Men & Women's Health Flashcards
Alpha blockers
“alpha-adrenergic antagonists”
dynamic component of BPH is smooth muscle tone; alpha receptors stimulate constriction of prostate smooth muscles and may cause urinary obstruction; therefore antagonizing these receptors prevents constriction
Alpha blockers have quick onset of relief (within days)
Alpha blockers: alpha-1 selective antagonists
long-acting: terazosin & doxazosin
approved for HTN and BPH
take at bedtime to prevent orthostatic effects; also start with low doses and titrate up to relief of symptoms to avoid orthostasis
Alpha blockers: Uroselective agents
Afluzosin & Tamsulosin
ability to relieve BPH symptoms without decreased likelihood of hypotension
Alpha blockers: Uroselective agents: Tamsulosin
long-acting
selective antagonism at the alpha-1A receptor
decreases intra-urethral pressure without systemic BP reduction
Start at 0.4mg daily- usually no titration required (may still be some systemic effect, esp. with 0.8mg daily dosing)
SE: abnormal ejaculation (educate, but not a reason to DC)
Alpha blockers: Uroselective agents: afluzosin
Not selective for a specific alpha receptor subtype
extended release form displays clinical uroselectivity (selects prostate over vascular tissue)
even less systemic hypotension than tamsulosin
does not result in significant ejaculatory dysfunction, but it is more costly than tamsulosin
5alpha-Reductase Inhibitors
finasteride & dutaseride
reduce hypertrophy of the prostate gland itself by inhibiting the enzyme that converts testosterone to dihydrotestosterone (DHT) in prostate cells (DHT is a prostate growth regulator)
5alpha-Reductase Inhibitors: Finasteride
specific inhibitor of type 2 5alpha-reductase
reduces prostate size by 20-30%
***key predictor for positive treatment outcome is baseline prostate volume (need prostate volume of greater than 40mL to see benefit)
average of 6mo to see significant symptom reduction, so is often used in conjunction with alpha blockers initially
5alpha-Reductase Inhibitors: Dutaseride
inhibits both type 1 & 2 5alpha-Reductase
similar considerations as finasteride
need baseline prostate volume of 40-50mL to see positive outcomes and symptom relief
BPH Therapy
goal: improve symptoms, limit progression, prevent complications
mild BPH: watchful waiting (usually lack symptoms and may never experience disease progression)
Moderate/severe BPH: alpha blockers; uroselective agent if patient likely to have BP issues; 5alpha-Reductase inhibitor as add-on therapy if patient has prostate size greater than 40mL
Severe BPH and/or Secondary complications: surgical intervention
Phosphodiesterase-Inhibitors
sildenafil, vardenafil, tadalafil
inhibit PDE type 5, which inhibits degradation of cGMP, resulting in elevated levels of cGMP which results in relaxation of smooth cavernosal smooth muscle
still requires arousal to facilitate response
tadalafil has a longer half-life and don’t need to take directly prior to sex
sildenafil and vardenafil have absorption problems with high fat meals
Phosphodiesterase Inhibitors: Contraindications & Precautions
Avoid nitrate use (additive hypotensive effects; safe window not well established- 24-48hrs)
precaution for concurrent use with non-specific alpha blockers for BPH (hypotension due to systemic vasodilation)
acute ETOH use may cause additive dizziness
use lower doses in renal/hepatic dysfunction
CYP450 3A4 Inhibitors
best to avoid in: Recent MI/stroke, CHF class II and higher, uncontrolled arrhythmias, and hypotensive patients
ADRs: priapism (immediate ER), headache, flushing, dyspepsia, vision changes
Erectile Dysfunction Treatment
phosphodiesterase inhibitors are typically first-line
consider referral to urologist if first line does not work
under advice of urology expert, other meds such as apomorphine or intracavernosal injections may be used
Oral Contraceptives
most are combined estrogen & progestin (COC)
