Download Lesions, Swelling, Pain and Dysfunction: Men’s Health Update

Lesions, Swelling, Pain and Dysfunction:
Men’s Health Update
Thomas W. Barkley, Jr., DSN, ACNP-BC
Associate Professor of Nursing
Director of Graduate and Nurse Practitioner Programs
California State University, Los Angeles
and
President, Barkley & Associates
www.NPcourses.com
©2009 Barkley & Associates
I have no current affiliation or financial arrangement
with any grantor or commercial
interests that might have direct interest in the subject
matter of this CE Program.
©2009 Barkley & Associates
Objectives
„
Identify common disorders requiring specific
pharmacotherapy for select male conditions
„
Recognize common pharmacologic agents prescribed
for select male conditions
„
State differences between select male conditions and
various pharmacologic therapies specific to each
©2009 Barkley & Associates
9.3.42
Lesions, Swelling, Pain and Dysfunction:
Men’s Health Update
Topical Outline
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Epididymitis
Prostatitis
Balanitis
Benign Prostatic Hypertrophy (BPH)
Prostate Cancer
Erectile Dysfunction
Men’s STIs/STDs Update:
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Herpes Genitalis
Genital Warts
Chlamydia
Gonorrhea
Syphilis
Chancroid
LGV
©2009 Barkley & Associates
Men’s Reproductive System
1. Prostate gland: Produces a
fluid which forms part of the
semen (the liquid which
appears as ejaculate)
2. Seminal vesicles: Sit at the
back of the prostate gland;
produce the thick milky
fluid of the semen
3. Vas deferens: Tube which
carries sperm from the
testicles to the urethra
4. Scrotum: Sac which hold the
testicles
5. Urethra: Tube which carries
urine from the bladder and
semen through the penis
©2009 Barkley & Associates
Men’s Reproductive System
6. Penis: Made up of spongy
tissue which fills with blood
during an erection
7. Foreskin: Covers the glans
and can be pulled back for
cleaning - this is removed
when a man is circumcised
8. Glans: Helmet shaped head
of the penis
9. Epididymis: Area where
sperm are stored in the
testicles
10. Testicles: Produce sperm
and the male sex hormone
testosterone
©2009 Barkley & Associates
9.3.42
Epididymitis
©2009 Barkley & Associates
Epididymitis
„
Inflammatory reaction of the epididymis caused by either an
infectious agent or local trauma
„
Exclusive to males of all ages, but usually found in sexually
active men or older males
„
> 600,000 case reported yearly
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May be caused by congenital urologic structural disorders with
possible pre-disposition to infections
©2009 Barkley & Associates
Epididymitis - Symptoms
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Dysuria
Urgency
Frequency
Low back/perineal
pain
Fever/chills
Malaise
Scrotal edema*
©2009 Barkley & Associates
9.3.42
©2009 Barkley & Associates
Epididymitis: Signs/Symptoms
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Tender/painful swelling of the scrotum with erythema
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Unilateral testicular pain & tenderness
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+ Phren’s test
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Urethral discharge and/or dysuria
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Hydrocele or epididymoorchitis (late in condition)
©2009 Barkley & Associates
Epididymitis
Male reproductive organs
1 Ductus deferens
2 Epididymis
3 Testicle
Examples of
Epididymitis
©2009 Barkley & Associates
9.3.42
Causes & Underlying Factors
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Young, prepubertal boys:
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> 35 yrs or with underlying
urologic disease:
Coliform Bacteria
„ Gram-negative aerobic rods
Almost always as a
complication of urologic disease „ Mycobacteria
„
Young, sexually active men:
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Chlamydia trachomatis
Neisseria Gonorrhoeae
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Note: Diabetics are especially prone
to develop extensive scrotal infections,
including Fournier’s gangrene.
AIDS Patients:
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CMV & Salmonella
epididymitis
Toxoplasmosis: always to be
considered as cause
©2009 Barkley & Associates
Complications
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Atrophy of the affected testicle
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Scrotal abscess
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Chronic epididymitis
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Rarely: impaired fertility
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Epididymoorchitis
©2009 Barkley & Associates
Types of Epididymitis
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Bacterial
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Non Bacterial
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Tuberculosis
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Fungal
©2009 Barkley & Associates
9.3.42
Bacterial Epididymitis
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Usually results from an infection spreading to
the epididymis from other urogenital organs
(e.g., prostate, bladder, kidney, etc.)
