advancing male health in ottawa: 2010 and beyond part...
TRANSCRIPT
Advancing Male Health in Ottawa:2010 and Beyond
Part 2
Anthony J. Bella MD, FRCSCDivision of Urology, Department of Surgery and
Department of NeuroscienceUniversity of Ottawa
Outline of Clinical Practice
Erectile DysfunctionPeyronie’s DiseasePenile Implant/Reconstructive SurgeryLow Testosterone States
Penile Rehabilitation Following Treatment for Prostate CancerTreatment-Resistant ED
Acknowledgements
Prostate Cancer Research Foundation of CanadaNEAUACMSHCCanadian Institute of Health ResearchCanadian Foundation for Innovation
Endowed Chair in Men's Health Research
Objectives
Brief Review of Previous Discussion Erectile Dysfunction - Quality of Life and Window into Men's Health
Objectives
Brief Review of Previous Discussion Erectile Dysfunction - Quality of Life and Window into Men's Health
Peyronie's Disease
Objectives
Brief Review of Previous Discussion Erectile Dysfunction - Quality of Life and Window into Men's Health
Peyronie's Disease
Penile Fracture?
Objectives
Brief Review of Previous Discussion Erectile Dysfunction - Quality of Life and Window into Men's Health
Peyronie's Disease
Penile Fracture?
Testosterone Deficient States
Objectives
Brief Review of Previous Discussion Erectile Dysfunction - Quality of Life and Window into Men's Health
Peyronie's Disease
Penile Fracture?
Testosterone Deficient States
And Just What is a Penile Implant?
Clinically Relevant
Practical, Minimally-Time Consuming and Positively Impact Patient Care
Clinically Relevant
Practical, Minimally-Time Consuming and Positively Impact Patient Care
Etiology of Erectile Dysfunction
Psychological
SystemicDiseases
Drugs
Neurological•Sensory•Motor•Autonomic•Neurotransmitters
Hormonal•Testicular•Pituitary•Thyroid
Arterial•Arterial•Arteriolar
Cavernosal
•Tunica albuginea•Cavernous muscle•Endothelium•Fibroblastic Trabeculae•Emissary Vein
Organic Aetiology of ED
We now understand that the aetiology of ED is primarily organic in the majority of individuals
The psychological aspects manifest themselves subsequently because the negative emotional effects of ED are so wide-ranging and devastating
Focus on the penis alone has evolved to focus on the value of achieving a dependable, hard erection that is the catalyst to the emotional benefits associated with sex in a relationship
Case-Finding and Work-Up for ED
Health care practitioner comfort with male sexual dysfunction
Positive impact on Men's Health Care and on Quality of Life
Simple, straight-forward approach (ask or questionnaire)
Tests - keep things simple - lipids, blood sugar, BP, smoking, diabetes, and obesity
Focused physical examination
Identify anxiety, depression, partner-issues
Treatment Success = Monitor Treatment
ED Treatment
DevicesVacuum constriction devices
1st International Consultation on Erectile Dysfunction. Paris, France: World Health Organization; 1999. American Urological Association Education and Research, Inc. The Management of Erectile Dysfunction: An Update, 2005.
Lifestyle Changes/EducationRisk factor managementSexual education/counseling
Oral Agents (PDE5 Inhibitors)Viagra® (sildenafil citrate)Levitra® (vardenafil HCl)Cialis® (tadalafil)
Surgical OptionsPenile implantsVascular surgery
Injectable AgentsIntracavernosal injections (alprostadil)Intraurethral medications (alprostadil)
ED Treatment
DevicesVacuum constriction devices
1st International Consultation on Erectile Dysfunction. Paris, France: World Health Organization; 1999. American Urological Association Education and Research, Inc. The Management of Erectile Dysfunction: An Update, 2005.
