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63 Cards in this Set

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what is the definition of urinary incontinence?
the ivoluntary loss of urine which is objectively demonstrable and a social or hygienic problem
describe the normal physiology of the bladder w/ regards to filling and emptying
filling:
sympathetic stim of B receptors (detrusor muscle relaxation)
sympathetic stim of a receptors (urethral pressure increased)
inhibition of parasympathetic system cholinergic receptors (detrusor muscle relaxation)
emptying:
inhibition of sympathetic a receptors (urethral pressure decreased)
parasympathetic stim of cholinergic receptors (detrusor muscle contraction)
describe the age related changes in the physiology of the bladder
reduced bladder capacity
uninhibited bladder contractions (increse in spontaneous contractions)
elevated postvoid residual urine volume
decreased strength of pelvic support muscles
reduced urethral closure pressure
what are the physical consequences of incontinence?
skin breakdown (rash)
infections
falls (rushing to the bathroom)
what are the psychological consequences of incontinence?
poor self esteem
embarassment
depression
sleep disturbances
what are some social consequences of incontinence?
rescricted activities (like falls)
reduced interactions
avoidance of sexual activity
what are some economic consequences of incontinence?
primary care education
medication and supplies
occupation issues/absence
nursing home placement
what is acute urinary incontinence and what are the causes?
transient or reversible urinary incont
DIAPPERS
D: delirium (reversible confusion, not oriented) dementia
I: infections (UTI, etc.)
A: atrophic vaginitis (estrogent helps support vag walls, after menopause - weakness) alcohol ingestion
P: pharmacologic agents
P: psychological causes (depression and grief)
E: endocrine disorders (hyperglycemia and hypercalcemia) excessive UO
R: restricted mobility: (physical restraints and environmental barriers)
S: stool impaction (chronic constipation or fecal incontinence)
drugs can also cause acute urinary incont
which drugs are associated w/ acute urinary incontinence?
TCAs, antipsychs, antihist, opioid analgesics, CCBs: reduce bladder wall contractility leading to overflow --> urinary retention w/ resultant frequency
ephedrine/pseudoephedrine: increases urethral sphincter pressure leading to retention -->resultant frequency
EtOH, caffeine, diuretics: increase urine production leading to leakage--> potential to cause frequency and urgency
what are the 4 types of chronic urinary incont?
urge, stress, overflow, functional, (can also have mixed sx)
describe urge incontinence
most common type
overactivity due to involuntary detrusor muscle contractions; leakage of urine associated w/ sudden, strong desire to void, characterized by sx of frequency (>8xs/day)and nocturia (>2x/night)
what is idiopathic detrussor overactivity and which type of incontinence is it associated w/?
urge incontinence
local or surrounding infection, inflammation or irritation of the bladder (UTI, atrophic vaginitis, cystitis, bladder stone)
what is neurogenic detrussor oveactivity and which type of incontinence is it associated w/?
urge incont
brain centers that inhibit bladder contractions are impaired by a neuro condition (CVA, MS, parkinson's, alzheimer's, spinal cord injury)
what is OAB (overactive bladder)
characterized by urgency w/ or w/o urge incontinence usually w/ frequency and nocturia
describe stress incontinence
weakness of pelvic floor muscle and/or urethral sphincter malfunction
hormonal deficiency following menopause allows atrophy of genitourinary tissues
vaginal deliver is a risk factor for transient UI and later in life incont
leakage of urine occurs w/ increases in ab pressure (coughing, sneezing, laughing, straining-lifting heavy things)
nocturnal sx are minimal
occurs in men after prostate surgery (sphincter damage)
what are the two contibuting factors to overflow incontinence?
leakage of uring assoicated w/ an overfilled bladder; caused by outlet obstuction or detrusor underactivity
what are some causes of outlet obstruction?
