Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NRS 271A: optho, pulm, GU, Renal, Heme/onc > BPH, ED & Urinary Incontinence > Flashcards

BPH, ED & Urinary Incontinence Flashcards

1
Q

Pathophys of BPH

A
  • Circulating Testosterone:
    • 90% from testes
    • 10% from adrenal glands
  • Adult males <40 yo
    • prostate size stays the same ~15-20gm
  • > 40 yo
    • testosterone enters prostate cells
      • type II 5 alpha reductase is converted to dihydrotestosterone (DH-T)
  • androgens (i.e. testosterone) has not direct effect on stromal tissue
    • overgrowth of muscle or stromal tissue around the urethra
      • caused by testosterone → estrogen (in peripheral) → stimulates growth of stromal cells
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

LUTS and BPH

A

lower urinary tract symptoms (LUTS)

  • when pt has BPH → will eventually experience LUTS
  • 3 contributing factors:
    • static factors:
      • anatomic obstruction
    • dynamic factors:
      • excessive stimulation of alpha (1A)-receptors on smooth muscle of prostate and urethra → contraction
    • Detrusor Factors:
      • instability of detrusor muscle due to excessive hypertrophy and outlet obstruction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Symptoms of BPH

A
  • obstruction due to static or dynamic factors:
    • decreased force of the urinary stream
    • urinary dribbling
    • inability to completely empty bladder
  • Detrusor instability
    • irritable voiding sxs
      • urinary urgency and frequency
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

AUA-7 Score + IPSS

A

assessing severity of the LUTS in BPH

  • AUA-7
    • American urologic association score
  • IPSS
    • international prostate symptoms score = previous 7 question + Quality of Life
    • Mildly Symptomatic: 0-7
    • Moderately Symptomatic: 8-19
    • Severely Symptomatic: 20-35
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Treatment Algorithm for BPH

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Tx for Mild Sxs of BPH

A

Mild Sxs = 0-7 on IPSS

Watchful waiting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Tx for Moderate to severe symptoms with no BPH complications

A
  • prostate less than 30g?
    • alpha-adrenergic antagonist
      • if response, continue
      • if no response (1-2 weeks) , surgery
  • Prostate ≥ 30 g?
    • 5alpha-reductase inhibitor
      • if response, continue
      • if no response, try combo of this + alpha adrenergic antagonist or surgery
    • combo of alpha adrenergic antagonist + 5-alpha reductase inhibitor
      • if response, continue
      • if no response, surgery
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Tx of severe symptoms of BPH and BPH complications

A

surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Alpha Antagonists Overview with BPH

A
  • reduce the dynamic factor
  • relax bladder neck, prostatic urethra, and prostate smooth muscle
  • all agents in the class are equally effective
  • onset = days - weeks
  • good trial period = 1-2 weeks
  • Mostly metabolized by the liver except silodosin (Rapaflo) -→ need to adjust for renal function
  • SEs:
    • dose limiting hypotension, syncope
      • less frequent with ER formulation and uroselective (alpha 1a blockers)
    • ejaculation disorders (tamsulosin)
  • DDI:
    • additive BP lowering effect
      • +other antihypertensives
      • +diuretics
      • +phosphodiesterase inhibitors
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Terazosin (Hytrin)

A

non-selective alpha antagonist

  • dose given at bedtime
  • hypotensive
  • extensive metabolism by liver
  • floppy iris (when undergoes cataract surgery) → no need to d/c
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Doxazosin

A

non-selective alpha blocker

  • longest half life
  • cardiovascular side effects
  • SEs similar to terazosin:
    • hypotension
    • intraoperative floppy iris syndrome
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Alfuzosin (uroxatral)

A

uroselective alpha 1A +alpha1D blocker

  • better absorption with food (Alf likes to eat a lot)
  • caution with renal disease
  • least amount of SEs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Tamsulosin (Flomax)

A

uroselective alpha 1A + 1D blocker

  • best absorbed on an empty stomach, “tammy is skinny b/c she does not eat food and is also extra floppy”
  • caution in renal and hepatic impairment
  • lowest hypotension
  • can cause ejaculation disorder
  • 40x higher risk of floppy iris than terazosin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Silodosin (Rapaflo)

A

uroselective alpha 1A +1D blocker

  • food decreases extent of absorption → less hypotensive
  • SEs same as tamsulosin
    • causes ejaculation disorder
  • CrCl = 30-50ml/min → half dose (4mg q day)
  • contraindicated in CrCl <30ml/min
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

5-alpha reductase inhibitor MOA

A

prevent testosterone from being converted to DHT (DHT→which would normally promote tissue growth)

Finasteride and dutasteride

  • Reduce the static factor → shrinkage of prostate by 20-25%
  • 2 types of 5-alpha reductases in prostate
    • type II = much more abundant than type I
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

