ED and BPH - Exam 2 Flashcards
how does erection occur?
increased arterial flow, relaxation of smooth musculature in both corpora cavernous, increased venous resistance
muscle contraction increases rigidity of penis w/ increase in intra-cavernous mmHg > systolic BP
what is erectile dysfunction?
consistent inability to generate or maintain and erection
ED etiologies?
vascular, neurogenic, hormonal, drug induced, psychogenic, Peyronie’s Disease
arterial vascular etiology of ED
caused by arterial obstruction
increased flow gives you erection, so obstruction would decrease flow, so then no erection
venous vascular etiology of ED
caused by venous leak
leakage would decrease venous resistance -> can develop erection, but can’t maintain it
what nervous system makes pt develop an erection? what NS maintains the erection? what causes the dysfunction?
erection develop is autonomic nervous system function
maintaining erection is parasympathetic nervous system
damage to either can cause dysfunction
neurogenic causes of ED
MS, Parkinson’s, CVA, spinal injury/tumor
d/t damage to autonomic NS and/or parasympathetic NS
how does hypogonadism cause ED?
b/c have decrease in testosterone, so decrease erection
how does hyperprolactinemia and HPA dysfunction cause ED?
b/c have decrease in GnRH -> decr testosterone -> decr erection
what drugs cause ED?
antihypertensives (BB’s, diuretics, alpha-agonists), antidepressants (SSRIs), opioids, 5-alpha-reductase inhibitors (finasteride)
ED caused by psychogenic, occurs in?
younger people
what is Peyronie’s disease? what type of cause of ED?
penile deformity or curvature of penis due to scarring and fibrosis -> mechanical cause of ED
ED may be an early of what?
early sign of CAD
ED and CAD develop from what?
endothelial dysfunction
endothelial dysfunction results from? imbalance b/w?
decrease in NO, thus impaired arterial vasodilation
imbalance b/w vasodilation and vasoconstriction
ED w/o obvious caused should be screened for what? why?
for CVD (esp before initiating pharmacologic therapy for sexual dysfunction)
b/c of increased cardiac risk associated with sexual activity
what is the etiology of Peyronie’s disease?
subtle trauma to penis and subsequent scarring and development of fibrous plaque -> during erection causes curvature
loss of penile length means?
Peyronie’s disease
what is SHIM? what does it do?
sexual health inventory for men
classifies severity of ED dysfunction into 5 categories
5 categories of SHIM
severe, moderate, mild-moderate, no ED (based on score of over 6 months)
men that are sexually competent and then all of a sudden one night they can’t perform, means what?
psychogenic ED
ex: performance anxiety, current sexual partner issues, emotional problems
sporadic ED problems that become more chronic, means what?
more of an organic cause
signs of hypogonadism?
hypogonadism can contribute to ED
sign:
- lack of/loss of normal male hair patterns
- gynecomastia
- small testes
lack of cremasteric reflex in pt that has ED may indicate?
neurogenic disease
penile plaques in pt that has ED may indicate?
Peyronie’s disease
what pulses should be examined for pt with ED? what may they be like?
femoral and peripheral pulses - may be diminished or asymmetric
what bruits may pt with ED have?
femoral bruits
what labs should be checked in pt with ED?
Fasting glucose and/or A1c (DM is a cause)
TSH (hypothyroidism is a cause)
Lipid profile (checking for CAD)
Testosterone
- serum prolactin (if testosterone is low) - helps determine what the primary cause is
- LH
what is NPT testing for ED?
nocturnal penile tumescence testing
-while sleeping, it detects number, tumescence, rigidity of nighttime erection
what does a normal NPT mean?
psychogenic or hormonal cause of ED
what does an impaired NPT mean?
vascular or neurogenic cause of ED
what imaging can you use for pt with ED? what does it show?
