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83 Cards in this Set
- Front
- Back
What is the defintion of Urinary Incontinence?
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The inability to voluntarily control urine loss
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How does age increase the risk of UI?
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Incidence increases with age
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"UI is only normal in _____"
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Babies
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What are the complications of UI?
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Distress, Depression, Social Withdrawal, Isolation
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What is the prevalence of UI?
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Affects ~20% of home care clients,
25% of older hospital patients, Up to 50% of nursing home residents |
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Which of the muscarinic receptors are responsible for the Bladder Smooth Muscles?
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M2 and M3
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What are the age related changes to the Urinary Tract?
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1) Decrease in bladder capacity & elasticity
2) Decrease in strength of Detrusor Muscle 3) Increase in spontaneous detrusor muscle contractions 4) Decrease in ability to postpone urination 5) Decrease in Urethral closing pressure 6) Decrease in Estrogen in post-menopausal women 7) Increase prostate size in older women |
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What are the risk factors for developing UI?
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i) Females (if childbirth, high impact exercise, hysterectomy)
ii) Males (Prostate disease) iii) Age: Risk increases with age iv) Neurologic Conditions (Stroke/PD/AD/MS/Spinal Cord Injury/Cognitive Impairment) v) Other conditions: DM/HD/Some Cancers, Obesity, Chronic Cough, Smoking vi) Potentially reversible factors: Fecal Impaction, Alcohol, Caffeine Intake, Some meds |
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What are the common causes of UI?
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D = Delirium
I = Infection A = Atrophic Vaginitis P = Pharmaceuticals P = Psychological E = Excessive Urine Output R = Reduced Mobility/Retention S = Stool Impaction; Also Stress |
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What are the types of Urinary Incontinence?
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1) Stress Incontinence: Occurs with some physical activity
2) Urge Incontinence 3) Mixed Incontinence: Equally as often either physical activity and with sense of urgency 4) Overflow Incontinence: Usually caused by an under-active bladder/outlet obstruction 5) Functional Incontinence: Due to factors outside the GU system |
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What are examples of how Anti-cholinergic drugs can cause Urinary Incontinence?
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Inhibits bladder contraction --> Urinary Retention/Sedation/Constipation
[FAH, TCAs] |
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What are examples of how Narcotic Analgesic drugs can cause Urinary Incontinence?
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Interferes with bladder contraction --> Urinary Retention/Constipation/Sedation
[Opiates] |
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What are examples of how NSAIDs can cause Urinary Incontinence?
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Blocks production of PGE2 (which is involved in detrusor contraction)
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What are examples of how Diuretics can cause Urinary Incontinence?
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In high doses or when taken later in the day
[Furosemide, HCTZ] |
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What are examples of how Psychotropis can cause Urinary Incontinence?
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Increased Anticholinergic Side Effects; Impairs cognition, Decreased Bladder Awareness, Slow Mobility
[Sedatives, Antidepressants, Antipsychotics] |
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What are examples of how ACEIs can cause Urinary Incontinence?
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May cause a cough which can precipitate Stress UI
[Captoprils, Ramiprils] |
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What are examples of how CCBs can cause Urinary Incontinence?
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Impairs Bladder Contractions --> May cause retention/constipation
[Nifedipine, Diltiazem, Verapamil] |
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What are examples of how α-Adrenergic Agonists can cause Urinary Incontinence?
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Increases Sphincter Tone --> Urinary Retention/Contributes to Overflow Incontinence
[Nasal Decongestants: Pseudoephedrine] |
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What are examples of how α-Adrenergic Blockers can cause Urinary Incontinence?
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Decreases Urethral Sphincter Tone --> Contributes to Incontinence
[Terazosin, Doxazosin] |
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What are examples of how β-Adrenergic Blockers can cause Urinary Incontinence?
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Interferes with Urethral relaxation and leaves α-adrenergic activity is unopposed
[Propranolol] |
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What are examples of how Acetylcholinesterase Inhibitors can cause Urinary Incontinence?
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Increased OAB Symptoms
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What are the goals of therapy for Urinary Incontinence?
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1) Relieve Symptoms
2) Prevent Complications 3) Avoid Treatment side effects 4) Increases functional capacity of bladder 5) Improves QOL |
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What are the treatment measures for UI?
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1) Lifestyle Choices
2) Address issues of Restricted Mobility 3) Address functional incontinence issues 4) Behavioural Stages 5) Intermittent Catherization 6) Protective Undergarments 7) Medications |
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What are the lifestyle choices that can help UI?
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1) Moderate intakes of foods and beverages that cause Diuresis
2) Manage constipation/bowel obstruction 3) Maintain fluid intake (1.5-2.0 L/day); limit after 6pm 4) Increased fluids in frail elderly may decrease Urge Incontinence 5) Lose Weight if BMI>30kg/m2 6) Stop Smoking 7) Modify high impact exercise if necessary |
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How can you address issues of restricted mobility for UI?
