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Obesity loss, and illness severity (among other factors), is critical to f,EY POIXT mitigate complications. such as inf'ection and poor wound . Pregnant patients who require surgery should HVC healing. Loss of 107, to l5'X, of total body weight during the undergo the same preoperative medical evaluation as preceding 6 months, a BMI less than 18.5. and a serum albu nonpregnant patients; additional diagnostic testing is min level less than 3.0 g/dl (30 g/L) indicate severe malnu- unnecessary. trition and are key predictive factors of poor surgical outcomes. Patients with these features warrant preoperative nutritional interventions with high-protein, high calorie oral supplementation. Finally, before any major surgery geriatric patients and Obesity their families should be educated on delirium risk and preven, Definition and Epidemiology tion, potential fbr functional and cognitive decline, and pos Obesitll defined as a BMI of 30 orgreater. is one olthe big sible need fbr skilled nursing at discharge. gest health problems in the United States and increases risk For more information, see Hospital Medicine Principles. for mortality, type 2 diabetes mellitus, cardiovascular dis- ease. obstructive sleep apnea, mental health disorders. liver Pregnant Patients disease. and many cancers. Obesity in midlife is consist

loss, and illness severity (among other factors), is critical to f,EY POIXT mitigate complications. such as inf'ection and poor wound . Pregnant patients who require surgery should HVC healing. Loss of 107, to l5'X, of total body weight during the undergo the same preoperative medical evaluation as preceding 6 months, a BMI less than 18.5. and a serum albu nonpregnant patients; additional diagnostic testing is min level less than 3.0 g/dl (30 g/L) indicate severe malnu- unnecessary. trition and are key predictive factors of poor surgical outcomes. Patients with these features warrant preoperative nutritional interventions with high-protein, high calorie oral supplementation. Finally, before any major surgery geriatric patients and Obesity their families should be educated on delirium risk and preven, Definition and Epidemiology tion, potential fbr functional and cognitive decline, and pos Obesitll defined as a BMI of 30 orgreater. is one olthe big sible need fbr skilled nursing at discharge. gest health problems in the United States and increases risk For more information, see Hospital Medicine Principles. for mortality, type 2 diabetes mellitus, cardiovascular dis- ease. obstructive sleep apnea, mental health disorders. liver Pregnant Patients disease. and many cancers. Obesity in midlife is consist In women of childbearing age undergoing surgery a men. ently associated with increased risk tbr dementia. The United States is the most obese developed country,. rvith strual history should be obtained and pregnancy testing per rates of obesity at 39.8'1, and overweight (BMI of 25.0 29.9) formed if pregnancy is possible. at 71.8"/,. Although high quality evidence is lacking and the Waist circumference is another marker of health related current body of evidence suggests that surgery does not to obesity. Measurements at the top of the iliac crests of 102 cm negatively affect obstetric or maternal outcomes. elective (40 in) or greater in men and 88 cm (35 in) or greater in surgery should be delayed until after pregnancy. If surgery women is correlated with visceral adiposity and increased risk cannot be delayed until after delivery, pertbrming surgery for diabetes mellitus, cardiovascular disease, and all cause during the second trimester is pref'erred, if possible. mortality (Table 32). Pregnant patients who require surgery should undergo a standard preoperative medical evaluation; additional diag xtl PorxTs nostic testing is unnecessary unless directed by the obste o Obesity increases risk for mortality, type 2 diabetes trician. Modifications to surgical and anesthetic techniques mellitus, cardiovascular disease, obstructive sleep may be required because of the anatomic and physiologic apnea, mental health disorders, liver disease, and changes of pregnancy. Close collaboration among the many cancers. obstetrician, surgeon, anesthesiologist, and internist is . Waist circumference of 102 cm (40 in) or greater in men essential. Notably, pregnancy is considered a hypercoagu and 88 cm (35 in) or greater in women is associated lable state, and the ACCP recommends perioperative with increased risk fbr diabetes mellitus, cardiovascular mechanical or pharmacotogic VTE prophylaxis for preg disease, and all-cause mortality. nant patients.

In women of childbearing age undergoing surgery a men. ently associated with increased risk tbr dementia. The United States is the most obese developed country,. rvith strual history should be obtained and pregnancy testing per rates of obesity at 39.8'1, and overweight (BMI of 25.0 29.9) formed if pregnancy is possible. at 71.8"/,. Although high quality evidence is lacking and the Waist circumference is another marker of health related current body of evidence suggests that surgery does not to obesity. Measurements at the top of the iliac crests of 102 cm negatively affect obstetric or maternal outcomes. elective (40 in) or greater in men and 88 cm (35 in) or greater in surgery should be delayed until after pregnancy. If surgery women is correlated with visceral adiposity and increased risk cannot be delayed until after delivery, pertbrming surgery for diabetes mellitus, cardiovascular disease, and all cause during the second trimester is pref'erred, if possible. mortality (Table 32). Pregnant patients who require surgery should undergo a standard preoperative medical evaluation; additional diag xtl PorxTs nostic testing is unnecessary unless directed by the obste o Obesity increases risk for mortality, type 2 diabetes trician. Modifications to surgical and anesthetic techniques mellitus, cardiovascular disease, obstructive sleep may be required because of the anatomic and physiologic apnea, mental health disorders, liver disease, and changes of pregnancy. Close collaboration among the many cancers. obstetrician, surgeon, anesthesiologist, and internist is . Waist circumference of 102 cm (40 in) or greater in men essential. Notably, pregnancy is considered a hypercoagu and 88 cm (35 in) or greater in women is associated lable state, and the ACCP recommends perioperative with increased risk fbr diabetes mellitus, cardiovascular mechanical or pharmacotogic VTE prophylaxis for preg disease, and all-cause mortality. nant patients. TABLE 32. Classification of Overweight and Obesity by BMI Disease Risk" Relative to Normal Weight and Waist Circumference Category BMI Obesity Class Men: <102 cm (40 in) Men: >102 cm (40 in) Women: <88 cm (35 in) Women: >88 cm (35 in) Underweight <1 8.5

TABLE 32. Classification of Overweight and Obesity by BMI Disease Risk" Relative to Normal Weight and Waist Circumference Category BMI Obesity Class Men: <102 cm (40 in) Men: >102 cm (40 in) Women: <88 cm (35 in) Women: >88 cm (35 in) Underweight <1 8.5 Normal 18.5-24.9 Overweight 25.0-29.9 lncreased High Obesity 30.0-34.9 I High Very high 3s.0-39.9 il Very high Very high Extreme obesity >40 lil Extremely high Extremely high normal weight Reoroduced lronr N ational Heart,Lung,andBloodlnstitute.Aimforahealthyweight www.nhlbi.nih.gov/health/educational/lose wt/BMl/bmi dis.htm.AccessedJonell,2O2l 42

