EXAM 2 Urinary Incontinence and Pregnancy Dr. Dowling Flashcards
What is the first-line treatment for urinary incontinence?
Nonpharmacolgic treatment
Second-line treatment for urge incontinence
Antimsucarinics
beta-3 agonists
Second-line treatment for stress incontinence
-Duloxetine (SSRI)
-topical estrogen
-alpha agonists
Types of Urinary Incontinence
-Urge Urinary Incontinence (UUI): the bladder is to reactive to urine, smooth (detrusor) muscle contract -> urge
-> symptom of overactive bladder
-StressUrinary Incontinence (SUI)
-> involuntary leakage during exertion (sneezing, coughing)
-Overflow Incontinence (OI)
-> incomplete emptying of bladder -> leads to frequent loss of urine
-Mixed Incontinence: Combi of UUI, SUI, OI
-Functional Incontinence
-> result of decreased mobility or low physical functioning -> decreased awareness of signals to urinate (cognitive issue or immobility), the body doesn’t recognize the signals
Which muscle of the bladder is involved in urge urinary incontinence
detrusor smooth muscle
Which structure of the urinary system is involved in stress urinary incontinence (SUI)?
Urethra
the structure that keeps urine in place before voiding is weakened -> loss of urine due to abdominal pressure (sneezing, coughing, laughing)
Which type of urinary incontinence is a consequence of BPH?
Overflow Incontinence (OI)
patients cant void completely -> over time urine accumulates in the bladder and breaks through the urethra -> Overflow -> continuous or frequent loss of a stream of urine during daily activity
Do we see Overflow Inncontinece in man or women?
In men: due to enlarged prostate -> causing incomplete emptying
maybe seen in women: physiologic effect or medical side effects
How do the muscles of the bladder and the urethra behave before voiding?
Bladder: relaxed
Urethra: contracted and closed
How do the muscles of the bladder and the urethra behave in urgency incontinence?
Bladder contracts , inappropriate signals (may be too early)
the urethra is still closed -> but the contraction pushes the urine out
How do the muscles of the bladder and the urethra behave in stress continence?
Bladder: relaxed
the urethra is not restricted as is should be –> leakage (drops) of urine
What might contribute to a weakening of the urethra?
in women: childbirth, trauma over time
in men: prostate surgery
How do alpha-receptor agonists cause urine incontinence?
Urethral contraction
-> urinary retention (more common in men)
-> overflow incontinence
How do alpha-receptor antagonists cause urine incontinence?
Urethral relaxation -> stress incontinence
In which disease state are alpha-antagonists beneficial?
BPH
-alpha-blocker (Tamsulosin)
-5-alpha reductase inhibitor (finasteride)
-PDE-4 inhibitor (Tadalafil)
Which drugs cause reduced bladder contractility resulting in urinary retention?
side-effect induced reduction in bladder contractility
-Calcium channel blocker
-Narcotic analgesics
-Antipsychotics
effect of reduction in bladder contractility used for treatment in disease states
-Anticholinergics
-beta-3 agonist
Which drug may cause Urethral relaxation and reduced bladder contractility at the same time?
TCA
alpha antagonist effect: urethral relaxation (stress incontinence)
anticholinergic effect: reduced bladder contractility
Which drugs cause Polyuria resulting in urgency and frequency?
-diuretics
-alcohol
-acetylcholinesterase inhibitors
-> (bind to muscarinic receptors -> inducing contraction of detrusor muscles, also activating parasympathetic nervous system by inhibiting ACh esterase (more ACh)
How do sedative hypnotics affect urinary incontinence?
Delirium
immobility -> may cause functional incontinence
caution with the use of: benzos, zolpidem (ambien), lunesta
How does an ACEi cause urinary incontinence?
Cough as a side effect of ACEi
-> stress incontinence
Which drugs are used in the treatment of overactive bladder (UUI)?
(drugs are 2nd line)
-antimuscarinics
-beta-3 agonists
-oxybutynin patch or gel
use extended-release if possible (lower anticholinergic ADE: dry mouth, dry eyes, constipation…)
Which receptor is responsible for bladder contractility and is a drug target for antimuscarinics in the treatment of overactive bladder?
