Integrated Treatment of the Adult Geriatric Male Patient

Transcription

1 Michigan Osteopathic Association David D. Wartinger, D.O., J.D. Michigan State University College of Osteopathic Medicine May 13, Integrated Treatment of the Adult Geriatric Male Patient BPH Prostate Cancer Low Testosterone Erectile Dysfunction Incontinence Hematuria 1

2 The Urological Magic Bullet 5 alpha Reductase Inhibitor Proscar/Avodart Alpha Adrenergic Blocker Minipress / Hytrin / Cardura / Flowmax / Uroxatrol / Rapiflo Testosterone Replacement Androderm / Androgel / Testim/ Axiron/ Fortesta/ Natesto / Striant / injection or implant / not Oral Erectile Dysfunction Viagra/ Levitra / Cialis 1 st choice for symptomatic BPH, low T and ED Avodart 0.5 mg PO q daily Uroxatrol 10 mg PO q daily AndroGel 2 pumps q AM applied to skin Cialis 5 mg PO q bedtime 2

3 Transitional Zone develops BPH Peripheral Zone develops CaP 5 Obstructive Voiding Symptoms Decreased force of stream Hesitancy Straining Incomplete bladder emptying Nocturia 6 3

4 Irritative Voiding Symptoms Frequency Urgency Occasionally dysuria 7 Voiding Dysfunction Factors Changes in bladder, prostate and /or urethra Bladder instability Decreased bladder compliance Urethral stricture; bladder neck contracture 8 4

5 BPH Natural History Incidence of AUR or Significance PVR 2% per year 9 Figure 2. The validated AUA Symptom Score tool for voiding symptoms 10 5

6 Medical Therapy for BPH Shrink or stop growth of prostate Open urethral channel within prostate 11 Inhibit Production of DHT finasteride (Proscar) 1992 dutasteride (Avodart) 2001 Prevent or reduce acinar gland growth 12 6

7 Relax Smooth Muscle of Prostate and Bladder Neck Alpha Blockers Antihypertensives terazosin (Hytrin) doxazosin (Cardura) Prostate Specific tamsulosin (Flomax) alfuzosin (Uroxatrol) 13 Minimally Invasive Procedures for BPH Transurethral microwave procedures (TUMT) Transurethral needle ablation (TUNA) Water-induced thermotherapy High intensity focused ultrasound (HIFU) 14 7

8 Conventional Surgical Therapy Transurethral Resection of the Prostate Gold Standard treatment Resectoscope minute operation Wire loop General or spinal anesthesia 15 Laser Surgery Variations for BPH Photo selective Vaporization of the Prostate (PVP) Interstitial Laser Coagulation (ILC) 16 8

9 Prostate Cancer: Screening and Management Prostate Cancer (CaP) Treatment Stratagem Early detection while tumor confined to prostate or surrounding tissues and can be cured by either removal or treatments aimed at the primary 17 Prostate Cancer: Screening and Management PSA and Overdiagnosis Identification of patients with CaP that don t benefit from diagnosis or treatment of their disease 18 9

10 Prostate Cancer: Screening and Management United States Preventative Services Task Force (USPSTF) Fair evidence that [PSA Screening] is ineffective or that harms outweigh the benefits. PSA screening and DRE in asymptomatic patients 19 Prostate Cancer: Screening and Management AUA DISAGREES with USPSTF PSA used since 1986, total CaP deaths decreased 30% Decreased dire consequences of advanced CaP American Cancer Society (ACS) and the American Society of Clinical Oncologists (ASCO) agree with AUA 20 10

11 Prostate Cancer: Screening and Management Localized Prostate Cancer Treatment Radiation Surgery Cryosurgery High intensity focused ultrasound Expectant management (watchful waiting) 21 Prostate Cancer: Screening and Management Hormone Therapy for CaP Most commonly used after metastasis Only palliative, not curative Hormone refractory or androgen independent 22 11

12 Prostate Cancer: Screening and Management Summary of CaP Treatment No free lunch Surgery with 30 year life expectancy, localized CaP Radiation or expectant management for patients, over 70 years of age and localized CaP Metastatic CaP, palliative with hormone manipulation 23 Testosterone Replacement 1. Only men with symptoms of low testosterone 2. Blood levels confirm low testosterone as cause of symptoms 12

