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Therapeutics - Exam 5 > Lectures 54,55,56 > Flashcards

Lectures 54,55,56 Flashcards

Men's Health -- Scott

1
Q

BPH anatomy

A

enlarged prostate blocks urine flow from the bladder

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2
Q

BPH pathophysiology

A

common growth after age 40 (90% notice decrease of urine flow by 80 yo)
influence by alpha-1 adrenergic receptors and type II 5-alpha reductase in prostate gland

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3
Q

alpha-1 adrenergic receptors

A

stimulation by NE results in smooth muscle contraction with subsequent narrowing urethra

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4
Q

type II 5-alpha reductase

A

converts testosterone to DHT (responsible for prostate enlargement and growth)

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5
Q

obstructive symptoms of BPH

A

decreased force of stream
hesitancy to initiate voiding
strain or push to urinate
terminal dribbling
intermittency

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6
Q

irritative symptoms of BPH

A

nocturia
frequency
urgency
dysuria
incontinence
QOL

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7
Q

noctura

A

2 or more voids per nigh
redistribution of edema

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8
Q

hypogonadism anatomy

A

incomplete/delayed sexual maturity of the testes

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9
Q

hypogonadism pathophysiology

A

either onset of puberty at 9.5 to 14 yos
or delayed puberty with lack of testicular growth at 14 yo (2% of genpop)

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10
Q

hypogonadism etiology

A

constitutional delay of growth and puberty (CDGP)
functional hypogonadism (secondary to another chronic illness)
organic/genetic hypogonadism

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11
Q

hypogonadism risk factors

A

aging
chronic illness (diabetes, AIDS, rheumatoid arthritis, CKD)
long-term use of corticosteroids
obesity (gradual decrease in mean serum testosterone levels over time)

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12
Q

specific symptoms of hypogonadism

A

reduced libido
gynecomastia
loss of body hair
reduced muscle bulk and strength

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13
Q

ED anatomy

A

persistent inability to achieve and maintain penile erection sufficient for satisfactory sexual performance
either psychogenic, reflexogenic, or nocturnal type

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14
Q

psychogenic ED mechanism

A

secondary stimulation to audiovisual or fantasy
released ACH –> release of nitrous oxide from NANC neurons –> stimulation

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15
Q

reflexogenic ED mechanism

A

elevated levels of cGMP –> Ca2+ release –> smooth muscle relaxation –> blood flooding chambers –> prevent the draining of blood –> erection

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16
Q

nocturnal ED mechanism

A

3 to 6 erections per night (20 to 30 minutes)
controlled by sacral nerves associated with REM sleep, suppression of sympathetic nervous system, and full bladder

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17
Q

ED etiology

A

diseases and conditions
physical
drug-induced
unhealthly lifestyle

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18
Q

diseases and conditions causes of ED

A

diabetes
HTN
coronary atery disease
MS/Parkinson’s/Stroke (medical preoptic area of the brain)
low testosterone levels (rarely)

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19
Q

physical causes of ED

A

injury
surgeries (damage of cavernous nervous)
medicines
radiation

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20
Q

drugs that cause ED

A

antidepressants (SSRIs - 70%)
antihypertensive agents
estrogen/anti-androgens
5-alpha-reductase inhibitors
cancer chemotherapy

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21
Q

unhealthy lifestyle causes of ED

A

tobacco smoking (mostly)
excessive EtOH
obesity
inadequate sleep/fatigue
stress

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22
Q

drugs that may cause drug-induced priapism

A

ED drugs (especially alprostadil)
antidepressants (bupropion, trazodone, fluoxetine, sertraline, lithium)
antipsychotics (clozapine, chlorpromazine)
anticoagulants (heparin, warfarin)
cocaine
others (EtOH, prazosin, hydroxyzine)

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23
Q

priapism

A

prolonged, rigid erection in the absence of appropriate stimulation

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24
Q

non drug therapies of ED

A

vacuum erection devices
penile prosthesis
focused shock wave therapy

25
Q

vacuum erection devices

A

PRO – very effective, 60 to 80%
CON – avoid in sickle-cell patients

26
Q

penile prosthesis

A

irreversible semi-rigid insert pump
only use when other treatments fail
replace every 5 to 10 years

27
Q

focused shock wave therapy

A

PRO – non-invasive, targets vascular function
CON – not FDA approved

28
Q

non drug therapies of BPH

A

minimally invasive surgeries/prostatectomy
avoid drugs with strong anticholinergic properties (Benadryl)
botox injections

29
Q

minimally invasive surgeries/prostatectomy

A

transurethral resection of the prostate (TURP) or transurethral laser enucleation)
PRO – used for severe symptoms and complications
CONS – benefits may be short-lived; risk of acute urinary retention immediately following procedure

30
Q

avoid drugs with strong anticholinergic properties

A

PROS – decrease contractility of bladder detrusor muscles, resulting in urinary retention

31
Q

botox injections

A

induces prostatic atrophy to treat BPH

32
Q

5-alpha-reductase inhibitors

A

finasteride (5mg QD), dutasteride (0.5mg QD)
treats – alopecia, moderate symptoms of BPH if there is large prostate and increased PSA

33
Q

5-alpha-reductase inhibitors PROS/CONS

A

PROS – men with prostate size above 40grams benefit most; decrease PSA by half in 6 months
CONS – women should avoid handling tablets

