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GU Disorders

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Kristin Smith

on 18 November 2013

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Transcript of GU Disorders

Pharmacotherapy for Genitourinary Tract Disorders and Vaginitis

Jennifer, Kristin, and Tessa

Urinary Tract Infection
Urinary Tract Infection (UTI) is a broad term used to describe inflammation of the urethra, bladder, and kidney.
Bacteria, yeast, or chemical irritants can cause inflammation in the urinary tract.
10% of women experience one episode per year.
60% of women experience at least one in a lifetime.
Peak age is 18 to 24 years.

Causes
Women to men ratio is 30:1 due to short urethra and its proximity to rectum
Sexual intercourse is a contributing factor
After the age 65, the ratio in women to men becomes closer to 1.
Escherichia coli is the causative pathogen in 85% to 90%
Staphylococcus saprophyticus accounts for 5% to 20%
Risk factors for men are:
Homosexuality
intercourse with an infected partner
Uncircumcised
Predisposing Factors
Others May Include:
Ineffective bladder emptying
Estrogen deficiency
Delayed postocital micturition
HX of Childhood UTI
Structural defects
Diagnostic Criteria
Symptoms of CYSTITIS may include:
Urinary Urgency
Frequency
Dysuria
Abrupt Onset
Pressure or fullness in the suprapubic area
Back pain
Symptoms of PYELONEPHRITS
Flank pain
Nausea and Vomiting
Temperature greater than 100.4 F
With or Without symptoms of Cystitis
Complicated and Uncomplicated UTI
Complicated
Occurs in a man
A postmenopausal or pregnant woman
A patient with urinary structural defects, neurologic lesions, or a catheter.
Symptoms persisted for more than 7 days
In sexually active men with symptoms of cystitis, urethritis must be ruled out.
Pyelonephritis presents with recurrent fevers, chills, flank pain, and a positive urine culture
Uncomplicated
Occurs in pre-menopausal
Sexually active
non-pregnant women who has not recently had a UTI.
Cultures
Cultures are not preformed if the criteria for uncomplicated are met, due to cost
The Leukocte dipstick is 75% to 95% sensitive to detecting pyuria.
Hematuria occurs in half of all acute UTIs.
Pre and Post treatment/cultures should be done on ALL MALES and suspected pyelonephritis except for post cultures unless the symptoms recur in 2 weeks.
Urine culture with 10 (5)/mL organisms or greater is a diagnostic indicator of UTI with or without symptoms.
A paitent who has symptoms and a culture with 10 (2)/mL organisms or greater is treated.
Initiating Drug Therapy
Antibiotic
Infection complicated or uncomplicated
Male or Female
For Women infected with E.Coli cure rates are 90% to 95% with 3 days of therapy
Age
Goals of Therapy
Destroy the offending organism
Relieve Symptoms
Prevent Complications
So many choices, what shall I choose??
First Line Therapy for Uncomplicated
Bactrim
The first line choice for cystitis is TMP-SMZ (Bactrim).
Decreases the number of E. Coli in vaginal and fecal reservoirs.
Can not be used in patients with Sulfa Allergies
Normal dose is:
Adult: 1 DS q12 for 10D
Children: 5mg/kg/d in divided doses for 10D
Adverse Events
Nausea/Vomiting
Anorexia
Megaloblastic anemia
Hallucinations
Depression
Seizures
Contraindications
Megaloblastic anemia
Pregnancy (Category C)
Breast Feeding
Not recommended for children under 2
G6PD deficiency
Special Considerations
May consider newer macrolide antibiotics
Drink at least 8 glasses of fluids
7D therapy recommend for postmenopausal women and in men.
