Urology

Question 1

What drugs can affect continence?

Answer 1

• a-agonists/antagonists
• Alcohol
• Anticholinergics
• CCB
• Diuretics
• Narcotics
• Antidepressants
• Antipsychotics
• Sedative/hypnotics

Question 2

What exams should be done for incontinence?

Answer 2

• Digital rectal/pelvic exam
• Neuro exam
• PVR
• Cystoscopy
• U/A with micro
• Serum BUN/Cr
• PSA
• History

Question 3

What is desmopressin nasal spray (Noctiva) for?

Answer 3

Nocturnal polyuria adults (awakening 2x per night)

Question 4

What monitoring should be done for Noctiva?

Answer 4

Na+ (can cause hyponatremia)

Question 5

What are some causes of urge incontinence (AOB)?

Answer 5

• a-blockers in women
• Estrogen use in women
• Cystitis
• Stones
• Tumor
• Neurologic issues***

Question 6

How should we treat OAB?

Answer 6

Smooth muscle relaxants (anti-muscarinic)

Question 7

Which anti-muscarinic drugs have low BBB crossing?

Answer 7

• Trospium
• Tolterodine
• Fesoterodine

Question 8

Which anti-muscarinic drugs are better and why?

Answer 8

Darifenacin and Solifenacin

They are M3 specific, which causes less CNS side effects

Question 9

What are dose-dependent side effects of smooth muscle relaxants?

Answer 9

• Anticholinergic stuff
• Confusion/delirium/dementia**

Question 10

What is the hierarchy for smooth muscle relaxant drugs for OAB?

Answer 10

1. Solifenacin (best efficacy and low dry mouth risk)
2. ER tolterodine (less risk of dry mouth than IR)
3. Fesoterodine (good efficacy but has dry mouth and high risk of discontinuation)
4. IR tolterodine (less risk of dry mouth than oxybutynin)
5. Oxybutynin (just sucks in general)

Question 11

What are the best smooth muscle relaxant drugs for OAB?

Answer 11

Solifenacin and ER tolteradine

Question 12

Who should not use imipramine or other TCAs for OAB?

Answer 12

Elderly at risk for orthostasis, cardiac arrhythmias, or other anti-cholinergic effects

Question 13

When is Botox indicated for OAB?

Answer 13

Failure or intolerance to anticholinergic medication for NEUROLOGIC-related OAB

Question 14

What is the biggest problem with Botox for OAB?

Answer 14

High infection risk and transient urinary retention

Question 15

When should Mirabegron be avoided and why?

Answer 15

Those with high blood pressure

It can cause sinus tachycardia and hypertension

Question 16

Vibegron is well-tolerated, but what are the biggest concerns with it?

Answer 16

Infections
- URI, UTI, bronchitis, nasopharyngitis

Question 17

What benefit does vibegron have over mirabegron?

Answer 17

NO BP WARNING!!

Question 18

What is the 1st line treatment for OAB?

Answer 18

Behavioral therapies

+/- pharm if necessary

Question 19

T/F: Antimuscarinics and B3-agonists should be avoided together

Answer 19

FALSE: can be used together for refractory cases

Question 20

What are some treatments for stress incontinence? (increase intra-urethral pressure)

Answer 20

• Pseudoephedrine
• Midodrine
• Estrogen (vaginal application)
• Duloxetine 40 mg BID (OFF-LABEL)

Question 21

How can we treat overflow incontinence?

Answer 21

Bethanechol
- increase bladder tone but efficacy in question

Question 22

What are symptoms of BPH?

Answer 22

• Incomplete emptying
• Frequency
• Intermittency
• Urgency
• Weak stream
• Straining
• Nocturia

Question 23

What are non-pharm options for BPH?

Answer 23

• Incontinent pads
• TURP
• Urethral dilation
• Foley catheters

Question 24

What is the hierarchy for a-1 blockade strength of BPH drugs?

Answer 24

Terazosin > doxazosin > prazosin

Question 25

T/F: Alpha blockade drugs can be used to treat BPH AND lower blood pressure

Answer 25

FALSE: they have been proven ineffective for lowering BP

Question 26

What are adverse effects of a-1 blockers?

Answer 26

- Postural hypotension - Dizziness/vertigo - Blurred vision - Drowsiness - Asthenia (weakness) - "First dose" effect (syncope)

Question 27

What is the potency hierarchy for a1A-selective blockers?

