Urology in the Older Patient Flashcards
M3 Receptor
Used in the voidance phase.
Blocked with ACh inhibitors.
B3 Receptor
Used in the storage phase.
Stimulate with norepinephrine.
Causes of incontinence
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)
Medications affecting continence
Alpha agonists/antagonists
Alcohol
Anticholinergics
Cholinesterase inhibitors
CCBs
Diuretics
Narcotics
Antidepressants
Antipsychotics
Sedative/hypnotic
Desmopressin Nasal Spray
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
Overactive bladder (urge incontinence)
Involuntary leakage of urine
Involuntary contraction of bladder
Detrusor hyperreflexia (cystitis, stones, tumor, neurologic)
Smooth muscle relaxants
Antimuscarinic or “atropine like”
Antispasmodics with local anesthetic properties
M3 receptor agents for OAB
Solifenacin and Darifenacin
Preferred agents due to decreased CNS effects
Antimuscarinic agents for OAB
Oxybutynin, tolterodine, trospium, fesoterodine, dicyclomine, propantheline
Not as preferred, but less BBB crossing with tolterodine, trospium, and fesoterodine
ADEs of smooth muscle relaxants
Dose dependent:
Dry mouth
Dry eyes/blurred vision
Urinary retention
Palpitations
Constipation
Dizziness/drowsiness
Confusion/delirium/dementia (w/ anticholinergics)
IR or ER for OAB
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.
Mirabegron ER (Myrbetriq)
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
Virabegron (Gemtesa)
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
OAB first line treatment
Behavioral therapies: Bladder training, bladder control strategies, pelvic floor muscle training, fluid management with or without pharm
OAB second line treatment
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
Stress incontinence
Involuntary leakage with “stress”
Intra-abdominal pressure
Sneezing, laughing, coughing
Decreased pelvic muscle musculature
Alpha-receptor agonist for stress incontinence
Pseudoephedrine
SE: Insomnia, HTN, HA, tremor, palpitations
Estrogen replacement for stress incontinence
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)
Duloxetine for stress incontinence
Not FDA approved
Overflow incontinence
Leak urine throughout the day
“weight” of the urine increased due to BPH, neuropathies, anticholinergics
Bethanechol (Urecholine)
Stimulates muscarinic receptors
Bladder tone (push all the pee out)
AE:
GI cramping, diarrhea, salivation
Orthostasis with reflex tachy
Urgency
Bronchial constriction
BPH Etiology
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)
Symptoms of BPH
Incomplete emptying
Frequency
Intermittency
Urgency
Weak stream
Straining
Nocturia
Non-pharm management of BPH
Incontinent pads
TURP
Urethral dilation
Foley catheters
Others
Alpha-1 inhibitors for BPH
Terazosin>doxazosin>prazosin
AE:
Postural hypotension
Dizziness/vertigo
Blurred vision
Drowsiness
Asthenia
“First dose” effect (added effect with other HTN meds)
Alpha-1a specific blockers
Silodosin»Alfuzosin ~ Tamsulosin
Take Alfuzosin with food to increase F
AE:
Rarely hypotension, vertigo, drowsiness
Floppy iris syndrome
Ejaculatory dysfunction
CYP450 metabolism
Finasteride
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
Dutasteride
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
5-alpha1-reductase ADEs
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)
Drugs to avoid in BPH
TCAs
Diphenhydramine
Disopyramide
Pseudoephedrine
Ephedrine
Anticholinergic
Tadalafil
PDE5 inhibitor-mediated smooth muscle relaxation of the prostate, bladder, urethra and their vascular supply
Alpha-1a blocker and PDE5 inhibitor
Superior to monotherapy in treating lower UTI symptoms and erectile dysfunction
Saw Palmetto
No significant difference in improving symptoms or objective measures of BPH
Pathophysiology of ED
NO to cGMP leading to smooth muscle relaxation, which is degraded by PDE5
IIEF-5 Questionnaire
1-7: Severe ED
8-11: Moderate ED
12-16: Mild-moderate ED
17-21: Mild ED
22-25: No ED
Risk factors for ED
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
Drugs associated with ED
Diuretics
Antihypertensive drugs
Cardiac or cholesterol drugs
Antidepressants
Tranquilizers
H2 antagonists
Hormones
Cytotoxic agents
Immunomodulators
Anticholinergic agents
Recreational drugs
Sedative-hypnotics
Regular NSAID use
Drug therapy for ED
Androgens
PDEi
Adrenergic-receptor antagonists
Apomorphine
Trazodone
Phosphodiesterase Inhibitors
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
May use both nitrates and PDE5i if:
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
Do not use both nitrates and PDE5i if:
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
Sildenafil
~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”
Vardenafil
~10 mg/day
Onset: 60 minutes
Duration: 4-6 hours
High fat meal: Decreases Cmax
Vision changes: <2%
Wait time nitrates: 24h
Tadalafil
~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”
Avanafil
~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”
Pearls for PDE5i
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