BPH***
prostate carcinoma
urethral stricture
what are some causes of detrusor underactivity?
autonomic neuropathy
damage to bladder innervations (tumor, radiation, surgery)
what are the obstructive sx associated w/ overflow incont?
hesitancy
dribbling
poor stream
incomplete emptying
what are the irritative sx associated w/ overflow incont?
urgency
frequency
nocturia
describe functional incontinence
leakage of urine occurs in the setting of normal bladder and urethral fx
common in debilitated and institutionalized geriatric pts
individual is either unwilling or unable to reach the toilet
pt may have:
functional disabilities (OA), environmental factors, psychologic unwillingness, cognitive impairment
what is mixed incontinence?
leakage of uring attributed to multiple factors
combo of different types of incont
treat voiding sx, which are most bothersome
describe the components of a voiding hx and diary
volume and time of fluid ingested
volume and time of urine voided
number of incont episodes
amount and type of absorbent products used
activities associated w/ incont
what type of informaion should be obtained for the history component of diagnosing UI?
symptoms: onset, duration, severity, voiding hx and diary
medical: conditons, childbirths
surgical: prostate, gynecologic
medications: antichols, alpha agonists, diuretics, narcotics
what should a PE involve in diagnosing UI
abdominal: masses, bladder distension
neuro: cog fx, mobility/dexterity
rectal: prostate size, fecal impaction
pelvic: atrophic vag, prolapse
skin: rash, infx
what labs should be collected when diagnosing UI?
fasting glucose (r/o DM)
BUN/SCr (when dehydrated, may begin to concentrate urine --> aggravates bladder to go more
serum electrolytes
PSA
urinalysis
what is postvoid residual urine volume (pvr urine vol)?
amount of urine remaining in bladder after voiding (normal <50-100mL)
high postvoid residual urine volume (>100) may be related to: bladder weakness, outlet obstruction
measured by catheterization or ultrasound (less invasive)
what are the types of non-pharm strategies used to treat UI?
absorbent products, lifestyle mod, environmental mod, behavioral intervention, urine collection devices
describe the use of absorbent products in tx of UI
management after primary eval
used in many settings
different products absorb varying amts (least --> most absorb: pads, shields, guards, undergarments, briefs)
counsel on skin care and perform routine checks for rash/skin breakdown
problem: pt/caregiver may loose interest in continence
what factors should be considered for product selection?
functional disability of pt
type/severity of incont
time of incont
pt gender
availability of caregivers
pt preference
success or failure of prev products
cost
describe the lifestyle modifications used to tx UI
regulate fluid intake (dont cut too much, dehydration and urine concentration will irritate bladder)
eliminate bladder irritants (caffeine, EtOH, spicy foods)
maintain bowel regularity
wt mgmt (overweight increases risk for stress incont)
what are some environmental modifications in the tx of UI?
bathroom aids/bedside commode
decrease toilet height/distance
unrestrictive clothing
what are some behavioral interventions in the mgmt of UI?
pelvic muscle exercises (Kegel exercises):
stengthens pelvic floor muscles
imagine stopping flow of urine, do not use accessory muscles (ab and butt)
timed voiding: toileting on a fixed schedule (q 2 h while awake)
habit training: scheduled voiding w/ adjustment of interval based on pts voiding pattern
promted voiding: caregive asks pt if they need to go at appropriate and scheduled times
bladder training: scheduled toileting w/ progressively increasing voiding intervals using relaxation and reinforcement techniques
describe the steps involved in kegel exercises
1. empty the bladder
2. tighten pelvic floor muscle and hold for 3 seconds
3. relax muscle for 3 seconds (or as long as muscles were tightened)
4. goal is to increase to 5 then 10 s as muscle gets stronger
5. increase up to 10 exercises at a time and three times per day
what are some challanges of behavioral interventions?
requires active participation and cooperation
involves ability to learn and retain skills
describe the use of urine collection devices in tx of UI
external catheter: condom attached to tube that drains urine into collecting bag, different technique for fastening bag around woman's urethra
intermittent bladder catheterization: catheter is inserted and removed for each emptying; used for overflow incont due to inability of bladder to contract
indwelling bladder catheter: catheter remains in bladder for long period of time; used for overflow incont due to obstruction
describe the treatment of acute incontinence
resolve acute medical illness (UTI, etc.)
treat chronic med conditions (DM)
d/c offending meds
describe the treatment of urge incontinence
identify and manage exacerbating factors (DM, HF)
adjust timing and amt of fluid ingested
implement bladder training as FIRST LINE
pharmacotherapy augments behavioral tx
pharmacotherapy targets the uninhibited bladder contractions - ANTICHOLINERGICS
what are the current drugs used to treat urge incontinence?
