1. Urinary Incontinence Tova Ablove, Alev Wilk Primary Care Conference, 10/12/05

2. Urinary Incontinence No Financial Disclosures No Financial Disclosures

3. Objectives Case Examples: Dr. Wilk Case Examples: Dr. Wilk Management Issues: Dr. Ablove Management Issues: Dr. Ablove  Treatment options  Referral options Question & Answer Question & Answer

4. Case One 47 y.o. woman with stress incontinence with some urgency, no leakage nor nocturia. 47 y.o. woman with stress incontinence with some urgency, no leakage nor nocturia. No urinary dribbling, frequency, dysuria, constipation No urinary dribbling, frequency, dysuria, constipation Three uneventful vaginal deliveries; fourth pregnancy: twins by C-section. Three uneventful vaginal deliveries; fourth pregnancy: twins by C-section. PMH: Raynaud’s PMH: Raynaud’s Denies tobacco or alcohol use; Labor and Delivery RN Denies tobacco or alcohol use; Labor and Delivery RN

5. Case One Exam: NL cardiovascular, GI, Kidney. Genital: no notable atrophy or pelvic floor laxity; negative UA Exam: NL cardiovascular, GI, Kidney. Genital: no notable atrophy or pelvic floor laxity; negative UA Has attempted Kegel exercises for several months without improvement Has attempted Kegel exercises for several months without improvement Recommendations: Pessary? Pelvic Floor Physical Therapy Program? Referral to subspecialty? Recommendations: Pessary? Pelvic Floor Physical Therapy Program? Referral to subspecialty?

6. Case Two 55 y.o. woman with stress incontinence when she coughs, laughs, or exercises 55 y.o. woman with stress incontinence when she coughs, laughs, or exercises No dribbling, urgency, frequency, dysuria, postvoid fullness, constipation No dribbling, urgency, frequency, dysuria, postvoid fullness, constipation G 0 P 0 G 0 P 0 Depression on Celexa Depression on Celexa

7. Case Two Denies tobacco or alcohol use; Recently divorced Denies tobacco or alcohol use; Recently divorced Exam: NL cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UA Exam: NL cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UA Recommendations: Estrogens? Pessary? Pelvic Floor Physical Therapy Program? Referral to subspecialty? Recommendations: Estrogens? Pessary? Pelvic Floor Physical Therapy Program? Referral to subspecialty?

8. Case Three 81 y.o. women with stress, urge incontinence and urinary leakage 81 y.o. women with stress, urge incontinence and urinary leakage No constipation, burning with urination No constipation, burning with urination History of UTI this past year; Osteoporosis with recurrent TL fractures and LBP History of UTI this past year; Osteoporosis with recurrent TL fractures and LBP G2P2 G2P2 IV forteos monthly; prn muscle relaxant IV forteos monthly; prn muscle relaxant

9. Case Three Exam: bladder prolapse; vulvovaginal atrophy. Otherwise normal exam Exam: bladder prolapse; vulvovaginal atrophy. Otherwise normal exam Recommendations: pessary, pelvic floor exercises. Recommendations: pessary, pelvic floor exercises.

10. Case Four 76 y.o. woman with stress and urge incontinence, urinary leakage; nocturia 1-2x per night 76 y.o. woman with stress and urge incontinence, urinary leakage; nocturia 1-2x per night Urinary frequency, constipation, postvoid fullness Urinary frequency, constipation, postvoid fullness G6P6; s/p oophorectomy, partial colectomy G6P6; s/p oophorectomy, partial colectomy Depression, COPD, HTN, schizophrenia, anxiety Depression, COPD, HTN, schizophrenia, anxiety Current smoker: 63 pack years; no alcohol; retired RN and widowed Current smoker: 63 pack years; no alcohol; retired RN and widowed

11. Case Four Albuterol, cogentin, valium, benadryl, depakote, advair, meclizine, zyprexa, piroxicam, quinine, risperidone, trazodone Albuterol, cogentin, valium, benadryl, depakote, advair, meclizine, zyprexa, piroxicam, quinine, risperidone, trazodone Exam: Stable cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UA Exam: Stable cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UA Recommendations: Estrogen? Pelvic Floor Physical Therapy Program? Referral to subspecialty? Recommendations: Estrogen? Pelvic Floor Physical Therapy Program? Referral to subspecialty?