Answer 27

Silodosin >> Alfuzosin ~ Tamsulosin

Question 28

Which a1A-blockers cause the most and least ejaculatory dysfunction?

Answer 28

Silodosin causes the most Alfuzosin does not cause it

Question 29

What are the 5-a reductase drugs we have for BPH?

Answer 29

Finasteride (type II, <50% symptom improvement) Dutasteride (type I and II, more potent)

Question 30

How long does finasteride therapy last?

Answer 30

3-6 months

Question 31

Between finasteride and dutasteride, which drug has more symptom improvement?

Answer 31

Dutasteride

Question 32

Which drugs should be avoided in BPH and why?

Answer 32

- TCAs - Diphenhydramine - Disopyramide - Pseudoephedrine - Ephedrine - Anticholinergics THEY CAUSE URINARY RETENTION - harder to contract detrusor muscle

Question 33

What drug combo may be better than monotherapy to treat UT symptoms and erectile dysfunction

Answer 33

Sildenafil and alfuzosin

Question 34

What is ENTADFI?

Answer 34

The first FDA approved combo product with finasteride and tadalafil

Question 35

T/F: Saw Palmetto is ineffective for BPH

Answer 35

TRUE

Question 36

When should we try a PDE5 for BPH?

Answer 36

- Initial therapy if the patient also has ED - After failing an alpha blocker

Question 37

When should we consider 5ARI addition for BPH?

Answer 37

Prostate >30cc

Question 38

What is last-line therapy for BPH?

Answer 38

Surgery

Question 39

What is the questionnaire used to categorize ED?

Answer 39

IIEF-5

Question 40

What are risk factors for ED?

Answer 40

- Diabetes - Tobacco - Lower urinary tract symptoms - CV disease - Depression/stress

Question 41

What drugs can cause ED?

Answer 41

- Thiazide diuretics - Beta blockers (not nebivolol) - Cardiac/cholesterol drugs - Antidepressants - H2 antagonists - Hormones - Recreational drugs - Anticholinergics - Immunomodulators - Cytotoxic drugs (cancer) - Tranquilizers - Sedative hypnotics - Opioids* - Long-term NSAIDs*

Question 42

T/F: Number of medications has a positive association with ED

Answer 42

TRUE

Question 43

What is the first-line drug class for ED pharmacotherapy?

Answer 43

PDE-5

Question 44

When should PDE5 dose reductions be necessary?

Answer 44

With CYP3A4 inhibitors

Question 45

What are contraindications to PDE5 therapy?

Answer 45

- Concomitant nitrate therapy - Uncontrolled HTN - Severe congestive HF - Recent MI - Heart disease - High-risk arrhythmias - Obstructive cardiomyopathy - Unstable angina

Question 46

What are precautions with PDE5?

Answer 46

- Hypotension - Additive effects with a-blockers - Can cause GERD

Question 47

What PDE5 has the shortest onset?

Answer 47

Avanafil

Question 48

What PDE5 has the longest onset?

Answer 48

Vardenafil

Question 49

What is the longest acting PDE5?

Answer 49

Tadalafil

Question 50

Which PDE5 has the most vision changes associated?

Answer 50

Sildenafil (3-11%)

Question 51

What is "the little blue pill" or "Vitamin V"?

Answer 51

Sildenafil

Question 52

What is "the weekender"?

Answer 52

Tadalafil

Question 53

What is "the quickie"?

Answer 53

Avanafil

Question 54

What PDE5s are affected by high fat meals?

Answer 54

Sildenafil and Vardenafil

Question 55

What is first line treatment for erectile dysfunction?

Answer 55

- Treat underlying disease - Discontinue contributing medications - Remove risk factors - Give testosterone for hypogonadism

Question 56

Patient says PDE5 is not working. What should you do?

Answer 56

- Make sure they get the timing correct - Let them know they can take up to 8 doses until effect - Consider titrating up dosage

Question 57

What is second-line pharmacotherapy for ED?

Answer 57

- Vacuum erection device - Intracavernosal or intraurethral alprostadil

Question 58

What are other possible drug therapy options for ED?

Answer 58

- Yohimbine, Phentolamine (adrenergic agonists) - Androgens - Apomorphine - Trazodone*