Urinary Incontinence for Medical Students

1. Urinary Incontinence for Medical Students Kieran J. O’Flynn, Department of Urology, Salford Royal Foundation Trust, Manchester, U.K

2. Themes • Functions of the Urinary Bladder • Aetiology and definitions • Patient assessment • What investigations should be done and why? • Surgical Management • Non operative • Operative • Neuropathic bladder

3. Lower Urinary Tract Function 1. Urine storage - Reservoir: Bladder 2. Urine release - Outlet: Urethra Bladder Urethra • Functionof the Pelvic Floor • 1. Support of the pelvic viscera • LUT Function • Reproduction and Sexual Function Birder L et ICI 2008

4. Monthly and slight Monthly and damp Monthly and wet Monthly and soaked Prevalence and Severity of Urinary Incontinence by Sex and Age Group 35 Females 30 25 20 Prevalence % 15 10 5 0 40-49 50-59 60-69 70-79 80+ Age group (years) Perry S et al. J Public Health Med 2000; 22(3):427-34.

5. Monthly and slight Monthly and damp Monthly and wet Monthly and soaked Prevalence and Severity of Urinary Incontinence by Sex and Age Group 35 Males 30 25 20 Prevalence % 15 10 5 0 40-49 50-59 60-69 70-79 80+ Age group (years) Perry S et al. J Public Health Med 2000; 22(3):427-34.

6. Urinary Incontinence Stress 49% Mixed 29% Urge 22% Bladder over activity 95% Other Stress Other Men Women Hampel C,et al, Urology 1997:50(suppl 6A);4-14.

7. Stress Incontinence • Symptom– complaint involuntary leakage on exertion, coughing or sneezing • Sign – observation of involuntary leakage on effort or exertion, sneezing or coughing • Urodynamic observation (diagnosis) • Involuntary leakage associated with an increase in abdominal pressure in the absence of a detrusor contraction

8. Aetiological factors in genuine stress incontinence and prolapse • Parity • Obesity • Age • Ethnicity • Others Congenital factors Connective tissue disorders Pudendal neuropathy Pelvic surgery hypoestrogenism respiratory disorders

10. Normal pelvis Typical post partum pelvis

11. PREGNANCY / INTRAPARTUM INJURY Levator ani muscle Muscle tears Connective tissue Breakage Stretching Pudendal/Perineal nerve Acute denervation Loss of muscle tone Chronic denervation Aging Connective tissue failure GENITAL PROLAPSE After Strohbehn,1998

12. Urge incontinence - definition • Involuntary loss of urine resulting from an increase in bladder pressure secondary to a true bladder contraction • Detrusor overactivity - idiopathic • Detrusor hyper-reflexia – disturbance of the neural control mechanisms X

13. How do we make a diagnosis? • History / Symptom score • Mobility and cognitive status • Abdominal examination • Sacral examination (sensory / motor reflexes) • Demonstrate incontinence • Post void urine

14. Storage Voiding Sensation Frequency Nocturia Urgency When does leakage occur? Hesitancy Poor stream Terminal dribble UTI symptoms Haematuria* Painful bladder Dysuria Absent sensation History

15. Examination Physical examination (including neurology) Mobility and cognitive status Abdominal examination Demonstrate incontinence Assessment of prolapse Vaginal, speculum and bimanual Pelvic floor assessment Neurological examination (S3) PR?

16. Additional factors in Elderly Incontinence • Delirium • Infection • Pharmaceuticals • Psychological problems • Excess urine output • Restricted mobility • Stool impaction DIPPERS Resnick, 1996

17. Initial investigations • Urine testing • (Flow rate) and assessment of residual urine • Bladder chart

18. Further investigations • Urodynamics? • Probable diagnosis is unclear • Neuropathy is suspected • Unsuccessful primary therapy • Surgery proposed • Cystoscopy? • Red flags • Renal function? • Possible CKD

19. Principles for the management of urinary incontinence Get the diagnosis right! Establish patient’s expectations and priorities Conservative therapies Surgery

