BPH

Question 1

1. A uroselective α-adrenergic antagonist inhibits this α-adrenergic receptor in prostatic smooth muscle?
   A. α1A
   B. α1D
   C. α1B
   D. α2A
   E. α2B

Answer 1

A

Question 2

2. Use of a 5α-reductase inhibitor can be expected to reduce the volume of an enlarged prostate gland by this percentage.
   A. 10
   B. 20
   C. 50
   D. 75
   E. 100

Answer 2

B

Question 3

3. Use of an α-adrenergic antagonist or a 5α-reductase inhibitor can be expected to have this clinical effect in patients with symptomatic BPH:

A. Decrease peak urinary flow rate
B. Increase postvoid residual urine volume
C. Increase detrusor relaxation
D. Improve bladder emptying
E. Increase urinary frequency

Answer 3

D

Question 4

4. Which of these agent(s) has/have a low likelihood of causing cardiovascular adverse effects in a patient with BPH who also is receiving antihypertensives for essential hypertension?

Alfuzosin, Tamsulosin, Silodosin

A. 1 only
B. 2 only
C. 3 only
D. 1 and 3 only
E. 1, 2, and 3

Answer 4

E

Question 5

5. Which one of the following statements about tadalafil’s use for LUTS is correct?

A. It should be dosed on demand or when needed.
B. It is indicated for patients with complications of BPH.
C. It works by causing relaxation of the detrusor muscle.
D. It produces an increase in peak urinary flow rate.
E. It reduces the AUA symptom score by at least 3 points.

Answer 5

E

Question 6

6. The benefits of combination treatment with a 5α-reductase inhibitor and α-adrenergic antagonist for BPH includes all of the following except:

A. Increasing urinary flow rate
B. Decreasing AUA Symptom Score
C. Decreasing prostate gland size
D. Increasing need for prostatectomy
E. Decreasing risk of acute urinary retention

Answer 6

D

Question 7

7. Which one of the following statements about mirabegron’s use for LUTS is correct?
   A. It reduces obstructive voiding symptoms.

B. It reduces irritative voiding symptoms.
C. It shrinks an enlarged prostate.
D. A common adverse effect is erectile dysfunction.
E. It is contraindicated in patients taking nitrates.

Answer 7

B

Question 8

8. Which one of the following agents requires a dosage reduction in a patient with an estimated creatinine clearance of 30 to 40 mL/min (0.50 to 0.67 mL/s)?

A. Tamsulosin
B. Alfuzosin
C. Silodosin
D. Dutasteride
E. Finasteride

Answer 8

C

Question 9

9. The treatment of choice for a patient with recurrent urinary tract infections and acute urinary retention secondary to BPH is:

A. α-adrenergic antagonist
B. β3-agonist
C. combination of α-adrenergic antagonist and 5α reductase inhibitor
D. prostatectomy
E. mirabegron plus tadalafil

Answer 9

D

Question 10

10. Which one of the following statements about functionally uroselective α-adrenergic antagonists is correct?

A. Doxazosin and terazosin are pharmacologically uroselective.
B. Functionally uroselective agents are more likely formulated as controlled release, rather than immediate release.
C. Uroselective agents are more likely to be effective for treating genitourinary tract
disorders than disorders of other organ systems.
D. Hypotension is more likely to occur with clinically uroselective agents than with nonclinically uroselective agents.
E. Clinically uroselective agents should not be taken along with a 5α reductase inhibitor.

