Men's Health Matters

INTENSIVE UPDATE AUGUST 24 - 26, 2018 & BOARD REVIEW Loews Chicago O’Hare Hotel Rosemont, IL

INNOVATIVE • COMPREHENSIVE • HANDS-ON

Michael Bradley, DO

The American College of Osteopathic Family Physicians is accredited by the American Osteopathic Association Council to sponsor continuing medical education for osteopathic physicians.

The American College of Osteopathic Family Physicians designates the lectures and workshops for Category 1-A credits on an hour-for-hour basis, pending approval by the AOA CCME, ACOFP is not responsible for the content.

8/13/2018

Men’s Health Matters

Michael J. Bradley D.O. DME/Program Director Family & Community Medicine Residency Reading, PA

Objectives

• Overview • Case based board preparation education • Focus topics: – Testicular Cancer – Prostate Cancer – Benign Prostatic Hypertrophy – Abdominal Aortic Aneurysm – Secondary Osteoporosis – Erectile Dysfunction – Male Hypogonadism

1 8/13/2018

Men’s Health

• Health promotion is foundation of family medicine • Men are affected by: – Unique and multidisciplinary aspects of issues – Specific illnesses and diseases that impact life expectancy • Life expectancy of men -76 • Average – men die 5 years earlier then women • Urologic issues – – cause significant apprehension – leading reason men seek medical care

Men’s Health

• Men – – Nearly 1/3 do not have primary care physician – Avoid seeking medical care for cultural and social reasons – Challenging to persuade men to participate in preventive medicine • Men’s Health = proactive prevention • Men’s Disease = reactive management • June = Men’s Health Month

2 8/13/2018

Men’s Health

Threats (CDC Leading causes of death US men 2015) Prevention • Heart Disease • Get regular medical care • Cancer • Maintain healthy diet • Unintentional injury • Exercise regularly • COPD/lower respiratory diseases • Practice safe sex • Stroke • Limit alcohol • Refrain from smoking • DM • Practice environmental and • Suicide automobile safety • Alzheimer’s disease • Get adequate sleep • Influenza/pneumonia • Manage stress/ask for help • Chronic liver disease • Get vaccinated and regular screenings

Case 1

29 yo white male presents with painless swelling in his left testicle. – Perform thorough history and exam – Suspicion for testicular cancer – Orders: ultrasound, basic labs, serum tumor markers and CXR Results support Dx. Confirmed with histology after radical inguinal orchiectomy.

3 8/13/2018

Question 1

Serum tumor markers revealed markedly elevated alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-HCG) with mild elevation of lactate dehydrogenase (LDH). Most likely, this testicular cancer is a: – A. Seminoma – B. Leydig cell tumor – C. Sertoli cell tumor – D. Non-seminoma – E. Sex-cord stromal tumors

Testicular Cancer

• Most common solid malignancy in males 15-35 • 1% of all cancers in men • 8850 annual cases in the US

50% 50% Non- Seminomas Seminomas

95% Germ Cell Tumors

4 8/13/2018

Testicular Cancer

Cryptorchidism

Germ Cell Caucasian Neoplasia In Situ

Risk Factors Personal/ HIV Family Hx of infection Testicular Cancer

Infertility/ Hypospadias Subfertility

Testicular Cancer

• Present as nodule or painless swelling • 30%-40% c/o dull ache or heavy sensation

Clinical Suspicion

Serum Tumor Ultrasound Markers CBC, Chemistries CXR (AFP, β-HCG, LDH)

Dx – radical inguinal orchiectomy/histology

5 8/13/2018

Testicular Cancer

• Consider cryopreservation of sperm to preserve fertility • Initial tx – radical inguinal orchiectomy • Staging – histology; TMN; tumor markers • Further tx – active surveillance, chemotherapy, radiation therapy, retroperitoneal lymph node dissection • Post tx – monitor tumor marker levels, exam, imaging

Testicular Cancer Serum Tumor Markers

AFP β-HCG LDH Seminoma - +/-

Non-Seminoma +/-

6 8/13/2018

Testicular Cancer

• Screening – Do Not Screen – Grade D (USPSTF) • Outlook – – one of the most curable solid neoplasms – 5 year survival rate > 95% – 8850 annual cases – 400 die of disease – Incidence increasing • Osteopathic Considerations – Sympathetic Innervation = T10-11

