Transcript Urinary Incontinence in Women

Urinary Incontinence in Women
Dr Mangala Dissanayake
OBJECTIVES
 Identify the various forms of Urinary Incontinence
(UI) in females
 To become knowledgeable about the treatment
interventions available
 To understand the impact of Urinary Incontinence
Prevalence of Urinary Incontinence
• 33% of women >65 have some degree of UI
• 26% of women>18 experience various degree of SI
• 15% to 30% of non-institutionalized older adults
(19% men; 39% women)
• Prevalence increases with age and Menopause
• Incidents are more in female until the age of 80
Prevalence of UI
Epidemiology
Incontinence in women – 19 billion dollars / yr
“Silent Epidemic”
Urinary Incontinence is Often Under-Diagnosed
and Under-Treated
• Only 32% of primary care physicians routinely ask
about incontinence.
• 50-75% of patients never describe symptoms to
physicians
• 80% of urinary incontinence can be cured or
improved.
Definition
• UI is the involuntary loss of urine
that is objectively demonstrable and
a social or hygienic problem.
International Continence Society
Risk and Contributing Factors
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Age
Parity
Obesity
Vaginal delivery
Episiotomy ?
Diabetes, BA, Chronic constipation
Stroke
Estrogen depletion
Genitourinary surgery and radiation
Depression ,Dementia , Parkinson
Health Burden
Age and Menopause
• Detrusor overactivity (20% of healthy continent)
•  PVR ,  nocturia,  UO later in day
• Atrophic vagintis & urethritis
•  ability to postpone voiding,  total bladder capacity, 
detrusor contractility
•  urine concentrating ability,  flow
Consequences of UI
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Cellulitis, Pressure ulcers, UTI
Sexual Problems
Falls with fractures
Sleep deprivation
Social withdrawal, depression
Embarrassment (50%), interference with activities
 Caregiver burden, contributes to institutionalization
Costs
Types of UI
• Transient UI (Acute)
• Established UI (Chronic)
Urge UI
Stress UI
Mixed UI
Overflow UI
“Functional” UI
Prevalence in women
Stress : 49%
Urge : 22%
Mixed : 29%
Transient UI (Acute)
• Lower urinary tract pathology
• Precipitated by reversible factors
• Causes: Delirium, UTI, Medications, Psychiatric
disorders, Stool impaction
• Restricted mobility
Causes for Transient UI
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D
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Delirium
Infection
Atrophic Vulvovaginitis
Psychological
Pharmacologic agents
Endocrine, excessive UO
Restricted Mobility
Stool impaction
Pharmacologic Causes
• sedatives
•  awareness, detrusor activity
Func & O UI
• loop diuretics
• Diuresis overwhelms bladder
capacity Urge & O UI
• alcohol
• caffeine
• cholinergics
(donepezil)
• Polyuria,  awareness  Urge &
Functional UI
• Polyuria,  detrusor activity  Urge
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 detrusor activity  Urge
Culligan PJ Urinary Incontinence in women Evaluation
and Management AFP 12-1-01
Physiology
Stress Urinary incontinence
Involuntary loss of urine due to increase abdominal pressure
without Detrusor contraction
Stress incontinence
STRESS INCONTINENCE
• Most common type in women in < 75 years old
• Occurs with increase in abdominal pressure- cough, laugh,
sneeze, etc
• Hyper motility of bladder neck and urethra associated with
aging, child birth, hormonal changes
• Intrinsic sphincter problems( pelvic irradiation, surgery,
trauma, incontinence surgery)
• No urgency or nocturia
Treatment : Stress Incontinence
• Nonsurgical
– Pelvic floor muscle training (Kegel’s)
– Biofeedback
– Electrical stimulation
– Pessaries
– Duloxetine is a selective serotonin and
norepinephrine reuptake inhibitor.
Non Surgical
• Modest improvements
– Pt’s with a small amount of leakage
– Pt’s who want a conservative trial
– Pt’s with significant comorbidities
Duloxetine
Combined serotonin and noradrenaline reuptake inhibitor
Mechanism of action
• Increased synaptic concentration of
noradrenaline and 5-hydroxytryptamine
within the pudendal nerve results in increased
stimulation of urethral striated muscles within
the sphincter thus enhancing contraction.
• Increase sphincter activity in the storage
phase of the micturition cycle
Authors’ conclusions
Duloxetine
• Duloxetine treatment can significantly improve
the quality of life of patients with stress urinary
incontinence, but it is unclear whether or not
benefits are sustainable
• Adverse effects are common but not serious.
About one in three participants allocated
duloxetine reported adverse effects (most
commonly nausea) related to treatment, and
• One in eight allocated duloxetine stopped
treatment as a consequence.