Lifestyle Changes/EducationRisk factor managementSexual education/counseling
Oral Agents (PDE5 Inhibitors)Viagra® (sildenafil citrate)Levitra® (vardenafil HCl)Cialis® (tadalafil)
Surgical OptionsPenile implantsVascular surgery
Injectable AgentsIntracavernosal injections (alprostadil)Intraurethral medications (alprostadil)
ED Treatment
DevicesVacuum constriction devices
1st International Consultation on Erectile Dysfunction. Paris, France: World Health Organization; 1999. American Urological Association Education and Research, Inc. The Management of Erectile Dysfunction: An Update, 2005.
Lifestyle Changes/EducationRisk factor managementSexual education/counseling
Oral Agents (PDE5 Inhibitors)Viagra® (sildenafil citrate)Levitra® (vardenafil HCl)Cialis® (tadalafil)
Surgical OptionsPenile implantsVascular surgery
Injectable AgentsIntracavernosal injections (alprostadil)Intraurethral medications (alprostadil)
Key Elements to a Successful ED Treatment Program
Optimal Erection Hardness
Confidence/Self-Esteem
Sexual Satisfaction
EDTreatmentSuccess
Source: Mulhall JP et al. J Sex Med. 2007;4:1626-1634.
Patient
PartnerHealthcare Professional
Social Context
PsychologicalContext
Cultural Context
Risk Factors for Heart Disease and ED
AgeDyslipidemiaHypertension DiabetesSmokingSedentary lifestyleObesityDepressionMale gender
AgeAgeDyslipidemiaDyslipidemiaHypertensionHypertensionDiabetesDiabetesSmokingSmokingSedentary lifestyleSedentary lifestyleObesityObesityDepressionDepressionCAD, peripheral vascular diseaseCAD, peripheral vascular disease
EDCoronary Artery Disease (CAD)
Billups KL. Curr Sex Health Rept. 2004;1:137-141.
Thompson IM, et al. JAMA 2005
Erectile Dysfunction, Endothelial Dysfunction and Cardiovascular Events
Thompson IM, et al. JAMA 2005
Erectile Dysfunction, Endothelial Dysfunction and Cardiovascular Events
Why Does Erectile Dysfunction Occur Sooner Than CV Disease?
TIA / Stroke5-7Carotid
Angina / MI3-4Coronary
Erectile dysfunction1-2 Penile
Critical eventsDiameter (mm)Artery
The artery size hypothesis
Improved32FMD, nitrate, endothelin-1
High CV riskTadalafil2005Rosano G et al.
Improved10Brachial FMDHealthy IRSildenafil2005Gori T et al.
Improved64Brachial FMDHeart failureSildenafil/ramipril2005Hryniewicz et al.
Unchanged9Brachial FMDSmokersSildenafil2004Dishy V et al.
Improved14Brachial FMDAcute smokingSildenafil2004Vlachopoulos C et al.
Improved31Brachial FMDSmokersCilostazol2003Oida K et al.
Improved20Brachial achSmokersSildenafil2003Kimura M et al.
Improved14Brachial FMDDiabetes 2Sildenafil2002Desouza C et al.
Improved24Coronary achCADSildenafil2002Halcox JP et al.
Unchanged11Brachial FMDHealthy menSildenafil2001Dishy V et al.
Improved48Brachial FMDHeart failureSildenafil2000Katz SD et al.
ResultsNumberAssesmentPopulationMedicationYearGroup
FMD = flow-mediated dilation; CAD = coronary artery disease CV = cardiovascular; IR = ischemia/reperfusion
Is there a cardiac effect for PDE-5 inhibitors?
