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Pharmacy 301 > 301 Urinary incontinence and UTIs > Flashcards

301 Urinary incontinence and UTIs Flashcards

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1
Q

What is nocturnal enuresis?

A

Involuntary urination happens at night while sleeping, after age when person should be able to control his or her bladder

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2
Q

What is urinary incontinence?

A

Urinary incontinence (UI) also known as involuntary urination is any uncontrolled leakage of urine
Sensation of full bladder does not wake child

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3
Q

What is nocturnal enuresis caused by?

A

Caused by over production of urine at night, exceeding capacity of bladder to hold

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4
Q

Causes of bedwetting

A

Insufficient secretion of antidiuretic hormone (ADH) at night
Bladder dysfunction
Impaired brain arousal

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5
Q

Vasopressin mechanism:
Stimuli for Vasopressin Release
Release Site
Effects of Vasopressin
Overall Effect

A
  1. Hyperosmolarity, angiotensin II, decreased atrial receptor firing & sympathetic stimulation
  2. Posterior Pituitary
  3. V₁ Receptors (Blood Vessels): Constriction → Increased Systemic Vascular Resistance, V₂ Receptors (Kidneys): Fluid reabsorption → Increased Blood Volume
  4. Increased Arterial Pressure
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6
Q

ADH hormone (vasopressin) released by and acts on?

A

Pituitary gland
Acts on V2 receptors in distal kidney tubule to increase water reabsorption

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7
Q

Diabetes insipidus

A

ADH is reduced or absent, lack of sensitivity, leading to production of large volumes of dilute urine

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8
Q

Risk factors of bedwetting

A

Bedwetting family history
Male gender (2:1 male to female ratio)
Delay in attaining bladder control
Obesity
Psychological/behavioural disorders, such as ADHD, autism spectrum disorder & anxiety, depressive & conduct disorders

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9
Q

Underlying causes of bedwetting

A

Constipation
Diabetes
UTIs - if symptoms are recent
Behavioural or emotional problems
Family problems

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10
Q

Types of bedwetting

A
  1. Primary bedwetting without daytime symptoms - re-assure & provide non-pharmacological/pharmacological management
  2. Primary bedwetting with daytime symptoms - refer to specialist teams
  3. Secondary bedwetting - identify underlying cause, especially if child has been dry at night for 6 months
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11
Q

What is desmopressin?

A

Analogue of ADH and selective to V2 receptors in kidneys

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12
Q

How does desmopressin work?

A

Reduces amount of urine body produces at night; this mimics action of body’s own naturally occurring ADH

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13
Q

Management of nocturnal enuresis

A

Avoid blame and reassure parents
Bedwetting common in children under 5
Give advice on:
Diet and fluid intake
Toileting patterns
Lifting and waking
Positive reward systems

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14
Q

Enuresis alarms

A

1st line
High long-term success rate
Recommended for children 7+
Can be used younger but based on maturity & motivation

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15
Q

Desmopressin onset and short term improvement

A

Provides rapid onset in improvement or when short-term improvement is required
Start low & titrate up on response
Continue 3 months then stop for 1 week to check dryness

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16
Q

What should be cautioned with desmopressin?

A

Due to fluid retention, reduce fluid intake as blood becomes dilute and can cause hyponatraemia
Reduce fluids 1 hour before medication and 8 hours after

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17
Q

Patient and carer advice for desmopressin and hyponatraemic convulsions

A

Patients being treated for primary nocturnal enuresis should be warned to avoid fluid overload (including during swimming)
Stop taking desmopressin during an episode of vomiting or diarrhoea (until fluid balance normal)
* Patients being treated for primary nocturnal enuresis should be warned to avoid fluid overload (including during swimming)
Stop taking desmopressin during an episode of vomiting or diarrhoea (until fluid balance normal)

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18
Q

Imipramine

A

TCA
Last-line and used only when everything else failed

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19
Q

How does imipramine work?

A

Combination of increasing bladder activity (anticholinergic effects), improving arousal from sleep and enhancing bladder sphincter control (smooth muscle tone)

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20
Q

When should you consider imipramine?

A

Children and young people with bedwetting who have not responded to all other treatments & have been assessed by healthcare professional with expertise in management of bedwetting that has not responded to alarm and/or desmopressin

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21
Q

Why is imipramine and antimuscarinics often discontinued?

