Men's Health Flashcards
The main role of the prostate is what
sexual function and fertility
What are the 4 zones of the prostate? What are the two to know and why?
Anterior, Peripheral, central, transition
Peripheral is 70% of the volume and is where most of the prostate cancer happens
Transition zone is 10% of volume and correlates with BPH
What is BPH
Benign prostatic hyperplasia-> proliferation of epithelial and smooth muscle cells in transition zone.
What symptoms does BPH tend to correlate with?
urinary symptoms, but that’s not always accurate
___ is one of the most common reasons for urology referral and up to 30% of men will receive treatment
BPH
BPH is now called ____
Lower urinary tract symptoms.
What are causes of lower urinary tract symptoms besides prostate enlargement
bladder instability, decreased bladder compliance, decreased bladder capacity, pelvic floor/neuro changes
What are the two big buckets of symptoms that patients with LUTS will experience?
Voiding symptoms (hesitancy, decreased stream, incomplete emptying) Storage (frequency, urgency, dysuria, nocturia)
What is the first thing to evaluate in a patient that is experiencing LUTS? What are other good non urological things to check?
medications!!
Then infection, behavior (caffeine), D2M, stones or strictures, neuro, cancer
The prostate exam (does/does not) correlate with degree of symptoms. It (can/cannot) help predict response to medical therapy
does not
can help!
What two things should be ordered on blood work for LUTS
serum creatinine (kidney problems) PSA
What is PSA
enzyme that liquefies the seminal fluid after ejactulation. it is a rough indicator of prostate size and can be elevated in BPH and prostate cancer.
What does the Post-Void residual test look at?
ability for bladder to empty.
This will be due to squeeze, obstruction, or both. (a large volume does not mean 100% that there is an obstruction)
The Urodynamics test is really only ordered by ___ because it is reserved for ____
urology, complex patients
this is a pressure flow study that is good for patients with previous surgery, large volume residuals, incontinence, overactive bladder, or neuro problems
Cystoscopy should be done if _____ is present to rule out _____
hematuria, cancer
This can find the pathology
What are the severity levels of the IPSS/AUA Sx score
out of 35
mild 0-7
moderate 7-15
severe >15
With a mild score on the IPSS/AUA, what is the indicated treatment?
watchful waiting
reduce fluid intake, limit EtOH and caffeine, avoid cold and allergy meds (anti-his), double voiding, quit smoking
With a moderate score on the IPSS/AUA, what is the indicated treatment?
nonsurgical
With a severe score on the IPSS/AUA, what is the indicated treatment?
surgery, this is from very serious things like retention, recurrent UTIs, hematuria, stones, renal insufficiency
α blocker MOA for moderate IPSS/AUA score
relax muscle of prostate and bladder neck, urine flows more easily.
______ are first line therapy for moderate IPSS/AUA and gland <40g.
α blockers
onset of effect from α blockers is _____
within several weeks
What are side effects of α blockers
dizziness and low BP after sitting or standing up
What are the non selective α-1a antagonists
terazosin, doxazosin, prazosin (not used)
What are the selective α-1a antagonists?
tamsulosin, alfuzosin, silodosin
Which α 1 antagonist is bad to use if CrCl is <30mL
silodosin . its a selectoive α-1a antagonist
Also be careful in people with sever liver dysfunction
What is MOA of α-1 antagonists
block NE on α 1 receptors (α-1a in prostate) on tissues and smooth muscle-> SM relaxation, counter obstruction-> enhance urine outflow-> decrease PVR
α-1 antagonists work ____ but they do not ______
quickly (benefit with continued use)
prevent need for prostate surgery, decrease prostate size or PSA levels
Non selective α-1 antagonists block receptors ______ (location). For dosing, they should be ______
outside prostate
started with low dose and titrated to effective dose
α-1b receptors bound by non selective α 1 antagonists cause AEs:
hypotension, first dose syncope, dizziness
Full effect for non selective α 1 antagonists may take ____
several weeks bc of the slow dose titration
Selective α-1 antagonists are selective for the 1a receptors on ______
stromal and capsule
Selective α-1 antagonists have a _______ risk of hypotension because:
Dosing (does/does not) require titration
decreased, selective for prostate 1a receptors
does not require a dose titration
Selective α-1 antagonists can be used with _______ medications and is safe to use in patients with _____
anti-HTN meds
CVD (angina, HTN, ppl taking anti-hypertensives)
The effect from selective α-1 antagonists will be seen in ____
1 week
_____ is a selective α-1 antagonist that requires no dose changes based on renal or liver dysfunction
tamsulosin
What are AEs with selective alpha1 antagonists:
tiredness, asthenia, anejaculation (silodosin especially)
floppy iris syndrome (block 1a receptors at iris dilator muscles-> worse with tamsulosin)
5-α-reductase inhibitors cause the prostate to ____ and decrease PSA levels by ____
shrink, 50%
this can help reduce urinary retension and the need for surgery and risk for prostate cancer
5-α-reductase inhibitors take ____ months for effect and have AEs:
4-6 months
decreased sex drive or difficulty with erection or ejaculation
The two main used 5ARIs are
finasteride and dutasteride
5ARIs are indicated when prostate size ____ and need to be take at least __ months for benefit.
