Men s Health Ted Jablonski MD CCFP FCFP. ASA Banff March Associate, Crowfoot Village Family Practice, Calgary AB

Transcription

1 Men s Health 2018 UP date on DOWN below Dr Ted Jablonski MD CCFP FCFP ASA Banff March Ted Jablonski MD CCFP FCFP Associate, Crowfoot Village Family Practice, Calgary AB Medical Lead Calgary Foothills PCN Clinical Assistant Professor, University of Calgary, Department of Family Medicine Clinical Associate Men s Sexual Health Clinic SAIU (Southern Alberta Institute of Urology, RVH Calgary) Medical Director Jablonski Sexual Health and Wellness 1

2 CFPC CoI Templates: Slide 1 Faculty/Presenter Disclosure Faculty: Dr Ted Jablonski MD CCFP FCFP #91934 Conflict of Interest Declaration / Disclosure 2018 Relationships with commercial interests: Prinicipal Investigator ( ) Prinicipal Investigator in Clinical studies funded by Pfizer, Lilly, Cortria Speaker s Bureau, Advisory Board Honoraria Abbott Laboratories, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Edelman, Eli Lilly, GlaxoSmithKline, Janssen Ortho, Lundbeck, Merck Frosst, Novartis, Paladin labs, Pfizer, Sanofi Aventis, Schering, Servier, Shire, Solvay, Takeda, Valeant, Watson CFPC CoI Templates: Slide 2 Disclosure of Commercial Support This program has not received financial support This program has not received in kind support Potential for conflict(s) of interest Commercial products for companies that I have worked for on clinical studies, advisory boards, CHE development and CHE presentations will be mentioned including on, and some off label uses pf pharmacotherapies 2

3 CFPC CoI Templates: Slide 3 Mitigating Potential Bias Within the discussion of any medical diagnosis I will mention nonpharmacologic and pharmacologic therapies that are of use, compare and contrast them and discuss the pros and cons of each, presenting the information in the most nonbiased way possible. OBJECTIVES Define an approach to Men s sexual health in primary care / family medicine and what is normal Manage key topics in Male Sexual health Describe unusual or controversial sexual health issues of

4 dr j s SEX MED PEARLS Men s Sexual Health 2018 practical clinical tips contact@drtedjablonski.com 4

5 is a terminal, SEXUALLY TRANSMITTED condition with a 100% mortality rate... 5

6 WHO says Sexual health is a state of physical, emotional, mental and social wellbeing in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. SEXUAL MEDICINE Definition Place in FP / role of FP What s NORMAL? Is sometimes NOT that SEXY Can be challenging (ESL,religious beliefs, cultural differences) 6

7 MEN S SEXUAL HEALTH 7

8 NORMAL Penile size Time to Ejaculation Latency phase Frequency of activity Normal Libido Masturbation Post vasectomy The average penile measurements were: Flaccid length 9.16 cm (3.61 in.) Flaccid stretched length cm (5.21 in.) Erect length cm (5.17 in.) Flaccid girth or circumference 9.31 cm (3.67 in.) Erect circumference cm (4.59 in.) MEN S SEXUAL HEALTH Are you satisfied with your SEX LIFE? 8

9 HOT in 2018 There s no better time to be single CNN health article Jan % and growing (age of marriage up to median 29.5 years old for men) markers of health are better peoplepartner/index.html 9

10 COMMON MALE SEXUAL DYSFUNCTIONS LIBIDO ERECTION EJACULATION And other PENIS PELVIC FLOOR PROSTATE NEUROENDOCRINE T LOW LIBIDO 10

11 LOW LIBIDO PEARL 1. Low T 2. Mental health 3. Substance abuse HYPERSEXUAL DISORDER 11

12 HYPERSEXUAL DISORDER PEARL aka SEX ADDICTION 1. OCD/addictions 2. Counselling / rehab 3. Naltrexone ERECTILE DYSFUNCTION 12

13 ERECTILE DYSFUNCTION PEARL 1. ED = ED = ED 2. Psychogenic situational / abrupt onset / healthy TREATMENT RESISTANT ED 13

14 TREATMENT RESISTANT ED PEARL 1.Pills,pills and more pills 2.Check T, ensure correct dx 3.Intracavernosal injection (Trimix) 4. Alprostadil gel Still unavailable in Canada HOT in

15 Cycling, and Male Sexual and Urinary Function: Results from a Large, Multinational, Cross Sectional Study "The health benefits enjoyed by cyclists who ride safely will far out weight health risks /j.juro PREMATURE EJACULATION 15

