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Chapter 18 · Advanced Urology · Georgia

Common Urologic Medications Quick Reference

A fast look-up of the drug classes you will use most. Doses are typical adult starting points for reference only — always individualize, verify against a current formulary, check renal/hepatic dosing and interactions, and confirm allergies before…

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A fast look-up of the drug classes you will use most. Doses are typical adult starting points for reference only — always individualize, verify against a current formulary, check renal/hepatic dosing and interactions, and confirm allergies before prescribing.

18.1 BPH / LUTS

Drug (class)

Typical dose

Watch-outs / AU note

Tamsulosin (alpha-blocker)

0.4 mg daily

Bridge only — AU avoids > ~1 yr (cognitive concern). Retrograde ejaculation, dizziness, floppy iris (warn eye surgeon)

Alfuzosin / silodosin

10 mg / 8 mg daily

Same time-limited approach. Orthostasis; silodosin has high ejaculatory dysfunction but is the most uroselective

Doxazosin / terazosin

Titrate up from 1 mg qHS

More orthostatic hypotension; bedtime dosing; also lowers BP (occasionally useful)

Finasteride / dutasteride (5-ARI)

5 mg / 0.5 mg daily

Halves PSA (double it to interpret); slow onset (6–12 mo); sexual side effects. ALSO start immediately for gross hematuria with clots — acutely reduces prostatic bleeding via VEGF suppression (Ch. 2)

Tadalafil (PDE5)

5 mg daily

Treats LUTS and ED together. No nitrates; caution with alpha-blockers

AU procedural note: for definitive BPH therapy we use UroLift (< 50 g) and PAE (> 50 g). We do not offer Rezūm or GreenLight/PVP (Chapter 4).

18.2 OAB / storage symptoms

Drug (class)

Typical dose

Watch-outs / AU note

Mirabegron (beta-3 agonist)

25–50 mg daily

AU first-line oral OAB agent. Check BP (avoid in uncontrolled HTN); CYP2D6 interactions; favorable cognitive profile

Vibegron (beta-3 agonist)

75 mg daily

AU first-line; generally very well tolerated with little BP effect

Anticholinergics (oxybutynin, solifenacin, tolterodine, fesoterodine, trospium, darifenacin)

—

Used only very infrequently — AU strongly advises against (dementia, constipation, dry mouth, retention, falls). Prefer a beta-3 agonist or InterStim (Chapter 5)

OnabotulinumtoxinA (Botox)

100 units intradetrusor

For refractory OAB. Counsel on retention and the possible need for CIC; patient must be willing to catheterize

Desmopressin

Low dose, at bedtime

For true nocturnal polyuria only. MONITOR SODIUM (baseline, 1 wk, 1 mo). Avoid in elderly with risk factors, CHF, or baseline hyponatremia

18.3 Infection, stones, and pain

Drug

Use

Watch-outs / AU note

Methenamine hippurate (Hiprex)

Recurrent UTI prevention (AU first-line)

1 g BID with food; add vitamin C 500 mg to acidify urine; caution/avoid in renal impairment. Non-antibiotic, no resistance

Vaginal estrogen (Estrace) — women

Recurrent UTI prevention

Low-dose estradiol cream 2–3×/week; restores flora/tissue; minimal systemic absorption

Nitrofurantoin

Acute uncomplicated cystitis (true infection)

5 days. Avoid if eGFR < 30 or if pyelonephritis is suspected

TMP-SMX

Cystitis / pyelonephritis (if susceptible)

Sulfa allergy; interactions (warfarin, potassium)

Ceftriaxone + doxycycline

STI-related epididymitis

Ceftriaxone 500 mg IM x1 + doxycycline 100 mg BID x 10 d. Treat partners

Potassium citrate

Uric acid / hypocitraturic calcium stones

Alkalinizes urine (target pH 6.0–6.5); can DISSOLVE uric acid stones. GI upset; hyperkalemia risk

Thiazide (e.g., chlorthalidone)

Hypercalciuric calcium stones

Reduces urinary calcium. Monitor potassium and sodium

Phenazopyridine (Pyridium) / Uro-MP

Dysuria and stent colic (with mirabegron); Uro-MP is also AU first-line for IC/BPS

