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Pharmacy > 301 Men's Health > Flashcards

301 Men's Health Flashcards

1
Q

Define LUTS

A

Lower urinary tract symptoms

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2
Q

Common symptoms of LUTS

A

Weak urine flow, need to urinate more often especially at night, feeling that bladder has not emptied properly, difficulty starting to pass urine, dribbling urine, urgency

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3
Q

Voiding symptoms of LUTS

A

Weak or intermittent urinary stream, straining, hesitancy in starting urination, terminal dribbling & incomplete emptying

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4
Q

Storage symptoms of LUTS

A

Urinary urgency, urinary frequency, urge continence & nocturia

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5
Q

Major post-micturition symptoms of LUTS

A

Dribbling, sensation of incomplete emptying

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6
Q

Explain the potential causes of LUTS

A

Abnormalities or abnormal function of the prostate, urethra, bladder or sphincter

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7
Q

RED flags symptoms that warrant referral in LUTS

A

Pain on urination in last 3 months, fever might relate to UTI, bloody or cloudy urine in last 3 months could indicate UTI, urinary incontinence

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8
Q

Management options for LUTS in men:
Lifestyle
OTC

A
  1. Prudent fluid intake, balanced diet & regular exercise advice, limit caffeine & alcohol intake
  2. Tamsulosin up to 6 weeks, a1 adrenoceptor antagonist, relaxes smooth muscle around prostate & bladder outlet, increased urinary flow, indicated for men 45-75, 400mcg after same meal each day
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9
Q

Define erectile dysfunction

A

Inability to get or maintain an erection that’s firm enough for sexual activity

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10
Q

Psychogenic causes of erectile dysfunction

A

Mental health conditions, stress, relationship problems, lack of sexual knowledge, past sexual problems, sexual abuse & new relationships

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11
Q

Organic causes of erectile dysfunction

A

Cardiovascular disease, diabetes, hormonal imbalances & neurological disorders

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12
Q

Key questions to ask patient presenting with ED

A

Onset & frequency of symptoms
Medications
Stressful life events
Medical history
Lifestyle - diet, exercise, smoking & alcohol consumption

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13
Q

Pharmacological treatment of ED

A

Sildenafil - type 5 phosphodiesterase inhibitor (PDE5Is), work by prevent cGMP breakdown, increases cGMP levels and increases nitric oxide on corpus cavernosum, increasing blood flow to penis and relaxing smooth muscles in penis

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14
Q

What is the prostate?

A

Prostate gland is part of male reproductive system, gland circles the urethra

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15
Q

What does the prostate do?

A

Prostate secretions are important in component of semen - protects and nourishes sperm

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16
Q

Why is prostate difficult to examine?

A

Due to prostate’s position (behind pubic bone & front of rectum) it is difficult to examine
Digital rectal exam is required where surface of gland felt through wall of rectum

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17
Q

3 most common prostate conditions

A
  • Prostatitis
  • Benign Prostate Hyperplasia (BPH)
  • Prostate cancer
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18
Q

What is the prostate made up of?

A

Epithelial and stromal cells which produce secretions & needed for viability & growth of cells

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19
Q

Benign Prostatic Hypertrophy (BPH) anatomy

A

Most evident in transitional zone, closest to urethra
BPH cause increase in epithelial & stromal cells, closest to urethra so cause constriction & urgency

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20
Q

Why does benign prostatic hypertrophy occur?

A

Increased DHT
Testosterone helps nourishment of epithelial & stromal cells
Increasing age causes reduction in testosterone
Stromal cells produce enzymes that convert testosterone into DHT (x10 greater effect as DHT)

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21
Q

BPH prevalence

A

Occurs in men >45
20% men in 50s have symptoms of BPH
With age, prostate gradually enlarges
Reason not known, advancing age and DHT are only definite risk factors
No known preventing prostatic growth

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22
Q

Why does an enlarged prostate cause bladder symptoms?

A

The bladder sphincter is being pushed on constantly at the neck which detects fullness, causing nocturia and urgency

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23
Q

BPH symptoms

A
  • Weak urine stream prolonged voiding
  • Hesitancy in initiating voiding
  • “Stop/start” stream
  • Straining
  • Post-voiding dribbling
  • Sensation of incomplete emptying
  • Needing to urinate frequently
  • Feeling of urgency
  • Night-time urination
  • Overflow incontinence
  • Dysuria (painful urination)
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24
Q

BPD and OTC meds

A

Cough & cold remedies
Anticholinergic agents can decrease detrusor contractility
Sympathomimetics can increase bladder neck & prostate tone

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25
Q

What happens when the bladder is not completely emptied in men?

