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Men’s Health The Urological Outlook. Dr Andrew Yip Consultant Urologist Chief of Service Kwong Wah Hospital Hong Kong 7 November 2010. Male Urological Diseases. Benign prostatic hyperplasia Prostate cancer Erectile dysfunction Premature ejaculation . Prostatic problems.

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men s health the urological outlook

Men’s HealthThe Urological Outlook

Dr Andrew Yip

Consultant Urologist

Chief of Service

Kwong Wah Hospital

Hong Kong

7 November 2010

male urological diseases
Male Urological Diseases
  • Benign prostatic hyperplasia
  • Prostate cancer
  • Erectile dysfunction
  • Premature ejaculation
prostatic problems
Prostatic problems

↑number of patients

  • Ageing population
  • ↑public awareness
  • Effective medical treatments
hong kong
Hong Kong
  • Public urologic service
  • Non-emergency cases waiting time for first consultation 18-24 months
prostate disease
Prostate Disease

Prostatitis 2%

Prostatic cancer 18%

BPH 80%

three fundamental features of benign prostatic hyperplasia
Three fundamental features of Benign Prostatic Hyperplasia

Symptoms

Hyperplasia

Obstruction

Large prostate ≠obstruction

* clinical symptoms *

slide8

The prevalence of anatomical benign prostatic hyperplasia rises with age. By the age of 90 years, the disease is virtually universal in men.

slide9

Data from the Baltimore Longitudinal Study of Aging Suggest that the prevalence of symptomatic benign hyperplasia also increases progressively with age.

slide10

Decrease in maximum urinary flow rates over 3 years for different age groups detected in men from Olmstead County

the symptoms of bph may remain unchanged or deteriorate only slowly over time
The symptoms of BPH may remain unchanged or deteriorate only slowly over time

Improved with time: 15%

Worsening symptoms: 55%

Remain stable: 30%

slide12

Cumulative incidence of acute urinary retention over 6 years. The risks of this complication of benign prostatic hyperplasia rise progressively with age

differential diagnosis of lower urinary tract symptoms
Neurological conditions

Parkinson’s disease

Cerebrovascular accident

Multiple system atrophy ( Shy-Drager syndrome)

Cerebral atrophy

Multiple sclerosis

Neoplastic disorders

Prostatic cancer

Carcinoma in situ of the bladder

Inflammatory disorders

Urinary tract infection/bladder stone

Interstitial cystitis

Tuberculous cystitis

Other causes of obstruction

Bladder neck dyssynergia

External sphincter dyssynergia

Urethral stricture

Differential diagnosis of lower urinary tract symptoms
management
Management
  • watchful waiting
  • medical therapy
    • α blocker
    • Finasteride
    • phytotherapy
  • surgical therapy
slide15

Phytotherapy

About 30 different compounds base on seven major plant extracts:

slide16

Their mechanism of action is often unclear

  • Most were introduced into the market without firm proof of efficacy
  • They were not recommended by the WHO committees as appropriate treatment: although there is uniformity in the results of several meta-analyses to suggest clinical efficacy for these compounds, it was the opinion of the committee that the claim or the extent to which the various phytotherapies are beneficial in the management of BPH/LUTS cannot be confirmed conclusively without large, appropriately randomized clinical trials of adequate duration.
  • Proceedings of the 5th International Consultation on BPH, 1998
lifetime probability of developing cancer by site men 2000 2002
Lifetime Probability of Developing Cancer, by Site, Men, 2000-2002*

Site

Risk

All sites† 1 in 2

Prostate 1 in 6

Lung and bronchus 1 in 13

Colon and rectum 1 in 17

Urinary bladder‡ 1 in 28

Non-Hodgkin lymphoma 1 in 46

Melanoma 1 in 52

Kidney 1 in 64

Leukemia 1 in 67

Oral Cavity 1 in 73

Stomach 1 in 82

* For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2000 to 2002.

Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.0 Statistical Research and Applications Branch, NCI, 2005. http://srab.cancer.gov/devcan

prostate cancer trends in incidence and mortality 1973 1999 note influence of psa assay
Prostate Cancer Trends in Incidence and Mortality, 1973–1999Note Influence of PSA Assay

Rate per 100,000

prostate cancer incidence rates by stage
Prostate Cancer Incidence Rates by Stage

Localized

Regional

Distant

Unstaged

prostate cancer risk factors
Increased risk

Family history

10% CaP genetic

Multiple DNA Loci being examined

High fat diet

African-American race

Increasing age

Multiple Risk Factors Amplify Risk

Decreased risk

Low fat diet

Lycopene

Vit E, Selenium

Finasteride (Proscar)

Decreased total incidence

Increased high grade disease

Prostate Cancer Risk factors:
prostate cancers vary in their natural histories
Prostate Cancers Vary in Their Natural Histories

Death from Other Causes Death from Other Causes

Death From Prostate Cancer

Patient 1

Symptomatic Phase

Patient 3

Patient 2

Detectable PresymptomaticPhase

Progression of Disease

Death From Other Causes

Patient 4

Disease Not Detectable

Remaining Expected Lifetime

challenges of prostate cancer screening and treatment
Challenges of prostate cancer screening and treatment
  • Goal: Find clinically significant cancer at a point when a cure is possible
  • Goal: Avoid excessively aggressive treatment in clinically insignificant disease
  • Examine prognostic factors of diagnosed disease to predict if it will be significant
  • Consider patient medical issues, age, philosophy
prostate cancer not to be confused with benign prostatic hypertropy bph
Prostate Cancer: Not to be confused with Benign Prostatic Hypertropy (BPH)
  • BPH is age related enlargement of benign tissue
  • Enlarged tissue can cause urinary symptoms
  • Treatment initiated if symptoms are bothersome, infections or incomplete bladder emptying
  • In contrast, Prostate cancer in early stages has no symptoms
screening guidelines for the early detection of prostate cancer american cancer society
Screening Guidelines for the Early Detection of Prostate Cancer American Cancer Society
  • The prostate-specific antigen (PSA) test and the digital rectal examination (DRE) should be offered annually, beginning at age 50, to men who have a life expectancy of at least 10 years.
  • Men at high risk (African-American men and men with a strong family history of one or more first-degree relatives diagnosed with prostate cancer at an early age) should begin testing at age 45. Starting at age 40 can be considered.
  • For men at average risk and high risk, information should be provided about what is known and what is uncertain about the benefits and limitations of early detection and treatment of prostate cancer so that they can make an informed decision about testing.
features of prostate specific antigen
Features of prostate-specific antigen
  • glycoprotein whose function is to liquify semen
  • produced exclusively by prostatic epithelium
  • normal serum value less than 4 ng/ml
  • elevated in 25% of patients with BPH
  • increased in most cases of prostate cancer
  • tends to rise progressively with age and prostatic volume
interpretation of prostate specific antigen psa values
PSA value

< 4 ng/ml

4-10 ng/ml

> 10 ng/ml

Interpretation

8% cancer

20-25% cancer

>50% cancer

Interpretation of prostate-specific antigen (PSA) values
recommended age adjusted psa cut off values
Age (years)

40 - 49

50 - 59

60 - 69

70 - 79

PSA cut off value (ng/ml)

2.5

3.5

4.5

6.5

Recommended age-adjusted PSA cut-off values
prostate specific antigen psa
Prostate Specific Antigen (PSA)
  • Prostate specific, not cancer specific.
  • Lacks sensitivity and specificity.
  • Elevated in BPH, infection.
  • 25% of men with prostate cancer have PSA < 4.0.
digital rectal exam
Digital Rectal Exam
  • Poorly reproducible
  • Lacks sensitivity and specificity.
  • 25% of men with an abnormal DRE and a PSA < 4.0 have prostate cancer.
  • 50% of DRE-detected prostate cancer is non-organ confined.
prostate cancer screening
Prostate Cancer Screening
  • Serial PSA measurements.
  • Serial DRE.
  • Not enough to do one without the other.
traditional indication for prostate biopsy usually with le 10yrs
Traditional indication for Prostate Biopsy:Usually with LE >10yrs
  • Abnormal DRE regardless of PSA
  • Abnormal PSA velocity (.75 ng/dL/yr)
  • PSA > 4.0 or age appropriate range
    • Consider decreasing in men in 40’s, 50’s or with risk factors (FH/AAmerican)
  • Office procedure, LA, ultrasonic guidance

Elevated PSA does not mean prostate cancer

slide37

Screening is sensitive but not specific

  • Overdiagnosis is a problem but we are uncertain about the magnitude.
  • Treatment-related side effects are fairly common.

