ED/BPH Flashcards
Meds that cause ED
-Dopamine antagonists (antipsychotics)
-Estrogens, spironolactone, digoxin
-CNS depressants
(alcohol, benzodiazepines, opioids)
-Anticholinergics
-Alpha-2 agonists, beta blockers, diuretics
-5-alpha reductase inhibitors
SAD u wont have AABS at EDC
Sx/Signs of ED
Erectile dysfunction resulting in an inability to have satisfactory intercourse
-Low score on the International Index of Erectile Function (IIEF) survey
-Serum testosterone < 300 with repeat in 4 weeks
-Small testicles
-Decreased body hair
-Gynecomastia
Goals of ED Therapy
-Improve quantity and quality of erections suitable for satisfactory intercourse
-Minimum IIEF increase of 4 points, goal score of 20
Lifestyle Modifications for ED
*should be tried first
-Lower cardio risk (exercise, weight loss, diet)
-Avoid tobacco/alcohol
Treatment pathway for ED
- PDE5i ± testosterone supplementation if hypogonadism
-If CI or patient prefers, use vacuum device - If ineffective, ensure treatment is given at correct time and titrate up dose
- Alprostadil
- Penile prosthesis
Phosphodiesterase-5 inhibitors: AE/monitoring/DDI
“AFILS”
AE (BBB not to NAG but PH is Questionable)
-SX of hypotension
-Loss of blue-green color discrimination (sildenafil, tadalafil, avanafil)
-Priapism
-Hearing loss
-Sudden blindness
-QT prolongation (vardenafil)
DDI: All PDE5i’s
-Nitrates (additive risk for hypotension)
-Grapefruit juice (3A4 inhibitor)
*Vardenafil
-Type 1A or Type 3 antiarrhythmics (additive QT prolongation)
Phosphodiesterase-5 inhibitors: additional patient education
-You will still require sexual stimulation
-Take on empty stomach
-Max 1 dose daily
-Seek emergency care if erection last >4h
Testosterone: monitoring
Indicated only if hypogonadism is present
AE: (SMMHHH P)
-Sodium retention
-Hyperlipidemia
-Mood swings
-Hepatotoxicity
Cautions:
-Heart failure
-Hx of myocardial infarction or stroke
-Avoid in untreated prostate cancer
Testosterone: additional patient education
-Wash hands after use
-Cover application site to avoid transfer
-Females/children should avoid contact
-Avoid swim/shower for 3 hours
-Rotate application site every 7 days
Alprostadil (PGE1)
AE: (ALP has a bad HHIPP)
-Hematoma at site of injection (Caverject)
-Infection (Caverject)
-Hypotension, dizziness (uncommon)
-Priapism (rare)
-Pain at site of injection/insertion
Alprostadil (PGE1): additional patient education
-Inject at 90 degrees into shaft
-Wash hands before
-Tylenol for pain
-Apply pressure for 5 min
-Void prior, massage for urethral
Medications that can exacerbate BPH
-Anticholinergics (diphenhydramine, tricyclic antidepressants)
-Alpha-agonists (pseudoephedrine)
-Testosterone replacement (theoretical)
ATA boy bph
Symptoms and signs of BPH
-Diminished urinary flow rate
-Straining to urinate
-Suprapubic pain
-Increased urinary frequency/urgency
-Enlargement based on digital rectal exam (>20g)
-Possible serum prostate-specific antigen >1.5 ng/mL
Complications
* Renal failure
* Hematuria
* Urinary tract infection
* Bladder stones
* Bladder diverticula
Goals of therapy: BPH
-Control symptoms
-Reduce risk of complications
-Delay need for surgical intervention
-Minimum AUA score decrease of 3 points
Lifestyle modifications: BPH
-Void before bedtime
-Exercise
-Restrict fluids before bedtime
-Healthy diet
Avoid
-Excessive caffeine
-Excessive alcohol
Treatment pathway for BPH
≤7 = mild = wait and see
8-19 = moderate
1. Prostate < 40 gm AND
PSA ≤ 1.4 = Alpha 1 antagonist
2. Prostate > 40 gm OR
PSA > 1.4 = Alpha 1 antagonist PLUS 5α-reductase inhibitor
3. ED = PDE5i ± Alpha 1 antagonist
4. Irritative voiding symptoms
*Alpha 1 antagonist plus Anticholinergic OR Mirabegron
≥20 = severe + comp = surgery
Alpha 1 antagonists: monitoring
“OSINS”
AE: OH Be FR MASS
-Hypotension sx mainly with non-uroselective agents
-Floppy iris syndrome
-Retrograde ejaculation mainly with uroselective agents
CI:
-Alfuzosin: Mod-sev hepatic impairment
-Silodosin: Sev hepatic impairment, ClCr <30
DDI:
-Silodosin: Avoid 3A4 inhibitors
5α-reductase inhibitors: monitoring
“ASTERIDES”
AE: GELP 50
-Erectile dysfunction
-Decreased libido
-Gynecomastia
CI:
-Pregnancy category X
*Pregnant females or females wishing to become pregnant should avoid handling the drug
*Should also avoid contact with semen of men on the drug
PSA should decrease by 50% by 6 months: Evaluate for prostate cancer if not
6-12 mo for full effect
Only PDE5i we can use in BPH
TADALAFIL (Cialis)
5 mg QD
ClCr 30-50 then 2.5 mg QD
Avoid in <30 and severe hepatic impairment
Anticholinergics:
-Solifenacin (Vesicare)
-Tolterodine (Detrol)
Use ONLY if patient has irritative symptoms and has a post-void residual urine volume <100-150 mL (anticholinergics can cause urinary retention)
AE:
-Blurry vision
-Urinary retention
-Dry mouth
-Constipation
-Drowsiness
-Tachycardia
DDI:
Solifenacin
-If on strong 3A4 inhibitor, limit to 5 mg daily
Mirabegron, vibegron: B3 agonist
Use ONLY if patient has irritative symptoms
AE: HIDDN
-Mirabegron: small increase in BP
-Mild headache, dry mouth, nausea, diarrhea
