Presentation on theme: "Men’s Health Talk Dr. Kenneth R Thomas, August 28, 2012."— Presentation transcript:
1Men’s Health TalkDr. Kenneth R Thomas, August 28, 2012
2Grew up in backwoods Mississippi High school at MSMS Background – Dr. ThomasGrew up in backwoods MississippiHigh school at MSMSChemical Engineering undergrad at MSUMedical school at UMMCUrology training at University of VirginiaMarried with 4 childrenIn this community to serve
3Men’s Health Talk What should we cover? Erectile Dysfunction IncontinenceLow TestosteroneDifficulty Voiding
4Men’s Health TalkContact Info302 Hospital Road, Starkville MS 39759
6Erectile Dysfunction (ED) What is it?The inability to maintain an erection firm enough to have sexual intercourseHow prevalent is it?1 in 5 American men1Over 30 million American men2Over 150 million men worldwide2Causes: 90% physical, 10% psychogenic31. Selvin E, Burnett A, Platz E. Prevalence and risk factors for erectile dysfunction in the US. Am Jour of Med 2007(120)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 Nov;174(5):3. Mulligan T, Teitelman, J. Geriatric sexual dysfunction. Va Med Q Spring;118(2):97-9
7Main Physical Causes of ED4 VascularDiabetesMedicationPelvic Surgery, Radiation or TraumaMedicationVascularVascularNeurological CausesEndocrine ProblemsOtherDiabetes4. Goldstein I. Male sexual circuitry. Working Group for the study of central mechanisms in erectile dysfunction. Sci Am., Aug 2000;283(2):70-75
8Degree of ED by Age5 Prevalence of ED by Age and Severity (%) Severe ModerateMild or Mild/Moderate100%80%60%40%20%0%5. Data on file at AMS; Dymedex Market Research
9NO! Do you have to live with ED? Nearly every man can be successfully treated.
11Oral Medications Not effective in approximately 30% of cases6 Work only in response to sexual stimulation 7,8Must take at least ½ hour to one hour before anticipated sexual activity 7Viagra® can remain effective for up to 4 hours7, Cialis® can be effective up to 36 hours8High fat meals can affect absorption of Viagra7Estimated cost per pill: $15-$309AVIAGRA® is a registered trademark of Pfizer Inc. CIALIS® is a registered trademark of Eli Lilly and Company Corporation. 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 May 14;338(20):7. downloaded 7/21/118. downloaded 7/21/119A. downloaded 3/3/11
12Oral Medications Common side effects7,8 Some Cautions Headache, Facial Flushing, Stuffy Nose, Upset StomachSome CautionsCannot take with NITRATES7,8Precautions with alpha-blockers; medications for high blood pressure and for prostate problems7,8Tell Your Doctor if You:Have ever had any heart problems, stroke or low or high blood pressure7Have ever had liver or kidney problems77. downloaded 7/21/118. downloaded 7/21/11
13Vacuum Erection Device Some Advantages10Non-invasiveDrug freeCost effectiveSome DisadvantagesCumbersome12Unnatural erection12Erection is not warm to the touch12Bruising/burst blood vessels9B, 11Penile pain/discomfort11Numbness11Delayed ejaculation119B. Levine L, Dimitrious R. Vacuum constriction and external erection devices in erectile dysfunction. Urologic Clinics of North America 2001 May (28) No. 2,10. Yuan J., et al. Vacuum therapy in erectile dysfunction – science and clinical evidence. International Journal of Impotence Research. 2010; 12:11. The Process of Care Consensus Panel. The process of care model for evaluation and treatment of erectile dysfunction. Int J Impot Res. 1999;11: Position Paper12. Miner M.M., Kuritzky L. Erectile Dysfunction: A sentinel marker for cardiovascular disease in primary care. Cleveland Clinic Journal of Medicine May; 74 (3); 30-37
14Urethral Suppository: MUSE® Some AdvantagesNo needles or injectionsErection within 10 to 15 minutes13Some DisadvantagesPenile Pain & Burning13Inadequate penile ridigity14Must be refrigerated13Cost is approximately $25 per application14Patients with poor manual dexterity/vision or severe obesity may find administration difficult15MUSE is a trademark of VIVUS, Inc downloaded 11/12/1014. downloaded 2/15/1115. Shabsigh R, Lue T.F. A Clinician’s Guide to ED Management. MPR Urologist 2006; 76-77
