Submit the female and male genitala case studies as one document. Create 2 SOAP notes (male genitalia (1), female genitalia (2) ) Soap note guidelines attached. Female/male geni

SOAP Notes Guidelines

Subjective:

ID: Initials, age and gender only

Source: Who is giving information and their reliability

CC: Must be in pt own words and in quotes. One to two sentences maximum.

HPI: Fully describe the acute symptoms. Use acronym OLDCHARTS to fully describe the

symptoms presented in the CC

PMH:

Current Medications: list all meds including OTC and Herbal. Give dose, route and frequency.

Don’t include meds used to treat the acute symptoms mentioned in the HPI. OK to say “none” if

none

Disease Processes: list all diseases with date of diagnosis. OK to say “none” if appropriate.

Hospitalizations and Surgeries: List all with dates. OK to say “none” if appropriate.

Allergies: List all with typical reaction when exposed. Include environmental and food allergies.

If none, you need to say “no drug, food or environmental allergies”.

FH: *Only complete if the complaint logically leads to questions about family history. Can be

abbreviated. If bit relevant, say “non-contributory”.

ROS: Use textbook to address hx r/t symptoms associated with the system. Don’t repeat HPI-

should be hx of system before onset of acute symptoms. Is ok to say “see HPI for acute

symptoms” if you feel the need to refer to the acute symptoms but is not necessary.

Psych/Social: Include issues regarding habits, insurance, coping, stress here. For Children

include a statement about their growth and development. If school age- indicate how they are

doing in school.

Immunizations/Infectious Diseases: *Only complete if the complaint logically leads to questions

about Immunizations and communicable diseases. Can be abbreviated. For Children- indicate if

current on their immunizations. OK to say “none” if appropriate.

Violence Hx. – Domestic or environmental violence- Bullying for school age

Objective: BP: ____ P: ___ R: ___ Temp: ___ BMI: ____Ht: ___, Wt ___lbs.

(Children only- Include CDC growth chart)

Include entire assessment as described in your textbook for the system we are studying that

week.

Assessment: Medical diagnosis- plus 2 or 3 differential diagnoses

Plan: Provide complete medical and nursing plan of care. Must provide reference for your plan

in APA format. Faculty will provide references for abnormal findings.

References

Male Genitalia Case Study

Subjective:

CC: “I’m having trouble with my bladder”.

72 year old African American male, normally in good health. Has been gradually having

urinary complaints of difficulty starting his stream of urine, taking longer to empty his

bladder, and urgency with dribbling of urine. Tried taking Saw Palmeto, but hasn’t

noticed any improvement. Now has suprapublic pain since yesterday with urinary

burning, and terrible urgency to void for small amounts. Couldn’t sleep all last night with

running to the bathroom. Last general health exam was about 4 years ago. He hasn’t

needed any routine medications due to no chronic diagnoses and hates doctors and

especially rectal exams. Married happily for 49 years, but admits to having some

problems with maintaining erections during intercourse although he tries to initiate it

several times a week and his wife is a willing partner. No smoking, occasional ETOH, no

illicits. No relevant family history. He is a retired steel worker with medicare.

Objective:

T = 99 po, R = 16, P = 92, regular, B/P = 138/82

Tenderness to palpation over suprapubic area, no CVA tenderness, 100cc residual

bladder volume. Skin of genitaila is intact and evenly pigmented. No inguinal hernias

detected. Rectal exam reveals smooth rectal walls and enlarged prostate without

tenderness. Guiac neg. Moderate visiable hemoroids.

Urine dip – Mod amount of WBCs

Instructions

1. Prepare a SOAP note using the guidleines attached to the assignment link.

2. Submit the SOAP note to Blackboard- There is no ShadowHealth exam for the

breast.

3. Review the “Recording Information” PowerPoint which contains “tips for weekly

write ups”. You will be graded according to these tips.

4. If information is missing that you feel is important, you may add to the case study

facts as needed.

5. Your diagnosis and plan must be comprehensive and include the reference I

provided.