Unsettled issue

PotentialBenefits

PotentialHarms

  • PSA screening detects cancers earlier.
  • Treating PSA-detected cancers may be effective but we are uncertain which need to be treated.
  • PSA may contribute to the declining death rate but we are uncertain.
male sexual dysfunction
Male Sexual Dysfunction
  • Erectile dysfunction
  • Premature ejaculation
  • Delayed ejaculation
  • Retrograde ejaculation
  • Hypoactive sexual desire
erectile dysfunction ed
Erectile Dysfunction (ED)
  • A Common disease
  • High prevalence

MMAS 40-70 52%

Carson C C et al >40 22% (sometimes ornever)

Feldman HA et al J Urol 1994; 151:54-61

Carson CC et al J Urol 2002; 167(suppl):29-30

ed is prevalent and increases with age cologne male survey
ED Is Prevalent and Increases with Age: Cologne Male Survey

Braun M et al. Int J Impot Res. 2000;12:305-311.

massachusetts male aging study us under treatment of ed

Source:

Massachusetts Male Aging Study (US): Under-treatment of ED

n=639 (45 years of age)

Review:

Seek or receive treatment

10%

Reviewer Memo:

90% Never seek care

McKinlay JB. Int J Impot Res. 2000;12(suppl 4):S6-S11. Based on data from the Massachusetts Male Aging Study (MMAS). Source: AARP Modern Maturity. Sexuality Study. Washington DC, 1999.

Slide Modified:

Memo:

belgium observational study
Belgium Observational Study
  • 1492 ED patients
  • 25% ED>3 years
  • 74% were untreated

Claes H et al Int J Impot Res 2008; 20:418-424

ed is still a taboo topic
ED is still a taboo topic
  • Loss of manhood
  • Loss of self-esteem
ed treatment
ED Treatment
  • Patients – reluctant to seek treatment
  • Physicians – uncomfortable to discuss

under diagnosis

under treatment

why diagnosing ed is important

Source:

Why Diagnosing ED Is Important

Review:

  • ED screening may signal underlying disease:
    • Diabetes
    • Hypertension
    • Dyslipidemia and coronary artery disease (CAD)
    • Depression
  • ED can result in:
    • Anxiety
    • Decreased self-esteem
    • Reduced quality of life (QOL)
    • Negative effect on relationships

Reviewer Memo:

Goldstein I. Am J Cardiol. 2000;86(suppl):41F-45F.

Goldstein I. Int J Impot Res. 2000;12(suppl 4):S147-S151.

Francis ME., et al. J Urol. 2007;178:591-596.

Selvin E., et al. Am J Med. 2007;120:151-157.

Jackson G., et al. J Sex Med. 2006;3:28-36.

Slide Modified:

Memo:

ed a first sign of cardiovascular cv disease

Source:

ED: A First Sign of Cardiovascular (CV) Disease?

Review:

  • In a study of 30 men with ED (International Index of Erectile Dysfunction-Erectile Function domain [IIEF EF] =13.7±1.2, mean age, 46.2 years) and 27 age-matched normal men (IIEF EF domain=21.3±1.2; mean age, 46.6 years) with no history of CV disease or CV risk factors
  • Compared with normal men, men with ED had:
    • Objective evidence of clinical and penile vascular disease (mean penile peak systolic velocity=28±3 m/s)
    • Reduced brachial artery flow-mediated vasodilation (p=0.014)
    • Impaired maximal response to nitrates, 13±1.4% vs. 17.8±1.4% (p=0.02)
    • Improved ED with phosphodiesterase type 5 (PDE5) inhibitor treatment, mean change in IIEF-EF domain score=3

Reviewer Memo:

Kaiser DR et al. JACC. 2004;43:179-184.

Slide Modified:

Memo:

over the counter sexual enhancement products illegal
Over-the CounterSexual Enhancement Products (Illegal)

Hypoglycaemia

Sidenafil & Glibenclamide

Mainland China

Friends

Local pharmacies

Peddlers

unknown

Hong Kong Med J 2009, 15:196-200

over the counter sexual enhancement products illegal1
Over-the CounterSexual Enhancement Products (Illegal)

3 died

1 vegatative state

1 cognitive impairment

7 different kinds of products

- Sidenafil 64 (0.05-198)mg

- Glibenclamide 70 (0-158)mg

over the counter sexual enhancement products illegal2
Over-the CounterSexual Enhancement Products (Illegal)

Singapore – similar experience

3 patients died

over the counter analogues of ed drugs
Over-the CounterAnalogues of ED drugs

Power 58轟天炮

Jolex壯力仕

温養 ONYO 錠劑

勃樂

天力

ete ete

Acetildenafil

Piperidenafil

Acetildenafil

Piperidenafil

Hydroxyhomosildenafil

Hydroxyacetildenafil

treatment of ed hardness problem
Treatment of ED & Hardness problem

First line therapy

Oral medication – PDE5 inhibitors

Sidenafil (Viagra)

