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Eslami Evaluation and Management of Incontinence in Females

having them try a scheduled voiding trial with systematic delay of voiding initially at a 15 minute interval. This behavioral strategy has a reported 20% dry rate, and 75% of patients have at least a 50% reduction in the number of incontinent episodes with similar improvements in both stress and urge UI.4 Pelvic floor rehabilitation (Kegel exercises) which involves "drawing in" or "lifting up" of the perivaginal muscles (levator ani muscles) and anal sphincter for a 10-second contraction followed by a 10-second relaxation. Providing the patient with both written and verbal instructions increases the success. The exercise should be performed 30-80 times a day for at least 6 weeks and has been shown to have up to a 95% improvement rate.4,11 Biofeedback therapy is done with a single measurement (vaginal or anal probe) EMG or manometric methods with simulta- neous measurement of pelvic and abdominal/detrusor

muscle activity. It provides information about physio- logic activity that mediates bladder control and can be used in conjunction with pelvic muscle exercises and bladder training. It has a reported 54%-87% improve- ment and is useful for urge, stress, and mixed UI.4

Caregiver dependent interventions for urge and functional UI include scheduled toileting on a fixed schedule at regular intervals every 2-4 hours, including at night.4 It has a reported 29%-85% improvement in uncontrolled studies. Habit training is a toileting schedule that matches the patient's voiding habits and has a reported improvement in 86% of patients.4 Prompted voiding involves monitoring the patient, promoting the patient to use the toilet and praising the patient for maintaining continence. It is most useful in the nursing home setting and has a reported average reduction of 0.8-1.8 incontinent episodes per day.4

Drug

Dosage

α-Adrenergic agonists

Pseudoephedrine (Sudafed)

15-30 mg tid

Mechanism of Action

Type(s) of Incontinence

Potential Adverse Effects

Increase urethral smooth muscle contraction

Stress with sphincter weakness

Headache, tachycardia, elevation of BP

Table 3: Types of Drugs Used to Treat Urinary Incontinence

Conjugated estrogens (use with concomitant progestin in women who have not had hysterectomy)

Oral (Premarin)

0.3-0.625 mg/day

Topical Estring

0.5-1.0 g/applicator 7.5 mcg/24 hrs

Increase periurethral blood flow, strengthen periurethral tissues Same as above

Same as above

Stress, urge associated with atrophic vaginitis

Same as above

Same as above

Endometrial cancer, elevated BP, gallstones

Same as above Same as above

Anticholinergic/antispasmodic agents

Oxybutynin (Ditropan)

2.5-5.0 mg tid

(Ditropan XL)

5-30 mg qd

Increase bladder capacity

Propantheline (Pro-Banthine)

15-30 mg qid

Hyoscyamine (Levsin) 0.375 mg bid

Dicyclomine (Bentyl)

10-20 mg qid

Same as above

Tolterodine (Detrol) (Detrol LA)

1-2 mg bid 4 mg qd

Flavoxate (Urispas) Imipramine (Tofranil)

Same as above

100-200 mg tid 10-50 mg bid/tid

Same as above Diminish involuntary bladder contractions Same as above Increase bladder capacity and strengthen internal urethral sphincter

Urge with detrusor inability or hyperreflexia

Same as above

Same as above

Dry mouth (less with XL preparation), blurry vision elevated intraocular pressure, delirium, consti pation, urinary retention Dry mouth (compared to oxybutynin, have lower incidence), headache, urinary retention, dry eyes, constipation Same as above

Same as above

Same as above

Same as above

Unlabeled use

Same as above Urge and/or stress incontinence

Above effects plus post- ural hypotension, cardiac conduction disturbances

22

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