Men's Health Matters
David Skillinge, DO, FAAFP, FACOFP
ACOFP FULL DISCLOSURE FOR CME ACTIVITIES
Please check where applicable and sign below. Provide additional pages as necessary.
Name of CME Activity: ACOFP Intensive Update and Board Review in Osteopathic Family Medicine
Dates and Location of CME Activity: August 20-23, 2015, Loews Chicago O’Hare Hotel, Rosemont, IL
Topic(s):
Table Trainer: OMM Case Reviews: Pre-test Session
Thursday, 8/20/15
7:00-9:00pm
Men’s Health Matters
Friday, 8/21/15
11:15-11:45am
Table Trainer- OMT Breakout Session #4: OMT for Extremities
Friday, 8/21/15
2:45-4:15pm & 4:30-6:00pm
Saturday, 8/22/15
8:30-10:00am & 10:15-11:45 am
Table Trainer- Workshop: Examination Techniques for Office Orthopedics-Primary Orthopedics: What You Need to Know
Friday, 8/21/15
7:30-9:30pm
Proctor- Test-Taking Skills Workshop: Review of Clinical Scenarios Utilizing a Hands-On Approach in Preparation for Your Board
Examination
Saturday, 8/22/15
6:30-9:30pm
Name of Faculty/Moderator: David Skillinge, DO, FAAFP, FACOFP
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Signature:
Date:
7/10/2015
David Skillinge, DO, FAAFP, FACOFP
Please fax this form to ACOFP at 866-328-1835 or email to joank@acofp.org as soon as possible
Deadline: July 10, 2015
8/6/2015
ACOFP – Intensive Update and
Board Review Course
Primary Concerns in
Men’s Health
David Skillinge, DO, FAAFP, FACOFP
Objectives:
Recognize critical elements and formulate management
plan for the following conditions:





Benign Prostatic Hyperplasia
Prostate Cancer
Erectile Dysfunction
Abdominal Aortic Aneurism
Osteoporosis
Practice provided material by successfully completing
lecture questions.
Urinary Retention – based on
History and Physical Exam findings
History (LUTS)
Physical Examination
Possible Etiology
Frequency, urgency,
straining to void, weak
stream, stopping &
starting of a stream, etc.
Enlarged, firm, nontender, non-nodular
prostate on DRE; may
appear normal
Benign Prostatic
Hyperplasia
(BPH)
Fever; dysuria; back,
perineal, rectal pain
Tender, warm, boggy
prostate; possible penile
discharge
Acute Prostatitis
Weight loss;
constitutional
signs/symptoms
Enlarged nodular
prostate; may appear
normal
Prostate Cancer
Pain; swelling of foreskin
or penis
Edema of penis with nonretractable skin
Phimosis, paraphimosis
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Pathophysiology of BPH
BLADDER
PROSTATE
Central Zone
Transition Zone
Peripheral Zone
Urethra
Testosterone  Dihydrotestosterone (DHT) 
androgen receptors 
↑ GF’s  primarily TZ
(reduced apoptosis
with age)  uniform,
non-nodular
enlargement (BPH)
Kirby RS, G.P., Fast Facts: Benign Prostatic
Hyperplasia. 6th ed. 2010: Health Press
Limited.
Benign Prostatic Hypertrophy
 Risk Factors: age, ↑ BMI, DM, Dyslipidemia
 Protective effect:
 Alcohol (reduces testosterone, modulates sympathetic
tone). No effect on LUTS.
 High physical activity;
 Higher vegetable intake.
 Myth: sexual activity, HTN, smoking, liver cirrhosis




Parsons KJ, I.R., Alcohol Consumption is Associated With a Decreased Risk of Benign Prostatic Hyperplasia. The Journal of Urology,
2009. 182: p. 1463-1468
Walsh, P.C., Anatomic radical retropubic prostatectomy, in Campbell's Urology. 1998, Elsevier: Philadelphia. p. 2565-2588.