15Penile Injection Therapy Some DisadvantagesRisk of erection lasting 4 hours or more (priapism)16Possible bleeding at injection site16Possible pain at injection site16Requires training16Cavernosal fibrosis16Poor long-term tolerability17Fear of sticking needle in penis17Some AdvantagesEffective17On-set of erection within minutes1616. downloaded 7/21/1117. 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
16Penile ImplantsIdeal for men who have tried other treatments without successOn the market for over 30 yearsOver 300,000 implants to date18High patient and partner satisfaction19,2018. "Penile Prosthesis." The Sexual Medicine Web Site European Society for Sexual Medicine. 23 Jan downloaded 1/8/0919. 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 Sep;166(3):932-720. 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
17Penile Implant Versus Other Treatment Options Overall Patient Satisfaction with ED Treatments17n=22n=31n=32Percentage Satisfied17. 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
18Three-Piece Inflatable Penile Implant Some AdvantagesTotally concealed in bodyDevice is inflated to provide rigidity and deflated for concealmentErection longevity is controllableWhen deflated, the cylinders are soft and flaccidExpands 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
19Implants are Highly Recommended19 These recommendations pertain to the AMS Two-piece inflatable prosthesis19. 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 Sep; 166 (3) :932-7
20Benefits Offers a long-term solution to ED Provides the ability to have an erectionanytime you chooseAllows for greater spontaneity – have sex when the mood strikesEnables you to maintain an erection as long as you desireEliminates the need for costly pills or shotsFeels natural during intercourse19Does not interfere with ejaculation or orgasm19. 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 Sep; 166 (3) :932-7
21Possible RisksWill make latent natural or spontaneous erections as well as other interventional treatment options impossibleIf an infection occurs, the prosthesis may have to be removedMay cause the penis to become shorter, curved or scarredThere may be mechanical failures of the prosthesisPain (typically associated with healing process)
22As 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.
23Is a penile implant covered by insurance or Medicare? Insurance CoverageIs a penile implant covered by insurance or Medicare?
24Is a penile implant covered by insurance or Medicare? Insurance CoverageIs a penile implant covered by insurance or Medicare?YES!Most insurance carriers cover the cost of implant surgery
25Summary ED is a common problem Nearly every man can be successfully treated for EDPenile implants offer a long-term solutionTalk to your partner, talk to your Urologist25
26Brief 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
28Satisfying Solutions Understanding Male Continence
29What 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”
30Types of Incontinence Stress Urinary Incontinence (SUI) Leakage during a physical activity like lifting, exercising, sneezing, and coughing, most common following prostate cancer surgery.Urge IncontinenceLeakage associated with an overwhelming need to urinate…Gotta go, gotta go!Overflow IncontinenceLeakage when your bladder never completely emptiesTotal IncontinenceLeakage when the urinary sphincter muscle is completely deficient.
31How 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.
32What Causes Incontinence? Prostate Cancer Surgery(Radical Prostatectomy or TURP)Conditions such as diabetes, multiple sclerosis, Parkinson’s disease or strokePelvic TraumaBirth Defects
33Why Treat Incontinence? 150 men reported the practical inconveniences associated with incontinence21:52% Extra laundry37% Smell17% Extra expense12% Skin irritation11% Disturbed sleep21. Hunskaar s, Sandvik H. one hundred and fifty men with urinary incontinence. Scand J Prim Health Care 1993 v. 11 p
34NO! Am I the only one suffering from Incontinence? Worldwide, 55 million men suffer from incontinence22.5 million men in the United States suffer from incontinence22.Rate of incontinence ranges between 2.5% up to 69% after prostate surgery23.22. AMS Market Research on file23. 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):
35NO!Do you have to live with Incontinence?Can you Live Life Dry?YES!
