Transcript Tryzelaar-flomaxposterFINAL

Tamsulosin (“Flomax”) use for women with bladder outlet obstruction and urinary
incontinence in the nursing home: A demonstrative case and critical discussion of its use
L. Tryzelaar,
1Baystate
1
MD; M.
Klay,
2
NP;
S. Wheaton,
2
RN;
S. Sharma,
1
MD;
S. Bellantonio,
1
MD;
Medical Center/The Western Campus of Tufts University School of Medicine, Division of Geriatrics;
2Redstone Rehabilitation and Nursing Center, East Longmeadow, MA
Introduction
• Urinary incontinence (UI) is present in more than half of all nursing home
(NH) residents.
• It is associated with falls, urinary tract infections (UTIs), pressure ulcers and
dermatitis.
• Tamsulosin (“Flomax”), an alpha-blocking agent, has been used in women
with functional or anatomical bladder outlet obstruction, but its use is
controversial, because there are few high quality studies documenting its
efficacy in women.
• Tamsulosin has rarely been described in female NH residents.
Case Report
Nursing Home Course
Spring 2011
Diary/course
 Refusing E cream
Summer 2011  Patient confused; neg UA but positive UCx;
Fall 2011
Winter 2012
 Now mostly continent during the day.
 Geriatrics recommended to discontinue nortriptyline
and replace benzodiazepine with an antipsychotic for
agitation.
 Now again incontinent during the day, continent at
night.
 Noted on exam to have cystocele
 NP is considering a pessary.
PVR
Medication changes
200cc  Tamsulosin incr to 0.4mg BID.
98cc
 Antibiotics for questionable UTI
4cc





39cc
Tamsulosin decreased to 0.4mg daily.
Nortriptyline stopped.
Clonazepam weaned down to 0.25mg daily;
Quetiapine 12.5mg BID and as needed for severe agitation.
No medication changes.
HPI:
• 74 year old woman (P5G5) with a history of hysterectomy and recurrent UTIs,
occasional UI and moderate to severe dementia admitted to Redstone NH
because of inability for family to provide care at home (April 2010).
• During this time developed chronic UI, especially at night, and during her stay
has had treatment for two UTIs (winters of 2010 and 2011).
• In March 2011, a nurse practitioner specializing in UI consulted for assistance
with management of recurrent UTIs and incontinence.
• During the visit the patient complained of difficulty initiating urination.
Conclusion
• In this case, tamsulosin was used as part of a multidisciplinary
intervention lead by a urogynecology nurse practitioner involving a
search for causes, behavioral modifications, and medication
adjustment.
Functional history (FH)
• Further research is needed to determine which women will most
benefit from the use of tamsulosin.
• The patient was dependent for all independent activities of daily living. She
required assistance with bathing, dressing and eating.
Medications
References
Physical Exam
Discussion
•
•
•
•
• Tamsulosin (“Flomax”) is an alpha-blocker, thought to function at the bladder
neck, leading to improved urine flow with functional or anatomical bladder
outlet obstruction in women.
Urogynecology Nurse
Practitioner Plan of Care
• The use of tamsulosin is controversial in women.
• Most of the studies showing a benefit are case control or case series
studies1,2,3.
• Multiple studies show no benefit over placebo in women 4,5,6.
• Expert consensus groups do not recommend it’s use in women7.
• Potential side effects (e.g. orthostatic hypotension, increased congestive
heart failure incidence, etc).
Afebrile, BP 130/79
Pleasantly confused
Abdomen and adnexa soft NT ND
Normal external genitalia, perineum, urethra, Cervix surgically absent.
Vaginal atrophy.
• PVR 108cc. Cystometrogram: Tolerated filling to 450cc. No leaking with
stress while catheter in place. Normal exam.
• Vaginal atrophy: Estradiol cream 0.1% ½ applic QHS x 30d. E-string 2mg q
12 weeks.
• Functional urinary incontinence: Tamsulosin 0.4mg daily. Kegel exercises
taught. Advised follow PVR and check orthostatic BP 3x per day. The patient
was ordered for scheduled toileting.
• This patient’s UI was likely multifactorial, involving functional and anatomical
bladder outlet obstruction and cognitive dysfunction. A multifaceted plan
involving adjustment of medications, scheduled toileting, the use of estrogen
cream, and the use of an alpha-blocker, lead to an improved outcome.
• The role of tamsulosin in this improvement is unclear.
1. Kessler TM, Studer UE, Burkhard FC. 2006. ”The effect of terazosin on functional
bladder outlet obstruction in women: a pilot study.” J Urol; 176(4 Pt. 1):1487.
2. P. Thind, G. Lose, H. Colstrup and K.E. Andersson, 1992. “The effect of alphaadrenoceptor stimulation and blockade on the static urethral sphincter function in
healthy females. Scand J Urol Nephrol, 26, p. 219.
3. Low et al, 2008. Low BY, Liong ML, Yuen KH, et al. 2008. ”Terazosin therapy for
patients with female lower urinary tract symptoms: a randomized, double blind,
placebo controlled trial.” J Urol; 179(4):1461.
4. H. Lepor and G. Machi. 1992. “Comparison of AUA Symptom Index in unselected
males ad females between fifty-five and seventy-nine years of age.” Urology, 42,
p. 36.
5. Robinson D, Cardozo L, Terpstra G, et al. 2007. ”A randomized double blind
placebo-controlled multicentre study to explore the efficacy and safety of
tamsulosin and tolterodine in women with overactive bladder syndrome.” BJU
Int ; 100(4):840.
6. Dwyer PL, Teele JS. 1992. ”Prazosin: a neglected cause of genuine stress
incontinence.” Obstet Gynecol; 79:117-121.
7. Abrams P, Andersson KE, Brubaker L, Cardoza L. 2010. ” Fourth International
Consultation on Incontinence Recommendations of the International Scientific
Committee: Evaluation and treatment of urinary incontinence, pelvic organ
prolapse, and fecal incontinence.” Neurourol Urodyn; 29(1):213-40.