Transcript Urinary Incontinence: when and where to refer

Urinary Incontinence
Tova Ablove, Alev Wilk
Primary Care Conference, 6/22/05
Urinary Incontinence
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No Financial Disclosures
Objectives
Overview of Urinary Incontinence in
Women: Dr. Ablove
 Presentation of Cases: Dr. Wilk
 Initial Management Issues:
 Urodynamic testing for all women? OR
 Therapy trials based on history and exam
only: medication, pelvic floor exercises,
pessary?
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Incontinence
14% of healthy postmenopausal have daily
incontinence.
41% of healthy postmenopausal have
incontinence at least once per month.
Brown et al. obstetrics and gynecology 1996
Types of Urinary Incontinence
Urge
– urine loss
accompanied by
urgency resulting
from abnormal
Bladder
contractions
Stress
– urine loss resulting
from sudden
increased intraabdominal pressure
(eg, laugh, cough, sneeze)
Mixed symptoms
– combination of
stress and urge
incontinence
Sudden increase
in intra-abdominal
pressure
Uninhibited
detrusor
contractions
Urethral pressure
Urinary Incontinence and OAB
OAB
SUI
z Mixed
(UUI+SUI)
UUI
• Urgency
• Frequency
• Nocturia
Detrol® LA
Evaluation
History
 Physical
 Labs
 Testing
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History
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HPI
 Identify #1
complaint
 Frequency &
duration of sx
Medications
Musculo-skeletal
 Mobility- screen for
falls
 Back pain/disease
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Autoimmune
 MS
 Fibromyalgia
 IBS
 Crohns
Heart failure
Neurologic/psychiatric
 Stroke, depression,
dementia
History
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Diabetes
Gynecologic
 Hormonal status
 Prolapse
 STDs
 Sexual activity
 Pregnancy
 Chronic pelvic pain
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Bladder disease
 Interstitial cystitis
 Cancer
 Chronic cystitis
Kidney disease
 Infections
 Stones
 Insufficiency
Physical Examination
 Perform
general, abdominal (including
bladder palpation), and neurologic exams
 Perform pelvic and rectal exam in females
and rectal exam in males
 Observe for urine loss with vigorous cough
 Check for urinary retention
Fantl JA et al. Managing Acute and Chronic Urinary Incontinence. Clinical Practice
Guideline. Quick Reference Guide for Clinicians, No. 2, 1996 Update. Rockville, MD:
Agency for Health Care Policy and Research; January 1996. AHCPR publication 960686.
Pelvic Anatomy
Pelvic Exam
Laboratory Tests
 Urinalysis
to evaluate for hematuria, pyuria,
bacteriuria, glucosuria, proteinuria
 Urine culture
 Wet mount
 Vaginal cultures
 Herpes cultures not usually done on initial
evaluation
 Blood work if compromised renal function is
suspected
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Treatments
Treat patient’s most bothersome form of
voiding dysfunction first.
 Treat conditions that can mimic or
exacerbate overactive bladder
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The objective is to improve quality of life.
Treatable Conditions That
Mimic or Exacerbate OAB
Urinary tract infection
 Urogenital aging
 Bladder outlet obstruction
 Prolapse *
 Stress incontinence *
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Treatments
Overactive bladder
 Drugs anticholinergic, local estrogen
 Pelvic floor rehab
 Bladder drill
 Treat bladder outlet obstruction
 Acupuncture
 Neuromodulation
 Botox injections
Drugs
Predominant anticholinergic or antimuscurinic
action
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Oxybutnin
Tolterodine
Hyoscyamine
Imipramine
Darifenacin
Solifenacin
Close follow up needed especially in geriatric
patients
Treatments: Stress Incontinence
Pelvic floor rehabilitation
 Local estrogen
 Incontinence pessary
 Collagen
 Surgery
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OAB: When to Consider Referral
to a Specialist
Symptoms do not respond to initial treatment
within 2–3 months
 Hematuria without infection on urinalysis
 Symptoms suggestive of poor bladder emptying
(hesitancy, poor stream, terminal dribbling)
 Evidence of unexplained neurologic or
metabolic disease
 Significant pelvic organ prolapse is present
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Abrams P, Wein AJ. The Overactive Bladder:
A Widespread and Treatable Condition. Erik Sparre Medical AB; 1998.