Obesity Screening and Evaluation hyperpigmentation) should also be performed. Examining patients with obesity may require adaptations, such as using a The U.S. Preventive Services Task Fbrce (USPSTF) recom scale with an adequate weight limit and using an appropri mends screening adults lor obesity by measuring height and ately sized blood pressure cuff. weight and calculating BMl. Clinicians should ask patients Laboratory evaluation should include thyroid and liver with obesity about their diet (for example, using a 24 hour function, lipid levels, and screening fbr diabetes. Other labora- diet recall), including intake of sugar sweetened beverages tory testing should be based on patient specific signs, symp and processed foods and eating patterns (such as late night toms, and risk factors. Although obesity is associated with eating or stress eating). Clinicians should also ask about higher risk for certain cancers, recommendations for cancer physical activity patterns, sleep duration and quality, social screening are the same as for patients without obesity. support, emotional factors, weight history, previous weight Screening for cardiovascular disease is reserved for sympto loss attempts, and health and weight loss goals. A thorough matic patients. medication history is recommended to identify medications that may contribute to weight gain (Table 33). Physicians t(EY POIilI should inquire about symptoms of obesity-related condi- . The U.S. Preventive Services Task Force recommends tions, such as heart disease, obstructive sleep apnea, osteoar screening all adults for obesity by calculating BML thritis, and erectile dysf unction. Physical examination should include measurements of waist circumference, heart rate, blood pressure, and oxygen Treatment saturation. Cardiorespiratory thyroid, and skin examination In approaching obesity management, use of nonjudgmental (to detect hirsutism, acanthosis nigricans, striae, and language is important to engage patients and build trust. Treatment options for obesity include lifestyle modification, TABLE 33, Medications That Promote Weight Gain pharmacotherapy, and bariatric surgery. American College of and Alternatives Cardiologz/American Heart Association/The Obesity Society Medications That Promote Alternatives guidelines recommend lifestyle modification that includes weight Gain reduced calorie intake, increased physical activity, and Antidiabetic drugs (insulin, Metformin, GLP-1 agonists, behavioral therapy. Similarly, the USPSTF recommends sulfonylureas, SGLT-2 inhibitors, acarbose, ofl'ering or referring patients with obesity to intensive, mul- thiazolid inediones, DPP-4 inhibitors" meglitinides) ticomponent behavioral interventions. For obese patients at highest risk who have tried lifestyle modification for at least Antihype rtensives ACE inhibitors, angiotensin (a-blockers, F-blockers) receptor blockers, thiazide 3 to 6 months without success, pharmacotherapy or surgical diuretics, calcium channel intervention may be considered. Even small amounts of blockersb weight loss are beneficial; loss of 3'U, to 5% of initial body Glucocorticoids Other disease-modi{ying weight is associated with improvement in glycemic control, agents (e.g., methotrexate, blood pressure, Iipid levels, and symptoms associated with biologic agents) depending on indication, lowest dose of obesity-related conditions, such as osteoarthritis and sleep glucocorticoid or alternative apnea. routes (localjoint injection vs. oral) Lifestyle Modification Progestins (especially depot Copper lUD, low-dose i njections) combi ned oral contraceptives Readiness to make lifestyle changes should be assessed. Engaging family members and other social supports may Anticonvulsant drugs Topiramate, zonisamide, (carbamazepine, gabapentin, felbamate, lamotrigine, increase adherence to lifestyle change. Patients should be valproic acid, pregabalin) levetiracetam, phenytoin" encouraged to set a weight loss goal, but given the often slow Antidepressant and mood- Bupropion, fluoxetine, and unpredictable pace of weight loss, patients may also be stabilizing drugs (tricyclic venlafaxine, sertraline" encouraged to focus on achieving process goals, such as main- antidepressants, paroxetine, taining healthy habits. citalopram, escitalopram, mirtazapine, monoamine oxidase inhibitors, lithium) Reduced Dietary Enerry Intake Antipsychotic drugs Ziprasidone, aripiprazole, The calorie intake required to achieve a calorie deficit for a (clozapine, olanzapine, haloperidol given person varies according to basal ener5/ expenditure' quetiapine, risperidone) clinicians can estimate basal enerS' expenditure in calories DPP-4 = dipeptidyl peptidase 4; GLP 1 = glucagon like peptide 1; IUD = using the Harris-Benedict Equation (www.bmi-calculator.net/ intrauterine; SGLT 2 = sodium glucose cotransporter 2. bmr calculator/harris-benedict equation/). Typical dietary "DPP 4 inhibitors, phenytoin, and sertraline are weight neutral. calorie intake ranges required to produce weight loss are 1200 LCalcium channel blockers may cause edema. to 1500 kcal/d for women and 1500 to 1800 kcal/d for men'

Screening and Evaluation hyperpigmentation) should also be performed. Examining patients with obesity may require adaptations, such as using a The U.S. Preventive Services Task Fbrce (USPSTF) recom scale with an adequate weight limit and using an appropri mends screening adults lor obesity by measuring height and ately sized blood pressure cuff. weight and calculating BMl. Clinicians should ask patients Laboratory evaluation should include thyroid and liver with obesity about their diet (for example, using a 24 hour function, lipid levels, and screening fbr diabetes. Other labora- diet recall), including intake of sugar sweetened beverages tory testing should be based on patient specific signs, symp and processed foods and eating patterns (such as late night toms, and risk factors. Although obesity is associated with eating or stress eating). Clinicians should also ask about higher risk for certain cancers, recommendations for cancer physical activity patterns, sleep duration and quality, social screening are the same as for patients without obesity. support, emotional factors, weight history, previous weight Screening for cardiovascular disease is reserved for sympto loss attempts, and health and weight loss goals. A thorough matic patients. medication history is recommended to identify medications that may contribute to weight gain (Table 33). Physicians t(EY POIilI should inquire about symptoms of obesity-related condi- . The U.S. Preventive Services Task Force recommends tions, such as heart disease, obstructive sleep apnea, osteoar screening all adults for obesity by calculating BML thritis, and erectile dysf unction. Physical examination should include measurements of waist circumference, heart rate, blood pressure, and oxygen Treatment saturation. Cardiorespiratory thyroid, and skin examination In approaching obesity management, use of nonjudgmental (to detect hirsutism, acanthosis nigricans, striae, and language is important to engage patients and build trust. Treatment options for obesity include lifestyle modification, TABLE 33, Medications That Promote Weight Gain pharmacotherapy, and bariatric surgery. American College of and Alternatives Cardiologz/American Heart Association/The Obesity Society Medications That Promote Alternatives guidelines recommend lifestyle modification that includes weight Gain reduced calorie intake, increased physical activity, and Antidiabetic drugs (insulin, Metformin, GLP-1 agonists, behavioral therapy. Similarly, the USPSTF recommends sulfonylureas, SGLT-2 inhibitors, acarbose, ofl'ering or referring patients with obesity to intensive, mul- thiazolid inediones, DPP-4 inhibitors" meglitinides) ticomponent behavioral interventions. For obese patients at highest risk who have tried lifestyle modification for at least Antihype rtensives ACE inhibitors, angiotensin (a-blockers, F-blockers) receptor blockers, thiazide 3 to 6 months without success, pharmacotherapy or surgical diuretics, calcium channel intervention may be considered. Even small amounts of blockersb weight loss are beneficial; loss of 3'U, to 5% of initial body Glucocorticoids Other disease-modi{ying weight is associated with improvement in glycemic control, agents (e.g., methotrexate, blood pressure, Iipid levels, and symptoms associated with biologic agents) depending on indication, lowest dose of obesity-related conditions, such as osteoarthritis and sleep glucocorticoid or alternative apnea. routes (localjoint injection vs. oral) Lifestyle Modification Progestins (especially depot Copper lUD, low-dose i njections) combi ned oral contraceptives Readiness to make lifestyle changes should be assessed. Engaging family members and other social supports may Anticonvulsant drugs Topiramate, zonisamide, (carbamazepine, gabapentin, felbamate, lamotrigine, increase adherence to lifestyle change. Patients should be valproic acid, pregabalin) levetiracetam, phenytoin" encouraged to set a weight loss goal, but given the often slow Antidepressant and mood- Bupropion, fluoxetine, and unpredictable pace of weight loss, patients may also be stabilizing drugs (tricyclic venlafaxine, sertraline" encouraged to focus on achieving process goals, such as main- antidepressants, paroxetine, taining healthy habits. citalopram, escitalopram, mirtazapine, monoamine oxidase inhibitors, lithium) Reduced Dietary Enerry Intake Antipsychotic drugs Ziprasidone, aripiprazole, The calorie intake required to achieve a calorie deficit for a (clozapine, olanzapine, haloperidol given person varies according to basal ener5/ expenditure' quetiapine, risperidone) clinicians can estimate basal enerS' expenditure in calories DPP-4 = dipeptidyl peptidase 4; GLP 1 = glucagon like peptide 1; IUD = using the Harris-Benedict Equation (www.bmi-calculator.net/ intrauterine; SGLT 2 = sodium glucose cotransporter 2. bmr calculator/harris-benedict equation/). Typical dietary "DPP 4 inhibitors, phenytoin, and sertraline are weight neutral. calorie intake ranges required to produce weight loss are 1200 LCalcium channel blockers may cause edema. to 1500 kcal/d for women and 1500 to 1800 kcal/d for men' 43

