Our New Focus on Sleep

“Sleep is a topic that I have become extremely interested in. It’s a topic that, I will be honest, that I probably ignored more than I should in terms of my Men’s Health practice up until several years ago. When I was at Hopkins, I had the benefit of working very closely with the sleep medicine program there. One of the physicians there I became very good friends with.

The more we looked at it, in screening for problems, especially as, for instance, sleep apnea or insomnia. But there are other problems, such as a lack of sleep, shift disorder, where it just throws your whole circadian rhythm off. We were picking up quite a few men in my Men’s Health practice, who again were coming in for sexual health issues, but I would pick up sleep problems. So 30 to 40% of the men that I would see coming in to me for ED, low testosterone, we would pick up a concern in the area of Sleep Medicine. It could be sleep apnea. That’s probably the one that has the greatest link to cardiovascular risk. Some had insomnia. Some men just weren’t getting enough sleep.

If you’re getting less than six hours sleep a night, you really put yourself at significantly increased cardiovascular risk. I was picking up men who were just having that sleep deprivation. And I picked up a lot of men that were on shift disorders, that were late night workers and were having problems there.

We really want to focus a lot on sleep, because we know we’re going to pick up a lot of it.

So sleep’s important. It’s a major part of Men’s Health and I look forward to really developing a good working relationship with the sleep medicine centers and colleagues who run Sleep Medicine centers in the Nashville area. Because just like I’m sure I’m going to pick up a lot of sleep problems, I’m sure that they have many men in their practice who have erectile dysfunction or Sexual Health issues that need to be addressed.

So sleep’s important for erectile dysfunction and testosterone. As a matter of fact, if you have low testosterone, and you have sleep apnea, you really ought to have the apnea addressed first before you treat a man with low testosterone. There’s a lot of interplay there. That’s a very important aspect of Men’s Health.”

Linking Sexual Medicine & Cardiology

“I have a long history of interacting and working with Cardiologists. Actually, this started over 25 years ago, when I took my first faculty position at the University of Minnesota, and I was in charge of the Erectile Dysfunction Clinic. What I noticed was that men in their thirties, forties, fifties were coming in to me – mostly men in their forties and fifties – after either an angioplasty, after a heart attack, and they were coming in to me for their ED. And as I was treating them, and I was working them up, I would just ask them, ‘When did you first develop erectile dysfunction problems? Was it after your heart problems, or before?’ And I was getting 2/3 of these men, who on the surface looked fairly healthy, they weren’t medical train wrecks, but they were telling me that they had ED anywhere from 3 to 5 years before their heart problems.

I kept hearing that story over and over and over again. And it just so happened that my fellowship training – I did a three-year research fellowship, after Urology residency – was all on Vascular Biology and Vascular Medicine. So it clicked with me that there was something more going on.

So I just approached my Cardiology colleagues, and I said, ‘Look, I think there’s something more going on. Tell me about heart disease.’ And I would tell them about the penis, and the blood flow, and why we thought it was a marker. And to make a long story short, this was 25 years ago.

If you look at the literature now, it’s very clear. The things that were somewhat speculative before, are now very clear, that erectile dysfunction can be an early marker. But what it did for me early on was, I worked very closely with Cardiology, because when I pick a man up, one of the things I said is, ‘This guy may need a preventive Cardiology work up.’ So some of the latest research that we’ve done has shown, not only do you need for instance a stress test, if you have erectile dysfunction, especially if you’re a man between, say, 40 and 50, or, say, 40 to 60, that you probably need, if you have erectile dysfunction, there’s a good chance that you need to be further evaluated.

Now, that could be Primary Care. A lot of times it’s Cardiology. So we may get a stress test, we may actually get what’s called a calcium score, to look for sub-clinical or undetected cardiovascular disease. So the Cardiology link has been really critical with what I do, because I think it’s the most important link with erectile dysfunction.

So I have a great relationship with my Cardiology colleagues, especially once they get to know me. Because, at first it was like, ‘Why is this Urologist sending these problems in?’ But once we talk, then we have a great rapport, it becomes a two-way street. There’s a lot that I’m going to see, I’m going to send to them. And I’ll tell you, we pick up men, who come in, who look fairly healthy, with erectile dysfunction. They go to Cardiology, they get assessed, they pick up blockage in the coronary arteries that needs to have intervention. So, we do pick these men up.

