Lecture 7 (GU)-Exam 4 Flashcards
1
Q
What is Acute simple cysitis?
A
UTI that is confined to the bladder
2
Q
What are the symptoms of acute complicated cystitis (upper urinary)
A
Symptoms involving upper urinary extension beyond bladder: fever, chills, fatigue, or any other systemic illness presentation; flank pain, CVA tenderness, pelvic pain, nausea, vomiting
3
Q
What are special populations? (2)
A
Pregnancy and renal transplant
4
Q
Acute simple cystitis
* What symptoms only?
* Increasing incidence of what?
* Obtain what? (2)
A
- Lower urinary tract symptoms only (dysuria, frequency, urgency, hematuria & suprapubic pain)
- Increasing incidence of multi-drug resistant (MDR) gram-negative organisms
- Obtain urinalysis, gram stain, ± urine culture
5
Q
Acute Simple Cystitis
* What should you start?
A
Start empiric treatment to cover the most likely organisms if urinalysis consistent with urinary tract infection
6
Q
Acute Simple Cystitis
* Treatment should focus on what most common organisms? 4)
* txt can begin without what?
A
- E. Coli (75 to 95%)*
- Klebsiella sp
- Proteus sp
- Staphylococcus saprophyticus (sexually active females)
Treatment can begin without obtaining urine culture
*
7
Q
Urinalysis:
* What can be negative in peds?
A
Nitrites may be negative with a high Leukocyte esterase because they are not potty trained therefore the nitrite cannot build up in the bladder
8
Q
Urinalysis:
* What is normal specific gravity?
* What does it mean if it is high or low?
A
- Normal: 1.010
- High: Dehydrated
- Low: fluid overloaded
9
Q
What do you commonly see in urinalysis of UTI? What do you need to be careful of?
A
LE, nitrates, maybe blood, WBC (need to be careful because fever can increase it), bacteria (be careful because you need a clean catch)
10
Q
Collention of urine for urinalysis
* What is the colony count for suprapibic aspiration, urinary catheter and midstream to be considered a UTI?
A
11
Q
Acute simple cystitis (non preg) empiric therapy
* What is first line (2)? For how long?
* What is second line? (1)
A
*First line:
* Nitrofurantonin 100 mg PO BID: 5days
* TMP-SMX 1 DS PO BID: 3 days
*Second line:
* Cephalexin 500 mg: 5-7days
*
12
Q
SMX/TMP
* What is the MOA?
A
inhibit bacterial DNA synthesis; each inhibit different steps in bacterial folate synthesis; no folate = no nucleic acids = no DNA
13
Q
Sulfamethoxazole / trimethoprim (SMX/TMp)
* Dosing based on what?
* What is the dose?
* Allergic reaction to what?
A
- Dosing based on TMP component
- One double strength tablet = 160 mg TMP/ 800mg SMX
- Allergic reaction to sulfonamide group: can cross react with other drugs with sulfonamide group including hydrochlorothiazide and glyburide
14
Q
Sulfamethoxazole / trimethoprim (SMX/TMP)
* CI?
* What type of inhibitor? What does it increase?
A
- CI: pregnancy, infants < 2 months
- CYP450 2C9 inhibitor - increases warfarin levels
*
15
Q
What are the SE of Sulfamethoxazole / trimethoprim? (6)
A
- Nausea, vomiting
- Skin rash, photosensitivity, erythema multiforme, Stevens-Johnson syndrome
- Bone marrow suppression
- Hemolytic anemia – patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency
- Crystalluria / nephritis
- Kernicterus in neonates
*
16
Q
A
17
Q
Nitrofurantoin (Macrobid)
* What is the MOA?
* Bactericidal where? Cannot use for what?
* Low what?
A
- Inhibition of bacterial ribosomal proteins -> inhibition of protein synthesis, aerobic metabolism, DNA, RNA, and cell wall synthesis
- Bactericidal in urine; poor concentrations in kidneys – do not use for pyelonephritis
- Low resistance rates
18
Q
What are the SE of nitrofurantonin? (4)
A
- GI distress – take with food
- Increased liver enzymes
- Headache
- Pulmonary toxicity (cough, dyspnea, pleural effusions, pleuritic chest pain, infiltrates) – rare
* MC in elderly; patients with reduced glomerular filtration rate
19
Q
When is nitrofurantonin CI?
A
pregnant patients in 3rd trimester due to risk of fetal hemolytic anemia; anuria; oliguria; creatinine clearance < 30 ml/min/1.73m2 (J Am Geriatr Soc 2019;67:674)
20
Q
A
21
Q
Symptomatic abacteriuria
* Patients with what?
