BPH & Urinary Incontinence

Question 1

What are 6 drugs/classes that can worsen BPH?

Answer 1

• centrally-acting anticholinergics (ex. benztropine)
• drugs with anticholinergic effects (antihistamines, decongestants, phenothiazines, TCAs)
• caffeine
• diuretics
• SNRIs
• testosterone products

Question 2

What are the lower urinary tract symptoms (LUTS) that are the s/sx of BPH?

Answer 2

• hesitancy, intermittent urine flow, straining or a weak stream of urine
• urinary urgency, leaking, or dribbling
• urinary frequency, especially nocturia

Question 3

What is the first-line treatment for BPH? Which receoptors are primarily found on the prostate? What is a risk of this class?

Answer 3

alpha-1 blockers are first-line. They cause relaxation of smooth muscle in the prostate and bladder neck, which reduces bladder outlet obstruction and improves urinary flow.

Alpha-1A receptors are primarily found in the prostate. Non-selective alpha blockers (terazosin and doxazosin) have more side effects.

Risk of alpha-blockers: intraoperative floppy iris syndrome
- there are alpha receptors on the iris dilator muscle in the eye, so pts undergoing cataract surgery may develop this.
- if cataract surgery is planned, alpha-blocker treatment should be delayed until the surgery has been completed

Question 4

What is the brand name of doxazosin? Why are the non-selective alpha-1 blockers given at bedtime? Do alpha blockers shrink the prostate?

Answer 4

Doxazosin (Cardura, Cardura XL)

These are given at bedtime to help minimize the initial orthostasis/dizziness.

Alpha blockers do not shrink the prostate or decrease PSA. These work on the LUTS.

Question 5

What is the common 5 alpha reductase inhibitor that blocks the conversion of testosterone to DHT? How long do these agents require to reach maximal efficacy? Do these effect the size of prostate and PSA levels?

Answer 5

finasteride (Proscar)

These agents may require 6 months to reach maximal efficacy.

5 alpha-reductase inhibitors shrink the prostate and decrease PSA levels

Question 6

Which PDE5 inhibitor is approved for BPH? What are 5 warnings with this medication?

Answer 6

tadalafil (Cialis)

Warnings
- color discrimination
- hearing loss
- vision loss
- hypotension
- priapism

Obviously don’t use this w/ alpha blockers due to hypotension

Question 7

What are 5 risk factors for OAB?

Answer 7

• age > 40 yo
• diabetes
• prior vaginal delivery
• obesity
• neurologic conditions
• drugs that increase incontinence (alcohol, cholinesterase inhibitors, diuretics, sedatives)

Question 8

What is step wise approach to OAB treatment (urge/mixed)?

Answer 8

1. behavioral therapies are considered first-line to improve OAB symptoms.
   - pelvic floor muscle exercises (Kegel exercises), gluid management, avoiding caffeines
2. if severe symptoms, can start with behavioral therapy AND anticholinergic meds or beta-3 agonist
   - trial drug for 4-8 weeks before modifying treatment)
   - anticholinergic: oxybutynin ER or transdermal patch first choice
   - beta-3 agonist: mirabegron
3. Botox injection
   - higher efficacy, more expensive, requires injection
4. nerve stimulation or surgical treatment

Question 9

What are the brand names of these anticholinergics:
- oxybutynin ER
- oxybutynin patch
- tolterodine
- solifenacin

Answer 9

oxybutynin ER (Ditropan XL) - long acting, so less dry mouth
oxybutynin patch (Oxytrol)
tolterodine (Detrol)
solifenacin (Vesicare) - M3 selective, so fewer CNS effects

Question 10

What is a benefit of using beta-3 agonists?

Answer 10

beta-3 agonists relax the detrusor muscle, but cause less dry mouth than anticholinergics

Question 11

What medication is FDA approved for nocturia in adults?

Answer 11

Desmopressin - antidiuretic hormone, so it decreases urine production