Authors’ conclusions
Duloxetine
• Better than placebo
• Improved QOL
• May improve outcome in combination with
pelvic floor training- Ghoniem 2005
Surgery
A Burch
Colposuspension
C Tension-free Vaginal Tape
B Fascial
Sling
Stress Urinary Incontinence
Less Invasive Surgery: Trans-obturator Tapes
Anatomical landmarks
Tape passes through medial edge of obturator foramen just
below the insertion of the adductor longus tendon
Priurethral Injection for SUI
Stress Urinary Incontinence
Surgical Treatment: Cure Rates
Objective cure rates for first procedure and recurrent incontinence6
Procedure
Mean (%)
95% CI
First Procedure
Mean (%)
95% CI
Recurrent Incontinence
Slings
93.9
89.2 - 98.6
86.1
82.4 - 89.8
Burch colposuspension
89.8
87.6 - 92.1
82.5
76.3 - 88.7
Needle suspension
86.7
75.5 - 97.9
86.4
72.4 - 100
Anterior vaginal repair
67.8
62.9 - 72.8
N/A
N/A
Injectables
45.5
28.5 - 62.5
57.8
43.2 - 72.4
Urge Incontinence
Incontinence accompanied by or
immediately preceded by urinary
urgency
Urge incontinence
Urge incontinence
URGE INCONTINENCE
• OAB, Detrusor instability, irritable bladder,
detrusor hyperactivity.
• Most common UI > 75 years of age
• Abrupt desire to void urine cannot be
suppressed
• Associated with frequency / nocturia.
• Causes- infection, vaginitis, tumor, stones,
idiopathic ( Hormonal)
Urge incontinence
URGE INCONTINENCE
URGE INCONTINENCE
Treatment
Patient education
 Timed voiding
 Habit training
 urge inhibition
 bladder training
 Diet modification
Surgery
Local Oestrogen
URGE INCONTINENCE
Treatment- Anticholinergic Drugs
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Oxybutynin
Tolterodine
Trospium
Darifenacin
Variety of preparations: Immediate Release;
Extended Release; Transdermal
• Outcomes same; Try different agent if one doesn’t
work.
• Continue for at least 4 weeks
***** ALL these drugs suppress the detrusor contractility and MAY CAUSE URINARY
RETENTION!!! ALWAYS CHECK PVR PRIOR TO PRESCRIBING!!!
Antimuscarinic therapy
Side Effects
• 43%–83% of women abandon antimuscarinic
therapy by 1 month
• At 1 year-35% women are still taking the
medication
Mirabegron
• Beta-3 adrenoreceptor agonist
• Promotes relaxation of the detrusor muscle
– Reduce incontinence episodes
– Reduced urgency
– Reduced frequency
Vs placebo
(pooled data of 3 phase III RCTs)
• US Food and Drug Administration (FDA)
approved in 2012
HRT and UI
Conclusion
• At present, systemic HRT administration
should not be recommended for treatment or
prevention of UI in postmenopausal,
especially older, women.
• Urinary incontinence may be improved with
the use of local oestrogen treatment
URGE INCONTINENCE
Refractory to Treatment
OVERFLOW INCONTINENCE
 Over Distension of Bladder
 Bladder outlet obstructionStricture, Cystocele, fecal
impaction
 Non contractile bladderDiabetes, Spinal injury.
 Filling occurs to the stretch
limit of the bladder
 Large PVR >400cc
 Dribbling, frequency
 High rates of infections
Pessary
OVERFLOW INCONTINENCE
 Patient education
 “Double voiding
technique”
 Diet modification
 Avoid caffeine/alcohol
 Barrier product to prevent
skin breakdown
 Reassess the Medication
• Obstruction—Treat cause;
-antagonist- Tamsulosin,
Prazosin
• Detrusor Underactivity
intermittent selfcatheterization
• Bethanechol ( used to treat
underactive detrusor
function with elevated PVR)
OVERFLOW INCONTINENCE
Tamsulosin
• Efficacy and Safety of
Tamsulosin for the
Treatment of Nonneurogenic Voiding
Dysfunction in Females: A
8-Week Prospective Study
• Tamsulosin was found to be
effective in female patients
with voiding dysfunction
regardless of obstruction
grade.
Tamsulosin Vs Prazosin in OI
• Tamsulosin and prazosin are both effective in
palliating symptoms of women with voiding
dysfunction and improving their urodynamic
parameters.
• Tamsulosin may be the preferred drug to
prescribe because of its more amenable side
effect profile and greater patient satisfaction.
Mixed Incontinence
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Features of both urge and stress incontinence.
Common in older women
4-55% mixed type of UI
Management: bladder retraining, pelvic muscle
exercises, Diet Modifications
• pharmacologic agents- Antichloinergic,
Imipramine
MIXED INCONTINENCE
“Functional” Incontinence
• Unable or unwilling to toilet due to physical
impairment, cognitive dysfunction,
environmental barriers
• No underlying GU dysfunction
• Diagnosis of exclusion
EVALUATION OF INCONTINENCE
History
Physical exam ( including Neuro and
abdominal , pelvic and rectal examination)
Clinical testing- Stress test, PVR by
catheterization or ultrasound.
Laboratory testing- UA, Urine culture, FBS ,B
Urea.
URODYNAMIC TESTING
Cesarean Section Vs UI
• Pregnancy per se increases UI, irrespective of
mode of delivery
• Elective/ Pre labour Cesarean section has low
incidents of UI in Post partum period
• Advantage disappears with age and in
subsequent pregnancies