52. Urinary Incontinence Flashcards
____ is the sudden feeling of needing to urinate
Urinary urgency
____ is the primary symptom of overactive bladder (can occur with or without incontinence and usually accompanied by urinary frequency and nocturia
urinary urgency
____ is voiding ≥ 8x during waking hours
Urinary frequency
___ is ≥2 awakenings in the night to urinate
Nocturia
____ is involuntary leakage of urine
Urinary incontinence
BPH is the most common cause of ____ incontinence
Overflow
___ incontinence is a/w neuropathy and often present in those with diabetes, stokes, dementia, Parkinson disease or MS
Urge
The outer muscular layer of the bladder is known as the ___ muscle
Detrusor
The detrusor muscle is innervated mainly by the ___ nervous system while the bladder neck is innervated by the ___ nervous system
parasympathetic (ACh acting on muscarinic eeceptors)
Sympathetic
Both voluntary and involuntary contractions of the detrusor muscle are mediated by ___ activation of __ receptors
ACh
Muscarinic
Which type of muscarinic receptor is responsible for both emptying contractions and involuntary bladder contractions?
M3 receptor
Risk factors for overactive bladder (OAB)
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
___ is considered first line to improve OAB symptoms
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
First line drugs for urge/mixed incontinence
Anticholinergics (e.g. oxybutynin) or beta-3 receptor agonist (e.g. mirabegron)
(in addition to behavioral therapy)
____ 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
Botox
For urge/mixed incontinence, adequate drug trial of ___ is recommended before modifying treatment or adding
4-8 weeks
____ 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
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)
MOA of anticholinergic drugs (antimuscarinic drugs)
Competitively bind to muscarinic receptors and block ACh from binding > limits contractions of detrusor muscle
Anticholinergic meds ER formulations are preferred over IR formulation d/t lower risk of ___
dry mouth
Anticholngeric meds that are more selective for M3 receptors have lower risk of ____
CNS side effects
Selective: solifenacin, darifenacin, and fesoterodine
Non-selective: oxybutynin
Beers Criteria recommends avoiding anticholinergic meds in pts aged 65 and older d/t risk of ___
delirium and cognitive impairment
Which anticholinergic med comes in IR, ER, gel and patch formulations?
Oxybutynin
Contraindications for anticholinergic drugs
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
What is the brand name of Oxybutynin OTC patch ?
Oxytrol for Women
Warnings for anticholinergic drugs
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
Side effects of anticholinergic drugs
Dizziness and drowsiness (greatest with oxybutynin), xerostomia (dry mouth), constipation
Others: dry eyes/blurred vision, urinary retention, application site reactions with topical gel/patch
Which anticholinergic drug is an OROS formulation (leaves ghost shell)
Ditropan XL (Oxybutynin ER)
Which oxybutynin formulations cause less dry mouth and constipation?
Patch and gel (compared to oral forms)
Anticholinergic side effects: peripheral
Dry mouth
Dry eyes/blurred vision
urinary retention
constipation
tachycardia
Anticholinergic side effects: central
Sedation
Dizziness
Cognitive impairment
Dry mouth is a major reason for non-adherence with anticholinergic treatment. What are some ways to minimize dry mouth?
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)
MOA Beta-3 agonist
Relax detrusor muscle and increase bladder capacity by activating beta-3 receptors
Warnings for beta-3 agonists
Urinary retention in pts with BPH and when used with antichoilnergic drugs
Mirabegron: increased BP, angioedema of the face/lips/tongue/larynx
Although more effective, ___ is considered third-line treatment for pts who are refractory to first-and second-line treatment options
Botox
The only medication FDA-approved treatment of nocturia in adults is ____
Desmopressin
MOA desmopressin
Antidiuretic hormone analog that temporarily decreases urine production (take before bed)
Boxed warning for desmopressin
Severe, light threatening hyponatremia
Contraindications for desmopressin
Increased risk of severe hyponatremia or fluid retention (e.g. uncontrolled HTN, HF)
