Urinary Incontinence Flashcards
What is urinary incontinence?
Involuntary loss of urine
Men vs. women. Who is urinary incontinence more prevalent in?
Women > men (30% vs. 5%)
What are the medical consequences of urinary incontinence? (4)
- Urinary tract infections (UTIs), urosepsis
- Skin irritation, breakdown, infection
- Disrupted sleep
- Falls
What are the psychosocial consequences of UI? (3)
- Embarrassment
- Isolation
- Depression
What are 2 myths about UI?
- Inevitable part of aging
- Nothing can be done
What relevant anatomy should we as pharmacists know for UI? (4)
- Detrusor muscle (muscarinic = contraction. B3 stimulation = relaxation)
- Internal sphincter (alpha-adrenergic stimulation = contraction)
- External sphincter
- Pelvic floor muscle
Transient/modifiable causes of incontinence can be remembered as DIAPPERS. What does that stand for?
Delirium
Infection
Atrophic vaginitis
Pharmaceuticals
Psychological
Excessive urine output
Reduced mobility
Stool impaction
What are some non-modifiable factors associated with UI? (7)
- Increased age
- Menopause
- Pregnancy/childbirth
- Diabetes
- Stroke
- Conditions affecting mobility
- Neurologic injury/disease
What are some modifiable factors associated with UI? (9)
- Certain medications
- Constipation/impaction
- UTI
- Smoking
- Caffeine intake
- Fluid intake
- High-impact physical activities
- Heavy lifting/straining
- Obesity
What are some investigations that can be done to check for UI? (5)
- History and physical
- Type of incontinence
- Reversible causes - Lab tests
- Urinalysis, urine culture - Bladder diary
- Post-void urinary residual test
- Urodynamic tests
What are the different types of urinary incontinence? (5)
- Urgency
- Stress
- Mixed
- Overflow
- Functional
What is urgency urinary incontinence?
Leakage associated with a sudden, uncontrollable need to void
What % of pts with incontinence have urge UI?
14%
What are 2 causes of urge urinary incontinence?
- Overactive Bladder (OAB)
- Detrusor Overactivity
- Urgency with or without actual incontinence (OAB-dry vs. OAB-wet)
- Daytime frequency, nocturia
What is stress urinary incontinence?
Leakage with increased abdominal pressure (e.g., exercise, sneezing, coughing)
What % of UI pts have stress UI?
Women or men more likely?
50%
More common in women
What is mixed UI?
Both urgency and stress incontinence
What % of UI pts have mixed UI?
Men or women more likely?
32%
More common in women
What is overflow UI?
Leakage of urine from a full bladder
What are some common causes of overflow UI? (4)
Common with urinary retention
- Poor detrusor contractility or
- Bladder outlet obstruction (e.g., BPH)
- Elevated post-void residual (>100mL)
What is functional incontinence?
Inability to reach the toilet
What are some potential causes of functional incontinence? (4)
- Reduced mobility
- Constrictive clothing
- Inaccessible toilets or substitutes
- Dementia
What are some goals of treatment for UI? (5)
- Relieve distressing urinary symptoms
- Improve bladder function
- Prevent complications
- Avoid treatment side effects
- Improve QoL
Go through the stepwise approach to UI treatment (4)
- Lifestyle modifications
- Behaviour modifications
- Medications
- Minimally invasive procedures/surgery
What are some lifestyle factors that can be done to help with UI? (4)
- Decrease weight if BMI >30kg/m^2
- Stress incontinence in middle-aged women - Decrease alcohol and caffeine
- Restrict fluids in the evening if nocturia
- Take diuretics in am - Quit smoking
What are some behaviour modifications that can be done to help with UI? (3)
- Pelvic floor muscle training
- FIRST-LINE for urge, stress, and mixed UI
- Adequate trial = 6-12 weeks - Bladder training
- Urge UI
- Void regularly q1-2h, increased by 15 mins each week
- Most effective in combination with drug tx - Scheduled/prompted toileting
- q2-3h
What are 3 groups of pharmacological treatment for urge UI?
