1
Q
What is the treatment of choice if primary hypogonadism is the cause of erectile dysfunction
A
androgen therapy
2
Q
Contraindications for androgen therapy
A
- prostate cancer
2. obstruction of bladder neck by prostatic hypertrophy
3
Q
What are the 6 types of androgen therapy
A
- Oral (rarely used)
- Buccal mucoadhesives
- Injectables
- Transdermal preparations
- Implantable subcutaneous pellets
- Gel
4
Q
name for testosterone buccal mucoadhesive
A
Striant
5
Q
Three types of injectable testosterone and dosing
A
- Testosterone cypionate (Depo-Testosterone) q 2-3 weeks
- Testosterone enanthate (Delatestryl) q 2-3 weeks
- Testosterone undecoanoate (Aveed) q 10 weeks
6
Q
What is special about Aveed injectable
A
- Must be done in clinic by certified professionals, 30 min monitoring after ea injection
- Risk of POME (pulmonary oil microembolism)
- risk of anaphylaxis
7
Q
Disadvantage to injectables
A
- tendency to produce uneven effects between doses
- pain associated with IM injection
8
Q
Transdermal testosterone preparations
- name
- ADR
A
Androderm
- skin irritation
- contact dermatitis
- itching
9
Q
Implantable subcutaneous testosterone pellets
- name
- where implanted
- disadvantage
A
- Testopel
- fat tissue of buttocks
- less flexible dosing (once it’s in it’s in)
- if have complication, pellets have to be sx removed
10
Q
Testosterone Gel
- name
- disadvantage
A
- Androgel
- Virilization of women and children
- counsel men to cover application site with clothing to avoid contact with others
11
Q
How to monitor effectiveness of androgen therapy
A
Baseline, f/u after therapy initiation, then yearly:
- Testosterone
- Hematocrit
- Serum lipid values
- LFTs
- PSA and DRE
12
Q
What are the 7 therapy options for ED if not primary hypogonadism (in order of selection)
A
- Comorbidities and psychosexual dysfunction
- Phosphodiesterase-5 inhibitors (PDE-5)
- Intra-urethral Alprostadil
- Intravacernous Vasoactive Drug injections
- Vacuum constriction
- Semi-rigid/inflatable prosthesis
- vascular surgery
13
Q
PDE5 Inhibitors
- how fit into tx selection
A
- 1st line if ED not caused by comorbidities, medications, primary hypogonadism
14
Q
List the 4 PDE5 inhibitors
A
- Sildenafil citrate (Viagra)
- Vardenafil (Levitra or Staxyn)
- Tadalafil (Cialis)
- Avanafil (Stendra)
*all considered equal, some work better in some people
15
Q
ADR PDE5 inhibitors
A
Mild to moderate, self limiting, more common in higher doses
- HA
- Flushing
- Dyspepsia
- Nasal congestions
- Hypotension (uncommon, CV assessment should be done before therapy)
- Acute hearing loss (rare)
16
Q
PDE5 Inhibitors contraindications
A
Use with short- or long-acting nitrate drugs – potentiate hypotensive effects, risk of severe hypotension and MI or stroke
- Viagra 24 hours before or after nitrate
- Cialis 48 hours before/after nitrate
- Levitra and Stendra no official standard but probably 24 hours
17
Q
Intra-urethral Alprostadil
- name
A
MUSE - medicated urethral system for erection
18
Q
Intra-urethral Alprostadil
- advantages
A
- ED associated with neurogenic, vasculogenic, psychogenic, mixed etiologies
- Local application
- minimal systemic effects
- rarity of drug interactions
19
Q
Intra-urethral Alprostadil
- Disadvantages
A
- inconsistent results
- penile pain
- urethral pain/burning
20
Q
Intra-urethral Alprostadil
- best results when used with what?
- where should therapy be initiated?
A
- Effectiveness is increased with concurrent use of Actis, penile-constricting device
- Therapy should be initiated in physicians office due to complicaitons of urethral bleeding, vasovagal reflex, hypotension, priaprism
21
Q
Intracavernous vasoactive drug injection
- what is the only approved drug by FDA in US?
A
Alprostadil
22
Q
Intracavernous vasoactive drug injection of alprostadil
- success
- low rates of what common ADRs
A
- erection in more than 70% men
- relatively low rate priapism and fibrosis
23
Q
Intracavernous vasoactive drug injection of alprostadil
- 4 common ADR
A
- penile pain
- hematoma
- fibrosis (pressure on injection site for 5 min to avoid)
- priaprism
24
Q
Where inject Intracavernous vasoactive drug?
A
- dorso-lateral aspect of proximal third of penis
- avoid visible veins
- switch sides
- max 1 per 24 hours
25
What are the three injectible intracavernous vasoactive drugs used?
