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Endocrinology > Treatment of Urinary Incontinence > Flashcards

Treatment of Urinary Incontinence Flashcards

1
Q

Urinary Incontinence

A
  • Involuntary loss of urine at inappropriate times and places
  • Involuntary loss of urine to a degree sufficient to be a problem
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2
Q

Detrusor

A
  • Muscular layer of the bladder
  • Parasympathetic cholinergic receptors
  • Stimulation by acetylcholine causes detrusor CONTRACTION
  • Beta-3 stimulation causes RELAXATION
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3
Q

Internal sphincter

A
  • Located at bladder base at the proximal end of the urethra
  • Alpha adrenergic receptors
  • Stimulation causes CONTRACTION (closing) of the bladder outlet
  • Sympathetic nervous system
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4
Q

External sphincter

A
  • Located at the distal end of the urethra
  • Composed of striated muscle, under VOLUNTARY CONTROL
  • Somatic nervous system
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5
Q

What are the risk factors for urinary incontinence?

A
  • Immobility
  • Impaired cognition/delirium
  • Medications
  • Morbid obesity
  • Smoking
  • Environmental barriers
  • High-impact physical activities
  • Diabetes (polyuria could increase risk of having UI)
  • Stroke
  • Estrogen depletion
  • Pelvic muscle weakness
  • Pregnancy
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6
Q

What are the causes of transient/iatrogenic urinary incontinence?

A
  • D = Delirium
  • I = Infection
  • A = Atrophic vaginitis/urethritis (after menopause)
  • P = Pharmaceuticals
  • P = Psychological dysfunction
  • E = Endocrine (hypercalcemia the body tries to get rid of calcium [polyuria])
  • R = Restricted mobility
  • S = Stool impaction
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7
Q

What drug category causes sensory issues in urinary incontinence?

A

CNS acting drugs
(ex: Benzos–> being confused and not being able to interpret cues to avoid)

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8
Q

What drug category causes polyuria?

A
  • Diuretics
  • Lithium
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9
Q

What drug categories INCREASES bladder contractility (of the detrusor muscles)?

A
  • Beta blockers
  • Cholinergic
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10
Q

What drug categories DECREASE outlet resistance (of internal sphincter)?

A

Alpha blockers

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11
Q

What drug categories DECREASE bladder contractility (of the detrusor muscle)?

A
  • Anticholinergics
  • Beta agonist
  • NSAID
  • Calcium channel blockers
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12
Q

What drug categories INCREASE outlet resistance (of the internal sphincter)?

A
  • Alpha agonist
  • Narcotic analgesics
  • Estrogens
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13
Q

What is the first line for the treatment of urinary incontinence?

A
  • Non-surgical, non-pharmacological intervention
  • Bladder diary
  • Scheduled voiding
  • Pelvic floor exercises
  • Caffeine and alcohol reduction
  • Weight loss
  • Fluid management
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14
Q

What is the third line of treatment of urinary incontinence?

A
  • Intradetrusor onabotulinumtoxin A
  • Peripheral tibial nerve stimulation
  • Sacral neuromodulation
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15
Q

What is the 4th line of treatment of urinary incontinence?

A
  • Augmentation cystoplasty
  • Urinary diversion
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16
Q

What are some non-pharmacologic options?

A
  • Bladder-retraining
  • Catheterization
  • “Kegel” exercises–> pelvic floor exercises
  • Surgery
  • Hygiene
  • Undergarments and shields
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17
Q

What are some therapies/devices that could be used in treatment?

A
  • Device to support the bladder neck (pessary)
  • Urethral occlusive devices (plugs or shields)
  • External collection systems (condom caths)
  • Catheterization (indwelling, intermittent, suprapubic)
  • Surgical treatment
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18
Q

What are the different types of incontinence?

A
  • Functional
  • Urge
  • Stress
  • Overflow
  • Mixed
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19
Q

What is functional incontinence?

A

Involuntary loss of urine due to inability to use toilet or toilet substitute

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20
Q

What are the causes of involuntary incontinence?

A
  • Physical–> broken hip
  • Cognitive–> advanced dementia
  • Environmental factors–> bathroom location
  • Limited mobility (common cause)
  • Change in mental status (common cause)
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21
Q

What are the treatments of involuntary incontinence?

A
  • Eliminate causes
  • Scheduled voiding
  • Assistive devices
  • Behavioral therapy
  • Undergarments, pads
  • External collection devices
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22
Q

What are some complications from absorbent products?

A
  • Skin irritation and maceration
  • Urine odor
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23
Q

How do you treat skin irritation and maceration from absorbent products?

A
  • Change every 2-4 hours
  • Use skin protectants (barrier creams and ointments)
  • Pressure ulcers–need to contact PCP
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24
Q

How do you mitigate urine odor from absorbent?