A

Side effects

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22
Q

Role of autonomic NS on bladder control

A

Parasympathetic - contract bladder
Sympathetic - relax bladder

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23
Q

Bladder control mechanism:
Bladder muscle (detrusor)
Bladder neck

A
  1. M₃ Receptors (Cholinergic - ACh): Contraction
    β₃ Receptors (Adrenergic - NA): Relaxation
  2. M₃ Receptors (Cholinergic - ACh): Relaxation
    α₁L Receptors (Adrenergic - NA): Contraction
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24
Q

Types of incontinence:
Stress urinary

A

Result of weakening/damage to muscles used to prevent urination, such as pelvic floor muscles & urethral sphincter, when physical activity or movement puts pressure on bladder

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25
Types of incontinence: Urgency urinary
Result of overactivity of detrusor muscles, controls bladder resulting in intense, sudden urge to urinate, associated with overactive bladder syndrome
26
Types of incontinence: Mixed urinary
Combination of both stress and urge of incontinence which results in patients experiencing symptoms of both types
27
Types of incontinence: Overflow
Caused by obstruction or blockage in bladder, preventing it from emptying fully
28
Drug induced incontinence
Alpha-1, adrenoceptor antagonists (alfuzosin, doxazosin, tamsulosin) Antipsychotics (chlorpromazine & haloperidol) Anticholinergics - (causes retention so can cause 'overflow') Anti-parkinsonism drugs Antidepressants BZDs Beta blockers Diuretics HRT
29
Urinary incontinence management in women
Reduce caffeine intake Fluid intake - avoid drinking excessive or reduced amount of fluid each day Weight loss, especially if BMI is 30kg/m2 or greater Smoking cessation Supervised pelvic floor muscle training - especially after pregnancy Surgery Medication
30
Choice of medication for urinary incontinence in women
Antimuscarinics Mirabegron Duloxetine Desmopressin (Nocturia)
31
When are antimuscarinics recommended in incontinence?
Recommended for urge incontinence and overactive bladder syndrome (OAB)
32
Low acquisition cost antimuscarinic drugs for incontinence
Oxybutynin (immediate release) Tolterodine (immediate release) Or darifenacin (once daily preparation) can be used for 1st line
33
What to offer women with incontinence when unable to tolerate oral antimuscarinics?
Offer a transdermal OAB drug to women unable to tolerate oral medication
34
Side effects of antimuscarinics
Dry mouth (high in oxybutynin IR) Dry eyes, constipation, blurred vision Reduced cognitive function (oxybutynin reduces, while trospium does not cross BBB) Avoid close-angle glaucoma QT prolongation (high oxybutynin, sometimes tolterodine, none trospium but studies only in healthy adults) Antimuscarinic load e.g. amitriptyline Diagnosis of dementia
35
What do adrenergic receptors do and why do they have a role in OAB treatment?
Stimulation of beta receptors leads to activation of adenylyl cyclase to release cAMP and inhibition of detrusor muscle Beta3-receptors are present in bladder wall and beta 3 agonists have a role in OAB
36
Mirabegron and OAB
Recommended as 2nd line treatment for patients who cannot tolerate antimuscarinics or have minimal benefits from these meds
37
Mirabegron cautions in OAB patients
QT interval prolongation history Bladder outflow obstruction Patients taking CYP3A4 inhibiting drugs Renal impairment Hepatic impairment
38
What type of agonist is mirbegron?
Beta 3
39
Mirabegron and drug safety
Mirabegron is now contraindicated in patients with severe uncontrolled hypertension (systolic BP >80mmHg and diastolic >110mmHg or both) Regular monitoring of BP important, especially in patients with pre-existing hypertension
40
What is duloxetine used for?
Pharmacological treatment recommended for stress UI
41
How does duloxetine work?
Selective inhibitor of 5-HT and NE receptor sites and works centrally to activate pudendal nerve which facilitates the sphincter activity during urine storage but not during voiding Stronger closure of urethra during urine storage which may explain efficacy in SIU as physical stress induced
42
When should duloxetine not be used?
1st line for omen with predominant stress UI, can offer duloxetine as 2nd line for women with stress UI but only if they prefer drug treatment instead of surgery
43
Why is duloxetine failed for SUI in US approval?
Due to liver toxicity and suicidal events
44
UTI prevalence
More common in women (50% at some stage) but more serious in men (complicated UTIs)
45
Types of UTIs: lower UTI
Cystitis common bladder infection caused by bacteria from GI entering urethra
46
Types of UTIs: they can be...
1. Uncomplicated is UTI form affecting healthy individual with structurally & functionally normal urinary tract 2. Complicated UTIs occur in individuals with anatomical, functional or medical conditions increase infection risk or complicate treatment
47
Types of UTIs: upper UTI
An infection of upper part of urinary tract (ureters & kidneys) - pyelonephritis
48
Types of UTIs: recurrent UTI
2 or more episodes of UTI in 6 months or 3 or more episodes in 1 year
49
Types of UTIs: catheter-associated UTI
Women with a catheter in situ within previous 48 hours
50
