Urinary Incontinence Flashcards
Urgency Urinary Incontinence (UUI)
-Bladder ___
-Involuntary loss of urine associated with ?
-Most often related to ____ due to invol bladder contractions
-Detrusor muscle contracts innapropriately during?
-Whats a symptom syndrome characterized by urinary urgency with or w/o incontinence ?
-__ and __ are DISTINCT and shouldnt be ?
-What should be negative?
-Diagnosis by ?
- OVERACTIVITY
- urgency
- detrusor (bladder) overactivity due to invol bladder contractions
- Urinary storage
- Overactive BLADDER (OAB)
- OAB, Detrusor overactivity , used interchangeably
- urinalysis and culture
- urodynamic studies
Stress Urinary Incontinence (SUI)
- ___ underactivity
- Involuntary loss of urine on ? (3)
- Decreased or inadequate ___
- Urethral muscles compromised and cant ?
Women > Men - RF for women ? (6)
- RF for men? (3)
- DIagnosis?
- urethral
- effort, physical exertion, sneezing/coughing
- urethral closure forces
- counter the intra abdominal forces during phsyical activity
- preg , childbirth, menopause, cognitive impairment, obseity and aging
- Prior LUT surgery , neurological disease or otehr injury compromising sphincter
- cough stress test
Causes of Urinary Incontinence (DIAPPERS)
-Describe
- delirium
- infection
- atrophic
- pharmacologic
- physchological
- endocrine/excess urine output
- restricted mobility
- stool impaction
Localized or Systemic Illnesses that can influence LUT function
1. D
2.D
3.U
4.D
5. C
6. P
7. Ne
8.Post
9. Congen
- dementia/delirium
- depression
- UTI (cystitis)
- DM
- COnstipation
- Pelvic malignancy
- Neuro disease (stroke, PD, MS, spinal cord injury)
- Post meno pausal atrophic urethritis or vaginitis
- congen malformations of Urinary tract
For each Symptom, differentiate between if the sx is present in UUI (bladder overactivity) or SUI (urethral UNDERactivity)
- Urgency
- Frequency WITH urgency
- Leaking during physical activity
- Amount of urinary leakage with each episode of incontinence
- Ability to reach toilet in time following an urge to void
- nocturnal incontinence
- nocturia
- Yes for UUI
- YES for UUI, rarely for SUI
- YES for SUI
- UUI = large if present, SUI = usually small
- UUI = no or barely, SUI = Yes
- UUI = Yes, SUI = rare
- UUI = usually, SUI = seldom
Signs of UI
1. Pt will NEED a PE and brief neuro assessment
-What 4 exams are included in the work up?
- abdominal exam
-neurologic assessment of perineum
-pelvic exam in women
-genital and prostate exam in men
Medication Therapy in OAB and UUI
1. Avoid anti-muscarinic agents in pts with ? (3)
- Antimusc agents used cautiously in which pt’s ? (4)
- Need to manage __ and ___ before abandoning effective antimusc therapy
- What are newer alternatives for UUI’s?
- Narrow angle glaucoma, severe impaired gastric emptying or severe urinary retention (Postvoid residual > 250-300 mL)
- Frail pt’s
-those w/mild impaired gastric emptying
-Hx of mild urinary retention
- on other meds with anticholinergic properties - constipation, dry mouth
- B3 agonists
Non pharm for UI :
Surgery vs Non pharm options
-Name a couple
- Surgery is rarely part of initial management
- lifestyle mods
- pelvic floor muscle rehab
- external neuromodulation
- alt medicine therapies
- anti - incontinence devices
- supportive interventions
- Scheduling regimens
TX of OAB in adults
- First line tx’s
(2) - Second line tx’s
(4) - 3rd line tx (2)
- Behavioral therapies (bladder training and control strategies, pelvic floor muscle training, fluid management)
-can be combined with pharmacologic therapies - Oral antimusc or B3 agonist
-ER formulations preferred
-TD Oxybutynin (patch or gel) may be offered
-Combo therapy with oral antimusc and B3 agonist acceptable for pt’s refractory to monotherapy w/either class of drug - Intradetrusor botulinum toxin A ( 100 units), in pt’s refractory to first and second line tx
-peripheral tibial nerve stim or sacral neuromod w/refractory OAB or candidates not eligible for second line therapy
UUI : Oxybutynin
1. Whats oldest and cheapest?
2. What effects? (ae’s?)
3. whats an issue?