On the other hand, I tell my Cardiology friends, ‘Look, many of the men who you see have erectile dysfunction. And I know that you’re busy, and you have a lot of things that you’re focusing on. But these men, a lot of them have ED. If you’re too busy, or if you are uncomfortable, send them in to see me.’ Because one of the things that we do know is, many men in a Cardiology practice will be on medicines, where the pills aren’t the best option for them, or aren’t really a good option, so they need to come in for injections.

So what started out 25 years ago as really kind of an observation that developed into a lot of research, has really turned into a great two-way pathway. Especially at Hopkins, I had a great relationship. Matter of fact, I was actually an adjunct member of the Preventive Cardiology Group there. That’s how closely we worked together.”

Collaborating with Urology Colleagues

“I am a Urologist by training. So I went to Johns Hopkins for my residency. I did a fellowship after residency, where I specialized in Sexual Medicine issues, and blood flow-related issues. I have a physician assistant who’s working with me, Ken Mitchell. He also is a fully trained Urology PA. But initially, Ken started in Family Medicine, so his core is Family Medicine, but he then worked with a Urology group, so he’s a fully Urology-trained PA who also specializes in Sexual Medicine. I know Urology in and out.

For the past 20, 25 years, my practice has focused on Sexual Medicine. So I did mostly the medical side of erectile dysfunction, low testosterone, I did Peyronie’s and I did the medical management for the BPH that we see.

Many times in my Sexual Medicine practice I pick up a lot of General Urology concerns. I’ll pick up men that have elevated PSA’s. Whether you just pick them up, or with testosterone therapy, they need to have a prostate biopsy. I would refer those to my colleagues who did General Urology. We often times will get to the point where the medical management for the BPH just wasn’t adequate and the men needed additional therapy, and those were actually referred in. So, even though I’m a Urologist, my area of interest is very focused and niched at this point, so that General Urology really becomes another referral for me.

And so, I spend a lot of time talking with my colleagues. One, because I’m going send a lot of things out to them and I want to have a very smooth exchange. And the second thing is, many of them are quite busy with General Urology and they’ll send some of the erectile dysfunction issues that they want to send to me.

I’m very happy that I trained as a Urologist, I think it’s given me a very unique perspective on my Men’s Health, Sexual Medicine career now.

I also in the past, the surgeries I used to do, I used to do a lot of penile prostheses surgery. I do not plan to that at Precision Men’s Health, because we’re really focused on setting up a medical management type program. But again, from a Urology perspective, having done these surgeries, I know exactly how to work these men up. I know that having a prosthesis at the right time is an excellent treatment option.

And so, really what I’m looking for in my Urology colleagues, somebody who I like and trust, so when I refer people I know they’re getting good care. It’s not really a matter of, ‘Will I be referring? It’s more finding a like-minded provider that we can work together, so that the patient will get overall the best care.”

Close Collaboration with Endocrinology

“Another group that we refer to quite commonly and work closely with are Endocrinologists. Several reasons for this. One: Endocrinologists see a lot of diabetics and they usually see the diabetics who have the most severe problem. So it’s not at all uncommon that their men with diabetes that they see are going to have erectile dysfunction, and so it’s a natural referral. And not only do they have erectile dysfunction, men with diabetes tend to have the more severe type of erectile dysfunction, so that the pills often are not satisfactory and they end up needing injections or surgery or other things. So, that’s one area.

The other area that we actually get that we see quite a bit with Endocrinology is the area of low testosterone. Because even though my Endocrinology colleagues are quite good at treating low testosterone, sometimes they are so consumed with everything else they have to do that they’ll send patients. And the most common patients I see who maybe have undetected low testosterone are the diabetics who come and who are not responding well to therapy. We may pick up that their testosterone is low and with some of these men, when you treat it, they can actually get a better response to managing their blood sugar.

So, certainly we get a lot of referrals in from Endocrinology, but there are also a lot of referrals out. So, for instance, we pick up a lot of men that maybe have thyroid problems that need a very thorough workup and those I would send out to Endocrinology.

Some of the more complex Endocrine cases that we may see are younger men. Prolactin is another one of the things that we can see elevated that maybe comes from what’s called the pituitary gland that can trigger erectile dysfunction. Those I would send in to my Endocrinology colleagues who specialize in this area.