Vardenafil (Levitra)

Tadalafil (Cialis)

how to use pde5 inhibitor correctly
How to use PDE5 inhibitor correctly?
  • 1 hour before sex (usually effect by 30 mins)
  • Empty stomach (2 hours after meal)
  • Require sexual stimulation
  • No nitrate therapy – heart disease stroke
  • Maximum – one dose per day (in Hong Kong, once per week)
  • No tolerance phenomenon

Patients can take if stable

slide55

Premature Ejaculation (PE)

  • What is the definition?
  • What is normal intercourse time?
  • What is the cause?
  • How common?
  • Any consequence?
  • What treatment method?
slide57

Intercourse Time (IELT)

Normal population

Waldenger et al

Patrick et al

Corty & Guardiani

Median 5.4 minutes

Median 7.3 minutes

Median 7-13 minutes

PE patients

Waldenger et al

McMahon et al

90% within 60 sec

Median 30 sec

Mean 43.5 sec

slide58

Severe PE cases

  • 20% of patients
  • Ejaculation – during foreplay on attempt to penetrate on putting on condom begin after penetration
slide59

Three controls necessary to define PE:

  • IELT
  • Lack of voluntary control
  • Negative personal consequence
slide61

Life-long PE

International Society of Sexual Medicine 2008 (Evidence –based definition)

  • Ejaculation which always or nearly always occurs priors to or within about 1 min of vaginal penetration; &
  • Inability to delay ejaculation on all or nearly all vaginal penetrations; &
  • Negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy

McMahon et al J Sex Med 2008; 5: 1590-1606

slide62

Hypotheses of PE

Adapted from Perelman, Atlas of Male Sexual Dysfunction, 2004

Different types of PE may have different etiology

slide63

Misconceptions in Local Patients

  • Too frequent masturbations
  • Too frequent nocturnal emissions
  • Premarital sex
  • Too much cold foods
slide64

Serotonin & PE

  • Presence of low synaptic levels of serotonin in regions of the CNS that modulates ejaculation
  • Variations in 5-HT receptor sensitivity

serotonin → delay ejaculation

slide65
How common is PE?

What is the prevalence?

prevalence of pe is similar across countries
Prevalence of PE is similar across countries

PEPA Study

PEPA: Premature ejaculation perceptions and attitudes

Porst et al. (2007) Eur Urol 51:816–824

prevalence of pe is consistent across age groups
Prevalence of PE is consistent across age groups

PEPA Study

Porst et al. (2007) Eur Urol 51:816–824

PEPA: Premature ejaculation perceptions and attitudes

slide68

Most respondents had not sought help

Janssen-Cilag, Australia, 2008

slide71

Folklore Methods

  • Cold shower
  • Scrotal traction
  • Special positions during sex
  • Alcohol
  • Recreational drugs
slide72

Current PE Treatment Options

  • Self-help treatment
  • Behavioural therapy
  • Topical treatment ( local anaesthetics)
  • PDE5 inhibitors
  • SSRIs
  • PE specific SSRI – Dapoxetine
  • Other not recommended
selective serotonin reuptake inhibitors ssris increase serotonin levels in the synaptic cleft
Selective Serotonin Reuptake Inhibitors (SSRIs) increase serotonin levels in the synaptic cleft

Serotonin neurotransmission is locally regulated by the serotonin transporter (5-HTT) re‑uptake system

As serotonin is released, the transporter system is activated, removing serotonin from the synaptic cleft and preventingover-stimulation of postsynaptic serotonin receptors

SSRIs inhibit the serotonin transporter system, increasing levels of serotonin in the synaptic cleft and delay ejaculation

5-HTT

5-HTT

5-HTT

5-HT

5-HT

5-HT

Axon

Axonal

Terminal

5-HTT

Synaptic

Cleft

Post-Synaptic Neuron

5-HTT = serotonin transporter system

5-HT = serotonin

Giuliano (2007) Trends Neurosci. 30(2):79–84;

Adapted from McMahon et al (2004) Disorders of orgasm and ejaculation in men. In Sexual Medicine: Sexual dysfunctions in men and women. 2nd International Consultation on Sexual Dysfunctions, Paris

slide76

Dapoxetine (Priligy)

First oral agent approval for PE

New short-acting SSRI

slide78

Conclusion

  • PE is the most common male sexual dysfunction 20% prevalence rate
  • Negative impact on sexual satisfaction & couple relationship
  • Great distress to sufferers
  • Poor rates of treatment seeking
  • A neglected area of male sexual health
  • Unmet therapeutic need filled by Dapoxetine