Phar 454 - Urinary Incontinence

Front 1

What is the defintion of Urinary Incontinence?

Back 1

The inability to voluntarily control urine loss

Front 2

How does age increase the risk of UI?

Back 2

Incidence increases with age

Front 3

"UI is only normal in _____"

Back 3

Babies

Front 4

What are the complications of UI?

Back 4

Distress, Depression, Social Withdrawal, Isolation

Front 5

What is the prevalence of UI?

Back 5

Affects ~20% of home care clients,
25% of older hospital patients,
Up to 50% of nursing home residents

Front 6

Which of the muscarinic receptors are responsible for the Bladder Smooth Muscles?

Back 6

M2 and M3

Front 7

What are the age related changes to the Urinary Tract?

Back 7

1) Decrease in bladder capacity & elasticity

2) Decrease in strength of Detrusor Muscle

3) Increase in spontaneous detrusor muscle contractions

4) Decrease in ability to postpone urination

5) Decrease in Urethral closing pressure

6) Decrease in Estrogen in post-menopausal women

7) Increase prostate size in older women

Front 8

What are the risk factors for developing UI?

Back 8

i) Females (if childbirth, high impact exercise, hysterectomy)

ii) Males (Prostate disease)

iii) Age: Risk increases with age

iv) Neurologic Conditions (Stroke/PD/AD/MS/Spinal Cord Injury/Cognitive Impairment)

v) Other conditions: DM/HD/Some Cancers, Obesity, Chronic Cough, Smoking

vi) Potentially reversible factors: Fecal Impaction, Alcohol, Caffeine Intake, Some meds

Front 9

What are the common causes of UI?

Back 9

D = Delirium

I = Infection

A = Atrophic Vaginitis

P = Pharmaceuticals

P = Psychological

E = Excessive Urine Output

R = Reduced Mobility/Retention

S = Stool Impaction; Also Stress

Front 10

What are the types of Urinary Incontinence?

Back 10

1) Stress Incontinence: Occurs with some physical activity

2) Urge Incontinence

3) Mixed Incontinence: Equally as often either physical activity and with sense of urgency

4) Overflow Incontinence: Usually caused by an under-active bladder/outlet obstruction

5) Functional Incontinence: Due to factors outside the GU system

Front 11

What are examples of how Anti-cholinergic drugs can cause Urinary Incontinence?

Back 11

Inhibits bladder contraction --> Urinary Retention/Sedation/Constipation

[FAH, TCAs]

Front 12

What are examples of how Narcotic Analgesic drugs can cause Urinary Incontinence?

Back 12

Interferes with bladder contraction --> Urinary Retention/Constipation/Sedation

[Opiates]

Front 13

What are examples of how NSAIDs can cause Urinary Incontinence?

Back 13

Blocks production of PGE2 (which is involved in detrusor contraction)

Front 14

What are examples of how Diuretics can cause Urinary Incontinence?

Back 14

In high doses or when taken later in the day

[Furosemide, HCTZ]

Front 15

What are examples of how Psychotropis can cause Urinary Incontinence?

Back 15

Increased Anticholinergic Side Effects; Impairs cognition, Decreased Bladder Awareness, Slow Mobility

[Sedatives, Antidepressants, Antipsychotics]

Front 16

What are examples of how ACEIs can cause Urinary Incontinence?

Back 16

May cause a cough which can precipitate Stress UI

[Captoprils, Ramiprils]

Front 17

What are examples of how CCBs can cause Urinary Incontinence?

Back 17

Impairs Bladder Contractions --> May cause retention/constipation

[Nifedipine, Diltiazem, Verapamil]

Front 18

What are examples of how α-Adrenergic Agonists can cause Urinary Incontinence?

Back 18

Increases Sphincter Tone --> Urinary Retention/Contributes to Overflow Incontinence

[Nasal Decongestants: Pseudoephedrine]

Front 19

What are examples of how α-Adrenergic Blockers can cause Urinary Incontinence?