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Easy to remove clothing, Improve environmental issues: Toilet accessibility, lighting
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How can you address functional incontinence issues for UI?
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Physical, Mobility, Stroke, Arthritis, Cognitive Issues: Psychological Unwillingness
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What are examples of Behavioural Strategies for UI?
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1) Habit training: Go right after dinner, same time everyday
2) Prompted Voiding: Go when they need to 3) Bladder training: Strict timing of bladder 4) Pelvic Floor Muscle Traning (PFMT)" More effective if <50yrs old, minimum of 3 months 5) Intravaginal Pessaories for Stress UIs |
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Intermiteent Catherization is recommended for which type of UI?
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Overflow Incontinence
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What are the characteristics of Urge Incontinence/Overactive Bladder Wet?
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Preceded by sudden, compelling desire to pass urine; with symptoms of Overactive bladder (frequency, urgency, nocturia) and often results in leakage en route to bathroom
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What is the pathophysiology of Urge Incontinence?
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1) Overactive detrusor during filling phase caused by Inflammation/Irritation
2) Impaired brain centre (stroke/Parkinson's/Dementia) 3) Medications 4) Metabolic Disorders (Encephalopathy ) |
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"Medications are an integral part of therapy for Urge Incontinence" True or False?
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TRUE
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What is the goal of therapy for Urinary Incontinence?
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To decrease amplitude and frequency of detrusor contractions
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What are the treatment options for Urge Incontinence?
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1) Anticholinergics
2) Onabotuliniumtoxin A (Botox) 3) Mirabegron 4) Tricyclic Antidepressants 5) Flavoxate |
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What is the concern with Anticholinergics in the Elderly?
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Decline in Cognition
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What are the methods to help Anticholinergic therapy to improve side effect profile/safety/compliance?
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i) Once daily dosing
ii) Alternate routes of administration iii) Muscarinic subtype selectivity (detrusor muscle M2, M3) iv) In Elderly; Start Low & Titrate Up v) If patient has minimal response after 4 weeks discontinue the drug vi) If patient has adequate responses; aim for lowest effective dose (re-asseess in 6-12 months) |
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What is the evidence for Onabotulinium Toxin A (Botox) for Urge Incontinence?
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Both groups had similar reduction (~3/day) over 6 months, However botox group potentially had better response 6 months after discontinuing treatment
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What is the MOA of Mirabegron for Urge Incontinence?
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Selective Beta-3 Agonist
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What are the contraindications of Mirabegron for Urge Incontinence?
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1) Pregnancy
2) Severe Uncontrolled Hypertension defined as SBP >180mmHg and/or DBP>110mmHg |
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What are the warning signs of Mirabegron for Urge Incontinence?
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1) Signals in studies that increased risk of Neoplasms (breast,lung)
2) Measure BP at baseline and periodically 3) Dose dependent QTC prolongation, HR increase |
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What are the anticholinergics used for Urge Incontinence?
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1) Darifenacin
2) Oxybutyrin 3) Solifenacin 4) Tolterodine 5) Trospium |
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What is the receptor affinity for Darifenacin?
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M3 Selective
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What is the receptor affintiy for Oxybutyrin?
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M1, M2, M3, M4 Selective
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What is the receptor affinity for Solifenacin?
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M3 Selective
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What is the receptor affinity for Tolterodine?
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M1, M2, M3, M5 Selective
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What is the receptor affinity for Trospium?
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M2 & M3 Selective
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Which of the anticholinergics used are excreted by the heapatic method?
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Darifenacin, Oxybutyrin, Solifenacin, Tolterodine
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Which of the anticholinergics used are excreted by renal method?
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Trospium
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"Oxybutyrin is a prodrug" True or False?
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FALSE
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Which of the anticholinergics can cause QTC prolongation?
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Solifenacin, Tolterodine
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Which of the anticholinergics require a dose reduction if CrCl <30ml/min?
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Solifenacin, Trospium
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What is the efficacy of Anticholinergics compared to placebo?
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1) Anticholinergics reduces leaks (0.58/day)
2) Anticholinergics reduced micturations (0.64/day) [NNT=7] |
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What is the efficacy of Oxybutyrin compared to Tolterodine?
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1) Oxybutyrin has more dry mouth (no differences in incontinence outcomes)
2) No difference between ER vs IR (except less dry mouth) |
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What is the efficacy of Darifenacin compared to Oxybutyrin and Tolterodine?
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No difference to Oxy or Tolt
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What is the efficacy of Solifenocin compared to Oxybutyrin and Tolterodine?
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Less dry mouth than Oxy, Inconsistent vs Tolteridone
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What is the efficacy of Oxybutyrin Topical Gel?