A

Stagnant urine accumulates - risk of bacterial infection & cystitis & possible acute pyelonephritis due to retrograde flow of trapped urine

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26
Q

What happens when acute urinary retention occurs in men?

A

Painful & distressing
Must be relieved with catheterisation

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27
Q

BPH treatment:
Observation
Lifestyle
Modification of existing meds and/or co-existing medical conditions

A
  1. Mild to moderate symptoms, regular monitoring (annual) with physical exam and symptom assessment
  2. Reduce fluid or diuretic intake or modify behaviours to reduce symptom severity, avoid excess night time fluids, caffeine or alcohol, void bladder before long trips, meetings, bedtime
  3. May improve symptoms & reduce diuresis, improve diabetes control, adjust diuretic meds
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28
Q

BPH: lifestyle advice

A

Reduce fluid consumption before going out & going to bed, caffeine & alcohol
Schedule toilet visits
Manage constipation
Review meds. e.g. diuretics
Bladder training - wait longer after voiding
Use distraction techniques

29
Q

BPH treatment: prostate and bladder specific

A
  1. Alpha blockers, 5a-reductase inhibitors, combination therapy, tadalafil - help sexual symptoms
  2. Major surgical intervention
  3. Minimally invasive surgical treatments
30
Q

Stepwise approach of BPH treatment

A

Watchful waiting -> alpha blocker and/or 5a-reductase inhibitor (used instead of alpha blocker if S/Es intolerable) -> surgery (tadalafil)

31
Q

Alpha blockers:
Examples
MOA

A

Prazosin, tamsulosin, alfuzosin
- Selectively block alpha receptors in sympathetic NS
- Relaxes bladder neck & prostatic smooth muscle
- Improves urinary flow rate and IPSS (international prostate symptom score)
- Benefits seen after 48 hrs with full effect seen after 4-6 weeks- Benefits continue for up to 3 years

32
Q

Licensing of tamsulosin

A

Need to give 2 weeks, see if these work
Give another 4 weeks, ask for GP to review to give formal diagnosis
No longer licensed after 6 weeks use

33
Q

Alpha blockers:
Effectiveness
S/Es

A
  1. Prazosin = shorter duration of action = BD dosing & S/Es differ
  2. CV effects - orthostatic hypotension (1st dose hypotension especially in elderly)
    CNS effects - weakness, tiredness, headache & drowsiness
34
Q

Alpha blockers:
Subtypes
S/Es ADR

A
  1. a1a, a1b, a1d
  2. Postural hypotension, dizziness, fatigue, headache, drowsiness, nasal congestion, ejaculatory dysfunction
35
Q

Alpha blockers:
Prazosin
Terazosin
Indoramin
Doxazosin
Tamsulosin
Alfuzosin

A
  1. Not selective for a1a
  2. Need dose titration, increased ADR incidence
  3. Readily absorbed, 1st pass effect, alcohol interaction
  4. t0.5, 22h, OD, titrate dose
  5. a1a & a1b selective
  6. High prostate selectivity, t0.5, 5h but OD, CYP3A4
36
Q

5a-reductase inhibitors: finasteride or dutasteride
MOA
S/Es
Pharmacist note

A
  1. Inhibits 5a-reductase conversion of testosterone to DHT (potent cellular androgen that stimulates prostate growth), gradually reduces prostate size, decreases urinary outflow resistance, reduce symptoms, men with large prostates (40-40cm3 +)
  2. Decreased libido (3%), impotence (8%), decreased ejaculate volume (4%), can reduce PSA (important in monitoring for prostate cancer)
  3. Women who are/could be pregnant DONT handle broken or crushed tablets without gloves
37
Q

Combination of alpha blocker with 5a-reductase inhibitor

A
  • Alpha blockers improve bladder & prostate smooth muscle tone & improve urinary flow rate
  • 5a-reductase inhibitors reduce prostate size
  • Similar effects on QoL to alpha blocker alone in 1st 18 months
  • Disadvantages: long term required to see benefits & even most men will not see benefit
  • Optimal duration unknown
38
Q

