Men’s Health

Jeff Eaton NP

Disclaimers

I am paid by:

York Hospital

The University of Southern Maine

Elsevier Publishing

I am not paid by any pharmaceutical company or vendor of any type

Educational Disclaimers

I believe in self directed, life long learners

So I will try to generate some learning issues for you (and maybe give a few pearls along the way).

General Issues of Men’s Health

• Difference in Life Expectancy (F>M) 2 years in 1900 5+ in 2000

• About 25% less likely to have a health visit• Gender Issues- Health behaviors

(Marriage is protective)– Risk factors/Accidents– Suicide/Homicide– Lung Cancer

ADITO –Men’s health edition…

8:00 Reggie Bleak 63 CPX (Up a lot at night to pee)

8:45 Keith Barrister 54 ED

9:15 John (Jack) Zalinski 16 Scrotal abnormality

9:30 Paul Lange 72 Follow up abnormal PSA

9:45 Ben Coulter 28 Personal (Blood in Ejaculate)

10:00 Kenneth Parsons 15 WCC

10:30 Henry Dodge 83 Growing a third testicle

10:45 Maurice Lamontagne 64 Fatigue- wonders if Testosterone

11:00 Richard Lange 41 CPX (? Rectal pap)

8:00 Reggie Bleak 63 CPX (Up a lot at night to pee)

Need to r/o Cancer -- How?

Consider other diagnoses such as heart failure, electrolyte issue, diabetes

His IPSS is 12 (Mod 8-19) - same as AUA score but has QOL measure (can find on Wikipedia among others)

He has been taking Saw Palmetto- do we care?

Labs

PSA is 0.9

PHI useful ? – Prostate Health Index

PSA velocity?

Free PSA? PSA Index?

Why had he not had a screening PSA?

USPSTF rec against

ACS from website “Starting at age 50, men should talk to a doctor (sic) about the pros and cons of testing so they can decide if testing is the right choice for them.

If you are African American or have a father or brother who had prostate cancer before age 65, you should have this talk with a doctor starting at age 45.”

AUA – see next page

AUA The guideline makes the following specific statements:

PSA screening in men under age 40 years is not recommended.

Routine screening in men between ages 40 to 54 years at average risk is not recommended.

For men ages 55 to 69 years, the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, shared decision-making is recommended for men age 55 to 69 years that are considering PSA screening, and proceeding based on patients’ values and preferences.

To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce over diagnosis and false positives. 

Routine PSA screening is not recommended in men over age 70 or any man with less than a 10-15 year life expectancy.

Med Treatments

Tamsulosin – selective (1a) alpha blocker

Start with 0.4 mg ($90 cash)– can increase to 0.8

Other alpha (1 not 1a) blockers such as Doxasozin ($19 cash- CVS) can be used but will cause more orthostatic hypotension

Meds II BPH

5 alpha reductase inhibitor meds

Finasteride- ($85 Cash) often takes 3 months to work- more SEs ED (3%), decreased libido and gynecomastia

Avodart ($200 Cash) is comparable (both isoenzymes but success about the same)

8:45 Keith Barrister 54 ED

Work up

History- look for beta blockers, spironolactone, saw palmetto, calcium blockers, zinc deficiency (DM)

Testosterone deficiency?

ED Labs

PSA it was 1.6

AM testosterone it was 311

CMP sugar was 101 otherwise normal

ED- Medication Options

PDE-5 Inhib Meds

Sildenafil- 1hr- t ½ 4hr- Watch the fat

20 mg generic???

Vardenafil- 1 hr- t1/2 4-6 h – No fat

Tadalafil- 1 hr- t ½ 15-17 h – fat okay

Avanafil (Stendra)- 15-30 minutes t1/2 5 hrs- No fat

Other meds

Often by Urology

Caverject- Injectable Alprostadil

MUSE- Urethral supp Alprostadil

Does DHEA help? Maybe…

Up to Date says Trazadone

9:15 John (Jack) Zalinski 16Scrotal abnormality

My girlfriend was feeling my scrotum and she said it felt weird and so I felt it after and it feels kind of like a bag of worms but I only notice it on the left side. Is that normal?

Varicocele

Infertility?

