AN APPROACH TO URINARY INCONTINENCE IN PRIMARY CARE

1. AN APPROACH TO URINARY INCONTINENCE IN PRIMARY CARE Len Lotimer Annual Update Day in Obstetrics and Gynecology Wednesday October 22, 2008 Raed Sayed Ahmed MBChB,FRCS(c)

2. OBJECTIVES • Recognize the impact of urinary incontinence. • List types of urinary incontinence. • Outline management options.

3. BACKGROUND • Urinary incontinence affects 10–70% of women living in a community setting and up to 50% of nursing home residents1. • Prevalence of incontinence appears to increase gradually during young adult life, has a broad peak around middle age, and then steadily increases in the elderly2. 1. Abrams P, Cardozo L, Khoury S, Wein A, editors.Incontinence. 2nd ed. Plymouth, UK: Health Publication Ltd; 2002. 2. Hannestad YS, Rortveit G, Sandvik H, Hunskaar S. Acommunity-based epidemiological survey of female urinary incontinence: the Norwegian EPINCONT study. Epidemiology of Incontinence in the County of Nord-Trondelag. J Clin Epidemiol 2000;53:1150–7.

4. QUALITY OF LIFE ISSUES • Impacts negatively on one’s physical, psychological, sexual, social and overall quality of life. • More likely to suffer from depression than their continent peers1. • Urinary incontinence, Alzheimer’s disease, and stroke are the 3 chronic health conditions that most adversely affect an individual’s health-related quality of life2. 1-Vigod SM, Stewart DE, Major Depression in Female Urinary Incontinence Psychosomatics 47:147-151, April 2006 2-Wallace SA, Roe B, Williams K, Palmer M. Bladder training for urinary incontinence in adults.Cochrane Database Syst Rev 2004; Issue 1(Art. No.: CD001308. DOI: 10.1002/14651858.CD001308.pub2)

5. TYPES OF INCONTINENCE • Stress Urinary Incontinence (SUI): Leaking of urine with coughing, sneezing, straining, exercise or any other type of exertion. 50% of individuals withincontinence have SUI.

6. TYPES OF INCONTINENCE • Urge Incontinence (UI): Leaking of urine associated with the sudden uncontrollable urge to empty the bladder. The urge to empty the bladder cannot be delayed and leakage occurs. UI is a key symptom of the overactive bladder syndrome.

7. TYPES OF INCONTINENCE • Overflow incontinence (OI) is constant leaking or dribbling from a full bladder. • Mixed incontinence (MI) is a combination of stress and urge incontinence.

8. MANAGEMENT OF URINARY INCONTINENCE History: • Leaking with L/C/S or U • Urgency/Frequency/Nocturia • Prev. therapies • PMH • Past Surgical History • Medications

9. MANAGEMENT OF URINARY INCONTINENCE Physical: • Cough test • Speculum/Bimanual. Investigations: • Urine analysis and Culture. • Voiding diary

10. MANAGEMENT OF URINARY INCONTINENCE STRESS • Conservative/Life style • Kegels • Pessaries • Surgery URGE • Conservative/Life style • Bladder protocol • Kegels • Anticholinergics

11. DIFFERENTIAL DIAGNOSIS Differential Diagnosis of Urinary Incontinence Genitourinary etiology 1-Filling and storage disorders Urodynamic stress incontinence Detrusoroveractivity (idiopathic) Detrusoroveractivity (neurogenic) Mixed types 2-Fistula Vesical Ureteral Urethral 3-Congenital Ectopic ureter Epispadias Nongenitourinary etiology 4-Functional Neurologic Cognitive Psychologic Physical impairment 5-Environmental 6-Pharmacologic 7-Metabolic ACOG Practice Bulletin No. 63 Urinary Incontinence in Women

12. PREDICTING TYPE OF INCONTINENCE FROM SYMPTOMS • Urgency is accepted as both a sensitive and specific symptom for OAB. • Leakage with stress maneuvers is highly sensitive for stress urinary incontinence.

13. WHEN TO REFER? • Previous continence or prolapse surgery. • Moderate to severe prolapse. • Objective clinical findings do not correlate with symptoms. • Trials of therapy fails to improve symptoms. • Sterile hematuriaor pyuria. • Irritative voiding symptoms, such as frequency, urgency, and urge incontinence, in the absence of any reversible causes. • Bladder pain. • Recurrent cystitis. • Suburethralmass.

14. BEHAVIOURAL TREATMENTS • Evidence that conservative management can help control urinary incontinence including: • Behaviour training • Education • Scheduled voiding • Positive reinforcement • Pelvic muscle exercises with various techniques 1. 1-Wallace SA, Roe B, Williams K, Palmer M. Bladder training for urinary incontinence in adults. Cochrane Database Syst Rev 2004; Issue 1(Art. No.: CD001308. DOI: 10.1002/14651858.CD001308.pub2)

15. BEHAVIOURAL TREATMENTS Healthy bladder behaviours: • Caffeine/alcohol (coffee, tea, carbonated drinks). • Non-caffeinated fluids (1.5-2.0 litres) per day. • Take your time voiding. • Healthy weight. • Don’t smoke. • Avoid constipation.

16. PELVIC FLOOR RETRAINING • Requires education. • Cochrane review1 recommended that PFMT be included in first-line conservative management. • Effect greater in younger women (40’s and 50’s) with SUI alone, who participate in a supervised PFMT program for at least three months. 1-Hay-Smith EJC,Dumoulin C. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews 2006, Issue 1.

17. VAGINAL WEIGHT • Evidence that weighted vaginal cones are better than no active treatment in women with SUI. • May be of similar effectiveness to PFMT and electrostimulation.

18. ESTROGEN TREATMENT • No compelling, objective evidence. • May improve urogenital aging symptoms such a vaginal dryness and some sensory bladder symptoms.

19. DRUG THERAPIES Types of drugs used to treat patients with overactive bladder (OAB): • Anticholinergic medications (e.g., oxybutynin, tolterodine, impramine, trospium): these reduce feelings of urgency and inhibits contraction of the detrusor muscle. • Tricyclic antidepressants (e.g., imipramine): these exert an anticholinergic effect by blocking norepinephrine or serotonin amine uptake. • Combined anticholinergics and smooth muscle relaxants (e.g., oxybutynin chloride).

20. PESSARIES • The pessary presses on the urethra through the vaginal wall and holds up the bladder neck and uterus, if present. • It may also pinch the urethra closed to help retain urine in the bladder. • It is usually not necessary to remove the pessary to urinate. Normal bladder contractions can usually force urine out through the pinched-off urethra.

21. RETROPUBIC SUSPENSION TECHNIQUE • Stress incontinence procedure. • Also called colposuspension or Burch procedure. • Stitches are placed on both sides of the urethra. • Provide a rigid backboard to the urethra. • Good long term efficacy.

22. MID-URETHRAL SLING • Stress incontinence procedure. • Minimally-invasive procedure. • Highly effective. • Polypropylene mesh ribbon place under the urethra. • mesh is applied around the midurethra in order to hold it securely. • provides support without fixation of the bladder neck.

23. SACRAL NERVE MODULATION (SNM) • A device is implanted to stimulate electrically the sacral nerves in an attempt to manage voiding conditions. • It is a reversible procedure, in that the device can be removed without permanent injury. • The role of SNM is to manage patients who have not been treated successfully with behaviour therapy, drug therapy, or external stimulation (for urgency incontinence).