Rosen R, A.J., Boyle P, et al, Lower urinary tract symptoms and male sexual dysfunction: the multinational survey of the aging male.
Europian Urology, 2003. 44(6): p. 637-649
Paolone, D.R., Benign Prostatic Hyperplasia. Clinical Geriatric Medicine, 2010(26): p. 223-239
BPH – LUTS Evaluation/Follow-Up
American Urological Association BPH Symptom Score Index
Questionnaire
Can be accessed on-line: http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/bphmanagement/chapt_1_appendix.pdf
1. Incomplete emptying (0-5)
2. Frequency (0-5)
3. Intermittency (0-5)
4. Urgency (0-5)
5. Weak stream (0-5)
6. Straining (0-5)
7. Nocturia (0-5)
Score
<7
8-19
20-35
Severity
Mild BPH
Moderate BPH
Severe BPH
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BPH – Physical Exam
 Abdominal Exam – percussion and palpation of the
bladder (might be palpable with >200 ml);
 External Genitalia – meatal stenosis or severe
phimosis;
 Digital rectal exam – prostate size estimation,
tenderness, nodularity, fecal impaction.


Selius, B., Subedi, R, Urinary Retention in Adults: Diagnosis and Initial Management. American Family Physician, 2008. 77(5): p. 643650.
Paolone, D.R., Benign Prostatic Hyperplasia. Clinical Geriatric Medicine, 2010(26): p. 223-239
BPH – Work Up (revised AUA
guidelines, 2010)
 URINALYSIS (infection, hematuria, proteinuria, glucosuria, etc.)
 SERUM PSA (When life expectancy is > 10 years and if the diagnosis
of prostate cancer can modify the management. From the AUA PSA
Best Practice Statement: 2009 Update)
AGE
50’s
60’s
70’s
PSA Level
(prostate >40 ml)
~ 1.6 ng/ml
~ 2.0 ng/ml
~ 2.3 ng/ml
 FREQUENCY/VOLUME CHART (When significant nocturia is a
predominant symptom)
 OPTIONAL TESTS: Flow rate recording & residual urine
measurement.
McVary KT, R.C., Avins AL, Barry MJ, et al, Guideline: Management of Benign Prostatic Hyperplasia (BPH). 2010, American Urological
Association
BPH – Treatment Options
Severity Score
<7
8-19
20-35
Severity
Mild BPH
Moderate BPH
Severe BPH
Treatment
Watchful
Waiting
• Watchful
waiting;
• If bothered –
consider
medical Tx
• Medical Tx;
• More invasive
procedures
 Watchful waiting – behavioral modifications; severity scores (change by 3
points is acceptable improvement)
 Medical Therapy – ɑ-Adrenergic Receptors blockers, 5ɑ-Reductase Inhibitors,
Combo is promising
 Minimally Invasive Therapy
 Transurethral Microwave Therapy (TUMT)
 Transurethral Needle Ablation (TUNA)
 Surgery (TURP, TUIP, open prostatectomy, & laser procedures)
Paolone, D.R., Benign Prostatic Hyperplasia. Clinical Geriatric Medicine, 2010(26): p. 223-239
Edwards, J.L., Diagnosis and Management of Benign Prostatic Hyperplasia. American Family Physician, 2008. 77(10): p. 1403-1410.
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Prostate Gland – Osteopathic
Consideration
 Dx: Viscero-Somatic Dysfunction
 Goal of therapy: improve circulation and lymphatic
drainage
 Innervations:
 Parasympathetic: pelvic splanchnic nerves (S2-S4)
 Sympathetic: inferior hypogastric plexus (L1-L2)
 Chapman’s Points :
 Anterior: myofascial tissue along the posterior margin of the
iliotibial (IT) band
 Posterior: sacral base (superior sacrum), bilaterally.
