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Dr. Chip
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Experience:  Over 20 yrs of Family Practice
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I started taking Rapaflo about 4 weeks ago for relief from

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I started taking Rapaflo about 4 weeks ago for relief from urinary retention. Although urodynamics test have yet to be conclusive, my problem is thought to originate from a problem with my bladder neck. It is also possible that I may have  detrusor underactivity either primary or secondary to the bladder neck obstruction.


 


I have been on Flomax for years with no noticeable benefit, but I notice significant easing of symptoms with Rapaflo (I was given the drug as a sample by a nurse practitioner). Have you heard of this working for bladder neck problems where Flomax failed to relieve symptoms? However, I had no side effects with the Flomax; with the Rapaflo I have retrograde ejaculation and diminished libido. I believe the diminished libido, while still present, is present to a lesser degree than in the first couple weeks of taking Rapaflo. Can you comment on the body adjusted to either of the preceding side effects over time? Could the retrograde ejaculation actually be a sign that the medicine is more effective at relaxing my bladder neck?


 


Also, since the Rapiflo is reducing my symptoms but also has adverse side effects, is there another alpha blockers that may work for me but not have the side effects of retrograde ejaculation and/or reduced libido; e.g., Uroxatral? What would you recommend I try? Would increasing the Flomax to 0.8 a day be a possible scenario, or not likely since 0.4 does not help.


 


I just noticed in reading a profile of Rapaflo that the user is advised to tell his doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of: other alpha-blocker drugs (such as doxazosin, prazosin), drugs for high blood pressure, drugs for male erectile problems (such as sildenafil, tadalafil, vardenafil), other drugs that affect the removal of silodosin from your body (such as cyclosporine, diltiazem, erythromycin, fluconazole, verapamil, St John's worth).


 


I take Metoprolol (50-100 mg a day) for symptomatic mitral valve prolapse and St. John's Wort (Kira Brand) for depression. However, my use of the St. John's Wort has been intermittent.


 


Given the above precautions on drugs for high blood pressure (as a beta blocker my understanding is that Metoprolol lowers blood pressure) and the use of St. John's Wort, should I have any concerns? Specifically, I cannot tell from the wording above, but do both Metapropol and St. John's Wort interfere with the removal of silodosin from your body, or is that just a feature or St. John's Wort?


 


 What is the effect of interfering with the removal of silodosin from your body? What implications exist for your health or the effectiveness of the Rapaflo? Part of the reason I ask it that I am considering increasing my dosage of St. Johns Wort to the recommended 900 mg a day, and want to know if any side effects may occur.


 


Thank you!


 


 Added Note: I do not have an enlarged prostate. The first symptoms of urinary retention began in my late thirties.


 


Optional Information: Gender: Male Age: 55

Submitted: 2 years ago.
Category: Health
Expert:  Dr. Chip replied 2 years ago.
HI--you have several questions in the above posting, and I'd like to take them one at a time. First, what exactly is the nature of this assumed bladder neck obstruction, and have you had cystoscopy? Second, are you asking if there may be another medication that works without the retrograde ejaculation and lowered libido?
Customer: replied 2 years ago.
I'll get back to you with more information tongiht after I review my medicall records. Thank you.
Expert:  Dr. Chip replied 2 years ago.
OK
Customer: replied 2 years ago.

 

I had video urodynamics done in December 2009 that I have subsequently been told by other urologists failed because I did not urinate. The diagnosis of the urologist who did the test was: "In view of long history, he may have bladder neck dysynnergia v. Hinmans syndrome. Plan: Three options: no treatment v. start CIC v. Bladder neck incision."

 

At the urging of my urologist I did begin catherization before bed and upon waking (that was her recommendation to prevent further bladder decompensation); however, I had five infections if less than four months. Subsequent urologists said that these infections were caused by only using a catheter twice a day while retaining large amounts of urine. CIC is clean, but it is not sterile. A urologist here on "Just Answers" concurred.

 

I had a cytoscopy in November 2007 with the only reportable findings of: Posterior urethra showed lateral lobe hypertrophy, relative significant. No bladder stones or mucosal lesions identified. Prostate gland approximately 3 cm in size. Uroflo revealed a voiced volume of 296 ml with a flow time of 31 seconds and an average flow of 4 ml per second and a peak flow of 13 ml second. Post void residual was 155 ml."

