Witches and Wizards: Urology Flashcards
common causes of incontience
- urethral obstructio (bph, strictures, stensosis)
- impaired bladder contraction (dm, ms, spinal injuries)
- incompetent sphincter (stress incontinene: sneezing, laughing)
- bladderr inflammation (uti)
- bladder stones (obstruciton, metabolic disease, uti)
- malignancy
meds affecting continence
- alpha agonst/antag
- etoh - more urine production
- ccbs - smooth muscle relaxers
- duretics - increase urine productiion
- sedative/hypotic - less aware of need to urinate
-
anticholinergics
- narcs
- antipsch
- antidepresssant
- pseudoephedrine causes retention dt agonism at beta 3 receptor
what volume charactierizes post void residual
50ml left in bladder after urination
By what mechanism do anticholinergic/antimuscarinic drugs cause confusion/delirium/dementia?
decreased levels of acetylcholine synthesis or the number of acetylcholine receptors -> decrease in cholinergic activity
stress incontience treatment
- pseudoephdrine
- midodrine
- estrogen replacement (vagina applciation in older pts)
- duloxetine (not fda pproved)
overflow incontence treatment
bethanechol
bethanechol MOA
stimulates muscarinic recedptors
bethanechol ADR
- gi cramping
- orthostasis with reflex tachy
- urgency
- bronchial constriction
OAB treatment guidelines
- behavioral therapy
- meds (ER over IR)
another name for urge incotenice
OAB
anticholinergic meds for treatment of OAB
hyoscymaine
antimuscharinic meds for treatment of OAB
- oxybutinin
- tolterodine
- trospium
- festoerdine
- dicyclomine
- prapantheline
which antimuscarnics don’t cross bbb
- tolterodine
- trospium
- festerodine
festerodine
- increased efficacy but increased risk of xerostomia and risk of withdrawal
- has renal considerations
- DDI CYP3A4
anti muscarnic used to treat OAB
antispasmodics meds for treatment of OAB
- oxybutinin
- flavoxate
M3 speicifc meds for treatment of OAB
- darifenacin
- solifenacin
both have CYP3A4 DDI; M3 specific in theory means less ADR
antimuscarinic ADR
- hot hare
- red beet
- dry boe
- blind bat
- mad haatter
TCAs and OAB
imipramine (and ohter TCAs) have antimuscarnic properties, however do NOT use these in geriatrics to treat OAB
B3 adrenergic receptor agonistts meds for treatment of OAB
- mirabegron
- vibegron
MOA: detrusor msucle relaxation
mirabegron ADR
- nausea
- HA
- dizziness
- HTN - cautio in uncontrolled HTN
- diarrhea OR consitpatin
dose redue for hepatic or renal dysfunction
vibegron ADR
- nausea
- HA
- URI
- UTI
- diarrhea OR consptation
- bronchtis
- naspharyngitis
NO BP
dose reduce for severe hepatic or renal dysfunction
treatment for nocturia
desmopressin intranasal (vasopressin/antidiuretic hromone)
butlike don’t actually use this in geriatric population lol
desmopressin populations to avoid in
- avoid:
- fludi retention
- hyponatremia
- nasal conditions - contraindicated:
- hyponatremia
- polydipsia
- conmittant use of loop diuretics, systemic or inhaled glucocorticoids
- eGFR < 50
- SIADH
- diseases causing electrolyte abnormality
- HF II-IV
- uncontrlled HTN
desmopressin monnitoring
Na levels
desmopressin dose
- 50-65: 1.66mg in either nostril
- 65+: 0.83 in either nostril (can increase after 1 week if Na levels wNL)
botox and OAB
- IM injectio to detrusor during cystoscopy
- better efficac than meds but can go overboard and just shut down the bladder lol
