A renewed effort to establish a new Office of Men’s Health, which would improve coordination of initiatives throughout the federal government and improve education, awareness, and screening programs to improve men’s health, is now underway in Washington.

Led by the nonprofit Men’s Health Network (MHN), the initiative seeks to establish a new entity within the U.S. Department of Health and Human Services (HHS) to provide education and awareness of men’s unique health needs, including diseases such as testicular and prostate cancer.

“Establishing an Office of Men’s Health is vital to the support and promotion of messaging to men and their families,” said Ana Fadich-Tomsic, MHN’s vice president.

“We at MHN strive to provide free educational events and materials to communities across the country, so that every man has a fighting chance against prostate cancer,” she said. “Our outreach efforts could be greatly amplified with an established Office of Men’s Health to disseminate the information and provide recommendations for men to follow throughout the year, including Men’s Health Month and other awareness periods, similar to how the Office of Women’s Health supports Women’s Health Week and Breast Cancer Awareness Month.”

MHN seeks support of congressional caucus

Establishing an Office of Men’s Health within the federal government requires Congress to pass authorizing legislation, so Fadich-Tomsic said MHN has drafted a proposed bill and is seeking the support of the Congressional Men’s Health Caucus, co-chaired by Reps. Donald M. Payne, Jr. (D-NJ) and Markwayne Mullin (R-OK).

A spokesperson for Payne said his boss was “working with” MHN, but that the prospects for the enabling legislation needed to establish an Office of Men’s Health are unknown. Similar efforts have been made in previous years but have been unsuccessful. Both Payne and Mullin have been active supporters of MHN, participating in the organization’s annual workout events on Capitol Hill.

Urologist elected to AMA Board of Trustees

“We’ve been working with the Men’s Health Caucus to see if they’re interested in being a sponsor of the legislation,” Fadich-Tomsic said. “They have a lot going on, but we’re hopeful because we’ve been getting good responses.”

Representatives of MHN have been in touch with officials at HHS and the Centers for Medicare & Medicaid Services and have been told that they support the initiative if Congress approves the legislation.

“We’ve talked to all the different agencies, but not the White House as yet,” Fadich-Tomsic said, explaining that it is difficult to know who, exactly, to contact there. “So, we haven’t been able to sit down with the Trump administration. With the Obama administration, we had a dialogue on men’s health that we hosted. We brought in people from corporations and speakers to discuss why focusing on men’s health is important, how it benefits women’s health, and family health overall.”

In addition, she said MHN has contacted the governors of all 50 states, mayors of major cities, and other legislators urging them to support the legislative initiative.

“We work closely with the American Urological Association, and they participated in briefings with us,” she said. “They provided us with speakers and every year I attend their annual meeting and sit on their panels. Also, I work with the Urology Care Foundation, as well as LUGPA and the American Society for Men’s Health.”

Men’s health a concern for women, govt.

The draft legislation, which has yet to be introduced, is called the “Men’s Health Awareness and Improvement Act.” Among key points made in the bill:

• Risks to the health and well-being of men and their families are on the rise because of a lack of education on, awareness of, and pursuit of preventive screening and care.

• It is a health crisis that is also a concern for women regarding their fathers, husbands, sons, and brothers.

• The U.S. Census Bureau predicts that in 2020, 45% of people age 65 and over will be men and 55% will be women, a marked decline in the male population.

• Men’s health is a concern to government, which must absorb the high costs of premature death and disability, including the cost of caring for dependents.

• Educating men, their families, and health care providers about the importance of early detection of men’s health issues can result in reducing mortality rates and improving health and the nation’s overall economic well-being.

• Of concern is the physical, mental, and emotional well-being of military men (and women) returning from war zones and the country’s veterans.

• According to the National Cancer Institute, cancer mortality is markedly higher among men than women.

• Prostate cancer is the most frequently diagnosed cancer among men, with nearly 165,000 diagnosed this year alone and almost 30,000 facing death.

Uro groups offer takes on Medicare for All

According to the bill, the Office of Men’s Health would be headed by a director appointed by the HHS secretary. It would conduct, support, coordinate, and promote programs and activities to improve the state of men’s health in the U.S. and consult with HHS offices and agencies to coordinate public awareness, education, and screening programs and activities relating to men’s health. Emphasis would be on colorectal and prostate cancer, diabetes, cholesterol, and mental health screening programs for men identified as being at increased risk of developing such conditions and diseases.

Establishing the new Office of Men’s Health would build upon the success of the Office of Women’s Health, according to Fadich-Tomsic.

“We’re trying to show this would not take away from Office of Women’s Health,” she explained. “We’re trying to make it an even playing field.” 

Articles

Advocates work toward Office of Men’s Health 

I recently got married and my spouse and I were advised to purchase term life insurance. Is life insurance really worth the cost?

