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Geriatrics > Urinary Incontinence > Flashcards

Urinary Incontinence Flashcards

1
Q

What is UI?

A

Complaint of involuntary leakage of urine

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2
Q

How does UI affect QOL?

A 
Depression
Loss of independence
Lack of self-esteem
Decreased social engagement
Reason for older adults being institutionalized
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3
Q

Is UI more common in men or women?

A

Women

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4
Q

What happens to the genitourinary system with age that may lead to UI?

A

Kidneys become less able to concentrate urine
Bladder has less capacity
Bladder may not empty completely

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5
Q

What is normal micturition?

A

Urethral sphincter maintains adequate tone to resist passage of urine from bladder until voluntary voiding is initiated
Bladders expand to accommodate increasing volumes of urine, w/o a significant increase in bladder pressure
Normal micturition occurs with a coordinated set of actions that leads to a rise in intravesicular pressure - decreased urethral resistance and bladder contraction

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6
Q

What is acetylcholine?

A

Primary neurotransmitter in the lower urinary tract

Mediates voluntary and involuntary contractions of the detrusor muscle

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7
Q

What are the main cholinergic muscarinic receptors responsible for micturition?

A

M2 and M3

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8
Q

What does M1 receptor affect?

A

Stomach and Brain

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9
Q

What does M2 affect?

A

Bladder and heart

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10
Q

What does M3 affect?

A

Bladder and salivary

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11
Q

What does M4 affect?

A

Areas of the brain

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12
Q

What are the reversible causes?

A 
DIAPPERS
Delirium
Infection
Atrophic vaginitis
Pharmaceuticals
Psychological condition
Excess urine output
Reduced mobility
Stool impaction
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13
Q

What are the mechanisms of persistent UI?

A 
Stress UI
Urge UI
Overflow incontinence
Mixed incontinence and other types
Functional Incontinence
Overactive Bladder (OAB)
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14
Q

What is stress UI?

A

Urethral sphincter underactivity - results in involuntary loss of urine

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15
Q

What causes stress UI?

A

During exertion (cough, sneezing, exercise)
Volume lost is proportional to exertion
Most common in women during/post menopause, pregnancy, child birth, cognitive impairment and age
Men after urinary tract surgery or injury

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16
Q

What is urge UI?

A

Inability to delay voiding after sensation of bladder fullness is perceived

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17
Q

What is urge UI associated with?

A

Detrusor hyperactivity

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18
Q

How do we define urge UI?

A

Frequency, urgency, and nocturia are commonly experienced as a result of involuntary bladder contractions

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19
Q

How is frequency defined?

A

Going more than 8 times a day

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20
Q

How is urgency defined?

A

A sudden, strong desire to urinate

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21
Q

What is Overflow incontinence?

A

urethral overactivity and/or bladder underactivity

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22
Q

What is the least common type of UI?

A

Overflow incontinence

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23
Q

When does overflow incontinence happen?

A

When the bladder is filled to capacity but is unable to empty - causing urine leakage - lower ab fullness, weak urinary stream, interrupted stream, incomplete bladder emptying

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24
Q

What are the most common causes of overflow incontinence?

A

BPH and prostate cancer

Neurologic less common

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25
Q

What is mixed incontinence and other types?

A

Combination of bladder overactivity and urethral underactivity

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26
Q

What is functional incontinence?

A

Incontinence that is not related to bladder or urethral factors, but rather another primary disease state

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27
Q

What is OAB?

A

Urinary urgency w/ or w/o urge incontinence, frequency, nocturia

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28
Q

What is the cornerstone of UI treatment?

A

Nonpharmacologic therapy

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29
Q

What are the nonpharmacologic therapies for UI?

A

Behavior modification
Pelvic floor muscle exercises +/- biofeedback
Environmental changes

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30
Q

What are pharmacologic therapies for UI?