Female Genitalia Case Study

Subjective Data:

Pt- Mary Jones, age 40, African American Female

CC: “I’m itching so much down there and it burns when I urinate”

HPI: Pt c/o experiencing itching of the vulva, not relieved by vagasil or douching with vinegar

and water for 1 week. States itching has increased since last night and now it burns when she

urinates. Pt c/o vague discomfort in the lower abdomen (3 of 10). She states she tried to douche

last night but it only made the itching worse. Pt is married with 2 children. She and her husband

use condoms for birth control. She reports douching weekly with vinegar and water. She cleanses

her external genitalia daily with soap and water. She denies previous vaginal discharge or

infections.

PMH: Diabetes Type II since 2005 treated with Metformin 850 mg Bid po. Last HgbA1c was

8.3% one month ago. Her fasting BS was 188 per AM glucometer this am.

Denies surgeries and relevant family history. Is an unemployed paralegal without health

insurance. Reports drinking a six pack of light beer each week. Smokes ½ pack of light cigarettes

daily and uses marijuana most weekend with friends.

Objective Data:

Vitals: Temp 99.8 0

F (37.7 o C), Apical 88 b/m, Resp 22/min, BP 132/82, Glucometer (non-

fasting) 233

Urine Dipstick- Large amt bacteria, trace blood

Physical Labia Majora and minora is covered with a papular red rash. Thick white, odorless

vaginal drainage is noted. Tenderness to palpation of external genitalia. Speculum exam reveals

erthymous vaginal walls with white drainage. Urine cloudy yellow. Uterus is midline and not

enlarged. Ovaries are non tender.

Instructions

1. Prepare a SOAP note using the guidelines attached to the assignment link.

2. Submit the SOAP note to Blackboard- There is no ShadowHealth exam for the breast.

3. Review the “Recording Information” PowerPoint which contains “tips for weekly write

ups”. You will be graded according to these tips.

4. If information is missing that you feel is important, you may add to the case study facts as

needed.

5. Your diagnosis and plan must be comprehensive and include the reference I provided.

412 THE CONSULTANT PHARMACIST AUGUST 2016 VOL. 31, NO. 8

IN PRACTICE

Introduction Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a nonmalignant adenomatous overgrowth of the periurethral prostate gland that is commonly seen in aging men. The enlarged prostate has been thought to contribute to the impairment of the bladder’s ability to completely empty, which in turn contributes to the overall lower urinary tract symptoms (LUTS). According to the American Urological Association’s (AUA) Guidelines for the Management of

BPH, this is thought to occur as a result of direct bladder outlet obstruction (BOO) and increased smooth muscle tone and resistance from the enlarged prostate.1 Chronic BOO secondary to BPH may lead to urinary retention, renal insufficiency, recurrent urinary tract infections, hematuria, and bladder calculi. In addition, symptoms attributed to BPH can potentially have a huge impact on quality of life (QOL) and sleep patterns.1 The prevalence of histopathologic BPH is age dependent, with initial development usually occurring after age 40.1 In men 60

Todd J. Woodard, Kendra R. Manigault, Niesha N. McBurrows, Tiffany L. Wray, Laresa M. Woodard

Management of Benign Prostatic Hyperplasia in Older Adults Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a nonmalignant adenomatous overgrowth of the periurethral prostate gland commonly seen in aging men. Historically, it has been assumed that the pathophysiology of lower urinary tract symptoms in men is the result of bladder outlet obstruction associated with prostate enlargement. Symptoms such as urinary hesitancy, incomplete bladder emptying, dribbling or prolonged urination, nocturia, urinary urgency, and/or urge incontinence are common. Understanding the differential diagnosis and ordering appropriate laboratory tests are essential in accurately identifying a BPH diagnosis. Management can be broken down into medical or pharmacological and surgical therapies. This article aims to provide an overview of BPH and its management in older adults.

KEY WORDS: Benign prostatic hyperplasia, BPH, Incontinence, Men’s health, Older adults, Urinary, Urology.

