Urology & Urinary Incontinence

Urology & Urinary Incontinence Ellie Tabar ,PharmD Jan 29,2025 PHAR 840/ IPC Immunologic Conditions and Special Populations Learning Objectives • Understand the main types and causes of urinary incontinence. • Identify symptoms of urinary incontinence. • Set treatment goals for urinary incontinence. • Recommend non-drug therapies for overactive bladder. • Know when to use anticholinergic or beta-3 agonist drugs for overactive bladder. • Compare properties of commonly used overactive bladder medications. Treatment • Name: Mary, 62 years old. panasam sump • Chief Complaint: Frequent urination, urgency, and waking up 3 times per night to urinate for the past 6 months. • Medical History: • Controlled hypertension. • No significant cognitive issues or glaucoma. • Current Medications: • Lisinopril 10 mg daily. • Calcium supplement 500 mg daily. • Treatment Attempts: • Started using Oxytrol patch (OTC) 2 months ago but reports minimal improvement. • Complains of dry mouth and difficulty using the patch consistently. Anticholigernis Background: Overactive Bladder (OAB) • Urinary incontinence: Involuntary leakage of urine • Urinary urgency: Sudden, strong need to urinate • Urinary frequency: Voiding 8+ times during waking hours • Nocturia: Waking up 2+ times per night to urinate OAB types: • OAB wet: Includes incontinence episodes • OAB dry: Urgency without incontinence Urinary Incontinence (UI) • Involuntary leakage of urine, not a normal part of aging Causes: • Dysfunction in the urethra, bladder, or both, leading to overactivity or underactivity • Issues with the bladder outlet or urinary sphincter Prevalence: • Affects all age groups but peaks in women around menopause • Becomes more common after age 65 is to How does nervous system going beeffected Urinary Incontinence (UI) • Risk Factors:  Pregnancy, childbirth, menopause  Aging, cognitive impairment, obesity Dreschoice shock septic Efm NEandDopamine Bacteria Blood vessels AdernergI 4drug yppAfrine doriosis simmunosupress Dumbless I sideeffectfor Bansumpathytic salvation anak urination mucus Bradycardia nervoussus o contraindicatatecasthmal contra Hf emouis Pathophysiology and Etiology • Bladder Function Basics: • The detrusor muscle coordinates to store and expel urine • Controlled by the nervous system: • Parasympathetic system: Stimulates detrusor muscle using acetylcholine on muscarinic receptors • Sympathetic system: Controls bladder neck • Somatic system: Regulates external sphincter nopower noionotropic Mechanism Drug Mechanisms • Anticholinergics: Block acetylcholine on M2 and M3 receptors to reduce contractions • Mirabegron: Relaxes the detrusor muscle by acting as a beta-3 receptor agonist Risk Factors • Age > 40 years • Diabetes • Prior vaginal delivery • Obesity • Neurologic conditions (e.g., stroke, Parkinson’s disease) Other Factors: • Restricted mobility, pelvic injury, drugs causing incontinence (e.g., diuretics) Forms of Urinary Incontinence Stress Incontinence: • Urine leaks during activities that put pressure on the bladder (e.g., coughing, sneezing, exercise) Urge Incontinence: • Sudden, strong need to urinate, often linked to conditions like diabetes, strokes, Parkinson’s disease, or multiple sclerosis Mixed Incontinence: • Combination of stress and urge incontinence. Forms of Urinary Incontinence Overflow Incontinence: • Leakage due to the bladder exceeding its storage capacity, often without the urge to urinate • Common cause: Enlarged prostate (BPH) Functional Incontinence: • No bladder abnormalities, but cognitive, physical, or social barriers hinder access to the toilet (e.g., dementia, mobility issues) prob muscle 9580 prostate narrowing large itdown prostate treating Impacts and Comorbidities of Overactive Bladder (OAB) • Common Comorbidities: • Falls and fractures • Skin breakdown and infections • Urinary tract infections (UTIs) • Depression and sexual dysfunction • Social Implications: • Low self-esteem and lack of intimacy. • Social isolation and dependence on caregivers. • Sleep disturbances and limits on travel. • Other Impacts: • Dehydration from limiting fluid intake • Financial burden (e.g., cost of pads and adult diapers) • Reduced overall quality of life Non-Drug Treatments Behavioral Therapies: First-line treatment for improving symptoms • Bladder training: Gradually increase time between bathroom trips • Delayed or scheduled voiding: Establish a regular urination schedule • Pelvic floor muscle exercises: Kegel exercises strengthen muscles to control urine flow • Urge control techniques: Distraction and self-assertion to delay voiding Non-Drug Treatments Lifestyle Modifications: • Fluid management: Avoid excessive drinking or limit intake at night • Dietary changes: Reduce bladder irritants (e.g., caffeine, alcohol, spicy foods) • Weight loss: Improves symptoms by reducing pressure on the bladder • Medication review: Avoid drugs that worsen OAB or adjust timing (e.g., diuretics) • When to Consider Surgery: • Reserved for rare, non-neurogenic patients with severe symptoms after all other treatments fail Kegel Exercise Instructions • How to Identify the Muscles: • Imagine stopping urination midstream • The “pulling” sensation indicates the correct muscles • Proper Technique: • Tighten pelvic muscles for 3 seconds, then relax for 3 seconds • Perform three sets of 10 exercises per day to reduce wetting episodes General Approach Drug Treatments for Incontinence • Start with behavioral therapy (e.g., Kegels, bladder training, weight loss) • For more severe symptoms, add drug therapy based on the type of incontinence • Use a stepwise approach to escalate treatments Urinary Incontinence 1. First-Line Treatments: • Antimuscarinic Medications:  Examples: Oxybutynin, Tolterodine, Solifenacin • Mechanism: Block muscarinic receptors to reduce involuntary bladder contractions. • Considerations: Monitor for side effects such as dry mouth, constipation, and blurred vision • Beta-3 Adrenergic Agonists:  Examples: Mirabegron • Mechanism: Stimulate beta-3 receptors to relax the detrusor muscle, increasing bladder capacity. • Considerations: Monitor blood pressure; avoid in patients with uncontrolled hypertension. Other Options: Urge Incontinence / Mixed Incontinence • OnabotulinumtoxinA (Botox): • High efficacy but requires injections. • Expensive. • Nerve Stimulation / Surgery: Reserved for severe or refractory cases. • Special Populations: • Postmenopausal Women: Vaginal estrogen creams/rings can help with vaginal atrophy but are not FDA-approved for OAB. Stress Incontinence • Medications for stress incontinence are not FDAapproved for this use. • Their efficacy is minimal, and they are often used when treating other conditions alongside incontinence. nooky Anticholigernic 1. Pseudoephedrine: • Mechanism: Agonist of norepinephrine (NE) and epinephrine (Epi) that increases bladder outlet resistance Medications Commonly Used: • Side Effects: Tachycardia, Palpitations, Nervousness or anxiety, Headache and insomnia • When to Use: Consider only when side effects are manageable 2. Duloxetine: • Mechanism: Serotonin-norepinephrine reuptake inhibitor (SNRI) • Uses: Commonly prescribed for patients with both incontinence and depression • Limitations: Limited efficacy for stress incontinence but may help when dual conditions are present para Anticholinergic Drugs for Overactive Bladder (OAB) contractand emptybladder Anticholinergic radiognergic Mechanism of Action: • Block muscarinic receptors in the bladder detrusor muscle • Reduce involuntary bladder contractions, decreasing urgency and frequency axagonist of comsalusin woeportasym iontractionofthevesseld knowhowoften I • Side Effects: Dry mouth, constipation, blurred vision, dizziness Key Considerations • Cognitive Impairment: Long-term use may be associated with an increased risk of cognitive decline, especially in older adults • Contraindications: Uncontrolled narrow-angle glaucoma, urinary retention, gastric retention • Monitoring: Assess for anticholinergic side effects and cognitive changes; consider periodic evaluation of therapy necessity Patient Counseling • Hydration: Maintain adequate fluid intake; manage dry mouth with sugar-free gum or candies • Adherence: Emphasize the importance of consistent medication use for optimal benefit • Lifestyle: Combine pharmacotherapy with behavioral interventions like bladder training and pelvic floor exercises Beta-3 adrenergic agonists B3 agonist Beta-3 adrenergic agonists Beta-3 adrenergic agonists, such as mirabegron and vibegron, work by targeting beta-3 adrenergic receptors located in the detrusor muscle of the bladder. 