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Urinary Incontinence

Urinary Incontinence

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Urinary Incontinence

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  1. Urinary Incontinence Tova Ablove, Alev Wilk Primary Care Conference, 10/12/05

  2. Urinary Incontinence • No Financial Disclosures

  3. Objectives • Case Examples: Dr. Wilk • Management Issues: Dr. Ablove • Treatment options • Referral options • Question & Answer

  4. Case One • 47 y.o. woman with stress incontinence with some urgency, no leakage nor nocturia. • No urinary dribbling, frequency, dysuria, constipation • Three uneventful vaginal deliveries; fourth pregnancy: twins by C-section. • PMH: Raynaud’s • Denies tobacco or alcohol use; Labor and Delivery RN

  5. Case One • Exam: NL cardiovascular, GI, Kidney. Genital: no notable atrophy or pelvic floor laxity; negative UA • Has attempted Kegel exercises for several months without improvement • Recommendations: Pessary? Pelvic Floor Physical Therapy Program? Referral to subspecialty?

  6. Case Two • 55 y.o. woman with stress incontinence when she coughs, laughs, or exercises • No dribbling, urgency, frequency, dysuria, postvoid fullness, constipation • G0P0 • Depression on Celexa

  7. Case Two • Denies tobacco or alcohol use; Recently divorced • Exam: NL cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UA • Recommendations: Estrogens? Pessary? Pelvic Floor Physical Therapy Program? Referral to subspecialty?

  8. Case Three • 81 y.o. women with stress, urge incontinence and urinary leakage • No constipation, burning with urination • History of UTI this past year; Osteoporosis with recurrent TL fractures and LBP • G2P2 • IV forteos monthly; prn muscle relaxant

  9. Case Three • Exam: bladder prolapse; vulvovaginal atrophy. Otherwise normal exam • Recommendations: pessary, pelvic floor exercises.

  10. Case Four • 76 y.o. woman with stress and urge incontinence, urinary leakage; nocturia 1-2x per night • Urinary frequency, constipation, postvoid fullness • G6P6; s/p oophorectomy, partial colectomy • Depression, COPD, HTN, schizophrenia, anxiety • Current smoker: 63 pack years; no alcohol; retired RN and widowed

  11. Case Four • Albuterol, cogentin, valium, benadryl, depakote, advair, meclizine, zyprexa, piroxicam, quinine, risperidone, trazodone • Exam: Stable cardiovascular, GI, Kidney. Genital: vaginal atrophy; negative UA • Recommendations: Estrogen? Pelvic Floor Physical Therapy Program? Referral to subspecialty?

  12. Case Five • 48 y.o. woman with polyuria (every 30 minutes while awake) and pelvic pressure • Voiding diary • No dysuria, postvoid fullness, constipation • Three uncomplicated vaginal births; tubal ligation; Leep procedure 1993 • Premenstrual syndrome dysphoria on fluoxetine

  13. Case Five • Denies tobacco or alcohol use; CNA • Exam: NL cardiovascular, GI, Kidney. Genital: pelvic floor “prolapse”; negative UA & glucose; PVR: 100cc. • Recommendations: Oxybutinin for “overactive bladder”; Pelvic Floor Physical Therapy Program? Referral to subspecialty?

  14. Pelvic organ prolapse and Pessaries

  15. RingPessary

  16. Oval Pessary

  17. GellhornPessary

  18. DonutPessary

  19. CubePessary

  20. GershungPessary

  21. IncontinenceDish

  22. Drugs Predominant anticholinergic or antimuscurinic action • Oxybutnin • Tolterodine • Hyoscyamine • Imipramine • Darifenacin • Solifenacin Close follow up needed especially in geriatric patients

  23. Oxybutynin • Potent muscarinic receptor antagonist with some degree of selectivity for M3 and M1 receptors • Usual dose • Short acting 2.5-5 mg tid • Long acting 5-30 mg qd • Patch 3.9mg 2x/week (96hr) • ICI: Physiologically/pharmacologically effective and recommended based on good-quality randomized controlled trials 1/A

  24. Tolterodine • Nonselective muscarinic receptor antagonist • Usual dose • Short acting 2mg bid • Long acting 4mg qd • ICI: Physiologically/pharmacologically effective and recommended based on evidence from good-quality randomized trials 1/A

  25. Hyoscyamine sulfate • Anticholinergic • Usual adult dose .375 mg bid • Controlled studies of effects on bladder hyperactivity are lacking 2/D

  26. Imipramine • Anticholinergic and alpha adrenergic actions • Useful for mixed incontinence. • Can cause postural hypotension and bundle branch block • Usual dose 10 to 25mg tid • ICI: 2/C

  27. Darifenacin • M3 receptor selective • The recommended starting dose is 7.5 to 15 mg / day • ICI: Physiologically/pharmacologically effective and recommended based on evidence from good-quality randomized trials 1/A Enablex [package insert]. 2004.

  28. Solifenacin • Nonselective muscarinic receptor antagonist • Half life of 45-68hrs • Usual dose • 5 to 10 mg po qd • ICI: Physiologically/pharmacologically effective and recommended based on evidence from good-quality randomized trials 1/A

  29. What is InterStim Therapy? • Implantable, programmable neuromodulation system.

  30. Mechanism of Action • Mechanism of action for SNS is not fully understood at this time - many theories exist. • Generally agreed that stimulation of the sacral nerves modulates the neural reflexes that influence the bladder, sphincter and pelvic floor that control/influence voiding. Reference: Chancellor MB, Chartier-Kastler EJ. Principles of sacral nerve stimulation (SNS) for the treatment of bladder and urethral sphincter dysfunctions. International Neuromodulation Society 2000; 3: 15-26.

  31. InterStim Therapy Indications: overactive bladder, and or urinary retention, in patients who have failed or could not tolerate more conservative treatments.

  32. Multichannel Urodynamic Equipment

  33. Cystometrogram

  34. Urethral Pressure Profile

  35. Micturition Profile

  36. Uroflowmetry