I ve Got a Secret Identifying and Treating Urinary Incontinence in the Elderly
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1 Page 1 I ve Got a Secret Identifying and Treating Urinary Incontinence in the Elderly Identifying and Treating Urinary Incontinence in the Elderly Wanda C. Hancock, MHSA, PA-C Supported by an educational grant from Astellas PharmCon is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education Legal Disclaimer: The material presented here does not necessarily reflect the views of Pharmaceutical Education Consultants (PharmCon) or the companies that support educational programming. A qualified healthcare professional should always be consulted before using any therapeutic product discussed. Participants should verify all information and data before treating patients or employing any therapies described in this educational activity. Accreditation: Pharmacists: L01-P Pharmacy Technicians: L01-T Nurses: N-661 CE Credits: 1.0 contact hour This program has been brought to you by an educational grant from Astellas Target Audience: Pharmacists, Technicians & Nurses Program Overview: I ve got a secret Or keeping her secret should not be Maxine s first and foremost concern when out shopping with the grand kids. When she visits the pharmacy in search of adult incontinence briefs, are you ready to help her with her bladder control issues? As frontline providers, pharmacist can help patients cope with this debilitating and embarrassing disorder. This program will educate pharmacists on barriers to diagnosis and treatment of urinary incontinence, treatment options and strategies to engage and counsel patients about urinary incontinence. Objectives: Describe the etiology and epidemiology of urinary incontinence in the elderly Identify the current pharmaceutical therapies used to treat urinary incontinence to include their mechanisms of action, efficacy, primary contraindications and adverse effects Review the pharmacist s role in identifying and treating UI to include counseling strategies for lifestyle and behavioral modification to improve patient adherence and outcomes I ve Got a Secret Identifying and Treating Urinary Incontinence in the Elderly Speaker: Wanda Hancock received her Bachelor of Science degree in Physician Asstant, her Masters of Health Service Administration, and her Bachelor of Science degree in Radiologic Technology from the Medical University of South Carolina. She served as a consultant and surgical PA for Coastal Surgical Associates. Currently, she serves as a Professor Emeritus at The Medical University of South Carolina, College of Health Professions in the Department of Health Professions Speaker Disclosure: Ms. Hancock has no actual or potential conflicts of interest in relation to this program This program has been brought to you by an educational grant from Astellas PharmCon is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education Objectives Describe the etiology and epidemiology of urinary incontinence in the elderly Identify the current pharmaceutical therapies used to treat urinary incontinence to include their mechanisms of action, efficacy, primary contraindications and adverse effects Review counseling strategies for life style and behavioral modification to improve patient adherence and outcomes. Legal Disclaimer: The material presented here does not necessarily reflect the views of Pharmaceutical Education Consultants (PharmCon) or the companies that support educational programming. A qualified healthcare professional should always be consulted before using any therapeutic product discussed. Participants should verify all information and data before treating patients or employing any therapies described in this educational activity.
2 Page 2 Continence The ability to store urine without leakage Smooth urinary sphincter function is essential The involuntary loss of urine that is objectively demonstrable and is of social and hygienic concern. Something is broken!
