Urological Health Q3 Sep 2019 by Mediaplanet UK&IE

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MR NEIL BARBER How a minimally invasive procedure can reduce BPH symptoms. » p3

STEPHEN FRY How taboo words can aﬀect the stigma attached to urology diseases. » p6

PROF. ROGER KIRBY The importance of preference when considering treatment for prostate cancer. » p10

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There are risks associated with all medical procedures. Potential complications with SpaceOAR Hydrogel include inﬂammatory reactions, infection, bleeding, and pain or discomfort from the injection.

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1. Hamstra DA, Mariados N, Sylvester J, et al. Continued benefit to rectal separation for prostate radiation therapy: Final results of a phase III trial. Int J Radial Oncol Biol Phys. 2017 Apr1; 97(5): 976-85. 2. Hamstra DA, Mariados N, Sylvester J, et al. Sexual quality of life following prostate intensity modulated radiation therapy (IMRT) with a rectal/ prostate spacer: Secondary analysis of a phase 3 trial. Pract Radiat Oncol. 2018 Jan - Feb;8(1):e7-e15. CAUTION: The law restricts these devices to sale by or on the order of a physician. All the images are the property of Boston Scientific. All trademarks are the property of their respective owners. © 2019 Boston Scientific Corporation or its affiliates. All rights reserved. URO-664709-AA AUG 2019 CONTENT IS PROVIDED BY BOSTON SCIENTIFIC. BOSTON SCIENTIFIC IS DEDICATED TO TRANSFORMING LIVES THROUGH INNOVATIVE MEDICAL SOLUTIONS THAT IMPROVE THE HEALTH OF PATIENTS AROUND THE WORLD.

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Why more men need to know what BPE is

WRITTEN BY: PROFESSOR CHRIS CHAPPLE Secretary General, European Association of Urology

Do you know what benign prostatic enlargement (BPE) is? If not, you are not alone. A survey was recently conducted in the United Kingdom, France and Germany, which found that, out of the 1,002 male respondents in the UK, aged 50 and above, 37.5% did not know what BPE is. France reported 33%, while in Germany 45% of men were unfamiliar with BPE. (See figure 1.)

How can a shed be good for your health? Originating in Australia, the Men’s Sheds movement is building momentum in the UK; where over 500 groups are changing the lives of an estimated 11,000 men through improving their health.

en’s Sheds (or Sheds) are similar to garden sheds – a place to pursue practical interests at leisure, to practice skills and enjoy making and mending. The difference is that garden sheds, and their activities, are often solitary in nature while Men’s Sheds are the opposite. They’re about social connections and friendship building, sharing skills and knowledge and, of course, a lot of laughter and tea. Sheds are whatever the members (or Shedders as they’re affectionately known) want them to be. Although labelled ‘sheds’, they often aren’t sheds at all. They can be empty offices, portable cabins, warehouses, garages and, in at least one case, a disused mortuary. Ma ny Sheds get i nvolved i n community projects too – restoring village features, helping maintain parks and green spaces, and building things for schools, libraries and individuals in need. Activities in Sheds vary greatly, but you can usually find woodworking, metalworking, repairing and restoring, electronics, model buildings or even car building in a typical Shed. Sheds typically attract older men, but many have younger members and women too. Whatever the activity, the essence of a Shed is not a building, but the connections and relationships between its members. How are Sheds good for your health? A recent focus on the impact of loneliness has emphasised how it can affect both mental and physical health: increasing the risks of dementia, heart disease and depression. It has been estimated that loneliness and poor social connections can be as bad as smoking 15 cigarettes a day and is more detrimental to health than obesity. The UK Men’s Sheds Association, a support and advice charity for Men’s Sheds in the UK, conducted a survey with over 500 Shedders to capture health benefits men expressed they’d gained through joining a Men’s Shed. The results highlighted men

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felt they had gained new friendships and increased their happiness, while reducing feelings of anxiety and depression. James, from Forest of Dean Men’s Shed, says “I have made new friends and learnt some great things, it’s probably saved my life, or at least my sanity.” Megan’s dad is a shedder in Biggin Hill, she says: “My Dad suffered a stroke two years ago now, and this is where the Men’s Shed stepped in. The Shed is a safe, social place for my dad to go to - he loves going twice a week. It takes the pressure off my mum and has been so beneficial to his health and wellbeing. It’s keeping him busy and healthy.” Along with positives for individuals and their families, communities benefit from their activities to an estimated volunteering value of £10.5 million. Many Men’s Sheds support their local community, repairing items for individuals, and supporting other groups in a variety of ways, from making play equipment for local pre-schools to planters for care homes. As well as the boost for local communities, 88% of Shedders say they feel more connected to their community through being part of their local Shed. WRITTEN BY LAURA WINKLEY