Urinary analgesic; orange/blue urine. AU's go-to for the symptomatic stent, and half of our IC first-line pair

Hydroxyzine

IC/BPS — AU first-line (with Uro-MP)

Antihistamine/mast-cell stabilizer; dose at bedtime (sedating). Especially useful with an atopic/allergic history (Chapter 27)

Suzetrigine (Journavx)

Non-narcotic acute pain (stone, stent, post-op)

Oral NaV1.8 inhibitor; opioid-sparing — AU-favored analgesic

Ketorolac

Renal colic

Given IM in the office; first-line for colic if renal function allows; avoid in CKD, bleeding risk, and pre-op

AU recurrent-UTI note: prevent with Hiprex, vaginal estrogen (Estrace), reduced sugar, and daily CIC irrigation (~300 cc sterile/distilled water) — we do not use D-mannose, cranberry, or probiotics (Chapter 6). Antibiotics are reserved for the rare true, symptomatic infection.

18.4 Men's health and oncology (see Chapters 20 and 22)

Drug

Use

Watch-outs

Sildenafil / tadalafil (PDE5)

Erectile dysfunction

NEVER with nitrates; caution with alpha-blockers. Needs sexual stimulation to work

Testosterone (gel preferred at AU)

Hypogonadism

Monitor T, hematocrit, PSA. Avoid if seeking fertility. Gel 1st, pellets 2nd, injections last (Chapter 22)

Enclomiphene / clomiphene / hCG

Hypogonadism when fertility must be preserved

Raises endogenous testosterone without suppressing spermatogenesis

Anastrozole

Elevated estradiol on TRT

Low dose; check estradiol; avoid over-suppression (bone, libido)

Denosumab (biosimilar)

Bone health

Every ADT patient: baseline DEXA + 60 mg q6 months. Every bone-mets patient: baseline DEXA + 120 mg every 12 weeks instead. All need dental clearance, calcium and vitamin D levels, and OTC calcium citrate + vitamin D3 gummies providing 1,200 mg calcium daily; never miss doses, and transition to Zometa if denosumab is stopped (Chapter 23)

Semaglutide

Medical weight loss

Titrate 0.25 → 2.4 mg weekly; GI side effects; hold before anesthesia (Chapter 24)

Prescribing safety reflexes

  • Nitrates + PDE5 inhibitor = dangerous hypotension — screen every ED patient for nitrate use, including “poppers.”

  • 5-ARIs lower PSA by ~50% — adjust interpretation and evaluate any rise.

  • AU strongly advises against anticholinergics (used only very infrequently) — prefer beta-3 agonists for OAB (dementia plus constipation, dry mouth, retention, falls).

  • Alpha-blockers are a short-term bridge, not lifelong therapy — move to a definitive BPH procedure.

  • Recurrent UTIs are prevented, not repeatedly treated — reach for Hiprex, vaginal estrogen, sugar reduction, and CIC irrigation before antibiotics.

  • Never prescribe testosterone to a man trying to conceive.

  • Reserve fluoroquinolones for when they are truly needed (tendon, aortic, neuropsychiatric, and dysglycemia warnings).

  • Check renal function before nitrofurantoin, Hiprex, NSAIDs, and contrast.

Clinical Pathway

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A 'which agent do I reach for' aid built from the chapter's own drug tables. Doses are typical adult starting points for reference only — always individualize, verify against a current formulary, check renal and hepatic dosing and interactions, and confirm allergies before prescribing.

Medical therapy for obstructive symptoms — and the reminder that it is a bridge to a procedure, not the destination.

