Geriatrics: Urinary Incontinence

Question 1

Desmopressin (Noctiva)

Answer 1

ADH analog
Indication: nocturnal polyuria
Monitor: Na+ levels
CI: hyponatremia concomitant use of diuretics or inhaled corticosteroids, eGFR < 50, HF, uncontrolled HTN
Dosing:
- 50 to 65: 1 spray 1.66 mcg
- >65: 1 spray 0.83 mcg

Question 2

B3 adrenergic receptor action

Answer 2

relaxation of detrusor muscle

Question 3

M3 receptor action

Answer 3

Contraction of detrusor muscle

Question 4

Urge incontinence (Over Active Bladder)

Answer 4

involuntary leakage of urine
involuntary contraction of bladder

Question 5

Urge incontinence 1st line treatment

Answer 5

Behavioral therapies:
- bladder training
- bladder control strategies
- pelvic floor muscle training
- fluid management

Question 6

Urge incontinence 2nd line

Answer 6

• Oral antimuscarinics or B3 agonists
• ER > IR
• Combo anti-M and B3 agonist if not responding to monotherapy
• Narrow angle glaucoma patients: NO anti-M drugs

Question 7

Anti-muscarinic drugs

Answer 7

Darifenacin (Enablex)
Solifenacin (Vesicare)
Tolterodine
Trospium (Sanctura)
Fesoterodine
Oxybutynin

Question 8

M3 specific anti-muscarinics

Answer 8

Darifenacin (Enablex)
Solifenacin (Vesicare)

Question 9

Anti-muscarinic ADEs

Answer 9

dry mouth
dry eyes/blurred vision
urinary retention
palpitations
constipation
dizziness/drowsiness
confusion/delirium/dementia

Question 10

Preferred anti-muscarinics

Answer 10

Solifenacin
Darifenacin
ER tolterodine

Question 11

Other smooth muscle relaxants for OAB

Answer 11

Imipramine or other TCAs
- ADE: orthostasis, cardiac arrhythmia, anticholinergic effects

Botox
- ADE: transient urinary retention, UTI

Question 12

B3 adrenergic receptor agonists

Answer 12

Mirabegron ER (Myrbetriq)
Vibegron (Gemtesa)

Question 13

Mirabegron ER (Myrbetriq)

Answer 13

B3 receptor agonist -> detrusor muscle relaxation
t1/2 = 50 hrs
ADE:
- nausea, HA, HTN, diarrhea, constipation, dizziness, sinus tachycardia
Precaution: uncontrolled HTN (> 180/110)

Question 14

Vibegron (Gemtesa)

Answer 14

B3 receptor agonist -> detrusor muscle relaxation
t1/2 = 30.8 hrs
ADE:
- nausea, HA, diarrhea, constipation, nasopharyngitis, bronchitis, URI, UTI
No HTN warning

Question 15

Stress incontinence

Answer 15

Involuntary leakage with stress (sneezing, laughing, coughing)
- decreased pelvic wall musculature

Question 16

Stress incontinence: therapies to increase intra-urethral pressure

Answer 16

Pseudoephedrine
- ADE: insomnia, HTN, HA, tremor, palpitations

Midodrine
- peripheral a1 receptor antagonism

Question 17

Stress incontinence: estrogen replacement

Answer 17

causes proliferation of urethral mucosa -> improves mucosal outflow resistance
Vaginal application only in geriatric patients
ADE: abnormal pap/mammogram, bleeding, DVT

Question 18

Stress incontinence: Duloxetine

Answer 18

Not FDA approved
Suppresses bladder activity through 5HT receptor mechanisms and enhances external urethral sphincter activity via 5HT2 and a1 adrenergic mechanisms

Question 19

Overflow incontinence

Answer 19

Leak urine throughout the day
“weight” of urine
can be caused by:
- BPH
- Neuropathies
- Anticholinergics

Question 20

Overflow incontinence treatment

Answer 20

Bethanechol (Urecholine)
Stimulates M-receptors -> bladder tone
ADE:
- GI cramping / diarrhea / salivation
- orthostasis with reflex tachycardia
- urgency
- bronchial constriction