1 in 6 men

R sided demands work up

Mostly reassurance

9:30 Paul Lange 72Follow up abnormal PSA

Paul was seen by one of your associates about 3 weeks ago for a complaint of fatigue and aching in the pelvic region. He thought his prostate was maybe a little boggy on rectal exam. Your associate did a PSA and it was 8 and he started Paul on treatment for prostatitis.

Prostatitis

Fever, chills, malaise, myalgia, dysuria, pelvic/perineal pain, and cloudy urine

So if you repeat the PSA now and it is 3.5 or anything lower than before it supports the dx of prostatitis but…

Prostatitis- Medication Options

Uncomplicated, with risk of STD (Age < 35 years): Ceftriaxone 250 mg IM x 1 dose or Cefixime 400 mg po x 1dose

Then Doxycycline 100 mg po bid x 10 days

Uncomplicated with low risk of STD: [Levofloxacin 500-750 mg IV/po once daily] or [Ciprofloxacin (500-

750 mg po or 400 mg IV) twice daily] x 10-14 days (minimum) OR

TMP-SMX 1 DS tablet (160 mg of the TMP component) po bid x 10–14 days (minimum)

Some authorities recommend 4 to 6 weeks of therapy.

- Above is cut and paste from the Sanford Guide 2015

9:45 Ben Coulter 28Personal (Blood in Ejaculate)

I had sex with my girlfriend and we used a condom. When I went to throw the condom away it had blood in it. It has never happened before but I felt I should check with you.

Work up?

Eval

Has he travelled to Africa, South America or East Asia? (schistosomiasis)

TRUS?

15-28% have prostatitis

If no GC/Chlamydia or Prostatitis just reassurance unless lasts a month then GU referral

Hematospermia- Med options

Treatment for GC and Chlamydia

Ceftriaxone 250 mg IM x 1 dose + (Azithromycin 1 gm po x 1 dose or Doxycycline 100 mg po q12h) x 7 days. NOTE: use combination therapy even if NAAT is negative for chlamydia

Chlamydia- Doxycycline 100 mg bid po x 7 days or Azithromycin 1 gm po as single dose

Treatment for prostatitis as just noted

10:00 Kenneth Parsons 15 WCC

He REALLY does not want a genital exam- what do you do?

What if he needs sports clearance?

Benefits of Teen genital exams…

USPSTF says no indication for clinical testicular exam for cancer screening

“Hernias and varicoceles do not usually preclude sports participation, but the sports examination can also serve as an appropriate time to screen for testicular masses if the athlete is not receiving regular general examinations.” AAFP

So in this case…

Do the benefits outweigh the risks?

How about in general?

From kevinmd.com “I think men feel much more sensitive, especially male teenagers … very secretive about anything having to do with their genital organs.” Do genital exams decrease the probability of care later on?

10:30 Henry Dodge 83 Growing a third testicle

I was feeling my scrotum in the shower while I was getting washed up and it feels like I have a third testicle. Should we do anything?

US reports

Spermatocele- just a big epididymal cyst- can ignore unless other symptoms or male is younger than 40 or so

Hydrocele- can happen with testicular cancer but generally harmless – I refer if younger than 50 otherwise base on whether it is growing

10:45 Maurice Lamontagne 64Fatigue- wonders if Testosterone

My wife says she thinks my energy is down and she has been seeing these ads on TV and thinks I might have “Low T” .

Workup?

Hypogonadism- Lab Approach- Algorithm from UpToDate

FSH and LH? From the endocrine society guidelines: “ We recommend measurement

of serum L H and FSH levels to distinguish between primary (testicular) and secondary (pituitary-hypothalamic) hypogonadism.

In men with secondary hypogonadism, we suggest further evaluation to identify the etiology of hypothalamic and/or pituitary dysfunction. This evaluation may include measurements of serum prolactin and iron saturation, pituitary function testing, and magnetic resonance imaging of the sella turcica.

Karotype- I would only do if sm firm testicles, gynecomastia and hx of learning disabilities – mostly an issue if fertility is an issue.

Other Lab Thoughts

Dunphy et al says check a Prolactin---but they don’t say what to do with it….

Hey what about Free testosterone? – less affected by obesity, age, narcotics

Do PSA (and DRE and testicular exam ) and CBC before starting testosterone (repeat these at 3 months)

Low T Treatment

*75–100 mg of testosterone enanthate or cypionate

administered intramuscularly (IM) weekly,

or 150–200 mg administered every 2 weeks.

