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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? • Ejaculation, the release of semen at climax, is triggered when the man reaches a critical level of excitement. • 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 • • • • 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 • • • • • • 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 • • • • 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. • A single PSA test cannot show you if a prostate cancer is present or if it is slow or fast growing. • At present, a normal result is anything up to 4ng/mL. • 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. • 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 • 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 • 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. • 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 • • 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 • • • • • • • • • 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