Geriatrics Part II Flashcards
Urinary Incontinence
involuntary leakage of urine
overactive bladder (most common type of urinary incontinence)
Patients with UI may experience
loss of independence: loss of physical, social activity, social isolation
lack of self-esteem: depression, anxiety
additional medical complications
Frequency of UI types in women
urge (63%)
stress (21%)
Frequency of UI types in men
urge (59%)
overflow (29%)
Normal bladder function
- stretch receptors notify brain that bladder is full and needs to empty - beta3 receptors support detrusor relaxation/filling
- neurologic stimulation initiates contraction - Ach receptors in the dome, alpha-adrenergic receptors in the base and proximal urethra (modulate sphincter muscles around the outlet)
- sphincter relaxes allowing release of urine
beta vs cholinergic receptors
beta receptors - relaxation
cholinergic receptors - focus on squeezing
Age-related changes to the bladder and urethra
decrease bladder capacity/elasticity
increase spontaneous detrusor contractions
decrease sphincter compliance
may result in: incomplete bladder emptying and decrease ability to postpone urination
Types of Incontinence
overflow
stress
urge
Overflow
urethral blockage
bladder unable to empty properly (inappropriate sphincter relaxation)
Stress
relaxed pelvic floor
increased abdominal pressure
Urge
bladder oversensitivity from infection
neurologic disorders
Urge urinary incontinence
aka: overactive bladder
hyperactivity of detrusor muscle causes sudden & poorly predictable voiding
may cause large or small volume accidents
symptoms include: urgency (unpredictable or unable to control), frequency (excessive feelings of urination)
causes can be neurologic or medications (acetylcholinesterase inhibitors for Alzheimer’s disease)
Prescribing cascade
need for more meds in order to treat the side effects experienced from another med
Stress urinary incontinence
outlet incompetence (external urethral sphincter) with abdominal pressure
women > men ( due to estrogen deficiency/lifetime experience of childbirth)
most often small volume of accidents
risk factors include: multiple births, estrogen deficiency
can be exacerbated or caused by alpha-antagonists
Stress urinary incontinence symptoms classically associated with
laughter
alcohol
caffeine
cough
Overflow incontinence
results from outlet obstruction or inability to or uncoordinated detrusor constriction
most commonly from BPH or prostatic blockage of urethra
Overflow incontinence symptoms
abdominal discomfort or pain
frequency
feeling the need to void shortly after voiding
Neurogenic bladder
disruption in neurologic innervation of the bladder
inability or uncoordinated detrusor constriction
may also be atony of bladder muscle - stroke, neuropathy (including sever uncontrolled diabetes), spinal cord injury
Neurogenic bladder symptoms
small urine volume during voiding, small volume accidents
loss of feeling that bladder is full
dribbling of urine
frequency, urgency
increases risks of UTI
increases risks of kidney stones
Functional incontinence
inability to get to the bathroom in a timely fashion
causes: physical impairment (mobility), change in mental status (dementia), UTI, medications (sedating)
Medication causes for incontinence
frequency: diuretics, alpha antagonists
urgency: acetylcholinesterase inhibitors
overflow: alpha antagonists, antihistamines
UI treatments: non-pharmacological
should be provided for all types of urinary incontinence
1. scheduled/timed voiding
2. pelvic floor muscle strengthening (Kegel): 30-60x/day
3. avoiding irritants: coffee, alcohol, caffeine, avoid water before bed
4. absorbent products (pads, shields, adult diapers)
5. catheters
UI pharmacologic treatment for overflow
alpha-antagonists
injections or surgery
UI pharmacologic treatment for stress
estrogen
alpha-agonists
SNRI
injections or surgery
UI pharmacologic treatment for urge
anticholinergic/antimuscarinic
beta3 agonist
injections or surgery
UI pharmacologic treatment for neurogenic
injections or surgery
Goal of pharmacologic treatment for urge UI
reduce detrusor contraction frequency
Anticholinergic/antimuscarinic medications
oxybutynin
tolterodine
solifenacin
darifenacin
trospium
fesoterodine
Anticholinergic/antimuscarinic adverse events
dry mouth
constipation
fatigue
confusion
tachycardia
B3 agonist medications
mirabegron
vibegron
B3 agonist adverse events
mirabegron: minor increase in BP, UTI
vibegron: minor, UTI
Max benefit of these meds (for urge UI)
takes at least 4 weeks to achieve
taper down over course of 2-4 weeks when stopping med
Stress UI management
- non-pharmacologic management –> kegel
- duloxetine 40 mg BID, increased sphincter tone to prevent leaks
- topical estrogen (vaginal atrophy) - estrogen vaginal cream, intravaginal cream inserted via applicator, 21 days on, 7 days off
- alpha-agonists
- vaginal pessaries or surgery
Overflow UI management
- address the obstruction
- alpha-adrenergic blockers (if BPH) - doxazosin, tamsulosin (less hypotension)
- catheterization
Neurogenic UI management
no pharmacologic managment routinely effective - focused on non-pharmacologic management
intermittent catherterization
botulism A toxin (botox) injections (bladder or urinary sphincter)
surgery - augmentation cystoplasty, bladder walls and intestinal walls connected to improve storage capacity
Catheters
intermittent straight
indwelling
condom
suprapubic
Monitoring
review efficacy after 4-8 weeks
monitor consistently for adverse events
Pharmacists role in UI
assess for contributing factors
educate and support non-pharmacologic management
modify dosage forms as needed
redognize treatment-related ADR
prevent complications, support QOL
support deprescribing when appropriate