PE, also known as benign prostatic hyperplasia (BPH), is a non-cancerous increase in the size of the prostate gland. The symptoms include frequent urination (including at night), difficulty in urinating and/or a weak stream of urine, and pain while urinating. You need to know what your prostate is The results of the survey also showed that 75% of men above the age of 50, did not know what the prostate’s main function is. The prostate is a gland vital to men’s sexual health as it produces prostatic fluid which nourishes and protects the sperm. During ejaculation, the prostate squeezes this fluid into the urethra and it is then expelled with sperm as semen. (See figure 2.) It’s time to talk about urological health Having an enlarged prostate does not

only affect the men who suffer from it, but their partners as well. In the past, it was considered taboo to talk about urological and sexual health issues, but times have changed. Campaigns such as Urology Week encourage open discussions among patients, their partners and/or family, and their urologists. Urology Week is an annual initiative of the European Association of Urology (EAU) where national urological societies, urology practitioners, urology nurses and patients organise diverse activities to spread the word on the importance of urological health. From 23rd to 27th September this year, Urology Week aims to increase awareness of BPE: What the condition is, symptoms to look for, its treatability despite its prevalence, and the importance of consulting a urologist. Urolog ists and other healthcare providers all over Europe are preparing a wide range of activities

for Urology Week 2019 such as television and radio press conferences; marathons; open days at clinics and many others. You too can take part in Urology Week 2019. Visit urologyweek.org to add an event of your own and to view other events planned in other countries. Download the posters, share your event or your story via social media, and include the hashtag #urologyweek. No matter the effort, big or small, you can make a difference and help boost awareness. And always remember, BPE is treatable and your urologist can help.

Sponsored by

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New prostate technology reduces side effects from radiotherapy A PROMOTIONAL SUPPLEMENT DISTRIBUTED ON BEHALF OF MEDIAPLANET, WHICH TAKES SOLE RESPONSIBILITY FOR ITS CONTENTS

New advancements in prostate cancer mean that men who underwent radiotherapy in a randomised clinical study reported fewer bowel, urinary and sexual side effects at median three year follow-up compared to control patients thanks to a new hydrogel spacing technology.2

rostate cancer is currently one of the most common cancers in the UK; more than 40,000 cases are diagnosed each year.1 Typical treatment plans include a high dose of radiotherapy that aims to effectively kill cancer cells so they cannot spread any further. Due to the prostate being close to other organs and tissues, such as the rectum, there is a risk of long-term damage and side effects such as rectal

pain, bowel and urinary leakage and sometimes erectile dysfunction. New gel solution can reduce side effects of radiotherapy S p a c e OA R H yd r o g e l , a N IC E approved water-based hydrogel spacing device, available across the UK via private and co-pay providers has recently been adopted by NHS England’s Innovation Programme. Inserted via a fine needle into the

space between the prostate and rectum, under anaesthetic, the gel fills the cavity between the prostate and rect um, creating about 1cm of space. This allows the oncologist to deliver radiation to the prostate and reduce exposure to surrounding healthy tissues. The only prostate-rectum spacing device to be supported by a 222patient randomised control trial and over 50,000 implants world-wide,

this has had very positive patient outcomes.2,3 P rofe s s or A m it B a h l i s t he Consultant Clinical Oncologist and Clinical Director based at The Bristol Haematology and Oncology Centre, was the first to use this new technology when it became available on the NHS Innovation Technology Programme (ITP) earlier in the spring. P rofe s s or B a h l s ays: “ When looking at treatment options, the risks of these procedures are low but it’s understandable that patients are wor r ied about t hem when they include terms such as ‘rectal toxicity’. Toget her w it h wor r ie s over erectile dysfunction or urinary incontinence, it can make the choice between radiotherapy and surgery quite tough. “Now, I am able to say to patients that I can perform a small procedure that will reduce these side effects and minimise radiation exposure to healthy organs and tissues I haven’t had anyone turn it down yet.” A 15-20-minute treatment under anaesthetic The treatment itself is minimally invasive and takes around 15-20 minutes as a day procedure, under gener a l or lo c a l a n ae s t he t ic,

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depending on the patient. P rofessor B a h l ex pla i n s: “Essentially, it is a fine needle t h r o u g h t h e p e r i n e u m , i nt o the peri-rectal fat. The idea is to dispense the gel between the posterior part of the prostate and the anterior part of the rectum, where the prostate touches the rectum. The gel then forms a soft spacer to separate these tissues. Once the patient has undergone radiotherapy, the gel is broken down by the body and naturally absorbed in about six months.” Spacer means radiotherapy clinicians can be more accurate This technique gives about a centimetre of additional space for the clinician to see a clearer margin between the organs during radiotherapy. “ The prostate moves when a patient breathes,” adds Professor Bahl, “And, despite all technical advances, without that additional gap, we just can’t be as accurate. What this means is that essentially the outcomes are the same but the long-term side effects are much better.” That was certainly the case for 71-year old Alan Clarke, who was

