Urinary symptoms

Benign prostatic hyperplasia (BPH) is one of the most common problems of elderly men, affecting more than 40% of men over age 70. BPH results in the urinary symptoms of hesitancy and frequency. Since prostate cancer affects a similar age group and often has similar presenting symptoms, the presence of BPH often complicates the diagnosis of prostate cancer, although it does not appear to increase the risk of developing prostate cancer.2,5... 

The most common adverse effects reported with LHRH agonist therapy include a disease flare-up during the first week of therapy, hot flashes, erectile impotence, decreased libido, and injection-site reactions.19 The disease flare-up is thought to be caused by initial induction of LH and FSH by the LHRH agonist and manifests clinically as either increased bone pain or increased urinary symptoms.19 This flare reaction usually resolves after 2 weeks and has a similar onset and duration pattern for the depot LHRH products.33,34... 

Elderly patients frequently do not experience specific urinary symptoms, but they will present with altered mental status, change in eating habits, or GI symptoms. 

The most common adverse effects of LHRH agonists are disease flare-up during the first week of therapy (e.g., increased bone pain, urinary symptoms), hot flashes, erectile impotence, decreased libido, and injection-site reactions. 

The evidence suggests that non-glucosidic jS-sito-sterols improve urinary symptoms and flow measures. Their long-term effectiveness, safety and ability to prevent BPH complications are not known (see Wiltetal., 2002). 

Mechanism of Action An anticholinergicthat relaxes detrusor and other smooth muscle by cholinergic blockade, counteracting muscle spasm in the urinary tract, Thera-peuticEffect Produces anticholinergic, local anesthetic, and analgesic effects, relieving urinary symptoms. 

Heart rate changes Dental caries, dry mouth Constipation Urinary symptoms Blockade of muscarinic receptors, possibly M2 and M3 Tachycardia Nausea and vomiting Diarrhea Sedation Dry mouth Constipation Urinary retention Lower dose or switch to alternate antidepressant May respond to HS dosing Use candies, gum potential for tooth decay in longterm use Use suppositories May lead to paralytic ileus in toxicity Richelson, 1990... 

Terazosin is another reversible 04-selective antagonist that is effective in hypertension (see Chapter 11) it is also approved for use in men with urinary symptoms due to benign prostatic hyperplasia (BPH). Terazosin has high bioavailability but is extensively metabolized in the liver, with only a small fraction of unchanged drug excreted in the urine. The half-life of terazosin is 9-12 hours. 

Saw palmetto relieves urinary symptoms and flow measures associated with an enlarged prostate it does not reduce the enlargement. Saw palmetto is chiefly employed to manage prostatic enlargement or benign prostatic hyperplasia (BPH). A hexane extract inhibits 5-alpha reductase, the enzyme needed for the conversion of testosterone into dihydrotestosterone (DHT). Saw palmetto further antagonizes DHT binding at prostatic receptor sites, which increases the metabolism and excretion of DHT. It is also used to treat BPH-related inflammation (see Chapter 55). 

P. africanum improved specific urinary symptoms and flow measures. In six double-blind trials involving 430 participants, men receiving P. africanum were more than twice as likely to be rated by their physician as having overall improvement in symptoms compared with men taking placebo. P. africanum reduced nocturia compared with placebo. P. africanum also increased peak urine flow compared with placebo. Additionally, P. africanum reduced residual urine volume. 

Finasteride was developed as the first orally active, specific inhibitor of 5a-reductase for clinical use. Clinical studies in men with BPH demonstrated that treatment with finasteride reduced prostate size, improved urinary symptoms, and reduced the risk of developing serious BPH-related outcomes, including acute urinary retention (AUR) and the need for surgery, confirming the effects of DHT on the prostate. Additional studies also demonstrated that finasteride is an effective treatment in men with AGA. Several small studies have also suggested it is moderately efficacious in women with hirsutism. A number of other inhibitors of 5a-reductase are also presently in development for the treatment of BPH and AGA. 