Answer 10

B

Question 11

11. A patient takes doxazosin controlled-release tablets 8 mg orally every day for 1 month. However, he runs out of medication and does not take it for 3 days. Upon resuming his medication, he should:

A. Restart doxazosin controlled-release tablets 8 mg orally every day
B. Switch to doxazosin immediate-release tablets, start at 2 mg orally every day and then slowly retitrate up
C. Start doxazosin controlled-release tablets 4 mg orally every day and then slowly retitrate up to 8 mg daily over 3 to 4 weeks
D. Double the dose of doxazosin controlled-release tablets, start at 16 mg orally every day for 3 days, then decrease to 8 mg orally every day
E. Start doxazosin controlled-release tablets 4 mg orally on day 1, then 4 mg orally twice a day on day 2, then 8 mg orally on day 3 and thereafter

Answer 11

C

Question 12

12. Which one of the following side effects of finasteride could be treated with a
    phosphodiesterase inhibitor?
    A. GynecomastIa
    B. Decreased libido
    C. Erectile dysfunction
    D. Retrograde ejaculation
    E. Hirsutism

Answer 12

C

Question 13

13. RR has an AUA Symptom Score of 6. A diagnosis of mild LUTS due to BPH is made.
    The treatment of choice is:
    A. Watchful waiting
    B. α-Adrenergic antagonist
    C. 5α-Reductase inhibitor
    D. Anticholinergic agent
    E. Minimally invasive surgery

Answer 13

A

Question 14

14. RR has an AUA Symptom Score of 25. The clinical presentation is consistent with severe BPH. DRE reveals a 25 g (0.9 oz) prostate. The patient has no BPH-related
    complications. The treatment of choice is:

A. Watchful waiting
B. α-Adrenergic antagonist
C. 5α-Reductase inhibitor
D. α-Adrenergic antagonist +5α-reductase inhibitor
E. Transurethral resection of the prostate

Answer 14

B

Question 15

15. SS has an AUA Symptom Score of 35 and complains of severe LUTS. DRE reveals a 50g (1.8 oz) prostate and PSA is 1.9 ng/mL (1.9 mcg/L). The patient has no BPH-related complications. The treatment of choice is:

A. Watchful waiting
B. α-Adrenergic antagonist
C. 5α-Reductase inhibitor
D. α-Adrenergic antagonist + 5α-reductase inhibitor
E. Transurethral resection of the prostate

Answer 15

D

Question 16

1. Alfuzosin behaves like a uroselective agent. The reason for this is because:

A. The recommended daily dose is subtherapeutic
B. It has β-adrenergic antagonist effects
C. It is available only as an extended-release formulation
D. It has M3 cholinergic inhibitory effects

Answer 16

C

Option C: Correct. Alfuzosin is only available as a fixed daily dose, extended release
formulation, which produces relatively constant serum levels. This contributes to its lack
of hypotensive adverse effects.

Question 17

2. Which one of the following symptoms or signs are characteristic of the post-finasteride syndrome?
   A. Prostate shrinkage
   B. Persistent sexual dysfunction
   C. Renal failure
   D. Hepatic failure

Answer 17

B

Option B: Correct. The post=finasteride syndrome is a constellation of adverse effects including chronic fatigue, penile and scrotal shrinkage, persistent sexual dysfunction, and gynecomastia which persist after finasteride is discontinued.

Question 18

3. Which one of the following statements correctly describes the potential benefit of
   mirabegron in patients with BPH?

A. PVR decreases
B. Irritative voiding symptoms decrease
C. Urinary flow rate increases
D. Prostate size decreases

Answer 18

B

Option B: Correct. Mirabegon relaxes the detrusor muscle, thereby reducing involuntary bladder contractions. Irritative voiding symptoms will decrease.

Question 19

4. Which of the following medications slows progression of BPH and reduces the need for surgical intervention?

A. Silodosin
B. Dutasteride
C. Tadalafil
D. Darifenacin

Answer 19

B

Option B. Correct. Dutasteride and finasteride have been shown to halt the progression of BPH disease, reduces the development of complications of BPH, and reduces the need for surgery.

Question 20

5. AA is a 59-year-old man with moderate BPH symptoms, chronic pain, and Parkinson disease. He takes tamsulosin 0.8 mg daily, hydrocodone/acetaminophen around the clock, benztropine 1 mg three times a day, and levodopa/carbidopa at maximum daily doses. The patient’s chronic pain and Parkinson disease are well controlled on current medications, which he has been taking regularly for the past 5 years. The patient has been admitted thrice this month for acute urinary retention and gross hematuria. What would be the best option for managing this patient?

