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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.

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Urinary Incontinence

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  1. Urinary Incontinence Victoria Cook Consultant in obstetrics and Gynaecology The Hillingdon Hospital

  2. Objectives • Make a provisional diagnosis of cause of incontinence • Formulate appropriate management plan • When to refer • Who to refer to

  3. Incontinence in Women • Major impact on quality of life • 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

  4. 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

  5. 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

  6. Stress Incontinence or Overactive Bladder? • Leakage • What makes her leak • how much • Pad usage • Frequency of Micturition • Nocturia • Urinary Urgency • Bedwetting • Sex

  7. Stress Incontinence or Overactive Bladder? • Examination • Abdominal mass • Pelvic mass • Prolapse • Leakage seen on coughing • Vulval hygiene • Investigations • MSU • Frequency volume chart • (Urodynamics)

  8. Management of Urinary Incontinence • 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)

  9. Management of Overactive Bladder

  10. Treatment of Overactive Bladder • Conservative measures • Review all other medication which may be exacerbating symptoms • Diuretics • Amlodipine • Other antihypertensives • Anticholinergics • Contraindicated with glaucoma • (Botox)

  11. NICE GUIDANCE • Treat predominant symptom • Oxybutynin Hydochoride • 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

  12. 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

  13. Which Anticholinergic?

  14. 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!

  15. Treatment of Stress Incontinence

  16. Treatment of Stress Incontinence • Life style advice • Physiotherapy • Duloxetine • Surgery • TVT • Bulkamid bladder neck injections • Colposuspension

  17. Stress Incontinence • Yentreve (duloxetine) • 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

  18. Surgery • TVT • Over night stay • Good success rates 80-90% • 2 weeks off work • Risks of urgency, poor voiding, tape erosion • Bulkamid • Bladder neck injection – polyacrylamide hydrogel • Day case / overnight stay • Long term results unknown • Useful in mixed incontinence, young, old, failed TVT

  19. Mixed Incontinence • 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!

  20. 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

  21. Who To Refer To? Urology Neurology Botox Bladder pain Other pathology Urogynaecology Prolapse Fibroids Other gynae issues Both Stress incontinence Overactive bladder Recurrent UTI

  22. Any Questions? I can be contacted on: victoria.cook@thh.nhs.uk

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