Men's Health Flashcards
What are the 2 physiological methods of prostate growth?
- Epithelial (glandular) tissue growth, stimulated by androgens
- Stromal (smooth muscle) tissue growth, innervated by α1-adrenergic receptors
What are the 2 components causing BPH?
- Static (gland) component → hormonal factors causes the overproduction of DHT, causing the enlargement of the prostate tissue
- Dynamic (muscular) component → increase in smooth muscle tissue and agonism of α1 receptors causes the narrowing of the urethra outlet
What is the PSA cutoff for BPH progression?
greater than 1.5 ng/mL
What medication can worsen BPH? (5)
- Anticholinergics (AH, tricyclic AD)
- α1-adrenergic agonists (decongestants)
- Opioid analgesics (tramadol)
- Diuretics
- Testosterone
According to the AUA-SI scale, what scores indicate mild, moderate and severe BPH?
mild ≤ 7
moderate 8-19
servere ≥ 20
What are the complications of BPH? (5)
- Recurrent UTI
- Bladder stones
- Acute urinary retention
- Urinary incontinence
- Hematuria
Non-pharmaco management for BPH? (4)
- Limit fluid intake in the evening
- Minimise caffeine and alcohol intake (they act as diuretics)
- Educate patient to take time to empty their bladder completely and often
- Avoid medications that can exacerbate symptoms
List the selective α-Adrenergic Antagonists (2)
alfuzosin, tamsulosin
List the non-selective α-Adrenergic Antagonists
terazosin, prazosin
When should α-Adrenergic Antagonists be used?
in those classified with moderate or severe LUTS with a small prostate (< 40g)
What is the onset for α-Adrenergic Antagonists?
Fast (within days to weeks)
What are the general side effects of α-Adrenergic Antagonists? (4)
muscle weakness, fatigue, ejaculatory disturbances and headache (due to high BP to the brain)
Hence usually administered at bedtime to decrease orthostatic effects
For IFIS risk, how should α-Adrenergic Antagonists be adjusted?
hold off for 2-3 weeks
List the 5ARI drugs
Finasteride, Dutasteride
When should 5ARIs be used?
moderate or severe LUTS with large prostate (> 40g)
also in patients who want to avoid surgery or cannot tolerate the side effects of α1-antagonists
What is the onset of action for 5ARIs?
6-12 months
What are the side effects of 5ARIs? (4)
- higher instance of ejaculatory disorders as compared to α-blockers (reduced semen during ejaculation or delayed ejaculation)
- decreased libido
- ED (3-16%)
- Gynecomastia and breast tenderness
What is the only PED5i approved for use in BPH?
Tadalafil
What is the onset of action for PDE5i?
Days to weeks
What is the only class that shrinks prostate size and decreases PSA?
5ARI
What is the main side effect of PDE5is?
Significant hypotension
When should anti-muscarinics be used?
Patients with irritative voiding symptoms
What consideration must be made for patients starting anti-muscarinics?
(hint: testing parameter)
PVR must be less than 250ml
What is the most common combination
α1-ANTAGONIST + 5 ARI
(one dilates, one shrinks prostate)
(one works fast, other takes time)
What is the second most common combination
5ARI + PDE5i
(one causes ED, other treats it)
What combination should be avoided
α1-ANTAGONIST + PDE5 INHIBITOR
How does ACh cause an erection?
ACh increases NO, which stimulates guanylyl cyclase to increase cGMP, hence RELAXING MUSCLES
ACh and PgE stimulate adenylyl cyclase, increasing cAMP, hence causing VASODILATION and blood flow
Explain the physiology of detumescence
Deactivate PNS - PDE5 degrades cGMP
Activate SNS - induces SM contraction, hence vasoconstriction
What are the 4 broad categories of organic ED?
Vascular (artherosclerosis, PVD)
Hormonal (hypogonadism, hypoprolacinemia)
Nervous (central like stroke or peripheral like DM or neuropathy)
Medication-induced
What are the 6 medications that can induce ED?
- BP meds (methyldopa, BB, thiazide diuretics)
- Anticholinergics (1st gen AH, tricyclic AD)
- Dopamine antagonists (metoclopramide)
- SSRIs (fluoxetine)
- 5ARIs (finasteride)
- CNS depressants (benzodiazepines)
What are the s/sx of ED?
loss of interest in sexual activity, depression, performance anxiety, embarrassment, anger, low self-esteem and disharmony in a relationship
What SHIM score indicates moderate to severe ED?
below 11 points
What other evaluation should be done in ED patients?
CV - exercise stress test
Which PDE5is need to be taken on an empty stomach?
Sildenafil and Vardenafil
Which PDE5i causes muscle pain?
Tadalafil
Which PDE5is cause ocular issues (colour discrimination and light sensitivity)
Sildenafil and Vardenafil
In which patient groups should PDE5is be started at a lower initial dose? (3)
patients ≥ 65 years old
patients taking α-blockers, patients with renal failure (drugs are renally cleared)
those taking CYP3A4 inhibitors
Which PDE5i causes QTc prolongation?
Vardenafil
What are the general side effects of PDE5is? (6)
Headaches, rhinitis, flushing, muscle and back pain, dizziness, hypotension, prolonged erections and priapisms
How long should nitrates not be taken after each PDE5i
avanafil - 12h
sildenafil and vardenafil - 24h
tadalafil - 48h
What are the side effects of testosterone replacement?
irritability, aggressive behaviour, undesirable hair growth, high BP, hepatotoxicity, dyslipidemia, polycythemia, and prostatic hyperplasia (testosterone contraindicated in prostate cancer)
What is alprostadil’s MOA?
Alprostadil is a prostaglandin E1 analogue that stimulates adenylyl cyclase and increases cAMP levels, inducing smooth muscle relaxation and causes an erection
What are some side effects of intraurethral alprostadil?
pain, warmth or burning sensations in the urethea, voiding difficulties, bleeding or spotting, priapism and partners may experience vaginal burning or itching
What are some side effects of intracavernosal alprostadil?
higher risk of priapism, bleeding, hematoma and fibrosis