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the first patient to have the hydrogel treatment at Bristol earlier this year. Alan was first diagnosed with prostate cancer back in 2010. He says: “It came about after a random check on my PSA level; my GP sent me for a biopsy as my results were borderline and it turned out that there were cancer cells within my prostate. I had to have 37 doses of radiotherapy, five days a week for seven weeks. “It was a complete surprise for me as I had never expected to be told I would have cancer.” Men should talk more about prostate cancer For ex-motor mechanic, Alan, this was his first experience of prostate cancer. “A lot of men don’t talk about prostate cancer, and they should. This was the first I had really heard about it, but I would end up going to work in the morning and back to the hospital in the afternoon for my treatment. I just got on with it and didn’t really ask questions.” Luckily, Alan’s treatment worked. Over the past nine years, he has had regular check-ups, but earlier this year, his PSA results showed that something was wrong. Alan says: “When I heard that the cancer had come back, I knew that there would be complications

because of my previous treatment. I had a big holiday to Australia coming up to celebrate my step-daughter’s and great-granddaughter’s birthdays, so I just hoped I would be able to go.” Day surgery allowed me to continue my travel plans Alan met Professor Bahl at The Bristol Haematology and Oncology Centre and was told about the gel. Alan was deemed a good patient to receive the spacer as he was more likely to receive potential side effects due to his previous treatment. On the day, Professor Bahl simply m i xe d t wo s y r i nges toget her, inserted the needle into the space – where the gel sets – within seconds. Alan was allowed home later that day and, after one dose of high-intensity radiotherapy, he was allowed to travel the next month. “We have always been big on travel in my family, so I’m very glad the treatment allowed me to continue with my plans so quickly with no real side effects. I’ve now got a cruise booked to Canada in October and can’t wait to see what it’s like in the autumn.” Spacer gel being rolled out across NHS England Now the spacer gel is available in

INTERVIEW WITH:

PROFESSOR AMIT BAHL Consultant Clinical Oncologist and Clinical Director, The Bristol Haematology & Oncology Centre

Now, I can perform a small procedure that will reduce radiation exposure to the rectum and minimise long-term side effects for my patients. I haven’t had anyone turn it down yet.” several hospitals across England, and is covered by all major private insurance providers, but Professor Bahl is hoping it will be made available more widely in the future. Professor Bahl says: “We are very grateful that the NHS ITP programme is embracing new technologies and that hospitals across the UK will benefit. Equally, I would say to

URO-672615-AA SEP 2019

patients that, if it is not being offered in your local hospital then there is the option of discussing with your clinical oncologist regarding other avenues for availing this treatment.” The ITP programme aims to approve a reimbursement for all men considered eligible to have the new spacer gel inserted. In studies, its use has been shown to reduce life-changing side effects, such as rectal complications, by 75% compared to control patients at a median of three years of follow-up.1 Alan highly recommends the treatment. He says: “I had anaesthetic so, in terms of the waist down, I was numb. A little uncomfortable over the next few days but that was to be expected. Now, my life is back to normal; I go on long haul flights, shopping trips with the wife and do the gardening. If you’re considering radiotherapy, I would say, ‘go for it.’” WRITTEN BY: GINA CLARKE

Results from case studies are not necessarily predictive of results in other cases. Results in other cases may vary. There are risks associated with all medical procedures. Please talk with your doctor about the risks and benefits associated with SpaceOAR Hydrogel. Potential complications associated with SpaceOAR Hydrogel include, but are not limited to: inflammatory reactions, infection, bleeding, and pain or discomfort from the injection. CAUTION: The law restricts these devices to sale by or on the order of a physician. Indications, contraindications, warnings and instructions for use can be found in the product labelling supplied with each device. Information for use only in countries with applicable health authority registrations. This material not intended for use in France.

SpaceOAR hydrogel is clinically proven, minimally invasive spacer designed to minimise urinary, sexual, bowel side effects and protect quality of life for prostate cancer patients undergoing radiation therapy.

1: NHS. 2018. Prostate Problems. [ONLINE] Available at: https://www.nhs.uk/conditions/prostate-problems/. [Accessed 9 September 2019]. 2: Hamstra DA, Mariados N, Sylvester J, et al. Continued benefit to rectal separation for prostate radiation therapy: Final results of a phase III trial. Int J Radiat Oncol Biol Phys. 2017 Apr 1;97(5):976-85. 3: Data on file with Boston Scientific.

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Why some men are opting to put off prostate cancer surgery Thousands of British men are now choosing to have their prostate cancer monitored instead of having surgery or radiotherapy. It is an important decision that must be carefully considered.

