Genitourinary, BPH, Erectile Dysfunction Flashcards by Dylan Null

Release of urine from the bladder

Micturition

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Involuntary leakage of urine

Urinary Incontinence

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Problem outside of the urinary tract (reversible)

Transient UI

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Caused by an abnormality of the urinary tract.

Established UI

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Nervous system involved in prevention micturition with the relaxation of the detrusor muscle and contraction of the internal sphincter (bladder filling)

Sympathetic

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Stimulation of this adrenergic receptor relaxes Detrusor muscle to increase capacity.

B3-adrenergic

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Stimulation of this adrenergic receptor tightens the internal bladder sphincter.

a-Adrenergic

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Nervous system responsible for micturition.

Parasympathetic

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Neurotransmitter that mediates involuntary and voluntary bladder contraction

Acetylcholine (M3)

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Transient Causes of Urinary Incontinence:

DIAPPERS

Delirium + Dementia
Infection
Atrophic Urethritis
Pharmaceuticals
Psychological
Excessive Urine Output
Restricted Mobility
Stool Impaction

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Common Medications that cause Urinary Incontinence

Antihypertensives
Diuretics
Psychotherapeutics

Alcohol
Antihistamines + Anticholinergics
Narcotics

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Loss of small amounts of urine with increased abdominal pressure
- sneezing or coughing

Stress UI
- most common type
- pregnancy and childbirth
- menopause

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Signs and Symptoms of Stress UI

Urine leakage with Physical Activity
- volume is related to exertion level

Never Occurs during Inactivity
- No Nocturia

PVR: Normal (0 - 100mL)

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Non-Pharmacologic Interventions for Stress UI

Lifestyle Modifications
Scheduling Regimens
Pelvic Floor Exercises
External Neruomodulation
- non implantable electrical stimulation

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Pharmacologic Interventions for Stress UI

Duloxetine
α1-adrenergic receptor agonists
Estrogens

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Medication that inhibits serotonin and norepinephrine reuptake.

Increases internal urethral and external urethral sphincter muscle tone.

NOT FDA approved for treatment of Stress UI

Duloxetine

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Adverse Drug Reactions of Duloxetine

Nausea
Headache
Constipation
Dry Mouth
Insomnia

often decrease or resolve with time

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Precautions with Duloxetine

Hepatotoxicity
Renal Impairment
CYP1A2 Inhibitors
- Ciprofloxacin + Fluvoxamine

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Contraindications with Duloxetine

MAO-I use within last 14 days

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Medication that increases contraction of urethral smooth muscle via stimulation of α1-receptors

α1-Adrenergic Agonists
- Pseudoephedrine
- Phenylephrine

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When are α1-Adrenergic Agonists most effective?

With Estrogen (women only)

NOT FDA approved

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Contraindications of α1-Adrenergic Agonists

MAO-I use within 14 days

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Medication that increases urethral epithelium proliferation, local circulation, and the number and sensitivity of urogenital α-adrenergic receptors.

Estrogen

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How do you use Estrogen for Stress UI

Use only topical products with urethritis or vaginitis due to estrogen deficiency being present.

NO benefit seen with oral and may increase risk of UI.

Do NOT use combination products with progestins
- decrease vaginal muscle tone

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Contraindications to Topical Estrogen

Abnormal Vaginal Bleeding DVT or PE Stroke or MI history Carcinoma of the breast Hepatic Dysfunction Pregnancy

Sudden and intense urge to urinate leading to involuntary loss of urine. Detrusor muscle inappropriately contracts, leading to increased urinary frequency and urgency.

Overactive Bladder - Urge UI

Overactive Bladder Risk Factors

Age Neurologic Disease BPH Prostate Cancer

Signs and Symptoms of Overactive Bladder

↑ Frequency (> 8 times per day) ↑ Urgency Nocturia PVR: Usually Normal

Overactive Bladder Pharmacologic Treatments

Anticholinergics B3-Adrenergic Agonists Botulinum Toxin A Tricyclic Antidepressants

Medications that antagonize muscarinic receptors. Decrease detrusor contractions Increase bladder storage

Anticholinergics

Precautions with Anticholinergics (Oxybutynin)

First Gen H1 Antihistamines Muscle Relaxants TCAs Antipsychotics

Contraindications of Anticholinergics

Gastric Retention Uncontrolled Narrow Angle Glaucoma

Medication that increases bladder capacity by relaxing the detrusor muscle during the storage phase of stimulation. Decreases frequency Increases volume per void

Mirabegron (B3-Adrenergic Agonists)

Adverse Drug Reactions of Mirabegron

Hypertension UTI

Mirabegron is a moderate Inhibitor of what?

CYP2D6 - start with lowest possible dose of Digoxin.

Neurotoxin that inhibits the release of Acetylcholine at the Neuromuscular Junction Injected directly into the detrusor muscle to prevent muscle contraction.

