Transcript Stress incontenence voordrag 2011 feb

Retha van Rensburg
February 2011
Periurethral injection of Autologous
Adipose-Derived
Stem
Cells
with
Controlled- Release Nerve Growth Factor
for the treatment of
Stress Urinary Incontinence
in the Male rat Urethra.
(S)VNL
PRESENTING
PROBLEM
• 44y female
• Mother of 3 (girl 14y; twins 9y)
• C/O leaking urine while playing tennis and
running
• Trampolining with the twins is impossible
History
Medical
• Pituitary adenoma
Surgical
• 2 x caesarean sections
• Repair ITB left
Examination
Further questioning:
Urine leaks on coughing, sneezing, running and
jumping
No urge incontinence or any signs of overactive
bladder
Examination:
Pelvic exam:
urine loss with cough
no signs of prolapse
BMI = 25.4 (overweight)
Biological
Stress
incontinence
Personal
Wants to
run/play with
kids & tennis
Contextual
Her kids and
social tennis
group wants
her back
Bio-psycho-social model
“THE SILENT EPIDEMIC”
Urinary incontinence (UI) in the
female
Myths:
 Urinary incontinence / prolapse is a natural
part of aging
 Nothing can be done about it
 Surgery is the only solution
Urinary incontinence
• Defined as involuntary urinary leakage
• May occur as a result of:
– functional abnormalities of the lower urinary tract
– other illnesses
• These tend to cause leakage in different
situations
Types of UI
Classification
Symptoms
Stress UI
on effort, exertion, or sneezing
or coughing
Mixed UI
with urgency and exertion,
effort, sneezing or coughing
Urge UI or overactive
bladder syndrome
(OAB)
with or immediately preceded
by a sensation of urgent need
to urinate, with or without
frequency
Prevalence in women
Stress : 49%
Urge : 22%
Mixed : 29%
Genuine Stress Incontinence:
 Loss of urine with increases in abdominal
pressure
 Caused by pelvic floor damage/weakness or
weak sphincter(s)
 Symptoms include loss of urine with cough,
laugh, sneeze, running, lifting, walking
Urge Incontinence:
 Loss of urine due to an
involuntary bladder
spasm (contraction)
 Complaints of urgency,
frequency, inability to
reach the toilet in time,
up a lot at night to use
the toilet
 Multiple triggers
Mixed Incontinence:
 Combination of stress and urge incontinence
 Common presentation of mixed symptoms
 Urodynamics necessary to confirm
Fecal Incontinence:
• Approximately 10% women with urinary
incontinence have incontinence of flatus or
stool
Spot the risk factors
Spot the risk factors
Associations and possible risk factors include:
– age
– obstetric factors such as pregnancy and parity
– menopause and hysterectomy
– lower urinary tract symptoms
– family history and genetics
– smoking, diet and obesity
– cognitive or functional impairment
Increased Intra-abdominal Pressure:
(main risk for SUI)
 Pulmonary disease
 Constipation/straining
 Lifting
 Exercise
 Ascites/hepatomegaly
 Obesity
Patient Evaluation:
History
 Physical examination
 Urinalysis
 Urodynamic studies
Patient History:
 Focus on medical, neurologic, genitourinary
history
 Review voiding patterns/fluid intake
 Voiding diary
 Review medications (rx and non-rx)
 Explore symptoms (duration, most
bothersome, frequency, precipitants)
 Assess mental status and mobility
Thüroff. 2006 European
Association of Urology
Patient Evaluation:
 History
Physical examination
 Urinalysis
• Urodynamic studies
Physical Examination:
 General examination
 Edema, neurologic abnormalities, mobility,
cognition, dexterity




Abdominal examination
Pelvic and rectal exam
Examination of back and lower limbs
Observe urine loss with cough
Patient Evaluation:
 History
 Physical examination
Urinalysis
• Urodynamic studies
Patient Evaluation:
 History
 Physical examination
 Urinalysis
Urodynamic studies
Urodynamic studies
• Expensive
• Invasive
 PVR (Postvoid Residual Volume) - if indicated
–Symptoms of incomplete emptying
–Longstanding diabetes mellitus
–History of urinary retention
–Failure of pharmacologic therapy
–Pelvic floor prolapse
–Previous incontinence surgery
Management
Manage conservatively
Pelvic floor
muscle
training
Bladder
training
Antimuscarinic treatment
Stress
UI
Mixed
UI
*
*
Urge UI
or OAB
First
pregnancy
*
*
*
*
*
Training and drugs
Pelvic floor muscle training (alone and in combination with
adjunctive therapies is effective - rates of 'cure' and
'cure/improvement' up to 73% and 97% respectively)
Physiotherapy
 Pelvic floor exercises
 Eight contractions, three times a day, 3 months minimum
Vaginal cones
Devices for reinforcement
Pessaries
 Support devices to correct the prolapse
 Pessaries to hold up the bladder
Neumann. BMC Women's Health 2006, 6:11 and NICE guidelines
Kegelcones. Weighted
vaginal cones used to
strengthen the pelvic floor
musculature.
