Geriatrics - Urology Flashcards
Incontinence - Causes
urethral obstruction (BPH)
impaired bladder contraction (DM, MS, detrusor hyperactivity)
incompetent sphincter (stress)
bladder inflammation (UTI)
bladder stones (UTI, obstruction)
malignancy
Incontinence - Potential Drug Causes
alpha-blockers & alpha-agonists
alcohol
anticholinergics
cholinesterase inhibitors
calcium channel blockers
diuretics
narcotics
antidepressants
antipsychotics
sedative-hypnotics
Nocturnal Polyuria - Treatment
desmopressin nasal spray
indication: wakening 2 or more times per night to urinate
Desmopressin Nasal Spray - Monitoring
sodium levels
Desmopressin Nasal Spray - CIs
hyponatremia
polydipsia
primary enuresis
concomitant diuretics or steroids
eGFR < 50
NYHA class II-IV
uncontrolled hypertension
SIADH
Overactive Bladder - Causes
potentially alpha-blockers in women
potentially estrogens 30-60 mg
cystitis
stones
tumor
neurologic impairment
OAB - Smooth Muscle Relaxants
oxybutynin
tolterodine
trospium
darifenacin
solifenacin
dicyclomine
hyoscyamine
OAB Drugs - Less CNS Effects
tolterodine
trospium
darifenacin
solifenacin
fesoterodine
OAB Drugs - Adverse Effects
dose-dependent:
dry mouth & eyes
urinary retention
palpitations
constipation
dizziness
confusion / delirium / dementia
OAB - Other Drugs
TCAs (imipramine)
botox - IM injection with inadequate response or intolerance to ACh medication
OAB - Beta-3 Adrenergic Receptor Agonists
mirabegron
AEs: nausea, headache, hypertension, constipation, sinus tachycardia
vibegron
AEs: nausea, headache, diarrhea, URI, UTI
OAB - First-Line Treatment
behavioral therapies
OAB - Second-Line Treatment
PO antimuscarinics or beta-3 agonists
ER better than IR
combination antimuscarinic & beta-3 agonist if refractory to monotherapy
Stress Incontinence - Alpha Receptor Agonists
increase intra-urethral pressure
pseudoephedrine 15-30 mg TID
midodrine 2.5-5 mg TID
Stress Incontinence - Estrogen Replacement
proliferation of urethral mucosa -> improves mucosal outflow resistance
vaginal application acceptable
Stress Incontinence - Other Drugs
duloxetine 40 mg BID
Overflow Incontinence - Causes
BPH
neuropathies
anticholinergics
Overflow Incontinence - Drugs
bethanechol 10 mg TID
stimulates muscarinic receptors
AEs: cramping, diarrhea, salivation, orthostasis, urgency, bronchial constriction
BPH - Etiology
proliferation of stromal & epithelial cells due to hormonal and aging processes -> increased prostate size
BPH - Symptoms
incomplete emptying
frequency
intermittency
urgency
weak stream
straining
nocturia
BPH - Non-Pharmacological Management
incontinence pads
TURP
urethral dilation
Foley catheter
surgeries
BPH - Alpha-1 Blockers
silodosin
tamsulosin
alfuzosin
terazosin
doxazosin
prazosin
Alpha-1 Blockers - Adverse Effects
postural hypotension
dizziness
blurred vision
asthenia
Alpha-1 Selective Blockers
silodosin (most selective)
alfuzosin
tamsulosin
Alpha-1 Selective Blockers - Adverse Effects
floppy iris syndrome
ejaculatory dysfunction
DDIs (450-metabolized)
BPH - 5-Alpha-Reductase Inhibitors
finasteride
dutasteride
5-Alpha-Reductase Inhibitors - Adverse Effects
impotence
libido
ejaculation volume
gynecomastia
pregnancy X
BPH - Drugs to Avoid
pseudoephedrine
ACh drugs
BPH - PDE-5 Inhibitor
tadalafil 5 mg QD
cannot combine with alpha-blockers (symptomatic hypotension)
Erectile Dysfunction - Risk Factors
metabolic syndrome
DM
BPH
CV disease
tobacco smoking
central neurologic conditions
spinal cord injury
depression
endocrinologic conditions
ED - Potentially Worsening Drugs
diuretics
antihypertensive drugs
digoxin
gemfibrozil
H2RAs
cytotoxic agents
immunomodulators
ACh drugs
alcohol, cocaine
opioids, NSAIDs
ED - Treatment
androgens
PDE5 inhibitors
adrenergic receptor antagonists
apomorphine
trazodone
intracavernous therapy
transurethral therapy
ED - PDE-5 Inhibitors
sildenafil
tadalafil
vardenafil
avanafil
PDE-5 Inhibitors - Precautions
CYP3A4 DDIs
additive effects with alpha-blockers
GERD
CI: concurrent nitrate therapy, MI or stroke within 2 weeks, cardiac arrhythmias, uncontrolled hypertension, unstable angina
Sildenafil - Dosing & PK
25-100 mg
onset 30-60 min
duration 2-4 hrs
high-fat meal lowers effect
wait time w/ nitrates 24 hrs
blurred vision common
Vardenafil - Dosing & PK
5-20 mg
onset 60 min
duration 4-6 hrs
high-fat meal lowers effect
wait time w/ nitrates 24 hrs
Tadalafil - Dosing & PK
5-20 mg
onset 30-45 min
duration 24-36 hrs
high-fat meal - no effect
wait time w/nitrates 48 hrs
Avanafil - Dosing & PK
50-200 mg
onset 15 min
duration 4-6 hrs
wait time w/nitrates 12-24 hrs
ED - Guidelines
- treat underlying diseases, remove medications that could contribute
- testosterone if hypogonadism
- PDE5 inhibitors for at least 7-8 doses
- vacuum erection device
- intracavernous or intraurethral alprostadil
- penile prosthesis
OAB - Antimuscarinics CIs
narrow angle glaucoma
caution: delayed gastric emptying or urinary retention
