Geriatrics - Urology

Question 1

Incontinence - Causes

Answer 1

urethral obstruction (BPH)
impaired bladder contraction (DM, MS, detrusor hyperactivity)
incompetent sphincter (stress)
bladder inflammation (UTI)
bladder stones (UTI, obstruction)
malignancy

Question 2

Incontinence - Potential Drug Causes

Answer 2

alpha-blockers & alpha-agonists
alcohol
anticholinergics
cholinesterase inhibitors
calcium channel blockers
diuretics
narcotics
antidepressants
antipsychotics
sedative-hypnotics

Question 3

Nocturnal Polyuria - Treatment

Answer 3

desmopressin nasal spray

indication: wakening 2 or more times per night to urinate

Question 4

Desmopressin Nasal Spray - Monitoring

Answer 4

sodium levels

Question 5

Desmopressin Nasal Spray - CIs

Answer 5

hyponatremia
polydipsia
primary enuresis
concomitant diuretics or steroids
eGFR < 50
NYHA class II-IV
uncontrolled hypertension
SIADH

Question 6

Overactive Bladder - Causes

Answer 6

potentially alpha-blockers in women
potentially estrogens 30-60 mg
cystitis
stones
tumor
neurologic impairment

Question 7

OAB - Smooth Muscle Relaxants

Answer 7

oxybutynin
tolterodine
trospium
darifenacin
solifenacin
dicyclomine
hyoscyamine

Question 8

OAB Drugs - Less CNS Effects

Answer 8

tolterodine
trospium
darifenacin
solifenacin
fesoterodine

Question 9

OAB Drugs - Adverse Effects

Answer 9

dose-dependent:
dry mouth & eyes
urinary retention
palpitations
constipation
dizziness
confusion / delirium / dementia

Question 10

OAB - Other Drugs

Answer 10

TCAs (imipramine)
botox - IM injection with inadequate response or intolerance to ACh medication

Question 11

OAB - Beta-3 Adrenergic Receptor Agonists

Answer 11

mirabegron
AEs: nausea, headache, hypertension, constipation, sinus tachycardia

vibegron
AEs: nausea, headache, diarrhea, URI, UTI

Question 12

OAB - First-Line Treatment

Answer 12

behavioral therapies

Question 13

OAB - Second-Line Treatment

Answer 13

PO antimuscarinics or beta-3 agonists
ER better than IR
combination antimuscarinic & beta-3 agonist if refractory to monotherapy

Question 14

Stress Incontinence - Alpha Receptor Agonists

Answer 14

increase intra-urethral pressure

pseudoephedrine 15-30 mg TID
midodrine 2.5-5 mg TID

Question 15

Stress Incontinence - Estrogen Replacement

Answer 15

proliferation of urethral mucosa -> improves mucosal outflow resistance

vaginal application acceptable

Question 16

Stress Incontinence - Other Drugs

Answer 16

duloxetine 40 mg BID

Question 17

Overflow Incontinence - Causes

Answer 17

BPH
neuropathies
anticholinergics

Question 18

Overflow Incontinence - Drugs

Answer 18

bethanechol 10 mg TID
stimulates muscarinic receptors

AEs: cramping, diarrhea, salivation, orthostasis, urgency, bronchial constriction

Question 19

BPH - Etiology

Answer 19

proliferation of stromal & epithelial cells due to hormonal and aging processes -> increased prostate size

Question 20

BPH - Symptoms

Answer 20

incomplete emptying
frequency
intermittency
urgency
weak stream
straining
nocturia

Question 21

BPH - Non-Pharmacological Management

Answer 21

incontinence pads
TURP
urethral dilation
Foley catheter
surgeries

Question 22

BPH - Alpha-1 Blockers

Answer 22

silodosin
tamsulosin
alfuzosin
terazosin
doxazosin
prazosin

Question 23

Alpha-1 Blockers - Adverse Effects

Answer 23

postural hypotension
dizziness
blurred vision
asthenia

Question 24

Alpha-1 Selective Blockers

Answer 24

silodosin (most selective)
alfuzosin
tamsulosin

Question 25

Alpha-1 Selective Blockers - Adverse Effects

Answer 25

floppy iris syndrome ejaculatory dysfunction DDIs (450-metabolized)

Question 26

BPH - 5-Alpha-Reductase Inhibitors

Answer 26

finasteride dutasteride

Question 27

5-Alpha-Reductase Inhibitors - Adverse Effects

Answer 27

impotence libido ejaculation volume gynecomastia pregnancy X

Question 28

BPH - Drugs to Avoid

Answer 28

pseudoephedrine ACh drugs

Question 29

BPH - PDE-5 Inhibitor

Answer 29

tadalafil 5 mg QD cannot combine with alpha-blockers (symptomatic hypotension)

Question 30

Erectile Dysfunction - Risk Factors

Answer 30

metabolic syndrome DM BPH CV disease tobacco smoking central neurologic conditions spinal cord injury depression endocrinologic conditions

Question 31

ED - Potentially Worsening Drugs

Answer 31

diuretics antihypertensive drugs digoxin gemfibrozil H2RAs cytotoxic agents immunomodulators ACh drugs alcohol, cocaine opioids, NSAIDs

Question 32

ED - Treatment

Answer 32

androgens PDE5 inhibitors adrenergic receptor antagonists apomorphine trazodone intracavernous therapy transurethral therapy

Question 33

ED - PDE-5 Inhibitors

Answer 33

sildenafil tadalafil vardenafil avanafil

Question 34

PDE-5 Inhibitors - Precautions

Answer 34

CYP3A4 DDIs additive effects with alpha-blockers GERD CI: concurrent nitrate therapy, MI or stroke within 2 weeks, cardiac arrhythmias, uncontrolled hypertension, unstable angina

Question 35

Sildenafil - Dosing & PK

Answer 35

25-100 mg onset 30-60 min duration 2-4 hrs high-fat meal lowers effect wait time w/ nitrates 24 hrs blurred vision common

Question 36

Vardenafil - Dosing & PK

Answer 36

5-20 mg onset 60 min duration 4-6 hrs high-fat meal lowers effect wait time w/ nitrates 24 hrs

Question 37

Tadalafil - Dosing & PK

Answer 37

5-20 mg onset 30-45 min duration 24-36 hrs high-fat meal - no effect wait time w/nitrates 48 hrs

Question 38

Avanafil - Dosing & PK

Answer 38

50-200 mg onset 15 min duration 4-6 hrs wait time w/nitrates 12-24 hrs

Question 39

ED - Guidelines

Answer 39

1. treat underlying diseases, remove medications that could contribute 2. testosterone if hypogonadism 3. PDE5 inhibitors for at least 7-8 doses 4. vacuum erection device 5. intracavernous or intraurethral alprostadil 6. penile prosthesis

Question 40

OAB - Antimuscarinics CIs

Answer 40

narrow angle glaucoma caution: delayed gastric emptying or urinary retention