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Quick onset (< 24 hours)
©2009 Barkley & Associates
Other (Non-Bacterial) Epididymitis
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Viral: usually with a very quick onset
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Trauma: initially not associated with fever and
generalized symptoms
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Idiopathic: unknown cause, usually not
associated with fever; perhaps caused by
rupture of the sperm ducts, causing sperm to
leak into the tissue
©2009 Barkley & Associates
Treatment
Pharmacologic:
„ Analgesics
„ Antibiotics
Non-Pharmacologic:
„ Ice packs
„ Scrotal elevation
„ Bed rest
„ Surgical aspiration
©2009 Barkley & Associates
9.3.42
Pharmacologic Treatment: Analgesics
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Acetaminophen with or without Codeine:
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For relief of pain and discomfort
NSAIDs:
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Ibuprofen
©2009 Barkley & Associates
Pharmacologic Treatment:
Epididymitis Antibiotics
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In sexually active men: Active agents against N. Gonorrhoeae
and Chlamydia should always be included in treatment
„ Ceftriaxone 250 mg IM single dose +
Doxycycline 100 mg PO BID x 10 days
Azithromycin 1 gm PO single dose
„
If > 35 years of age (older men), consider:
„ Ofloxacin 300 mg p.o. BID x 10 days
„ Levofloxacin 500 mg p.o. every day x 10 days
©2009 Barkley & Associates
Prostatitis
©2009 Barkley & Associates
9.3.42
Prostatitis
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50% of men experience symptoms of
prostatitis in their lifetime
~ 2 million physician visits per year, included
a diagnosis of prostatitis
Inflammation of the prostate gland
Characterized by perineal pain and irregular
urination and (if severe) chills and fever
©2009 Barkley & Associates
Acute Bacterial Prostatitis
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Infection of the prostate
Causative agents: Gram negative bacteria,
E. Coli
Nonbacterial prostatitis – young men
Chlamydia
Mycoplasma
„ Gardnerella
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„
©2009 Barkley & Associates
Acute Bacterial Prostatitis
Presentation/Exam
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Fever/Chills
Low back pain
Dysuria
Urgency
Frequency
Nocturia
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Prostate –
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Warm
Tender to palpation
Firm or Boggy
©2009 Barkley & Associates
9.3.42
Acute Bacterial Prostatitis
Diagnostic Tests
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Urine culture – positive for causative agent
©2009 Barkley & Associates
Acute Bacterial Prostatitis –
Management
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Hospitalization if septicemia or urinary retention is suspected
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Possible agents:
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Trimethoprim Sulfamethoxizole (Bactrim)
Ofloxacin
Ciprofloxacin
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Chronic: Finasteride (Proscar) – lowers the amount of
testosterone; prostate shrinks; SE: less interest in sex and
erectile/ejaculation problems
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Sitz bath TID for 30 minutes each treatment
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No sexual intercourse until acute phase resolves
©2009 Barkley & Associates
Balanitis
©2009 Barkley & Associates
9.3.42
Balanitis
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Inflammation of the superficial tissues of the
penile head (glans penis)
Exclusive to males of all ages, especially
sexually active men
Uncircumcised men are more at risk for
balanitis due to the presence of the foreskin
Most of the organisms associated with
balanitis are already present on the penis, but
in very small numbers
©2009 Barkley & Associates
Balanitis
Moist and scattered lesion
of balanitis
Dry scaly, confluent lesion
of balanitis
©2009 Barkley & Associates
Symptoms of Balanitis
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Itching and tenderness
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Pain, local edema and dysuria
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Urethritis with or without discharge
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Painful erection with altered sexual function
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Rarely: severe ulcerations which may lead to
superimposed bacterial infections
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Rarely: lymph node enlargement
©2009 Barkley & Associates
9.3.42
Balanitis: Causes & Risk Factors
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Poor hygiene
Sexual contact
Urinary catheters
Trauma (frictional or accidental wounds)
Allergic reaction to chemical irritants (e.g.,
soap, lubricant jelly, condoms, etc.)