- Antimuscarinics
- Beta-3 adrenergic agonist
- Intravaginal estrogen
- If associated with vaginal atrophy
- Usually more for stress or mixed UI
First-line pharmacotherapy for urge UI is?
Antimuscarinics
What is the MOA of antimuscarinics in urge UI?
Relax detrusor muscle
How efficacious are antimuscarinics in urge UI?
Cochrane review –> 4 less leaks and 5 less voids per week
What are some contraindications of antimuscarinics in urge UI? (3)
- Urinary retention
- Angle-closure glaucoma
- Gastric retention
What are the most common adverse effects of antimuscarinics? (6)
- Dry mouth
- Constipation
- Blurred vision
- Confusion
- Cognitive impairment
- Increased heart rate
Antimuscarinics, use with caution in: (6)
- Frail older adults
- Cognitive impairment
- Dementia
- Parkinson’s disease
- DO NOT USE WITH CHOLINESTERASE INHIBITORS
- Caution with other drugs with anticholinergic effects
True or False? Once started, anti-muscarinics don’t need to be evaluated often
False - re-evaluate often
What are the 3 first-line antimuscarinic meds that are not EDS?
- Oxybutynin
- Tolterodine
- Solifenacin
What is the main ADE of oxybutynin?
Dry mouth (dose-related)
What dosage forms does oxybutynin come in? (3)
- IR tablet
- XL tablet
- Topicals
- Transdermal patch
- Transdermal gel
What are the theoretical advantages of selective antimuscarinics? (3)
- Increased selectivity for bladder muscarinic (M3) receptors (solifenacin, darifenacin, trospium)
- Decreased lipophilicity –> decreased BBB penetration (tolterodine, trospium)
- Decreased ADEs - cognitive impairment, dry mouth, constipation
True or False? Other than oxybutynin, solifenacin, or tolterodine, the rest of the antimuscarinics are EDS
True
What are 3 second-line selective antimuscarinics?
- Trospium
- Darifenacin
- Fesoterodine
A newer agent for urge UI is mirabegron. What is the MOA?
Beta-3 agonist
- Relaxes the detrusor smooth muscle and increased storage capacity
Describe the efficacy of mirabegron
Similar (modest) efficacy as antimuscarinics
- No anticholinergic side effects
- Limited data in frail older adults
Mirabegron is contraindicated when?
With uncontrolled HTN
What are the ADEs of mirabegron? (5)
- Increased BP
- Tachycardia
- Headache
- Constipation
- UTIs
Supratherapeutic doses of mirabegron were found to ________ ___
increase QTc
What are the 2 drug therapies for stress UI?
- Vaginal estrogen
- Duloxetine (unlabelled use, not well-studied)
True or False? Systemic estrogen is useful in stress UI
False - not recommended
What is a special cause of UI in men?
Benign Prostate Hypertrophy (BPH)
What to know about urge UI and BPH? (2)
- Commonly coexist in men
- BPH should be treated first - If still symptomatic, antimuscarinic therapy may be started
- Provided there is no urinary retention
What effect does alcohol have on continence?
Decreases awareness of need to void, polyuria
What effect do alpha-agonists have on continence?
Increased urethral resistance –> decreased urine flow
What effect do alpha-antagonists have on continence?
Decreased urethral resistance –> urine loss
What effect do anticholinergics have on continence? (4)
- Decreased bladder emptying
- Sedation
- Delirium
- Constipation
What effect do acetylcholinesterase inhibitors have on continence?
Stimulation of bladder contraction –> urine loss
What effect do antipsychotics (typical) have on continence? (3)
- Anticholinergic
- Rigidity
- Sedation
What effect do CCBs have on continence?
Pedal edema –> nighttime polyuria
What effect do GABAergic agents have on continence? (3)
- Sedation
- Dizziness
- Pedal edema –> nighttime polyuria
What effect do NSAIDs have on continence?
Pedal edema –> nighttime polyuria
What effect do loop diuretics have on continence? (3)
- Polyuria
- Frequency
- Urgency
What effect do narcotic analgesics have on continence? (4)
- Urinary retention
- Constipation
- Sedation
- Delirium
What effect do sedative hypnotics have on continence? (3)
- Sedation
- Delirium
- Decreased mobility
