Urinary Incontinence Tova Ablove, Alev Wilk Primary Care Conference, 10/12/05
Urinary Incontinence • No Financial Disclosures
Objectives • Case Examples: Dr. Wilk • Management Issues: Dr. Ablove • Treatment options • Referral options • Question & Answer
Case One • 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 • Has attempted Kegel exercises for several months without improvement • Recommendations: Pessary? Pelvic Floor Physical Therapy Program? Referral to subspecialty?
Case Two • 55 y.o. woman with stress incontinence when she coughs, laughs, or exercises • No dribbling, urgency, frequency, dysuria, postvoid fullness, constipation • G0P0 • Depression on Celexa
Case Two • 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 • No constipation, burning with urination • History of UTI this past year; Osteoporosis with recurrent TL fractures and LBP • G2P2 • IV forteos monthly; prn muscle relaxant
Case Three • Exam: bladder prolapse; vulvovaginal atrophy. Otherwise normal exam • Recommendations: pessary, pelvic floor exercises.
Case Four • 76 y.o. woman with stress and urge incontinence, urinary leakage; nocturia 1-2x per night • Urinary frequency, constipation, postvoid fullness • G6P6; s/p oophorectomy, partial colectomy • Depression, COPD, HTN, schizophrenia, anxiety • Current smoker: 63 pack years; no alcohol; retired RN and widowed
Case Four • 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 • 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 • Denies tobacco or alcohol use; CNA • Exam: NL cardiovascular, GI, Kidney. Genital: pelvic floor “prolapse”; negative UA & glucose; PVR: 100cc. • Recommendations: Oxybutinin for “overactive bladder”; Pelvic Floor Physical Therapy Program? Referral to subspecialty?
Drugs Predominant anticholinergic or antimuscurinic action • Oxybutnin • Tolterodine • Hyoscyamine • Imipramine • Darifenacin • Solifenacin Close follow up needed especially in geriatric patients
Oxybutynin • Potent muscarinic receptor antagonist with some degree of selectivity for M3 and M1 receptors • Usual dose • Short acting 2.5-5 mg tid • Long acting 5-30 mg qd • Patch 3.9mg 2x/week (96hr) • ICI: Physiologically/pharmacologically effective and recommended based on good-quality randomized controlled trials 1/A
Tolterodine • Nonselective muscarinic receptor antagonist • Usual dose • Short acting 2mg bid • Long acting 4mg qd • ICI: Physiologically/pharmacologically effective and recommended based on evidence from good-quality randomized trials 1/A
Hyoscyamine sulfate • Anticholinergic • Usual adult dose .375 mg bid • Controlled studies of effects on bladder hyperactivity are lacking 2/D
Imipramine • Anticholinergic and alpha adrenergic actions • Useful for mixed incontinence. • Can cause postural hypotension and bundle branch block • Usual dose 10 to 25mg tid • ICI: 2/C
Darifenacin • M3 receptor selective • The recommended starting dose is 7.5 to 15 mg / day • ICI: Physiologically/pharmacologically effective and recommended based on evidence from good-quality randomized trials 1/A Enablex [package insert]. 2004.
Solifenacin • Nonselective muscarinic receptor antagonist • Half life of 45-68hrs • Usual dose • 5 to 10 mg po qd • ICI: Physiologically/pharmacologically effective and recommended based on evidence from good-quality randomized trials 1/A
What is InterStim Therapy? • Implantable, programmable neuromodulation system.
Mechanism of Action • Mechanism of action for SNS is not fully understood at this time - many theories exist. • Generally agreed that stimulation of the sacral nerves modulates the neural reflexes that influence the bladder, sphincter and pelvic floor that control/influence voiding. 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.
InterStim Therapy Indications: overactive bladder, and or urinary retention, in patients who have failed or could not tolerate more conservative treatments.