* Most have infections with what?
* Consider and rule out what?
A
- Patient with dysuria and pyuria with negative urinalysis and no or minimal bacterial growth on culture
- Most have infections with small numbers of bacteria
- Consider and rule out sexually transmitted organisms including Chlamydia, N. gonorrhea for sexually active females
22
Q
Symptomatic abacteriuria
* Other organisms include what?
* Treat how?
* Refer to who and when?
A
- Other organisms include Ureaplasma urealyticum, Gardnerella vaginalis
- Treat as per simple cystitis guidelines
- Refer to urology if no response to treatment
23
Q
Asymptomatic bacteriuria (ASB)
* What is the patient experiencing?
* Most patients are what groups? (2)
* Studies have not demonstrated what?
A
- No symptoms with ≥ 1 urine culture with > 105 organisms/mL of the same organism
- Most patients are elderly or female
- Studies have NOT demonstrated a treatment benefit in most patients
24
Q
Asymptomatic bacteriuria (ASB)
* Who gets screened and treated?
A
- Pregnant patients: Screen at 12 to 16 weeks with urine culture; rescreen those with ASB
- Patients undergoing invasive urologic procedures
25
Treatment of cystitis / ASB in pregnancy
* What regimens can considered safe in preg? (3)
* Amoxicillin 500mg PO TID or 875mg PO BID x 4 to 7 days
* Cephalexin 250 to 500mg PO QID x 4 to 7 days
* Nitrofurantoin 100mg PO BID x 4 to 7 days
| *
26
Treatment of cystitis / ASB in pregnancy
* What should you avoid? (2)
* What is recommended after treatment?
Avoid:
* Trimethoprim-sulfamethoxazole
* Fluoroquinolones
Confirmation of bacteria clearance after treatment is recommended
27
UTI: complicated / catheter related
* Associated with what?
* _ _ related?
* What are the MC organisms (3)
* All patients need what?
Associated with obstruction, azotemia, vesicoureteral reflux, transplant patients
Foley catheter related
MC organisms:
* Enterobacteriaceae
* Pseudomonas aeruginosa
* Enterococcus sp.
All patients need urinalysis, gram-stain, urine culture
28
UTI: complicated / catheter related
* What is First-line empiric therapy for patients without systemic illness or at high-risk of multi-drug resistant organisms? (2)
Ciprofloxacin or levofloxacin PO
29
UTI: complicated / catheter related
* First-line empiric therapy for patients with systemic illness or high-risk of MDR organisms? (3)
Ertapenem, piperacillin-tazobactam, cefepime
30
UTI: complicated / catheter related
* Duration of treatment?
Exact duration dependent on patient response and additional symptoms
31
Pyelonephritis (complicated)
* What is it?
* MC in who?
* What are the sxs?
* Bacteria ascend to the kidneys via the ureters OR
* Secondary to blood stream infection
* MC women 18 to 40 years
* Cystitis symptoms plus signs and symptoms of systemic illness including fever, costovertebral angle tenderness, nausea and vomiting, sepsis
32
Pyelonephritis (complicated)
* Elderly may have what?
* CBC with what?
* UA shows what?
* Patients may have what?
* Elderly may have hypotension or mental status changes
* CBC with leukocytosis and left shift
* UA shows pyuria, bacteriuria, and possible hematuria
* Patients may have hydronephrosis secondary to obstruction.
33
34
Multi drug resistant organisms:
* What are the risk factors for MDR gram negative organisms?
35
Multi-drug resistant organisms
* What are the gram positive resistant organisms (2)
* Enterococcus sp (faecium or faecalis)
* MRSA
36
Extended spectrum beta lactamase
* Enzymes that can inactivate what?
* Remain susceptible to what?
* Exclusively what organisms?
37
Which of the following is the treatment of choice for a nursing home patient who has asymptomatic bacteriuria with no history of diabetes or structural abnormalities of the genitourinary tract?
* Ciprofloxacin
* TMP-SMX
* Cephalexin
* No treatment
* Repeat urinalysis
* No treatment
38
Pyelonephritis:
* What are the MC organisms? (6 but know the top 3)
39
Pyelonephritis:
* What labs do you need to run?
* Most patients require what?
* Patients should respond to what?
