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Clin Med 3 > ED and BPH - Exam 2 > Flashcards

ED and BPH - Exam 2 Flashcards

1
Q

how does erection occur?

A

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

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2
Q

what is erectile dysfunction?

A

consistent inability to generate or maintain and erection

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3
Q

ED etiologies?

A

vascular, neurogenic, hormonal, drug induced, psychogenic, Peyronie’s Disease

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4
Q

arterial vascular etiology of ED

A

caused by arterial obstruction

increased flow gives you erection, so obstruction would decrease flow, so then no erection

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5
Q

venous vascular etiology of ED

A

caused by venous leak

leakage would decrease venous resistance -> can develop erection, but can’t maintain it

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6
Q

what nervous system makes pt develop an erection? what NS maintains the erection? what causes the dysfunction?

A

erection develop is autonomic nervous system function

maintaining erection is parasympathetic nervous system

damage to either can cause dysfunction

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7
Q

neurogenic causes of ED

A

MS, Parkinson’s, CVA, spinal injury/tumor

d/t damage to autonomic NS and/or parasympathetic NS

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8
Q

how does hypogonadism cause ED?

A

b/c have decrease in testosterone, so decrease erection

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9
Q

how does hyperprolactinemia and HPA dysfunction cause ED?

A

b/c have decrease in GnRH -> decr testosterone -> decr erection

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10
Q

what drugs cause ED?

A

antihypertensives (BB’s, diuretics, alpha-agonists), antidepressants (SSRIs), opioids, 5-alpha-reductase inhibitors (finasteride)

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11
Q

ED caused by psychogenic, occurs in?

A

younger people

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12
Q

what is Peyronie’s disease? what type of cause of ED?

A

penile deformity or curvature of penis due to scarring and fibrosis -> mechanical cause of ED

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13
Q

ED may be an early of what?

A

early sign of CAD

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14
Q

ED and CAD develop from what?

A

endothelial dysfunction

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15
Q

endothelial dysfunction results from? imbalance b/w?

A

decrease in NO, thus impaired arterial vasodilation

imbalance b/w vasodilation and vasoconstriction

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16
Q

ED w/o obvious caused should be screened for what? why?

A

for CVD (esp before initiating pharmacologic therapy for sexual dysfunction)

b/c of increased cardiac risk associated with sexual activity

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17
Q

what is the etiology of Peyronie’s disease?

A

subtle trauma to penis and subsequent scarring and development of fibrous plaque -> during erection causes curvature

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18
Q

loss of penile length means?

A

Peyronie’s disease

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19
Q

what is SHIM? what does it do?

A

sexual health inventory for men

classifies severity of ED dysfunction into 5 categories

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20
Q

5 categories of SHIM

A

severe, moderate, mild-moderate, no ED (based on score of over 6 months)

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21
Q

men that are sexually competent and then all of a sudden one night they can’t perform, means what?

A

psychogenic ED

ex: performance anxiety, current sexual partner issues, emotional problems

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22
Q

sporadic ED problems that become more chronic, means what?

A

more of an organic cause

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23
Q

signs of hypogonadism?

A

hypogonadism can contribute to ED

sign:

  • lack of/loss of normal male hair patterns
  • gynecomastia
  • small testes
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24
Q

lack of cremasteric reflex in pt that has ED may indicate?

A

neurogenic disease

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25
Q

penile plaques in pt that has ED may indicate?

A

Peyronie’s disease

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26
Q

what pulses should be examined for pt with ED? what may they be like?

A

femoral and peripheral pulses - may be diminished or asymmetric

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27
Q

what bruits may pt with ED have?

A

femoral bruits

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28
Q

what labs should be checked in pt with ED?

A

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
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29
Q

what is NPT testing for ED?

A

nocturnal penile tumescence testing

-while sleeping, it detects number, tumescence, rigidity of nighttime erection

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30
Q

what does a normal NPT mean?

A

psychogenic or hormonal cause of ED

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31
Q

what does an impaired NPT mean?

