Inkontinensia Urin 1718.pdf

FARMAKOTERAPI
 INKONTINENSIA
 URIN Oleh : Dita Ayulia D.S. M.Sc.,Apt.

TL. Wanita usia 65 th, multipara, mempunyai gejala urgency, frequency, dan nocturia selama beberapa tahun terakhir. Simptom yg dialamainya memburuk secara progresif dan dia sekarang kencing 10 kali atau lebih setiap hari dan 2-3 kali pada malam hari. Dia merasa ingin pergi ke toilet sepnjang waktu tanpa dipicu oleh aktivitas seperti batukbersin, “seperti pd wanita hamil”, dan dia kadang-kadang tidak dapat pergi ke toilet pd waktunya, meskipun sering tidak ada banyak urin untuk dikeluarkan. Dia tdk mempunyai riwayat ISK. Dia saat ini mendapat terpi kalsium, vit. D, dan bifosfonat sesudah didiagnosis oleh dokter menderita osteoporosis tahun lalu. Dia tdk mempunyai riwayat merokok dan minum alkohol dan termasuk wanita yg setia pd pasangan. Pasien diberikan duloxetin 80 mg 2xseahri

JH, 63 tahun, seorang arsitektur, mengeluhkan gejala urinari (sering berkemih) kepada dokter keluarganya. Dia memiliki riwayat hipertensi dan 8 tahun terakhir mendapatkan terapi diuretik thiazid dan ACEI. Satu tahun yang lalu, JH memiliki gejala dan tanda mengalami benign prostatic hypertrophy, yang kemudian melakukan prostectomy untuk menghilangkan gejala tersebut. Dia mengeluhkan bahwa keinginan untuk buang air segera meningkat disertai dengan frekuensi yang sering dan berasa mengganggu kualitas hidupnya. Dokter memberikan terapi dengan oxybutynin 5 mg 3 x sehari.

Pengertian Pengeluaran urin tanpa disadari dengan jumlah dan frekuensi yang cukup sering sehingga mengakibatkan masalah dan gangguan kesehatan atau sosial

Etiologi

Anatomi Saluran Urin

PROSES BERKEMIH

7

Patogenesis

Gejala dan Tanda ●

Gejala : perasaan ingin buang air kecil dan

peningkatan frekuensi buang air kecil ( lebih dari 8 kali dalam sehari) , kadang nocturia ●

Tanda: ● Peningkatan volume residu urin pada pasien dengan overflow incontinence

● Terjadinya eritema, kerusakan, dan ulserasi kulit perineal pada inkontinensia urin kronis

