URINARY INCONTINENCE(UI)
Learning Objectives
• Upon completion of this session, the students will be able to:
– Describe the normal micturition cycle.
– List the physiologic factors responsible for the maintenance of urinary continence.
– Explain the pathophysiologic basis for the main types of urinary incontinence.
– Compare and contrast the clinical presentations of the main types of urinary
incontinence.
– Discuss the risk factors for the main types of urinary incontinence.
– Identify those drugs that can precipitate new-onset or aggravate existing urinary
incontinence.
– Select an appropriate non-pharmacologic and drug for urinary incontinence based on
patient-specific data.
– Formulate appropriate counseling information to be provided
Introduction
• Urinary incontinence (UI) is defined as involuntary leakage of urine
• It is frequently accompanied by other bothersome lower urinary tract
symptoms, such as urgency, increased daytime frequency, and nocturia
• It is a common yet underdetected and underreported health problem
that can significantly affect quality of life.
• Patients with UI may have depression as a result of the perceived lack
of self-control, loss of independence, and lack of self-esteem, and they
often curtail their activities for fear of an "accident."
• UI may also have serious medical and economic ramifications for
untreated or undertreated patients, including perineal dermatitis,
worsening of pressure ulcers, urinary tract infections, and falls.
Micturition cycle
• Filling Storage void
• To prevent incontinence during the bladder filling and
storage phase of the micturition cycle, the urethral
sphincter, must maintain adequate closure
• Urethral closure or resistance to flow is maintained to a
large degree by:
– Proximal (under involuntary control) urinary
sphincters
– Distal (under both voluntary and involuntary control)
urinary sphincters
Cont’d…
• Normal bladder emptying occurs with opening of the urethra
concomitant with a volitional bladder contraction
• Acetylcholine is the neurotransmitter that mediates both
volitional and involuntary contractions of the bladder
– Bladder smooth muscle cholinergic receptors are mainly of
the M2 variety;
– However, M3 receptors are responsible for both emptying
contraction of normal micturition and involuntary bladder
contractions
Pathophysiology
• UI occurs as a result of over-functioning or
under-functioning of the urethra, bladder, or
both.
• Urethral under-activity is known as stress UI
(SUI) and occurs during activities such as
exercise, lifting, coughing, and sneezing.
– The urethral sphincter no longer resists the
flow of urine from the bladder during
Cont’d…
• Bladder over activity is known as urge UI (UUI)
and is associated with increased urinary
frequency and urgency, with or without urge
incontinence.
– The detrusor muscle is overactive and
contracts inappropriately during the filling
phase.
Cont’d…
• Urethral over-activity and/or bladder underactivity
is known as overflow incontinence.
– The bladder is filled to capacity but is unable to
empty, causing urine to leak from a distended
bladder past a normal outlet and sphincter.
– Common causes of urethral over-activity include
• Benign prostatic hyperplasia
• prostate cancer
• In women, cystocele formation or surgical
overcorrection after UI surgery.
• Mixed incontinence includes the combination of bladder
overactivity and urethral underactivity
• Functional incontinence is not caused by bladder- or urethra-
specific factors but rather occurs in patients with conditions
such as cognitive or mobility deficits.
Medications that Influence Lower Urinary Tract
Function
Medication Effect
Diuretics, acetylcholinesterase inhibitors Polyuria, frequency, urgency
-Receptor antagonists Urethral relaxation and stress urinary
incontinence in women
-Receptor agonists Urethral constriction and urinary retention in
men
Calcium channel blockers Urinary retention
Narcotic analgesics Urinary retention from impaired contractility
Sedative hypnotics Functional incontinence caused by delirium,
immobility
Antipsychotic agents Anticholinergic effects and urinary retention
Anticholinergics Urinary retention
Antidepressants, tricyclic Anticholinergic effects, -antagonist effects
Alcohol Polyuria, frequency, urgency, sedation,
delirium
Angiotensin-converting enzyme inhibitors Cough as a result of ACEIs may aggravate
(ACEIs) stress urinary incontinence by increasing
Localized or systemic illnesses may result
in UI
• Dementia/delirium
• Depression
• Urinary tract infection (cystitis)
• Postmenopausal atrophic urethritis or vaginitis
• Diabetes mellitus
• Neurologic disease (e.g., stroke, Parkinson's
disease, multiple sclerosis, spinal cord injury)
• Pelvic malignancy
• Constipation
• Congenital malformations
Clinical presentation
Clinical Presentation of Urinary Incontinence Related to
Urethral Overactivity and/or Bladder Underactivity
• General
– Important but rare type of UI in both men and women.
