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  1. Men’s HealthThe Urological Outlook Dr Andrew Yip Consultant Urologist Chief of Service Kwong Wah Hospital Hong Kong 7 November 2010

  2. Male Urological Diseases • Benign prostatic hyperplasia • Prostate cancer • Erectile dysfunction • Premature ejaculation

  3. Prostatic problems ↑number of patients • Ageing population • ↑public awareness • Effective medical treatments

  4. Hong Kong • Public urologic service • Non-emergency cases waiting time for first consultation 18-24 months

  5. Prostate Disease Prostatitis 2% Prostatic cancer 18% BPH 80%

  6. BPH is the most prevalent disease to affect men beyond middle age (%)

  7. Three fundamental features of Benign Prostatic Hyperplasia Symptoms Hyperplasia Obstruction Large prostate ≠obstruction * clinical symptoms *

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

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

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

  11. The symptoms of BPH may remain unchanged or deteriorate only slowly over time Improved with time: 15% Worsening symptoms: 55% Remain stable: 30%

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

  13. 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

  14. Management • watchful waiting • medical therapy • α blocker • Finasteride • phytotherapy • surgical therapy

  15. Phytotherapy About 30 different compounds base on seven major plant extracts:

  16. 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

  17. Prostate Cancer

  18. 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

  19. Prostate Cancer Trends in Incidence and Mortality, 1973–1999Note Influence of PSA Assay Rate per 100,000

  20. Prostate Cancer Incidence Rates by Stage Localized Regional Distant Unstaged

  21. 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:

  22. 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

  23. 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

  24. 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

  25. Diagnostic triad for early detection of prostate cancer

  26. 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.

  27. 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

  28. 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

  29. 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

  30. 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.

  31. 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.

  32. Prostate Cancer Screening • Serial PSA measurements. • Serial DRE. • Not enough to do one without the other.

  33. 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

  34. 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.

  35. Male Sexual Dysfunction • Erectile dysfunction • Premature ejaculation • Delayed ejaculation • Retrograde ejaculation • Hypoactive sexual desire

  36. 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

  37. ED Is Prevalent and Increases with Age: Cologne Male Survey Braun M et al. Int J Impot Res. 2000;12:305-311.

  38. 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:

  39. 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

  40. ED is still a taboo topic • Loss of manhood • Loss of self-esteem

  41. ED Treatment • Patients – reluctant to seek treatment • Physicians – uncomfortable to discuss under diagnosis under treatment

  42. 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:

  43. 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:

  44. Danger of Over-the Counter‘Natural’ or ‘Herbal’ Products 30% patients

  45. Over-the CounterSexual Enhancement Products (Illegal) Hypoglycaemia Sidenafil & Glibenclamide Mainland China Friends Local pharmacies Peddlers unknown Hong Kong Med J 2009, 15:196-200

  46. 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

  47. Over-the CounterSexual Enhancement Products (Illegal) Singapore – similar experience 3 patients died