Urinary Incontinence (Exam 1 Cut Off)

Question 1

Bladder Control

Answer 1

• Inhibited by CNS, frontal lobe
• Parasympathetic - detrusor muscle around bladder to contract
• Sympathetic - internal sphincter (alpha stimulation causing contraction)

Question 2

Mechanism of Stress UI

Answer 2

• Stress UI: during exertion, urethral sphincter no longer able to resist flow, intra-abdominal pressure exerted
• Risk factors: pregnancy, childbirth, menopause, obesity, age, cognitive impairment, TURP

Question 3

Mechanism of Urge UI

Answer 3

• Overactive detrusor muscle that contracts during filling, involuntary
• Symptoms: >8 times per day, nocturnia, sudden urges
• Risk factors: aging, neurological disease, bladder outlet obstruction

Question 4

Overflow Incontinence

Answer 4

• Bladder filled to capacity at all times and unable to empty
• Urine leaks from distended bladder
• Large volumes of residual urine
• Urethral overactivity
• More common in men

Question 5

Bladder underactivity

Answer 5

• Detrusor progressively weakened: unable to contact
• Most common in long-term chronic bladder obstruction
• Occurs in both sexes

Question 6

Mixed/Other UI

Answer 6

• Mixed: combinations can coexist

- Functional UI: dementia, cognitive or mobility impairment, UTI, constipation

Question 7

Medications + UI

Answer 7

• Diuretics
• alpha antagonists and agonists
• CCB
• Narcotics
• Sedative hypnotics
• Antipsychotics/anticholinergics
• Alcohol
• ACE-I

Question 8

Reversible Causes of UI

Answer 8

DIAPPERS
D - Delirium
I - Infection
A - Atrophic vaginitis/urethritis
P - Psychiatric disorders
P - pharmacological treatments
E - Excessive urine output
R - Restricted mobility
S - Stool impaction

Question 9

Nonpharm Treatment - UI

Answer 9

• Behavioral interventions
• Lifestyle modifications
• Anti-incontinence device
• Toileting substitutes
• Absorbent products
• Catheters

Question 10

Prevention of Skin Breakdown

Answer 10

• Skin protectants: petrolatum, butt paste, lanolin
• Moisturizers
• Cleansers

Question 11

Pharmacologic Treatment - UI

Answer 11

• Interfere with hyperactive detrusor muscle
• Anticholingeric activity
• Review AC drugs
• Oxybutynin - best drug for UI, can be pull/patch
• Major SE: dry mouth, dry eyes, constipation
• Better selectivity for urinary bladder than tolterodine

Question 12

Tolterodine

Answer 12

• Detrol
• Similar efficacy for ER/IR
• Reduce dose for renal/hepatic insufficiency
• SE: dry mouth

Question 13

Solifenacin Succinate

Answer 13

• Vesicare
• More selective for M3 muscarinic receptors in bladder/GI tract
• Less effective at lower doses than tolterodine

Question 14

Darifenacin

Answer 14

• Enablex

- More selective for M3 in bladder and GI tract

Question 15

Trospium

Answer 15

• Sanctura
• Reduce for once a day for elderly
• ADR: dry mouth
• Take on empty stomach

Question 16

Fesoterodine

Answer 16

• Toviaz

- SE: Dry mouth

Question 17

TCA

Answer 17

• Imipramine, nortriptyline, or desipramine

- If additional indication

Question 18

Mirabegron

Answer 18

• Myrbetriq
• Beta3 adrenoreceptor agonist
• Approved for urge UI
• Renal adjustments: CrCl between 15-29 mL/min: do not exceed 25 mg, <15 mL/minute not recommended
• Common treatment, considered very safe

Question 19

UI Guidelines

Answer 19

• Behavior therapy first
• Anti-muscarinics first, preferably ER formulation (lower rates of dry mouth)
• Unacceptable reactions should change doses or medications
• Use SNS or PTNS to those who can’t use or are refractory to other treatments

Question 20

Anti-muscarinic CI

Answer 20

• Narrow-angle glaucoma
• Impaired gastric emptying/history of urinary retention (extreme caution)
• Caution with multiple anticholinergics and frail OAB patients
• Manage constipation/dry mouth before abandoning

Question 21

Stress/Mixed UI Pharmacologic Treatment

Answer 21

• 1st line: pelvic floor muscle training
• Consider contributing causes
• Continence pessary/vaginal inserts
• Surgery
• Estrogens: modifies muscarinic receptors on detrusor, increases closing pressure on sphincter, do NOT use oral estrogen

Question 22

Overflow Incontinence: Secondary to BPH

Answer 22

• Alpha antagonists: block NE on urinary sphincter

- 5alpha - reductase inhibitor: reduce prostate sie

Question 23

Overflow Incontinence: Secondary to hypotonic/atonic bladder

Answer 23

• Catheterization

- Indwelling or intermittent

Question 24

Overflow Incontinence: Failure to Treatment

Answer 24

• Surgery
• Increase outlet resistance
• Decreasing detrusor instability
• Removing outlet obstruction
• Electrical stimulation for refractory urge incontinence

Question 25

SNRI

Answer 25

• Investigational Therapy
• Duloxetine
• Stimulate contraction urethral sphincter muscle
• Approved for UI in Europe
• Can cause QT prolongation, liver toxicity

Question 26

Other Investigational Therapies

Answer 26

• Neurokinin-1 Receptor Antagonists: Aprepitant and Serlopitant
• SMP-986: blocks sodium channels and muscarinic receptors, effects bladder contraction
• Magnetic stimulation therapy
• Tachykinins - may mediate bladder/spinal reflex signaling