Lecture 1 - Urinary Incontinence & BPH Flashcards
Who is urinary incontinence more common in?
Women, due to having babies
Reversible causes & Management of incontinence…DRIIPP
Delirium
Restricted mobility, injury, restraint
Infection
Stool Impaction
Polyuria
Pharmaceuticals
Urge Urinary Incontinence (UUI)
involuntary voiding preceded by brief warning
Causes: Detrusor muscle instability, involuntary contraction
Overactive bladder = w/ or w/o urge incontinence
UUI Treatment
Nonpharm = 1st (Lifestyle/ Surgery)
Pharm = 4-6 week response, switch if no response
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
UUI Treatment, Anticholingeric side effects
Dry mouth
visual disturbances
Constipation
Dry skin
UUI Treatment, Anticholinergic precautions
Arrythmias
CVD
GI issues
Dementia
elderly
UUI Treatment, Anticholinergic precautions CI
GI obstruction
closed & narrow angle glaucoma
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
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
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
UUI Treatment efficacy
Doesn’t decrease events by much
most agents used 4-8 weeks to see effect
continuation rats drop drastically over time
Mirabegron (Myrbetriq) drug class
B3 agonist
Mirabegron (Myrbetriq) Drug interactions
moderate CYP2D6
substate of 2D6, 3A4, p-gp
Mirabegron (Myrbetriq) Dosing
50mg/day
25mg/day if eGFR 15-30
Not studied < 15
Mirabegron (Myrbetriq) SE/CI
HTN (avoid if severe, uncontrolled > 180/110)
Nasopharyngitis
UTI
Constipation
Tachycardia
Headache
Mirabegron (Myrbetriq) efficacy
Full effect in 4-8 weeks
Good in combo w/ solifenacin but more SE
Vibegron (Gemetsa) drug class
B3-agonist
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
