Urinary Incontinence & rUTI’s

1. Urinary Incontinence &rUTI’s R Hamid FRCSEd FRCS (Urol), MD(Res) Consultant Urological Surgeon Female, Reconstruction & Neuro-Urologist National Hospital for Neurology & Neurosurgery, University College London Hospitals & LondoN Spinal Injuries Unit Royal National Orthopaedic Hospital Stanmore

2. The Normal Bladder • Holds 400 - 500mls • The pressure at end fill is <15cmH20 • Can hold on for as long as needed! • No pain on filling • No incontinence • Bladder empties with no residual volume • With normal pressure and high flow • No abdominal straining • No UTI

3. Definition • Incontinence - The complaint of any involuntary urinary leakage1 • Overactive bladder - urgency, with or without urge incontinence, usually in the presence of frequency and nocturia • Stress incontinence – urinary leakage on effort, exertion, sneezing or coughing without a desire to pass urine • Mixed incontinence - a combination of the above 2 types 1 Abrams et al (2002). Standardisation Subcommittee of the International Continence Society. Neurourol & Urodyn. 21:167-78

4. Types of urinary incontinence • Urge incontinence • Stress incontinence • Neuropathic incontinence • Mixed incontinence • Male Incontinence • Overflow incontinence 3

5. How UI presents

6. Spot the Risk Factor Age Obstetric and Gynaecological factors LUTS Smoking and obesity Cognitive or functional impairment

7. Medications • diuretics • antidepressants • antihypertensives • hypnotics & sedatives • narcotics & analgesics • Other factors • pregnancy • psychological issues OAB Screening Can Help Diagnose Other Causes of Bladder Symptoms • Local pathology • infection • bladder stones • bladder tumors • interstitial cystitis • outlet obstruction • Metabolic factors • diabetes • polydipsia Fantl JA et al. Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline No. 2, 1996 Update. Rockville, MD: Agency for Health Care Policy and Research; March 1996. AHCPR publication 96-0682.

8. Barriers to Treatment • Patient misconceptions and fears: “Part of normal aging or everyday life” “Not severe or frequent enough to treat” “Too embarrassing to discuss” “Treatment won't help”

9. Triggers to Bladder Overactivity • Key in the door • Running water • Telephone boxes (red ones!) • Proximity to the toilet • Stress i.e. giving lectures, exams etc!

10. Assessment & Initial management • Categorise UI as SUI / UUI or OAB / mixed UI • Use urine dipstick tests to detect blood, glucose, protein, leucocytes and nitrites • Ask the woman to complete a bladder diary for at least 3 days, covering variations in usual activities (e.g. working and leisure days) • Flow rate & PVR? • Start treatment on this basis • Identify factors that may require referral

11. Suggested Reasons for Referral • Evidence of complicated neurologic or metabolic disease • Failed previous incontinence surgery • Elevated PVR volume • Radical pelvic surgery • Symptomatic prolapse • Prostate problems • Surgery planned (2nd opinion) • Symptoms do not respond to initial treatment within 2 to 3 months • Hematuria without infection on urinalysis • Recurrent symptomatic UTI • Symptoms suggestive of poor bladder emptying • Pelvic bladder, vaginal, or urethral pain Abrams P. Wein AJ. The Overactive Bladder – A Widespread and Treatable Condition. 1998.

12. Working diagnosis? OAB? Yes No Treat if: Frequency and urgency, with or without urge incontinence, and normal urinalysis >8 weeks tx Failed Yes Care Pathway Consider referral to specialist Abrams P. Wein AJ. The Overactive Bladder – A Widespread and Treatable Condition. 1998.