– Urethral overactivity is usually due to prostatic enlargement (males) or cystocele
formation or surgical overcorrection following stress incontinence surgery in women.
• Symptoms
– Lower abdominal fullness, hesitancy, straining to void, decreased force of stream,
interrupted stream, sense of incomplete bladder emptying. May have urinary
frequency and urgency. Abdominal pain if acute urinary retention is present.
• Signs
– Increased postvoid residual urine volume.
• Diagnostic Tests
– Digital rectal examination or transrectal ultrasound to rule out prostatic enlargement.
Renal function tests to rule out renal failure due to acute urinary retention.
Treatment
• Desired outcome
– The goal of therapy is to decrease the signs and
symptoms of most distress to the patient.
Nonpharmacologic Management
• Lifestyle modifications,
• Toilet scheduling regimens,
• Pelvic floor muscle rehabilitation
• Surgery
Pharmacologic treatment
Urethral Underactivity: Stress Urinary Incontinence
• The goal of treatment of SUI is to improve urethral
closure by
– Stimulating α-adrenergic receptors in the smooth muscle
of the bladder neck and proximal urethra,
– Enhancing supportive structures underlying the urethral
epithelium, or
– Enhancing serotonin and norepinephrine effects in the
micturition reflex pathways.
Stress SUI……(Urethral underactivity)
Drug Class Drug Therapy (Usual Dose) Comments
Duloxetine 40–80 mg/day (one or two Even though not FDA approved, duloxetine is first-line
doses) therapy; most adverse events diminish with time, so
support patient during initial period of use
Alpha- Pseudoephedrine (15–60 mg Pseudoephedrine and phenylephrine are alternative first-
Adrenergic three times daily) with food, line therapies for women with no contraindication (notably
agonists water, or milk. hypertension); phenylpropanolamine was the preferred
Phenylephrine (10 mg four times agent in the class until its removal from the U.S. market in
daily) 2000
Estrogen Works best if urethritis or Considered a less-effective alternative to -adrenergic
vaginitis due to estrogen agonists and duloxetine. Combined -adrenergic agonist and
deficiency is present estrogen may be somewhat more effective than -adrenergic
agonist alone in postmenopausal women
Imipramine 25–100 mg at bedtime Imipramine is an optional therapy when first-line therapy is
inadequate
Urge UI (UUI)…..Overactive bladder
Drug Class Drug Therapy (Usual Dose) Comments
Anticholinergic agents Oxybutynin IR (2.5–5 mg two, three, or four times daily), Anticholinergics are first-line
OR antispasmodics oxybutynin XL (5–30 mg daily), oxybutynin TDS (3.9 mg/day) drug therapy (oxybutynin or
(apply one patch twice weekly), oxybutynin gel (1 sachet [100 tolterodine is preferred)
mg] topically daily), tolterodine IR (1–2 mg twice daily),
tolterodine LA (2–4 mg daily), trospium chloride extended
release (60 mg daily), solifenacin (5–10 mg daily), darifenacin
(7.5–15 mg daily), fesoterodine (4–8 mg daily)
Tricyclic antidepressants Imipramine, doxepin, nortriptyline, or desipramine (25–100 TCAs are generally reserved for
(TCAs) mg at bedtime) patients with an additional
indication (e.g., depression,
neuropathic pain)
Topical estrogen (only in Conjugated estrogen vaginal cream (0.5 g) three times per Marginally effective for OAB; few
women with urethritis week for up to 8 months. Repeat course if symptom adverse effects with vaginal
or vaginitis) recurrence, or use estradiol vaginal insert/ring [2 mg (one cream and insert
ring)] and replace after 90 days if needed
Overflow UI….(Urethral overactivity and/or bladder
underactivity)
Drug Class Drug Therapy Comments
(Usual Dose)
Cholinomimetics Bethanechol (25–50 mg •Avoid use if patient has asthma or heart
three or four times daily) disease.
on an empty stomach •Short-term use only.
• Increases bladder •Never give IV or IM because of life-
muscle tone threatening cardiovascular and severe
gastrointestinal reactions
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