 

I also had a cyctoscopy in August 2003 which stated: "There were no strictures encountered. The prostate was hyperemic and obstructive, approximately 10-15 grams in size, tribolar. Benign prostatic hypertrophy with chronic prostatitis, no evidence of urethral stricture, and hypogonadism."

 

I went an urologist at Stanford a few weeks ago and he wants to do urodyamics again. According to "Urodynamics Made Easy" by Dr. Christopher R Chapple, copyright 2009, "Video urodynamics is necessary to make the diagnosis of bladder neck obstruction. In this condition the bladder neck does not open completely during voiding and there is little or no flow during a well sustained detrusor contraction."

 

The Stanford urologist said given my age and duration of the condition, 99% of the time the problem is the bladder neck and not the prostate. (I assume he meant if there is a blockage and the problem is not just detrusor underactivity). I showed him a copy of the relevant pages in the book and he pointed to the representation showing a "tight bladder neck".

 

He warned that if the urodynamics revealed the need for a TUBIN (Transurethral Incision of the Bladder Neck), a possibility exists for retrograde ejaculation and accompanying reduced sensation at orgasm. He said probability was about 20% with single incision and 40% with bilaterial incision. But like every other doctor he said "But if you're one of the 20% it doesn't matter what the odds are". That must be on the final test at medical school! Most urologists cannot give you a percentage for that side effect and the literature goes all the way from zero percent for a single incision to retrograde ejaculation happening "most of the time". I read an article recently that said that a modified TUBIN exists which preserves antegrade ejaculation by preserving a portion of the supramontanal tissue. (Urology International, January 18, 2008)

 

The doctor told me to try Sudafed to see if that would produce antergrade ejaculation with the Rapiflo. He said that would also show whether antergrade could be produced via Sudafed if I had the TUBIN, and I had the retrograde ejaculation side effect. I am concerned about doing that since I have had tachycardia episodes from mitral valve prolapse, and take Metropopol daily as a result.

 

Since I wrote the above question, I know have read the following:

 

Tamsulosin (Flomax) did not cause retrograde ejaculation. It causes
anejaculation (absence of ejaculation) probably due to the drug's
effect on the D2 (dopaminergic) receptors. In addition it seems to
have an effect on the 5HT1a (serotoninergic) receptors. We all know
what fiddling with serotonin does to sexual function from the SSRI
experience. (I know that personally from taking Prozac a decade ago!)

 

From Medscape:

 

A recent comparative study (ABEJAC Study) of alfuzosin and tamsulosin in young, healthy volunteers has objectively confirmed the increased risk of ejaculatory disorders in patients receiving tamsulosin.[9] This disorder is not due to tamsulosin's effect on the bladder neck and thus is not retrograde ejaculation (Figure 4).

 

(Well, there goes my thinking that the Rapiflo may be working because it is having the retrograde ejaculation effect on me.)

 

This effect could be due to differential peripheral effects on the seminal vesicles and/or vas deferens or central actions involving binding to 5HT1A and D2 receptors involved in the ejaculation mechanism. A novel, mechanistic study by Giuliani and colleagues[10] explored the central differences of these 2 agents in adult Wistar rats. A central facilitatory role of 8-OH-DPAT, a 5HT1A agonist, on ejaculation is well documented. Using various inhibitors of 5HT1A and D2-like receptors, which were co-injected intracerebroventrically concurrently with 8-OH-DPAT, these investigators determined that tamsulosin's effect was likely due to interaction with D2 receptors centrally. These and other pioneering studies will help us map out uncharted central pathways involved in many aspects of sexual function (arousal, erection, ejaculation, and orgasm).

 

The article has graphs that show that alfuzosin has little to no effect on ejaculatory function, even at increased dosages.

 

Uroxatral worth a try?

 

Thank you for your assistance.

Expert:  Dr. Chip replied 2 years ago.
Well, you certainly have done extensive research. That particular question you mentioned above wasn't on my med school test, but that is the problem with statistics--they're relevant only for large numbers of patients and don't precisely apply to the one. You can always roll boxcars at the crap table on the first roll even though the number seven normally would be the most likely roll. So is your only question about the Uroxatral?
Customer: replied 2 years ago.

