Top 200: Urinary Incontinence, Erectile Dysfunction

  1. What is Urinary Incontinence (UI)?
    Involuntary loss of urine
  2. What factors give an increased risk for urinary incontinence?
    • Females
    • Obesity (BMI >30)
    • Advanced age (>50 yo)
    • Poor functional status
  3. What are acute causes of urinary incontinence?
    • Urinary tract infection
    • Medications
    • Constipation
    • Tumor
  4. What are chronic causes of urinary incontinence?
    • Muscle/tissue weakness
    • Urinary tract abnormality
    • ↑ during menstrual cycle
    • Nerve damage
    • Idiopathic (unknown)
  5. What are they types of urinary incontinence?
    • Urge (Overactive Bladder)
    • Urinary urgency with increased frequency and nocturia, with or without urinary incontinence
    • ↑ bladder muscle contraction or nerve problems
    • Patients are going to have to go more frequently (>8 times a day and more than once at night).
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    • Stress
    • Loss of urine on exertion, sneezing, or
    • coughing
    • Bladder pressure > urethral pressure

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    • Mixed
    • Both urge and stress combined

    • Overflow
    • Patients can never completely void their bladder with this type
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    • Functional
    • Something may be anatomically wrong to cause incontinence.
  6. What are the two most common types of urinary incontinence?
    Urge and Stress are the most common.
  7. What is a major cause of stress induced urinary incontinence in females?
  8. What are some treatment options for urinary incontinence?
    • Lifestyle modifications
    • Kegel exercise
    • Pelvic floor muscle training (PFMT)
    • Bladder training
    • Intravaginal Devices (pessaries)
    • Medications
    • Nerve stimulation
    • Surgery
  9. What is a pessarie?
    • inserted intravaginally
    • puts pressure on the urethra, reducing involuntary urination
  10. What is bladder training?
    Getting patients on a scheduled fluid intake and bathroom break schedule so that they can expect when to urinate.
  11. What are some lifestyle modifications for urinary incontinence?
    • lose weight
    • stop smoking
  12. What is the point of Kegel exercises?
    Kegel exercises = strengthen the muscles so patients can have control.
  13. Kegel Exercises
    Tone pelvic muscles

    Pelvic muscles wrap around the pelvic floor.

    Women have less strength in their pelvic muscles because they have three openings instead of two like men.

    • Find the Pubococcygeus Muscles (PC):
    • You have found these muscles if you can stop the flow of urine when you urinate
    • Squeeze muscle → hold contraction up to 10 secs → release
    • 10-20 repetitions three times a day

    • Contract ONLY pelvic muscles
    • Not a quick therapy: may take 6 weeks to see any improvement

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  14. What are some medications for urinary incontinence?
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  15. What type of receptors do all urinary incontinence medications work on?
    • All UI medications are muscarinic, but there are
    • differences.

    M2 muscarinic receptors in saliva glands.

    M3 muscarinic in bladder.

    Therefore, M3 is better target for UI therapy.
  16. Which UI medication is the most selective?
    Enablex (Darfenecin) is highly selective.

    It is 90x more selective than other UI agents.

    It’s expensive, newer, so not used as often.
  17. Which UI medication is used the most?
    Detrol (Tolterodine) is used the most. It is also selective for M3 receptors.
  18. What are the goals of treatment for urinary incontinence?
    • decrease urge
    • decrease urination
    • may take weeks to months for full efficacy
  19. Tolterodine
    Detrol (Tolterodine)

    Urge incontinence/Overactive bladder

    Competitive muscarinic receptor antagonist

    ↓ bladder contractions, detrusor pressure, and incomplete voiding

    Administer once (ER) or twice (IR) daily

    Dose reductions in hepatic/renal insufficiency

    Side effects: Dry mouth, headache, constipation, blurred vision, dizziness

    May take weeks to months for full efficacy
  20. What is BPH?
    BPH = Benign Prostatic Hyperplasia

    Enlarged prostratepresses on urethraurination and bladder problems

    Prostate size increases with age

    Enlarged prostate = pressure on bladder.

    • Prostate wraps around urethra, so if enlarged,
    • flow is decreased.

    Men will see enlarged prostate in 30’s, so progressive condition.

    90% of men will have BPH by 80 years of age.

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  21. What are symptoms of BPH?
    • Dribbling at the end of urination
    • Urinary retention
    • Incomplete bladder emptying
    • Incontinence
    • Nocturia
    • Slowed/delayed/strained urination
  22. What are treatment options for BPH?
    • Lifestyle modifications
    • Urinate with initial urge
    • Avoid alcohol and caffeine
    • Avoid drinking close to bedtime
    • Avoid OTC decongestants/antihistamines
    • Regular exercise
    • Kegel exercises
    • Reduce stress
  23. Why should OTC decongestants and antihistamines be avoided in patients with BPH?
    Because decongestants and antihistamines have anticholinergic effects, which include reducing the ability to urinate.
  24. What are some anticholinergic effects?
    • Recall acetylcholine is a neurotransmitter. Therefore, when blocked, the following effects are typically seen:
    • constipation
    • dry mouth
    • blurred vision
    • dizziness
    • slowing of urination
  25. What are the pharmacologic treatment options for BPH?
    • Alpha 1-blockers
    • 5-alpha reductase inhibitors
    • Muscarinic blockers
  26. What are the alpha 1-blockers?
    • Doxazosin (Cardura®)
    • Prazosin (Minipress®)
    • *Tamsulosin (Flomax®)
    • Terazosin (Hytrin®)
    • Alfuzosin (Uroxatral®)
    • Silodosin (Rapaflo®)
  27. What are the 5-alpha reductase inhibitors?
    • *Finasteride (Proscar®)
    • Dutasteride (Avodart®)
  28. What else are hytrin and cardura commonly used for besides UI?
  29. Tamsulosin
    Tamsulosin (Flomax®)

    Generic now available!