Duplex Doppler imaging or Angiography
- deep penile artery angio identifies obstruction
- doppler identifies venous leak
if vascular etiology is suspected for ED then do what?
do doppler/angiography
if fail the oral medication trial then do injection trial typically prostaglandin or vasodilating agent to better assess mechanism of failure
what risk factors must you treat and identify for ED?
identify and treat CV risk factors
-smoking, obesity, HTN, HDL
if pt with ED is having psychological cause, how do you treat them?
psychotherapy, sex therapy, psychoactive meds
-but worried about SSRIs and antidepressants b/c they cause ED
will testosterone replacement therapy alone solve ED?
NO!!! better to combine testosterone w/ PDE-5 inhibitor as one improved libido and other ED
what meds are FIRST LINE therapy for ED?
PDE-5 inhibitors
-sildenafil, tadalafil, vardenafil, avanafil
how do PDE-5 inhibitors work for ED?
nitric oxide induced vasodilation
PDE-5 inhibitors only function with what for ED?
only function w/ sufficient sexual arousal -> need to have libido -> benefits of testosterone and PDE-5
sildenafil is esp useful for what pts with ED?
diabetics, radical prostatectomy pts, Parkinson’s pts
why tadalafil is good for ED? what else can it improve?
b/c can take ow dose daily, so good for pt’s with “complete” ED
can also improve LUTS d/t BPH
PDE-5 inhibitors absolute C/I?
DON’T USE WITH NITRATES!!!
PDE-5 inhibitors relative C/I?
use w/ alpha-adrenergic antagonists -> causes hypotension
can take together with doxazosin, but use with caution
what is SECOND LINE tx for ED? how do they work?
Vacuum-assisted erection devices
increases blood flow and restricts venous outflow by putting ring on penile base -> erection
occlusive ring used with Vacuum-assisted erection devices may prevent what? not good for what people?
may prevent ejaculation d/t pressure on urethra
-not good for people for fertility
what is THIRD LINE tx for ED?
Penile self-injection with Prostaglandin-E1
- directly inject into the corpus cavernous and acts as smooth muscle vasodilator
- must use sterile technique and inject with insulin needle
most common side effect of injection of Prostaglandin-E1?
penile pain
if pt with ED has spinal cord injury or MS (neurogenic causes of ED), what should be changed about the dose of Prostaglandin-E1? why?
should lower dose of med b/c of risk of priapism
priapism = pathologic sustained erection >4-6hrs
intraurethral use of Prostaglandin-E1 for ED is C/I in who?
in sickle cell anemia or sickle cell trait, leukemia, MM
b/c all have risk factors for priapism
can you use Prostaglandin-E1 injection for ED in pts with penile implant or Peyronie’s?
No!!! C/I in these cases
what is LAST LINE tx for ED?
Surgical options:
- penile prostheses
- penile revascularization (but low success rates unless young, non-smoker, and healthy but have recent focal artery occlusion)
what is priapism? emergency?
prolonged >4-6 hrs erection unresolved by ejaculation
UROLOGIC EMERGENCY!!!
if priapism is untreated, what does it lead to?
ischemia and then corporal fibrosis and necrosis of penis
what are the 2 types of priapism?
low flow and high flow
what is low flow priapism?
extremely painful, ischemic cause
M/C cause
what is high flow priapism?
trauma/arterial injury
most common cause of priapism?
low flow -> ischemic cause
what drugs can cause priapism?
antihypertensives (CCB, hydrazine, prazosin)
anticoag’s (heparin, warfarin)
psychotropics (SSRIs, Haldol, trazado, phenothiazine)
Hormone therapy (testosterone, GNRH, tamoxifen, androstenedione)
what RBC disorders can cause priapism and why?
sickle cell anemia, leukemia, thalassemia
-have miss-shapended RBCs -> don’t allow blood to leave -> prolonged erection
what ED tx can cause priapism?
intrapenile injections with PGE-1
what is the tx for priapism?
first do penile nerve block with lidocaine or bupivacaine w/out epinephrine
then inject phenylephrine to cause vasoconstriction
if injection with phenylephrine for tx of priapism doesn’t work, then what do you do?
perform aspiration of the corpora cavernosa to remove blood, then follow with saline irrigation (or diluted phenylephrine for irrigation
if necessary, inject an alpha-adrenergic agonist
what is LAST LINE tx for priapism if phenylephrine or aspiration fail?
surgery
what is BPH histologic dx?
cellular proliferation of the prostate at the central transition zone (gland)
is BPH a risk factor for cancer?
