RECOGNIZING SYMPTOMS OF AN ENLARGE PROSTATE

The prostate gland has two important functions: To produce ejaculatory fluid and to act as a barrier to retrograde UTIs. Prostate enlargement, or benign prostatic hyperplasia (BPH), can produce a constellation of unpleasant symptoms that result when the enlarged gland forces the bladder to work harder to expel urine. The prostatic obstruction is both anatomic (compression of the urethra) and dynamic (increased muscle tone of the prostate and bladder neck). Primary-care nurse practitioners and physician assistants are in an ideal position to recognize and evaluate the symptoms of BPH, review the differential diagnoses, recommend treatment, refer patients as necessary, and ensure follow-up. The Clinical Advisor spoke to Richard J. Macchia, MD, chair of the Department of Urology and a Distinguished Teaching Professor at the SUNY Downstate Medical School in Brooklyn, N.Y., and Ivan Rothman, ARNP, an NP with urology certification at the University of Washington Medical Center Urology Clinic and faculty member at the University of Washington School of Nursing in Seattle. Both clinicians have expertise in BPH, which affects nearly 50% of men aged 50 years and older.
Q: Who is most likely to get BPH?

Dr. Macchia: Any man is susceptible, but with age, an enlarged prostate becomes more and more likely.

Mr. Rothman: Generally, men diagnosed with BPH are older than 40.

Q: Which symptoms besides frequent urination should alert primary-care providers (PCPs) to the possibility of BPH?

Mr. Rothman: Be on the lookout for any kind of voiding problem. The two main types are irritative and obstructive. Irritative refers to frequency and urgency, and obstructive refers to difficulty starting, slow stream, and post-void dribbling. Waking up at night can be a problem in and of itself and is always worth evaluating. The best office-based diagnostic tools are the symptoms and the score on the American Urological Association (AUA) Symptom Index (SI) (available at www.auanet.org/guidelines/main_reports/bph_management/chapt_1_appendix.pdf, accessed July 8, 2008). This is a well-validated paper-and-pencil screening tool.

Dr. Macchia: Getting the AUA SI score is something any primary-care clinician can do. The patient answers seven self-administered questions about complete voiding, frequency, stopping and starting, urgency, weak stream, straining, and nocturia. Severity of symptoms is quantified by rating each on a scale of 0-5. A man with no symptoms would score 0, and a man with all the symptoms at maximum severity would score 35. When a patient comes to me with lower urinary tract symptoms (LUTS), I ask him to fill out the AUA SI. Any abnormality of urination should trigger the AUA inventory. The International Prostate Symptom Score is similar to the AUA SI.

In addition, ask patients about their “bother” factor: Two patients may have the same symptoms, but one will say, “We have to do something about this; it's driving me crazy,” while the other will tell you it's not a problem.

When patients complain of symptoms, be sure to obtain a complete history because there are many nonurologic causes of LUTS (e.g., diverticulitis). Basically, any pathology in the pelvis can present as LUTS. There is no substitute for a thorough history. Instruct patients to bring in all their medications. It is very difficult to care for patients without knowing what they are taking. What was listed in your notes three months ago is ancient history. In my experience, 30% of patients who state they are on the same medications as at the last office visit are, in fact, not.

After taking the patient's history, I conduct a physical examination with emphasis on the genitalia and prostate. The primary purpose of digital rectal examination (DRE) is to search for any lumps and bumps and to estimate the size of the prostate.

Q: Besides doing a DRE for an enlarged prostate, are there any other office-based diagnostic steps that can be taken?

Mr. Rothman: I always evaluate patients with voiding problems for infection and malignancy. With UTI, look for RBCs, WBCs, and bacteria in the urine. For malignancy, look for hematuria (RBCs).

Dr. Macchia: Dipsticks can be overly sensitive and give false positives for hematuria. I prefer the full urinalysis with microscopic examination, which can show the presence or absence of RBCs, WBCs, bacteria, fungi, and more. It is also important to know what formed elements are in the urine. Formed elements may be an indication that kidney disease is causing the hematuria.
Q: How often should prostate-specific antigen (PSA) be tested?

