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

Transcription

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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
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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.
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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
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Lesions, Swelling, Pain and Dysfunction:
Men’s Health Update
Topical Outline

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
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
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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
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Epididymitis
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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

May be caused by congenital urologic structural disorders with possible pre-disposition to infections
Epididymitis - Symptoms
Dysuria
Urgency
Frequency
Low back/perineal pain
Fever/chills
Malaise
Scrotal edema*

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Epididymitis: Signs/Symptoms

Tender/painful swelling of the scrotum with erythema

Unilateral testicular pain & tenderness

+ Phren’s test

Urethral discharge and/or dysuria

Hydrocele or epididymoorchitis (late in condition)
Epididymitis
Male reproductive organs
1 Ductus deferens
2 Epididymis
3 Testicle
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Causes & Underlying Factors

Young, prepubertal boys:

Young, sexually active men:

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Coliform Bacteria
Almost always as a complication of urologic disease
Chlamydia trachomatis
Neisseria Gonorrhoeae
Complications

Atrophy of the affected testicle

Scrotal abscess

Chronic epididymitis

Rarely: impaired fertility

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Epididymoorchitis
Types of Epididymitis
Bacterial
Non
Bacterial
Tuberculosis
Fungal
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Bacterial Epididymitis

Usually results from an infection spreading to the epididymis from other urogenital organs (e.g.,
prostate, bladder, kidney, etc.)

Quick onset (< 24 hours)
Other (Non-Bacterial) Epididymitis

Viral: usually with a very quick onset

Trauma: initially not associated with fever and generalized symptoms

Idiopathic: unknown cause, usually not associated with fever; perhaps caused by rupture of the
sperm ducts, causing sperm to leak into the tissue
Treatment
Pharmacologic:
Analgesics
Antibiotics
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Pharmacologic Treatment: Analgesics

Acetaminophen with or without Codeine:

NSAIDs:

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For relief of pain and discomfort
Ibuprofen
Pharmacologic Treatment:
Epididymitis Antibiotics

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
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Prostatitis
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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

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Acute Bacterial Prostatitis
Infection of the prostate
Causative agents: Gram negative bacteria,
E. Coli
Nonbacterial prostatitis – young men

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Presentation/Exam

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Fever/Chills
Low back pain
Dysuria
Urgency
Frequency
Nocturia
Diagnostic Tests

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Chlamydia
Mycoplasma
Gardnerella
Urine culture – positive for causative agent
Acute Bacterial Prostatitis –
Management

Hospitalization if septicemia or urinary retention is suspected

Possible agents:

Trimethoprim Sulfamethoxizole (Bactrim)
Ofloxacin
Ciprofloxacin

Chronic: Finasteride (Proscar) – lowers the amount of testosterone; prostate shrinks; SE: less interest in sex and
erectile/ejaculation problems

Sitz bath TID for 30 minutes each treatment

No sexual intercourse until acute phase resolves
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Balanitis
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Balanitis
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

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Balanitis
Symptoms of Balanitis

Itching and tenderness

Pain, local edema and dysuria

Urethritis with or without discharge

Painful erection with altered sexual function

Rarely: severe ulcerations which may lead to superimposed bacterial infections

Rarely: lymph node enlargement
Balanitis: Causes & Risk Factors
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

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Types of Balanitis

Candidal

Trichomonal

Mycoplasma

Chlamydial

Anaerobic
Candidal Balanitis
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

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Treatment
Pharmacologic:
Analgesics
Ointment & Creams
Topical corticosteroids
Antibiotics
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Balanitis: Non-Pharmacologic Treatment

Hygiene:

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Retraction and bathing of prepuce several times daily

Warm sitz baths:

If a Foley catheter is used: strict catheter care
Ease edema and erythema
Circumcision:

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
Pharmacologic Treatment: Analgesics

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
Pharmacologic Treatment

Clotrimazole 1% cream: topical cream; kills fungi and yeasts by interfering with their cell membranes

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

Topical Corticosteroids: QID for severe dermatitis

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Balanitis: Considerations

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Betamethasone: apply thin film BID
Always assess for evidence of other STDs in sexually active men
If lesions do not heal, refer for biopsy (i.e., pre-malignant/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

Progressive, benign hyperplasia of prostate gland tissue

By 50 years, ~ 50% of men

By 80 years, ~ 80%-90% of men

Etiology is unknown

The most common cause of bladder obstruction in men over the age of 50 years
BPH – Symptoms
(He’s got the ‘goes’ - maybe)
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Frequency