NO!!!
what zone of the prostate do you see hyperplasia (BPH)?
transition zones
if pt was castrated, can they get BPH?
NO!!! b/c the prevalence of it increases with age in hormonally dependent way
what can untreated BPH cause?
acute urinary retention, recurrent UTI, hydronephrosis, renal failure d/t to bladder outlet
LUTS sx’s for BPH 2 categories
storage/irritative sx’s and obstructive sx’s
how do irritative sx’s of BPH occur?
b/c prostate is so big that it irritates the bladder wall -> constant force against it
how do obstructive sx’s of BPH occur?
prostate is so large that blocks off bladder
what are the irritative sx’s of BPH?
urgency, frequency, nocturia, incontinence
what are the obstructive sx’s of BPH?
hesitancy, decreased force of stream, dribbling post-void, straining to urinate, unable to or incomplete emptying of bladder
what is the AUA score for BPH?
American urologic association’s sx’s score which assesses the severity of sx’s of BPH
when should AUA score for BPH be calculated?
before starting therapy it should calculated for every pt as it is the single most important tool in evaluation
the higher the calculated AUA score for BPH means what?
more severe sx’s and increased effect of pt’s life
what is the single most important tool in evaluation of BPH sx’s?
AUA sx score
-should be done on all BPH pts before starting therapy
what meds may be causing impaired bladder function or increased outflow resistance for BPH pt?
anticholinergic drugs (decr muscle contraction)
sympathomimetic drugs (increase tone in prostate causing outflow symptoms)
what should pt with BPH keep a diary of?
keep a voiding diary
-nocturia, void volume
may provide as much or more info than AUA sx’s score
what is the primary component of physical exam for BPH pt?
DRE
-prostate will feel uniformly enlarged, firm, and rubbery
what do you want to measure in pt with BPH?
post void residual volume
if miss prostatitis (as possible dx) for pt coming in with BPH, what are you setting them up for?
sepsis
what is the first testing to do for BPH? what are you looking for?
urinalysis - UTI, hematuria
why test for serum Cr in BPH pt?
looking for AKI from bladder obstruction
serum PSA and BPH?
increase in BPH is correlated with risk of sx progression (normal < 4)
men w/ prostate Ca can have normal PSA
men w/ high PSA can have prostatic dz other than CA
what upper tract imaging do you do for BPH? when do you do imaging?
Transrectal U/S - detects mass and total prostate volume (monitor this)
or CT
do imaging if Cr is high, UTI, hematuria, hx of calculi, CKD
other tests for BPH that are usually ordered by specialist?
max urinary flow rate (urodynamic profile)
post-void residual volume
urine cytology (done for irritative sx’s and RF’s for bladder malignancy like smoking, industrial exposure)
cystoscopy (not routine recommendation)
flow rate >15ml/sec excludes what?
important bladder outlet obstruction for BPH
what is a normal post-void residual volume? when do you get worried?
Normal = <12 ml
get worried when PVR >150-200mL
do bladder scan with U/S
cystoscopy and BPH?
- Not routine recommendation
- Assist in planning for surgical management of BPH
- Useful for detecting bladder malignancy, urethral stricture, calculi
- Recommended and performed by urologist
when must you refer BPH pt for urologic evaluation prior to tx?
- Hydronephrosis
- Renal insufficiency
- Urinary retention
- Recurrent UTI
- Sx’s in setting of autonomic or severe peripheral neuropathy
- Sx’s following invasive tx of urethra or prostate
- <45yo
- Abnormality on DRE of prostate (asymmetry, induration, nodule)
- Hematuria in absence of UTI
- Incontinence
- Severe symptoms AUA score >20
when can you consider watchful waiting as treatment for BPH?
if AUA severity score < 8 (mild)
-no bladder outlet obstruction, renal insufficiency, recurrent infection (if have these can’t do watchful waiting)
when can you NOT do watchful waiting as tx for BPH?
if pt has bladder outlet obstruction, renal insufficiency, recurrent infection
behavioral modifications for tx of BPH?
