Urology Flashcards
What drugs can affect continence?
- a-agonists/antagonists
- Alcohol
- Anticholinergics
- CCB
- Diuretics
- Narcotics
- Antidepressants
- Antipsychotics
- Sedative/hypnotics
What exams should be done for incontinence?
- Digital rectal/pelvic exam
- Neuro exam
- PVR
- Cystoscopy
- U/A with micro
- Serum BUN/Cr
- PSA
- History
What is desmopressin nasal spray (Noctiva) for?
Nocturnal polyuria adults (awakening 2x per night)
What monitoring should be done for Noctiva?
Na+ (can cause hyponatremia)
What are some causes of urge incontinence (AOB)?
- a-blockers in women
- Estrogen use in women
- Cystitis
- Stones
- Tumor
- Neurologic issues***
How should we treat OAB?
Smooth muscle relaxants (anti-muscarinic)
Which anti-muscarinic drugs have low BBB crossing?
- Trospium
- Tolterodine
- Fesoterodine
Which anti-muscarinic drugs are better and why?
Darifenacin and Solifenacin
They are M3 specific, which causes less CNS side effects
What are dose-dependent side effects of smooth muscle relaxants?
- Anticholinergic stuff
- Confusion/delirium/dementia**
What is the hierarchy for smooth muscle relaxant drugs for OAB?
- Solifenacin (best efficacy and low dry mouth risk)
- ER tolterodine (less risk of dry mouth than IR)
- Fesoterodine (good efficacy but has dry mouth and high risk of discontinuation)
- IR tolterodine (less risk of dry mouth than oxybutynin)
- Oxybutynin (just sucks in general)
What are the best smooth muscle relaxant drugs for OAB?
Solifenacin and ER tolteradine
Who should not use imipramine or other TCAs for OAB?
Elderly at risk for orthostasis, cardiac arrhythmias, or other anti-cholinergic effects
When is Botox indicated for OAB?
Failure or intolerance to anticholinergic medication for NEUROLOGIC-related OAB
What is the biggest problem with Botox for OAB?
High infection risk and transient urinary retention
When should Mirabegron be avoided and why?
Those with high blood pressure
It can cause sinus tachycardia and hypertension
Vibegron is well-tolerated, but what are the biggest concerns with it?
Infections
- URI, UTI, bronchitis, nasopharyngitis
What benefit does vibegron have over mirabegron?
NO BP WARNING!!
What is the 1st line treatment for OAB?
Behavioral therapies
+/- pharm if necessary
T/F: Antimuscarinics and B3-agonists should be avoided together
FALSE: can be used together for refractory cases
What are some treatments for stress incontinence? (increase intra-urethral pressure)
- Pseudoephedrine
- Midodrine
- Estrogen (vaginal application)
- Duloxetine 40 mg BID (OFF-LABEL)
How can we treat overflow incontinence?
Bethanechol
- increase bladder tone but efficacy in question
What are symptoms of BPH?
- Incomplete emptying
- Frequency
- Intermittency
- Urgency
- Weak stream
- Straining
- Nocturia
What are non-pharm options for BPH?
- Incontinent pads
- TURP
- Urethral dilation
- Foley catheters
What is the hierarchy for a-1 blockade strength of BPH drugs?
Terazosin > doxazosin > prazosin
T/F: Alpha blockade drugs can be used to treat BPH AND lower blood pressure
FALSE: they have been proven ineffective for lowering BP
What are adverse effects of a-1 blockers?
- Postural hypotension
- Dizziness/vertigo
- Blurred vision
- Drowsiness
- Asthenia (weakness)
- “First dose” effect (syncope)
What is the potency hierarchy for a1A-selective blockers?
Silodosin»_space; Alfuzosin ~ Tamsulosin
Which a1A-blockers cause the most and least ejaculatory dysfunction?
Silodosin causes the most
Alfuzosin does not cause it
What are the 5-a reductase drugs we have for BPH?
Finasteride (type II, <50% symptom improvement)
Dutasteride (type I and II, more potent)
How long does finasteride therapy last?
3-6 months
Between finasteride and dutasteride, which drug has more symptom improvement?
Dutasteride
Which drugs should be avoided in BPH and why?
- TCAs
- Diphenhydramine
- Disopyramide
- Pseudoephedrine
- Ephedrine
- Anticholinergics
THEY CAUSE URINARY RETENTION - harder to contract detrusor muscle
What drug combo may be better than monotherapy to treat UT symptoms and erectile dysfunction
Sildenafil and alfuzosin
What is ENTADFI?
The first FDA approved combo product with finasteride and tadalafil
T/F: Saw Palmetto is ineffective for BPH
TRUE
When should we try a PDE5 for BPH?
- Initial therapy if the patient also has ED
- After failing an alpha blocker
When should we consider 5ARI addition for BPH?
Prostate >30cc
What is last-line therapy for BPH?
Surgery
What is the questionnaire used to categorize ED?
IIEF-5
What are risk factors for ED?
- Diabetes
- Tobacco
- Lower urinary tract symptoms
- CV disease
- Depression/stress
What drugs can cause ED?
- Thiazide diuretics
- Beta blockers (not nebivolol)
- Cardiac/cholesterol drugs
- Antidepressants
- H2 antagonists
- Hormones
- Recreational drugs
- Anticholinergics
- Immunomodulators
- Cytotoxic drugs (cancer)
- Tranquilizers
- Sedative hypnotics
- Opioids*
- Long-term NSAIDs*
T/F: Number of medications has a positive association with ED
TRUE
What is the first-line drug class for ED pharmacotherapy?
PDE-5
When should PDE5 dose reductions be necessary?
With CYP3A4 inhibitors
What are contraindications to PDE5 therapy?
- Concomitant nitrate therapy
- Uncontrolled HTN
- Severe congestive HF
- Recent MI
- Heart disease
- High-risk arrhythmias
- Obstructive cardiomyopathy
- Unstable angina
What are precautions with PDE5?
- Hypotension
- Additive effects with a-blockers
- Can cause GERD
What PDE5 has the shortest onset?
Avanafil
What PDE5 has the longest onset?
Vardenafil
What is the longest acting PDE5?
Tadalafil
Which PDE5 has the most vision changes associated?
Sildenafil (3-11%)
What is “the little blue pill” or “Vitamin V”?
Sildenafil
What is “the weekender”?
Tadalafil
What is “the quickie”?
Avanafil
What PDE5s are affected by high fat meals?
Sildenafil and Vardenafil
What is first line treatment for erectile dysfunction?
- Treat underlying disease
- Discontinue contributing medications
- Remove risk factors
- Give testosterone for hypogonadism
Patient says PDE5 is not working. What should you do?
- Make sure they get the timing correct
- Let them know they can take up to 8 doses until effect
- Consider titrating up dosage
What is second-line pharmacotherapy for ED?
- Vacuum erection device
- Intracavernosal or intraurethral alprostadil
What are other possible drug therapy options for ED?
- Yohimbine, Phentolamine (adrenergic agonists)
- Androgens
- Apomorphine
- Trazodone*
