Urinary Incontinence Flashcards
Urge incontinence
related to neuropathy, present in pts with Parkinsons, MS, stroke, and DM
Stress incontinence
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)
Mixed incontinence
mixture of urge and stress incontinence
functional incontinence
normal bladder function but the patient has some sort of physical or mental disability preventing them from getting to toilet
overflow incontinence
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
overactive bladder
the bladder begins contracting to pee before the bladder is even full.
non drug treatment is first line
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
drugs are 2nd line. the classes that help are
- 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
selective anticholinergics like darifenacin or solifenacin have less cognitive SE
this because they are M3 (muscarinic receptor 3 specific)
long acting anticholinergics (oxybutynin ER or transdermal Oxytrol) are used initially for drug tx
long acting forms have less anticholinergic SE
how long should pt try drug tx before modifying their regimen/trying a different drug
4-8 weeks
SE of Mirabegron (myrbetriq) a beta 3 agonist (relaxes the detrusor muscle and increases bladder capacity)
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
extended release anticholinergic drugs preferred over IR due to decreased SE
oxybutinin IR 5 mg PO BID-QID and what are the other formulations
ER (ditropan xl) 5-30 mg PO daily
patch (oxytrol) one twice weekly
intravaginal cream (gelnique) 10% 1 pump/day
Anticholinergic drugs
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)
remember anticholinergic SE
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
anticholinergic CI
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)
which patches should be removed before an MRI (CD REST) because they have aluminum coils
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.
onabotulinumtoxin A (botox) dose and SE, boxed warning, etc..
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)
how to decrease risk of dry mouth (since this may be a reason for poor adherance)
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
decrease the dose of fesoterodine, solifenacin, tolterodine, and tropsium (dont use XR) in CrCl < 30
Oxybutynin ER (ditropan XL) can leave a ghost tablet in the stool
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
OAB stands for
overactive bladder
Potency units of botox are NOT interchangeable
treatment of nocturia
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
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