37Behavioral Modification and Medication Decrease fluid intakeUrinate frequentlyAvoid caffeine, alcoholAvoid activity that increases intra-abdominal pressureNo FDA approved medication for stress incontinence in men
38Absorbent Products: Pads, Diapers Is this a satisfactory solution for you?Are these the best solution?How often are you changing them?Skin irritation and rashesInconvenience
39Absorbent Products: Pads, Diapers Cost is a factor…Cost Comparison of Wearing 5 Pads a Day for 10 YearsEntrust Undergarments $0.99 eachActive Style Pads $0.52 eachCoveen Drip Collectors $1.05 eachDepends Undergarments $0.52 eachCost/10 years2424. 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):
40Devices: Clamps25 Cunningham Clamp, C3-clamp Some Advantages Non-medical, non-surgicalEasy to useFunctionalInexpensiveSome DisadvantagesScarringPainSkin and tissue problems25. downloaded 1/7/10
41Devices: Catheters26 External vs. Internal Some Advantages FunctionalSome DisadvantagesUrinary tract infectionDamage to the penis from friction with the condomUrethral blockage26. downloaded 11/17/10
42Collagen Injections Collagen, carbon beads, autologous fat Success rates for collagen ~ 17% after prostatectomy2727 Klingler HC et al. Incontinence after radical prostatectomy: surgical treatment options.Curr Opin Urol 2006; 16:60-64
43Surgical OptionsAdVance® Male SlingAMS 800® Urinary Control System
44AdVance Male Sling: Benefits Outpatient surgeryMay be performed under spinal or general anesthesiaOften no catheter necessary upon dischargeNo device activation requiredMay begin to notice improvement following procedure28Restored dignity and quality of life28. Rehder P., Gozzi C. Transobturator Sling Suspension for Male Urinary Incontinence Including Post-Radical Prostatectomy. Eur Urol 2007
45AdVance Male Sling System AdVance is not for people with:Urinary tract infectionsBlood coagulation disordersCompromised immune systems or any other condition that would compromise healingRenal insufficiency and urinary tract obstructionFor a complete list of risks associated with AdVance, refer to device labeling atRx Only
46AMS 800® Urinary Control System Artificial Urinary Sphincter (AUS)The Gold Standard for treatment of incontinenceThe cuff wraps around the urethra and is inflated/closed at restPump in the scrotum deflates/opens sphincter and allows urinationThe next slide will illustrate how this system worksThe artificial urinary sphincter is similar to a penile prosthesis in concept but on a much smaller scale.This cuff wraps around the urethra and is closed at rest. When one feels the sensation to urinary, he simply pumps the control located in the scrotum and the cuff deflates, allowing the urine to drain. The cuff then spontaneously inflates after about a minute.4646
47AMS 800® Urinary Control System Artificial Urinary Sphincter (AUS)Outpatient procedureEffectively gives most men the ability to achieve continence91% of patients would have the device placed again2982% of patients would recommend it to a friend29Device is placed completely inside the body, providing simple, discreet urinary controlPublished clinical data shows long-term effective results29. B. Kahlon, et al. Quality of life and patient satisfaction after artificial urinary sphincter. Can Urol Assoc J. Jan 2011: 1-5
48AMS 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 anesthesiaWith an irreversibly blocked lower urinary tractWith irresolvable detrusor hyperreflexia or bladder instabilityWith a known allergy or sensitivity to rifampin, mimocycline or other tetracyclinesWho have challenges optimally using their handsRx Only
49As 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 urinationYou should talk to your doctor about the benefits and risks before moving forward with any treatment option. For additional product and risk information visit:
50Summary Incontinence is a common problem Some treatments are more effective than othersSurgical treatment options offer proven, long-term solutionsTalk to your Urologist – talk to your partnerYou can Live Life Dry!
51Brief Summary – AMS AUS 800The 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
54Low 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 normalHow many men are estimated to have Low T?Approximately 4 in 10 men over age 45 may have low testosteroneThe percentage rises as men get olderLow 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 conditionsMulligan T et al. Int J Clin Pract. 2006;60(7):
55Percentage of Men with Low Testosterone Rises as They Age HIM Study: prevalence of hypogonadism in 2165 men > age 45 presenting to 95 primary care practices 160.050%50.046%40%40%39%40.034%Percentage of men with low testosterone30.020.010.00.085+Total(45+)45–5455–6465–7475–84Age Range, Years1. Mulligan T et al. Int J Clin Pract. 2006;60(7):
56Want are Some of the Signs and Symptoms of Low Testosterone?
57What Can I Do if I Think I Have Low T? Low T is diagnosed based on symptoms you may be experiencing, as well as testosteroneTestosterone 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.
58Treatment OptionsIf 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.
59Understanding Prostate Health Dr. Kenneth R Thomas, August 28, 2012
61Overview of the Prostate Walnut sized gland at base of the male bladderSurrounds the urethraProduces fluid that transports sperm during ejaculation
62Prostate Conditions Enlarged Prostate • Prostatitis • Prostate Cancer Each condition affects the prostate differently
63Aging and the ProstateBPH affects more than 26 million men each year in the United StatesProstate grows to a normal size in teenage years and then begins to grow again around the age of 50By age 60, half of all men have an enlarged prostateAffects most men by age 80Stress and diet are contributing to an increased presence of enlarged prostate in younger men
64What is BPH? Benign Prostatic Hyperplasia (BPH) Commonly known as enlarged prostateNon-cancerous enlargement of the prostate glandBPH is not an indication or a predictor of cancerThe opposite is also true – your PSA level is not an indicator of BPH
65Normal vs. Enlarged Prostate As the prostate enlarges, pressure can be put on the urethra• Causes urinary problems• It is usually not life-threateningIn general, the size of the prostate does notcorrelate to severity of symptomsNormal ProstateEnlarged Prostate
66Recognizing the Symptoms of BPH Frequent urinationMultiple trips to the bathroom at nightSudden urge to urinateDifficult or painful urinationWeak or slow urine flowIncomplete elimination of urineStopping and starting of flow
67BPH Affects Quality of Life Many men who suffer from BPH experience a reduction in quality of life.Avoiding travelInterruption of leisure activitiesUsing the bathroom stalls instead of urinalsDisruption of sleep patterns
68How is an Enlarged Prostate Diagnosed? Medical HistoryPhysical ExamSymptoms – AUA Symptom ScoreBothersome – How much of a bother is it to you?