Other options for BPH: tadalafil

A
  • Phosphodiesterase inhibitor
  • MOA in BPH not clear (may involve smooth muscle blood perfusion in bladder & prostate)
  • 5mg OD
  • Not improve urinary flow
  • Most effective for severe symptoms in young men with low BMI
  • Men with ED
  • No long term safety & efficacy
39
Q

Phytotherapy for BPH

A
  • Saw Palmetto & Pygeum africanum
  • Can povide modest improvement in urinary symptoms & flow (need trials!)
  • Cochrane review says no more effective than placebo in LUTS
  • Others: Beta-sitosterol plant extract, Rye grass pollen extract
40
Q

Antimuscarinics in BPH

A

Some men, storage symptoms predominant
But have absence of serious obstructive symptoms
Symptom complex categorised as overactive bladder syndrome
Treatment: bladder training & anticholinergics (oxybutynin) may use alone or in combo with BPH specific treatment

41
Q

Surgery in BPH

A

Final treatment option
Become less common with intro. of more effective treatment
Effective for symptom relief but higher complication rates
Less invasive: TURP (transurethral resection of prostate), TUIP (transurethral incision of prostate), TUMP (transurethral microwave thermotherapy), TUNA (transurethral needle ablation)
Adverse S/Es: sexual (loss ejaculation & ED), incontinence

42
Q

OTC tamsulosin supply criteria

A

Male 45-75
Symptoms of BPH for 3 months +
2 week supple initially
If improvement, further 4 week supply made
After 6 weeks, all patients referred to GP for further assessment

43
Q

What is prostatitis?

A

Inflammation of prostate gland
Most common genitourinary disease in men 18-50
May be bacterial (acute or chronic) infection or non-bacterial

44
Q

4 main types of prostatitis

A
  1. Acute bacterial prostatitis
  2. Chronic bacterial prostatitis
  3. Chronic pelvic pain syndrome
  4. Asymptomatic inflammatory prostatitis
45
Q

Bacterial prostatitis:
Caused by
Associated with

A

G- e.g. E.coli, proteus spp, Klebsiella spp and Ps. Aeruginosa
Acute prostatitis associated with UTI & urine cultures are positive
Chronic prostatitis, only seminal fluid cultures are positive

46
Q

Abacterial prostatitis

A

No pathogens are found in urine or seminal fluid but leucocytes found in urine or seminal fluid after prostate massage

47
Q

Symptoms of acute prostatitis

A
  • Severe pain
  • Dysuria
  • Increased frequency of urination
  • Symptoms of acute infection (fever, discharge, arthralgia, myalgia)
48
Q

Symptoms of chronic prostatitis

A

Most prominent - pelvic pain (perineal, testicular, penile, lower abdominal)
Urinary symptoms tend to be milder than acute prostatitis

49
Q

Acute bacterial prostatitis treatment

A

Treat according to C&S
Quinolones usually suitable and penetrate prostate well
4-6 week course to ensure organism eliminated & to prevent spread to adjacent tissues

50
Q

Chronic non-bacterial prostatitis

A

Thermotherapy & stress management have been tried
Alpha blockers help with LUTS symptoms
Antibiotics may be prescribed in case a low-grade infection is missed

51
Q

All prostatitis patient treatment

A

Regular analgesics (paracetamol or ibuprofen)
Laxative/stool softener (docusate or lactulose) may harden stools in rectum if pressing on inflamed prostate

52
Q

Quinolones in prostatitis:
MOA
Which agent?
Dosage
Length of course
S/Es

A
  1. Inhibit enzymes DNA gyrase & topoisomerase IV, prevent DNA re-ligation
  2. Ciprofloxacin for prostatitis
  3. 500mg BD for 14 days
  4. Carry out assessment if needing another 14 days
  5. Anorexia, constipation, dizziness, eye disorders, tinnitus, GI discomfort, skin reactions
53
Q

Erectile dysfunction incidence and organic causes

A

~50% men 40-70
Vasculogenic conditions (atherosclerosis, HTN, DM, hypercholesterolaemia)
Neurogenic (MS, PD, stroke)
Hormonal (hypogonadism, hypothyroidism, hyperthyroidism)
Anatomical (Peyronie’s disease, hypospadias)

54
Q

Erectile dysfunction psychological factors

A

Anxiety, depression, emotional problems, Hx of psychological abuse, fatigue/tiredness, recreational drugs, excess alcohol

55
Q

Medications contributing to ED

A

Antihypertensives
Antidepressants
Antihistamines
PD meds
Chemotherapy
Alcohol
Amphetamines
Barbiturates
Cocaine
Marijuana
Methadone
Nicotine
Opiates