- Alprostadil
- papaverine
- phentolamine
26
papaverine ADR (2)
- priapism
| - corporal fibrosis
27
phentolamine ADR (2)
- hypotension
| - reflex tachycardia
28
Vacuum constriction
vacuum is applied to penis for a few minutes, causing tumescence and ridigidy which is sustained using a constricting ring at the base of the penis
29
Two surgery options
1. Penile prosthesis implantation
| 2. Vascular surgery
30
Disadvantage to penile prosthesis
- unnatural erection
| - risk of infection
31
Advantage to vascular surgery
May be curative, esp for young men with congenital or traumatic erectile dysfunction with focal arterial occlusion but no vascular dz
32
Dosing recommendation for tadalafil (Cialis)
- 10 mg before planned sexual activity
- May increase to 20 or decrease to 5 based on efficacy and tolerability
- Duration of action is 36 hours
- OR daily dose 2.5 mg (or 5mg) without regard to sexual activity
33
Tadalafil drug interactions (2)
1. Long and short acting nitrates – hypotension
| 2. Stabilize on alpha-blocker before initiating tadalafil therapy, start with 5 mg dose to avoid hypotensive response
34
Lab tests prior to initiation of and to monitor ED therapy
1. urinalysis: evaluate for potential infection/organic problems causing ED
2. CBC - infection
3. Glucose - DM
4. Cr - renal fn
5. fasting lipid profile: atherogenic cause, monitor androgen therapy
6. serum T
35
Serum testosterone
- level to be considered hypogonadal
- what is needed for dx of testosterone deficiency
- <300 ng/dL
| - TWO morning serum measurements <300
36
List the 3 drug types currently approved by FDA for management of pts with prostatic hyperplasia
1. Alpha-blockers
2. 5-alpha reductase inhibitor therapy
3. PDE5
37
List the 5 types of alpha-blockers
- non-selective
- selective
all are "-zosins"
Non-selective:
- Terazosin (Hytrin) –
- Doxazosin (Cardura)
Selective:
- Tamsulosin (Flomax) –
- Alfuzosin (Uroxatral)
- Silodosin (Rapaflo)
38
alpha-blockers ADR
- dizziness (MC)
- orthostatic hypotension (MC): first dose effect, worse when used with other antihypertensives
- lower ejaculate volume (more common in selective)
39
Alpha-blockers ADR
- Use carefully with PDE-5 Inhibitors: unacceptable reductions in BP, orthostatic hypotension
40
Alpha-blockers Contraindications
Planned cataract surgery – may develop intraoperative floppy iris syndrome (retinal detachment, lens problems, endophthalmitis post-operatively)
41
How long does it take Alpha-blockers to take effect
2-6 weeks before benefits can be adequately assessed
42
5-Alpha Reductase Inhibitors
| - when use
sx of BPH with enlarged prostate glands
43
5-Alpha Reductase Inhibitors
| - two types
"-asteride"
- Finasteride (Proscar)
- Dutasteride (Avodart)
44
5-Alpha Reductase Inhibitors how long to take effect
might take 6-12 months for full expression to be noted
45
5-Alpha Reductase Inhibitors
| ADRs (5)
- Erectile dysfunction
- Decreased volume of ejaculate
- Decreased libido
- Gynecomastia
- **Preg women should not handle due to risk to male fetus
46
5-Alpha Reductase Inhibitors and prostate cancer
May lower risk of less life-threatening prostate cancer and increase risk of more life-threatening prostate cancer → DRE and PSA super important
47
PDE5 Inhibitors
| - which one
Tadalafil (Cialis) is the only one approved by FDA for BPH in US
48
When use Tadalafil for BPH
- Use in those who do not get adequate relief from alpha-blocker alone OR men with ED and mild BPH
49
How dose tadalafil if adding to alpha-blocker therapy
Start lowest dose and titrate up to avoid hypotension
50
What is the role of OTC preparations in the management of prostatic hyperplasia: saw palmetto, beta sitosterol, and pygeum.
None really - lack of published data
51
Doxazosin dosing in BPH
- Starting dose: 1 mg daily
| - Maintenance dose: 1-8 mg daily
52
Tamsulosin dosing in BPH
- Starting dose: 0.4 mg daily
| - Maintenance dose: 0.4-0.8 mg daily
53
Most common bacterial cause of acute and chronic bacterial prostatitis
- Acute: E. coli (klebsiella pneumonia and proteus mirabilis)
- Chronic: E. coli
54
2 abx and duration to treat acute prostatitis
1. Trimethoprim/sulfamethoxazole (Bactrim)
2. Fluorquinolone (Cipro)
- Duration: 4 weeks
55
2 abx and duration to treat chronic prostatitis
1. Fluoroquinolone (1st line)
2. Trimethoprim/sulfamethoxazole (Bactrim)
- Duration: 4-6 weeks, up to 12 weeks
56
Two antibiotics that may be used for long-term suppressive therapy for patients with recurrent prostatitis
1. Cipro (500 mg three times weekly)
| 2. Bactrim (regular strength daily)