Question 1

7 8/13/2018

Case 2

56 yo African-American male presents for routine well visit. No specific complaints. – PMHx – HTN, asthma – FHx – father – HTN, DM, prostate cancer – PE - unremarkable

Question 2

What is most appropriate to offer to this patient regarding screening for prostate cancer? – A. PSA – B. DRE – C. PSA and DRE – D. Informed decision making – E. No screening

8 8/13/2018

Prostate Cancer

• 2nd most common cancer in men worldwide • 1 in 6 lifetime risk in US men • Age < 40 rare • Age > 40 incidence rises rapidly • Risk factors – Increasing AGE * – African-American ethnicity – Family hx – Limited factors – diet, hormones, obesity

Prostate Cancer

• Screening – informed decision making (ACS, AUA, USPSTF) – Men 55-69 informed decision making (USPSTF –updated in 2017; previously grade D all men) – Men ≥ 70 - do not screen – Grade D (USPSTF) • Screening discussions – – Age 40-45 high risk males – Age 50 average risk males • PSA – controversial • DRE – not recommended • Dx – histology (> 95% AdenoCa) via biopsy after PSA↑

9 8/13/2018

Prostate Cancer

• Tx considerations – – TMN staging – (Mets – seminal vesicles, lymph nodes, bladder, bones) – Gleason score/grade group – Serum PSA level – Estimated outcome with each tx group – Potential complications with each tx approach – Patient’s general medical condition, age, comorbidity, personal preference

Prostate Cancer - Tx

• Risk stratified groups – AUA, NCCN guidelines – Very low risk - active surveillance (AS), low risk options – Low risk – AS, radiation therapy (RT), radical prostatectomy (RP) – Intermediate risk – RT, RP, +/- androgen deprivation therapy (ADT) – High risk – RT, RP + node dissection, adjuvant RT and/or ADT – Very high risk – RT + ADT, RP + node dissection – Clinical lymph node involvement – RT + ADT – Disseminated metastases – ADT + orchiectomy +/- chemotx • Osteopathic Considerations – prostate T10-L2; options vary per risk group; may be aimed at symptoms; contraindicated/caution with mets

10 8/13/2018

Question 2

What is most appropriate to offer to this patient regarding screening for prostate cancer? – A. PSA – B. DRE – C. PSA and DRE – D. Informed decision making * – E. No screening

Case 3

64 yo male presents with persistent urinary frequency, slow stream, and urinary hesitancy. ∙Worsening over the last 12 months ∙DRE reveals enlarged, symmetrical nontender prostate without nodules ∙PMHx – elevated blood pressure ∙Labs - unremarkable ∙Other causes were ruled out = Dx of benign prostatic hypertrophy

11 8/13/2018

Question 3

What would be the best treatment to offer this patient after behavior modifications have been ineffective? – A. Anticholinergic agent – B. 5-alpha –reductase inhibitor – C. Alpha-1 blocker – D. Referral to urologist for TURP procedure – E. Phosphodiesterase type 5 inhibitor

Benign Prostatic Hypertrophy (BPH)

• Prevalence of BPH – – Age 31-40 = 8% – Age 50 = 50% – Age >80 = >80% • Risk factors – – Blacks > whites > Asian – Advanced age – Hormone levels - ↓testosterone and estradiol – Genetic factors – Excessive alcohol consumption may ↓ risk

12 8/13/2018

BPH

• Benign prostatic hyperplasia = histologic dx • Benign prostatic hypertrophy = enlargement • Clinical manifestations = patient complaint • Lower Urinary Tract Symptoms (LUTS) from BPH – Storage symptoms – increased daytime frequency, nocturia, urgency, urinary incontinence – Voiding symptoms – slow, splitting, spraying, or intermittent urinary stream; hesitancy, straining to void, terminal dribbling – Irritative symptoms – frequency and urgency

BPH • Dx = Presumptive Dx • Based on LUTS – storage, voiding, and/or irritative symptoms and diffusely enlarged firm, nontender prostate on exam • Must R/O other potential causes – UTI, prostatitis, stricture, cancers, stones, phimosis, paraphimosis (consider UA, PSA, Creatinine)

PE LUTS BPH findings

13 8/13/2018

BPH

• LUTS – – Ø correlation with prostate size or physiologic abnormalities – Vary over time – Prevalence increases with age – AUA/IPSS scale – use to quantify and monitor symptom progression over time