34
Q

alpha-adrenergic blockers

A

alfuzosin, doxazosin, and tamsulosin (qhs), silodosin, terozosin
treats – BPH

35
Q

alpha-adrenergic blockers PROS/CONS

A

PROS – improves urine flow; equal clinical effectiveness
CONS – does not reduce size of prostate gland; dizziness is main SE but also somnolence, headache, asthenia, blurred vision, and abnormal ejaculation; rapaflo has retrograde ejaculation (decreased volume); intraoperative floppy iris syndrome reported by flomax so inquire about flomax

36
Q

alprostadil

A

treats – ED, injection is specifically best for neurogenic ED
dosing – urinate first then insert suppository, roll penis for 10 to 30 seconds, and then take dose (P); max of two per day (P); questionable usage with oral agents (P); titrate to dose that produces an erection lasting 1 hour

37
Q

Alprostadil PROS/CONS

A

PROS – more acceptable to many patients than injection (P); onset within 5-10 minutes (P); usable if pt fails to respond to PDE-5 inhibitors (I); no sexual stimulation required (I)
CONS – less effective than transurethral injection (P); local irritation, penile pain, risk of priapism, and cavernosal plaques or area of fibrosis

38
Q

PDE-5 inhibitors

A

treats – ED, BPH
sildenafil (viagra), tadalafil (cialis)
adjust dose to produce an erection that lasts no longer than 1 hour
monitoring – if patient is on oral/transdermal nitrates or alpha-blocker have severe CAD or have an erection longer than 4 hours

39
Q

PDE-5 inhibitor PROS/CONS

A

PROS – first line treatment for ED; promotes smooth muscle relaxation; enhances development and maintenance of erection
CONS – sexual stimulation is required; interacts with CYP3A4 inhibitors (grapefruit juice) to prolong effect; food delayed absorption by an hour
SE – headache and non-arteritic ischemic optic neuropathy notable

40
Q

sildenafil (viagra) dosing

A

25,50,100mg 30 to 60 minutes before intercourse for ED
20 mg TID for pulmonary HTN

41
Q

tadalafil (cialis) dosing

A

2.5,5,10,20mg 60 minutes before intercourse for ED (2.5 or 5 should only be used in QD dosing)
40mg QD for pulmonary HTN
5mg QD used for moderate BPH

42
Q

testosterone supplements

A

treats – hypogonadism, ED (if hypogonadism present)
monitoring – should be monitored 3 to 6 months after initiating therapy (goal of 400 to 700 ng/dL)

43
Q

testosterone supplements PROS

A

comes in many different formulations (patches, gels, solutions IM depo, buccal, SQ pellets, and capsules)
patch = best form in physiologically similar
IM injection = most economical
enhances sexual interest, frequency of sexual acts, and nocturnal erections

44
Q

testosterone supplements CONS

A

oral capsule needs to be taken with food
OTC products has unknown efficacy/negative impacts
black box warning for gel formulation due to secondary exposure

45
Q

alpha-blocker key information

A

equal clinical effectiveness
can cause dizziness**, fatigue, headache, orthostatic hypotension, and retrograde ejaculation (Rapaflo)
inquire about cataracts when first filling RX for flomax (intra operative floppy iris syndrome may occur)

46
Q

5-alpha-reductase inhibitor key information

A

benefits men with prostate size over 40g
women should avoid handling tablets due to risk of abnormal development of external genitalia in male fetus
combination product with alpha-blocker is more effective than either agent alone

47
Q

PDE-5 inhibitors key information

A

take on demand vs daily dosing (1-2 hours prior to intercourse)
dosing with respect to meals
report erections that last over 4 hours
report any visual or hearing complaints
report palpitations or dizziness
avoid nitrates

48
Q

testing for hypogonadism/low-T

A

serum testosterone levels should be tested in the morning to measure total testosterone levels
< 300 ng/dL is positive for low-T, confirmed with 2nd test if free testosterone < 5ng/dL

49
Q

hypogonadism diagnosis

A

must have low-T and symptoms to be diagnosed

50
Q

types of alopecia in men

A

androgenic alopecia
alopecia areata
alopecia universalis
traction alopecia
drug-induced alopecia

51
Q

androgenic alopecia

A

most common, 50% of men; gradual onset usually by age 40
hereditary

52
Q

alopecia areata

A

hair loss in patches
responds to monoclonal antibodies
autoimmune

53
Q

alopecia universalis

A

complete loss of all body hair

54
Q

pathophysiology of androgenic

A

hereditary
terminal hair –> hair follicle shrinks –> shortening/thinning
due to more DHT being present in the scalp

55
Q

treatment of alopecia

A

finasteride (propecia)
minoxidil (rogaine)
topical finasteride and minoxidil
hair transplant (non-pharm)

56
Q

finasteride (propecia) mechanism

A

inhibits type II 5-alpha reductase from converting testosterone to DHT

57
Q

minoxidil (rogaine) mechanism

A

enlarges miniaturized hair follicles
increases blood supply to follicles

58
Q

strategies to talk about men’s health disorders

A

be upfront about the difficulty of the topic
ask permission to ask those intimate questions
may need to lead with a close-ended question (would you say this describes your current diagnosis accurately?)
start with the hard question to ease tension
be confident and appear as knowledgable and comfortable to ease concerns
do not discredit the patient’s feeling (I can understand that this may be embarrassing…)

Therapeutics - Exam 5 (8 decks)

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