A 
Anticholinergic/antispasmodic (first line)
Beta-3 receptor agonist
TCAs
Botox
Sacral nerve stimulation
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31
Q

How does anticholinergic/antispasmodics work in UI?

A

Suppresses premature detrusor contractions, enhancing bladder storage, relieves urge sx

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32
Q

What are the efficacy considerations for anticholinergic/antispasmodics?

A

Modest reduction in UI
Similar efficacy demonstrated in all agents
Full continence achieved in 9-13%

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33
Q

What are the ADRs for anticholinergics?

A 
Use caution with cognitive impairment
Drowsiness
Dry mouth
Decreased sweating
Urinary hesitancy and/or retention
Hot flashes
Fever
Vasodilation
Amblyopia
Transient blurred vision
Mydriasis
Cyclopegia
Decreased lacrimation and increased ocular tension
Decreased GI mobility
Constipation
34
Q

What drugs are selective for M3?

A

Solifenacin and darifenacin - theoretically less ADRs

35
Q

What is our only beta-3 adrenergic receptor antagonist?

A

Myrbertiq

36
Q

What is the MOA of Myrbetriq?

A

Activates beta-3 receptors causing relaxation of the detrusor muscle, increasing the urinary storage capacity of the bladder

37
Q

What is the indication for Myrbetriq?

A

Overactive bladder with sx of urge UI, urgency, and frequency

38
Q

What are the ADRs for Myrbetriq?

A

N/D, HA, HTN, constipation, dizziness, tachycardia, nasopharyngitis and UTI

39
Q

What drugs are anticholinergic/antispasmodics for UI?

A 
Oxybutynin (Ditropan XL)
Tolterodine (Detrol LA)
Fesoterodine (Toviaz)
Trospium (Sanctura XR)
Darifenacin (Enablex)
Solifenacin (Vesicare)
40
Q

What is Ditropan XL’s dosing strategies?

A 
IR tabs/Liquid 5mg/5mL
-5mg PO BID-TID
-Max 20mg/day
ER tabs
-5-10 mg QD
-Max30 mg/day
Transdermal patch
-3.9 mg/day patch twice weekly
Topical gel
-10% = 1 packet daily
-3% = 3 pumps QD
41
Q

What is Detrol LA’s dosing strategy?

A

IR tablets
- 1-2 mg PO BID
ER Capsules
- 2-4 mg PO QD

42
Q

What drugs require renal and hepatic dose adjustments?

A

Detrol LA
Darifenacin
Solifenacin
Myrbetriq

43
Q

What is a SE of Detrol LA?

A

Potential for QTc prolongation

44
Q

What should be avoided with most anticholinergic/antispasmodic agents? Which one does not need to worry?

A

Grapefruit juice

Sanctura XR

45
Q

What is the dosing strategy for Toviaz?

A

ER tabs

- 4-8 mg PO daily

46
Q

What is the dosing strategy for Sanctura XR?

A

IR tabs
- 20mg BID
ER caps
- 60mg QD

47
Q

What is the dosing strategy for Enablex?

A

ER tabs

- 7.5-15 mg QD

48
Q

What anticholinergic/antispasmodic agent only requires hepatic dose adjustments?

A

Derifenacin

49
Q

What DDI does Enablex have?

A

Metoprolol (2D6)

50
Q

Which agents cause the worst constipation?

A

Enablex/vesicare

51
Q

What are nonpharmacologic treatments of stress incontinence?

A 
1st line: pelvic floor exercises
Absorptive pads
Behavioral modifications (weight loss)
Devices
Surgery
Urethral injection with bulking agents
52
Q

What are the pharmacologic treatments of stress incontinence?

A

Alpha-adrenergic agonists (pseudoephedrine, phenylephrine) 1st line
Estrogens
Duloxetine

53
Q

What is the efficacy of duloxetine in stress incontinence?

A

Benefits in incontinence episodes, number of micturitions per day and QOL

54
Q

People with what disease should be discouraged to use duloxetine?

