Lecture 1 - Urinary Incontinence & BPH Flashcards by Patryk Lasiuk

Who is urinary incontinence more common in?

Women, due to having babies

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Reversible causes & Management of incontinence…DRIIPP

Delirium
Restricted mobility, injury, restraint
Infection
Stool Impaction
Polyuria
Pharmaceuticals

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Urge Urinary Incontinence (UUI)

involuntary voiding preceded by brief warning

Causes: Detrusor muscle instability, involuntary contraction

Overactive bladder = w/ or w/o urge incontinence

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UUI Treatment

Nonpharm = 1st (Lifestyle/ Surgery)

Pharm = 4-6 week response, switch if no response

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Non-pharm Treatment UUI

Diet = monitor fluid, caffeine, bladder irritants (artificial sweetener, spicy food)

Exercise and weight loss
Smoking cessation
Scheduling regimens
Muscle Rehab
Surgery

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UUI Treatment, Anticholingeric side effects

Dry mouth
visual disturbances
Constipation
Dry skin

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UUI Treatment, Anticholinergic precautions

Arrythmias
CVD
GI issues
Dementia
elderly

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UUI Treatment, Anticholinergic precautions CI

GI obstruction
closed & narrow angle glaucoma

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Toxidrome Poem for Anticholinergic

Blind as a bat
Mad as a hatter
Red as a beet
Hot as a hare
Dry as a bone
The bowel and bladder lose their tone
and the heart runs alone

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Solifenacin Info

M3 selectivity > M2

non-inferior to oxybutynin, superior to tolterodine

SE: less than oxybutynin/tolterodine, more than darifenacin

Dose: 5mg/day max, renal impairment < 30, mod/severe hepatic impairment

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Darifenacin info

truly selective M3

non inferior oxybutynin,superior tolterodine

SE: less than oxybutynin

Dose: no renal dose adjust, if moderate hepatic impairment then max 7.5mg/day

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UUI Treatment efficacy

Doesn’t decrease events by much
most agents used 4-8 weeks to see effect
continuation rats drop drastically over time

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Mirabegron (Myrbetriq) drug class

B3 agonist

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Mirabegron (Myrbetriq) Drug interactions

moderate CYP2D6
substate of 2D6, 3A4, p-gp

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Mirabegron (Myrbetriq) Dosing

50mg/day

25mg/day if eGFR 15-30

Not studied < 15

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Mirabegron (Myrbetriq) SE/CI

HTN (avoid if severe, uncontrolled > 180/110)
Nasopharyngitis
UTI
Constipation
Tachycardia
Headache

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Mirabegron (Myrbetriq) efficacy

Full effect in 4-8 weeks

Good in combo w/ solifenacin but more SE

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Vibegron (Gemetsa) drug class

B3-agonist

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Vibegron (Gemetsa) info

not recommended eGFR < 15
no CYP2D6 interactions, or BBB pen**

Vibegron (Gemetsa) SE

Headache
Nasopharyngitis
Diarrhea
Nausea

Drug w/ highest efficacy for UUI

Botox, 1.6-1.9 episodes per day

injected into 20 sites via urethra every 6-12 weeks

Stress Urinary Incontinence (SUI) causes

weak pelvic floor muscles
Sphincter incompetence
Trauma/damage to urethra
Women»>Men

Stress Urinary Incontinence triggers

coughing
sneezing
laughing
exercising
weight lifting

Pelvic Floor muscle training

helpful for prevention of postpartum SUI

most effective = 3X10 sets, hold 10 sec

FDA approved drugs for SUI?

None in USA, off-label duloxetine due to suicidal risk...can be used if person is also depressed n used for that too

Overflow Urinary Incontinence Treatment

surgery self-catheterization some drugs

Functional barrier incontinence

person unable or unwilling to reach the toilet

Functional barrier treatments

move barriers PT assistive deices scheduled or prompted toileting

how to treat Mixed UI

initial therapy depends on predominate symptoms

counseling tips for incontinence

reduce fluid intake during day avoid caffeinated Bev minimize artificial sweeteners, acidic and spicy foods

Moderate to severe BPH TXM options

Behavioral/lifestyle modifications Med therapy Procedural options

a-adrenergic antagonists mOA

prostate smooth muscle tone mediated via a1-receptor inc tone leads to reduction in flow rate/inc LUTS Blockage of receptor leads to improvement of flow rate/LUTS

Which a-antagonists are more uroselective?

3rd gen.... Tamsulosin = Flomax Alfuzosin = Uroxatral Silodosin = Rapaflo

a-antagonist info

reduce symptoms 5-9pts in IPSS scores, within about a week Dont affect prostate size Once daily dosing (except prazosin) Go to agents

A-antagonist SE

Vasodilatory Ejaculatory dysfunction HA, Dizziness, asthenia, respiratory/nasal congestion

A-antagonist DI

caution in combo w/ PDE5inhib

Main goal of 5a-reductase inhib

shrink prostate also shown to dec BPH progression

5a-reductase inhib important info

a-blockers work quicker and better on symptoms 5a-reductase take weeks/months to work

5a-reductase inhib SE

Preg category X Gynecomastia, dementia, depression links Sexual side effects PFS = side effects after stopping finasteride

Combo therapy used for....

pts with enlarged prostate use a-blocker with 5a-reductase combo better than solo drugs, but comes with more SE

Combo therapy cut offs

LUTS symptoms + PSA > 1.5ng Prostate size > 30cc, 40g on imaging, palpable on DRE

Mod/Severe LUTS, Prostate < 40 or PSA < 1.4 use...

a-blockers

Mod/Severe LUTS, Prostate > 40 or PSA 1.4

5a antagonist or 5a reductase + a-blocker

Mod/Severe LUTS, ED

phosphodiesterase inhib or 5a reductase + a-blocker

Mod/Severe LUTS, predominante irritative voiding symptoms

add anticholinergic or B3 agonist to a-blocker or 5a-reductase