* Blood cultures, UA, gram-stain, urine culture – adjust antibiotic regimen based on culture results
* Most patients require hospital admission and broad-spectrum IV antibiotics
* Patients should respond to proper therapy in 12 to 24 hours
40
Pyelonephritis
* If no or limited response in 3 to 4 days; investigate further for what?
* Patient can be discharged when?
* If no or limited response in 3 to 4 days; investigate further for resistant organisms, abscess formation, obstruction, etc
* Patient can be discharged when clinically improving, meets criteria for IV to PO conversion, and oral antibiotic appropriate based on culture and sensitivity report
41
Pyelonephritis – Empiric inpatient treatment
* Low-risk resistant bacteria (MC) First-line? (3)
* Ceftriaxone
* Ciprofloxacin
* Levofloxacin
## Footnote
Be careful because Ceftriazone is 10-14 days therapy
42
Pyelonephritis – Empiric inpatient treatment
* High-risk resistant bacteria first line (4)
* Ertapenem
* Meropenem
* Piperacillin-tazobactam
* Cefepime
43
Pyelonephritis – Empiric inpatient treatment
* How long is treatment for uncomplicated and complicated?
* What defines complicated?(6)
Uncomplicated
* 5 to 7 days
* 10 to 14 days beta-lactams
Complicated – 14 days
* Obstruction
* Underlying renal disease
* Male sex
* Immunosuppression
* Kidney stone disease
* Anatomic or function urinary tract abnormality
44
Pyelonephritis – Empiric outpatient treatment
* What is first line low-risk resistant bacteria?
* Ciprofloxacin
* Levofloxacin
45
Pyelonephritis – Empiric outpatient treatment
* What is the duration for uncomplicated and complicated?
* What makes it complicated?(3)
Uncomplicated
* 5 to 10 days
* 10 to 14 days beta-lactams
Complicated – 14 days
* Male sex
* Stone disease
* Anatomic or function urinary tract abnormality
46
UTI – adult men
* What are the sxs?
* Who is it uncommon in?
* MCC?
* Always considered what?
* Dysuria, frequency, urgency +/- suprapubic pain
* Uncommon in men < 60 years of age
* MCC = instrumentation of urinary tract (e.g, catheterization, renal stones)
* Always considered a complicated infection
47
UTI – adult men
* All patients need what?
* If sexually active, what do you need to rule out?
* If recurrent infection, what do you need to rule out?
* What makes up an acute bacterial prostatitis?
* All patients UA and culture
* If sexually active rule out gonococcal and chlamydia infections (NAAT)
* If recurrent infection, rule out prostatitis
* Cystitis + bladder outlet obstruction = acute bacterial prostatitis
48
Recommended cystitis regimens - men
* What is first line txt (4)
* What is the duration?
Antibiotic
* TMP-SMX
* Ciprofloxacin
* Levofloxacin
* Nitrofurantoin (Macrobid)
Duration:
* 7 days
49
* What antibiotics do not penetrate prostate?
* Recurrent UTIs must be evaluated for what?
* Nitrofurantoin, beta-lactams, fosfomycin do not penetrate prostate
* Recurrent UTIs; evaluated for benign prostate hypertrophy, other obstruction, prostatitis
50
Urinary tract symptom relief
* Phenazopyridine (AZO, Pyridium): MOA and SE?
* Local anesthetic / analgesic on urinary tract mucosa
* SE: Orange-yellow urine, Headache, Dizziness and Stomach cramping
51
urinary tract symptom relief
52
Epididymo-orchitis
* What are the SXS? (5)
* Systemic symptoms MC with what?
* Must r/o what?
53
Epididymo-orchitis
54
Epididymo-orchitis
* How do you DX it?
* MC organism with age over and under 35?
55
What are non antibiotics for epididymo-orchitis
Bed rest, scrotal elevation (because positive prehn sign-> decrease pain with scrotal elevation), analgesics
56
Epididymo-orchitis
57
How do you treat Epididymo-orchitis in MSM?
MSM – treat for STI and enteric organisms: ceftriaxone 500mg IM x 1 and levofloxacin 750mg PO daily x 10 to 14 days
58
A 19 year-old man comes to the office because he has had a fever, frequent urination, urgency, dysuria and scrotal pain for the past 2 days. On physical examination, he has a temperature of 101 degrees F, scrotal swelling, and purulent urethral discharge is visible on penile examination. Gram stain of the discharge shows gram negative intracellular diplococci. Which of the following is the most appropriate antibiotic therapy?
* Nitrofurantoin
* Ceftriaxone + doxycycline
* Azithromycin
* Levofloxacin
* TMP-SMX
Ceftriaxone + doxycycline
59
Acute bacterial prostatitis
* Acute onset of what?
