Transcript Urinary incontinence

Urinary Incontinence
Victoria Cook
Consultant in obstetrics and
Gynaecology
The Hillingdon Hospital
Objectives
• Make a provisional diagnosis of cause of
incontinence
• Formulate appropriate management plan
• When to refer
• Who to refer to
Incontinence in Women
• Major impact on quality of life
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Fear of cough / cold
Stop exercising
Avoidance of sex
Fear of odour
Worry about pads – cost, visibility, leakage
Limitations of clothing
Toilet mapping
Housebound
• Yet may take years to present for help
– Embarassment
– Acceptance that it is normal after having kids
Definitions (ICS 2002)
• Over active bladder
– Urgency with or without urge incontinence, usually
accompanied by frequency and nocturia
• Urge incontinence
– Involuntary leakage accompanied by or immediately
preceded by urgency
• Stress incontinence
– Involuntary leakage on effort or exertion or on sneezing
or coughing
• Urgency: The complaint of a sudden, compelling desire
to pass urine, that is difficult to defer
• Frequency: Usually accompanies urgency with or
without urge incontinence. Refers to a patient’s
complaint of voiding too often by day
• Nocturia: Usually accompanies urgency with or without
urge incontinence. Patient has to wake at night one of
more times to void
1. Abrams P et al. Urology 2003;61:37-49
Differential diagnosis
Normal Bladder
OAB
Stress
Incontinence
Stress Incontinence or Overactive
Bladder?
• Leakage
– What makes her leak
– how much
– Pad usage
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Frequency of Micturition
Nocturia
Urinary Urgency
Bedwetting
Sex
Stress Incontinence or Overactive
Bladder?
• Examination
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Abdominal mass
Pelvic mass
Prolapse
Leakage seen on coughing
Vulval hygiene
• Investigations
– MSU
– Frequency volume chart
• (Urodynamics)
Management of Urinary Incontinence
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Behavior modification
Bladder retraining
Weight loss
Pelvic floor exercises
Fluid management – what, when, how much
Reduction in caffeine
• Bladder and bowel foundation
– www.bladderandbowelfoundation.org
– Just can’t wait toilet card (£5)
Management of Overactive
Bladder
Treatment of Overactive Bladder
• Conservative measures
• Review all other medication which may be
exacerbating symptoms
– Diuretics
– Amlodipine
– Other antihypertensives
• Anticholinergics
– Contraindicated with glaucoma
• (Botox)
NICE GUIDANCE
• Treat predominant symptom
• Oxybutynin Hydochoride
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Cheap
Works well
Side effect profile can be a problem
All other anticholinergics have been developed to
improve side effects
• Reasonable first line as long as
– patient aware there are alternatives
– Patient can be reviewed within 6 weeks to ensure they
are tolerating the drug
Which Anticholinergic?
• (Detrusitol (tolterodine) 4mg XL)
• Vesicare (solifenacin) 5mg or 10mg
• Lyrinel (oxybutynin) XL 5mg, 10mg, 15mg or
20mg
• Kentera (oxybutynin) patches
• Emselex (darifenacin) 7.5mg or 15mg
• Toviaz (fesoterodine) 4mg or 8mg
• Regurin (trospium) 20mg twice daily
Which Anticholinergic?
Vesicare 5mg
increasing to
10mg if necessary
and if tolerated
Lyrinel in increasing
doses if no success
with Vesicare
Kentera if side effects
a problem with
Vesicare
Emselex if IBS
or bowel problems
Exacerbated by
Vesicare
Botox
• Unlicensed
• Seems to be very effective
• Multiple injections into the detrusor muscle via
cystoscopy
• Evidence of long term safety in other disciplines
• But needs repeat injections approx 12 monthly
• Expensive!
Treatment of Stress Incontinence
Treatment of Stress Incontinence
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Life style advice
Physiotherapy
Duloxetine
Surgery
– TVT
– Bulkamid bladder neck injections
– Colposuspension
Stress Incontinence
• Yentreve (duloxetine)
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Start at 20mg twice daily
Increase to 40mg twice daily after 2 weeks
This is to reduce side effects
It is working at level of urinary sphincter
NOT by reducing depression!
Patients either love it or hate it
Surgery
• TVT
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Over night stay
Good success rates 80-90%
2 weeks off work
Risks of urgency, poor voiding, tape erosion
• Bulkamid
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Bladder neck injection – polyacrylamide hydrogel
Day case / overnight stay
Long term results unknown
Useful in mixed incontinence, young, old, failed TVT
Mixed Incontinence
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Lifestyle advice
Physiotherapy
Treat overactive bladder
Duloxetine can be very useful
I try to avoid surgery as they do badly
Now using Bulkamid – time will tell!
When to Refer
• Overactive bladder
– If patient not responding or unable to tolerate
anticholinergic (oxybutynin plus one other)
– Glaucoma
• Stress incontinence
– If patient doesn’t respond to pelvic floor exercises
(preferably with physiotherapist)
• Prolapse
• Other factors
Who To Refer To?
Urogynaecology
Urology
Both
Neurology
Stress incontinence
Prolapse
Botox
Overactive bladder
Fibroids
Bladder pain
Recurrent UTI
Other gynae issues
Other pathology
Any Questions?
I can be contacted on:
[email protected]