4. What can we use for dry mouth ?
5. Which formulation produces less dry mouth? Bc of this, it is better ___ than IR
- DDI’s with ?
- Also avail in ___
- TDS is OTC for ?
-Bypasses ____ and __
-More __ and associated with ?
-Rotate __ to avoid local pruritis and erythema - whats ir dose?
- XL Dose?
- Patch?
- IR version
- substantial non urinary antimusc effects (dry mouth, constipation, dizzi, vision changes)
- Adherence
- Sugarless gum, candy, saliva sub
- XL formulation ,tolerated
- other anticholinergic drugs and CYP3A4 inhibs
- Topical gel (ETOH based)
- OAB in women > 18
-first pass hepatic and gut metab
- tolerable, improved QOL
-Application site - 2.5mg PO 2-4x daily
- 5-30 mg PO once daily
- 3.9 mg/day - 1 patch applied 2x weekly
Tolterodine : UUI
1. equal efficacy as oxybutynin but better ___ bc of ?
2. Hepatic metabolism using which enzymes
3. DDI with ?
4. major interaction with ? ***
5. How many weeks for max benefit
6. AE’s ? (5)
7. If concomitant use of Class 1a and 3 , what must u monitor?
8. Which formulation causes less dry mouth ? This improves OAB sx’s in men taking ?
- Dose for Tolterodine IR and Tolterodine LA?
- tolerated (less lipophilicty)
- CYP2D6 (for EM) , CYP 3A4 for PM
- CYP 3a4 inhibs
- Duloxetine
- 8 weeks
- dry mouth, dyspepsia, HA, constipation, Dry eyes
- QT prolongation
- Tolterodine LA (Once daily)
- alpha adrenergic BLOCKERS - IR : 1 mg twice daily
LA : 2 mg once daily
Fesoterodine Fumarate (UUI)
1. Indicated for sx’s of? (3)
2. Has more dry mouth than ?
3. Discontinue rate high due to AE’s such as ? (4)
- Urinary frequency, urgency, and urgency incontinence
- Tolterodine LA
- Dry mouth, constipation, dyspepsia, dry eyes
Trospium Chloride :
1. Caution in which creatinine clearance and age??
2. In above pt population , give the IR dose ___ and ER u should ___
3. Trospium IR has less __ than oxybutynin IR (but is non inferior)
4. Anticholinergic AE’s are more pronounced in ?
5. DDI’s with ? (6) P,M,V,E,A,M
6. The drug has poor __ and food reduces it by __
7. WHats the usual dose of IR?
- CrCL < 30 , Age >= 75
- 20 mg once daily, avoid!
- dry mouth
- age >= 75
- Procainamide , morphine, vancomycin, EtOH, antacids, metformin
- Bioavail (<10%), 70-80%
- 20 mg po BID
Other 2nd Gen AntiMusc
- Solifenacin Succinate
-has less dry mouth than?
-DDI With ? (2)
-What happens at higher doses? - Darifenacin
-Improves ___ and ___
-DDI With ?
- oxybutynin IR
- CYP3a4 inhib and inducers
-QT interval prolongation - QOL, urinary sx’s
- Substrates of CYP2D6
Mirabegron (UUI)
1. WHat kind of drug ?
2. Efficacy like Tolterodine ER such as lower # of ___ and __ and increased ____
3. Modestly effective but with non signif improvements in ?
4. When do u see the efficacy?
5. COmmon ADE”s? 4
6. PM of CYP2d6 can lead to ?
7. Dose?
Vibegron (UUI)
-Also a B3 agonist, only 1% anticholinergic ae’s
-Dose is 75 mg PO daily
- B3 adrenergic agonist
- incontinent episodes, micturations per 24 hrs, volume voided
- UUI
- 4-8 weeks
- HTN, Nasopharyngitis, HA (But less anticholinergic ae’s! only about 3%) , UTI
- Incr mirabegron concentrations
- 25 mg daily start
