From the 5th Edition of the Geriatrics Review Syllabus: Prostate Disease and Male Sexual Dysfunction

**sub**Benign Prostate Diseases **endsub** Tomas Griebling, MD, Assistant Professor of Urology and Assistant Scientist for the Center on Aging at the University of Kansas, Lawrence, KS, spoke about prostate disorders. He reviewed benign conditions of the prostate that affect older adults, including benign prostatic hyperplasia (BPH) and prostatitis. Benign Prostatic Hyperplasia Benign prostatic hyperplasia affects almost all men over the age of 40 in the U.S. Symptoms most commonly consist of urinary urgency, frequency, a decreased force in the urinary stream, nocturia, a feeling of incomplete emptying, and a sense of postvoid dribbling. The diagnosis is most commonly made using uroflowmetry, checking postvoid residual and elevated prostate-specific antigen (PSA) blood levels, and conducting a rectal examination. Dr. Griebling cautioned that the size of the prostate gland itself does not correlate with symptomatology, as men can have significant obstructive BPH with a relatively small prostate gland. Treatment for BPH usually begins with a type of alpha-blocker therapy, followed by finasteride, a 5-alpha reductase inhibitor that shrinks the prostate gland. Finasteride is most effective in men who are symptomatic and who have a large prostate, but it has a much slower onset of action (4-6 months) than the alpha-blockers. Furthermore, this medication, because of its effects on testosterone, will also alter PSA. The use of such drugs as finasteride as long-term, potential preventive medications for BPH is being examined. Surgical therapy for BPH includes transurethral resection of the prostate (TURP), a very safe procedure performed under general or regional anesthesia. Open prostatectomy, through a suprapubic or retropubic approach, is usually reserved for men who have very large glands (over 100 grams in size). The prostate is left intact, as opposed to radical prostatectomy, where it is removed. There are minimally invasive surgical techniques now available that involve applying some type of energy to the prostate, such as radiation, microwave thermotherapy, or prostatic stents, to decrease resistance in the bladder. Overall, most invasive techniques have shown to be promising, but none have had the overall success rate of transurethral resection, explained the speaker. Prostatitis Prostatitis is a common problem seen in both younger and older men. The two forms of prostatitis are acute and chronic prostatitis. Acute prostatitis is triggered by a bacterial infection and causes a prostatic loculated abscess, which is treated by TURP. Symptoms include dysuria, burning with urination, frequency, urgency, and pelvic pain. Diagnosis of prostatitis is made primarily by examination and a urinalysis. An elevated white cell count calls for a complete blood count. Diagnosis may also require obtaining prostatic secretions for examination, a post-prostate examination, a urine culture, or ultrasound. Treatment of prostatitis may be symptomatic, including warm sitz baths, dietary modification (eliminating foods rich in potassium, acids, or caffeine that can worsen symptoms), and developing a bowel regimen to eliminate constipation and pelvic discomfort. Short-term (about 2 weeks) antibiotic therapy is used for acute bacterial prostatitis, and long-term antibiotics may be considered with chronic prostatitis. Typical antibiotic choices include a fluoroquinolone, such as levofloxacin, ciprofloxacin, or doxycycline. Patients with an elevated PSA should be started on chronic antibiotics for 1-2 months. If the PSA level lowers, if is probably related to prostatitis, but if the level has not lowered or has elevated, the concern is for a prostate cancer. Summary Benign prostate diseases are very common in older men. The impacts of these disorders can be quite significant on patients, affecting clinical comorbidities, functional status, and quality of life. Treatment must include the most effective pharmacologic or surgical options, while considering the wishes of the patient and his family. Care must be individualized to each patient and be placed in the context of patients’ overall health. **sub**Disorders of Male Sexual Function **endsub** Thomas Mulligan, MD, Professor of Medicine and Service Line Chief of Geriatrics at Maguire Veterans Affairs Medical Center in Richmond, VA, began his talk with the case of a 46-year-old man who had a radical prostatectomy with nerve-sparing for early-stage prostate cancer. At 3-6 months after the surgery, the patient reported erectile dysfunction (ED), which typically diminishes approximately 12 months postsurgery. Permanent ED is associated with prostatectomy, explained Dr. Mulligan, but transient postsurgical ED occurs consistently with nerve-sparing, as those nerves are pulled out of the way and cut through to remove the prostate. Erectile dysfunction is defined as the inability to achieve or maintain an erection sufficient for satisfactory activity. About 40% of all men, and approximately 60% of 60-year-old men will have minimal, moderate, or complete ED. Erection depends upon several factors, including psychological background. For example, men who were sexually abused as children may have difficulty with ED. Erection is also dependent upon testosterone, primarily for libido, upon the autonomic and somatic nervous systems, and upon hydraulic mechanisms, such as penile arterial inflow and venous outflow. Dr. Mulligan simplified the process: “The neural component is such that the brain recognizes erotic stimuli, [such as] sight, sound, fantasy, smell…[and] ultimately, the limbic system processes these stimuli and the primary output is via the parasympathetic nervous system.” The nerve supply is carried through the pelvic plexus, which innervates the bladder, the prostate, the rectum, and the penis, and in men who have had a radical prostatectomy, it travels to the posterolateral portion of the prostate. The mechanism of erection is important in understanding flaccidity, which is maintained by tonic alpha-adrenergic activity in the sympathetic nervous system, causing contraction of the penile, arterial, and cavernosal smooth muscles, thus maintaining a high penile arterial resistance. The brain processes the erotic stimuli, causing a decrement in