* What is often present?
* Acute onset of irritative symptoms (dysuria, urgency) or obstructive symptoms (urinary hesitancy or urinary retention), suprapubic, rectal, or perineal pain
* Fever, chills, malaise, myalgias often present
60
Acute bacterial prostatitis
* Can be complicated by what?
* How do you dx it?
* Can be complicated by bacteremia, epididymitis, prostatic abscess, conversion to chronic prostatitis
* DX – clinical; obtain UA/ midstream urine for cultures/blood cultures if febrile
61
Acute bacterial prostatitis
* MC pathogens for over 35 and under 35?
≤ 35 years
* N. gonorrhea
* C. trachomatis
Over 35 years
* Enterobacteriaceae
* Coliforms (E. coli, Klebsiella, Citrobacter)
* Enterococcus sp
62
Acute bacterial prostatitis
* What are the risk factors? (6)
* Benign prostatic hypertrophy (BPH)
* Genitourinary infections
* Epididymitis, orchitis, urethritis, UTIs
* High-risk sexual behavior
* History of STIs
* Prostate manipulation
63
ABP - Treatment
64
Chronic bacterial prostatitis
* What are the sxs?
* What do you need to have?
* What are MC pathogens?
* Indolent infection with low grade fever, urinary frequency, dysuria, urgency, perineal discomfort
* Chronic infection and positive urine or prostatic fluid cultures
* MC pathogens: Enterobacteriaceae (80%), Enterococcus (15%), P. aeruginosa
65
Chronic bacterial prostatitis
* What is the treatment?
* Fluoroquinolones and TMP-SMX as per ABP treatment
* Prolonged duration – **minimum of 6 weeks**
66
nephrolithiasis
* Role of pharmacotherapy primarily supportive? (6)
* Decrease pain
* Decrease nausea and vomiting
* Provide initial hydration
* Treat or prevent infections
* Facilitate stone clearance
* Prevent recurrences – recommendations specific to stone type
67
Nephrolithiasis Treatment
* What are the drugs for stone clearance?
* Tamsulosin – increased passage of stones > 5mm but < 10mm by 80% (4 weeks)
* Nifedipine – no better than placebo
68
Treatment of kidney stones: Calcium oxalate
* What are the risk factors?
* Insensitive to what?
* What should be avoided?
* What is the txt?
| *
* Risk factors for calcium oxalate stones include higher urine calcium, higher urine oxalate, and lower urine citrate.
* This stone type is insensitive to pH in the physiologic range
* Excessive calcium intake (>1200 mg/d) should be avoided.
* **A thiazide diuretic**, in doses higher than those used to treat hypertension, can substantially lower urine calcium excretion
| *
69
Treatment of kidney stones: Calcium phosphate
* What are risk factors?
* Calcium phosphate stones are more common in who?
* Calcium phosphate stones share risk factors with calcium oxalate stones, but additional factors include:
* Higher urine phosphate levels and higher urine pH (typically ≥6.5) are associated with an increased likelihood of calcium phosphate stone formation.
* Calcium phosphate stones are more common in patients with distal renal tubular acidosis and primary hyperparathyroidism
## Footnote
Calcium oxalate: Risk factors for calcium oxalate stones include higher urine calcium, higher urine oxalate, and lower urine citrate.
70
Treatment of kidney Stones: Uric acid stones:
* What are the risks?
* What is going on with the urine pH? What is the prevention?
* Uric acid stones; risks are persistently low urine pH and higher uric acid excretion.
* Urine pH is the predominant influence on uric acid solubility; therefore, the mainstay of prevention of uric acid stone formation entails increasing urine pH
71
Treatment: Struvite Stones
* Struvite stones may grow how?
* Struvite stones require what?
* What is the prevention?
* Struvite stones may grow quickly and fill the renal pelvis (staghorn calculi).
* Struvite stones require complete removal by a urologist
* New stone formation can be avoided by the prevention of UTIs
72
Treatment: Cystine
* Not easily what?
* What is unlikely to be successful?
* Cystine stone prevention?
* May tx with what?
* Cystine excretion is not easily modified
* Long-term dietary cystine restriction is not feasible and is unlikely to be successful
* Cystine stone prevention is on increasing cystine solubility
* May tx with medication that covalently binds to cystine and a medication that raises urine pH.
73
MOA of alpha-1 blockers (tamulosin)?