BPH / LUTSMedical therapy for obstructive symptoms — and the reminder that it is a bridge to a procedure, not the destination. STEP 1 · FRAME ITDecide what the drug is for:relief now, gland shrinkage, orboth LUTS and EDAlpha-blockers work in days; 5-ARIs take6–12 months; tadalafil covers two… WHICH ALPHA-BLOCKER? DEFAULTStart tamsulosin 0.4 mg dailyBridge only — AU avoids use beyondabout 1 year. ALTERNATIVESSwap to alfuzosin 10 mg orsilodosin 8 mg dailySame time-limited approach astamsulosin. WHEN BP HELPSTitrate doxazosin or terazosin upfrom 1 mg qHSMore orthostatic hypotension — but theBP effect is occasionally useful. STEP 3 · 5-ARIAdd finasteride 5 mg ordutasteride 0.5 mg daily for thelarge glandSlow onset — and the drug you startimmediately for gross hematuria with… STEP 4 · TWO BIRDSUse tadalafil 5 mg daily when LUTSand ED travel togetherOne drug, both complaints. STEP 5 · DEFINITIVELOCAL POLICYMove to the AU procedure ratherthan refilling foreverUroLift under 50 g, PAE over 50 g.

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The four levers

  • Alpha-blocker — fast symptomatic relief, short-term bridge
  • 5-ARI — shrinks the gland over 6–12 months, and stops prostatic bleeding
  • Tadalafil — LUTS and ED together
  • Definitive procedure — the actual endpoint
Ch 18.1

Which alpha-blocker?

Dosing

  • Tamsulosin 0.4 mg daily

Our position

  • Bridge only — AU avoids > ~1 yr because of the cognitive concern

Watch-outs

  • Retrograde ejaculation
  • Dizziness
  • Floppy iris — warn the eye surgeon before cataract surgery
Ch 18.1

Dosing

  • Alfuzosin 10 mg daily
  • Silodosin 8 mg daily

Watch-outs

  • Orthostasis
  • Silodosin has high ejaculatory dysfunction — but it is the most uroselective

Our position

  • Same time-limited approach — these are bridges too
Ch 18.1

Dosing

  • Titrate up from 1 mg qHS
  • Bedtime dosing

Watch-outs

  • More orthostatic hypotension than the uroselective agents
  • Also lowers blood pressure — occasionally useful, sometimes not
Ch 18.1

Dosing

  • Finasteride 5 mg daily
  • Dutasteride 0.5 mg daily

Counsel

  • Slow onset — 6–12 months
  • Sexual side effects

The other indication

  • Start immediately for gross hematuria with clots — acutely reduces prostatic bleeding via VEGF suppression (Ch. 2)

Pitfalls

  • A 5-ARI halves the PSA — double it to interpret, and evaluate any rise.
Ch 18.1

Dosing

  • Tadalafil 5 mg daily

Pitfalls

  • No nitrates.
  • Caution when combined with alpha-blockers.
Ch 18.1
Local policy

AU procedural note

  • For definitive BPH therapy we use UroLift (< 50 g) and PAE (> 50 g)
  • We do not offer Rezūm or GreenLight/PVP (Chapter 4)

Pitfalls

  • Alpha-blockers are a short-term bridge, not lifelong therapy — move to a definitive BPH procedure.
Ch 18.1

Beta-3 first, anticholinergics essentially never, and an escalation ladder that ends in Botox or InterStim.

OAB / storageBeta-3 first, anticholinergics essentially never, and an escalation ladder that ends in Botox or InterStim. STEP 1 · FRAME ITSeparate storage symptoms fromtrue nocturnal polyuriaThey lead to completely different drugs. FIRST-LINE: PICK A BETA-3 AGONIST OPTION ALOCAL POLICYStart mirabegron 25–50 mg dailyAU first-line oral OAB agent. OPTION BLOCAL POLICYStart vibegron 75 mg dailyAU first-line; generally very welltolerated. STEP 3 · AVOIDDo not reach for ananticholinergicUsed only very infrequently — AUstrongly advises against them. STEP 4 · REFRACTORYOffer onabotulinumtoxinA 100 unitsintradetrusor for refractory OABOnly for a patient willing tocatheterize. STEP 5 · DEVICEConsider InterStim instead of ananticholinergicThe chapter's named alternative when abeta-3 agonist is not enough. STEP 6 · NOCTURIATIME-CRITICALUse low-dose desmopressin atbedtime only for true nocturnalpolyuria — and monitor sodiumBaseline, 1 week, 1 month.

