Urinary Incontinence

Tova Ablove, Alev Wilk Tova Ablove, Alev Wilk

Primary Care Conference, 10/12/05Primary Care Conference, 10/12/05

Urinary Incontinence

No Financial DisclosuresNo Financial Disclosures

Objectives

Case Examples: Dr. WilkCase Examples: Dr. Wilk Management Issues: Dr. AbloveManagement Issues: Dr. Ablove

Treatment optionsTreatment options Referral optionsReferral options

Question & AnswerQuestion & Answer

Case One

47 y.o. woman with stress incontinence with some 47 y.o. woman with stress incontinence with some urgency, no leakage nor nocturia.urgency, no leakage nor nocturia.

No urinary dribbling, frequency, dysuria, No urinary dribbling, frequency, dysuria, constipationconstipation

Three uneventful vaginal deliveries; fourth Three uneventful vaginal deliveries; fourth pregnancy: twins by C-section.pregnancy: twins by C-section.

PMH: Raynaud’sPMH: Raynaud’s Denies tobacco or alcohol use; Labor and Delivery Denies tobacco or alcohol use; Labor and Delivery

RNRN

Case One

Exam: NL cardiovascular, GI, Kidney. Exam: NL cardiovascular, GI, Kidney. Genital: no notable atrophy or pelvic floor Genital: no notable atrophy or pelvic floor laxity; negative UAlaxity; negative UA

Has attempted Kegel exercises for several Has attempted Kegel exercises for several months without improvementmonths without improvement

Recommendations: Pessary? Pelvic Floor Recommendations: Pessary? Pelvic Floor Physical Therapy Program? Referral to Physical Therapy Program? Referral to subspecialty?subspecialty?

Case Two

55 y.o. woman with stress incontinence when she 55 y.o. woman with stress incontinence when she coughs, laughs, or exercisescoughs, laughs, or exercises

No dribbling, urgency, frequency, dysuria, No dribbling, urgency, frequency, dysuria, postvoid fullness, constipationpostvoid fullness, constipation

GG00PP00

Depression on CelexaDepression on Celexa

Case Two

Denies tobacco or alcohol use; Recently divorcedDenies tobacco or alcohol use; Recently divorced Exam: NL cardiovascular, GI, Kidney. Genital: Exam: NL cardiovascular, GI, Kidney. Genital:

vaginal atrophy; negative UAvaginal atrophy; negative UA Recommendations: Estrogens? Pessary? Pelvic Recommendations: Estrogens? Pessary? Pelvic

Floor Physical Therapy Program? Referral to Floor Physical Therapy Program? Referral to subspecialty?subspecialty?

Case Three

81 y.o. women with stress, urge 81 y.o. women with stress, urge incontinence and urinary leakageincontinence and urinary leakage

No constipation, burning with urinationNo constipation, burning with urination History of UTI this past year; Osteoporosis History of UTI this past year; Osteoporosis

with recurrent TL fractures and LBPwith recurrent TL fractures and LBP G2P2G2P2 IV forteos monthly; prn muscle relaxantIV forteos monthly; prn muscle relaxant

Case Three

Exam: bladder prolapse; vulvovaginal Exam: bladder prolapse; vulvovaginal atrophy. Otherwise normal examatrophy. Otherwise normal exam

Recommendations: pessary, pelvic floor Recommendations: pessary, pelvic floor exercises.exercises.

Case Four

76 y.o. woman with stress and urge incontinence, 76 y.o. woman with stress and urge incontinence, urinary leakage; nocturia 1-2x per nighturinary leakage; nocturia 1-2x per night

Urinary frequency, constipation, postvoid fullnessUrinary frequency, constipation, postvoid fullness G6P6; s/p oophorectomy, partial colectomyG6P6; s/p oophorectomy, partial colectomy Depression, COPD, HTN, schizophrenia, anxietyDepression, COPD, HTN, schizophrenia, anxiety Current smoker: 63 pack years; no alcohol; retired Current smoker: 63 pack years; no alcohol; retired

RN and widowedRN and widowed

Case Four

Albuterol, cogentin, valium, benadryl, depakote, Albuterol, cogentin, valium, benadryl, depakote, advair, meclizine, zyprexa, piroxicam, quinine, advair, meclizine, zyprexa, piroxicam, quinine, risperidone, trazodonerisperidone, trazodone

Exam: Stable cardiovascular, GI, Kidney. Genital: Exam: Stable cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UAvaginal atrophy; negative UA

Recommendations: Estrogen? Pelvic Floor Recommendations: Estrogen? Pelvic Floor Physical Therapy Program? Referral to Physical Therapy Program? Referral to subspecialty?subspecialty?

Case Five

48 y.o. woman with polyuria (every 30 minutes 48 y.o. woman with polyuria (every 30 minutes while awake) and pelvic pressurewhile awake) and pelvic pressure

Voiding diaryVoiding diary No dysuria, postvoid fullness, constipationNo dysuria, postvoid fullness, constipation Three uncomplicated vaginal births; tubal ligation; Three uncomplicated vaginal births; tubal ligation;

Leep procedure 1993Leep procedure 1993 Premenstrual syndrome dysphoria on fluoxetinePremenstrual syndrome dysphoria on fluoxetine

Case Five

Denies tobacco or alcohol use; CNADenies tobacco or alcohol use; CNA Exam: NL cardiovascular, GI, Kidney. Genital: Exam: NL cardiovascular, GI, Kidney. Genital:

pelvic floor “prolapse”; negative UA & glucose; pelvic floor “prolapse”; negative UA & glucose; PVR: 100cc.PVR: 100cc.

Recommendations: Oxybutinin for “overactive Recommendations: Oxybutinin for “overactive bladder”; Pelvic Floor Physical Therapy Program? bladder”; Pelvic Floor Physical Therapy Program? Referral to subspecialty? Referral to subspecialty?

