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?
Pelvic organ prolapse and Pessaries
Ring
Pessary
Oval Pessary
Gellhorn
Pessary
Donut
Pessary
Cube
Pessary
Gershung
Pessary
Incontinence
Dish
Drugs
Predominant anticholinergic or antimuscurinic
action






Oxybutnin
Tolterodine
Hyoscyamine
Imipramine
Darifenacin
Solifenacin
Close follow up needed especially in geriatric
patients
Drug & Dose
Oxbutinin
Short acting 2.5-5.0 mg
bid - tid
Selective M1, M3
receptor antagonist
ICI: 1/A
Long acting 10-30 mg qd
patch 3.9 mg 2x/week
Tolterodine
Short acting 1-2 mg bid
Long acting 2-4 mg qd
Hyoscyamine
Short acting .125 mg sl q4-6hrs
Long acting .375 mg bid
Non selective
muscarinic receptor
antagonist
ICI: 1/A
Anticholinergic
ICI: 2/D
Drug & Dose
Imipramine
10-25 mg tid
Anticholinergic and
Alpha adrenergic action
ICI: 2/C
Can cause postural
hypotension, confusion,
and heart block
Darifenacin
7.5–25 mg qd
Selective M3 receptor
antagonist
ICI: 1/A
Can cause bowel
obstruction at higher
doses
Solifenacin
5–10 mg qd
Non selective
muscarinic receptor
antagonist
ICI: 1/A
Half life 45–68 hrs
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.
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
 Usual
muscarinic receptor antagonist
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.
Multichannel Urodynamic
Equipment
Cystometrogram
Urethral Pressure Profile
Micturition Profile
Uroflowmetry