mens health

Question 1

Major Male Health Issues

Associated with Advancing Age

Answer 1

Coronary Heart Disease
LUTS - lower urinary tract symptoms
BPH
Prostate Cancer
Testicular Cancer
Erectile Dysfunction
Hypogonadism “Andropause”

Question 2

prostate cancer is most common in what race

Answer 2

blakc

Question 3

PSA screening

Answer 3

screening for prostate cancer
currently very controversial
leading to too many false positives*** - subsequent tests and biopsies
begin screening at age 40
f/u every 2-4 years based on risk
f/u every year in high risk groups
value of screening in over 75 yo ???
More specific testing???

Question 4

serum testosterone pattern

Answer 4

kick starts puberty then decreases with age
200 - 900 - 200
peaks at around 22

Question 5

role of testosterone

Answer 5

Bone and muscle growth
Hair growth
Sexual organ maturation
Spermatogenesis
Increased libido

Question 6

hypogonadism

Answer 6

Hormonal deficiency (“Andropause”)
Risk Factors: Aging, Chronic Illness (Diabetes, AIDS, Rheumatoid arthritis, CKD), Long-term use of corticosteroids, Obesity 
testosterone deficiency symptoms: decreased libido, weight gain, loss of energy, may play some role in ED
diagnosis: low testosterone WITH specific signs and symptoms, must have both for diagnosis, initial test done in the AM to measure total testosterone and confirm with second test

Question 7

total testosterone level under ___ is positive for low testosterone

Answer 7

300 ng/dL

Question 8

confirmation of low testosterone

Answer 8

A total testosterone test or free testosterone test should be repeated to confirm diagnosis.
Because testosterone is bound to Sex Hormone Binding Globulin (SHBG), a free testosterone test should be performed in patients that are suspected of having altered SHBG concentrations.
Free testosterone level under 5 ng/dl confirms low
testosterone

Question 9

conditions that could decrease SHBG

Answer 9

Moderate obesity
Nephrotic syndrome
Hypothyroidism
Use of glucocorticoids, progestins, and androgenic steroids

Question 10

conditions that could increase SHBG

Answer 10

Aging
Hepatic cirrhosis
Hyperthyroidism
Use of anticonvulsants
Use of estrogens
HIV infection

Question 11

many formulations of testosterone replacement products

Answer 11

Patches
Gels
Solutions
IM depo
Buccal
SQ Pellets

Question 12

testosterone injection

Answer 12

Testosterone enanthate or cypionate, 75-100 mg IM weekly or 200 mg every two weeks
Supraphysiologic conc during part of dosing interval – possible mood swings

Question 13

testosterone patch

Answer 13

One to two 5 mg patches applied nightly* over the skin of the back, thigh, or upper arm, away from pressure areas.
**Most similar to physiologic testosterone levels.
Avoid prolong exposure to H2O for 3 hrs after application.

Question 14

testosterone gel

Answer 14

5–10 g of a 1% testosterone gel applied daily over a covered area of non-genital skin.

• Shoulders, upper arms, abdomen
• Patients should wash hands after application

Question 15

testosterone solution

Answer 15

30mg – 120mg (1 to 4 applications) applied to the arm pits once daily.

• Wash hands after use.
• Apply deodorant prior to application.

Question 16

testosterone buccal tablet

Answer 16

30 mg of a bioadhesive buccal testosterone tablet applied to buccal mucosa every 12 hours.
-Do not chew or swallow

Question 17

testosterone SQ pellets

Answer 17

Pellets implanted SQ at intervals of 3 to 6 months

• Dose and regimen vary with the formulation used.
• Onset delayed 3-4 months with first dose

Question 18

testosterone contraindications

Answer 18

Prostate cancer
Breast cancer
Hematocrit > 50%
Baseline PSA greater than 4 ng/ml, or PSA >
3 ng/ml in men at high risk of prostate cancer
Recent or poorly controlled CVD

Question 19

testosterone black box warning

Answer 19

Black Box Warning for Gel formulation: Concerns with secondary exposure to children.
There is some controversy regarding the cardiac risk associated with testosterone supplementation - Injection more than patches and gels
On 9/18/14, the FDA Advisory Panel voted to impose strict new limitations on the multibillion-dollar testosterone drug industry.

