Urinary Incontinence Flashcards
What is UI?
Complaint of involuntary leakage of urine
How does UI affect QOL?
Depression Loss of independence Lack of self-esteem Decreased social engagement Reason for older adults being institutionalized
Is UI more common in men or women?
Women
What happens to the genitourinary system with age that may lead to UI?
Kidneys become less able to concentrate urine
Bladder has less capacity
Bladder may not empty completely
What is normal micturition?
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
What is acetylcholine?
Primary neurotransmitter in the lower urinary tract
Mediates voluntary and involuntary contractions of the detrusor muscle
What are the main cholinergic muscarinic receptors responsible for micturition?
M2 and M3
What does M1 receptor affect?
Stomach and Brain
What does M2 affect?
Bladder and heart
What does M3 affect?
Bladder and salivary
What does M4 affect?
Areas of the brain
What are the reversible causes?
DIAPPERS Delirium Infection Atrophic vaginitis Pharmaceuticals Psychological condition Excess urine output Reduced mobility Stool impaction
What are the mechanisms of persistent UI?
Stress UI Urge UI Overflow incontinence Mixed incontinence and other types Functional Incontinence Overactive Bladder (OAB)
What is stress UI?
Urethral sphincter underactivity - results in involuntary loss of urine
What causes stress UI?
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
What is urge UI?
Inability to delay voiding after sensation of bladder fullness is perceived
What is urge UI associated with?
Detrusor hyperactivity
How do we define urge UI?
Frequency, urgency, and nocturia are commonly experienced as a result of involuntary bladder contractions
How is frequency defined?
Going more than 8 times a day
How is urgency defined?
A sudden, strong desire to urinate
What is Overflow incontinence?
urethral overactivity and/or bladder underactivity
What is the least common type of UI?
Overflow incontinence
When does overflow incontinence happen?
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
What are the most common causes of overflow incontinence?
BPH and prostate cancer
Neurologic less common
What is mixed incontinence and other types?
Combination of bladder overactivity and urethral underactivity
What is functional incontinence?
Incontinence that is not related to bladder or urethral factors, but rather another primary disease state
What is OAB?
Urinary urgency w/ or w/o urge incontinence, frequency, nocturia
What is the cornerstone of UI treatment?
Nonpharmacologic therapy
What are the nonpharmacologic therapies for UI?
Behavior modification
Pelvic floor muscle exercises +/- biofeedback
Environmental changes
What are pharmacologic therapies for UI?
Anticholinergic/antispasmodic (first line) Beta-3 receptor agonist TCAs Botox Sacral nerve stimulation
How does anticholinergic/antispasmodics work in UI?
Suppresses premature detrusor contractions, enhancing bladder storage, relieves urge sx
What are the efficacy considerations for anticholinergic/antispasmodics?
Modest reduction in UI
Similar efficacy demonstrated in all agents
Full continence achieved in 9-13%
What are the ADRs for anticholinergics?
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
What drugs are selective for M3?
Solifenacin and darifenacin - theoretically less ADRs
What is our only beta-3 adrenergic receptor antagonist?
Myrbertiq
What is the MOA of Myrbetriq?
Activates beta-3 receptors causing relaxation of the detrusor muscle, increasing the urinary storage capacity of the bladder
What is the indication for Myrbetriq?
Overactive bladder with sx of urge UI, urgency, and frequency
What are the ADRs for Myrbetriq?
N/D, HA, HTN, constipation, dizziness, tachycardia, nasopharyngitis and UTI
What drugs are anticholinergic/antispasmodics for UI?
Oxybutynin (Ditropan XL) Tolterodine (Detrol LA) Fesoterodine (Toviaz) Trospium (Sanctura XR) Darifenacin (Enablex) Solifenacin (Vesicare)
What is Ditropan XL’s dosing strategies?
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
What is Detrol LA’s dosing strategy?
IR tablets
- 1-2 mg PO BID
ER Capsules
- 2-4 mg PO QD
What drugs require renal and hepatic dose adjustments?
Detrol LA
Darifenacin
Solifenacin
Myrbetriq
What is a SE of Detrol LA?
