Pharmacological Therapy
Urologists utilize clinical history, elimination diaries, noninvasive urodynamics, and conventional urodynamics to help gain an understanding of each patient’s unique bladder characteristics. It is from this information that urologists can determine wheth
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John Weaver and Paul Austin
27.1 Introduction Urologists utilize clinical history, elimination diaries, noninvasive urodynamics, and conventional urodynamics to help gain an understanding of each patient’s unique bladder characteristics. It is from this information that urologists can determine whether implementing pharmacologic therapy will benefit a patient; furthermore, this information helps the physician tailor the correct pharmacotherapy to each patient based on their individual bladder physiology. Figure 28.1 shows a treatment algorithm which includes the optimal time to initiate pharmacotherapy for two common urologic issues: frequency and incontinence. There is a multitude of pharmacotherapy agents in an urologist’s armamentarium, and having an in-depth understanding of each agent is key in helping to determine the correct drug needed for each clinical scenario.
27.2 Anticholinergics The most commonly prescribed pharmacotherapy for bladder dysfunction in pediatric patients is anticholinergics. Anticholinergics act on muscarinic receptors which are found in the detrusor muscle of the bladder. Bladder contractions are initiated by stimulation of these receptors with the release of acetylcholine from cholinergic nerves. The bladder consists of primarily M2 and M3 muscarinic receptor subtypes that the anticholinergics will selectively target. Anticholinergics competitively inhibit the binding of acetylcholine to muscarinic receptors at the neuromuscular junction thereby reducing the frequency and intensity of detrusor contractions J. Weaver, M.D. • P. Austin, M.D. (*) Division of Urologic Surgery, St. Louis Children’s Hospital, Washington University School, St. Louis, MO, USA e-mail: [email protected] © Springer International Publishing AG, part of Springer Nature 2018 G. Mosiello et al. (eds.), Clinical Urodynamics in Childhood and Adolescence, Urodynamics, Neurourology and Pelvic Floor Dysfunctions, https://doi.org/10.1007/978-3-319-42193-3_27
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Uroflow/EMG
Evidence of external sphincter dyssynergia
Biofeedback/ botox injection
Normal flow with or without short lagtime
Evidence of internal sphincter dyssynergia
Start selective alpha– blocker (i.e. tamsulosin) or non– selective alpha– blockers in select patients.
If symptoms persist If symptoms persist
Anticholinergic therapy
If no improvement consider adding non–selective alpha blocker (ie, terazosin or doxazosin) or using them on their own
Consider using Imipramine
Fig. 27.1 Treatment algorithm for urinary frequency and/or urinary incontinence
during the filling phase of the bladder. This subsequently results in an increase in the functional capacity of the bladder and compliance [1, 2]. By increasing bladder compliance, anticholinergics also decrease pressures in noncompliant neurogenic bladders thereby helping to protect the upper tracts in these patients. Anticholinergics are also particularly useful in decreasing the uninhibited, pathologic contractions associated with overactive bladders. By decrea
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