NAPLEX: Male & Female Health - Urinary Incontinence

overactive bladder sx

- urinary urgency

- urinary frequency (voiding >8 times during waking hours)

- nocturia (> awakenings in the night to urinate)

- urinary incontinence

urinary incontinence types

urge

sudden and unstoppable urge to urinate - associated with neuropathy

Often present in those with DM, stroke, dementia, Parkinson disease, or MS

urinary incontinence types

stress

urine leaks out during any form of exertion (exercise, coughing, sneezing, laughing) as a result of pressure on bladder

urinary incontinence types

mixed

combination of urge and stress incontinence

urinary incontinence types

functional

no abnormality in bladder but pt is cognitively, socially, or physically impaired thus hindering access to toilet (ex: pt in wheelchair)

urinary incontinence types

overflow

leakage that occurs when quantity of urine stored in bladder exceeds its capacity - often occurs without urge to urinate

BPH = most common cause

risk factors for overactive bladder

Age >40 y/o

Diabetes

Prior vaginal delivery

Neurologic conditions (Parkinson disease, stroke, dementia)

Drugs that increase incontinence (alcohol, cholinesterase inhibitors, diuretics, sedatives)

Restricted mobility

Hysterectomy

Pelvic injury

OAB pathophysiology

inappropriate stimulation of muscarinic receptors on detrusor muscle → involuntary contractions + feeling of urinary urgency

M3 receptor responsible for what in human bladder

emptying contractions + involuntary bladder contractions

OAB non drug treatment

behavioral therapy which can include

Bladder training

Delayed or scheduled voiding

Pelvic floor muscle exercise (Kegel exercise)

Urge control techniques (distraction, self assertions)

Fluid management

Dietary changes (avoiding dietary irritants like caffeine)

Weight loss

OAB drug treatment

urinary incontinence / mixed incontinence

1st line = anticholinergics (oxybutynin), beta 3 receptor agonists (mirabegron)

- adequate trial of 4-8 wks recommended before modifying treatment or adding second drug

2nd line = botox

last line = nerve stimulation, surgical intervention

long acting anticholinergics have ____ (more/less) SE and ____ (can/cannot) cause cognitive impairment

long acting anticholinergics have less SE but can cause cognitive impairment

selective anticholinergics have ____ (more/less) cognitive SE

less

why is botox not used as a first line treatment for OAB

although it has higher efficacy it has a high cost + inconvenient route of administration

OAB treatment

stress incontinence

- pseudophendrine (can cause tachycardia, palppitations, nervousness/anxiety, headache, insomnia)

- duloxetine; has very little efficacy for incontinence but good for treating multiple conditions (ex: incontinence, depression)

which anticholinergic drugs are more selective for the M3 receptor

solifenacin

darifenacin

festerodine

anticholinergic peripheral SE

Dry mouth

Dry eyes / blurred vision

Urinary retention

Constipation

Tachycardia

anticholinergic central SE

Sedation

Dizziness

Cognitive impairment

anticholinergic treatment

ways to decrease risk of dry mouth

Extended release formulas

Use gel or patch

Beta 3 agonists have lower incidence of dry mouth

Non drug options: avoid mouthwashes with alcohol, use ice chips, sugar free candy or gum

anticholinergic drug DDIs

Additive effects when used w other medications that have anticholinergic effects

Lowest dose of tolterodine, solifenacin, darifenacin, fesoterodine should be used if taking strong CYP450 3A4 inhibitors

Acetylcholinesterase inhibitors used for dementia (donepezil) increase acetylcholine in CNS - can worsen dementia sx

beta 3 agonists cause ____ (more/less) dry mouth than anticholinergic drugs

less

beta 3 agonist DDIs

Moderate CYP2D6 inhibitor

Levels of metoprolol are increased when co-administered

Levels of tamoxifen are decreased with co-administered

Use caution in combination with digoxin (use lowest dose of digoxin + monitor levels)

botox DDIs

aminoglycosides

drugs affecting neuromuscular transmission can increase SE

nocturia treatment

desmopressin

when to administer desmopressin

before bed

anticholinergic drug examples

- oxybutynin

- tolterodine

- trospium

- solifenacin

- darifenacin

- festoerodine

oxytrol for women CI

Pain or burning when urinating

Blood in urine

Unexplained lower back or side pain

Cloudy or foul smelling urine

Age < 18 y/o

Male sex

anticholinergic drug renal dose adj

↓ dose if CrCl <30 with fesoterodine, solifenacin, tolterodine, trospium

diotropan XL counseling

OROS formulation and can leave ghost shell in stool

oxybutynin patch and gel cause ____ (more/less) dry mouth and constipation than oral forms

less

oxybutynin patch counseling

- place on dry, intact skin on abdomen, hips, or buttocks

- avoid reapplication to same site within 7 days

- remove patch before MRI

- dosed 2x/week

beta 3 agonists examples

- mirabegron (mybetriq)

- vibegron (gemtesa)

beta 3 agonist SE

Nasopharyngitis

Headache

Constipation

Diarrhea

Dizziness

Mirabegron: UTI, ↑ BP, angioedema of face lips tongue larynx

when can efficacy be seen with beta 3 agonists

within 8 wks

mirabegron (mybetriq) renal dose adj

CrCl 15-29: 25 mg daily

CrCL <15: not recommended

botox dosing

100 units total dose administered as 0.5 mL (5 units) injections across 20 sites (given intradetrusor) - repeat no sooner than 12 wks from previous administration (max 360 units)

In adults treated with Botox for more than one indication do not exceed total dose of 360 units in a 3 mo interval

botox SE

UTI

Urinary retention

Dysuria

prophylactic antimicrobial therapy + botox administration schedule

Prophylactic antimicrobial therapy (excluding aminoglycosides) should be administered 1-3 days prior to, on day of, and 1-3 days following Botox admin

desmopressin SE

Hyponatremia

Headache

HTN

Xerostoma (Nocdurna)

desmopressin CI

Pt with increased risk of hyponatremia (excessive fluid intake, illness or drug that can cause fluid or electrolyte imbalance including CKD, SIADH, loop diuretics, systemic or inhaled glucocorticoids), pt w increased risk of fluid retention (uncontrolled HTN, heart failure)

Nasal conditions (nasal spray)

desmopressin monitoring

serum NA

- baseline

- 1 wk

- 1 mo

how long does it take for mirabegron (mybetriq) to become effective

8 wks