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Exam 9 > Men's Health > Flashcards

Men's Health Flashcards

1
Q

The main role of the prostate is what

A

sexual function and fertility

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2
Q

What are the 4 zones of the prostate? What are the two to know and why?

A

Anterior, Peripheral, central, transition
Peripheral is 70% of the volume and is where most of the prostate cancer happens
Transition zone is 10% of volume and correlates with BPH

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3
Q

What is BPH

A

Benign prostatic hyperplasia-> proliferation of epithelial and smooth muscle cells in transition zone.

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4
Q

What symptoms does BPH tend to correlate with?

A

urinary symptoms, but that’s not always accurate

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5
Q

___ is one of the most common reasons for urology referral and up to 30% of men will receive treatment

A

BPH

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6
Q

BPH is now called ____

A

Lower urinary tract symptoms.

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7
Q

What are causes of lower urinary tract symptoms besides prostate enlargement

A

bladder instability, decreased bladder compliance, decreased bladder capacity, pelvic floor/neuro changes

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8
Q

What are the two big buckets of symptoms that patients with LUTS will experience?

A 
Voiding symptoms (hesitancy, decreased stream, incomplete emptying)
Storage (frequency, urgency, dysuria, nocturia)
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9
Q

What is the first thing to evaluate in a patient that is experiencing LUTS? What are other good non urological things to check?

A

medications!!

Then infection, behavior (caffeine), D2M, stones or strictures, neuro, cancer

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10
Q

The prostate exam (does/does not) correlate with degree of symptoms. It (can/cannot) help predict response to medical therapy

A

does not

can help!

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11
Q

What two things should be ordered on blood work for LUTS

A 
serum creatinine (kidney problems)
PSA
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12
Q

What is PSA

A

enzyme that liquefies the seminal fluid after ejactulation. it is a rough indicator of prostate size and can be elevated in BPH and prostate cancer.

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13
Q

What does the Post-Void residual test look at?

A

ability for bladder to empty.

This will be due to squeeze, obstruction, or both. (a large volume does not mean 100% that there is an obstruction)

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14
Q

The Urodynamics test is really only ordered by ___ because it is reserved for ____

A

urology, complex patients
this is a pressure flow study that is good for patients with previous surgery, large volume residuals, incontinence, overactive bladder, or neuro problems

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15
Q

Cystoscopy should be done if _____ is present to rule out _____

A

hematuria, cancer

This can find the pathology

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16
Q

What are the severity levels of the IPSS/AUA Sx score

A

out of 35
mild 0-7
moderate 7-15
severe >15

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17
Q

With a mild score on the IPSS/AUA, what is the indicated treatment?

A

watchful waiting

reduce fluid intake, limit EtOH and caffeine, avoid cold and allergy meds (anti-his), double voiding, quit smoking

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18
Q

With a moderate score on the IPSS/AUA, what is the indicated treatment?

A

nonsurgical

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19
Q

With a severe score on the IPSS/AUA, what is the indicated treatment?

A

surgery, this is from very serious things like retention, recurrent UTIs, hematuria, stones, renal insufficiency

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20
Q

α blocker MOA for moderate IPSS/AUA score

A

relax muscle of prostate and bladder neck, urine flows more easily.

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21
Q

______ are first line therapy for moderate IPSS/AUA and gland <40g.

A

α blockers

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22
Q

onset of effect from α blockers is _____

A

within several weeks

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23
Q

What are side effects of α blockers

A

dizziness and low BP after sitting or standing up

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24
Q

What are the non selective α-1a antagonists

A

terazosin, doxazosin, prazosin (not used)

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25
Q

What are the selective α-1a antagonists?