A

vascular or neurogenic cause of ED

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32
Q

what imaging can you use for pt with ED? what does it show?

A

Duplex Doppler imaging or Angiography

  • deep penile artery angio identifies obstruction
  • doppler identifies venous leak
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33
Q

if vascular etiology is suspected for ED then do what?

A

do doppler/angiography

if fail the oral medication trial then do injection trial typically prostaglandin or vasodilating agent to better assess mechanism of failure

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34
Q

what risk factors must you treat and identify for ED?

A

identify and treat CV risk factors

-smoking, obesity, HTN, HDL

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35
Q

if pt with ED is having psychological cause, how do you treat them?

A

psychotherapy, sex therapy, psychoactive meds

-but worried about SSRIs and antidepressants b/c they cause ED

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36
Q

will testosterone replacement therapy alone solve ED?

A

NO!!! better to combine testosterone w/ PDE-5 inhibitor as one improved libido and other ED

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37
Q

what meds are FIRST LINE therapy for ED?

A

PDE-5 inhibitors

-sildenafil, tadalafil, vardenafil, avanafil

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38
Q

how do PDE-5 inhibitors work for ED?

A

nitric oxide induced vasodilation

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39
Q

PDE-5 inhibitors only function with what for ED?

A

only function w/ sufficient sexual arousal -> need to have libido -> benefits of testosterone and PDE-5

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40
Q

sildenafil is esp useful for what pts with ED?

A

diabetics, radical prostatectomy pts, Parkinson’s pts

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41
Q

why tadalafil is good for ED? what else can it improve?

A

b/c can take ow dose daily, so good for pt’s with “complete” ED

can also improve LUTS d/t BPH

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42
Q

PDE-5 inhibitors absolute C/I?

A

DON’T USE WITH NITRATES!!!

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43
Q

PDE-5 inhibitors relative C/I?

A

use w/ alpha-adrenergic antagonists -> causes hypotension

can take together with doxazosin, but use with caution

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44
Q

what is SECOND LINE tx for ED? how do they work?

A

Vacuum-assisted erection devices

increases blood flow and restricts venous outflow by putting ring on penile base -> erection

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45
Q

occlusive ring used with Vacuum-assisted erection devices may prevent what? not good for what people?

A

may prevent ejaculation d/t pressure on urethra

-not good for people for fertility

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46
Q

what is THIRD LINE tx for ED?

A

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
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47
Q

most common side effect of injection of Prostaglandin-E1?

A

penile pain

48
Q

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?

A

should lower dose of med b/c of risk of priapism

priapism = pathologic sustained erection >4-6hrs

49
Q

intraurethral use of Prostaglandin-E1 for ED is C/I in who?

A

in sickle cell anemia or sickle cell trait, leukemia, MM

b/c all have risk factors for priapism

50
Q

can you use Prostaglandin-E1 injection for ED in pts with penile implant or Peyronie’s?

A

No!!! C/I in these cases

51
Q

what is LAST LINE tx for ED?

A

Surgical options:

  • penile prostheses
  • penile revascularization (but low success rates unless young, non-smoker, and healthy but have recent focal artery occlusion)
52
Q

what is priapism? emergency?

A

prolonged >4-6 hrs erection unresolved by ejaculation

UROLOGIC EMERGENCY!!!

53
Q

if priapism is untreated, what does it lead to?

A

ischemia and then corporal fibrosis and necrosis of penis

54
Q

what are the 2 types of priapism?

A

low flow and high flow

55
Q

what is low flow priapism?

A

extremely painful, ischemic cause

M/C cause

56
Q

what is high flow priapism?

A

trauma/arterial injury

57
Q

most common cause of priapism?

A

low flow -> ischemic cause

58
Q

what drugs can cause priapism?

A

antihypertensives (CCB, hydrazine, prazosin)

anticoag’s (heparin, warfarin)

psychotropics (SSRIs, Haldol, trazado, phenothiazine)

Hormone therapy (testosterone, GNRH, tamoxifen, androstenedione)

59
Q

what RBC disorders can cause priapism and why?