3 day treatment for non-pregnant women w UC
Nitrofurantoin-
(Macrobid, Macrodantin)
A long history of good efficacy
7 day course
Very little resistance
Dosage:
Macrobid- 100mg q12h for 7D
Macrodantin- 100mg QID for 7D
Adverse Effects
Nausea
Pulmonary allergic reaction
Dizziness
Hemolytic Anemia
Contraindications
Anuria
Obliguria
Pregnancy at Term
Nursing Mother
Special Considerations
Take with food to increase absorption
Ciprofloxacin (Cipro)-
Flucorquiolones
First line therapy for uncomplicated pyelonephritis
Usually given first if culture results are not available because of their broad spectrum activity.
No follow up required if the symptoms resolve
Dosages:
Adult: 100-250 mg for 3D for uncomplicated cystitis and 7D for complicated cystitis
500mg for 10-14 Days for uncomplicated pyelonephritis
Adverse Events
Nausea
Diarrhea
Altered Taste
Dizziness
Drowsiness
Headache
Insomnia
Agitation
Confusion
Serious: pseudomembranous colitis and Stevens-Johnson Syndrome
Contraindications
Allergy to fluroquinolones
Avoid in patients less that 18 years
Pregnancy
Use Caution in: Renal Disease, central nervous system disease, and breast feeding.
Special Considerations
Raises serum level of theophyline
Avoid taking with aluminum- or magnesium-contain antacids.
Food slows absorption
**Interacts with antacids, theophyline, warfarin, probenecid, digoxin, foscarnet, and glucocorticoids.
Second Line Therapy
Fluoroquinoles and Fosfomycin
Recommended for recurrent cystitis.
7 Day is recommended if a 3 day course does not resolve symptoms.
Fluoroquinoles are not recommended as first line for uncomplicated cystitis.
Used for UTIs in men and postmenopausal women.
Used for patients with complicated UTIs and pyleonephritis.
Second Line Therapy
Used for recurrent UTIs
Women who have had 3 or more
Prophylaxis treatment
Treatment can be based on a previous culture.
Common Second Line
Levofloxacin (Levaquin)
Adult dose:
200 mg Q12 for 3 D for uncomplicated cystitis and 7D for complicated cystitis;
200-300mg for uncomplicated pyelonephritis.
Adverse Effects
Nausea
Diarrhea
Photosensitivity
Contraindications
Pregnancy (Category C)
Breast Feeding
Children
Special Considerations
Increase fluid intake
Avoid taking aluminum or magnesium containing antacids or sucralfate, iron, and multivitamins with zinc because these can decrease absorption.
Common Second Line cont.
Norfloxacin (Noroxin)
Adult dose:
400mg Q12h for 3D for uncomplicated cystitis and 7D for complicated cystitis
10-14 Days for uncomplicated Pyelonephritis.
Adverse Effects
Seizures
Dizziness
Nausea
Headache
Tendonitis
Tendon rupture
Contraindications
Pregnancy (Category C)
Breast Feeding
Children
Special Considerations
Increase fluid intake
Avoid taking aluminum or magnesium containing antacids or sucralfate, iron, and multivitamins with zinc because these can decrease absorption.
Not recommended for the elderly patients. Requires creatinine clearance of 40 mL/min.
Urinary Analgesics
Methenamine (Urised)
Dose:
2 tabs QID
Adverse Effects:
Rash
Antiocholinergic Effects
xerostomia
Flushing
Difficulty urinating
acute urinary retention w/BPH
tachycardia
dizziness
blurry vision
urine or fecal discoloration
Contraindications:
Glaucoma
not for use in patients younger than 6
Pregnancy (Category C)
Breast Feeding
Bowel Obstruction
Cardiospasm
Special Considerations:
May cause blue green discoloration of urine or feces.
It is not antibacterial
Third Line Therapy
Third Line Therapy
Culture and Sensitivity Testing
Then Treat based on Results
Phenazopyridine (Pyridium)
200 mg TID
Contraindications
GI Obstruction
Obstructive Uropathies
Glaucoma
Special Considerations
Discolors urine
Take after meals
Reduce dose after improvement
Special Considerations
Elderly
Usually Asymptomatic
Lactobacilli diminish and pH decreases
10-20% older than 65 has bacteriuria related factors such as:
fecal incontinence
incomplete bladder emptying
malnutrition
increased urine
UTI in a man is complicated and usually Proteus, Klebsiell, Serratia, Psudomonas, and Enterococcus
Treatment is 7-10 days in women
10-14 days for men with uncomplicated UTIs.