74
What are the types of incontinence? (6)
75
76
Stress incontinence:
* When do you do pharmacotherapy?
* What is mainstay treatment?
* What else can you do as supportive?
* What is last line?
77
Stress incontinence: other therapies
* What can you use for post menopausal women with tissue atrophy?
* What else can you use that is not guideline based? (2) What has it shown?
* Topical estrogen for post menopausal women with tissue atrophy
* Laser therapies – not guideline based
* Duloxetine – not guideline based but has shown improvement in symptoms in clinical trials; may increase urethral muscle tone
78
Recommend pelvic floor muscle strengthening
79
What happens in overactive bladder?
80
Overactive bladder
* What is first line?
81
Overactive bladder
* What are bladder irritants?(6)
82
Overactive bladder
* What are culprit medications?(4)
83
Overactive bladder
* What is second and third line?
84
bladder control:
* What happens when parasympathetic control is activated?
Activation = voiding stimulated
* Acetylcholine binds to muscarinic receptors on detrusor muscle
* Stimulates detrusor muscle contraction
85
bladder control:
* What happens when sympathetic control is activated?
Activation = urine retention
* Norepinephrine binds to beta 3 receptors on the detrusor muscle
* Stimulations detrusor muscle relaxation
86
Medications for OAB
* What are the two ways medication can work?
Parasympathetic blockers (muscarinic antagonists)
* Block muscarinic receptors on the detrusor muscle
* Inhibits detrusor muscle contraction
Sympathetic stimulation (Beta 3 stimulation)
* Bind to and activate beta-3 receptors on the detrusor muscle
* Stimulates detrusor muscle relaxation
87
Antimuscarinics:
* What is the MOA?
* What are the SE?
* CI?
88
Antimuscarinics:
* Generally, all antimuscarinics have what?
* Specific agent choice based on what?
* Start with what?
* What is recommended before changing therapies?
* Generally, all antimuscarinics have equivalent efficacy for OAB
* Specific agent choice based on adverse effects, frequency, formulation
* Start with lowest dose and increase as tolerated
* Management of constipation and dry mouth is recommended before changing therapies
89
Antimuscarinics - OAB
* What are the four medications? What are their SE?
90
Antimuscarinics - OAB
* metabolized by what?
* Solifenacin and tolterodine SE?
91
Antimuscarinics - OAB
* What are four other drugs besides darifenacin, fesoterodine, solifenacin, tolterodine? What are the SE?
## Footnote
*
92
Antimuscarinics: OAB
* Oxybutynin: What are SE? Often not tolerated by who?
* Ditropan: SE?
* Gelnique: What type of rxn?
* Oxytrol: Available without what? What can happen at the site?
93
Beta-3 adrenergic agonist: mirabegron
* MOA?
* First line for who?
* Metabolized by what?
* Requires dose reduction for who?
* MOA: Beta-3 agonist; activates beta-3 receptors in the bladder resulting in relaxation of detrusor smooth muscle
* First-line for patients at high risk of anticholinergic side effects from antimuscarinics
* Metabolized by CYP3A4 and 2D6
* Requires dose reduction for severe renal and hepatic insufficiency
94
Beta-3 adrenergic agonist: mirabegron
* What are the SE?
* medication can be used how?
* Hypertension (10%) – dose related
* Can be used alone or in combination with antimuscarinics for OAB
95
E. Oxybutynin
96
What are the most common causes of overflow incontinence?
BPH and prostate malignancies
97
Benign Prostatic Hyperplasia (BPH)
* Increasingly common as what?
* What are obstructive sxs?
* What are irritative symptoms?
Benign prostatic hyperplasia (BPH) increasingly common as men age
Obstructive symptoms
* Decreased stream force
* Decreased flow rate
* Incomplete bladder emptying
* Hesitancy / straining
Irritative symptoms (50 to 80%)
* Frequency
* Urgency
* Nocturia
98
Evaluation of BPH
* Complete what?
* What are the PE components? (8)
99
What are the different scores of the American Urology Association BPH Symptom Score?
* Mild: ≤ 8
* Moderate: 8-19
* Severe: ≥ 20
100
101
BPH – treatment Guidelines
* What are the modifications for ALL patients? (7)
* Decreased fluid intake – especially at night
* Limit caffeine and alcohol intake
* Avoid bladder irritants
* Avoid contributing medications
* Weight loss, increase physical activity
* Pelvic floor strengthening
* Bladder training
102
BPH – treatment Guidelines
* What is for moderate and moderate to severe disease?
