1. Urogynecology Nurse Practitioner Plan of Care
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, MD;1 M. Klay, NP;2 S. Wheaton, RN;2 S. Sharma, MD;1 S. Bellantonio, MD;1 1Baystate Medical Center/The Western Campus of Tufts University School of Medicine, Division of Geriatrics; 2Redstone Rehabilitation and Nursing Center, East Longmeadow, MA
Introduction
Nursing Home Course
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.
Diary/course
PVR
Medication changes
Spring 2011
Refusing E cream
200cc
Tamsulosin incr to 0.4mg BID.
Summer 2011
Patient confused; neg UA but positive UCx;
98cc
Antibiotics for questionable UTI
Fall 2011
Now mostly continent during the day.
Geriatrics recommended to discontinue nortriptyline and replace benzodiazepine with an antipsychotic for agitation.
4cc
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.
Winter 2012
Now again incontinent during the day, continent at night.
Noted on exam to have cystocele
NP is considering a pessary.
39cc
No medication changes.
Case Report
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.
Functional history (FH)
The patient was dependent for all independent activities of daily living. She required assistance with bathing, dressing and eating.
Medications
Physical Exam
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.
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.
Further research is needed to determine which women will most benefit from the use of tamsulosin.
References
Kessler TM, Studer UE, Burkhard FC  ”The effect of terazosin on functional bladder outlet obstruction in women: a pilot study.”  J Urol; 176(4 Pt. 1):1487.
P. Thind, G. Lose, H. Colstrup and K.E. Andersson, “The effect of alpha-adrenoceptor stimulation and blockade on the static urethral sphincter function in healthy females. Scand J Urol Nephrol,  26, p. 219.
Low et al, Low BY, Liong ML, Yuen KH, et al  ”Terazosin therapy for patients with female lower urinary tract symptoms: a randomized, double blind, placebo controlled trial.”  J Urol; 179(4):1461.
H. Lepor and G. Machi “Comparison of AUA Symptom Index in unselected males ad females between fifty-five and seventy-nine years of age.” Urology,  42, p. 36.
Robinson D, Cardozo L, Terpstra G, et al  ”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.
Dwyer PL, Teele JS  ”Prazosin: a neglected cause of genuine stress incontinence.”  Obstet Gynecol; 79:
Abrams P, Andersson KE, Brubaker L, Cardoza L ” 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):
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.
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).
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.
Urogynecology Nurse Practitioner Plan of Care
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.