very year, around 47,000 British men will find out they have prostate cancer. Those with an aggressive form of the disease will need rapid treatment in the form of surgery, radiotherapy or sometimes chemotherapy. However, if it is classed as being ‘low risk’ or slow-growing and looks likely to stay that way for some time, then it is often possible to have no treatment at all - an approach known as active surveillance (AS). For a man who just been told that he has a type of cancer that kills 11,000 men every year, the idea of having no active treatment for it, can be a difficult one to get his head around. But sometimes, doing nothing is the safest option. Active surveillance is an alternative to active treatment, which involves regularly monitoring low-risk or slow-growing prostate cancer instead of undergoing radical treatment such as surgery or radiotherapy. It allows some men to avoid, or delay, the start of treatments that can carry side effects such as incontinence, sexual and bowel dysfunction – all of which can have a long-term impact on their quality of life. Researching the potential for active surveillance Up until relatively recently, it was thought there wasn’t enough evidence for doctors to recommend it. That’s why the Movember Foundation invested in researching active surveillance through the GAP3 project. The aim is to create the world’s largest centralised database of men with prostate cancer on active surveillance. It includes clinical, MRI and genomics data from over 15,100 men in 12 countries who have chosen active surveillance. It will allow clinicians to better identify men who are suitable for active surveillance and more accurately determine when a man’s cancer has progressed to the point that he needs active treatment. Data suggest more UK men are opting out of surgery There are signs that the trend towards AS in the UK is rising. Earlier this year, the National Prostate Cancer Audit Annual Report showed that the proportion of low-risk men who opted for radical treatment in 2016-17 fell from 8% to 4% in one year. This is good news because the problem of men being overtreated has been one of the challenges we face in treating prostate cancer. But just because it’s the right path for some men – that doesn’t make it an easy decision. Choosing whether to have treatment or not can be very tough. It’s vital that men get the information they need and understand the risks involved so that they can make an informed decision about their own treatment and no man is left regretting that choice later down the line.

WRITTEN BY: PAUL VILLANTI Executive Director, Programmes, Movember Foundation

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Risk-based management of early prostate cancer WRITTEN BY: PROFESSOR ROGER KIRBY Editor-in-Chief, Trends in Urology and Men’s Health

The need for treatment following a diagnosis of prostate cancer should take into consideration, not only the stage and grade of the disease, but also patient preferences.

n low-risk cases (PSA <10ng/ ml and Gleason score ≤6), the majority of men are now advised to undergo a period of active surveillance in order to determine whether or not intervention by surgery or radiotherapy is required. The recently revised NICE guidelines1 on the diagnosis and management of prostate cancer have proposed PSA measurement and accompanying digital rectal examination every four months, with reassessment at 12 months using a multiparametric MRI, followed by a repeat biopsy. In the absence of evidence of progression, follow up should continue with regular PSA determinations either in primary or secondary care. If cancer progression becomes apparent, then the need for more definitive treatment will need to be discussed. Evidence currently shows that patients treated by surgery or radiotherapy, after an initial period of active surveillance, do not seem to have worse outcomes than those that were treated at the time of the original diagnosis. In intermediate-risk cases (PSA 10–20ng/ml, or Gleason score 7), following an initial discussion about active surveillance, most urologists advise definitive treatment to prevent the development of local complications and/or metastatic spread. Eliminating early prostate cancer by removing the gland The most reliable way of permanently eliminating early prostate cancer is to remove the gland before the cancer has spread. This is most com mon ly ach ieve d by keyhole surgery, with or without robotic assistance. With careful technique and an experienced surgeon, the risk of more t ha n temp ora r y s t re s s urinary incontinence is

The recent vogue for active surveillance will reduce the potential for ‘overtreatment’ of low-risk cancers.” 2–5%. The chances of erectile dys© NATTAKORN MANEERAT function (ED), however, are considerably greater. This risk needs to be discussed with patients. ED can be managed reasonably effectively with regular phosphodiesterase 5 inhibitor therapy and/or prostaglandin injections. Radiotherapy treatment Alternatively, the patient can be offered treatment by radiotherapy, using either external beam radiation, usually preceded by at least three months androgen blockade, or brachytherapy. Other newer ‘focal’ therapies, which target the tumour rather than the entire prostate, such as high-intensity focused ultrasound (HIFU), are still regarded as experimental and should only be employed within the context of a clinical trial. Active surveillance is not advised for high risk cancer In high-risk patients (PSA >20ng/ml or Gleason score 8–10) with localised disease, active surveillance is not advised. Instead, surgery or radiotherapy, plus hormone treatment is recommended. The choice between these options w ill depend on patient preference and on the local extent of the tumour. If, for example, there is evidence of bulky local disease and/ or seminal vesicle involvement, the decision should be more likely to include radiotherapy. If it looks as though the tumour can be removed in its entirety, with negative surgical margins, then radical prostatectomy may be possible. However, patients in this category should be informed that subsequent ‘multimodality’ treatment with radiotherapy and hormone treatment may often be required.

1: National Institute for Health and Care Excellence (NICE). Prostate cancer: diagnosis and management (NG131), May 2019 (https://www.nice.org.uk/guidance/ng131; accessed 22 July 2019).

The patient must be actively involved in treatment decisions The diagnosis and management of early prostate cancer continues to generate much discussion and controversy. Recently, several studies have reported superior outcomes for surgery as opposed to either radiotherapy or ‘watchful waiting’. However, every treatment option carries the risk of side-effects, which need to be carefully explained to both the patient and his partner. The recent vogue for active surveillance, which features prominently in the recently updated NICE guidelines, will reduce the potential for ‘overtreatment’ of low-risk cancers that are destined never to affect the patient within their natural lifespan. Anxieties persist that current methods of initial diagnosis and staging, and subsequent identification of disease progression, are still suboptimal. The use of genomic markers may prove useful refinements by providing prognostic information. These include the ProlarisTM or Oncotype DxTM tests, which identify and quantify markers of cell cycle progression. Current extensive research seems likely to identify other clinically useful biomarkers, as well as alternative treatment options, which cause less morbidity.