Tipe Inkontinensia Urin

Urologic Disorders

rologic Disorders

thereby products contain polymer that absorbs and wicksand urine away assuring appropriate therapy. tract surgery or injury compromising theasphincter). from the body Symptoms URINE LEAKAGE Physical therapy Gait and/or strength training Used for frail elderly patients with mobility impairments that make reaching ■ Urine leakage with physical activity (volume is proportional a toilet in timely fashion difficult UI represents a spectrum of severity in terms of both volume of to activity level). No UI with physical inactivity, especially leakage and degree of bother to the patient. To carefully consider when supine (no nocturia). May develop urgency and frethe level of patient discomfort when discussing urine leakage, that quency pooled as results of two open-label studies, tolterodine potential pharmacodynamic interaction involves thethe mutual antaga compensatory mechanism (or as a separateLA was mustofprobe during the agents patientand interview to accurately component bladder overactivity). associated with of significantly greater patient-perceived improvementclinician onism anticholinergic cholinergic stimulants, such as determine precise nature of the problem.used to treat dementia. in Diagnostic bladder control the the acetylcholinesterase inhibitors Tests and fewer withdrawals due to adverse effects than Use of absorbent products, such as panty liners, pads, or briefs, is oxybutynin XL. ofHowever, the treatments were similar in terms of urethral meatus while patient coughs or strains. ■ Observation an obvious point of discussion, but the clinicianOxybutynin must keep in mind patients’ or physicians’ perception of benefit over baseline and proExtended-Release Transdermal The oxybutynin that use of these products varies among patients. The number and portions of withdrawals due to lack of efficacy. However, the lack of transdermal system (TDS), which delivers 3.9 mg/day, is applied type of pads may not relate to the amount or type of incontinence, as blinding may PRESENTATION have introduced patient and observer bias.62 twice (every 3 or 4 days). Transdermal absorption CLINICAL OF URINARY their use is aweekly function of personal preference and hygiene. A high of oxybutyOxybutynin XL, available only in a tablet formulation, is adminnin from this formulation bypasses first-pass hepatic and gut metabINCONTINENCE RELATED TO BLADDER number of absorbent pads may be used every day by a patient with istered once daily, with or without food, and should not be crushed olism, resulting in similar plasma oxybutynin but lower OVERACTIVITY severe, high-volume UI or, alternatively, by a fastidiously hygienicplasma DEO or chewed (see Table 88–4). Like oxybutynin IR, the dosage doespatientconcentrations with levelschanges achieved after administration of with low-volumecompared leakage who simply pads often to General 51,63,64 not require adjustment in patients of advanced age or in patientspreventan equivalent dose via the oral route. dosage adjustment of wetness or odor. Nevertheless, a large number ofNo pads that are ■ Can bladder impairment. overactivity and UI without urgencyshould if 44 theproduct patient for as “soaked” is indicative of high-volume with renalhave or hepatic However, treatment bedescribed the by TDS advancing age is necessary. sensory input from the lower urinary tract is absent. urine loss. initiated at the smallest recommended dosage in the elderly (5 mg Oxybutynin TDS is superior to placebo in reducing the number of Symptoms of the volume of urine loss, the desireand to seek evalua- the volume once daily).32,54 The maximum benefit of oxybutynin XL may not be Regardless incontinence episodes and micturitions