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Intensive Update and Board Review Course ACOFP 54th Annual Convention & Scientific Seminars Men's Health - Medical Concerns for the Aging Male Igor Altman, DO 3/7/2017 The Aging Male Primary Concerns in Men’s Health Igor Altman, DO, MBA Assistant Professor of Clinical Family Medicine University of Illinois Hospital and Health System Chicago, Illinois Objectives: Recognize critical elements and formulate management plan for the following conditions: Benign Prostatic Hyperplasia Prostate Cancer Erectile Dysfunction Abdominal Aortic Aneurism Androgenetic Alopecia Practice provided material by successfully completing lecture questions. 1 3/7/2017 Urinary Retention – based on History and Physical Exam findings History (LUTS) Physical Examination Possible Etiology Frequency, urgency, Enlarged, firm, non- Benign Prostatic straining to void, weak tender, non-nodular Hyperplasia stream, stopping & prostate on DRE; may (BPH) starting of a stream, etc. appear normal Fever; dysuria; back, Tender, warm, boggy Acute Prostatitis perineal, rectal pain prostate; possible penile discharge Weight loss; Enlarged nodular Prostate Cancer constitutional prostate; may appear signs/symptoms normal Pain; swelling of foreskin Edema of penis with non- Phimosis, paraphimosis or penis retractable skin Pathophysiology of BPH Testosterone Dihydro- testosterone (DHT) androgen receptors BLADDER ↑ GF’s primarily TZ PROSTATE (reduced apoptosis Central Zone with age) uniform, Transition Zone non-nodular Peripheral Zone enlargement (BPH) Urethra Kirby RS, G.P., Fast Facts: Benign Prostatic Hyperplasia. 6th ed. 2010: Health Press Limited. 2 3/7/2017 Benign Prostatic Hypertrophy Risk Factors: age, ↑ BMI, DM, Dyslipidemia 88% of men in their 80s have BPH Myth: sexual activity, HTN, smoking, liver cirrhosis Protective effect: Alcohol (reduces testosterone, modulates sympathetic tone). No effect on LUTS. High physical activity; Higher vegetable intake. Parsons KJ, I.R., Alcohol Consumption is Associated With a Decreased Risk of Benign Prostatic Hyperplasia. The Journal of Urology, 2009. 182: p. 1463-1468 Walsh, P.C., Anatomic radical retropubic prostatectomy, in Campbell's Urology. 1998, Elsevier: Philadelphia. p. 2565-2588. Rosen R, A.J., Boyle P, et al, Lower urinary tract symptoms and male sexual dysfunction: the multinational survey of the aging male. Europian Urology, 2003. 44(6): p. 637-649 Paolone, D.R., Benign Prostatic Hyperplasia. Clinical Geriatric Medicine, 2010(26): p. 223-239 BPH – Physical Exam Abdominal Exam – percussion and palpation of the bladder (might be palpable with >200 ml); External Genitalia – meatal stenosis or severe phimosis; Digital rectal exam – prostate size estimation, tenderness, nodularity, fecal impaction. Selius, B., Subedi, R, Urinary Retention in Adults: Diagnosis and Initial Management. American Family Physician, 2008. 77(5): p. 643- 650. Paolone, D.R., Benign Prostatic Hyperplasia. Clinical Geriatric Medicine, 2010(26): p. 223-239 3 3/7/2017 BPH – LUTS Evaluation/Follow-Up American Urological Association BPH Symptom Score Index Questionnaire Can be accessed on-line: http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/bph- management/chapt_1_appendix.pdf 1. Incomplete emptying (0-5) 2. Frequency (0-5) 3. Intermittency (0-5) 4. Urgency (0-5) 5. Weak stream (0-5) 6. Straining (0-5) 7. Nocturia (0-5) Score < 7 8-19 20-35 Severity Mild BPH Moderate BPH Severe BPH BPH – Work Up (revised AUA guidelines, 2010) URINALYSIS (infection, hematuria, proteinuria, glucosuria, etc.) SERUM PSA (When life expectancy is > 10 years and if the diagnosis of prostate cancer can modify the management. From the AUA PSA Best Practice Statement: 2009 Update) AGE 50’s 60’s 70’s PSA Level ~ 1.6 ng/ml ~ 2.0 ng/ml ~ 2.3 ng/ml (prostate >40 ml) FREQUENCY/VOLUME CHART (When significant nocturia is a predominant symptom) OPTIONAL TESTS: Flow rate recording & residual urine measurement. McVary KT, R.C., Avins AL, Barry MJ, et al, Guideline: Management of Benign Prostatic Hyperplasia (BPH). 2010, American Urological Association 4 3/7/2017 BPH – Treatment Options Severity Score < 7 8-19 20-35 Severity Mild BPH Moderate BPH Severe BPH Treatment Watchful • Watchful • Medical Tx; Waiting waiting; • More invasive • If bothered – procedures consider medical Tx Watchful waiting – behavioral modifications; severity scores (change by 3 points is acceptable improvement) Medical Therapy – ɑ-Adrenergic Receptors blockers, 5ɑ-Reductase Inhibitors, Combo is promising Minimally Invasive Therapy Transurethral Microwave Therapy (TUMT) Transurethral Needle Ablation (TUNA) Surgery (TURP, TUIP, open prostatectomy, & laser procedures) Paolone, D.R., Benign Prostatic Hyperplasia. Clinical Geriatric Medicine, 2010(26): p. 223-239 Edwards, J.L., Diagnosis and Management of Benign Prostatic Hyperplasia. American Family Physician, 2008. 