About Trends Trends in Urology and Men’s Health covers subjects that particularly affect men. These subjects include cardiovascular disease, urological, sexual and mental health issues. The journal publishes six times a year and includes concise, evidence-based, educational and practical articles aimed at urologists, GPs and specialist nurses.

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Proton beam therapy can help to win the war against prostate cancer WRITTEN BY: DR JASON LESTER Senior Consultant Clinical Oncologist, Rutherford Cancer Centre South Wales

Prostate cancer is now the most common cancer in the UK. Each year in the UK, 47,000 men are diagnosed with prostate cancer. It accounts for 26% of all new cancer cases in men, and the disease kills more men than breast cancer kills women.

pproximately one in eight men will get prostate cancer at some point in their lives.1 While survival rates for prostate cancer have been improving, there has been a significant increase in incidence. Since the early 1990s, prostate ca ncer i ncidence has increased by 41% and is projected to rise further in the coming decades. The most common treatments for men with localised prostate cancer are surgery, to remove the prostate gland, and radiotherapy. The treatment of localised prostate cancer is effective, and most men will be cured of their disease. A key challenge, however, is minimising side effects from treatment, which is important to help men maintain a good quality of life. A new type of treatment with more accurate radiation High energy proton beam therapy (PBT) is now available in the UK to treat men with localised prostate cancer. Conventional radiotherapy uses high energy X-rays called photons to destroy cancer cells. PBT uses beams of protons to achieve the same effect. Side effects from conventional radiotherapy are as a result of radiation damage to the normal tissues near the cancer. Unlike conventional radiotherapy, the properties of protons allow them to enter and travel through tissue with

The most common treatments for men with localised prostate cancer are surgery - to remove the prostate gland - and radiotherapy.”

patients compared to those treated with conventional radiotherapy. Researchers leading the study also highlighted that reduced toxicity w it h PBT did not come at t he expense of reduced effectiveness.

minimal dose deposition in normal tissue on the way to the target, and minimal dose to the tissues beyond the target. This means PBT can reduce the risk and severity of side effects compared to conventional radiotherapy.

Three centres in the UK able to offer PBT therapy In early 2018, the Rutherford Cancer Centre in South Wales became the first clinic in the UK to treat prostate cancer patients with high energy PBT. There are now two new Rutherford PBT centres in Reading and Newcastle. In addition, there is an NHS PBT facility at The Christie NHS Foundation Trust in Manchester. Dr Jason Lester, an oncologist from the Rutherford Cancer Centre Sout h Wa les, who has t reated a number of patients with PBT, including prostate cancer patients, says: “While proton beam therapy is not a magic bullet that can treat all cancers, we have seen that it can be a very effective treatment for prostate cancer. To date, we have seen no significant long-term side effects from treatment.”

Proton beam therapy is the preferred treatment option for children Because of the precision of PBT t reat ment, it is c u r rent ly t he preferred option for treating cancers in children because there is almost always less radiation dose to normal tissues compared to conventional radiotherapy, and this reduces the chance of serious complications. In adults, PBT is used to treat cancers that are near critical structures, such as the optic nerve or spinal cord, where conventional X-ray treatment may cause damage. As demand for precision radiotherapy grows, there is debate about the benefits that PBT can offer other cancer patients, including those with prostate cancer. A recent study by the University of Pennsylvania revealed that the risk of side effects was t wo -t h i rds lower for PBT

Read more at therutherford.com

PATIENT STORY

A patient’s experience of proton beam therapy treatment

ennis Allen was a prostate cancer patient who was diagnosed with the disease last year and opted for proton beam therapy after doing his own research. “I was diagnosed with prostate cancer in March 2018. A PSA test came back as high and I was referred to the Churchill Hospital in Oxfordshire, where I had a biopsy. “The biopsy confirmed that it was cancer. As a very healthy person, I was shocked. I was referred to a number of consultants and oncologists and they spoke to me about conventional radiotherapy and a prostatectomy, but nobody mentioned proton beam therapy.”

DENNIS ALLEN Prostate cancer patient No one had told me PBT was an option “Here I was, facing a high chance of extreme side effects such as impotence and incontinence with conventional treatments (40% chance of both occurring) and yet I had no symptoms to suggest there was anything wrong with me. I did my own research and met a friend who had heard about proton beam therapy and, after investigation, I decided to opt for the treatment. I was shocked and frustrated that up until that point, no one told me about this treatment, despite the enormous benefits. “I received proton treatment at the Rutherford centre in Newport in October 2018, which lasted for four weeks. Each treatment session under the beam only lasted for a few minutes – it takes longer to make a slice of toast – and I felt no pain or discomfort throughout. I feel absolutely normal, as if I have been cured of a disease I never knew I had. I had no symptoms, felt nothing during the treatment and had no side effects afterwards. “I was very fortunate to receive this treatment. Many prostate cancer sufferers are risking dreadful side effects, including impotence and incontinence, and it could potentially be avoided. It is crucial that people are aware of this option.”

