52. Urinary Incontinence

Question 1

____ is the sudden feeling of needing to urinate

Answer 1

Urinary urgency

Question 2

____ is the primary symptom of overactive bladder (can occur with or without incontinence and usually accompanied by urinary frequency and nocturia

Answer 2

urinary urgency

Question 3

____ is voiding ≥ 8x during waking hours

Answer 3

Urinary frequency

Question 4

___ is ≥2 awakenings in the night to urinate

Answer 4

Nocturia

Question 5

____ is involuntary leakage of urine

Answer 5

Urinary incontinence

Question 6

BPH is the most common cause of ____ incontinence

Answer 6

Overflow

Question 7

___ incontinence is a/w neuropathy and often present in those with diabetes, stokes, dementia, Parkinson disease or MS

Answer 7

Urge

Question 8

The outer muscular layer of the bladder is known as the ___ muscle

Answer 8

Detrusor

Question 9

The detrusor muscle is innervated mainly by the ___ nervous system while the bladder neck is innervated by the ___ nervous system

Answer 9

parasympathetic (ACh acting on muscarinic eeceptors)
Sympathetic

Question 10

Both voluntary and involuntary contractions of the detrusor muscle are mediated by ___ activation of __ receptors

Answer 10

ACh
Muscarinic

Question 11

Which type of muscarinic receptor is responsible for both emptying contractions and involuntary bladder contractions?

Answer 11

M3 receptor

Question 12

Risk factors for overactive bladder (OAB)

Answer 12

Age > 40yo
DM
Prior vaginal delivery
Obesity
Neurologic conditions (e.g. Parkinson disease, stroke, dementia)
Drugs that increase incontinence (e.g. alcohol, cholinesterase, inhibitors, diuretics, sedatives)
Restricted mobility
Hysterectomy
Pelvic injury

Question 13

___ is considered first line to improve OAB symptoms

Answer 13

Behavioral therapies

Examples: bladder training, delayed or scheduled voiding, pelvic floor muscle exercises (Kegel), urge control techniques, fluid management, dietary changes (caffeine), weight loss, and other lifestyle measures

Question 14

First line drugs for urge/mixed incontinence

Answer 14

Anticholinergics (e.g. oxybutynin) or beta-3 receptor agonist (e.g. mirabegron)

(in addition to behavioral therapy)

Question 15

____ has higher efficacy but is not first line for urge/mixed incontinence d/t cost and route of administration through the urethra and into the detrusor muscle

Answer 15

Botox

Question 16

For urge/mixed incontinence, adequate drug trial of ___ is recommended before modifying treatment or adding

Answer 16

4-8 weeks

Question 17

____ are meds used for stress incontinence are not FDA-approved for this use and have minimal efficacy but there is a lack of more effective options

Answer 17

Pseudoephedrine (agonist of NE and Epi)
Duloxetine (typically used when treating 2 conditions with one drug e.g incontinence/depression) but little efficacy for incontinence)

Question 18

MOA of anticholinergic drugs (antimuscarinic drugs)

Answer 18

Competitively bind to muscarinic receptors and block ACh from binding > limits contractions of detrusor muscle

Question 19

Anticholinergic meds ER formulations are preferred over IR formulation d/t lower risk of ___

Answer 19

dry mouth

Question 20

Anticholngeric meds that are more selective for M3 receptors have lower risk of ____

Answer 20

CNS side effects
Selective: solifenacin, darifenacin, and fesoterodine
Non-selective: oxybutynin

Question 21

Beers Criteria recommends avoiding anticholinergic meds in pts aged 65 and older d/t risk of ___

Answer 21

delirium and cognitive impairment

Question 22

Which anticholinergic med comes in IR, ER, gel and patch formulations?

Answer 22

Oxybutynin

Question 23

Contraindications for anticholinergic drugs

Answer 23

Uncontrolled narrow angle glaucoma, urinary retention, gastric retention, decreased gastric motility

Oxytrol for Women OTC: pain and burning when urinating, blood in urine, unexplained lower back or side pain, cloudy or foul-smelling urine, male sex, age < 18yo, urinary or gastric retention, glaucoma, accidental urine loss only d/t coughing, sneezing, laughing

Question 24

What is the brand name of Oxybutynin OTC patch ?

Answer 24

Oxytrol for Women

Question 25

Warnings for anticholinergic drugs

Answer 25

Agitation, confusion, drowsiness, dizziness, blurred vision - caution if performing tasks that require mental alertness (driving, machinery)

Others: hallucinations and/or HA, angioedema of the face, lips, tongue, and/or larynx

Question 26

Side effects of anticholinergic drugs

Answer 26

Dizziness and drowsiness (greatest with oxybutynin), xerostomia (dry mouth), constipation
Others: dry eyes/blurred vision, urinary retention, application site reactions with topical gel/patch

Question 27

Which anticholinergic drug is an OROS formulation (leaves ghost shell)

Answer 27

Ditropan XL (Oxybutynin ER)

Question 28

Which oxybutynin formulations cause less dry mouth and constipation?

Answer 28

Patch and gel (compared to oral forms)

Question 29

Anticholinergic side effects: peripheral

Answer 29

Dry mouth
Dry eyes/blurred vision
urinary retention
constipation
tachycardia

Question 30

Anticholinergic side effects: central

Answer 30

Sedation
Dizziness
Cognitive impairment

Question 31

Dry mouth is a major reason for non-adherence with anticholinergic treatment. What are some ways to minimize dry mouth?

Answer 31

Try ER formulations (lower risk than IR)
Try oxybutynin gel or patch (lower risk than oral)
Beta-3 agonists have a lower incidence of dry mouth and can be helpful in pts who cannot tolerate anticholinergics
Try non-drug options (avoid mouth washes with alcohol, use ice chips, water, sugar-free candy/gum)

Question 32

MOA Beta-3 agonist

Answer 32

Relax detrusor muscle and increase bladder capacity by activating beta-3 receptors

Question 33

Warnings for beta-3 agonists

Answer 33

Urinary retention in pts with BPH and when used with antichoilnergic drugs
Mirabegron: increased BP, angioedema of the face/lips/tongue/larynx

Question 34

Although more effective, ___ is considered third-line treatment for pts who are refractory to first-and second-line treatment options

Answer 34

Botox

Question 35

The only medication FDA-approved treatment of nocturia in adults is ____

Answer 35

Desmopressin

Question 36

MOA desmopressin

Answer 36

Antidiuretic hormone analog that temporarily decreases urine production (take before bed)

Question 37

Boxed warning for desmopressin

Answer 37

Severe, light threatening hyponatremia

Question 38

Contraindications for desmopressin

Answer 38

Increased risk of severe hyponatremia or fluid retention (e.g. uncontrolled HTN, HF)