Modi RG, S.N., Urology, in Clinical Anatomy and Osteopathic Manipulative Medicine. 2006, Lippincott Williams & Wilkins. p. 249-250
Question 1
Which of the following is the most frequent and major
reason for treating BPH?
a) Symptoms that trouble the patient sufficiently
enough that he wishes to have something done
b) Azotemia, hydronephrosis, bladder decompensation,
and overflow incontinence
c) Acute urinary retention
d) Severe recurrent hematuria
e) Recurrent UTIs associated with increased residual
urine.
Question 2
Which of the following individuals are most likely to
have a higher risk of BPH?
a) Asian Americans
b) African Americans
c) Obese men
d) Men with prior vasectomy
e) Smokers
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Prostate Cancer (PCa)
EPIDEMIOLOGY
 2nd leading cause of cancer death in men
 During lifetime – 1 man in 6 (16%) will be Dx’d with Pca
 1 in 35 ( ~3% ) will die from PCa
 50% at 50 & 80% at 80 y/o
RISK FACTORS
 One 1st degree relative – x2 fold
 Two or more 1st degree relatives – at least x4 fold
 African-American ethnicity
 Diet high in Omega-6 fatty acids (linoleic acid) from vegetable
oils and red meats (Low level of evidence)

Scher, H.I., Benign and Malignant Diseases of the Prostate, in Harrinson's Principles of Internal Medicine, K.D. Fauci AS, Longo DL, Braunwald E,
Hauser SL, Jameson JL, Loscalzo J, Editor. 2008, McGraw Hill Medical. p. 594-600

U.S. Preventive Services Task Force Grade Definitions

Hitzeman N, M.M., Screening for Prostate Cancer: Prostate-Specific Antigen Testing Is Not Effective. American Family Physician, 2011. 83(7): p. 802-804

What are the key statistics about prostate cancer?, American Cancer Society
Prostate Cancer – where?
BLADDER
PROSTATE
Central Zone
Transition Zone
Peripheral Zone
~ 70% of PCa begin in the
peripheral zone
~ 15%-20% in the central
zone
~ 10%-15% of PCa cases
develop in the
transitional zone
Metastases – seminal
vesicles, bladder, LN’s,
BONES; less commonly
– intestines, liver, lungs
Urethra
Crawford, D.F., Understanding the Epidemiology,
Natural History, and Key Pathways Involved
in Prostate Cancer. J of Urol. 2009, 73: p. 4-10
Prostate Cancer – Diagnosis
 DRE – digital rectal exam – enlarged, nodular or indurated
gland (might be normal);
 Serum [PSA] – conventional screening cut-point is 4.0
ng/ml;
 Velocity of PSA rise
 >0.35 ng/ml in one year in patients with baseline PSA of < 4.0
ng/ml, or
 > 0.75 ng/ml in one year in patients with baseline PSA of 4.0
to 10.o ng/ml
 Transrectal ultrasound-guided biopsy
 12 Bx cores is recommended (detects 31% more Ca than
traditional 6 Bx cores)
Heidenreich A, A.G., Bolla M, Joniau S, et al, EAU Guideline on Prostate Cancer. Europian Urology, 2007. 53: p. 68-80
Carter HB, F.L., Kettermann A, et al, Detection of life-threatening prostate cancer with prostate-specific antigen velocity during a window of
curability. J of Natl Cancer Inst, 2006. 98(21): p. 1521-27.