Obesity Evidence shows that any diet that achieves a calorie defi- also shown success. Continued visits for at least 1 year after cit will produce weight loss. Those who choose low-fat options initial weight loss increase the chances of maintaining weight should be vigilant about the sugar and sodium contents of loss. these products. Although general teaching is that calories are equivalent, calories listed on nutrition labels are measured in Pharmacologic Therapy a calorimeter and may be processed differently physiologi Pharmacotherapy is an option for patients with BMI of 30 or cally; calories from sugar-sweetened sodas may not be pro- greater, or with BMI of 27 or greater and at least one obesity cessed in the same way as calories from leafy green vegetables. associated comorbid condition who have not achieved weight Patients should be advised to gradually consume more loss goals with a trial of at least 3 to 6 months of lifestyle modi guideline-advised healthy foods, including fruits, vegetables, fication. Weight is typically regained once these medications legumes, nuts, whole grains, fish, and lean meats (see Routine are stopped and thus should be used alongside lifestyle modi- Care of the Healthy Patient). Patients should be advised to fication. Pharmacotherapy is effective, but potential weight choose a diet that they will be most likely able to maintain and loss benefit should be balanced against risk for adverse events encouraged to find healthy foods they enjoy. and cost. Very low calorie diets (<800 kcal/d) produce accelerated Table 34 describes the mechanism of action, expected weight loss but require medical supervision. They should be weight loss, and side effects of commonly used agents; all have reserved for situations requiring rapid weight loss, such as demonstrated higher rates of achieving 5% or greater weight preparation for surgery. loss compared with placebo. Orlistat has the best long term safeg data and Iowest rate of discontinuation due to side Exercise effects. Liraglutide and phentermine topiramate produced the Lifestyle interventions should include moderate- to vigorous- greatest weight loss but had higher rates of discontinuation intensity physical activity for at least 150 minutes per week due to side effects. and resistance training at least tvvice per week. Exercise does As with all other comprehensive weight loss interven not contribute as much to initial weight loss as does reduced tions, patients should be monitored regularly. Patients who do calorie intake, but long term commitment to regular physical not show weight reduction after 12 weeks of therapy should activity is important for maintaining weight loss and improv- discontinue pharmacotherapy. ing cardiovascular health. Because patients are often initially Patients are inundated with advertisements for over-the deconditioned, gradual progression may be required, and it counter weight loss supplements and devices, which may should be emphasized that any physical activity is better claim greater safety and effectiveness than prescription medi- than none. cations. Forweight loss supplements, systematic reviews show little evidence of effectiveness. Moreover, some supplements Behavioral Therapy may be associated with significant adverse effects. Ma huang/ The Centers for Medicare & Medicaid Services allow payment ephedra (ephedrine), for example, has been associated with for "intensive behavioral weight loss counseling" by primary myocardial infarction and stroke. Some weight loss supple care providers. The content ofthis counseling in practice var- ments may also have additional undisclosed ingredients, most ies widely, as does its effectiveness. Using motivational inter commonly sibutramine. Physicians should discuss the lack of viewing techniques is encouraged (see Routine Care of the effectiveness and potential for side effects of supplements dur Healthy Patient). Specific components associated with ing weight loss counseling and advise discontinuation. increased effectiveness include a calorie deficit of at least Commonly used herbal weight loss supplements and potential 500 kcal/d, at least 150 minutes of moderate to vigorous physi, side effects can be found at https://ods.od.nih.gov/factsheets/ cal activity per week, and the use of trained interventionists Weightloss HealthProfessional/ and https://medlineplus.gov/ (nutritionists, behavioral therapists, or exercise therapists). druginfo /herb _ Al1. html. Interventions should incorporate regular self-monitoring of weight using a scale and calorie intake as well as education on Bariatric Surgery controlling or altering the environment to avoid excess calorie Guidelines recommend surgery for patients with a BMI of 40 intake. Other interventions include removing calorie-dense or greater or for those with a BMI of 35 or greater who have snacks and beverages from the home and workplace or replac- obesity associated comorbid conditions. Bariatric surgery reli ing them with lower-calorie options, and engaging in alternate ably results in weight loss and may also produce improve behaviors (walking, chewing gum) in situations in which the ments in diabetes control, blood pressure, and lipid profiles. patient might be tempted to eat. Cardiovascular and overall mortality may also be improved in High-intensity programs (>14 sessions over >6 months) patients with severe obesity. delivered by trained interventionists are associated with suc The risks associated with bariatric surgery exceed those cessful weight loss. Face to-face interventions most reliably associated with nonsurgical treatments. Therefore, candidates result in weight loss and have the largest effects on weight, but for bariatric surgery should be selected carefully on the basis interventions delivered electronically or by telephone have of risk-benefit analysis. Patients should have acceptable 44

Obesity TABLE 34. Medications for Weight Loss Medication Mechanism of Action Weight Loss Versus Placebo at Common Side Effects (Odds 52 Weeks in Meta-analysis of Ratio for Discontinuation Versus Randomized Controlled Trials Placebo) Liraglutide GLP-1 receptor agonist; delays 5.2 kg (1 1.6 lb) Gastrointestinal upset, headache, (injectable) gastric emptying nasopharyngitis (2.82) Contraindications: MTC, MEN2, pregnancy Naltrexone- Opioid antagonist plus s ks (10.9 lb) Gastrointestinal upset, headache, bupropion norepinephrine/dopamine upta ke dizziness, insomnia, dry mouth, inhibitor; suppresses appetite tachycardia, hypertension, a nxiety, tremor (2.60) Contraindications: opioid use or withdrawal, u ncontrolled hypertension, history of seizures, eating disorder

TABLE 34. Medications for Weight Loss Medication Mechanism of Action Weight Loss Versus Placebo at Common Side Effects (Odds 52 Weeks in Meta-analysis of Ratio for Discontinuation Versus Randomized Controlled Trials Placebo) Liraglutide GLP-1 receptor agonist; delays 5.2 kg (1 1.6 lb) Gastrointestinal upset, headache, (injectable) gastric emptying nasopharyngitis (2.82) Contraindications: MTC, MEN2, pregnancy Naltrexone- Opioid antagonist plus s ks (10.9 lb) Gastrointestinal upset, headache, bupropion norepinephrine/dopamine upta ke dizziness, insomnia, dry mouth, inhibitor; suppresses appetite tachycardia, hypertension, a nxiety, tremor (2.60) Contraindications: opioid use or withdrawal, u ncontrolled hypertension, history of seizures, eating disorder Orlistat Lipase inhibitor; decreases 2.6 kg (s.B lb) Oi ly stools, increased defecation, triglyceride absorption fecal urgency/incontinence ( 1 .84) Contraindications: pregnancy, malabsorption syndrome, cholestasis Phentermine- Noradrenergic/GABA receptor B.B ks (19.4 lb) Paresthesias, dizziness, taste topiramate activator and AMPA glutamate alterations, insomnia, constipation, receptor inhibitor; suppresses dry mouth, tachycardia, cognitive appetite changes (2.32) Contraindications: g laucoma, hyperthyroidism

Orlistat Lipase inhibitor; decreases 2.6 kg (s.B lb) Oi ly stools, increased defecation, triglyceride absorption fecal urgency/incontinence ( 1 .84) Contraindications: pregnancy, malabsorption syndrome, cholestasis Phentermine- Noradrenergic/GABA receptor B.B ks (19.4 lb) Paresthesias, dizziness, taste topiramate activator and AMPA glutamate alterations, insomnia, constipation, receptor inhibitor; suppresses dry mouth, tachycardia, cognitive appetite changes (2.32) Contraindications: g laucoma, hyperthyroidism Data from Khera R, Murad MH, Chandar AK, et al. Association of pharmacological treatments for obesity with weight loss and adverse events: a systematic review and meta- analysis. JAMA. 201 6;315:2424 34. IPMID: 27299618] doi:1O.1O01/jama.2016.7 602 I

Data from Khera R, Murad MH, Chandar AK, et al. Association of pharmacological treatments for obesity with weight loss and adverse events: a systematic review and meta- analysis. JAMA. 201 6;315:2424 34. IPMID: 27299618] doi:1O.1O01/jama.2016.7 602 I surgical risk, understand the necessity oflifelong dietary and Gastric banding involves placement of a silicone fluid lifestyle measures for sustained weight loss, and be willing to filled band around the proximal stomach, creating a small adhere to lifelong follow up. Candidates should not have psy stomach pouch with subsequent reduction in calorie intake by chological or psychiatric conditions that impede adherence to increasing satiety. Gastric banding has greatly fallen in popu- these requirements. larity owing to modest efficacy and high rates of revision and has been largely replaced by sleeve gastrectomy. Techniques All bariatric procedures result in loss of excess weight in The most commonly performed bariatric surgical procedures the short term and up to 70'l. of excess weight with Roux-en-Y are sleeve gastrectomy and Roux-en-Y gastric bypass. Sleeve and 60% with sleeve gastrectomy at 2 years. Long-term gastrectomy has become the most common bariatric proce (5 year) data are less robust but suggest sustained weight loss. dure in the United States. Sleeve gastrectomy is accomplished More recently, other surgical and nonsurgical procedures by excising the part ofthe stomach along the greater curva have been developed. These include restrictive procedures (endo- ture, creating an approximately 857, reduction in size. It scopic suturing or stapling in a manner that replicates sleeve gas results in restriction of caloric intake via a smaller stomach trectomy), pills that expand in the stomach, devices intended to and hormonal (glucagon-like peptide-l [GLP 1] and related decrease calorie absorption (duodenal jejunal liners), and intra hormones) appetite suppression. The smaller gastric surface gastric balloons. Intragastric balloons are tlpically placed endo- area also results in less production of ghrelin, an appetite scopically and are FDA indicated in patients with BMI of 30 to 40 stimulant. with one or more obesi$ related comorbidities. These and other Roux-en-Y gastric bypass involves detaching the proximal related techniques are less invasive and may carry less risk than stomach and creating a small pouch, which is reattached to a surgical procedures, but more data on long term outcomes are limb of the small intestine. Weight loss results from decrease needed. in calorie intake because of the small stomach pouch, malab sorption due to bypassing much of the stomach and proximal Postoperative Care small intestines, and appetite suppression due to changes in Rates of 30 day postoperative complications range from 1.3'1, GLP 1 and related hormones. to 8.7"/,,. Complications include hemorrhage or leakage at the

