men's health Flashcards
Name the assessment methods for benign prostate hyperplasia (BPH)?
digital rectal exam, ultrasound, maximum urinary flow rate (Qmax), post-void residual (PVR; normal should be < 100mL), prostate specific antigen (PSA; elevated if > 1.5ng/mL; very high levels may indicate prostate cancer
Name the stages, characteristics, and proposed treatment for BPH, under the MOH LUTS/BPH guidelines 2015
stage 1: IPSS-QOL < 3 and PVR < 100mL; watchful waiting with annual or more frequent re-assessment
stage 2: IPSS-QOL >= 3 and PVR < 100mL; pharmacological treatment
stage 3: irrespective of QOL, if PVR > 100mL and uroflow < 10mL/s; surgical option
stage 4: irrespective of QOL, urinary complications have developed (urinary retention, bladder stones, recurrent UTI, persistent macroscopic haematuria); surgery (TURP_
List the medications that may cause / worsen BPH symptoms?
- anti-cholinergics (incl. anti-histamines and tricyclic depressants)
- a1 adrenoreceptor agonists (incl. decongestants containing pseudoephedrine / phenylephedrine)
- opioid analgesics
- diuretics
- testosterone
Describe the non-pharmacological management for BPH symptoms?
Limit fluid intake at night
Limit caffeine and alcohol intake (both are mild diuretics)
Avoid medications that can exacerbate symptoms
Educate patients to take their time to empty their bladder completely and often
List the pharmacological agents that are used in the management of BPH, and their compelling indications?
- a1 adrenoreceptor antagnoist (non-selective/selective)
compelling indication: patient is symptomatic with IPSS-QOL>3, more beneficial in patients with prostate size < 40g (=<2 finger breadths) - 5-alpha reductase inhibitor
compelling indication: patients with prostate size > 40g (> 2 finger breadths) / PSA > 1.5ng/mL - Phosphodiesterase-5 inhibitor
compelling indication: patients with concurrent erectile dysfunction and BPH - Anti-muscarinic agents
compelling indication: add on if patient has irritative/storage (overactive bladder) symptoms (but ensure PVR < 250mL / 150mL for more conservative dosing)
Describe the a1 adrenoreceptor agonists used in the management of BPH, including the MOA, types and differences (non-selective vs selective), onset, S/E and monitoring
a1 adrenoreceptor antagonists:
MOA: antagonises the adrenoreceptor, resulting in smooth muscle relaxation, of the prostate, bladder (incl. bladder neck and internal sphincter) and urethra walls
Non-selective : binds to both peripheral vascular smooth muscle receptor and urinary smooth muscle receptors
Examples: doxazosin, terazosin
S/E: dizziness, first dose syncope, orthostatic hypotension (need to titrate slowly to therapeutic dose)
Selective: binds to only urinary smooth muscle receptors
Examples: tamsulosin, alfuzosin, sildosin
S/E: ejaculatory disturbance (delayed/retrograde ejaculation; sildosin > tamsulosin > alfuzosin)
General S/E for both non-selective and selective: muscle weakness, headache, fatigue, ejaculatory disturbance, orthostatic hypotension (bedtime administration preferred), intraoperative floppy iris syndrome (tamsulosin most commonly associated; iris prolapse during cataract surgery, hence to avoid initiation until completion of surgery or hold for 14 days before surgery)
Onset: days to weeks
Monitoring: symptom relief, side effects
Describe the 5-alpha reductase inhibitors (5-ARIs) used in the management of BPH, including the MOA, examples, S/E, onset and monitoring?
5-ARIs:
MOA: inhibits the enzyme that converts testosterone to dihydrotestosterone, hence suppressing the growth and reducing the size of the prostate
Examples: finesteride, dutasteride
S/E: sexual disturbances (incl. ejaculatory disorders, decreased libido and erectile dysfunction), gynecomastia and breast tenderness
Onset: months (may take up to 6-12 months to decrease prostate size)
Monitoring: obtain baseline PSA levels before initiation, and monitor PSA afterwards
note: contraindicated in pregnant women / child bearing age females (teratogenic)
Describe the phosphodiesterase-5 inhibitors (PDE5i) used in the management of BPH, including the MOA, examples, S/E, DDI, onset and monitoring?
PDE-5i (BPH):
MOA: exact MOA unkown, but probably due to smooth muscle relaxation mediated by the potentiation of nitric oxide-cGMP mechanism during parasympathetic stimulation
Examples: only Tadalafil 5mg OD, take regardless of food, is approved for BPH treatment
S/E: muscle and back pain (esp. Tadalafil), headache, flushing, dizziness, hypotension, prolonged erection and priapism (seek ED treatment if erection > 4hrs), sudden hearing loss (very rare)
DDI: do not take with nitrates (contraindication, due to potentially life threatening hypotension; nitrates should be avoided 48h after administration of tadalafil), do not take with alcohol (potentiates hypotension), do not take with CYP34A inhibitors
Onset: days to weeks
Monitoring: symptoms relieve and adverse effects
Describe the anti-muscarinics used in the management of BPH, including the MOA, and examples
MOA: antagonises the muscarinic receptors of the bladder detrusor muscle, promoting the relaxation of the bladder and decreasing the involuntary contraction of the bladder
Examples: oxybutynin, tolterodine, solifenacin, tropsium, darifenacin, fesoterodine
Describe the evaluation required for ED?
