Block 5: Urinary Incontinence

Question 1

What is UI?

Answer 1

Inability to hold urine in the bladder due to loss of voluntary control over the urinary sphincter resulting in the involuntary passage of urine

Question 2

What is the diagnosis criteria of UI?

Answer 2

D elirium
I nfection
A trophic urethritis or vaginitis
P harmaceuticals
P sychological
E xcessive urine production
R estricted mobility
S tool impaction

Question 3

What are the causes of UI?

Answer 3

1. Weakness of the muscles holding the bladder in place
2. Menopause
3. Dysfunction of bladder muscle and urethral sphincter
4. Medications

Question 4

What does normal mictyrituon look like?

Answer 4

Urine storage is under sympathetic control:
1. Inhibits detrusor contraction
2. Increases sphincter control

Voiding is under parasympathetic control:
1. Induces detrusor contraction
2. Induces relaxation of sphincter control

Question 5

What are some of the causes of UI?

Answer 5

1. Weakened pelvic floor muscles
2. Menopause

Question 6

What are the pharm tx of UI?

Answer 6

1. ANticholinergics
2. alpha-adrenergic antagonists
3. Diuretics, calcium channel blockers
4. Sedative-hypnotics
5. ACE inhibitors
6. antiparkinsonian medications
7. Estrogen
8. TCA

Question 7

How does alpha adrenergic antagonists affect continence?

Answer 7

1. ↓ smooth muscle tone in the urethra
2. May precipitate stress urinary incontinence in women

Question 8

How does ACEis effect continence?

Answer 8

Can cause cough and exacerbate UI

Question 9

How does anticholinergics effect continence?

Answer 9

1. ↑ urinary retention and constipation
2. May impair cognition and reduce effective toileting ability

Question 10

How does CCB effect continence?

Answer 10

1. ↑ urinary retention and constipation
2. Dependent edema which can contribute to nocturnal polyuria

Question 11

How does cholinesterase inhibitors effect continence?

Answer 11

↑ bladder contractility and urgency UI

Question 12

How does diuretics effect continence?

Answer 12

Diuresis and precipitate UI

Question 13

How does lithium effect continence?

Answer 13

Polyuria due to DI

Question 14

How does opioid effect continence?

Answer 14

Urinary retention, constipation, confusion, immobility

Question 15

How does pschotropic drugs effect continence?

Answer 15

Confusion and impaired mobility

Question 16

How does Sedative serotonin re-uptake inhibitors effect continence?

Answer 16

↑ cholinergic transmission and may lead to UI

Question 17

An inability to delay urination due to suddenbladder contractions causing uncontrollable urges, frequently at night;also referred to as unstable or overactive bladder?

Answer 17

Urgency incontinence

Question 18

Leakage of small amounts of urine due toincreased intra-abdominal pressure sometimes associated with suddenexertion (e.g.sneezing, coughing, climbing stairs. Laughing) and muscleweakness in the urinarysystem?

Answer 18

Stress incontinence

Question 19

Not being able to get to the toilet in time dueto an issue outside the urinary system (e.g.mobility issues, cognition,medications)?

Answer 19

Functional incontinence

Question 20

Dribbling of urine associated with a distendedbladder causing difficulty with voluntary voiding, possibly caused byblockage or neurologic conditions?

Answer 20

Overflow incontinence

Question 21

S/s of urge UI?

Answer 21

1. Urgency/ Frequency: Urgency/ Frequency: >8 times per day
2. Large amount of urine loss: >100 mL and may empty completely
3. Nocturia or nocturnal incontinence (enuresis): > time per night and/or nocturnal incontinence and sleep disturbance
4. Inability to reach toilet following urge to void
5. > 8 times per day
6. Large amount of urine loss: >100 mL and may empty completely
7. Nocturia or nocturnal incontinence (enuresis): > time per night and/or nocturnal incontinence and sleep disturbance
8. Inability to reach toilet following urge to void

Question 22

S/s of stress UI?

Answer 22

1. Urine leakage during physical activity, lifting, coughing, sneezing
2. Small-to-moderate urine loss, depending on level of activity
3. Able to reach toilet in time to complete void
4. Occasional urgency
5. In severe forms, urine loss on ambulating
6. Rare nocturia and enuresis

Question 23

S/s of overflow UI?

Answer 23

1. Sensation of bladder or abdominal fullness
2. Sensation of incomplete bladder emptying
3. Sensation of perineal bulge (cystocele/anterior wall prolapse)
4. Hesitancy
5. Straining to void
6. Decreased or incomplete urine stream; dribbling
7. Frequency common/ Urgency common

Question 24

What is mixed UI?

Answer 24

Presence of both stress and urge symptoms/ Presence of overflow and urge (men)

Question 25

What are tx for UI?

Answer 25

1. Absorptive pads 1. Behavioral Modification, Toileting assistance programs 1. Devices 1. Pelvic muscle rehabilitation 1. Medications 1. Surgery

Question 25

What are normal voiding patterns?

Answer 25

**< 60 years of age** * Every 4-5 hours * No awakening at night to urinate **> 60 years of age** * Every 3-4 hours * Awakens once or more to urinate

Question 26

What are absorbent products?

Answer 26

1. Quickly absorbs and contains urine and its odor 2. Feminine products do not = absorbent products 3. Panty liners, pads, guards, undergarments, protective underwear, briefs, and under pads

Question 27

What is the 1st line for UI?