THE UK’S NETWORK OF PROTON BEAM THERAPY CENTRES South Wales | North East | Thames Valley | North West

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The discussion of erectile problems is still taboo

While there might not be an underlying cardiovascular cause identified, the risk factors associated with erectile dysfunction include smoking, alcohol, obesity, high blood pressure, high cholesterol levels, reduced levels of exercise and depression. INTERVIEW WITH:

DUNCAN J SUMMERTON Consultant Urological Surgeon, University Hospitals of Leicester NHS Trust Honorary Associate Professor, University of Leicester President, British Association of Urological Surgeons

t can be difficult, more than difficult for some, to go to your GP and talk about a problem with your ‘downstairs’. But, stigma and embarrassment aside, a number of us may not necessarily know which parts of the body ‘urology’ specifically refers to, with the UK lagging behind the rest of Europe on patient education. That’s according to Consultant Urological Surgeon, Mr Duncan Summerton, from The University Hospitals of Leicester NHS Trust. What does ‘urology’ actually refer to? “Essentially, we’re talking about the urinary tract, comprising of the kidneys, the bladder, the prostate, urethra, testes and the penis.” Urology also covers non-cancerous as well as

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cancer of these organs. Erectile dysfunction (ED) is just one of a number of many medical complaints that fall under the tag of being a urological issue, with bladder and prostate problems also making up a large percentage of the complaints dealt with by GPs in the UK. However, it appears to be the most difficult to talk about, with men’s partners often playing a big part in encouraging their other halves to talk to their GP. A visit to the GP is important, as erectile dysfunction can be an indicator of more serious underlying cardiovascular problems.

Buzz Aldrin and Stirling Moss act as role models in talking about their illness, yet erectile dysfunction still carries that stigma.” Indeed, until recently, very few men had spoken publicly. Now though, England cricket legend, Ian Botham, has gone on record, describing how much treatment for his erectile dysfunction has helped him, saying it was the “best health decision he’d ever made.” So, the message is clear. Going and seeing your GP could both open up a range of options and may even save your life.

Erectile dysfunction may be a sign of poor cardiovascular health The arteries that supply blood to the penis are roughly the same diameter of those that supply the heart, so, an issue downstairs may suggest the patient needs to be investigated more fully from a general and cardiac viewpoint. “Around 6% of men who complain of ED will have some form of cardiovascular episode (twice the rate of those men who don’t suffer from ED) within three years, so it’s really important that men from middle-age upwards do talk about it with their GP. “Once someone presents with erectile dysfunction, invariably they’ll have a full health screening to ensure that there isn’t anything more serious at play.” With the links to other potential underlying issues with the heart, slightly older men may have a reason to finally take that jump. Yet, Mr Summerton believes all sufferers would benefit from more public figures talking about their erectile issues. “Prostate cancer had the likes of

WRITTEN BY: JAMES ALDER Mr Summerton is also the President of The British Association of Urological Surgeons, an organisation specialising in providing support and education on urological issues to both patients and professionals. The organisation celebrates its 75th anniversary in 2020. Over 92% of all consultant urologists in the UK belong to BAUS, and it is a constantly evolving organisation and a registered charity. The mission of BAUS is to: “To promote the highest standard in the practice of urology for the benefit of patients by fostering education, research and clinical excellence” and our vision is: “All those involved in urology are supported to deliver excellent care.”

Why men need to be more honest about erectile dysfunction One patient reveals how erectile dysfunction caused by an underlying condition made his life a misery — and how an implant procedure gave him back his confidence... and his sex life.

ichael Moore was a married man of 28 when he began experiencing issues with erectile dysfunction, which shattered his confidence and affected his mental health. “I began feeling extremely depressed,” he remembers. When Michael fi nally went to see his doctor (“It took me six months to find the courage”), he was given various treatments, but none of them worked. This went on for more than 20 years. Michael's erectile dysfunction wasn't psychological, however. It was being caused by an underlying neurological condition, which he discovered when he was finally diagnosed with multiple sclerosis in 2015/2016. MS was the cause of my erectile dysfunction By the time he was referred to Mr Vaibhav Modgil, Consultant Urological Surgeon and Andrologist — a specialist in male sexual and reproductive health — Michael admits he was in a dark place psychologically. “I wanted to get back some control,” he says. “A nd I wanted normality again for myself and my wife.” “It's far more com mon t han people thin k, and doesn't just affect older men,” says Mr Modgil. “The vast majority of cases I see in my clinic are organic, rather than purely psychological; although there is no doubt psychogenic ED is more

