實證醫學個案報告 泌尿科 林鴻裕 醫師 2008/08/16

EBM worksheet Clinical scenario Question by PICO Search strategy Search outcome Citations Evidence appraisal Conclusion Plain-language explanation Policy or practice change

Clinical scenario 蘇先生，40歲男性，台灣人，本身並無特殊過往病史，病患身高181cm,體重172kg, BMI: 52.2 ， 該病患因體重過重至減重中心就診，因同時合併有性功能障礙的問題，故轉至泌尿科就診。蘇先生想知道肥胖與性功能之間的關係為何？影響程度有多大？減輕體重可以改善性功能嗎？

Background knowledge

Kronenberg: Williams Textbook of Endocrinology, 11th ed. Definition of Obesity Body mass index (BMI) is calculated by dividing weight (in kilograms) by height (in meters squared). There is a strong curvilinear relation between BMI and relative body fat mass. However, the current practical definition of obesity is based on the relationship between BMI and health outcome rather than BMI and body composition. Gallagher D, Heymsfield SB, Heo M, et al: Health percentage body fat ranges: an approach for developing guidelines based on body mass index.  Am J Clin Nutr  2000; 72:694-701.

TABLE 35-1 -- WEIGHT CLASSIFICATION BY BODY MASS INDEX Obesity Class BMI (kg/m2) Risk of Disease Underweight   <18.5 Increased Normal 18.5-24.9 Overweight 25.0-29.9 Obesity I 30.0-34.9 High II 35.0-39.9 Very High Extreme Obesity III ≥40.0 Extremely High Adapted from the National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report. Obes Res 1998;6(suppl 2):51S-209S.

Kronenberg: Williams Textbook of Endocrinology, 11th ed. Sexual dysfunction is a more general term that includes libidinal, orgasmic, and ejaculatory dysfunction, in addition to ED.[1] Erectile dysfunction, previously referred to as impotence, is a more specific term that denotes the inability of the male to attain or maintain an erection sufficient for satisfactory sexual intercourse. [2] [3] 1. Benet AE, Melman A: The epidemiology of erectile dysfunction.  Urol Clin North Am  1995; 22:699-709. 2. NIH Consensus Development Panel on Impotence : NIH Consensus Conference. Impotence.  JAMA  1993; 270:83-90. 3. The Process of Care Consensus Panel : The process of care model for evaluation and treatment of erectile dysfunction.  Int J Impot Res  1999; 11:59-70.discussion 70-74.

Background knowledge Obesity:根據行政院衛生署於2002年公佈國人最新肥胖定義（成人）：BMI超過24──體重過重；超過27──肥胖。 BMI（Body Mass Index，身體質量指數）？身高與體重之間關係的一種指標，數值越大代表一個人越胖。個人體重（公斤）除以身高（公尺）兩次，就是個人BMI的數值例如身高170公分，體重80公斤，BMI值為80÷1.7÷1.7＝27.68。 10

Background knowledge 勃起功能障礙的定義。 根據美國國家衛生院所訂的定義: 勃起功能障礙（一般俗稱「陽痿」）是指男性沒有能力勃起，或無法維持勃起以達到滿意的性行為。以前稱為「性無能」，但現在醫學界已較恰當的「勃起功能障礙」稱之。 台灣男性醫學會

Question by PICO P (Patient) : 蘇先生， 40歲男性，台灣人，本身並無特殊病史 I (Intervention) :體重肥胖,性功能障礙 C (Comparison) : 減輕體重 O (Outcome) : 蘇先生性功能改善的程度 Q (Question) : BMI改善的程度與性功能改善的程度間的關係為何？

Search strategy

Search outcome  Finally, 2 papers are cited !

Citations Duschek EJ, Gooren LJ, Netelenbos C. Comparison of effects of the rise in serum testosterone by raloxifene and oral testosterone on serum insulin-like growth factor-1 and insulin-like growth factor binding protein-3. Maturitas. 2005 Jul 16;51(3):286-93. PMID: 15978972 [PubMed - indexed for MEDLINE] Esposito K, Giugliano F, Di Palo C, Giugliano G, Marfella R, D’Andrea F, D’Armiento M, Giugliano D. Effect of lifestyle changes on erectile dysfunction in obese men: a randomized controlled trial.JAMA. 2004 Jun 23;291(24):2978-84. PMID: 15213209 [PubMed - indexed for MEDLINE]

Evidence appraisal

Jadad checklist (8/11) Was the study described as randomized?” (+) Was the study described as double-blind?” (-) Was there a description of withdrawals and drop outs? (+) Were the objectives of the study defined? (+) Were the outcome measures defined clearly? (+) Was there a clear description of the inclusion and exclusion criteria?(+) Was the sample size justified (e.g., power calculation)? (-) Was there a clear description of the interventions? (+) Was there at least one control (comparison) group? (+) Was the method used to assess adverse effects described? (-) Were the methods of statistical analysis described? (+)

英國Oxford Center證據應用等級 Level Therapy/Prevention, Aetilogy/Harm 1 a 將隨機對照臨床研究(Randomized Clinical Trial, RCT)以系統性評論(systemic review, SR)後的結果。 b 具有嚴格的信賴區間的個別RCT研究。 c 無論使用何種研究方法，但其研究結果為完全正面、完全負面或完全無效果(all or none)的研究結果。 2 a 將同質性的世代研究(cohort studies)以系統性評論的結果。 個別世代研究或是質量較不足的RCT研究。 以多數結果為基礎的研究，及生態學的研究("Outcomes" research; ecological studies)。 3 a 將同質的個案對照研究(case control studies)以系統性評論後的結果。 個別的個案對照研究(individual case control study)。 4 病例統計報告，以及質量較不足的個案對照研究。 5 未經嚴謹評估的意見，或者基礎生理學、一般實驗室研究及必要原則。 (Produced by Bob Phillips, Chris Ball, Dave Sackett, Doug Badenoch, Sharon Straus, Brian Haynes, Martin Dawes since November 1998) 27

英國Oxford Center證據應用等級 Esposito K, Giugliano F, Di Palo C, Giugliano G, Marfella R, D’Andrea F, D’Armiento M, Giugliano D. Effect of lifestyle changes on erectile dysfunction in obese men: a randomized controlled trial.JAMA. 2004 Jun 23;291(24):2978-84. Level Іb

Citations Horasanli K, Boylu U, Kendirci M, Miroglu C. Do lifestyle changes work for improving erectile dysfunction?Asian J Androl. 2008 Jan;10(1):28-35. Review. PMID: 18087641 [PubMed - indexed for MEDLINE] 29

Conclusion  lifestyle changes, including a reduced calorie diet and increased exercise, improve erectile function in obese men. Interventions focused on modifiable health behaviors may represent a safe strategy to improve erectile function and reduce cardiovascular risk in obese patients. . 30

Plain-language explanation 蘇先生，您的體重過重” BMI（身體質量指數）過高”當您改變您的飲食習慣，減少熱量的攝取並增加運動， 可改善您的性功能障礙的問題並減少心血管疾病的危險性。 31

Policy or practice change 經告知其肥胖與性功能障礙的問題後，蘇先生決定先減輕體重，若體重減輕後性功能改善仍不佳時，再考慮接受其他治療。 32

Q (Question) ↓ New Clinical scenario BMI改善的程度與性功能改善的程度間的關係為何？ 減少多少calorie可改善性功能多少程度呢？ 內科減重或外科手術減重的成效為何？如何決定接受何種治療？ 不同的外科手術減重的成效為何？如何決定接受何種手術治療？ ↓ New Clinical scenario

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