genito urinary system

1. Genitourinary system
Dr T Sarayu
Pg y1 AIMS KOCHI

2. Dysuria is a painful sensation of burning, tingling, or stinging of the
urethra and meatus associated with voiding
A/W
1) Frequency
2) Urgency
3) Supra pubic pain
Seen in:
1) Infectious cystitis
2) Inflammatory cystitis
3) Infection of the urethra,prostate, or vagina
4) Non-infectious conditions : indwelling catheter, interstitial cystitis,
radiation cystitis, bladder carcinoma, or calculi
Page 675 oxford textbook of palliative care 6th edition

3. ● Symptomatic patients: urine c/s
Antimicrobial therapy
● To alleviate both pain and infection: phenazopyridine
hydrochloride
● 200 mg orally up to three times a day(dont exceed
600mg/day)
● MOA :unknown
● It has topical analgesic effect on mucosa
● s/e : orange discoloration of urine/contact lens

4. Overactive bladder (OAB)
● Urgency frequency syndrome , Nocturia/ +/- incontinence
● A/W suprapubic pressure, pelvic pain
CONSERVATIVE MGMT:
● Timed voiding (void based on a set schedule every 4–6 hours)
● Double voiding (void two times in a row)
● Urge suppression (try to hold urine until urge to void passes)
● Fluid-intake management, in combination with pelvic floor
muscle

5. ● OAB attributed to detrusor muscle overactivity during the
bladder filling/urine storage phase
● Neurogenic, myogenic, or idiopathic in nature
● Detrusor smooth muscle activity is predominantly under the
control of the parasympathetic system and involves
acetylcholine acting on muscarinic receptors

7. Pharmacological treatment of overactive bladder (OAB)
Anti cholinergic therapy using muscarinic receptor antagonists
(tertiary or quaternary amines)
The following anticholinergic agents have been approved by the
FDA for the treatment of OAB
Tertiary amines: oxybutynin, tolterodine, darifenacin, solifenacin,
and fesoterodine
Quaternary amine: Trospium chloride

8. ● These agents block acetylcholine at the muscarinic receptors
on the bladder and thus reduce the frequency and intensity of
the involuntary detrusor contraction.
● Anticholinergic agents have the potential to bind to the five
muscarinic receptors throughout the body in the central
nervous system, eyes, salivary glands, and smooth muscle
● Side effects are caused d/t action at other sites

13. Pharmacokinetics
Bio availability 25-30%
Distribution: protein bound
Metabolised: hepatic, via dealkylation, amide hydrolysis,
glucoronidation, oxidation.
Excretion: 55% urine 35% feces
T ½ 50 hrs

14. Adverse effects
● Bladder pain
● Bloody or cloudy urine
● Blurred vision
● Difficult, burning, or painful urination
● Dizziness
● Frequent urge to urinate
● Headache
● Lower back or side pain
● Nervousness
● Pounding in the ears
● Slow, fast, or irregular heartbeat

15. Interactions
The metabolism of Mirabegron can be decreased when combined with
Amiodarone.
The risk or severity of QTc prolongation

16. Interventional options
UROLOGY PROCEDURES
● Intra-detrusor injection of onabotulinumtoxinA, percutaneous
tibial nerve stimulation, and sacral neuromodulation
● cystoscopy with intradetrusor injection of onabotulinumtoxinA
is an effective procedure to prevent bladder overactivity for a
prolonged period of time.
● If no improvement with the above-mentioned therapies,
surgical urinary diversion can be performed, This typically
involves creation of an ileal urinary conduit, with or without
removal of the bladder

17. Obstructive urinary disorders

18. BPH - Lower urinary tract obstruction
● Benign prostatic hyperplasia (BPH) is a common condition
encountered in aging men and a common cause of lower urinary
tract symptoms
BPH INCLUDES
● Bladder outlet obstruction (BOO), lower urinary tract symptoms
(LUTS), and benign prostatic enlargement (BPE).
● BPH and lower urinary tract symptoms, treatment with alpha-
blockers and/or 5-alpha-reductase inhibitors

19. Alpha-blockers
● Alpha-blockers act by relaxing prostatic smooth muscle and
decreasing outflow resistance
● Tamsulosin and silodosin,specific to the alpha-1a receptor
● Tamsulosin is dosed 0.4 mg daily, UPTO 0.8 mg is used if
there is no improvement after 2–4 weeks.
● Silodosin is dosed 8 mg daily unless there is renal impairment
with a glomerular filtration rate of 30–50 mL/min, in which
case 4 mg daily is appropriate. If the glomerular filtration rate
is less than 30 mL/min, silodosin is contraindicated.

20. 5-Alpha-reductase inhibitors
● Finasteride and Dutasteride
● They prevent the conversion of testosterone to di-
hydrotestosterone to decrease the size of the prostate via
inhibition of growth factor production, and take approximately
3 months to reach full effect
● Finasteride: 5 mg daily
● Dutasteride is dosed at 0.5 mg daily
● No adjustments are required for renal impairment
● These medications have no known role in treating women with
retention

22. Antidepressants:
● Tricyclic Antidepressants (TCAs): Medications such as
amitriptyline or nortriptyline may be used for neuropathic pain
associated with conditions like radiation cystitis or neuropathic
pain in the pelvic region
● Selective Serotonin and Norepinephrine Reuptake Inhibitors
(SNRIs): Duloxetine, for example, can be beneficial for
neuropathic pain

23. ● i/c/o pelvic malignancies, nerve compression causing
neuropathic pain
● Gabapentin and pregabalin can be used
● Muscle Relaxants:
● Baclofen or Tizanidine: These can be considered for muscle
spasms or hypertonicity contributing to genitourinary pain.

24. Urinary retention
● Many medications used for palliative medicine have adverse side
effects, including urinary retention.
● Like opioids, antidopaminergics, benzodiazepines, antidepressants,
calcium channel antagonists, antihistamines, and any drug with
anticholinergic properties such as antipsychotics, tricyclic
antidepressants, antiparkinsonian agents, and atropine
● Review of pt medication plays an imp role
● Treatment options for urinary retention include double voiding,
intermittent catheterization, or indwelling catheterization with
urethral or a suprapubic catheter.

25. Upper urinary tract obstruction
● Blockage in ureter or kidney
● Symptoms of obstruction include flank pain, nausea, emesis,
haematuria, and fevers. O/e costovertebral angle tenderness
is a hallmark sign
● Hydronephrosis
● Renal calculi
● Pyelonephritis
● AKI

27. Approach
● Treatment for upper urinary tract obstruction is based on
patient goals, symptoms, presence of infection, and acute
changes in renal function
● Asymptomatic HUN observation with RFT monitoring is
sufficient
● Bilateral obstruction also includes the option to treat only one
side
● This could be considered if one kidney appears atrophic or is
clinically asymptomatic without pain or infection

28. Thankyou