BPH American Urological Association/International Prostate Symptom Score

14 8/13/2018

BPH

BPH - Tx

• Behavior modifications – avoid caffeine, alcohol, and drinking before bed; double voiding • Medical – – Alpha-adrenergic antagonist (alpha-1 blockers) – 5-alpha –reductase inhibitor – Anticholinergic agents – Beta-3 adrenergic agonist – Phosphodiesterase type 5 inhibitors • Surgical – mostly transurethral procedures – failed medical tx; persistent, severe symptoms; associated injury – hydronephrosis, renal dysfunction, urinary retention

15 8/13/2018

BPH Osteopathic considerations – sympathetics T10-L2

Question 3

What would be the best treatment to offer this patient after behavior modifications have been ineffective? – A. Anticholinergic agent – B. 5-alpha –reductase inhibitor – C. Alpha-1 blocker * – D. Referral to urologist for TURP procedure – E. Phosphodiesterase type 5 inhibitor

16 8/13/2018

Case 4

62 yo male presents for follow up of AAA that was reported on recent ultrasound as 4 cm. He remains asymptomatic. He admits to significant stress with his job. – PMHx – HTN, DM, hyperlipidemia, tobacco abuse – Exam – BP 148/90 HR 82 – Otherwise unremarkable

Question 4

In attempts to provide the best guidance and tx for this patient, you advise your patient to: – A. Optimize BP control – B. Optimize glycemic control – C. Optimize cholesterol levels – D. Quit smoking – E. Begin a stress reduction program

17 8/13/2018

Abdominal Aortic Aneurysm (AAA)

• Focal dilation 50% greater than normal diameter of aorta • Infrarenal aorta ≥ 3 cm • Men – diameter alone defines AAA and predicts clinical events (diameter less predictive of clinical events in women) • 4-8% of men > 50 (M>F) • Age-related increase (M>F) • 7000 deaths in US annually from ruptured AAA

AAA Increased Risk – Older Age – Male gender – Cigarette smoking – Caucasian race – Atherosclerosis Decreased Risk – HTN – Female gender – Family hx of AAA – Non-Caucasian race – Other large artery – Diabetes aneurysms

18 8/13/2018

AAA

• Dx – imaging studies obtained in patient based on risk factors or exam of AAA ≥ 3 cm • Ultrasound – – Inexpensive; widely available – sensitivity and specificity ~ 100% for AAA > 3cm – Ideal for screening – evidence supports cost effectiveness

AAA Screening

• USPSTF – Grade B – Men 65-75 who have ever smoked (100 lifetime cigarettes) - one time screening abdominal ultrasound (women – insufficient evidence to screen) • USPSTF – Grade C – Men 65-75 who have never smoked – selective screening based on medical hx, family hx, other risk factors and personal values (women – no screening) – Men > 75 – unlikely to benefit from screening – No repeat of negative tests

19 8/13/2018

AAA Tx

• Prevent rupture due to mortality risk • Balance comorbidity of repair with rupture risk • Watchful waiting for small aneurysm < 5.5 cm – 3-4 cm – q12 month ultrasound – 4-4.5 cm – q 6 month ultrasound – > 4.5 cm – refer to vascular surgeon • Medical tx aimed at reducing rate of expansion • Smoking cessation ONLY tx proven effective for reducing rate of enlargement • Repair of AAA > 5.5cm

AAA

• Outlook – AAA mortality has ↓50% since the 1990’s – possibly due to ↓ smoking, ↑ awareness, ↑ screening, ↑ endovascular repair

• Osteopathic considerations – – Sympathetics depend on level of AAA – Infrarenal T9-L2 – Caution with rotary techniques – Caution with abdominal tx

20 8/13/2018

Question 4

In attempts to provide the best guidance and tx for this patient, you advice your patient to: – A. Optimize BP control – B. Optimize glycemic control – C. Optimize cholesterol levels –D. Quit smoking * – E. Begin a stress reduction program

Case 5

72 yo male presents for follow up of chronic medical problems. He denies any specific complaints but he is noted to have loss of height upon routine measurement. – PMHx – HTN, hyperlipidemia, DM, asthma – Meds – lisinopril, atorvastatin, metformin, albuterol, montelukast, prednisone – Compliant with meds which have not changed in > 12 months

