301 Men's Health Flashcards
Define LUTS
Lower urinary tract symptoms
Common symptoms of LUTS
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
Voiding symptoms of LUTS
Weak or intermittent urinary stream, straining, hesitancy in starting urination, terminal dribbling & incomplete emptying
Storage symptoms of LUTS
Urinary urgency, urinary frequency, urge continence & nocturia
Major post-micturition symptoms of LUTS
Dribbling, sensation of incomplete emptying
Explain the potential causes of LUTS
Abnormalities or abnormal function of the prostate, urethra, bladder or sphincter
RED flags symptoms that warrant referral in LUTS
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
Management options for LUTS in men:
Lifestyle
OTC
- Prudent fluid intake, balanced diet & regular exercise advice, limit caffeine & alcohol intake
- 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
Define erectile dysfunction
Inability to get or maintain an erection that’s firm enough for sexual activity
Psychogenic causes of erectile dysfunction
Mental health conditions, stress, relationship problems, lack of sexual knowledge, past sexual problems, sexual abuse & new relationships
Organic causes of erectile dysfunction
Cardiovascular disease, diabetes, hormonal imbalances & neurological disorders
Key questions to ask patient presenting with ED
Onset & frequency of symptoms
Medications
Stressful life events
Medical history
Lifestyle - diet, exercise, smoking & alcohol consumption
Pharmacological treatment of ED
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
What is the prostate?
Prostate gland is part of male reproductive system, gland circles the urethra
What does the prostate do?
Prostate secretions are important in component of semen - protects and nourishes sperm
Why is prostate difficult to examine?
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
3 most common prostate conditions
- Prostatitis
- Benign Prostate Hyperplasia (BPH)
- Prostate cancer
What is the prostate made up of?
Epithelial and stromal cells which produce secretions & needed for viability & growth of cells
Benign Prostatic Hypertrophy (BPH) anatomy
Most evident in transitional zone, closest to urethra
BPH cause increase in epithelial & stromal cells, closest to urethra so cause constriction & urgency
Why does benign prostatic hypertrophy occur?
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)
BPH prevalence
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
Why does an enlarged prostate cause bladder symptoms?
The bladder sphincter is being pushed on constantly at the neck which detects fullness, causing nocturia and urgency
BPH symptoms
- 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)
BPD and OTC meds
Cough & cold remedies
Anticholinergic agents can decrease detrusor contractility
Sympathomimetics can increase bladder neck & prostate tone
What happens when the bladder is not completely emptied in men?
Stagnant urine accumulates - risk of bacterial infection & cystitis & possible acute pyelonephritis due to retrograde flow of trapped urine
What happens when acute urinary retention occurs in men?
Painful & distressing
Must be relieved with catheterisation
BPH treatment:
Observation
Lifestyle
Modification of existing meds and/or co-existing medical conditions
- Mild to moderate symptoms, regular monitoring (annual) with physical exam and symptom assessment
- 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
- May improve symptoms & reduce diuresis, improve diabetes control, adjust diuretic meds
BPH: lifestyle advice
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
BPH treatment: prostate and bladder specific
- Alpha blockers, 5a-reductase inhibitors, combination therapy, tadalafil - help sexual symptoms
- Major surgical intervention
- Minimally invasive surgical treatments
Stepwise approach of BPH treatment
Watchful waiting -> alpha blocker and/or 5a-reductase inhibitor (used instead of alpha blocker if S/Es intolerable) -> surgery (tadalafil)
Alpha blockers:
Examples
MOA
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
Licensing of tamsulosin
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
Alpha blockers:
Effectiveness
S/Es
- Prazosin = shorter duration of action = BD dosing & S/Es differ
- CV effects - orthostatic hypotension (1st dose hypotension especially in elderly)
CNS effects - weakness, tiredness, headache & drowsiness
Alpha blockers:
Subtypes
S/Es ADR
- a1a, a1b, a1d
- Postural hypotension, dizziness, fatigue, headache, drowsiness, nasal congestion, ejaculatory dysfunction
Alpha blockers:
Prazosin
Terazosin
Indoramin
Doxazosin
Tamsulosin
Alfuzosin
- Not selective for a1a
- Need dose titration, increased ADR incidence
- Readily absorbed, 1st pass effect, alcohol interaction
- t0.5, 22h, OD, titrate dose
- a1a & a1b selective
- High prostate selectivity, t0.5, 5h but OD, CYP3A4
5a-reductase inhibitors: finasteride or dutasteride
MOA
S/Es
Pharmacist note
- 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 +)
- Decreased libido (3%), impotence (8%), decreased ejaculate volume (4%), can reduce PSA (important in monitoring for prostate cancer)
- Women who are/could be pregnant DONT handle broken or crushed tablets without gloves
Combination of alpha blocker with 5a-reductase inhibitor
- 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
Other options for BPH: tadalafil
- 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
Phytotherapy for BPH
- 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
Antimuscarinics in BPH
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
Surgery in BPH
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
OTC tamsulosin supply criteria
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
What is prostatitis?
