BPH, Erectile Dysfunction

Question 1

Benign Prostatic Hyperplasia: Lower urinary tract symptoms

Answer 1

• Weak stream
• Hesitancy
• Stream intermittency
• Post void dribbling
• Nocturia

Question 2

BPH: complications

Answer 2

• urinary retention

- Recurrent UTI

Question 3

What are the 2 scoring measures for BPH?

Answer 3

1. Urinary Symptoms (AUA symptom score 0-35)

2. Impact on quality of life (Bother index 0-6)

Question 4

What exam must be performed for a patient with BPH?

Answer 4

DRE (note size, consistency, +/- tenderness)

Question 5

BPH: urologic testing (with expected findings)

Answer 5

1. Urofow study (low flow rate)
2. Post void residual (high residual)
3. Cystoscopy (trabeculation, obstructive prostate into lumen)
4. Urodynamic study (low flow, elevated pressure in bladder)

Question 6

Name some conservative lifestyle modifications that can be done for mild BPH

Answer 6

• Avoid drinking too much water before bed
• If leg edema, elevate legs to help eliminate fluid before bed
• Avoid caffiene, and alcohol
• Double void to completely empty bladder
• Avoid pseudoephedrine/alpha agonist (causes sphincter to contract more forcefully)

Question 7

BPH medications: phytotherapy

Answer 7

Saw palmetto

Question 8

BPH medications: alpha blockers

Answer 8

cause relaxation of smooth muscle that restricts flow of urine

Question 9

Alpha-1 blockers

Answer 9

Terazosin

Doxazosin

Question 10

Alpha-1A blockers

Answer 10

Tamsulosin
Silodosin
Alfuzosin

(more specific and less likely to cause orthostatic hypotension)

Question 11

Alpha-Blockers: ADEs

Answer 11

• Dizziness
• Nasal congestion
• Orthostatic hypotension
• Retrograde ejaculation
• Floppy iris syndrome*

Question 12

5-alpha reductase inhibitors: MOA

Answer 12

• block conversion of testosterone to DHT
• Decrease prostate size/volume
• Increase urinary max flow rates
• Decrease risk of BPH progression

Question 13

When would you tell your patient to expect results if you were starting them on a 5-alpha reductase inhibitor?

Answer 13

can take 6 months to see effect

alpha blockers are much quicker to give benefit

Question 14

Which medication lowers PSA by 50% and is most beneficial in large prostates with PSA >1.4?

Answer 14

5 alpha reductase inhibitors

Question 15

Name 2 examples of 5 alpha reductase inhibitors

Answer 15

1. Finasteride

2. Dutasteride

Question 16

5 alpha reductase inhibitors: ADE

Answer 16

• impotence
• Decreased libido
• Lower ejaculatory volume
• Gynecomastia

Question 17

Which is the only PDE5-inhibitor that is approved for BPH and erectile dysfunction?

Answer 17

Tadalafil (cialis)

Question 18

What is the gold standard surgery for BPH?

Answer 18

TURP - Transurethral Resection of Prostate

Question 19

TURP complications/side effects

Answer 19

1. Retrograde ejaculation
2. TUR syndrome (Hyponatremia, confusion, hypertension, visual changes)
3. Hematuria

Question 20

What is the main benefit or reason why one would elect for a Photoselective Vaporization of Prostate proceedure?

Answer 20

-can be done safely on anticoagulation patient

Question 21

Holmium Laser Enucleation of Prostate

Answer 21

Good for large prostates that previously could only be done with open surgery

Question 22

What are some endocrine issues that could lead to erectile dysfunction?

Answer 22

Hyperprolactinemia*
Thyroid disorder
Hypogonadism

Question 23

Name some medications that can cause ED?

Answer 23

Antihypertensives ** (beta blockers, thiazides, clonidine, methyldopa)

Antidepressants and antipsychotics (ex. TCAs, MAo-Is, Lithium)

Question 24

Name the medications that can reduce testosterone (3)

Answer 24

1. Cimetidine
2. Spironolactone
3. Ketoconizole

Question 25

What can nocturnal penile tumescence help determine?

Answer 25

whether the ED is physiologic or psychologic

Question 26

What is the best test to look for arterial insufficiency?

Answer 26

Penile duplex Doppler sonography

Question 27

What is the best test to look for venous leak?

Answer 27

Cavernosometry/Cavernosography

Question 28

Name some important initial measures for ED?

Answer 28

- Deterime if heart is healthy enough for sex - Stop smoking - Lose weight - Moderate alcohol - Change meds (if indicated)

Question 29

What are contraindicated with phosphodiesterase-5 inhibitors?

Answer 29

nitrates

Question 30

PDE-5 Inhibitors MOA

Answer 30

block PDE-5, allowing c-GMP to continue vasodilating

Question 31

What is important to remember about using PDE-5 inhibitors and alpha blockers?

Answer 31

lowest dose of each, separate doses

Question 32

PDE-5 side effects

Answer 32

- nasal congestion - facial flushing - headache - dyspepsia - back pain - visual changes/loss of vision

Question 33

What is important to remember about proper use of the VED

Answer 33

remove constricting ring after intercourse

Question 34

Medicated urethral system for erection (MUSE)

Answer 34

Alprostadil - prostaglandin E-1 - First dose under medical supervision (3% will have hypotension)

Question 35

Penile injection

Answer 35

- Alprostadil or (Prostaglandin E1 + Phenotolamine + Papaverine) - MAX of 3 per week - First dose under medical supervision

Question 36

Priaprism

Answer 36

>4 hours - Pain, stasis, hypoxia to cavernosal tissues, acidosis, fibrosis - EMERGENCY!!

Question 37

Priaprism: Tx

Answer 37

- Aspirate with 18 gauge needle | - Inject phenylephrine (vasoconstrictor)

Question 38

Penile Prothesis: non-inflatable

Answer 38

- malleable or semi-rigid | - two rods that can be bent into and out of position of use