Dr. Macchia: After the history, the exam, and the full urinalysis, I discuss with the patient the advisability of measuring his PSA. Generally, I follow the AUA guidelines for PSA testing. It is prudent to follow the guidelines of some national organization. The AUA guidelines are fairly simple: If the patient is African American or has a family history of prostate cancer, he should be getting an annual prostate checkup starting at age 40. If he doesn't fall into either category, start at age 50. While PSA-based true population screening is controversial, what you do in your office with a given patient is straightforward. Failure to discuss the pros and cons of PSA testing with a patient can have unpleasant medical and legal repercussions.

Mr. Rothman: The value of the PSA test is keenly debated. PSA recommendations, which were due to be released by a subcommittee of the AUA in May 2008, have been delayed while members sort through the considerations. Of course, you look at the PSA to screen for prostate cancer. There is no reason you would use it to evaluate voiding dysfunction per se.
Q: When do you order ultrasound or x-rays?

Dr. Macchia: In patients with bothersome or high-score LUTS, I do a simple in-office sonogram to determine whether or not the patient has a significant amount of postvoid residual urine (PVR). In an adult male, we would like to see PVR <100 a="" an="" and="" aua="" biopsy.="" br="" bump="" can="" cc.="" conjunction="" considerable="" diagnosis="" doesn="" either="" elevation="" found="" general="" give="" in="" information="" is="" it="" lead="" lump="" misery.="" more="" nobody="" obtain="" of="" only="" or="" performed="" prostate.="" prostate="" psa="" pvr="" score="" should="" si="" similar="" sonogram="" t="" testing="" that="" the="" there="" to="" unindicated="" unless="" with="" you="">
But some clinicians are ordering prostate sonograms routinely, and like all other tests, sonograms have false positives.

Mr. Rothman: Nonspecific, hypoechoic lesions that are indistinguishable from prostate cancer may show up on prostate ultrasound. One should be wary of ordering prostate ultrasound in men older than 40 without a biopsy.
Q: What signs or symptoms warrant referral to a urologist?

Mr. Rothman: You should refer if the patient has blood in the urine and needs a workup for malignancy. Also refer if one or two attempts at drug therapy have not controlled voiding symptoms to the patient's satisfaction.
Dr. Macchia: Refer any patient with LUTS for which you do not have a specific diagnosis, LUTS you cannot eliminate, an abnormal PSA (based on whatever criteria you use), any abnormality on the rectal exam (especially a lump or bump), or hematuria.

Q: What medications are available?

Dr. Macchia: If you think it is likely that the patient has bothersome LUTS or a large PVR attributable to BPH, the first step is to treat with medication. The most commonly prescribed drugs are the alpha blockers tamsulosin (Flomax) and alfuzosin (Uroxatral). I also use the alpha blockers doxazosin (Cardura) and terazosin (Hytrin). By reducing the dynamic outflow obstruction, the strength of the urinary stream can be immediately improved, as can the PVR. Irritability of the bladder can also be decreased over time. One needs to look at both the approved and commonly used off-label dosages for the alpha blockers. I often use higher-than-approved doses of alpha blockers in an attempt to avoid surgery, especially in patients with multiple conditions that raise the risk of morbidity. You must document and advise the patient whenever any medication is used in an off-label manner.
If the prostate is more dramatically enlarged, you can simultaneously start a 5a-reductase inhibitor (e.g., finasteride [Proscar] or dutasteride [Avodart]), which shrinks the prostate. Be aware that these drugs reduce PSA by 50% over time, and this must be taken into account when using PSA to screen for cancer. You really want to max out the pharmacologic therapy before referring for minimally invasive surgery. Many drug companies have informational booklets, and I encourage passing these on to patients.

Mr. Rothman: Alpha blockers are first-line therapy. There is not enough evidence to say one is better than the others. I start with the least expensive or most easily tolerated alpha blocker. If that does not work, change to another one. If you use an alpha blocker with a variable dose, increasing the dose is reasonable. It is also reasonable to add a 5a-reductase inhibitor to an alpha blocker. Most men with BPH are treated by primary-care providers. The AUA SI can be used effectively for monitoring response to therapy. Occasionally, when patients have severe irritative and obstructive symptoms, you may want to add an anticholinergic drug. This is best done in consultation with a urologist. As for nutraceutical supplements, I have seen one study in favor of and one study opposed to saw palmetto. I still recommend trying it; it's safe, easy to obtain, inexpensive, and potentially helpful. It also may help the patient adjust to the idea that he needs to take medication.