surgical risk, understand the necessity oflifelong dietary and Gastric banding involves placement of a silicone fluid lifestyle measures for sustained weight loss, and be willing to filled band around the proximal stomach, creating a small adhere to lifelong follow up. Candidates should not have psy stomach pouch with subsequent reduction in calorie intake by chological or psychiatric conditions that impede adherence to increasing satiety. Gastric banding has greatly fallen in popu- these requirements. larity owing to modest efficacy and high rates of revision and has been largely replaced by sleeve gastrectomy. Techniques All bariatric procedures result in loss of excess weight in The most commonly performed bariatric surgical procedures the short term and up to 70'l. of excess weight with Roux-en-Y are sleeve gastrectomy and Roux-en-Y gastric bypass. Sleeve and 60% with sleeve gastrectomy at 2 years. Long-term gastrectomy has become the most common bariatric proce (5 year) data are less robust but suggest sustained weight loss. dure in the United States. Sleeve gastrectomy is accomplished More recently, other surgical and nonsurgical procedures by excising the part ofthe stomach along the greater curva have been developed. These include restrictive procedures (endo- ture, creating an approximately 857, reduction in size. It scopic suturing or stapling in a manner that replicates sleeve gas results in restriction of caloric intake via a smaller stomach trectomy), pills that expand in the stomach, devices intended to and hormonal (glucagon-like peptide-l [GLP 1] and related decrease calorie absorption (duodenal jejunal liners), and intra hormones) appetite suppression. The smaller gastric surface gastric balloons. Intragastric balloons are tlpically placed endo- area also results in less production of ghrelin, an appetite scopically and are FDA indicated in patients with BMI of 30 to 40 stimulant. with one or more obesi$ related comorbidities. These and other Roux-en-Y gastric bypass involves detaching the proximal related techniques are less invasive and may carry less risk than stomach and creating a small pouch, which is reattached to a surgical procedures, but more data on long term outcomes are limb of the small intestine. Weight loss results from decrease needed. in calorie intake because of the small stomach pouch, malab sorption due to bypassing much of the stomach and proximal Postoperative Care small intestines, and appetite suppression due to changes in Rates of 30 day postoperative complications range from 1.3'1, GLP 1 and related hormones. to 8.7"/,,. Complications include hemorrhage or leakage at the 45

\ Men's Health anastomosis (bypass procedures) or staple line (sleeve gastrec- TAB LE 3 5 . Nutrient Deficiencies and Replacement After tomy), venous thromboembolism, and bowel obstruction. Bariatric Surgeryo Anastomotic leaks usually occur within the first week and Nutrient Routine Replacement may present with nonspecific findings, including low-grade Deficiency Replacement Therapy if Deficient fever, tachycardia, and respiratory symptoms. Barium swallow lron Multivitamin with iron, Ferrous sulfate or contrast-enhanced CT is recommended diagnostic testing or elemental iron 325 mg/d orally, or when a leak is suspected; if suspicion is high and imaging is 40-80 mg/d orally; lV iron if oral is take with vitamin C ineffective or not negative, surgical exploration should be considered. 500 mg/d tolerated Weight should be monitored closely in the early postop Vitamin 812 Vitamin 812 500 pgld Vitamin B12 1000 pgld erative period. In patients with diabetes, sulfbnylureas orally, or 1000 gg lM orally, or 1000 pg lM should be discontinued and insulin should be adjusted. As monthly monthly patients lose weight, frequent reassessment of medications Folic acid Multivitamin with Folate 1 mg/d until is required. folate replete, then 400-800 pg/d orally Long term postsurgical care focuses on preventing and For women of identifying nutritional deficiencies, managing adherence to childbearing age, folate 1 mg/d orally lifestyle modifications, and monitoring for behaviors that lead to weight regain. Vitamin D deficiency is universal in Calcium Calcium citrate 1200- 1500 mg/d orally patients after bariatric surgery leading to reduced intestinal Vitamin D Vitamin D 400-1000 vitamin D 50,000 u absorption of calcium and phosphorus with resultant sec U/d orally weekly orally for 3 mo, ondary hypoparathyroidism. Persistent secondary hyper then reassess parathyroidism can last for years alter bariatric surgery and Thiamine Thiamine 50-100 mg/d 100 mg three times annual monitoring of calcium, albumin, parathyroid hor orally daily until symptoms mone, and 2S-hydroxyvitamin D levels is recommended. resolve Annual monitoring of other nutrients, including vitamin B,r, Vitamin A Multivitamin daily Vitamin A 10,000 U/d folate, iron, and ferritin is often recommended (see Routine orally with ongoing monitoring Care of the Healthy Patient). Other considerations for moni- Vitamin E Multivitamin daily Vitamin E 400 U/d toring include thiamine, vitamin A, zinc, copper, and 24-hour orally urinary calcium. Table 35 lists the anticipated nutritional deficiencies and recommended replacement strategies. Vitamin K Multivitamin daily Mtamin K 10 mg/d orally Table 36 describes post bariatric surgery syndromes and Copper Multivitamin with Copper 2-4 mg/d their management. minerals daily orally Tinc Multivitamin with Zinc22O mg/d orally I(EY POIlIIS minerals daily, HVC . Lifestyle modifications that are eflective lor the treatment 15 mg/d

anastomosis (bypass procedures) or staple line (sleeve gastrec- TAB LE 3 5 . Nutrient Deficiencies and Replacement After tomy), venous thromboembolism, and bowel obstruction. Bariatric Surgeryo Anastomotic leaks usually occur within the first week and Nutrient Routine Replacement may present with nonspecific findings, including low-grade Deficiency Replacement Therapy if Deficient fever, tachycardia, and respiratory symptoms. Barium swallow lron Multivitamin with iron, Ferrous sulfate or contrast-enhanced CT is recommended diagnostic testing or elemental iron 325 mg/d orally, or when a leak is suspected; if suspicion is high and imaging is 40-80 mg/d orally; lV iron if oral is take with vitamin C ineffective or not negative, surgical exploration should be considered. 500 mg/d tolerated Weight should be monitored closely in the early postop Vitamin 812 Vitamin 812 500 pgld Vitamin B12 1000 pgld erative period. In patients with diabetes, sulfbnylureas orally, or 1000 gg lM orally, or 1000 pg lM should be discontinued and insulin should be adjusted. As monthly monthly patients lose weight, frequent reassessment of medications Folic acid Multivitamin with Folate 1 mg/d until is required. folate replete, then 400-800 pg/d orally Long term postsurgical care focuses on preventing and For women of identifying nutritional deficiencies, managing adherence to childbearing age, folate 1 mg/d orally lifestyle modifications, and monitoring for behaviors that lead to weight regain. Vitamin D deficiency is universal in Calcium Calcium citrate 1200- 1500 mg/d orally patients after bariatric surgery leading to reduced intestinal Vitamin D Vitamin D 400-1000 vitamin D 50,000 u absorption of calcium and phosphorus with resultant sec U/d orally weekly orally for 3 mo, ondary hypoparathyroidism. Persistent secondary hyper then reassess parathyroidism can last for years alter bariatric surgery and Thiamine Thiamine 50-100 mg/d 100 mg three times annual monitoring of calcium, albumin, parathyroid hor orally daily until symptoms mone, and 2S-hydroxyvitamin D levels is recommended. resolve Annual monitoring of other nutrients, including vitamin B,r, Vitamin A Multivitamin daily Vitamin A 10,000 U/d folate, iron, and ferritin is often recommended (see Routine orally with ongoing monitoring Care of the Healthy Patient). Other considerations for moni- Vitamin E Multivitamin daily Vitamin E 400 U/d toring include thiamine, vitamin A, zinc, copper, and 24-hour orally urinary calcium. Table 35 lists the anticipated nutritional deficiencies and recommended replacement strategies. Vitamin K Multivitamin daily Mtamin K 10 mg/d orally Table 36 describes post bariatric surgery syndromes and Copper Multivitamin with Copper 2-4 mg/d their management. minerals daily orally Tinc Multivitamin with Zinc22O mg/d orally I(EY POIlIIS minerals daily, HVC . Lifestyle modifications that are eflective lor the treatment 15 mg/d of obesity include a calorie deficit of at least 500 kcal/d, Selenium Multivitamin with 2pg/kg/d if related m ine ra ls cardiomyopathy at least 150 minutes of moderate to vigorous physical activity per week, and the use of trained intervention lM = intramuscularly.

of obesity include a calorie deficit of at least 500 kcal/d, Selenium Multivitamin with 2pg/kg/d if related m ine ra ls cardiomyopathy at least 150 minutes of moderate to vigorous physical activity per week, and the use of trained intervention lM = intramuscularly. ists (nutritionists, behavioral therapists, or exercise "See Table 1 5. All medications and supplements should be in liquid, crushed, or chewableformforthel 2monthsaftersleevegastrectomyandforthefirst3months therapists). after Roux en-Y gastric bypass.

