Sexual Dysfunction/BPH

Question 1

Common Comorbidities with ED

Answer 1

• HTN
• Atherosclerosis
• Neuropathy, diabetes
• Depression
• Stress
• Spinal Cord Injury
• Stroke

Question 2

Drugs that Cause ED/Sexual Dysfxn

Answer 2

• Alcohol
• Antidepressants: SSRIs and SNRIs
• Anti-HTN: B-blockers, clonidine, thiazides
• Antipsychotics: first-generation (chlorpromazine), prolactin raising 2nd gen (risperidone, paliperidone)
• BPH Meds: Finasteride, dutasteride, silodosin (retrograde ejaculation)

Question 3

Natural Products for ED

Answer 3

• Yohimbe - “insufficient evidence” and concerning SE
• L-arginine - “possibly effective,” similar SE to PDE5i, avoid additive effects
• Panax ginseng - “possibly effective,” bleeding risk

Question 4

Viagra

Answer 4

• Sildenafil (Revatio used for PAH)
• Start at 50 mg ~1 hour before sex
• Decreased efficacy with high-fat or large meal

Question 5

Levitra/Staxyn

Answer 5

• Vardenafil
• Start at 10 mg ~1 hour before sex
• Decreased efficacy with high-fat or large meal

Question 6

Cialis

Answer 6

• Tadalfil (Adcirca for BPH)
• Also used for BPH
• Daily dosing: 2.5-5 mg QD
• On-demand dosing: 5-20 mg PRN, start at 10 mg ~30 minutes before sex
• SE: back pain

Question 7

Stendra

Answer 7

• Avanafil

- Use 15-30 minutes before sex

Question 8

PDE5i Information

Answer 8

• CI: Use with nitrates (hypotensive risk)
• Warning: impaired color discrimination, hearing loss, vision loss, hypotension, priapism (>4 hr), seek medical help with chest pain
• SE: HA, flushing, dizziness, dyspepsia
• No more than 1 dose per day if used for ED

Question 9

Decreased PDE5i Dose Criteria

Answer 9

• > = 65 yo
• Using alpha-blocker
• Using CYP3A4 inhibitor
• Severe renal or liver disease
• Reduce starting doses in half (Viagra - 25 mg, Levitra/Cialis - 5 mg, Stendra - 50 mg

Question 10

PDE5i DDI

Answer 10

• Absolute CI with nitrates
• Make sure patient is stable on alpha-1 blocker before starting PDE5i (no hypotension/dizziness)
• May need to adjust doses with CYP3A4 inducers/inhibitors

Question 11

Prostaglandin E1

Answer 11

• Aloprostadil
• Vasodilator that is either injected into penis or inserted (pellet) into urethra
• Must refrigerate pellets
• SE: Penile pain, priapism

Question 12

Drugs that Worsen BPH

Answer 12

• Centrally-acting anticholinergics
• Drugs with anticholinergic SE: antihistamines, decongestants, phenothiazines, TCAs
• Caffeine
• Diuretics
• SNRIs
• Testosterone products

Question 13

Sxs of BPH

Answer 13

• Hesitency, intermittent urine flow, straining/weak stream
• Urinary urgency, leaking, dribbling
• Incomplete bladder emptying
• Urinary frequency (nocturia)
• Bladder obstruction
• Severe renal failure

Question 14

Natural Products for BPH

Answer 14

• Saw palmetto: unlikely to be effective

- Lycopene: for prostate cancer prevention, no evidence for BPH use

Question 15

Alpha-1 Blocker Information

Answer 15

• First-line for moderate to severe sxs of BPH
• Can be used with 5 alpha reductase inhibitor (hypotension risk with PDE5i)
• Cause relaxation of smooth muscle in prostate/bladder neck and reduces outlet obstruction to improve urinary flow
• Warning: orthostatic hypotension, syncope, intraoperative floppy iris syndrome (cataract surgery)
• SE: Dizziness, fatigue, HA, abnormal ejaculation
• Non-selective drugs often given at bedtime to minimize hypotensive SE
• May take 4-6 weeks to take full effect

Question 16

Cardura/Cardura XL

Answer 16

• Doxazosin
• Non-selective alpha-1 blocker
• Given at bedtime and titrated up slowly
• XL is a OROS formulation that can leave a ghost tablet

Question 17

Terazosin

Answer 17

• Non-selective alpha-1 blocker

- Given at bedtime and titrated up slowly

Question 18

Flomax

Answer 18

• Tamsulosin
• Selective alpha-1 blocker
• 0.4 mg PO QD

Question 19

Rapaflo

Answer 19

• Silodosin
• Selective alpha-1 blocker
• Can cause retrograde ejaculation

Question 20

5 alpha-reductase inhibitor Information

Answer 20

• Block testosterone to dihydrotestosterone conversion
• Used to treat sxs BPH with enlarged prostate
• Used with alpha blockers to improve sxs, decrease risk of urinary retention, and decrease need for surgery (TURP)
• Take 6 months or longer for maximal efficacy
• Shrink prostate and lower PSA
• Can be used with PDE5i or alpha-1 blockers

Question 21

Proscar

Answer 21

• Finasteride
• 5 alpha-reductase inhibitor
• Propecia used for alopecia
• CI: women of child-bear potential, preggo (shouldn’t handle/take meds)
• SE: Impotence, decreased libido, ejaculation disturbance, breast enlargement/tenderness

Question 22

Cialis

Answer 22

• Tadalafil
• Used for ED or BPH
• Adcirca used for PAH
• CI: nitrates
• Warnings: color discrimination, vision/hearing loss, priapism, chest pain => seek medical help
• SE: HA, flushing, dizziness, dyspepsia, back pain