Sometimes symptoms of BPH occur in younger men who have never had chronic illness. Patients with BPH need to understand that they have a chronic illness, which needs treatment. The transition to prescription medications can be easier if you start with something OTC.
Q: What lifestyle changes do you recommend?

Dr. Macchia: While there are pathologic conditions that can cause nocturia and must be ruled out, the vast majority of cases are attributable to BPH. I tell patients that when the bladder fills up, they have to go to the bathroom whether it's in the middle of the day or the middle of the night. If they don't want to get up at night, I tell them to start restricting fluid intake four to six hours before going to sleep. I say, “You have the other 18-20 hours of the day to drink all you want.” If people drink fluids at night, especially if they're already well hydrated, their kidneys will put out more and more urine. Alcohol is a special case because it's a diuretic.

A heart-healthy lifestyle is probably good for the prostate. Supplements and minerals are being vigorously promoted, with few data to support their use. However, I recommend patients take a good men's daily multivitamin tablet. Does it work? That's hard to say. The problem with BPH is the 30% placebo rate. Sometimes BPH gets better on its own.
Mr. Rothman: Bus drivers, truck drivers, and airline pilots delay voiding for very long periods of time. This causes the bladder to stretch, become hypocontractile, and lose its ability to function. More frequent urination, when possible, would be beneficial.

Quitting smoking will help reduce prostate size, though we're not sure what the underlying mechanism is.
Q: What are the consequences of untreated BPH?

Dr. Macchia: Some patients with minimal symptoms might have a large PVR. I have had patients with more than 1,000 cc of residual urine who had no pain or other symptoms. The bladder had become chronically distended and desensitized. If that continues, the bladder loses its compliance. The muscle then becomes more and more inefficient at pushing out urine. Ultimately the muscle becomes a useless piece of tissue.

Mr. Rothman: Acute urinary retention has to be treated with catheterization and frequently with surgery to reduce prostate size. For patients with milder symptomatology though, there is no clear evidence that early treatment will prevent future problems.
Q: What misconceptions about BPH do patients often bring to their PCP?

Dr. Macchia: Far too many patients believe they are going to go back to urinating the way they did when they were in high school. The prostate gland and urinary system get old just like everything else. The symptoms of a vast majority of patients can be improved but not totally eliminated. Also, patients frequently do not realize that stress can cause urinary tract symptoms.
Q: What cautionary advice do you have for PCPs with regard to BPH diagnosis and treatment?

Dr. Macchia: It is a misconception that only enlarged prostates cause problems and that an enlarged prostate always causes a problem. A small prostate may lead to obstruction and a large one might not. Do not assume LUTS are attributable to BPH or a UTI, and always be careful to rule out a malignancy.

Ms. Lippert is a medical writer and editor in the New York City area.
Read On
* American Urological Association. Diagnosis of BPH. Available at: www.urologyhealth.org/adult/index.cfm?cat=09&topic=173, accessed July 8, 2008.
* American Urological Association. Management of BPH. Available at: www.auanet.org/guidelines/bph.cfm, accessed July 8, 2008.
* Cortlandt Forum. Benign prostatic hyperplasia: applying the guidelines to clinical practice. www.cortlandtforum.com/content/fileadmin/files
/Supplements/PDFs/BPH_CF.pdf, accessed July 8, 2008.
*  http://www.clinicaladvisor.com/recognizing-symptoms-of-an-enlarged-prostate/article/120878/

DETERMINING WHEN MEN NEED TESTOSTERONE

Klinefelter syndrome is a genetic disorder and cause of primary hypogonadism.

