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Men's and Women's Health EXAM 3
Men's and Women's Health EXAM 3 - Ruscin
33
Pharmacology
Graduate
12/07/2011

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Term
receptor activity in the bladder, urethra, prostate
Definition
ACETYLCHOLINE:
agonists - contract bladder smooth muscle
antagonists - relax bladder smooth muscle

ALPHA1 ADRENERGIC:
agonist - contracts urethra, bladder neck, prostate tissue
antagonist - relax urethra, bladder neck, prostate tissue

smooth muscle of the bladder responds to calcium; CCBs (nifedipine, amlodipine) can cause similar effects to anticholinergics
Term
defining BPH
Definition
the definition of clinical BPH includes 3 considerations: symptoms, prostate size, and obstruction

men may have LUTS (lower urinary tract symptoms), with or without an enlarged prostate, and these men may or may not have bladder outflow obstruction

obstruction and/or irritative symptoms can occur both in the presence and in the absence of BPH

for example, the irritative symptoms commonly arising in women as they age are not attributed to an enlarged prostate

conversely, a man may have prostatic enlargement without experiencing obstructive or irritative symptoms

technically, BPH is diagnosed in the presence of histologic evidence of hyperplasia whereas the term lower urinary tract symptoms (LUTS) refers to a clinical syndrome characterized by irritative and/or obstructive symptoms

LUTS can occur regardless of whether or not BPH is present

few patients have histologic documentation of BPH, but they have presumptive BPH on the basis of findings of prostate enlargement during digital rectal exam or imaging studies. these patients are considered to have CLINICAL BPH (presumptive BPH that has not been histologically confirmed)
Term
prevalence of LUTS with age
Definition
[image]

study results indicated that most symptoms gradually progress with age - particularly nocturia, which showed the most dramatic increase

other symptoms including hesitancy (data not shown), weak stream, urgency, and frequency, were more frequently seen in the older population

even in "normal" subjects, urinary symptoms and urodynamic variables may evolve with age; in elderly subjects they warrant careful interpretation
Term
role of androgens
Definition
androgens are required for normal cell proliferation and differentiation in the prostate, and also actively inhibit cell death

in the prostate 5alpha reductase converts testosterone into 5alpha DHT

DHT induces androgenic effects by binding to androgen receptors; is a more potent androgen than testosterone
Term
prostate size
Definition
young adult male:
20-25 grams

enlarged:
greater than or equal to 30 grams

significantly enlarged:
greater than or equal to 40 grams

CombAT study: mean 55 grams
Term
Clinical LUTS/BPH OBSTRUCTIVE symptoms
Definition
obstructive = voiding issue

hesitancy

straining

weak flow

terminal dribbling

prolonged voiding

incomplete emptying

retention
Term
Clinical LUTS/BPH IRRITATIVE symptoms
Definition
irritative = storage issue (similar to overactive bladder disorder)

frequency

urgency

nocturia

urge incontinence

small voided volume

dysuria
Term
COMPLICATIONS OF BPH
Definition
URINARY RETENTION

RENAL IMPAIRMENT

URINARY TRACT INFECTION

gross hematuria

bladder stones

bladder damage

OVERFLOW INCONTINENCE

WORSENING SYMPTOMS (AUA-SI SCORE)
Term
overflow incontinence
Definition
occurs when intravesicular pressures exceed intraurethral pressures - ONLY at HIGH volumes

bladder outlet obstruction - BPH, neoplasm

impaired afferent sensation

diabetic neuropathy, spinal cord lesions below T-11

MUSCLE RELAXANTS, CALCIUM CHANNEL BLOCKERS, ANTICHOLINERGICS (ALL RELAX THE BLADDER)

clinical features: palpable or percussable bladder, suprapubic tenderness, low urinary flow rates, INCREASED POST-VOID RESIDUAL URINE (PVR)
Term
post void residual (PVR)
Definition
amount of urine remaining in the bladder following attempt by the patient to empty the bladder

normal: < 50 cc
increased: > 50 cc

assessed by straight catheter placement post void or estimated with bladder scanner
Term
acute urinary retention (AUR)
Definition
painful

initial management by catheterization (often in ER setting)

refractory urinary retention may require surgical intervention
Term
American Urological Association - Symptom Index (AUA-SI)
Definition
scored from 0-35 with 35 the worst

DON'T HAVE TO KNOW CUT OFFS...BUT:

mild = 0-7
moderate = 9-19
severe = 20-35
Term
prostate specific antigen (PSA)
Definition
normal PSA: < 4 ng/ml
elevated PSA: > 4 ng/ml

screening PSA for prostate cancer:
several factors can increase PSA - prostatitis, BPH, digital rectal exam, ejaculation in last 24 hours, catheterization

other parameters:
PSA velocity/density - how quickly the number rises

just a screening tool, not a great predictor of prostate cancer
Term
MEDICATIONS THAT MAY EXACERBATE LUTS
Definition
drugs with ANTICHOLINERGIC ACTIVITY:
antihistamines
antidepressants
overactive bladder medications
mechanism - lessen detrusor muscle contractions
daily use associated with 2-3 point increase in AUA-SI

