Urinary Incontinence and Medical Management

1. Urinary Incontinence and Medical Management Mani Vijayan RN MS CCNS- Rx CCTC

2. Definition Urinary incontinence (UI): - a condition in which involuntary loss of urine is a social or hygienic problem and is objectively demonstrable.

4. Magnitude of Problem 13 million Americans affected 1/2 of those in nursing homes Females > males 1 in 4 will be affected older patients 2 : 1 (>65 years) younger patients 5 : 1

5. Cost of Care $16.3 billion dollars - 75 % spent on women

6. Pathophysiology

7. Causes Urinary Incontinence Transient : D. I. A. P. E. R D: Delirium or acute confusion I: Infection (symptomatic UTI) A: Atrophic vaginitis or urethritis P: Pharmaceutical agents P: Psychological disorders (depression, behavioral disturbances)

8. Transient cause cont E: Excess urine output (due to excess fluid intake, alcoholic or caffeinated beverages, diuretics, peripheral edema, congestive heart failure, or metabolic disorders such as hyperglycemia or hypercalcemia) R: Restricted mobility (limits ability to reach a bathroom in time) S: Stool impaction

9. Neurological causes Cortical lesion: stroke Spinal cord lesion Peripheral nerve disease: Diabetic peripheral neuropathy Metastatic carcinoma: epidural spinal cord compression

10. Pharmacological Anticholinergic, antipsychotic, antidepressants Alpha-adrenergic agonists Alpha-antagonist Diuretics ACE inhibitors Anti-parkinson

11. Types of UI Stress Urge (Overactive) Mix (Stress and Urge) Overflow Functional

12. Diagnostic evaluation AUA symptoms survey Bladder scan Urodynamic cystoscopy

13. Stress Incontinence urine leakage associated with increased abdominal pressure. exercise/activities change in position coughing sneezing

14. Management alpha-adrenergic agonists, which stimulate receptors that respond to norepinephrine, hormone and neurotransmitter.

15. Alpha-adrenergic Agonists  selectively stimulates alpha adrenergic receptors. - has two subclasses a1 and a2. a1 agonists: stimulates phospholipase C activity: vasoconstriction and mydriasis; used as vasopressors, nasal decongestants and eye exams

16. Alpha-adrenergic Agonists a2 agonists: inhibits adenylyl cyclase activity. - reduce brainstem vasomotor center-mediated activation;

17. Alpha-adrenergic Agonists Pseudoephedrine Norepinephrine ephedrine

18. alpha-adrenergic agonists Pseudoephedrine hydrochloride is found in cough and cold preparations and antihistamines. Sudafed . Adult - Nonextended release: 60 mg PO qidExtended release: 120 mg PO bid Pediatric - Not established

19. Hormone Hormone replacement therapy (HRT) maintain and restore the health of urethral tissues in women - vaginal estrogen is given at 0.5-2.0g per day.

20. Duloxetine - balanced inhibitor of serotonin and norepinephrine reuptake : - increases serotonin and norepinephrine levels in the sacral spinal cord, thereby enhancing pudendal nerve activity, which leads to increased contraction of the urethral sphincters

21. Urge Incontinence (Overactive) uninhibited bladder contraction from detrusor hyperactivity - abnormalities of the CNS inhibitory pathway - bladder inflammation

22. Management Anticholinergic Muscarinic receptor antagonist Antispasmodic Alpha-1-adrenergic blocking agents

23. Anticholinergic relax smooth muscle tissue and have an antispasmodic effect on overactive bladder.

24. Anticholinergic Agents Oxybutynin chloride (Ditropan�XL) Inhibits action of acetylcholine on smooth muscle and has direct antispasmodic effect on smooth muscle - Adult 5 mg PO bid/tid; not to exceed 5 mg qid - Pediatric 1-5 years: 0.2 mg/kg/dose PO bid/qid>5 years: Administer as in adults

25. Anticholinergic Agents Propantheline bromide (Pro-Banthine�) is prescribed to stop bladder muscle contractions (overactive bladder). Adult -7.5-15 mg PO 30 min ac and 30 mg qhs Pediatric -2-3 mg/kg/d PO divided q4-6h and hs.

26. Common side effects dry mouth, visual blurring, nausea, constipation, tachycardia (fast heartbeat), drowsiness and confusion.

27. Muscarinic receptor antagonist blocks nerve receptors that respond to the chemical muscarine. Both bladder contraction and salivation (formation of saliva) are controlled by muscarinic receptors.

28. Tolterodine tartrate (DetrolLA�) Adult - 2 mg PO bid; reduce to 1 mg bid if patient does not tolerate well Pediatric - Not established

29. Common Side Effects Urinary retention Gastric retention Narrow-angle glaucoma

30. Antispasmodic Medications Hyoscyamine sulfate (Levbid, Levsin, Levsinex) - Blocks action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands, and CNS, which, in turn, has antispasmodic effects.

