BPH & Urology Flashcards
Erectile Dysfunction
- options for treatment
First Line Treatment : PDE5i : phosphodiesterase type 5 inhibitors
others
- vacuum erection device (VED)
- intraurethral alprostadil (IU) : with in-office testing to be preformed
- intravacernosal injection (ICI): with in-office testing to be preformed
testosterone deficeincy: fors thos with a total T < 300 and signs/symptoms = testosterone can be given only as add-on thearpy, never monothearpy
PDE5i
Names
relative dosing: when can be used daily
spcifics for hepatic and renal impairment
Names
Sildenafil
- 1 hour before sex
- best option if bad liver because it can be adjusted dose wise
- adjust dose is CrCl < 30
Vardenafil
- 1 hour before sex
- not used if hepatic issues or if QTc prolongation: arrythmic risk
- dissolve on tongue one (Staxyn) should not be used if on alpha-adrenergic antagonists (HTN too)
Tadafinil
- can be before sex, or one dose daily!
- not recommende if liver issues
- dose adjust if CrCl < 50
Avanafil
- 15 minutes before sex (quickest onset)
- not recommened if liver issue
- dont use of CrCl < 30
Relationship between PDE5i and CVD risk
- low risk group
- intermediate
- high risk
Low Risk Group
- asymptomatic CVD
- well controlled HTN
- Milde CHF (class I or II)
- can use a PDE5i
Intermediate Risk Group
- history of stroke, TIA or PAD
- moderate CHF (class III)
- mild or moderate stable angina
- This group needs a CV workup and stress test prior to being rx. a PDE5i
High Risk
- uunstable/refractory angina
- controlled HTN
- severe CHF (class IV)
- PDE5i are CONTRAINDICATED in this group
PDE5i
MOA
ADE & monitoring
Contraindications
MOA
- work to increase cGMP in the corpus cavernosum; allowing an erection to occur via dilation
ADE
- dyspepsia
- HA, flushing, congestion (due to the vasodilation effect)
- visual disturbances (green/blue)
- hearling loss
- hypotension
- priapism: sustained erection lasting longer thatn 4 hours
- back pain & muscle aches = tadafinil
- QTc prolongation, palpatations and dizzy = vardenafil
Contraindications
- cannot be used with medications that have nitrates in them!
- must withhold these meds for 24 hours (48 hours if tadafinil because longer action)
- can result in severe hypotension due to additive dilation effect: need to aggressive rehydrate and give pressors
Drug Interactions with the PDE5i
PDE5i’s are CYP3A4 substrates: thus inhibitors will increase thier concentration and inducers will decrease their concentration
inhibitors: SSRI (fluoxetine), verapamil & diltazem (CCBs), calirthromycin, fluconzaole, grapefruit juice
inducers: rifamin, carbamazipine, phenyotonin, phenobarb.
a high fat meal will decrease the effectiveness of vardenifil and sildenafil
Vacuum Assisted Erection Devices
- how they work
- counseling
- Adverse effects
- CI
How they work
- 2nd line treatment if unable to use PDE5i
- vacuum device placed around penis, band on the end, pulls blood into the penis when vacuum happens
Counseling
- battery powered or manual
- takes a few weeks for technique
- applt lubricate at penis and base of device
- do not use vasaline: will damage
Adverse Effects
- pain, brusing or injury
Contracindications
- sickel cell
- history or priapsm
- severe penial curvature
Intraurethral Agents
- names
- MOA
- ADE
- Avoid in who
must go into office to find out proper dosing
Names
- Alprostadil
MOA
- a suppository that is direclty administered into the head of penis, while standing after urination
- sex should occur 10-30 minutes after
- walk for 10 minutes until absorbed; massage gently to avoid leakage
Avoid in
- those with uretheral stricture/ureitheritis
- cannot use if partner is pregnant
ADE
- aching pain, burning, bleeding or tearing
- priapism
- hypotension and dizzy
- partner can experience pain/burning
Intracevernosal Injection
MOA
ADE
Caution use….