3 Page 3 Etiology of Incontinence Can t store or can t empty Intrinsic urethral deficiency Urethral hypermobility Detrusor overactivity Decreased compliance Retention Classification Stress Urge Mixed Functional Unconscious Nocturnal Enuresis Continuous Overflow Stress Urinary Incontinence (SUI) Episodic High intra-abdominal pressure Minimal amounts Mostly daytime leaking
4 Page 4 Etiology (SUI) Sphincter dysfunction Estrogen deficiency Trauma / pelvic surgery Obesity Chronic cough Constipation Urge Urinary Incontinence Overwhelming urge Episodic Involuntary Detrusor instability Uninhibited bladder contractions Frequency > 8 voids daily Nocturia 2-3 X per night OAB & Urge Incontinence Etiology (UUI) Recurrent UTI Vaginitis Stones Urethritis Dehydration Habitual voiding
5 Page 5 Mixed Incontinence Components of SUI Components of UUI Most elderly have a mixture of the two Functional Unaware Neither stress nor urge Episodic Enuresis Medications Diuresis Mobility Continuous Overflow Incontinence Obstruction Hypotonic bladder Neurogenic bladder Transient Incontinence D delirium I infection A atrophic vaginitis P pharmaceuticals P psychological E excess production R restricted mobility S stool impaction/constipation
6 Page 6 Evaluation Physical Examination History Sudden onset Bladder diary SCI Bladder diary Testing UA, C&S Post Void Residual Urodynamics Metabolites, HgA1c, BUN/Creatinine General Ambulation Recall / alertness Abdomen Mass Tenderness Distention Pelvis Vaginal tissues Atrophy Prolapsed organs Prostate Size Texture Rectal Treatment Treatment options Behavioral training Medications Conservative management Surgical management
7 Page 7 Behavioral training Timed voiding Dietary control Crude maneuvers Kegel exercise Constipation management Dietary Control No caffeinated beverages Reduce carbonated or acidic drinks Increase fiber in diet DM control is essential Hydration Weight loss Training Crude maneuvers Kegel exercises Timed voiding Evaluate current medications Medications Anticholinergics Antimuscarinics Alpha blockers Calcium Channel Blockers
8 Page 8 Anticholinergics DDAVP /Amitriptyline Tolterodine tartrate (Detrol LA) Solifenacin (VESIcare) Darifenacin (Enablex) Oxybutynin (Ditropan) Trospium chloride (Sanctura) Fesoterodine (Toviaz) Other medications Hyoscyamine Flavoxate Dicyclomine Propantheline Medications Inhibition of muscarinic cholinergic receptors Combine with conservative measures Chemical structure Tertiary amines Quaternary amines M3 selectivity General considerations Contraindications Adverse effects Urinary retention Gastric retention GI obstruction Narrow angle glaucoma Myastenia gravis Eye Salivary Intestines Heart Brain
9 Page 9 OAB / UUI medications Drug Dose Action ASE Considerations Other medications Atrophic vaginitis Alpha blockers Oxybutynin chloride 2.5 5mg anticholingergic dry mouth, dry eyes, constipation Closed angle glaucoma Tolterodine tartrate 2 4 mg BID Anticholinergic Dry mouth, dyspepsia Less effects with ER 2 4 mg daily Trospium Chloride 20 mg BID/QD dry mouth, dry eyes, constipation Does not cross BBB Solifenacin succinate 5 10 mg QD M3 receptor Dry mouth, dyspepsia, constipation Concern for prolonged antagonist QT interval Darifenacin mg QD M3 receptor Dry mouth, dyspepsia, constipation Dose reduction with hydrobromide antagonist LFT Impipramine HCL mg qhs Tricyclic antidepressant, Conjugated estrogen cream Estradiol cream Estradiol ring Estradiol PV tablets Tamsulosin Alfuzosin Terazosin Doxazosin Conservative Management Pelvic Floor Muscle training Vaginal weights Pelvic Floor Electrical Stimulation Device Biofeedback training Intermittent catheterization Condom catheter Bulking agents Surgical Management Anterior repairs Retropubic suspensions Transvaginal suspensions Sling procedures Artificial urinary sphincter
10 Page 10 The End References Gomella, LG, et al. The 5-Minute Urology Consult, 2 nd edition, Lippincott Williams & Wilkins Publishers, Philadelphia, PA, pages Hanno, P.M., Malkowics, S.B., and Wein, A.J. Penn Clinical Manual of Urology, Saunders Elsevier, Philadelpia, PA, pages Macfarlane, MT. Urology, House Officer Series, 4 th edition, Lippincott, Williams & Wilkins, Philadelphia, PA, pages Newman, DK. Managing and Treating Urinary Incontinence, Health Professions Press Baltimore, MD. Tanago, E.A. and McAninch, J.W. Smith s General Urology. 16 th edition, Lange Medical Books/McGraw Hill Publishing, NY, NY, pages Vasavada, S.P., et al. Female Urology, Urolgynecology and Voiding Dysfunction, Taylor & Francis Group, Boca Raton, FL, pages 1-64, , Verathon, Program of Excellence in Extended Care. Wein, A.J., et al. Campbell-Walsh Urology, 9 th edition, Saunders, Elsevier Publishing, Philadelphia, PA, pages Wieder, JA. Pocket Guide to Urology, 3 rd edition, Griffith Publishing, Caldwell, ID, pages Notes Notes
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