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PHAR350 > Urinary Incontinence > Flashcards

Urinary Incontinence Flashcards

1
Q

What is urinary incontinence?

A

involuntary loss of urine

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2
Q

What is the relationship between urinary incontinence and age?

A

prevalence increases with age
-prevalence increases to 30-60% in age 65+

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3
Q

What are the medical consequences of urinary incontinence?

A

urinary tract infections, urosepsis
skin irritation, breakdown, infection
disrupted sleep
falls (rushing, waking up at night)

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4
Q

What are the psychosocial consequences of urinary incontinence?

A

embarrassment
isolation
depression
DECREASED QOL

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5
Q

Is urinary incontinence well diagnosed?

A

underdiagnosed
-50-70% do not report symptoms or seek medical advice
-health care providers need to ask

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6
Q

Describe the detrusor muscle.

A

muscarinic –> contraction (cholinergic)
-ACh = increased contractility
B3 stimulation –> relaxation
-increasing bladder storage capacity

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7
Q

Describe the internal sphincter.

A

alpha-adrenergic stimulation –> contraction

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8
Q

Which muscles in the bladder are under voluntary control?

A

external sphincter: voluntary control
pelvic floor muscle: voluntary control

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9
Q

What are the transient/modifiable causes of incontinence?

A

DIAPPERS
delirium (may be medication related)
infection (may be medication related)
atrophic vaginitis
pharmaceutical
psychological
excessive urine output (may be medication related)
reduced mobility (may be medication related)
stool impaction (may be medication related)

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10
Q

What are the non-modifiable factors associated with urinary incontinence?

A

increased age
menopause
pregnancy/childbirth
diabetes
stroke
conditions affecting mobility
neurologic injury/disease

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11
Q

What are the modifiable factors associated with urinary incontinence?

A

certain medications
constipation/impaction
UTI
smoking
caffeine intake
fluid intake
high-impact physical activities
heavy lifting/straining
obesity

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12
Q

What are the types of urinary incontinence?

A

urgency
stress
mixed
overflow
functional

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13
Q

Which type of urinary incontinence is most common?

A

stress

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14
Q

Describe urge incontinence.

A

leakage associated with a sudden, uncontrollable need to void
14% patients with incontinence
overactive bladder (OAB)/detrusor overactivity
-urgency with or without actual incontinence (OAB-wet vs OAB-dry)
-daytime frequency, nocturia

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15
Q

Describe stress incontinence.

A

leakage with increased abdominal pressure
-ex: exercise, sneezing, coughing
50% incontinence cases
more common in women

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16
Q

Describe mixed incontinence.

A

both urgency and stress incontinence
32% patients with UI
more common in women

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17
Q

Describe overflow incontinence.

A

leakage of urine from a full bladder
common with urinary retention
-poor detrusor contractility or
-bladder outlet obstruction (ex: BPH)
-elevated post-void residual (>100ml)

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18
Q

Describe functional incontinence.

A

impaired ability to reach the toilet
-reduced mobility
-constrictive clothing
-inaccessible toilets or substitutes
-dementia

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19
Q

What are the goals of therapy for urinary incontinence?

A

relieve distressing urinary symptoms
improve bladder function
prevent complications
avoid treatment side effects
improve quality of life

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20
Q

What is the stepwise approach to treatment of urinary incontinence?

A

lifestyle modification
behavior modification
medications
minimally invasive procedures, surgery

21
Q

What are the lifestyle modifications to make to help with urinary incontinence?

A

decrease weight if BMI > 30 kg/m2
-esp if stress incontinence in middle aged women
decrease alcohol and caffeine intake
restrict fluids in the evening if nocturia
-take diuretics in AM
quit smoking

22
Q

What are the behavior modifications to make to help with urinary incontinence?

A

pelvic floor muscle training
-adequate trial x 6-12 weeks
bladder training
-void regularly q1-2h, increase by 15 mins each week
-most effective in combination with drug tx
-urge UI
scheduled/prompted toileting
-q2-3h

23
Q

What is the place in therapy for pelvic floor muscle training?

