Sexual Dysfunction: Initiating Discussions & Types PDF

SEXUAL DYSFUNTION: **Initiating Discussions About Sexual Function (Acronyms) :**   +-----------------------------------------------------------------------+ | **[ALLOW:]** | | | |  ...

SEXUAL DYSFUNTION: **Initiating Discussions About Sexual Function (Acronyms) :**   +-----------------------------------------------------------------------+ | **[ALLOW:]** | | | |   | | | | - **A**sk about sexual function and activity | | | | - **L**egitimize problems; acknowledge as a clinical issue | | | | - Identify **L**imitations to the evaluation of sexual fx | | | | - **O**pen up the discussion; option for referrals | | | | - **W**ork with patient to develop goals & management plan | +=======================================================================+ | **[PLISSIT:]** | | | |   | | | | - Obtain **p**ermission (e.g. I routinely discuss sexual issues | | with my patients; is that OK with you?) | | | | - Give **l**imited **i**nformation (don't inform about "normal" fx) | | | | - Give **s**pecific **s**uggestions that the patient may try | | | | - Consider **i**ntensive **t**herapy with specialist(s) | +-----------------------------------------------------------------------+ | **[BETTER: ]** | | | |   | | | | - **B**ring up topic non-judgemental (e.g. Do you have any sexual | | concerns?) | | | | - **E**xplain sexuality part of QOL | | | | - **T**ell about available resources | | | | - **T**ime discussion to a time of patient's preference | | | | - **E**ducate on impact of treatment on sex & sexuality | | | | - **R**ecord that topic discussed | +-----------------------------------------------------------------------+   +-----------------------------------------------------------------------+ | **Female Sexual Dysfunction:** | +=======================================================================+ | **Epidemiology:** 40% of female have sexual concerns; 12% | | distressing. Often associated with depression/anxiety. | | | |   | | | | **Types**: | | | | 1. Hypoactive sexual desire disorder | | | | 2. Female sexual interest/arousal disorder | | | | 3. Substance or medication induced | | | | 4. Female orgasmic disorder (difficulty experiencing &/or [↓ ]{.math | |.inline}intensity orgasm) | | | | 5. Genito-pelvic pain/penetration disorder {Dyspareunia=pain with | | sex, or Vaginismus difficulty with intercourse} | | | |   | +-----------------------------------------------------------------------+ | **Drug Treatments for Female Sexual Dysfunction:** | +-----------------------------------------------------------------------+ | +---------------------+---------------------+---------------------+ | | | **Drug** | **Used for** | **Comment \[see | | | | | | related charts for | | | | | | dosing & side | | | | | | effect | | | | | | information\]** | | | +=====================+=====================+=====================+ | | | **Estrogens** | wvaginal atrophy | - systemic | | | | | | estrogen for | | | | w**systemic** | wDryness | vasomotor sx; | | | | (tabs, patches, | | | | | | gel) | wdyspareunia | - vaginal | | | | | | estrogen low | | | | w**vaginal**(tablet | | dose for local | | | | s | | symptoms, | | | | VAGIFEM, IMVEXXY; | | dryness, | | | | creams PREMARIN; | | atrophy | | | | ring ESTRING) | | {testosterone | | | | | | 2% sparingly to | | | | | | posterior | | | | | | fourchette x3 | | | | | | months has been | | | | | | tried.} | | | | | | | | | | | | - {**[Ospemifene | | | | | | OSPHENA]{.under | | | | | | line}** | | | | | | 60mg po daily | | | | | | | | | | | | - Acts | | | | | | estrogen | | | | | | like; AE: | | | | | | [↑]{.math | | | | | |.inline} | | | | | | hot | | | | | | flashes, | | | | | | ?[↑]{.math | | | | | |.inline} | | | | | | stroke, | | | | | | DVT}. | | | | | | | | | | | | - {**[Estradiol | | | | | | IMVEXXY]{.under | | | | | | line}** | | | | | | 4 & 10 mcg vag | | | | | | insert; | | | | | | | | | | | | - AE: HA; | | | | | | indication: | | | | | | mod-sev | | | | | | dyspareunia | | | | | | , | | | | | | Caution: | | | | | | ?[↑]{.math | | | | | |.inline}CV | | | | | | dx, CA}. | | | +---------------------+---------------------+---------------------+ | | | **Testosterone | w ↓sexual desire | wlimited | | | | (Androgens)** | | efficacy/study; | | | | | | lack official | | | | wgel compounded 1%; | | indication in | | | | oral? ANDRIOL | | females Canada; | | | | | | {Masculinization | | | | - Much lower dose | | with doses used for | | | | than males | | males! } | | | +---------------------+---------------------+---------------------+ | | | **BuPROPion | w ↓sexual desire | wmay be useful in | | | | WELLBUTRIN** | | SSRI-induced sexual | | | | | (magnitude of role | dysfx \~150mg/day | | | | wrange | uncertain) | (switch to or add | | | | 150-300-400mg/day | | on); limited study. | | | | | | | | | | | | {Avoid if seizure | | | | | | risk.