Urinary Incontinence Flashcards
What is urinary incontinence?
involuntary loss of urine
What is the relationship between urinary incontinence and age?
prevalence increases with age
-prevalence increases to 30-60% in age 65+
What are the medical consequences of urinary incontinence?
urinary tract infections, urosepsis
skin irritation, breakdown, infection
disrupted sleep
falls (rushing, waking up at night)
What are the psychosocial consequences of urinary incontinence?
embarrassment
isolation
depression
DECREASED QOL
Is urinary incontinence well diagnosed?
underdiagnosed
-50-70% do not report symptoms or seek medical advice
-health care providers need to ask
Describe the detrusor muscle.
muscarinic –> contraction (cholinergic)
-ACh = increased contractility
B3 stimulation –> relaxation
-increasing bladder storage capacity
Describe the internal sphincter.
alpha-adrenergic stimulation –> contraction
Which muscles in the bladder are under voluntary control?
external sphincter: voluntary control
pelvic floor muscle: voluntary control
What are the transient/modifiable causes of incontinence?
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)
What are the non-modifiable factors associated with urinary incontinence?
increased age
menopause
pregnancy/childbirth
diabetes
stroke
conditions affecting mobility
neurologic injury/disease
What are the modifiable factors associated with urinary incontinence?
certain medications
constipation/impaction
UTI
smoking
caffeine intake
fluid intake
high-impact physical activities
heavy lifting/straining
obesity
What are the types of urinary incontinence?
urgency
stress
mixed
overflow
functional
Which type of urinary incontinence is most common?
stress
Describe urge incontinence.
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
Describe stress incontinence.
leakage with increased abdominal pressure
-ex: exercise, sneezing, coughing
50% incontinence cases
more common in women
Describe mixed incontinence.
both urgency and stress incontinence
32% patients with UI
more common in women
Describe overflow incontinence.
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)
Describe functional incontinence.
impaired ability to reach the toilet
-reduced mobility
-constrictive clothing
-inaccessible toilets or substitutes
-dementia
What are the goals of therapy for urinary incontinence?
relieve distressing urinary symptoms
improve bladder function
prevent complications
avoid treatment side effects
improve quality of life
What is the stepwise approach to treatment of urinary incontinence?
lifestyle modification
behavior modification
medications
minimally invasive procedures, surgery
What are the lifestyle modifications to make to help with urinary incontinence?
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
What are the behavior modifications to make to help with urinary incontinence?
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
What is the place in therapy for pelvic floor muscle training?
1st line for urge, stress, and mixed UI
What are the treatment options for urge incontinence?
antimuscarinics
B3 adrenergic agonists
intravaginal estrogen
-if associated with vaginal atrophy
-usually more for stress or mixed UI
What is the 1st line pharmacotherapy for urge incontinence?
antimuscarinics
How do antimuscarinics work for urge incontinence?
relax detrusor muscle
What is the efficacy of antimuscarinics for urge incontinence?
modest efficacy
-Cochrane review –> 4 less leaks and 5 less voids per week
What are the contraindications to antimuscarinics?
urinary retention
angle-closure glaucoma
gastric retention
What are the common adverse effects of antimuscarinics?
dry mouth
constipation
blurred vision
confusion, cognitive impairment
increased heart rate
What are some cautions to be aware of with antimuscarinics?
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
What should we be doing often with antimuscarinics?
re-evaluating
-deprescribe if no benefit
What is a common adverse effect of oxybutynin?
dry mouth
-dose related
What makes oxybutynin different from other antimuscarinics?
non-selective
-equal benefit on brain and bladder
Which selective antimuscarinic is the best?
~ = efficacy across the board
What is the theoretical advantage of selective antimuscarinics?
increased selectivity for bladder muscarinic (M3) receptors
-solifenacin, darifenacin, trospium
decreased lipophilicity –> decreased BBB penetration
-tolterodine, trospium
decreased AEs - cognitive impairment, dry mouth, constipation
Which selective antimuscarinics are 1st line for urge UI?
tolterodine LA
solifenacin
all other antimuscarinics + mirabegron are EDS
Which selective antimuscarinics are 2nd line for urge UI?
trospium
darifenacin
fesoterodine
What is the only B3 agonist available?
mirabegron
What is the MOA of mirabegron?
B3 agonist
-relaxes the detrusor smooth muscle and increases storage capacity
What is the efficacy of mirabegron?
similar (modest) efficacy as antimuscarinics
-no anticholinergic side effects
-limited data in frail older adults
What is a contraindication to mirabegron?
uncontrolled hypertension
What are the adverse effects of mirabegron?
increased BP
tachycardia
headache
constipation
UTIs
What is a caution to be aware of with mirabegron?
supratherapeutic doses were found to prolong QTc
-caution with history of long QT or with other QTc prolonging drugs
What are the pharmacologic options for stress urinary incontinence?
vaginal estrogen
duloxetine
Describe the efficacy of vaginal estrogen for stress incontinence.
may be beneficial if urogenital atrophy present
mixed results in studies
Which form of estrogen should not be used for stress incontinence?
systemic
What is the evidence for duloxetine in stress incontinence?
unlabelled use, not well studied
Which urinary issues commonly coexist in men?
urge UI and BPH
-BPH should be treated first
-if still symptomatic, antimuscarinic therapy may be started (provided there is no urinary retention)
What are some drug-related causes of urinary incontinence?
alcohol
alpha-agonists
alpha-antagonists
anticholinergics
cholinesterase inhibitors
typical antipsychotics
CCBs
GABAergic agents
NSAIDs
loop diuretics
narcotic analgesics
sedative hypnotics