can be used in adults with inadequate response or intolerance tto anticholinergic med
alpha blocker MOA in BPH
reduce tone in bladder → urine can flow through urethra
alpha blockers
list the agents
- nonspecific: terazosi, doxazosin, prazosin
- alpha 1a specific: sildosin, alfuzosin, tamsulosin
alfuzosin admin
take with food, 50% decrease in absorption if taken on empty stomach
alpha (nonselective) blockers ADR
- hypotension
- dizziness
- blurred vision
- drowsiness
- astenia
alpha 1a selective blockers ADR
- RARELY hypotnsion, vertigo, drowsiness (dt alpha 1 specificity)
- floppy iris syndrome
- ejaculatory dysfunction
alpha 1a selective blockers DDI
they are metabolized by CYP (alfuzosin is CYP3A4)
5-alpha reductase inhibition (5aRI) MOA in BPH
reduces an enlarged prostate (3-6 month for symptom improvement (atrophies cells)
5alpha reductace inhibitors
- finasteride: inhibit type II 5-alpha-1 reductase, decrease DHT
- dutasteriode: selective inhibitor of type I and II 5-alpha reductase; more potent
PDE5 inhibitor MOA in BPH
unclear, but ptentially smooth muscle relaxation of prostate, bladder, urethra
study shows that alfuzosin + sildenafil may be better tahn monotherapy
drrugs to avoid in bph
- Saw palmetto: not effective
- anticholinergics: reduce effect of detrusor contracton and bph pts need biggg push
- TCAs
- diphenhydramine
- disopyramide
- pseudoephedrine
- ephedrine
Jalyn is a combo medication of:
dutasteride and tamsulosin
can be good in pts with reallllly enlarged prostate
ENTADFI is a combo medicatio of
finasteride and tadalafil
BPH treatment guideliens
- alpha blocker (if conmittant ED, can start with PDE5)
- if lack of response to alpha blocker or cannot tolerate:
- consider PDE5 trial
- if prstate > 30 cc, consider addition of 5aRI
- surgical options - if indadequate reponse to PDE5 trial or additio of 5aRI, consider surgery
drugs associated with ed
- diuretics: TZDs and spironolactone
- anti-HTN: BB (except nebivolol), methyldopa, clonidine
- if possible, switch to ace, arb, ccb
- cardiac or cholesterol drugs: digoxin, gemfibrozil
- antidepressants: SSRI, TCA, Li, MAOI
- tranquilizers: haldol, phenothiazines (chlorpromazine)
- H2RA: cimetidine
- hormones: progesterone, estrogen, CS, 5-alpha reductase inhibitors
- cytotoxic agents: MTX
- immunomodualtors: intereron alpha
- anticholinergic: dispyramide, anticonvulsants
- recreational drugs: etoh, cocaine
- opioids
- nsaids
PDE5 inhibitor MOA in ED
smooth musle relaxatio -> inflow of blood
doesn’t cause an erectio, prevents if from going away
PDE5 and nitrates
contraindicated; nitrate wait times
- sildenafil: 24 hrs
- vardenafil: 24 hrs
- tadalafil: 48 hrs
- av anafil: 24 hrs
PDE5 and high fat meals
high fat meals
- decrease tmax and cmax of sildenafil
- cmax of vardenafil
PDE5 with longest onset
vardenafil at 60 min
sildenafil onset and duration
- onset: 30-60 min
- duration 2-4 hrs
PDE5 iwtth longest duration
tadalafil: 24-36 hrs
PDE5 iwht fastest osnet
avanafil: 15 min
PDE5 ADR
- GERD dt lower esophageal sphincter relaxation
- hypotension
- blurred vision (mostly sildenafl)
how long should a pt waint until a PDE5 is considered ineffective at trating ED
pt should have 7-8 doses before med is cosidered ineffective
vardenafil onset and duration
- onset 60 min
- duration 4-6 hrs
tadalafil onset and duration
- onset: 30-45 min
- duratoni: 24-36 hrs
avanafil onset and duration
- onset: 15 min
- duration: 4-6 hrs
