- Количество слайдов: 39
Urinary Incontinence Tova Ablove, Alev Wilk Primary Care Conference, 10/12/05
Urinary Incontinence n No Financial Disclosures
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 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 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, 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 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 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 floor exercises. n
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, 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 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, 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
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 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: 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 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 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 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 of effects on bladder hyperactivity are lacking 2/D
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 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 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.
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 failed or could not tolerate more conservative treatments.
Multichannel Urodynamic Equipment
Urethral Pressure Profile