MSOP 1010 - Clinical Decision Making - Men's Health PDF

MSOP 1010 Professional Practice & Prescribing Clinical Decision Making – Men’s Health Dr. Suky Bhamra  Learning Objectives Identify the steps required to facilitate decision making when considering issues which affect men’s health. Gather in...

MSOP 1010 Professional Practice & Prescribing Clinical Decision Making – Men’s Health Dr. Suky Bhamra  Learning Objectives Identify the steps required to facilitate decision making when considering issues which affect men’s health. Gather information to enable application of a structured decision-making process when responding to men’s health problems. Identify management options for male patients presenting with ‘men’s health problems’.  Lecture Overview Men’s health: Erectile dysfunction Prostate problems - prostate enlargement - prostatitis - prostate cancer Hair loss - male pattern baldness Low testosterone = Hypogonadism Mental health  Men’s Health Men generally, don’t seek help for medical conditions as quickly or easily as women. They will often delay or ignore seeking help. Reasons can include: fear/ anxiety, working patterns, embarrassment. Some medical worries can cause unnecessary anxiety and loss of quality of life. The most common concerns male patients will present to a community pharmacy with are male pattern baldness (hair loss) and erectile dysfunction. Men’s Health  Erectile Dysfunction (ED) Erectile dysfunction is when: Unable to get an erection Unable to keep an erection for long enough to have sex Causes Stress Tiredness Drinking too much alcohol Recreational drugs Medical conditions: High blood pressure or high cholesterol Diabetes Depression or anxiety Hormone problems  Erectile Dysfunction (ED) Risk factors Sedentary lifestyle Obesity Smoking Hypercholesterolaemia Hypertension Medicines e.g. beta-blockers, antidepressants, corticosteroids etc Erectile dysfunction may be an early sign of: Heart and blood vessel problems Diabetes High blood pressure High cholesterol Liver disease or alcoholism Kidney disease Multiple sclerosis  Erectile Dysfunction (ED) Treatment Non-pharmacological management = Lifestyle changes: - Exercise Lose weight/ BMI if it is high Smoking cessation Reduce alcohol consumption Vacuum pumps = encourage blood to flow to the penis, causing an erection. They work for most men and can be used if medicine is not suitable or does not work. Topical gels e.g. Eroxon (contains Aqua, ethanol (35%), propylene glycol, glycerine, carbomer, potassium hydroxide – no actual active ingredient) Eroxon gel delivers a rapid cooling followed by a gradual warming effect which stimulates the nerve endings of the glans penis, helping men to get an erection within 10 minutes of application  Erectile Dysfunction (ED) Treatment Pharmacological management = phosphodiesterase type-5 inhibitor =first-line drug treatment for erectile dysfunction. Mode of action = increase blood flow to the penis. They do not initiate an erection—stimulation is required. Short acting phosphodiesterase type-5 inhibitors = Avanafil, sildenafil and vardenafil suitable for occasional use as required. Long acting phosphodiesterase type-5 inhibitors = Tadalafil Used as a regular lower daily dose to allow for spontaneous (rather than scheduled) sexual activity OTC can buy: Sildenafil and Tadalafil  Erectile Dysfunction (ED) Treatment options to buy OTC https://www.boots.com/healthhub/mens-health/erectile-dysfunction-service  Prostate problems The prostate is a small gland found only in men and trans women. It surrounds the tube that carries urine out of the body (urethra). The prostate gland produces a thick, white fluid that gets mixed with sperm to create semen. The prostate gland is about the size and shape of a walnut but tends to get bigger as you get older. It can sometimes become swollen or enlarged by conditions such as: prostate enlargement prostatitis (inflammation of the prostate) prostate cancer Most patients with prostate issues will have to be referred to the GP/ nurse. You should know what the conditions are/ how they present to make appropriate referrals.  