Block 5: Urinary Incontinence Flashcards
Inability to hold urine in the bladder due to loss of voluntary control over the urinary sphincter resulting in the involuntary passage of urine
What is the diagnosis criteria of UI?
D elirium
I nfection
A trophic urethritis or vaginitis
P harmaceuticals
P sychological
E xcessive urine production
R estricted mobility
S tool impaction
What are the causes of UI?
- Weakness of the muscles holding the bladder in place
- Menopause
- Dysfunction of bladder muscle and urethral sphincter
- Medications
What does normal mictyrituon look like?
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
What are some of the causes of UI?
- Weakened pelvic floor muscles
- Menopause
What are the pharm tx of UI?
- ANticholinergics
- alpha-adrenergic antagonists
- Diuretics, calcium channel blockers
- Sedative-hypnotics
- ACE inhibitors
- antiparkinsonian medications
- Estrogen
- TCA
How does alpha adrenergic antagonists affect continence?
- ↓ smooth muscle tone in the urethra
- May precipitate stress urinary incontinence in women
How does ACEis effect continence?
Can cause cough and exacerbate UI
How does anticholinergics effect continence?
- ↑ urinary retention and constipation
- May impair cognition and reduce effective toileting ability
How does CCB effect continence?
- ↑ urinary retention and constipation
- Dependent edema which can contribute to nocturnal polyuria
How does cholinesterase inhibitors effect continence?
↑ bladder contractility and urgency UI
How does diuretics effect continence?
Diuresis and precipitate UI
How does lithium effect continence?
Polyuria due to DI
How does opioid effect continence?
Urinary retention, constipation, confusion, immobility
How does pschotropic drugs effect continence?
Confusion and impaired mobility
How does Sedative serotonin re-uptake inhibitors effect continence?
↑ cholinergic transmission and may lead to UI
An inability to delay urination due to suddenbladder contractions causing uncontrollable urges, frequently at night;also referred to as unstable or overactive bladder?
Urgency incontinence
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?
Stress incontinence
Not being able to get to the toilet in time dueto an issue outside the urinary system (e.g.mobility issues, cognition,medications)?
Functional incontinence
Dribbling of urine associated with a distendedbladder causing difficulty with voluntary voiding, possibly caused byblockage or neurologic conditions?
Overflow incontinence
S/s of urge UI?
- Urgency/ Frequency: Urgency/ Frequency: >8 times per day
- Large amount of urine loss: >100 mL and may empty completely
- Nocturia or nocturnal incontinence (enuresis): > time per night and/or nocturnal incontinence and sleep disturbance
- Inability to reach toilet following urge to void
- > 8 times per day
- Large amount of urine loss: >100 mL and may empty completely
- Nocturia or nocturnal incontinence (enuresis): > time per night and/or nocturnal incontinence and sleep disturbance
- Inability to reach toilet following urge to void
S/s of stress UI?
- Urine leakage during physical activity, lifting, coughing, sneezing
- Small-to-moderate urine loss, depending on level of activity
- Able to reach toilet in time to complete void
- Occasional urgency
- In severe forms, urine loss on ambulating
- Rare nocturia and enuresis
S/s of overflow UI?
- Sensation of bladder or abdominal fullness
- Sensation of incomplete bladder emptying
- Sensation of perineal bulge (cystocele/anterior wall prolapse)
- Hesitancy
- Straining to void
- Decreased or incomplete urine stream; dribbling
- Frequency common/ Urgency common
What is mixed UI?
Presence of both stress and urge symptoms/ Presence of overflow and urge (men)
What are tx for UI?
- Absorptive pads
- Behavioral Modification,Toileting assistance programs
- Devices
- Pelvic muscle rehabilitation
- Medications
- Surgery
What are normal voiding patterns?
< 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
What are absorbent products?
- Quickly absorbs and contains urine and its odor
- Feminine products do not = absorbent products
- Panty liners, pads, guards, undergarments, protective underwear, briefs, and under pads
What is the 1st line for UI?
Behavioral interventions
What are the types of behavioral interventions?
- Lifestyle changes
- Weight loss
- Dietary modifications
- Smoking cessation
- Exercise modification
- Limit caffeine and alcohol
Examples of toileting assistance programs?
- Encourage individuals to recognize bladder cues and communicate their needs to the caregiver
- Scheduled toileting
- Habit training
- Prompted voiding
What are examples of pelvic muscle rehabilitiation?
- Kegel exercises
- Intravaginal weights
- Biofeedback
- Pelvic support devices
What are tx of SUI?
- SNRI (Duloxetine)
- Alpha agonists(pseudoephedrine)
- Low dose Tricyclics (imipramine)
- Estrogens (in postmenopausal)
Duloxetine
Brand, MOA, ADR
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
Examples of a-adrenergic agonists?
ADR, CI
Pseudoephedrine
ADR: HTN, HA, dry mouth, nausea, insomnia, restlessness
CI: : HTN, tachyarrhythmias, CAD, MI, hyperthyroid, renal failure, narrow-angle glaucoma
Estrogens use in UI?
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
Tx for overflow incontinence?
Treat underlying disorder
1. Surgical intervention
2. BPH meds
3. Cholinergic drugs, e.g., bethanechol (Urecholine) –Rarely effective
4. Intermittent catheterization
Tx for urge UI?
Behavioral
Nonspecific anticholinergics:
* Oxybutynin (Ditropan or Oxytrol)
* Tolterodine (Detrol)
* Trospium (Sanctura)
Selective drugs for M3:
* Darifenacin (Enablex)
* Solifenacin (Vesicare)
What are the risk factors of overactive bladder?
- Normal aging
- Neurologic
- Stroke
- Spinal cord injury
- Multiple sclerosis
- Hyperactive involuntary bladder contractions
What are presentations of OAB?
Frequency: > 8 micturition/day
Urgency: Immediate need to urinate that cannot be ignored
Urge incontinence, nocturia, nocturnal incontinence, unpredictable urine leakage
What is the treatment for OAB?
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
What are the ADRs of anticholinergics?
Dry mouth, constipation, HA, DZ
Oxybutynin
Brand, MOA, ADR, CI, DDI
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
Oxybutynin dosage forms?
- Oxybutynin IR
- Oxybutynin XL
- Transdermal Oxybutynin
Tolterodine
Brand, MOA
Detrol®, Detrol LA®
MOA: Decreases contraction of detrusor muscle of normal and overactive urinary bladder
Trospium
Brand, MOA
Sanctura
MOA: Antimuscarinic agent in the bladder and GI tract tissues
Solifenacin
Brand, MOA, DDI
Vesicare
MOA: Antagonist at M1, M2, and M3 muscarinic receptors
DDI: Potent CYP3A4 inhibitor
Darifenacin
Brand, MOA, DDI
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
Fesoterodine
Brand, MOA, DDI, ADR
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
Mirabegron
Brand, Indication, MOA, ADR
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
What is electrical implant?
Sacral nerve stimulator which inhibits or prevents unwanted detrusor contractions for severe urge incontinence