Allergic reaction to medications
Obesity
©2009 Barkley & Associates
Types of Balanitis
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Candidal
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Trichomonal
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Mycoplasma
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Chlamydial
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Anaerobic
©2009 Barkley & Associates
Candidal Balanitis
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Most common type
Frequently follows intercourse with an infected
partner
Also occurs without sexual contact in diabetic
patients or patients taking oral antibiotics
Recurrent candidal balanitis causes fissuring of
the prepuce, with fibrosis and sclerosis
©2009 Barkley & Associates
9.3.42
Treatment
Pharmacologic:
„ Analgesics
„ Ointment & Creams
„ Topical
corticosteroids
„ Antibiotics
Non-Pharmacologic:
„ Meticulous hygiene
maintenance
„ Warm sitz baths
„ Circumcision
©2009 Barkley & Associates
Balanitis: Non-Pharmacologic Treatment
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Hygiene:
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Warm sitz baths:
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Retraction and bathing of prepuce several times daily
If a Foley catheter is used: strict catheter care
Ease edema and erythema
Circumcision:
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Consider if symptoms are severe or recurrent
May be necessary if phimosis or meatitis occurs
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Note: Severe phimosis may require prompt slit drainage, if unable to
void
©2009 Barkley & Associates
Pharmacologic Treatment:
Analgesics
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Acetaminophen: for minor pain and fever
caused by the skin irritation and infection
AND/OR
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Codeine: for patients with more severe cases or
low pain threshold
©2009 Barkley & Associates
9.3.42
Pharmacologic Treatment
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Clotrimazole 1% cream: topical cream; kills fungi and
yeasts by interfering with their cell membranes
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Applied to affected areas TID
Bacitracin ointment: Topical antibiotic used to treat
and prevent bacterial infections.
>Applied to affected areas 3 to 4 times daily
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Topical Corticosteroids: QID for severe dermatitis
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Betamethasone: apply thin film BID
©2009 Barkley & Associates
Balanitis: Considerations
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Always assess for evidence of other STDs in sexually
active men
If lesions do not heal, refer for biopsy (i.e., premalignant/malignant lesions, carcinoma of the penis,
etc.)
When possible, always treat underlying cause to avoid
future recurrences
Even though uncircumcised men are at a higher risk,
there is no significant difference in the rate of
occurrence, compared to those who are circumcised
©2009 Barkley & Associates
Benign Prostatic Hypertrophy (BPH)
©2009 Barkley & Associates
9.3.42
Benign Prostatic Hypertrophy (BPH)
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Progressive, benign hyperplasia of prostate
gland tissue
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By 50 years, ~ 50% of men
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By 80 years, ~ 80%-90% of men
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Etiology is unknown
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The most common cause of bladder
obstruction in men over the age of 50 years
©2009 Barkley & Associates
BPH – Symptoms
(He’s got the ‘goes’ - maybe)
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Frequency
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Urgency
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Nocturia
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Dribbling
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Retention
©2009 Barkley & Associates
©2009 Barkley & Associates
9.3.42
BPH – Physical Exam
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Bladder distention may
be present
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Prostate is nontender
with either asymmetrical
or symmetrical
enlargement
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Smooth, rubbery
consistency with possible
nodules
©2009 Barkley & Associates
BPH – Diagnostic Tests
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U/A - rules out UTI, no hematuria
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Uroflowmetry
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Abdominal ultrasound - rule out upper tract
pathology
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Serum creatinine/BUN normal
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American Urological Association-International
Prostate Symptom Score (AUA/IPSS)
©2009 Barkley & Associates
BPH – Diagnostic Tests
PSA Normal Levels
(Age-specific ranges based on having had a previous PSA < 4 ng/mL)
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Age 40-49 years: < 2.5 ng/mL
Age 50-59 years: < 3.5 ng/mL
Age 60-69 years: < 4.5 ng/mL
Age 70-79 years: < 6.5 ng/mL
©2009 Barkley & Associates
9.3.42
BPH – Diagnostic Tests
„ Major
Reasons for PSA Elevation:
„ Prostate
Cancer
„ Prostate Enlargement
„ Prostatitis
©2009 Barkley & Associates
Relative Risk of Prostate Enlargement by PSA Level
(Wright et al., 2002; http://www.avodart.com/m07_01.html)
©2009 Barkley & Associates
BPH – Management
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Observe: Watchful waiting
Consult/refer as needed
Medications to decrease bulk and/or tone of gland
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Alpha-blockers
5-alpha-reductase inhibitors
Combination therapy
Herbal preparations (saw palmetto?) – not FDA regulated
Minimally invasive procedures (numerous)
Surgery
©2009 Barkley & Associates
9.3.42
BPH Pharmacotherapy
Alpha adrenergic blockers
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Originally developed to
treat HTN
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Relax smooth muscle in
the prostate and around
the bladder neck
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Similar efficacy
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Best for normal-sized to
moderately enlarged
prostates
Hytrin
terazosin
Cardura
doxazosin
Flomax
tamsulosin
Uroxatral
alfuzosin
Minipress
prazosin
©2009 Barkley & Associates
