Bladder and urinary disorders

Question 1

• Methods for managing urinary incontinence include

Answer 1

pelvic floor exercises and bladder training

Question 2

licensed for use in moderate to severe stress incontinence in women

Answer 2

• Duloxetine is licensed for use in moderate to severe stress incontinence in women. It may be more effective when used as an adjunct to pelvic floor exercises.

Question 3

Antimuscarinic drugs examples

Answer 3

Oxybutynin, Tolterodine and Solifenacin

Question 4

Antimuscarinic drugs such as Oxybutynin

Answer 4

reduce the urge to urinate and increase bladder capacity.

Question 5

Side effects of Oxybutynin

Answer 5

• Side effects limit the use of Oxybutynin, but they may be reduced by starting at a lower dose.
• A modified-release preparation is effective and has fewer side effects.

Question 6

a selective beta3 agonist

Answer 6

• Mirabegron, a selective beta3 agonist is licensed for the treatment of urinary incontinence associated with overactive bladder syndrome. Caution: QT interval prolongation

Question 7

Nocturnal enuresis is

Answer 7

the involuntary discharge of urine during sleep, which is common in young children.

Question 8

Children are expected to be

Answer 8

dry by a developmental age of 5 years.

Question 9

Nocturnal enuresis treatment

Answer 9

• If changes to fluid intake, diet and toileting behaviour are ineffective (more than 1-2 wet beds per week) … an enuresis alarm is recommended (continue until 2 weeks of uninterrupted dry nights.
• If the alarm use is inappropriate or undesirable, then treatment with oral/sublingual desmopressin is recommended for children over 5 years. Side effect of desmopressin in hyponatraemic convulsions.

Question 10

Stop desmopressin in

Answer 10

vomiting/diarrhoea until normal fluid balance. Avoid concomitant drugs that increase vasopressin secretion (TCAs)

Question 11

 Urinary retention is

Answer 11

the inability to voluntarily urinate.

Question 12

• Acute urinary retention is

Answer 12

a medical emergency characterised by the abrupt development of inability to pass urine (over a period of hours)

Question 13

CHRONIC urinary retention is

Answer 13

• gradual (over months/years) development of inability to empty bladder completely, characterised by a residual volume greater than 1 litre or distended/palpable bladder

Question 14

The most common cause of urinary retention in men is

Answer 14

 Benign Prostatic Hyperplasia (enlarged prostate)

Question 15

Treatment of acute urinary retention

Answer 15

• Catheterisation is carried out immediately. Before the catheter is removed… an alpha adrenoceptor blocker (e.g. Alfuzosin, Tamsulosin, Doxazosin, Prazosin, Indoramin or Terazosin), should be given for atleast 2 days to manage acute urinary retention.

Question 16

Treatment of chronic urinary retention

Answer 16

• Intermittent bladder catheterisation should be offered before an indwelling catheter.
• In men who have symptoms that are bothersome, drug treatment should only be offered when other management options have failed.
• Men with moderate-severe symptoms should be offered an alpha-adrenoceptor blocker (alfuzosin, Tamsulosin or Doxazosin). Review treatment initially after 4-6 weeks and then every 6-12 months.

Question 17

Treatment of urinary retention due to Benign Prostatic Hyperplasia

Answer 17

• An alpha-adrenoceptor blocker, these drugs relax smooth muscle in BPH producing an increase in urinary flow rate and an improvement in obstructive symptoms.
• In patients with an enlarged prostate and who are considered to be at high risk of progression (e.g. elderly) a 5a reductase inhibitor (Finasteride/Dutasteride) can be used (also in combination with above)

Question 18

Alpha-adrenoceptor blockers examples, Patient counselling + side effects

Answer 18

examples - doxazosin, alfuzosin, tamsulosin

The first dose may cause hypotension, so it should be taken at night, following this the next doses should be taken in the morning.

• side effects: male breast tissue (report lumps, pain or nipple discharge), depression + suicidal thoughts (stop + report)

Question 19

Finasteride is not prescribable in

Answer 19

NHS for treatment of androgenetic alopecia in men

Question 20

5a-reductase inhibitors example and cautions

Answer 20

• Finasteride + duasteride
• Conception and Contraception: both drugs are excreted in the semen and use of a condom is recommended if sexual partner is pregnant or likely to become pregnant
• Handling and storage: women of childbearing potential should avoid handling leaking capsules of Dutasteride and crushed or broken tablets of Finasteride
• Patient and carer advice: cases of male breast cancer have been reported. Patients should report any changes in breast tissue such as lumps, pain or nipple discharge.
• MHRA: Rare reports of depression and suicidal thoughts in men taking finasteride (Propecia/Proscar)