Pharmacologic Therapies

Various medications have been used to treat the different forms of urinary incontinence. However, most current medications are used for urge or mixed incontinence, because there is little evidence that adrenergic agonists help stress incontinence (Alhasso et al., 2005) (Table 4-18). The anti-cholinergic, antimuscarinic medications prescribed for urge incontinence work by blocking cholinergic receptors in the bladder, which in turn diminishes bladder contractility. This class of medications is effective but has adverse side effects (e.g., dry mouth, constipation) related to the cross-reactivity with muscarinic receptors in the salivary glands and colon (Alhasso et al., 2006). Additional side effects include dry eyes, blurry vision, and risk of urinary retention. Anticholin-

Table 4-18 Drug Treatment for Urinary Incontinence

Generic Drugs (Trade Name)

Dosages

Mechanisms of Action

Type of Incontinence

Antimuscarinic

Darifenacin (Enablex)

7.5-15 mg qd

Lessen involuntary bladder contractions and increase bladder capacity

Urge or mixed

Oxybutynin (Ditropan) (Ditropan XL) (Oxytrol transdermal)

5-30 mg qd (extended release) 3.9-mg patch every 4 days

Lessen involuntary bladder contractions and increase bladder capacity

Urge or mixed

Solifenacin (Vesicare)

5-10 mg qd

Lessen involuntary bladder contractions and increase bladder capacity

Urge or mixed

Tolterodine (Detrol) (Detrol XL)

1-2 mg bid

2-4 mg qd (extended-release)

Lessen involuntary bladder contractions and increase bladder capacity

Urge or mixed

Trospium (Sanctura) (Santura XR)

20 mg bid

60 mg qd (extended release)

Lessen involuntary bladder contractions and increase bladder capacity

Urge or mixed

Estrogen

Topical estrogen Topical cream

0.5-1.0 g qd for 2 weeks, then twice weekly

Strengthen periurethral tissues Increase periurethral blood flow

Urge, associated with severe vaginal atrophy or atrophic

Vaginal ring

One ring every 3 months

Stress

Vaginal tablets

One 25-^g tablet qd for 2 weeks, then twice weekly

Cholinergic Agonist

Bethanechol (Urecholine)

10-30 mg tid

Stimulate bladder contraction

Overflow, with atonic bladder

Alpha-Adrenergic Antagonists

Alfuzosin (UroXatral)

10 mg qd

Relax smooth muscle or urethra and prostate capsule

Urge, and symptoms associated with BPH

Tamsulosin (Flomax)

0.4 mg qd

Terazosin (Hytrin)

1-10 mg qhs

qd, Every day; tid, three times daily; bid, twice daily, qhs, every night at bedtime; BPH, benign prostatic hypertrophy.

ergics in the elderly patient can also worsen cognitive function or cause drug-induced delirium, mimicking dementia. Newer medications that are theoretically more uroselective and preferentially bind to the muscarinic receptors in the bladder may be associated with fewer adverse side effects. Incontinence medications should not be prescribed to those patients with untreated closed-angle glaucoma and in memory-impaired patients already taking cholinesterase inhibitors, to prevent further deterioration of memory function. The anticholinergic agents and cholinesterase inhibitors work in direct opposition and, if taken together, can lead to rapid loss of cognitive function (Sink et al., 2008).

Alpha-adrenergic antagonists are helpful in treating urge incontinence in men with benign prostatic hypertrophy (BPH). Hypotension is a common side effect with traditional alpha agents. The newer agents have less adverse side effects and should be used in older men who have low blood pressure or episodes of dizziness. The addition of an antimus-carinic drug can be considered in those men who are still symptomatic on alpha-antagonist therapy. For long-term treatment of overflow incontinence in men, 5a-reductase inhibitors alone or in combination have been shown to reduce the voiding symptoms from BPH as well as the incidence of urinary retention (McConnell et al., 2003).

The role of estrogen in the treatment of incontinence in the elderly patient remains uncertain. Topical estrogen is often prescribed for older women with urge incontinence related to atrophic vaginitis or severe vaginal atrophy. Conversely, combination estrogen/progestin oral hormone therapy has been associated with increased frequency of incontinence (Cody et al., 2009; Grady et al., 2001; Rossouw et al., 2002).

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