Urgency

Nocturia

Dribbling

Retention
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BPH – Physical Exam

Bladder distention may be present

Prostate is nontender with either asymmetrical or symmetrical enlargement

Smooth, rubbery consistency with possible nodules
BPH – Diagnostic Tests

U/A - rules out UTI, no hematuria

Uroflowmetry

Abdominal ultrasound - rule out upper tract pathology

Serum creatinine/BUN normal

American Urological Association-International Prostate Symptom Score (AUA/IPSS)
PSA Normal Levels
(Age-specific ranges based on having had a previous PSA < 4 ng/mL)
Age 40-49 years: < 2.5 ng/mL

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Major
Reasons for PSA Elevation:
Prostate
Cancer
Prostate Enlargement
Prostatitis
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Relative Risk of Prostate Enlargement by PSA Level
(Wright et al., 2002; http://www.avodart.com/m07_01.html)
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BPH – Management

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

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Herbal preparations (saw palmetto?) – not FDA regulated
Minimally invasive procedures (numerous)
Surgery
BPH Pharmacotherapy
Alpha adrenergic blockers
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Originally developed to treat HTN

Relax smooth muscle in the prostate and around the bladder neck

Similar efficacy

Best for normal-sized to moderately enlarged prostates

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
Warnings/Considerations:

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

Can lower blood pressure to unhealthy levels when taken with erectile dysfunction drugs such as sildenafil (Viagra), vardenafil
(Levitra) and tadalafil (Cialis)

Follow up every 3-6 months during the first year of therapy
Enzyme (5-alpha-reductase) inhibitors for BPH

Shrink the prostate

Reduces the amount of testosterone that turns into dihydrotestosterone (DHT), a hormone required for prostate gland growth

Attaches to receptors on the prostate cells; encourages them to grow/multiply

Inhibitors reduce the prostate's "appetite" for DHT by reducing the number of receptor sites where DHT can attach
for BPH
Equally effective

Take longer to work ~ 3 – 6 months

More costly than alpha blockers

Increase urine flow rate

Reduce urinary symptom index scores by an average of 3 points
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for BPH

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

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How safe are the newer 5-alpha-reductase inhibitors?
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
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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

Hepatic impairment – not studied

PSA reestablished after 6 months – isolated should be doubled after 6 months for comparison to prestudy
baseline
Adverse events:
Impotence
Decreased libido
Ejaculation disorders
Gynecomastia
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Alpha blockers + 5-alpha-reductase inhibitors
Combination Therapy for BPH

Most tested: doxazosin + finasteride

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

Side effects – assumed similar to the combination effect (not significantly studied)
Saw palmetto

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)
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Prostate Cancer
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PROSTATE CANCER
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Most common form of cancer, other than skin cancer, among men in the United States

# 2 cause of cancer-related death among men

About 70% of all diagnosed prostate cancers are found in men aged 65 years or older

Over the past 20 years, the survival rate for prostate cancer has increased from 67% to 97%

Death rate higher for African-American men than for any other racial or ethnic group

Cause unknown; High-fat diets are implicated
Symptoms
ASYMPTOMATIC
May appear to be BPH
In later stages:

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Bone pain
Uremia
Prostate Cancer - Examination
Adenopathy
Bladder distension
Prostate palpates harder than normal

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Prostate Cancer –Tests

Prostate-specific antigen (PSA) > 4 abnormal

Approximately 40% of prostate cancer patients present with normal PSA values!
(not a very sensitive test!)
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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
Erectile Dysfunction (ED)
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!

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What Causes Erectile Dysfunction?

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
Causes of ED: Diuretics & Antihypertensives

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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)
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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)
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Causes of ED: Antihistamines
Dimehydrinate (Dramamine)
Diphenhydramine (Benadryl)
Hydroxyzine (Vistaril)
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Meclizine (Antivert)
Promethazine (Phenergan)
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Causes of ED
NSAIDS
Naproxen (Anaprox, Naprelan, Naprosyn)
Indomethacin (Indocin)
Muscle Relaxants
Cyclobenzaprine (Flexeril)
Orphenadrine (Norflex)
Anti-arrythmics
Disopyramide (Norpace)
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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)
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Causes of ED
Recreational Drugs
Alcohol
Amphetamines
Barbiturates
Cocaine
Marijuana
Methadone
Nicotine
Opiates
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Erectile Dysfunction: Treatment