} | | | | | | | | | | | |   | | | +---------------------+---------------------+---------------------+ | | | **Phosphodiesterase | wlittle benefit in | wlimited data; may | | | | Inhibitors** (PDE-5 | females; may ↓SSRI | be effective in | | | | inhibitors) | AEs | females with | | | | | | autonomic nerve | | | | e.g. Sildenafil | w? ↓ sexual desire, | damage such as in | | | | VIAGRA (also | arousal, orgasm | multiple sclerosis | | | | tadalafil CIALIS, | | patients | | | | vardenafil LEVITRA) |   | | | | | | | wofficial | | | | | | indication only in | | | | | | males; conflicting | | | | | | results in studies | | | | | | | | | | | | [Not] | | | | | | recommended by ACOG | | | +---------------------+---------------------+---------------------+ | | | **Vaginal | wvaginal dryness / | w**REPLENS** | | | | Moisturizer**, OTC | dyspareunia | requires regular | | | | etc. | | use daily or 3x/wk; | | | | | w↓ arousal | minimal AEs | | | | - REPLENS | | | | | | -Moisturizer | | w**KY** generally | | | | | | used intermittently | | | | - KY JELLY | | before intercourse | | | | -Lubricant | | | | | | | | wCan help resolve | | | | - Gynatrof | | issues 2° to drugs | | | | -Hyaluronic+Vit | | causing dryness! | | | | E gel | | | | | +---------------------+---------------------+---------------------+ | | | |   | | | |   | | | | - **[K-Y Intense, Zestra]** OTC: massage oils (borage | | seed oil, evening primrose oil, angelica root extract & coleus); | | for female genitalia to [↑]{.math.inline}arousal; but [↑]{.math | |.inline} burning | | | | - [Flibanserin **Addyi**] - 100mg hs \$85/8 tab; | | hypoactive sexual desire disorder: HSDD (acquired, generalized) | | pre & post menopausal (≤60yr female); | | | | - trial≤ 8wk | | | | - **AE**: ↓BP, dizziness, somnolence, nausea, fatigue; | | | | - **DI**: 3A4/2C19; concomitant alcohol use [↑]{.math | |.inline}risk of depression & syncope; caution if liver dx. | | | | - [Bremelanotide **Vyleesi**] hypoactive sexual desire | | dx: HSDD acquired, generalized in premenopausal females; | | | | - 1.75mg SC 45mins before anticipated sexual activity (max 1 | | dose/day, 8/month); | | | | - **AE**: nausea, [↑ ]{.math.inline}BP; | | | | - **CI**: naltrexone | | | | - [Prasterone **Intrarosa**]: DHEA | | (dehydroepiandrosterone) for dyspareunia due to menopause, daily | | vaginal insert, | | | | - **AE**: abnormal pap smear & discharge | | | | - [Alprostadil **Caverject**]: cream compounded, apply | | locally, [↑ ]{.math.inline}arousal | | | | - [Apomorphine **Movapo**]: PO, | | investigational,[↑]{.math.inline} arousal; [↑]{.math | |.inline}emesis | | | | - [Topical lidocaine] for dysparenunia (various; 4% | | aqueous: applied 3 min pre-penetration in females with hx of | | breast ca; â sexual distress score). | | | | - [Ospemifene **Osphena**]: estrogen agonist/antagonist | | 60mg po OD: dyspareunia & urogenital sx (see also comment section | | above) | | | |   | | | |   | | | | - Role for counselling, psychotherapy, CBT, physio, devices e.g. | | dilators, diet, & other non-drug! **Psychological/relational | | issues key!!!** | | | | - "Don't forget to set the mood"; good long-term relationships | | require ongoing investment of time, effort, energy, ideas; music | | | | - [Age/menopause]: apart from dryness/trouble | | lubricating, sexual problems do not necessarily ↑ with age. | | | | - Surgical menopause may have greater impact than natural menopause | | (? due to ↓ androgen). | | | | - Pelvic floor or bladder dysfunction, endometriosis, uterine | | fibroids: may be associated with dyspareunia. | | | | - Other: [↑]{.math.inline}prolactin, renal failure, stoma , cancer | | (active or hx of) mayðpain, ↓desire, anxiety/fear/guilt, body | | image, sleep apnea. | | | |   | | | | Other: may consider a **TCA (**tricyclic antidepressants) **to â | | vulvodynia (chronic pain of the vulvar area)**; gabapentin not | | effective. | | | |   | +-----------------------------------------------------------------------+   +-----------------------------------------------------------------------+ | **Male Sexual Dysfunction:** | +=======================================================================+ | - **Always assess potential causes** e.g. distance biking, | | interpersonal issues, conflict, etc. txð psychological, | | counselling, etc. | | | | "Merely restoring erections is usually not sufficient to restore a | | poor sexual relationship". Also assess for ? á CV risk. | | | | - **Pornography**: frequent access may contribute to loss of | | libido, impotence/ED, critical of partner, relationship issues, | | etc. | | | | - **↓Libido**: age, androgen deficiency, psychological/depression, | | recreational drugs including alcohol, nicotine, marijuana & | | opioids. | | | | - **Erectile dysfunction (ED)**: may reflect ↓ blood flow to | | corpora cavernosae. | | | | - **tx**: PDE5 inh, alprostadil inj or urethral suppository, | | vacuum device, prosthesis penile | | | | - {if rapid onset (& not post-surgery): often performance | | anxiety, disaffection with partner or emotional issue; tx ð | | counselling.} | | | | - **Gradual/complete loss of [nocturnal] erections**: | | suggests possible neurologic or vascular disease. | | | | - **Non-sustained erections** after penetration: | | | | - due to | | | | - 1\) anxiety or | | | | - 2\) vascular steal syndrome ([↑]{.math.inline} oxygen demand | | during | | sex) | | | | - **Ejaculation disorders:** | | | | - e.g. delayed ejaculation (DE): caused by tissue damage in | | prostate surgery or failure of Alpha-adrenergic clamping of | | bladder neck sphincter resulting in retrograde ejaculation. | | Also may be caused by medication. | | | | - **Premature ejaculation**: common \~30% of males. | | | | - "persistent or recurrent with minimum stimulation "; normal | | latency in RCTs= 2+ min.; PEj often occuring \3hrs/wk, limit alcohol to ≤2 drinks/day, avoid | | cannabis, Mediterranean diet, ?CPAP if sleep apnea. | | | | - **Assess and treat CV risk.