13. Treatment options for OAB - (PC) • Life style changes • Recommend caffeine reduction • First-line treatment is Bladder re-training lasting at least 6 weeks • Antimuscarinic drug - oxybutynin • If oxybutynin is not tolerated, alternatives are solifenacin, tolterodine, trospium, or different oxybutynin formulations • Carry out an early treatment review after any change in drug

14. Conservative Management Behaviour modification Dietary changes / weight loss Advice on fluid management Reduction in caffeine intake Reduction in alcohol intake

15. Behavioural TherapyBladder Re-training • Described by Frewen • Timed voiding • Bladder Training • Voiding Diary • Fluid management • Successful in > 50% • Reduced success longterm Payne CK. Urology 2000: 55 (Suppl 5A); 3-5 Burgio KL, Burgio LD. Clin Geriatri Med 1986: 2 (4); 809-827

16. Drugs - Antimuscuranics

17. Modest improvement in QOL • High withdrawal rates • One in three report dry mouth • No significant difference in withdrawal rates with placebo Limitation is EFFICACY especially in severely incontinent patients

18. New Therapy - Mirabegron • β-3 adrenoreceptors in the bladder are known to have a role in bladder relaxation • Mirabegron (β-3 adrenoreceptors) reduces the number of micturitions and incontinence episodes in a 24-h period compared with placebo • Dry mouth and gastrointestinal disturbances are the most common side effects, but these have been rated as mild to moderate • A small rise in mean heart rate and blood pressure has been shown • Mirabegron - is it a promising alternative or supplement to antimuscarinics? Bhindee A. Int J Urogynae. 2012 Oct;23(10):1345-8

19. OAB + / - urge UI (PC) • In postmenopausal women with vaginal atrophy offer intravaginal oestrogens for OAB symptoms • In women with UI who also have cognitive impairment prompted and timed toileting programmes may help reduce leakage episodes • Do not routinely use electrical stimulation in OAB

20. OAB + / - urge UI (SC) If conservative treatments have fail consider referring to secondary care for: • Botulinum toxin A • pTENS • Sacral nerve stimulation • Augmentation cystoplasty • Urinary diversion

21. Intravesical Botulinum Toxin

22. pTENS System First described McGuire 1983 Acupuncture augmented with electrical current 12 weeks 30 minute sessions Subjective success 59-64% Objective success 47-56% (50% reduction in leakage episodes)

23. Sacral Neuromodulation Bladder activity inhibited by modulation of: afferent sacral somatic nerve fibres that inhibit parasympathetic motor nerves through interneurones First described Tanagho & Schmidt 1982

24. Clam Cystoplasty Described in 1888 in Italian dogs Popularised for IDO by Bramble in 1980s 85% cure

25. Stress incontinence – urinary leakage on effort, exertion, sneezing or coughing without a desire to pass urine Stress Urinary Incontinence Females Males – Post prostatic surgery Bump RC.Obstet Gynecol Clin North Am. 1998;25:723–746

26. Pad testing - Definition International Continence Society • 1g loss / hour • 8-10g loss / 24 hour

27. Stress UI Management (PC) • First-line treatment for stress or mixed UI should be pelvic floor muscle training (PFMT) lasting at least 3 months • PFMT should consist of at least eight contractions (slow & fast) three times a day • If PFMT is beneficial, continue an exercise programme

28. Drugs - Duloxetine • Ten randomised trials 3944 adults • 50% reduction in Incontinence Episode Frequency • 3% improvement in subjective cure (improved QOL) ie small effect • High incidence ‘mild’ side effects nausea (33%) • No advantage of combination PFE over either treatment alone Duloxetine Should not be used as 1st line Not to used as 2nd line May be offered as alternative to surgery Counsel about side effects P Mariappan, AA Alhasso, A Grant, JMO N'Dow Serotonin andnoradrenaline reuptake inhibitors (SNRI) for stress urinary incontinence in adults Cochrane Database of Systematic Reviews 2005

29. Drugs - Oestrogens • Twenty eight trials 2926 women • Subjective improvements • urge 57% versus 28% • stress 43% versus 27% • Insufficient data to address oestrogen type, dose and route • 4 small RCTs • max n=56 • No benefit

30. Challenges: Compliance ↓ over time No fast outcomes Strength: Safe Conservative treatment - Summary More RCTs needed Consistency in PFMT programs Consistency in outcome assessment

31. Surgical management SUI (SC) • Intramural bulking agents • Synthetic slings using a retropubic ‘top-down’ or a transobturator foramen approach • Autologous slings • Retropubic operations - open/lap colposuspension • Artificial urinary sphincter • Bladder neck closure / Mitrofanoff / Ileal conduit

