Urinary Incontinence

Question 1

Risk factors: Medications

Answer 1

• Estrogen blockers; alpha blockers; cholinesterase inhibitors
• Meds that can affecte the urinary tract functions
• Polyuria, frequency, urgency: diuretics, ETOH
• Urethral relaxation can be caused by alpha blockers causing worsening stress incontinence
• Urinary retention can be seen with anticholinergics, CCB, narcotics, and antipsychotics

Question 2

Urge Urinary Incontinence

Answer 2

Suggest detrusor overactivity PLUS impaired compensatory mechanisms

• Idiopathic, age-related, secondary to lesions in cerebral and spinal pathways
• Due to bladder outlet obstruction or bladder irritation (infection, stones, tumor)
• Occurs with urgency: sudden need to void; most common in both men and women

Question 3

UI and Stress UI

Answer 3

• Damage to the pelvic floor supports and sphincter failure
• Leakage associated with coughing, sneezing, laughing, and physical activity
• Second most common form in women
• Seen in men after prostectomy

Question 4

Mixed UI

Answer 4

Leakage occurs with both urgency and activity

• Seen in women
• Mixed is typically focused on treating the patients worst symptoms first-lifestyle modifications, and medical therapy; surgery to improve stress UI

Question 5

Meds associated w/ UI

Answer 5

• Alcohol
• Alpha adrenergic agonists
• ACEi
• Anticholinergics
• Alpha adrenergic blockers
• CCB
• Antipsychotics
• estrogen
• cholinesterase inhibitors
• Loop diuretics
• Narcotics and NSAIDS
• TCA
• Sedative hypnotics
• Gabapentin
• Thiazolidediones

Question 6

UI Red flags

Answer 6

• Abrupt onset
• Pelvic pain
• Hematuria

Question 7

Persistent types of UI

Answer 7

• Stress
• Urge
• Mixed (stress and urge)
• Overflow
• Functional

Question 8

Stress UI

Answer 8

• Loss of urine due to pressure on the bladder exceeding ability of sphincter to control
• Causes: relative incompetence of sphincter, weakness of supporting structures, malposition of bladder/urethra

Question 9

Stress UI Symptoms

Answer 9

Leakage of small amounts of urine with laughing, physical activity, sneezing, coughing

• Rarely occurs at night
• In men only after urethral manipulations (e.g prostate surgery)

Question 10

Tx for Stress UI

Answer 10

• Behavioral
• Pharm: alpha agonists such as pseudephedrine. Low dose tricyclics (imipramine), estrogens (postmenopausal)
• Surgical: Pessaries. Bladder neck suspension. Injections of collagen
• Products-padding

Question 11

Goal of tx for Stress UI

Answer 11

-Stimulate adrenergic receptors in the bladder neck smooth muscle, enhance micturition reflex

Question 12

Stress UI Meds: Duloxetine

Answer 12

• Inhibits serotonin and NE reuptake
• S/E: nausea, HA, insomnia, dry mouth
• Not FDA approved

Question 13

Stress UI Meds: Alpha Adrenergic agonists

Answer 13

• Enhance micturition reflect by activating alpha adrenergic receptors
• S/E: HTN, HA, dry mouth, nausea, insomnia
• DO not use in those with uncontrolled HTN, CAD, hyperthyroidism, renal failure, narrow angle glaucoma

Question 14

Stress UI Meds: Estrogen

Answer 14

• Increases urethral epithelium proliferation
• Topical use only
• limited side effects give topical
• typically use if vaginal atrophy is present

Question 15

Urge UI

Answer 15

• Involuntary loss of urine due to uncontrolled contraction of bladder with and without warning
• Causes: GU changes of aging
• –Irritative/neurologic condition,such as infections, diabetes mellitus, bladder stones, tumors, stroke or dementia, and increased intra-abdominal pressure changes

Question 16

S/S of Urge UI

Answer 16

• losses of variable (often large) amounts
• little or no warning time
• associated frequency
• occurs both day and night

Question 17

Urge Behavioral tx

Answer 17

• Bladder training
• Kegal exercises
• prompted voiding, schedule voiding
• biofeedback
• Electrical stimulation

Question 18

Urge UI Med: Antimuscarinic

Answer 18

-Oxybutynin (Ditropan or Oxytrol)
-Tolterodine (Detrol)
-Trospium (Sanctura)
-Solifenacin
-Darifencacin
-Fesoterodine
S/E include: dry mouth, constipation, dizziness, blurred vision, potential drug to drug interactions with other anticholinergics

Question 19

Avoid using antimuscarinics

Answer 19

• Advanced dementia
• Gastric or urinary retention
• Uncontrolled narrow glaucoma

Question 20

Urge UI meds: Mirabegron

Answer 20

• beta 3 adrenergic agonist
• goal is to decrease incontintent episodes
• adverse: htn, nasopharyngitis, UTIs and QTc prolongation. Higher cost

Question 21

Urge UI meds: Tricyclic antidepressants (alternative)

Answer 21

• TCAs are no more effective than oxybutynin IR
• Imipramine, doxepine, notriptyline
• Adverse: Orthostatic Hotn, cardiac conduction abnormalities, dizziness, confusion

Question 22

Urge UI Meds: Botulinium toxin A (alternative)

Answer 22

• for select patients who’ve failed first and second line therapies and/or those who have detrusor overactivity due to neuro conditions
• -Paralyzes the muscle by preventing the release of acth into the synapse. Effects last 4-8 months

Question 23

Overflow UI

Answer 23

Unpredictable involuntary losses of urine due to overdistention of the bladder

• Obstructive: prostate hypertrophy; urethral stenosis
• Neurogenic; spinal cord injury, neuropathy

Question 24

Tx of Overflow UI

Answer 24

• Surgical interventions
• neurogenic: cholinergic drugs e.g bethanechol (urecholine) rarely effective
• Intermittent catheters

Question 25

Functional UI

Answer 25

Inappropriate urination despite normally functioning bladder and sphincter
-Causes: cognitive or emotional, dementia, behavioral strokes, arthritis, restraints