So it’s another good example of a two-way referral pattern, but also an important interaction in order for men to ultimately get the best care. It’s another group that we work very closely with.”

Urinary and Sexual Disorders After Laparoscopic TME for Rectal Cancer in Males

BACKGROUND: Urinary and sexual dysfunctions are frequent after surgery for rectal cancer. Total mesorectal excision (TME) improves local recurrence and survival rates, and does not hamper recognition and sparing of hypogastric and pelvic splanchnic nerves. It is not known how laparoscopic rectal resection could change functional complication rates.

MATERIALS AND METHODS: From a global series of 1,216 laparoscopic interventions for colorectal diseases, 35 cases of males less than 70 years old, undergoing rectal resection and TME for a T1-3M0 medium and low rectal cancer were selected. Urinary and sexual functions after the operations were retrospectively recorded by means of specific tools (International Prostate Symptom Score (IPSS) and IIEF questionnaires, respectively).

RESULTS: None of the patients necessitated permanent or intermittent catheterization. More than half the patients had no complaints about urinary functions; about one third had nocturia; 72% of the patients had an IPSS less that 10, and no case of IPSS worse that 31 was recorded. Sexual desire was reduced and spontaneous erectile function was impaired in almost half the cases, while induced erections were possible in about 90% of cases; about 70% of patients still had the possibility of penetration and a normal ejaculation and orgasm after the intervention.

DISCUSSION AND CONCLUSIONS: The present series confirms previous data and contribute to the creation of a benchmark specifically related to the laparoscopic approach to which surgeons should face when informing the patients before the operation. While severe urinary dysfunction is rare, sexual impairment remains a serious concern after rectal resection with TME.

The International Index of Erectile Function (IIEF):  a state-of-the-science review

The International Index of Erectile Function (IIEF): a state-of-the-science review

The International Index of Erectile Function (IIEF) is a widely used, multi-dimensional self-report instrument for the evaluation of male sexual function. It is has been recommended as a primary endpoint for clinical trials of erectile dysfunction (ED) and for diagnostic evaluation of ED severity. The IIEF was developed in conjunction with the clinical trial program for sildenafil, and has since been adopted as the ‘gold standard’ measure for efficacy assessment in clinical trials of ED. It has been linguistically validated in 32 languages and used as a primary endpoint in more than 50 clinical trials. This review summarizes early stages in the psychometric validation of the instrument, its subsequent adoption in randomized clinical trials with sildenafil and other ED therapies, and its use in classifying ED severity and prevalence. The IIEF meets psychometric criteria for test reliability and validity, has a high degree of sensitivity and specificity, and correlates well with other measures of treatment outcome. It has demonstrated consistent and robust treatment responsiveness in studies in USA, Europe and Asia, as well as in a wide range of etiological subgroups. Although only one direct comparator trial has been performed to date, the IIEF is also sensitive to therapeutic effects with treatment agents other than sildenafil. A severity classification for ED has recently been developed, in addition to a brief screening version of the instrument. This review includes the strengths as well as limitations of the IIEF, along with some potential areas for future research.

Male sexual dysfunction after rectal cancer surgery

PURPOSE: The aims of the study were to determine the extent of male sexual dysfunction after surgical treatment of rectal cancer and to examine the outcome of postoperative treatment with sildenafil.

METHODS: A prospective study was performed in patients who underwent attempted curative total mesorectal excision (TME) for low rectal cancers. Sexual function scores were determined by questionnaire preoperatively and at 3 and 12 months postoperatively. Outcomes were examined in patients who were sexually active preoperatively.

RESULTS: From 2000 to 2007, 207 patients underwent TME at our institution, of whom 49 (24%) were sexually active preoperatively. Erectile dysfunction and ejaculatory problems were present in 80% and 82%, respectively of the 49 patients at 3 months postoperatively, and in 76% and 67%, respectively at 12 months. Lateral lymph node dissection was a strong risk factor for postoperative sexual dysfunction. The impotency rate was 37% and 47% of patients were unable to ejaculate. Sildenafil was administered to 16 patients who requested the drug during follow-up, and sexual dysfunction was improved in 11 of these patients (69%).

CONCLUSION: Sexual dysfunction occurs frequently after rectal cancer treatment and is mainly caused by surgical damage in lateral lymph node dissection. Sildenafil may be effective for the treatment of sexual dysfunction.