Pelvic organ prolapse and Pessaries

RingPessary

Oval Pessary

GellhornPessary

DonutPessary

CubePessary

GershungPessary

IncontinenceDish

Drugs

Predominant anticholinergic or antimuscurinic Predominant anticholinergic or antimuscurinic action action

OxybutninOxybutnin TolterodineTolterodine HyoscyamineHyoscyamine Imipramine Imipramine DarifenacinDarifenacin SolifenacinSolifenacin

Close follow up needed especially in geriatric Close follow up needed especially in geriatric patients patients

Drug & Dose

Oxbutinin Selective M1, M3 receptor antagonistICI: 1/A

Short acting 2.5-5.0 mg bid - tid

Long acting 10-30 mg qd

patch 3.9 mg 2x/week

 

Tolterodine 

Non selective muscarinic receptor antagonistICI: 1/A

Short acting 1-2 mg bid

Long acting 2-4 mg qd

Hyoscyamine 

AnticholinergicICI: 2/D

Short acting .125 mg sl q4-6hrs

Long acting .375 mg bid

Drug & Dose

Imipramine  10-25 mg tid Anticholinergic and Alpha adrenergic actionICI: 2/CCan cause postural hypotension, confusion, and heart block

Darifenacin  7.5–25 mg qd Selective M3 receptor antagonistICI: 1/ACan cause bowel obstruction at higher doses

Solifenacin  5–10 mg qd Non selective muscarinic receptor antagonistICI: 1/AHalf life 45–68 hrs

Notes:  • All of the above can cause dry mouth and

constipation. • Caution in patients with glaucoma especially

uncontrolled narrow angle glaucoma. • Caution with concomitant use with antifungals. • With the exception of Solfinacin and Tolterodine

these drugs can cross the blood brain barrier and cause confusion and somnolence in some patients.

• All of the above drugs can cause urinary retention which is dose related.

   

Oxybutynin

Potent muscarinic receptor antagonist with some Potent muscarinic receptor antagonist with some degree of selectivity for Mdegree of selectivity for M33 and M and M11 receptors receptors

Usual doseUsual doseShort acting 2.5-5 mg tidShort acting 2.5-5 mg tidLong acting 5-30 mg qdLong acting 5-30 mg qdPatch 3.9mg 2x/week (96hr)Patch 3.9mg 2x/week (96hr)

ICI: Physiologically/pharmacologically effective and ICI: Physiologically/pharmacologically effective and recommended based on good-quality randomized recommended based on good-quality randomized controlled trials 1/Acontrolled trials 1/A

Tolterodine Nonselective muscarinic receptor antagonistNonselective muscarinic receptor antagonist Usual dose Usual dose

Short acting 2mg bidShort acting 2mg bidLong acting 4mg qdLong acting 4mg qd

ICI: Physiologically/pharmacologically ICI: Physiologically/pharmacologically effective and recommended based on effective and recommended based on evidence from good-quality randomized trials evidence from good-quality randomized trials 1/A1/A

Hyoscyamine sulfate

AnticholinergicAnticholinergic Usual adult dose .375 mg bidUsual adult dose .375 mg bid Controlled studies of effects on bladder Controlled studies of effects on bladder

hyperactivity are lacking 2/Dhyperactivity are lacking 2/D

Imipramine

Anticholinergic and alpha adrenergic Anticholinergic and alpha adrenergic actionsactions

Useful for mixed incontinence.Useful for mixed incontinence. Can cause postural hypotension and bundle Can cause postural hypotension and bundle

branch blockbranch block Usual dose 10 to 25mg tid Usual dose 10 to 25mg tid ICI: 2/CICI: 2/C

Darifenacin

M3 receptor selectiveM3 receptor selective The recommended starting dose is 7.5 to 15 The recommended starting dose is 7.5 to 15

mg / daymg / day ICI: Physiologically/pharmacologically ICI: Physiologically/pharmacologically

effective and recommended based on effective and recommended based on evidence from good-quality randomized trials evidence from good-quality randomized trials 1/A 1/A

Enablex [package insert]. 2004.

Solifenacin

Nonselective muscarinic receptor antagonistNonselective muscarinic receptor antagonist Half life of 45-68hrsHalf life of 45-68hrs Usual dose Usual dose

5 to 10 mg po qd5 to 10 mg po qd ICI: Physiologically/pharmacologically ICI: Physiologically/pharmacologically

effective and recommended based on effective and recommended based on evidence from good-quality randomized evidence from good-quality randomized trials 1/Atrials 1/A

What is InterStim Therapy? Implantable, Implantable,

programmable programmable neuromodulation neuromodulation system.system.

Mechanism of Action

Mechanism of action for SNS is not fully Mechanism of action for SNS is not fully understood at this time - many theories understood at this time - many theories exist.exist.

Generally agreed that stimulation of the Generally agreed that stimulation of the sacral nerves modulates the neural reflexes sacral nerves modulates the neural reflexes that influence the bladder, sphincter and that influence the bladder, sphincter and pelvic floor that control/influence voiding.pelvic floor that control/influence voiding.

Reference: Chancellor MB, Chartier-Kastler EJ. Principles of sacral nerve stimulation (SNS) for the treatment of bladder and urethral sphincter dysfunctions. International Neuromodulation Society 2000; 3: 15-26.

InterStim Therapy

IndicationsIndications::

overactive bladder, overactive bladder, and or urinary and or urinary retention, in patients retention, in patients who have failed or who have failed or could not tolerate could not tolerate more conservative more conservative treatments.treatments.

Multichannel Urodynamic Equipment

Cystometrogram

Urethral Pressure Profile

Micturition Profile

Uroflowmetry