Question 20

testosterone monitoring

Answer 20

Patients should be monitored 3 to 6 months after initiating therapy.

• Testosterone levels should be measured with a goal between 400 and 700 ng/dL
• Hematocrit should be measured: if over 54%, therapy should be stopped and reinitiated when it drops to a safe level.

Question 21

androgen misuse and abuse

Answer 21

Androgen therapy has been misused by athletes to increase physical capabilities.
Potential side effects of supraphysiologic doses:
-Gynecomastia
-Weight gain
-Acne
-Decreased testicular size
-Mood alteration
-Hepatotoxicity

Question 22

BPH pathophysiology

Answer 22

normal size gland (under 20 g)
surrounds the proximal urethra
growth is common after age 40
contains several types of tissue: Embedded with alpha-1a adrenergic receptors, Stimulation by NE results in smooth muscle contraction with subsequent narrowing of urethra
Type-II 5-alpha reductase in the prostate gland: Converts testosterone to dihydro-testosterone [DHT], High concentrations also found in scalp
Dihydro-testosterone [DHT]: responsible for prostate enlargement and growth, some men appear to be genetically predisposed to producing large quantities

Question 23

BOO

Answer 23

bladder outlet obstruction
Decreased force of stream
Hesitancy to initiate voiding
Strain or push to urinate
Terminal dribbling
Intermittency

Question 24

irritative symptoms

Answer 24

Secondary to incomplete bladder emptying
Nocturia
Frequency
Urgency
Dysuria
Urge incontinence
QOL

Question 25

diagnosis of BPH made by

Answer 25

clinical symptoms digital exam measuring flow rate measuring residual volume: Bladder scan, over 25-30ml AUA Symptom Score (mild 1-7; moderate 8-19; severe 20-35) - treatment depends on severity

Question 26

complications of BPH

Answer 26

chronic renal failure overflow urinary incontinence recurrent UTIs diminished quality of life

Question 27

role of pharmacist in BPH

Answer 27

Advise on OTC products Encourage evaluation - especially if at high risk for prostate CA Advise on proper use of Rx medications Screen for potential ADRs from meds

Question 28

goals of BPH therapy

Answer 28

Control symptoms Decrease AUA score by at least 3 pts Prevent Complications Delay need for surgery

Question 29

treatment of BPH

Answer 29

Watchful waiting. | Only treat when symptoms adversely impact QOL

Question 30

non-drug BPH therapy for all patients

Answer 30

Avoid drugs with strong anti-cholinergic properties: decreases contractility of bladder detrusor muscle, results in urinary retention Examples: Antihistamines (esp 1st gen, Ex: Benadryl®), Tricylcic antidepressants, Cogentin®, Artane®, Scopolamine, Anti-muscarinics (Ditropan®) Approximately half of men with BPH also have OAB. Men with both have better symptom control using a combo of alpha-antagonists plus anti-muscarinics. **Anti-muscarinics should be avoided in BPH pts with post-void residual over 200 ml and/or max urine flow rate of under 5 ml/sec. Restrict fluid, EtOH, and caffeine intake in PM Avoid diuretics and nasal decongestants, if possible. Use Kegel exercises

Question 31

mild BPH drug therapy

Answer 31

Non-drug measures Some pts stabilize and do not progress Self-treatment with CAM therapy