Peyronie’s Disease
• Acquired penile deformity secondary to scarring of the tunica albuginea
• Cause penile deformity (curve, hourglass, cork-screw, combination)
• Often accompanied by pain (acute phase)
• Associated with erectile dysfunction
Peyronie’s Disease: Defining the Problem
• Remains a therapeutic dilemma
• Physically and psychologically debilitating
• Approximately 4% of men
Normal Tunica Peyronie’s Disease
Ultrastructural Changes: Scanning EM
• Cohort data suggests prevalence 4-9%, dependent on age distribution
• Cohort data suggests prevalence 4-9%, dependent on age distribution
• 12% spontaneous improvement, 40% stable, 48% worsening
• Cluster 50-55 years of age
• Cluster 50-55 years of age
• Men less than 40 - multiple plaques, more significant deviation
• Nearly 1/2 of men have clinically meaningful depression, and 80-90% have psychological manifestations
PEYRONIE’S DISEASE: EVALUATION
• History - degree, duration, EF
• No disease-specific questionnaire
• Physical examination include SPL
• Position, number, size
• ICI erection, high-resolution US, calipers
PENTOXIFYLLINE - SHOW ME THE PROOF?
PENTOXIFYLLINE - SHOW ME THE PROOF?
• Decrease TGF-1, increase cAMP, decrease collagen 1 production
PENTOXIFYLLINE - SHOW ME THE PROOF?
• Decrease TGF-1, increase cAMP, decrease collagen 1 production
• Decrease size of plaques (rat model)
PENTOXIFYLLINE - SHOW ME THE PROOF?
• Decrease TGF-1, increase cAMP, decrease collagen 1 production
• Decrease size of plaques (rat model)
• Case reports - decrease corporal fibrosis post-priapism, decrease calcifications in PD
PENTOXIFYLLINE - SHOW ME THE PROOF?
• Decrease TGF-1, increase cAMP, decrease collagen 1 production
• Decrease size of plaques (rat model)
• Case reports - decrease corporal fibrosis post-priapism, decrease calcifications in PD
• Double-blind placebo controlled trial shows benefit in early Peyronie's disease
INTRALESIONAL THERAPY
INTRALESIONAL THERAPY
INTRALESIONAL THERAPY
INTRALESIONAL THERAPY
• Likely not 50% response rate as previously projected
PENILE TRACTION THERAPY
SURGICAL MANAGEMENT OF PEYRONIE'S DISEASE: PLICATION PROCEDURES
WHEN IS PENILE PLICATION AN OPTION FOR PEYRONIE'S DISEASE?
• Patient selection for any surgical approach for Peyronie'sdisease is paramount
WHEN IS PENILE PLICATION AN OPTION FOR PEYRONIE'S DISEASE?
• Patient selection for any surgical approach for Peyronie'sdisease is paramount
• Stable curvature, limits sexual function (<60 degrees and uniplanar are not absolute requirements)
WHEN IS PENILE PLICATION AN OPTION FOR PEYRONIE'S DISEASE?
• Patient selection for any surgical approach for Peyronie'sdisease is paramount
• Stable curvature, limits sexual function
• Maintained erectile function
• Sufficient penile length
Graphic Courtesy of L Messenger in Brant WO, Bella AJ, Lue TF. J Sex Med 4: 277-281, 2007
TYPES OF PENILE PLICATION SURGERY
Tunical Manipulation
• Classic Nesbit's/wedge repair
• Plication with partial thickness shaving of the tunica
TYPES OF PENILE PLICATION SURGERY
Tunical Manipulation
• Classic Nesbit's/wedge repair
• Plication with partial thickness shaving of the tunica
Non- or Minimally Disruptive to the Tunica
• Plication without tunical incision
• Minimal-tension (Lue 16-dot) technique
LUE 16-DOT TECHNIQUE