common among younger men, it can be linked to diabetes, conditions affecting the nerves and even sleeprated issues, for instance. Cancer treatments such as pelvic surgery, chemotherapy and radiotherapy, can also cause ED.” Treatment options for erectile dysfunction First-line therapy tends to be tablet treatment. “If patients don't respond to tablets, injections into the penis and topical treatments are available to produce erections,” says Mr Modgil. “While these might work for some people, others don't want to inject into their penis, as it kills spontaneity.” Vacuum pump devices designed to engorge the penis are also available; but, again, these are neither discreet nor spontaneous enough for some patients. If these solutions don't work, and all other options have been exhausted, penile implant surgery — a procedure that is available on the NHS in specialised centres — may be a consideration. “There are two types of penile implants,” says Mr Modgil. “With the semi-rigid or malleable implant, two malleable rods are placed within the penis that can be pulled up into the erect position. “Then there's the inflatable penile implant, which involves fitting two cylinders into the body of the penis. A pump sits within the scrotum and a reservoir sits within the abdomen. When the patient squeezes the pump in the scrotum, fluid leaves

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Penile prosthesis: what are they and who can get one?

E INTERVIEW WITH:

INTERVIEW WITH:

VAIBHAV MODGIL Consultant Urological Surgeon and Andrologist

MICHAEL MOORE Patient

It’s far more common than people think, and doesn’t just affect older men.”

I lost any kind of sex life from my late twenties through to my early fifties.”

the reservoir and makes it way to the cylinders to provide an erection. This results in an on-demand erection, when the patient wants, for as long as they want. No part of the device is externally visible with what is usually a very small scar either above or below the base of the penis.”

same day as their surgery. “However, people should understand that this, like any operation, is a significant undertaking,” says Mr Modgil. “The operation must be carried out at a specialist centre under the care of an experienced team. It's also the point of no return, because surgery eviscerates erectile tissue in the penis — so the only way a patient will get an erection afterwards is with an implantable device. “It's a last resort option for most patients, but it works incredibly well.” Its availability is not wellknown, however. In fact, Mr Modgil often speaks to healthcare professionals, and even GPs, who are unaware of this type of surgery. Michael's been impressed with

Return to positive self-worth and body image Michael, now in early fifties, chose this option and underwent surgery in March. In the vast majority of cases, patients are able to return home a day later. More recently, the team at Manchester Royal Infirmary have started performing 'day-case' procedures for selected patients, allowing them to return home the

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the results of the surgery, from both a physical and mental standpoint. “My sex life hasn't been this good since I was 18! Psychologically, it's boosted me, too, changing my overall mental health. In fact, the procedure has done more than cure my ED. It has also had a positive effect on my feelings of self-worth and body image.” “Let's be honest,” says Michael. “Erectile dysfunction isn't an easy subject for men to talk about with anyone — let alone admit to in the pages of a national newspaper. “Even though ED was a result of my MS, it doesn’t make it any easier that my friends and family will know about it! That said, there must be hundreds of men who have felt the way I was feeling for years. So, if there's anything I can do to change that, I will.” WRITTEN BY: TONY GREENWAY

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rectile dysfunction is still an embarrassing issue for men, but one that is increasingly common. While there are many treatments to try first, for some men, the only alternative will be a surgical procedure such as a penile prosthesis. Clinical nurse practitioner, Clare Akers, advises men on the various treatment options available for men with erectile dysfunction, no matter their age. It’s something she feels both the medical profession and the media have a role in making less taboo. She says: “All too often, a patient will come to us with erectile dysfunction. This could have developed after surgery for prostate cancer, for example, or by having diabetes. The sad thing is they believe that they’re not entitled to surgical help because they are too old or not in a relationship. But there isn’t an age limit and you don’t have to be in a relationship to have a penile prosthesis. I have to bust myths to help patients understand their options Clare finds it important to be truthful to the men who come to see her, often having heard rumours of a bionic penis but not sure of the mechanics. Her role as a clinical nurse practitioner is to make sure that all other medical treatments and options have been exhausted, and then to explain the alternatives if they are fit enough for surgery. It is essential that the men understand that a penile prosthesis is irreversible and, like with any surgery, carries some risks, all of which she explains carefully to ensure men remain fully informed. She says the main difference between the two types of penile prosthesis available is that one maintains an erection at all times (malleable prosthesis), which can

INTERVIEW WITH:

CLARE AKERS Clinical Nurse Practitioner

be concealed, “I often describe it as ‘bendy rods’ that are inserted into the penis. Whereas, the other type consists of a mechanical device (inflatable prosthesis) that is fitted into the penis, scrotum and pelvis, which can be inflated and deflated through a pump in the scrotum.” The inflatable penile prosthesis is not detectable from the outside, whereas the malleable looks less concealable, and yet after surgery men can return to a normal life with sensation and orgasmic function. Making men feel whole again Clare often finds men are worried about the possibility of embarrassment, such as walking through an airport scanner or not being able to continue their hobbies, but that’s not the case.She says: “There is often discomfort from the procedure in the first four to six weeks and then if they have the inflatable penile prosthesis they must be taught how to inflate and deflate the device, but, within three months, men should be able to return to normal activity and regain their sex life. WRITTEN BY GINA CLARKE

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Myths and facts about bladder incontinence WRITTEN BY: DEBORAH WYATT Director, talkhealth