sympathetic activity, and thus a decrement in penile arterial resistance. There is an increase in parasympathetic activity, whereby impulses travel down to the penis via the cavernosal nerves, and a variety of neurotransmitters are released, including acetylcholine, vasoactive peptide, nitric oxide, and cyclic guanosine monophosphate. There is a markedly increased arterial inflow system with a diminished venous outflow system. Within the corpora cavernosa, pressure equilibrates to mean arterial pressure, which results in penile rigidity. Causes of ED Erectile dysfunction can be classified as organic, as a result of vascular disease, neurologic disease, or hormonal or cavernosal abnormalities, or as psychogenic, due to central inhibition of the erectile mechanism. The most common cause of ED is vascular disease. Risk of ED is increased with smoking, hypercholesterolemia, diabetes mellitus, and hypertension. Arterial occlusive disease can diminish arterial inflow, thus preventing the pressure that is needed for an erection, and can cause penile hypoxia, often resulting in trabecular fibrosis, which can lead to venous leakage syndrome. ED can also be caused by diabetes or Parkinson’s disease. Neurotransmitters must reach the penis to induce smooth muscle relaxation, which increases arterial inflow and mean arterial pressure to cause rigidity. Other common causes of ED may include pelvic injury, prostatectomy, and several medications. Drugs that have anticholinergic effects can interfere with the release of neurotransmitters that are necessary for erection. In addition, if arterial pressure drops too low, it can impair the ability to transfer enough pressure into the corpora cavernosa to create a rigid erection. “For years, people thought that you really needed testosterone for erections,” said Dr. Mulligan, but data from the literature has shown no link between testosterone and erections in the human (J Gen Intern Med, 1993). Testosterone is necessary for libido and it facilitates nerve conduction velocity along the pelvic nerve, but is not necessary for erection. Treatment If a patient complains of ED, the physician must first examine the historical factors in order to differentiate between psychogenic, medication-induced, and organic ED; the patient may simply be affected by lack of interest or difficulty with orgasm rather than flaccidity. If the patient’s libido is good, hypogonadism can be ruled out. An abrupt onset with no sleep- associated erections usually means drug-induced ED. Psychogenic ED has a sudden onset and present or persistent sleep-associated erections that are long-lasting. Patients with organic ED have a gradual onset of symptoms with no sleep-associated erections. Other factors to consider include a history of lipid disorders, tobacco use, hypertension, coronary disease, diabetes, peripheral arterial disease, alcoholism, stroke, or cardiovascular disease. A drug history should also be taken; alcohol, antidepressants, antihistamines, beta-blockers, hydrochlorothiazide, estrogen, and luteinizing hormone–releasing hormone (LHRH) agonists can all affect erectile function. A physical examination should be focused: a penile plaque indicates venous ED; autonomic neuropathy is most likely neurogenic ED; and a femoral bruit would indicate vascular or arteriogenic ED. Diagnostic intracavernosal injection with a vasoactive agent is recommended by some investigators to determine the etiology and the response to therapy (J Am Geriatr Soc, 1997). Physicians need to be aware of false claims, warned Dr. Mulligan. With psychogenic ED, often the patient only needs reassurance or possibly sex therapy. Treatment for patients with drug-induced ED is simply to eliminate or switch the offending drug. In a patient who has a decreased libido, a testosterone trial is recommended. Patients with organic ED may require vacuum devices, intracavernosal injections, intraurethral prostaglandin E1, oral sildenafil or vardenafil, or surgery. A vacuum device creates a vacuum that pumps blood into the penis and causes an erect-like state that is then maintained with a constrictor band. While these devices require manual dexterity and cut down on spontaneity, there is a one-time cost to purchase them, they are reusable, and they are noninvasive, reasonably functional devices. Intracavernosal injections, most commonly used with papaverine and prostaglandin E1, have been shown to be very effective, particularly in patients who did not respond to oral therapy. Papaverine induces smooth muscle relaxation. Although it is not yet approved by the U.S. Food and Drug Administration (FDA) for the treatment of ED, it was widely used and is inexpensive. Complications may include prolonged erections (10% of patients) or fibrosis (3%), and the indicated dose is 30-60 mg, with an onset of 10-15 minutes, lasting about 60 minutes. Prostaglandin E1, approved by the FDA, also induces smooth muscle relaxation, and thus vasodilation. It is less often associated with prolonged erections, but often results in penile pain and is more costly. The typical dose is 5-20 mcg, with onset similar to papaverine within 10-15 minutes, lasting about 60 minutes. Another treatment available is the FDA-approved medicated urethral system for erection (MUSE), a less invasive intrapenile injection. Complications include a higher frequency of pain, hypotension, and urethral trauma (about 6% of cases) because of the higher dosing requirements. The drug must be injected at 500-1000 mcg intraurethrally, deposited as a pellet that is absorbed into the corpora cavernosa. Sildenafil, the first available FDA-approved orally administered treatment for ED, inhibits phosphodiesterase type 5 and enhances the effect of nitric oxide, which increases cyclic guanosine monophosphate. However, it does not create an erection in the absence of sexual stimulation. Dosages used are 25-100 mcg with an onset of 60 minutes, lasting for about four hours. Sildenafil lowers blood pressure by about 10 mm Hg and is contraindicated in patients who use nitrates. Vardenafil, a newer phosphodiesterase inhibitor that will soon be released, has a better side-effect profile. Summary Erectile dysfunction is very common and has a negative impact on quality of life. Evaluation and treatment can easily be provided by a primary care physician, not just by a urologist.