Alpha adrenergic blockers
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See effects within ~ 1-2 days (increased urinary flow; urinate
less often)
Often 4 to 6 point decrease in urinary symptom index score
Major Side Effects:
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Decreased ejaculate
Low blood pressure
Dizziness
Headache
Stomach or intestinal irritation
Stuffy nose
©2009 Barkley & Associates
Alpha adrenergic blockers
Warnings/Considerations:
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Risk of intraoperative floppy iris syndrome (IFIS) in patients
taking tamsulosin (Flomax) or others
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IFIS – characterized by the iris not responding appropriately during
cataract surgery
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Can lower blood pressure to unhealthy levels when taken with
erectile dysfunction drugs such as sildenafil (Viagra),
vardenafil (Levitra) and tadalafil (Cialis)
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Follow up every 3-6 months during the first year of therapy
©2009 Barkley & Associates
9.3.42
Enzyme (5-alpha-reductase)
inhibitors for BPH
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Shrink the prostate
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Reduces the amount of
testosterone that turns into
dihydrotestosterone (DHT), a
hormone required for prostate
gland growth
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Attaches to receptors on the
prostate cells; encourages them
to grow/multiply
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Inhibitors reduce the prostate's
"appetite" for DHT by reducing
the number of receptor sites
where DHT can attach
Finasteride
(Proscar)
Dutasteride
(Avodart)
©2009 Barkley & Associates
5-alpha-reductase inhibitors
for BPH
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Equally effective
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Take longer to work ~ 3 – 6 months
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More costly than alpha blockers
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Increase urine flow rate
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Reduce urinary symptom index scores by an
average of 3 points
©2009 Barkley & Associates
5-alpha-reductase inhibitors
for BPH
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With moderate disease to severe disease, may
significantly decrease the need for surgery and the
incidence of urinary retention
Major Side Effects:
„ Erection problems
„ Decreased sexual desire
„ Reduced semen release during ejaculation
„ Side effects may cease when meds are discontinued
or after ~ 1 year of therapy
©2009 Barkley & Associates
9.3.42
How safe are the newer 5-alphareductase inhibitors?
©2009 Barkley & Associates
Dutasteride (Avodart)
Contraindications:
„ Women and children
„ Patients with known hypersensitivity to 5-reductase inhibitors
Warnings/Precautions:
„ Dutasteride is absorbed through the skin
„ Women who are pregnant or may be pregnant should not
handle Avodart Soft Gelatin Capsules because of the
possibility of absorption of dutasteride and the potential risk of
a fetal anomaly to a male fetus (feminization; decreased
anogenital distance, nipple development, hypospadias)
„ Women should use caution whenever handling; if contact is
made with leaking capsules, the contact area should be washed
immediately with soap and water
©2009 Barkley & Associates
Dutasteride (Avodart)
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Men being treated should not donate blood until at
least 6 months have passed following their last dose.
Purpose: prevent administration of dutasteride to a
pregnant female transfusion recipient
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Hepatic impairment – not studied
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PSA reestablished after 6 months – isolated should be
doubled after 6 months for comparison to prestudy
baseline
©2009 Barkley & Associates
9.3.42
Dutasteride (Avodart)
Adverse events:
„ Impotence
„ Decreased libido
„ Ejaculation disorders
„ Gynecomastia
©2009 Barkley & Associates
Alpha blockers + 5-alpha-reductase inhibitors
Combination Therapy for BPH
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Most tested: doxazosin + finasteride
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One study found this combination to significantly
reduce the risk of further prostate enlargement to the
point where invasive surgery was not needed
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Works best for those with large prostates and high
PSAs
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Side effects – assumed similar to the combination
effect (not significantly studied)
©2009 Barkley & Associates
Saw palmetto
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Medicinal element taken from the partially dried ripe
fruit of the American dwarf palm tree
Studies shown effectiveness in reducing BPH
symptoms
Appears to have efficacy similar to that of finasteride
No known drug interactions
Not FDA regulated
(Gordon & Shaughnessy, 2003)
©2009 Barkley & Associates
9.3.42
Prostate Cancer
©2009 Barkley & Associates
PROSTATE CANCER
„
Most common form of cancer, other than skin cancer,
among men in the United States
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# 2 cause of cancer-related death among men
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About 70% of all diagnosed prostate cancers are
found in men aged 65 years or older
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Over the past 20 years, the survival rate for prostate
cancer has increased from 67% to 97%
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Death rate higher for African-American men than for
any other racial or ethnic group
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Cause unknown; High-fat diets are implicated
©2009 Barkley & Associates
Symptoms
ASYMPTOMATIC
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May appear to be BPH
In later stages:
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Bone pain
Uremia
©2009 Barkley & Associates
9.3.42
Prostate Cancer - Examination
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Adenopathy
Bladder distension
Prostate palpates harder than normal
©2009 Barkley & Associates
Prostate Cancer –Tests
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Prostate-specific antigen (PSA) > 4 abnormal
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Approximately 40% of prostate cancer patients
present with normal PSA values!