M3 receptors
but also located in salivary glands, lower bowl, ciliary smooth muscle
The blockage of which muscarinic receptors will cause CNS side effects?
M1 receptor
Antimuscarinics may not M-receptor specific
-> ADE: dry mouth, dizziness, constipation, blurred vision, urinary retention
When are antimuscarinics contraindicated?
patients with:
-hypersensitivity
-urinary retention
-narrow-angle glaucome
Name the antimuscarinics
Oxybutynin (Ditropan, Oxytrol, Gelnique)
Tolterodine (Detrol)
Darifenacin (Enablex)
Solifenacin (Vesicare)
Fesoterodine (Toviaz)
Trospium chloride (Sanctura)
!know Brand names!
Where does oxybutinin act in UI treatment?
decreases the contraction of the smooth muscle in the bladder
decreases urgency and frequency
but increases urinary retention (more storage, may be a disadvantage in BPH)
Special population to be cautios
-elderly due to side effects (note this is also the population that suffers from urinary incontinence)
-renal and hepatic impairments - may need dose adjustments
How should antimuscarinics be titrated
slowly
IR: every 1-2 months
ER: Weekly
Which formulation is associated with fewer side antimuscarinic side effects?
ER formulation
How does Tropium chloride different from other antimuscarinics?
-doesnt penetrate the BBB as easy
-no CYP metabolism -> less side effects
MOA of beta-3 agonists
REMEMBER: alpha-blocker cause contraction of detrusor muscle
beta-3 agonist increases sympathetic action and causes detrusor relaxation -> increased bladder storage
What are the used beta-3 agonists
-begrons
Mirabegron ER (Myrbetriq)
ADE: HTN, headache, urinary retention, UTI, nasopharyngitis
-> CYP2D6 inhibitor
Vibegron (Gemtesa)
diarrhea, nausea, headache, urinary retention, UTI, nasopharyngitis
What is the first line treatment for stress-induced incontinence?
Pelvic Floor muscle training PFMT (Kegel excercises) for at least 3 months
2nd line treatment for SUI
Duloxetine (off-label)
topical/intravaginal estrogen
alpha agonist
surgery
How does Duloxetine work in incontinence therapy?
increases sphincter muscle tone
-> redused frequency of episodes of incontinence
-ADE: nausea, some increase in BP
How does estrogen work in incontinence therapy?
manage post-menopausal and estrogen withdrawal symptoms
-> Strength of the urethra decreases with menopause
topical creams, vaginal ring, vaginal inserts works best (oral estrogen may make it worse)
How long should vaginal topicals be used?
topical: Vagifem
daily for 2 weeks
then once weekly
should only be used in patients with menopausal-induced continence
How do Alpha agonists work in UR treatment?
increases urethral closure pressure
-moderate efficacy and many ADE
ADE: HTN, headache, dry mouth, nausea, insomnia, restlessness
What type of incontinence is involved in patients taking zolpidem or benzos and having incontinence only at night?
Functional incontinence
it seems like the sedative-hypnotics prevents them from waking when they need to urinate
-> consider D/C the hypnotic and change the drug
A 50 yo female patient experiences urine leakage when coughing, what is the recommended treatment?
- Pelvic Floor muscle training PFMT, if it fails ->
- evalutae for menopause -> estrogen topical
- Duloxetine (SNRI)
alpha-agonist: moderate efficacy - last line
A 48 yo female experiences urinating at night and daytime, losing large amounts of urine before reaching the toilet
Urgent urinary incontinence -> overactive bladder (too much contraction of detrusor muscle)
treatment:
antimuscarinics or beta-3 agonists
What are concerns when using antimuscarinics and how to mitigate them?
age (elderly)
-dry mouth, constipation, dizzines, urinary retention
-use topical oxybutynin to mitigate the side effects
What are concerns when using beta-3 agonists and how to mitigate them?
-begrons; Mirabegron, Vibegron
HTN, urinary retention, UTI, nasopharyngitis
