CDM 4 Exam 2 Review Urologic Disorders Incontinence I Urinary incontinence A Definition involuntary leakage of urine nuring home blacement embarrassment loss of independence UTIS falls decubitis ulcers B Definitions 1 Histological BPH characterized by stromal and epithelial cell hyperplasia beginning in the periurethral zone of the prostate 2 Clinical BPH progressive non malignant growth of the prostate gland surrounding the urethra gradually compressing it and hindering urine flow C Bladder anatomy and normal urinary continence 1 Compliant urethral sphincter tone during bladder filling storage a Proximal involuntary b Distal voluntary involuntary c Suppression of detrusor muscle activity 2 Bladder emptying a Voluntary contraction b Bladder outlet opening near complete emptying D Bladder innervation drug therapy targets 1 Bladder detrusor muscle a Mediated by parasympathetic b ACh Muscarinic post synaptic receptors Five subtypes c M2 and M3 d M3 is predominant drug therapy target 2 Several other non ACh pathways thought to contribute to UI a 5HT DA K and Ca channels etc E The prostate 4 20 g in typical adult male 1 Static Component a Prostate gland enlargement b Stromal and epithelial cell c Androgen and estrogen hyperplasia mediated d Compression of the urethra e Bladder outlet obstruction a Prostate and bladder neck smooth muscle b adrenergic receptor stimulation 2 Dynamic component c Contraction of smooth muscle around urethra d Bladder outlet obstruction II Mechanisms of UI A Types of incontinence 1 Overflow urethral blockage bladder unable to empty properly 2 Stress relaxed pelvic floor increased abdominal pressure a Risk factors women pregnancy menopause age i Men uncommon in otherwise health patients prior history of UTI or surger 3 Urge Bladder oversensitivity from infection Neurologic disorders 1 4 B Urge Urinary Incontinency UUI 1 Bladder over activity and involuntary contractions 2 Commonly referred to as overactive bladder OAB 3 Urge frequency nocturia Incontinence variable between patients a b Differential diagnosis to rule out other disorders 4 No underlying cause in majority of UUI patients 5 Associated risk factors Spinal cord injury MS parkinson s BPH 6 Can be exacerbated by meds co morbidities C Stress Urinary incontinence SUI 1 Referred as urethral underactivity most common in women 2 Weak urethral sphincter pregnancy elderly cognitive decline obesity 3 Physical activity and excessive intra abdominal pressure cause urine leakage coughing sneezing physical exercise D Overflow UI 1 Overactive urethral tone and impaired contractility impaired bladder emptying a Chronic urethral obstruction i e BPH b Referred to as mixed incontinence E Functional incontinence absence of bladder urethral defects 1 Co morbidities prevent access to facilities Dementia s p surgery UTIs etc III Nonpharm UI treatment A Behavioral interventions First line therapy for UUI SUI and Mixed UI B Lifestyle modifications minimize exacerbating factors caffeine C Scheduled toileting Relaxation bladder training prompts D Pelvic muscle rehab kegel exercise acupuncture etc IV UUI OAB Drug therapy options A Anti cholinergic agents first line therapy ANTI SPLUD 1 contractions storage improve symptoms 2 Oxybutynin Ir XL transdermal Ditropan a Topical gel Gelnique b 2 5 5 mg BID QID IR c 5 30mg daily XL 2 d IR active metabolite ADE IR clearance in elderly but not XR 3 Tolterodine IR LA detrol a LA 4 mg daily b Dose reduction in hepatic failure 4 Trospium chloride sanctura a 20 mg BID b With antacids dose dumping 5 Solifenacin vesicare 5 10 mg once daily 6 Darifenacin ER enablex 7 5 15 mg once daily 7 Fesoterodine ER Toviaz 4 8 mg once daily 8 Contraindications urinary retention overflow UI bowl obstruction narrow angel 9 Warnings overuse improper use can risk of retention 10 Drug interactions Alcohol benzos opioid analgesics 11 ADE Anti splud HA blurred vision glaucoma B Beta 3 adrenergic agonists subtype accounts for 95 presence in human bladder mediates detrusor relaxaion increase bladder capacity no change in micturition pressure 1 Mirabegron Myrbetriq poor PO bioavailability XR product a 25 mg PO once daily to start can to 50 mg after 8 weeks CrCl 15 29 NO dose b Moderate CYP2D6 inhibitor CAUTION WITH METOPROLOL c ADE HTN UTI HA Nasopharyngitis B1 stimulation at high doses BP effects less anticholinergic ADE HTN and constipation ADE potential for UTI and retention C Other 2nd line agents 1 TCAs desipramine nortriptyline preferred 2 Propantheline flavoxate dicylomine hysocyamine modest effect 3 Botox D AUA 2014 guideline 1 Nonpharm pharm best more effective than either alone 2 Anticholinergics better LA vs IR tolerability V SUI drug therapy options A Duloxetine 2st FDA approved and DOC for SUI 1 5ht and NE proposed active role with urethral and external sphincter tone 2 urinary frequency QOL 3 ADE nausea constipation dry mouth dizziness HA 4 40 80 mg day DO NOT ABRUPTLY WITHDRAW 5 Metabolism 1A2 2D6 B Venlafaxine 75 mg PO once daily incontinence frequency voiding intervals QOL Nausea C Estrogens 1 urethral tone alpha adrenergic upregulation contraction pelvic muscle strengthening 2 TOPICAL PRODUCTS ONLY D Alpha adrenergic agonists ephedrine midorine limited role combo with estrogen may be more effective VI Benign Prostatic Hyperplasia Lower urinary tract LUTS A Voiding obstructive hesitancy straining weak flow terminal dribbling prolonged voiding retention intermittency overflow incontinence B Storage irritative frequency urgency nocturia urge incontinence small voided volume pain C Evaluation and diagnosis 1 Complete medical history to rule out other causes of symptoms i e prostate cancer 3 2 Digital rectal and neurologic exam 3 Urinalysis hematuria UTI 4 Prostate specific antigen PSA PSA correlates with prostate size and risk of VA 5 Value of PSA as a screen tool is controversial D Symptom Assessment International prostate symptom score IPSS 1 American Urological Associateion symptom index AUASI 2 3 4 Successful tx score peak flow rate and Qmax of bother score IPSS only E Moderate to severe BPH symptom tx options 1 Watchful waiting 2 Medication 3 Minimally Invasive Therapy a Transurethral microwave needle ablation 4 Surgical Therapy a Transurethral resection of the prostate TURP gold standard b Laser vaporization c Open prostatectomy d Robotic laparoscopic VII Medical treatments for BPH LUTS BOO bladder outlet obstruction A adrenergic antagonists 1 Prostate smooth muscle tone is mediated via alpha1