COC: less than 1 in 100 pg with perfect use
Progestin only: 2 of 100 pg with perfect use
missed doses can increased risk of pg
OC: Estrogen Component MOA/ADRs
prevents ovulation
alters endometrial lining and hinders implantation of egg
ADR: n/v, irritability, *clots, breast enlargement/tenderness, bloating/edema, cyclic HA
OC: Progestin Component MOA/ADRs
causes cervical mucous thickening (entry barrier)
reduces Fallopian tube mobility (decreases sperm transport)
alters endometrial lining and hinders implantation of egg
ADR: inc’d bleeding/spotting, diarrhea, fatigue, lactation, decreased libido, depressed mood (adding estrogen may decrease ADR)
“ACHES” mneumonic
for clots with estrogen pill use
A: abdominal pain (severe) C: chest pain/cough/SOB H: headache (severe), weakness, numbness E: eye/vision problems S: severe leg/calf pain
Depo-Medroxyprogeseterone Acetate (Depo Provera)
IM q3mo
progestin only
approx 3 in 100 pg
Ortho Evra patch
estrogen/progestin combo
change weekly x3wk, no patch on week 4
apply to buttocks, stomach, upper outer arm, or torso
studies showed no diff in absorption with heat, cold, or water (but be careful if patch falls off!)
Nuva Ring
estrogen/progestin combo
insert vaginally once a month
leave in for 3 weeks, take out week 4
DIAPPERS mneumonic
determining underlying cause of incontinence (will guide therapy)
D: delirium I: infection A: atrophic vaginitis/urethritis (due to decreased estrogen levels) P: pharmaceuticals P: psychological factors E: excess urine output/polyuria R: restricted mobility S: stool impaction/constipation
Stress incontinence
during episodes of elevated intra-abdominal pressure (cough, laugh, sneeze, lifting)
occurs most frequently in women, and may occur short term post partum
non-pharm tx often best choice
may use alpha-adrenergic agonists, estrogens, or TCAs
Urge incontinence
characterized by loss of moderate to large amounts of urine with the inability to delay voiding if the bladder is perceived on being full
often associated with increased frequency
tx with anticholinergics, oxybutynin, tolterodine (Detrol), or TCAs
Overflow incontinence
related to outflow obstruction
characterized by leaking small amounts of urine, poor stream, dribbling, and feeling of incomplete emptying (often associated with BPH)
Functional incontinence
functionally fine, but cannot reach toilet (mobility/dementia)
Mixed incontinence
two or more underlying pathologies
Treatment of Urinary Incontinence
multiple non-pharm therapies (pelvic wall muscle strengthening exercises)
pharm tx includes: alpha-adrenergic agonists, estrogens, tricyclic antidepressants (TCAs), anticholinergics
alpha-adrenergic agonists for urinary incontinence
promote contraction of smooth muscle and increase sphincter tone
not considered appropriate tx in most algorithms due to lack of evidence
pseudo-ephedrine sometimes used to manage mild stress incont (federally regulated OTC)
estrogen use for urinary incontinence
for incont in post-menopausal women with urogenital atrophy
used for stress incontinence
topical or intra-vaginal preparations
tricyclic antidepressant (TCA) use for urinary incontinence
inhibit NE uptake and may increase urethral tone due to an enhanced alpha-adrenergic effect
used for stress & urge incontinence
used for their anticholinergic effects
imipramine most widely used for this indication; also used for bed-wetting in children
anticholinergics used for urinary incontinence
effective for control
questionable decrease of AchE inhibitors used to treat dementia (drugs may act against each other)
oxybutynin
anticholinergic and smooth muscle relaxant properties
may be used as scheduled or as needed before an event
tolterodine
competetive agonist of muscarinic receptors
CYP2D6 & 34A metabolism- check for drug interactions
Treatment of Overflow incontinence
most often related to BPH
use BPH meds such as alpha adrenergic antagonists (alpha blockers) or 5alpha-reductase inhibitors