33. Results Generally >80% in 1 yr >70% long term Well tolerated High satisfaction rates Need for SIC BUT Increasing concern re long term issues i.e. erosion 50

34. Mixed UI • Determine treatment according to whether stress or urge UI is the dominant symptom • Generally treat urge component first

35. Neuropathic Bladder

36. Management of Neuropathic incontinence Upper motor neuron type injury Anticholinergic medications & self catheterization Intravesical Botox Clam cystoplasty Sacral anterior root stimulator Indwelling catheters Condom sheaths

38. OAB with or without urge UI OAB with or without urge UI Assess and categorise Lifestyle interventions Urodynamics if appropriate, not routinely for pure stress UI Stress UI Mixed UI Refer Stress UI AssessmentConservative managementSurgical management Treatment Pathway

39. Conclusions • Urinary incontinence is a significant problem • It has a considerable impact on QoL • The treatments are generally effective • Patient wishes must be taken into account

40. Conclusions • Lifestyle and bladder training • Anticholinergics • Botulinum Toxin • Sacral Neuromodulation • Stress UI – Midurethral tapes of abdominal operations

41. rUrinary Tract Infection

42. Types of UTI’s • Uncomplicated lower UTI (cystitis) • Uncomplicated pyelonephritis • Complicated UTI with or without pyelonephritis • Urosepsis 63

43. History • Subjective • dysuria, urgency, frequency, nocturia • Personal • scented products, hygiene, fluid intake • Sexual • frequency, number of partners, use of latex or spermicides, routes • Obstetric and gynecological • last menstrual period, symptoms of atrophic changes • Medication • anticholinergics, psychotropics, immunosuppressives

44. Diagnosis Dipstick analysis pH and Specific Gravity Blood Protein Nitrites specificity 94% Leukocyte esterase specificity 74-95% (Howes, 2005)

45. HistoryPredisposition to rUTI • Previous diagnosis • Diabetes mellitus • Pregnancy • Elderly Hillebrand L, Harmanli OH, Whiteman V, Khandelwal M. Urinary tract infections in pregnant women with bacterial vaginosis.Am J Obstet Gynecol. 2002 May;186(5):916-7

46. Anatomical / Functional predisposition to rUTI • Impaired bladder emptying • Dysfunction • Neuropathy • BOO • Diverticulum Brockmann WP, Busch R. [Comparison between sonography and intravenous pyelography in follow-up controls in recurring urinary tract infections] Rontgenblatter. 1985 Oct;38(10):332-6.

47. Anatomical / Functional predisposition to rUTI • Upper tract • Obstruction • VUR • Calculi • very difficult to eradicate if UTI and stones

48. Investigation of Female rUTI • MSSU when symptomatic • USS renal tract with post void residual • KUB • Targeted flexible cystoscopy • 8% yield • macroscopic haematuria • microscopic haematuria between UTIs • persistent UTI

49. Treatment of Female UTI • 3 days oral antibiotics or x1 high dose • 1 day regimes have been associated with high failure rates • Greater than 3 days have been deemed unnecessary (Delzell & Fitzsimmons, 2005; NGC, 2000). • 14 days antibiotics if pyelonephritis Ronald A, Nicolle LE, Harding G.Single dose treatment failure in women with acute cystitis. Infection. 1992;20 Suppl 4:S2769. Lutters M, Vogt N.Antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women. Cochrane Database Syst Rev. 2002;(3):CD001535. Roberts JA. Management of pyelonephritis and upper urinary tract infections.Urol Clin North Am. 1999 Nov;26(4):753-63.

50. Treatment of Female rUTI • Topical oestrogen (postmenopausal) • General advice • Hygiene • increase fluid intake • Double voiding • Void after sexual intercourse • Cranberry juice • Live yoghurt Xu R, Wu Y, Hu Y.[Prevention and treatment of recurrent urinary system infection with estrogen cream in postmenopausal women] Zhonghua Fu Chan Ke Za Zhi. 2001 Sep;36(9):531-3. Stothers L.A randomized trial to evaluate effectiveness and cost effectiveness of naturopathic cranberry products as prophylaxis against urinary tract infection in women.Can J Urol. 2002 Jun;9(3):1558-62