SYMPATHOMIMETIC AGONISTS
appetite suppressants
decongestants
mechanism - block relaxation of the internal urethral sphincter

DIHYDROPYRIDINE CALCIUM CHANNEL BLOCKERS
nifedipine
amlodipine
mechanism - relax smooth muscle

symptoms may also be increased with caffeine and alcohol
Term
treatment for LUTS/BPH
Definition
watchful waiting

MEDICAL THERAPY:
ALPHA BLOCKERS
5ALPHA REDUCTASE INHIBITORS
ANTICHOLINERGICS/ANTISPASMOTICS (for irritative symptoms only!)
PHYTOTHERAPY (herbs)
TADALAFIL (Cialis)

surgery:
transurethral resection of the prostate (TURP)
transurethral incision of the prostate (TUIP)

transurethral microwave thermotherapy
Term
alpha1 blockers
Definition
alpha1 blockers: terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), alfuzosin (Uroxatral), silodosin (Rapaflo)

prazosin (Minipress) not FDA approved for BPH

phenoxybenzamine - old school, blocks alpha1 and alpha2; tachycardia and arrhythmias

inhibit alpha adrenergic mediated contraction of prostatic smooth muscle = relief of bladder outlet obstruction

FIRST LINE OF PRESCRIBED MEDICAL THERAPY

efficacy documented by multiple clinical randomized trials; long term efficacy is less well documented

low risk of morbidity

can be discontinued at any time

WORK QUICKLY - DAYS TO WEEKS

titration required with terazosin and doxazosin b/c of BP effects

all have a possible interaction with PDE-5 inhibitors

alfuzosin (Uroxatral) and silodosin (Rapaflo) should not be administered with potent CYP3A4 inhibitors (ketoconazole)
Term
alpha adrenergic blockers for BPH: adverse events profiles differ slightly
Definition
dizziness, fatigue or somnolence, and nasal congestion reported for all alpha blockers

headache worse with alfuzosin (Uroxatral) and silodosin (Rapaflo)

hypotention, dizziness, and syncope worst with terazosin (Hytrin) and doxazosin (Cardura)
no BP effects with tamsulosin (Flomax)
sligh BP effects with alfuzosin (Uroxatral) and silodosin (Rapaflo)

abnormal ejaculation worst with silodosin (Rapaflo), followed by tamsulosin (Flomax)
if patient is complaining of this symptoms recommend alfuzosin (Uroxatral)

intraoperative floppy iris syndrome is possible with all
DO NOT recommend stopping the alpha blocker; the patient will be given eye drops before surgery to prevent this problem
Term
what to expect from medical therapy for BPH with alpha blockers: terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), alfuzosin (Uroxatral), and silodosin (Rapaflo)
Definition
averate 4-6 point improvement in AUA-SI

patients will perceive this level of symptom improvement as a meaningful change

symptoms improvement may be noticeable in DAYS TO WEEKS
Term
5alpha reductase inhibitors
Definition
type 2: finasteride (Proscar)
type 1 and type 2: dutasteride (Avodart)

reduce DHT levels in serum and prostate
reduces prostate size, increases peak urinary flow, and reduces BPH symptoms

most useful in men with enlarged prostates (> 35 grams)

not as effective for symptom relief as alpha blockers
Term
what to expect from medical therapy for BPH with 5alpha reductase inhibitors: finasteride (Proscar) and dutasteride (Avodart)
Definition
average 3 point improvement in AUA-SI; perceived as a meaningful change

symptom improvement takes MUCH longer (UP TO 6 MONTHS OR LONGER)

combination therapies produce on average 5-7 point improvement in AUA-SI; symptom improvement may begin in days to weeks (due to alpha blocker initially)
Term
ADRs with 5alpha reductase inhibitors
Definition
primarily sexually related including decreased libido, ejaculatory dysfunction, erectile dysfunction

breast changes (lumps, pain, or nipple discharge)

LOWERS PSA BY ABOUT 50%
if a patient's PSA stays constant while on a 5alpha reductase inhibitor, it should be interpreted as an increase

combination therapy:
ADRs reflect the combined AE profile of both alpha blockers and 5alpha reductase inhibitors
Term
advise/tips to patients
Definition
decrease fluid intake at bedtime

decrease caffeine and alcohol intake

avoid cold medications with alpha sympathomimetic/anticholinergic drugs

use a voiding diary to record symptoms

use of dietary supplements? usually not recommended
Term
adherence
Definition
an adequate duration for treatment trial is at least 2-4 weeks after patient has achieved usual maintenance dose (alpha blockers)

medical therapy for BPH is intended to be continuous
if alpha blocker is discontinued it should be reinstituted using initial dosing regimen and titrated to effective dose

may take SIGNIFICANTLY longer to see benefits with 5alpha reductase - up to 6 months!
Term
contraindications and precautions
Definition
alpha blockers and 5alpha reductase inhibitors are metabolized in the liver (CYP3A4)
caution advised in patients with impaired hepatic function
caution in patients with moderate to severe hepatic impairment, and in combination with potent CYP3A4 inhibitors (ritonavir, ketoconazole), for ALFUZOSIN IN PARTICULAR