Risk factors for sexual dysfunction after rectal cancer treatment

This study aimed to identify risk factors for long-term sexual dysfunction (SD) after rectal cancer treatment. Patients with resectable rectal cancer were randomised to total mesorectal excision with or without preoperative radiotherapy (PRT). Preoperatively and at 3, 6, 12, 18 and 24 months postoperatively, SD scores were filled out in questionnaires. Possible risk factors for postoperative deterioration of sexual functioning, including patients’ demographics, tumour-specific factors and treatment-related variables, were investigated with univariate and multivariable regression analyses. Increase in general SD, erectile dysfunction and ejaculatory problems were reported by 76.4, 79.8 and 72.2 percent of the male patients, respectively. Risk factors were nerve damage, blood loss, anastomotic leakage, PRT and the presence of a stoma. In female patients, increase in general SD, dyspareunia and vaginal dryness were reported by 61.5, 59.1 and 56.6 percent, respectively. This was associated with PRT and the presence of a stoma. SD occurs frequently after rectal cancer treatment and is caused by surgical (nerve) damage with an additional effect of PRT. Patients should be informed preoperatively, and education of surgeons in neuroanatomy may provide the key to the improvement of functional outcome.

Total Cholesterol and High Density Lipoprotein Cholesterol as Important Predictors of Erectile Dysfunction

Although erectile dysfunction is frequently seen in patients with manifestations of arteriosclerotic disease, the independent contribution of serum cholesterol in predicting erectile dysfunction is unclear. The aim of this study was to examine the relation between serum cholesterol and erectile dysfunction. Medical histories, physical examinations, and blood tests were obtained at Cooper Clinic, Dallas, Texas, from 3,250 men aged 26-83 years (mean, 51 years) without erectile dysfunction at their first visit, who had one more clinic visit, all between 1987 and 1991. These men were followed 6-48 months after the first clinic visit (mean, 22 months). Erectile dysfunction was reported in 71 men (2.2%) during follow-up. Every mmol/liter of increase in total cholesterol was associated with 1.32 times the risk of erectile dysfunction (95% confidence interval 1.04-1.68), while every mmol/liter of increase in high density lipoprotein cholesterol was associated with 0.38 times the risk (95% confidence interval 0.18-0.80). Men with a high density lipoprotein cholesterol measurement over 1.55 mmol/liter (60 mg/dl) had 0.30 times the risk (95% confidence interval 0.09-1.03) as did men with less than 0.78 mmol/liter (30 mg/dl). Men with total cholesterol over 6.21 mmol/liter (240 mg/dl) had 1.83 times the risk (95% confidence interval 1.00-3.37) as did men with less than 4.65 mmol/liter (180 mg/dl). Those differences remained essentially unchanged after adjustment for other potential confounders. The authors conclude that a high level of total cholesterol and a low level of high density lipoprotein cholesterol are important risk factors for erectile dysfunction.

The ‘Oh by the Way’ Question About ED

“One of the things that a lot of my friends in primary care tell me is, they will be doing their evaluation. They have multiple problems they to look at, and then they get I call the ‘oh, by the way’ handshake at the door, and you’ll be getting up to leave, and as you’re shaking the patient’s hand, they’ll say, “Oh, by the way, there’s one more thing I wanna talk to you about.” And everyone knows what it is. It’s usually, erectile dysfunction, your head kinda drops because you’re like, “Boy, this is at the end of the visit.” So, what do you do? And a lot of times, at that point, you really can’t address it at that visit, so either you have to schedule them back, or you have to hurriedly give them some sort of therapy, or some sort of treatment.

The reason that goes on is because a lot of times that’s why the man came in. And they’ve been kinda sitting on their hands the whole time waiting to be asked. And again, it’s not that other practices can’t do that, of course they can. But that what we are specifically designed and geared to do. So a lot of times when you come in to me, I already know you have the problem, ’cause you’re coming in for that. But when I’ve spoken to a lot of my primary care colleagues, they really appreciate the fact that, if they pick that up, there’s somewhere they can send them, where they know, not only are we gonna take good care of the sexual medicine issue, but we’re gonna communicate that back to them, what’s going on. And we really wanna work with them, so that we can address all the underlying reasons that they have the erectile dysfunction in the first place.”