Medication choices:

sildenafil (Viagra)

vardenafil (Levitra)

tadalafil (Cialis)
…known as the
phosphodiesterase inhibitors
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Phosphodiesterase (PDE) inhibitors

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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
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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
Phosphodiesterase (PDE) inhibitors
Erectile Dysfunction:
BREAKING NEWS
New ED Drugs On The Way!
(DeNoon & Chang, 2006)
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One works fast

One lasts long

One promises to be the next best thing to a cure!
Near a Cure for Erectile Dysfunction?
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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

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:

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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!
Additional Findings:
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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
Long Acting Erection Drug, SLx-2101 (Goldstein, 2006)
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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:

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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!!)
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
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Men’s STDs/STIs Update
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Herpes Genitalis
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Herpes Genitalis
Cause:

Herpes simplex virus (HSV) types 1 and 2
90-95% of genital herpes caused by type 2
Prevalence:

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Primary infections ~ 200,000 annually
Recurrent infections more common
Estimated > 45 million Americans infected
1/5 adolescents (> 12 years old) and adults infected
Genital Herpes: Initial Visits to Physicians’ Offices (1996-2004)
http://www.cdc.gov/std/stats/tables/table47.htm
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Herpes Genitalis: Presentation

Pruritic vesicles
Vesicles rupture to form shallow ulcers
Resolve spontaneously
Viral shedding occurs intermittently without clinical symptoms
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Genital Herpes
What about asymptomatic
viral shedding,
especially in discordant couples?
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Genital Warts
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GENITAL WARTS
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Single or multiple soft, fleshing, papillary or sessile, painless keratinized growth around anus, penis, urethra or
perineum
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GENITAL WARTS (Condyloma acuminata)
Cause: Human papillomavirus (HPV)
Prevalence:
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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
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

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GENITAL WARTS Treatment

Remove warts

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Risk is 17 times higher among gay and bisexual men, as well as those with compromised immune systems (HIV)
Cryosurgery
Trichloroacetic acid (TCA)
Bichloroacetic acid (BCA)
Laser treatment
No therapy has been shown to completely eradicate HPV
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Chlamydia
Chlamydia: Signs/Symptoms
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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

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Ceftriaxone 125 mg IM x 1 dose
Report to Health Department (in most states)
Gonorrhea
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Gonorrhea
Cause: Neisseria gonorrheae, a gram-negative diplococcus
Prevalence:
Most commonly reported communicable disease in the United States
Estimated 1.5 million per year
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Gonorrhea:
Symptoms

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Dysuria
Increased frequency of urination
Purulent urethral discharge
Testicular pain
Many to most patients may be asymptomatic
Gonorrhea
Diagnosis: DNA probe or culture
Treatment:
Ceftriaxone (Rocephin) 125 mg IM x 1 dose
Report to the health department

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Syphilis
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Syphilis
Cause: Treponema pallidum, a spirochete with 6 to 14 regular spirals
Prevalence:
40,000 cases annually in the United States

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Highest level in the past 40 years
Syphilis: Symptoms
Primary:
Chancre is painless
Indurated ulcer
Located at the site of exposure
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Syphilis: Symptoms
Latent:
Seropositive
Asymptomatic
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Syphilis Chancre
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Secondary syphilis - palms and soles
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Syphilis
Serologic
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Tests:
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Nontreponemal: VDRL/RPR

Treponemal tests:

FTA-ABS (fluorescent treponemal antibody absorption

MHA-TP (microhemaglutination assay for antibody to T. pallidum)
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
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Chancroid
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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

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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%
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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
Lymphogranuloma Venereum (LGV)
Cause: Immunotypes L1, L2 or L3 of Chlamydia trachomatis
Prevalence:
Endemic in Asia, Africa and large cities in the United States
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LGV: Symptoms

2 to 3 mm painless vesicle, bubo or non-indurated ulcer

Regional adenopathy follows in approximately one month

Stiffness and aching in groin followed by unilateral swelling of inguinal region
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Lymphogranuloma Venereum
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LGV
Diagnosis:
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May be confused with chancroid

Definitive diagnosis requires isolating C. trachomatis from an appropriate specimen and
confirming isolate as an LGV immunotype
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
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