Urinary Incontinence and Medical Management Mani Vijayan RN

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Urinary Incontinence and Medical Management

• Mani Vijayan RN MS CCNS- Rx CCTC

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Definition

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

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Magnitude of Problem

• 13 million Americans affected
• 1/2 of those in nursing homes
• Females gt males
• 1 in 4 will be affected
• older patients 2 1 (gt65 years)
• younger patients 5 1

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Cost of Care

• 16.3 billion dollars
• - 75 spent on women

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Pathophysiology
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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)

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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

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Neurological causes

• Cortical lesion stroke
• Spinal cord lesion
• Peripheral nerve disease Diabetic peripheral
  neuropathy
• Metastatic carcinoma epidural spinal cord
  compression

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Pharmacological

• Anticholinergic, antipsychotic, antidepressants
• Alpha-adrenergic agonists
• Alpha-antagonist
• Diuretics
• ACE inhibitors
• Anti-parkinson

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Types of UI

• Stress
• Urge (Overactive)
• Mix (Stress and Urge)
• Overflow
• Functional

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Diagnostic evaluation

• AUA symptoms survey
• Bladder scan
• Urodynamic
• cystoscopy

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Stress Incontinence

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

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Management

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

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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

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Alpha-adrenergic Agonists

• a2 agonists inhibits adenylyl cyclase activity.
• - reduce brainstem vasomotor center-mediated
  activation

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Alpha-adrenergic Agonists

• Pseudoephedrine
• Norepinephrine
• ephedrine

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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

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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.

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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

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Urge Incontinence (Overactive)

• uninhibited bladder contraction from detrusor
  hyperactivity
• - abnormalities of the CNS inhibitory pathway
• - bladder inflammation

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Management

• Anticholinergic
• Muscarinic receptor antagonist
• Antispasmodic
• Alpha-1-adrenergic blocking agents

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Anticholinergic

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

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Anticholinergic Agents

• Oxybutynin chloride (DitropanXL)
• 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/qidgt5 years
  Administer as in adults

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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.

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Common side effects

• dry mouth, visual blurring, nausea, constipation,
  tachycardia (fast heartbeat), drowsiness and
  confusion.

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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.

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Tolterodine tartrate (DetrolLA)

• Adult
• - 2 mg PO bid reduce to 1 mg bid if patient
  does not tolerate well
• Pediatric
• - Not established

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Common Side Effects

• Urinary retention
• Gastric retention
• Narrow-angle glaucoma

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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.

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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 weightlt2
  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

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Contraindication

• obstructive urinary tract disorders
• glaucoma
• severe inflammation of the large intestine
  (ulcerative colitis)

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Trospium (Santura)

• reduces smooth muscle tone in the bladder
• Adult
• - 20 mg PO bid take on empty stomach at least 1
  h before mealsCrCl lt30 mL/min 20 mg PO hsgt75
  years May titrate dose downward to 20 mg PO qd
  based on tolerability
• Pediatric - Not established

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Toviaz (fesoterodine)

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

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Flavoxate (Urispas)

• Counteracts smooth muscle spasms of urinary
  tract.
• Adult
• - 100 or 200 mg PO tid/qid reduce dose when
  symptoms improve
• Pediatric
• - lt12 years Not establishedgt12 years
  Administer as in adults

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Other common

• Enablex (Darifenacin)
• Vesicare (Solifenacin)

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Overflow Bladder

• incomplete bladder emptying secondary to impaired
  detrusor contractility or bladder outlet
  obstruction
• Causes
• Benign Prostate Hypertrophy/ enlarge prostate
• Neurogenic bladder

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Alpha adrenergic blocking agents

• relax striated and smooth muscle, decreasing
  urethral resistance and relieving symptoms.

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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

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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

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Contraindication

• Concomitant use of PDE5i two drug classes can
  potentially cause symptomatic hypotension

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Side effects

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

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Mix Incontinence

• coexistence of stress and urge incontinence

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Management

• treatment
• - any or combination of drug for urge and
  stress incontinence

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Functional Incontinence

• normal voiding systems but difficulty reaching
  the toilet because of physical or psychological
  impediments
• Dementia
• Arthritis

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Management

• Facilitate toileting according to functional
  limitation.
• Bedside commode
• Time voiding

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END
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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. 200618
  (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. 1979121551-554
• Burgio  KL, Locher  JL, Goode  PS, Hardin  JM a
  randomized controlled trial.  JAMA.
   199828019952000.
• Chutka D. S., Fleming K. C., Evans M.
  P., Urinary incontinence in the elderly
  population. Mayo Clin Proc. Jan 199671(1)93-101
  

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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.  199828020345.
  
• 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 2000163(2)646-51.
• National Prescribing Service,Managing Urinary
  Incontinence". http//www.nps.org.au/health_profes
  sionals/publications/nps_news/current/nps_news_66_
  managing_urinary_incontinence_in_primary_care

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References

• Oxybutynin transdermal (Oxytrol) for overactive
  bladder.  Med Lett Drugs Ther.  200345389.
• 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.  20015741421
• .
• Wein AJ, Rackley RR. Overactive bladder a better
  understanding of pathophysiology, diagnosis and
  management. J Urol. 2006175 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, SandersPA.