Urinary incontinence

Question 1

What is the MC/Majority muscarinic receptor subtype found in smooth muscle of the bladder?

Answer 1

M2

Question 2

What are M3 receptors responsible for?

Answer 2

Emptying contractions of normal micturition AND

involuntary bladder contractions

Question 3

What are most pharmacological antimuscarinic therapy aimed at?

Answer 3

Anti-M3

Question 4

What are the pharmacological therapies of choice in urge incontinence (bladder overactivity)?

Answer 4

Anticholinergic/antispasmodic agents

Question 5

What are the pharmacological therapies of choice in stress incontinence (urethral underactivity)

Answer 5

1. α-adrenergic receptor AGONISTS
2. Topical (vaginal) estrogens

*Alone or Both

Question 6

Define Overflow Incontinence

Answer 6

Results of:

1. Uretheral overactivity
2. +/- Bladder under activity

Question 7

Overflow incontinence etiology

Answer 7

BPH

Question 8

Result of Overflow incontinence

Answer 8

urine leakage from a distended bladder past a normal or even overactive outlet and sphincter

Question 9

What is the goal of treatment in stress urinary incontinence?

Answer 9

Improve urethral closure mechanism by stimulating α-adrenergic receptors in smooth muscle of: Bladder neck and Proximal Urethra

Question 10

What medication aggravates SUI?

Answer 10

Alpha Blockers

Question 11

Define Urge Urinary Incontinence

Answer 11

1. Bladder overactivity

2. Involuntary bladder (detrusor) contraction

Question 12

Define urinary frequency

Answer 12

Micturition >8x/day

Question 13

Define urinary urge

Answer 13

Sudden compelling desire to urinate that is difficult to delay

Question 14

According to the AUA Guidelines, What is FIRST LINE treatment in overactive bladder in adults (OAB)?

Answer 14

Behavioral therapies:

1. Bladder training
2. Bladder control strategies
3. Pelvis floor muscle training
4. Fluid management

*Behavioral therapies may be combined with antimuscarinic therapies

Question 15

According to the AUA Guidelines, What is SECOND LINE treatment in overactive bladder in adults (OAB)?

Answer 15

Oral Antimuscarinics:

1. Darifenacin
2. Fesoterodine
3. Oxybutynin
4. Solifenacin
5. Tolterodine
6. Trospium

Question 16

According to the AUA Guidelines, What is THIRD LINE treatment in overactive bladder in adults (OAB)?

Answer 16

1. Sacral Neuromodulation: Severe refractory OAB sx’s, not candidate for 2nd line Tx
2. Posterior Tibial Nerver Stimulation
3. Intradetrusor Botox: Refractory to 1st/2nd line Tx

Question 17

Who is timed voiding used in? How often should they be voiding?

Answer 17

Pt’s with cognitive or physical impairments

Void every 2 hrs

Question 18

Define Habit retraining and what population it is recommended in

Answer 18

• Scheduled toiling with adjustments of voiding intervals (longer or shorter) based on pt’s voiding pattern
• Institutionalized or homebound patients w/ cognitive or physical impairments

Question 19

Who is bladder training recommended in?

Answer 19

Stress, Urgency, and mixed incontinence in pt’s who are:

1. Cognitive
2. Able to toilet
3. Motivated to comply with training program

Question 20

Who is pelvic floor muscle rehab/exercises recommended in?

Answer 20

Stress, Urgency, and mixed incontinence in pt’s who:

1. Can isolate and correctly contract pelvic floor muscles
2. Cognitive
3. Motivated

Question 21

What form of anticholinergics are associated with fewer anticholinergic ADE’s? What ADE in particular?

Answer 21

1. Extended Release (ER)
2. Long-Acting (LA)

*Dry Mouth

Question 22

anticholinergic CI?

Answer 22

1. Urinary/Gastric retention
2. Severely decreased GI motility
3. Angioedema
4. MG
5. Uncontrolled narrow-angle glaucoma
6. Elderly-Mental status change, risk of falls

Question 23

List the Beta-3 Agonist and MOA

Answer 23

Mirabegron*

Bladder smooth muscle relaxation–>Reduces frequency of rhythmic bladder contractions during filling phase–>increased bladder capacity–>improves OAB

Question 24

Mirabegron ADE

Answer 24

Increase BP: CI in pt’s with severe uncontrolled HTN (180/110)

Question 25

Mirabegron drug interaction

Answer 25

``` CYP2D6 Inhibitor Dose adjustments in CYP2D6 substrates: 1. TCA's 2. Antipsychotics 3. SSRI's 4. Beta Blockers 5. Type 1 antiarrhythmics ```

Question 26

What is an advantage of Mirabegron? Good alternative in what population?

Answer 26

Lack of anticholinergic ADE's Lack of adverse cognitive effects Consider in elderly

Question 27

Botulinum Toxin A Clinical Indications

Answer 27

Detrusor overactivity assoc. w/ Neuro condition & OAB

Question 28

Botulinum Toxin ADE's

Answer 28

1. Dysuria 2. Hematuria 3. UTI 4. Urinary retention

Question 29

Onset of Botulinum Toxin? Duration?

Answer 29

Onset=3-7 days post injection | Duration= 6-8 months

Question 30

List the dual inhibitor of Serotonin and NE Reuptake Inhibitor (SNRI) that is approved in Europe only. Clinical Application of this drug?

Answer 30

Duloxetine | Stress incontinence: Urethral Underactivity

Question 31

Duloxetine MOA

Answer 31

Facilitates bladder-to-sympathetic reflex pathway= | Increased urethral & external urethral sphincter tone

Question 32

Duloxetine ADE's

Answer 32

1. Nausea 2. HA 3. Constipation 4. Dry Mouth 5. Insomnia

Question 33

List the Alpha-Adrenergics. Clinical Application?

Answer 33

1. Phenylpropanolamine (withdrawn) 2. Norfenefrine 3. Norephedrine *Stress incontinence

Question 34

Alpha-Adrenergics ADE's

Answer 34

1. HTN 2. HA 3. Dry mouth 4. Nausea 5. Insomnia 6. Restlessnees

Question 35

Why was Phenylpropanolamine withdrawn?

Answer 35

Risk of stroke

Question 36

Alpha-Adrenergics CI's

Answer 36

1. HTN 2. Tachyarrhythmias 3. CAD 4. MI 5. Narrow-angle glaucoma 6. Cor Pulmonale 7. Renal Failure 8. Hyperthyroidism

Question 37

List the Cholinomimetic. Clinical application?

Answer 37

Bethanecol: Overflow (atonic Bladder) 1. BPH 2. Severe urinary retention

Question 38

Bethanecol ADE's

Answer 38

SLUDGE