ABBREVIATIONS: AUA = American Urological Association, AUA-SI = American Urological Association Symptom Index, BOO = Bladder outlet obstruction, BPH = Benign prostatic hyperplasia, CAM = Complementary and alternative medicine, DRE = Digital rectal examination, IFIS = Intraoperative floppy iris syndrome, IPSS = International Prostate Symptom Score, LUTS = Lower urinary tract symptoms, MIT = Minimally invasive therapy, PDE-5 = Phosphodiesterase type 5, PSA = Prostate- specific antigen, QOL = Quality of life, TUIP = Transurethral incision of the prostate, TUMT = Transurethral microwave thermotherapy, TUNA = Transurethral needle ablation, TURP = Transurethral resection of the prostate, TUVP = Transurethral electrovaporization.

nocturia, urinary urgency, and urge incontinence.6,7 Unfortunately, these symptoms are not specific to BPH, and the presence of these symptoms is not sufficient to make a diagnosis of BPH.8

Diagnosis and Evaluation The diagnosis of BPH begins with obtaining a complete medical history, including a description of any specific urinary symptoms the patient may be experiencing.9 Providers should assess for the severity, annoyance, and impact of LUTS on QOL. As previously mentioned, problems with urine storage, voiding, and post-micturition symptoms (i.e., dribbling) comprise types of LUTS, though presenting symptoms may depend on the underlying pathophysiology causing them.10 It is also important to screen for hematuria, dysuria, and pain. During the evaluation of patients with LUTS, other potential causes of LUTS must be excluded (Table 2).11-13 Other diagnostic components of the relevant medical history include a record of voiding habits, and results of the American Urological Association Symptom Index (AUA-SI) and the International Prostate Symptom Score (IPSS), which are questionnaires that address LUTS symptoms and impact on QOL. The AUA-SI is commonly used to assess a patient’s obstructive and irritative voiding symptoms. Patients rate seven symptoms from 0 to 5 (0 corresponds to no problems, 5 corresponds to severe symptoms) based on their perceived severity. Scores less than 8 are categorized as mild, scores between 8 and 19 are

years of age and older, 50% have been diagnosed with BPH, and 75% of men older than 70 years of age have one or more symptoms attributable to BPH. By 85 years of age, 90% of men have symptoms of BPH. 2 The treatment of BPH poses a substantial burden to the health care system, with annual expenditures attributable to the treatment of BPH and its associated symptoms estimated at $4 billion.3 Because the prevalence and costs associated with BPH are substantial, the last decade has brought significant advancements in our understanding of BPH and increased interest in its management.

Pathophysiology and Clinical Manifestations Located anterior to the rectum, the prostate is a heart- shaped, walnut-sized gland that is located below the urinary bladder. The prostate surrounds the proximal urethra, and its major function is to secrete fluids that make up a portion of the ejaculate volume. The weight of a normal prostate in an adult male is between 7 grams and 16 grams. Physical examination of the prostate must be done by digital rectal examination (DRE), and it is manually palpated by placing a finger into the rectum. 4

BOO in men with BPH is said to be attributed to both static and dynamic factors. Static factors relate to an anatomic enlargement of the prostate gland, which encroaches on the prostatic urethra and bladder outlet, thereby obstructing urinary flow. The dynamic obstruction is related to the tension of the prostate’s smooth muscle.5 Symptoms of BPH can be a result of these static and/or dynamic manifestations, and this should be taken into account when drug therapy is considered. Historically, it has been assumed that the pathophysiology of LUTS in men is the result of BOO associated with prostate enlargement. LUTS are not classified as a disease, but as a group of disorders affecting the prostate and bladder that share a common clinical manifestation. LUTS can be categorized into voiding and storage symptoms (Table 1). Voiding symptoms may include urinary hesitancy, the sensation of incomplete bladder emptying, weak urinary stream, terminal or postmicturition dribbling, or prolonged urination. Storage symptoms can include increased urinary frequency,

THE CONSULTANT PHARMACIST AUGUST 2016 VOL. 31, NO. 8 413

Table 1. Lower Urinary Tract Symptoms

Source: Reference 6, 7.

Voiding Storage

Urinary hesitancy Urinary frequency Poor urinary flow Nocturia Sensation of complete bladder emptying Urinary urgency Weak urinary stream Urge incontinence Post-micturition dribbling Prolonged urination

414 THE CONSULTANT PHARMACIST AUGUST 2016 VOL. 31, NO. 8

considered moderate, and scores greater than or equal to 20 are categorized as severe.14

Physical examination aids in reaching the correct diagnosis, and begins with inspection of the male genitalia, careful DRE to estimate prostate size, and assessment for tenderness to palpation of prostate and for structures like the bladder. If the prostate is enlarged it may feel soft and symmetric without any nodules or indurations during DRE. Performing a related neurological exam helps to rule out other causes of urinary symptoms and assist with determining the differential diagnosis. Laboratory and procedural tests of diagnostic use encompass urinalysis followed by urine culture if abnormal, serum prostate-specific antigen (PSA) level, ultrasound of the prostate and upper and lower urinary tract, post-void residual volume

measurement, cystoscopy, and uroflowmetry.15 Measuring the PSA may be beneficial if the DRE is deferred. The PSA is a marker that may correlate with prostate size or enlargement. A prostate is considered enlarged when the volume is greater than 40 mL (Table 3). A detailed approach guides appropriate diagnosis and management recommendations.