ists (nutritionists, behavioral therapists, or exercise "See Table 1 5. All medications and supplements should be in liquid, crushed, or chewableformforthel 2monthsaftersleevegastrectomyandforthefirst3months therapists). after Roux en-Y gastric bypass. o Pharmacologic therapy may be used as an adjunct to Data from Marcotte E, Chand B. Management and prevention of surgical and nutritional complications after bariatric surgery. Surg Clin North Am. 201 6;96:843 56. lifestyle modifications in patients with a BMI of 30 or IPMID: 274738051 doi: 1 0.1 01 6/j.suc.201 6.03.006 greater or in patients with a BMI of 27 or greater who have overweight- or obesity-associated comorbid conditions. HVC . Systematic reviews show little evidence that over-the Men's Health counter weight loss supplements are effective. o Bariatric surgery should be reserved for patients with a Male Sexual Dysfunction BMI of 40 or greater or for those with a BMI of 35 or Erectile Dysfunction greater who have obesity associated comorbid conditions. Erectile dysfunction (ED) refers to the inability to achieve or o Long term postsurgical care focuses on preventing maintain an erection necessary for satisfactory sexual per formance. The most common causes are vascular disease: nutritional deficiencies, managing adherence to lifestyle neurologic disease, including stroke and postoperative modifications, and monitoring for behaviors that lead to weight regain. nerve injury; medications; androgen deficiency; and psychological issues. 46

Men's Health Syndrome Cause Monitoring/Therapy Dumping syndrome/postprandial Rapid transit of undigested food into small Avoid foods high in simple sugar; replace with hypog lycemia (tachycard ia, intestines h i g her-fi ber/h i g h -p rotei n food s sweating, abdominal pain, Early symptoms (1 hour postprandial) caused Avoid sweetened beverages (including nausea, vomiting, diarrhea) by fluid shift into the Gl traa (no hypoglycemia) alcohol) Late symptoms (2-3 hours postprandial), hypoglycemia caused by insulin surge in response to hyperglycemia Chronic loose stool May relate to rapid transit of food to small Adherence to dietary modifications to avoid intestines, similar to dumping syndrome dumping syndrome Consider small intestine bacterial overgrowth Rifaximin if bacterial overgrowth is suspected Kidney stones lncreased urinary oxalic acid related to fat Diet low in fat and oxalate, calcium malabsorption supplementation, increased hydration Gallstones Bile stasis, increased biliary cholesterol Ultrasonography if symptomatic saturation with rapid weight loss Cholecystectomy is definitive treatment Ursodeoxycholic acid shown to be effective prophylactically in meta-analysis of RCTs Gastric or marginal ulceration Often associated with NSAID use Avoid NSAIDs and smoking Endoscopy to confirm PPI therapy

Syndrome Cause Monitoring/Therapy Dumping syndrome/postprandial Rapid transit of undigested food into small Avoid foods high in simple sugar; replace with hypog lycemia (tachycard ia, intestines h i g her-fi ber/h i g h -p rotei n food s sweating, abdominal pain, Early symptoms (1 hour postprandial) caused Avoid sweetened beverages (including nausea, vomiting, diarrhea) by fluid shift into the Gl traa (no hypoglycemia) alcohol) Late symptoms (2-3 hours postprandial), hypoglycemia caused by insulin surge in response to hyperglycemia Chronic loose stool May relate to rapid transit of food to small Adherence to dietary modifications to avoid intestines, similar to dumping syndrome dumping syndrome Consider small intestine bacterial overgrowth Rifaximin if bacterial overgrowth is suspected Kidney stones lncreased urinary oxalic acid related to fat Diet low in fat and oxalate, calcium malabsorption supplementation, increased hydration Gallstones Bile stasis, increased biliary cholesterol Ultrasonography if symptomatic saturation with rapid weight loss Cholecystectomy is definitive treatment Ursodeoxycholic acid shown to be effective prophylactically in meta-analysis of RCTs Gastric or marginal ulceration Often associated with NSAID use Avoid NSAIDs and smoking Endoscopy to confirm PPI therapy Hypotension, hypog lycemia lmproved blood pressure and insulin sensitivity Adjust medications as indicated; consider with weight loss proactive reduction in dose (especially antidiabetic medications) Gastric outlet obstruction Sleeve gastrectomy can be complicated by Upper Gl series to confirm stenosis May require endoscopic dilation or surgical Presents with dysphagia or vomiting revision Chronic abdominal pain/nausea Various, including nonadherence to diet Evaluate with endoscopy or CT recommendations, device slippage (gastric Re-educate patient on diet modifications if no band procedures), bowel obstruction other cause is identified Consider low-dose antidepressant therapy Gastroesophageal reflux lncidence usually decreases after diversion Evaluate with endoscopy procedures but may increase after sleeve PPI therapy, lifestyle modification gastrectomy Depression May be present preoperatively or develop Monitor for signs of depression and treat with postoperatively multimodal approach SSRIs may be less effective post bariatric surgery due to reduced bioavailability Regain of weight lost Disordered eating, excess intake of high-calorie Re-educate patient on diet modifications liquid/semisolid foods or supplements Refer to psychiatric care or counseling if indicated Gl = gastrointestinal; PPI = proton pump inhibitor; RCT = randomized controlled trial; SSRI = selective serotonin reuptake inhibitor.

Hypotension, hypog lycemia lmproved blood pressure and insulin sensitivity Adjust medications as indicated; consider with weight loss proactive reduction in dose (especially antidiabetic medications) Gastric outlet obstruction Sleeve gastrectomy can be complicated by Upper Gl series to confirm stenosis May require endoscopic dilation or surgical Presents with dysphagia or vomiting revision Chronic abdominal pain/nausea Various, including nonadherence to diet Evaluate with endoscopy or CT recommendations, device slippage (gastric Re-educate patient on diet modifications if no band procedures), bowel obstruction other cause is identified Consider low-dose antidepressant therapy Gastroesophageal reflux lncidence usually decreases after diversion Evaluate with endoscopy procedures but may increase after sleeve PPI therapy, lifestyle modification gastrectomy Depression May be present preoperatively or develop Monitor for signs of depression and treat with postoperatively multimodal approach SSRIs may be less effective post bariatric surgery due to reduced bioavailability Regain of weight lost Disordered eating, excess intake of high-calorie Re-educate patient on diet modifications liquid/semisolid foods or supplements Refer to psychiatric care or counseling if indicated Gl = gastrointestinal; PPI = proton pump inhibitor; RCT = randomized controlled trial; SSRI = selective serotonin reuptake inhibitor. :

Hypotension, hypog lycemia lmproved blood pressure and insulin sensitivity Adjust medications as indicated; consider with weight loss proactive reduction in dose (especially antidiabetic medications) Gastric outlet obstruction Sleeve gastrectomy can be complicated by Upper Gl series to confirm stenosis May require endoscopic dilation or surgical Presents with dysphagia or vomiting revision Chronic abdominal pain/nausea Various, including nonadherence to diet Evaluate with endoscopy or CT recommendations, device slippage (gastric Re-educate patient on diet modifications if no band procedures), bowel obstruction other cause is identified Consider low-dose antidepressant therapy Gastroesophageal reflux lncidence usually decreases after diversion Evaluate with endoscopy procedures but may increase after sleeve PPI therapy, lifestyle modification gastrectomy Depression May be present preoperatively or develop Monitor for signs of depression and treat with postoperatively multimodal approach SSRIs may be less effective post bariatric surgery due to reduced bioavailability Regain of weight lost Disordered eating, excess intake of high-calorie Re-educate patient on diet modifications liquid/semisolid foods or supplements Refer to psychiatric care or counseling if indicated Gl = gastrointestinal; PPI = proton pump inhibitor; RCT = randomized controlled trial; SSRI = selective serotonin reuptake inhibitor. : Assessment of ED begins with obtaining a comprehen with ED include coronary atherosclerosis, diabetes mellitus, sive history including medical, surgical, sexual, and psycho hyperlipidemia, hypertension, androgen deficiency, obesity, ' social histories. Clinicians should clarify whether the problem spinal cord injury and prostate cancer therapy. ! is attaining or maintaining erections, whether it occurs with Psychogenic ED, which is ED due to psychological or t masturbation or with partners, and whether nocturnal and interpersonal factors, is common and may coexist with other I early morning erections are present. The International Index etiologies. ED that occurs with preserved ability to achieve of Erectile Function (www.croesoffi ce.orglPortals / 0 /Short nocturnal and early morning erections should raise suspicion I 5 IIEF.pdfl is a tool to rapidly assess ED symptoms and subse for psychogenic ED. Psychogenic ED is more common in l quently monitor treatment effect. An accurate medication list younger patients and in those with a history ofsexual abuse. t should be elicited because many medications are associated Physical examination should include assessment of i with ED (Table 37). Medical conditions commonly associated heart rate, blood pressure, and body mass index as well as t I ! 47 i t

Men's Health TABLE 37. Drugs CommonlyAssociated With Erectile although its use is associated with chronic fibrotic changes Dysfunction (4.97, incidence) and injection site pain. Priapism is a side effect ; Antidepressants (monoamine oxidase inhibitors, selective of both formulations (approximately 1.9% incidence), and . serotonin reuptake inhibitors, tricyclic antidepressants) proper patient education is required. Benzodiazepines When pharmacotherapy is not an option, patients can be offered a vacuum erection device. which has been shown to be I Opioids, nicotine, alcohol, amphetamines, barbiturates, , cocaine, marijuana both safe and effective. Implantation of a penile prosthesis is Anticonvu lsants (phenytoin, phenobarbital) reserved for patients in whom other management options fail.

