Urinary Incontinence

Question 1

Urge incontinence

Answer 1

related to neuropathy, present in pts with Parkinsons, MS, stroke, and DM

Question 2

Stress incontinence

Answer 2

pee upon any form of exertion due to pressure on the bladder (laughing, sneezing, exercise, etc.)

treated with Pseudoephedrine (NE/E agonist, SE: increased HR, palpitations, HA, insomnia, nervousness/anxiety) or Duloxetine (if they also have depression)

Question 3

Mixed incontinence

Answer 3

mixture of urge and stress incontinence

Question 4

functional incontinence

Answer 4

normal bladder function but the patient has some sort of physical or mental disability preventing them from getting to toilet

Question 5

overflow incontinence

Answer 5

the amount of pee in the bladder is way too much but there is no urge to pee, until the bladder finally can’t take it anymore.

common cause of incontinence in BPH patients

Question 6

overactive bladder

Answer 6

the bladder begins contracting to pee before the bladder is even full.

Question 7

non drug treatment is first line

Answer 7

kegel exercises (pelvic floor muscles TID - flex and count to 8, then relax and count to 10 repeat. ten times)
bladder training (using a schedule along with what you drink)
delayed or scheduled voiding
fluid management
dietary changes to avoid bladder irritants
weight loss and lifestyle changes

Question 8

drugs are 2nd line. the classes that help are

Answer 8

• anticholinergics like oxybutinin (always first to start, if fails, increase dose or try others)
  avoid anticholinergics in those 65 and older bc of risk of cog. impairment and delirium
• beta 3 receptor agonists mirabegron (Myrbetriq)

or onabotulinumtoxin (botox) - most effective, but costly and invasive

• nerve intervention, surgical intervention, and indwelling catheters are the last resort

Question 9

selective anticholinergics like darifenacin or solifenacin have less cognitive SE

Answer 9

this because they are M3 (muscarinic receptor 3 specific)

Question 10

long acting anticholinergics (oxybutynin ER or transdermal Oxytrol) are used initially for drug tx

Answer 10

long acting forms have less anticholinergic SE

Question 11

how long should pt try drug tx before modifying their regimen/trying a different drug

Answer 11

4-8 weeks

Question 12

SE of Mirabegron (myrbetriq) a beta 3 agonist (relaxes the detrusor muscle and increases bladder capacity)

Answer 12

GI upset, dizziness, HA, increased BP slightly, nasopharingitis, UTI,

WARNINGS: increased BP, angioedema of the face, lips, tongue, pharynx; urinary retention in patients with BPH when used with anticholinergics

takes 8 weeks to work

Question 13

extended release anticholinergic drugs preferred over IR due to decreased SE

Question 14

oxybutinin IR 5 mg PO BID-QID and what are the other formulations

Answer 14

ER (ditropan xl) 5-30 mg PO daily
patch (oxytrol) one twice weekly
intravaginal cream (gelnique) 10% 1 pump/day

Question 15

Anticholinergic drugs

Answer 15

oxybutinin
solifenacin (vesicare) 5-10 mg daily
tolterodine (detrol) 1-2 mg PO BID
tolterodine ER (detrol LA) 2-4 mg daily
darifenacin (enablex)
fesoterodine (toviaz)
Tropsium (santura)

Question 16

remember anticholinergic SE

Answer 16

cant see, cant pee, cant spit, cant poopoo

dizziness, drowsiness (greatest with oxybutinin and less w/ the newer and selective agents), dry mouth, application site reactions

Question 17

anticholinergic CI

Answer 17

glaucoma
65 and older
urinary retention
gastric retention/decrease motility

oxtrol patch for women otc - avoid use if pt has pain or burning when urinating blood in urine or unexplained bladder or back pain or side pain, cloudy or foul smelling urine (because thats sign of UTI), male sex, <18 yrs old, urinary or gastric retention, glaucoma, accidental urine loss that is only due to coughing, sneezing laughing (because thats just stress incontinence)

Question 18

which patches should be removed before an MRI (CD REST) because they have aluminum coils

Answer 18

scopolamine (transderm scop)
testosterone (androderm)
rotigotine (neupro)
estrogen (some including alora)
diclofenac (flector)
clonidine (catapres TTS)

packaging is not clear on whether or not the patch for this oxytrol rx and otc contains metal, so best to take it off too.

Question 19

onabotulinumtoxin A (botox) dose and SE, boxed warning, etc..

Answer 19

100 u total over 20 sites
no more than q3 months (don’t ever exceed 360 units in 3 months).

requires antibiotics before and after administration

SE: urinary retention, dysuria, UTI’s

BOXED WARNING:
boxtulinium effects has the risk of spreading and affect breathing and swallowing

Contraindication: infection at the targeted injection site, UTI, or urinary retention

Monitor: post void residual volume, symptoms of OAB (overactive bladder)

Question 20

how to decrease risk of dry mouth (since this may be a reason for poor adherance)

Answer 20

extended release formulations

oxybutynin patch or gel

mirabegron. - lower incidence of dry mouth

avoid mouthwashes with alcohol, use ice chips, water, sugar free candy or gum

Question 21

decrease the dose of fesoterodine, solifenacin, tolterodine, and tropsium (dont use XR) in CrCl < 30

Question 22

Oxybutynin ER (ditropan XL) can leave a ghost tablet in the stool

Question 23

oxytrol patch should be placed twice weekly on dry, intact skin on the abdomen, hips or butt, avoid reapplying to same site within 7 days. available otc too for women >18 yrs

Question 24

OAB stands for

Answer 24

overactive bladder

Question 25

Potency units of botox are NOT interchangeable

Question 26

treatment of nocturia

Answer 26

desmopressin tablet (DDAVP) 0.2-0.6 mg at bedtime helps to temporarily decrease the urine production.

BOXED warning: hyponatremia (CI in pts with risk of severe hyponatremia: excessive fluid intake, electrolyte imbalances, CKD, SIADH, loop diuretics, systemic/inhaled steroids), pts with increased risk of fluid retention (uncontrolled HTN, HF)

Do not use nasal sprays with any nasal conditions

SE: hyponatremia, HA, HTN, dry mouth

monitor sodium levels at baseline, at one week, and at one month

Question 27

Gelnique - a gel of oxybutynin 10% should be applied on dry, intact skin on abdomen, upper arms or thighs, shoulders, rotate application sites never do same on consecutive days