Graphic Courtesy of L Messenger in Brant WO, Bella AJ, Lue TF. J Sex Med 4: 277-281, 2007
LUE 16-DOT TECHNIQUE
Graphic Courtesy of L Messenger in Brant WO, Bella AJ, Lue TF. J Sex Med 4: 277-281, 2007
LUE 16-DOT TECHNIQUE
Graphic Courtesy of L Messenger in Brant WO, Bella AJ, Lue TF. J Sex Med 4: 277-281, 2007
LUE 16-DOT TECHNIQUE
Graphic Courtesy of L Messenger in Brant WO, Bella AJ, Lue TF. J Sex Med 4: 277-281, 2007
LUE 16-DOT TECHNIQUE
Graphic Courtesy of L Messenger in Brant WO, Bella AJ, Lue TF. J Sex Med 4: 277-281, 2007
LUE 16-DOT TECHNIQUE
Graphic Courtesy of L Messenger in Brant WO, Bella AJ, Lue TF. J Sex Med 4: 277-281, 2007
DRAWBACKS AND LIMITATIONS
Does not allow for recovery of Peyronie's length loss
Penile shortening
Requires satisfactory erectile function
DRAWBACKS AND LIMITATIONS
Does not allow for recovery of Peyronie's length loss
May contribute to further penile shortening
Requires satisfactory erectile function
DRAWBACKS AND LIMITATIONS
Does not address hinge, hourglass or notching deformity
May result in penile pain, palpable knots, sensation changes (NVB mobilization)
Incomplete correction or recurrence
May contribute to erectile dysfunction
Penile Fracture?
A Few Words About Testosterone…
Symptoms of Testosterone Deficiency
Loss of libido/ "Erectile Dysfunction:
Fatigue
Depression
Irritability/Anger
Joint pain
Decrease in muscle mass
Joint Pain
Osteoporosis
Increase in abdominal fat/lipid profile
Symptoms of Testosterone Deficiency
Mechanism of Testosterone Production
-
T
Hypothalamus
Pituitary
Testes
- Feedback
GnRH
LH
Veidhuis JD, Reproductive Endocrinology, 3rd ed, 1991.
Pathophysiology of Testosterone Deficiency
Primary Hypogonadism (Testicular Dysfunction)
Hypothalamus
Pituitary
Testes
ReducedFeedback
GnRH
LH
T
-
-
Hormone Levels:— ↓ T
— ↑ LH
— ↑ GnRH
Causes: — premature testicular failure, Klinefelter
syndrome (47 XXY), undescended testes, orchiectomy, injury, testicular cancer, radiation, chemotherapy, virus, alcohol
Pathophysiology of Testosterone Deficiency
Secondary Hypogonadism (Pituitary Dysfunction)
Hormone Levels:— ↓ T
— ↓ or inappropriately normal LH
Causes: — Pituitary tumors (i.e. prolactinomas,
acromegaly), radiation, craniopharyngiomas, sarcoidosis, β-thalassemia major
Hypothalamus
Pituitary
Testes
ReducedFeedback
GnRH
T
or normal LH
-
-
Pathophysiology of Testosterone Deficiency
Secondary/Tertiary Hypogonadism (Hypothalamic Dysfunction)
Hormone Levels:— ↓ T
— ↓ or inappropriately normal LH
— ↓ GnRH
Causes: — Kallman’s syndrome (with anosmia),
idiopathic hypogonadotropic hypogonadism, head trauma
Hypothalamus
Pituitary
Testes
ReducedFeedback
GnRH
T
or normal LH
-
-
What is the effect does low testosterone have on ED?
25-33% of men who fail a PDE5 inhibitor will be hypogonadalIf hypogonadal, replacing T alone usually does not restore erectionCombination therapy with T and PDE5 inhibitor
Erectile Dysfunction and Testosterone Deficiency
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Q 3 Q 4 Q 12
IIEF
Scor
e
Baseline TRT Off TRT
Kalinchenko S et al. Aging Male 8:94,2003
Effect of androgen replacement therapy plus PDE5 inhibitors in hypogonadal men with diabetes
Advancing Male Health in Ottawa:2010 and Beyond
Part 2
Anthony J. Bella MD, FRCSCDivision of Urology, Department of Surgery and
Department of NeuroscienceUniversity of Ottawa