial urinary sphincter. Can Urol Assoc J. Jan 2011: 1-5 AMS 800 ® Urinary Control System Artificial Urinary Sphincter (AUS) Outpatient procedure Effectively gives most men the ability to achieve continence 91% of patients would have the device placed again 29 82% of patients would recommend it to a friend 29 Device is placed completely inside the body, providing simple, discreet urinary control Published clinical data shows long-term effective results

48 AMS 800 ® Urinary Control System Artificial Urinary Sphincter (AUS) The AMS 800 is not for those men: Who are not good candidates for surgical procedures or anesthesia With an irreversibly blocked lower urinary tract With irresolvable detrusor hyperreflexia or bladder instability With a known allergy or sensitivity to rifampin, mimocycline or other tetracyclines Who have challenges optimally using their hands Rx Only

49 As with most surgical procedures, inherent risks are present and potential adverse reactions may occur. Although rare, some of the most severe risks include infection, erosion, and perforation. Some potential adverse reactions to surgical procedures to correct incontinence include: Pain/Discomfort/Irritation Inflammation Incomplete correction of urinary incontinence Urinary Tract Infections/Obstruction/Retention Urge symptoms Difficulty with urination You should talk to your doctor about the benefits and risks before moving forward with any treatment option. For additional product and risk information visit:

50 Summary Incontinence is a common problem Some treatments are more effective than others Surgical treatment options offer proven, long-term solutions Talk to your Urologist – talk to your partner You can Live Life Dry!

51 The AMS Sphincter 800 Urinary Prosthesis device is intended to treat urinary incontinence due to reduced outlet resistance (Intrinsic Sphincter Deficiency). The device is contraindicated in patients who are determined to be poor surgical candidates, have an irreversibly blocked lower urinary tract, have irresolvable detrusor hyperreflexia or bladder instability, or (for the AMS 800 with InhibiZone ® ) have a known sensitivity or allergy to rifampin, minocycline or other tetracyclines. Patients with urinary tract infections, diabetes, spinal cord injuries, open sores or regional skin infections may have increased infection risk. Device-skin erosion may occur. Proper patient evaluation, selection and counseling of realistic expectations should occur. Possible adverse events include, but are not limited to, compromised device function, pain/discomfort, delayed wound healing, migration and recurrent incontinence. Prior to using these devices, please review the Instructions for Use for a complete listing of indications, contradictions, warnings, precautions and potential adverse events. Rx Only Brief Summary – AMS AUS 800

52 Questions on Male Continence?

53 Low Testosterone (Male Hypogonadism)

54 Low Testosterone (Low T) What is it? Low testosterone (sometimes called “hypogonadism” or “low T”) occurs when a man’s body produces less testosterone than is normal How many men are estimated to have Low T? Approximately 4 in 10 men over age 45 may have low testosterone The percentage rises as men get older Low testosterone is more common in men who are obese, type-2 diabetic, have high cholesterol or have high blood pressure than in men without these conditions Mulligan T et al. Int J Clin Pract. 2006;60(7):762-769.

55 Percentage of Men with Low Testosterone Rises as They Age 1. Mulligan T et al. Int J Clin Pract. 2006;60(7):762-769. 39% 34% 40% 46% 50% 0.0 10.0 20.0 30.0 40.0 50.0 60.0 Total (45+) 45–5455–6465–7475–84 85+ Age Range, Years Percentage of men with low testosterone HIM Study: prevalence of hypogonadism in 2165 men > age 45 presenting to 95 primary care practices 1

56 Want are Some of the Signs and Symptoms of Low Testosterone?

57 What Can I Do if I Think I Have Low T? Low T is diagnosed based on symptoms you may be experiencing, as well as testosterone Testosterone levels are determined via a simple blood test. Depending on the results, your healthcare professional may repeat the test. Talk to your doctor about your symptoms and ask if a blood test to check your testosterone levels is right for you.

58 Treatment Options If you are diagnosed with Low T, there are available treatment options you can discuss with your healthcare professional. Treatments currently include testosterone gels, injections, and slow release testosterone pellets.

59 Understanding Prostate Health Dr. Kenneth R Thomas, August 28, 2012

60 Overview of the Prostate and BPH

61 Overview of the Prostate Walnut sized gland at base of the male bladder Surrounds the urethra Produces fluid that transports sperm during ejaculation

62 Prostate Conditions Enlarged Prostate Prostatitis Prostate Cancer Each condition affects the prostate differently

63 Aging and the Prostate BPH affects more than 26 million men each year in the United States Prostate grows to a normal size in teenage years and then begins to grow again around the age of 50 By age 60, half of all men have an enlarged prostate Affects most men by age 80 Stress and diet are contributing to an increased presence of enlarged prostate in younger men

