NG123 medical treatment options for LUTs

Question 1

What medical treatments are available for the treatment of:

a) stress incontinence
b) overactive bladder
c) nocturia

Answer 1

Duloxetine

Anti-cholinergics, mirabegron, vaginal oestrogen (if there is associated vaginal atrophy)

Desmopressin

Question 2

Describe the parasympathetic neural control of bladder filling and voiding

Answer 2

Sacral nerves 2-4
Muscarinic receptors M3 in detrusor muscle
Nitric oxide receptors in smooth muscle of urethra
Contract detrusor during voiding
Relax smooth muscle of urethra during voiding

Question 3

Describe the sympathetic neural control of bladder filling and voiding

Answer 3

T10-L2 Via iliohypogastric and pelvic nerve supply
Alpha-adrenergic receptors in the bladder and the smooth muscle of the urethra
Inhibit parasympathetic activity in detrusor muscle during filling
Contract smooth muscle of urethra during filling

Question 4

How do anti-muscarinics work for treating overactive bladder?

Answer 4

Anti-muscarinics are a group of anti-cholinergic medications which blood muscarinic receptors preventing acetylcholine from binding to the receptor

In overactive bladder, blockade of M3 receptors inhibits parasympathetic activity of the detrusor muscle

Question 5

In which patients are anti-muscarinics contraindicated?

Answer 5

Neurological: Myasthenia gravis
GI: Severe ulcerative colitis, toxic megacolon, paralytic ileus, pyloric stenosis
Bladder: significant outflow obstruction, urinary retention
Elderly: oxybutnin should not be prescribed in patients with risk of sudden deterioration of physical and mental health

Question 6

What are the most common side effects of all anti-muscarinics used for OAB?

Answer 6

Dry mouth, Constipation, Blurred vision , Somnolence, Dizziness 
Nausea, vomiting, dyspepsia 
Urinary retention 
Headache 
Skin flushing 
Palpitations and tachycardia

Question 7

Who should anti-muscarinics be used with caution in?

Answer 7

Cardiac (congestive heart failure, coronary artery disease, arrythmias/tachycardia, hypertension)
Elderly (>65 year olds risk of worsening dementia, particularly avoid oxybutinin)
GI (ulcerative colitis, GORD)
Neuro: autonomic neuropathy
Eyes: acute angle closure glaucoma
Thyroid: hyperthyroidism

Question 8

Which drugs should NOT be used to treat OAB?

Answer 8

Flavoxate and propantheline (anti-muscarinics)

Imipramine (Tricyclic antidepressant)

Question 9

Which drugs can be used to treat OAB according to NICE guidance?

Answer 9

Oxybutinin (but not in older women) - comes in immediate, prolonged and transdermal and topical gel
Darifenacin – prolonged release tablets only
Fesoteridine – prolonged release tablets only
Solfenacin – immeadiate release tablets
Propiverine hydrochloride – immediate and modified release tablets
Tolteradine – immediate and prolonged release tablets
Tropsium hydrochloride – immediate and prolonged release tablets

Question 10

What is the mechanism of action for mirabegron?

Answer 10

Mirabegron is a selective agonist of the B3 receptor

Question 11

What is the indication for using mirabegron?

Answer 11

In patients who anti-muscarinic drugs are contraindicated, ineffective or have unacceptable side effects

Question 12

What are the main side effects and contraindications to mirabegron?

Answer 12

Contraindication = severe hypertension
Women with hypertension need their BP monitored on mirabegron
Can cause: arrythmias, hypertension, constipation, nausea, diarrhoea, dizziness, headache

Question 13

What kind of drug is duloxetine?

Answer 13

Serotonin and selective noradenaline reuptake inhibitor – an antidepressant and the only licenced drug for stress incontinence

Question 14

What are the contraindications and cautions for duloxetine?

Answer 14

Contraindicated in under 18s, hepatic impairment, severe renal impairment, uncontrolled hypertension
Caution in hypertension, bleeding disorders, uncontrolled seizures, mania or bipolar, cardiac disease, susceptibility to hyponatraemia, angle-closure glaucoma, elderly women
Has to be withdrawn slowly like other anti-depressants

Question 15

What is the indication for using duloxetine for incontinence

Answer 15

Duloxetine is not a first or second line treatment for stress incontinence. It should only be considered if patients do not want surgery or surgery is contraindicated

Question 16

What is the mechanism of action for desmopressin?

Answer 16

Acts on V2 receptors on the renal collecting duct – works as an anti-diuretic

Question 17

In which patients can desmopressin be considered?

Answer 17

Patients with overactive bladder and incontinence who have bothersome nocturia

Question 18

What are the contraindications and cautions with desmopressin and how should it be monitored?

Answer 18

Desmopressin can lead to hyponatraemia and fluid retention and therefore sodium levels should be monitored 3 days after commencing treatment – stop if hyponatraemia is present, also BP and weight should be monitored
Avoid in patients over 65 with cardiac disease or hypertension
Avoid in patients with history of hyponatraemia
Use with caution in patients with cystic fibrosis

Question 19

How should intravaginal oestrogen be prescribed and monitored for women with vaginal atrophy?

Answer 19

Treatment for OAB in postmenopausal women with vaginal atrophy
Daily for max 4 weeks, then twice weekly
Monitor for symptoms of endometrial hyperplasia and cancer at least annually

Question 20

Who is intravaginal oestrogen contraindicated in?

Answer 20

Cancer: active/previous/suspected breast ca, active/suspected endometrial ca
Hyperplasia: untreated
Liver disease: active, or previous with persistently abnormal LFTs
Thromboembolic risk: previous or active VTE, active or recent MI or angina, thrombophilic disorder