Testosterone deficiency, or hypogonadism, is the most common type of hormonal deficiency in men. In middle-aged men, testosterone levels decrease 1%-2% yearly with advancing age. Studies suggest that approximately 20% of men in their 60s and 50% of those in their 80s have low serum testosterone levels.¹ Obesity, metabolic syndrome, type 2 diabetes mellitus, and hypertension may increase the risk of hypogonadism.²

Men with testosterone deficiency have symptoms that are often underrecognized, underreported, or denied by the patient and the clinician alike. Some of the symptoms overlap with those of other chronic conditions, especially depression and fatigue. Key complaints that should lead to the suspicion of testosterone deficiency are changes in sexual function (especially a decline in erectile quality), libido, and ejaculate volume.³ Other symptoms include:

• Infertility 
• Decrease in beard and body hair growth 
• Increase in body fat 
• Decrease in size or firmness of testicles 
• Decrease in muscle mass 
• Development of breast tissue (gynecomastia) 
• Loss of bone mass (osteoporosis )

Testosterone deficiency can also contribute to mental and emotional changes. As testosterone levels decrease, some men may experience symptoms similar to those of menopause in women but without the certain cessation of reproductive function. Besides depression, these symptoms may include irritability, fatigue, and decreased sex drive.

Other than aging, there are several other causes of testosterone deficiency in an adult male, and these are categorized as primary, secondary, or combined. Causes of primary hypogonadism include Klinefelter syndrome (a chromosome abnormality), undescended testes, injury to the testes, or testicular damage attributable to radiation or chemotherapy.

Secondary hypogonadism results from failure of the pituitary to produce enough follicle-stimulating hormone and luteinizing hormone to stimulate the testes. Common causes include obesity, stress, aging, recreational drug use, and pituitary lesions or other endocrine causes.

Combined hypogonadism exhibits characteristics of both primary and secondary causes and is commonly seen with cirrhosis, aging, and sickle cell disease.

Clinical exam

The clinician should first investigate possible causes of acquired testicular failure (e.g., mumps orchitis, trauma, radiation exposure, surgery, and chemotherapy). Inquire about both prescription and recreational drug use, since certain agents (e.g., spironolactone, marijuana, heroin, and methadone) may interfere with testosterone synthesis. Establish whether there is a history of paternity—an indicator that at some point in the past, the testosterone level likely was normal.

The diagnosis of testosterone deficiency is based on examination findings and a test of the serum testosterone levels. Specific issues to consider in the physical exam include developmental anomalies in the genital system. Examine the genitalia for hypospadias (a congenital opening of the urethra on the undersurface of the penis), and check the scrotum for signs of cryptorchidism (undescended testes). Determine whether both testes are palpable, their position in the scrotum, and their consistency and size. Examine for signs of Klinefelter syndrome, such as tall stature (especially if the legs are disproportionately long), small or soft testes, and a eunuchoid body status, although many patients will not demonstrate a “typical” Klinefelter habitus. Finally, evaluate the extent of body virilization. Inquire about the rate of beard growth, libido and sexual function, muscle strength, and energy levels. Check for gynecomastia. The physical examination is typically unhelpful in making the diagnosis of testosterone deficiency, except in cases of profound and long-term hypogonadism.

From the July 2009 Issue of Clinical Advisor »

http://www.clinicaladvisor.com/determining-when-men-need-testosterone/article/139598/

FACT, PRESUMPTIONS and MYTHS of Obesity

What really causes Obesity?. Do you know someone who are obese and they believed that it has something to do with their genes? Or eating food with high in calorie content contribute to that obesity?. Mass media including the use of world wide web, social network, contribute to rapid dissemination of information regarding obesity, but what is the fact of obesity that is supported by science and what are these myths and presumptions regarding obesity? Many held belief about obesity are found to be not supported by science as suggested in the review of literature posted in The New England Journal of Medicine

According to Krista Casazza, PhD, RD from University of Alabama at Birmingham and colleagues, We define myths as beliefs held to be true despite substantial refuting evidence, presumptions as beliefs held to be true for which convincing evidence does not yet confirm or disprove their truth, and facts as propositions backed by sufficient evidence to consider them empirically proved for practical purposes.

Myths

We review seven myths about obesity, along with the refuting evidence. Seven Myths about Obesity. provides anecdotal support that the beliefs are widely held or stated, in addition to reasons that support conjecture.

