Urinary incontinence Flashcards
What is the role of the PNS and Ach in bladder physiology
PNS impulses travel to pelvic nerves (S2-S4) as primary motor control
Ach is the primary NT in the lower urinary tract- it activates post-synaptic muscarinic receptors causing volitional and involuntary contraction of detrusor muscle
What are the responsibilities of the muscarinic receptors in the bladder
MC in bladder: M2 (M2:M3 usually 3:1)
M3: emptying contractions and involuntary bladder contractions
*Pharm therapy is based mainly on M3 receptors
What abnormalities can cause UI
Urethral (bladder outlet and urinary sphincter)
bladder
combination
UI symptoms are
overfunction of bladder/urethra
underfunction of bladder/urethra
What are the types of urinary incontinence
Overflow: urethral block= bladder does not empty properly
Stress: relaxed pelvic floor/ high intra-abd pressure
Urge: bladder oversensitive 2/2 infection, or, neuro d/o
What is the Tx of choice for urge incontinence
Anti-cholinergics and anti-spasmodics; Oxybutynin, darifenacin, fesoterodine, tolterodine
(second line is trospium)
1. suppress premature detrusor contractions= better blader storage
2. relieve UUI Sx and complications
What is the Tx of choice for stress incontinence
Alpha agonists and topical vaginal estrogens
the urethra is underactive so we want to stimulate it
1. improve urethral closure
2. enhance supportive structures
enhance serotonin and NE effects in micturition pathway
What is overflow incontinence associated with
BPH
What disease states can lead to UI
dementia/delerium depression Cystitis Post-menopause atrophic urethritis DM Neuro (parkinsons, MS, SCI) pelvic malignancy constipation congenital malformation
What meds can affect the urinary tract
diuretics alpha antagonits and agonists CCB Narcotics sedative hypnotics
What is overflow incontinence
Urethral overactivity + Bladder underactivity
Bladder is filled to capacity at all times and unable to empty= urine leaks from a distended bladder
What can secondarily cause overflow incontinence
BPH
Malignant prostatic hypertrophy
What is stress incontinence
UI during exertional activities
increased intra-abdominal pressure/ weak pelvic floor
2/2 pregnancy, childbirth, menopause, obesity, cognitive impairment, and age
(uncommon in men)
What is the goal of SUI therapy
improve urethral closure mechanism by stimulating alpha adrenergic receptors in smooth muscle of bladder neck
- No role for med Tx to manage SUI s/p radical prostatectomy
- Sx exacerbated if taking alpha blockers (prazosin)
What is urge incontinence
Involuntary detrusor bladder contractions during bladder filling and urine storage; overwhelming urge to urinate followed by loss of urine
*running to the bathroom is worse! try to sit still!
Symptoms of Urge incontinence are
urinary frequency (peeing >8xday) and urgency (sudden compelling desire to urinate)
What are RF for urge incontinence
normal aging neuro dz (stroke, parkinsons, MS, SCI) bladder outlet obstruction (BPH, prostate cancer)
Big things to remember when choosing Tx for incontinence
Tx is not static, it can change over time
Tx choice depends on age, comorbidities, and other meds
If goals are not achieved, add a second agent!
Tx for Overactive bladder
- Behavioral therapy, +/- antimuscarinics
- Oral antimuscarinics (oxybutynin, darifencin, solifencin, fesoterodine, tolterodine)
- ER formulation better (less xerosis)
- +/- transdermal oxybutynin - Sacral neuromodulation; Peripheral tibial nerve stimulation; Intradetrusor botox
Non-pharmacologic Tx choice for urinary incontinence
Behavior changes: fluid and caffeine intake, stop smoking, wt loss, prevent constipation
PT: gait/strength training
Timed voiding: Toilet every 2 hours while awake (good for pt with cognitive or physical impairment)
Bladder training: timed voiding, urgency suppression strategies, reinforcement
Pelvic floor muscle training: Kegals
External neuromodulation (non-pharm) Tx choices for UI are
Acupuncture Alarms, pesaries undergarments Radiofrequency heat (more collagen) Estrogen therapy
What are the ADE of anti-cholinergics (Tx UUI)
anticholinergic effects (dry, hot, blind, mad, red) If topical: pruritis, erythema **Avoid open fire or smoke until alcohol based gel has dried
CI to anticholinergics include
urinary retention angioedema MG narrow angle glaucoma AMS or fall risk in elderly *Monitor renal or hepatic condition, esp if on concomitant medication
What is Mirabegron
Stimulates B3 receptors in the bladder smooth muscle= bladder relaxes and can store more
Good Tx for overactive bladder, elderly (less ADE than anticholinergics)
Who should not take Mirabegron
Those with ESRD or severe hepatic impairment
Caution is w/ bladder outlet obstruction or if on an antimuscarinic
Caution if with CVD
ADE of Mirabegron are
High BP (do not use if w/ uncontrolled HTN >180/110)
What are drug interactions of Mirabegron
It is a CYP2D6 inhibitor, so it interacts with CYP2D6 substrates (TCA, SSRI, BB, antipsychotics, type 1 anti-arrhythmics)
Does NOT interact with cholinergics
How is botox used
It temp paralyzes smooth or striated uscle; AKA detrusor muscle in bladder
Takes 3-7 days, lasts 6-8 months
ADE of botox as an OAB Tx are
dysuria
hematuria
UTI
urinary retention
What is Duloxetine
Cymbalta! an SNRI that helps control ascending and descending urethral smooth muscle, and external urinary sphincter (increases sphincter muscle tone)
What are ADE of Duloxetine
nausea HA constipation dry mouth insomnia
What are the alpha agonists used to Tx SUI, and their ADE
Norfenefrine, norephedrine
ADE: HTN, HA, dry mouth, nausea, insomnia, restless`
What are contraindications to using alpha agonits
HTN tachyarrhythmia CAD MI cor pulmonale hyperthytoid renal failure narrow angle glaucoma
What med is good for pediatric bedwetting
Imipramine
What is a good med for overflow (atonic) bladder
Bethanecol, a Cholinomemitic (cholinergic); increases PNS= forceful contraction of bladder. good for post-op or to Tx BPH
ADE: cholinergic side effects (MUDPILES)