Back 19

Decreases Urethral Sphincter Tone --> Contributes to Incontinence

[Terazosin, Doxazosin]

Front 20

What are examples of how β-Adrenergic Blockers can cause Urinary Incontinence?

Back 20

Interferes with Urethral relaxation and leaves α-adrenergic activity is unopposed

[Propranolol]

Front 21

What are examples of how Acetylcholinesterase Inhibitors can cause Urinary Incontinence?

Back 21

Increased OAB Symptoms

Front 22

What are the goals of therapy for Urinary Incontinence?

Back 22

1) Relieve Symptoms

2) Prevent Complications

3) Avoid Treatment side effects

4) Increases functional capacity of bladder

5) Improves QOL

Front 23

What are the treatment measures for UI?

Back 23

1) Lifestyle Choices

2) Address issues of Restricted Mobility

3) Address functional incontinence issues

4) Behavioural Stages

5) Intermittent Catherization

6) Protective Undergarments

7) Medications

Front 24

What are the lifestyle choices that can help UI?

Back 24

1) Moderate intakes of foods and beverages that cause Diuresis

2) Manage constipation/bowel obstruction

3) Maintain fluid intake (1.5-2.0 L/day); limit after 6pm

4) Increased fluids in frail elderly may decrease Urge Incontinence

5) Lose Weight if BMI>30kg/m2

6) Stop Smoking

7) Modify high impact exercise if necessary

Front 25

How can you address issues of restricted mobility for UI?

Back 25

Easy to remove clothing, Improve environmental issues: Toilet accessibility, lighting

Front 26

How can you address functional incontinence issues for UI?

Back 26

Physical, Mobility, Stroke, Arthritis, Cognitive Issues: Psychological Unwillingness

Front 27

What are examples of Behavioural Strategies for UI?

Back 27

1) Habit training: Go right after dinner, same time everyday

2) Prompted Voiding: Go when they need to

3) Bladder training: Strict timing of bladder

4) Pelvic Floor Muscle Traning (PFMT)" More effective if <50yrs old, minimum of 3 months

5) Intravaginal Pessaories for Stress UIs

Front 28

Intermiteent Catherization is recommended for which type of UI?

Back 28

Overflow Incontinence

Front 29

What are the characteristics of Urge Incontinence/Overactive Bladder Wet?

Back 29

Preceded by sudden, compelling desire to pass urine; with symptoms of Overactive bladder (frequency, urgency, nocturia) and often results in leakage en route to bathroom

Front 30

What is the pathophysiology of Urge Incontinence?

Back 30

1) Overactive detrusor during filling phase caused by Inflammation/Irritation

2) Impaired brain centre (stroke/Parkinson's/Dementia)

3) Medications

4) Metabolic Disorders (Encephalopathy )

Front 31

"Medications are an integral part of therapy for Urge Incontinence" True or False?

Back 31

TRUE

Front 32

What is the goal of therapy for Urinary Incontinence?

Back 32

To decrease amplitude and frequency of detrusor contractions

Front 33

What are the treatment options for Urge Incontinence?

Back 33

1) Anticholinergics

2) Onabotuliniumtoxin A (Botox)

3) Mirabegron

4) Tricyclic Antidepressants

5) Flavoxate

Front 34

What is the concern with Anticholinergics in the Elderly?

Back 34

Decline in Cognition

Front 35

What are the methods to help Anticholinergic therapy to improve side effect profile/safety/compliance?

Back 35

i) Once daily dosing

ii) Alternate routes of administration

iii) Muscarinic subtype selectivity (detrusor muscle M2, M3)

iv) In Elderly; Start Low & Titrate Up

v) If patient has minimal response after 4 weeks discontinue the drug

vi) If patient has adequate responses; aim for lowest effective dose (re-asseess in 6-12 months)

Front 36

What is the evidence for Onabotulinium Toxin A (Botox) for Urge Incontinence?

Back 36

Both groups had similar reduction (~3/day) over 6 months, However botox group potentially had better response 6 months after discontinuing treatment

Front 37

What is the MOA of Mirabegron for Urge Incontinence?

