Genitourinary Disorders

Question 1

HB is a 73-year old patient with BPH who has been stabilized on Flomax CR 0.4mg daily. He has just been diagnosed with depression. Which of the following antidepressants would be contraindicated for this patient?
a) Escitalopram
b) Paroxetine
c) Venlafaxine
d) Nortriptyline
e) Moclobemide

Answer 1

D. Nortriptyline is a tricyclic antidepressant and, like all of that class, has a high incidence of anticholinergic side effects, including urinary hesitancy. None of the other agents would be contraindicated.

Question 2

Lower urinary tract symptoms and benign prostatic hyperplasia goals of therapy

Answer 2

1. improve or abolish lower urinary tract symptoms
2. delay or prevent clinical progression of BPH
3. Prevent the sequelae of long-term bladder outlet obstruction (UTIs, bladder stones, hydronephrosis)

Question 3

Lower urinary tract symptoms and benign prostatic hyperplasia diagnosis/investigation: medical hx

Answer 3

1. Hx:
   - voiding (weak, interrupted stream, dribbling, hesitancy, straining) and storage (nocturia, frequency, urgency) sx
   - onset and progresion, degree of inconvenience or bother, International Prostate Symptom Score (IPSS), and voiding diary
   - details if urethral infxn, instrumentation or injury (trauma, surgery, radiation)

Question 4

Lower urinary tract symptoms and benign prostatic hyperplasia diagnosis/investigation: Physical examination

Answer 4

2. PE:
   - abdomen (bladder distention, flank tenderness)
   - external genitalia (phimosis, meatal stenosis, urethral mass/induration)
   - DRE, document prostate size, consistency, symmetry and tenderness, note anal tone and rectal abnormalities

Question 5

Lower urinary tract symptoms and benign prostatic hyperplasia diagnosis/investigation: lab tests

Answer 5

3. Lab tests:
   - urinalysis (and urine culture if bacteriuria/pyuria)
   - PSA (prostate specific antigen) controversial. baseline for asx pts aged 40-54 years.Pts w/ higher risk for prostate cancer (+ fam hx, black african/caribbean descent), sooner. Pts 55-69 yoa discuss benefits and harm with their family dr. >70yoa or life expectancy or less than 10-15 yrs, not recommended. In LUTS, detects cancer as cause; in combination with age, predicts prostate volume. High PSA values = greater risk of clinical progression of LUTS. 5-alpha-reductase inhibitors (check meds) decrease serum PSA levels.

Question 6

Lower urinary tract symptoms and benign prostatic hyperplasia diagnosis/investigation: additional tests

Answer 6

4. Additional tests when hx is not clear, PE or labs are abnormal, or response to tx unsatisfactory:
   - serum creatinine
   - urine cytology
   - cystourethroscopy
   - urodynamic studies (uroflowmetry)
   - renal/bladder/transrectal ultrasonography
   - IV urography
   - CT abdomen and pelvis

Question 7

Lower urinary tract symptoms and benign prostatic hyperplasia: nonpharmacological choices

Answer 7

• manage pts with minimal sx with reassurance and active surveillance (regular reassessment)
• advice pts with problematic nocturia to avoid caffeine and alcohol in the evening
• advise pts with pedal edema to elevate legs prior to retiring

Question 8

Lower urinary tract symptoms and benign prostatic hyperplasia: pharmacological choices

Answer 8

• nonselective alpha1-adrenergic receptor antagonist (alpha blocker): alfuzosin, doxazosin, terasozin
• selective alpha1-adrenergic receptor antagonist (alpha blocker): silodosin, tamsulosin
• 5-alpha-reductase inhibitors: dutasteride, finasteride

Question 9

alpha blockers and heart failure studies

Answer 9

clinical trials have been mixed. 2021 Canadian study found patients >66 yoa with BPH who were exposed to alpha-blocker or 5-alpha-reductase inhibitor therapy (alone or in combination) had increased association with new cardiac failure (highest risk with nonselective alpha blockers alone).

Question 10

alpha1-adrenergic receptor antagonists

Answer 10

Alfuzosin, doxazosin, silodosin, tamsulosin, terazosin

Question 11

alpha1-adrenergic receptor antagonist - how the work?

Answer 11

used to block alpha1-adrenergic receptors that mediate smooth mm activity in the bladder neck, prostate and prostatic capsule, reducing the dynamic component of bladder outlet obstruction.

Question 12

alpha1-adrenergic receptor antagonist - how long they take to work?

Answer 12

over a period of days to weeks, urinary flow rates may improve by 1-3mL/sec and sx scores by 1-3 points. Does not influence prostate size.

Question 13

alpha1-adrenergic receptor antagonist - how to dose?

Answer 13

To avoid first-dose syncope, start doxazosin and terazosin at a low dosage and gradually increase until sx improve or intolerance occurs. Dose titration is not necessary with alfuzosin, silodosin, and tamsulosin.