UTIs and bacteriuria
Presence of bacteria in urine with patient being/or not being symptomatic
51
Uncomplicated symptoms of UTIs
1. Dysuria - discomfort, pain, burning, tingling or stinging with urination 2. New nocturia - waking at night >1 times to pass urine 3. Cloudy urine to naked eye 4. Urgency/frequency
52
Complicated symptoms of UTIs
1. Kidney pain/tenderness in back under ribs 2. New/different myalgia, flu like illness 3. Shaking chills (rigor) or temp >37.9 4. N + V
53
UTI: urinalysis results pH Blood Nitrites Leukocyte esterase
1. Represent urine acidity - raised in UTI 2. Amount of RBCs, Hb & myoglobin in urine - positive for blood in UTI 3. Breakdown product of G- organisms like E.Coli - positive for nitrites in UTI 4. Enzyme produced by neutrophils indicate WBC presence in urine - positive for leukocyte esterase in UTI
54
55
UTI complications
1. Acute or chronic pyelonephritis 2. Renal or peri renal abscess 3. Pyonephrosis 4. AKI or CKD Urosepsis 6. Increased risk of pre-term delivery or low birth weight 7. Reduced QoL
56
Uncomplicated UTI treatment
1st: treat according to culture sensitivity Nitrofurantoin 100mg MR BD for 3 days OR if low risk of resistance trimethoprim 200mg BD for 3 days 2nd: if no improved symptoms for 48 hours or C/Is Nitrofurantoin 100mg MR BD for 3 days (if not 1st) Pivmecilliam 400mg STAT, then 200mg TDS for 3 days Fosfomycin 3g single dose sachet
57
What changes from uncomplicated to complicated UTI treatment?
Length increases to 7 days
58
UTI in pregnancy
Complications of UTI to infant, consider when managing Perform mid-stream urine (MSU) for culture and sensitivity before antibiotic treatment Repeat C&S when antibiotic complete
59
UTI in pregnancy treatment depending on culture & sensitivity
- Cefalexin 500mg TDS for 7 days - Amoxicillin 500mg TDS for 7 days - Nitrofurantoin 100mg MR BD for 7 days (avoid 3rd tri) - Trimethoprim 200mg BD for 7 days (avoid in 1st tri)
60
ESBLs (extended-spectrum beta-lactamases)
- Resistant to many penicillin & cephalosporin antibiotics - 2 main bacteria that produce ESBLs are E.coli & Klebsiella species - ESBLs E.coli produce most often are CTX-M enzymes - E.coli with ESBLs may cause UTIs which progress to blood poisoning, can be life-threatening
61
UTIs: E.coli & B-lactam antibiotics
E.coli most common organism degrade B-lactams with extended spectrum (such as 3rd generation cephalosporins)
62
UTI: resistance agents
- If UTI resistant to trimethoprim, nitrofurantoin & amoxicillin then after C&S pivmecillinam 400mg STAT then 200mg TDS - For ESBL producing organisms, pivmecillinam 400g TDS for 7 days (a penicillin but low C.diff risk) or fosfomycin 3g granules (hospital outpatients)
63
Recurrent UTIs (non-pregnant)
Rule out RED flags if haematuria present Choice is single dose antibiotic after exposure to trigger or low-dose daily antibiotic as prophylaxis
64
Recurrent UTIs (non-pregnant) treatment
- Trimethoprim 100mg nocte or nitrofurantoin 50-100mg nocte for 6 months then review, soe rotate to avoid resistance but evidence weak - Or amoxicillin 250mg at night (off-label indication) or cefalexin 125mg at night - Provide self-care advice - Cranberry product limited evidence - not NICE recommended & interacts with warfarin
65
UTI: self-care advice
- Analgesia (paracetamol, NSAIDs) - Adequate fluid intake - Don't recommend OTC cranberry products or urine-alkalising products - Avoid alcohol, fizzy drinks & caffeine - Wipe front to back (bacteria spread) - Urinate after sex - Vaginal douches & washes - be careful
66
67
UTI: catheter patients
- Avoid Foley catheters if possible Catheters usually colonise large no. of bacteria - Dipstick always positive - Treat with Abx when symptomatic e.g. fever & dysuria, not if asymptomatic
68
UTI: pathogenesis of UTI 1. Colonisation 2. Uroepithelium penetration 3. Ascension
1. Pathogen colonises periuretheral area & ascends through urethra upwards towards bladder 2. Fimbria allow bladder epithelial cell attachment & penetration, following penetration bacteria continue to replicate & form biofilms 3. Once sufficient bacteria colonisation, bacteria ascend on ureter towards kidney, fimbria aid ascension, bacterial toxins play role by inhibiting peristalsis (reduced urine flow)
69
UTI: pathogenesis of UTI 4. Pyelonephritis 5. AKI
4. Infection of renal parenchyma causes pyelonephritis, while infection of renal parenchyma usually result of bacterial ascension, can occur from haematogenous spread 5. If inflammatory cascade continues, tubular obstruction & damage occur, leading to interstitial oedema, may lead to interstitial nephritis causing AKI
70
UTI: pyelonephritis - acute
Caused by E.coli Symptoms: flank/renal angle pain, myalgia, flu-like symptoms, rigors or raised temp, N + V Complications: sepsis, renal scarring, recurrent UTIs, renal abscess, pre-term labour in pregnancy, emphysematous pyelonephritis
71
UTI: acute pyelonephritis treatment
Refer to specialist for high risk groups (pregnant, recurrent infection), rule out sepsis, MSU - Cefalexin 500mg BD or TDS for 7-10 days - Co-amoxiclav 500/125mg TDS for 7-10 days - Trimethoprim 200mg BD for 14 days - Ciprofloxacin 500mg BD for 7 days - only when other antibiotics inappropriate

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