Management

Nonpharmacological Therapy Watchful waiting or active surveillance is commonly utilized in BPH patients who are asymptomatic or have mild symptoms (AUA-SI < 8); however, patients with moderate or severe symptoms (AUA-SI ≥ 8) who have not developed complications or are not bothered by their symptoms may also elect to use this monitoring strategy (Table 4).1,16 During watchful waiting, patients return to clinic at regular intervals (12 months) for evaluation of symptoms but do not receive treatment.1 Symptom improvement with watchful waiting may be negligible, but a slight improvement has been seen in up to one third of men.1,17

MANAGEMENT OF BPH

Table 2. Common Differential Diagnoses for BPH

Abbreviation: BPH = Benign prostatic hyperplasia. Source: References 7, 11-13.

Neurogenic Bladder Prostatitis Bladder Cancer Prostate Cancer Urinary Tract Infection Diabetes Erectile Dysfunction Cardiovascular Disease Neurologic Disease Sexually Transmitted Diseases

Table 3. PSA Level Correlation to Prostate Volume of 40 mL

Abbreviation: PSA = Prostate-specific antigen. Source: References 7, 13.

Age PSA Level

≥ 50 1.6 mcg/L ≥ 60 2.0 mcg/L ≥ 70 2.4 mcg/L

Table 4. American Urologic Association Symptom Index

Source: References1, 7, 13, 15.

Score Recommendation

< 8 (Mild symptoms) Watchful waiting

8-19 (Moderate symptoms) Pharmacotherapy (if bothersome) OR Surgery (if BPH complications)

20-35 (Severe symptoms) Pharmacotherapy (if bothersome) OR Surgery (if BPH complications)

THE CONSULTANT PHARMACIST AUGUST 2016 VOL. 31, NO. 8 415

Behavior modification may also minimize LUTS and is often recommended in addition to watchful waiting.1,14 Recommendations include limiting fluid intake in the evening to decrease risk of nocturia, avoiding excessive alcohol and caffeine, consuming a healthy diet, smoking cessation, and exercise. Physical activity was associated with a decreased risk of BPH, surgery for BPH, and symptomatic BPH when compared with inactivity, emphasizing the benefit of increased activity in BPH patients.15,18

In addition, avoiding drugs that can exacerbate urinary symptoms is an important facet of behavior modification.1,16 Several drug classes should be used with caution or avoided in patients with BPH (Table 5). In general, medications with significant anticholinergic effects (e.g., antihistamines, tricyclic antidepressants) should be avoided because of risk of acute urinary retention; alpha-adrenergic agonist (e.g., pseudoephedrine, phenylephrine) may cause muscle contractions and problems with bladder emptying. Beta-adrenergic agonist (e.g., terbutaline) may prevent voiding resulting from relaxation of the bladder detrusor muscle.14 Testosterone supplementation should be avoided or used with caution in patients with BPH because of testosterone’s role in prostate enlargement.14 Large doses of diuretics can cause polyuria and increase the frequency of voiding in patients with BPH. Symptom distress may be decreased by avoiding triggers and medication management.1

Pharmacological Therapy

Alpha 1 Receptor-Antagonists

There are three alpha1 adrenoceptor subtypes: α1A, α1B,

and α1D. The α1B subtype regulates blood pressure via vascular smooth muscle contraction, and α1D subtype is thought to be associated with bladder muscle contraction and sacral spinal cord innervation.19 The α1a adrenoceptors in the human prostate, bladder base, bladder neck, prostatic capsule, and prostate urethra mediate contraction of the smooth muscle in these tissues.20 In response to alpha-adrenergic receptor stimulation, smooth muscles in the prostate gland contract, causing

