Raising Hope for Fading Manhood

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Dr Ho Siew Hong lectured to participants of 'Clarifiying Misconceptions' Public Forum

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Raising Hope for Fading Manhood

  1. 1. Raising Hope for Fading Manhood Dr Ho Siew Hong Consultant Urologist S H Ho Urology and Laparoscopy Centre Gleneagles Hospital
  2. 2. Fading manhood – Myth or Fact? <ul><li>Aging </li></ul><ul><li>Females --> Menopause </li></ul><ul><li>Men-no-pause </li></ul><ul><li>Gradual process </li></ul>
  3. 3. Changes as a man ages <ul><li>Muscle and bone structure </li></ul><ul><li>Fat distribution </li></ul><ul><li>Mental – short term memory, concentration, restful sleep </li></ul><ul><li>Medical problems – hypertension, diabetes, heart diseases, prostate problems </li></ul><ul><li>Sexual function – erectile dysfunction </li></ul>
  4. 4. What is Erectile Dysfunction (ED) ? <ul><li>Consistent or recurrent inability of a man to attain and/or maintain a penile erection sufficient for sexual activity </li></ul><ul><li>Independent of sexual desire and the ability to have an orgasm and ejaculate </li></ul>National Institute of Health, USA
  5. 5. Hope for the fading manhood? <ul><li>YES </li></ul>
  6. 6. Do I have ED ? <ul><li>Doctor - Family Physician / Specialist </li></ul><ul><li>Medical and psychological history from patient and partner </li></ul><ul><li>Sexual history </li></ul><ul><li>IIEF Questionaire </li></ul><ul><li>Focused physical examination </li></ul>
  7. 7. Current treatment for ED <ul><li>Tablets – PDE 5 inhibitors </li></ul><ul><li>Testosterone replacement therapy </li></ul><ul><li>Intracavernosal injection </li></ul><ul><li>Vacuum device </li></ul><ul><li>Surgery </li></ul>
  8. 8. Oral erectogenic medications <ul><li>Phosphordiesterase inhibitors (PDE5I) </li></ul><ul><li>Approved for treatment of erectile dysfunction by FDA in 1998 </li></ul><ul><li>Arrived in shores of Singapore in 21 st century </li></ul><ul><li>1 st line of treatment for organic ED </li></ul><ul><li>Levitra, Viagra, Cialis </li></ul>
  9. 9. Are they effective? <ul><li>Effective in 80% - 84 % </li></ul><ul><li>Satisfactory erection for penetration </li></ul><ul><li>In the presence of sexual stimulation </li></ul><ul><li>Correct dosing </li></ul><ul><li>Correct method of administration </li></ul><ul><li>Less effective in patients with serious diabetes mellitus, hypertension and other long standing medical conditions </li></ul>
  10. 10. What are the side-effects? <ul><li>Headache 15% </li></ul><ul><li>Flushing 3 – 10% </li></ul><ul><li>N congestion 5 – 10% </li></ul><ul><li>Indigestion 3 - 10% </li></ul><ul><li>Visual disturbance (blue vision) 5% </li></ul>
  11. 11. Contra-indications <ul><li>All patients taking medications with nitrates </li></ul><ul><li>Caution: heart problems (ischaemic heart, valve) </li></ul><ul><li>Cause sudden and severely low blood pressure </li></ul>
  12. 12. How to use them effectively and safely? <ul><li>Only use with prescription from a doctor (not a friend !) </li></ul><ul><li>Regular check-ups with doctor </li></ul><ul><li>Correct dose, timing and expectation </li></ul><ul><li>Do not over dose or mix and match (more does not mean better !) </li></ul><ul><li>Talk to your partner </li></ul>
  13. 13. What if PDE5I is not effective?
  14. 14. In non-responders to PDE-5 inhibitors, look for co-morbidities <ul><li>Failure rate of 18 – 37% is reported </li></ul><ul><li>Depending on co-morbidities thereof: </li></ul><ul><li>Hypogonadism 50% </li></ul><ul><li>Diabetes mellitus 35% </li></ul><ul><li>LUTS / BPS 22% </li></ul><ul><li>Hypertension 23% </li></ul>Yassin et al. IJIR Vol. 14, Suppl. 3, 9/2002
  15. 15. Testosterone level and aging
  16. 16. Function of Testosterone Lower voice Muscle mass Body and facial hair Penile length and width increase Mental – aggressive, active, interest in opposite sex, libido, memory, concentration Acne Prostate enlarges