; Antidepressants (monoamine oxidase inhibitors, selective of both formulations (approximately 1.9% incidence), and . serotonin reuptake inhibitors, tricyclic antidepressants) proper patient education is required. Benzodiazepines When pharmacotherapy is not an option, patients can be offered a vacuum erection device. which has been shown to be I Opioids, nicotine, alcohol, amphetamines, barbiturates, , cocaine, marijuana both safe and effective. Implantation of a penile prosthesis is Anticonvu lsants (phenytoin, phenobarbital) reserved for patients in whom other management options fail. Antihypertensives and diuretics (thiazide diuretics, loop diuretics, clonidine, spironolactone; possibly a-blockers, Premature Ejaculation B-blockers, calcium channel blockers, ACE inhibitors) Premature ejaculation, or male early ejaculation, is one of the 5n-Reductase inhibitors (dutasteride, finasteride) most common sexual disorders in men. It is defined as ejacula- Antihistamines and H2-blockers (dimenhydrinate, tion with minimal stimulation that occurs earlier than desired. diphenhydramine, hydroxyzine, meclizine, promethazine, cimetidine, nizatidine, ranitidine) It is often associated with psychological distress, low self esteem, anxiety, and depression. Intravaginal ejaculatory NSAIDs (naproxen, indomethacin) latency time is the amount of time for ejaculation to occur Parkinson disease medications (levodopa, bromocriptine, after penile intravaginal insertion and is frequently used as an biperiden, trihexyphenidyl, benztropine, procyclidine) objective measure of premature ejaculation. A cutoff time of less than 1 minute is considered abnormal when associated with psychological distress. Although the specific etiologz is examination of genitalia and secondary sex characteristics. unknown, dysfunction of 5 hydrorytryptamine receptors and The American Urological Association (AUA) 2018 erectile dys- penile hypersensitivity are thought to be involved. function guideline recommends obtaining a morning total Therapy is aimed at extending the time between vaginal testosterone level for all patients. ED is a significant risk factor penetration and ejaculation. Treatment options include phar- for coronary arteriosclerosis, and its presence without clear macotherapy (first line) and behavioral techniques. The most etiolos/ should prompt evaluation for cardiovascular risk effective long term (>8 weeks) pharmacologic therapy is the factors; screening for diabetes mellitus, hypertension, and combination of a selective serotonin reuptake inhibitor (SSRI) hyperlipidemia should be performed. If hypothyroidism is and a PDE 5 inhibitor. Other long term therapies demon- suspected, a serum thyroid stimulating hormone level should strated to be more effective than placebo are, in decreasing be obtained. order of efficacy, topical anesthetics, paroxetine monotherapy, Nonpharmacologic treatment options include lifesgle PDE-5 inhibitor monotherapy, other SSRI monotherapy, and modifications, such as smoking cessation, exercise, and weight clomipramine (a tricyclic antidepressant). Onset of effect dif optimization. Psychological counseling should be considered fers among therapies. An increase in intravaginal ejaculatory in patients with a psychosocial etiolos/. Phosphodiesterase 5 (PDE 5) inhibitors are first-line pharmacotherapy for ED and latency time can be seen shortly after initiation with topic anesthetics. Response to SSRIs is more delayed but can be seen function by increasing the vasodilatory effects of endogenous as soon as several days after initiation, with most patients nitric oxide. The PDE-s inhibitors avanafil, sildenafil, tadalafil, achieving benefit within several weeks. SSRI efficacy may and vardenafil are FDA approved for on-demand use, and each decrease after 6 to 12 months of daily use owing to upregula have a similar efficacy; tadalafil, the longest-acting PDE-S inhibitor, is FDA approved for daily use. All PDE 5 inhibitors tion of 5 hydroxytryptamine receptors. Behavioral therapy should also be considered and may be used in combination require sexual stimulation to be effective and should be taken with pharmacotherapy. on an empty stomach. Common side effects include dyspepsia, headache, flushing, dizziness, and visual disturbances. PDE-5 inhibitors should not be used concurrently with nitrates Decreased Libido owing to the potential for severe hypotension. The third Decreased libido is defined as a reduced desire or inclination Princeton Consensus Conference provides guidelines for the to engage in sexual activities, sexual thoughts, or fantasies. safety of ED treatment in patients with known cardiovascular When associated with concomitant marked personal or inter disease or risk factors (Table 38). Testosterone therapy may be personal distress, the condition is termed hypoactive sexual considered with documented androgen deficiency after dis- desire disorder. Although decreased libido is commonly expe cussion of risks and benefits. rienced as part of normal aging, numerous medical and psy- Pharmacologic options for patients who have contraindi chiatric conditions can cause decreased libido: these include cations to PDE 5 inhibitors include intraurethral and injected alcohol use, mood disorders, and systemic illness. Medications intracavernosal alprostadil. Alprostadil causes arterial smooth associated with erectile dysfunction similarly can induce muscle relaxation, leading to penile vasodilation. Intracavernosal decreased libido. Treatment involves addressing the underly alprostadil appears to be the more effective formulation, ing causative factors. Testosterone treatment should be

Antihypertensives and diuretics (thiazide diuretics, loop diuretics, clonidine, spironolactone; possibly a-blockers, Premature Ejaculation B-blockers, calcium channel blockers, ACE inhibitors) Premature ejaculation, or male early ejaculation, is one of the 5n-Reductase inhibitors (dutasteride, finasteride) most common sexual disorders in men. It is defined as ejacula- Antihistamines and H2-blockers (dimenhydrinate, tion with minimal stimulation that occurs earlier than desired. diphenhydramine, hydroxyzine, meclizine, promethazine, cimetidine, nizatidine, ranitidine) It is often associated with psychological distress, low self esteem, anxiety, and depression. Intravaginal ejaculatory NSAIDs (naproxen, indomethacin) latency time is the amount of time for ejaculation to occur Parkinson disease medications (levodopa, bromocriptine, after penile intravaginal insertion and is frequently used as an biperiden, trihexyphenidyl, benztropine, procyclidine) objective measure of premature ejaculation. A cutoff time of less than 1 minute is considered abnormal when associated with psychological distress. Although the specific etiologz is examination of genitalia and secondary sex characteristics. unknown, dysfunction of 5 hydrorytryptamine receptors and The American Urological Association (AUA) 2018 erectile dys- penile hypersensitivity are thought to be involved. function guideline recommends obtaining a morning total Therapy is aimed at extending the time between vaginal testosterone level for all patients. ED is a significant risk factor penetration and ejaculation. Treatment options include phar- for coronary arteriosclerosis, and its presence without clear macotherapy (first line) and behavioral techniques. The most etiolos/ should prompt evaluation for cardiovascular risk effective long term (>8 weeks) pharmacologic therapy is the factors; screening for diabetes mellitus, hypertension, and combination of a selective serotonin reuptake inhibitor (SSRI) hyperlipidemia should be performed. If hypothyroidism is and a PDE 5 inhibitor. Other long term therapies demon- suspected, a serum thyroid stimulating hormone level should strated to be more effective than placebo are, in decreasing be obtained. order of efficacy, topical anesthetics, paroxetine monotherapy, Nonpharmacologic treatment options include lifesgle PDE-5 inhibitor monotherapy, other SSRI monotherapy, and modifications, such as smoking cessation, exercise, and weight clomipramine (a tricyclic antidepressant). Onset of effect dif optimization. Psychological counseling should be considered fers among therapies. An increase in intravaginal ejaculatory in patients with a psychosocial etiolos/. Phosphodiesterase 5 (PDE 5) inhibitors are first-line pharmacotherapy for ED and latency time can be seen shortly after initiation with topic anesthetics. Response to SSRIs is more delayed but can be seen function by increasing the vasodilatory effects of endogenous as soon as several days after initiation, with most patients nitric oxide. The PDE-s inhibitors avanafil, sildenafil, tadalafil, achieving benefit within several weeks. SSRI efficacy may and vardenafil are FDA approved for on-demand use, and each decrease after 6 to 12 months of daily use owing to upregula have a similar efficacy; tadalafil, the longest-acting PDE-S inhibitor, is FDA approved for daily use. All PDE 5 inhibitors tion of 5 hydroxytryptamine receptors. Behavioral therapy should also be considered and may be used in combination require sexual stimulation to be effective and should be taken with pharmacotherapy. on an empty stomach. Common side effects include dyspepsia, headache, flushing, dizziness, and visual disturbances. PDE-5 inhibitors should not be used concurrently with nitrates Decreased Libido owing to the potential for severe hypotension. The third Decreased libido is defined as a reduced desire or inclination Princeton Consensus Conference provides guidelines for the to engage in sexual activities, sexual thoughts, or fantasies. safety of ED treatment in patients with known cardiovascular When associated with concomitant marked personal or inter disease or risk factors (Table 38). Testosterone therapy may be personal distress, the condition is termed hypoactive sexual considered with documented androgen deficiency after dis- desire disorder. Although decreased libido is commonly expe cussion of risks and benefits. rienced as part of normal aging, numerous medical and psy- Pharmacologic options for patients who have contraindi chiatric conditions can cause decreased libido: these include cations to PDE 5 inhibitors include intraurethral and injected alcohol use, mood disorders, and systemic illness. Medications intracavernosal alprostadil. Alprostadil causes arterial smooth associated with erectile dysfunction similarly can induce muscle relaxation, leading to penile vasodilation. Intracavernosal decreased libido. Treatment involves addressing the underly alprostadil appears to be the more effective formulation, ing causative factors. Testosterone treatment should be 48

