Transcript Urgency incontinence

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Overactive bladder
Maryam hajhashemy
OB,GYN / Fellowship of Pelvic Floor
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Definition
OAB defined based on symptoms
Urgency, with or without urge incontinence, usually
with frequency and nocturia
In the absence of pathological or metabolic
that might explain these symptoms conditions
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The amount of leakage ranges from a few
drops to completely soaked undergarments.
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Urgency incontinence is more common in older
( comorbid conditions )
It is believed to result from detrusor overactivity
This may be secondary to neurologic disorders
( spinal cord injury), bladder abnormalities, or may
be idiopathic.
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EVALUATION
The initial evaluation of urinary incontinence includes :
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1 - characterizing and classifying the type of
incontinence
2 - identifying underlying conditions ( neurologic
disorder or malignancy) that may manifest as urinary
incontinence.
3 - identifying potentially reversible causes of
incontinence.
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Do you go to the toilet more than 8 times a day?
Do you often wake up during the night needing to
go to the toilet?
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Do you have to hurry to make the toilet in time?
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Do you often not reach the toilet in time?
Voiding diaries
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1 - urinary incontinence is associated with high fluid
intake.
2 - severity of the problem
3 - identify the maximum time interval that the
woman can reasonably wait between voids, a
measure used to guide bladder training.
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Impact on quality of life
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symptoms that are most bothersome to the patient
-International Consultation on Incontinence Questionnaire
-Kings Health Questionnaire
-Pelvic Floor Distress Inventory
-Pelvic Floor Impact Questionnaire
-Patient Global Impression of Improvement (PGII)
-Patient Global Impression of Severity (PGIS)
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Physical examination
1 - vaginal atrophy
2 - pelvic masses
3 - pelvic organ prolapse
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Laboratory tests
Urinalysis
Infection
Hematuria
Glycosuria
Proteinuria
Renal function
urinary retention
u/c
cytology
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Clinical tests
cough stress test
Post void residual
Urodynamic testing
Urethral mobility evaluation
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Treatment
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INITIAL TREATMENT
Lifestyle modification :
1 - Weight loss
2 - Dietary changes
3 - Constipation
4 - Smoking cessation
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Supplemental modalities:
* Supervised pelvic floor therapy
* Vaginal weighted cones
* Biofeedback
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Bladder training
timed voiding
Voiding diary
Urgency between voiding
intervals are gradually increased
Topical vaginal estrogen
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Pharmacologic therapy
The combination of medication with behavioral
therapy is more effective
counsel patients to continue pelvic floor exercise
and other behavioral therapies while initiating
medical treatment.
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Antimuscarinics:
They are thought to act primarily by increasing
bladder capacity and decreasing urgency by
blocking basal release of acetylcholine during
bladder filling .
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Antimuscarinic Agents
There are six antimuscarinic agents available in
different doses and formulations:
oxybutynin
tolterodine
darifenacin
solifenacin
fesoterodine
trospium
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These are available in tow form:
• Immediate-release
• Extended- release
Adverse drug effects
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dry mouth
dry eyes
blurred vision
Tachycardia
Constipation
Drowsiness
Dizziness
Headache
cognitive deficits
peripheral edema
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Dry mouth and constipation are the most common
reason for discontinuation .
Constipation and compensatory fluid intake for
dry mouth may exacerbate urinary incontinence.
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Contraindication:
Gastric retention
Angle-closure glaucoma
Urinary retention
post void residual
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women at higher risk for urinary retention
symptoms worsen
large pelvic organ prolapse
taking other medications with anticholinergic effects.
Routine monitoring of post void residual in all patients on
antimuscarinics is not needed.
Comparison of Antimuscarinic Agents
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No evidence for the superiority of one
antimuscarinic agent over another
Extended-release agents have lower rates of
adverse effects than immediate release agents.
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Choice of agent and dosing
Cost
Dosing frequency
Drug-drug interactions
Potential side effects
Comorbid conditions
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Start with the lowest available dose
Titrate up as needed after 2 weeks
Assess response to treatment after four to six weeks
12 weeks to have full efficacy.
Avoid prematurely declaring treatment failure.
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Insufficient improvement or unable to tolerate
Different antimuscarinic or change in class of
medication (mirabegron)
Patients may respond to one antimuscarinic and not
another
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agent and dosing
Oxybutynin(Ditropan) tab:5,10mg
2.5to5mg /qid
Tolterodin(Detrol)
1to2mg/ bid
tab:1,2mg
Solifenacin(vesicare)
tab:5,10mg
Darifenacin(Enablex)
tab:7.5,15mg
5to10mg /d
7.5to15mg /d
Mirabegron
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beta adrenoceptor agonist
1 - do not tolerate antimuscarinic medications
2 - have contraindications to antimuscarinic medications
3-add it to antimuscarinics for combination therapy in
persistent symptoms
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Thirdline therapies
Refractory urgency incontinence symptoms
Try at least one or two pharmacotherapies
Referred to a specialist
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Third line therapies include:
Acupuncture
Botulinum toxin injection
Percutaneous tibial nerve stimulation
Sacral neuromodulation (SNM)
SURGERY ???
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These may include :
1 - Augmentation cystoplasty
2 - Urinary diversion
3 - Placement of a suprapubic catheter
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