A

tamsulosin, alfuzosin, silodosin

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26
Q

Which α 1 antagonist is bad to use if CrCl is <30mL

A

silodosin . its a selectoive α-1a antagonist

Also be careful in people with sever liver dysfunction

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27
Q

What is MOA of α-1 antagonists

A

block NE on α 1 receptors (α-1a in prostate) on tissues and smooth muscle-> SM relaxation, counter obstruction-> enhance urine outflow-> decrease PVR

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28
Q

α-1 antagonists work ____ but they do not ______

A

quickly (benefit with continued use)

prevent need for prostate surgery, decrease prostate size or PSA levels

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29
Q

Non selective α-1 antagonists block receptors ______ (location). For dosing, they should be ______

A

outside prostate

started with low dose and titrated to effective dose

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30
Q

α-1b receptors bound by non selective α 1 antagonists cause AEs:

A

hypotension, first dose syncope, dizziness

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31
Q

Full effect for non selective α 1 antagonists may take ____

A

several weeks bc of the slow dose titration

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32
Q

Selective α-1 antagonists are selective for the 1a receptors on ______

A

stromal and capsule

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33
Q

Selective α-1 antagonists have a _______ risk of hypotension because:
Dosing (does/does not) require titration

A

decreased, selective for prostate 1a receptors

does not require a dose titration

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34
Q

Selective α-1 antagonists can be used with _______ medications and is safe to use in patients with _____

A

anti-HTN meds

CVD (angina, HTN, ppl taking anti-hypertensives)

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35
Q

The effect from selective α-1 antagonists will be seen in ____

A

1 week

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36
Q

_____ is a selective α-1 antagonist that requires no dose changes based on renal or liver dysfunction

A

tamsulosin

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37
Q

What are AEs with selective alpha1 antagonists:

A

tiredness, asthenia, anejaculation (silodosin especially)

floppy iris syndrome (block 1a receptors at iris dilator muscles-> worse with tamsulosin)

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38
Q

5-α-reductase inhibitors cause the prostate to ____ and decrease PSA levels by ____

A

shrink, 50%

this can help reduce urinary retension and the need for surgery and risk for prostate cancer

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39
Q

5-α-reductase inhibitors take ____ months for effect and have AEs:

A

4-6 months

decreased sex drive or difficulty with erection or ejaculation

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40
Q

The two main used 5ARIs are

A

finasteride and dutasteride

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41
Q

5ARIs are indicated when prostate size ____ and need to be take at least __ months for benefit.

A

> 40-50gm

6months

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42
Q

5ARIs (do/do not) need dose adjustments in renal or liver dx due to ___

A

do not, few drug interactions

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43
Q

5ARIs cause more _____ than α-1 antagonists. There are three main domains affected, what are they

A

sexual dysfunction
erectile dysfunction: decreased NO
ejaculatory dysfunction: decreased prostatic secretions
gynecomastia: increased testosterone->estrogen in peripheral tissues

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44
Q

Phosphodiesterase Type 5 inhibitors MOA:

A

inhibit PDE5 enzyme-> up cGMP-> more SM relax in prostate

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45
Q

What are the commonly used PD5is

A 
tadalafil 
sidelafil (viagra)
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46
Q

The greatest benefit of PD5i’s is when used in combination with _____

A

α-1 antagonist

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47
Q

Urge predominant symptoms best medication to use are___ and ___

A

anticholinergic/antimuscarinic (not retaining)

β-3 agonist

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48
Q

What are the commonly used β 3 agonists

A

mirabegron and vibegron

49
Q

MOA of anticholinergics for use with urge

A

decreased detrusor contractions and improve storage

50
Q

Greatest benefit with anticholinergic medications for urge symptoms is when they are used with ____

A

α 1 antagonists

51
Q

anticholinergic dosing ?

A

effect in 1-2 weeks, start low titrate slow

52
Q

Caution use in anticholinergic medication in ____

A

older patients

53
Q

MOA of β 3 agonists

A

β3 in bladder detrusor-> increase cAMP-> detrusor relax

54
Q

β 3 agonists are good for geriatrics because

A

there are few side effects

55
Q

If a patient wants to take palmetto what to tell them

A

sure, there’s no real effect

56
Q

What is the gold standard surgery for LUTS

A

Transurethral resection of the prostate

57
Q

Serum PSA a ______ increases overtime with both ___ and ____

A

serine protease

BPH and prostate cancer

58
Q

What are the main classifications for ED

A

psychogenic, neurologic, hormonal, arterial, venous

59
Q

What is the physiology of an erection?