Question 32

moderate BPH drug therapy

Answer 32

Non-drug measures Alpha-blockers +/- Hormone therapy PDE Inhibitors

Question 33

Alpha-1a Adrenergic Blockade

Answer 33

``` Developed for tx of HTN Relaxes smooth muscle tone of prostate gland and bladder neck - improves urine flow Does NOT reduce size of prostate gland Onset in 1-6 weeks Decreases AUA score by 30-40% Equal clinical effectiveness between all agents notice improvement in around 1 week treat HTN separately ```

Question 34

Alpha-1 adrenergic blockers dosing

Answer 34

Alfuzosin* - 10 mg QD - do not crush Doxazosin - start 1 mg QHS, up to 4-8 mg QHS Silodosin* - 4 mg QD; 4-8 mg QD taken with a meal** Tamsulosin* - 0.4 mg QD, 0.4-0.8 mg QD taken half hour before same meal each day - do not crush Terazosin - 1 mg QHS; 10-20 mg QHS

Question 35

alpha-1 adrenergic blockers side effects

Answer 35

**dizziness fatigue HA orthostatic hypotension retrograde ejaculation **Intra-operative Floppy Iris Syndrome has been observed during cataract surgery in some patients treated with alpha-1 blockers, especially tamsulosin. Complicate the procedure and increase the risk of post-op complications. Inquire about cataracts when first filling Rx for tamsulosin.

Question 36

PDE inhibitors

Answer 36

May be indicated if pt also has ED Effectiveness similar to alpha antagonists - Tadalafil 5 mg daily Relaxes smooth muscle tone of prostate gland and bladder neck - improves urine flow

Question 37

hormonal therapy

Answer 37

5-alpha reductase inhibitors which decreases dihydrotestosterone (DHT) production decreases size of prostate gland by 20 - 25% men with prostate over 40 grams benefit most onset of action may be as long as six months MAY decrease risk of prostate cancer Side effects are usually mild and transient (15% d/c tx during the first year) Impotence, decreased libido, decreased ejaculatory volume, breast tenderness **Decreases PSA by 50% in 6 months Category X - Women (in child bearing years) should avoid handling tablets

Question 38

finasteride

Answer 38

moderate BPH hormone therapy 5 mg PO QD t1/2: 3-16 hours

Question 39

dutasteride

Answer 39

moderate BPH hormone therapy 0.5 mg PO QD t1/2: 6 weeks

Question 40

combination therapy for BPH

Answer 40

``` more effective than either agent alone finasteride+tamsulosin duasteride+tamsulosin finasteride+tadalafil : BPH + ED tamsuloson+tolterodine : BPH + OAB ```

Question 41

treatment of severe BPH

Answer 41

Minimally Invasive Therapies: Transurethral microwave thermotherapy [TUMT], Transurethral needle ablation [TUNA], Prostatic stent placement, Interstitial laser coagulation, Balloon Dilation [TUDP], High-intensity focused ultrasound therapy Benefits may be short-lived Risk of acute urinary retention immediately following procedure Invasive Surgical Therapies: Transurethral Incision of the Prostate [TUIP], Transurethral Resection of the Prostate [TURP], Transurethral electrovaporization, Transurethral laser enucleation, Open prostatectomy

Question 42

ED definition

Answer 42

a consistent inability to obtain or sustain an erection sufficient for intercourse in at least 50% of attempts

Question 43

etiology of ED

Answer 43

15-25% of 65 YO 50% of 75 YO diseases and conditions - DM, HTN, CAD, MS, parkinsons physical: injury, surgery, medicine, radiation unhealthy lifestyle: excessive EtOH, tobacco, obesity, inadequate sleep, stress fatigue/lack of time??? "if you dont use it, youll lose it" ***

Question 44

drug induced sexual dysfunction

Answer 44

antideppresants, antihypertensives, estrogen/anti-androgen, chemo

Question 45

step wise treatment ED

Answer 45

1: treat or eliminate known causes 2: oral PDE-5 inhibitors 3: intraurethral or intracavernous tx 4: possible combination therapy 5: penile prosthesis

Question 46

treatment of drug induced ED

Answer 46

d/c drug if possible, select agent with lower risk of ED | use oral PDE5 inhibitor

Question 47

treatment or organic ED

Answer 47

Evidence of hormonal deficiency - Treat hypogonadism, Low testosterone levels with symptoms (decreased libido), under 300 ng/dL * *Rarely the cause of ED * *oral phosphodiesterase inhibitor if no contraindications * *vacuum erection device - if not a candidate for PO tx * *intra-urethral or intra-cavernosal therapy - if nothing else effective

Question 48

treatment of psychogenic ED

Answer 48

counseling with partner | oral agents

Question 49

oral therapies for ED

Answer 49

**first-line treatment of choice for most patients originally studied as tx for angina promotes smooth muscle relaxation in the penis by inhibition of phosphodiesterase-5 - Inhibits the hydrolyzation of cGMP to 5’ GMP sexual stimulation is required