  17. 17. Late Onset Hypogonadism <ul><li>ADAM, PADAM, Andropause </li></ul><ul><li>‘ clinical and biochemical syndrome associated with advancing age and characterized by typical symptoms and a deficiency in serum testosterone levels. It may result insignificant detriment in the quality of life and adversely affect the function of multiple organ systems ’ </li></ul><ul><li>ISA, ISSAM, and EAU recommendations </li></ul><ul><li>SUA recommendations </li></ul>
  18. 18. Clinical manifestation of LOH <ul><li>The easily recognized features of diminished sexual desire (libido) and erectile quality and frequency, particularly nocturnal erections </li></ul><ul><li>Changes in mood with concomitant decreases in intellectual activity, cognitive functions, spatial orientation ability, fatigue, depressed mood and irritability </li></ul><ul><li>Sleep disturbances </li></ul><ul><li>Decrease in lean body mass with associated diminution in muscle volume and strength </li></ul><ul><li>Increase in visceral fat </li></ul><ul><li>Decrease in body hair and skin alterations </li></ul><ul><li>Decreased bone mineral density resulting in osteopenia, osteoporosis and increased risk of bone fractures </li></ul>
  19. 19. Diagnosing Andropause <ul><li>Symptoms </li></ul><ul><li>Blood tests: Testosterone </li></ul><ul><li>Tests usually done in the morning </li></ul>
  20. 20. Treatment for Andropause
  21. 21. Testosterone replacement therapy <ul><li>Tablets – Andriol </li></ul><ul><li>Injections - 3 weekly - 3 monthly (Nebido) </li></ul><ul><li>Skin patch, gel </li></ul>
  22. 22. Effect of Castration and Androgen Substitution on Trabecular Smooth Muscle and Connective Tissue Content in the Corpus cavernosum Traish A et al. Endocrinol 140(4): 1861-1868 (1999) Control Castrated + Vehicle Castrated + Testosterone
  23. 23. Overall Response Rate to Testosterone Treatment for Erectile Dysfunction in Hypogonadal Men: Results of a Meta-Analysis Jain P et al. J Urol 164: 371-375 (2000) 203 (57.02 %) 356 Total 14 (100 %) 14 Conway 1988 12 (100 %) 12 Skakkebaek 1981 22 (75.86 %) 29 Arver 1996 10 (43.48 %) 23 Morales 1997 3 (50 %) 6 Kwan 1983 5 (100 %) 5 Ahmed 1988 3 (75 %) 4 Carey 1988 6 (100 %) 6 Davidson 1979 6 (42.86 %) 14 Carani 1990 5 (38.46 %) 13 Benkert 1979 10 (100 %) 10 Nankin 1986 4 (100 %) 4 McClure 1991 10 (83.33 %) 12 Jacobs 1982 21 (95.45 %) 22 Spark 1980 12 (66.67 %) 18 Ou 1991 60 (36.59 %) 164 Baskin 1989
  24. 24. <ul><li>Testosterone treatment improves bone mineral density and may reduce the incidence of fractures. </li></ul><ul><li>Testosterone treatment improves body composition, muscle function, and erythropoiesis. </li></ul><ul><li>Testosterone treatment improves libido and nocturnal erections. </li></ul><ul><li>Pilot studies and ongoing clinical studies support the role of testosterone in the management of all components of the metabolic syndrome and its associated diseases. </li></ul>Summary and Conclusions
  25. 25. Monitoring and Safety <ul><li>Monitoring </li></ul><ul><li>Baseline: DRE, PSA, fasting lipids, Hb and Hct </li></ul><ul><li>Improvement in symptoms </li></ul><ul><li>DRE, PSA, Hb and Hct every 3 months for 1 st year, </li></ul><ul><li>then yearly, fasting lipids yearly </li></ul><ul><li>Safety </li></ul><ul><li>no clear relationship between HRT and prostate cancer </li></ul><ul><li>anecdotal reports linking HRT to prostate cancer </li></ul><ul><li>Not recommended in patients with or suspected of prostate cancer </li></ul>
  26. 26. Take home message <ul><li>There is hope for the fading manhood </li></ul><ul><li>PDE 5 inhibitor tablets are effective in 80% </li></ul><ul><li>Recognize condition of low male hormone (testosterone) </li></ul><ul><li>Testosterone replacement in selected patients is effective </li></ul><ul><li>Treatment must be discussed, administered and monitored by health care professionals </li></ul>
  27. 27. Thank you

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