increasing tion and therapy for UI in all patients almost always is elective ■ Urinary micturitions per day),therapy urgency or withafter or dose voided per micturition.43,44 It is similar to oxybutyninand realized for frequency up to 4(>8 weeks after starting IR in reducing contingent on the degree of bother to the individual patient. As with withoutNo urgeknown incontinence; (≥1drug–drug micturitioninteractions per escalation. clinicallynocturia relevant the frequency of UUI episodes and improving patient-perceived use of absorbent products, patients differ with regard to the amount enuresis may with night) eitherand oxybutynin XL be orpresent. oxybutynin IR have been identified.of urine urinary leakage.65 Oxybutynin TDS and tolterodine LA are signifiloss they will tolerate before considering the condition Diagnostic Testsdrugs with anticholinergic activity may increase However, other cantlyenough superior to placebo and similar to each other in reducing the bothersome to seek assistance. overall anticholinergic (i.e., produce an additive or synergisfrequency of UUI episodes, increasing the volume voided per mictustudieseffects are the gold standard for diagnosis. ■ Urodynamic Urinalysis and urine culture should be negative (rule 54 out tic pharmacodynamic interaction), as might be expected. rition, attaining complete continence, and improving quality of life.43 AnotherSYMPTOMS urinary tract infection as cause of frequency). Under the best of circumstances, UI is difficult to categorize based Incontinence TABLE 88-4 Pharmacotherapeutic Options in Patients with Urinary on symptoms alone (Table 88–2).22 In a study of patients who symptoms and patient history, Type Drug Class Drug Therapy (Usual Dose) appeared to have SUI based on Comments CLINICAL PRESENTATION OF URINARY urodynamics showed that only 72% of patients had SUI as the sole INCONTINENCE RELATEDagents/ TO URETHRAL Overactive bladAnticholinergic Oxybutynin IR (2.5–5 mg two, three or four times daily), 23 Anticholinergics are first-line drug therapy (oxybutynin or cause of incontinence. OVERACTIVITY AND/OR BLADDER oxybutynin XL (5–30 mg daily), oxybutynin TDS (3.9 mg /day); der antispasmodics tolterodine is preferred) Patients with urethral underactivity or SUI characteristically UNDERACTIVITY (apply one patch twice weekly), tolterodine IR (1–2 mg twice complain of urinary leakage with physical activity. Volume of daily), tolterodine LA (2–4 mg daily), trospium chloride (20 mg General leakage is proportional to the level of activity. They will often leak once or twice daily), solifenacin (5–10 mg daily), darifenacin urine during periods of exercise, coughing, sneezing, lifting, or even ■ Important but rare type of UI in both men and women. (7.5–15 mg daily) Urethral overactivity usually is due to prostatic enlargement Tricyclic antidepressants Imipramine, doxepin, nortriptyline, or desipramine (25–100 mg TCAs are generally reserved for patients with an addi(males) or cystocele formation or surgical overcorrection (TCAs) at bedtime) tional indication (e.g.,from depression, neuropathic pain) Overactivity TABLE 88-2 Differentiating Bladder following stress incontinence surgery in women. Topical estrogen (only in Conjugated estrogen vaginal cream (0.5 g) three timesUrethral per weekUnderactivity Marginally effective; few adverse effects with vaginal Symptoms women with urethritis for up to 8 months. Repeat course if symptom recurrence, or cream and insert Bladder Urethral or vaginitis) use estradioltovaginal fullness, hesitancy, straining void,insert/ring [ 2 mg (one ring)] and replace ■ Lower abdominal Overactivity Underactivity Symptoms 90 dayssense if needed. decreased force of stream, interrupted after stream, of

