Chapter 32 Agents for Urinary Incontinence and Urinary

Chapter 32 Agents for Urinary Incontinence and Urinary Analgesia Mosby items and derived items © 2009, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 1

Drug Overview Anticholinergics Ø Bladder-Targeted Anticholinergics Ø darifenacin, solifenacin Antispasmodics Ø oxybutynin chloride, tolterodine flavoxate, propantheline Cholinergic Agonists Ø bethanechol chloride Mosby items and derived items © 2009, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 2

Drug Overview Posterior Pituitary Hormone Ø desmopressin Urinary Tract Analgesia Ø phenazopyridine Mosby items and derived items © 2009, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 3

Drug Overview Indications: Drug Specific Ø Ø Ø Ø Dysuria Neurogenic bladder Overactive bladder Urge incontinence, frequency, urgency Adjunctive therapy of peptic ulcer Primary nocturnal enuresis (intranasal) Urinary retention Mosby items and derived items © 2009, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 4

Mechanism of Action Anticholinergics Ø Blockade of muscarinic actions • Inhibit the action of acetylcholine on bladder smooth muscle Cholinergic Agonists Ø Stimulation of parasympathetic system • Release of acetylcholine, increasing detrusor muscle tone Mosby items and derived items © 2009, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 5

Mechanism of Action desmopressin Ø Strong antidiuretic; decreases urine output for approximately 6 hours Urinary Tract Analgesia: phenazopyridine Ø An azo dye that is excreted in the urine; exerts a topical analgesic effect on urinary tract mucosa Mosby items and derived items © 2009, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 6

Treatment Principles Standardized Guidelines Ø Urinary Incontinence: Guide to Diagnosis and Management, by Brigham and Women’s Hospital, 2004 (www. guidelines. gov) Evidence-Based Recommendations Stress incontinence—beneficial: SSIs (duloxetine); likely to be beneficial: Pelvic floor electrical stimulation, pelvic floor muscle exercises, vaginal cones; tradeoff between benefits and harms: Estrogen supplements Ø No evidence regarding urge incontinence Ø Mosby items and derived items © 2009, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 7

Treatment Principles Cardinal Points of Treatment Ø Urge incontinence • First line: oxybutynin, darifenacin, solifenacin, tolterodine, trospium • Second line: TCAs • Third line: flavoxate, propantheline, dicyclomine Ø Stress incontinence • Estrogen cream, ring, imipramine, pseudoephedrine, duloxetine Mosby items and derived items © 2009, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 8

Treatment Principles Nonpharmacologic Treatment Ø Mainstay of treatment • Fluid management • Bladder training • Bladder retraining • Pelvic floor muscle rehabilitation Pharmacologic Treatment Ø Ø Female stress incontinence Urge incontinence Mosby items and derived items © 2009, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 9

Treatment Principles How to Monitor Patient Variables Ø Ø Ø Geriatrics Pediatrics Pregnancy and lactation Mosby items and derived items © 2009, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 10

Treatment Principles Patient Education Ø Ø Ø Response and side effects Hydration and fiber intake Avoid hot environments Alcoholic beverages should be avoided Bethanechol: Take on an empty stomach to avoid the side effects of nausea and vomiting Mosby items and derived items © 2009, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 11

Anticholinergics oxybutynin chloride (Ditropan, Ditropan XL, Oxytrol transdermal patch) Ø Ø Ø Contraindications Warnings Precautions Pharmacokinetics Adverse reactions Drug interactions Mosby items and derived items © 2009, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 12

Antispasmodics propantheline (Pro-Banthine) Ø Ø Ø Contraindications Drug interactions Dosage and administration Mosby items and derived items © 2009, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 13

Cholinergic Agonists bethanechol chloride (Urecholine) Ø Ø Contraindications Warnings/precautions Drug interactions Dosage and administration Mosby items and derived items © 2009, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 14

Posterior Pituitary Hormone desmopressin Ø Ø Ø Contraindications Warnings Precautions Drug interactions Dosage and administration Mosby items and derived items © 2009, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 15

Urinary Tract Analgesia phenazopyridine (Pyridium) Ø Ø Ø Contraindications Precautions Adverse effects Patient education Dosage and administration Mosby items and derived items © 2009, 2004 by Mosby, Inc. , an affiliate of Elsevier Inc. 16