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1) Pts with >5 daily episodes at baseline experience a 71% median reduction in incontinence episodes
2) Pts with 2-3 daily episodes at baseline experience an 89% reduction in incontinence episodes associated with OAB |
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What are the relevant drug interactions of Oxybutyrin and Tolterodine?
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Metabolized by CYP3A4
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What are the relevant drug interactions of Trospium?
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Food/Digoxin/Metformin/Morphine/Vancomycin
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What are the relevant drug interactions of Darifenacin?
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Azoles/Imipramine
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What are the relevant drug interactions of Solifenacin?
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Azoles
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What are the contraindications of Anticholinergics?
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1) Urinary Retention
2) Uncontrolled Narrow Angle Glaucoma 3) Myasthenia Gravis |
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What are the most common side effects of Anticholinergics?
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Constipation/Gastric Disturbances
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"Patients taking Solifenacin were less likely to discontinue treatment compare to patients taking Oxybutyrin" True or False?
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TRUE
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What causes Stress Incontinence?
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Occurs during activities that increase intra-abdominal pressures , due to urethral hypermobility and external sphincter deficiency
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"Stress Incontinence only occurs in the elderly patients" True or False?
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False; May occur at any age
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When does Stress Incontinence occur in Women?
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1) More common among post-menopausal women
2) In pre-menstrual women: during high impact activity, in weeks prior to menstruation, post child birth |
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When does Stress Incontinence occur in Men?
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More common after prostatectomy
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What is the goal of therapy for Stress Incontinence?
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To increase proximal urethral pressure primarily stimulated by α-adrenergic receptors and to increase tone of pelvic floor muscle
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What is the recommended 1st steps for Stress Incontinence?
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i) Lifestyle Adjustments (Smoking Cessation, Achieve Optimal BMI, Control Fluid Intake)
ii) Pelvic Floor Exercises iii) Electrical Stimulation iv) Biofeedback |
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What is the recommended 2nd steps for Stress Incontinence?
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i) Surgical Options [Women] (Bladder neck suspension, implantation of sacral nerve stimulation or artificial sphincter, Tension free vaginal tape, suburethral slings)
ii) Consider risks of surgery iii) Alternatives: Injections of Bulking Agents |
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What is the recommended 3rd steps for Stress Incontinence?
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i) Estrogen in women with post menopausal urogential atrophy
(oral: Increased risk of Stress UI, Vaginal: Inconsistent evidence) ii) Conjugated Estrogen vaginal cream iii) Estradiol 17β vaginal rings/tablets |
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What are other medications that have been considered for Stress Incontinence?
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1) Pesudoephedrine: Ineffective
2) Tricyclic Antidepressants: Imipramine (in elderly avoid or use cautiously) 3) Duloxetine: Limited Evidence [Avoid in severe renal impairment CrCl <30ml/min) [NSS for cure vs placebo] |
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What causes of Overflow Incontinence?
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Usually caused by an under-active bladder and/or outlet obstruction
1) Due to urethral obstruction (e.g.BPH), Distended Bladder 2) Also due to Detrusor Sphincter dysnergia 3) Detrusor muscle and external urethral sphincter contract at the same time |
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What are the symptoms of Overflow Incontinence?
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1) Nocturia, Dribbling, Straining, Incomplete Emptying
2) Sensation of Full Bladder 3) Weak, Slow urine stream; may stop and start |
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What can cause Overflow Incontinence?
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i) Diabetic Neuropathy, Low spinal cord injury, Pelvic Surgeries
ii) Multiple Sclerosis, Fecal Impaction, Prostate Enlargements
iii) Use of anticholinergic and α-adrenergic agonist medications |
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"Overflow incontinence is more common in women than in men" True or False?
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False; more common in Men
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What are the Treatment options for Overflow Incontinence?
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1) Address underlying causes
2) Reduces dose or discontinue medications that cause urinary retention |
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What is Mixed Urinary Incontinence?
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Have characteristics of both urge and stress incontinence, Try to use a single drug to treat both bothersome symptoms
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What is Functional Urinary Incontinence?
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Due to factors outside the GU system (e.g. Psychological Unwillingness)
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How should the symptoms of UI be monitored?
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Patient: Daily,
Pharmacists: q4 weeks. Monitor for a decrease in number of incontinence episodes |
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What should be done if there is no improvement in 1-4 weeks of the UI symptoms?
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Increased dose/ Consult with MD/ Consider alternative product if no response with Max dose
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What are the functions of Absorbent Products?
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1) Absorb urine quickly
2) Lock In Wetness 3) Keep Skin Dry 4) Reduce Odour |
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"Absorbent Products are the same as Sanitary Napkins" True or False?
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FALSE
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What are other functional barriers for UI?
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Liners, Pads, Step In Undergarments, Side Tape (pull off) Undergarments
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