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endo > men's health > Flashcards

men's health Flashcards

1
Q

component of prostate

A

1) epithelial (glandular) tissue

  • androgen stimulate growth

2) stromal (smooth muscle tissue)

  • innervated by alpha 1 adrenergic receptor
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2
Q

effect of noradrenaline

A
  • prostate smooth muscle maintained by noradrenaline released from adrenergic nerves & stimulating post-junctional alpha-1 adrenoreceptors
  • brain receive stimulation -> release noradrenaline -> stimulate vein & arteries to constrict -> contraction of internal sphincter in bladder -> X pee
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3
Q

testosterone and DHT

A

testosterone converted by Type II 5alpha-reducrtase in prostate to DHT -> normal growth/enlargement of prostate

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4
Q

pathophysiology of BPH - components

A

1) static component

  • hormonal factor -> enlarge prostate tissue -> press onto organ -> irritative symptoms

2) dynamic component

  • increase smooth muscle tissue & agonism of alpha 1 receptor -> vasoconstriction of prostate -> narrowing of urethra outlet
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5
Q

long term bladder response to obstruction (BPH)

A

1) early phase

  • bladder force urine through narrowed urethra by contracting more forcefully

2) over time

  • bladder hypertrophy -> decompensate when detrusor muscle achieve highest state of hypertrophy -> need to urinate more frequently (overactivity)
  • detrusor irritable and overly sensitive
  • contract abnormally in response to small amt of urine
  • X full & strong contraction
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6
Q

when does BPH clinical presentation start to show

A

> 65 yo

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7
Q

obstructive/voiding symptoms for BPH

A
  • hesitancy, weak stream, sensation of incomplete emptying, dribbling, straining, intermittent flow
  • happen in early stages
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8
Q

irritative/storage symptoms of BPH

A
  • several years of untreated BPH
  • dysuria, frequency, nocturia, urgency, urinary incontinence
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9
Q

assessment components for BPH

A

1) digital rectal exam (DRE)

  • yearly after age of 40
  • feel abnormalities (nodules)

2) ultrasonography

  • volume/size

3) max urinary flow rate

4) postvoid residual (PVR)

  • normal < 100ml, > 200ml inadequate

5) prostate specific antigen (PSA)

6) medication history

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10
Q

medications vs BPH

A

1) anticholinergic

  • decrease bladder muscle contractility
  • 1st gen antihist, tricyclic antidepressant

2) alpha 1 adrenergic agonist

  • contract prostate smooth muscle
  • decongestant

3) opioid analgesic: increase urinary retention

4) diuretics: increase frequency

5) testosterone: Stimulate prostate growth

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11
Q

classifications of BPH

A

1) stage I

  • X bothered, QoL < 3
  • X significant outflow obstruction/complications, residual urine < 100ml
  • j observe

2) Stage II

  • bothered, QoL ≥ 3
  • X significant outflow obstruction/complication, residual urine < 100ml
  • pharmacotherapy

3) Stage III

  • irrespective symptoms
  • significant outflow obstruction/complication, uroflow < 10 ml/s, residual urine > 100ml
  • surgery

4) stage IV

  • irrespective symptoms
  • retention of urine, bladder calculi, recurrent UTI, persistent macroscopic haematuria
  • surgery (TURP)
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12
Q

nonpharmaco BPH

A

1) limit fluid intake in evening
2) minimise caffeine & alcohol intake
3) education
4) avoid meds that exacerbate symptoms

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13
Q

treatment algorithm for BPH (QoL ≥ 3)

A

1) prostate ≤ 2 fingerbreadth

  • w ED: PDE5i
  • wo ED: alpha 1 antagonist

2) voiding diary

  • overactive bladder (anti-muscarinic)

3) prostate ≥ 2 fingerbreadth

  • QoL 3-4: alpha 1 antagonist
  • QoL 5 - 6: combination(alpha 1 + 5ARI)
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14
Q

alpha adrenergic antagonist for BPH - MOA

A
  • competitive reversible antagonist
  • block adrenoreceptor on smooth muscle of prostate -> reduce vasoconstriction induced by noradrenaline -> relax muscle tone -> relieve obstruction -> increase urine flow -> reduce enlarged bladder -> reduce pain & discomfort
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15
Q

alpha adrenergic antagonist - non selective

A
  • good if need BP lowering effect
  • Doxazosin
  • titrate slowly to prevent hypotension & syncope
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16
Q

alpha adrenergic antagonist for BPH - selective

A

1) alfuzosin, silodosin
2) tamsulosin

  • well absorbed orally, 0.4mg OD
  • highly plasma protein bound
  • metabolised by CYP (food drug interaction)
  • excreted unchanged in urine
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17
Q