(not a very sensitive test!)
©2009 Barkley & Associates
Prostate Cancer – Management
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Consult/refer
Accurate staging is critical
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Watchful waiting…
Treatment options include surgery, radiation,
and/or hormone therapy
©2009 Barkley & Associates
9.3.42
Erectile Dysfunction
©2009 Barkley & Associates
Erectile Dysfunction (ED)
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Inability to achieve and sustain an erection
suitable for sexual intercourse
~ 52% of men aged 40-70 have ED
~ 5% of 40-year-old men and
15-25% of 65-year-old men
experience ED on a long-term basis
Not considered “normal” at any age!
©2009 Barkley & Associates
What Causes Erectile Dysfunction?
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For an erection to occur:
Nerves to the penis must be properly functioning
„ Blood circulation to the penis must be adequate
„ Must be a stimulus from the brain
„
„
Common causes: atherosclerosis, nerve
diseases, psychological factors/stress,
depression, performance anxiety, penile injury
and medications
©2009 Barkley & Associates
9.3.42
Causes of ED: Diuretics & Antihypertensives
Hydrochlorothiazide (Esidrix, HydroDIURIL, Lotensin)
Triamterene (Maxide, Dyazide)
Furosemide (Lasix)
Bumetanide (Bumex)
Methyldopa (Aldomet)
Clonidine (Catapres)
Verapamil (Calan, Isoptin, Verelan)
Nifedipine (Adalat, Procardia)
Hydralazine (Apresoline)
Captopril (Capoten)
Enalapril (Vasotec)
Metoprolol (Lopressor)
Propranolol (Inderal)
Labetalol (Normodyne)
Atenolol (Tenormin)
Phenoxybenzamine (Dibenzyline)
Spironolactone (Aldactone)
©2009 Barkley & Associates
Causes of ED: Antidepressants, anti-anxiety and
antiepileptic drugs
Fluoxetine (Prozac)
Tranylcypromine (Parnate)
Sertraline (Zoloft)
Isocarboxazid (Marplan)
Amitriptyline (Elavil)
Amoxipine (Asendin)
Clomiprimine (Anafranil)
Desipramine (Norpramin)
Nortriptyline (Pamelor)
Phenelzine (Nardil)
Buspirone (Buspar)
Chlordiazepoxide
(Librium)
Clorazepate (Tranxene)
Diazepam (Valium)
Doxepin (Sinequan)
Imipramine (Tofranil)
Lorazepam (Ativan)
Oxazepam (Serax)
Phenytoin (Dilantin)
©2009 Barkley & Associates
Causes of ED: Antihistamines
Dimehydrinate (Dramamine)
Diphenhydramine (Benadryl)
Hydroxyzine (Vistaril)
Meclizine (Antivert)
Promethazine (Phenergan)
©2009 Barkley & Associates
9.3.42
Causes of ED
NSAIDS
Naproxen (Anaprox, Naprelan, Naprosyn)
Indomethacin (Indocin)
Muscle Relaxants
Cyclobenzaprine (Flexeril)
Orphenadrine (Norflex)
Anti-arrythmics
Disopyramide (Norpace)
©2009 Barkley & Associates
Causes of ED
H-2 Receptor Antagonists
Cimetidine (Tagamet)
Nizatidine (Axid)
Ranitidine (Zantac)
Parkinson’s Disease Medications
Biperiden (Akineton)
Benztropine (Cogentin)
Trihexyphenidyl (Artane)
Procyclidine (Kemadrin)
Bromocriptine (Parlodel)
Levodopa (Sinemet)
©2009 Barkley & Associates
Causes of ED
Recreational Drugs
Alcohol
Amphetamines
Barbiturates
Cocaine
Marijuana
Methadone
Nicotine
Opiates
©2009 Barkley & Associates
9.3.42
Erectile Dysfunction: Treatment
„
Medication choices:
„
sildenafil (Viagra)
„
vardenafil (Levitra)
„
tadalafil (Cialis)
…known as the
phosphodiesterase inhibitors
©2009 Barkley & Associates
Phosphodiesterase (PDE) inhibitors
„
Prevent the breakdown of nitric oxide, a chemical
messenger that promotes relaxation and opening of
the blood vessels that supply erectile tissue in the
penis
„
Under the influence of nitric oxide, these vessels
expand and stay dilated
„
Increased blood flow makes erectile tissue swell and
compress the veins that carry blood out of the penis,
resulting in a full erection
©2009 Barkley & Associates
Phosphodiesterase (PDE) inhibitors
Sildenafil
(Viagra)
Vardenafil
(Levitra)
Tadalafil
(Cialis)
Works?