Answer 27

Behavioral interventions

Question 28

What are the types of behavioral interventions?

Answer 28

1. Lifestyle changes 1. Weight loss 1. Dietary modifications 1. Smoking cessation 1. Exercise modification 1. Limit caffeine and alcohol

Question 29

Examples of toileting assistance programs?

Answer 29

1. Encourage individuals to recognize bladder cues and communicate their needs to the caregiver 2. Scheduled toileting 3. Habit training 4. Prompted voiding

Question 30

What are examples of pelvic muscle rehabilitiation?

Answer 30

1. Kegel exercises 2. Intravaginal weights 3. Biofeedback 4. Pelvic support devices

Question 31

What are tx of SUI?

Answer 31

1. SNRI (Duloxetine) 1. Alpha agonists(pseudoephedrine) 1. Low dose Tricyclics (imipramine) 1. Estrogens (in postmenopausal)

Question 32

Duloxetine | Brand, MOA, ADR

Answer 32

Cymbalta **MOA:** Central serotoninergic and noradrenergic regions are involved in ascending and descending control of urethral smooth muscle and the external urethral sphincter **ADR:** N/V/D, headache, insomnia, dry mouth, fatigue, dizziness, ↑ BP

Question 33

Examples of a-adrenergic agonists? | ADR, CI

Answer 33

Pseudoephedrine **ADR:** HTN, HA, dry mouth, nausea, insomnia, restlessness **CI:** :  HTN, tachyarrhythmias, CAD, MI, hyperthyroid, renal failure, narrow-angle glaucoma

Question 34

Estrogens use in UI?

Answer 34

Not FDA approved Estring, vaginal estrogen cream for 2 months - 1 year Best used when SUI exists with urethritis or vaginitis due to estrogen deficiency

Question 35

Tx for overflow incontinence?

Answer 35

Treat underlying disorder 1. Surgical intervention 2. BPH meds 3. Cholinergic drugs, e.g., bethanechol (Urecholine) – Rarely effective 4. Intermittent catheterization

Question 36

Tx for urge UI?

Answer 36

**Behavioral** **Nonspecific anticholinergics:** * Oxybutynin (Ditropan or Oxytrol) * Tolterodine (Detrol) * Trospium (Sanctura) **Selective drugs for M3:** * Darifenacin (Enablex)        * Solifenacin (Vesicare)

Question 37

What are the risk factors of overactive bladder?

Answer 37

1. Normal aging 2. Neurologic 3. Stroke 4. Spinal cord injury 5. Multiple sclerosis 6. Hyperactive involuntary bladder contractions

Question 38

What are presentations of OAB?

Answer 38

**Frequency:** > 8 micturition/day **Urgency:** Immediate need to urinate that cannot be ignored Urge incontinence, nocturia, nocturnal incontinence, unpredictable urine leakage

Question 39

What is the treatment for OAB?

Answer 39

**Behavioral modification (1st line):** * Maintain bladder diary * Scheduled voiding * Alter fluid intake * Pelvic floor exercises **1st line: anticholinergics** * Oral agents: START LOW AND GO SLOW **Other:** * Oxybutynin * Tolterodine * Trospium

Question 40

What are the ADRs of anticholinergics?

Answer 40

Dry mouth, constipation, HA, DZ

Question 41

Oxybutynin | Brand, MOA, ADR, CI, DDI

Answer 41

Ditropan **MOA:** Increases bladder capacity, diminishes the frequency of contractions, and delays the initial desire to void **ADR:** orthostatic hypotension, and weight gain **CI:** narrow angle glaucoma, dementia, GI obstruction, urinary retention **DDI:** CNS depressants, antihistamine, other anticholinergics, or alcohol

Question 42

Oxybutynin dosage forms?

Answer 42

* Oxybutynin IR * Oxybutynin XL * Transdermal Oxybutynin

Question 43

Tolterodine | Brand, MOA

Answer 43

Detrol®, Detrol LA® **MOA:** Decreases contraction of detrusor muscle of normal and overactive urinary bladder

Question 44

Trospium | Brand, MOA

Answer 44

Sanctura **MOA:** Antimuscarinic agent in the bladder and GI tract tissues

Question 45

Solifenacin | Brand, MOA, DDI

Answer 45

Vesicare **MOA:** Antagonist at M1, M2, and M3 muscarinic receptors **DDI:** Potent CYP3A4 inhibitor

Question 46

Darifenacin | Brand, MOA, DDI

Answer 46

Enablex **MOA:** Antagonist at the M1, M3, and M5 muscarinic cholinergic receptors **DDI:** Daily dose should not exceed 7.5 mg if coadministered with CYP3A4 inhibitors

Question 47

Fesoterodine | Brand, MOA, DDI, ADR

Answer 47

Toviaz **MOA:** Prodrug hydrolyzed to the active metabolite, 5-hydroxymethyl tolterodine **DDI:** Dosage adjustment if CrCl < 30mL/min or in patients taking potent CYP3A4 inhibitors **ADR:** Dry mouth and constipation

Question 48

Mirabegron | Brand, Indication, MOA, ADR

Answer 48

Myrbetriq **Indication:** UI and OAB **MOA:** Stimulation of beta 3 receptors in the detrusor mediates bladder relaxation **ADR:** Increase BP, Prescribe carefully in patient with renal and hepatic impairment

Question 49

What is electrical implant?

Answer 49

Sacral nerve stimulator which inhibits or prevents unwanted detrusor contractions for severe urge incontinence