A. Discontinue hydrocodone/acetaminophen
B. Discontinue benztropine
C. Increase tamsulosin to 1.6 mg daily
D. Offer surgery for BPH

Answer 20

D

Option D: Correct. This patient has two indications for surgical intervention: persistent gross hematuria and repeated episodes of acute urinary retention.

Question 21

6. BB takes tadalafil 20 mg as needed for erectile dysfunction, averaging one to two
   doses/week. He also has moderate LUTS secondary to BPH and has heard that tadalafil is effective for BPH. The patient consults the pharmacist for instructions on whether he could use his current tadalafil prescription to treat BPH. Your correct response should include the following information:

A. The patient would need to split a tadalafil tablet in half and take half tablet daily.
B. The FDA has not approved tadalafil for BPH, so this approach is not recommended.
C. The patient would need to take tadalafil along with an α-adrenergic antagonist or a
5α-reductase inhibitor to get any benefit from treatment.
D. The usual dose for BPH is 5 mg daily. If prescribed, the patient would need a lower
dose tablet strength of tadalafil for BPH.

Answer 21

D

Option D: Correct. The usual dose of tadalafil for BPH is 5 mg daily. This patient would need an additional prescription for the lower dose tablet if his physician prescribes tadalafil for BPH.

Question 22

7. CC takes doxazosin extended release 8 mg daily for moderate LUTS secondary to BPH. His AUA symptom score has only improved by 1 point since he began treatment 2 months ago. His physician decides to add tadalafil to his regimen. What precaution should be taken prior to starting tadalafil?

A. Stabilize the patient’s blood pressure on doxazosin before starting tadalafil.
B. Hold doxazosin for 48 hours, then start tadalafil, and resume doxazosin only after the patient appears to tolerate tadalafil.
C. Decrease the daily dose of doxazosin by 50% before starting tadalfil.
D. Separate daily administration of doxazosin and tadalafil by at least 12 hours.

Answer 22

A

Option A: Correct. Both tadalafil and doxazosin cause peripheral vasodilation and lower blood pressure. It is recommended that a patient’s blood pressure be stabilized on
doxazosin first, before adding tadalafil.

Question 23

8. RR is a 70-year-old man with BPH. He is treated for 6 months with tamsulosin 0.4 mg daily. Although he tolerates tamsulosin and reports no adverse effects, the patient
   complains of moderate-severe irritative voiding symptoms which interrupt his sleep and cause embarrassing urine leakage during the day. The best treatment approach would be:

A. Increase tamsulosin to 0.8 mg daily
B. Add finasteride
C. Add tolterodine
D. Add tadalafil

Answer 23

C

Option C: Correct. Tolterodine is an antimuscarinic agent which relaxes the detrusor muscle and inhibits bladder contraction. It is the best choice for reducing irritative voiding symptoms.

Question 24

9. The pharmacist must provide counseling to a patient receiving silodosin and dutasteride for BPH. Which one of the following instructions or statements is correct?

A. Discontinue silodosin after 3 months.
B. Continue to take the medication as long as LUTS responds to treatment.
C. Drug therapy is working when the AUA Symptom Score increases by 6 points.
D. Dutasteride-induced erectile dysfunction will be alleviated by silodosin.

Answer 24

B

Option B: Correct. This combination works best in patients with moderate-to-severe
LUTS and a prostate gland that is at least 30 g in size. Patients should continue to take the combination as long as they experience clinically significant improvements in LUTS. The cost:benefit is optimal when patients continue on combination therapy for at least 4 years.

Question 25

10. Which statement about floppy iris syndrome due to α 1 -adrenergic antagonists is correct? A. α 1 -adrenergic antagonists should be held for 1 month prior to cataract surgery. B. This adverse effect is dose-related. C. This is associated with intraoperative complications during cataract surgery. D. Cyanopsia is a symptom of floppy iris syndrome.

