• Dysfunction of bladder outlet (urethral sphincter weakness) leading to transient loss of small amounts of urine when intra-abdominal pressure increases
• Coughing, laughing, sneezing, bending, lifting
• Posterior urethrovesicular angle changes (parity, surgery)
• Strength or responsiveness of urethral sphincter
• Patients often dry at night

• CNS dysregulation, stroke, PD, AD, neoplasm, NPH
• Hyperreflexia of afferent pathways
• Deconditioned voiding reflexes
• Clinical feautres: urgency, frequency, nocturia, frequent small volume voiding
• No characteristic features on physical exam, although CNS dysfunction may be apparent

• Occurs when intravesicular pressure exceed intraurethral pressures -- ONLY at HIGH volumes
• Bladder outlet obstruction (BPH, neoplasm)
• Impaired afferent sensation
• Diabetic neuropathy, spinal cord below T-11
• Muscle relaxants, calcium channel blockers, anticholinergics
• Clinical features: palpable or percussable bladder, suprapubic tenderness, low urinary flow rates, post-void residual urine

• The inability of a normally continent person to reach the toilet in time to avoid an accident
• Musculoskeletal limitations -- joint pain, arthritis, muscle weakness
• Unfamiliar setting, lack of conventional toilet facilities
• Clinical features: accidents on the way to the toilet and early morning incontinence are suggestive of this type

The following may aggravate or unmask other causes:

• Potent fast acting diuretics (lasix)
• Sedative hypnotics, neuroleptics
• Muscle relaxants
• Alpha1 agonists -- PPA, pseudoephedrine
• Alpha 1 antagonists -- terazosin, prazosin
• Anticholinergics
• Calcium channel blockers

• Scheduling regimens/timed voiding
• Prompted voiding
• Bladder training
• Pelvic floor exercise/Kegel exercises
• Vaginal weight training
• Biofeedback
• Pessaries/bladder neck support prostheses

• Kegel exercises
• Topical estrogens/estring -- atrophic vaginitis
• Pseudoephedrine
• Duloxetine (not FDA approved but has shown improvement in symptoms)

• Prazosin
• Terazosin
• Doxazosin
• Phenoxybenzamine
• Bethanechol
• 5-alpha reductase inhibitors (finasteride, dutasteride)

• Anticholinergics
• Oxybutynin
• Oxybutynin XL
• Oxybutynin patch
• Tolterodine
• Tolerodine LA
• Trospium chloride
• Solifenacin
• Darifenacin
• Fesoterodine

DEO highest with oxybutynin IR

DEO lowest with patch/gel

• 1 patch every 3-4 days
• Replace the patch the same 2 days every week (pref. Sun and Wed)
• Rotate site application

MOA

Antimuscarinic

Side Effects

Dry mouth, constipation, dyspepsia, headache

CI

Urinary retention, gastric retention, narrow-angle glaucoma

MOA

Antimuscarinic (M3 selective)

Side Effects

Dry mouth, constipation, blurred vision, urinary retention, dry eyes

CI

Urinary retention, gastric retention, narrow angle glaucoma

MOA

Antimuscarinic (M3 selective)

Side Effects

Dry mouth, constipation, blurred vision, dyspepsia, abdominal pain

CI

Urinary retention, gastric retention, narrow angle glaucoma

MOA

Antimuscarinic (non-selective)

Side Effects

Dry mouth, constipation, blurred vision, dyspepsia, abdominal pain

• Reduce incontinence episodes
• Reduce frequency episodes
• Increase bladder storage (volume voided)
• Decrease urgency episodes
• May decrease nocturia

• Avoid sedative hypnotic drugs
• Scheduled bathroom visits
• Bedside commode
• Assist with functional disabilities