Male & Female Health Part 2

Drugs that Cause Erectile/Sexual Dysfunction

Alcohol

Antidepressants

• Especially SSRIs & SNRIs

Beta-Blockers, Clonidine, Thiazides

First-generation antipsychotics (e.g., Chlorpromazine)

Prolactin-raising second-generation antipsychotics (e.g., Risperidone, Paliperidone)

Finasteride, Dutasteride, Silodosin

Natural Products for Erectile Dysfunction

Yohimbe

L-arginine

Panax ginseng

Phosphodiesterase Type 5 (PDE-5) Inhibitors

• MOA: blocks PDE5 from degrading cGMP, which causes smooth muscle relaxation

[First Line Treatment; DO NOT increase libido]

Sildenafil (Viagra) → 50mg 1hr before

Tadalafil (Cialis) → 10mg 30min before

Vardenafil → 10mg 1hr before

Avanafil → 100mg 15-30min before

[AVOID Nitrates or Riociguat]

[Color discrimination, Hearing loss, Vision loss, Hypotension, Priapism (ED if >4hrs)]

[Headache, Flushing, Dizziness, Dyspepsia, Backpain(mainly Tadalafil)]

[Decreased efficacy with high-fat or large meals]

When to Reduce the Dose of PDE-5 Inhibitors?

• >/= 65 YO

• Using an alpha-blocker

• Using a CYP3A4 inhibitor

• Severe renal or liver disease

[Reduce dose by 50%]

Prostaglandin E1

• vasodilator that allows blood to flow into the carvernosal arteries

Alprostadil

• inject into the penis, or a pellet is inserted through the urethra

• Causes penile pain, priapism

Hypoactive Sexual Desire Disorder

Flibanserin

• 5-HT1A agonist & 5-HT2A antagonist

• Boxed - alcohol, REMS, CYP3A4

• Hypotension, Syncope

Bremelanotide

• nonselective melanocortin receptor agonist

• Avoid within uncontrolled HTN or known CVD

[Both for Premenopausal Females ONLY]

Forms of Urinary Incontinence 

Urge - A sudden and unstoppable urge to urinate; Associated with neuropathy

Stress - Urine leaks out during any form of exertion

Mixed - Urge + Stress incontinence

Functional - No abnormality in the bladder

Overflow - Leakague due to the quantity of urine stored in the bladdere exceeds its capacity (usually cause by BPH)

Risk for Overactive Bladder

• > 40 YO

• Diabetes

• Prior vaginal delivery

• Obesity

• Neurologic conditions

• Drugs that increase incontinence

• Restricted mobility

• Hysterectomy

• Pelvic injury

Non-Drug Treatment for Incontinence

• FIRST LINE is behavioral therapies

• Pelvic floor muscle exercises (Kegel Exercises)

• Fluid management

Drug Treatment for Incontinence

Behavioral Therapy with Anticholinergic or Beta-3 Agonist 

• OnabotulinumtoxinA (Botox) Injection

  • Nerve Stimulation or Surgical Treatment

Anticholinergics (Antimuscarinics) for Incontinence

• MOA: competitively bind to muscarinic receptors & block acetylcholine from binding

Oxybutynin IR, Oxybutynin ER (Ditropan XL), Oxybutynin patch (Oxytrol)

• Most drowsiness & dizziness

Tolterodine (Detrol), Tolterodine ER (Detrol LA)

Trospium IR/XR

Solifenacin (Vesicare)

Darifenacin

Fesoterodine

[AVOID in > 65 YO, Uncontrolled narrow-angle glaucoma]

[Agitation, Confusion, Drowsiness, Dizziness, Blurred vision, Dry mouth, Constipation]

To Decrease Dry Mouth Risk in Anticholinergic Treatment

• Try extended-release

• Try oxybutynin gel or patch

• Beta-3 agonists have less risk

• Try non-drug options

Beta-3 Agonists

• MOA: relax the detrusor muscle & increase bladder capacity by activating beta-3 receptors

Mirabegron (Myrbetriq)

Vibegron (Gemtesa)

[Less dry mouth] [Mirabegron increases BP]

Nocturia Treatment

Desmopressin (DDAVP)

• an antidiuretic hormone analog that temporarily decreases urine production

• Boxed - severe, life-threatening hyponatremia

• AVOID PT with increased risk of fluid retention (e.g., uncontrolled HTN, HF)

Drugs that Can Worsen BPH

• Centrally-acting Anticholinergics (e.g., Benztropine)

• Antihistamines

• Decongestants

• Phenothiazines

• TCAs

• Caffeine

• Diuretics

• SNRIs

• Testosterone products

Natural Product fo BPH

• Saw Palmetto

• Lycopene for prostate cancer prevention

BPH Treatment

Mild disease → watchful waiting

Moderate-Severe

• Alpha-Blockers (First Line) used alone or in combination with 5 alpha-reductase inhibitor

• 5 alpha-reductase inhibitor

Alpha-Blockers for BPH

MOA: Inhibits alpha-1 adrenergic receptors, causing relaxation of smooth muscle in the prostate & bladder neck to help reduce bladder outlet obstruction & improves urinary flow

Alpha-1A (mainly in prostate); Alpha-1B & Alpha-1D (In heart & arteries)

• Nonselective have more side effects than selective

Nonselective Alpha-1 Blockers

• Doxazosin (Cardura, Cardura XL)

• Terazosin

• [HS to minimize orthostasis/dizziness]

Seletive Alpha-1 Blockers

• Tamsulosin (Flomax) → 0.4 mg QD

• Alfuzosin

• Silodosin → can cause Retrograde Ejaculation

ALL Alpha Blockers

• Orthostatic hypotension/syncope

• Intraoperative Floppy Iris Syndrome (IFIS) can occur in cataract surgery

• Require 4-6 weeks

• They DO NOT shrink the prostate or change PSA levels

5 Alpha-Reductase Inhibitors

MOA: block the conversion of testosterone to DHT

Finasteride (Proscar)

Dutasteride

[AVOID women of child-bearing potential, pregnancy]

[For BPH with enlarged prostate → They CAN Shrink prostate & PSA levels]

[Impotence, reduced libido, ejaculation disturbances, breast enlargement, tenderness]

[Require 6 months for maximal efficacy]