5alpha reductase inhibitors - contraindicated for pregnant women
patients should be cautioned that pregnant women should not handle crushed or broken tablets
patients should be advised not to donate blood until at least 6 months since last dose to avoid transfer to pregnant females
Term
combination therapy of alpha blocker and 5 alpha reductase inhibitor
Definition
appropriate for men with LUTS associated with demonstrable prostate enlargement

addition of a 5alpha reductase inhibitor to an alpha blocker has been shown to reduce risk of BPH related complications

those most likely to benefit from combination therapy are those with high risk of progression (larger prostates)

one combo product available commercially (Jalyn - dutasteride + tamsulosin)
Term
medical therapy of prostatic symptoms (MTOPS) trail
Definition
primary research question: to determine if medical therapy prevents or delays the clinical progression of BPH as defined by 1 or more of the following:
AUR
renal insufficiency due to BPH
recurrent UTI
incontinence
> 4 point risk in baseline AUA-SI confirmed within 2-4 weeks

combination therapy (doxazosin + finasteride) was better than any therapy alone and better than placebo

MTOPS study demonstrated that long term medical therapy with an alpha blocker, 5alpha reductase inhibitor, or both, not only improves symptoms but also reduces the clinical progression of BPH, defined as:
worsening of symptoms (increased AUA-SI)
acute urinary retention
incontinence
urinary tract infection
renal insufficiency
Term
PREDICT Study
Definition
similar to MTOPS

placebo, doxazosin, finasteride, or both

primary outcome = urinary flow rate and symptom control

doxazosin superior to placebo, finasteride, or both

finasteride not different from placebo
Term
CombAT Study
Definition
also similar to MTOPS, but more severe BPH (mean prostate size 55 cc)

tamsulosin, dutasteride, or both

2 years - combo therapy improved symptoms and flow rates

4 years - combo superior to tamsulosin, but no dutasteride alone; combo better than either monotherapy for clinical progression
Term
tamsulosin + tolterodine (Detrol) for LUTS and OAB
Definition
men with symptoms of both BPH and overactive bladder (urgency, frequency, nocturia)

placebo, tolterodine, tamsulosin, or both

placebo and monotherapy showed no benefit in symptoms, but combo therapy did (urgency, incontinence, nocturia)

antimuscarinics not currently included in treatment guidelines

patient on anticholinergic with BPH. how do you measure if his obstructive symptoms are getting better? (relaxing the bladder too much)
PVR
if PVR goes from 30 to 150 then he is getting some urinary retention
Term
treament of BPH
Definition
mild sx:
watch and wait
OR
alpha antagonist
OR
5 alpha reductase inhibitor
if response, continue; no response, combo or surgery

moderate sx:
alpha antagonist
OR
5alpha reductase inhibitor
if response, continue; no response, combo or surgery

moderate to severe sx (with large prostate):
alpha antagonist
AND
5alpha reductase inhibitor
if response, continue; no response, surgery

severe sx and complications:
surgery
Term
saw palmetto
Definition
extract from the Saw Palmetto Berry

MOA:
thought to have 5alpha reductase properties
possibly anti inflammatory properties

efficacy - may reduce symptoms of BPH

ADRs - mild GI distress; generally safe
some concerns of masking prostate cancer due to potential to lower PSA

Saw Palmetto for BPH Study:
no significant change in AUA-SI or peak urinary flow rates at 1 year
found no significant lowering of PSA
Term
prostate cancer screening
Definition
digital rectal exam:
useful tool; can detect cancer in some men with normal PSA
sensitivity of DRE is 59%
some limitations - only posterior and lateral parts can be palpated; early/small tumomrs may not be palpated

PSA testing (prostate specific antigen):
20-30% of tumors missed if PSA used alone
15% of men with intermed or high grade tumors had wnl SPA
some suggest - PSA density/velocity

biopsy:
consider if abnormalities noted with DRE or PSA

PSA in combination with a DRE is the BEST screening tool; if these are suspicious, you move on to the prostate biopsy

"PSA based screening results in small or no reduction in prostate cancer specific mortality and is associated with harms related to subsequent evaluation and treatments, some of which may be unnecessary"
Term
prostate cancer - chemoprevention
Definition
no benefit of vitamin E, selenium, dutasteride, or finasteride on prostate cancer risk
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