Urinary Incontinence

what is urinary incontinence?

Loss of bladder control with involuntary loss of urine frequently accompanied by bothersome lower urinary tract symptoms (LUTS)

what 3 factors are used for LUTS

1. urgency

• sudden desire, often painful 

2. frequency

• increased micturition (Urination)

3. nocturia 

• interruption of sleep to pee

T/F: urinary incontinence is more common in men

• false

  • more common in women

what is the most common type of urinary incontinence?

• stress incontinence 

what organs are a part of the upper urinary tract system?

• kidneys

• ureter 

hollow muscular tube channeling urine out of the bladder is what organ? 

• urethra 

internal sphincter

• smooth muscle 

• involuntary 

• CLOSED at rest 

external sphincter 

• striated muscle 

• voluntary

• relaxation = urination

to urinate, the internal sphincter is (open/closed) and the external sphincter is (open/closed) 

• internal = open 

• external = open

what type of receptors are in the detrusor muscle? which one is there more of? Which one causes the contractions? 

• M2 

• M3 

• more M3 

• M3 causes contractions 

• B3 receptors 

what NT activates detrusor muscle ?

• ACh → M3

• NE → B3

what is the main type of receptor in the urothelium?

• B3

what is the main type of receptor in the internal sphincter? what NT activates it? What happens when it is activated?

• alpha1

  • use NE → cause contraction → continence/ maintain storage

what is the main type of receptor in the external urethral sphincter? what is the NT used? What is the effect? 

• nicotinic 

  • ACh → voluntary contraction (Continence)

what is the b3 agonists mechanism of action in urge incontinence?
a) increases bladder storage by relaxing detrusor smooth muscle 

b) Blocks smooth muscle contraction by binding to muscarinic receptors 

c) Blocks alpha receptors to promote urethral relaxation 

d) increases urination by blocking sodium and chloride absorption in the nephron 

b) Blocks smooth muscle contraction by binding to muscarinic receptors

what happens during the storage phase?

• detrusor relaxation (B3 stimulation) 

• urethral internal sphincter contraction (A1 activation, external sphincter active) 

what happens during the voiding phase? 

• aparasympathetic ACh release → M3 receptor activation → detrusor contraction

• internal sphincter relaxation (reduced alpha1 stimulation + voluntary relaxation of external sphincter)

which of the following stimulates bladder smooth muscle contraction?

a) ACh

b) beta-3 agonists 

c) alpha-1 agonists 

a) ACh

what are not modifiable risk factors for urinary incontinence?

• age 

• gender 

what are the modifiable urinary incontinence risk factors?

DIPPERS 

• delirium, infection, pharmaceuticals, psychological, excess urine output, restricted mobility, stool impaction/constipation 

Caffeine

Smoking

what are the 3 types of urinary incontinence?

1. stress urinary incontinence

2. urge urinary incontinence / overactive bladder 

3. overflow urinary incontinence 

• mixed incontinence 

• functional incontinence 

what are symptoms of stress urinary incontinence?

• involuntary loss of urine on effort or physical exertion (sneezing, physical activity) 
  

• not complete void

• minimal nocturia 

what causes stress urinary incontinence/

• abnormalities with urethra and/or urinary sphincter

  • decreases/inadequate urethral closure forces → unintentional micturition 

SUI risk factors for women 

• pregnancy

• vaginal childbirth 

• menopause 

• obesity 

• chronic conditions (Ex. COPD → constant coughing) 

• aging 

list the medications that worsen SUI

1. alpha1-blockers 

2. estrogen depletion therapies 

3. angiotensin converting enzyme (ACE) inhibitors 

4. diuretics 

5. sedatives / CNS depressants 

why do alpha-1 blockers worsen stress urinary incontinence?

• relax smooth muscle of urethra; sphincter → easier leakage

why do estrogen depletion therapies worsen stress urinary incontinence?

• decrease estrogen = atrophy of urethra mucosa and pelvic tissue

why do ACE inhibitors worsen stress urinary incontinence?

• ADR: chronic cough → repeated rises in abdominal pressure 

why do diuretics worsen stress urinary incontinence?

• indirect

  • more urine = more opportunities for leakage 

why do sedatives/CNS depressants worsen stress urinary incontinence?

• indirect 

  • decreases voluntary pelvic floor control 

UUI/OAB symptoms

• urinary urgency

• urinary frequency 

• nocturia 

• not complete voiding, but high volume loss 

what causes UUI/OAB

• abnormalities with bladder

  • detrusor muscle contracts inappropriately during urine storage → urge to urinate → voids before bladder is completely full

what are the risk factors for UUI/OAB

• considered idiopathic 

• aging 

• neurological diseases (ex. spinal cord injury, MS, etc) 

• bladder outlet obstruction (BPH, prostate cancer) 

• Cystitis 

• obesity 

what medications worsen UUI/OAB

1. diuretics 

2. cholinesterase inhibitors 

3. alcohol/caffeine

why do a diuretics worsen UUI/OAB?

• promotes increased urine production

why do a diuretics worsen cholinesterase inhibitors?

• increase in circu

what are overflow urinary incontinence symptoms?

