Advancing Male Health in Ottawa: 2010 and Beyond Part...

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

Peyronie's Disease

Objectives

Peyronie's Disease

Penile Fracture?

Objectives

Peyronie's Disease

Penile Fracture?

Testosterone Deficient States

Objectives

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

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

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

• 12% spontaneous improvement, 40% stable, 48% worsening

• 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?

• 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

• 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

• Stable curvature, limits sexual function (<60 degrees and uniplanar are not absolute requirements)

• 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

DRAWBACKS AND LIMITATIONS

Does not allow for recovery of Peyronie's length loss

Penile shortening

Requires satisfactory erectile function

Does not allow for recovery of Peyronie's length loss

May contribute to further penile shortening

Requires satisfactory erectile function

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

Hypothalamus

Pituitary

Testes

- Feedback

Veidhuis JD, Reproductive Endocrinology, 3rd ed, 1991.

Pathophysiology of Testosterone Deficiency

Primary Hypogonadism (Testicular Dysfunction)

Hypothalamus

Pituitary

Testes

ReducedFeedback

Hormone Levels:— ↓ T

— ↑ LH

— ↑ GnRH

Causes: — premature testicular failure, Klinefelter

syndrome (47 XXY), undescended testes, orchiectomy, injury, testicular cancer, radiation, chemotherapy, virus, alcohol

Secondary Hypogonadism (Pituitary Dysfunction)

— ↓ or inappropriately normal LH

Causes: — Pituitary tumors (i.e. prolactinomas,

acromegaly), radiation, craniopharyngiomas, sarcoidosis, β-thalassemia major

Hypothalamus

Pituitary

Testes

ReducedFeedback

or normal LH

Secondary/Tertiary Hypogonadism (Hypothalamic Dysfunction)

— ↓ or inappropriately normal LH

— ↓ GnRH

Causes: — Kallman’s syndrome (with anosmia),

idiopathic hypogonadotropic hypogonadism, head trauma

Hypothalamus

Pituitary

Testes

ReducedFeedback

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

Q 3 Q 4 Q 12

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

Advancing Male Health in Ottawa: 2010 and Beyond Part...

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