Inkontinensia Urin Urge

Urge inkontinensia urine juga sering disebut Overactive bladder

a

Inkontinensia Urin Stres SECTION 10

Urologic Disorders

62 blinding may have introducedproducts patient and aobserver bias. twice weekly (every 3 or 4 days). Transdermal absorption of oxybutycontain polymer that absorbs and wicks urine away from the body Oxybutynin XL, available only in a tablet formulation, is adminnin from this formulation bypasses first-pass hepatic and gut metabPhysicalonce therapy Gait and/orfood, strength training Used for frail patients withoxybutynin mobility impairments that make reaching istered daily, with or without and should not be crushed olism, resulting in elderly similar plasma but lower plasma DEO 1402 a toilet in timely fashion difficult or chewed (see Table 88–4). Like oxybutynin IR, the dosage does concentrations compared with levels achieved after administration of not require adjustment in patients of advanced age or in patients an equivalent dose via the oral route.51,63,64 No dosage adjustment of 44 CLINICAL PRESENTATION with renal orresults hepaticof impairment. However, should be the TDS product for advancing age is necessary. that pooled two open-label studies,treatment tolterodine LA was potential pharmacodynamic interaction involves the mutual antaginitiated the smallest recommended dosage in the elderly (5 mg Oxybutynin TDS is superior placebo in reducing the number of associatedatwith significantly greater patient-perceived improvement onism of anticholinergic agentstoand cholinergic stimulants, such as 32,54 once daily).control incontinence episodes and micturitions increasing the volume Theand maximum benefit of oxybutynin XL may not be CLINICAL PRESENTATION OF URINARY Stress inkontinensia urine sering in bladder fewer withdrawals due juga to adverse effects than the acetylcholinesterase inhibitors used toand treat dementia. voided per INCONTINENCE micturition.43,44 It is similar realized for XL. up However, to 4 weeks startingwere therapy or inafter dose to oxybutynin RELATED TO IR in reducing oxybutynin theafter treatments similar terms of berhubungan dengan urethral underactivity escalation. No known clinically relevant drug–drug interactions the frequency of UUI episodes and improving URETHRAL UNDERACTIVITY patients’ or physicians’ perception of benefit over baseline and proExtended-Release Transdermal Oxybutynin patient-perceived The oxybutynin 65 with either IR have been identified. urinary leakage. TDS delivers and tolterodine LA are signifiportions of oxybutynin withdrawals XL dueor tooxybutynin lack of efficacy. However, the lack of transdermal systemOxybutynin (TDS), which 3.9 mg/day, is applied General 62 increase However, other drugs with anticholinergic activity may cantly superior to placebo and similar to eachabsorption other in reducing the blinding may have introduced patient and observer bias. twice weekly (every 3 or 4 days). Transdermal of oxybutyTheepisodes, patient bypasses usually notes during activities such as exercise, ■UUI overall anticholinergic effectsonly (i.e.,inproduce additive or issynergisfrequency of increasing theUI volume voided permetabmictuOxybutynin XL, available a tabletan formulation, adminnin from this formulation first-pass hepatic and gut 54 43 tic pharmacodynamic as might expected. rition, complete continence, and improving quality of life. running, and Occurs istered once daily, withinteraction), or without food, andbe should not beAnother crushed olism, attaining resulting in similarlifting, plasmacoughing, oxybutynin butsneezing. lower plasma DEOmuch more in women (seen only men with lower or chewed (see Table 88–4). Like oxybutynin IR, the dosage does concentrationscommonly compared with levels achieved after in administration of urinary 51,63,64 tract surgery or injury compromising the sphincter). not require adjustment in patients of advanced age or in patients an equivalent dose via the oral route. No dosage adjustment of TABLE 88-4 Pharmacotherapeutic Options in Patients with Urinary Incontinence 44 with renal or hepatic impairment. However, treatment should be the TDS product for advancing age is necessary. SymptomsComments Type Drug Class Drug Therapy (Usual Dose) initiated at the smallest recommended dosage in the elderly (5 mg Oxybutynin TDS is superior to placebo in reducing the number of Urine leakage with physical activity isorproportional ■ episodes 32,54 Overactive bladAnticholinergic Oxybutynin IR (2.5–5 mg not two, be three or four times daily), Anticholinergics are first-line therapy(volume (oxybutynin once daily). incontinence and micturitions anddrug increasing the volume The maximumagents/ benefit of oxybutynin XL may 43,44 to activity level). No UI with physical inactivity, der (5–30 mg daily), TDSper (3.9 micturition. mg/day); tolterodine is preferred) voided realized for up to antispasmodics 4 weeks after startingoxybutynin therapyXLor after dose oxybutynin It is similar to oxybutynin IR in reducing especially when supine (no nocturia). May patient-perceived develop urgency and fre(apply one patch twice weekly), tolterodine IR (1–2 mg twice escalation. No known clinically relevant drug–drug interactions the frequency of UUI episodes and improving daily), tolterodine LA (2–4 mg daily), trospium chloride (20 mg 65 quency as a compensatory mechanism as a separate with either oxybutynin XL or oxybutynin IR have been identified. urinary leakage. Oxybutynin TDS and tolterodine LA are(or signifionce or twice daily), solifenacin (5–10 mg daily), darifenacin component of bladder overactivity). However, other drugs with anticholinergic activity may increase cantly superior to placebo and similar to each other in reducing the (7.5–15 mg daily) overall anticholinergic effects (i.e., produce an additive or synergisfrequency of UUI episodes, increasing the volume voided per mictuDiagnostic Tests Tricyclic antidepressants Imipramine, doxepin,54nortriptyline, or desipramine (25–100 mg TCAs are generally reserved for patients with an addi- 43 tic pharmacodynamic interaction), as might be expected. rition, attaining complete continence, and improving quality ofpain) life. Another (TCAs) at bedtime) tional depression, neuropathic ofindication urethral(e.g., meatus while patient coughs or strains. ■ Observation