I threw a lot at you. lol Amazing though the differences of opinion of urologists (I have had every possible procedure recommended and ready to operate without a valid urodynamics test to discern whether my problem is due to a blockage or just detreusor underactivity). I didn't become this informed until hearing other uroliogist contradict each other and then doing research myself.

 

I don't want to have the surgery if the problem will remain due to detrusor underactivity! And the urologist who recommended twice a day, and the nurse practitioner that told me even once a day would help - what were they thinking!!

 

Anyone, blowing off a little steam. Kind of scary out there is you don't have a certain basic knowledge as a patient. Even then, you need to overcome doctors' hesitancy to answer your questions because they think you are too challenging and take too much time. The doctor who made the recommendations of twice a day kicked me out of her practice because I was taking too much of her time and too many phone calls (she never returned one; just ill advised return calls from her nurse).

 

So, now to the questions:

 

1. Uroxatral worth a try? Any experience with this medication? Maybe could work like Rapilflo for me in reducing symptoms but without the side effects? Do you know how many days on average it takes to know whether the medication is working for you; i.e., full effect? Do you know why I am having decreased libido with the Rapiflo but not the Flomax?

 

2. I read a profile of Rapaflo that the user is advised to tell his doctor or pharmacist of all prescription and nonprescription/herbal products you may use.....drugs for high blood pressure, other drugs that affect the removal of silodosin from your body (such as cyclosporine, diltiazem, erythromycin, fluconazole, verapamil, St John's worth).

 

I take Metoprolol (50-100 mg a day) for symptomatic mitral valve prolapse (occasional tachycardia) and St. John's Wort (Kira Brand) for depression. However, my use of the St. John's Wort has been intermittent.

 

Given the above precautions on drugs for high blood pressure (as a beta blocker my understanding is that Metoprolol lowers blood pressure) and the use of St. John's Wort, should I have any concerns? Specifically, I cannot tell from the wording above, but do both Metapropol and St. John's Wort interfere with the removal of silodosin from your body, or is that just a feature or St. John's Wort?

 

What is the effect of interfering with the removal of silodosin from your body? What implications exist for your health or the effectiveness of the Rapaflo? Part of the reason I ask it that I am considering increasing my dosage of St. Johns Wort to the recommended 900 mg a day, and want to know if any side effects may occur.

 

3. Should I have any concern taking Sudafed to produce antegrade ejaculation given my history of mitral valve prolapse and occasional tachycardia?

 

I realize you may not be able to fully answer all these questions, but just provide the best professional opinion you can give under the circumstances, and/or questions I need to ask my urologist.

 

Thank you!

Expert:  Dr. Chip replied 2 years ago.
OK--this may take a bit here. What exactly do you mean by the removal of the Rapaflo from your body? And, I apologize if this was mentioned, but have you had testosterone levels checked?
Customer: replied 2 years ago.

 

One of the web sites pertaining to Rapaflo had the he following caution regarding problems with the removal (I cannot find the URL):

 

"I just noticed in reading a profile of Rapaflo that the user is advised to tell his doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of: other alpha-blocker drugs (such as doxazosin, prazosin), drugs for high blood pressure, drugs for male erectile problems (such as sildenafil, tadalafil, vardenafil), other drugs that affect the removal of silodosin from your body (such as cyclosporine, diltiazem, erythromycin, fluconazole, verapamil, St John's worth)."

 

Since I take both a beta blocker (Metoprolpol) and St. John's Wort (intermittently; I am planning to take 9000 mg a day), I was seeking advice on interactions of these drugs with Rapaflo. A scan of other sites does not seem to mention problems with interactions with these drugs, however. Appreciate any knowledge you may have on potential interactions.

 

I am on testosterone supplementation, applying 5g of Androgel a day (although I miss a couple days a week, and have been prescribed 10g a day (medical records show no reason for increasing dosage, and I was never told the dosage was to be increased. In fact, one of the doctor's in my former urologist office stopped the testosterone supplementation without my approval when my primary urologist was on maternity leave). It was difficult to get approval back for the medication, but eventually I did. However, the next urologist I saw recommended against taking the Androgel because he said it would interfere with my body's own production of testosterone (former urologists said this was not a concern), and that unless the testosterone level was very low (< 100 ng/dL) he does not prescribe the medication in the absence of clear symptoms.