21 8/13/2018

Question 5

You discuss the height loss and offer to screen this patient for osteoporosis because you are concerned this may be present secondary to: – A. Lisinopril therapy – B. Metformin therapy – C. Atorvastatin therapy – D. Montelukast therapy – E. Prednisone therapy

Osteoporosis (OP)

• Leading cause of morbidity and mortality in older people • 1.5 million men > 65 • 3.5 million men at risk • Overall F>M but men may have ↑risk of 2⁰ OP due to numerous health conditions and medications associated with ↑ risk

22 8/13/2018

Osteoporosis

• Incidence of hip fx - men 10 years later than women • 60 yo male - 25% lifetime risk of osteoporotic fx • 90 yo male – 1 in 6 will have hip fx • M

Osteoporosis

• 1 ⁰ - low peak bone mass and age-related bone loss • Defined – – Low bone mass, microarchitectural disruption and skeletal fragility resulting in ↑’d risk in fx – Bone Mineral Density (BMD) – • Not as well standardized in men as women • Age ≥ 50 - BMD T-score ≤ -2.5 (SD below young healthy male reference mean) • Secondary causes/contributing factors found in 40 -60% of men with osteoporotic fx

23 8/13/2018

Secondary Osteoporosis

– Glucocorticoid tx - # 1 • Androgen deprivation tx – Hypogonadism • Hyperparathyroidism – Vitamin D deficiency • Celiac disease – Anticonvulsant drugs • Inflammatory bowel disease – Hypercalciuria • Rheumatoid arthritis – Alcohol abuse • COPD – Smoking • CKD – Low physical activity • Bariatric surgery – Low body weight/weight • Meds – PPI’s, SSRI’s, opioids, loss chemotx, others

Osteoporosis

• Endocrine Society and Nat’l Osteoporosis Foundation – Recommends screening all men > 70 and men 50-70 with RF – Recommend comprehensive panel of blood/urine tests to identify men at ↑’d risk for 2⁰ osteoporosis • American College of Physicians – screen all men > 70 and men with RF if candidate for tx • USPSTF - insufficient evidence to screen men • Screening – check BMD with DXA

24 8/13/2018

Osteoporosis

• Tx – – Lifestyle measures – weight bearing exercise – Calcium + Vitamin D supplementation – Tx secondary causes when able – Consider testosterone tx for hypogonadal males – Bisphosphonates – Parathyroid hormone therapy for severe OP • Osteopathic considerations – – rotary techniques/HVLA contraindicated – consider soft tissue, MFR, BLT

Question 5

25 8/13/2018

Case 6

58 yo male presents with complaint of lack of energy. Upon thorough questioning, the patient discusses this lack of energy really means he is dissatisfied with his sex life due to difficulty attaining erections. • Medical/sexual hx and PE completed • Evaluation/appropriate tests completed • Possible underlying conditions addressed

Question 6

The first line treatment that should be discussed and offered to this patient assuming there are no contraindications: – A. Intraurethral alprostadil – B. Injectable alprostadil – C. Vacuum pump – D. Penile implant – E. Phosphodiesterase-5 inhibitor

26 8/13/2018

Erectile Dysfunction (ED)

• Male sexual dysfunction – Age 40 - 40% – Decreased libido – Abnormal ejaculation – ED • ED – – Overall prevalence 16% – Age 20-30 - 8% – Age 50 -59 – 18% – Age 70-75 - 37%

ED – Risk Factors

• Advancing age • Depression • Diabetes mellitus • Stress • HTN • CVA • Obesity • Spinal cord/back injury • Dyslipidemia • Multiple sclerosis • Cardiovascular disease • Dementia • Smoking • Pelvic trauma • Obstructive sleep apnea • Priapism • Restless leg syndrome • Endocrine disorders – • Scleroderma testosterone, prolactin, thyroid • Drugs – antidepressants (SSRI’s, • Peyronie’s disease others), spironolactone, sympathetic • Prostate surgery blockers (beta-blockers, others), thiazide diuretics, ketoconazole, • Prostate cancer tx cimetidine

27 8/13/2018

ED – Risk Factors

• 8 out of the 12 most commonly prescribed meds list ED as a side effect • 25% of ED thought to be due to meds • Decreased risk – – Exercise – Frequent sexual activity