Urologic Disorders

TABLE 88-4 Type

Stress Overactive bladder

Stress

Topical estrogen (only in Conjugated estrogen vaginal cream (0.5 g) three times per week Marginally effective; few adverse effects with vaginal women with urethritis Options for up 8 months. Repeat course if symptom recurrence, or cream and insert Pharmacotherapeutic in toPatients with Urinary Incontinence or vaginitis) use estradiol vaginal insert/ring [2 mg (one ring)] and replace Drug Class Drug Dose) afterTherapy 90 days if(Usual needed. CLINICALComments PRESENTATION OF URINARY a Duloxetine 40–80 mg/day (one ormgtwo doses) Even though RELATED notare FDA approved, duloxetine is first-lineor Anticholinergic agents/ Oxybutynin IR (2.5–5 two, three or four times daily), Anticholinergics first-line drug (oxybutynin INCONTINENCE TOtherapy BLADDER therapy; most adverse events diminish with time, so antispasmodics oxybutynin XL (5–30 mg daily), oxybutynin TDS (3.9 OVERACTIVITY mg/day); tolterodine is preferred) support patient during initial period of use (apply one patch twice weekly), tolterodine IR (1–2 mg twice α-Adrenergic agonists Pseudoephedrine (15–60 mgmg three times daily) with food, water, Pseudoephedrine and phenylephrine are alternative General daily), tolterodine LA (2–4 daily), trospium chloride (20 mg or milkor twice daily), solifenacin (5–10 mg daily), darifenacin first-line therapies for women with no contraindication once ■ Can have(notably bladder overactivity and UI without urgency if hypertension); phenylpropanolamine was Phenylephrine (10 mg four times daily) (7.5–15 mg daily) sensory input from the lower urinary tract is from absent. the are preferred agent in the for class until itswith removal Tricyclic antidepressants Imipramine, doxepin, nortriptyline, or desipramine (25–100 mg TCAs generally reserved patients an addithe U.S. market in 2000. (TCAs) at bedtime) Symptoms tional indication (e.g., depression, neuropathic pain) Estrogen See estrogens (above). Workscream best if(0.5 urethritis vaginitis Consideredeffective; a less-effective alternative to αwith -adrenergic Topical estrogen (only in Conjugated estrogen vaginal g) threeortimes per are week Marginally few adverse effects vaginal ago■ Urinary frequency (>8 micturitions per day), urgency with or present. nists and duloxetine. Combined α -adrenergic agonist women with urethritis for up to 8 months. Repeat course if symptom recurrence, or cream and insert without urge incontinence; nocturia (≥1than micturition per and estrogen may be somewhat more effective αor vaginitis) use estradiol vaginal insert/ring [2 mg (one ring)] and replace night) andadrenergic enuresis mayalone be inpresent. agonist postmenopausal women. after 90 days if needed. Imipramine 25–100 mg at bedtime Imipramine an optional therapyduloxetine when first-line therapy Duloxetinea 40–80 mg/day (one or two doses) thoughisnot FDA approved, is first-line DiagnosticEven Tests is inadequate. therapy; most adverse events diminish with time, so

SECTION 10

Nonpharmacologic Management (continued) TABLEat88-3 night) and enuresis be present. initiated the smallest recommended dosage in of theUrinary elderlyIncontinence (5 mg Oxybutynin TDS is may superior to placebo in reducing the number of 32,54 once daily). incontinence episodes and micturitions and increasing the volume The maximum benefit of oxybutynin XL may not be Diagnostic Tests Description Patient Characteristics Intervention 43,44 per micturition. realized for up to 4 weeks after starting therapy or after dose ■voided is similar oxybutynin in reducing Urodynamic studies areItthe gold to standard for IR diagnosis. Supportive interventions escalation. No known clinically relevant drug–drug interactions the frequency of urine UUI and improving Female and male urinals, bedside commodes, elevated toilet Used for patients withepisodes mobility impairments thatnegative make patient-perceived reaching a toilet Toileting substitutes and Urinalysis and culture should be (rule outin 65 withother either oxybutynin XL or oxybutynin IR have been identified. urinary leakage. Oxybutynin TDS and tolterodine LA are signifiseats timely fashion difficult environmental urinary tract infection as cause of frequency). However, other drugs with anticholinergic activity may increase cantly superior to placebo and similar to each other in reducing the modifications overall anticholinergic effects (i.e., produce additive orand synergisfrequency offor UUI episodes, increasing the volume voided per mictuAbsorbent products Variety of reusable andan disposable pads pant systems; some Used all types of incontinence 54 and wicks urine away products as contain a polymer that absorbs tic pharmacodynamic interaction), might be expected. rition, attaining complete continence, and improving quality of life.43 Another