** [ED often a harbinger of | | CVD] e.g. smaller penile arteries; provides a 2-5 | | year window to ↓ CV risk before first event. Statins may modestly | | ↓ ED symptoms. Watch for DIs with CV meds. | | | | - **Address drug-induced ED** (table 2) by adjusting drug therapy | | when possible | | | |   | | | |  | | | |   | | | | **1st line drug therapy:** oral PDE5 inhibitor. Effective, | | convenient, & well-tolerated. | | | | [←]{.math.inline} If failure of oral PDE5 inhibitor: often retry. | | See Table 1, **Managing PDE5 inhibitor failure.** | | | | **2nd line drug therapy**: penile injections or urethral | | suppositories. Effective but limited by pain, penile fibrosis, & | | needle phobia. | | | | **Alternate therapies**: | | | | [Vacuum pump]: but cumbersome, may cause bending at base | | of penis, 30min max, & penis cold to touch. | | | | [Surgical prosthesis]: effective, but risks include | | scarring, penile shortening, and infections 2-4%. | | | | [Others]: | | | | **red ginseng** 0.5-2g/d (weak evidence), | | | | **yohimbine** 5-100mg/d (weak evidence), | | | | **apomorphine** 2-3mg prn (low efficacy).- discontinued in Canada, | | see below | | | | Note: PDE5 inhibitors are often found as **adulterants** in herbal | | and male enhancement products | +-----------------------------------------------------------------------+ | **PDE5 Inhibitors:** Reduce catabolism of cGMP resulting in smooth | | muscle relaxation of the corpus cavernosum & ↑ blood flow into penis | | (need sexual stimulation to produce actual erection). All appear | | equally effective (although few head-to-head RCTs), with success | | rates around 60-70% vs 25-35% placebo | | | | - Have shown efficacy in all etiologies of ED (i.e. vascular, | | neurological, hormonal, cavernosal, drug-induced, or | | psychogenic). | | | | - **Tadalafil** (others off-label): üBPH, üRaynaud\'s. | +-----------------------------------------------------------------------+ | ------------------- ----------------------------------------------- | | --------------------------------------------- ------------ ---------- | | **Generic/TRADE** **Adverse Events AE / Contraindications CI / Dr | | ug Interactions DI / Monitor M / Comments** **Dosing** **Cost** | | ------------------- ----------------------------------------------- | | --------------------------------------------- ------------ ---------- | | | | +---------------+---------------+---------------+---------------+ | | | A screenshot | **AE:** | A chart of | ![A table | | | | of a phone | Well-tolerate | different | with | | | | Description | d; | types of | different | | | | automatically | overall NNH≈5 | pills | types of | | | | generated | but few pts | Description | medication | | | | | quit; | automatically | Description | | | |   | [similar | generated | automatically | | | | | rates]{.under | with medium | generated | | | |   | line} | confidence | with medium | | | | | of AE between | | confidence](m | | | |   | agents. |   | edia/image8.p | | | | | | | ng) | | | | | Common: |   | | | | | | **flushing** | |   | | | | | 4-11%, |   | | | | | | **headache** | | | | | | | 10-14%, | | | | | | | **dyspepsia** | | | | | | | 4-7%, | | | | | | | **myalgia** | | | | | | | (tadalafil | | | | | | | 2-4% \> | | | | | | | sildenafil/va | | | | | | | rdenafil | | | | | | | 0-0.5%), | | | | | | | **back pain** | | | | | | | (tadalafil | | | | | | | 5%), **blue | | | | | | | vision** | | | | | | | (benign; | | | | | | | sildenafil | | | | | | | 3%), **nasal | | | | | | | congestion**, | | | | | | | diarrhea, | | | | | | | dizziness, | | | | | | | blurred | | | | | | | vision, rash. | | | | | | | | | | | | | | **[Serious & | | | | | | | rare]{.underl | | | | | | | ine}**: | | | | | | | MI, priapism, | | | | | | | QT-prolongati | | | | | | | on | | | | | | | (vardenafil), | | | | | | | serious | | | | | | | ocular events | | | | | | | (e.g. 16 in | | | | | | | 10,000 pts), | | | | | | | hearing loss, | | | | | | | ?amnesia, | | | | | | | ?↓smell, | | | | | | | ?seizures, | | | | | | | ?sickle cell | | | | | | | crisis, | | | | | | | ?melanoma. | | | | | | | Hot flashes | | | | | | | if used in | | | | | | | females | | | | | | | | | | | | | |   | | | | | | | | | | | | | |  | | | | | | | | | | | | | |   | | | | | | | | | | | | | | **CI**: | | | | | | | concurrent | | | | | | | use of | | | | | | | **nitrates** | | | | | | | (including | | | | | | | street | | | | | | | 'poppers', & | | | | | | | see DI below) | | | | | | | or riociguat | | | | | | | (drug for | | | | | | | pulmonary | | | | | | | HTN); | | | | | | | previous | | | | | | | episode of | | | | | | | NAION | | | | | | | (non-arteriti | | | | | | | c | | | | | | | anterior | | | | | | | ischemic | | | | | | | optic | | | | | | | neuropathy). | | | | | | | | | | | | | |   | | | | | | | | | | | | | | **[Precaution | | | | | | | s:]{.underlin | | | | | | | e}** | | | | | | | anatomical | | | | | | | penis | | | | | | | deformation; | | | | | | | CVD (e.g. | | | | | | | arrhythmia, | | | | | | | recent | | | | | | | MI/stroke, | | | | | | | uncontrolled | | | | | | | HTN, coronary | | | | | | | ischemia, | | | | | | | HF); ↑risk of | | | | | | | priapism | | | | | | | (e.g. sickle | | | | | | | cell anemia, | | | | | | | multiple | | | | | | | myeloma, | | | | | | | leukemia); | | | | | | | retinitis | | | | | | | pigmentosa/re | | | | | | | tinal | | | | | | | abnormalities | | | | | | | (tadalafil | | | | | | | preferred). | | | | | | | | | | | | | |   | | | | | | | | | | | | | | **DI:** | | | | | | | | | | | | | | [nitrates]{.u | | | | | | | nderline}: | | | | | | | ↑↑ | | | | | | | hypotensive | | | | | | | effect & | | | | | | | ↑↑HR. **Avoid | | | | | | | within 24hr** | | | | | | | of sildenafil | | | | | | | and | | | | | | | vardenafil, | | | | | | | and **48hr** | | | | | | | of tadalafil. | | | | | | | | | | | | | | [A-1 | | | | | | | blockers]{.un | | | | | | | derline} | | | | | | | (non-selectiv | | | | | | | e | | | | | | | e.g. | | | | | | | doxazosin, & | | | | | | | especially on | | | | | | | initiation): | | | | | | | ↑ hypotension | | | | | | | risk. Space | | | | | | | 4-6hrs apart, | | | | | | | use lowest | | | | | | | effective | | | | | | | dose. | | | | | | | | | | | | | | [other | | | | | | | antihypertens | | | | | | | ives | | | | | | | & | | | | | | | alcohol]{.und | | | | | | | erline}: | | | | | | | may | | | | | | | potentiate | | | | | | | hypotensive | | | | | | | effect; use | | | | | | | caution and | | | | | | | monitor BP. | | | | | | | | | | | | | | [↑ PDE5 | | | | | | | inhibitor | | | | | | | levels:]{.und | | | | | | | erline} | | | | | | | CYP3A4 | | | | | | | inhibitors | | | | | | | (e.g. | | | | | | | grapefruit, | | | | | | | clarithro, | | | | | | | verapamil, | | | | | | | azole | | | | | | | antifungals, | | | | | | | protease | | | | | | | inhibitors, | | | | | | | cimetidine). | | | | | | | | | | | | | | [↓ PDE5 | | | | | | | inhibitor | | | | | | | levels]{.unde | | | | | | | rline}: | | | | | | | CYP3A4 | | | | | | | inducers | | | | | | | (e.g. | | | | | | | carbamazepine | | | | | | | , | | | | | | | phenobarbital | | | | | | | , | | | | | | | phenytoin, | | | | | | | rifampin, | | | | | | | bosentan, St | | | | | | | John's Wort). | | | | | | | | | | | | | |   | | | | | | | | | | | | | | **M:** LFTs, | | | | | | | renal | | | | | | | function | | | | | | | (unneeded for | | | | | | | vardenafil), | | | | | | | CV risk | | | | | | | factors, | | | | | | | changes to | | | | | | | visual | | | | | | | acuity, | | | | | | | changes to | | | | | | | hearing. | | | | | | | | | | | | | |   | | | | | | | | | | | | | | **PAH | | | | | | | (**pulmonary | | | | | | | arterial | | | | | | | hypertension | | | | | | | ) | | | | | | | **indication* | | | | | | | *: | | | | | | | | | | | | | | - **REVATIO | | | | | | | ** | | | | | | | 20-80mg | | | | | | | po TID: | | | | | | | max≥60mg/ | | | | | | | d; | | | | | | | **avoid | | | | | | | in | | | | | | | kids;** | | | | | | | | | | | | | | - **ADCIRCA | | | | | | | ** | | | | | | | 20-40mg | | | | | | | po daily; | | | | | | | max | | | | | | | 40mg/d; | | | | | +---------------+---------------+---------------+---------------+ | +-----------------------------------------------------------------------+ | **Penile Injections & Urethral Suppositories** | +-----------------------------------------------------------------------+ | - **Alprostadil** CAVERJECT | | | | - 20mcg **intracavernosal inj**. | | | | - 2-5mcg (neurogenic ED) or 5-20mcg (vascular ED) 10-30min | | pre-sex. | | | | - **AE**: penile pain 37%, penile fibrosis 3%, priapism 4%. | | \$170/4 doses | | | | - **Alprostadil** MUSE | | | | - 250,500,1000mcg **urethral supp**. | | | | - 250-500mcg 10-30min pre-sex. | | | | - **AE**: penile pain 32%, urethral bleeding 5%, dizziness 2%. | | ↓efficacy vs injection. \$318/4 doses | | | | - **Alprostadil + Papaverine + Phentolamine** | | | | - Tri-Mix **compounded intracavernosal inj**. | | | | - May ↑ efficacy and ↓ pain associated with alprostadil. \$110 | | for 10-20 doses | | | |   | | | |   | | | | A close-up of a computer screen Description automatically generated | | | |   | +-----------------------------------------------------------------------+      A screenshot of a computer Description automatically generated URINARY INCONTINECE (ADULT): Urinary Incontinence in Adults: +-----------------------------------------------------------------------+ | **Introduction** | +=======================================================================+ | - can be broadly described as relating to storage dysfunction or | | voiding dysfunction | | | | - Affects 29% of older females and 5% of older males | | | | - complaint of involuntary leakage of urine | | | | - most common types of UI are stress, urgency, overflow and | | functional. | | | | - Differentiating the type of incontinence is necessary, as | | each has a unique treatment approach | | | | - Most common: Stress incontinence (55.3%) | | | | - **[Females]**: due to weakened pelvic floor | | muscles---reduced pelvic floor muscle strength causes | | urethral and bladder-neck mobility, resulting in urethral | | sphincter incompetence | | | | - "stress" from laughing, coughing, exercise, abdominal | | obesity) increases pressure inside the bladder that | | overcomes the ability of the compromised urethral | | sphincter to close the urethra, and urine leakage results | | | | - Intrinsic sphincter deficiency is a less common form of | | stress incontinence and may result from pelvic or other | | bladder surgery or irradiation, a vaginal birth or a | | neurological disorder | | | | - Urgency incontinence (22.4%) | | | | - due to inability to delay voiding when an urge is perceived. | | | | - Overactive bladder (OAB) is a syndrome that often leads to | | urgency incontinence | | | | - Causes of urgency incontinence include detrusor (bladder wall | | muscle) hyperactivity or instability and CNS disorders (e.g., | | parkinsonism, stroke, spinal cord injury, multiple | | sclerosis). | | | | - Mixed incontinence (17.3%) | | | | - Includes features of both stress and urgency incontinence | | | | - Overflow incontinence (mostly in males,  ≥40 years) | | | | - occurs when there is leakage of urine due to a distended | | bladder, commonly referred to as chronic retention of urine. | | | | - due to detrusor underactivity ("underactive bladder"), which | | can include neurogenic bladder (disorder or problem with the | | nerve control of continence and voiding function, e.g., as a | | result of diabetes or stroke), or bladder outlet obstruction | | (e.g., benign prostatic hyperplasia) | | | | - Functional incontinence | | | | - is the loss of urine caused by the inability to mobilize to | | or use the toilet and does not involve changes in the lower | | urinary tract | | | | - Causes include physical constraints (e.g., restricted | | mobility, difficulty removing clothing), cognitive | | factors (e.g., depression, neurocognitive disorder | | \[dementia\]) and environmental barriers (e.g., access to | | toilet, positioning). | +-----------------------------------------------------------------------+ | **Goals of Therapy** | +-----------------------------------------------------------------------+ | - Relieve urinary symptoms | | | | - Prevent complications (e.g., depression, falls, skin breakdown, | | urinary tract infections) | | | | - Improve quality of life | | | | - Avoid treatment side effects | | | | - Improve bladder function | +-----------------------------------------------------------------------+ | **Investigations** | +-----------------------------------------------------------------------+ | One of the most common, the 3IQ (incontinence questionnaire), was | | designed to help family physicians identify urinary incontinence and | | distinguish between stress, urgency and mixed types. | | | |   | | | | It consists of 3 questions and takes only about 30 seconds to | | complete: | | | | 1. During the last 3 months, have you leaked urine (even a small | | amount)? (Yes or no; if no, questionnaire completed) | | | | 2. During the last 3 months, did you leak urine (check all that | | apply): | | | | a. When you were performing some physical activity, such as | | coughing, sneezing, lifting or exercise? | | | | b. When you had the urge or feeling that you needed to empty | | your bladder, but you could not get to the toilet fast | | enough? | | | | c. Without physical activity and without a sense of urgency? | | | | 3. During the last 3 months, did you leak urine most often (check | | only one): | | | | a. When you were performing some physical activity, such as | | coughing, sneezing, lifting or exercise? (Stress only or | | stress predominant incontinence) | | | | b. When you had the urge or feeling that you needed to empty | | your bladder, but you could not get to the toilet fast | | enough? (Urgency only or urgency-predominant incontinence) | | | | c. Without physical activity and without a sense of urgency? | | (Other cause only or other cause predominant) | | | | d. About equally as often with physical activity as with a sense | | of urgency? (Mixed incontinence) | | | |   | | | | +------------------------------------------------------------------+ | | | - Urologic History: | | | | | | | | - characteristics of symptoms, e.g., onset, frequency and | | | | severity of symptoms | | | | | | | | - degree of bother of symptoms (impact on emotional | | | | well-being and daily function) | | | | | | | | - previous treatments for urinary symptoms, e.g., medical, | | | | mechanical (pessaries), surgical, containment products | | | | (including number of pads/products used per day) | | | | | | | | - bladder diary for 3 days to determine fluid intake, | | | | frequency, timing, and amount of voiding and urine | | | | leakage (recording for longer periods is challenging for | | | | patients and does not provide additional significant | | | | information for decision-making). | | | | | | | | - Medical History: | | | | | | | | - obstetrical history (including vaginal versus Cesarean | | | | deliveries, use of forceps) | | | | | | | | - menopausal status | | | | | | | | - possible causes such as diabetes, depression, mobility | | | | or cognitive impairment, previous bladder surgeries, or | | | | neurologic conditions such as multiple sclerosis, stroke | | | | or spinal cord injury | | | | | | | | - bowel habits (e.g., history of constipation) | | | | | | | | - Surgical History: | | | | | | | | - pelvic surgery (including prostate surgery) | | | | | | | | - Medication History: | | | | | | | | - current prescription medications (e.g., loop diuretics, | | | | SGLT2 inhibitors), nonprescription medications (e.g., | | | | anticholinergics, antihistamines, decongestants) and | | | | natural health products | | | | | | | | - recent medication changes (new medications started or | | | | medications discontinued) | | | | | | | | - Lifestyle Factors: | | | | | | | | - diet | | | | | | | | - fluid intake and history (volume, type---notably | | | | caffeinated products) | | | | | | | | - alcohol intake | | | | | | | | - smoking history | | | | | | | | - Physical Examination: | | | | | | | | - review of systems (generally recommended with a full | | | | bladder) | | | | | | | | - neurologic | | | | | | | | - mental