 

I was prescribed Androgel at age 47 when another former urologist said my free testosterone was on the borderline of normal for a 50 year-old man. When he left the office, my next urologist never ordered free testosterone tests (until I requested) and had no knowledge of its importance (as an aside, the urologist who recommended against Androgel said the test for free testosterone was not reliable).

 

I am a little leery of the medication because of the conflicting advice, and the fact that my father and his brother had prostate cancer, but only upon age 70. But maybe I should be more consistent with its use, and increase the dosage to 10 g a day to see if that would counteract the decrease in libido caused by the Rapaflo?

 

My latest (10/8/10)0 results of testosterone are listed below. As you can see, I need to have my total testosterone at a certain level to get sufficient free testosterone because my % of free testosterone is low.

 

 

Total Testosterone

412

250 - 1100

ng/dL

Total Testosterone was measured by LCMSMS. The LCMSMS method
correlates well with our extraction/RIA method.

% Free Testosterone

0.86

1.5 - 2.2

%

L

Free Testosterone

35.4

35.0 - 155.0

pg/mL

 

 

So generally happy with the better urine flow with the Rapaflo (although when went to Stanford PVR was still 400 mil. Maybe that was an anomaly, because my stream and feeling of not being able to empty my bladder have increased. However, the side effects of no ejaculation and decreased libido are disturbing, which is why I am considering another alpha-adrenergic blockers such as Uroxatral. Your recommendation? Curious why I am having these side effects with Rapaflo while I did not experience them at all with Flomax?

 

Thank you for your assistance!

Expert:  Dr. Chip replied 2 years ago.
There are no specific adverse interactions between metoprolol, Rapaflo, and St. John's Wort except for the provision to monitor blood pressure lowering. The Uroxatral is worth the try to see if it solves the problem because you specific problems aren't listed with it. I'm sure you probably have more to ask, so, please, if we need to continue, just tell me.
Customer: replied 2 years ago.

Do you have any knowledge of why the Rapaflo causes retrograde or lack of ejaculation (do you know which?) and decreased libido while Flomax does not?

 

Apparently no correlation with whether the drug works for you or not?

 

If the Uroxatral fails, next alternative choice(s)? Since the Rapflo is working for me, it give me new hope to avoid surgery, especially if I can find another alpha-adrenergic blocker that works for me like Rapaflo without the side effects.

 

Will accept after response. Thank you.

Expert:  Dr. Chip replied 2 years ago.
As for the retrograde ejaculation with Rapaflo, the suggestion--and that's the term the experts use--is that it indicates the level of smooth muscle relaxation caused by the drug. Flomax is also an alpha 1 blocker so potentially both drugs could cause the same side effects, or no side effects, or one might when the other didn't. In your case, I'd have to say that it's a selective effect--it's just happens with you that the two don't act exactly the same when it comes to side effects. The alternatives to Uroxatral include Cardura, Avodart, and Proscar.
Customer: replied 2 years ago.

According to Medscape Urology:

 

http://www.medscape.org/viewarticle/503691

 

"The 5-alpha-reductase inhibitors are associated with an increased incidence of impotence, whereas among the alpha-blockers, tamsulosin is associated with a dose-related incidence of ejaculatory disorders. Alfuzosin, doxazosin, and terazosin are not (Figure 3).[8]

 

A recent comparative study (ABEJAC Study) of alfuzosin and tamsulosin in young, healthy volunteers has objectively confirmed the increased risk of ejaculatory disorders in patients receiving tamsulosin.[9] This disorder is not due to tamsulosin's effect on the bladder neck and thus is not retrograde ejaculation (Figure 4).

 

Avoadart and Proscar are 5-alpha-reductase inhibitors and are an entirely different class of medication. They work by blocking the production of a natural substance that enlarges the prostate This shrinks the prostate. My prostate is normal size. Yet, an urologist still recommened Avodart, and I tried for six months with Flomax with no improvement.. The Avodart had similar side effects to the Rapliflo (diminished ejaculation andlibido), just not as severe.

 

I am asking what would be the preferred alpha-blocker if the Uroxatral fails?

 

Thank you.

Expert:  Dr. Chip replied 2 years ago.
Well, preferred is a nebulous term since the only way one can see if there are going to be side effects from a medication is to try it. Cardura, Hytrin, and minipress are the direct alternatives to Uroxatral.
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