Urinary Incontinence Flashcards
Urinary incontinence (UI) is described as…
Involuntary loss of urine
A sufficient volume is whatever causes problems for the individual
Medical consequences of UI may include…
UTI’s, urosepsis
SKin irritation, breakdown, infection
Disrupted sleep
Falls
Psychological consequences of UI may include…
Embarassment
Isolation
Depression
Lower quality of life
Relevant bladder anatomy for us as pharmacists to know include…
Detrusor muscle
Internal sphincter
External sphincter
Pelvic floor muscle
The detrusor muscle contracts and relaxes in response to…
Contracts - muscarinic (cholinergic)
Relaxes - Beta3 stimulation
The internal sphincter contracts in response to…
Alpha-adrenergic stimulation
The external sphincter + pelvic floor muscle contracts and relaxes in response to…
Voluntary control
Transient/modifiable causes of incontinence may include…
DIAPPERS
Delirium
Infection
Atrophic vaginitis
Pharmaceuticals
Psychological
Excessive urine output
Reduced mobility
Stool impaction
Modifiable factors associated with UI may include…
Certain medications
Constipation/impaction
UTI
Smoking
Caffeine + fluid intake
High-impact physical activity
Heavy lifting/straining
Obesity
Investigations for UI may include…
History and physical (type of incontinence, reversible causes)
Lab tests (urinsalysis)
Bladder diary
Post-void urinary residual test
Urodynamic tests
Urge urinary incontinence is…
Leakage associated with a sudden, uncontrollable need to void
AKA overactive bladder (OAB), detrusor overactivity
Stress urinary incontinence is…
Leakage with increased abdominal pressure
(exercise, sneezing, coughing)
Mixed urinary incontinence is…
A combination of both urgency and stress incontinence
Overflow urinary incontinence is…
Leakage of urine from a full bladder
Common with urinary retention - poor detrusor contractility, bladder outlet obstruction, elevated post-void residual
Functional incontinence is…
Impaired ability to reach the toilet
Reduced mobility, constrictive clothing, inaccessible toilets/substitutes, dementia
Goals of treatment with UI involve…
Relieve distressing urinary symptoms
Improve bladder function
Prevent complications
Avoid treatment side effects
Improve quality of life
Lifestyle modifications for improving UI may include…
Weight loss, if BMI is greater than 30
Decrease consumption of alcohol + caffeine
Restrict fluids in evening if nocturia, take diuretics in AM
Quit smoking
Behaviour modifications for UI may involve…
Pelvic floor muscle training
Bladder training
Scheduled/prompted toileting
Pelvic floor muscle training can be used first line for…
Urge, stress, and mixed UI
Adequate trial of pelvic floor muscle training is…
6-12 weeks
Does require a good level of commitment
Bladder training is primarily used for ____, and involves…
Urge UI - build up bladder storage capacity, & let the body adjust (void regularly q1-2h, increased by 15 minutes each week)
Most effective in combination with drug treatment
Pharmacological treatment for urge UI may include…
Antimuscarinics (1st line) + Beta-3 adrenergic agonist
Intravaginal estrogen if associated with vaginal atrophy
Estrogen is usually more for stress/mixed UI
Antimuscarinics for urge UI work by…
Relaxing the detrusor muscle
Efficacy of antimuscarinics for urge UI is…
Modest - 4 less leaks and 5 less voids per week
Not everyone finds them to be beneficial
Contraindications to using antimuscarinics for urge UI may include…
Urinary retention
Angle-closure glaucoma
Gastric retention
Most common AE’s of antimuscarinics involve…
Dry mouth
Constipation
Blurred vision
Confusion, cognitive impairment
Increased heart rate
Antimuscarinics with urge UI are cautioned in these patients…
Frail older adults +/- cognitive impairment, dementia, Parkinson’s
Other drugs with anticholinergic effects
Should NOT be used with cholinesterase inhibitors; re-evaluate often
A common antimuscarinic used for urge UI includes…
Oxybutynin - IR/XL tablet, topicals
The different selective antimuscarinics for urge UI have ____ efficacy
Equal efficacy across the board
Theoretical advantage of selective antimuscarinics include…
Increased selectivity for bladder muscarinic (M3) receptors
Decreased lipophilicity
Decreased adverse effects
Lower rates of cognitiive impairment, dry mouth, constipation
First-line selective antimuscarinics for urge UI include…
Tolterodine
Solifenacin
Second-line selective antimuscarinics for urge UI includes…
Trospium
Darifenacin
Fesoterodine
EDS is required for all of these
The beta-3 agonist used for urge UI is ____ and works via…
Mirabegron - relaxes detrusor smooth muscle and increases storage capacity
Efficacy of mirabegron to the antimuscarinics is…
Similar - modest efficacy
Advantages of mirabegron to the muscarinics include…
No anticholinergic side effects
AE’s with mirabegron include…
Increased BP
Tachycardia
Headache
Constipation
UTI’s
Larger doses may increase QTc
CI with uncontrolled hypertension
Generally well tolerated
Drug therapy for stress UI may include…
Vaginal estrogen (NOT systemic)
Duloxetine
Efficacy of vaginal estrogen for UI is…
Beneficial for UI if urogenital atrophy is present - mixed results in studies
Efficacy of duloxetine for stress UI is…
Not well-studied - unlabelled use
For UI in men, we should…
Consider BPH and treat this first before UI - if still symptomatic, antimuscarinic therapy may be started provided there is NO urinary retention
Drug-related causes of UI may include…
Anything that can cause:
Constipation
Excess urine output/retention
Lower extremity edema
Anything that may cause functional impairment
Alpha stimulants/antagonists
Anticholinergics
Diuretics
Sedating agents