13 Symptoms of Low Testosterone Low sex drive (libido) Erectile dysfunction Fatigue and poor energy level Decreased muscle mass Hair loss Difficulty concentrating Depression Irritability Low sense of well-being Forms of Testosterone Skin patch (transdermal): Androderm worn on arm or upper body, applied once a day Gels: AndroGel and Testim absorbed through skin, applied once a day, comes in packets AndroGel, Axiron and Fortesta comes in pump Natesto gel applied inside the nose Mouth Patch: Striant tablet sticks to upper gums, applied twice a day Injections and implants: Injection directly into the muscles Implanted pellets into the soft tissue Oral? Negative effects on liver Bypass the liver with other delivery methods 13

14 Risks of Testosterone Therapy Rash, itching or irritation at application site Evidence for increased risk of: Heart attack Stroke Acne Fluid Retention Breast Enlargement Decreased Testes Size Increased Aggression Mood Swings Decreased Sperm Count Infertility PSA Increase Cholesterol/Lipids Benefits and Risks of long-term testosterone therapy are UNKNOWN. 14

15 Conditions that may worsen with testosterone therapy Benign Prostatic Hypertrophy (BPH): Prostate grows naturally under the stimulation of testosterone Prostate Cancer (CaP): Can stimulate prostate cancer to grow Screen for CaP before starting testosterone CaP or elevated PSA should probably not receive testosterone treatment Sleep Apnea Blood Clots: Risk of deep vein thrombosis and pulmonary embolism Congestive Heart Failure Testosterone Replacement vs. Performance Enhancing Steroids Testosterone replacement only achieves physiologic levels of hormone Doping uses much higher doses of testosterone and often combined ( stacked ) with other substances 15

16 Definition The inability to achieve and maintain an erection sufficient for satisfactory sexual intercourse 31 Erectile Dysfunction Estimated to affect million men in the US One or more factors Psychological Neurologic Hormonal Arterial Venous 32 16

17 Erectile Dysfunction Silent Marker for later development of cardiovascular disease 33 Figure 1. Anatomy of the Penis. The penile erection occurs as a result of 3 processes: a) smooth muscle relaxation among arteries and trabecular tissue increases blood flow, which b) lengthens and enlarges penis through sinusoidal filling, and c) expanded sinusoids compress the subtunical venous plexus, reducing venous outflow

18 Block Phosphodiesterase Enzyme Activity Sildenafil Vardenafil Tadalafil 35 Hormonal ED Androgen deficiency Decrease in nocturnal erections decreases libido Erections with visual sexual stimulation preserved Androgen may not be essential for erection 36 18

19 Sexual Function over time Progressively declines in healthy aging men Latent period between sexual stimulation and erections increases Erections are less turgid Ejaculation less forceful Ejaculatory volume decreases Refractory period between erections lengthens Decrease in serum testosterone 37 Recommended Laboratory Tests Urinalysis Complete Blood Count Fasting blood glucose Creatinine Cholesterol Triglycerides Testosterone 38 19

20 If Testosterone low Serum free (or bioavailable) testosterone Prolactin Lutenizing hormone 39 Erectile dysfunction is not just a sexual health issue, it may be a serious harbinger of lifethreatening cardiovascular conditions 40 20

21 ED is as important a CV disease risk factor as Smoking, or Family history of Heart Disease 41 Erectile Dysfunction Treatment Drug Therapy Administration: oral, injected directly into penis, inserted into distal urethra March 1998 sildenafil, first pill Vardenafil and tadalafil Phosphodiesterse (PDE) inhibitors 42 21

22 Erectile Dysfunction Treatment Intracavernosal Injections Inject drugs into penis to engorge with blood Papaverine hydrochloride, phentolamine, and alprostadil (a prostaglandin E2) Widen blood vessels, induce and maintain erections Side effects: persistent erection (priapism) and scarring 43 Erectile Dysfunction Treatment Intraurethral Injections Insert pellet of alprostadil into urethra, prefilled applicator MUSE, inch into urethra Onset 8 to 10 minutes, may last 30 to 60 minutes Side effect: penile pain, warmth or burning sensation in urethra, redness of penis, minor urethra bleeding or spotting 44 22

23 Erectile Dysfunction Treatment Vacuum Erection Devices Creates partial mechanical vacuum Draws blood into penis, engorging and expanding it 3 components: plastic cylinder, pump and elastic band 45 Erectile Dysfunction Treatment Penile Surgery Procedures to improve erections 1. Implant a device, make rigid 2. Reconstruct arteries, improve flow 3. Occlude veins, prevent leak 46 23