Back 37

Selective Beta-3 Agonist

Front 38

What are the contraindications of Mirabegron for Urge Incontinence?

Back 38

1) Pregnancy

2) Severe Uncontrolled Hypertension defined as SBP >180mmHg and/or DBP>110mmHg

Front 39

What are the warning signs of Mirabegron for Urge Incontinence?

Back 39

1) Signals in studies that increased risk of Neoplasms (breast,lung)

2) Measure BP at baseline and periodically

3) Dose dependent QTC prolongation, HR increase

Front 40

What are the anticholinergics used for Urge Incontinence?

Back 40

1) Darifenacin

2) Oxybutyrin

3) Solifenacin

4) Tolterodine

5) Trospium

Front 41

What is the receptor affinity for Darifenacin?

Back 41

M3 Selective

Front 42

What is the receptor affintiy for Oxybutyrin?

Back 42

M1, M2, M3, M4 Selective

Front 43

What is the receptor affinity for Solifenacin?

Back 43

M3 Selective

Front 44

What is the receptor affinity for Tolterodine?

Back 44

M1, M2, M3, M5 Selective

Front 45

What is the receptor affinity for Trospium?

Back 45

M2 & M3 Selective

Front 46

Which of the anticholinergics used are excreted by the heapatic method?

Back 46

Darifenacin, Oxybutyrin, Solifenacin, Tolterodine

Front 47

Which of the anticholinergics used are excreted by renal method?

Back 47

Trospium

Front 48

"Oxybutyrin is a prodrug" True or False?

Back 48

FALSE

Front 49

Which of the anticholinergics can cause QTC prolongation?

Back 49

Solifenacin, Tolterodine

Front 50

Which of the anticholinergics require a dose reduction if CrCl <30ml/min?

Back 50

Solifenacin, Trospium

Front 51

What is the efficacy of Anticholinergics compared to placebo?

Back 51

1) Anticholinergics reduces leaks (0.58/day)

2) Anticholinergics reduced micturations (0.64/day) [NNT=7]

Front 52

What is the efficacy of Oxybutyrin compared to Tolterodine?

Back 52

1) Oxybutyrin has more dry mouth (no differences in incontinence outcomes)

2) No difference between ER vs IR (except less dry mouth)

Front 53

What is the efficacy of Darifenacin compared to Oxybutyrin and Tolterodine?

Back 53

No difference to Oxy or Tolt

Front 54

What is the efficacy of Solifenocin compared to Oxybutyrin and Tolterodine?

Back 54

Less dry mouth than Oxy, Inconsistent vs Tolteridone

Front 55

What is the efficacy of Oxybutyrin Topical Gel?

Back 55

1) Pts with >5 daily episodes at baseline experience a 71% median reduction in incontinence episodes

2) Pts with 2-3 daily episodes at baseline experience an 89% reduction in incontinence episodes associated with OAB

Front 56

What are the relevant drug interactions of Oxybutyrin and Tolterodine?

Back 56

Metabolized by CYP3A4

Front 57

What are the relevant drug interactions of Trospium?

Back 57

Food/Digoxin/Metformin/Morphine/Vancomycin

Front 58

What are the relevant drug interactions of Darifenacin?

Back 58

Azoles/Imipramine

Front 59

What are the relevant drug interactions of Solifenacin?

Back 59

Azoles

Front 60

What are the contraindications of Anticholinergics?

Back 60

1) Urinary Retention

2) Uncontrolled Narrow Angle Glaucoma

3) Myasthenia Gravis

Front 61

What are the most common side effects of Anticholinergics?

Back 61

Constipation/Gastric Disturbances

Front 62

"Patients taking Solifenacin were less likely to discontinue treatment compare to patients taking Oxybutyrin" True or False?

Back 62

TRUE

Front 63

What causes Stress Incontinence?

Back 63

Occurs during activities that increase intra-abdominal pressures , due to urethral hypermobility and external sphincter deficiency

Front 64

"Stress Incontinence only occurs in the elderly patients" True or False?

