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Urinary Incontinence Tova Ablove, Alev Wilk Primary Care Conference, 10/12/05 Urinary Incontinence Tova Ablove, Alev Wilk Primary Care Conference, 10/12/05

Urinary Incontinence n No Financial Disclosures Urinary Incontinence n No Financial Disclosures

Objectives Case Examples: Dr. Wilk n Management Issues: Dr. Ablove u Treatment options u Objectives Case Examples: Dr. Wilk n Management Issues: Dr. Ablove u Treatment options u Referral options n Question & Answer n

Case One n n n 47 y. o. woman with stress incontinence with some Case One n n n 47 y. o. woman with stress incontinence with some urgency, no leakage nor nocturia. No urinary dribbling, frequency, dysuria, constipation Three uneventful vaginal deliveries; fourth pregnancy: twins by C-section. PMH: Raynaud’s Denies tobacco or alcohol use; Labor and Delivery RN

Case One Exam: NL cardiovascular, GI, Kidney. Genital: no notable atrophy or pelvic floor Case One Exam: NL cardiovascular, GI, Kidney. Genital: no notable atrophy or pelvic floor laxity; negative UA n Has attempted Kegel exercises for several months without improvement n Recommendations: Pessary? Pelvic Floor Physical Therapy Program? Referral to subspecialty? n

Case Two n n 55 y. o. woman with stress incontinence when she coughs, Case Two n n 55 y. o. woman with stress incontinence when she coughs, laughs, or exercises No dribbling, urgency, frequency, dysuria, postvoid fullness, constipation G 0 P 0 Depression on Celexa

Case Two n n n Denies tobacco or alcohol use; Recently divorced Exam: NL Case Two n n n Denies tobacco or alcohol use; Recently divorced Exam: NL cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UA Recommendations: Estrogens? Pessary? Pelvic Floor Physical Therapy Program? Referral to subspecialty?

Case Three 81 y. o. women with stress, urge incontinence and urinary leakage n Case Three 81 y. o. women with stress, urge incontinence and urinary leakage n No constipation, burning with urination n History of UTI this past year; Osteoporosis with recurrent TL fractures and LBP n G 2 P 2 n IV forteos monthly; prn muscle relaxant n

Case Three Exam: bladder prolapse; vulvovaginal atrophy. Otherwise normal exam n Recommendations: pessary, pelvic Case Three Exam: bladder prolapse; vulvovaginal atrophy. Otherwise normal exam n Recommendations: pessary, pelvic floor exercises. n

Case Four n n n 76 y. o. woman with stress and urge incontinence, Case Four n n n 76 y. o. woman with stress and urge incontinence, urinary leakage; nocturia 1 -2 x per night Urinary frequency, constipation, postvoid fullness G 6 P 6; s/p oophorectomy, partial colectomy Depression, COPD, HTN, schizophrenia, anxiety Current smoker: 63 pack years; no alcohol; retired RN and widowed

Case Four n n n Albuterol, cogentin, valium, benadryl, depakote, advair, meclizine, zyprexa, piroxicam, Case Four n n n Albuterol, cogentin, valium, benadryl, depakote, advair, meclizine, zyprexa, piroxicam, quinine, risperidone, trazodone Exam: Stable cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UA Recommendations: Estrogen? Pelvic Floor Physical Therapy Program? Referral to subspecialty?

Case Five n n n 48 y. o. woman with polyuria (every 30 minutes Case Five n n n 48 y. o. woman with polyuria (every 30 minutes while awake) and pelvic pressure Voiding diary No dysuria, postvoid fullness, constipation Three uncomplicated vaginal births; tubal ligation; Leep procedure 1993 Premenstrual syndrome dysphoria on fluoxetine

Case Five n n n Denies tobacco or alcohol use; CNA Exam: NL cardiovascular, Case Five n n n Denies tobacco or alcohol use; CNA Exam: NL cardiovascular, GI, Kidney. Genital: pelvic floor “prolapse”; negative UA & glucose; PVR: 100 cc. Recommendations: Oxybutinin for “overactive bladder”; Pelvic Floor Physical Therapy Program? Referral to subspecialty?