24 Often treatable Identify patients who might benefit from treatment Treatment depends on etiology Identify the etiology Urge Incontinence Sudden sensation to void Unable to suppress sensation fully Severe case, may not be aware sensation until actually leaking 24

25 Overactive Bladder (OAB) Newer term Frequency and Urgency With or without Urge Incontinence Overflow Incontinence Occurs at extreme bladder volumes, or Bladder volume reaches the limit of viscoelastic properties Elevation in detrusor pressure Incomplete bladder emptying Obstruction Poor bladder contractility 25

26 Overflow Incontinence Symptoms Constant dribbling Extreme frequency Evaluation of the Incontinent Patient History Physical examination Laboratory tests Possibly urodynamic testing 26

27 Evaluation of the Incontinent Patient Urinalysis Hematuria Pyuria Glucosuria Proteinura Cytology, if hematuria or irritative voiding symptoms Evaluation of the Incontinent Patient Urine Culture and Sensitivity if Pyuria Bacteriuria Treat infection prior to further W/U > 3 RBC/HPF, further investigation 27

28 Evaluation of the Incontinent Patient Post Void Residual (PVR) Measure with ultrasound or catheter Normal <50ml / >200 ml abnormal Increased PVR, Bladder outlet obstruction Poor bladder contractility Differentiate with urodynamic testing Treatment of Urge Incontinence Bladder contracts with or without warning Timed voiding Remind patients to void every 1-2 hours during the day Void before urge to void 28

29 Urge Incontinence Anticholinergic Antimuscarinics Mainstay of medical therapy Side Effects Urinary retention Dry mouth Constipation Nausea Blurred vision Tachycardia Drowsiness Confusion Urge Incontinence Poor Bladder Compliance Primary Goal: treat high bladder pressure Complete bladder emptying ICC and anticholinergics May add to anticholinergic antimuscarinics and alpha-agonists Bladder augmentation when medical management fails 29

30 Treatment of Overflow Incontinence Treated by emptying the bladder Relieve Obstruction Males Urethral stricture Prostatic obstruction Treatment of Urethral Stricture Disease Urethral dilation Internal urethrotomy Urethroplasty 30

31 Treatment of Prostatic Obstruction Gold Standard TURP Transurethral Resection of the Prostate Treatment of Overflow Incontinence Poor detrusor contractility ICC (intermittent clean catheterization) 31

32 Treatment of Indwelling Catheters Not optimum long term treatment Eventually infected urine Predisposes to bladder calculi Possible ultimate squamous cell carcinoma Treatment of Males with Stress Incontinence Artificial urinary sphincter Cuff compresses bulbar urethra Gold Standard Male slings Compress under urethra Elevate the urethra to more retro pubic position Lesser degrees of incontinence, pad weight test 32

33 Summary Key Diagnostic Points Urge Incontinence Symptoms Urgency Frequency Nocturia Unable to reach the toilet with urge Summary Key Diagnostic Points Stress Incontinence Symptoms Leakage with physical activity Signs Bladder neck mobility Positive stress test 33

34 Summary Key Diagnostic Points Mixed Incontinence Symptoms Urgency Frequency Nocturia Unable to reach the toilet with urge Leakage with physical activity Signs Bladder neck mobility Positive stress test Summary Key Diagnostic Points Overflow Incontinence Symptoms Frequency Nocturia Urgency Leakage with physical activity Signs High post void residual 34

35 Summary Key Treatment Urge Incontinence Avoidance of bladder irritants Timed voiding Pelvic muscle exercises Weight loss Summary Key Treatment Urge Incontinence Anticholinergics Antimuscarinics - Nonselective for M3 Receptor Propantheline (Pro-Banthine) 7.5 to 30 mg orally, three to five times daily Tolterodine (Detrol LA) 4 mg orally daily Trospium (Sanctura) 20 mg orally two times daily Solifenacin (Vesicare) 5 10 mg orally, daily 35

36 Summary Key Treatment Urge Incontinence Anticholinergics Antimuscarinics Selective for M3 Receptor Darifenacin (Enablex) 7.5 to 15 mg orally, daily Summary Key Treatment Urge Incontinence Anticholinergic Antimuscarinics/Smooth Muscle Relaxant Oxybutynin Regular (Ditropan) 2.5 to 5.0 mg orally, one to three times daily Extended Release (Ditropan XL) 5 30 mg orally, daily Transdermal (Oxytrol) 4.9 mg patch twice per week Hyoscyamine (Lesin) to mg orally, two to four times daily 36

