What are the 4 different types of urinary incontinence?
- Stress incontinence
- Urge incontinence/OAB
- Overflow incontinence
- Mixed incontinence: combination of stress and urge (MC)
What are the classes of mediations used to treat OAB?
- Antimuscarinics
- Beta-3 Agonist
- Local Estrogen
- Paralytic Agent
What is the MOA of antimuscarinics?
Relax/block excess detrusor activity
What is the efficacy/benefit of antimuscarinics?
Modest benefit, no improvement on the sphincter
What are the ASEs of antimuscarinics?
- Dry mouth
- Dry eyes
- Confusion
- Constipation
- Dizziness
- Blurred vision
What are the drug interactions that you need to note before giving an antimuscarinic?
- Alzheimer agents: Donepezil and Galantamine
- Antihistamines, Anti-Depression, B/P meds: cause addictive SEs
What are the drugs in the antimuscarinic class?
- Oxybutynin (Patch or PO)
- Tolterodine
- Fesoterodine
- Darifenacine
- Solifenacine
What is an advantage of the Oxybutynin patch?
- Avoids 1st pass effect
- Low steady drug levels
- Less antimuscarinic SEs
Are the new antimuscarinics more receptor sensitive or specific?
More receptor specific
What is the MOA of Beta-3 Agonist?
Relaxes the detrusor smooth muscle during urine storage phase thus increasing bladder capacity
What is the efficacy/benefit of Beta-3 Agonist?
- Modest benefit
- Full Effect takes up to 8 wks
What is the ASE of Beta-3 Agonist?
HTN
What are the drug interactions that you need to note before giving a Beta-3 Agonist?
Warfarin
- need to monitor INR
What drug is apart of the Beta-3 Agonist class?
Mirabegron
What is the MOA of local estrogen?
- Plumps up the tissue around the bladder sphincter
- Applied to vaginal/external urethra
What is the efficacy/benefit of local estrogen?
Benefit post menopausal women w/vaginal atrophy
What is the MOA of Paralytic agents?
- Prevents muscular contraction by inhibiting Ach release at the NM junction
What drug is apart of the Paralytic agents?
Botulinum Toxin A intravesical injection
What medication can contribute to or interfere with treatment of OAB?
- Diuretics: thiazides and loop diuretics
- Anticholinergic medications: use for nocturnal enuresis
- Cholinergic Medications: Bethanechol [use to wake the bladder], Aricept, Exelon, Pilocarpine
What drug is apart of the Cholinergic agonists?
Bethanechol
What is the MOA of Bethanechol?
Stimulates parasympathetic nervous system, increases bladder muscle tone causing contractions with initiate urinate.
What is the Bethanechol place in therapy?
- Neurogenic bladder
- Acute postoperative and postpartum NON-obstructive urinary retention
- Neurogenic atony of the bladder w/ urinary retention
What is the ASEs of Bethanechol?
Increase HR contractility
What are the 4 non-pharmacological treatments for OAB?
- Timed/prompted voiding
- Pelvic flood muscle strengthening exercises (Kegels)
- Biofeedback
- Eliminate suspected bladder irritants
What does Timed/prompted voiding help with? and describe the “best patient” for this treatment.
- Helps avoid full bladder
- Good for pt w/stress, overflow, and functional incontinence
What does Pelvic flood muscle strengthening exercises (Kegels) help with? and describe the “best patient” for this treatment.
- Connect brain with bladder to gain conscious control of pelvic flood muscle and sphincters
- Need motived pts willing to learn
Pelvic floor muscle strengthening exercises (Kegels) may not help pts with what?
May NOT help pts w/ nerve damage or dementia
What does Biofeedback help with? and describe the “best patient” for this treatment.
- Helps to learn how to contract pelvic floor muscles, need special equipment
- Pt needs to be motivated and willing to learn
What are possible bladder irritants that should be eliminated?
- Sugar substitutes, diet sodas
- Caffeine
- Alcohol
What is the MC organism and preferred treatment for Acute uncomplicated cystitis?
- MC Organism: E.coli
- Preferred: Nitrofurantoin
What is the MC organism and preferred treatment for Recurrent cystitis including prophylaxis?
- MC Organism: E.coli
- Preferred: Nitrofurantoin
What is the MC organism and preferred treatment for Pyelonephritis?
- MC Organism: E.coli
- Preferred: Ciprofloxacin
What is the MC organism and preferred treatment for Vaginal yeast infection?
- MC Organism: Candida albicans
- Preferred: Azole topicals or Fluconazole oral
What is the MC organism and preferred treatment for Bacterial prostatitis; acute and chronic?
- MC Organism: E.Coli
- Preferred: Cipro or TMP/SMS, Cipro or Levo
What is the MC organism and preferred treatment for Chlamydia?
- MC Organism: Chlamydia trachomatis
- Preferred: Azithro 1g PO or Doxy x7 days
What is the MC organism and preferred treatment for Genital Herpes?
- MC Organism: Herpes simplex
- Preferred: Acyclovir or Valacyclovir
What is the MC organism and preferred treatment for Gonorrhea?
- MC Organism: Neisseria gonorrhea
- Preferred: Ceftriaxone IM x1 + Azithro 1g PO x1
What is the MC organism and preferred treatment for Syphilis?
- MC Organism: Treponema pallidum
- Preferred: Penicillin G benzathine IM x1
What is the MC organism and preferred treatment for Trichomoniasis?
- MC Organism: Trichomonas vaginalis
- Preferred: Metronidazole 2mg PO x1
What is the clinical effectiveness and typical treatment strategies for the use of acyclovir or valacyclovir for genital herpes?