SE of alpha adrenergic antagonist for BPH

A

1) general

  • muscle weakness, fatigue, headache

2) non selective

  • dizziness
  • first dose syncope & orthostatic hypotension (prevent w bedtime admin)

3) uroselective

  • ejaculatory disturbance (S > T > A)

4) intraoperative floppy iris syndrome - only tamsulosin

  • complicate cataract surgery
  • block alpha 1 receptor in iris dilator muscle
  • avoid initiation until cataract surgery completed or hold at least 14 days before surgery
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18
Q

alpha adrenergic antagonist for BPH - CI

A

use alpha1 adrenoreceptor antagonist (prazosin)

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19
Q

5 alpha reductase inhibitor (5ARIs) for BPH - MOA

A
  • competitively inhibit 5 alpha reductase
  • reduce conversion of testosterone to DHT
  • reduce prostate size (improve urine flow, reduce frequency of urinary retention, reduce need for surgical procedure for transurethral resection & prostatectomy
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20
Q

5 alpha reductase inhibitor (5ARIs) for BPH - benefit

A

1) slow progression of disease
2) decrease need for surgery
3) decrease size of prostate
4) reduce PSA levels

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21
Q

5 alpha reductase inhibitor (5ARIs) - disadvantages

A

slow onset (6-12 months)

22
Q

5 alpha reductase inhibitor (5ARIs) for BPH - PK

A

1) absorption

  • well absorbed orally
  • 5mg OD
  • X dose adjustment even if renal/hepatic impair or old

2) distribution

  • highly plasma protein bound

3) metabolism

  • liver, t1/2 6h

4) elimination

  • 50% unchanged faeces
  • metabolites urine & faeces
23
Q

5 alpha reductase inhibitor (5ARIs) for BPH - AE

A

1) ejaculatory disorder (reduce semen, delayed)
2) decreased libido & sexual potency
3) ED, gynaecomastia, breast tenderness

24
Q

5 alpha reductase inhibitor (5ARIs) for BPH - CI

A

pregnant, women, child

25
Q

phosphodiesterase 5 inhibitor (PDE5i) for BPH

A
  • smooth muscle relaxation
  • tadalafil
  • take wo regards to timing of sex
  • significant hypotension
26
Q

combination therapy for BPH

A

1) alpha 1 antagonist + 5ARI

  • 1st line
  • alpha blocker onset wks, 5ARI months
  • finasteride + doxazosin

2) 5ARI + PDE5i

  • mitigate sexual AE
  • X initiate PDE5i if unstable angina

3) alpha 1 antagonist + PDE5i

  • high risk hypotension
27
Q

anti-muscarinic for irritative/storage BPH

A
  • block muscarinic receptor in detrusor muscle = decrease involuntary contraction of bladder
  • oxybutynin
28
Q

definition of ED

A
  • persistent (at least 6 month) inability to achieve/maintain erection of sufficient duration & firmness to complete satisfactory intercourse
29
Q

what happens during erection

A

1) Activated parasympathetic system (Ach)

** activated processes

  • increase NO production -> increase activity of guanylate cyclase -> increase cGMP production
  • Ach + prostaglandin -> increase adenyl cyclase -> increase cAMP

** process outcome

  • smooth muscle relax (more space for blood to flow in) + vasodilation -> corpora cavernosa fill up w blood -> swelling -> compression of venules against tunica albuginea (decrease venous outflow)

2) functional hormonal system

  • testosterone: encourage libido
30
Q

detumescence

A
  • subsiding of erection
  • process:
    1) deactivate parasympathetic (cGMP deactivated by PDE-5 -> stop vasodilation)
    2) activate sympathetic system
    ** induce smooth muscle contraction via aplha2 adrenergic receptor of arterioles -> reduce blood flow
  • possible inhibitory effect be serotonin
31
Q

aetiology of organic ED

A

1) vascular

  • atherosclerosis, peripheral vascular disease (PVD), HTN, DM

2) hormonal

  • hypogonadism
  • hyperprolactinemia (suppress testosterone production)

3) nervous

  • central: spinal cord trauma/disorder, stroke, CNS tumour
  • peripheral: DM, neuropathy, urethral surgery

4) medication induced

32
Q

medication induced for organic ED

A

1) clonidine, methyldopa, BB (except nevibolol), thiazide diuretics

  • decrease penile flow
  • alternative: Nevibolol, ACEi, ARBs, loop diuretic

2) anticholinergic

  • TCAs, 1st gen antihistamine, phenothiazine
  • decrease ACh activity
  • alternatives: bupropion, trazodone, 2nd gen antihistamine, atypical antipsychotic (2nd gen)

3) dopamine antagonist (metoclopramide)

  • dopamine cause sexual arousal/stimulation
  • alternatives: PPis, erythromycin

4) serotonin selective reuptake inhibitor (SSRIs)

