ED, BHP, Prostatitis Flashcards
What is the treatment of choice if primary hypogonadism is the cause of erectile dysfunction
androgen therapy
Contraindications for androgen therapy
- prostate cancer
2. obstruction of bladder neck by prostatic hypertrophy
What are the 6 types of androgen therapy
- Oral (rarely used)
- Buccal mucoadhesives
- Injectables
- Transdermal preparations
- Implantable subcutaneous pellets
- Gel
name for testosterone buccal mucoadhesive
Striant
Three types of injectable testosterone and dosing
- Testosterone cypionate (Depo-Testosterone) q 2-3 weeks
- Testosterone enanthate (Delatestryl) q 2-3 weeks
- Testosterone undecoanoate (Aveed) q 10 weeks
What is special about Aveed injectable
- Must be done in clinic by certified professionals, 30 min monitoring after ea injection
- Risk of POME (pulmonary oil microembolism)
- risk of anaphylaxis
Disadvantage to injectables
- tendency to produce uneven effects between doses
- pain associated with IM injection
Transdermal testosterone preparations
- name
- ADR
Androderm
- skin irritation
- contact dermatitis
- itching
Implantable subcutaneous testosterone pellets
- name
- where implanted
- disadvantage
- Testopel
- fat tissue of buttocks
- less flexible dosing (once it’s in it’s in)
- if have complication, pellets have to be sx removed
Testosterone Gel
- name
- disadvantage
- Androgel
- Virilization of women and children
- counsel men to cover application site with clothing to avoid contact with others
How to monitor effectiveness of androgen therapy
Baseline, f/u after therapy initiation, then yearly:
- Testosterone
- Hematocrit
- Serum lipid values
- LFTs
- PSA and DRE
What are the 7 therapy options for ED if not primary hypogonadism (in order of selection)
- Comorbidities and psychosexual dysfunction
- Phosphodiesterase-5 inhibitors (PDE-5)
- Intra-urethral Alprostadil
- Intravacernous Vasoactive Drug injections
- Vacuum constriction
- Semi-rigid/inflatable prosthesis
- vascular surgery
PDE5 Inhibitors
- how fit into tx selection
- 1st line if ED not caused by comorbidities, medications, primary hypogonadism
List the 4 PDE5 inhibitors
- Sildenafil citrate (Viagra)
- Vardenafil (Levitra or Staxyn)
- Tadalafil (Cialis)
- Avanafil (Stendra)
*all considered equal, some work better in some people
ADR PDE5 inhibitors
Mild to moderate, self limiting, more common in higher doses
- HA
- Flushing
- Dyspepsia
- Nasal congestions
- Hypotension (uncommon, CV assessment should be done before therapy)
- Acute hearing loss (rare)
PDE5 Inhibitors contraindications
Use with short- or long-acting nitrate drugs – potentiate hypotensive effects, risk of severe hypotension and MI or stroke
- Viagra 24 hours before or after nitrate
- Cialis 48 hours before/after nitrate
- Levitra and Stendra no official standard but probably 24 hours
Intra-urethral Alprostadil
- name
MUSE - medicated urethral system for erection
Intra-urethral Alprostadil
- advantages
- ED associated with neurogenic, vasculogenic, psychogenic, mixed etiologies
- Local application
- minimal systemic effects
- rarity of drug interactions
Intra-urethral Alprostadil
- Disadvantages
- inconsistent results
- penile pain
- urethral pain/burning
Intra-urethral Alprostadil
- best results when used with what?
- where should therapy be initiated?
- Effectiveness is increased with concurrent use of Actis, penile-constricting device
- Therapy should be initiated in physicians office due to complicaitons of urethral bleeding, vasovagal reflex, hypotension, priaprism
Intracavernous vasoactive drug injection
- what is the only approved drug by FDA in US?
Alprostadil
Intracavernous vasoactive drug injection of alprostadil
- success
- low rates of what common ADRs
- erection in more than 70% men
- relatively low rate priapism and fibrosis
Intracavernous vasoactive drug injection of alprostadil
- 4 common ADR
- penile pain
- hematoma
- fibrosis (pressure on injection site for 5 min to avoid)
- priaprism
Where inject Intracavernous vasoactive drug?
- dorso-lateral aspect of proximal third of penis
- avoid visible veins
- switch sides
- max 1 per 24 hours
What are the three injectible intracavernous vasoactive drugs used?