    Treatment of symptomatic BPH alone or in combination with 5 α reductase inhibitor

    α-Adrenergic receptor blocker

    Combination therapy resulted in ↑ urine flow rate

    Side effects: Orthostatic hypotension, dizziness, weakness, ↓ libido, insomnia, rhinitis, abnormal ejaculations, ejaculatory problems, intraoperative floppy iris syndrome

    Administer 30 minutes after the same meal each day
  30. Finasteride
    Finasteride (Proscar®)

    • Treatment of symptomatic BPH alone or with an
    • α-adrenergic blocker (usually Doxazosin)

    5 α Reductase Inhibitor

    ↓ prostate size

    • Combination therapy resulted in ↑ symptom
    • relief and ↑ urine flow rate

    • Side effects: Erectile dysfunction, ↓ libido,
    • breast size/tenderness, rash
  31. Which pharmacologic treatment for BPH has pregnancy category X and therefore should not even be handled by pregnant women?
    Finasteride (Proscar®)
  32. What is ED?
    • ED = Erectile Dysfunction
    • Inability to achieve or maintain an erection
    • Affects 65 percent of men between 40 and 70 years of age

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  33. What is the mechanism for penile arousal?
    • ArousalAch released from pelvic nerve
    • nitric oxide released from cavernosal nervessmooth muscle relaxation↑arterial inflow/ ↓ venous outflowpenile rigidity
  34. What might endothelial damage do to the mechanism of action for a penile erection?
    Endothelial damage →nitric oxide production
  35. What are possible risk factors for ED?
    • Cardiovascular (CV) disease
    • Diabetes
    • Depression
    • Alcoholism
    • Smoking
    • Penile trauma
    • Neurologic disease
    • Obesity
    • Renal disease
  36. What are the goals of treatment for ED?
    Increased sexual function

    Improve quality and quantity of erections suitable for intercourse

    Maintain adequate erection for patient and partner satisfaction
  37. What are some lifestyle modifications for ED?
    • increased physical activity
    • dietary changes
    • disease state management
  38. What pharmacological treatments are usually used to treat ED?
    Phosphodiesterase type 5 (PDE5) inhibitors
  39. PDE5 Inhibitors
    Inhibits cGMP (cyclic guanine monophosphate)

    cGMP builds up causing smooth muscle relaxation which therefore causes increased inflow of blood

    • Similar effectiveness among the drug options, although Cialis (Tadalafil) has a delayed effect/longer acting
    • Grapefruit juice may increase concentration
    • Contraindicated with nitrates
  40. What are the side effects of PDE5 inhibitors?
    • headache
    • flushing
    • dyspepsia
    • rhinitis
    • impaired color discrimination
    • dizziness
    • hypotension
    • Cardiovascular effects
    • sudden hearing loss
  41. Which are PDE5 inhibitors contraindicated with?
  42. What might grapefruit juice do to PDE5 inhibitors?
    increase concentration plasma levels
  43. What is the mechanism of action of PDE5 inhibitors?
    Inhibits cGMP (cyclic guanine monophosphate)

    cGMP builds up causing smooth muscle relaxation, which then causes increased inflow of blood

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  44. What type of receptor do PDE5 inhibitors work on?
    NANC = Nonadrenergic/Noncholinergic Neuron

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  45. What are the PDE5 inhibitors?
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  46. What herbal product is used to treat ED?
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    Derived from the bark of the yohimbe tree

    Herbal Product

    Treatment of ED (NOT recommended due to lack of studies confirming efficacy)

    Selective α2 adrenergic blocker

    Produces a vasodilatory response

    Efficacy not proven

    Side effects: Dizziness, anxiety, flushing, headache, hypertension, tachycardia, tremor
  47. What are possible surgical or procedural options for ED?
    • Vasoactive injection therapy, such as Alprostadil
    • (Caverject®)
    • Vacuum pump devices
    • Penile prosthesis
  48. What is a Penis Vacuum Pump Device?
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    Vacuum pressure draws arteriolar blood into the penis

    Onset of action: 2-30 minutes

    Manual or battery-operated pumps

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  49. How long do Penis Vacuum Pump Devices take to work?
    Onset of action: 2-30 minutes
  50. How do I use the Penis Vacuum Pump Device?
    • place plastic tube over penis
    • press tube flush against lower abdomen to create a vacuum chamber
    • place tension ring around penis base
    • may take up to 30 minutes to get an erection
    • do not leave on longer than 30 minutes
  51. What are some advantages of the Penis Vacuum Pump Device?
    • easy to operate
    • partner can participate
    • non-invasive
  52. What are some disadvantages of the Penis Vacuum Pump Device?
    • delayed onset of action
    • constriction band can be painful
  53. Drug List
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Card Set
Top 200: Urinary Incontinence, Erectile Dysfunction
Top 200: Spring 2011, Urinary Incontinence, Erectile Dysfunction