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63 Cards in this Set
- Front
- Back
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what is the definition of urinary incontinence?
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the ivoluntary loss of urine which is objectively demonstrable and a social or hygienic problem
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describe the normal physiology of the bladder w/ regards to filling and emptying
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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) |
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describe the age related changes in the physiology of the bladder
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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 |
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what are the physical consequences of incontinence?
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skin breakdown (rash)
infections falls (rushing to the bathroom) |
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what are the psychological consequences of incontinence?
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poor self esteem
embarassment depression sleep disturbances |
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what are some social consequences of incontinence?
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rescricted activities (like falls)
reduced interactions avoidance of sexual activity |
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what are some economic consequences of incontinence?
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primary care education
medication and supplies occupation issues/absence nursing home placement |
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what is acute urinary incontinence and what are the causes?
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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 |
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which drugs are associated w/ acute urinary incontinence?
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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 |
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what are the 4 types of chronic urinary incont?
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urge, stress, overflow, functional, (can also have mixed sx)
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describe urge incontinence
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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) |
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what is idiopathic detrussor overactivity and which type of incontinence is it associated w/?
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urge incontinence
local or surrounding infection, inflammation or irritation of the bladder (UTI, atrophic vaginitis, cystitis, bladder stone) |
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what is neurogenic detrussor oveactivity and which type of incontinence is it associated w/?
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urge incont
brain centers that inhibit bladder contractions are impaired by a neuro condition (CVA, MS, parkinson's, alzheimer's, spinal cord injury) |
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what is OAB (overactive bladder)
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characterized by urgency w/ or w/o urge incontinence usually w/ frequency and nocturia
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describe stress incontinence
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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) |
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what are the two contibuting factors to overflow incontinence?
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leakage of uring assoicated w/ an overfilled bladder; caused by outlet obstuction or detrusor underactivity
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what are some causes of outlet obstruction?
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BPH***
prostate carcinoma urethral stricture |
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what are some causes of detrusor underactivity?
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autonomic neuropathy
damage to bladder innervations (tumor, radiation, surgery) |
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what are the obstructive sx associated w/ overflow incont?
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hesitancy
dribbling poor stream incomplete emptying |
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what are the irritative sx associated w/ overflow incont?
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urgency
frequency nocturia |
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describe functional incontinence
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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 |
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what is mixed incontinence?
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leakage of uring attributed to multiple factors
combo of different types of incont treat voiding sx, which are most bothersome |
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describe the components of a voiding hx and diary
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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 |
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what type of informaion should be obtained for the history component of diagnosing UI?
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symptoms: onset, duration, severity, voiding hx and diary
medical: conditons, childbirths surgical: prostate, gynecologic medications: antichols, alpha agonists, diuretics, narcotics |
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what should a PE involve in diagnosing UI
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abdominal: masses, bladder distension
neuro: cog fx, mobility/dexterity rectal: prostate size, fecal impaction pelvic: atrophic vag, prolapse skin: rash, infx |
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what labs should be collected when diagnosing UI?
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fasting glucose (r/o DM)
BUN/SCr (when dehydrated, may begin to concentrate urine --> aggravates bladder to go more serum electrolytes PSA urinalysis |
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what is postvoid residual urine volume (pvr urine vol)?
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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) |
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what are the types of non-pharm strategies used to treat UI?
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absorbent products, lifestyle mod, environmental mod, behavioral intervention, urine collection devices
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describe the use of absorbent products in tx of UI
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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 |
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what factors should be considered for product selection?
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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 |
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describe the lifestyle modifications used to tx UI
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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) |
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what are some environmental modifications in the tx of UI?
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bathroom aids/bedside commode
decrease toilet height/distance unrestrictive clothing |
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what are some behavioral interventions in the mgmt of UI?
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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 |
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describe the steps involved in kegel exercises
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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 |
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what are some challanges of behavioral interventions?
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requires active participation and cooperation
involves ability to learn and retain skills |
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describe the use of urine collection devices in tx of UI
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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 |
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describe the treatment of acute incontinence
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resolve acute medical illness (UTI, etc.)
treat chronic med conditions (DM) d/c offending meds |
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describe the treatment of urge incontinence
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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 |
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what are the current drugs used to treat urge incontinence?
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oxybutynin (Ditropan, Oxytrol)
Tolterodine (Detrol) Trospium (Sanctura) solifenacin (VESIcare) darifenacin (Enablex) |
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describe the differences among the antimuscarining agents?
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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) |
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which muscarinic receptors are located in the bladder?
what is the result of receptor blockade? |
M2 and M3
blocks detrusor contraction |
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what is the result of non-specific blockade of muscarinic receptors? is the ideal med for urge incont an M3 selective agent?
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ADRs
M3 blockade will still result in dry mouth, constipation, etc. |
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what is the initial dose of oxybutynin ER (Ditropan ER)
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5 mg qd
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describe the dose and administration for trospium (Sanctura)
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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 |
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descibe the use of the oxybutynin patch (Oxytrol)
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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 |
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what is the initial dose of tolteradine ER (Detrol LA)?
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4 mg qd
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what are the contraindications/precautions to use of anti-muscarinics/anticholinergics
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urinary retention, gastric retention, narrow angle glaucoma, hypersensitivity, bladder outflow obstruction, reduced GI motility, redued hep fx, reduced renal fx
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what anticholinergic ADRs are geriatric pts sensitive to?
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dry mouth, blurry vision, constipation, dyspepsia, drowsiness, dizziness, tachycard, HA
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anticholinergics may ineract w/ which classes of drugs?
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3A4 inhibs (macrolides, azoles, PIs)
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which drugs may have an additive anticholinergic effects when used w/ anticholinergic agents?
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antihistamine
skeletal muscle relaxants TCAs Antipsychs |
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what is the advantage to using ER forms of anticholinergics in the treatment of urge incont?
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more stable blood level and fewer ADRs, also improve adherence
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what are the monitoring parameters for using anticholinergics for urge incont?
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urinary sx: urgency, frequency, nocturia
incont episodes ADRs QOL |
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what are some potential reasons for treatment failure in using antichols for urge incont?
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ADRs limit dose titration
inadequate maintenance dose unrealistic pt expectations conditions contribute to sx |
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what are some 2nd line meds for the tx of urge incont?
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TCAs: imipramine (Tofranil), doxepin (Adapin)
amitriptyline is highly antichol and has a high SE profile TCAs reserved for pts w/ additional med indications |
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what is the main cause of overflow incontinence?
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BPH
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describe tx for overflow incont
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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) |
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what is a disadvantage of using Proscar for overflow incont
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may take 6-12 months to work; usually reserved for men w/ larger prostates
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what are some surgical procedures for overflow incont?
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TURP (for BPH) or prostatectomy (CAP)
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true or false: bethanechol (urecholine) a cholinergic agonist, has uncertain efficacy for detrusor underactivity
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true
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true or false: there is no FDA approved drug for the tx of stress incont
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true
some products are used off label |
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what is first line tx for stress incont?
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pelvic floor exercises
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what pharmacotherapy might be used for stress incontinence?
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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 |
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what is last line for stress incont?
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several surgical options exist, though some pts will continue w/ sx
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