ED/BPH

Question 1

Meds that cause ED

Answer 1

-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

Question 2

Sx/Signs of ED

Answer 2

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

Question 3

Goals of ED Therapy

Answer 3

-Improve quantity and quality of erections suitable for satisfactory intercourse
-Minimum IIEF increase of 4 points, goal score of 20

Question 4

Lifestyle Modifications for ED

Answer 4

*should be tried first

-Lower cardio risk (exercise, weight loss, diet)
-Avoid tobacco/alcohol

Question 5

Treatment pathway for ED

Answer 5

1. PDE5i ± testosterone supplementation if hypogonadism
   -If CI or patient prefers, use vacuum device
2. If ineffective, ensure treatment is given at correct time and titrate up dose
3. Alprostadil
4. Penile prosthesis

Question 6

Phosphodiesterase-5 inhibitors: AE/monitoring/DDI
“AFILS”

Answer 6

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)

Question 7

Phosphodiesterase-5 inhibitors: additional patient education

Answer 7

-You will still require sexual stimulation
-Take on empty stomach
-Max 1 dose daily
-Seek emergency care if erection last >4h

Question 8

Testosterone: monitoring

Answer 8

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

Question 9

Testosterone: additional patient education

Answer 9

-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

Question 10

Alprostadil (PGE1)

Answer 10

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

Question 11

Alprostadil (PGE1): additional patient education

Answer 11

-Inject at 90 degrees into shaft
-Wash hands before
-Tylenol for pain
-Apply pressure for 5 min
-Void prior, massage for urethral

Question 12

Medications that can exacerbate BPH

Answer 12

-Anticholinergics (diphenhydramine, tricyclic antidepressants)
-Alpha-agonists (pseudoephedrine)
-Testosterone replacement (theoretical)

ATA boy bph

Question 13

Symptoms and signs of BPH

Answer 13

-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

Question 14

Goals of therapy: BPH

Answer 14

-Control symptoms
-Reduce risk of complications
-Delay need for surgical intervention
-Minimum AUA score decrease of 3 points

Question 15

Lifestyle modifications: BPH

Answer 15

-Void before bedtime
-Exercise
-Restrict fluids before bedtime
-Healthy diet

Avoid
-Excessive caffeine
-Excessive alcohol

Question 16

Treatment pathway for BPH

Answer 16

≤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

Question 17

Alpha 1 antagonists: monitoring
“OSINS”

Answer 17

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

Question 18

5α-reductase inhibitors: monitoring
“ASTERIDES”

Answer 18

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

Question 19

Only PDE5i we can use in BPH

Answer 19

TADALAFIL (Cialis)
5 mg QD
ClCr 30-50 then 2.5 mg QD
Avoid in <30 and severe hepatic impairment

Question 20

Anticholinergics:
-Solifenacin (Vesicare)
-Tolterodine (Detrol)

Answer 20

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

Question 21

Mirabegron, vibegron: B3 agonist

Answer 21

Use ONLY if patient has irritative symptoms

AE: HIDDN
-Mirabegron: small increase in BP
-Mild headache, dry mouth, nausea, diarrhea