  • increased serotonin in brain
  • decrease testosterone
  • alternatives: bupropion, trazodone

5) finasteride, dutasteride

  • decrease testosterone
  • alternative: terazosin, alfuzosin

6) CNS depressant (benzodiazepine, anticonvulsant)

  • suppress perception of psychic stimulus
  • alternative: gabapentin
33
Q

psychogenic ED

A
  • thought/feeling
  • malaise, loss of attraction, stress, performance anxiety, mental disorder, sedation
34
Q

other aetiology ED

A

smoking, excessive alcohol, illicit drug use, obesity

35
Q

Sexual health inventory for men (SHIM)

A
  • mild to no ED: 17 - 21 points
  • moderate to severe: < 11 points
36
Q

evaluation of cardiovascular disease for ED

A
  • ED potential early symptom of comorbid CVD
  • sex = sympathetic activation = increase HR & BP = increase MI risk
  • generally:
    1) low risk: ok
    2) unknown, X low risk: exercise stress test
    3) unstable/severe symptomatic CVD: defer until stabilised
  • cardiac rehab & regular exercise until reduce risk of CV complications w sexual activity
37
Q

nonpharmaco for ED

A

1) modifiable risk factors

  • smoking, control weight, control glucose/BP/fluid, exercise, decrease alcohol

2) psychotherapy
3) vacuum erection device (VED)
4) surgery: penile implant

38
Q

types of pharmacotherapy for ED

A

1) PDE5i
2) testosterone replacement
3) alprostadil

39
Q

PDE5i for ED - MOA

A

inhibit PDE5 -> inhibit catabolism of cGPM -> enhance cGMP activity -> induce smooth muscle relaxation -> increase blood flow -> erection

40
Q

PDE5i for ED - general

A

cause & enhance erection after sexual stimulation

41
Q

PDE5i for ED - types

A

1) tadalafil

  • long enough t1/2 for OD dose
  • taken regardless of food
  • hepatic & renal adjustment

2) sildenafil

  • 5mg OD
  • onset 30-60 mins
  • taken before sex
  • empty stomach (2 hrs after food)
  • X adjustment if hepatic/renal impair or old
  • metabolised by liver (CYP3A4 major, CYP2C9 minor)

3) vardenafil

  • taken before sex
  • empty stomach (2 hrs after food)
  • hepatic dose adjustment
42
Q

PDE5i for ED - lower initial dose for

A

1) ≥ 65 yo
2) on alpha blockers
3) renal failure
4) CYP3A4 inhibitor

43
Q

PDE5i for ED - SE

A

1) headache, rhinitis, flushing, muscle & back pain, dizziness, hypotension
2) prolonged erection & priapism (seek treatment if > 4 hrs)
3) sudden hearing loss
4) QTc prolongation (Vardenafil)
5) muscle pain (esp tadalafil)
6) ocular problem

  • sildenafil, vardenafil
  • irreversible problem w colour discrimination (blue -> green)
  • light sensitivity
  • nonarteritic anterior ischaemic optic neuropathy (NAION)
    ** hyperperfusion, seek immediate help
44
Q

PDE5i for ED - drug interactions

A

1) nitrates

  • avoid 24 hrs after sildenafil vardenafil, 28 hrs after tadalafil

2) anti-HTN, alcohol
3) CYP3A4

45
Q

testosterone replacement for ED - normal ranges

A

300 - 1100 ng/dL or 10.4 - 38.2 nmol/L

46
Q

testosterone replacement for ED - Indication

A

symptomatic hypogonadism confirmed by

1) decreased libido
2) low serum testosterone concentration

47
Q

testosterone replacement for ED - SE

A

irritability, aggressive behaviour, undesirable hair growth, increase BP, dyslipidemia, polycythaemia (increase clot & stroke risk), prostatic hyperplasia

48
Q

testosterone replacement for ED - monitoring

A

testosterone

  • 1 - 3 months
  • 6 - 12 month interval
  • discontinue if X improve after 3 month
49
Q

alprostadil for ED - general

A

X require sexual stimulation, fast onset, super invasive

50
Q

alprostadil for ED - MOA

A

stimulate adenyl cyclase -> increase cAMP -> induce smooth muscle relaxation -> erection

51
Q

alprostadil for ED - DDi

A

X PDE5i concurrent

52
Q

alprostadil for ED - dosage form

A

1) intraurethral pellet

  • duration: 30 - 60 mins
  • SE: pain, warmth/burning sensation in urethra, voiding difficulties, bleed, priapism, partner vaginal burn/itch

2) intracavernosal

  • better efficacy
  • higher risk of priapism, bleeding, haematoma, fibrosis
  • :( : fear of needle, invasiveness, complicated
  • X more than 3x per wk

endo (8 decks)

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