56
Q

Counselling with ED patient:
Need to deal with
Lifestyle measures

A
  1. Discretion, understanding, gauge patient’s willingness to talk
  2. Lose weight, smoking cessation, take regular exercise, cut down on alcohol consumption, cease recreational drug use
57
Q

ED treatment:
Recommended approach
Medications

A
  1. = Combo of meds + lifestyle measures
  2. 1st line (regardless of cause) = oral phosphodiesterase type-5 inhibitors, act by increasing blood flow to penis, do not initiate an erection - stimulation required
58
Q

MOA of phosphodiesterase type-5 inhibitors:
Normal physiology of erection
Role of PDE-5
Action of PDE-5 inhibitors
Result

A
  1. Sexual stimulation releases NO in penile tissue, NO activates guanylate cyclase, increasing cGMP, cGMP relaxes smooth muscles in corpus cavernosum, increasing blood flow & erection
  2. Enzyme breaks down cGMP, reduces smooth muscle relaxation, limit blood flow to penis
  3. Sildenafil, tadalafil, block action of PDE-5, prevents cGMP breakdown, maintaining smooth muscle relaxation & increase blood flow
  4. Enhanced sustained erection during sexual stimulation
59
Q

ED phosphodiesterase inhibitor choices

A

Avanafil, sildenafil, tadalafil, vardenafil
A, S and V - shorter acting, used for occasional use (PRN)
T - longer acting, can be used PEN but used at lower daily dose for spontaneous sexual activity or frequent sex

60
Q

S/Es in ED treatment

A

Headache (1 in 10)
Hot flushes
Rhinorrhoea
Back pain
Indigestion
Visual disturbances
(Caution using nitrates within 24 hrs)

61
Q

ED treatment S/Es:
Headache
Flushing
Nasal congestion
Dizziness & hypotension
Visual disturbances
Muscle pain/back pain

A
  1. Vasodilation effects of cerebral blood vessels
  2. Relaxing of systemic blood vessels causing skin redness
  3. Relaxing of nasal vasculature
  4. Due to systemic BP reduction
  5. Linked to PDE-6 inhibition in retina
  6. Caused by vasodilation & increased blood flow to skeletal muscles
62
Q

Which, sildenafil and tadalafil, causes a higher risk for visual disturbances?

A

Sildenafil
Has a higher affinity for inhibiting PDE6 (enzyme in retina that controls cGMP levels)

63
Q

ED 2nd line treatment

A

Alprostadil (prostaglandin E1 analogue)
Intercavernosal injection (Caverject) OR urethral application (sticks - Muse or Cream - Vitaros)

64
Q

Priapism associated with alprostadil treatment:
Aspiration
Lavage of the corpora
If both do not work

A

Sustained erection does not subside
1. 20-50ml blood aspirated from penis using 19-21 gauge butterfly needle inserted into corpus cavernosum, repeat on other side if needed
2. If aspiration unsuccessful, 2nd butterfly inserted into opposite corpus cavernosum, normal saline injected through 1st needle & drained through 2nd
3. Intracavernosal injection of sympathomimeticwith a-adrenergic receptors (adrenaline or metaraminol or phenylephrine (not licensed))
Care with CHD, HTN and MAOIs
If all fails, consider surgical intervention

65
Q

OTC management of ED

A

Sildenafil (Viagra connect)
Tadalafil (Cialis)

66
Q

What is premature ejaculation?

A

Common male sexual problem
Characterised by brief sexual latency, loss of control & psychological distress

67
Q

Premature ejaculation:
Non-drug treatment
Drug treatment

A
  1. Recommended in patients where causes few problems or who do not wish to take meds.
  2. Patients with life-long problems, dapoxetine (short acting SSRI) is licensed to be used PRN (1-3hrs before sexual activity), other SSRIs & TCAs used as regular, daily treatment (unlicensed indications)
68
Q

Dapoxetine:
MOA
Indications
Dose

A
  1. Short acting SSRI
  2. Premature ejaculation in men with ALL: poor control over ejaculate, Hx of PE over 6 months, marked distress of difficulty, intravaginal ejaculatory latency time of <2 mins
  3. 30mg taken 1-3hrs before sexual activity, subsequent doses adjusted, review after 4 weeks or 6 doses and every 6 months after, not recommended >65, max. 1 dose a day, max. 60mg a day

Pharmacy (23 decks)

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