Term life insurance can be a useful tool to ensure that some or all of your family’s financial goals can still be met if you or your spouse was to die prematurely. For example, most people who own a home with a mortgage should consider a policy that equals the length of the mortgage. This guarantees that the balance is paid off, so the surviving spouse or family members are not left trying to pay it off unexpectedly. Other common goals include guaranteeing children’s college educations will be paid for or that the spouse can still maintain a certain standard of living.

The above examples usually necessitate temporary life insurance because there is a specific amount of time a person needs to be covered. A mortgage may require coverage that lasts 15, 20, or 30 years. Once the mortgage is paid off, the need to insure against this debt goes away. The same idea applies to when your children’s college education is paid off. Once they are done with college, your need to cover that expense with insurance disappears.

Setting up a trust confers several financial advantages

Coverage to guarantee a spouse’s lifestyle may only be necessary until you reach your planned retirement date. By the time you retire, your spouse’s standard of living is guaranteed if you properly saved and planned.

If your life insurance needs are temporary, then term insurance is likely the most appropriate vehicle. Term insurance has no cash value or savings component attached to it, meaning that if you don’t use it, you won’t get any of your premiums back. However, because of this, these policies tend to be significantly less expensive than a whole life or variable product. Quite simply, you pay your premium, and if you die during that policy year, the death benefit is paid to your beneficiary.

"The design of the policy will vary by need"

The design of the policy will vary by need. For example, decreasing term insurance has a level premium, but a decreasing death benefit. It is generally used in conjunction with financial obligations that decrease over time, such as mortgages or other types of amortized loans.

Annual renewable term insurance has a yearly increasing premium, which increases with the higher mortality cost associated with being a year older, and a year closer to your expected mortality age. It is primarily used for financial obligations that remain constant for a relatively short period of time.

Level premium term insurance, on the other hand, offers a level premium payment amount over a fixed number of years, typically 10, 15, 20, or 30 years. This would be appropriate for needs that are finite in length, such as ensuring coverage until a young child has completed college, becoming self-insured through an increased net worth, or reaching retirement age with sufficient retirement income to meet your needs.

When getting married, don’t forget financial planning

Other provisions, known as riders, can be added to certain policies for an additional cost. The waiver of premium rider allows you to stop making premium payments if you become disabled and are unable to earn an income. The accidental death rider obligates the insurance company to pay out double or, in some cases, triple the stated death benefit if the insured dies in an accident. An accelerated death benefit rider allows you to receive a portion of your own death benefit while you are alive if you have a major medical condition that is expected to lead to death within a short period of time.

Overall, term life insurance can be worth the expense when it comes to making sure certain financial obligations are met. The features of these policies will vary. We recommend speaking with your financial adviser about which policies and features would be most effective for you.

What is the typical process for getting approved for a term insurance policy?

Most companies require you to complete an application. In this application, you will sign a HIPAA release form. This will give the insurance company permission to request medical records from your physicians. Most companies will examine 5-10 years of past medical records. Additionally, depending on the size of the policy, they may require a paramedical exam. This typically includes collecting blood and urine samples.

Once all the information has been gathered, an underwriter will determine whether you are approved and in which health class you are approved.

The information in this column is designed to be authoritative. The publisher is not engaged in rendering legal, investment, or tax advice.

"If your life insurance needs are temporary, then term insurance is likely the most appropriate vehicle," writes Jeff Witz, CFP.

How term life insurance can help ensure financial goals are met

Among the top allegations against physicians resulting in payment in the National Practitioner Data Bank, failure to diagnose, delay in diagnosis, and failure to monitor rank first, third, and seventh, respectively. (Also see my recent article, 

“HHS program collects data on malpractice, adverse actions,”

 July 2019, page 21). Losing patients to follow-up can result in these allegations and create risk to the patients and the practice. In this article, I will discuss how seemingly mundane practice operations can contribute to or help mitigate risk in this area.

How to improve patients’ access to their health information

Urologists face a work force shortage and are among the busiest surgical specialists in the U.S. 

, resulting in pressure to see more patients per unit of time. More patient appointments also mean more pressure on the staff scheduling return visits and those answering phones, as well as more opportunities for costly reschedules, no-shows, and cancellations. A busy practice has many potential points of failure in this area, which are magnified when the occasional patient “falls through the cracks.” Every urology practice should have in place written policies to minimize these points of failure, cross-train on those policies, and constantly reinforce adherence to them.

The first set of policies should address scheduling guidelines for your practice and providers. Common points of failure in the urology practice are elective surgical appointments, postoperative appointments, emergency encounters, and even routine follow-up appointments.

Elective surgeries typically require the coordination of several schedules (patient, provider, and facility), insurance verification, and more than one phone call. Your policy should make sure there is no opportunity to “lose” these patients and track where they are in the process.