oxybutynin (Ditropan, Oxytrol)
Tolterodine (Detrol)
Trospium (Sanctura)
solifenacin (VESIcare)
darifenacin (Enablex)
describe the differences among the antimuscarining agents?
delivery system/dosage form
PK features
chemical structures
- quaternary amine (trospium - doesnt cross BBB - good for elderly)
- tertiary amine (tolteradine)
ability to cross BBB (lipophilic - oxybutinin***, tolteradine)
presence of active metabs (oxybut)
musc recept selectivity (darifenacin)
which muscarinic receptors are located in the bladder?
what is the result of receptor blockade?
M2 and M3
blocks detrusor contraction
what is the result of non-specific blockade of muscarinic receptors? is the ideal med for urge incont an M3 selective agent?
ADRs
M3 blockade will still result in dry mouth, constipation, etc.
what is the initial dose of oxybutynin ER (Ditropan ER)
5 mg qd
describe the dose and administration for trospium (Sanctura)
recommended dose is 20 mg bid in morning and night; take one hour before meals or on an empty stomach
for pts w/ severe renal impairment (CrCl <30 mL/min), recommended dose is 20 mg qhs
descibe the use of the oxybutynin patch (Oxytrol)
apply immediately after from removal of pouch
avoid re-app to same site w/in 7 days
avoid rubbing patch w/ exercise and bathing
do not cut/trim patch prior to application
ADRs = skin erythema and pruritis
apply to hib/ab/butt
apply 2xs/week
what is the initial dose of tolteradine ER (Detrol LA)?
4 mg qd
what are the contraindications/precautions to use of anti-muscarinics/anticholinergics
urinary retention, gastric retention, narrow angle glaucoma, hypersensitivity, bladder outflow obstruction, reduced GI motility, redued hep fx, reduced renal fx
what anticholinergic ADRs are geriatric pts sensitive to?
dry mouth, blurry vision, constipation, dyspepsia, drowsiness, dizziness, tachycard, HA
anticholinergics may ineract w/ which classes of drugs?
3A4 inhibs (macrolides, azoles, PIs)
which drugs may have an additive anticholinergic effects when used w/ anticholinergic agents?
antihistamine
skeletal muscle relaxants
TCAs
Antipsychs
what is the advantage to using ER forms of anticholinergics in the treatment of urge incont?
more stable blood level and fewer ADRs, also improve adherence
what are the monitoring parameters for using anticholinergics for urge incont?
urinary sx: urgency, frequency, nocturia
incont episodes
ADRs
QOL
what are some potential reasons for treatment failure in using antichols for urge incont?
ADRs limit dose titration
inadequate maintenance dose
unrealistic pt expectations
conditions contribute to sx
what are some 2nd line meds for the tx of urge incont?
TCAs: imipramine (Tofranil), doxepin (Adapin)

amitriptyline is highly antichol and has a high SE profile
TCAs reserved for pts w/ additional med indications
what is the main cause of overflow incontinence?
BPH
describe tx for overflow incont
remove offending drug or tx chronic dx process
catheterization for acutely obstructed pt
pharm for BPH aimed at decreasing urethral pressure:
a-adrenergic antag: terazosin (Hytrin), tamsulosin (Flomax)
5a reductase inhibs: finasteride (Proscar)
what is a disadvantage of using Proscar for overflow incont
may take 6-12 months to work; usually reserved for men w/ larger prostates
what are some surgical procedures for overflow incont?
TURP (for BPH) or prostatectomy (CAP)
true or false: bethanechol (urecholine) a cholinergic agonist, has uncertain efficacy for detrusor underactivity
true
true or false: there is no FDA approved drug for the tx of stress incont
true
some products are used off label
what is first line tx for stress incont?
pelvic floor exercises
what pharmacotherapy might be used for stress incontinence?
a-adrenergic agonists promote urethral sphincter closure
HRT used in the past (conflicting results, paradox exacerbation) po agents not recommended - long term risks
duloxetine (Cymbalta) under investigation for female stress incont: dual reuptake inhib of 5HT and NE, increases urethral resistance to leakage during periods of uring storage
what is last line for stress incont?
several surgical options exist, though some pts will continue w/ sx