Men's Health TABLE 38. Third Princeton Consensus Conference Guidelines for Treatment of Erectile Dysfunction in Patients with Cardiovascular Disease or Cardiac Risk Factors Risk Level Treatment Recommendation Low Risk Patients who are able to do moderate-intensity exercise without Can initiate or resume sexual activity ortreatfor ED with a PDE-5 symptoms inhibitor (if not using nitrates) Successfully revascularized patients (e.g., coronary artery bypass grafting, coronary stenting, or angioplasty) Asymptomatic controlled hypertension Mild valvular disease Mild left ventricular dysfunction (NYHA functional class I or ll) who can achieve 5 METs without ischemia as determined by recent exercise testing lntermediate/lndeterminate Risk Mild to moderate stable angina Further cardiac evaluation and restratification before resumption of sexual activity or treatment for ED Recent Ml (2-8 wk ago)without intervention and awaiting exercise ECG lf the patientcan complete 4 minutes of the standard Bruce treadmill protocol without symptoms, arrhythmias, or a decrease Heart failure (NYHA functional class lll) in blood pressure, treatment for ED can be safely initiated Noncardiac atherosclerotic disease (clinically evident PAD, history of stroke/TlA)

lntermediate/lndeterminate Risk Mild to moderate stable angina Further cardiac evaluation and restratification before resumption of sexual activity or treatment for ED Recent Ml (2-8 wk ago)without intervention and awaiting exercise ECG lf the patientcan complete 4 minutes of the standard Bruce treadmill protocol without symptoms, arrhythmias, or a decrease Heart failure (NYHA functional class lll) in blood pressure, treatment for ED can be safely initiated Noncardiac atherosclerotic disease (clinically evident PAD, history of stroke/TlA) High Risk Unstable or refractory angina Defer sexual activity or ED treatment until cardiac condition is stabilized and reassessed Uncontrolled hypertension Moderate to severe heart failure (NYHA functional class lV) Recent Ml(<2 wk ago) without intervention High-risk arrhythmia (exercise-induced ventricu lar tachycardia, ICD with frequent shocks, poorly controlled atrial fibrillation) Obstructive hypertrophic cardiomyopathy with severe symptoms Moderate to severe valvular disease (particularly aortic stenosis) ED=erectiledysfunction;lCD=implantablecardioverter-defibrillator;METs=metabolicequivalents;Ml=myocardialinfarction;NYHA=NewYorkHeartAssociation; p{! = peripheral artery disease; PDE = phosphodiesterase; TIA = transient ischemic attack. Recommendations from Nehra A, Jackson G, Miner M, et al. The Princeton lll Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc.2012;87:7 66-78.IPMID:22862865] doi:1 0.1 0 1 6/j.mayocp.20 1 2.06.0 1 5

ED=erectiledysfunction;lCD=implantablecardioverter-defibrillator;METs=metabolicequivalents;Ml=myocardialinfarction;NYHA=NewYorkHeartAssociation; p{! = peripheral artery disease; PDE = phosphodiesterase; TIA = transient ischemic attack. Recommendations from Nehra A, Jackson G, Miner M, et al. The Princeton lll Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc.2012;87:7 66-78.IPMID:22862865] doi:1 0.1 0 1 6/j.mayocp.20 1 2.06.0 1 5 considered only when sexual dysfunction is accompanied by vagina before ejaculation), and vasectomy. The efficacy of documented androgen deficiency and after a discussion of these contraceptive options are described in Table 39. risks and benefits of treatment with the patient. Vasectomy, or male sterilization, is an office surgical pro- cedure performed under local anesthesia in which the vas I(EY POITTS deferens is either occluded or severed to prevent transport of o Erectile dysfunction is a significant risk factor for coro spermatozoa during ejaculation. Vasectomy, considered both nary arteriosclerosis, and its presence without clear eti- highly safe and effective, appears to be underutilized com- ologr should prompt evaluation for cardiovascular risk pared with female sterilization (tubal ligation). factors. Men interested in undergoing vasectomy should be coun- . Oral phosphodiesterase-s inhibitors are first line medi- seled that the procedure is intended to be permanent and that cal therapy for erectile dysfunction; however, they are it does not result in immediate sterility. Patients must use contraindicated in patients taking nitrates. another contraceptive until azoospermia is conftrmed by post- vasectomy semen analysis. Complications are generally minor and include local bleeding and infection. Asymptomatic sper- Reproductive Counseling and matic granuloma formation is common but symptomatic Male Sterilization granulomas are infrequent (approximately 5%); granulomas Three forms of male contraception are available: male con typically resolve within 3 to 4 weeks with conservative treat- doms, the withdrawal method (withdrawing penis from ment, such as NSAIDs. Vasectomy does not increase the risk

considered only when sexual dysfunction is accompanied by vagina before ejaculation), and vasectomy. The efficacy of documented androgen deficiency and after a discussion of these contraceptive options are described in Table 39. risks and benefits of treatment with the patient. Vasectomy, or male sterilization, is an office surgical pro- cedure performed under local anesthesia in which the vas I(EY POITTS deferens is either occluded or severed to prevent transport of o Erectile dysfunction is a significant risk factor for coro spermatozoa during ejaculation. Vasectomy, considered both nary arteriosclerosis, and its presence without clear eti- highly safe and effective, appears to be underutilized com- ologr should prompt evaluation for cardiovascular risk pared with female sterilization (tubal ligation). factors. Men interested in undergoing vasectomy should be coun- . Oral phosphodiesterase-s inhibitors are first line medi- seled that the procedure is intended to be permanent and that cal therapy for erectile dysfunction; however, they are it does not result in immediate sterility. Patients must use contraindicated in patients taking nitrates. another contraceptive until azoospermia is conftrmed by post- vasectomy semen analysis. Complications are generally minor and include local bleeding and infection. Asymptomatic sper- Reproductive Counseling and matic granuloma formation is common but symptomatic Male Sterilization granulomas are infrequent (approximately 5%); granulomas Three forms of male contraception are available: male con typically resolve within 3 to 4 weeks with conservative treat- doms, the withdrawal method (withdrawing penis from ment, such as NSAIDs. Vasectomy does not increase the risk 49

Men's Health TABLE 39. Pregnancy Rates With Use of Male TABLE 40. Symptoms and Signs Suggestive of Androgen Contraception Deficiency in Men Women Experiencing Unintended More Specific Symptoms and Signs Pregnancy Within First Year lncomplete or delayed sexual development, eunuchoidism of Use (%) Reduced sexual desire (libido) and activity Method Perfect Usea Typical Useb (Efficacy) (Effectiveness) Decreased spontaneous erections Male condoms L/O 13% Breast discomfort, gynecomastia Withdrawal method 4% 20"/" Loss of body (axillary and pubic) hair, reduced shaving