Eichler K, H.S., Wilby J, Myers L, Bachmann LM, Kleijnen J, Diagnostic value of systematic biopsy methods in the investigation of prostate
cancer: a systematic review. J of Urol, 2006. 175(5): p. 1605-12
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Prostate Cancer -- Types
 Pre-cancerous lesions
 PIN – prostate intraepithelial neoplasia; (low/high
grade)
 ASAP – atypical small acinar proliferation;
 PIA – proliferative inflammatory atrophy ;
 Cancerous lesions
 THE MOST COMMON – adenocarcinoma
 RARE (4%) – sarcomas, small cell carcinomas, and
transitional cell carcinomas
Crawford, D.F., Understanding the Epidemiology, Natural History, and Key Pathways Involved in Prostate Cancer. J of Urol. 73:
p. 4-10
Prostate Cancer -- Classification
GLEASON SCORE = first + second most common pattern on
biosies
 Grade 1 – well differentiated without infiltration
 Grade 2 – well differentiated with some infiltration
 Grade 3 – moderately differentiated
 Grade 4 – poorly differentiated
 Grade 5 – undifferentiated
 Score between 2 & 10
 < 6 – indolent malignancy with good prognosis
 7 – intermediate to high risk
 > 8 – aggressive with ↑ risk of systemic disease
Harnden P, S.M., Coles B, Staffurth J, Mason MD, Should the Gleason grading system for prostate cancer be modified to
account for high-grade tertiary components? A systematic review and meta-analysis. The Lancet Oncology, 2007. 8(5): p.
411-419
Prostate Cancer – Treatment
National Comprehensive Cancer Network Recommendations:
 Stage (by DRE, MRI, and metastases)
 Grade (histology – Gleason score)
 PSA level (predicts recurrence: 4 – 10 – low, 10 – 20 –
intermediate, > 20 – high risk)
 Comorbidity-adjusted life expectancy (CALE)


“10-year rule” – treat only if a comorbidity-adjusted life
expectancy is at least 10 years
Determination is based upon Charlson Comorbidity Index Table
 Treatment Options – Observation, RP, EBRT,
Brachytharapy, Hormone Therapy, and combination.
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Prostate Cancer – Survival Rate
 Localized Malignancy – 5-yr survival rate is ~ 95-99%
 Advanced Metastatic Disease – 5-yr survival rate is ~
10 % with the median survival rate of 4 months.
Jemal A, S.R., Ward E, Hao Y, Xu J, Thun MJ, Cancer Statistics, 2009. A Cancer Journal for Clinicians, 2009. 59(4): p. 225-249
Prostate Cancer – Osteopathic
Consideration
CONTRAINDICATED
 Visceral Manipulation
 HVLA, if the proper diagnosis NOT established
(i.e. mets?)
May use soft tissue techniques for
symptoms relief – fatigue, back
pain
S
Sterrett, W., Disorders of the male genitourinary system, in Osteopathic Medicine, C.W. Hoag JM, Bradford SG, Editor. 1969, McGraw-Hill p. 657675
Question 3
Risk factors for Prostate Ca include which of the
following?
a) Castration before age 40
b) African American race
c) Asian American race
d) Obesity
e) Young age
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Erectile Dysfunction (ED) –
Definition
“ ED is the persistent inability to achieve or
maintain penile erection sufficient for
satisfactory sexual performance. ED lasting
for 3 months is considered a reasonable
length of time to warrant evaluation and
consideration of treatment.”
Qaseem A, S.V., Denberg TD, Casey DE, et al., Hormonal Testing and Pharmacologic Treatment of Erectile Dysfunction: a clinical practice guideline
from the American College of Physicians. Ann Intern Med, 2009. 151(9): p. 639-649
Erectile Dysfunction (any degree) –
Epidemiology









~ 18 % of the male population aged 20 years & older;
~ 27 % of current smokers ( 40 & older);
~ 38 % of men with treated HTN (40 & older);
~ 42 % among men with BPH;
~ 50 % among men with diabetes;
~ 50 % among men with CV disease;
~ 70 % in men aged 70 years & older;
~ 88 % with HTN, HLD, DM, & smoking (40 & older);
~ 93 % among men with PCa.
Selvin E, B.A., Platz EA, Prevalence and risk factors for erectile dysfunction in the US. The American Journal of Medicine, 2007. 120(2): p. 151-157
Normal Sexual Response –
Requires:
An intact LIBIDO (visual, olfactory, tactile,
imaginative, & hormonal stimuli, i.e. testosterone)
2. The ability to achieve & maintain penile ERECTION,
3. EJACULATION, &
4. DETUMESCENCE
1.