One helpful practice is to create a resource in your practice management (PM) scheduling software called “Surgery scheduling,” and schedule an “appointment” for the patient on that schedule. Then, the staff working the steps in the process can work their “appointments” every day from that schedule and track the status. Once the surgery date has been determined, the patient should be scheduled in your PM system just like an office appointment.

Avoid having redundant schedule platforms or booking surgery appointments on software that was not designed for privacy, tracking, reporting, and compliance (Outlook, Google calendar, etc.). Best practice is to schedule the future postoperative appointment at the same time the surgery is scheduled to minimize the chance a surgical patient will not get an appointment; this is also a common courtesy to the patient and a reminder that they need postoperative care and follow-up.

The patient with the chronic indwelling ureteral stent requiring periodic exchange deserves special mention. Many of these patients and their providers see no benefit in an office appointment between exchanges and simply schedule periodic elective surgeries to change the stent. These patients are particularly vulnerable to complications, and your practice should never rely solely on the patient to “call us to schedule in 4 months.” Create a placeholder appointment in the PM system that reminds the scheduler when it is time to reschedule.

Patients that are seen first in an acute setting-hospital or emergency room-are also vulnerable to being lost: They are not preregistered in the practice systems, often have multiple providers, may not hear or comprehend the rationale for following up, and in some cases may seek to avoid accountability for expensive hospital bills.

The best practice to ensure these patients follow up is to submit charges daily and use the first charges as a prompt to attempt to contact the patient by phone as soon as possible, even if they are still in the hospital. Be sure your physicians and staff understand financial policies and the responsibility of the practice, if any, to continue to follow the patient after their acute episode (patients with indwelling stents, for example).

Finally, don’t forget the routine process that happens at your checkout desk-scheduling routine appointments. Many patients will resist making an appointment at checkout for a variety of reasons, and some may even refuse (see below). This is particularly common for an annual or semiannual appointment months in the future. In this case, it is best to make a “placeholder appointment” that can then be moved, if necessary, when the patient calls back with a firm date and time. Your policy should ensure that no patient whom the provider intended to continue to follow is ever missing from your future appointments schedule.

While some practices use “recalls” to cut down on no-shows 

, this creates another resource-intensive workflow and an inability to easily mine data on “future appointments.” I recommend keeping it simple-every active patient should have a future appointment.

Addressing missed appointments, cancellations

Now that your practice has established a standard scheduling policy that addresses all of the common scenarios, you need a companion policy that addresses the common issues of refusal to schedule an appointment, missed appointments, cancellations, and reschedules. That policy should address how, when, and how often to attempt to contact the patient; how and when to notify the provider; and how the outcome is documented in the medical record. While some circumstances are more serious than others (eg, the patient with testis cancer who misses his surveillance appointment), the process will usually involve non-clinical staff and is best kept simple without exceptions or discretion.

For example, your policy might state that patients who miss an appointment are first contacted by phone; if this is unsuccessful, a written letter is generated; if this attempt doesn’t generate an appointment within 2 weeks, a certified letter is routed to the physician for signature-who is the best decision maker regarding whether to send the letter. Another decision is whether to terminate the physician/patient relationship and can be addressed at the final point in your policy.

Open Payments data: What you should know about 2019 update

Whether you decide to have one step or five steps, your policy should ensure that the provider is aware of every patient who permanently drops off the schedule and is given an opportunity to contact the patient and/or create the appropriate documentation in the medical record. Cancellations usually come in the form of a phone call, and the policy will need to address what your staff says to the patient and the workflow for communicating the outcome to the provider.

Your policy for rescheduling may require more parameters; for example, rescheduling office visits versus procedures, rescheduling within a certain time frame, or rescheduling new versus established patients. Again, you will need to strike a balance between one-size-fits-all (safest) and creating different rules for different situations (riskier).

Bottom line: Urologists are at risk of malpractice allegations not only for their actions, but sometimes for their inactions. The physician/patient relationship creates some accountability for both parties, but the information imbalance means that the physician bears the greater responsibility for taking reasonable steps for continuity of care. Be sure your practice has written policies that address the common reasons patients may be lost to follow-up, and that you follow those policies. 

Written policies should address scheduling guidelines and appointment cancellations, advises Robert A. Dowling, MD.

Losing patients to follow-up? Here’s what you can do

Urology Times reached out to three urologists (selected randomly) and asked them each the following question: How has your management of BPH patients changed?

"The gold standard is still TURP [transurethral resection of the prostate], and, of course, medications and transurethral microwave thermal therapy. I don’t try anything new unless it’s been tried a million times by somebody else. I’m not an early adopter.

I don’t think anyone says those newer treatments can compare to the TURP. Heated steam is not as good; microwave is not as good; GreenLight laser is not as good, although that’s a form of transurethral vaporization of the prostate gland. Those are pretty equivalent. That’s the only thing that comes close to the results you get with TURP.