Women
7% of pregnant women are asymptomatic
Pyelonephritis will develop in 30% if left untreated
Can result in prematurity or still births
Amoxicillin is effective in approximately two thirds of pregnant women
Cephalexin, Sulfa, and nitrofurantonin is safe ONLY IN the first and second trimester
Pregnant women should be screened regularly
Bacteriuria in pregnancy is associated with 20-30% incidence of pyelonephriis and premature delivery, IUG, retardation, increased risk of death, and congenital anomalies.
Children
UTI in children indicate genitourinary anomaly
Start Treatment quickly
increased risk of renal scarring in children under age 5
occurs in 32 to 40%
Renal/Bladder US recommended under the age of 2.
treatment of 7 to 14 days
Lifestyle Changes and Alternative Medicine
Voiding after intercourse
direction of toilet paper
contraception
Drinking 6-8 glasses of water
empty bladder completely
urinate every 2 hours
Avoid tea, coffee, alcohol, cola, chocolate :(, spicy foods
Cranberry:
300-400 mg BID
Vitamin C 500 mg every 4 hours
Prostatic Disorders
and Erectile Dysfunction

Prostatic Disorders
The incidence of prostatic disorders increase with age
50-70% men older than 50 have BPH
Prostate Cancer is the second most common cancer affecting men.
Black men have the highest incidence
Treatment is self limited
Occurs because of:
Inflammation
Infection
BPH
Prostate Cancer
Management of prostatic disorders is specific tot he particular disorder (cancer vs noncancerous) with some overlap in treatment.
Prostatitis
Bacterial invasion
Acute or Chronic
Escherichia coli and Pseudomonas
Non-Bacterial prostatitis is an inflammatory disorder
Prostatitis
Pain in the lower abdomen
difficulty in bladder emptying wth or without a stream during nurination
nocturia
fever to 104 F
painful ejaculation
pain in the rectal or peritoneal areas
Diagnostic
4 urine cultures: initiall void, followed by a midstream, prostatic massage secretions, then a urine after the prostatic massage
Goals of Drug Therapy
The goal of pharmacotherapy for prostatitis is to eradicate the causative organism.
restore the prostate health
often becomes chronic, repeated trials of antibiotics may be indicated
First Line Therapy
Fluroquinoles
First line therapy
Therapy last for 4 to 6 weeks
Ciprofloxacin (Cipro)
500 mg BID
Norfloxacin (Noroxin)
400 mg BID
Levofoxacin (Levaquin)
250 mg Daily
Adverse Effects
Headache
diarrhea
nausea
drowsiness
altered taste
insomnia
agitation
confusion
SJS
p. colitis
Contraindications
allergy to macrolides
pregnancy and lactation
Special Considerations
May interfere w theophyille met
use caution hepatic/renal disease
Trimethoprim-Sulfamethoxazole (TMP-SMZ, Septra, Bactrim)
TMP-SMZ
160 mg of TMP with
800 mg SMZ
PO Q12 hours
more powerful if given separate
inhibits growth of bacteria because of its PABA
Drug to Drug Interactions
Dilantin
oral hypoglycemics
Coumadin- may prolong the INR
Adverse Effects
GI distress
Rash
Contraindications
Allergy to Sulfa and Sulfa products
Second-Line Therapy
Doxyclcline, azithromycin, and clarithromycine are second line agents
if infections is not resolved in 4-6 weeks, continue up to 12 weeks.