30 minutes
60 mins
15 minutes
Lasts?
4 hours
4 hours
up to 36 hours
Usual
50 mg/d
Dose?
Max Dose? 100 mg/d
10 mg /d
10 mg/d
20 mg/d
20 mg/d
Take?
Without food
Without food
With or
without food
Available?
20, 25, 50, 100 mg 2.5, 5, 10, 20 mg 5, 10, 20 mg
©2009 Barkley & Associates
9.3.42
Erectile Dysfunction:
BREAKING NEWS
New ED Drugs On The Way!
(DeNoon & Chang, 2006)
„
One works fast
„
One lasts long
„
One promises to be the next best thing to a
cure!
©2009 Barkley & Associates
Erectile Dysfunction
Near a Cure for Erectile Dysfunction?
„
For now, it is called hMaxi-K
„
Suitably enough for an erection treatment, it is a form of gene
therapy called naked DNA
„
Its DNA carries a human genetic code into target cells
„
When the cell reads this code, it makes a protein. In the case of
hMaxi-K, it is a protein that tells smooth muscles to relax
©2009 Barkley & Associates
Erectile Dysfunction
„
First human trial (Melman, 2006) reported 11 men
with erectile dysfunction received injections of the
gene therapy directly into the penis
„
Because this was the first human study, the doses
used were smaller than those expected to have a true
effect on erections
„
The study was successful in two ways:
„
„
It was safe
Two men who received higher doses of hMaxi-K had
greatly improved erections -- which occurred only during
sexual arousal -- for six months after a single treatment!
©2009 Barkley & Associates
9.3.42
Erectile Dysfunction
Additional Findings:
„
Sex doesn’t have to be planned – allows one to get a normal
erection whenever aroused
„
hMaxi-K will also be effective for a wide range of diseases
that arise from the failure of smooth muscle to relax
„ Overactive bladder
„ Asthma
„ Irritable bowel syndrome
„ BPH
„ Premature labor
„ Premenstrual syndrome
©2009 Barkley & Associates
Erectile Dysfunction
Long Acting Erection Drug, SLx-2101 (Goldstein, 2006)
„
Like Viagra, Cialis, and Levitra, SLx-2101 works by inhibiting an
enzyme that makes smooth muscles contract
„
Unlike other approved erection drugs, SLx-2101 is two drugs in
one:
„
„
„
„
When first taken, SLx-2101 is a powerful erection drug
While it is still working, the body begins to process it into a second drug,
SLx-2101m1, also a powerful erection drug
Acts well beyond 48 hours
Interestingly, SLx-2101 improves erections not only in men with
ED, but also in men already able to have erections! (woo hoo!!)