Botulinum Toxin A

Adverse Drug Reactions of Botulinum Toxin A

Urinary Retention UTI Dysuria Hematuria

Medication that decreases bladder contractility and increases outlet resistance via anti-cholinergic and a-agonists effects.

Tricyclic Antidepressants (TCAs)

Efficacy of Tricyclic Antidepressants

No more effective than Oxybutynin IR with increased ADRs USED ONLY WITH: - depression - neuropathic pain - mixed UI - Nocturnal incontinence with altered sleep patterns

Which two TCAs are preferred due to decreased ADRs?

Desipramine Nortriptyline

Leakage of urine due to over-distened bladder that is unable to empty

Overflow Incontinence

What is the PVR of Overflow Incontinence?

INCREASED (> 100 mL)

Associated with Urgency Incontinence (Mechanism)

Detrusor Overactivity

Associated with Stress Incontinence (Mechanism)

Sphincter Dysfunction

Associated with Overflow Incontinence (Mechanism)

Bladder Outlet Obstruction

Anatomic enlargement of the prostate due to androgen stimulation. Contraction of prostate around the urethra and narrowing due to excessive alpha-adrenergic tone.

Benign Prostatic Hyperplasia (BPH)

Clinical Symptoms of BPH Collectively referred to as LUTS - Lower Urinary Tract Symptoms

Obstructive (Early) → can't get it out - decreased flow and force - hesitancy - straining - dribbling - incomplete emptying Irritative (Late) → can't keep it in - Increased Frequency - Nocturia - Urgency - Dysuria - Urge Incontinence

Complications of BPH

Acute Renal Failure Hematuria UTIs Bladder Stones CKD

When should Anticholinergics be avoided for BPH?

PVR ≥ 250 mL

What medication classes can be used to treat BPH?

Alpha-Adrenergic Antagonists 5-alpha Reductase Inhibitors Phosphodiesterase Inhibitors (PDE5-I) Anticholinergics

Medication that causes relaxation of the musculature of the prostate and bladder. ENHANCED URINARY OUTFLOW Does NOT reduce prostate size

Alpha-Adrenergic Antagonists

What is the most commonly used Alpha-Adrenergic Antagonists (3rd Generation)?

Tamsulosin (Flomax)

Side Effects of Tamsulosin

Ejaculatory Dysfunction Floppy Iris Syndrome

What should be monitored when taking Alpha-Adrenergic Antagonists

Blood Pressure Heart Rate (decreases both)

Considerations for Alpha-Adrenergic Antagonists (Tamsulosin)

Take at Bedtime Inform Ophthalmology if patient needs cataract surgery.

Medication that decreases the conversion of Testosterone to DHT. Decreases Prostate Size

Finasteride (5-Alpha Reductase Inhibitor)

What is needed yearly when taking Finasteride?

Prostate Specific Antigen Digital Rectal Exam

Finasteride vs. Flomax.

Similar Effectiveness Delays onset of Improvement (6 months) MORE USELF IN LARGE PROSTATE > 40 grams

Adverse Drug Effects of Finasteride

Pregnancy Category X - Stop 3 months prior to conception Sexual Dysfunction

Increases cGMP and leads to smooth muscle relaxation in prostate and bladder.

Tadalafil (Cialis)

Who is Tadalafil reserved for?

BPH Erectile Dysfunction

Who should avoid Tadalafil?

CrCl < 30 Hepatic Impairment

Side Effects of Tadalafil

Priapism Headache Flushing

When should Combination treatments for BPH be used? (Tamsulosin + Finasteride)

Prostate Size > 40 g + PSA > 1.4 ng/mL

What should you do before starting a patient on a combo therapy for BPH

Stabilize on Alpha Blocker first.

What herbal substance can be used for BPH?

Saw Palmetto

Causes of Organic Erectile Dysfunction (80% of ED)

Vascular Neurologic Hormonal

Medication for Erectile Dysfunction that increases cGMP concentrations and causes the release of Nitric Oxide.

Phosophodiesterase-5 Inhibitors (PDE-5) - all agents considered equally effective

Adverse Drug Reactions of PDE-5 Inhibitors

Changes in Blue-Green Vision Hearing Loss QT Prolongation - Vardenafil Hypotension

How long should you wait to administer nitrates after taking Tadalafil?

48 hours

How do you take PDE-5 Inhibitors?

30-60 minutes before sex - 2 hrs for Tadalafil On an Empty Stomach Avoid Alcohol

What should you do if you experience angina during sexual activity while taking a PDE-5 Inhibitor?

Stop Sex - relax 5 to 10 minutes Emergency Care if no relief

Prostaglandin E1 analog that causes direct dilation of cavernosal arteries. 1st dose must be taken under supervision of a provider.

Intracavernosal Alprostadil (Caverject)

Contraindications to Caverject?

Penis Deformation Priapism Leukemia Myeloma Sickle Cell Disease

Side Effects of Caverject

Penile Pain - treat with Tylenol Penile Scars Priapism - medical care if longer than 1 hour