• frequent or constant dribbling or urine “weak stream”

• feeling of incomplete bladder emptying

• nocturia 

obstructive urinary symptoms

• - abnormahesitancy

• straining to void 

what causes overflow urinary incontinence?

• abnormalities with urethra and/or urinary sphincter (overactivity)

• abnormalities with bladder (Underactivity)

what are risk factors for OUI

• bladder obstruction

• detrusor underactivity 

  • neurological disorders, age, chronic bladder overdistension 

what medications can worsen OUI?

1. alpha-1 agonists

2. tricyclic antidepressants 

3. antihistamines 

why do a alpha-1 agonists worsen OUI?

• increase urethral resistance or closure pressure 

why do tricyclic antidepressants worsen OUI?

• increase urethral resistance or closure pressure

why do antihistamines worsen OUI?

• promotes urinary retention

“pressure problem”; urethral closure failure is

a) stress UI 
b) urge UI 
c) overflow UI 

d) functional UI 

a) stress UI 

bladder overactivity; “Can’t hold it” is

a) stress UI 
b) urge UI 
c) overflow UI 

d) functional UI 

b) urge UI 

bladder underactivity or outlet obstruction; “Can’t empty it” is

a) stress UI 
b) urge UI 
c) overflow UI 

d) functional UI 

c) overflow UI 

bladder underactivity or outlet obstruction; “Can’t empty it” is

a) stress UI 
b) urge UI 
c) overflow UI 

d) functional UI 

c) overflow UI 

external (Non-urinary) cause is

a) stress UI 
b) urge UI 
c) overflow UI 

d) functional UI 

d) functional UI 

what is 1st line treatment?

• NON-pharmacological treatment 

  • behavioral therapy 

T/F: surgery is usually last line option and is more common with stress incontinence

• true

what are behavioral therapy examples

• dietary fluid management (<2 L per day)

• weight loss 

• timed voiding/bladder training 

• pelvic floor muscle training 

T/F: guidelines recommend pharmacological treatment for stress incontinence

• false 

  • NOT recommended 

  • use vaginal estrogen (cream/ring) or off-label Duloxetine (Off label) 

what pharmacological classes are recommended for the treatment of urge/OAB? 

• antimuscarinics 

• beta-3 agonists

• combination

• desmopressin (Nocturia-limited use)

what pharmacological classes are recommended for the treatment of overflow? 

• due to BPH = BPH treatment

• bethanechol (urinary retention)

antimuscarinic agents MOA

• antagonists at M2 + M3 bladder receptors → inhibiting involuntary detrusor contractions → bladder storage 

ADR Of antimuscarinic agents

• dry mouth 

• constipation 

• blurry vision 

• fatigue cognitive dysfunction

contraindications for antimuscarinics

• narrow-angle glaucoma 

• urinary retention 

extreme caution for antimuscarinic agents

• dementia 

• cognitive impairment 

rank oxybutynin dosage forms from least tolerable to most

• IR < ER < patch < gel

oxybutynin dosing for gel

• apply contents of 1 sachet once daily 

oxybutynin IR dosing

• 5 mg 2-3 times a day, increase at 5 mg increments every 2 weeks, max 5 mg 4 times a day 

T/F: you can switch a patient from fesoterodine to tolterodine if theyr are hypersensitive to fesoterodine

• false

  • should NOT, both agents have a similar metabolite 

fesoterodine dose

• - initiate at 4 mg daily, increase to max 8 mg daily 

trospium dose

• IR: @0 mg BID

• ER: 60 mg daily

• take without food

solifenacin dose

• initiate at 5 mg daily; increase to max of 10 mg/day

solifenacin risk

• prolonged QTc w/ 10 mg dose 

darifenacin dose

• initiate at 7.5 mg daily; can increase to 15 mg daily 

which antimuscarinics negatively impairs cognition in elderly? 

• oxybutynin 

• tolterodine

which antimuscarinics don’t impair cognition in elderly? 

• fesoterodine 

• trospium 

beta 3 agonist MOA

• stimulate B3 receptors in detrusor muscle → Relaxation during filling phase → increase bladder capacity + decrease urgency 

mirabegron should be avoided in what patients

• severe uncontrolled hypertension (>180/110 mmHg)

T/F: VIbegron can be used in patients with elevated BP

• true

MIrabegron dosing

• 25 mg daily ; can be increased to 50 mg daily after 4-8 weeks (If tolerated) 

vibegron dosing

• 75 mg oral daily (no titration needed)

• can be taken with or without food 

what drug is typically started for a patient with UUI

• oxybutynin 

  • as long as no CI 

• can add Beta-3 agonist if symptoms still not relieved ith antimuscarinic

T/F: you can use 2 antimuscarinics together

• -false 

  • do not use them together

if there are ADRs, what can be done?

• decrease dose 

what is the preferred option for geriatrics?

• solifenacin or trospium = preferred

• darifenacin and fesoterodine = no short-term cognitive changes 

  • oxybutynin = worst offender 

what is the most common dose limiting reason for antimuscarinics?

• anticholinergic ADRs

what is the last line in stress incontinence?

• pharmacotherapy