A

Nonprescription chlorophyll tablets (Derifil, Pals, Nullo), available but rarely used

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25
Q

What is urge urinary incontinence (UUI)

A
  • Inability to delay voiding
  • Sudden loss of moderate to large amounts of urine, usually accompanies with a strong desire to void, known as urgency
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26
Q

What is the treatment of urge urinary incontinence?

A
  • Behavioral therapy
  • Pharmacological options
27
Q

Anticholinergic/antispasmodics

A
  • DOC
  • MOA: Antagonize muscarinic cholinergic receptors
28
Q

What are the side effects of immediate-release oxybutynin?

A
  • Dry mouth cited as major reason patients discontinue therapy
  • Constipation
  • Vision impairment
  • Confusion
  • Tachycardia
  • Orthostatic hypotension

However no clinically relevant DDIs

29
Q

Transdermal Oxybutynin

A
  • Apply twice weekly; every 3-4 days
  • Apply to abdomen, hip, or buttock area that is clean and dry
  • Bypasses first pass metabolism (less side effects)
30
Q

What are the side effects of transdermal oxybutynin?

A

Most common:
* Pruritis
* Erythema at the application site

  • Dry mouth, constipation, dizziness (occur less freqeuntly than IR)
31
Q

Oxybutynin chloride 10% gel

A
  • Apply contents of one sachet once daily to dry, intact skin on the abdomen, upper arms/shoulders or thighs
  • Rotate application sites, avoid use of same site on consecutive days
32
Q

What are some patient counseling points of Oxybutynin chloride 10% gel?

A
  • Should NOT be applied to recently shaved skin
  • Avoid smoking until gel has dried (EtOH based)
  • Wash hands IMMEDIATELY after application
  • To avoid potential transfer to another person, cover application site with clothing after gel has dried if skin-to-skin contact is anticipated
  • Can apply sunscreen 30 min before or after application
  • Showering 1 hour after application does NOT affect absorption
33
Q

Tolterodine (Detrol, Detrol LA)

A
  • MOA: Acts by muscarinic receptor blockade in the bladder wall and detrusor muscle
  • Can be considered as first line therapy
34
Q

What is the metabolism of tolterodine (Detrol, Detrol LA)?

A
  • Extensive first pass hepatic metabolism
  • Polymorphic metabolism:
    • Extensive metabolizers primary pathway involves the cytochrome 2D6 isozyme
    • Poor metabolizers primary pathway involves the cytochrome 3A4 isozyme (elimination may be inhibited by fluoxetine, macrolides, azoles, and grapefruit juice)
35
Q

What are the some patient counseling points of tolterodine (Detrol, Detrol LA)?

A
  • Recommened dose 1 mg BID (IR) or 2 mg (LA) QD for patients with REDUCED hepatic function and those receiving CYP3A4 and CYP2D6 inhibiting drugs
  • No renal dosage adjustment
  • LA product should be taken less than 2 hours before or 4 hours after antacid administration
36
Q

What is the side effects of tolterodine (Detrol, Detrol LA)?

A
  • Dry mouth
  • Dyspepsia
  • Headache
  • Constipation
  • Dry eyes
37
Q

What are side effects of Imipramine (Tofranil)?

A
  • Above plus ortho hypotension and EKG effects
  • Reserved for patients with additional indication (depression)
38
Q

Trospium chloride (Sanctura)

A
  • Poorly absorbed
  • Food reduces bioavailability by 70-80%
  • Cleared renally
  • Dose reduction to 50% if CrCl < 30 ml/min
39
Q

What is the patient counseling points of Trospium Chloride (Sanctura)?

A
  • Expected anticholinergic effects
  • Increased in patients > 75 yo, so reduce frequency to daily instead of BID
  • Administer 1 hour BEFORE meals or on an empty stomach
40
Q

Solifenacin succinate (Vesicare)

A
  • An antagnoist at M1, M2, and M3 muscarinic cholinergic receptors
  • “Uroselective”
  • If ECrCl < 30 ml/min or moderate hepatic impairment–> should NOT exceed 5 mg
  • Do NOT use in severe hepatic impairment
  • Do NOT exceed 5 mg if coadministered with potent CYP3A4 inhibitors
41
Q

What are the side effects of Solifenacin succinate (Vesicare)?

A
  • Dry mouth
  • Constipation
  • Blurred vision
  • Similar extent as tolterodine and oxybutynin
42
Q

Darifenacin ER (Enablex)

A
  • An antagnoist at M1, M2, and M3 muscarinic cholinergic receptors
  • Extensively metabolized by 2D6 and 3A4
43
Q

What are the side effects of Darifenacine ER (Enablex)?

A
  • Dry mouth
  • Constipation
  • And other anticholinergic effects
44
Q

What are the side effects of Fesoterodine fumarate (Toviaz)?