Training and drugs
•Bladder training (OAB)
•6 weeks minimum
 Regular voiding by the clock
 Gradual increase in time between voids
 Double voiding
•Antimuscarinic drugs
•Immediate-release oxybutynin as first choice
Offer support and advice for side effects
Treatment:
Non-surgical
Fluid management
 Avoid caffeine and alcohol
 Avoid drinking a lot of fluids in the evening
Reduce caffeine, alcohol, and smoking
Surgical management
Surgical management
If conservative treatments have failed for:
• stress UI offer
• - retropubic mid-urethral procedures
- alternatively colposuspension or rectus fascial sling
• overactive bladder with or without urge UI
offer
- sacral nerve stimulation
Surgery:
For stress incontinence
Bladder neck elevation
 Burch repair
 Marshall-marchetti-krantz repair
 Sling
 Needle suspension
 Injections
 Tension free vaginal tape (TVT)
Refer??
Refer??
• Uncertain diagnosis / unclear treatment plan
• Unsuccessful therapy / patient requests
further therapy
• Surgical intervention considered / previous
surgery failed
• Hematuria without infection
Refer?? (cont)
•
•
•
•
•
•
Existence of other co-morbid conditions
Recurrent symptomatic UTI’s
Recurrent symptoms of difficult bladder emptying
Symptomatic pelvic prolapse
Suprapubic or pelvic pain
Neurologic conditions: MS; spinal cord lesions/
injury
• Diabetes mellitus
Prevalence
UI is common but hidden
Estimated 4 million women over 40 years regularly
incontinent in UK (NIICE guidelines)
Prevalence
• South Africa ?
• USA : 17 million people
Annual cost 55.8 Billion $ (2009)
14th On list - Beats AIDS and STD’s !!!
UI in sport
UI in sport
Thyssen et al (2002)
• 291 elite female athletes and dancers
• 51.9% had experienced urine loss,
• 43% while participating in their sport
• and 42% during their daily life.
• urine leakage was the highest in gymnastics
(56%), ballet (43%) and aerobics (40%)
respectively
Vosloo. 2008
UI in sport (cont)
Nygaard et al (1994)
• 144 nulliparous women (mean age of 19.9
years)
• 28% experienced urine leakage while
participating in sport.
• Gymnastics, again, had the highest prevalence
(67%), followed by basketball (66%), tennis
(50%) and field hockey (42%). Golf was the
safest option with no leakage reported.
Vosloo. 2008
UI in sport (cont)
• Eliasson et al (2002)
• stress urinary incontinence prevalence 35 elite
Swedish trampolinists (12 –22 years of age)
• a staggering 80% reported involuntary leakage
during trampolining
• Including all participants aged over 15
• duration of training and training frequency were
significantly associated with incontinence
• in most, leakage started after 1–4 years of
training.
Vosloo. 2008
UI in recreational sport
UI in recreational sport
• Salvatore et al (2008)
• 679 women of fertile age, practising
recreational sports activity.
• UI was reported by 101 women (14.9%).
• Of these, 32 (31.7%) complained of UI only
during sports activity
• 48 (47.5%) only during daily life and
• 21 (20.8%) in both circumstances.
Salvatore. 2008
UI in recreational sport (cont)
• Body mass index and parity were significantly
associated with the risk of UI
• higher rate of incontinence was found in
women participating in basketball (16.6%),
• athletics (15%),
• and tennis or squash (11%).
Salvatore. 2008
UI in recreational sport (cont)
• 10.4% of women abandoned their
favourite sport, because of SUI
• a further 20% limited the way they
practised their favourite sport to
reduce leakage episodes
Salvatore. 2008
Compounding Problems:
Compounding Problems:
 Embarrassment leads to silence
 Time constraints lead to inadequate
attention
 Knowledge limits lead to patients accepting
 Technology limits lead to inadequate
investigation
 Resource limits lead to inadequate access
Disease
Impact
Disease Impact
• Severe impact on daily activities
• Many do not seek care
• Misdiagnosis ? UTI especially
• Coping mechanisms
- Voiding frequently (Q 15 min/ Sleep
impact)
- Mapping toilet locations / Quickstop?
- Reducing intake
- Dark clothes to mask Incontinence
- Pad Use
Abandon and limit the way they practised
their favourite sport
Quality of Life Impact:
 Fear of losing bladder control
 Embarrassment
 Impact on relationships
 Discomfort and skin irritation
What happened to Mrs Z
Rx
• Physiotherapy
• In addition to running and playing
tennis , she is doing her Kegel’s
regularly
• Trampolining: she is still on the
sidelines
Take home message
• SUI is prevalent in the female athlete
• Professional
• Recreational
• In most cases, a preliminary diagnosis of
urinary incontinence can be made and
treatment initiated based on findings of the
medical history, physical examination and
simple laboratory testing.
Take home message
• Ask the question, the patient
will not always volunteer the
info
THE END
Resources
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•
•
•
•
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Neumann, et al. Pelvic floor muscle training and adjunctive therapies for the treatment of
stress urinary incontinence in women: a systematic review. BMC Women's Health 2006, 6:11
The quick reference guide a summary of the recommendations for healthcare professionals.
www.nice.org.uk/CG040
Salvatore, et al. The impact of urinary stress incontinence in young and middle-age women
practising recreational sports activity: an epidemiological study. Br J Sports Med
2009;43:1115–1118
Culligan ,et al. Urinary Incontinence in Women: Evaluation and Management. Am Fam
Physician 2000;62:2433-44
Thüroff, et al. Guidelines on Urinary Incontinence. European Association of Urology 2006
Vosloo. Conservative management of female urinary incontinence. Continence UK,.2008;2(4)