37 Summary Key Treatment Urge Incontinence Anticholinergic/Alpha-Agonist For urge or mixed Imipramine (Tofranil) Not FDA approved for this indication 10 to 25 mg, once to three times daily Summary Key Treatment Stress Incontinence Behavioral Changes Weight loss Quitting smoking Pelvic muscle exercises 37

38 Summary Key Treatment Stress Incontinence Alpha Agonists Pseudoephedrine (Sudafed) Not FDA approved for this indication 30 to 60 mg, up to four times per day Summary Key Treatment Stress Incontinence Anitcholinergics / Alpha Agonist Imipramine (Tofranil) Not FDA approved for this indication 10 to 25 mg, once to three times daily 38

39 HEMATURIA REFERENCE CHART MICHIGAN STATE UNIVERSITY ml ml ml ml ml ml ml ml ml ml ml ml SG U Row A SG U Row B SG U Row C Column = Added ML Blood Per Cup Specimen Cup 50 ML Rows = Specific Gravity of Urine SG U VISUAL ESTIMATION OF BLOOD IN GROSS HEMATURIA IRB #02-970/APP #i David D. Wartinger, D.O., J.D. Osteopathic Surgical Specialties College of Osteopathic Medicine Michigan State University Shannon Grochulski-Fries ABSTRACT Very small amounts of blood can be visually detected in the urine and may be the only warning sign of a life threatening problem. A systematic documentation of the visual appearance of gross hematuria specimens was not previously performed. The clinical advantage of possessing a library of photographs documenting exact volumes of blood in known urine specimen volumes was not appreciated. To simulate hematuria, known quantities of anticoagulated blood were added to 50 ml urine specimens of various specific gravities/concentrations and then photographed on white graph paper. The gross hematuria specimen photographs were arranged sequentially to create a Hematuria Reference Chart. An unknown hematuria specimen can now be visually matched to the Hematuria Reference Chart to determine blood loss per ml of voided urine. The Hematuria Reference Chart is available on-line to health care INTRODUCTION professionals and patients for documentation, education and diagnosis. Hematuria is not normal and its cause must be determined. Most episodes of gross hematuria are not due to life threatening conditions or diseases; but, some OBJECTIVE: episodes are the only warning sign of a life threatening problem. Very small amounts of blood can be visually detected in urine and the amount of blood does not reliably predict the seriousness of the underlying cause of the hematuria. The presence of visible blood in the urine can cause fear and anxiety in patients and healthcare providers alike. Accurately estimating the volume of blood mixed in the urine can help direct treatment and eliminate unwarranted concerns of serious blood loss. Without a reference standard, estimating blood loss from hematuria is imprecise and without scientific basis. CAUSES OF HEMATURIA Cancer Trauma Inflammation Infection Foreign Bodies Vascular Glomerular Disease Hematologic Activity Menstruation Loin Pain Hematuria Syndrome METHODS AND MATERIALS A photographic library of simulated gross hematuria specimens was created and arraigned to produce a hematuria reference chart. Voided urine was collected from a solitary volunteer during various hydration states to obtain urine of different specific gravities / concentration. Increasing amounts of whole anti-coagulated blood were added to volumes of collected urine to create 50 ml simulated gross hematuria specimens. The simulated gross hematuria specimens were photographed (in clear urine specimen cups) on white graph paper background with blue lines. All of the simulated gross hematuria specimen photographs and the Hematuria Reference Chart were uploaded to YouTube and Google Images. PROCEDURE FOR USING HRC Example: Step 1: Verify a total of 50 ml of gross hematuria sample in a clear standard 120 ml urine specimen cup viewed on a background of white graph paper. Step 2: Select the most appropriate row based on urine specific gravity and match the unknown specimen to the column of added blood on the HRC. Step 3: Calculate blood loss from hematuria (Voided volume/50 X added blood volume from HRC/cup) = total whole blood loss in ml/void. If patient voids 500 ml: 500ml/50=10; 10 x 0.034ml= 0.34 total whole blood loss ml/void DISCUSSION The online availability of the Michigan State University College of Osteopathic Medicine Hematuria Reference Chart enables patients and health care providers to quantify and document hematuria. Even when patients don t have online access to the Hematuria Reference Chart, they can photograph their hematuria specimen using a smartphone and send the pictures to their caregiver for comment. Urinary blood loss can now be tracked over the duration of the disease. The Hematuria Reference Chart is both an educational and diagnostic tool with documentation capabilities. This study was approved by the Michigan State University IRB: IRB#: SI 39