©2009 Barkley & Associates
Erectile Dysfunction
Faster, Shorter-Acting Erection Drug (Nehra, 2006)
„
Avanafil
„
Avanafil reaches maximum blood concentrations 35 minutes
after it is taken
„
It has a half-life of 90 minutes (Compared with 4 hours for
Levitra and Viagra and 17.5 hours for Cialis)
„
Good for personal preferences and men who take nitrate-based
drugs (e.g., Nitrostat, Isordil, and Imdur)
„
Men taking a nitrate-based drug while on avanafil had less of a
drop in blood pressure and less of an increase in blood
pressure than men who took the heart drug while on Viagra
©2009 Barkley & Associates
9.3.42
Men’s STDs/STIs Update
©2009 Barkley & Associates
Herpes Genitalis
©2009 Barkley & Associates
Herpes Genitalis
Cause:
„
„
Herpes simplex virus (HSV) types 1 and 2
90-95% of genital herpes caused by type 2
Prevalence:
„
„
„
Primary infections ~ 200,000 annually
Recurrent infections more common
Estimated > 45 million Americans infected
„ 1/5 adolescents (> 12 years old) and adults infected
©2009 Barkley & Associates
9.3.42
Genital Herpes: Initial Visits to
Physicians’ Offices (1996-2004)
http://www.cdc.gov/std/stats/tables/table47.htm
300,000
269,000
250,000
208,000
200,000
1966
150,000
136,000
1976
1986
1996
2004
100,000
56,000
50,000
19,000
0
©2009 Barkley & Associates
Herpes Genitalis: Presentation
„
„
„
„
Pruritic vesicles
Vesicles rupture to form
shallow ulcers
Resolve spontaneously
Viral shedding occurs
intermittently without
clinical symptoms
„
„
„
„
„
„
Inguinal adenopathy
present with initial case
Fever/chills
Headache
Malaise
Dysuria
Dyspareunia
©2009 Barkley & Associates
©2009 Barkley & Associates
9.3.42
Genital Herpes
What about asymptomatic
viral shedding,
especially in discordant couples?
©2009 Barkley & Associates
Genital Warts
©2009 Barkley & Associates
GENITAL WARTS
Single or multiple soft, fleshing, papillary or sessile,
painless keratinized growth around anus, penis,
urethra or perineum
©2009 Barkley & Associates
9.3.42
GENITAL WARTS (Condyloma acuminata)
Cause: Human papillomavirus (HPV)
Prevalence:
„
The most common symptomatic viral STD in U.S.
„
Accounts for > than 1 million office visits per year
„
Estimated 3 million cases of HPV are reported annually
©2009 Barkley & Associates
GENITAL WARTS (Condyloma acuminata)
„
Over ½ of sexually active men in the U.S. will
have HPV at some time in their lives
„
~ 1% of sexually active men in the U.S. have
genital warts at any one time
„
The incidence of penile cancer is increasing
„
„
In this country, penile cancer accounts ~ 0.2% of all
cancers in men (especially rare in circumcised men)
~ 1,910 men will be diagnosed with anal
cancer in 2006
„
Risk is 17 times higher among gay and bisexual men, as well as
those with compromised immune systems (HIV)
©2009 Barkley & Associates
GENITAL WARTS Treatment
„
Remove warts
Cryosurgery
Trichloroacetic acid (TCA)
„ Bichloroacetic acid (BCA)
„ Laser treatment
„
„
„
No therapy has been shown to completely
eradicate HPV
©2009 Barkley & Associates
9.3.42
Chlamydia
©2009 Barkley & Associates
Chlamydia: Signs/Symptoms
Males
„
Often Asymptomatic
„
Urethral discharge
„
Dysuria
„
Testicular pain and/or
swelling
„
Inguinal adenopathy
©2009 Barkley & Associates
Chlamydia
„
Treatment:
„
„
„
Azithromycin (Zithromax) 1 g p.o. x 1 dose
Doxycycline (Adoxa) 100 mg p.o. BID x 7-10 days
NOTE: Due to high rate of coexistence with
gonorrhea, both diseases are commonly treated
simultaneously
„
„
Ceftriaxone 125 mg IM x 1 dose
Report to Health Department (in most states)
©2009 Barkley & Associates
9.3.42
Gonorrhea
©2009 Barkley & Associates
Gonorrhea
Cause: Neisseria gonorrheae, a gram-negative
diplococcus
Prevalence:
„ Most commonly reported communicable disease in
the United States
„ Estimated 1.5 million per year
©2009 Barkley & Associates
Gonorrhea:
Symptoms
„
„
„
„
„
Dysuria
Increased frequency of