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Ask yourself

  • Urgency, frequency, urge incontinence → beta-3 agonist
  • Night-time volume problem → desmopressin, and only for true nocturnal polyuria
Ch 18.2

First-line: pick a beta-3 agonist

Local policy

Dosing

  • Mirabegron 25–50 mg daily

Our position

  • AU first-line oral OAB agent
  • Favorable cognitive profile

Watch-outs

  • Check the blood pressure — avoid in uncontrolled hypertension
  • CYP2D6 interactions
Ch 18.2
Local policy

Dosing

  • Vibegron 75 mg daily

Our position

  • AU first-line
  • Generally very well tolerated, with little BP effect
Ch 18.2

The class

  • Oxybutynin, solifenacin, tolterodine, fesoterodine, trospium, darifenacin

Our position

  • Used only very infrequently — AU strongly advises against

Why

  • Dementia
  • Constipation
  • Dry mouth
  • Retention
  • Falls

Instead

  • Prefer a beta-3 agonist or InterStim (Chapter 5)
Ch 18.2

Dosing

  • OnabotulinumtoxinA (Botox) 100 units intradetrusor

Counsel first

  • Counsel on retention and the possible need for CIC
  • The patient must be willing to catheterize — do not inject someone who is not
Ch 18.2

Where it sits

  • Prefer a beta-3 agonist or InterStim over anticholinergics (Chapter 5)
Ch 18.2
Time-critical

Dosing

  • Low dose, at bedtime

Monitoring

  • MONITOR SODIUM — baseline, 1 week, 1 month

Avoid in

  • The elderly with risk factors
  • CHF
  • Baseline hyponatremia
  • Nocturia that is not true nocturnal polyuria
Ch 18.2

Prevention before antibiotics, alkalinization for the right stone, and an opioid-sparing analgesic ladder.

Infection, stones, painPrevention before antibiotics, alkalinization for the right stone, and an opioid-sparing analgesic ladder. STEP 1 · SORT ITDecide which of the three problemsyou are actually treatingRecurrent UTI prevention, a truesymptomatic infection, a stone metaboli… STEP 2 · PREVENTLOCAL POLICYPrevent recurrent UTI with Hiprex1 g BID plus vitamin CAU first-line, non-antibiotic, noresistance. STEP 3 · PREVENTLOCAL POLICYAdd vaginal estrogen for womenwith recurrent UTIRestores flora and tissue with minimalsystemic absorption. STEP 4 · TREATTreat a true acute cystitis withnitrofurantoin for 5 daysFor a true infection — not forbacteriuria. STEP 5 · TREATCover STI-related epididymitiswith ceftriaxone plus doxycyclineAnd treat the partners. STEP 6 · STONESMatch the stone chemistry to thedrugPotassium citrate alkalinizes; athiazide lowers urinary calcium. STEP 7 · STENT PAINLOCAL POLICYReach for Pyridium / Uro-MP fordysuria and stent colicAU's go-to for the symptomatic stent —paired with mirabegron. STEP 8 · IC/BPSLOCAL POLICYPair hydroxyzine at bedtime withUro-MP for IC/BPSAU first-line — especially with anatopic history. STEP 9 · ACUTE PAINLOCAL POLICYUse ketorolac for colic andsuzetrigine to stay off opioidsKetorolac is given IM in the office andis first-line for renal colic if renal…

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The four buckets

  • Recurrent UTI → prevention first, antibiotics rarely
  • True symptomatic infection → the right short antibiotic course
  • Stone type → potassium citrate or a thiazide
  • Pain → ketorolac, suzetrigine, Pyridium/Uro-MP, hydroxyzine
Ch 18.3
Local policy

Dosing

  • Methenamine hippurate (Hiprex) 1 g BID with food
  • Add vitamin C 500 mg to acidify the urine

Our position

  • AU first-line for recurrent UTI prevention
  • Non-antibiotic — no resistance

Watch-outs

  • Caution or avoid in renal impairment — check renal function first
Ch 18.3
Local policy