What’s your biggest frustration with prior authorization?

I did five microwaves today because guys requested it, as opposed to a TURP. They’re all going back to work tomorrow. They’ll have hardly any side effects. It doesn’t work that great, however. The good thing is, it has no sexual side effects. I tell them it’s not good as a long-term treatment, that in about 4-5 years they’ll need something else, but they still want TUMT. I do it because patients ask.”

“The way I work up BPH patients has changed considerably because of these new treatments."

“The way I work up BPH patients has changed considerably because of these new treatments. Previously, I’d usually go right to laser vaporization of the prostate, but now that UroLift and Rezum are available, I like to know the shape and size of the gland. It’s important in order to figure out the best procedure for the patient.

What are you doing to safeguard patient information?

We offer both the Rezum and the UroLift. I also do the TURP and laser prostate vaporization. I tell patients that improvements in the flow and their symptoms are probably going to be best with traditional treatments, such as TURP or laser. But patients who are very motivated in preserving ejaculatory function aren’t going to be happy with the TURP; that usually includes the younger guys. I tell them there’s a treatment that helps preserve sexual function, but it may not be as good as traditional treatments at improving your prostate symptoms, so it’s a trade-off.

Also, UroLift and Rezum have only been around for a couple of years. We don’t know what the long-term improvements will be.

Personally, I like laser prostate vaporization. Historically, TURP was the gold standard, but results with laser vaporization are comparable, with lower bleeding risks, and patients go home the same day. That’s the gold standard. I trained in the era of lasers, so I’m a big believer in them. It’s the same operation as TURP, just with newer technology that makes it easier.

What do you tell male patients about men’s health clinics?

I think new procedures like UroLift and Rezum are here to stay for very specific patients-patients with mild to moderate symptoms, who are mainly interested in preserving their sexual function.”

"I basically choose the procedure based on the patient’s anatomy."

“For the vast majority of my patients, I usually stick to either traditional TURP-I’m a fairly young urologist, just 8 years out of residency-or GreenLight photoselective vaporization.

I basically choose the procedure based on the patient’s anatomy. If they have a large or medium lobe, I do a traditional TURP because I like to resect it. GreenLight works as well as traditional TURP. The benefit is that most of my patients go home the same day.

We looked at Rezum and UroLift as potential new therapies, but UroLift was hard to get off the ground. We had to get a bunch of patients interested right off the bat and try to coordinate them for the same day, because they wanted to do multiple cases all at once to get us up to speed. That was just a logistical challenge.

What is your primary concern about the ban of POP mesh?

Then, while we were looking at Rezum, patients who had these procedures elsewhere, both Rezum and UroLift, came to me with complications. Granted, it’s very anecdotal-I’m sure many people had good experiences.

My chairman used to say, it seems these new procedures come along, but we always go back to TURP. Alternative therapies make their run, but none seem to have the legs to be meaningful long-term options.

One of my partners refers people to a local interventional radiologist for prostatic artery embolization, but I don’t know what he uses for his basis.”

"I basically choose the procedure based on the patient’s anatomy," says one urologist.

How has your management of BPH patients changed?

Androgen deprivation therapy (ADT) for advanced prostate cancer may increase the likelihood of urethral atrophy in men with an artificial urinary sphincter (AUS), thereby contributing to an increased risk of AUS cuff erosion.

In examining a database of men who underwent AUS at a tertiary urban medical center between 2008 and 2017, those with a history of ADT, confirmed by a low serum testosterone level, were 1.5 times more likely to require an AUS cuff of 3.5 cm compared with men with a normal testosterone level and no history of ADT use, reported Michael Davenport, MD, at the AUA annual meeting in Chicago.

The finding confirms previous observations linking hypogonadism, among other factors such as pelvic radiation, to adverse outcomes after sphincter placement, as well as histologic data showing that hypogonadism leads to a decrease in periurethral vascularity and urethral atrophy, said Dr. Davenport, a fellow in reconstructive, trauma, and prosthetic urology, University of Texas Southwestern Medical Center-William P. Clements Jr. University Hospital, Dallas.

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Men with primary ADT have also been found to lose penile length, which suggests that castration can lead to genital and urethral atrophy.

Together with these prior findings, the study “confirms the adverse relationship between hypogonadism and urethral homeostasis,” Dr. Davenport said.

“It highlights the importance of perioperative counseling in men with advanced prostate cancer [with a history of ADT use] and potentially compromised urethras, so they go into surgery knowing they have a higher incidence of a poor outcome,” added Dr. Davenport, who worked on the study with Allen F. Morey, MD, and colleagues.

AUS remains the gold standard for the management of male urinary stress incontinence, with patient satisfaction rates consistently greater than 90%. Many men with an AUS, however, require revision or replacement. The primary reason for revision is urethral atrophy, said Dr. Davenport.