urination
Purulent urethral
discharge
Testicular pain
Many to most patients
may be asymptomatic
©2009 Barkley & Associates
9.3.42
Gonorrhea
Diagnosis: DNA probe or
culture
Treatment:
„ Ceftriaxone (Rocephin)
125 mg IM x 1 dose
„ Report to the health
department
©2009 Barkley & Associates
Syphilis
©2009 Barkley & Associates
Syphilis
Cause: Treponema pallidum, a spirochete with 6 to 14
regular spirals
Prevalence:
„ 40,000 cases annually in the United States
„
Highest level in the past 40 years
©2009 Barkley & Associates
9.3.42
Syphilis: Symptoms
Primary:
„ Chancre is painless
„ Indurated ulcer
„ Located at the site of
exposure
Secondary:
Highly variable skin rash
on palmar and plantar
surfaces
„ Mucous patches
„ Condylomata lata
„ Lymphadenopathy
„ Malaise
„ Anorexia
„ Alopecia
„ Arthralgias
„
©2009 Barkley & Associates
Syphilis: Symptoms
Latent:
„ Seropositive
„ Asymptomatic
Tertiary:
„ Leukoplakia
„ Cardiac insufficiency
„ Aortic aneurysm
„ Meningitis
„ Hemiparesis
„ Hemiplegia
©2009 Barkley & Associates
Syphilis Chancre
©2009 Barkley & Associates
9.3.42
Secondary syphilis - palms and soles
©2009 Barkley & Associates
Syphilis
„
Serologic Tests:
„ Nontreponemal:
„ Treponemal
„ FTA-ABS
VDRL/RPR
tests:
(fluorescent treponemal antibody
absorption
„ MHA-TP
(microhemaglutination assay for
antibody to T. pallidum)
©2009 Barkley & Associates
Syphilis: Treatment
Primary, secondary or early
„
Benzathine penicillin G - 2.4 million units IM x 1
Late, latent, and indeterminate length, tertiary
„
Benzathine penicillin G - 2.4 million units IM weekly x 3
weeks
Penicillin allergic
„
„
Doxycycline 100 mg p.o. BID or
Erythromycin 500 mg p.o. QID
Report to health department
©2009 Barkley & Associates
9.3.42
Chancroid
©2009 Barkley & Associates
Chancroid
„
Cause: Hemophilus ducreyi,
a gram-negative bacillus
„
Symptoms
„
„
„
Women - usually asymptomatic
Men - single (though may be
multiple) superficial, painful
ulcer, surrounded by an erythematous halo
Ulcers may be necrotic or severely erosive
©2009 Barkley & Associates
Chancroid: Diagnosis
„
„
„
„
Probable diagnosis is usually a matter of exclusion
Involves genitalia and unilateral bubo (or both)
Painful genital ulcers in absence of T. pallidum and
HSV (by inspection or culture) with coexisting tender
inguinal lymphadenopathy is suggestive of chancroid
Definitive diagnosis of chancroid is made
morphologically, though the sensitivity of the test is
no greater than 80%
©2009 Barkley & Associates
9.3.42
©2009 Barkley & Associates
Chancroid: Treatment
„
Azithromycin (Zithromax) 1
gm p.o. x 1 dose OR
„
Ceftriaxone (Rocephin) 250
mg IM x 1 dose OR
„
Ciprofloxacin (Cipro) 500
mg p.o. BID x 3 days OR
„
Erythromycin 500 mg p.o.
QID x 7 days
„
HIV + patients need a
longer course of therapy
©2009 Barkley & Associates
Lymphogranuloma Venereum (LGV)
Cause: Immunotypes L1, L2 or L3 of
Chlamydia trachomatis
Prevalence:
Endemic in Asia, Africa and large cities in the
United States
©2009 Barkley & Associates
9.3.42
LGV: Symptoms
„
2 to 3 mm painless vesicle, bubo or nonindurated ulcer
„
Regional adenopathy follows in approximately
one month
„
Stiffness and aching in groin followed by
unilateral swelling of inguinal region
©2009 Barkley & Associates
Lymphogranuloma Venereum
©2009 Barkley & Associates
LGV
Diagnosis:
„
May be confused with chancroid
„
Definitive diagnosis requires isolating C.
trachomatis from an appropriate specimen and
confirming isolate as an LGV immunotype
©2009 Barkley & Associates
9.3.42
LGV
Treatment:
„
„
Doxycycline 100 mg p.o. BID x 21 days
Erythromycin 500 mg p.o. QID x 21 days
„
Aspirate buboes to prevent ulcerations
©2009 Barkley & Associates
©2009 Barkley & Associates
www.NPcourses.com
©2009 Barkley & Associates
9.3.42
~ THANK YOU ~
P.O. Box 69901
West Hollywood, CA 90069
310.684.3880
www.NPcourses.com
©2009 Barkley & Associates
9.3.42