status, cognition | | | | | | | | - evidence of central or peripheral neurologic disease | | | | | | | | - pelvic examination (to assess tone and to rule out | | | | pelvic masses, organ prolapse, latent stress | | | | incontinence, urogenital atrophy) | | | | | | | | - rectal examination (tone, masses, impaction) | | | | | | | | - physical impairment (dexterity, mobility, | | | | vision--indicating interference with function) | | | | | | | | - Investigations: | | | | | | | | - cough test (if immediate leakage, likely stress | | | | incontinence; if delayed leakage, likely urgency | | | | incontinence) | | | | | | | | - urinalysis (to rule out infection, glucosuria, | | | | hematuria) | | | | | | | | - post-void residual volume (PVR; \ start low dose and titrate slowly | | | | - \*\*increased risk of dementia as a result of cumulative | | anticholinergic effects  | | | | - selective agents (darifenacin, solifenacin, trospium) | | demonstrate reduced side effects and improve adherance | | | |   | | | | - Vaginal estrogen for females with postmenopausal urogenital | | atrophy may be an option  | | | |   | | | | - **Mirabegron** is a beta~3~-adrenergic agonist indicated for the | | treatment of urgency incontinence. | | | | - Better tolerated, can reduce the number of urgency episodes | | by 1/day | | | |   | | | | - Intravesicular **botulinum toxin (onabotulinumtoxinA) - BOTOX** | |  is approved for use in Canada for refractory overactive bladder | | and in neurogenic detrusor overactivity (e.g,. spinal cord | | injury) | | | | - administered via cystoscopy, which is invasive and performed | | in hospital or specialized clinics | | | |   | | | | A screenshot of a medical chart Description automatically generated | | | |   | | | |  | | | |   | +-----------------------------------------------------------------------+ |   | +-----------------------------------------------------------------------+ |   | | | | A person lying on the floor Description automatically generated | | | |   | +-----------------------------------------------------------------------+ | **Mixed Incontinence** | +-----------------------------------------------------------------------+ | - Treat patients with mixed UI for the predominant symptom (e.g., | | stress or urgency symptoms) | +-----------------------------------------------------------------------+ | **Overflow Incontinence** | +-----------------------------------------------------------------------+ | **[Non-Pharm: ]** | | | | - The approach to treatment for overflow UI should address the | | underlying condition causing the chronic retention of urine. | | Chronic retention of urine due to a noncontractile bladder may be | | due to detrusor underactivity or bladder outlet obstruction | | (e.g., BPH). ​ | | | | - The first-line approach consists of addressing reversible causes | | of overflow UI such as medications that cause urinary retention | | (e.g., anticholinergics, calcium channel blockers, | | sympathomimetics).​ | | | | - Chronic underactivity can be treated with catheterization | | (intermittent, indwelling, suprapubic).​ | | | | - For patients with overflow UI as a result of BPH, medical or | | surgical interventions may be appropriate | | | | **[Pharm: ]** | | | | - Chronic retention of urine due to detrusor underactivity is | | poorly responsive to pharmacologic therapy | | | | - See BPH notes | +-----------------------------------------------------------------------+ | **Choices during Pregnancy and Breastfeeding** | +-----------------------------------------------------------------------+ | - Stress UI is the most common type during pregnancy (63%), and | | this is associated with an increased risk of experiencing stress | | UI after pregnancy | | | | - Urgency and frequency increase from the first to third | | trimester | | | | - rates of incontinence up to 74% by week 36 | | | | - Due to result of a combination of physiological changes, such | | as hormonal changes and weight gain by the pregnant patient, | | uterus and fetus, which results in reduced strength of the | | pelvic floor muscles and increased pressure on the bladder | | | | - Many patients report a resolution of urinary symptoms after | | delivery. | | | | - increases the prevalence of long-term stress incontinence and | | nocturia, especially in those who have had \>1 child | | | | - Episiotomy, operative vaginal delivery, exposure to oxytocin | | in labour or vaginal delivery of an infant weighing \>4 kg | | increase the risk of subsequent pelvic floor dysfunction | | | | - **[Management: ]** | | | | - preventative measures, with PFMT found to be effective when | | implemented during pregnancy | | | | - Interventions to reduce time in labour and device-assisted | | delivery (e.g., use of forceps), avoid episiotomy, or | | consider Cesarean section may reduce the risk of subsequent | | UI | | | | - Evidence is scant | | | | - \*\*\*PFMT | +-----------------------------------------------------------------------+ | **Therapeutic Tips** | +-----------------------------------------------------------------------+ | - Provide patient education regarding management alternatives | | (risks, benefits), determine patient expectations and involve the | | patient in the decision-making process. | | | | - Pharmacologic interventions provide symptomatic benefit but are | | not curative. | | | | - Treat all secondary causes (e.g., UTI, constipation, lifestyle | | factors, medications or poor mobility) either before or | | concurrently with other management strategies. | | | | - Ensure baseline frequency, urgency or other symptoms are | | documented in order to assess for improvement. | | | | - Ensure baseline cognition is assessed in older adults to monitor | | for cognitive impairment. | | | | - Most nonpharmacologic interventions require 6--12 weeks for | | benefit; pharmacologic interventions take several weeks to | | achieve maximum effect. | | | | - As initial therapy, recommend the strategy that is the least | | invasive, is reversible and has the fewest side effects. | | | | - For stress UI, first-line treatment is pelvic floor muscle | | training; pharmacologic therapy is used as adjunct therapy or for | | refractory cases. | | | | - For urgency UI, bladder training is first-line treatment. | | Consider pharmacologic options if bladder training is | | unsuccessful. | | | | - Containment products designed for UI are distinct from menstrual | | products and cannot be substituted. The placement of the | | absorbent core, the absorbency and the odour prevention make | | these products unique. Ensure the patient is using the correct | | type of containment product for their anatomy and for the type of | | UI. | | | | - Be aware of challenges with persistence and adherence that can | | occur with both nonpharmacologic and pharmacologic treatments. | +-----------------------------------------------------------------------+    URINARY INCONTINENCE (CHILDREN) Urinary Incontinence in Children +-----------------------------------------------------------------------+ | **Introduction** | +=======================================================================+ | **[DayTime: ]** | | | |   | | | | - girls are usually trained earlier than boys | | | | - Daytime incontinence in children is defined as the repeated | | daytime voiding of urine into clothes at least twice per week for | | at least 3 consecutive months in a child ≥5 years of age | | | | - occurs in about 10% of children 4--6 years of age, declining | | to 4% in adolescents. | | | | - Girls are affected twice as often as boys. | | | | - It is considered a problem in a child ≥4 years of age who | | wets daily (primary) or who relapses after 6 consecutive | | months without daytime wetting (secondary) | | | | **[Possible causes: ]** | | | | A screenshot of a computer Description automatically generated | | | |   | | | | **[Nighttime:]** | | | |   | | | | - Enuresis is bedwetting during sleep (even nap time), more than | | twice weekly beyond 5 years of age for girls and 6 years of age | | for boys | | | | - primary enuresis, bladder control has never been achieved | | | | - more common in boys, occurs in 10--15% of 5-year-olds and | | 6--8% of 8-year-olds and declines to \1 symptom recurrence per month | | | | - combination therapy with desmopressin and an alarm may be | | effective. | | | |   | | | |   | | | | A screenshot of a medical chart Description automatically generated | | | |   | +-----------------------------------------------------------------------+ | **Therapeutic Tips** | +-----------------------------------------------------------------------+ | - Predictors of positive treatment outcome include a motivated | | child, supportive family and age over 10 years. | | | | - Predictors of treatment failure include developmental delay, low | | self-esteem, a history of behaviour problems or multiple wettings | | at night, frequent daytime voiding, intolerance or annoyance by | | caregiver, and unstable family dynamics.​ | | | | - The cause of most cases of daytime incontinence is uncovered by | | noninvasive investigations (history, physical exam, urinalysis, | | urine culture, and ultrasound of kidney and bladder). | | | | - Relative to desmopressin, enuresis alarms are superior in that | | once the child achieves dryness, there is less chance of | | relapse.​ The effects of desmopressin are immediate, whereas | | enuresis alarms take longer to reduce frequency of bedwetting | +-----------------------------------------------------------------------+ BPH: +-----------------------------------------------------------------------+ | **Goals of Therapy** | +=======================================================================+ | - Improve or abolish lower urinary tract symptoms (LUTS) | | | | - Delay or prevent clinical progression of benign prostatic | | hyperplasia (BPH) | | | | - Prevent the sequelae of long-term bladder outlet obstruction | | (urinary tract infections, bladder stones, hydronephrosis) | +-----------------------------------------------------------------------+ | **Investigations** | +-----------------------------------------------------------------------+ | - Thorough history with attention to: | | | | - voiding (weak/interrupted stream, dribbling, hesitancy, | | straining) and storage (nocturia, frequency, urgency) | | symptoms | | | | - onset and progression of LUTS and degree of inconvenience or | | bother; International Prostate Symptom Score (IPSS; | | see Table 1) and voiding diary | | | | - details of urethral infection, instrumentation or injury | | (trauma, surgery, radiation) | | | | - episodes of urinary tract infection (UTI), hematuria or | | urinary retention | | | | - Physical examination: | | | | - abdomen (bladder distention, flank tenderness) | | | | - external genitalia (phimosis, meatal stenosis, urethral | | mass/induration) | | | | - digital rectal examination (DRE); document prostate size, | | consistency, symmetry and tenderness; note anal tone and | | rectal abnormalities | | | | - Laboratory tests: | | | | - urinalysis (and urine culture if bacteriuria/pyuria) | | | | - **prostate specific antigen (PSA)** is controversial and | | recommendations vary among interested organizations. A | | baseline PSA is suggested for asymptomatic patients aged | | 40--54 years. Those at a higher risk of developing prostate | | cancer (positive family history, black African/Caribbean | | descent) should consider being tested earlier. Those aged | | 55--69 years should discuss the potential benefits and harm | | of PSA testing with their family physician. | | | | - Routine PSA testing is not recommended for patients over | | age 70 years or those with a life expectancy of less than | | 10--15 years. | | | | - **[In those with LUTS, PSA can be useful in detecting | | prostate cancer as a cause; in combination with age, PSA | | is a predictor of prostate volume]**.​ | | | | - Higher PSA values impart a greater risk of clinical | | progression of LUTS. | | | | -  5-alpha-reductase inhibitors decrease serum PSA levels | | and must be taken into consideration when evaluating PSA | | results (see 5-Alpha-reductase Inhibitors). | | | | - Other diagnostic tests are occasionally required when the history | | is not clear, physical examination or laboratory tests reveal | | abnormalities, or response to treatment is unsatisfactory: | | | | - serum creatinine | | | | - urine cytology | | | | - cystourethroscopy | | | | - urodynamic studies (e.g., uroflowmetry) | | | | - renal/bladder/transrectal ultrasonography | | | | - IV urography | | | | - CT abdomen and pelvis | | | |   | | | |  | | | |   | +-----------------------------------------------------------------------+ | **Therapeutic Choices** | +-----------------------------------------------------------------------+ | A diagram of a patient\'s life Description automatically generated | | | |   | +-----------------------------------------------------------------------+ | **[Non-Pharm:]** | | | |   | | | | - Manage patients with minimal symptoms with reassurance and active | | surveillance (regular reassessment). | | | | - Advise patients with problematic nocturia to avoid | | caffeine-containing beverages and alcohol in the evening. | | | | - Advise patients with pedal edema to elevate legs prior to | | retiring. | | | | - Avoid decongestants | | | |   | | | | **[Pharm options:]** | | | |   | | | | - A study found that patients \>66 years of age with BPH who were | | exposed to alpha-blocker or 5-alpha reductase inhibitor therapy | | (alone or in combination) had an increased association with new | | cardiac failure, with the highest risk for those exposed to | | nonselective alpha blockers alone | | | |   | | | | ***[alpha~1~-adrenergic receptor antagonists (Alpha | | blocker):]*** | | | |   | | | | - most commonly used to block alpha~1~-adrenergic receptors that | | mediate smooth muscle activity in the bladder neck, prostate and | | prostatic capsule, reducing the dynamic component of bladder | | outlet obstruction | | | | - AE: dizziness, headaches, asthenia and nasal congestion | | | | - may potentiate other antihypertensive medications | | | | - caution should be used when they are added to an ongoing regimen, | | particularly in the elderly | | | | - [Nonselective alpha~1~-adrenergic receptor | | antagonists] | | | | - all 5 have equal clinical effectiveness | | | | - Adverse events from doxazosin and terazosin may be reduced by | | taking them at bedtime. | | | | - **Alfuzosin** | | | | - **Doxazosin** | | | | - a low dosage and gradually increase until symptomatic | | improvement to avoid first-dose syncope | | | | - cost-effective | | | | - **Terazosin** | | | | - a low dosage and gradually increase until symptomatic | | improvement to avoid first-dose syncope | | | | - cost-effective | | | | - [selective alpha~1~-adrenergic receptor | | antagonists] | | | | - fewer systemic side effects because of their greater | | selectivity for the alpha~1A~-receptor subtype | | | | - **Silodosin** | | | | - 90% of patients develops decreased ejaculate volume | | when taking this med | | | | -  **tamsulosin** | | | | - 5-10 % of patients develops decreased ejaculate | | volume | | | | - linked to intraoperative floppy iris syndrome (IFIS) | | | |   | | | |   | | | | ***[5-alpha-reductase inhibitors ]*** | | | | - **Dutasteride** | | | | - [Inhibits types I and II] isoenzymes of | | 5-alpha-reductase which blocks the metabolism of testosterone | | to dihydrotestosterone | | | | - **Finasteride** | | | | - [inhibits type II] isoenzymes of | | 5-alpha-reductase which blocks the metabolism of testosterone | | to dihydrotestosterone | | | |   | | | | - net effect is a decrease in intraprostatic dihydrotestosterone | | and a [progressive reduction in prostatic volume of | | 20--30%] | | | | - may be accompanied by an improvement in urinary flow rates  | | | | - work best in patients with large prostates (≥40 mL) | | | | - low incidence of side effects | | | | - increased risk of self-harm and depression in patients ≥66 years | | of age but no increased risk of suicide | | | | - [decrease serum PSA levels by approximately 50% in patients with | | BPH and may partially suppress serum PSA in those with prostate | | cancer] | | | | - a new PSA baseline sh