5-alpha reductase inhibitors overview

A
  • slow onset
  • peak shrinkage in up to 6 months
  • reduce PSA levels
  • need at least 6 month to demonstrate effectiveness
  • relieve sxs in 30-70% of patients
  • no dose adjustment needed in renal impairment
  • SEs:
    • decreased libido
    • erectile dysfunction
    • ejaculation disorders
    • gynecomastia
    • breast tenderness
  • contraindicated in pregnant women → feminization of male fetus
  • women should handle with GLOVES
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Finasteride (Proscar)

A
  • Type II 5 alpha reductase inhibitor
  • inhibit 70-76% of serum dihydrotestosterone levels
  • half life slightly longer than dutasteride (6.2 hours vs 3-5 hours)
    • lasts 6 years
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Dutasteride (Avodart)

A

Type I and II 5-alpha reductase inhibitor

  • inhibits 90-95% of serum dihydrotestosterone levels
  • shorter half life than finasteride
19
Q

Dutasteride/Tamsulosin (Jalyn)

A

5alpha reductase inhibitor + alpha blocker

  • Indications:
    • high risk for BPH complications
      • prostate size > 30g
      • PSA > 1.5ng/mL
        • relieves sxs and reduces the need for prostatectomy by 67%
  • may d/c alpha blocker part of medication after 6-12 month of tx
20
Q

Herbal Therapies for BPH

A
  • commonly used in europe but not approved by FDA
  • Saw Palmetto
    • OTC.
    • no difference from placebo on:
      • urinary sx scores
      • urinary flow
      • prostate size
21
Q

Tadalafil (Cialis) and LUTS

A
  • approved for tx of LUTS
  • relaxation of smooth muscle of urethra
  • comparable to alpha blockers
  • does not increase urinary flow rate or reduce post-void residual volume
  • Best for BPH with ED
  • CrCl< 30ml/min? DO NOT USE; if CrCl < 50 = reduce dose
22
Q

Erectile Dysfunction

A
  • commonly occurs in men with systemic disorders such as:
    • DM
    • HTN
    • ischemic heart disease
    • increased age
  • identify the underlying etiology
    • medication induced? → SSRI, TCA, antipsychotics
  • Identify and the CV risks:
    • smoking
    • obesity
    • HTN
    • Dyslipidemia
  • initiate Therapy
    • PDE-5 inhibitors → 1st line
    • if ineffective → other treatments available
      • vacuum devices
      • penile self-injectable drugs
      • intraurethral alprostadil
23
Q

MOA of PDE-5 inhibitors

A

used for erectile dysfunction

PDE-5 usually breaks down cGMP (cGMP promotes smooth muscle relaxation → increased blood flow in the corpus cavernosum) so inhibiting PDE-5 = more cGMP

24
Q

Sildenafil (Viagra)

Revatio

A

decrease dose if CrCl <30mL/min

  • 30min -1 hour before activity
  • Revatio = used for pulmonary artery HTN
  • SEs:
    • headaches, dizziness, flushing
    • nasal congestion
    • UTI, diarrhea
    • reversible photosensitivity → “blue vision” – PDE-6 inhibition - retina
    • MI, stroke, hypotension
    • hearing loss
    • Priapism (prolonged erection) seizures
  • DDI:
    • vasodilators – ie alpha blockers
    • NITRATES → ALL CONTRAINDICATED
25
Q

Vardenafil (Levitra)

(Staxyn)

A
  • similar onset and duration as viagra 1 hour prior to activity
  • QT prolongation
  • high fat meals → lower peak serum concentration by 18%
    • delays absorption by 1 hour
  • ODT =more rapid onset
26
Q

Tadalafil (Cialis)

A

30 min before activity

has different structure than sildenafil and vardenafil

approved for BPH-LUTS and pulmonary artery htn

avoid use if CrCl <30mL/min

27
Q

Avanafil (Stendra)

A
  • 15 min before activity
  • +/- food
  • SEs:
    • HA, flushing, vertigo
    • nasal congestion, nasopharyngitis
    • back pain
    • angina, DVT
    • muscle spasms, pruritus
  • DDIs :
    • Nitrates = contraindication
    • alpha-blockers
    • antihypertensives
    • 3A4 inhibitors
28
Q

Types of Urinary Incontinence

A
29
Q

Treatments of SUI

A
  • if estrogen deficiency (atrophic urethritis or vaginitis) → vaginal estrogen (tablets and rings better than cream)
    • → avoid systemic estrogen as this may actually increase risk of new onset UI
  • Alpha Receptor Agonists
    • ephedrine – not recommended
    • phenylephrine – lack of data
    • Pseudoephedrine → Alpha 1 agonist
      • SEs: HTN, HA, dry mouth, nauseam insomnia, and restlessness
      • can add when estrogen alone is not working
  • Duloxetine
    • SNRI
      • off-label use
        • enhances serotonergic and adrenergic tone controlling smooth muscle and sphincters
          • avoid if CrCl <30mL/min
          • can raise BP
          • do not d/c abruptly → withdrawal syndrome
          • avoid in narrow-angle glaucoma
          • hepatotoxicity
30
Q