From their database of 643 men who had undergone sphincter replacement, he and co-investigators identified 67 men with a history of ADT in the setting of recurrent disease or in association with radiation and 32 normogonadal men with no history of ADT or radiation (control group). Placement in each group was confirmed serologically by measurement of serum testosterone level. Mean testosterone level was 125.4 in the men on ADT and 483.4 in the controls. Fifty-one of the men (76.1%) on ADT had a history of radiation compared with none of the men with a normal testosterone level.

About half (48.5%) of the men on ADT had urethral atrophy, defined as use of a 3.5-cm AUS cuff, compared with 28.1% in the control group 

=.08). Seventeen of the men on ADT (26.2%) developed AUS cuff erosion compared with one (3.7%) in the normal testosterone group.

Urethral lift found safe, efficacious in real-world setting

“Univariate analysis suggests an increased risk of erosion with history of ADT, but it falls off on multivariate analysis, likely because of the high co-incidence of radiation in this population. It’s very rare to find a patient just receiving ADT without radiation,” said Dr. Davenport.

Among men with 3.5-cm cuffs, the rates of urethral erosion were significantly higher among men who had been on ADT compared with the control group (31.2% vs. 11.1%; 

 did not find evidence to support adverse outcomes in ADT-exposed men undergoing primary AUS placement compared with ADT-naÃ¯ve men, Dr. Davenport noted, but they did not confirm the gonadal state with measurements of serum testosterone and no definition of urethral atrophy was provided 

Androgen deprivation therapy for advanced prostate cancer may increase the likelihood of urethral atrophy in men with an artificial urinary sphincter (AUS), thereby contributing to an increased risk of AUS cuff erosion.

ADT may increase likelihood of urethral atrophy

Are dip tests needed for onabotulinumtoxinA (onabotA [Botox]) bladder procedures when no symptoms of urinary tract infection (UTI) are present? A recent study presented at the AUA annual meeting in Chicago suggests the answer may be no.

Researchers from the Cleveland Clinic Glickman Urological & Kidney Institute, Cleveland found no significant risk of adverse events when patients with a urine dip that tests positive for a UTI but who do not have symptoms of this illness receive an onabotA injection into the bladder. Such injections are used to treat neurogenic detrusor overactivity.

“Almost half of our staff have stopped screening unless patients report symptoms of a UTI” based on the results of the survey, Laura Giusto, MD, who was a fellow at the Glickman Urological & Kidney Institute at the time of the study, told 

 She worked on the research with Howard Goldman, MD, and colleagues.

Metastatic bladder Ca: High ORR seen with immunotherapy combo

The analysis not only has the potential to reduce costs of care-from the cost of the urine dip test to time spent analyzing test results and calling the patient to share the results-but also medication costs when asymptomatic patients test positive for a UTI, said Dr. Giusto, now of Chesapeake Urology, Owings Mills, MD.

Many patients who are treated with onabotA for urinary incontinence and other bladder issues are tested for a UTI with a urine dipstick prior to the procedure. The safety insert that comes with the intradetrusor onabotA injection states that an injection should not be given if the patient has a UTI at the time of the procedure. As a result, many patients are tested for a UTI with a urine dipstick in the physician’s office on the day of the procedure.

Physicians’ response to a positive dip test varies. Some surgeons choose to proceed with the procedure if the patient is asymptomatic; others postpone the procedure.

The authors conducted a retrospective review of intradetrusor onabotA injections performed between 2016 and 2018. Exclusion criteria included indwelling catheter, recent urine culture, recent course of antibiotics, or no urine dip on the day of injection. A positive urine dip was defined as any combination of positive blood, leukocyte esterase, or nitrite. A negative urine dip was defined as complete absence of any blood, leukocyte esterase, or nitrite.

In all, 335 patients who underwent onabotA injections from 2016 to 2018 met the study criteria. The majority-56.7%-received 100 units of onabotA for a non-neurogenic diagnosis (73.4%). No clinically significant demographic differences were noted between the groups.

Difference in adverse event rates not statistically significant

The overall rate of adverse events, UTIs, and urinary retention was 16%, 9%, and 3%, respectively. Compared with patients whose urine dips tested negative for UTI, those with a positive urine dip had higher rates of adverse events (18.3% vs. 12.7%) but this difference was not statistically significant.

In both groups, the most common adverse event was uncomplicated UTI, followed by urinary retention. There was no difference in the rates of unplanned phone calls, office visits, emergency department encounters, or hospital readmissions between those who tested positive for UTI and those who did not. There were no major Clavien-Dindo-defined complications, and all adverse events were managed on an outpatient basis.

The findings suggest surgeons may consider proceeding with onabotA injection in a patient with a positive urine dip test as long as the patient does not display symptoms of UTI, Dr. Giusto said.