Back 64

False; May occur at any age

Front 65

When does Stress Incontinence occur in Women?

Back 65

1) More common among post-menopausal women

2) In pre-menstrual women: during high impact activity, in weeks prior to menstruation, post child birth

Front 66

When does Stress Incontinence occur in Men?

Back 66

More common after prostatectomy

Front 67

What is the goal of therapy for Stress Incontinence?

Back 67

To increase proximal urethral pressure primarily stimulated by α-adrenergic receptors and to increase tone of pelvic floor muscle

Front 68

What is the recommended 1st steps for Stress Incontinence?

Back 68

i) Lifestyle Adjustments (Smoking Cessation, Achieve Optimal BMI, Control Fluid Intake)

ii) Pelvic Floor Exercises

iii) Electrical Stimulation

iv) Biofeedback

Front 69

What is the recommended 2nd steps for Stress Incontinence?

Back 69

i) Surgical Options [Women] (Bladder neck suspension, implantation of sacral nerve stimulation or artificial sphincter, Tension free vaginal tape, suburethral slings)

ii) Consider risks of surgery

iii) Alternatives: Injections of Bulking Agents

Front 70

What is the recommended 3rd steps for Stress Incontinence?

Back 70

i) Estrogen in women with post menopausal urogential atrophy

(oral: Increased risk of Stress UI, Vaginal: Inconsistent evidence)

ii) Conjugated Estrogen vaginal cream

iii) Estradiol 17β vaginal rings/tablets

Front 71

What are other medications that have been considered for Stress Incontinence?

Back 71

1) Pesudoephedrine: Ineffective

2) Tricyclic Antidepressants: Imipramine (in elderly avoid or use cautiously)

3) Duloxetine: Limited Evidence [Avoid in severe renal impairment CrCl <30ml/min) [NSS for cure vs placebo]

Front 72

What causes of Overflow Incontinence?

Back 72

Usually caused by an under-active bladder and/or outlet obstruction

1) Due to urethral obstruction (e.g.BPH), Distended Bladder

2) Also due to Detrusor Sphincter dysnergia

3) Detrusor muscle and external urethral sphincter contract at the same time

Front 73

What are the symptoms of Overflow Incontinence?

Back 73

1) Nocturia, Dribbling, Straining, Incomplete Emptying

2) Sensation of Full Bladder

3) Weak, Slow urine stream; may stop and start

Front 74

What can cause Overflow Incontinence?

Back 74

i) Diabetic Neuropathy, Low spinal cord injury, Pelvic Surgeries

ii) Multiple Sclerosis, Fecal Impaction, Prostate Enlargements

iii) Use of anticholinergic and α-adrenergic agonist medications

Front 75

"Overflow incontinence is more common in women than in men" True or False?

Back 75

False; more common in Men

Front 76

What are the Treatment options for Overflow Incontinence?

Back 76

1) Address underlying causes

2) Reduces dose or discontinue medications that cause urinary retention

Front 77

What is Mixed Urinary Incontinence?

Back 77

Have characteristics of both urge and stress incontinence, Try to use a single drug to treat both bothersome symptoms

Front 78

What is Functional Urinary Incontinence?

Back 78

Due to factors outside the GU system (e.g. Psychological Unwillingness)

Front 79

How should the symptoms of UI be monitored?

Back 79

Patient: Daily,

Pharmacists: q4 weeks.

Monitor for a decrease in number of incontinence episodes

Front 80

What should be done if there is no improvement in 1-4 weeks of the UI symptoms?

Back 80

Increased dose/ Consult with MD/ Consider alternative product if no response with Max dose

Front 81

What are the functions of Absorbent Products?

Back 81

1) Absorb urine quickly

2) Lock In Wetness

3) Keep Skin Dry

4) Reduce Odour

Front 82

"Absorbent Products are the same as Sanitary Napkins" True or False?

Back 82

FALSE

Front 83

What are other functional barriers for UI?

Back 83

Liners, Pads, Step In Undergarments, Side Tape (pull off) Undergarments