Doxycycline(Vibramycin)
200 mg po as first dose
100-200 mg po Q12 after
Adverse Effects
GI Distress
potential acute hepatotoxicity
potential for nephrotoxicity
Special Considerations
Decreased effectiveness with food and dairy
do not take with food
can lead to DI b/c of antagonistic effect with antidiuretic hormone
Contraindications
Hypersensitivity to any of the tetracyclines
pregnancy and lactation
Special Considerations
In older men who are taking fluroquinoles, creatinine clearance must be monitored
Benign Prostatic Hyperplasia (BPH)
BPH common in men older than 50; rarely before 40.
6.3 million men have BPH
25% of men older than 55 and 50% of men older than age 75 experience decreased urinary flow.
BPH not well understood
Research in a drop in testosterone level and men whose testes were removed before puberty are main causes
Diagnostic Criteria
Complete social history and physical examination
Digital Rectal Exam
The use of the American Urological Association (AUA) Symptom Index Scale
Mild (0-7 points)
Moderate (8 to 19 points)
Severe (20-35 points)
Post void catherization-test residual, anything over 100 mL is significant
Other test:
X-ray
digital US
CT
MRI
BUN/Creatinine
PSA
Symptoms
Problems with urination including:
hesitant
interrupted
weak stream
urgency
dribbling
more frequent at night
painful urination
incontience
8 out of 10 cases, these symptoms suggest BPH. It may signal more serious conditions, like prostate cancer
Drug Therapy
Two major classes of drugs used to treat BPH
Adrenergic antagonist
Alpha Blockers i.e. doxazosin, terazosin, tamsulosin, and alfuzosin
They relax smooth muscle fibers of the bladder neck and prostate, thereby reducing the dynamic components of prostatic obstruction
functional antihypertensives
linked with fluid retention
5 alpha reductase inhibitors
Finasteride and dutasteride
Five alpha reductase inhibitors decrease leves of intracellular DHT without reducting testerone levels.
This leads to prostatic size reduction of about 30-30%
Alpha blockers will relieve symptoms within two weeks in comparison to finasteride.
Management of BPH can include:
Medical
Surgical
And Combination
Pharmacotherapy is prescribed in both.
Goals of Therapy
Reduce Bladder outlet obstruction, improve quality of life, fewer symptoms, and decreased residual urine volume
5 Alpha Reductase Inhibitors
Proscar (Finasteride)
5mg po daily
Adverse Events
Impotence
Decreased libido
smaller ejaculate volume
Contraindications
Not to be handled by pregnant women
Special Considerations
Inform patient that effective outcome of therapy may take up to 6 months
Avodart (dutasteride)
0.5 mg po daily
Same Adverse, contraindications, and special considerations as Proscar
5 alpha reductase inhibitors decrease PSA levels by 40-50%
Alpha Adrenergic Blockers
Cardura(doxazosin)
4-8 mg po Daily
Adverse Events
Dizziness
Headache
Fatigue
Malaise
Contraindications
Lactation
Caution in patients w/
CHF
Renal Failure
Hepatic Impairment
Special Considerations
May have secondary benefit to patients w/ cardiac disease
Avoid in combination with :
Alcohol
Nitrates
Other antihypertensive drugs
Flomax (tamsulosin HCL)
0.4 mg/d po Daily; increase to 0.8 mg
Adverse Events
Orthostasis
Headache
problems with ejaculation
Contraindications
Allergy
prostatic cancer
pregnancy
lactation
Considerations
interaction with cimetidine; decreases clearance
First Line Therapy:
Mild Symptoms AUA score less than 7
limit fluid intake after dinner
avoid decongestants
massage prostate after intercourse
void frequently
no medical treatment is recommended
Second Line Therapy:
AUA score greater than 7
Alpha adrenergic blocker or a 5 alpha reductase inhibitior
alpha adrenergic for pts who take antihypertensives and are effective across the range of prostate sizes
5 alpha reductase inhibitors- men w/ large gland and if the prostate is enlarged to 40 g or more
Third Line Therapy
Combination therapy
Fourth Line Therapy
Surgery
Patient Education:
Improvement will take time, not over night