1. Small Sustained Changes in Energy Intake or Expenditure
Myth number 1: Small sustained changes in energy intake or expenditure will produce large, long-term weight changes.
2. Setting Realistic Weight-Loss Goals
Myth number 2: Setting realistic goals for weight loss is important, because otherwise patients will become frustrated and lose less weight.
3.  Rate of Weight Loss
Myth number 3: Large, rapid weight loss is associated with poorer long-term weight-loss outcomes, as compared with slow, gradual weight loss.
4.  Diet Readiness
Myth number 4: It is important to assess the stage of change or diet readiness in order to help patients who request weight-loss treatment.
5.  Importance of Physical Education
Myth number 5: Physical-education classes, in their current form, play an important role in reducing or preventing childhood obesity.
6. Breast-Feeding and Obesity
Myth number 6: Breast-feeding is protective against obesity.
7. Sexual Activity and Energy Expenditure
Myth number 7: A bout of sexual activity burns 100 to 300 kcal for each participant. 
 

 Presumptions

Just as it is important to recognize that some widely held beliefs are myths so that we may move beyond them, it is important to recognize presumptions, which are widely accepted beliefs that have neither been proved nor disproved, so that we may move forward to collect solid data to support or refute them. Instead of attempting to comprehensively describe all the data peripherally related to each of the six presumptions shown in Table 2Presumptions about Obesity., we describe the best evidence

1.Value of Breakfast
Presumption number 1: Regularly eating (versus skipping) breakfast is protective against obesity.
2.  Early Childhood Habits and Weight
Presumption number 2: Early childhood is the period in which we learn exercise and eating habits that influence our weight throughout life.
3.Value of Fruits and Vegetables
Presumption number 3: Eating more fruits and vegetables will result in weight loss or less weight gain, regardless of whether any other changes to one's behavior or environment are made.
4.  Weight Cycling and Mortality
Presumption number 4: Weight cycling (i.e., yo-yo dieting) is associated with increased mortality.
5. Snacking and Weight Gain
Presumption number 5: Snacking contributes to weight gain and obesity.
6.  Built Environment and Obesity
Presumption number 6: The built environment, in terms of sidewalk and park availability, influences the incidence or prevalence of obesity.

Facts 

Facts about Obesity. lists nine such facts and their practical implications for public health, policy, or clinical recommendations. The first two facts help establish a framework in which intervention and preventive techniques may work. The next four facts are more prescriptive, offering tools that can be conveyed to the public as well established. The last three facts are suited to clinical settings.

They contend that public health efforts to counteract weight-loss and obesity misconceptions and myths should focus on the following nine evidence-based facts:

1. Recognizing genes as a large contributor to obesity, but not one that cannot be overcome with sufficient environmental influence
2. The importance of lower caloric intake in weight management strategies
3. The positive effect of exercise on health
4. The necessity of sufficient exercise as a routine activity to maintain weight loss
5. The importance of involving parents and families in weight-loss and management strategies for overweight children
6. Incorporating structured meals and meal replacements as weight-loss aids
7. The utility of pharmacological agents in effective weight-loss strategies
8. Recognizing bariatric surgery as a viable option for long-term weight loss, and to decrease rates of incident diabetes and mortality
9.The role of genetics in obesity and that realistic changes to lifestyle and environment can lead to weight loss.

The researcher also acknowledge that the myths and presumptions about obesity that  have discussed are just a sampling of the numerous unsupported beliefs held by many people, including academics, regulators, and journalists, as well as the general public. Yet there are facts about obesity of which we may be reasonably certain — facts that are useful today. While we work to generate additional useful knowledge, we may in some cases justifiably move forward with hypothesized, but not proved, strategies. However, as a scientific community, we must always be open and honest with the public about the state of our knowledge and should rigorously evaluate unproved strategies.

 ______________________________________
Source:
1.  http://www.nejm.org/doi/full/10.1056/NEJMsa1208051#t=articleResults
(Myths, Presumptions, and Facts about Obesity)
2. http://www.clinicaladvisor.com/common-obesity-beliefs-often-unsupported-by-science/article/278306/ (Common obesity beliefs often unsupported by science)