Inkontinensia Urin Overflow

CLINICAL PRESENTATION OF URINARY Overflow inkontinensia Gait and/or strengthurine training juga Used for frail elderly patients with mobility impairments that make reaching INCONTINENCE RELATED TO URETHRAL TABLE 88-4 Pharmacotherapeutic Options in Patients with Urinary Incontinence a toilet in timely fashion difficult sering berhubungan dengan urethral OVERACTIVITY AND/OR BLADDER Type Drug Class Drug Therapy (Usual Dose) UNDERACTIVITY Comments overactivity dan bladder underactivity from the body

Urologic Disorders

Physical therapy

Overactive blad-results Anticholinergic agents/ Oxybutynin IR (2.5–5 mgLA two,was three or four times daily), Anticholinergics are first-line drug therapy (oxybutynin or that pooled of two open-label studies, tolterodine potential pharmacodynamic interaction involves the mutual antagGeneral der antispasmodics oxybutynin XL improvement (5–30 mg daily), oxybutynin TDSof (3.9anticholinergic mg /day); tolterodine is preferred) associated with significantly greater patient-perceived onism agents and cholinergic stimulants, such as ■the Important of UI used in both men and women. (apply one patch effects twice weekly), IR (1–2 mgbut twicerare type in bladder control and fewer withdrawals due to adverse than tolterodine acetylcholinesterase inhibitors to treat dementia. daily), tolterodine LA (2–4 mg daily), trospium chloride (20 mg Urethral overactivity usually is due to prostatic enlargement oxybutynin XL. However, the treatments were similar in terms of once or twice daily), solifenacin (5–10 mg daily), darifenacin (males) or cystoceleTransdermal formation orOxybutynin surgical overcorrection patients’ or physicians’ perception of benefit over baseline and proExtended-Release The oxybutynin (7.5–15 mg daily) following stress incontinence surgery in women. portions of withdrawals due to lack of efficacy. However, the lack of transdermal system (TDS), which delivers 3.9 mg/day, is applied Tricyclic antidepressants Imipramine, doxepin, TCAs are generally reserved for patients with an addi62 nortriptyline, or desipramine (25–100 mg blinding may have introduced patient and observer bias. twice weekly (every 3 or 4tional days). Transdermal absorption of oxybutySymptoms (TCAs) at bedtime) indication (e.g., depression, neuropathic pain) Oxybutynin XL,Topical available only inina tablet formulation, is adminninthree from this bypasses first-pass hepatic gut metabestrogen (only Conjugated estrogen vaginal cream (0.5 times performulation week Marginally effective; few adverse effectsand with abdominal fullness, hesitancy, straining tovaginal void, ■ g)Lower istered once daily, with or without food, and should not be crushed olism, resulting in similar plasma oxybutynin but lower plasma DEO women with urethritis for up to 8 months. Repeat course if symptom recurrence, or cream and insert decreased force of stream, interrupted stream, sense of or chewed (see Table 88–4). Like oxybutynin IR, the dosage does concentrations compared with levels achieved after administration of or vaginitis) use estradiol vaginal insert/ring [ 2 mg (one ring)] and replace incomplete bladder emptying. May have urinary frequency 51,63,64 not require adjustment in patients of advanced in patients an equivalent dose via the oral route. No dosage adjustment of after 90 age days iforneeded. and urgency. Abdominal painnotif FDA acute urinary retention is a Stressrenal or hepatic Duloxetine 40–80 treatment mg /day (one should or two doses) Even thoughage approved,44duloxetine is first-line with impairment. However, be the TDS product for advancing is necessary. present. therapy; most adverse in events diminishthe withnumber time, so of initiated at the smallest recommended dosage in the elderly (5 mg Oxybutynin TDS is superior to placebo reducing 32,54 support patient during initial period of use Signs once daily). incontinence episodes and micturitions and increasing the volume The maximum benefit of oxybutynin XL may not be Pseudoephedrine three timesvoided daily) with water, Pseudoephedrine andtophenylephrine 43,44 perfood, micturition. realized for up toα-Adrenergic 4 weeksagonists after starting therapy or(15–60 aftermgdose It isurine similar oxybutyninareIRalternative in reducing postvoid residual volume. ■ Increased or milk first-line therapies for women with no contraindication escalation. No known clinically relevant drug–drug interactions the frequency of UUI episodes and improving patient-perceived (notably hypertension); phenylpropanolamine was Phenylephrine (10 mg four times daily) Diagnostic Tests65 with either oxybutynin XL or oxybutynin IR have been identified. urinary leakage. Oxybutynin TDS and tolterodine LA are signifithe preferred agent in the class until its removal from Digitalsuperior rectal examination orsimilar transrectal to rule the However, other drugs with anticholinergic activity may increase ■cantly to placebo to eachultrasound other in reducing the and U.S. market in 2000. out prostatic enlargement. Renal function tests to rule overall anticholinergic effects (i.e., produce additive or synergisfrequency of UUI increasing the volume per out mictuEstrogen Seean estrogens (above). Works best if urethritis or vaginitis are episodes, Considered a less-effective alternativevoided to α-adrenergic ago54 renal attaining failure due to acute urinary retention. tic pharmacodynamic interaction), as mightpresent. be expected. Another rition, complete continence, and improving quality of life.43 nists and duloxetine. Combined α-adrenergic agonist