A

sickle cell anemia, leukemia, thalassemia

-have miss-shapended RBCs -> don’t allow blood to leave -> prolonged erection

60
Q

what ED tx can cause priapism?

A

intrapenile injections with PGE-1

61
Q

what is the tx for priapism?

A

first do penile nerve block with lidocaine or bupivacaine w/out epinephrine

then inject phenylephrine to cause vasoconstriction

62
Q

if injection with phenylephrine for tx of priapism doesn’t work, then what do you do?

A

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

63
Q

what is LAST LINE tx for priapism if phenylephrine or aspiration fail?

A

surgery

64
Q

what is BPH histologic dx?

A

cellular proliferation of the prostate at the central transition zone (gland)

65
Q

is BPH a risk factor for cancer?

A

NO!!!

66
Q

what zone of the prostate do you see hyperplasia (BPH)?

A

transition zones

67
Q

if pt was castrated, can they get BPH?

A

NO!!! b/c the prevalence of it increases with age in hormonally dependent way

68
Q

what can untreated BPH cause?

A

acute urinary retention, recurrent UTI, hydronephrosis, renal failure d/t to bladder outlet

69
Q

LUTS sx’s for BPH 2 categories

A

storage/irritative sx’s and obstructive sx’s

70
Q

how do irritative sx’s of BPH occur?

A

b/c prostate is so big that it irritates the bladder wall -> constant force against it

71
Q

how do obstructive sx’s of BPH occur?

A

prostate is so large that blocks off bladder

72
Q

what are the irritative sx’s of BPH?

A

urgency, frequency, nocturia, incontinence

73
Q

what are the obstructive sx’s of BPH?

A

hesitancy, decreased force of stream, dribbling post-void, straining to urinate, unable to or incomplete emptying of bladder

74
Q

what is the AUA score for BPH?

A

American urologic association’s sx’s score which assesses the severity of sx’s of BPH

75
Q

when should AUA score for BPH be calculated?

A

before starting therapy it should calculated for every pt as it is the single most important tool in evaluation

76
Q

the higher the calculated AUA score for BPH means what?

A

more severe sx’s and increased effect of pt’s life

77
Q

what is the single most important tool in evaluation of BPH sx’s?

A

AUA sx score

-should be done on all BPH pts before starting therapy

78
Q

what meds may be causing impaired bladder function or increased outflow resistance for BPH pt?

A

anticholinergic drugs (decr muscle contraction)

sympathomimetic drugs (increase tone in prostate causing outflow symptoms)

79
Q

what should pt with BPH keep a diary of?

A

keep a voiding diary
-nocturia, void volume

may provide as much or more info than AUA sx’s score

80
Q

what is the primary component of physical exam for BPH pt?

A

DRE

-prostate will feel uniformly enlarged, firm, and rubbery

81
Q

what do you want to measure in pt with BPH?

A

post void residual volume

82
Q

if miss prostatitis (as possible dx) for pt coming in with BPH, what are you setting them up for?

A

sepsis

83
Q

what is the first testing to do for BPH? what are you looking for?

A

urinalysis - UTI, hematuria

84
Q

why test for serum Cr in BPH pt?

A

looking for AKI from bladder obstruction

85
Q

serum PSA and BPH?

A

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

86
Q

what upper tract imaging do you do for BPH? when do you do imaging?

A

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

87
Q

other tests for BPH that are usually ordered by specialist?

A

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)

88
Q

flow rate >15ml/sec excludes what?

A

important bladder outlet obstruction for BPH

89
Q

what is a normal post-void residual volume? when do you get worried?

A

Normal = <12 ml

get worried when PVR >150-200mL

do bladder scan with U/S

90
Q

cystoscopy and BPH?

A
  • Not routine recommendation
  • Assist in planning for surgical management of BPH
  • Useful for detecting bladder malignancy, urethral stricture, calculi
  • Recommended and performed by urologist
91
Q

when must you refer BPH pt for urologic evaluation prior to tx?