64 What is BPH? Benign Prostatic Hyperplasia (BPH) Commonly known as enlarged prostate Non-cancerous enlargement of the prostate gland – BPH is not an indication or a predictor of cancer – The opposite is also true – your PSA level is not an indicator of BPH

65 Normal vs. Enlarged Prostate As the prostate enlarges, pressure can be put on the urethra Causes urinary problems It is usually not life-threatening In general, the size of the prostate does not correlate to severity of symptoms Normal Prostate Enlarged Prostate

66 Recognizing the Symptoms of BPH Frequent urination Multiple trips to the bathroom at night Sudden urge to urinate Difficult or painful urination Weak or slow urine flow Incomplete elimination of urine Stopping and starting of flow

67 BPH Affects Quality of Life Many men who suffer from BPH experience a reduction in quality of life. – Avoiding travel – Interruption of leisure activities – Using the bathroom stalls instead of urinals – Disruption of sleep patterns

68 How is an Enlarged Prostate Diagnosed? Medical History Physical Exam Symptoms – AUA Symptom Score Bothersome – How much of a bother is it to you?

69 Treatment Options

70 Treatment Options for Enlarged Prostate Watchful Waiting Medication Heat Therapy (TUMT) Laser Therapy Surgery (TURP) Different treatments are appropriate for different patients

71 Treatment Option Watchful Waiting Advantages No surgery No drugs No side effects Disadvantages No improvements in symptoms Risk that symptoms will worsen

72 Treatment Option Medication Advantages No surgery Potential for symptom relief Disadvantages Must be taken daily Potential side effects - Lowered sexual drive, erection problems, nasal congestion and dizziness High out-of pocket cost - Average daily cost Flomax $3.28 ($1,197/yr) Avodart $2.54 ($927/yr) Over time may stop working

73 Treatment Option Transurethral Microwave Therapy (TUMT) Advantages Safe and effective In-Office Procedure Short procedure time Can be performed with only a mild oral sedative Disadvantages Catheterization required Best for mild symptoms Variable levels of short and long term functional improvements

74 Treatment Option Surgery (TURP) Transurethral Resection of the Prostate Advantages Proven approach Disadvantages Surgical procedure risks: Bleeding requiring transfusion Retrograde ejaculation rate: 53 - 75% ED rate of 6.3% Persistent incontinence General or regional anesthesia necessary Catheterization required Hospitalization required Activities after surgery restricted for about 6 weeks

75 An Advanced Treatment Option GreenLight Laser Therapy Over 375,000 patients treated worldwide Done in an outpatient setting and typically no overnight stay is required Provides rapid long-lasting symptom relief Dramatic urine flow improvement Safe and effective for use in men in urinary retention, with large prostates or on anticoagulant therapy Alternative to the cost, side effects and inconvenience of other therapies Per the American Urological Association guidelines, laser therapy provides equivalent symptom relief compared to TURP

76 How GreenLight Laser Therapy Works: Uses laser energy to remove excess prostate tissue by vaporization Laser energy is delivered through a small, flexible fiber inserted in the urethra The procedure can be performed in a hospital outpatient center or surgical center

77 Clinical Comparison GreenLight TURP Length of Hospital Stay Length of Catheterization 1.1 days 12.2 hours 3.4 days 44.5 hours

78 GreenLight Treatment Shots TURP like results with fewer side effects Photos courtesy of Mahmood A. Hai, M.D. Pre-opImmediate post-op3 months post-op

79 Side Effects Hematuria – Blood in the urine Bladder spasm or urgency Irritation of urinary tract – frequent urination, burning sensation Retrograde ejaculation -36% for GreenLight Procedure -53 - 75% for TURP Procedure

80 Affect on Erectile Function Does NOT affect Erectile function Does NOT affect your ability to take erectile dysfunction medications - There is no difference between pre-operative and post-operative function after treatment for men with either mild or no erectile dysfunction preoperatively.

81 Insurance Coverage Covered by Medicare and most private insurance companies Can be an economic alternative to the ongoing cost of medications

82 What to Expect During Treatment May be given medication to help you relax IV sedation or anesthesia that will allow you to sleep through the procedure Minimal to no discomfort

83 Post-Treatment Expectations Dramatic symptom improvement immediately Typically able to leave outpatient facility within hours after treatment Many patients leave without a catheter; however, if one is required it is typically removed in less than 24 hours Can resume normal activities within a few days and strenuous activities within two weeks

84 Am I Eligible For This Treatment? Of the BPH treatments available, GreenLight has the widest patient selection Potential candidates may include men who are: –- Not satisfied with medication therapy Loss of effectiveness, costs, side effects Don’t want to take medications Want better symptom relief than with medications -On anti-coagulation therapy -Mildly to severely symptomatic Consultation with your Urologist is required to determine if GreenLight is the best treatment option for you.

85 Questions?

86 Thank You

87 Men’s Health Talk Contact Info 302 Hospital Road, Starkville MS 39759 662-615-3756

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