16 PREMATURE EJACULATION PEARL 1.Most common dysfcn 2.Decrease anxiety 3.Increase Serotonin 4.Dapoxetine still unavailable in Canada DELAYED EJACULATION 16

17 DELAYED EJACULATION PEARL 1.Least common 2.Decrease anxiety / serotonin 3. personailty disorder 4. stimulant med trial (Dexedrine 5mg) PELVIC FLOOR 17

18 PELVIC FLOOR PEARL 1. Men have one 2. Chronic prostatitis think chronic pain syndrome ie pelvic floor dysfunction 3. OAB also exists PROSTATE 18

19 PROSTATE PEARL 1. BPH LUTS all about bother 2. Size matters DRE/PSA can define 3. Prostate cancer still 2 nd leading cause of cancer death in men PROSTATE PEARL 4. RP rates down to less than 5 % of low/grade indolent cancers (goal less than 1%) ACTIVE SURVEILLANCE rules! 19

20 PSA PSA 1. Place in surveillance of cancer and case finding / symptomatic 2. high risk (2 3 x inc risk for black and FHx 1 st degree relative) 3. PSA <1.0 Prognosticator 20

21 ERSPC at 13 years F/U The absolute risk reduction of death from prostate cancer at 13 years was 0 11 per 1000 person years or 1 28 per 1000 men randomised, which is equivalent to one prostate cancer death averted per 781 (95% CI ) men invited for screening or one per 27 (17 66) additional prostate cancer detected. After adjustment for non participation, the rate ratio of prostate cancer mortality in men screened was 0 73 (95% CI ). Interpretation In this update the ERSPC confirms a substantial reduction in prostate cancer mortality attributable to testing of PSA, with a substantially increased absolute effect at 13 years compared with findings after 9 and 11 years. ERSPC at 13 years F/U Screening was associated with a 21% reduction in risk for prostate cancer mortality and a 27% reduction after adjustment for nonparticipation. The number needed to invite (NNI) of 781 and number needed to detect (NND) of 27 to prevent one prostate cancer death represent a greater absolute benefit of screening than the NNI of 1,410 and NND of 48 after 9 years of follow up and the NNI of 979 and NND of 35 at 11 years. 21

22 Bottom Line While PSA screening every 4 years does decrease the rate of death from prostate cancer, this needs to be balanced against the number of people needing to be screened and overdiagnosis New data have finally put to rest the question of whether PSA screening reduces prostate cancer mortality. The controversy about PSA based screening should no longer be whether it can do good but whether we can change our behavior so that it does more good than harm Dr Andrew Vickers HOT in

23 Kegels for Men Are a Thing, and You Should Absolutely Be Doing Them lifting your nuts to your guts" or "shortening your penis." Hold 5 seconds and reapeat qid women/kegels formen benefits NEUROENDOCRINE T 23

24 NEUROENDOCRINE T Testosterone Deficiency Syndrome (TDS) Updated Canadian Guidelines CMAJ Dec 2015 TESTOSTERONE LEVELS DROP 1 % A YEAR (1.2% on avg) Treatable hypogonadism MUST be symptomatic and confirmed by LOW Testosterone readings Calc bioavailable T below 4.0 is most reliable value to confirm (Testosterone Deficiency Syndrome) ideally multiple/serial assessments be a purist (THINK hypothyroidism) 24

25 Use whatever treatment the patient is most comfortable with and encourage appropriate lifestyle changes clinical improvements take time (THINK obesity/metabolic syndrome) be a COACH! If on TRT monitor q 3monthly for 1 st year and annually thereafter (goal: T in therapeutic range and nil else untoward CBC (Hct under 54%), lipids (HDL) PSA (THINK diabetes) be an Accountant 25

26 TRT does NOT cause Prostate Cancer and EBM decreed CV safety is inconclusive AND / BUT very low T is associated with higher mortality (don t OVERTHINK) be an Expert Main limitations in existing evidence CV safety of testosterone replacement therapy has not been conclusively proven. Testosterone could possibly reduce the risk of CV events in men with proven testosterone deficiency Best EBM clinical studies are Incredibly underpowered for evaluation of clinical CV events (small sample size, short follow up, patients at low risk of CVD) 26

27 HOT in 2018 Ibuprofen may increase risk of fertility issues in men Ibuprofen alters human testicular physiology to produce a state of compensated hypogonadism 03/

28 PENILE CONCERNS PENILE CONCERNS PEARL 1. What s behind concern.. 2. PEYRONIE S DISEASE 3. Fractured penis 28

29 Q+A 29

30 THANKS 30