Prostate enlargement = Benign prostate enlargement (BPE) Prostate enlargement is a very common condition associated with ageing. More than 1 in 3 of all men over 50 will have some symptoms of prostate enlargement. It's not known why the prostate gets bigger as men get older. BPE is common in men aged over 50. It's not a cancer and it's not usually a serious threat to health. Causes: Hormonal changes linked to aging.  Prostate enlargement = Benign prostate enlargement (BPE) Signs and symptoms: Difficulty starting or stopping urinating A weak flow of urine Straining when urinating Feeling like you're not able to fully empty your bladder Prolonged dribbling after you've finished urinating Needing to urinate more frequently or more suddenly Waking up frequently during the night to urinate  Prostate enlargement = Benign prostate enlargement (BPE) Treatment/ management: Lifestyle changes: drinking less alcohol, caffeine and fizzy drinks limiting intake of artificial sweeteners exercising regularly drinking less in the evening Medicine to reduce the size of the prostate and relax the muscles of the bladder can be prescribed. Tamsulosin and alfuzosin = Alpha blockers that relax the muscle in the prostate gland and at the base of the bladder, making it easier to pee. Finasteride and dutasteride are 5-alpha reductase inhibitors = shrink the prostate gland Surgery = usually only in severe cases that do not get better with medicine, the inner part of the prostate can be surgically removed.  Prostatitis Prostatitis is inflammation (swelling) of the prostate gland. It can be very painful and distressing, but will often get better eventually. Prostatitis can come on at any age. But usually between 30 and 50. There are 2 main types of prostatitis: Chronic prostatitis – where the symptoms come and go over several months; it's the most common type Acute prostatitis – where the symptoms are severe and come on suddenly; it's rare, but potentially life-threatening and requires immediate treatment  Prostatitis Signs and symptoms Pain, which may be severe, in or around the penis, testicles, anus, lower abdomen or lower back Pain when urinating/ defecating Urination changes = increased frequency (particularly at night), problems starting or "stop-start" peeing, an urgent need to pee and, sometimes, blood in your urine Generally feeling unwell, with aches, pains and possibly a high temperature Lower back pain and pain on ejaculation Treatment Pain relief Antibiotics if infection suspected  Prostatitis Risk factors for prostatitis Acute prostatitis: had a recent urinary tract infection (UTI) a urinary catheter, a flexible tube that's used to drain urine from the bladder had a prostate biopsy a sexually transmitted infection (STI) HIV or AIDS a problem with your urinary tract had anal sex injured your pelvis Chronic prostatitis: are older have had prostatitis before have other painful abdominal conditions, such as irritable bowel syndrome (IBS) been sexually abused  Prostate Cancer In the UK, prostate cancer is the most common type of cancer in men, with more than 45,000 new cases diagnosed every year. Risk factors: 1. Age - the risk rises as you get older, and most cases are diagnosed in men over 50 years of age 2. Ethnic group – prostate cancer is more common among Black men than in White men, and is least common in Asian men 3. Family history – having a brother or father who developed prostate cancer under the age of 60 seems to increase your risk of developing it, and having a close female relative who developed breast cancer may also increase your risk of prostate cancer. 4. Obesity – a balanced diet and regular exercise may lower the risk of developing prostate cancer 5. Diet – research is ongoing into the links between diet and prostate cancer, and there is some evidence that a diet high in calcium is linked to an increased risk of developing prostate cancer  Prostate Cancer Early prostate cancer does not usually cause any symptoms. If the cancer has grown large enough to put pressure on the urethra, the symptoms of prostate cancer can be difficult to distinguish from those of prostate enlargement. Signs and symptoms of prostate cancer: needing to urinate more frequently, often during the night needing to rush to the toilet difficulty in starting to urinate (hesitancy) straining or taking a long time while urinating weak flow feeling that your bladder has not fully emptied blood in urine or blood in semen  Hair loss Male pattern baldness is a common type of hair loss that develops in most men at some stage. The medical term for this is androgenetic alopecia. Up to 80% of men have some hair loss by the age of 70. Age the hair loss starts is variable. Can take 15-25 years to go bald, but can be quicker. About three in ten men aged 30 years and half of men aged 50 years have significant balding. Can have effect on self-esteem and psychological impact (leading to depression).  