Are dip tests needed for onabotulinumtoxinA (onabotA [Botox]) bladder procedures when no symptoms of urinary tract infection are present? A recent study presented at the AUA annual meeting in Chicago suggests the answer may be no.

Positive dipstick does not preclude BTX injections

A recent study shows older women with decreased levels of serum testosterone are more likely to experience incontinence, but this does not necessarily mean urologists should be giving testosterone to older women, a study author says.

“What I do advocate is: We need to know a lot more about the impact of hormone levels on the aging bladder,” Michael B. Chancellor, MD, researcher for Beaumont Health, Royal Oak, MI.

The results, part of the Health, Aging, and Body Composition (Health ABC) study, sought to determine whether serum free testosterone levels were associated with urinary leakage in older women in a population-based cohort.

Nearly half of women ages 50 years and older experience incontinence, and this percentage increases as women get older-particularly after women go through menopause. During menopause, women experience a decline in testosterone. However, the relationship between loss of testosterone in the blood and urinary incontinence in older women is not well understood.

The authors studied 3,075 healthy and well-functioning Caucasian and African-American men and women ages 70 to 79 years participating in the Health ABC study. They measured serum free and total testosterone and administered urinary health questionnaires to each participant. Urinary incontinence was defined as self-reported daily urinary leakage.

Data were first split by gender and then grouped by self-reported urinary leakage (less than once per month, once per month or more, once per week or more, and daily). Then, a one-way ANOVA test was performed by gender between urinary leakage groups using both the free and total testosterone data. Additional testing was performed with pairwise Student’s t-tests, as the distribution of testosterone samples was approximately normal.

According to the survey results, women-but not men-with urinary incontinence had decreased serum testosterone compared with women who experienced urinary leakage less than once per month.

There was also a trend toward higher free testosterone in serum with women who experienced urinary leakage more than once per month or more than once per week.

This supports the hypothesis that testosterone may play an important role in supporting the health of muscles in the pelvic floor as well as those that maintain urethral support, Dr. Chancellor said, noting that androgen receptors are found throughout the pelvic floor and lower urinary tract. When muscles in these areas are healthy, they help prevent involuntary leakage of urine.

“Testosterone is a very controversial topic, not just in men, but also in women,” Dr. Chancellor said. He cautioned that more research is needed, as one of the limitations of the study is that urologists were not involved.

“It was much harder than I thought” to look at the impact of one hormone level on female incontinence, he said.

Low testosterone, incontinence may be linked in older women

 Editorial Council, is professor of urology, Oakland University William Beaumont School of Medicine, Royal Oak, MI.

 The abstract by Dr. Chancellor et al discussed in this editorial was selected for coverage in Urology Times by Dr. Padmanabhan while she was associate professor of urology at the University of Kansas Medical Center.

The significance of the “elixir of life” dates back to 1889 when Charles Edouard Brown-Sequard injected himself with liquid extracted from dog or guinea pig testicles. Testosterone has since been well studied for its anabolic, metabolic, and developmental properties in men and women. With the number of Americans 65 years and older doubling from 2018 to 2060, there is much focus on the effects of these associated hormone changes.

A large portion of serum testosterone is not biologically active. Total testosterone levels include both free testosterone and bound testosterone. Ninety-eight percent of testosterone circulates in the body bound to proteins (60% to albumin and 40% to sex hormone binding globulin). The remaining 2% is free (floating). Only the free and albumin-bound hormone are truly “bioavailable” to the cells.

There are multiple factors, such as smoking, obesity, and muscle mass, that impact total testosterone levels. Testosterone production has a circadian rhythm, which creates additional challenges for measurement. Testosterone levels decline in men, starting as early as 30 years, yet levels decline in women only after menopause. This decline has many associated signs and symptoms including, but not limited to: change in sleep patterns, worsening of sleep apnea, and physical, sexual, and emotional changes.

A recent study from Michael B. Chancellor, MD, of Oakland University William Beaumont School of Medicine assessed the correlation between decreased testosterone levels and urinary incontinence in older women who participated in the Health, Aging and Body Composition Study (see article 

 Nearly half of women >50 years of age experience incontinence, which continues to increase with age. Androgen receptors throughout the pelvic floor and lower urinary tract play an important role in pelvic floor musculature and function.

Prior studies have alluded to the diminishing effects of low testosterone on the pelvic floor musculature, yet the relationship between postmenopausal testosterone level and incontinence is unknown. This study was successful in collecting data from a large, healthy group of women and men 70-79 years old. Measurement of serum free testosterone and total testosterone was performed along with quality of life surveys and self-reported daily urinary leakage. The collection of free testosterone is important for the detection of bioavailable testosterone.

Results indicated that serum testosterone is decreased in women with urinary incontinence less than once per month and showed a trend toward higher free testosterone in women with incontinence more than once per month.

It is challenging to study the impact of testosterone level alone on postmenopausal incontinence, given the equally significant effects of diminished estrogen. The circadian rhythm and overall lower concentration of testosterone in women limits the reliability of measurement. 

Ideally, free and total testosterone should be drawn first thing in the morning and at alternate time points to ensure reliability of the test results. With involvement of urologists in the future, confounding factors-smoking , obesity, sleep patterns-should also be included in the evaluation to more accurately reflect the correlation.

Hormone replacement has become a fad, with creams, gels, and troche being created like designer jeans. Incontinence represents an expensive, multifactorial, health care beast. Testosterone replacement is not a panacea for incontinence. Future research with urologist involvement, to isolate confounding factors and consider serum level variability and other hormone effects, will be useful.

Send your comments to Dr. Padmanabhan c/o 

"Future research with urologist involvement, to isolate confounding factors and consider serum level variability and other hormone
	effects, will be useful," writes Priya Padmanabhan, MD, MPH.

Testosterone: A panacea for incontinence patients?

Sacral neuromodulation (SNM) placement in a single-stage procedure is likely to be less costly than a two-stage approach for most practitioners, according to the findings of a cost minimization analysis.

The research, which was presented at the AUA annual meeting in Chicago, showed that the potential for savings and the amount were tied to SNM success rates and reimbursement rates. In the ambulatory surgery center (ASC) setting, performing a single-stage procedure became potentially economically advantageous when the success rate of a two-stage procedure was ≥65.4%. For procedures done in an outpatient hospital department (OHD), the minimum SNM success rate needed to achieve savings with a single-stage operation was 61.4%.

Both of those thresholds are below the reported national average success rate of 69%, said Andrew J. Sun, MD, a urology resident at Stanford University, Stanford, CA.

At the two thresholds, the modeling determined that there would be an approximate $600 savings for procedures done in an ASC and an approximate savings of $1,350 for OHD procedures. At centers of excellence where the success rates are reported to be around 90%, the cost savings were estimated to reach approximately $5,000 per case, reported Dr. Sun, working with Christopher Elliott, MD, PhD, and colleagues.

“Payers control what we as practitioners can do. Currently, Medicare is the payer for the majority of SNM procedures and requires that placement be done in a two-stage approach,” he said.

“Our estimates are from theoretical models and do not incorporate the benefits of a single-stage procedure from the patient preference perspective, but we tried to make them as realistic and generalizable as we could. We hope that our findings will motivate payers to revisit their policies. It is notable that Kaiser Permanente, which is a closed system, has gone to a single-stage procedure in Southern California, likely reflecting the economic advantages of the single-stage approach.”

The base model used published data on SNM variables when available and 2017 national average reimbursements from Medicare for cost data.

“A previous study modeling the potential cost savings of a single-stage procedure used institution specific success rate and cost data. Therefore, its findings may not be generalizable,” Dr. Sun said.


	The inputs used for the base case analyses included a 69% success rate for the testing phase of the two-stage procedure and for single-stage cases, a 100% success rate for the second stage in a two-stage approach, and infection rates of 5% for a two-stage approach and 1.7% for a single-stage approach. The latter rate was extrapolated from published data on the infection rate associated with implantable cardiac defibrillators.

The model assumed that in cases where infection developed, 100% of devices would be removed and there would be one attempt at replacement. In cases of failure after single-stage implantation, it assumed that 50% of patients would elect to have the device surgically removed.

Sensitivity analyses were also performed that varied the infection rate and the rate of device removal upon failure after a single-stage procedure in the absence of infection. Results showed that the single-stage procedure remained less costly for most infection and removal rates, even assuming that 100% of single-stage patients who failed would want the device removed.

Dr. Sun noted that the main barrier for implementation is the lost revenue to facilities and, to a lesser extent, lost revenue for surgeons. Surgeons, however, could potentially make up for the lost revenue by filling the OR time and clinical visit time with another patient.

“The facility loss is harder to recoup, but potentially the OR time could be filled with a different case,” Dr. Sun said.

Sacral neuromodulation placement in a single-stage procedure is likely to be less costly than a two-stage approach for most practitioners, according to the findings of a cost minimization analysis.

Model highlights cost savings of single-stage SNM

Uncomplicated urinary tract infection is one of the most common indications for antimicrobial exposure in otherwise healthy women. In the past 20 years, antimicrobial resistance among uropathogens has increased dramatically. Overuse of antibiotics has led to ecological adverse effects known as “collateral damage”-specifically, the selection of drug-resistant organisms and the unwanted development of colonization or infection with multidrug-resistant organisms.