* Pharmacotherapy – moderate disease
* Interventional therapy – moderate to severe disease
103
Pharmacotherapy: Alpha1-adrenergic antagonists
* What is the MOA?
Alpha1-adrenergic antagonists - block alpha1 receptors in prostate
* Relax smooth muscle of prostate and bladder neck
* Improve urinary flow and decrease BPH symptoms
104
Pharmacotherapy: 5-alpha reductase inhibitors
* What is the MOA
5-alpha reductase inhibitors - inhibit type 2 alpha reductase; inhibits conversion of testosterone to dihydrotestosterone; decreasing testosterone’s stimulatory effect on prostate
* Reduce prostate enlargement
* Slow onset
105
106
Alpha1 blockers
* Where are a1a and a1b?
* α1a – primarily in prostate, bladder, urethra
* α1b – primarily in vasculature
107
Alpha1 blockers
* Similar efficacy; no benefit from what?
* What is the onset?
* What is a complication?
* Similar efficacy; no benefit from switching to alterative alpha blocker for efficacy
* Onset = days; no change in disease progression
* Intraoperative floppy iris syndrome (IFIS) – complications during cataract surgery
* MC with tamsulosin but all alpha1 blockers carry a risk
108
Nonselective agents alpha1 blockers:
* What are the SE?
* More selective agents with higher affinity for alpha 1a have what type of SE?
* Nonselective agents with similar affinity for alpha 1a and alpha 1b receptors have more orthostatic hypotension, syncope, erectile dysfunction
* Titrate dose up slowly
* More selective agents with higher affinity for alpha 1a have less hypotension but ejaculatory failure
109
5-Alpha Reductase Inhibitors
* What is the MOA?
Inhibits 5-alpha reductase in prostate
* Decreases the conversion of testosterone to more potent dihydrotestosterone
* Decreases intraprostatic and serum DHT levels by 70 to 90%
* Decreases prostate size
* Decrease prostate specific antibody production by 50%
110
5-Alpha Reductase Inhibitors
* Indicated for what?
* Reduction of prostate size?
* What is the onset?
* Initial Dual therapy with what?
Indicated for moderate to severe BPH
* Reduction of prostate size by up to 25%
* Delayed onset – 6 to 12 months
* Initial dual therapy with alpha1 blocker recommended for symptom control
| *
111
5-Alpha Reductase Inhibitors
* What is the SE?
* Erectile dysfunction (3 to 16%), decreased semen volume, decreased libido
* GI distress
* Asthenia
* Dizziness
* Headache
* Rash
* Gynecomastia
* Lowers PSA by 50% - double obtained number for comparison
112
5-Alpha Reductase Inhibitors
* What are the CI?
CI: pregnancy; exposure to male fetus may cause pseudohermaphroditic offspring
* Includes exposure to semen of men taking a 5-alpha reductase inhibitor
113
BPH - Phosphodiesterase-5 inhibitors: Tadalafil (Cialis)
* Alternative therapy for who?
* Use with?
* No benefit when?
* What is the MOA?
* Alternative therapy for patients not responding to or not tolerating alpha1 blockers or 5-alpha reductase inhibitors
* Use with alpha blockers may potentiate hypotension
* No benefit when used in combination with alpha blockers
* MOA – thought to PDE-5 mediated smooth muscle relaxation and increased tissue perfusion
114
Phosphodiesterase-5 inhibitors: Tadalafil (Cialis)
* May be used as first line for what?
* Appropriate to offer to who?
* May be used as first-line for patients with BPH and erectile dysfunction
* Appropriate to offer to patients with and without erectile dysfunction
115
Antimuscarinics or Beta-3 agonist
* Alone or in combination with what?
Alone or in combination with alpha blocker or for patients with moderate to severe lower urinary tract symptoms
116
C. Postural Hypotension
117
Neurogenic bladder
* Abnormal function of what?
* What is the Treatment?
* May help increase what?
* Neurogenic lower urinary tract dysfunction (NLUTD)
* Abnormal function of either the bladder, bladder neck, and/or its sphincters related to a neurologic disorder
* Treatment is complex and dependent on etiology of neurogenic dysfunction and primary deficiency
* Antimuscarinics or beta-3 agonists may help increase holding capacity
118
Neurogenic bladder
* Alpha blockers may improve what?
* Some patients may benefits from what?
* Some patients will require what?
* Alpha blockers may improve bladder emptying in patients who spontaneously void
* Some patients may benefit from lifestyle and behavior changes
* Some patients will require intermittent / continuous catheterization