> 40-50gm
6months
5ARIs (do/do not) need dose adjustments in renal or liver dx due to ___
do not, few drug interactions
5ARIs cause more _____ than α-1 antagonists. There are three main domains affected, what are they
sexual dysfunction
erectile dysfunction: decreased NO
ejaculatory dysfunction: decreased prostatic secretions
gynecomastia: increased testosterone->estrogen in peripheral tissues
Phosphodiesterase Type 5 inhibitors MOA:
inhibit PDE5 enzyme-> up cGMP-> more SM relax in prostate
What are the commonly used PD5is
tadalafil sidelafil (viagra)
The greatest benefit of PD5i’s is when used in combination with _____
α-1 antagonist
Urge predominant symptoms best medication to use are___ and ___
anticholinergic/antimuscarinic (not retaining)
β-3 agonist
What are the commonly used β 3 agonists
mirabegron and vibegron
MOA of anticholinergics for use with urge
decreased detrusor contractions and improve storage
Greatest benefit with anticholinergic medications for urge symptoms is when they are used with ____
α 1 antagonists
anticholinergic dosing ?
effect in 1-2 weeks, start low titrate slow
Caution use in anticholinergic medication in ____
older patients
MOA of β 3 agonists
β3 in bladder detrusor-> increase cAMP-> detrusor relax
β 3 agonists are good for geriatrics because
there are few side effects
If a patient wants to take palmetto what to tell them
sure, there’s no real effect
What is the gold standard surgery for LUTS
Transurethral resection of the prostate
Serum PSA a ______ increases overtime with both ___ and ____
serine protease
BPH and prostate cancer
What are the main classifications for ED
psychogenic, neurologic, hormonal, arterial, venous
What is the physiology of an erection?
sinusoidal smooth muscle relax + compress venous plexus-> up blood flow-> intracavernosal pressure over 100mmHg
What is detumescence
breakdown of second messengers by phosphodiesterase and sympathetic discharge
What are big 4 risk factors for ED
hypertension, hyperlipidemia, diabetes disorders, smoking
What are vascular disease causes of ED
aterosclerosis (smoking, DM, DL, HTN, obesity), venous leaks, pelvic or perineal trauma (cycling)
ED is a likely indicator of _______ and could be an early warning sign for _________
heart disease
increased risk of MI or stroke
men with ED had _____ the risk of heart attack
twice the risk
In men with DM, risk of ED is __ higher than non DM. Factors that contribute are
4 fold.
Age, duration of DM, glycemic control, diabetic complications
DM patients have a more severe less responsive to therapy
for HTN and ED, it is correlated to ___ and unrelated to ____
underlying vascular dz
side effects of HTN meds
smoking increases risk of ED __ fold. this is due to two potential mechanisms:
2 fold
impaired endothelium dependent smooth muscle relax, venoocclusive dysfunction
What drugs could affect ED
antidepressants and antipsychotics β blockers Thiazide diuretics spironolactone cimetidine (histamine-> antiandrogen) Ketoconazole, cyproterone acetate
SHIM questionnaire looks at what
sexual health inventory for men
what physical exam should be done for ED
GU exam, assess breasts for gynecomastia, hair distribution, palpate distal pulses, genital and perineal sensation
What labs should be ordered when ED is suspected
UA, CBC, fasting glucose, creatinine, lipid panel, testosterone
What are first line therapies for ED
modify reversible causes, oral medication
what are second line therapies for ED
vacuum therapy, penile injections, urethral suppository, penile impants
What are the third line therapies for ED
there are none
What are psychogenic causes of ED
performance anxiety, depression
loss libido, impaired NO
what are neurogenic causes of ED
stroke ,spinal cord injury, diabetic retinopathy
lack of nerve impulse
what are hormonal causes of ED
hypogonadism, hyperprolactinoma
not enough NO
What are vasuculogenic causes of ed
atherosclerosis, hypertension
what medications cause ED
anti-HTN, antidepressants, alcohol, tobacco
central suppression, vascular insufficiency
What are the approved phosphodiesterase type 5 inhibitors used for ED
viagra (sildenafil citrate), levitra/staxyn (vardenafil), cialis (tadalafil), stendra (avanafil)
PK feutres for sildenafil and vardenafil
1 hr to effect, short duration of action.
use on demand
do not take within 2 hours of fatty meal
PK features for avenafil
up to 30 minutes onset, short duration.
food doesn’t affect.