A

Chronic liver disease

55
Q

What is the guiding principle for the treatment of mixed incontinence?

A

Treat the predominate sx first

56
Q

How do we treat overflow incontinence?

A

Alpha blockers (tamsulosin, alfuzosin, doxazosin, terazosin, silodosin), 5-alpha reductase inhibitors (finasteride, dutasteride) and surgery

57
Q

What is fecal incontinence?

A

The involuntary voiding of feces into clothing or bedclothing

58
Q

How is continence maintained?

A

The external and internal sphincters and the puborectalis muscle

59
Q

What are the RFs for fecal incontinence?

A 
H/o UI
Presence of neurologic dz
Presence of psychiatric dz
Poor mobility
Age greater than 70 years
Dementia
60
Q

What are the causes of fecal incontinence?

A 
Fecal impaction
Loss of normal continence mechanism
Problems overwhelming normal continence mechanism
Psychologic and behavioral problems
Neoplasms
61
Q

What is the most common cause of fecal incontinence?

A

Fecal impaction

62
Q

What are the causes of loss of normal continence mechanism?

A

Local neuronal continence mechanism
Impaired neurologic control
Anorectal trauma/sphincter disruption

63
Q

What are problems that overwhelm normal incontinence mechanism?

A

Diarrhea colitis
Laxative
Radiation
Poor access to toilet

64
Q

What are psychologic and behavioral problems that may cause fecal incontinence?

A

Severe depression
Dementia
Cerebrovascular dz

65
Q

What is sarcopenia?

A

Loss of muscle mass and strength that occurs with aging - associated with functional impairment

66
Q

What are the factors affecting nutrition?

A 
Finances
Social (living alone)
Functional (ability to shop, cook, etc)
Cognition
Dysphagia
Chewing problems
Anorexia associated with medications of disorders
Delayed gastric emptying leading to early satiety
67
Q

How does overnutrition occur in elderly?

A

Overweight and obesity are not associated with increased mortality in older adults as it is in younger adults, except at extreme levels

68
Q

What nutrients are supposed to be included when weight loss is necessary in elderly?

A 
Protein
Vit D
Vit B12
Calcium
Fiber
Fluids
69
Q

How do we treat undernutrition?

A

Use of high calorie, nutrient dense meals and snacks should be encouraged
May need meal supplementation
Encourage use of MVT
Appetite stimulant therapy

70
Q

What are the appetite stimulants?

A

Mirtazapine
Dronabinol
Megestrol

71
Q

What is the MOA of mirtazapine?

A

Affects leptin levels (a hormone produced by adipose cells - affect satiety) and TNF alpha

72
Q

What is the starting dose of mirtazapine?

A

7.4 mg QHS d/t sedation; can titrate in 1-2 weeks

73
Q

Which patients do we use mirtazapine in?

A

Concomitant depression and/or insomnia

74
Q

What is dronabinol’s MOA?

A

Appetite stimulation occurs in he lateral hypothalamus. Also affects feeding behaviors, decrease nausea, and reward mechanisms

75
Q

What is the dronabinol dosing?

A

2.5 mg BID before lunch and dinner; may increase to a max dose of 20 mg per day. Also available in an oral solution; dosing is slightly different

76
Q

What is the MOA of megestrol?

A

Appetite stimulant effects thought to be separate from primary pharmacology as a glucocorticoid
May interfere with cachexin

77
Q

What is cachexin?

A

Hormone which inhibits lipogenic enzymes

78
Q

What is dronabinol approved for?

A

AIDs cachexia

79
Q

What is the dose for megestrol?

A

200-400 mg QD

Usually need to use suspension as tablets come in 20-40 mg

80
Q

How long until megestrol beings to work?

A

3 weeks

81
Q

Why is megestrol on the Beers list?

A

Risk of VTE

Geriatrics (15 decks)

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