- Acyclovir is dosed 4x a day for 7-10 days
- Valacylovir is dosed BID x7 days
- Pts are more likely to be compliment with Valacyclovir d/t only being dose BID rather than 4x a day
What is the treatment option for women with “hypoactive sexual disorder”?
Filbanserin 100mg PO qPM
What is the MOA of Filbanserin?
Increases dopamine and norepi by decreasing serotonin
What is the expectied time course of Filbanserin?
- Not an as needed must be taken regularly to be effective
Filbanserin is not effective for treating what?
Not effective for sexual dysfunction related to SE of medications (SSRIs)
What are the ASEs of Filbanserin?
- Sedation (MC)
- Dizziness
- Dleepiness
- Nausea
- Fatigue
- Hypotension
(take at bedtime)
What are the CIs of Filbanserin?
Avoid alcohol and CYP3A4 inhibitors
What is the tx options for “Men with hypoactive sexual desire or hypogonadism”?
Testosterone
- Patch
- Topical gel
- IM injection (Depo-testosterone)
What is the MOA of testosterone?
Reverse age-related decline of testosterone by supplementation
Testosterone may not be effective in who?
No clear benefit show for elderly men
What are the ASEs of testosterone?
- Increase risk for MI and CVA
- Increased RBC in bone marrow
- Prostate hypertrophy and prostate CA
- Lipid disturbances, lowers HDL
- Fluid retention (avoid in CHF)
- Acne
- Gynecomastia
What are the CI of testosterone?
- Prostate CA
- Elevated Hematocrit >55% -polycythemia
- CHF
What labs should be monitored and how often after starting testosterone?
- Monitor testosterone levels 3-6 mos after starting tx.
- Monitor LFT, HgB, and HCT, lipid panels periodically
What drug class is the 1st the first line tx for men with physiologic sexual dysfunction or erectile disorder (ED)?
Type 5 phosphodiesterase (5-PDE) inhibitors
What drugs are apart of the Type 5 phosphodiesterase (5-PDE) inhibitors?
- Sildenafil (Viagra)
- Tadalafil (Cialis)
What is the MOA of Type 5 phosphodiesterase (5-PDE) inhibitors?
- Inhibits break down of cyclic GMP by 5-PDE which potentiates SM relaxation and vasodilation.
- Nitric oxide increases relaxing SM in blood vessels in corpus cavernosum increases penile flow and erection during sexual stimulation
What is the expected time course of Type 5 phosphodiesterase (5-PDE) inhibitors?
30min to 4 hrs depending on dose and if taken with food
What are the ASEs of Type 5 phosphodiesterase (5-PDE) inhibitors?
- HypoTN
- HA
- Potential visual disturbances
- Priapism (rare)
What are the CI of Type 5 phosphodiesterase (5-PDE) inhibitors?
Cannot take if pt has had any form of nitrate within 48 hrs [potential fatal hypotension]
What drug class is the 1st line tx for benign prostatic hyperplasia (BPH)?
Alpha-1 blockers
What drugs are apart of the Alpha-1 blockers?
- Doxazosin
- Prazosin or Terazosin at HS
- Tamsulosin
- Silidosin
What is the MOA of Alpha-1 blockers?
Synthetic testosterone derivative, decreases synthesis of DHT
What is the ASEs of Alpha-1 blockers?
HypoTN
- caution w/safety [can limit dose titration to effect]
What drug class is the 2nd line tx for benign prostatic hyperplasia (BPH)?
5-Alpha Reductase Inhibitor
What drugs are apart of the 5-Alpha Reductase Inhibitor?
- Finasteride
- Dutasteride
What is the MOA of 5-Alpha Reductase Inhibitor?
Reduce prostate volume
5-Alpha Reductase Inhibitor are most effective in pts with what?
- Enlarged prostate
OR - PSA is >30
What are the ASEs of 5-Alpha Reductase Inhibitor?
- Impotence (poss. Permanent)
- Angioedema
What are safety precautions with 5-Alpha Reductase Inhibitor?
Do not let family members touch - potential for breast CA
What drug class is used for BPH as well as ED? and what is the MOA for treating BPH?
- 5-PDE inhibitors
- Improves sxs of BPH by SM relaxation of prostate tissue
What are the CI/safety concerns with Nitrofurantoin?
- Resistance rates are growing
- Not appropriate for most older adults/people with reduced kidney function or complicated UTI’s
What are the CI/safety concerns with Metronidazole?
Avoid alcohol consumption
What are the CIs with Fluoroquinolones?
- Epilepsy
- QT prolongation
- CNS lesions/inflammation
- H/o stroke
What are the safety concerns/ASEs of Fluoroquinolones?
- Phototoxicity
- Myasthenia gravis
- Tendon rupture
What are the CI/safety concerns with Sulfonamide antibiotics?
- Sulfa allergy
- Pregnancy
What are the CI/safety concerns with Penicillins?
- Allergy
What is a short-term treatment (up to 2 days) that can be purchased OTC (95 mg) or prescribed (100 or 200 mg) to manage urinary pain associated with a UTI?
Phenazopyridine
- numbs the bladder
When should you advise a pt to take Phenazopyridine?
- Use BID
- In the 1 and 2nd day of UTI
What should you tell the pt to expect when taking Phenazopyridine?
- Turns urine bright orange and can stain underwear
- Can stain contact lenses
What are the main CI/populations which should avoid using Phenazopyridine?
- Renal impairment
- Elderly: can accumulate in pts with renal insufficiency
- G6PD deficiency: hemolytic anemia