31. Dosage Adult - Immediate release: 0.125-0.25 mg PO/SL tid/qid ac and hsTime-release: 0.375-0.75 mg q12h Pediatric - Individualize dosage according to weight<2 years: 12.5 mcg/2.3 kg (not to exceed 75 mg/d) to 45.8 mcg/15 kg (not to exceed 275 mcg/d)2-10 years: 32 mcg/10 kg to 125/50 kg; not to exceed 0.75 mg/dose

32. Contraindication obstructive urinary tract disorders glaucoma severe inflammation of the large intestine (ulcerative colitis)

33. Trospium (Santura) reduces smooth muscle tone in the bladder Adult - 20 mg PO bid; take on empty stomach at least 1 h before mealsCrCl <30 mL/min: 20 mg PO hs>75 years: May titrate dose downward to 20 mg PO qd based on tolerability Pediatric - Not established

34. Toviaz (fesoterodine) relieve symptoms of an overactive bladder. Dosage 4mg daily Side Effect - same as other anticholinergic * decrease perspiration (stroke)

35. Flavoxate (Urispas) Counteracts smooth muscle spasms of urinary tract. Adult - 100 or 200 mg PO tid/qid; reduce dose when symptoms improve Pediatric - <12 years: Not established>12 years: Administer as in adults

36. Other common Enablex (Darifenacin) Vesicare (Solifenacin)

37. Overflow Bladder incomplete bladder emptying secondary to impaired detrusor contractility or bladder outlet obstruction Causes Benign Prostate Hypertrophy/ enlarge prostate Neurogenic bladder

38. Alpha adrenergic blocking agents relax striated and smooth muscle, decreasing urethral resistance and relieving symptoms.

39. Alpha-1-adrenergic blocking agents Doxazosin mesylate (Cardura�), 1-8 mg, once daily Tamulosin hydrochloride (Flomax�), 0.4-0.8 mg, once daily Terazosin hycrochloride (Hytrin�), 1-10 mg, once daily

40. Tamsulosin by relaxing the muscles in the bladder neck and prostate. an alpha1 adrenoceptor blocking agent Metabolism extensively metabolized by cytochrome P450 enzymes in the liver and less than 10% of the dose is excreted in urine unchanged. No renal or hepatic adjustment required

41. Contraindication Concomitant use of PDE5i two drug classes can potentially cause symptomatic hypotension

42. Side effects Dizziness, unusual weakness, drowsiness, trouble sleeping, blurred vision, runny nose, or problems ejaculating may occur.

43. Mix Incontinence coexistence of stress and urge incontinence

44. Management treatment: - any or combination of drug for urge and stress incontinence

45. Functional Incontinence normal voiding systems but difficulty reaching the toilet because of physical or psychological impediments Dementia Arthritis

46. Management Facilitate toileting according to functional limitation. Bedside commode Time voiding

47. END

48. References Alhasso A. A,. McKinlay J., Patrick K., Stewart L., (2006) Anticholinergic drugs versus non-drug active therapies for overactive bladder syndrome in adults.�Cochrane Database Syst Rev.�2006;18 (4): Bates P, Bradley WF, Glen E, Griffiths D, Melchior H, Rowan D, et al.�The standardization of terminology of lower urinary tract function.�J Urol.�1979;121:551-554 Burgio �KL, Locher �JL, Goode �PS, Hardin �JM a randomized controlled trial. �JAMA. �1998;280:1995�2000. Chutka D. S., Fleming K. C., Evans M. P.,�Urinary incontinence in the elderly population.�Mayo Clin Proc.�Jan�1996;71(1):93-101

49. References McDowell �BJ, Dombrowski �M, et al. �Behavioral vs drug treatment for urge urinary incontinence in older women: Resnick �NM. �Improving treatment of urinary incontinence. �JAMA. �1998;280:2034�5. Mills W, Grennland JE, McMurray G.�Studies of the pathophysiology of idiopathic detrusor instability: the physiologic properties of detrusor smooth muscle and its pattern of instability.�J Urol.�Feb�2000;163(2):646-51. National Prescribing Service,:Managing Urinary Incontinence". http://www.nps.org.au/health_professionals/publications/nps_news/current/nps_news_66_managing_urinary_incontinence_in_primary_care

50. References Oxybutynin transdermal (Oxytrol) for overactive bladder. �Med Lett Drugs Ther. �2003;45:38�9. Van Kerrebroeck �P, Kreder �K, Jonas �U, Zinner �N, Wein �A. �Tolterodine once-daily: superior efficacy and tolerability in the treatment of the overactive bladder. �Urology. �2001;57:414�21 . Wein AJ, Rackley RR.�Overactive bladder: a better understanding of pathophysiology, diagnosis and management.�J Urol.�2006;175 :5-10 Wein, A. J., Kavoussi, L. R., Novick, A. C., MD, Partin, A. W., Peters, C. A., (2007). Campbell-Walsh Urology Review Manual, 3rd Edition, Sanders:PA.