Parasympathetic NS (S2-S4 spinal segment)  Erection
Sympathetic NS (T12-L2 spinal segment)  Ejaculation
& Detumescence
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Normal Sexual Response
LIBIDO
Vasc Endo Cell
+
Parasymp NS
(S2-S4)
Nitric Oxide
PDE-5
Vasodilation &
ERECTION
cGMP
GMP
EJACULATION
Sympath NS
(T12-L2)
DETUMESCENCE
Erectile Dysfunction – Mechanisms
Failure to initiate
1.



Psychogenic (performance anxiety, depression, relationship conflict,
loss of attraction, sexual abuse in childhood, etc.)
Endocrinologic (hypogonadism – primary or secondary,
hyperprolactinemia)
Neurogenic (SCI, MS, peripheral neuropathy – DM or EtOH, surgical
disruption – RP)
Failure to fill the lacunar spaces
2.


Arteriogenic (atherosclerosis or traumatic arterial disease)
Vasoconstriction (tobacco, medications)
Failure to store adequate blood volume within the lacunar network
3.
Venooclusive dysfunction (aging, excessive glycosylation, hypoxia,
hypercholesterolemia)
Medication-related ED (thiazides, BB, estrogens, GnRH agonists, H2
blockers, spironoloctone, neuroleptics, tricyclics, & SSRI’s, etc.)
IN MAJORITY OF CASES – MULTIFACTORIAL !!!

McVary, K.T., Sexual dysfunction, in Harrisonn's Principles of Internal Medicine. 2007. p. 296-300
Erectile Dysfunction – Treatment
1.
Education, counseling, life-style modifications;
2. Manage comorbid conditions;
3. Initiate pharmacologic therapy with a PDE-5
inhibitor in men who seek Tx for ED and have no
contraindications for its use;
4. ACP does not recommend for or against the routine
hormone testing or treatment in the mngt of ED.
5. Hypogonadism – Testosterone Management
Qaseem A, S.V., Denberg TD, Casey DE, et al., Hormonal Testing and Pharmacologic Treatment of Erectile Dysfunction: a clinical practice guideline
from the American College of Physicians. Ann Intern Med, 2009. 151(9): p. 639-649
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Erectile Dysfunction – Treatment
 VCD – Vacuum Constriction Devices -- if PDE-5 inhibitors
are contraindicated ;
 Intraurethral Alprostadil (PGE-1) – if PDE -5 inhibitor fails;
 Intracavernosal Self-Injection of Alprostadil
 Surgery – Semi-rigid or Inflatable Penile Prosthesis – for
refractory ED
McVary, K.T., Sexual dysfunction, in Harrisonn's Principles of Internal Medicine. 2007. p. 296-300
Erectile Dysfunction – Osteopathic
Consideration
 Dx: ED – Pelvic Somatic Dysfunction (SD); however,
TART changes might also be found in the thoracic, lumbar,
and sacral regions!!!
 Goal:
1.
2.
Address restrictions over the inferior mesenteric ganglion
and facilitations at T12-L2 vertebral and paraspinal regions
to enhance sympathetic innervation and treat somatic
dysfunction;
Address sacroiliac somatic dysfunction to engage
parasympathetic innervation via pelvic splanchnic nerves at
the S2-S4 paraspinal region.
Simmons, S., The Neurologic System, in Osteopathic Manipulative Medicine: Review for the boards. 2001. p. 13-27
Modi RG, S.N., Urology, in Clinical Anatomy and Osteopathic Manipulative Medicine. 2006, Lippincott Williams & Wilkins. p. 249-250
Abdominal Aortic Aneurism (AAA)
 AAA – infrarenal aortic diameter ≥ 3cm
 4-9% in men and 1% in women
 ≈ 9K deaths annually in the US
 Almost all deaths from ruptured AAA – 65-80 y/o
 1-year incidence rates of rupture:
 9% -- 5.5-5.9cm
 10% -- 6-6.9cm
 33% -- ≥ 7cm
Johnston, K.W., et al., Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee
on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg, 1991. 13(3): p.