Dosing

  • Low-dose estradiol cream (Estrace) 2–3×/week

Why it works

  • Restores flora and tissue
  • Minimal systemic absorption

The full AU package

  • Hiprex, vaginal estrogen (Estrace), reduced sugar, and daily CIC irrigation (~300 cc sterile/distilled water)
  • We do not use D-mannose, cranberry, or probiotics (Chapter 6)
  • Antibiotics are reserved for the rare true, symptomatic infection
Ch 18.3

Dosing

  • Nitrofurantoin — 5 days for acute uncomplicated cystitis
  • TMP-SMX for cystitis or pyelonephritis if susceptible

Pitfalls

  • Avoid nitrofurantoin if eGFR < 30 or if pyelonephritis is suspected
  • TMP-SMX: sulfa allergy; interactions with warfarin and potassium
Ch 18.3

Dosing

  • Ceftriaxone 500 mg IM × 1
  • Doxycycline 100 mg BID × 10 days

Do not skip

  • Treat partners.
Ch 18.3

Potassium citrate

  • For uric acid and hypocitraturic calcium stones
  • Alkalinizes the urine — target pH 6.0–6.5
  • Can dissolve uric acid stones

Thiazide (e.g. chlorthalidone)

  • For hypercalciuric calcium stones
  • Reduces urinary calcium

Monitoring

  • Potassium citrate: GI upset and hyperkalemia risk
  • Thiazide: monitor potassium and sodium
Ch 18.3
Local policy

Use

  • Urinary analgesic for dysuria and stent colic — give with mirabegron

Our position

  • AU's go-to for the symptomatic stent
  • Uro-MP is also AU first-line for IC/BPS — half of our IC first-line pair

Counsel

  • Warn about orange/blue urine before they call about it.
Ch 18.3
Local policy

Dosing

  • Dose at bedtime — it is sedating

Our position

  • AU first-line for IC/BPS, with Uro-MP

Why this patient

  • Antihistamine / mast-cell stabilizer — especially useful with an atopic or allergic history (Chapter 27)
Ch 18.3
Local policy

Ketorolac

  • Given IM in the office
  • First-line for renal colic if renal function allows

Suzetrigine (Journavx)

  • Oral NaV1.8 inhibitor for non-narcotic acute pain — stone, stent, post-op
  • Opioid-sparing — AU-favored analgesic

Pitfalls

  • Avoid ketorolac in CKD, in bleeding risk, and pre-operatively.
Ch 18.3

ED, testosterone, bone health, and weight — with the fertility and nitrate rules that cannot be broken.

Men's health & oncologyED, testosterone, bone health, and weight — with the fertility and nitrate rules that cannot be broken. STEP 1 · ASK FIRSTAsk about nitrates and aboutfertility before you writeanythingThese two questions eliminate the twomost dangerous prescriptions on this… STEP 2 · EDPrescribe sildenafil or tadalafilfor erectile dysfunctionThey need sexual stimulation to work —say so out loud. STEP 3 · TRTLOCAL POLICYStart testosterone as a gel — gelfirst, pellets second, injectionslastGel is preferred at AU. STEP 4 · FERTILITYUse enclomiphene, clomiphene, orhCG when fertility must bepreservedRaises endogenous testosterone withoutsuppressing spermatogenesis. STEP 5 · ESTRADIOLAdd low-dose anastrozole only forelevated estradiol on TRTAnd check the estradiol you aretreating. STEP 6 · BONEGet the denosumab dose right — 60mg q6 months vs 120 mg every 12weeksTwo different indications, two differentregimens. STEP 7 · WEIGHTTitrate semaglutide 0.25 → 2.4 mgweekly for medical weight lossAnd remember it before any anesthetic.

