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What is Urinary Incontinence (UI)?
Involuntary loss of urine
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What factors give an increased risk for urinary incontinence?
- Females
- Obesity (BMI >30)
- Advanced age (>50 yo)
- Poor functional status
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What are acute causes of urinary incontinence?
- Urinary tract infection
- Medications
- Constipation
- Tumor
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What are chronic causes of urinary incontinence?
- Muscle/tissue weakness
- Urinary tract abnormality
- ↑ during menstrual cycle
- Nerve damage
- Idiopathic (unknown)
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What are the two most common types of urinary incontinence?
Urge and Stress are the most common.
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What is a major cause of stress induced urinary incontinence in females?
pregnancy
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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
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What is a pessarie?
- inserted intravaginally
- puts pressure on the urethra, reducing involuntary urination
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What is bladder training?
Getting patients on a scheduled fluid intake and bathroom break schedule so that they can expect when to urinate.
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What are some lifestyle modifications for urinary incontinence?
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What is the point of Kegel exercises?
Kegel exercises = strengthen the muscles so patients can have control.
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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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What are some medications for urinary incontinence?
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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.
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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.
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Which UI medication is used the most?
Detrol (Tolterodine) is used the most. It is also selective for M3 receptors.
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What are the goals of treatment for urinary incontinence?
- decrease urge
- decrease urination
- may take weeks to months for full efficacy
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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
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What is BPH?
BPH = Benign Prostatic Hyperplasia
Enlarged prostrate → presses on urethra → urination 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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What are symptoms of BPH?
- Dribbling at the end of urination
- Urinary retention
- Incomplete bladder emptying
- Incontinence
- Nocturia
- Slowed/delayed/strained urination
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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
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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.
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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
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What are the pharmacologic treatment options for BPH?
- Alpha 1-blockers
- 5-alpha reductase inhibitors
- Muscarinic blockers
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What are the alpha 1-blockers?
- Doxazosin (Cardura®)
- Prazosin (Minipress®)
- *Tamsulosin (Flomax®)
- Terazosin (Hytrin®)
- Alfuzosin (Uroxatral®)
- Silodosin (Rapaflo®)
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What are the 5-alpha reductase inhibitors?
- *Finasteride (Proscar®)
- Dutasteride (Avodart®)
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What else are hytrin and cardura commonly used for besides UI?
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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
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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
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Which pharmacologic treatment for BPH has pregnancy category X and therefore should not even be handled by pregnant women?
Finasteride (Proscar®)
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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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What is the mechanism for penile arousal?
- Arousal → Ach released from pelvic nerve →
- nitric oxide released from cavernosal nerves → smooth muscle relaxation →↑arterial inflow/ ↓ venous outflow → penile rigidity
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What might endothelial damage do to the mechanism of action for a penile erection?
Endothelial damage → ↓ nitric oxide production
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What are possible risk factors for ED?
- MEDICATIONS
- Cardiovascular (CV) disease
- Diabetes
- Depression
- Alcoholism
- Smoking
- Penile trauma
- Neurologic disease
- Obesity
- Renal disease
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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
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What are some lifestyle modifications for ED?
- increased physical activity
- dietary changes
- disease state management
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What pharmacological treatments are usually used to treat ED?
Phosphodiesterase type 5 (PDE5) inhibitors
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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
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What are the side effects of PDE5 inhibitors?
- headache
- flushing
- dyspepsia
- rhinitis
- impaired color discrimination
- dizziness
- hypotension
- Cardiovascular effects
- sudden hearing loss
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Which are PDE5 inhibitors contraindicated with?
Nitrates
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What might grapefruit juice do to PDE5 inhibitors?
increase concentration plasma levels
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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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What type of receptor do PDE5 inhibitors work on?
NANC = Nonadrenergic/Noncholinergic Neuron
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What are the PDE5 inhibitors?
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What herbal product is used to treat ED?
Yohimbine
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
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What are possible surgical or procedural options for ED?
- Vasoactive injection therapy, such as Alprostadil
- (Caverject®)Vacuum pump devices
- Penile prosthesis
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What is a Penis Vacuum Pump Device?
Vacuum pressure draws arteriolar blood into the penis
Onset of action: 2-30 minutes
Manual or battery-operated pumps
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How long do Penis Vacuum Pump Devices take to work?
Onset of action: 2-30 minutes
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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
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What are some advantages of the Penis Vacuum Pump Device?
- easy to operate
- partner can participate
- non-invasive
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What are some disadvantages of the Penis Vacuum Pump Device?
- delayed onset of action
- constriction band can be painful
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