alprostadil again, like the intraurethral but instead its an injection
MOA
- injection done 5-10 minutes before sex
- inject at 90 degree angle on the side of the shaft into the corpus cavernosum
Adverse REactions
- pain (give NSAIDS)
- menatoma at injection site
- fibrotic nodubles at shaft from injections
- priapism , hypotension and dizzy
Caution in
- sickel cell
- leukemia and myeloma
- thrombocytoenia because bleed risk
- obese pt, blind and severe arthritis (improper technique)
Councel: cannot use more then 1 injection a day, no more than 3 per week
Role of Testosterone Supplements
- when are they used
- specifics of each preparation
tesosterone can only be used as add-on treatment for those with testosterone < 300 in addition to other tretments
avoid PO because of the systemic effects
methyltestosteron: PO formulation = hepatotoxic
Testosterone cypionate: IM injection
Testosterone unanthate: IM Injection
Testosterone undecanoate: longer actin IM: risk of pulmonary oil embolism & anaphylaxis
Transdermal and topical formualtions (sprays, gels,etc.) less used becuase of the risk of transferring to partner
testosterone supplements
- ADE
- CI
- Counceling
ADE
- sodium/water retention
- hyperlipidemia
- polycythemia
- gynecomastia
- sleep apnea
- mood swings
- hepatotoxic = D/C med immediately
- VTE= D/C med immediately
- prostate enlargement
Caution in…
- those with significant CVD history
- around women breasfeeding or pregnant
Contraindication
- those with untreated prostate cancer or men with breast cancer
Counceling
- takes weeks to see clinical improvemnet (3-6 months for full effect)
Signs/Symptoms and Diagnosis of BPH which warrents medication
Treatment Goals (point decrease)
Symptoms
- obstructive (incomplete emptying, slow stream, etc.)
- irritative ( pain and uregency/frequency issues)
- recurrent UTIs, stones
- DRE: prostate size > 20 g = large
- urinalysis, BUN, SCr and PSA levels can clue you in
- urinary flow rate, postvoid residual volume
AUA Score of Prostate Symptoms
- mild = 0-7
- moderate = 8-19
- severe = 20 -35
Treatment Goals
1. control urinary symptoms
2. decrease the AUA index score by a minimum of 3 points
3. prevent progression of BPH disease (to avoid the need for surgery!)
Treatment for…
- mild/asymptomatic BPH
- Moderate/severe BPH
Mild/Asymptomatic
- watchful waiting
- adjust behaviors and lifetyle factors first
- d/c any medications which can be contributing
- follow-up in 6- 12 month intervals
Moderate/Severe
- initiate medications
- alpha-1-adrenergic antatgonists
- 5-alpha reductase inhibitors
- surgery eventaully (TURP,etc.)
Algorithim for moderate/severe BPH and initation of which medication
- prostate < or = 30 grams = Alpha-1-adrenergic antagonists
- prostate > 30 grams or PSA > 1.4 = add on 5 alpha reductase inhibitors
- compalints of erectile dysfunction = add on PDE5i
- complaints of irritative voiding symptoms = anticholenergic (dry up) or beta-3 agonist
severe LUTS or BPH = surgery
Alpha 1 adrenergic antagonists
- names
- specifics of each
Alpha-1 adrenergic antagonists (-Zosins)
- block the alpha 1 receptors within the bladder thus allowing pts. to urinary with easy (stops the blocking by relaxing the muscles in the bladder and prostate)
Names
- Prazosin : not recommended
- Terazosin: high risk of orthostatis hypotension
- Doxazonsin: high risk of orthostatic hypotension
- Alfuzosin: (ER) A for A+ (safest) cautioni crcl < 30 and cant use in liver disease
- Tamsulosin: use
- Silodosin: dont use if crcl < 30 and avoid with potent CYP 3A4 inhibitors
tamsulosin and silodosin shouldd be taken following the same meal each day
Alpha-1 Adrenergic meds
- ADE
- DDI
- Caution
- monitoring
ADE
- first-dose syncope
- orthostatic hypotension
- dizzy
- choose the uroselective tansulosin and silodosin to avoid these ^^
- intraoperative floppy iris syndrome
- ejaculatory dysfunction (silodosin)
DDI
- CYP3A4 inhibitos = watch out with these
- PDE5i and hypotension (separate by 4 hours)
cannot use an alpha 1 as monothearpy to treat BPH and HTN!!
monitor
-evalute afte 4-12 weeks of inititation
