Transcript Mens sexual health

Mens Sexual Health
Dr Dominic Rowley
SPR in Genitourinary medicine
GUIDE
St James’s Hospital
Erectile Dysfunction=Impotence
• is the persistent or recurrent inability to achieve
and/or maintain erection sufficient for
satisfactory sexual intercourse.
• Many men live with ED for years without seeking
medical advice, because of embarrassment or a
belief that ED cannot be treated
Erections
1. Sexual arousal-adequate testosterone
2. Intact nervous system
3. Adequate arteriolar blood flow
Mechanism of ejaculation
How Does Ejaculation Occur?
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Ejaculation, the release of semen at climax, is triggered when the man reaches a critical level of
excitement.
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sexual stimulation causes nerves in the penis to send chemical messages or impulses to the spinal
cord then to the brain then :
• First: the vas deferens, the tubes that store and transport sperm from the testes, contract to
squeeze the sperm toward the prostate gland and urethra and seminal vesicles release secretions
that make semen.
• Second: phase, muscles at the base of penis contract every 0.8 seconds and force the semen
out of the penis in up to five spurts
Erectile Dysfunction
• More than 50% of men over 40 will
experience some degree of ED at some stage
in their lives
• > 80 % physical cause
• Healthy men have 6-8 erections during
sleep,mostly REM,if nocturnal erections don’t
occur it is more likely to be physical in origin
physical
psychological
Physical
Diseases
Trauma
• Diabetes
• Vascular disease
• M.S
• Parkinsons
Disease
• Neurological
• Prostatic disease
• Peyronies
• Hypogonadism
• Spinal injuries
• Post operatative
• usually :
prostate surgery
• Colon/rectal
surgery
Meds
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Anti-hypertensives
Anti depressants
Pain meds
?NSAIDS(JOURNAL OF
UROLOGY FEB 2011)
Smoking
High blood sugars
cholesterol
Hypertension
Peripheral
vascular disease
Psychological
Stress
Depression
Psychosexual
• Loss of libido
• Poor
concentration
• Performance
anxiety
• Relationship
disharmony
“the blood at the head of my penis isnt
the same as it used to be”
Sexual
history
Stress?
examination
Blood
pressure
Depression?
Fasting
bloods
E.D
PSA+
PR
exam
testost
erone
Treatment
• PDE-5 inhibitors
– Increase blood flow to penis
– Take 30 mins to 1 hour before sex-can last upto 36 hours
• Sildenafil(viagra),tadalafil( cialis),vardenafil(levitra)
• Hormone
– Testosterone, now in patches( testogel)
• Pumps
• Injections
– By a urologist mostly
PROSTATE PROBLEMS
• Benign Prostatic Hypertrophy
– Rarely before 40 but ? 90 % men in their 70’s have
some symptoms of enlarged prostate
• Prostate Cancer
Symptoms
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A constant need to urinate esp at night
Hesitation
Poor flow
Taking longer to urinate
Terminal dribbling
Feeling that your bladder hasn’t emptied
properly
• Pain on urinating
Symptoms
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Erection difficulties
Rarely blood in urine
Lower back pain
Testicular pain
Prostate Cancer
• often slow growing cancer and problems may
not occur for many years
• prostate cancer is the second most common
cancer in men, after skin cancer.
• Each year about 2500 new cases of prostate
cancer are diagnosed.
• This means that 1 in 12 Irishmen will be
diagnosed during their lifetime
• Although there are many men with this disease,
most men do not die from it.
Tests for prostate cancer
PSA = Prostate Specific Antigen
• PSA is a protein made by the prostate gland that can be found into your
bloodstream.
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A single PSA test cannot show you if a prostate cancer is present or if it is slow or
fast growing.
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At present, a normal result is anything up to 4ng/mL.
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The rate at which the PSA doubles is important too, so PSA levels should be
compared regularly. For example, if your PSA was 2 last year and 4 this year, it may
need to be checked out.
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Controversy remains: The serum PSA level alone should not automatically lead to a
prostate biopsy.
But if > 50, african black or black caribbean or/and family history, screen with PSA
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Prostate Cancer tests
• Digital Rectal Exam (DRE)
– This involves your doctor putting a gloved finger
into your back passage/rectum to feel your
prostate. This test can find cancers in about half of
cases
Tests at the hospital
• Transrectal ultrasound scan (TRUS)
• Transrectal needle biopsy of the prostate
• The best way to diagnose prostate cancer is taking samples
of the tissues a biopsy
Other tests
• If the tests show that you have prostate cancer, you may
need other tests. This is called staging and can help your
doctor to decide on the right treatment for you.
• Bone scan
• X-rays
• MRI and CT
Treatment
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Watchful waiting
If men choose watchful waiting and show evidence of disease progression, they should be reviewed
by a member of the urological cancer MDT.
• Active surveillance
Active surveillance is the preferred option for low-risk men who are candidates for radical
treatment.
If men on active surveillance show evidence of disease progression, offer radical treatment.
Treatment
decisions should be made with the man, taking into account comorbidities and life expectancy.
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Radical treatments
All candidates for radical treatment should have the opportunity to discuss their treatment options
with a surgical oncologist and a clinical oncologist.
Offer adjuvant hormonal therapy for a minimum of 2 years to men receiving radiotherapy who have a
Gleason score of ≥ 8.
Treatment
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Locally advanced prostate cancer
– neoadjuvant and concurrent luteinising hormone-releasing hormone agonist (LHRHa)
therapy ,
Radiotherapy:including bracytherapy
Metastatic prostate cancer
– bilateral orchidectomy as an alternative to continuous LHRHa therapy
– monotherapy with bicalutamide (150 mg)4 if the man hopes to retain sexual function and
is willing to accept gynaecomastia and reduced survival
Treatment
Hormone-refractory prostate cancer
– docetaxel (within its licensed indications) only if Karnofsky score is ≥ 60%. Stop treatment after
10 planned cycles
– a corticosteroid (for example, dexamethasone 0.5 mg daily) as a third-line therapy after androgen
withdrawal and anti-androgen therapy
– spinal MRI if spinal metastases are found and spine-related symptoms develop
– decompression of the urinary tract by percutaneous nephrostomy or insertion of a double J stent
to men with obstructive uropathy.
Palliative care
Discuss the man’s preferences for palliative care (and those of his partner and carers) as soon
as possible.
Testicular cancer
• Peak incidence: 25-35
• Typically painLESS –dragging can occur or pain
due to mets
• No Urinary symptoms
• Testicle
• Solid lump not seperated from testis
• Ultrasound=hypo-echoic mass WITHIN testis
Scrotal masses
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Trauma
Hydrocoele
Epididymo-orchitis
Testicular torsion
Spermatocoele
Epididymal cyst
Variocoele
Hernia
Testicular tumor
Golden Rule
3 questions
1. A solid testicular mass is malignant untill
proven otherwise
2. Is it intrascrotal? Does it extend above the
testis e.g hernia
3. Can you transilluminate?Is it cystic
4. Is the mass an integral part of the testis?
Testicular tumors
• Germ cell-either seminoma or malignant
teratoma
– Very chemo sensitive,high 5 year survival rate
even when caught at late stage
• Lymphoma /other malignancies