Answer 25

C Option C: Correct. Floppy Iris Syndrome has three characteristics: a billowing iris (due to α 1 -adrenergic antagonism of the iris dilator muscle, which causes muscle relaxation), a small pupil, and a higher risk of postoperative complications during cataract surgery (because it must be performed through the pupil).

Question 26

11. A 65-year-old man with BPH presents to the urology clinic. He complains of nocturia, three times a night, urgency, and urinary incontinence. He wears adult diapers and smells of urine. He has a history of recurrent urinary tract infection, chronic prostatitis, and bladder calculi. On DRE, his prostate is estimated to be 40 g (1.4 oz). His AUA Symptom Score is 22 and peak urinary flow rate is 6 mL/s. The best treatment for this patient is: A. Watchful waiting B. Silodosin C. Tamsulosin plus dutasteride D. Prostate surgery

Answer 26

D Option D: Correct. This patient has severe LUTS and BPH complications. He is a candidate for surgical treatment which could address the etiology of his recurrent urinary tract infections, remove bladder calculi, and relieve his obstructive voiding symptoms.

Question 27

12. A patient with LUTS secondary to BPH complains of moderately bothersome voiding symptoms. The patient states that he is already taking “a bunch of medications for his heart” and some over the counter decongestants for hayfever and seasonal allergies. He doesn’t want to take additional medications for anything else. Which of the following lifestyle modifications is reasonable to implement? A. Discontinue decongestants, if possible. B. Take a diuretic once a day in the morning. C. Drink at least three cups of coffee every day. D. Initiate timed voidings every 8 hours while awake.

Answer 27

A Option A: Correct. Decongestants, eg, phenylephrine, pseudoephedrine, are α-adrenergic agonists. They cause contraction of prostatic, urethral, and bladder neck smooth muscle, which reduces the caliber of the urethra. This can contribute to obstructive voiding symptoms.

Question 28

13. SS is a 68-year-old man with BPH for which he has been treated with finasteride for the past year. Although his symptoms have improved, he complains that his bladder never seems to empty completely even if he strains and pushes down on his bladder to try to force the urine out. His PVR is 200 mL and peak urinary flow rate is 10 mL/s. The patient also has poorly controlled essential hypertension, which is being treated with two antihypertensives. The patient is not sexually active. Which medication should be avoided in this patient? A. Tamsulosin B. Silodosin C. Tadalafil D. Mirabegron

Answer 28

D Option D: Correct. As a direct extension of its β 3 -agonist effects, mirabegron causes vasoconstriction and increases blood pressure as an adverse effect. Patients with poorly controlled essential candidates should not receive mirabegron.

Question 29

14. BB is a 75-year-old man with BPH. His LUTS is of moderate severity and medical treatment is being considered. This patient has poor short-term memory and the physician wants to prescribe a once a day medication that requires no dose titration. Which medication would be the best choice? A. Terazosin immediate release B. Silodosin C. Prazosin D. Doxazosin extended release

Answer 29

B Option A: Incorrect. Terazosin immediate release must be initiated at a subtherapeutic dose of 1 mg and then slowly increased over several weeks to a full therapeutic dose. Patients may have to split up the daily dose to minimize hypotension. Option B: Correct. Silodosin is administered as a fixed dose of 8 mg daily. No dose titration is recommended.

Question 30

15. TT is a 60-year-old man with BPH. On DRE, the prostate gland is 40 g (1.4 oz). His AUA Symptom Score is 25, and his PSA is 2 ng/mL (2 mcg/L). The patient’s peak urinary flow rate is 8 mL/s and his PVR is 300 mL. The patient has had two episodes of acute urinary retention, which have required emergency room visits in the past 3 months. The best treatment for this patient is: A. Silodosin plus tolterodine B. Tamsulosin plus tadalafil C. Silodosin plus dutasteride D. Finasteride plus mirabegron

Answer 30

C Option C: Correct. This patient has severe LUTS, a low peak urinary flow rate and a very high PVR. He needs medical treatment to relax prostatic smooth muscle and shrink an enlarged prostate. Silodosin plus dutasteride would do just that.