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PHM 704 Pediatrics and Geriatrics > Urology in the Older Patient > Flashcards

Urology in the Older Patient Flashcards

1
Q

M3 Receptor

A

Used in the voidance phase.
Blocked with ACh inhibitors.

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2
Q

B3 Receptor

A

Used in the storage phase.
Stimulate with norepinephrine.

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3
Q

Causes of incontinence

A

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)

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4
Q

Medications affecting continence

A

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

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5
Q

Desmopressin Nasal Spray

A

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

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6
Q

Overactive bladder (urge incontinence)

A

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

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7
Q

Smooth muscle relaxants

A

Antimuscarinic or “atropine like”
Antispasmodics with local anesthetic properties

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8
Q

M3 receptor agents for OAB

A

Solifenacin and Darifenacin
Preferred agents due to decreased CNS effects

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9
Q

Antimuscarinic agents for OAB

A

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

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10
Q

ADEs of smooth muscle relaxants

A

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

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11
Q

IR or ER for OAB

A

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.

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12
Q

Mirabegron ER (Myrbetriq)

A

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

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13
Q

Virabegron (Gemtesa)

A

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

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14
Q

OAB first line treatment

A

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

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15
Q

OAB second line treatment

A

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

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16
Q

Stress incontinence

A

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

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17
Q

Alpha-receptor agonist for stress incontinence

A

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

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18
Q

Estrogen replacement for stress incontinence

A

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)

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19
Q

Duloxetine for stress incontinence

A

Not FDA approved

20
Q

Overflow incontinence

A

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

21
Q

Bethanechol (Urecholine)

A

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

22
Q

BPH Etiology

A

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)

23
Q

Symptoms of BPH

A

Incomplete emptying
Frequency
Intermittency
Urgency
Weak stream
Straining
Nocturia

24
Q

Non-pharm management of BPH

A

Incontinent pads
TURP
Urethral dilation
Foley catheters
Others

25
Q

Alpha-1 inhibitors for BPH

A

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

26
Q

Alpha-1a specific blockers

A

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

27
Q

Finasteride

A

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

28
Q

Dutasteride

A

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

29
Q

5-alpha1-reductase ADEs

A

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)

30
Q

Drugs to avoid in BPH

A

TCAs
Diphenhydramine
Disopyramide
Pseudoephedrine
Ephedrine
Anticholinergic

31
Q

Tadalafil

A

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

32
Q

Alpha-1a blocker and PDE5 inhibitor

A

Superior to monotherapy in treating lower UTI symptoms and erectile dysfunction

33
Q

Saw Palmetto

A

No significant difference in improving symptoms or objective measures of BPH

34
Q

Pathophysiology of ED

A

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

35
Q

IIEF-5 Questionnaire

A

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

36
Q

Risk factors for ED

A

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

37
Q

Drugs associated with ED

A

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

38
Q

Drug therapy for ED

A

Androgens
PDEi
Adrenergic-receptor antagonists
Apomorphine
Trazodone

39
Q

Phosphodiesterase Inhibitors

A

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

40
Q

May use both nitrates and PDE5i if:

A

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

41
Q

Do not use both nitrates and PDE5i if:

A

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

42
Q

Sildenafil

A

~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”

43
Q

Vardenafil

A

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

44
Q

Tadalafil

A

~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”

45
Q

Avanafil

A

~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”

46
Q

Pearls for PDE5i

A

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

PHM 704 Pediatrics and Geriatrics (21 decks)

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