Medication Summary

The goals of pharmacotherapy are to create continence, reduce morbidity, and prevent complications.

Class Summary

Anticholinergic medications (eg, oxybutynin, hyoscyamine, tolterodine) may be given to decrease detrusor instability and symptoms of urgency. Intermittent catheterization and anticholinergic management are usually used in combination to accomplish symptom-management goals, to create continence, to eliminate vesicoureteral reflux, to prevent UTIs, and to ensure low bladder-storage pressure. If these measures fail, augmentation cystoplasty should be considered.

Oxybutynin chloride (Ditropan XL, Gelnique, Oxytrol)

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Oxybutynin chloride, a tertiary amine muscarinic receptor antagonist, is a nonspecific relaxant on smooth muscles.

Tolterodine (Detrol, Detrol LA)

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Tolterodine is a competitive muscarinic receptor antagonist for overactive bladder. It differs from other anticholinergics by being selective for the urinary bladder over the salivary glands. Tolterodine has high specificity for muscarinic receptors and has minimal activity or affinity for other neurotransmitter receptors and other potential targets (eg, calcium channels).

Propantheline

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Propantheline blocks the action of acetylcholine at postganglionic parasympathetic receptor sites.

Hyoscyamine sulfate (Levsin/SL, Levsin, Hyosyne, Symax SL, Levbid)

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Hyoscyamine blocks the action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands, and the CNS, which, in turn, has antispasmodic effects. Hyoscyamine is absorbed well by the GI tract. Food does not affect absorption of this drug. Hyoscyamine is available in sublingual form (Levsin SL, Symax SL), conventional tablets (Levsin), and extended-release tablets (Levbid).

Class Summary

Agents in this class cause presynaptic paralysis of the myoneural junction and reduce abnormal contractions.

OnabotulinumtoxinA (BOTOX)

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OnabotulinumtoxinA injections are used in some patients with overactive bladders and may benefit bladder-augmentation candidates. Botulinum toxin may provide relief of spasticity without the systemic adverse effects of other antispasticity agents. It binds to receptor sites on the motor nerve terminals and, after uptake, inhibits the release of acetylcholine, blocking transmission of impulses in neuromuscular tissue.

In treating adult patients for 1 or more indications, the maximum cumulative dose generally should not exceed 360 U in a 3-month period. The recommended treatment dose of onabotulinumtoxinA is 200 U per treatment, divided into 30 injections of 1 mL.

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Media Gallery

Augmentation cystoplasty. Isolate segment of ileum chosen for augmentation on adequate mesentery, and reestablish intestinal continuity. Close ends of segment with suture, and open antimesenteric surface.
Augmentation cystoplasty. Fold ileal segment, and sew it upon itself. This detubularizes segment, reduces enteric contractions, and maximizes volume that segment contributes to urinary storage.
Augmentation cystoplasty. Anastomose augmenting segment to prepared bladder. Perform wide-mouthed anastomosis to ensure that augmentation is spherical. If this is not carried out properly, augmenting segment can exist only as poorly draining diverticulum that is prone to complications.

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Author

Pravin K Rao, MD Assistant Professor, Director of Reproductive Medicine and Surgery, Brady Urological Institute at Bayview Medical Center, Johns Hopkins Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Alan J Iverson, MD Staff Physician, Department of Urology, David Grant Medical Center

Alan J Iverson, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Edmund S Sabanegh, Jr, MD Chairman, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation

Edmund S Sabanegh, Jr, MD is a member of the following medical societies: American Medical Association, American Society of Andrology, Society of Reproductive Surgeons, Society for the Study of Male Reproduction, American Society for Reproductive Medicine, American Urological Association, SWOG

Disclosure: Nothing to disclose.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Endourological Society Board of Directors; President Elect North Central Section of the American Urological Association<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical.

Acknowledgements

R Duane Cespedes, MD Residency Program Director, Director of Female Urology and Urodynamics, Department of Urology, Wilford Hall Medical Center; Clinical Associate Professor, Department of Surgery, Division of Urology, University of Texas Health Science Center at San Antonio

R Duane Cespedes, MD is a member of the following medical societies: Alpha Omega Alpha and American Urological Association

Disclosure: Nothing to disclose.

Michael Grasso III, MD Director of Endourology, Lenox Hill Hospital; Professor and Vice Chairman, Department of Urology, New York Medical College

Michael Grasso III, MD is a member of the following medical societies: American Medical Association, American Urological Association, Endourological Society, Medical Society of the State of New York, National Kidney Foundation, Société Internationale d'Urologie (International Society of Urology), and Society of Laparoendoscopic Surgeons

Disclosure: Karl Storz Endoscopy Consulting fee Consulting; Boston Scientific Consulting fee Consulting; Cook Urologic Consulting fee Consulting

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Tissue Segment	Advantages	Disadvantages
Stomach	Decreases mucus, infection, and stones; better for short gut and acidosis/azotemia	Hemolytic dysuria syndrome
Jejunum	None (used only if other segments are contraindicated/unavailable)	Electrolyte disturbances; malabsorption
Ileum	Usually available, well-tolerated	Electrolyte disturbances; mucus
Large intestine	Usually available, well-tolerated	Electrolyte disturbances; mucus; sigmoid: strong contractions
Ureter	Minimizes mucus, infection, stones, and electrolyte effects	Rarely available

Intestinal Segment	Acid-Base Effect	K⁺	Cl⁺	Notes
Stomach	Alkalosis	↓	↓	Respiratory insufficiency, seizure, arrhythmia
Jejunum	Acidosis	↑	↓	Hyponatremia, azotemia, malabsorption
Ileum/colon	Acidosis	↓	↑	Diarrhea with loss of colon, ileocecal valve

Augmentation Cystoplasty Medication

Medication Summary

Anticholinergics, Genitourinary

Class Summary

Oxybutynin chloride (Ditropan XL, Gelnique, Oxytrol)