TABLE 88-4 Type Overflow Overactive(atonic bladbladder) der

Pharmacotherapeutic Options in Patients with Urinary Incontinence

Imipramine Drug Class Cholinomimetics Anticholinergic agents/ antispasmodics

25–100 mg at bedtime Drug Therapy (Usual Dose) Bethanechol fourortimes on an empty Oxybutynin IR(25–50 (2.5–5mg mgthree two, or three four daily) times daily), stomach oxybutynin XL (5–30 mg daily), oxybutynin TDS (3.9 mg /day); (apply one patch twice weekly), tolterodine IR (1–2 mg twice

tolterodine LA (2–4 mg daily), trospium chloride (20 mg IR, immediate-release; LA, long-acting; TDS, transdermal system; daily), XL, extended-release.

and estrogen may be somewhat more effective than αadrenergic agonist alone in postmenopausal women. Imipramine is an optional therapy when first-line therapy Comments is inadequate. Avoid use if patient asthmadrug or heart disease. Short-term Anticholinergics arehas first-line therapy (oxybutynin or use only. Never give IV or IM because of life-threatening tolterodine is preferred) cardiovascular and severe gastrointestinal reactions.

u o b

S

U o a u c

c l u

Mekanisme Kerja Obat ●

●

Anticholinergic agent = merupakan parasimpatolitik langsung, bekerja memblok ACh menduduki reseptor muskarinik (M3 di bladder dan internal spinchter) sehingga merintangi aktivitas saraf parasimpatik (keinginan untuk berkemih) TCA = menghambat reuptake serotonin dan NE ke saraf preganglin, sehingga konsentrasinya meningkat, dapat menduduki reseptok alpha, sehingga menstimulasi aktivitas saraf simpatik (mengurangi keinginan untuk berkemih)

Mekanisme Kerja Obat ●

●

●

Duloxetine = merupakan SSRI (selective serotonine reuptake inhibitors) = menghambat reuptake serotonin ke saraf preganglin, sehingga konsentrasinya meningkat, dapat menduduki reseptok alpha, sehingga menstimulasi aktivitas saraf simpatik (mengurangi keinginan untuk berkemih) alpha-adrenergic = berkeja secara tidak langsung dengan meningkatkan pengeluaran NE diujung-ujung saraf adrenergik sehingga meningkatkan aktivitas saraf simpatik (mengurangi keinginan untuk berkemih) Cholinomimetic = merupakan analog enzim achetylcholinesterase yang merupakan enzim pengkatalis sintesis ACh, sehingga konsentrasi ACh meningkat

Tata laksana terapi A.

Non Farmakologi 1. Edukasi kpd pasien pemahaman

Kesadaran pasien Kualitas hidup pasien

2.Behaviour training (diet, bladder training, pelvic floor exercise)

3. Penggunaan alat bantu terapi incontinance yg sesuai

Terapi non farmakologi

Terapi non farmakologi

Terapi non farmakologi

Penataksanaan inkontinensi urin pada geriatri

Monitoring terapi

TERIMA KASIH