- evaluation of signs and symptoms through the Sexual Health Inventory for Men (SHIM) scale; mild ED: score 17-21 points; moderate-severe ED: score < 11 points
- identification of underlying causes of ED (e.g. medication hx, social hx, surgical hx, lab results including glucose, BP, lipids and testosterone levels)
- cardiovascular work up
- ED may be an early symptom of unidentified co-morbid CVD and sexual activity activates sympathetic nervous system, thus increasing BP and HR, posing a risk for MI
- if patient has low CVD risk: ok
- if patient presents with unknown-moderate CVD risk: performance exercise stress testing
- if patient has severe / unstable symptomatic CVD: defer both sexual activity and the treatment of ED until condition stabilised
- advice patients on cardiac rehabilitation and regular exercise to reduce risk of CV complications with sexual activity
Describe the non-pharmacological management of ED?
addressing modifiable risk factors: stop smoking, reduce weight, control glucose / BP / lipids, increase exercise, decrease alcohol
psychotherapy
devices: vacuum erection devices (VEDs)
surgery: penile implant
List the pharmacological agents that are used in the management of ED and their compelling indications?
- PDE-5 inhibitors
- first line for all ED; sexual arousal is required for activity - testosterone replacement
- for ED patients symptomatic with decreased libido and low serum testosterone levels (normal: 300-1100 ng/dL or 10.4 - 38.2 nmol/L) (i.e. symptomatic hypogonadism) - alprostadil
- second line for ED; sexual arousal is not required for activity
Describe the phosphodiesterase-5 inhibitors (PDE5i) used in the management of ED, including the MOA, examples, S/E, DDI, onset and monitoring?
PDE-5i (ED):
MOA: inhibit PDE-5, potentiates nitric-oxide-cGMP mechanism during parasympathetic activation, resulting in increased smooth muscle relaxation and vasodilation (increase blood flow to corpora carvenosa)
Examples:
Sildenafil
- PO 50mg PRN, take 1hr before intercourse, on an empty stomach
- Dose range: 25mg to 100mg PRN
- specific S/E: green-blue colour discrimination difficulty, photosensitivity, nonarteritic anterior ischemic optic neuropathy (ischemia of optic nerve; instruct patients to stop and go to ED if sudden vision loss)
Vardenafil
- PO 10mg PRN, take 1hr before intercourse, on an empty stomach
- Dose range: 5mg to 20mg PRN
- specific S/E: green-blue colour discrimination difficulty, photosensitivity, nonarteritic anterior ischemic optic neuropathy (ischemia of optic nerve; instruct patients to stop and go to ED if sudden vision loss) + QTc prolongation
Tadalafil
- PO 5mg PRN / OD, take up to 36hr before intercourse, regardless of food
- Dose range: 2.5mg to 10mg PRN / OD
- specific S/E: muscle pain
Avanafil
- PO 100mg PRN, take 30 mins before intercourse, regardless of food
- Dose range: 50mg to 200mg PRN
General S/E of PDE-5i: muscle and back pain, headache, flushing, dizziness, hypotension, rhinitis, prolonged erection and priapism (seek ED treatment if erection > 4hrs), sudden hearing loss +/- tinnitus and dizziness (very rare)
DDI:
- do not take with nitrates (contraindication, due to potentially life threatening hypotension)
> avoid nitrates 24h after sildenafil / vardenafil
> avoid nitrates 48h after tadalafil
> avoid nitrates 12h after avanafil
- do not take with alcohol (potentiates hypotension)
- do not take with CYP34A inhibitors
Monitoring: efficacy and adverse effects, importantly, to monitor any changes in cardiac health status
name the risk factors for nonarteritic anterior ischemic optic neuropathy (ischemia of the optic nerve) with sildenafil / vardenafil?
DM, smoking, HTN, CVD, dyslipidemia, age > 50 yo
Describe S/E and monitoring for testosterone replacement, used in management of ED?
S/E: irritability, aggressive behaviour, undesirable hair growth, increase in BP, hepatotoxicity, dyslipidemia, polycythemia (increased risk of clots), prostatic hyperplasia (CI: prostate cancer)
monitoring: check serum testosterone within 1-3 months of initiation, and thereafter every 6-12 months; discontinue if no improvement after 3 months