A

sinusoidal smooth muscle relax + compress venous plexus-> up blood flow-> intracavernosal pressure over 100mmHg

60
Q

What is detumescence

A

breakdown of second messengers by phosphodiesterase and sympathetic discharge

61
Q

What are big 4 risk factors for ED

A

hypertension, hyperlipidemia, diabetes disorders, smoking

62
Q

What are vascular disease causes of ED

A

aterosclerosis (smoking, DM, DL, HTN, obesity), venous leaks, pelvic or perineal trauma (cycling)

63
Q

ED is a likely indicator of _______ and could be an early warning sign for _________

A

heart disease

increased risk of MI or stroke

64
Q

men with ED had _____ the risk of heart attack

A

twice the risk

65
Q

In men with DM, risk of ED is __ higher than non DM. Factors that contribute are

A

4 fold.
Age, duration of DM, glycemic control, diabetic complications
DM patients have a more severe less responsive to therapy

66
Q

for HTN and ED, it is correlated to ___ and unrelated to ____

A

underlying vascular dz

side effects of HTN meds

67
Q

smoking increases risk of ED __ fold. this is due to two potential mechanisms:

A

2 fold

impaired endothelium dependent smooth muscle relax, venoocclusive dysfunction

68
Q

What drugs could affect ED

A 
antidepressants and antipsychotics
β blockers
Thiazide diuretics
spironolactone
cimetidine (histamine-> antiandrogen)
Ketoconazole, cyproterone acetate
69
Q

SHIM questionnaire looks at what

A

sexual health inventory for men

70
Q

what physical exam should be done for ED

A

GU exam, assess breasts for gynecomastia, hair distribution, palpate distal pulses, genital and perineal sensation

71
Q

What labs should be ordered when ED is suspected

A

UA, CBC, fasting glucose, creatinine, lipid panel, testosterone

72
Q

What are first line therapies for ED

A

modify reversible causes, oral medication

73
Q

what are second line therapies for ED

A

vacuum therapy, penile injections, urethral suppository, penile impants

74
Q

What are the third line therapies for ED

A

there are none

75
Q

What are psychogenic causes of ED

A

performance anxiety, depression

loss libido, impaired NO

76
Q

what are neurogenic causes of ED

A

stroke ,spinal cord injury, diabetic retinopathy

lack of nerve impulse

77
Q

what are hormonal causes of ED

A

hypogonadism, hyperprolactinoma

not enough NO

78
Q

What are vasuculogenic causes of ed

A

atherosclerosis, hypertension

79
Q

what medications cause ED

A

anti-HTN, antidepressants, alcohol, tobacco

central suppression, vascular insufficiency

80
Q

What are the approved phosphodiesterase type 5 inhibitors used for ED

A

viagra (sildenafil citrate), levitra/staxyn (vardenafil), cialis (tadalafil), stendra (avanafil)

81
Q

PK feutres for sildenafil and vardenafil

A

1 hr to effect, short duration of action.
use on demand
do not take within 2 hours of fatty meal

82
Q

PK features for avenafil

A

up to 30 minutes onset, short duration.

food doesn’t affect.

83
Q

Tadalafil PK features

A

take 2 hours before intercouse. can get daily dose. duration of action up to 36hrs.

84
Q

Important to dose phosphodiesterase type 5 ___

A

high. increase to max dose for optimal sucess

85
Q

What are adverse effects of phosphodiesterase type 5 inhibitors

A

increases with does. vasodilation -> facial flushing, dyspepsia, nasal congestion, dizziness.
priapism (persistent erection), hypotension
increased light sensitivity (not tadalafil). inhibition of PDE6 isoenzyme in photoreceptors of retinal rods and cones

86
Q

The worse for AE: light sensitivity in PD5I? the best?