Question 50

PDE5 inhibitor examples

Answer 50

sildenafil start at 50 mg, max at 100, onset in 30 min, duration 4 hours, dose adjust for renal disease, DI with CYP3A4 inhibitors, lower dose w alpha blocker, take on empty stomach vardenafil start at 10 mg, max 20 mg, onset 30 min, duration 4 hours, take on empty stomach tadalafil 2.5-5mg daily, start at 10mg, max 20 mg, onset 60 min, duration 36 hours, dose adjust for renal disease, wont decrease BP, indicated for BPH, daily low dose may be more effective for some patients avanafil start 100 mg, max 200 mg, onset 30 min, duration 6 hours, DI with CYP3A4 inhibitors, lower dose w alpha blocker

Question 51

PDE5 inhibitors pearls

Answer 51

30-40% of patients do not respond -if not…try a larger dose -**Adjust dose to produce an erection that lasts no longer than 1 hour No known tachyphylaxis over time

Question 52

PDE5 inhibitors drug interactions

Answer 52

CYP3A4 Inhibitors -cimetidine, ketoconazole, erythromycin, ritonavir, grapefruit juice, others -prolongs the effect of the drugs food delays* absorption -Fatty meal can delay absorption of sildenafil and vardenafil by 1 additional hour

Question 53

PDE5 inhibitor SEs

Answer 53

*Most are mild and self-limiting headache (10%), flushing (10%), dyspepsia (7%), nasal congestion, lower back and limb pain (Tadalafil only), light sensitivity; blue tinge to vision (2-3%), NAION (nonarteritic ischemic optic neuropathy)??? - sudden vision loss

Question 54

PDE5 inhibitors precautions

Answer 54

***patients on oral or transdermal nitrates: DO NOT USE Dosing of nitrate after: -Viagra/Levitra: 24 hrs -Cialis: 48 hrs -patients on oral or transdermal nitrates -patients on alpha-blockers (start at lower dose) -patients with very severe CAD

Question 55

PDE5 inhibitors patient educations

Answer 55

Taking on demand vs. daily dosing - 1-2 hours prior to intercourse Dosing with respect to meals Report erections that last over 4 hours !!! Report any visual or hearing complaints Report palpitations or dizziness Avoid with nitrates

Question 56

PDE5 inhibitos for pulmonary hypertension

Answer 56

Sildenafil: Revatio 20 mg PO TID - generic available Tadalafil: Adcirca 40 mg PO once daily

Question 57

vacuum erection devices

Answer 57

``` **very effective (satisfaction rate up to 60-80%) slow onset (3-20 min) base ring used to maintain erection $150 - $450 bruising; numbness pain from bands blue, cool penis Avoid in sickle-cell pts ```

Question 58

transurethral suppositories

Answer 58

``` Alprostadil Pellets - MUSE 125mcg, 250mcg, 500mcg, 1000mcg more acceptable to many patients than injection less effective than injection onset within 5 -10 minutes penile pain 30%; burning 10% urinate first insert suppository role penis for 10-30 sec Max of 2 doses per day Use with oral agents ??? ```

Question 59

intracavernosal injections

Answer 59

``` Alprostadil Injection - Caverject ® -***DOC if pts fails PDE-5 Inhibitors -may be best for neurogenic ED -onset within 5 minutes -duration around 1 hour -injection technique must be taught [vary the site of injection] 30 - 35% discontinue use within 1 year Maximum of 1 injection/day; 3 per week Highly effective (70% to 90%) **No sexual stimulation required ```

Question 60

alprostadil inj SE/AE

Answer 60

some local irritation penile pain (10-40%) - Burning; dull pain risk of priapism- Most common during dose titration cavernosal plagues or areas of fibrosis (2-12%)

Question 61

intracavernosal injection agents

Answer 61

``` Alprostadil (27-30 gauge needle) -start at 2.5 mcg (many start @ 10 mcg) -usual range 10 - 20 mcg -max dose = 60 mcg -**titrate to dose that produces an erection lasting 1 hour -Efficacy better than papaverine Papaverine -7.5 - 60 mg when used alone -0.5 - 20 mg when used in combo -higher incidence of ADRs (35% incidence of priapism** and fibrosis) Phentolamine -Blocks adrenergic tone -0.5 - 1 mg doses used in combo -used in combination with papaverine ```

Question 62

priapism treatment

Answer 62

``` Erection > 4 hours Pain Phenylephrine 0.1 – 1 mg Blood aspiration Saline irrigation ```

Question 63

penile prostheses

Answer 63

``` Semi-rigid insert Pump irreversible only used when other treatments fail Replace every 5-10 yrs $10 - $15K ```