constriction of the prostatic urethra.13 Alpha1 receptor antagonists, commonly referred to as alpha1-blocker, work by relaxing smooth muscle tone in the prostate and the bladder neck.21 Terazosin, doxazosin, tamsulosin, alfuzosin, and silodosin are the alpha1-blockers that are approved by the Food and Drug Administration (FDA) for BPH. (Table 5 compares drug-specific features.) Terazosin, doxazosin, and alfuzosin are nonselective in that they block all three α1 adrenergic receptor subtypes, in comparison with tamsulosin, which blocks α1A and α1D adrenergic receptors with 10-fold greater affinity than α1B. Silodosin blocks α1A with 162-fold greater affinity than α1B adrenergic receptors.22 In addition to being FDA-approved for BPH, terazosin and doxazosin are also FDA-approved for hypertension. Prazosin is another alpha-blocker FDA-approved for hypertension but used off-label for BPH. Though terazosin, doxazosin, and prazosin are commonly used for hypertension, in particular comorbid hypertension, these medications are not recommended as first-line agents in the treatment of hypertension because they are less effective than thiazide diuretics and angiotensin-converting enzyme inhibitors in preventing cardiovascular outcomes.23 Terazosin and doxazosin also require dose titration, usually over several weeks, to minimize orthostatic hypotension and dizziness after initial administration, which could be problematic for the older adult and increase the risk of falls. Risk of orthostatic hypotension is increased when terazosin

Table 5. Medication Classes Associated with Lower Urinary Tract Symptoms

Source: References: 1, 7.

• Antihistamines (e.g., Diphenhydramine, Chlorpheniramine)

• Decongestants (e.g., Pseudoephedrine, Phenylephrine)

• Diuretics (e.g., Furosemide, Bumetanide)

• Opiates (e.g., Morphine, Oxycodone)

• Tricyclic Antidepressants (e.g., Amitriptyline, Imipramine)

• Testosterone Replacement (e.g., Depo-Testosterone, Androderm)

416 THE CONSULTANT PHARMACIST AUGUST 2016 VOL. 31, NO. 8

MANAGEMENT OF BPH

and doxazosin are combined with phosphodiesterase inhibitors used to treat erectile dysfunction, a common combination of medications found in older men. Tamsulosin, alfuzosin, and silodosin have a lower potential to cause hypotension and syncope than either terazosin or doxazosin.24 For tamsulosin and silodosin, the less effect on blood pressure is thought to result from its higher selectivity for the α1 receptors.19,20 Alfuzosin is not specific for the a subtypes, but its lower rate of orthostatic effects, relative to terazosin and doxazosin, is possibly a result of its extended-release formulation. This lower risk of hypotension may be an attractive option for older men at risk for falls. Symptomatic improvement may be seen as early as two to four weeks of therapy.13 All alpha-blockers can potentially lead to fall, fractures, and head trauma secondary to hypotension. Therapies for erectile dysfunction such as sildenafil, vardenafil, and tadalafil are selective inhibitors of cyclic guanosine monophosphate-specific phosphodiesterase type 5 (PDE-5). There are currently precautions in the prescribing information of these agents, as they can lower blood pressure significantly when used concomitantly with α1 receptor-antagonist.25-27 Patients should be on a stable alpha-blocker dose before starting PDE-5 inhibitors, sildenafil, vardenafil, and tadalafil. In patients who are stable on alpha1 receptor-antagonist, PDE-5 inhibitors should be initiated at lowest recommended dose.25-27 It is suggested that men separate the doses of alpha1 antagonist and PDE-5 inhibitors by at least four hours.24 In general it is recommended that tamsulosin, alfuzosin, and silodosin be used in men who are also using PDE-5 inhibitors.24 Ejaculatory dysfunction is a side effect associated with alpha1 blockers, particularly tamsulosin and silodosin. These particular side effects are important because erectile dysfunction commonly affects men with BPH. In a systemic review and meta-analysis, it was found that ejaculatory dysfunction was significantly more prevalent with alpha1 antagonist than placebo (P < 0.0001), in particular, considering tamsulosin (P = 0.006) or silodosin (P < 0.0001), with tamsulosin associated with significant lower risk of ejaculatory dysfunction than silodosin (P < 0.00001). Doxazosin and terazosin were associated with risk similar to placebo.28 Ejaculatory dysfunction

