Urology in the Older Patient

Question 1

M3 Receptor

Answer 1

Used in the voidance phase.
Blocked with ACh inhibitors.

Question 2

B3 Receptor

Answer 2

Used in the storage phase.
Stimulate with norepinephrine.

Question 3

Causes of incontinence

Answer 3

Urethral obstruction (BPH, strictures, stenosis)
Impaired bladder contraction (DM, MS, Spinal injuries, detrusor hyperactivity)
Incompetent sphincter (stress, incontinence/cystocele)
Bladder inflammation (UTI/interstitial cystitis)
Bladder stones (Obstruction/metabolic disease/UTI)
Malignancy (Bladder CA, carcinoma in situ, invasive CA)

Question 4

Medications affecting continence

Answer 4

Alpha agonists/antagonists
Alcohol
Anticholinergics
Cholinesterase inhibitors
CCBs
Diuretics
Narcotics
Antidepressants
Antipsychotics
Sedative/hypnotic

Question 5

Desmopressin Nasal Spray

Answer 5

Used for nocturnal polyuria, adults that awaken > 2 x per night to urinate
Beers criteria “avoid”
Careful in hyponatremia, fluid retention, nasal conditions.
Watch sodium levels

Question 6

Overactive bladder (urge incontinence)

Answer 6

Involuntary leakage of urine
Involuntary contraction of bladder
Detrusor hyperreflexia (cystitis, stones, tumor, neurologic)

Question 7

Smooth muscle relaxants

Answer 7

Antimuscarinic or “atropine like”
Antispasmodics with local anesthetic properties

Question 8

M3 receptor agents for OAB

Answer 8

Solifenacin and Darifenacin
Preferred agents due to decreased CNS effects

Question 9

Antimuscarinic agents for OAB

Answer 9

Oxybutynin, tolterodine, trospium, fesoterodine, dicyclomine, propantheline
Not as preferred, but less BBB crossing with tolterodine, trospium, and fesoterodine

Question 10

ADEs of smooth muscle relaxants

Answer 10

Dose dependent:
Dry mouth
Dry eyes/blurred vision
Urinary retention
Palpitations
Constipation
Dizziness/drowsiness
Confusion/delirium/dementia (w/ anticholinergics)

Question 11

IR or ER for OAB

Answer 11

ER preferred for decreased risk of dry mouth
Tolterodine preferred over oxybutynin
Solifenacin preferred over IR tolterodine
Fesoterodine preferred over ER tolterodine but has increased risk of withdrawal d/t ADEs and increased risk of dry mouth.

Question 12

Mirabegron ER (Myrbetriq)

Answer 12

B3 agonist for OAB
MOA: Detrusor muscle relaxation
PK: t1/2 = 50 hours, reduce dose for hepatic or renal dysfunction
SE: Nausea, headache, hypertension, diarrhea, constipation, dizziness, and sinus tachycardia
Precaution in uncontrolled hypertension

Question 13

Virabegron (Gemtesa)

Answer 13

B3 receptor agonist
MOA: Detrusor muscle relaxation
PK: t1/2 = 31 hours, dose reduction for severe hepatic or severe renal dysfunction
SE: Nausea, headache, diarrhea, constipation, nasopharyngitis, bronchitis, URI, UTI
No warning for HTN

Question 14

OAB first line treatment

Answer 14

Behavioral therapies: Bladder training, bladder control strategies, pelvic floor muscle training, fluid management with or without pharm

Question 15

OAB second line treatment

Answer 15

Oral antimuscarinics, oral B3 agonists
ER>IR
Combo oral antimuscarinics, oral B3 agonists if resistant to monotherapy
Do not use in anti-M narrow-angle glaucoma, extreme caution in decreased gastric emptying or urinary retention
Caution with anti-M and anticholinergics
Caution with anti-M or B3-agonists in the frail OAB patient

Question 16

Stress incontinence

Answer 16

Involuntary leakage with “stress”
Intra-abdominal pressure
Sneezing, laughing, coughing
Decreased pelvic muscle musculature

Question 17

Alpha-receptor agonist for stress incontinence

Answer 17

Pseudoephedrine
SE: Insomnia, HTN, HA, tremor, palpitations

Question 18

Estrogen replacement for stress incontinence

Answer 18

Causes proliferation of urethral mucosa
Improves mucosal outflow resistance
Use typical dosing for ERT - vaginal application only for Beers criteria
SE: Pap/mammogram, bleeding & DVT (moreso with oral formulations)

Question 19

Duloxetine for stress incontinence

Answer 19

Not FDA approved

Question 20

Overflow incontinence

Answer 20

Leak urine throughout the day
“weight” of the urine increased due to BPH, neuropathies, anticholinergics

Question 21

Bethanechol (Urecholine)

Answer 21

Stimulates muscarinic receptors
Bladder tone (push all the pee out)
AE:
GI cramping, diarrhea, salivation
Orthostasis with reflex tachy
Urgency
Bronchial constriction

Question 22

BPH Etiology

Answer 22

Proliferation of stromal and epithelial cells (static)
Due to hormonal (DHT) and aging process
Proliferation of SMC increases prostate size
Smooth muscle tone (dynamic) (tighter)

