incontinence Flashcards

1
Q

urge incontinence

A

-usually a result of detrusor instability, detrusor hyperactivity with impaired bladder contractility, or involuntary sphincter relaxation
-MUSCLE

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2
Q

stress incontinence

A

resulting from urethral sphincter failure - due to either anatomic changes or intrinsic sphincter deficiency (ISD)
-SPHINCTER

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3
Q

overflow incontinence

A

results from hypotonic or underactive detrusor secondary to drugs, fecal impaction, diabetes, lower spinal cord injury, disruption of the motor innervation of the detrusor muscle, urethral obstruction, or genital prolapse

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4
Q

mixed incontinence

A

refers to a combination of urge and stress incontinence, especially common in older women

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5
Q

treatment of urinary incontinence

A

-Pharmacological
-Behavioral- Weight loss, dietary changes, smoking cessation!, exercise (kegel)
-Surgical
-In general, the first choice should be the least invasive treatment with the fewest potential adverse complications for the patient.
-Before treatment, a complete evaluation (including a review of medication profile) and appropriate urodynamic testing should be completed

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6
Q

medication and effect chart

A
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7
Q

symptoms chart

A
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8
Q

muscarinic receptors- role in tx of incontinence

A

target M3 mostly

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9
Q

SNRI: duloxetine

A

-MOA – serotonin-norepinephrine reuptake inhibitor
-Use: Stress incontinence
-Not used often due to side effects, though there is a 50% improvement of symptoms
-can cause a slight increase in BP -> monitor in a HTN pt

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10
Q

alpha adrenergic agonists: phenylpropanolamine

A

-MOA: stimulates the urethal smooth muscle contraction
-Uses: Stress incontinence
-Not used routinely because only mildly efficacious

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11
Q

anticholinergics- propantheline

A

-Original prototype for anticholinergic agents used for urologic conditions.
-MOA – Muscarinic blocker - inhibits involuntary detrusor muscle contractions. Not as selective as other agents for incontinence so not used clinically
-Precautions – narrow angle glaucoma, elderly
-ADRs - urinary retention, blurred vision, dry mouth, nausea, constipation, tachycardia, drowsiness, and confusion
-not commonly used for elderly bc SE is consistent with elderly syndromes (glaucoma, constipation, etc.) -> beers list
-not used as much bc of SE

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12
Q

anticholinergics: muscarinic receptor antagonists- oxybutynin

A

-MOA - inhibit involuntary detrusor muscle contractions, delays desire to void,  urgency & frequency, direct antispasmodic effect on smooth muscle. (M3 > M1)
-Precautions – narrow angle glaucoma, elderly
-Active metabolite - N-desethyloxybutynin
-ADRs - dry mouth, dry skin, blurred vision, sedation, change in mental status, nausea, constipation. (Severity of ADRs increases with dosage)
-DDI – CYP3A4 substrate & inhibitor- many

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13
Q

oxytrol and gelnique

A

-Both applied topically for systemic effects
-Both bypass first-pass effect so less anticholinergic side effects
-Significantly less dry mouth
-Both – much more costly
-Oxytrol – patch. Apply twice weekly
-Gelnique – Gel. Apply daily

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14
Q

anticholinergics: tolterodine

A

-fesoterodine -new ER agent. Has same active metabolite as tolterodine. MAY be more effective in higher doses, but will also have more ADRs
-MOA –M3/M1 blocker. Has greater affinity for muscarinic receptors in bladder than saliva
-Precautions – narrow angle glaucoma, elderly
-ADRs - urinary retention, blurred vision, dry mouth, nausea, constipation, headache, drowsiness, and confusion
-DDI – CYP2D6 & CYP3A4 substrate

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15
Q

anticholinergics: darifenacin and solifenacin

A

-Darifenacin (Enablex); Selective M3 blocker
-Solifenacin (Vesicare): M3 > M1
-Same precautions as other anticholinerigics
-ADRs - same as others, but less severe. Less CNS effects b/c does not cross blood brain barrier (esp. solifenacin)
-less drowsey, less sx, not perfect
-DDIs - CYP450 substrate
-best agents right now

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16
Q

anticholinergics: tropsium Cl

A

-MOA – M3/M1 receptor blocker (similar to tolterodine)
-ADRs - same as others, less CNS side effects
-Renally excreted - NO CYP450 drug interactions!!!! -> this is the indication
-give to pt on multiple meds

17
Q

beta 3 agonist: mirabegron

A

-New drug class to treat incontinence
-Second-line after anticholinergics.
-MOA – Beta 3 agonist. Relaxes smooth muscle in the bladder and increases its storage capacity
-more volume each time they go
-ADR – HTN, tachycardia, headache, constipation, diarrhea
-DDI – CYP2D6 inhibitor
-No data yet to combine with anticholinergics
-Very expensive compared to currently available treatment options

18
Q

tricyclic antidepressants

A

-Useful b/c have anticholinergic properties
-NOT FDA-approved for incontinence
-Agents include:
-Imipramine (Tofranil)
-Amitriptyline (Elavil)
-Doxepin (Sinequan)

-More commonly used to treat nocturnal enuresis

19
Q

calcium channel blockers

A

-May be useful b/c calcium is involved in urinary muscle contractions
-Not FDA-approved, not many clinical studies
-Nifedipine (Procardia) – CCB most often used for Urinary Incontinence
-less spasms

20
Q

estrogen therapy

A

-Estrogen (oral or vaginal) may be considered as an adjunctive pharmacologic agent for postmenopausal women with stress incontinence or mixed incontinence.
-Conflicting data - some trials suggest hormone therapy may contribute to incontinence
-Conjugated estrogens and medroxyprogesterone may be used
-used for pts with atrophic vaginitis

21
Q

alpha 1 antagonists

A

-Used to treat overflow incontinence b/c will decrease sphincter tone
-Use “azosin” drugs
-BPH man gets newer azosins
-women would get an older azosin

22
Q

nocturnal enuresis- pediatrics

A

-Desmopressin (DDAVP) – nasal spray, PO
-PO may cause less hyponatremia
-Usually tried for 6 months

-MOA – Enhances reabsorption of water in kidneys by increasing cellular permeability of the collecting ducts
-Usually tried for up to 6 months

23
Q

antimuscarinic / beta 3 adrenergic agonist chart

A
24
Q

JL, a 78 year old female with a PMH of HTN, CHF and Alzheimer’s disease is diagnosed with urge incontinence. Her current medications include:
Enalapril 10 mg po bid
Carvedilol 12.5 mg po bid
HCTZ 25 mg po daily
Donepezil 10 mg po qhs (increased from 5 mg six weeks ago) -> this is for alzheimers

A

-diuretic and donepezil is contributing to incontinence
-d/c the HCTZ
-give an anticholinergic
-tropsium bc no SE