• Erections occur in response to: – Neural impulses 2⁰ visual/auditory stimuli – Tactile stimulus to penis/genital area – Nocturnal erections during REM sleep • Physiology – requires adequate blood flow and nitrous oxide; initiate, fill, store • ED – consistent/recurrent inability to achieve or sustain erection with sufficient rigidity and duration for sexual intercourse

28 8/13/2018

Sexual Physiology

Men Woman

ED –Evaluation/Dx

• Dx – made through hx, PE (We need to ask!) – Evaluation may trigger additional tests

29 8/13/2018

ED - Tx

Identify any underlying etiologies and treat any risk factors

Osteopathic considerations – holistic approach – goal is to correct any structural, biological, and chemical defects to restore normal function

Question 6

30 8/13/2018

Case 7

62 yo male presents to his family physician for a regular well visit. Upon questioning and ROS – he admits to feeling tired, depressed at times, and having decreased libido. Suspicion for low testosterone is confirmed with laboratory testing.

Question 7

The diagnosis of male hypogonadism is confirmed through the following: -A. Low testosterone -B. Low testosterone and semen analysis -C. Low total and low free testosterone -D. Low testosterone on 2 separate tests -E. Low testosterone on 2 separate tests and consistent signs and symptoms

31 8/13/2018

Male Hypogonadism

• Decrease in one or both of two major functions of testes: sperm production or testosterone production – 1⁰-disease of testes – 2⁰-disease of hypothalamus or pituitary • Dx= signs/symptoms + low serum testosterone (measured in AM on at least two occasions) and/or low sperm count – Low testosterone + ↑LH and/or FSH = 1⁰ – Low testosterone + normal or ↓LH/and/or FSH = 2⁰

Male Hypogonadism

• Population screening is not cost effective and is not recommended • Screen in cases of ↑clinical suspicion: – Sexual symptoms – Osteoporosis-associated fractures – HIV associated weight loss – Chronic use of glucocorticoids or long-acting opiates – Exam = incomplete virilization or small testes – Infertility

32 8/13/2018

Male Hypogonadism

• Incidence varies according to varied definitions and age – range 5.6%-39% • Clinical features depend upon: – age of onset – severity of testosterone deficiency – which functions of testes are effected

Causes

Primary Secondary • Congenital • Congenital – Klinefelter’s Syndrome – Isolated GnRH deficiency - Kallmann syndrome – Other chromosomal abnormalities – Prader-Willi syndrome – Genetic mutations – Laurence-Moon Biedl syndrome – Cryptorchidism • Acquired – Varicocele – Tumors – pituitary, metastatic, – Androgen synthesis disorders craniopharyngiomas, other • Acquired – Hypothyroidism – Infections (mumps) – Hyperprolactinemia – – Testicular torsion DM – Malnutrition – Trauma – Hemochromatosis – Exposure – meds/toxins/radiation – Drugs – opioids, marijuana, – Systemic illness – liver, kidney, HIV anabolic steroids

33 8/13/2018

Testosterone Tx

• May offer on individual basis if : Grade 2B – ↓testosterone + signs/symptoms – Potential benefits > risks • No Tx if both criteria not met Grade 1B • Goal of Tx: – Restore normal testosterone level (at least 300 ng/dl but can consider 500-600 ng/dl) • Osteopathic considerations – vary depending on clinical features, signs, and symptoms – Holistic approach – goal is to correct any structural, biological, and chemical defects to restore normal function

Testosterone Tx

Expected Benefits: Potential Concerns: • ↑Libido • Prostate cancer • ↑Hematocrit (2⁰ to • BPH stimulation of • Erythrocytosis erythropoiesis) • Increased risk of VTE • ↑↑Bone mineral density • ↓HDL • Slight improvement in • Uncertain effects on mood cardiovascular risk • Slight improvement in • Uncertain effects on sleep walking apnea • No ∆ in energy or cognition • Limit sperm production

34 8/13/2018

Testosterone Tx

• Tx options : – Transdermal – gels (preferred), patches, pumps, solutions – Injections – long-acting, extra-long-acting – Oral preps – not recommended 2⁰ adverse liver effects • Monitor: – Response vs. adverse effects – Risk of prostate cancer – Labs: serum testosterone, hematocrit, PSA

Question 7

35 8/13/2018

ACOFP Intensive Update & Board Review

Men’s Health Matters! Thank you