452-8.
Gillum, R.F., Epidemiology of aortic aneurysm in the United States. J Clin Epidemiol, 1995. 48(11): p. 1289-98.
Ashton, H.A., et al., The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised
controlled trial. Lancet, 2002. 360(9345): p. 1531-9.
Lederle, F.A., et al., Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. JAMA, 2002. 287(22): p. 2968-72.
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AAA – Major Risk Factors
 Male sex
 History of ever smoking (defined in surveys as 100
cigarettes in a person’s lifetime)
 Age 65 or older
Fleming, C., et al., Screening for abdominal aortic aneurysm: a best-evidence systematic review for the U.S. Preventive Services Task Force. Ann
Intern Med, 2005. 142(3): p. 203-11.
AAA Screening
 USPSTF – rating B recommendation
 One-time screening by U/S in men aged 65 to 75 who have ever
smoked (≥ 100 cigarettes in a person’s lifetime)
 CMS guidelines – will pay for one-time U/S if the beneficiary is
included in AT LEAST ONE of the following risk categories:
 FHx of AAA
 Man age 65 – 75 who has smoked at least 100 cigarettes in his
lifetime
CMS. Implementation of a One-Time Only Ultrasound screening for abdominal aortic aneurisms (AAA), resulting from a referral from an an initial
preventive physical examination. 2006 11/6/12 [cited 2013 July 2]; Available from: http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/downloads/MM5235.pdf.
USPSTF. Screening for Abdominal Aortic Aneurism: Recommendation Statement. 2005 [cited 2013 July 2]; Available from:
http://www.uspreventiveservicestaskforce.org/uspstf05/aaascr/aaars.htm
Screening U/S
 95% sensitive and 100% specific
 If negative at 65, 10-yr incidence rate of new AAAs is
0-4%; none exceeded 4cm
 Therefore, one-time negative U/S at the age of 65
virtually excludes the risk for future AAA rupture or
death
Fleming, C., et al., Screening for abdominal aortic aneurysm: a best-evidence systematic review for the U.S. Preventive Services Task Force. Ann
Intern Med, 2005. 142(3): p. 203-11.
Crow, P., et al., A single normal ultrasonographic scan at age 65 years rules out significant aneurysm disease for life in men. Br J Surg, 2001. 88(7): p.
941-4.
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Recommendations of other groups
The Society for Vascular Surgery and the Society for
Vascular Medicine and Biology:
 No further testing if aortic diameter is < 3cm;
 Yearly U/S – if 3 to 4 cm;
 Q 6 months – if 4-4.5cm;
 Referral to a vascular specialist if > 4.5cm
 Consider surgical repair if growth rate is ≥ 1cm/yr
 Surgical repair if > 5.5cm
Kent, K.C., et al., Screening for abdominal aortic aneurysm: a consensus statement. J Vasc Surg, 2004. 39(1): p. 267-9.
Ferket, B.S., et al., Systematic review of guidelines on abdominal aortic aneurysm screening. J Vasc Surg. 55(5): p. 1296-1304.
AAA – Osteopathic Considerations
Dx: Viscero-Somatic Dysfunction
Treatment: if back pain – gentle MFR
Contraindicated:
rotatory techniques, abdominal
manipulation
( colonic stimulation, engagement of the inferior
mesenteric ganglion, etc.)
Question 4
AAA is defined as the infrarenal aortic diameter:
A) ≥ 3.0 cm
B) ≥ 3.5 cm
C) ≥ 4.0 cm
D) ≥ 4.5 cm
E) ≥ 5.0 cm
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Osteoporosis (OP) in men
 US prevalence – 3-6% (13-18% in women)
 Worldwide – 1/3 of all osteoporotic fractures (OF)
 Men suffer OF ~10 yrs later in life than women
 5-yr mortality rate doubles (28% vs. 16%) (vertebral
fractures)
Leboime, A., C. B. Confavreux, et al. (2010). "Osteoporosis and mortality." Joint, bone, spine : revue du rhumatisme 77 Suppl 2: S107-112.