was significantly more common with combination therapy, compared with alpha1 antagonist alone (P < 0.0001) or with 5-alpha reductase inhibitors alone (P = 0.02), and was significantly more common with the 5-alpha reductase inhibitors, compared with placebo (P < 0.0001). Both finasteride (P < 0.0001) and dutasteride (P = 0.0002) were associated with significantly higher risk of ejaculatory dysfunction than placebo.28 Alpha1-blockers have also been associated with intraoperative floppy iris syndrome (IFIS). IFIS is observed during cataract surgery in patients taking alpha1-blockers. This condition is characterized by a flaccid and billowing iris, iris prolapse, and intraoperative pupil constrictions.29,30 It is important that patients who are undergoing cataract surgery be counseled to inform the ophthalmologist that they are on or have been on alpha1 receptor-antagonist. Prior to cataract surgery a thorough medication history should be obtained. Surgeons who are undertaking cataract surgery need to identify patients who have received in the past or are currently are receiving a1 receptor-antagonist so that intraoperative strategies can be employed to circumvent IFIS adverse events.31 Discontinuing a1 receptor-antagonist has not shown to prevent or decrease the severity of IFIS, thus the recommendation to stop alpha1 antagonist prior to surgery is no longer valid.32 Tamsulosin is most commonly associated with IFIS, but it can also be seen with terazosin, doxazosin, and alfuzosin.33

5-Alpha Reductase Inhibitors Finasteride and dutasteride are approved by FDA for BPH (see Table 6 for a comparison). They act by inhibiting the conversion of testosterone to dihydrotestosterone, suppressing prostate growth.34 Unlike alpha1 receptor- antagonists, which have been shown to relieve symptoms and work by relaxing smooth muscle tissue, 5-alpha reductase inhibitors actually reduce prostate volume by inducing epithelial atrophy.35 They do not provide immediate symptomatic relief and can take approximately six months before beneficial effects are seen.36 These agents are more effective in patients with a prostate size greater than 40 mL.37 In a meta-analysis comparing finasteride and dutasteride, there was no statistically

THE CONSULTANT PHARMACIST AUGUST 2016 VOL. 31, NO. 8 417

Table 6. Pharmacological Agents for BPH

Drug Name

Alfuzosin (Uroxatral)

Doxazosin (Cardura, Cardura XL)

Terazosin (Hytrin)

Silodosin (Rapaflo)

Tamsulosin (Flomax)

Dosage

10 mg daily

Immediate release: 1 mg daily; titrate every 1-2 weeks max of 8 mg daily

Extended release: 4 mg once daily; titrate every 3-4 weeks to max of 8 mg daily

1 mg at bedtime; titrate over several weeks; if no response after 4-6 weeks of 10 mg/day, may increase to 20 mg/day

8 mg daily

0.4-0.8 mg daily

Adverse Reactions

Dizziness, orthostatic hypotension, syncope, fatigue, headache, floppy iris syndrome

Dizziness, malaise, orthostatic hypotension, fatigue, headache, syncope, floppy iris syndrome

Dizziness, muscle weakness, orthostatic hypotension, syncope, floppy iris syndrome

Retrograde ejaculation, orthostatic hypotension, dizziness, floppy iris syndrome

Orthostatic hypotension, dizziness, headache, ejaculation failure, floppy iris syndrome

Renal

Use caution in severe renal impairment < 30 mL/min

No dosage adjustment recommendations provided in manufacturer’s labeling

No dosage adjustment necessary

Clcr > 50 mL/ minute: no dosage adjustment necessary

Clcr 30-50 mL/ minute: 4 mg once daily

Clcr < 30 mL/ minute: Use is contraindicated

Clcr ≥10: no dose adjustment necessary; Clcr < 10 mL/minute: has not been studied

Hepatic

Child Pugh B or C use is contraindicated

Mild to moderate hepatic dysfunction: use caution

Severe hepatic impairment: not recommended

No dosage adjustment provided in manufacturer’s labeling

Child Pugh A or B: no dosage adjustment necessary

Child Pugh C: contraindicated

Mild to moderate hepatic impairment: no adjustment necessary; severe impairment: There are no dosage adjustments provided in the manufacturer’s labeling

Clinical Pearls

When using concurrently with PDE-5 inhibitors initiate PDE-5

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