A

worse is sildenafil

best is tadalafil

87
Q

Tadalafil specific AE

A

lower back and limb muscle pain

inhibition of PDE11 isoenzyme in striated muscle cells

88
Q

What is penile injection therapy

A

smooth muscle relaxing mediation injected directly into penis (papaverine, phentolamine, PGE1)

89
Q

What is transurethral alprostaldil

A

smooth muscle relaxing urethra suppository mimics physiology of erection

90
Q

What are indications for penile impants

A

oral drug failure, scarred penis, peyronies disease, severe venous leak

91
Q

What are the 3 different penile impact models

A

malleable/semirigid rods

mechanical rod, inflatable

92
Q

What are the two requirements to have testosterone deficiency syndrome

A

deficiency in testosterone and relevant symptoms

93
Q

Low testosterone is seen in men with ____

A

HTN, dyslipidemia, DM, obesity

94
Q

What are the sexual symptoms of TDS

A

decreased desire, activity, sexual thoughts, morning erections
erectile dysfunciton, delayed ejaculations, smaller volume of ejaculation

95
Q

Physical symptoms of TDS

A

inability to perform vigorous activity, decreased muscle strength, fatigue, hot flushes, sweats

96
Q

Symptoms of TDS suggestive of osteoporosis

A

low trauma fractures, height loss, decreased bone mineral density

97
Q

Cognitive symtoms of TDS

A

impaired concentration, impaired verbal memory, impaired spatial performance

98
Q

What is a vacuum erection device

A

draw blood to penis, contraction band to keep blood in penis

99
Q

What are the primary causes of TDS

A

testicular failure (aging- obesity, systemic illness, meds, anorchia, cryptorchidism, genetic-Klinefelter’s, malnutrition, neurodegenerative, respiratory, trauma, viral orchitis)

100
Q

What is a congenital cause of TDS? what is a acquired cause of TDS

A

kallman’s syndrome

pituitary adenoma

101
Q

Late onset hypogonadism is associated with:

A

poor bone health, increased fat composition, depression

102
Q

What are causes of secondary TDS

A 
chronic dx (cirrosis), feedback inhibition due to rising estrogen (EtOH, steroid use, obesity), hormonal deficiency, inflammatory (Crohn's dz, arthritis), genetic disorders (prayer willis, kallmann)
*obstructive sleep apnea*?
103
Q

What are drugs associated with low T

A

antiarrhythmics, anticonvulsants, antifungals, chemotherapeutic agents, estrogen, gonadotropin releasing hormone agonists/antagonits, opiates, phenothiazine antipsychotics, progestins, statins, steroids, thiazide diuretics, ulcer drugs

104
Q

Lab test for diagnosis low T

A

plasma total testosterone test (morning same before 9AM)
plasma free or bioavaoiable testosterone test (non protein bound)
LH, FSH, prolactin, estradiol, hematocrit, PSA

105
Q

Testosterone replacement therapy delivery systems

A

IM, transdermal patches and gels, nasal swab, buccal patch, pellet implants, oral

106
Q

risks for Low T therapy

A

hepatotoxicity, edema in patients with CVD, CKD, CLD, gynecomastia, increased RBC, fix the sleep apnea

107
Q

Contraindications for low T therapy

A

breast cancer, advanced protest obstruction with voiding

108
Q

AEs for Low T oral tablets

A

liver and cholesterole effects

109
Q

AE for pellet impants for low T

A

in office procedure, infection, expulsion of pellet

110
Q

AE of intramuscular injections

A

fluctuations in mood or libido

polycythemia

111
Q

AEs for transdermal patches

A

skin reactions at application

112
Q

AE for transdermal gel

A

risk or tester one transfer to partner

113
Q

AE for buccal patch

A

gum irritation, halitosis

114
Q

Probably no association between testosterone levels and _______

A

incidence of prostate cancer

115
Q

studies suggest no risk in administering testosterone to men with _____

A

prostate cancer

116
Q

Montitoring low T includes

A

weight, peripheral edema, gynecomastia, BPH, sleep problems, libido, lab test (testosterone, Hgb/Hct, PSA, estradiol, Liver function)

117
Q

There is some studies that believe testosterone is associated with

A

increased risk of cardiac events. controversial at best

118
Q

Bioavailable testosterone levels ____ with each decade

A

diminish

Exam 9 (8 decks)

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