Pelvic organ prolapse and Pessaries Pelvic organ prolapse and Pessaries

Ring Pessary Ring Pessary

Oval Pessary Oval Pessary

Gellhorn Pessary Gellhorn Pessary

Donut Pessary Donut Pessary

Cube Pessary Cube Pessary

Gershung Pessary Gershung Pessary

Incontinence Dish Incontinence Dish

Drugs Predominant anticholinergic or antimuscurinic action n n n Oxybutnin Tolterodine Hyoscyamine Imipramine Darifenacin Drugs Predominant anticholinergic or antimuscurinic action n n n Oxybutnin Tolterodine Hyoscyamine Imipramine Darifenacin Solifenacin Close follow up needed especially in geriatric patients

Drug & Dose Oxbutinin Short acting 2. 5 -5. 0 mg bid - tid Drug & Dose Oxbutinin Short acting 2. 5 -5. 0 mg bid - tid Selective M 1, M 3 receptor antagonist ICI: 1/A Long acting 10 -30 mg qd patch 3. 9 mg 2 x/week Tolterodine Short acting 1 -2 mg bid Long acting 2 -4 mg qd Hyoscyamine Short acting. 125 mg sl q 4 -6 hrs Long acting. 375 mg bid Non selective muscarinic receptor antagonist ICI: 1/A Anticholinergic ICI: 2/D

Drug & Dose Imipramine 10 -25 mg tid Anticholinergic and Alpha adrenergic action ICI: Drug & Dose Imipramine 10 -25 mg tid Anticholinergic and Alpha adrenergic action ICI: 2/C Can cause postural hypotension, confusion, and heart block Darifenacin 7. 5– 25 mg qd Selective M 3 receptor antagonist ICI: 1/A Can cause bowel obstruction at higher doses Solifenacin 5– 10 mg qd Non selective muscarinic receptor antagonist ICI: 1/A Half life 45– 68 hrs

Notes: • All of the above can cause dry mouth and constipation. • Caution 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 n Potent muscarinic receptor antagonist with some degree of selectivity for M 3 Oxybutynin n Potent muscarinic receptor antagonist with some degree of selectivity for M 3 and M 1 receptors n Usual dose u Short acting 2. 5 -5 mg tid u Long acting 5 -30 mg qd u Patch 3. 9 mg 2 x/week (96 hr) n ICI: Physiologically/pharmacologically effective and recommended based on good-quality randomized controlled trials 1/A

Tolterodine n Nonselective muscarinic receptor antagonist n Usual dose Short acting 2 mg bid Tolterodine n Nonselective muscarinic receptor antagonist n Usual dose Short acting 2 mg bid u. Long acting 4 mg qd n ICI: Physiologically/pharmacologically effective and recommended based on evidence from good-quality randomized trials 1/A u

Hyoscyamine sulfate n Anticholinergic n Usual adult dose. 375 mg bid n Controlled studies Hyoscyamine sulfate n Anticholinergic n Usual adult dose. 375 mg bid n Controlled studies of effects on bladder hyperactivity are lacking 2/D

Imipramine Anticholinergic and alpha adrenergic actions n Useful for mixed incontinence. n Can cause Imipramine Anticholinergic and alpha adrenergic actions n Useful for mixed incontinence. n Can cause postural hypotension and bundle branch block n Usual dose 10 to 25 mg tid n ICI: 2/C n

Darifenacin M 3 receptor selective n The recommended starting dose is 7. 5 to Darifenacin M 3 receptor selective n The recommended starting dose is 7. 5 to 15 mg / day n ICI: Physiologically/pharmacologically effective and recommended based on evidence from good-quality randomized trials 1/A n Enablex [package insert]. 2004.

Solifenacin Nonselective muscarinic receptor antagonist Half life of 45 -68 hrs Usual dose u Solifenacin Nonselective muscarinic receptor antagonist Half life of 45 -68 hrs Usual dose u 5 to 10 mg po qd n ICI: Physiologically/pharmacologically effective and recommended based on evidence from good-quality randomized trials 1/A n n n

What is Inter. Stim Therapy? n Implantable, programmable neuromodulation system. What is Inter. Stim Therapy? n Implantable, programmable neuromodulation system.

Mechanism of Action Mechanism of action for SNS is not fully understood at this Mechanism of Action Mechanism of action for SNS is not fully understood at this time - many theories exist. n Generally agreed that stimulation of the sacral nerves modulates the neural reflexes that influence the bladder, sphincter and pelvic floor that control/influence voiding. n 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.

Inter. Stim Therapy Indications: overactive bladder, and or urinary retention, in patients who have Inter. Stim Therapy Indications: overactive bladder, and or urinary retention, in patients who have failed or could not tolerate more conservative treatments.

Multichannel Urodynamic Equipment Multichannel Urodynamic Equipment

Cystometrogram Cystometrogram

Urethral Pressure Profile Urethral Pressure Profile

Micturition Profile Micturition Profile

Uroflowmetry Uroflowmetry