Question 23

Symptoms of BPH

Answer 23

Incomplete emptying
Frequency
Intermittency
Urgency
Weak stream
Straining
Nocturia

Question 24

Non-pharm management of BPH

Answer 24

Incontinent pads
TURP
Urethral dilation
Foley catheters
Others

Question 25

Alpha-1 inhibitors for BPH

Answer 25

Terazosin>doxazosin>prazosin AE: Postural hypotension Dizziness/vertigo Blurred vision Drowsiness Asthenia "First dose" effect (added effect with other HTN meds)

Question 26

Alpha-1a specific blockers

Answer 26

Silodosin>>Alfuzosin ~ Tamsulosin Take Alfuzosin with food to increase F AE: Rarely hypotension, vertigo, drowsiness Floppy iris syndrome Ejaculatory dysfunction CYP450 metabolism

Question 27

Finasteride

Answer 27

Inhibits type II 5-alpha1-reductase Decreases DHT Needs 3-6 months of therapy to work to change enzymes resulting in atrophy Less than 50% have symptomatic improvement

Question 28

Dutasteride

Answer 28

Selective inhibitor of type I and II 5-alpha1-reductase More potent than finasteride Needs 3-6 months of therapy to work to change enzymes resulting in atrophy Better results with dutasteride than finasteride

Question 29

5-alpha1-reductase ADEs

Answer 29

Impotence Libido Ejaculation volume Gynecomastia/mastalgia Pregnancy category X - Women should not handle, secreted in to semen (Conc <100x what is needed to produce abnormalities)

Question 30

Drugs to avoid in BPH

Answer 30

TCAs Diphenhydramine Disopyramide Pseudoephedrine Ephedrine Anticholinergic

Question 31

Tadalafil

Answer 31

PDE5 inhibitor-mediated smooth muscle relaxation of the prostate, bladder, urethra and their vascular supply

Question 32

Alpha-1a blocker and PDE5 inhibitor

Answer 32

Superior to monotherapy in treating lower UTI symptoms and erectile dysfunction

Question 33

Saw Palmetto

Answer 33

No significant difference in improving symptoms or objective measures of BPH

Question 34

Pathophysiology of ED

Answer 34

NO to cGMP leading to smooth muscle relaxation, which is degraded by PDE5

Question 35

IIEF-5 Questionnaire

Answer 35

1-7: Severe ED 8-11: Moderate ED 12-16: Mild-moderate ED 17-21: Mild ED 22-25: No ED

Question 36

Risk factors for ED

Answer 36

Metabolic syndrome Lower UTI symptoms of BPH CV disease Tobacco smoking CNS conditions Spinal cord injury Depression or social or marital stress Endocrinologic conditions Diabetes

Question 37

Drugs associated with ED

Answer 37

Diuretics Antihypertensive drugs Cardiac or cholesterol drugs Antidepressants Tranquilizers H2 antagonists Hormones Cytotoxic agents Immunomodulators Anticholinergic agents Recreational drugs Sedative-hypnotics Regular NSAID use

Question 38

Drug therapy for ED

Answer 38

Androgens PDEi Adrenergic-receptor antagonists Apomorphine Trazodone

Question 39

Phosphodiesterase Inhibitors

Answer 39

Inhibits phosphodiesterase type 5 resulting in smooth muscle relaxation and the inflow of blood to the corpus cavernosum Goes through CYP3A4- dose reductions necessary CI: Nitrate therapy Additive effects with alpha-blockers May exacerbate GERD

Question 40

May use both nitrates and PDE5i if:

Answer 40

Asymptomatic CV disease with <3 risk factors for CV disease Well-controlled hypertension Mild congestive HF (NYHA class I or II) Mild valvular heart disease Had an MI > 8 weeks ago

Question 41

Do not use both nitrates and PDE5i if:

Answer 41

Unstable or refractory angina, despite treatment Uncontrolled hypertension Severe congestive heart failure (NYHA class IV) Recent MI or stroke within the past 2 weeks Moderate or severe valvular heart disease High-risk cardiac arrhythmias Obstructive hypertrophic cardiomyopathy

Question 42

Sildenafil

Answer 42

~50 mg/day Onset: 30-60 minutes Duration: 2-4 hours High fat meal: Decreases Tmax and Cmax Vision changes: Blurred/blue Wait time nitrates: 24h Nickname: "Little blue pill, vitamin v"

Question 43

Vardenafil

Answer 43

~10 mg/day Onset: 60 minutes Duration: 4-6 hours High fat meal: Decreases Cmax Vision changes: <2% Wait time nitrates: 24h

Question 44

Tadalafil

Answer 44

~10 mg/day Onset: 30-45 minutes Duration: 24-36 hours High fat meal: No effect Vision changes: <0.1% Wait time nitrates: 48h Nickname: "The weekender"

Question 45

Avanafil

Answer 45

~100 mg/day Onset: 15 minutes Duration: 4-6 hours High fat meal: No effect Vision changes: <2% Wait time nitrates: 24h Nickname: "the quickie"

Question 46

Pearls for PDE5i

Answer 46

Before determining ineffective: Ensure patient is taking dose at correct time, patient has had 7-8 doses, dose is titrated up Does not work unless you have stimulation