Genitourinary & Nephrology Flashcards
Pathophys of Erection
Acetylcholine –> Inc. NO and inc. PDE (prostaglandin E)
NO –> inc. cGMP
PDE –> in. cAMP
Both cGMP and cAMP decrease Calcium
Diseases that decrease blood flow, resulting in common organic causes of ED
- DM
- HTN
- Heart Disease
The #1 reason patient’s stop taking their ____ is because of sexual dysfunction.
SSRI/SNRI
Blood pressure meds that can cause sexual dysfunction
- BB
- Clonidine
- Methyldopa
Antipsychotics that can cause sexual dysfunction
- Haloperidol
- Chlorpromazine
- Thioridazine
- Fluphenazine
Basically all 1st generations and SSRI/SNRI’s (but less than 1st gens)
BPH Meds that can cause ED
Finasteride
Dutasteride
Silodosin
Opoids that can cause ED
ALL OF THEM
Methadone to a higher extent
Can nicotine and excessive alcohol cause ED?
YES!
The International Index of Erectile Function (IIEF): is it better to have a higher score or a lower score?
A higher score
Severe ED: Score of 5-7
If a patient is on an oral phosphodiesterase inhibitor and has not been reporting improvements in sexual function then what is a 2nd line tx option?
Intracavernosal therapy
If a pt undergoes intracavernosal therapy but does not seem to be improving then what is the next (3rd line) tx for ED?
Intraurethral alprostadil
If a pt undergoes intraurethral alprostadil therapy but does not seemt o be improving then what is the next (last line) therapy option for ED?
Penile prosthesis
Explain the pathophysiology of phosphodiesterase inhibitors?
Inhibits phosphodiesterase which slows down the breakdown of cGMP. This allows for the depression of calcium which relaxes smooth muscle –> erection!
What should be avoided while using phosphodiesterase inhibitors?
Alcohol and nitrates
A pt really wants to be put on a PDE inhibitor for his ED but it is also imperative that he takes his vasodilators. What should you council him on in regards of timing of these medications?
SPACE THEM OUT!
With Viagra and Levitra wait 24 hrs after taking the ED med before taking the nitrate.
If taking Cialis wait 48 hours
Which PDE inhibits both PDE-5 and PDE-6? What is the importance of PDE-6?
Sildenafil (Viagra)
PDE-6 is connected to rods and cones so if pt has visual changes they need to stop taking sildenafil (Viagra)
What 2 doses does alprostadil come in?
- ) Intracanvernous injection (Caverject or Edex)
2. ) Intraurethral (MUSE)
MOA of Alprostadil
Increases cAMP which decreases Ca+
Onset and duration of Alprostadil
Onset: 5-15 minutes
Duration: 14-44 minutes (depending on dosage)
Adverse reactions of alprostadil?
- Injection site reactions
- Fibrous deposits
- Curvature of penis
Functions of the prostate (2)
- Produce ejaculation fluids (40% of them)
2. Antibacterial secretions
What are the 3 layers of the prostate gland?
- Epithelial (glandular)
- Stromal (smooth muscle)
- Capsule (fibrous)
2 periods of growth of the prostate gland
- Puberty - 25yo
2. 40yo - end of life
Epithelial (glandular) tissue has ____ receptors while both stromal and capsule tissue has ____ receptors
Androgen receptors
alpha-1 receptors
Static v. Dynamic in BPH
Static - physical block; permanent enlargement of tissue
Dynamic - muscle contraction; effect urethral lumen
Medications that can induce BPH
- Testosterone
2. Alpha agonist - pseudoephedrine, ephedrine, phenylephrine
Medications that have adverse effects that mimic BPH
- Anticholinergics (antihistamines, phenothiazine, TCAs)
2. Diuretics (large doses)
Nonpharmacologic tx of BPH: What is entailed under “behavioral modification”?
- Medications review
- Restriction of fluids close to bedtime
- Minimize caffeine and ETOH
- Bladder training (frequently empty the bladder)
T/F: alpha one antagonists relax smooth muscle
True
5-alpha reducates inhibitors do not relax smooth muscle
T/F: alpha 1 antagonists halt disease progression of BPH
False
5-alpha reductase inhibitors halt disease progression
Which BPH drug can produce cardiovascular adverse effects
alpha 1 antagonists
2nd generation alpha 1 adrenergic antagonists
Prazosin
Terazosin
Doxazosin
Alfuzosin
3rd generation alpha 1 adrenergic antagonists
Tamsulosin
Silodosin
Differences between 2nd and 3rd generation alpha 1 adrenergic antagonists
- Time to sx relief is decreased from 2-6 weeks –> several days
- Receptor selectivity (inc. uroselection in 3rd generation)
- Frequency (3rd is once a day which increases pt adherence)
What is a rare but serious side effect of alpha 1 adrenergic antagonists
Floppy Iris Syndrome
ADRs of alpha 1 adrenergic antagonists
Dizziness Hypotension Syncope Muscle weakness HA
Finasteride and Dutasteride are _________________.
5-alpha reductase inhibitors
____ blocks conversion of testosterone to DHT more while _____ is more selective for prostatic enzymes and therefore has less adverse reactions.
Dutasteride
Finasteride
ADR of 5-alpha reductase inhibitors
Sexual dysfunction
Most common herbal product used for BPH
Saw palmetto
3 Types of Urinary Incontinence
- Stress
- Urge
- Overflow
A pt presents with frequency, urgency, nocturia, and enuresis (wetting the bed). What type of UI is this?
Urge
A pt presents with strain, hesitancy, dec. force of stream and having a sense of not emptying the bladder. What type of UI is this?
Overflow
Medications that induce or worsen UI?
- Diuretics
- Alpha receptor antagonists
- Sedation hypnotics
- Antidepressants (TCA)
- ETOH
- ACEi –> d/t cough side effect
First line for Stress UI
Duloxetine (Cymbalta)
First line for Overactive Bladder UI
Anticholinergic (Oxybutynin)
2nd line for stress UI?
Alpha adrenergic agonists:
–Pseudoephedrine and phenylephrine
