•••••• • acofp••••••• INTENSIVE

UPDATE & BOARD REVIEW

AUGUST 25 - 27, 2017 Loews Chicago O'Hare Hotel

Rosemont, IL

INNOVATIVE • COMPREHENSIVE • HANDS-ON

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Family Physicians

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Men's Health Matters

Michael Bradley, DO

8/7/2017

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Men’s Health Matters

Michael J. Bradley D.O.DME/Program Director

Family & Community Medicine ResidencyReading, PA

Objectives

• Overview

• Case based board preparation education

• Focus topics:– Testicular Cancer

– Prostate Cancer

– Benign Prostatic Hypertrophy

– Abdominal Aortic Aneurysm

– Secondary Osteoporosis

– Erectile Dysfunction

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• Leading causes of death – heart disease, cancer,

accidents, chronic lower respiratory disease, CVA, DM• Urologic issues –

– cause significant apprehension– leading reason men seek medical care

8/7/2017

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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

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.

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

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Testicular Cancer

• Most common solid malignancy in males 15-35

• 1% of all cancers in men

• 8850 annual cases in the US

95% Germ Cell

Tumors

50% Seminomas

50% Non-Seminomas

Testicular Cancer

Risk Factors

Cryptorchidism

Germ Cell Neoplasia In

Situ

Personal/ Family Hx of

Testicular Cancer

Infertility/ Subfertility

Hypospadias

HIV infection

Caucasian

Testicular Cancer

• Present as nodule or painless swelling

• 30%-40% c/o dull ache or heavy sensation

Dx – radical inguinal orchiectomy/histology

Clinical Suspicion

Ultrasound

Serum Tumor Markers

(AFP, β-HCG, LDH)

CBC, Chemistries CXR

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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 CancerSerum Tumor Markers

AFP β-HCG LDH

Seminoma - +/-

Non-Seminoma +/-

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

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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

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

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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↑

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

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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

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

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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

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

8/7/2017

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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)

LUTSPE

findingsBPH

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

BPHAmerican Urological Association/International Prostate Symptom Score

8/7/2017

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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

BPHOsteopathic considerations – sympathetic T10-L2

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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

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

8/7/2017

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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

AAAIncreased Risk– Older Age

– Male gender

– Cigarette smoking

– Caucasian race

– Atherosclerosis

– HTN

– Family hx of AAA

– Other large artery aneurysms

Decreased Risk– Female gender

– Non-Caucasian race

– Diabetes

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

8/7/2017

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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

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

8/7/2017

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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

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

8/7/2017

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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

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<F risk of OP but mortality rate ↑men

• Men 2x more likely to die after hip fx

• Men less likely to be evaluated or tx’d

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

8/7/2017

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Secondary Osteoporosis

– Glucocorticoid tx - # 1

– Hypogonadism

– Vitamin D deficiency

– Anticonvulsant drugs

– Hypercalciuria

– Alcohol abuse

– Smoking

– Low physical activity

– Low body weight/weight loss

• Androgen deprivation tx

• Hyperparathyroidism

• Celiac disease

• Inflammatory bowel disease

• Rheumatoid arthritis

• COPD

• CKD

• Bariatric surgery

• Meds – PPI’s, SSRI’s, opioids, 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

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

8/7/2017

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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 *

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

8/7/2017

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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• Diabetes mellitus• HTN• Obesity• Dyslipidemia• Cardiovascular disease• Smoking• Obstructive sleep apnea• Restless leg syndrome• Scleroderma• Peyronie’s disease• Prostate surgery• Prostate cancer tx

• Depression• Stress• CVA• Spinal cord/back injury• Multiple sclerosis• Dementia• Pelvic trauma• Priapism• Endocrine disorders –

testosterone, prolactin, thyroid

• Drugs – antidepressants (SSRI’s, others), spironolactone, sympathetic blockers (beta-blockers, others), thiazide diuretics, ketoconazole, cimetidine

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

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ED

• 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

ED –Evaluation/Dx

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

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

8/7/2017

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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 *

ACOFP Intensive Update & Board Review

Men’s Health Matters!

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