urinary incontinence/bph 1

What is urinary incontinence?

involuntary loss of urine from the bladder

Prevalence of urinary incontinence:

a. Female sex

b. Older adults

c. Long-term care residence

d. All of the above

All of the above

What is BPH (benign prostatic hyperplasia)?

enlargement of the prostate gland leading to urinary incontinence

Prevalence of BPH:

a. Female sex

b. Older adults

c. Post-menopause women

d. All of the above

Older adults

TERM

What part of the bladder forms a layer of its wall?

DEFINITION

Detrusor Muscle

TERM

Which part of the bladder controls involuntary urine flow from the bladder to the urethra?

DEFINITION

Internal urethral sphincter

TERM

Which part of the bladder controls voluntary urine flow from the bladder to the urethra?

DEFINITION

External urethral sphincter

Urge incontinence is caused by:

a. increase in detrusor muscle activity, no change in urethral activity

b. no change in detrusor muscle activity, decrease in urethral activity

c. increase in detrusor muscle activity, decrease in urethral activity

d. increase in detrusor muscle activity and/or decrease in urethral activity

increase in detrusor muscle activity, no change in urethral activity

Stress incontinence is caused by:

a. increase in detrusor muscle activity, no change in urethral activity

b. no change in detrusor muscle activity, decrease in urethral activity

c. increase in detrusor muscle activity, decrease in urethral activity

d. increase in detrusor muscle activity and/or decrease in urethral activity

no change in detrusor muscle activity, decrease in urethral activity

Mixed incontinence is caused by:

a. increase in detrusor muscle activity, no change in urethral activity

b. no change in detrusor muscle activity, decrease in urethral activity

c. increase in detrusor muscle activity, decrease in urethral activity

d. increase in detrusor muscle activity and/or decrease in urethral activity

increase in detrusor muscle activity, decrease in urethral activity

Overflow/BPH incontinence is caused by:

a. increase in detrusor muscle activity, no change in urethral activity

b. no change in detrusor muscle activity, decrease in urethral activity

c. increase in detrusor muscle activity, decrease in urethral activity

d. decrease in detrusor muscle activity and/or increase in urethral activity

decrease in detrusor muscle activity and/or increase in urethral activity

What factors contribute to the development of BPH?

Ongoing androgen-mediated stimulation of prostate stromal tissue growth

Excessive binding of norepinephrine to α1 receptors in prostate stromal tissue

Reduced nitric oxide leads to prostate smooth muscle contraction

What medications cause urinary incontinence?

Anticholinergics

Alpha-adrenergic agonists

Alpha-antagonists

ACE inhibitors

Antiparkinsonian medications

Diuretics

Prostate growth/constriction →

a. urethral narrowing → urine outflow obstruction → symptoms

b. symptoms → urine outflow obstruction → urethral narrowing

c. urine outflow obstruction → urethral narrowing → symptoms

d. urethral narrowing → symptoms → urine outflow obstruction

urethral narrowing → urine outflow obstruction → symptoms

Presentation of urge incontinence

Larger volume leakage

Urgency at rest

Nocturia/nocturnal enuresis (bed wetting)

Presentation of stress incontinence

Urine leakage associated with physical activity

Symptoms absent without physical activity

Presentation of mixed incontinence

BOTH urgency at rest AND leakage associated with physical activity

Presentation of overflow/BPH incontinence

Lower abdominal distension

Straining/Hesitancy

Sensation of incomplete voiding

High post-void residual bladder volume

Recurrent bladder spasms

What does mild BPH look like?

No symptoms though with markers of disease

(Slow peak urinary flow rate and/or high post-void residual urine volume)

What does moderate BPH look like?

Symptoms of BPH

What does severe BPH look like?

Symptoms AND complications of BPH (ex. renal dysfunction)

Prostate size in BPH

> 30-40 g

(PSA > 1.4 ng/mL as surrogate marker)

Therapeutic goals of urinary incontinence treatment

Improve quality of life

Reduce frequency of incontinence

Prevent development/worsening of pressure ulcers or infection

Normalize post void residual bladder volume

Reduce symptom burden

What is the first line treatment for urinary incontinence?

Non-pharmacological interventions

Lifestyle modification (Weight loss, Fluid/caffeine restriction, Smoking cessation)

Scheduled Voiding

Pelvic floor rehabilitation

Urine collection devices (catheters)

Surgery

What is the first line treatment for mild BPH (asymptomatic)?

Non-pharmacological interventions

Lifestyle modification (Weight loss, Fluid/caffeine restriction)

Scheduled voiding

Urine collection devices

What is the first line treatment for severe BPH (symptomatic)?

Surgery (resection or removal of the prostate)

What pharmacologic treatments are used to treat urge incontinence?

a. Antimuscarinics first, then β3 agonists and intravesicular botulinum toxin A

b. Vaginal estrogen and Duloxetine 40-80 mg daily

c. α1 blockers

d. α1 blockers, PDE5 inhibitors, 5α-Reductase inhibitors, Antimuscarinics and β3 agonists

Antimuscarinics first, then β3 agonists and intravesicular botulinum toxin A

What pharmacologic treatments are used to treat stress incontinence?

a. Antimuscarinics first, then β3 agonists and intravesicular botulinum toxin A

b. Vaginal estrogen and Duloxetine 40-80 mg daily

c. α1 blockers

d. α1 blockers, PDE5 inhibitors, 5α-Reductase inhibitors, Antimuscarinics and β3 agonists

Vaginal estrogen and Duloxetine 40-80 mg daily

What pharmacologic treatments are used to treat overflow/BPH incontinence in women?

a. Antimuscarinics first, then β3 agonists and intravesicular botulinum toxin A

b. Vaginal estrogen and Duloxetine 40-80 mg daily

c. α1 blockers

d. α1 blockers, PDE5 inhibitors, 5α-Reductase inhibitors, Antimuscarinics and β3 agonists

α1 blockers

What pharmacologic treatments are used to treat overflow/BPH incontinence in men?

a. Antimuscarinics first, then β3 agonists and intravesicular botulinum toxin A

b. Vaginal estrogen and Duloxetine 40-80 mg daily

c. α1 blockers

d. α1 blockers, PDE5 inhibitors, 5α-Reductase inhibitors, Antimuscarinics and β3 agonists

α1 blockers, PDE5 inhibitors, 5α-Reductase inhibitors, Antimuscarinics and β3 agonists

Which pharmacologic agent for urinary incontinence decreases urinary sphincter contractility?

α1 blockers

Which pharmacologic agents for urinary incontinence decrease prostate constriction?

α1 blockers and/or PDE5 inhibitors

Which pharmacologic agent for urinary incontinence limits prostatic hyperplasia?

5α-Reductase inhibitors

Which pharmacologic agents for urinary incontinence relax bladder contractility?

antimuscarinics and/or β3 agonists