Tx of Urge Urinary Incontinence (UUI)

A
  • first line = anticholinergic/antispasmodic
    • suppressing premature detrusor contractions (overstimulation of M2 & M3 receptors)
      • enhances bladder storage
    • all have similar SEs and CIs
      • urinary retention
      • gastric retention, constipation
      • uncontrolled narrow angle glaucoma
      • dry mouth, HA
      • orthostatic hypotension
    • immediate release:
      • oxybutynin
      • Tolterodine
        • higher rate of ADE esp in elderly → start at lowest dose
    • Extended Release
      • oxybutynin
      • trospium
      • tolterodine
      • fesoterodine
      • darifenacin
      • solifenacin
        • less dry mouth compared to IR
31
Q

Tertiary Amine AntiMuscarinic Agents

A

Oxybutynin (highly lipophilic), tolterodine, fesoterodine, solifenacin, darifenacin

  • can penetrate BBB → CNS SEs
  • sedation
  • mental status change
32
Q

Quaternary Amine Antimuscarinic Agent

A

Trospium (Sanctura)

    • charge → hydrophilic → cannot cross BBB → less CNS SEs
33
Q

Antimuscarinic Agents DDI

A
  • all metabolized by 3A4 and/or 2D6
    • except Trospium (hydrophilic and renal clearance)
      • CrCl <30mL/min = need dose reduction
  • need to reduce dose with 3A4 inhibitors
    • Tolterodine
    • fesoterodine
    • solifenacin
    • darifenacin
  • avoid use with
    • antagonism:
      • acetylcholinesterase inhibitors
        • donepezil
    • additive effects
      • anticholinergics
34
Q

Mirabegron (Myrbetriq)

A
  • MOA: selective beta-3 agonist → relaxes smooth muscle of bladder
  • Eliminated by the kidneys, avoid in ESRD
  • indication: overactive bladder
  • SEs: HTN, urinary retention, UTI, HA, tachycardia
  • DDI:
    • +digoxin → increased dig AUC by 27% → monitor level
  • 2D6 inhibitor (moderate)
    • +thioridazine → QT prolongation, urinary retention
      • anticholinergic → urinary retention
      • colchicine → increase colchicine level → toxic myopathy, rhabdomyolysis
35
Q

Tx of Overflow urinary Incontinence due to bladder underactivity

A
  • Cholinomimetic
    • bethanechol
      • mixed results
        • SEs: muscle and abd cramps, hypersalivation, diarrhea, bradycardia, and bronchospasm
  • Alpha Blockers → help outflow
    • prazosin, terazosin, doxazosin, tamsulosin, silodosin, alfuzosin
  • intermittent urethral cath, indwelling urethral, suprpubic cath,
36
Q

Monitoring of BPH

A

reduction of sxs score ≥ 3 points

perceive symptoms as not bothersome

if response → continue drug regimen and check q 6 months

  • repeat PSA and DRE annually
  • if no response (weeks after alpha blockers, 6 months after 5alpha reductase inhibitors) → surgery
37
Q

PDE-5 Inhibitors (list)

A
  • Sildenafil (Viagra, Revatio)
  • Vardenafil (Levitra, Staxyn)
  • Tadalafil (Cialis, adcirca)
  • Avanafil
38
Q

Duloxetine

A

SNRI → off label use = tx of stress urinary incontinence

  • enhances serotonergic and adrenergic tone controlling smooth muscle and sphincters
  • avoid if CrCl <30ml/min
  • raises BP
  • do not d/c abruptly → withdrawal
  • avoid in uncontrolled narrow-angle glaucoma
  • hepatotoxicity
39
Q

Oxybutynin

A

anticholinergic/antispasmodic drug recommended for UUI

  • tertiary amine
  • active metabolite
  • caution if CYP 3A4 inhibitors also being taken
40
Q

Tolterodine

A

anticholinergic/antispasmodic drug recommended for UUI

  • tertiary amine
  • active metabolite
  • oral Antacid interactions
41
Q

Trospium Chloride

A

anticholinergic/antispasmodic drug recommended for UUI

  • quaternary amine → does not cross BBB due to + charge
    • foods decrease absorption, give on empty stomach
      • altered in renal disease → dose reduction if CrCl <30ml/min
42
Q

Solifenacin

A

anticholinergic/antispasmodic drug recommended for UUI

  • tertiary amine
43
Q

Fesoterodine

A

anticholinergic/antispasmodic drug recommended for UUI

  • tertiary amine
  • pro-drug

NRS 271A: optho, pulm, GU, Renal, Heme/onc (10 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions