Men's Health Matters

INTENSIVE UPDATE AUGUST 24 - 26, 2018 & BOARD REVIEW Loews Chicago O’Hare Hotel Rosemont, IL INNOVATIVE • COMPREHENSIVE • HANDS-ON Men's Health Matters 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 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 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,

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