A

1st line for urge, stress, and mixed UI

24
Q

What are the treatment options for urge incontinence?

A

antimuscarinics
B3 adrenergic agonists
intravaginal estrogen
-if associated with vaginal atrophy
-usually more for stress or mixed UI

25
Q

What is the 1st line pharmacotherapy for urge incontinence?

A

antimuscarinics

26
Q

How do antimuscarinics work for urge incontinence?

A

relax detrusor muscle

27
Q

What is the efficacy of antimuscarinics for urge incontinence?

A

modest efficacy
-Cochrane review –> 4 less leaks and 5 less voids per week

28
Q

What are the contraindications to antimuscarinics?

A

urinary retention
angle-closure glaucoma
gastric retention

29
Q

What are the common adverse effects of antimuscarinics?

A

dry mouth
constipation
blurred vision
confusion, cognitive impairment
increased heart rate

30
Q

What are some cautions to be aware of with antimuscarinics?

A

frail older adults, cognitive impairment, dementia, and PD
-NNT = 32 at 90d; NNH (hip fracture) = 36 at 90d
do not use with cholinesterase inhibitors
caution with other drugs with anticholinergic effects

31
Q

What should we be doing often with antimuscarinics?

A

re-evaluating
-deprescribe if no benefit

32
Q

What is a common adverse effect of oxybutynin?

A

dry mouth
-dose related

33
Q

What makes oxybutynin different from other antimuscarinics?

A

non-selective
-equal benefit on brain and bladder

34
Q

Which selective antimuscarinic is the best?

A

~ = efficacy across the board

35
Q

What is the theoretical advantage of selective antimuscarinics?

A

increased selectivity for bladder muscarinic (M3) receptors
-solifenacin, darifenacin, trospium
decreased lipophilicity –> decreased BBB penetration
-tolterodine, trospium
decreased AEs - cognitive impairment, dry mouth, constipation

36
Q

Which selective antimuscarinics are 1st line for urge UI?

A

tolterodine LA
solifenacin
all other antimuscarinics + mirabegron are EDS

37
Q

Which selective antimuscarinics are 2nd line for urge UI?

A

trospium
darifenacin
fesoterodine

38
Q

What is the only B3 agonist available?

A

mirabegron

39
Q

What is the MOA of mirabegron?

A

B3 agonist
-relaxes the detrusor smooth muscle and increases storage capacity

40
Q

What is the efficacy of mirabegron?

A

similar (modest) efficacy as antimuscarinics
-no anticholinergic side effects
-limited data in frail older adults

41
Q

What is a contraindication to mirabegron?

A

uncontrolled hypertension

42
Q

What are the adverse effects of mirabegron?

A

increased BP
tachycardia
headache
constipation
UTIs

43
Q

What is a caution to be aware of with mirabegron?

A

supratherapeutic doses were found to prolong QTc
-caution with history of long QT or with other QTc prolonging drugs

44
Q

What are the pharmacologic options for stress urinary incontinence?

A

vaginal estrogen
duloxetine

45
Q

Describe the efficacy of vaginal estrogen for stress incontinence.

A

may be beneficial if urogenital atrophy present
mixed results in studies

46
Q

Which form of estrogen should not be used for stress incontinence?

A

systemic

47
Q

What is the evidence for duloxetine in stress incontinence?

A

unlabelled use, not well studied

48
Q

Which urinary issues commonly coexist in men?

A

urge UI and BPH
-BPH should be treated first
-if still symptomatic, antimuscarinic therapy may be started (provided there is no urinary retention)

49
Q

What are some drug-related causes of urinary incontinence?

A

alcohol
alpha-agonists
alpha-antagonists
anticholinergics
cholinesterase inhibitors
typical antipsychotics
CCBs
GABAergic agents
NSAIDs
loop diuretics
narcotic analgesics
sedative hypnotics

PHAR350 (17 decks)

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