- urinate in seated rather than standing position
- reduce consumption of caffeine, alcohol
- avoid fluids prior to bedtime or before going out
- double void to empty the bladder better -> void 2x in an hour
- avoid meds that cause urinary retention or possibly diuretics
when do you use meds as tx for BPH?
mild to moderate IPSS < 20 w/o:
- refractory retention
- BPH induced (kidney disease, bladder calculi, recurrent or persistent gross hematuria)
what are the FIRST LINE meds for BPH? therapeutic effects? where do they effect in the body?
alpha-1a blockers
-terazosin, doxazosin, tamsulosin, alfuzosin, silodosin
immediate therapeutic benefits
localized effect at prostate and bladder neck to relax smooth muscle -> easier outlet of urine
M/C adds of alpha-1a blockers?
Orthostatic hypotension and dizziness
when are terazosin and doxazosin initiated for tx of BPH?
at bedtime b/c of orthostatic hypotension adrenal
what other meds do alpha-1a blockers interact with? what is the interaction? separate doses? less interaction with which alpha-1a blocker?
PDE-5 inhibitors
potentiates hypotensive effects when used simultaneously (esp with terazosin, doxazosin)
separate doses by 4 hours
much less interaction with tamsulosin
what are the SECOND LINE meds for tx of BPH?
5-alpha-reductase inhibitors
Finasteride (M/C), Dutasteride
when do you NOT use 5-alpha-reductase inhibitors (Finasteride) for tx of BPH?
don’t use w/ irritative sx’s or concomitant ED (can worsen ED)
how does Finasteride (5-alpha-reductase inhibitor) work for tx of BPH? how long to work?
blocks conversion of testosterone to dihydrotestosterone which reduces the size of the prostate and therefore bladder outlet obstruction
takes 6-12 months until sx reduction is achieved
finasteride is more effective in what men with BPH?
men with larger prostates (>40ml by TRUS)
adrs of finasteride?
- decreased libido
- ED
- decreased ejaculate volume
- PSA reduction by 50% (take into account if monitoring for prostate CA)
when do you consider the use of PDE-5 inhibitors for BPH?
if pt has both ED and BPH < 20 IPSS (have to have mild-moderate score)
use Tadalafil
what anticholinergic agent do you use for BPH and for what sx’s?
use Oxybutynin
for irritative sx’s associated with overactive bladder (b/c will cause urinary retention)
side effects of anticholinergic meds (oxybutynin)?
dry mouth, drowsiness, decreased cognitive function, constipation, inhibition of gut motility
these adrs seriously limit dose increase and tolerance
when do you consider combo therapy for BPH?
- severe sx’s of BPH IPSS > 20
- poor response to monotherapy
- prostate >40ml and score >20
what combo meds for BPH?
alpha-blocker AND alpha-reductase inhibitor
when do you go to surgical therapy for BPH?
after 12-24 months of combo therapy and any progression of disease on therapy
what alternative therapy for BPH showed improved sx’s and increased flow rates?
Pygeum africanum (extract of bark from African plum tree)
what do surgeries for BPH do?
destroy prostate and improve output of urine
can do laser, microwave hyperthermia or electrovaporization, radiofrequencies
conventional surgical tx for BPH?
TURP (transurethral resection prostatectomy) -> BEST TO DO
bad adr of TURP?
transurethral resection syndrome = hypervolemic, hyponatremic state resulting from absorption of hypotonic irrigating solution
when do you do TUIP for BPH tx?
small prostate but severe sx’s w/ elevated bladder neck
when do you do open simple prostatectomy for BPH tx?
done if prostate is too large to remove endoscopically (i.e. > 100g)
operation of choice if coinciding bladder pathology (diverticulum of calculi)
END OF THE LINE!!!