77(10): p. 1403-1410. Indications for Urologic Referral Hematuria Recurrent UTIs Prior urologic surgery Urolithiasis Abnormal DRE Urinary retention LUTS refractory to medical menagement Elevated PSA 5 3/7/2017 Prostate Gland – Osteopathic Consideration Dx: Viscero-Somatic Dysfunction Goal of therapy: improve circulation and lymphatic drainage Innervations: Parasympathetic: pelvic splanchnic nerves (S2-S4) Sympathetic: inferior hypogastric plexus (L1-L2) Chapman’s Points : Anterior: myofascial tissue along the posterior margin of the iliotibial (IT) band Posterior: sacral base (superior sacrum), bilaterally. Modi RG, S.N., Urology, in Clinical Anatomy and Osteopathic Manipulative Medicine. 2006, Lippincott Williams & Wilkins. p. 249-250 Prostate Cancer (PCa) EPIDEMIOLOGY 2nd leading cause of cancer death in men During lifetime – 1 man in 6 (16%) will be Dx’d with Pca 1 in 35 ( ~3% ) will die from PCa 50% at 50 & 80% at 80 y/o RISK FACTORS One 1st degree relative – x2 fold Two or more 1st degree relatives – at least x4 fold African-American ethnicity Diet high in Omega-6 fatty acids (linoleic acid) from vegetable oils and red meats (Low level of evidence) Scher, H.I., Benign and Malignant Diseases of the Prostate, in Harrinson's Principles of Internal Medicine, K.D. Fauci AS, Longo DL, Braunwald E, Hauser SL, Jameson JL, Loscalzo J, Editor. 2008, McGraw Hill Medical. p. 594-600 U.S. Preventive Services Task Force Grade Definitions Hitzeman N, M.M., Screening for Prostate Cancer: Prostate-Specific Antigen Testing Is Not Effective. American Family Physician, 2011. 83(7): p. 802-804 What are the key statistics about prostate cancer?, American Cancer Society 6 3/7/2017 Prostate Cancer – where? ~ 70% of PCa begin in the peripheral zone ~ 15%-20% in the central BLADDER zone ~ 10%-15% of PCa cases develop in the PROSTATE transitional zone Central Zone Metastases – seminal Transition Zone vesicles, bladder, LN’s, Peripheral Zone BONES; less commonly – intestines, liver, lungs Crawford, D.F., Understanding the Epidemiology, Urethra Natural History, and Key Pathways Involved in Prostate Cancer. J of Urol. 2009, 73: p. 4-10 Recommendations for screening USPSTF – against screening for all men (2012) (Grade D) American Urologic Association (AUA) - strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man's values and preferences. (Evidence Strength Grade B) American Cancer Society (ACS) -emphasizes informed decision making for prostate cancer screening: men at average risk should receive information beginning at age 50 years, and black men or men with a family history of prostate cancer should receive information at age 45 years American College of Preventive Medicine (ACPM) - recommends that clinicians discuss the potential benefits and harms of PSA screening with men aged 50 years or older, consider their patients' preferences, and individualize screening decisions- 7 3/7/2017 “Final Recommendation Statement - Prostate Cancer: Screening, Accessed on-line www.uspreventiveservicestaskforce.org, 2/25/17 8 3/7/2017 Prostate Cancer – Diagnosis DRE – digital rectal exam – enlarged, nodular or indurated gland (might be normal); Serum [PSA] – conventional screening cut-point is 4.0 ng/ml; Velocity of PSA rise >0.35 ng/ml in one year in patients with baseline PSA of < 4.0 ng/ml, or > 0.75 ng/ml in one year in patients with baseline PSA of 4.0 to 10.o ng/ml Transrectal ultrasound-guided biopsy 12-20 Bx cores is recommended (detects 31% more Ca than traditional 6 Bx cores) Heidenreich A, A.G., Bolla M, Joniau S, et al, EAU Guideline on Prostate Cancer. Europian Urology, 2007. 53: p. 68-80 Carter HB, F.L., Kettermann A, et al, Detection of life-threatening prostate cancer with prostate-specific antigen velocity during a window of curability. J of Natl Cancer Inst, 2006. 98(21): p. 1521-27. Eichler K, H.S., Wilby J, Myers L, Bachmann LM, Kleijnen J, Diagnostic value of systematic biopsy methods in the investigation of prostate cancer: a systematic review. J of Urol, 2006. 175(5): p. 1605-12 Prostate Cancer -- Types Pre-cancerous lesions PIN – prostate intraepithelial neoplasia; (low/high grade) ASAP – atypical small acinar proliferation; PIA – proliferative inflammatory atrophy ; Cancerous lesions THE MOST COMMON – adenocarcenoma RARE (4%) – sarcomas, small cell carcinomas, and transitional cell carcinomas Crawford, D.F., Understanding the Epidemiology, Natural History, and Key Pathways Involved in Prostate Cancer. J of Urol. 73: p. 4-10 9 3/7/2017 Prostate Cancer -- Classification GLEASON SCORE = first + second most common
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