• One or two 5-mg nongenital, testosterone patches

applied nightly over the skin of the back, thigh,

or upper arm, away from pressure areas. (e.g. Androderm)

• 5–10 g of a 1% testosterone gel applied daily over

a covered area of nongenital skin (patients should

wash hands after application).- (e.g. Testim or androgel)

From Endocrine Society Guidelines‘ (Italics is me)

Low T Treatment II

Goal 500-600 – maybe a bit lower in older men

? Increase OSA -- probably not

Cardiac Disease- controversial

So what about OSA?

Overweight, HTN, nonrestorative sleep, High neck circ (>16 female, >17 male), ESS>10, snoring and observed stopping breathing

Home studies preferred by most insurancesAHI - <5 ok, 6-15 mild, 16-30 mod (can use oral

appliance – have to find a dentist who does them)

Above 30 or if preferred CPAP- Autopap- prob about 5-12 for settings, CPAP for most, BiPAP if pressures are high

Do you need a sleep specialist?

11:00 Richard Lange 41 CPX (? Rectal pap)

Rich read that Gay men should have a rectal pap smear- he wants your advice.

Gay male in an open marriage

Does it matter if he is a top, a bottom or a versatile?

Anal Pap IPatients are asked not to douche or have an enema or insert anything

into their anus for 24 hours prior to an anal cytology exam. Lubricants should not be used prior to obtaining a cytology sample

because the lubricant may interfere with the processing and interpretation of the sample.

We usually obtain the sample with the patient lying on their left side, but other positions are acceptable.

The buttocks are retracted to visualize the anal opening and a Dacron or polyester tipped swab moistened in tap water is inserted for approximately 2 to 3 inches into the anus. The swab can be felt to pass through the internal sphincter so the sample is obtained from the junction of the anus and rectum, which is where most of the HPV-related lesions are found. This area is slightly above the region that corresponds anatomically to the dentate line.

Anal Pap IIThe swab is rotated 360 degrees with firm lateral pressure applied to

the end of the swab, such that it is bowed slightly and then it is slowly withdrawn over a period of 15 to 30 seconds from the anus, continuing to rotate the swab in a circular fashion. The lateral pressure ensures that the mucosal surface, rather than rectal contents are sampled.

The swab is either smeared directly onto a glass slide and fixed as a conventional Pap smear by placing it into alcohol, or the swab is placed in a preservative vial and vigorously agitated to disperse the cells for liquid based cytology.

Regardless of method used, the sample must be fixed quickly within 15 seconds in order to avoid drying artifact, which occurs easily and makes interpretation difficult.

The slides are stained using the Papanicolau stain, hence the term Pap smear, and then are examined by the pathologist.

But are they necessary?

The best form of prevention for anal cancer may be a vaccination against HPV infection.

Anal HPV is present in approximately 65% of HIV negative MSMs and 95% of MSMs who are HIV positive.

Skin to Skin?

Good screening test? Usual Criteria: early diagnosis of a common disease, a treatable

condition, a high sensitivity and specificity, and ease of use

The anal pap smear is an underutilized available screening tool for anal cancer with a sensitivity of 50-75% for detection of ASIL and specificity of 50% (http://www.clinicalcorrelations.org/?p=6030)

However, in the United Kingdom, a cost-effective analysis of anal pap screening did not reveal promising results (same ref)

There are no current RCTs or actual Guidelines

Melanoma

• Death rates are highest in white men 3.3/100K as compared to 1.7 in women

• Men more likely to have lesions on back

Summary Men’s Health

• Underutilize health services

• Many causes of M & M related to health behaviors

• Specific reproductive health issues

Extra Slides

Here are some extra slides that I thought you might find interesting….

Finding Prostate Cancer Earlier Is Not Enough

Death from prostate cancer

Symptoms Appear

Situation 1: Not Screened

Survival Time

Situation 2

Survival Time

Situation 3

Survival Time

Death

= Lead Time = Life Extended

Found Early by Screening

Risk of Mortality From Prostate Cancer Among Men in a Randomized Trial

• PROSTATE REMOVED WATCHFUL WAITING

7.1% died of prostate cancer 14.9% died of other causes

13.6% died of prostate cancer14.7% died of other causes

Average age 65 years at entry; 8 years followup

What Happened to U.S. Prostate Cancer Mortality Rates as

Screening Rates Increased?

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