Potential for QTc prolongation
What should be avoided with most anticholinergic/antispasmodic agents? Which one does not need to worry?
Grapefruit juice
Sanctura XR
What is the dosing strategy for Toviaz?
ER tabs
- 4-8 mg PO daily
What is the dosing strategy for Sanctura XR?
IR tabs
- 20mg BID
ER caps
- 60mg QD
What is the dosing strategy for Enablex?
ER tabs
- 7.5-15 mg QD
What anticholinergic/antispasmodic agent only requires hepatic dose adjustments?
Derifenacin
What DDI does Enablex have?
Metoprolol (2D6)
Which agents cause the worst constipation?
Enablex/vesicare
What are nonpharmacologic treatments of stress incontinence?
1st line: pelvic floor exercises Absorptive pads Behavioral modifications (weight loss) Devices Surgery Urethral injection with bulking agents
What are the pharmacologic treatments of stress incontinence?
Alpha-adrenergic agonists (pseudoephedrine, phenylephrine) 1st line
Estrogens
Duloxetine
What is the efficacy of duloxetine in stress incontinence?
Benefits in incontinence episodes, number of micturitions per day and QOL
People with what disease should be discouraged to use duloxetine?
Chronic liver disease
What is the guiding principle for the treatment of mixed incontinence?
Treat the predominate sx first
How do we treat overflow incontinence?
Alpha blockers (tamsulosin, alfuzosin, doxazosin, terazosin, silodosin), 5-alpha reductase inhibitors (finasteride, dutasteride) and surgery
What is fecal incontinence?
The involuntary voiding of feces into clothing or bedclothing
How is continence maintained?
The external and internal sphincters and the puborectalis muscle
What are the RFs for fecal incontinence?
H/o UI Presence of neurologic dz Presence of psychiatric dz Poor mobility Age greater than 70 years Dementia
What are the causes of fecal incontinence?
Fecal impaction Loss of normal continence mechanism Problems overwhelming normal continence mechanism Psychologic and behavioral problems Neoplasms
What is the most common cause of fecal incontinence?
Fecal impaction
What are the causes of loss of normal continence mechanism?
Local neuronal continence mechanism
Impaired neurologic control
Anorectal trauma/sphincter disruption
What are problems that overwhelm normal incontinence mechanism?
Diarrhea colitis
Laxative
Radiation
Poor access to toilet
What are psychologic and behavioral problems that may cause fecal incontinence?
Severe depression
Dementia
Cerebrovascular dz
What is sarcopenia?
Loss of muscle mass and strength that occurs with aging - associated with functional impairment
What are the factors affecting nutrition?
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
How does overnutrition occur in elderly?
Overweight and obesity are not associated with increased mortality in older adults as it is in younger adults, except at extreme levels
What nutrients are supposed to be included when weight loss is necessary in elderly?
Protein Vit D Vit B12 Calcium Fiber Fluids
How do we treat undernutrition?
Use of high calorie, nutrient dense meals and snacks should be encouraged
May need meal supplementation
Encourage use of MVT
Appetite stimulant therapy
What are the appetite stimulants?
Mirtazapine
Dronabinol
Megestrol
What is the MOA of mirtazapine?
Affects leptin levels (a hormone produced by adipose cells - affect satiety) and TNF alpha
What is the starting dose of mirtazapine?
7.4 mg QHS d/t sedation; can titrate in 1-2 weeks
Which patients do we use mirtazapine in?
Concomitant depression and/or insomnia
What is dronabinol’s MOA?
Appetite stimulation occurs in he lateral hypothalamus. Also affects feeding behaviors, decrease nausea, and reward mechanisms
What is the dronabinol dosing?
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
What is the MOA of megestrol?
Appetite stimulant effects thought to be separate from primary pharmacology as a glucocorticoid
May interfere with cachexin
What is cachexin?
Hormone which inhibits lipogenic enzymes
What is dronabinol approved for?
AIDs cachexia
What is the dose for megestrol?
200-400 mg QD
Usually need to use suspension as tablets come in 20-40 mg
How long until megestrol beings to work?
3 weeks
Why is megestrol on the Beers list?
Risk of VTE