Fluoroquinolones have been linked to infection with methicillin-resistant Staphylococcus aureus and increasing fluoroquinolone resistance in gram-negative bacilli, such as Pseudomonas aeruginosa. Extended-spectrum Ã-lactamase (ESBL)-producing isolates have been described among patients with acute simple cystitis worldwide 

 Broad-spectrum cephalosporins have been linked to subsequent infections with vancomycin-resistant enterococci, ESBL–producing 

Klebsiella pneumoniae, Ã-lactam-resistant Acinetobacter species, and Clostridium difficile.

Recurrent urinary tract infections (rUTIs), defined as two culture-proven UTIs in a 6-month period or three culture-proven events in 1 year, make up a large percentage of UTIs seen in urologic practices. Although the American Urological Association has developed a guideline previously, the current climate of antibiotic overuse and resultant “collateral damage,” as well as the development of antibiotic-resistant organisms, has prompted the need for an updated guideline 

 that is heavily focused on treating not only symptoms, not only cultures, but rather the important combination of 

Prior to developing the guideline, we conducted a systematic review with the methodology team at the Pacific Northwest Evidence-based Practice Center. The final systematic review was conducted in conjunction with input from the Recurrent Urinary Tract Infection expert panel.

The index patient is an otherwise healthy adult female with an uncomplicated, culture-proven recurrent UTI associated with acute-onset symptoms. Central to a diagnosis of UTI is the symptom of dysuria. Dysuria is a highly specific symptom, with more than 90% accuracy for UTI in young women in the absence of concomitant vaginal irritation or increased vaginal discharge.

The following 16 recommendations are included in the AUA/CUA/SUFU guideline (table):

Clinicians should obtain a complete patient history and perform a pelvic examination in women presenting with rUTIs.

 Here it is emphasized that an exam should be performed to identify any treatable contributor to rUTIs, such as vaginal atrophy or cystocele.

To make a diagnosis of rUTI, clinicians must document positive urine cultures associated with prior symptomatic episodes. 

Since many women have symptoms that may mimic a UTI, such as overactive bladder and interstitial cystitis/bladder pain syndrome, we seek to document all prior episodes with urine cultures before we diagnose a woman as having rUTIs.

Clinicians should obtain repeat urine studies when initial urine specimen is suspect for contamination, with consideration for obtaining a catheterized specimen. 

Because of the high rate of overtreatment with antimicrobials, a sample with epithelial contamination and/or other factors implicating contamination (such as a culture growing “mixed flora’) warrants obtaining a catheterized sample.

Cystoscopy and upper tract imaging should not be routinely obtained in the index patient presenting with a rUTI.

 As urologists, we often feel obligated to work up rUTIs, but this is not necessary.

Clinicians should obtain urinalysis, urine culture, and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment in patients with rUTIs.

 Given what we know about antibiotic resistance, the days of empiric therapy are coming to an end.

Clinicians may offer patient-initiated treatment (self-start treatment) to select rUTI patients with acute episodes while awaiting urine cultures.

 We no longer advise self-start therapy without cultures. However, in a reliable patient who is committed to checking cultures before starting antibiotics, self-start therapy is still a good option.

Clinicians should omit surveillance urine testing, including urine culture, in asymptomatic patients with rUTIs.

 If there are no symptoms, we do not want to know what is in the urine!

Clinicians should not treat asymptomatic bacteriuria (ASB).

 This is very difficult to do, especially when a patient’s primary care provider may wish to treat the patient differently. Often this requires educating the patient’s entire care team.

Clinicians should use first-line therapy (ie, nitrofurantoin, TMP-SMX, fosfomycin) for the treatment of symptomatic UTIs in women depending on the local antibiogram.

 This information can be obtained from the microbiology lab at the hospital where one practices.

Clinicians should treat rUTI patients with an acute cystitis episode with as short a duration of antibiotics as reasonable, generally no longer than 7 days. 

Here we are trying to avoid overtreatment of patients with a course of antibiotics that are longer than necessary for acute cystitis.

In patients with rUTIs with acute cystitis episodes associated with urine cultures resistant to oral antibiotics, clinicians may treat with culture-directed parenteral antibiotics for as short a course as reasonable, generally no longer than 7 days. 

The AUA/CUA/SUFU guide focuses on a combination of symptoms and positive cultures.

Vol 47 No 10

Advocates work toward Office of Men’s Health

How term life insurance can help ensure financial goals are met

Losing patients to follow-up? Here’s what you can do

How has your management of BPH patients changed?

ADT may increase likelihood of urethral atrophy

Positive dipstick does not preclude BTX injections

Low testosterone, incontinence may be linked in older women

Testosterone: A panacea for incontinence patients?

Model highlights cost savings of single-stage SNM

New recurrent UTI guideline: What urologists need to know

Teleurology: The time has arrived

Uro Pipeline: FDA grants IDE approval to begin pivotal study of BPH device

Opioid prescribing varies widely among urologists