Hair loss Signs and symptoms Hair begins to thin (recede) at the sides (temples). Hair usually becomes thin on the top of the head. A bald patch gradually develops in the middle of the scalp. The receding sides and the bald patch on the top (the crown) gradually enlarge and join together, leaving a patch at the front. The patch at the front eventually thins as well.  Hair loss Causes: Permanent hair loss like male/female pattern baldness = genetic/ part of aging Temporary hair loss: an illness stress cancer treatment weight loss iron deficiency Treatment: Temporary = it will grow back usually once cause is eliminated/ treated. Permanent = no real guarantee treatment will work Pharmacological options = Finasteride (POM) and minoxidil Non-pharmacological options = wigs  Hair loss Minoxidil = Regaine scalp foam or solution Suitable for Men aged 18 - 49 years. Mode of action: Minoxidil affects the potassium channels present in vascular smooth muscles and hair follicles. This potassium channel activity induces the stimulation of the microcirculation around the hair follicles which induces arteriolar vasodilation, therefore encouraging conditions to support hair growth. It works by increasing the supply of blood and nutrients to the hair follicles, helping to strengthen the existing hairs and encouraging them to grow. Low testosterone = Hypogonadism  Low testosterone = Hypogonadism Natural testosterone is a steroid — an anabolic-androgenic steroid. "Anabolic" refers to muscle building, and "androgenic" refers to increased male sex characteristics. Role of testosterone in men: Development of the penis and testes Deepening of the voice during puberty Appearance of facial and pubic hair starting at puberty; later in life, it may play a role in balding Muscle size and strength Bone growth and strength Sex drive (libido) Sperm production. Note, women produce testosterone too, it is one of the male sex hormones (androgens) produced in the ovaries and adrenal glands responsible for ovarian function, bone strength and sexual behaviour including libido.  Low testosterone = Hypogonadism Low testosterone symptoms: Unexplained reduction in muscle mass Increase in body fat (esp. abdominal fat) Difficulty with concentration and memory = Lack of focus/ brain fog Fatigue Loss of body hair Mood changes = depressed/ anxious/ irritable Insomnia Erectile dysfunction Low sex drive Osteoporosis (weak bones) Treatment Testosterone replacement therapy (TRT) = testosterone gels  Mental Health As a pharmacist your role in MH will be to signpost patients to the most appropriate healthcare agency i.e. GP/ nurse/ mental health charities e.g. Mind Mental health covered in stage 3!  Mental Health – how can you help? Review medicines – identify anything which could be causing mood changes Listen and let the patient express their feelings Create an environment which facilitates wellbeing Encourage healthy lifestyle habits … such as? Eating well, exercise, CBT, Signpost https://www.rpharms.com/Portals/0/Documents/RPS%20mental%20health%20roundtable%20report%20June%202018_FINAL.pdf?ver=2018-06-04-100634-577  Mental Health – how can you help? Medicines which can cause depression/ low mood: Cardiovascular drugs Beta-blockers - metoprolol ACE-inhibitors – lisinopril Calcium channel blockers - felodipine Digoxin Corticosteroids – prednisolone Analgesics Codeine Opiates (esp during withdrawal) COX-2 inhibitors (celecoxib) Anti-Parkinson drugs Levodopa Amantadine Benzodiazepines  Recommended Reading FASTtrack: Managing Symptoms in the Pharmacy - Alan Nathan Community Pharmacy, 3rd Edition - Symptoms, Diagnosis and Treatment - Paul Rutter Symptoms in the Pharmacy: A Guide to the Management of Common Illness -Wiley-Blackwell