70Treatment Options for Enlarged Prostate Watchful WaitingMedicationHeat Therapy (TUMT)Laser TherapySurgery (TURP)Different treatments are appropriate for different patients
71Treatment Option Watchful Waiting Advantages No surgery No drugs No side effectsDisadvantagesNo improvements in symptomsRisk that symptoms will worsen
72Treatment Option Medication Advantages No surgery Potential for symptom reliefDisadvantagesMust be taken dailyPotential side effects - Lowered sexual drive, erection problems, nasal congestion and dizzinessHigh out-of pocket cost- Average daily cost Flomax $3.28 ($1,197/yr) Avodart $2.54 ($927/yr)• Over time may stop working
73Transurethral Microwave Therapy (TUMT) Treatment OptionTransurethral Microwave Therapy (TUMT)AdvantagesSafe and effectiveIn-Office ProcedureShort procedure timeCan be performed withonly a mild oral sedativeDisadvantagesCatheterization requiredBest for mild symptomsVariable levels of short and long term functional improvements
74Surgery (TURP) Transurethral Resection of the Prostate Treatment OptionSurgery (TURP) Transurethral Resection of the ProstateAdvantagesProven approachDisadvantagesSurgical procedure risks:Bleeding requiring transfusionRetrograde ejaculation rate: %ED rate of 6.3%Persistent incontinenceGeneral or regional anesthesia necessaryCatheterization requiredHospitalization required• Activities after surgery restricted for about 6 weeks
75An Advanced Treatment Option GreenLight Laser Therapy• Over 375,000 patients treated worldwideDone in an outpatient setting and typically no overnight stay is requiredProvides rapid long-lasting symptom reliefDramatic urine flow improvementSafe and effective for use in men in urinary retention, with largeprostates or on anticoagulant therapyAlternative to the cost, side effects and inconvenience of other therapiesPer the American Urological Association guidelines,laser therapy provides equivalent symptom relief compared to TURP
76How GreenLight Laser Therapy Works: Uses laser energy to remove excess prostate tissue by vaporizationLaser energy is delivered through a small, flexible fiber inserted in the urethraThe procedure can be performed in a hospital outpatient center or surgical center
77Clinical Comparison GreenLight TURP Length of Hospital Stay 1.1 days Length of Catheterization12.2 hours44.5 hours
78GreenLight Treatment Shots Pre-opImmediate post-op3 months post-opTURP like results withfewer side effectsPhotos courtesy of Mahmood A. Hai, M.D.
79Side Effects Hematuria – Blood in the urine Bladder spasm or urgency Irritation of urinary tract – frequent urination, burning sensationRetrograde ejaculation36% for GreenLight Procedure% for TURP Procedure
80Affect on Erectile Function Does NOT affect Erectile functionDoes 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.
81Insurance CoverageCovered by Medicare and most private insurance companiesCan be an economic alternative to the ongoing cost of medications
82What to Expect During Treatment May be given medication to help you relaxIV sedation or anesthesia that will allow you to sleep through the procedureMinimal to no discomfort
83Post-Treatment Expectations Dramatic symptom improvementimmediatelyTypically able to leave outpatient facility within hours after treatmentMany patients leave without a catheter; however, if one is required it is typically removed in less than 24 hoursCan resume normal activities within a few days andstrenuous activities within two weeks
84Am I Eligible For This Treatment? Of the BPH treatments available, GreenLight has the widest patient selectionPotential candidates may include men who are:- Not satisfied with medication therapyLoss of effectiveness, costs, side effectsDon’t want to take medicationsWant better symptom relief than with medicationsOn anti-coagulation therapyMildly to severely symptomaticConsultation with your Urologist is required to determine ifGreenLight is the best treatment option for you.