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LEARNING OBJECTIVES

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LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Explain the pathophysiology of the major types of urinary incontinence (UI, urge, stress, overflow, and functional) and pediatric enuresis.

  2. Recognize the signs and symptoms of the major types of UI and pediatric enuresis in individual patients.

  3. List the treatment goals for a patient with UI or pediatric enuresis.

  4. Compare and contrast anticholinergics/antispasmodics, α-adrenoceptor agonists, dual serotonin-norepinephrine reuptake inhibitors, vaginal estrogens, cholinomimetics, tricyclic antidepressants (TCAs), and vasopressin analogues in terms of mechanism of action, treatment outcomes, adverse effects, and drug–drug interaction potential when used to manage UI or pediatric enuresis.

  5. Identify factors that guide drug selection for an individual patient.

  6. Formulate a monitoring plan for a patient on a given treatment regimen based on patient-specific information.

  7. Describe indicators for combination drug therapy of UI or pediatric enuresis.

  8. Describe nonpharmacologic treatment approaches (including surgery) for UI or pediatric enuresis.

  9. Formulate appropriate patient counseling information for patients undergoing drug therapy for UI or pediatric enuresis.

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KEY CONCEPTS

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  • Image not available. Accurate diagnosis and classification of urinary incontinence (UI) type is critical to the selection of appropriate drug therapy.

  • Image not available. Many medications can influence the lower urinary tract, including those not used for managing genitourinary disorders, and can precipitate new onset or aggravate existing voiding dysfunction and UI.

  • Image not available. Patient-specific treatment goals should be identified. This frequently requires reaching a compromise between efficacy and tolerability of drug therapy. These goals are not static and may change with time.

  • Image not available. Nonpharmacologic treatment can allow the use of lower drug doses. The combination of both therapies may have at least an additive effect on UI signs and symptoms.

  • Image not available. The anticholinergic/antispasmodic drugs are the pharmacologic first-line treatments for urge UI. They are the most effective agents in suppressing premature detrusor contractions, enhancing bladder storage, and relieving symptoms.

  • Image not available. Patient characteristics (e.g., age, comorbidities, concurrent drug therapies, and ability to adhere to the prescribed regimen) can also influence drug therapy selection.

  • Image not available. Careful dose titration is necessary to maximize efficacy and tolerability.

  • Image not available. If therapeutic goals are not achieved, a switch to an alternative agent should be made.

  • Image not available. Vaginally administered estrogen plays only a modest role in managing stress urinary incontinence (SUI, urethral underactivity), unless it is accompanied by local signs of estrogen deficiency (e.g., atrophic urethritis or vaginitis).

  • Image not available. The major impediment to using the α-adrenoceptor agonist class in SUI is the extensive list of contraindications.

  • Image not available. The use of duloxetine in SUI is complicated by (a) the potential for multiple clinically relevant drug–drug interactions with CYP-450 2D6 and 1A2 inhibitors, (b) withdrawal reactions if abruptly discontinued, (c) high rates of nausea and other side effects, (d) hepatotoxicity that contraindicates its use in patients with any degree of hepatic impairment, and (e) its mild hypertensive effect. Another disconcerting finding is the high discontinuation rate when duloxetine is used in a "usual use" clinic environment (66%, two-thirds due to adverse events and one-third due to lack of efficacy).

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