20. Therapeutic options in stress incontinence Weight reduction Pelvic floor excercises Physiotherapy Electrical stimulation Pharmacotherapy Surgery Devices

21. Physiotherapy and Electrical Stimulation • Non invasive • 65-75% short term improvement with physio • Long term efficacy poorly documented • PFTM protocols well established • Variable protocols with electrical stimulation • Evidence for PFTM vs ES unclear Berghmans LC et al, BJU,1998,82,181-91

22. Surgical Treatment for Stress Incontinence Many different options available No operation cures all patients Success rates approx 80% Depends on Type /severity of incontinence Experience of surgeon Patient expectations Patient shape Primary versus redo surgery

23. TVT Procedure

24. Pharmacotherapy in Stress Incontinence • Alpha agonists • Side effects • Hormone replacement therapy • Duloxetine • Noradrenaline and 5HT re-uptake inhibitor • In clinical trials Clinical bottom line; not first line treatment for GSI

25. Treatment of the overactive bladder • Behavioural therapy • Drug therapy • Muscarinic receptor antagonists • Intravesical medication • Transdermal medication (oxybutynin) • Surgical management • Intravesical botox • Sacral neuromodulation • Bladder augmentation

26. Behavioural Therapy in Female Incontinence Urge Inhibition Timed Voiding Reinforcement Education Fluid / Dietary Management Pelvic floor exercises Frequency volume chart

27. Does medication help detrusoroveractivity?

28. Systematic review of anticholinergic therapy Herbison et al.2003. BMJ,326, 841-844

29. Does medication help?A little but patient will require lifestyle modification Urge Inhibition Timed Voiding Reinforcement Education Fluid / Dietary Management Pelvic floor exercises Frequency volume chart

30. Surgical treatment of the overactive bladder • Sacral neuromodulation • Percutaneous location of the sacral spinal nerves with a needle electrode • Test stimulation over a few days with voiding diary • Implantation of a stimulation system if the second stage was successful

31. Surgical treatment of the overactive bladder • Bladder augmentation • Clam cystoplasty • Autoaugmentation • Acellular collagen matrices?

32. When all else fails Condom drainage Pads Female collection device Urinals Commodes and chemical toilets Absorbent sheets Indirect aids for continence, zimmer

33. Problems with catheters Infection Encrustation / Blockage Bypassing Erosion Suprapubic catheter optimal for long term use

34. Take away messages Incontinence is common! Key to management is a correct diagnosis Most patients can be cured or at a minimum improved Need to reconcile patient’s wishes and expectations with a feasible management plan Non-compliance with the recommended therapy is an issue Long-term treatment is usually needed Need therapeutic agents that offer a favourable balance between efficacy and tolerability

36. Neurourology • Most processes that effect the brain, spinal cord and peripheral nerves can change bladder function

37. Neurological Lesions Resulting in Lower Urinary Tract Dysfunction Peripheral / Lower Motor Neurone Spinal Intracranial Spinal cord injury Sacral agenesis Myelitis Herpes zoster Tabes dorsalis Metastatic carcinoma Disc disease Spinal stenosis Diabetes mellitus Vitamin B12 deficiency Spina bifida Multiple sclerosis Spinal cord injury Spinal cord tumour primary or secondary Spinal cord infarction Multiple sclerosis Cervical spondylitis Spina bifida Myelitis Cerebrovascular disease Brain tumour Cerebral trauma Dementia Multiple sclerosis Encephalitis Cerebral palsy Parkinsons disease Shy Drager syndrome AIDS Lyme disease Hereditary Spastic Paraplegia

38. Summary • Functions of the Urinary Bladder • Aetiology and definitions • Patient assessment • What investigations should be done and why? • Surgical Management • Non operative • Operative • Neuropathic bladder

39. 45 year old woman with urinary frequency and poor response to anticholinergic medication

40. Prevalence of urinary incontinence 20-30% population Bothersome 7-12% Peaks 45-55 yrs Dips 55-70 yrs Increases beyond 70 yrs

41. Prevalence of incontinence in women