Article Figures & Data
Tables
- Table 1
Classification system and conditions affecting the pathways that control continence
CLASSIFICATION MECHANISMS DESCRIPTION Stress Intrinsic sphincter deficiency (eg, postsurgical); pelvic floor weakness -
usually small volume (5–10 mL) loss with cough, sneeze, laugh, etc
Urge Detrusor hyperreflexia (eg, central causes like stroke, NPH); detrusor instability (eg, local causes such as atrophic vaginitis, bladder cancer) -
larger volume of urine loss
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short period of time between onset of urgency and loss of urine
Overflow Detrusor inadequacy (eg, anticholinergic medications, diabetic neuropathy); outflow obstruction (eg, fecal impaction, BPH) -
constant dribbling with or without sensation of fullness
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frequency and urgency in older patients
Mixed -
Functional
Mobility; environmental barriers (eg, bedrails); cognition (eg, unable to recognize need to void or to recognize or use toilet) -
presence of mobility limitations or moderate to severe dementia
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environmental barriers especially in institutions (eg, bedrails)
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BPH—benign prostatic hypertrophy, NPH—normal-pressure hydrocephalus.
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MEDICATION CLASS CONTRIBUTING TO URINARY INCONTINENCE MECHANISM OF EFFECT Anticholinergics (TCAs, medications for urinary urgency, antihistamines, skeletal muscle relaxants, antiparkinsonian agents, antipsychotics) Inhibit bladder contraction and result in urinary retention; sedation Opiates Relax bladder; fecal impaction; sedation Diuretics Increased urine output; can have a substantial effect in the elderly Sedatives and hypnotics Impair cognition; functional incontinence Angiotensin-converting enzyme inhibitors Can cause cough and precipitate stress incontinence Calcium channel blocker Relax bladder and can cause retention α-Adrenergic agents Increase sphincter tone, contributing to overflow or retention α-Adrenergic blockers Decrease sphincter tone, contributing to stress incontinence Cyclooxygenase-2 selective NSAIDs and thiazolidinediones Fluid retention and resulting nocturnal diuresis -
NSAID—nonsteroidal anti-inflammatory drug, TCA—tricyclic antidepressant.
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DRUG CLASS USED TO TREAT GENERIC DRUG (TRADE NAME) INITIAL DOSE (USUAL DOSE) COMMENTS Anticholinergics Urge UI Oxybutynin (Ditropan)
Oxybutynin XL (Ditropan XL)
Oxytrol patch
Tolterodine (Detrol)
Tolterodine LA (Detrol LA)
Darifenacin (Enablex)
Solifenacin (Vesicare)
Trospium (Trosec)2.5 mg once daily at bedtime
(5 mg, 2–3 times daily)
5–10 mg once daily
(15–20 mg once daily)
36 mg every 3–4 d
1–2 mg twice daily
2–4 mg once daily
7.5 mg once daily (can increase at
2 wk to 15 mg once daily)
5 mg once daily
(can go to 10 mg once daily)
20 mg once daily at bedtime
(20 mg twice daily if eGFR > 30 mL/min)SEs: dry mouth, blurred vision, constipation, confusion, GI discomfort
SEs are common in the elderly; sustained-release reported to have fewer SEsEstrogen Stress UI Vaginal: -
Premarin (0.625 mg/g cream)
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Vagifem 25-μg (or 10–μg) vaginal tablet
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Estring 2-mg vaginal tablet
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EstroGel 2.5 g daily
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0.5–2 g vaginally twice weekly
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1 tablet vaginally twice weekly
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Ring vaginally every 90 d
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Apply as directed
The evidence for estrogen in stress UI is somewhat weak and controversial Antidepressants Stress or mixed UI TCA: imipramine 10–25 mg at bedtime (50–100 mg/d) Avoid or use caution in the elderly Moderate to severe stress UI SNRI: duloxetine 40–60 mg twice daily Limited evidence in the elderly α Blockers BPH Alfuzosin (Xatral)
Doxazosin (Cardura)
Tamsulosin (Flomax)
Tamsulosin CR (Flomax CR)
Terazosin (Hytrin)10 mg once daily after a meal
1–4 mg once daily at bedtime
0.4–0.8 mg once daily
0.4–0.8 mg once daily
1–5 mg once daily at bedtimeSEs: dizziness, postural hypotension -
Reproduced from the RxFiles: Drug Comparison Charts16 with permission.
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BPH—benign prostatic hypertrophy, CR—controlled release, eGFR—estimated glomerular filtration rate, GI—gastrointestinal, LA—long acting, SE—side effect, SNRI—serotonin noradrenergic reuptake inhibitor, TCA—tricyclic antidepressant, UI—urinary incontinence, XL—extended release.
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