Inflammation of prostate gland
Most common genitourinary disease in men 18-50
May be bacterial (acute or chronic) infection or non-bacterial
4 main types of prostatitis
- Acute bacterial prostatitis
- Chronic bacterial prostatitis
- Chronic pelvic pain syndrome
- Asymptomatic inflammatory prostatitis
Bacterial prostatitis:
Caused by
Associated with
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
Abacterial prostatitis
No pathogens are found in urine or seminal fluid but leucocytes found in urine or seminal fluid after prostate massage
Symptoms of acute prostatitis
- Severe pain
- Dysuria
- Increased frequency of urination
- Symptoms of acute infection (fever, discharge, arthralgia, myalgia)
Symptoms of chronic prostatitis
Most prominent - pelvic pain (perineal, testicular, penile, lower abdominal)
Urinary symptoms tend to be milder than acute prostatitis
Acute bacterial prostatitis treatment
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
Chronic non-bacterial prostatitis
Thermotherapy & stress management have been tried
Alpha blockers help with LUTS symptoms
Antibiotics may be prescribed in case a low-grade infection is missed
All prostatitis patient treatment
Regular analgesics (paracetamol or ibuprofen)
Laxative/stool softener (docusate or lactulose) may harden stools in rectum if pressing on inflamed prostate
Quinolones in prostatitis:
MOA
Which agent?
Dosage
Length of course
S/Es
- Inhibit enzymes DNA gyrase & topoisomerase IV, prevent DNA re-ligation
- Ciprofloxacin for prostatitis
- 500mg BD for 14 days
- Carry out assessment if needing another 14 days
- Anorexia, constipation, dizziness, eye disorders, tinnitus, GI discomfort, skin reactions
Erectile dysfunction incidence and organic causes
~50% men 40-70
Vasculogenic conditions (atherosclerosis, HTN, DM, hypercholesterolaemia)
Neurogenic (MS, PD, stroke)
Hormonal (hypogonadism, hypothyroidism, hyperthyroidism)
Anatomical (Peyronie’s disease, hypospadias)
Erectile dysfunction psychological factors
Anxiety, depression, emotional problems, Hx of psychological abuse, fatigue/tiredness, recreational drugs, excess alcohol
Medications contributing to ED
Antihypertensives
Antidepressants
Antihistamines
PD meds
Chemotherapy
Alcohol
Amphetamines
Barbiturates
Cocaine
Marijuana
Methadone
Nicotine
Opiates
Counselling with ED patient:
Need to deal with
Lifestyle measures
- Discretion, understanding, gauge patient’s willingness to talk
- Lose weight, smoking cessation, take regular exercise, cut down on alcohol consumption, cease recreational drug use
ED treatment:
Recommended approach
Medications
- = Combo of meds + lifestyle measures
- 1st line (regardless of cause) = oral phosphodiesterase type-5 inhibitors, act by increasing blood flow to penis, do not initiate an erection - stimulation required
MOA of phosphodiesterase type-5 inhibitors:
Normal physiology of erection
Role of PDE-5
Action of PDE-5 inhibitors
Result
- Sexual stimulation releases NO in penile tissue, NO activates guanylate cyclase, increasing cGMP, cGMP relaxes smooth muscles in corpus cavernosum, increasing blood flow & erection
- Enzyme breaks down cGMP, reduces smooth muscle relaxation, limit blood flow to penis
- Sildenafil, tadalafil, block action of PDE-5, prevents cGMP breakdown, maintaining smooth muscle relaxation & increase blood flow
- Enhanced sustained erection during sexual stimulation
ED phosphodiesterase inhibitor choices
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
S/Es in ED treatment
Headache (1 in 10)
Hot flushes
Rhinorrhoea
Back pain
Indigestion
Visual disturbances
(Caution using nitrates within 24 hrs)
ED treatment S/Es:
Headache
Flushing
Nasal congestion
Dizziness & hypotension
Visual disturbances
Muscle pain/back pain
- Vasodilation effects of cerebral blood vessels
- Relaxing of systemic blood vessels causing skin redness
- Relaxing of nasal vasculature
- Due to systemic BP reduction
- Linked to PDE-6 inhibition in retina
- Caused by vasodilation & increased blood flow to skeletal muscles
Which, sildenafil and tadalafil, causes a higher risk for visual disturbances?
Sildenafil
Has a higher affinity for inhibiting PDE6 (enzyme in retina that controls cGMP levels)
ED 2nd line treatment
Alprostadil (prostaglandin E1 analogue)
Intercavernosal injection (Caverject) OR urethral application (sticks - Muse or Cream - Vitaros)
Priapism associated with alprostadil treatment:
Aspiration
Lavage of the corpora
If both do not work
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
OTC management of ED
Sildenafil (Viagra connect)
Tadalafil (Cialis)
What is premature ejaculation?
Common male sexual problem
Characterised by brief sexual latency, loss of control & psychological distress
Premature ejaculation:
Non-drug treatment
Drug treatment
- Recommended in patients where causes few problems or who do not wish to take meds.
- 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)
Dapoxetine:
MOA
Indications
Dose
- Short acting SSRI
- 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
- 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
