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Define urinary incontinence
- involuntary leakage of urine
- can interfere with QOL and lead to depression and perceived loss of independence
- UI is half as common in men then in women
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what receptors in the base and neck of the bladder keep the internal sphincter contracted?
alpha-adrenergic
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what receptors in the bladder body keep the detrusor muscles relaxed
beta-3
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types of UI are due to problems with:
bladder, urethra, or both
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Urethral Underactivity (Stress Urinary Incontinence)
- occurs during exercetional activities (exercise, running, lifting, coughing, sneezing)
- urethral sphincter can not resist flow of urine from the bladder due to increasaed abdominal pressure that occurs during the activity
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risk factors of urethral underactivity (stress urinary incontinence)
- pregnancy
- child birth
- menopause
- cognitive impairment
- obesity
- age
- surgery (prostate surgery)
- injury
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bladder overactivity (urge urinary incontinence)
- detrusor muscle is overactive and inappropriately contracts during filling
- 2types: overactive bladder and detrusor overactivity
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overactive bladder
urinary urgency with frequency and nocturia that may occur with our without urinary incontinence
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detrusor overactivity
requires urodynamic diagnosis showing involuntary detrusor contraction during the filling stage
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risk factors for urge urinary incontinence
- age
- neurologic disease
- BPH or prostate cancer
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over-flow incontinence
- uncommon
- bladder is filled to capacity but is unable to empty which allows urine to leak
- urethral overactivity- resistance to flow of urine is increased which leads to obstruction and incomplete bladder emptying
- detrusor muscle becomes weakened and loses its ability to voluntarily contract
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diuretics
polyuria, frequency
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alpha-receptor antagonists
urethral relaxation
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narcotics
urinary retention
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antipsycotics
urinary retention
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anticholinergics
urinary retention
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ACE inhibitors
cough-stress incontinence
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immediate-release oxybutynin
- ditropan-anti-muscarinic agent
- gold standard, titrate slowly to prevent side effects of dry mouth, constipation, vision impairment, confusion, cognitive impairment, orthostatic hypotension, sedation, weight gain
- no hepatic or renal adjusments
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extended-release oxybutynin
- ditropan xl
- max effect may take 4 weeks
- no hepatic or renal adjustments
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extended-release transdermal oxybutynin
- ditropan
- apply patch twice weekly every 3 to 4 days, lower concentrations of active metabolites because avoids first pass
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immediate release tolterodine
- detrol
- may take up to 8 weeks to see max benefit
- hepatic and renal adjustments
- interactions with antacids and PPIs lead to rapid release of the drug
- dizziness, dyspepsia, HA, vision disturbances, constipation
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Tospium chloride
- Sanctura
- take on an empty stomach
- Non CYP
- no hepatic adjustments BUT need renal adjustments
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solifenacin succinate
- Vesicare
- no advantage over other agents
- hepatic and renal adjustments
- dry mouth, constipation, blurred vision
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darifenacin
- Enablex
- no advantage over the other agents
- hepatic adjustments and no renal
- dry mouth, constipation
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fesoteridine
- Toviaz
- no advantage over other agents
- hepatic and renal adjustments
- dry mouth, constipation, HA, dry eye
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Botulinum Toxin A
- direct injection into the muscle leads to paralysis
- still being studied but appears can receive injections every 3 to 9 months
- side effects are dose related- detrusor underactivity and urinary retention
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Cartheterization combined with medications
- usually in patients with urge incontinence that also have elevated post void residuals
- patients would intermittenly self carherize to prevent surgical placement of a catheter
- to help increase bladder storage any of the above medications can be used along the with catherization
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stress incontinence tx
- alph-adrenergic receptor blockers: prazosin, terasozin, doxazosin, tamulosizin, alfuzosin, methyldopa, chlonidine, guanfacine, labetolol
- improves urethral closure by stimulating the receptors in the bladder neck
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