12. Case Five 48 y.o. woman with polyuria (every 30 minutes while awake) and pelvic pressure 48 y.o. woman with polyuria (every 30 minutes while awake) and pelvic pressure Voiding diary Voiding diary No dysuria, postvoid fullness, constipation No dysuria, postvoid fullness, constipation Three uncomplicated vaginal births; tubal ligation; Leep procedure 1993 Three uncomplicated vaginal births; tubal ligation; Leep procedure 1993 Premenstrual syndrome dysphoria on fluoxetine Premenstrual syndrome dysphoria on fluoxetine

13. Case Five Denies tobacco or alcohol use; CNA Denies tobacco or alcohol use; CNA Exam: NL cardiovascular, GI, Kidney. Genital: pelvic floor “prolapse”; negative UA & glucose; PVR: 100cc. 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? Recommendations: Oxybutinin for “overactive bladder”; Pelvic Floor Physical Therapy Program? Referral to subspecialty?

14. Pelvic organ prolapse and Pessaries

15. Ring Pessary

16. Oval Pessary

17. Gellhorn Pessary

18. Donut Pessary

19. Cube Pessary

20. Gershung Pessary

21. Incontinence Dish

22. Drugs Predominant anticholinergic or antimuscurinic action Oxybutnin Oxybutnin Tolterodine Tolterodine Hyoscyamine Hyoscyamine Imipramine Imipramine Darifenacin Darifenacin Solifenacin Solifenacin Close follow up needed especially in geriatric patients

23. Drug & Dose OxbutininSelective M1, M3 receptor antagonist ICI: 1/A Short acting2.5-5.0 mg bid - tid Long acting10-30 mg qd patch3.9 mg 2x/week Tolterodine Non selective muscarinic receptor antagonist ICI: 1/A Short acting1-2 mg bid Long acting2-4 mg qd Hyoscyamine Anticholinergic ICI: 2/D Short acting.125 mg sl q4-6hrs Long acting.375 mg bid

24. Drug & Dose Imipramine 10-25 mg tidAnticholinergic and Alpha adrenergic action ICI: 2/C Can cause postural hypotension, confusion, and heart block Darifenacin 7.5–25 mg qdSelective M3 receptor antagonist ICI: 1/A Can cause bowel obstruction at higher doses Solifenacin 5–10 mg qdNon selective muscarinic receptor antagonist ICI: 1/A Half life 45–68 hrs

25. Notes: All of the above can cause dry mouth and constipation. Caution in patients with glaucoma especially uncontrolled narrow angle glaucoma. Caution with concomitant use with antifungals. With the exception of Solfinacin and Tolterodine these drugs can cross the blood brain barrier and cause confusion and somnolence in some patients. All of the above drugs can cause urinary retention which is dose related.

26. Oxybutynin Potent muscarinic receptor antagonist with some degree of selectivity for M 3 and M 1 receptors Potent muscarinic receptor antagonist with some degree of selectivity for M 3 and M 1 receptors Usual dose 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 ICI: Physiologically/pharmacologically effective and recommended based on good-quality randomized controlled trials 1/A

27. Tolterodine Nonselective muscarinic receptor antagonist Nonselective muscarinic receptor antagonist Usual dose 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 ICI: Physiologically/pharmacologically effective and recommended based on evidence from good-quality randomized trials 1/A

28. Hyoscyamine sulfate Anticholinergic Anticholinergic Usual adult dose.375 mg bid Usual adult dose.375 mg bid Controlled studies of effects on bladder hyperactivity are lacking 2/D Controlled studies of effects on bladder hyperactivity are lacking 2/D

29. Imipramine Anticholinergic and alpha adrenergic actions Anticholinergic and alpha adrenergic actions Useful for mixed incontinence. Useful for mixed incontinence. Can cause postural hypotension and bundle branch block Can cause postural hypotension and bundle branch block Usual dose 10 to 25mg tid Usual dose 10 to 25mg tid ICI: 2/C ICI: 2/C

30. Darifenacin M3 receptor selective M3 receptor selective The recommended starting dose is 7.5 to 15 mg / day 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 ICI: Physiologically/pharmacologically effective and recommended based on evidence from good-quality randomized trials 1/A Enablex [package insert]. 2004.

31. Solifenacin Nonselective muscarinic receptor antagonist Nonselective muscarinic receptor antagonist Half life of 45-68hrs Half life of 45-68hrs Usual dose Usual dose  5 to 10 mg po qd ICI: Physiologically/pharmacologically effective and recommended based on evidence from good-quality randomized trials 1/A ICI: Physiologically/pharmacologically effective and recommended based on evidence from good-quality randomized trials 1/A

32. What is InterStim Therapy? Implantable, programmable neuromodulation system. Implantable, programmable neuromodulation system.

33. Mechanism of Action Mechanism of action for SNS is not fully understood at this time - many theories exist. 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. 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.

34. InterStim Therapy Indications: overactive bladder, and or urinary retention, in patients who have failed or could not tolerate more conservative treatments.

35. Multichannel Urodynamic Equipment

36. Cystometrogram

37. Urethral Pressure Profile

38. Micturition Profile

39. Uroflowmetry