EXAM 2 Urinary Incontinence and Pregnancy Dr. Dowling

Question 1

What is the first-line treatment for urinary incontinence?

Answer 1

Nonpharmacolgic treatment

Question 2

Second-line treatment for urge incontinence

Answer 2

Antimsucarinics

beta-3 agonists

Question 3

Second-line treatment for stress incontinence

Answer 3

-Duloxetine (SSRI)
-topical estrogen
-alpha agonists

Question 4

Types of Urinary Incontinence

Answer 4

-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

Question 5

Which muscle of the bladder is involved in urge urinary incontinence

Answer 5

detrusor smooth muscle

Question 6

Which structure of the urinary system is involved in stress urinary incontinence (SUI)?

Answer 6

Urethra

the structure that keeps urine in place before voiding is weakened -> loss of urine due to abdominal pressure (sneezing, coughing, laughing)

Question 7

Which type of urinary incontinence is a consequence of BPH?

Answer 7

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

Question 8

Do we see Overflow Inncontinece in man or women?

Answer 8

In men: due to enlarged prostate -> causing incomplete emptying

maybe seen in women: physiologic effect or medical side effects

Question 9

How do the muscles of the bladder and the urethra behave before voiding?

Answer 9

Bladder: relaxed

Urethra: contracted and closed

Question 10

How do the muscles of the bladder and the urethra behave in urgency incontinence?

Answer 10

Bladder contracts , inappropriate signals (may be too early)

the urethra is still closed -> but the contraction pushes the urine out

Question 11

How do the muscles of the bladder and the urethra behave in stress continence?

Answer 11

Bladder: relaxed

the urethra is not restricted as is should be –> leakage (drops) of urine

Question 12

What might contribute to a weakening of the urethra?

Answer 12

in women: childbirth, trauma over time

in men: prostate surgery

Question 13

How do alpha-receptor agonists cause urine incontinence?

Answer 13

Urethral contraction

-> urinary retention (more common in men)
-> overflow incontinence

Question 14

How do alpha-receptor antagonists cause urine incontinence?

Answer 14

Urethral relaxation -> stress incontinence

Question 15

In which disease state are alpha-antagonists beneficial?

Answer 15

BPH

-alpha-blocker (Tamsulosin)
-5-alpha reductase inhibitor (finasteride)
-PDE-4 inhibitor (Tadalafil)

Question 16

Which drugs cause reduced bladder contractility resulting in urinary retention?

Answer 16

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

Question 17

Which drug may cause Urethral relaxation and reduced bladder contractility at the same time?

Answer 17

TCA

alpha antagonist effect: urethral relaxation (stress incontinence)
anticholinergic effect: reduced bladder contractility

Question 18

Which drugs cause Polyuria resulting in urgency and frequency?

Answer 18

-diuretics
-alcohol

-acetylcholinesterase inhibitors
-> (bind to muscarinic receptors -> inducing contraction of detrusor muscles, also activating parasympathetic nervous system by inhibiting ACh esterase (more ACh)

Question 19

How do sedative hypnotics affect urinary incontinence?

Answer 19

Delirium
immobility -> may cause functional incontinence

caution with the use of: benzos, zolpidem (ambien), lunesta

Question 20

How does an ACEi cause urinary incontinence?

Answer 20

Cough as a side effect of ACEi
-> stress incontinence

Question 21

Which drugs are used in the treatment of overactive bladder (UUI)?

Answer 21

(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…)

Question 22

Which receptor is responsible for bladder contractility and is a drug target for antimuscarinics in the treatment of overactive bladder?

Answer 22

M3 receptors

but also located in salivary glands, lower bowl, ciliary smooth muscle

Question 23

The blockage of which muscarinic receptors will cause CNS side effects?

Answer 23

M1 receptor

Antimuscarinics may not M-receptor specific

-> ADE: dry mouth, dizziness, constipation, blurred vision, urinary retention

Question 24

When are antimuscarinics contraindicated?

Answer 24

patients with:
-hypersensitivity
-urinary retention
-narrow-angle glaucome

Question 25

Name the antimuscarinics

Answer 25

Oxybutynin (Ditropan, Oxytrol, Gelnique) Tolterodine (Detrol) Darifenacin (Enablex) Solifenacin (Vesicare) Fesoterodine (Toviaz) Trospium chloride (Sanctura) !know Brand names!

Question 26

Where does oxybutinin act in UI treatment?

Answer 26

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)

Question 27

Special population to be cautios

Answer 27

-elderly due to side effects (note this is also the population that suffers from urinary incontinence) -renal and hepatic impairments - may need dose adjustments

Question 28

How should antimuscarinics be titrated

Answer 28

slowly IR: every 1-2 months ER: Weekly

Question 29

Which formulation is associated with fewer side antimuscarinic side effects?

Answer 29

ER formulation

Question 30

How does Tropium chloride different from other antimuscarinics?

Answer 30

-doesnt penetrate the BBB as easy -no CYP metabolism -> less side effects

Question 31

MOA of beta-3 agonists

Answer 31

REMEMBER: alpha-blocker cause contraction of detrusor muscle beta-3 agonist increases sympathetic action and causes detrusor relaxation -> increased bladder storage

Question 32

What are the used beta-3 agonists

Answer 32

-begrons Mirabegron ER (Myrbetriq) ADE: HTN, headache, urinary retention, UTI, nasopharyngitis -> CYP2D6 inhibitor Vibegron (Gemtesa) diarrhea, nausea, headache, urinary retention, UTI, nasopharyngitis

Question 33

What is the first line treatment for stress-induced incontinence?

Answer 33

Pelvic Floor muscle training PFMT (Kegel excercises) for at least 3 months

Question 34

2nd line treatment for SUI

Answer 34

Duloxetine (off-label) topical/intravaginal estrogen alpha agonist surgery

Question 35

How does Duloxetine work in incontinence therapy?

Answer 35

increases sphincter muscle tone -> redused frequency of episodes of incontinence -ADE: nausea, some increase in BP

Question 36

How does estrogen work in incontinence therapy?

Answer 36

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)

Question 37

How long should vaginal topicals be used?

Answer 37

topical: Vagifem daily for 2 weeks then once weekly should only be used in patients with menopausal-induced continence

Question 38

How do Alpha agonists work in UR treatment?

Answer 38

increases urethral closure pressure -moderate efficacy and many ADE ADE: HTN, headache, dry mouth, nausea, insomnia, restlessness

Question 39

What type of incontinence is involved in patients taking zolpidem or benzos and having incontinence only at night?

Answer 39

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

Question 40

A 50 yo female patient experiences urine leakage when coughing, what is the recommended treatment?

Answer 40

1. Pelvic Floor muscle training PFMT, if it fails -> 2. evalutae for menopause -> estrogen topical 3. Duloxetine (SNRI) alpha-agonist: moderate efficacy - last line

Question 41

A 48 yo female experiences urinating at night and daytime, losing large amounts of urine before reaching the toilet

Answer 41

Urgent urinary incontinence -> overactive bladder (too much contraction of detrusor muscle) treatment: antimuscarinics or beta-3 agonists

Question 42

What are concerns when using antimuscarinics and how to mitigate them?

Answer 42

age (elderly) -dry mouth, constipation, dizzines, urinary retention -use topical oxybutynin to mitigate the side effects

Question 43

What are concerns when using beta-3 agonists and how to mitigate them?

Answer 43

-begrons; Mirabegron, Vibegron HTN, urinary retention, UTI, nasopharyngitis