Pharmacotherapy

1. Pharmacotherapy is used for detrusor instability (urge incontinence) and stress urinary incontinence.

2. Oxybutynin (Ditropan) is the agent of choice (2.5-5 mg PO tid-qid). Start patients on 2.5 mg po bid and then titrate up based on symptoms. The primary side effects of anticholinergic medications include dry mouth, constipation, blurred vision, change in mental status, and nausea. These medications are contraindicated in patients with narrow angle glaucoma. Other anticholinergic agents, including propantheline, dicyclomine, and flavoxate, may be used in patients with a poor response to oxybutynin.

3. Tolterodine (Detrol) is a bladder selective anticholinergic agent that is associated with improved symptoms and reduced side effects.

4. Imipramine (Tofranil) has been shown to be effective in the treatment of both stress and detrusor instability (urge incontinence). Dosage is 25100 mg daily. Side effects include orthostatic hypertension and dry mouth.

5. Alpha-adrenergic agonists, phenylpropanolamine (PPA) and pseudoephedrine are useful in the treatment of stress incontinence. Dosage for PPA is 25-100 mg PO in a sustained release form (bid) and for pseudoephedrine, 15-30 mg PO tid.

6. Estrogen replacement, either oral or vaginal, should be used as an adjunctive agent for postmenopausal women with stress urinary incontinence. The combination of an alpha-agonist and estrogen have a synergistic effect. Progestin should be added in patients who have a uterus.

Medication

Dosage

Mechanism of Action

Indication

Oxybutynin (Ditropan)

2.5 mg bid-5 mg tid

Anticholinergic/Spas molytic

Detrusor instability

Hyoscyamine

(Levsin,

Cystospaz)

0.15 mg tid-qid 0.375 mg bid-tid (extended release)

Anticholinergic

Detrusor instability

Flavoxilate (Urispas)

100-200 mg tid-qid

Anticholinergic/Spas molytic

Detrusor instability

Tolterodine (Detrol)

2 mg bid

Anticholinergic

Detrusor instability

Propantheline bromide

(Pro-Banthine)

7.5 mg tid

Anticholinergic

Detrusor instability

Phenylpropanolamine (Entex)

5 mg bid

Alpha-adrenergic stimulation

Stress incontinence

Pseudoephedrine (Sudafed)

60 mg qid

Alpha-adrenergic stimulation

Stress incontinence

Medication

Dosage

Mechanism of Action

Indication

Imipramine (Tofranil)

25-75 mg daily

Anticholinergic and alpha-adrenergic stimulation

Detrusor instability Stress incontinence

Estrogen (Premarin)

0.625 mg po or vaginally, daily

Beneficial effects on urethral mucosa and sphincter

Detrusor instability Stress incontinence

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