1. Relaxation of the Detrusor Muscle: • These drugs activate beta-3 adrenergic receptors, leading to relaxation of the detrusor muscle during the storage phase of the bladder cycle. This increases bladder capacity and reduces episodes of urgency and frequency. Beta-3 adrenergic agonists 2. Reduction in Overactivity: • By relaxing the detrusor muscle, these drugs minimize involuntary bladder contractions, which are a hallmark of overactive bladder (OAB) 3. Preservation of Voiding Function: • Unlike antimuscarinics, beta-3 agonists selectively target storage-phase bladder activity without significantly impairing voiding-phase function, reducing the risk of urinary retention thecypfor Know NIM Caput Fptertoc substrate inhibitor mirabegron substratP inducer substrate to Beta-3 adrenergic agonists 1. Advantages: • Beta-3 adrenergic agonists are associated with fewer cognitive side effects compared to anticholinergics, making them suitable for older adults. • Can be combined with antimuscarinic drugs for greater symptom control 2. Patient Monitoring: • Blood Pressure: Regularly monitor BP for mirabegron due to potential for hypertension • Efficacy: Benefits typically seen within 4-8 weeks of therapy Beta-3 adrenergic agonists 3. Special Populations: OnabotulinumtoxinA (Botox) Mechanism of Action: • Inhibits acetylcholine release at the neuromuscular junction, reducing detrusor muscle overactivity. OnabotulinumtoxinA (Botox) Indications: • Third-line treatment for patients with refractory overactive bladder (OAB) who failed behavioral and pharmacologic therapies. Dosing: chip • Standard Dose: 100 units injected into the detrusor muscle. • Administered via 20 sites within the detrusor. • Repeat no sooner than 12 weeks from the previous injection. Monitoring: • Post-void residual (PVR) urine volume. • Symptoms of urinary retention or OAB improvement. OnabotulinumtoxinA (Botox) Safety and Side Effects: • Common: Dysuria, urinary tract infections (UTIs), urinary retention. • Rare but Serious: Spread of toxin beyond injection site causing muscle weakness or difficulty swallowing Contraindications: • Infection at the injection site • History of recurrent UTIs • Hypersensitivity to any Botox preparation OnabotulinumtoxinA (Botox) Anywhere youput medicationanywherein your Key Notes: body counts • Do not exceed 360 units in 3 months across multiple indications • Drug Interactions: Aminoglycosides or drugs affecting neuromuscular transmission may increase side effects Boxed Warning: • Botulinum Toxin Spread: Can cause life-threatening swallowing, speaking, or breathing difficulties if the toxin spreads from the injection site f A Nocturia Treatment Sodium dilute big somin Desmopressin (DDAVP) Mechanism of Action: • Acts as an antidiuretic hormone analog • Temporarily reduces urine production overnight to decrease nocturia episodes Dosing: • Sublingual Tablet (Nocdurna):  Females: 27.7 mcg 1 hour before bedtime  Males: 55.3 mcg 1 hour before bedtime • Nasal Spray and Injection forms also available for other indications • Side Effects: • Common: Headache, hypertension, xerostomia (dry mouth) Safety and Monitoring • Serious: Hyponatremia (low sodium levels) • Monitoring: • Check serum sodium at baseline, 1 week, and 1 month after initiation • Boxed Warning: Risk of severe hyponatremia, which can be life-threatening A Contraindications edema • Conditions associated with excessive fluid retention:  Congestive heart failure  Uncontrolled hypertension  Chronic kidney disease  Syndrome of inappropriate antidiuretic hormone secretion (SIADH) water • Use caution with loop diuretics or systemic/inhaled glucocorticoids pigs out Key Notes • Educate patients to limit fluid intake starting 1 hour before and up to 8 hours after dosing to minimize the risk of hyponatremia • Sublingual tablet is preferred for ease of use and minimal side effects • Name: Mary, 62 years old. • Chief Complaint: Frequent urination, urgency, and waking up 3 times per night to urinate for the past 6 months. • Medical History: • Controlled hypertension. • No significant cognitive issues or glaucoma. • Current Medications: • Lisinopril 10 mg daily. • Calcium supplement 500 mg daily. • Treatment Attempts: • Started using Oxytrol patch (OTC) 2 months ago but reports minimal improvement. • Complains of dry mouth and difficulty using the patch consistently.