A 43-year-old woman was admitted to hospital in December feeling unwell with a two-week history of urinary symptoms. She had decompensated cirrhosis of her liver on ultrasound and was taking pentoxifylline (oxpentifylline, Trental), co-amoxiclav, omeprazole and thiamine. She was jaundiced and confused with respiratory failure limiting speech to partial sentences. There was a marked deterioration in liver function overnight and she went into acute renal failure. 

One of the adverse effects of reboxetine is difficulty in passing urine (SEDA-21,13). Eight patients taking reboxetine (4-8 mg/day) had troublesome urinary hesitancy (5). They were successfully treated with tamsulosin (0.4 mg/day), and in two patients tamsulosin was withdrawn after 2 weeks without recurrence of the urinary symptoms. Reboxetine is a selective noradrenaline reuptake inhibitor and may therefore produce urinary symptoms by activating i-adrenoceptors in the bladder, which tamsulosin would be expected to reverse. However, tamsulosin is also effective for urinary symptoms caused by other mechanisms, for example benign prostatic hyperplasia. Whether its apparent effectiveness in reboxetine -induced dysuria represents specific pharmacological antagonism is therefore uncertain. 

A 46-year-old woman took tolterodine 4 mg/day for stress incontinence (623). Her urinary symptoms were... 

A systematic review and meta-analysis of randomized trials of S. repens in men with benign prostatic hyperplasia showed that saw palmetto extracts improve urinary symptoms and flow measures to a greater extent than placebo, and similar improvements in urinary symptoms and flow measures to the 5-alpha-reductase inhibitor finasteride with fewer adverse effects (6). 

Repo UK, Nieminen P. Pulmonary infiltrates with eosino-philia and urinary symptoms during disodium cromoglycate treatment. A case report. Scand J Respir Dis 1976 57(1) 1M. 

Blockade of alphai-adrenoceptors in the urinary tract leads to smooth muscle relaxation and improvement in urinary flow, and this pharmacological action has been used to ameliorate the urinary symptoms of benign prostatic hyperplasia. Prazosin can occasionally lead to urinary incontinence, particularly stress incontinence in women (1). 

Jacobsen SJ, Jacobson DJ, Girman CJ, etal. Treatment for benign prostatic hyperplasia among community dwelling men The Olmsted County Study of urinary symptoms and health status. J Urol 1999 162 1301-1306. 

Elderly patients frequently do not experience specific urinary symptoms, but they will present with altered mental status, change in eating habits, or gastrointestinal symptoms. In addition, patients with indwelling catheters or neurologic disorders commonly will not have lower tract symptoms, whereas flank pain and fever may be recognized. Many of the aforementioned patients, however, frequently will develop upper tract infections with bacteremia and no or minimal urinary tract symptoms. 

Asymptomatic bacteriuria represents patients who, in the absence of urinary symptoms, are found to have two consecutive urine cultures... 

Interstitial nephritis has been described from renal biopsies in patients treated with indinavir [119-124], in some cases with eosinophiluria and crystals (assumed to be indinavir) associated with histiocytes and giant cells in the renal tubules. Some of these patients were asymptomatic, while other had urinary symptoms as described above and crystalluiia. Renal atrophy associated with long-term use of indinavir was described in two patients with hematuria, pymia, and reversible renal insufficiency [125]. 

Relaxation of smooth muscle in the bladder neck, prostate, and prostate capsule produced by alpha,-adrenergic blockade results in a reduction in urethral resistance and pressure, bladder outlet resistance, and urinary symptoms. 

Receptor antagonists are not the drugs of choice in patients with pheochromocytoma, because a vasoconstrictor response to epinephrine can still result from activation of unblocked vascular (X2 adrenergic receptors, Receptor antagonists are attractive drugs for hypertensive patients with benign prostatic hyperplasia, since they also improve urinary symptoms. 

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