Urology

Question 1

What are the four types of urinary incontinence?

Answer 1

• urgency: associated with overactive bladder syndrome
• stress: due to urethral sphincter incompetence
• mixed: urgency and stress
• overflow: continuous urine leakage, often resulting from a hypotonic bladder or from a bladder outlet obstruction producing retention

Question 2

What pharmacological treatments are available for urgency incontinence and overactive bladder syndrome?

Answer 2

Muscarinic receptor antagonists (act on the PSNS):
- oxybutinin
- tolderodine
Beta3-adrenoreceptor agonists (act on the SNS):
- mirabegron

Question 3

What are the side effects of muscarinic blockade (e.g. oxybutinin treatment)?

Answer 3

• dry mouth
• tachycardia
• constipation
• blurred vision
• urinary retention

Question 4

What are the recommended treatments for stress incontinence?

Answer 4

• pelvic floor muscle training
• surgical intervention (surgical sling / colposuspension)
• drug therapy is limited (vaginal oestrogens, duloxetine) and only recommended if patient not for surgery

Question 5

How do you asses the severity of BPH?

Answer 5

International prostate severity score

Question 6

What is the mechanism of action of alpha blockers in BPH?

Answer 6

Alpha blockade induces smooth muscle relaxation so causes vasodilation and the fall in blood pressure reduces prostatic resistance to bladder outflow

Question 7

What adverse drug effects can alpha blockers have?

Answer 7

• orthostatic hypotension (particularly the first dose)
• headache
• dizziness
• ED
• rhinitis
• asthenia
• oedema

Question 8

If a man presents with LUTS, has a large prostate and is considered to be at high risk of progression to malignancy, what is the first line treatment?

Answer 8

A 5alpha reductase inhibitor
- dutasteride
- finasteride
A combination of alpha blocker and 5alpha reductase inhibitor may be offered

Question 9

What factors would put a man with a large prostate at greater risk of progression to malignancy?

Answer 9

• age
• poor urine flow
• higher symptom scores
• evidence of bladder decompensation (e.g. chronic urinary retention)
• higher PSA

Question 10

What is the mechanism of action of 5alpha reductase inhibitors in BPH?

Answer 10

• 5alpha reductase catalyzes the conversion of testosterone to dihydrotestosterone in the prostate
• inhibitors reduce the size of the prostate gland by limiting the availability of dihydrotestosterone

Question 11

What are the potential adverse effects of 5alpha reductase inhibitors?

Answer 11

• gynaecomastia
• decreased libido
• ejaculation disorders
• impotence

Question 12

What are the important cautions to give when prescribing 5alpha reductase inhibitors?

Answer 12

• verapamil and diltiazem increase concentrations of dutasteride
• in-utero exposure to 5alpha reductase inhibitors can cause genital malformations in the male foetus - pregnant women should not take them, handle them or be exposed to semen from a man who is taking them