Tadalafil PK features
take 2 hours before intercouse. can get daily dose. duration of action up to 36hrs.
Important to dose phosphodiesterase type 5 ___
high. increase to max dose for optimal sucess
What are adverse effects of phosphodiesterase type 5 inhibitors
increases with does. vasodilation -> facial flushing, dyspepsia, nasal congestion, dizziness.
priapism (persistent erection), hypotension
increased light sensitivity (not tadalafil). inhibition of PDE6 isoenzyme in photoreceptors of retinal rods and cones
The worse for AE: light sensitivity in PD5I? the best?
worse is sildenafil
best is tadalafil
Tadalafil specific AE
lower back and limb muscle pain
inhibition of PDE11 isoenzyme in striated muscle cells
What is penile injection therapy
smooth muscle relaxing mediation injected directly into penis (papaverine, phentolamine, PGE1)
What is transurethral alprostaldil
smooth muscle relaxing urethra suppository mimics physiology of erection
What are indications for penile impants
oral drug failure, scarred penis, peyronies disease, severe venous leak
What are the 3 different penile impact models
malleable/semirigid rods
mechanical rod, inflatable
What are the two requirements to have testosterone deficiency syndrome
deficiency in testosterone and relevant symptoms
Low testosterone is seen in men with ____
HTN, dyslipidemia, DM, obesity
What are the sexual symptoms of TDS
decreased desire, activity, sexual thoughts, morning erections
erectile dysfunciton, delayed ejaculations, smaller volume of ejaculation
Physical symptoms of TDS
inability to perform vigorous activity, decreased muscle strength, fatigue, hot flushes, sweats
Symptoms of TDS suggestive of osteoporosis
low trauma fractures, height loss, decreased bone mineral density
Cognitive symtoms of TDS
impaired concentration, impaired verbal memory, impaired spatial performance
What is a vacuum erection device
draw blood to penis, contraction band to keep blood in penis
What are the primary causes of TDS
testicular failure (aging- obesity, systemic illness, meds, anorchia, cryptorchidism, genetic-Klinefelter’s, malnutrition, neurodegenerative, respiratory, trauma, viral orchitis)
What is a congenital cause of TDS? what is a acquired cause of TDS
kallman’s syndrome
pituitary adenoma
Late onset hypogonadism is associated with:
poor bone health, increased fat composition, depression
What are causes of secondary TDS
chronic dx (cirrosis), feedback inhibition due to rising estrogen (EtOH, steroid use, obesity), hormonal deficiency, inflammatory (Crohn's dz, arthritis), genetic disorders (prayer willis, kallmann) *obstructive sleep apnea*?
What are drugs associated with low T
antiarrhythmics, anticonvulsants, antifungals, chemotherapeutic agents, estrogen, gonadotropin releasing hormone agonists/antagonits, opiates, phenothiazine antipsychotics, progestins, statins, steroids, thiazide diuretics, ulcer drugs
Lab test for diagnosis low T
plasma total testosterone test (morning same before 9AM)
plasma free or bioavaoiable testosterone test (non protein bound)
LH, FSH, prolactin, estradiol, hematocrit, PSA
Testosterone replacement therapy delivery systems
IM, transdermal patches and gels, nasal swab, buccal patch, pellet implants, oral
risks for Low T therapy
hepatotoxicity, edema in patients with CVD, CKD, CLD, gynecomastia, increased RBC, fix the sleep apnea
Contraindications for low T therapy
breast cancer, advanced protest obstruction with voiding
AEs for Low T oral tablets
liver and cholesterole effects
AE for pellet impants for low T
in office procedure, infection, expulsion of pellet
AE of intramuscular injections
fluctuations in mood or libido
polycythemia
AEs for transdermal patches
skin reactions at application
AE for transdermal gel
risk or tester one transfer to partner
AE for buccal patch
gum irritation, halitosis
Probably no association between testosterone levels and _______
incidence of prostate cancer
studies suggest no risk in administering testosterone to men with _____
prostate cancer
Montitoring low T includes
weight, peripheral edema, gynecomastia, BPH, sleep problems, libido, lab test (testosterone, Hgb/Hct, PSA, estradiol, Liver function)
There is some studies that believe testosterone is associated with
increased risk of cardiac events. controversial at best
Bioavailable testosterone levels ____ with each decade
diminish