There are many myths surrounding bladder incontinence; these are some of the most popular misconceptions. Myth – Bladder incontinence is rare and only affects women who have had children or older people. Incontinence is a lot more common than you may think. In fact, the NHS estimates that between three and six million people in the UK have some degree of bladder incontinence. Bladder weakness affects one in three women over the age of 18 and over half of these women never seek help from their doctor. Bladder weakness and incontinence is more likely to affect certain people such as women who are pregnant or have given birth and women who are experiencing menopause due to a decline in oestrogen levels. While bladder weakness also affects older age groups, men, for example, shouldn’t be overlooked, as they can also experience bladder incontinence at any age. A number of other life events and lifestyle choices can also trigger incontinence. These include: • Stress and anxiety; • Smoking; • Nerve damage from diabetes; • Neurological diseases e.g. MS, Parkinson’s; • Obesity; • Strenuous sports. Fact – There is more than one type of bladder incontinence There are different types of incontinence that can affect you at any stage of life. The three main types are: • Urge incontinence - when you have a strong need to urinate but can't reach the toilet in time – this can happen to you at any age; • Stress incontinence – when you experience bladder leaks when coughing, sneezing or laughing – which is more common in younger women; • Mixed incontinence - a combination of stress and urge incontinence. Myth – Bladder incontinence is an individual disease Incontinence isn’t a disease by itself, it’s a symptom for another health problem. Quite often, a temporary illness like an infection can be a cause of incontinence. Once you treat the cause, incontinence can go away. This is the same with long-term illnesses, such as diabetes and obesity for example. Diet changes, exercise, even surgery can improve both your condition and your bladder issue at the same time. Fact – Exercise can help Strong pelvic floor muscles can help you hold your urine and there are various exercises you can perform to help tighten these. Kegel exercises (pelvic floor) help both tighten and relax the muscles that control the release of your pee. Exercising your pelvic floor muscles is like pretending you have to urinate and then holding it by relaxing and tightening the muscles that control the flow of urine. If you’re struggling with these, ask your doctor or a physical therapist to help you perform the exercises correctly. Read more at healthawareness.co.uk

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Incontinence and mental health are linked

Whether it’s celebrities talking or something you see on the TV, urinary incontinence is becoming more well-known. But that doesn’t mean we’re doing anything about it.

or one in three women, urinary incontinence is something they will have to endure throughout their lives. Whether it was the outcome of pregnancy or the onset of menopause, there is certainly more acceptance these days that it can happen. However, little is mentioned about the psychological effects suffering can have. Incontinence can cause anxiety and embarrassment The anxiety that women can feel while suffering from urinary incontinence is a personal interest for Urology and Continence Nurse Specialist, Jane Brocksom, President of The British Association of Urological Nurses. “Mental health and incontinence go hand-in-hand,” she says. “I have ladies who can only plan a trip into town if they know where all the toilets will be. It is even stopping previously outgoing ladies from leaving the house because they are scared they might leak and embarrass themselves. It really is debilitating.” It can often seem like there is little choice for women but to suffer in silence. However, that’s not the case says Brocksom. “Often, I find that the act of speaking up and talking to your GP or a specialist nurse is half the battle. I find that, for a lot of ladies, being able to have a good chat and examine why you might be suffering often goes a long way to resolving some of the problems.” Feel yourself again with lifestyle re-training With women often juggling young families and older parents, there can be little opportunity to think of their own health. But often a frank

and honest chat with a professional can help women to re-evaluate their drinking and toilet habits. “I c a n’t rememb er le a r n i n g to drink or go to the toilet” says Brocksom. “Sometimes we just INTERVIEW WITH:

to live my life?” adds Brocksom. “If I can help a woman to feel able to leave the house or pick the grandkids up, that’s a huge step forward.” Certainly for Brocksom, making sure that women have access to specialist continence nurses is a big concern of hers. She says: “Women just need to know that there is someone there who cares about them. Mentally, that can make all the difference.” WRITTEN BY: GINA CLARKE

JANE BROCKSOM Urology and Continence Nurse Specialist and BAUN President

need a bit of re-education. We might drink five cups of tea a day and think we’re hydrated, but we’re not getting the good stuff that we need. Equally, our lives are more sedentary, so if we’re sat on an office chair for most of the day, our pelvic floor muscles just aren’t getting any training. And it’s this lifestyle evaluation that a health professional can offer.” A work out for your pelvic ﬂoor Today’s women have little training on the pelvic floor, or the need to rest after childbirth, so with the onset of the menopause causing the pelvic floor to weaken, it can often come as a shock that the body is not as robust as it once was. “It’s being able to evaluate and say I can’t do at 60 what I could do at 18, but how can I improve and continue

The British Association of Urological Nurses (BAUN) is a registered charity that aims to promote and maintain the highest standards in the practice and development of urological nursing and urological patient care. The charity’s objects are specifically restricted to the promotion of the advancement of education in urological nursing and urological patient care for the benefit of the community as a whole, and in particular the provision of training courses, endorsement schemes, education materials, meetings and conferences.

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