Walsh, J. S. and R. Eastell (2013). "Osteoporosis in men." Nature reviews. Endocrinology 9(11): 637-645.
Major Risk Factors
 Primary – Type I (genetic) & Type II (>70)
 Secondary
 Modifiable lifestyle factors
 Nutritional Deficiencies
 Predisposing comorbid conditions
 Medications
Walsh, J. S. and R. Eastell (2013). "Osteoporosis in men." Nature reviews. Endocrinology 9(11): 637-645.
Screening Osteoporosis (OP)
 USPSTF (2011) – no sufficient evidence to recommend for or
against screening
 National Osteoporosis Foundation & the
American Endocrine Society (2012) – BMD testing for all
men ≥ 70 y/o and men aged 50-69, based on risk factor profile
 American College of Physicians – assess “older” men for
OP risk factors and use DXA to screen men at higher risk and who are
candidates for medical treatment
(2011). "Screening for osteoporosis: U.S. preventive services task force recommendation statement." Annals of internal medicine 154(5): 356-364.
Watts, N. B., R. A. Adler, et al. (2012). "Osteoporosis in men: an Endocrine Society clinical practice guideline." The Journal of clinical
endocrinology and metabolism 97(6): 1802-1822.
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8/6/2015
Definition & Evaluation
 Fracture risk calculators –FRAX, Garvan, etc
 Predisposing comorbid conditions
 Laboratory data
 Review of medications
Korpi-Steiner, N., D. Milhorn, et al. (2014). "Osteoporosis in men." Clinical biochemistry 47(10-11): 950-959.
Treatment
Endocrine Society Clinical Practice Guidelines (2012)
 Lifestyle:
 1000-1200 mg calcium daily
 Vit D supplemetation to level at least 30 ng/ml
 Weight-bearing activities for 30-40 min/session , x3-4/wk
 Reduce ETOH consumption
 Smoking cessation
Treatment
 Selection of men for treatment:
 Hip or vertebral fracture without major trauma
 No fractures, but BMD of the spine, femoral neck,
and/or hip is ≥ 2.5 SD below the mean
 T-score -1 & -2.5 PLUS a 10-yr risk ≥ 20% (any Fx) and
10-yr risk of hip Fx ≥ 3% using FRAX
 Long-term glucocorticoid therapy in pharmacological
doses (e.g. prednisone or equivalent > 7.5 mg/day)
Watts, N. B., R. A. Adler, et al. (2012). "Osteoporosis in men: an Endocrine Society clinical practice guideline." The Journal of clinical
endocrinology and metabolism 97(6): 1802-1822
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8/6/2015
Therapeutic options for men at risk
 1st line – Bisphosphonates – alendronate, risedronate,
zoledronate – inhibit osteoclasts and induce their
apoptosis
 Anabolic agent – teriparatide – recombinant form of
PTH – enhances osteoblastogenesis & bone formation
 Monoclonal antibody agent – denosumab – mediates
osteoclastogenesis, thereby inhibiting resorptive
effects
Korpi-Steiner, N., D. Milhorn, et al. (2014). "Osteoporosis in men." Clinical biochemistry 47(10-11): 950-959
OP – Osteopathic Considerations
Dx: Somatic Dysfunction, depending on where the
dysfunction is
Treatment: soft tissues techniques
Contraindication:
rotatory techniques, i.e HVLA
Question 5
Based upon bone mineral density, Osteoporosis is
defined as:
A) T-score not less then 1 SD below the young adult
mean value
B) T-score between 1-2.5 SDs below the young adult
mean value
C) T-score exceeding 2.5 SDs below the young adult
mean value
D) T-score exceeding 3.5 SDs below the young adult
mean value
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