A
  • 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
92
Q

when can you consider watchful waiting as treatment for BPH?

A

if AUA severity score < 8 (mild)

-no bladder outlet obstruction, renal insufficiency, recurrent infection (if have these can’t do watchful waiting)

93
Q

when can you NOT do watchful waiting as tx for BPH?

A

if pt has bladder outlet obstruction, renal insufficiency, recurrent infection

94
Q

behavioral modifications for tx of BPH?

A
  • 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
95
Q

when do you use meds as tx for BPH?

A

mild to moderate IPSS < 20 w/o:

  • refractory retention
  • BPH induced (kidney disease, bladder calculi, recurrent or persistent gross hematuria)
96
Q

what are the FIRST LINE meds for BPH? therapeutic effects? where do they effect in the body?

A

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

97
Q

M/C adds of alpha-1a blockers?

A

Orthostatic hypotension and dizziness

98
Q

when are terazosin and doxazosin initiated for tx of BPH?

A

at bedtime b/c of orthostatic hypotension adrenal

99
Q

what other meds do alpha-1a blockers interact with? what is the interaction? separate doses? less interaction with which alpha-1a blocker?

A

PDE-5 inhibitors

potentiates hypotensive effects when used simultaneously (esp with terazosin, doxazosin)

separate doses by 4 hours

much less interaction with tamsulosin

100
Q

what are the SECOND LINE meds for tx of BPH?

A

5-alpha-reductase inhibitors

Finasteride (M/C), Dutasteride

101
Q

when do you NOT use 5-alpha-reductase inhibitors (Finasteride) for tx of BPH?

A

don’t use w/ irritative sx’s or concomitant ED (can worsen ED)

102
Q

how does Finasteride (5-alpha-reductase inhibitor) work for tx of BPH? how long to work?

A

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

103
Q

finasteride is more effective in what men with BPH?

A

men with larger prostates (>40ml by TRUS)

104
Q

adrs of finasteride?

A
  • decreased libido
  • ED
  • decreased ejaculate volume
  • PSA reduction by 50% (take into account if monitoring for prostate CA)
105
Q

when do you consider the use of PDE-5 inhibitors for BPH?

A

if pt has both ED and BPH < 20 IPSS (have to have mild-moderate score)

use Tadalafil

106
Q

what anticholinergic agent do you use for BPH and for what sx’s?

A

use Oxybutynin

for irritative sx’s associated with overactive bladder (b/c will cause urinary retention)

107
Q

side effects of anticholinergic meds (oxybutynin)?

A

dry mouth, drowsiness, decreased cognitive function, constipation, inhibition of gut motility

these adrs seriously limit dose increase and tolerance

108
Q

when do you consider combo therapy for BPH?

A
  • severe sx’s of BPH IPSS > 20
  • poor response to monotherapy
  • prostate >40ml and score >20
109
Q

what combo meds for BPH?

A

alpha-blocker AND alpha-reductase inhibitor

110
Q

when do you go to surgical therapy for BPH?

A

after 12-24 months of combo therapy and any progression of disease on therapy

111
Q

what alternative therapy for BPH showed improved sx’s and increased flow rates?

A

Pygeum africanum (extract of bark from African plum tree)

112
Q

what do surgeries for BPH do?

A

destroy prostate and improve output of urine

can do laser, microwave hyperthermia or electrovaporization, radiofrequencies

113
Q

conventional surgical tx for BPH?

A

TURP (transurethral resection prostatectomy) -> BEST TO DO

114
Q

bad adr of TURP?

A

transurethral resection syndrome = hypervolemic, hyponatremic state resulting from absorption of hypotonic irrigating solution

115
Q

when do you do TUIP for BPH tx?

A

small prostate but severe sx’s w/ elevated bladder neck

116
Q

when do you do open simple prostatectomy for BPH tx?

A

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!!!

Clin Med 3 (21 decks)

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