A
  • Dry mouth
  • Constipation
45
Q

Fesoterodine fumarate (Toviaz)

A

Starting dose is 4 mg once daily and could be increased to 8 mg except for severe renal insufficiency (ECrCl < 30 ml/min) and patients taking potent CYP3A4 inhibitors such as ketoconazole, itraconazole, and clarithromycin

46
Q

What are the anticholinergic/antispasmodics?

A
  • Oxybutynin
  • Tolterodine
  • Imipramine
  • Trospium chloride
  • Solifenacin
  • Darifenacin ER
  • Festerodine fumarate
47
Q

What is the MOA of Mirabegron (Myrbetriq)?

A

Activates beta-3 adrenergic receptors in bladder

48
Q

What are the side effects of Mirabegron (Myrbetriq)?

A
  • Elevations in BP
  • Nasopharyngitis
  • UTI
  • Constipation
  • Fatigue
  • Tachycardia
  • Abdominal pain
49
Q

What are some patient counseling points in Mirabegron (Myrbetriq)?

A

-Because of its hypertensive properties, mirabegron should NOT be used in patients with severe uncontrolled hypertension (systolic blood pressure of 180 mmHg or more and/or diastolic blood pressure of 110 mmHg or more)
-A moderate cytochrome P450 (CYP)2D6 inhibitor, may interact with drugs that are CYP2D6 substrates
* Dosage adjustments of drugs are metabolized by this enzyme may be needed
-NEED PERIODIC MONITORING OF BP
-Can be used for Alzheimer’s patients
-Some cardiovascular protective properties (not proven)

50
Q

What is the MOA of Vibegron (Gemtesa)?

A

Activates beta-3 adrenergic receptors in bladder

51
Q

What are the side effects of Vibegron (Gemtesa)?

A
  • Headache
  • UTI
  • Nasopharyngitis
  • Diarrhea
  • Nausea
  • URTI
52
Q

Post-void residual urinary incontinence

A
  • Normal–> < 50 mL
  • If no post-void residual—> urge incontinence
  • Anticholinergics is the best treatment
53
Q

Stress Urinary Incontinence

A
  • SMALL amount of urine loss upon coughing, sneezing, laughing, straining (due to INCREASED intraabdominal pressure)
  • Weakness of sphincter and pelvic floor muscles
  • Urethral hypermobility
54
Q

What is the treatment of stress urinary incontinence (SUI)?

A
  • Pelvic floor exercises (Kegel)
  • Behavioral therapy
  • Devices (Pessaries)
  • Pharmacological options
55
Q

Estrogen (topical)

A
  • For peri – or postmenopausal women with vaginal atrophy due to genitourinary syndrome of menopause (GSM)
  • Pharmacological option for stress urinary incontinence (NOT FDA approved)
56
Q

What is the MOA of estrogens (topical)?

A

Enhancement of urethral epithelium, local circulation, and numbers and/or sensitivity of urogenital alpha-adrenergic receptors in sphincter

57
Q

Duloxetine (Cymbalta)

A
  • Dual inhibitor of serotonin and norepinephrine reuptake
  • Serotoninergic and noradrenergic regions are involved in control of urethral smooth muscle and in the external urethral sphincter
  • Used in Europe, NOT US FDA APPROVED for stress urinary incontinence
58
Q

What are the side effects of Duloxetine (Cymbalta)?

A
  • Nausea (up to 46%)
  • HA
  • Insomnia
  • Constipation
  • Dry mouth
  • Small increase in BP
  • Withdrawal symptoms (sleep disturbances)
  • If drug is to be stopped, it should be reduced by 50% for two weeks before d/c
59
Q

Alpha-agonist

A
  • Use of nonprescription medications for incontinence is considered an off-label indications and should be prescribed by a physician
  • MOA: Affect urethral closure pressure and functional urethral length
  • No longer recommended because they are only MILDLY efficacious and have a high rate of AEs
60
Q

What are the side effects of Pseudo-ephedrine (Sudafed)?

A
  • HTN
  • HA (increased BP)
  • Dry mouth
  • Nausea
  • Anxiety
  • Insomnia
  • Restlessness
61
Q

What are some contraindications of alpha agonist?

A
  • HTN
  • Tachyarrhythmias
  • CAD
  • MI
  • Coronary pulmonale
62
Q

Overflow Incontinence (OFI)

A
  • Constant loss of SMALL volume of urine
  • Large volume of residual urine
  • Large, distended bladder
  • Symptoms include dribbling, sense of incomplete voiding, reduced force of stream, and urgency
63
Q

What are the treatments for Overflow incontinence (OFI)?

A
  • Relieve obstruction
  • Intermittent catherization
  • Pharmacologic options:
    • Alpha-1 adrenergic antagonist
    • Cholinergic agents (rarely used)
64
Q

What are some side effects of alpha-1 adrenergic antagonist?

A
  • Dizziness
  • Syncope
  • Orthostatic hypotension
  • HA
  • CNS effects

Endocrinology (10 decks)

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