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Two screening questions

  • Any nitrate use — including 'poppers' — before a PDE5 inhibitor
  • Is he trying to conceive? — before testosterone
Ch 18.4

Counsel

  • Needs sexual stimulation to work

Pitfalls

  • NEVER with nitrates — dangerous hypotension
  • Caution with alpha-blockers
Ch 18.4
Local policy

Our order of preference

  • Gel 1st, pellets 2nd, injections last (Chapter 22)

Monitoring

  • Testosterone
  • Hematocrit
  • PSA

Pitfalls

  • Never prescribe testosterone to a man trying to conceive.
Ch 18.4

Why this instead

  • Raises endogenous testosterone without suppressing spermatogenesis — the option for hypogonadism when fertility must be preserved
Ch 18.4

Dosing

  • Low dose

Monitoring

  • Check estradiol

Pitfalls

  • Avoid over-suppression — it costs bone and libido.
Ch 18.4

Dosing

  • Every ADT patient: baseline DEXA + 60 mg q6 months
  • Every bone-metastasis patient: baseline DEXA + 120 mg every 12 weeks instead
  • Do not give both regimens

Mandatory for every denosumab patient

  • Dental clearance before the first dose
  • Check calcium and vitamin D levels and correct abnormalities
  • OTC calcium citrate + vitamin D3 gummies providing 1,200 mg calcium daily

Pitfalls

  • Never miss doses (Chapter 23)
  • If denosumab is stopped, the patient must be transitioned to zoledronic acid (Zometa)
Ch 18.4

Dosing

  • Titrate 0.25 → 2.4 mg weekly

Pitfalls

  • GI side effects
  • Hold before anesthesia (Chapter 24)
Ch 18.4

The eight checks to run before any urologic prescription leaves your hands.

Prescribing safety reflexesThe eight checks to run before any urologic prescription leaves your hands. STEP 1 · HABITRun the safety reflexes before yousignThese are the errors this chapter isbuilt to prevent. REFLEX 1TIME-CRITICALScreen every ED patient fornitrate use, including 'poppers'Nitrates plus a PDE5 inhibitor equalsdangerous hypotension. REFLEX 2Double the PSA on a 5-ARI beforeyou interpret it5-ARIs lower PSA by ~50%. REFLEX 3LOCAL POLICYReach for a beta-3 agonist, not ananticholinergicAU strongly advises againstanticholinergics; they are used only… REFLEX 4LOCAL POLICYTreat the alpha-blocker as abridge, then book the procedureShort-term therapy, not lifelongtherapy. REFLEX 5LOCAL POLICYPrevent recurrent UTIs instead ofrepeatedly treating themHiprex, vaginal estrogen, sugarreduction, and CIC irrigation come… REFLEX 6TIME-CRITICALNever prescribe testosterone to aman trying to conceiveNo exceptions in this chapter. REFLEX 7Reserve fluoroquinolones for whenthey are truly neededThe warnings are real and cumulative. REFLEX 8Check renal function before fourspecific thingsNitrofurantoin, Hiprex, NSAIDs, andcontrast.

Select a box to open its teaching details.

Always

  • Individualize the dose
  • Verify against a current formulary
  • Check renal and hepatic dosing and interactions
  • Confirm allergies
Ch 18 — intro
Time-critical

Ask explicitly

  • Prescription nitrates
  • Recreational nitrites — 'poppers'
Ch 18 — prescribing safety reflexes

What to do

  • Adjust your interpretation for the ~50% reduction
  • Evaluate any rise
Ch 18 — prescribing safety reflexes
Local policy

Our position

  • Prefer beta-3 agonists for OAB

The harms

  • Dementia
  • Constipation
  • Dry mouth
  • Retention
  • Falls
Ch 18 — prescribing safety reflexes
Local policy

Our position

  • Alpha-blockers are a short-term bridge, not lifelong therapy — move to a definitive BPH procedure
Ch 18 — prescribing safety reflexes
Local policy

Our sequence

  • Hiprex
  • Vaginal estrogen
  • Sugar reduction
  • CIC irrigation
  • Then antibiotics — only for the rare true, symptomatic infection
Ch 18 — prescribing safety reflexes
Time-critical

Instead

  • Enclomiphene, clomiphene, or hCG — raise endogenous testosterone without suppressing spermatogenesis
Ch 18 — prescribing safety reflexes

The warnings

  • Tendon
  • Aortic
  • Neuropsychiatric
  • Dysglycemia
Ch 18 — prescribing safety reflexes

Check first

  • Nitrofurantoin — avoid if eGFR < 30
  • Hiprex — caution or avoid in renal impairment
  • NSAIDs — avoid in CKD
  • Contrast
Ch 18 — prescribing safety reflexes

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