TABLE 39. Pregnancy Rates With Use of Male TABLE 40. Symptoms and Signs Suggestive of Androgen Contraception Deficiency in Men Women Experiencing Unintended More Specific Symptoms and Signs Pregnancy Within First Year lncomplete or delayed sexual development, eunuchoidism of Use (%) Reduced sexual desire (libido) and activity Method Perfect Usea Typical Useb (Efficacy) (Effectiveness) Decreased spontaneous erections Male condoms L/O 13% Breast discomfort, gynecomastia Withdrawal method 4% 20"/" Loss of body (axillary and pubic) hair, reduced shaving Vasectomy 0.1"/" 0.15% Very small(especially <5 mL) or shrinking testes uUse of the contraceptive method exactly as instructed during each and every lnability to father children, low or zero sperm count episode of sexual intercourse. Height loss, low-trauma fracture, low bone mineral density bAll users of a particular method, including those who use it perfectly, those who use it correctly but do not use the method every time, those who use the method Hot flushes, sweats every time but not always correctly, and those who always use the method but do so incorrectly. Other, Less Specific Symptoms and Signs Adapted from Trussell J, Aiken ARA. Contraceptive eff cacy. ln: Hatcher RA, Nelson Decreased energy, motivation, initiative, and self-confidence AL, Trussell J, Cwiak C, Cason P, Po icar N4S, Edelman A, Aiken ARA, Marrazzo J, Kowal D, eds. Contraceptive technology 2 1 st ed. New York, NY: Ayer Company Feeling sad or blue, depressed mood, dysthymia Publishers, lnc., 201 8. Poor concentration and memory

Vasectomy 0.1"/" 0.15% Very small(especially <5 mL) or shrinking testes uUse of the contraceptive method exactly as instructed during each and every lnability to father children, low or zero sperm count episode of sexual intercourse. Height loss, low-trauma fracture, low bone mineral density bAll users of a particular method, including those who use it perfectly, those who use it correctly but do not use the method every time, those who use the method Hot flushes, sweats every time but not always correctly, and those who always use the method but do so incorrectly. Other, Less Specific Symptoms and Signs Adapted from Trussell J, Aiken ARA. Contraceptive eff cacy. ln: Hatcher RA, Nelson Decreased energy, motivation, initiative, and self-confidence AL, Trussell J, Cwiak C, Cason P, Po icar N4S, Edelman A, Aiken ARA, Marrazzo J, Kowal D, eds. Contraceptive technology 2 1 st ed. New York, NY: Ayer Company Feeling sad or blue, depressed mood, dysthymia Publishers, lnc., 201 8. Poor concentration and memory Sleep disturbance, increased sleepiness for advanced or high-grade prostate cancer. Less than 1'7, of Mild anemia (normochromic, normocytic, in the female range) patients require repeat vasectomy. Patients who desire fertility Reduced muscle bulk and strength after vasectomy can attempt either vasectomy reversal or lncreased body fat, BMI sperrn retrieval as part ofthe in uifro fertilization process. Diminished physical or work performance Reproduced from Bhasin S, Cunningham GR, Hayes FJ, et al; Task Force, Endocr ne Androgen Deficiency Socrety. Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2O10;95:2536 59. IPM lD: 20525905] dor:1 0.1 21O/p.2009 23 54. Copyrrg ht 20 1 0, As men age, semm total testosterone levels gradually decline. The Endocrine Society. Licensed under the Creative Commons Aftnbution The diagnosis of androgen deficiency should only be made NonCommercial NoDerivatives 4.0 lnternational License (htps://creatrvecommons. orgll icenses/by. nc'nd/4.0/). when a patient has two separate early morning serum total testosterone levels less than 300 ng/dl (10.4 nmol/L) com 40 years. a serum prostate specific antigen (PSA) level. If a bined with suggestive symptoms and/or signs (Table 40). Both patient's hematocrit is greater than 50'){,, testosterone therapy the Endocrine Society and the AUA recommend against should be \\,ithheld until the polycythemia is further evalu screening for androgen deficiency in asymptomatic men. ated. Persistently elevated serum PSA levels should be evalu Assessment of free and bioavailable testosterone should be ated before initiation of testosterone therapy. reserved for patients with serum total testosterone levels in the low normal range and for patients in whom alterations in sex If testosterone therapy is initiated. symptoms should be reevaluated within 12 months and periodically thereaflter. hormone binding globulin (SHBG) levels are suspected. Clinicians should adjust the patient's testosterone dose to Increased SHBG levels are found in men of advanced age or achieve a serum total testosterone level in the middle tertile of with liver disease, whereas decreased SHBG Ievels can occur the normal reference range (,150 600 ngrdt. [15.6 20.8 nmol ,l-l) with obesitli diabetes/insulin resistance, and glucocorticoid use. while monitoring symptoms. In men with androgen defi The decision to initiate testosterone therapy should be ciency and sexual dysfunction who experience no symptonl improvement despite normalization of testosterone lerels. tes individualized, involve shared decision making with the patient, and include a thorough discussion of benefits and tosterone treatment should be discontinued.

Sleep disturbance, increased sleepiness for advanced or high-grade prostate cancer. Less than 1'7, of Mild anemia (normochromic, normocytic, in the female range) patients require repeat vasectomy. Patients who desire fertility Reduced muscle bulk and strength after vasectomy can attempt either vasectomy reversal or lncreased body fat, BMI sperrn retrieval as part ofthe in uifro fertilization process. Diminished physical or work performance Reproduced from Bhasin S, Cunningham GR, Hayes FJ, et al; Task Force, Endocr ne Androgen Deficiency Socrety. Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2O10;95:2536 59. IPM lD: 20525905] dor:1 0.1 21O/p.2009 23 54. Copyrrg ht 20 1 0, As men age, semm total testosterone levels gradually decline. The Endocrine Society. Licensed under the Creative Commons Aftnbution The diagnosis of androgen deficiency should only be made NonCommercial NoDerivatives 4.0 lnternational License (htps://creatrvecommons. orgll icenses/by. nc'nd/4.0/). when a patient has two separate early morning serum total testosterone levels less than 300 ng/dl (10.4 nmol/L) com 40 years. a serum prostate specific antigen (PSA) level. If a bined with suggestive symptoms and/or signs (Table 40). Both patient's hematocrit is greater than 50'){,, testosterone therapy the Endocrine Society and the AUA recommend against should be \\,ithheld until the polycythemia is further evalu screening for androgen deficiency in asymptomatic men. ated. Persistently elevated serum PSA levels should be evalu Assessment of free and bioavailable testosterone should be ated before initiation of testosterone therapy. reserved for patients with serum total testosterone levels in the low normal range and for patients in whom alterations in sex If testosterone therapy is initiated. symptoms should be reevaluated within 12 months and periodically thereaflter. hormone binding globulin (SHBG) levels are suspected. Clinicians should adjust the patient's testosterone dose to Increased SHBG levels are found in men of advanced age or achieve a serum total testosterone level in the middle tertile of with liver disease, whereas decreased SHBG Ievels can occur the normal reference range (,150 600 ngrdt. [15.6 20.8 nmol ,l-l) with obesitli diabetes/insulin resistance, and glucocorticoid use. while monitoring symptoms. In men with androgen defi The decision to initiate testosterone therapy should be ciency and sexual dysfunction who experience no symptonl improvement despite normalization of testosterone lerels. tes individualized, involve shared decision making with the patient, and include a thorough discussion of benefits and tosterone treatment should be discontinued. risks. According to the American College ol Physicians, cli XEY POITIS nicians should consider testosterone therapy in patients o The diagnosis of androgen deficiency should only be made with androgen deficiency to improve sexual dysfunction but when a patient has two separate early morning semm avoid its use for improving vitality, energy levels, physical total testosterone levels less than 300 ng/dl (10.4 nmol/l-) function, or cognition. Patients should be informed that combined with suggestive symptoms and/or signs. evidence is insufficient to clearly describe the effect of tes- o Clinicians should consider testosterone therapy in tosterone therapy on the risk lor development of prostate patients with androgen deficiency to improve sexual cancer, venous thromboembolism, and cardiovascular dis dysfunction but should avoid its use for improving ease. The AUA recommends obtaining a baseline hemo globin level and hematocrit and, in patients older than vitaliry enerS/ levels, physical function, or cognition.

risks. According to the American College ol Physicians, cli XEY POITIS nicians should consider testosterone therapy in patients o The diagnosis of androgen deficiency should only be made with androgen deficiency to improve sexual dysfunction but when a patient has two separate early morning semm avoid its use for improving vitality, energy levels, physical total testosterone levels less than 300 ng/dl (10.4 nmol/l-) function, or cognition. Patients should be informed that combined with suggestive symptoms and/or signs. evidence is insufficient to clearly describe the effect of tes- o Clinicians should consider testosterone therapy in tosterone therapy on the risk lor development of prostate patients with androgen deficiency to improve sexual cancer, venous thromboembolism, and cardiovascular dis dysfunction but should avoid its use for improving ease. The AUA recommends obtaining a baseline hemo globin level and hematocrit and, in patients older than vitaliry enerS/ levels, physical function, or cognition. 50