Sexual Health
Rise slowly from sitting or standing
Lifestyle Changes:
void frequently
decrease fluid after dinner
avoid diuretics and alcohol
avoid anticholinergics, antihistamines,and antidepressants
Alternative therapies:
Saw palmetto
Pygeum
Zinc
Prostate Cancer
1 of every 11 men will have cancer of the prostate;
increase risk with age;
greater than 80% have been in men age 65 or older
more common in African American men
Men of Asian heritage have the lowest incidence
Cause is unknown, but increased risk with genetics
Workplace with cadmium is correlated with the later onset of prostate cancer
95% are adenocarinomas
Symptoms:
BPH symptoms, but with no remission
Difficulty in defecation
Diagnostic Criteria:
3 screening tools are used
DRE (all men over 40 should have)
PSA (all men over 50 should have; should be less than 2.7 in younger than 40 and 4.0 or less in men older than 40)
If either are abnormal then an US (pt must avoid ejaculation 48 hours prior, may cause a false positive)
Confirmation needs further testing
Erectile Dysfunction
Erectile Dysfunction (ED) most common sexual problem in men
The incidence increases with age
about 5% of men age 40 experience ED
15-25% of men age 65
est. 10-20 million American men suffer from ED
Causes
Damage to nerves, arteries, smooth muscles, and fibrous tissue
Chronic diseases
diabetes
kidney disease
chronic alcoholism
multiple sclerosis
atherosclerosis
vascular disease
neurological disease 70% of all ED
Risk Factors see box 33.1 page 491
Surgery
Injury to the penis, spinal cord, prostate, bladder, and pelvis
Obesity
sedentary lifestyle
Many common drugs
antihpertensives
antihistamines
antidepressants
tranquilizers
appetite suppressants
cimetide
anticholinergics
corticosteroids
diuretics
nicotine
alcohol
analgesic
Psychological factors
stress
anxiety
guilt
depression
low self-esteem
fear of sexual failure
Diagnostic
Initial diagnostic workup should be limited to a fasting serum glucose level and lipid panel, thyroid stimulating hormone test, and morning total testosterone level
Before therapy:
Cardiac workup, physical exam, and any further investigation from blood work.
Goals of Therapy:
Enable the patient to achieve sexual satisfaction and to achieve and maintain an erection
First Line Therapy:
Life Style Changes
PDE5 inhibitor- patient is at low risk of a cardiac event if:
fewer than 3 risk factors for coronary artery disease, controlled HTN, mild, stable angina, uncomplicated MI more than 8 weeks previously, mild valvular disease, and New York Heart Association Class 1 heart failure.
First Line Therapy
Viagra (sildenafil)
50 mg 30 to 60 minutes before intercourse
dose range from 25-100mg
max is one dose per day
food can delay absporption
Cialis (vardenafil)
10mg per day
range from 5-20 mg
taken without restriction of food or alcohol
Levitra (vardenafil)
10 mg per day
range from 2.5-20 mg
take 60 minutes before intercourse
food can delay absorption
Time frame for response
Viagra and Levitra are rapidly absorbed, reaching max plasma concentrations in 30-120 mins. Half life is 4 hours and no more than one dose per 24 hour period.
Cialis has an onset of 30 mins and allows intercourse for at least 30 hours.
Drug
Adverse Events
Contraindications
Considerations
Cialis
Headache
Flushing
GI Disturbance
Nasal Congestion
Rash
Priapism
Nitrates
Alpha Blockers except for tramulosin 0.4 mg once a day
Food and alcohol make no difference in absorption
may remain in system for 36 hours
Levitra
Same as above
Nitrates
Alpha Blockers
High-fat meals delay absorption
Viagra
Same as above
and color disturbances
Nitrates
within 4 hours of an alpha block and at at dose no greater than 25 mg
Same as above
Second Line Therapy
If PDE5 inhibitors are not successful in treating ED, the patient should be referred to a urologist.
Penile IV therapy
Medical intraurethral system for erection
vacuum erection device
penile prostheses
Follow up in 6 months for a cardiac work up and check for effectiveness
Full transcript