- Alprostadil
- papaverine
- phentolamine
papaverine ADR (2)
- priapism
- corporal fibrosis
phentolamine ADR (2)
- hypotension
- reflex tachycardia
Vacuum constriction
vacuum is applied to penis for a few minutes, causing tumescence and ridigidy which is sustained using a constricting ring at the base of the penis
Two surgery options
- Penile prosthesis implantation
2. Vascular surgery
Disadvantage to penile prosthesis
- unnatural erection
- risk of infection
Advantage to vascular surgery
May be curative, esp for young men with congenital or traumatic erectile dysfunction with focal arterial occlusion but no vascular dz
Dosing recommendation for tadalafil (Cialis)
- 10 mg before planned sexual activity
- May increase to 20 or decrease to 5 based on efficacy and tolerability
- Duration of action is 36 hours
- OR daily dose 2.5 mg (or 5mg) without regard to sexual activity
Tadalafil drug interactions (2)
- Long and short acting nitrates – hypotension
2. Stabilize on alpha-blocker before initiating tadalafil therapy, start with 5 mg dose to avoid hypotensive response
Lab tests prior to initiation of and to monitor ED therapy
- urinalysis: evaluate for potential infection/organic problems causing ED
- CBC - infection
- Glucose - DM
- Cr - renal fn
- fasting lipid profile: atherogenic cause, monitor androgen therapy
- serum T
Serum testosterone
- level to be considered hypogonadal
- what is needed for dx of testosterone deficiency
- <300 ng/dL
- TWO morning serum measurements <300
List the 3 drug types currently approved by FDA for management of pts with prostatic hyperplasia
- Alpha-blockers
- 5-alpha reductase inhibitor therapy
- PDE5
List the 5 types of alpha-blockers
- non-selective
- selective
all are “-zosins”
Non-selective:
- Terazosin (Hytrin) –
- Doxazosin (Cardura)
Selective:
- Tamsulosin (Flomax) –
- Alfuzosin (Uroxatral)
- Silodosin (Rapaflo)
alpha-blockers ADR
- dizziness (MC)
- orthostatic hypotension (MC): first dose effect, worse when used with other antihypertensives
- lower ejaculate volume (more common in selective)
Alpha-blockers ADR
- Use carefully with PDE-5 Inhibitors: unacceptable reductions in BP, orthostatic hypotension
Alpha-blockers Contraindications
Planned cataract surgery – may develop intraoperative floppy iris syndrome (retinal detachment, lens problems, endophthalmitis post-operatively)
How long does it take Alpha-blockers to take effect
2-6 weeks before benefits can be adequately assessed
5-Alpha Reductase Inhibitors
- when use
sx of BPH with enlarged prostate glands
5-Alpha Reductase Inhibitors
- two types
“-asteride”
- Finasteride (Proscar)
- Dutasteride (Avodart)
5-Alpha Reductase Inhibitors how long to take effect
might take 6-12 months for full expression to be noted
5-Alpha Reductase Inhibitors
ADRs (5)
- Erectile dysfunction
- Decreased volume of ejaculate
- Decreased libido
- Gynecomastia
- **Preg women should not handle due to risk to male fetus
5-Alpha Reductase Inhibitors and prostate cancer
May lower risk of less life-threatening prostate cancer and increase risk of more life-threatening prostate cancer → DRE and PSA super important
PDE5 Inhibitors
- which one
Tadalafil (Cialis) is the only one approved by FDA for BPH in US
When use Tadalafil for BPH
- Use in those who do not get adequate relief from alpha-blocker alone OR men with ED and mild BPH
How dose tadalafil if adding to alpha-blocker therapy
Start lowest dose and titrate up to avoid hypotension
What is the role of OTC preparations in the management of prostatic hyperplasia: saw palmetto, beta sitosterol, and pygeum.
None really - lack of published data
Doxazosin dosing in BPH
- Starting dose: 1 mg daily
- Maintenance dose: 1-8 mg daily
Tamsulosin dosing in BPH
- Starting dose: 0.4 mg daily
- Maintenance dose: 0.4-0.8 mg daily
Most common bacterial cause of acute and chronic bacterial prostatitis
- Acute: E. coli (klebsiella pneumonia and proteus mirabilis)
- Chronic: E. coli
2 abx and duration to treat acute prostatitis
- Trimethoprim/sulfamethoxazole (Bactrim)
- Fluorquinolone (Cipro)
- Duration: 4 weeks
2 abx and duration to treat chronic prostatitis
- Fluoroquinolone (1st line)
- Trimethoprim/sulfamethoxazole (Bactrim)
- Duration: 4-6 weeks, up to 12 weeks
Two antibiotics that may be used for long-term suppressive therapy for patients with recurrent prostatitis
- Cipro (500 mg three times weekly)
2. Bactrim (regular strength daily)