Stress Incontinence: When to
Consider Referral to a Specialist
If patient desires treatment and is not
interested in conservative therapy or has
tried and failed conservative therapy.
When to refer for Cystoscopy
To rule out stones, cancer, foreign bodies,
chronic inflammation
 To confirm normal anatomy prior to
surgery.
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Recurrent UTIs especially if they are resistant to
therapy
Hematuria
Irritative bladder symptoms especially in
postmenopausal women and smokers
Recurrent incontinence
With suspicion of interstitial cystitis
When to Refer for Urodynamics?
Urinary retention
 Incontinence that fails initial therapy
 History of Neurologic disease
 Prolapse desiring surgery
 Prolapse as part of the clinical picture of
incontinence
 Prior pelvic surgery
 Mixed incontinence
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1996 Agency for Health Care Policy and Research
Weider et al 2001
Handa et al 1995
Case One
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48 y.o. woman with polyuria (every 30 minutes
while awake) and pelvic pressure for 6 months
Voiding diary- frequency 16x/24hrs, nocturia 12x/night, no leak episodes
No dysuria, postvoid fullness, constipation
Three uncomplicated vaginal births; tubal ligation;
Leep procedure 1993
Premenstrual syndrome dysphoria on fluoxetine
Case One
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Denies tobacco or alcohol use; CNA
Exam: NL cardiovascular, GI, Kidney. Genital:
pelvic floor “prolapse to introitus”; negative UA &
glucose; PVR: 100cc.
Recommendations:
 Oxybutinin for “overactive bladder”?
 Pelvic Floor Physical Therapy Program?
 Referral to subspecialty?
Case Two
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76 y.o. woman with stress and urge incontinence,
urinary leakage; nocturia 1-2x per night
Urinary frequency, constipation, postvoid fullness
G6P6; s/p oophorectomy, partial colectomy
Depression, COPD, HTN, schizophrenia, anxiety
Current smoker: 63 pack years; no alcohol; retired
RN and widowed
Case Two
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Albuterol, cogentin, valium, benadryl, depakote,
advair, meclizine, zyprexa, piroxicam, quinine,
risperidone, trazodone
Exam: Stable cardiovascular, GI, Kidney. Genital:
vaginal atrophy; negative UA. PVR 60cc.
Recommendations:
 Estrogen?
 Pelvic Floor Physical Therapy Program?
 Referral to subspecialty?
Case Three
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55 y.o. woman with stress incontinence when she
coughs, laughs, or exercises
No dribbling, urgency, frequency, dysuria,
postvoid fullness, constipation
G0P0
Depression on Celexa
Case Three
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Denies tobacco or alcohol use; Recently divorced
Exam: NL cardiovascular, GI, Kidney. Genital:
vaginal atrophy; negative UA. PVR 60cc.
Recommendations:
 Estrogens?
 Pessary?
 Pelvic Floor Physical Therapy Program?
 Referral to subspecialty?
Case Four
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44 y.o. woman with stress incontinence and
urinary leakage, nocturia x2 at night
No dribbling, urgency, frequency, dysuria,
constipation
Four vaginal, uneventful vaginal deliveries;
hysterectomy and bladder suspension procedure
1990
HTN, fibromyalgia, GERD on ranitidine and
atenolol
Case Four
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Denies tobacco or alcohol use; CNA
Exam: NL cardiovascular, GI, Kidney. Genital:
atrophic vulva & pelvic floor laxity; negative UA.
PVR 40cc.
Has attempted Kegel exercises without
improvement
Recommendations:
 Medications? Pessary?
 Pelvic Floor Physical Therapy Program?
 Referral to subspecialty?
Case Five
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36 y.o. woman with stress incontinence recently
exacerbated by URI symptoms
No dribbling, urgency, frequency, dysuria,
postvoid fullness, constipation.
G5P5, s/p C-section 1988
Intermittent asthma, neck pain
Ortho evra patch, prn maxair, skelaxin
Case Five
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Denies tobacco or alcohol use; Bus driver
Exam: NL cardiovascular, GI, Kidney. Genital:
grossly normal; negative UA. PVR 20cc
Has attempted Kegel exercises without
improvement
Recommendations:
 Medications? Pessary?
 Pelvic Floor Physical Therapy Program?
 Referral to subspecialty?