URINARY INCONTINENCE IN WOMEN

1. URINARY INCONTINENCE IN WOMEN Karen Findlay and Emma Cole GPST2

2. Aims • What is incontinence • What are the types of incontinence • Risk factors for incontinence in women • History taking • The bladder diary • Examination • Investigating incontinence • Management of the types of incontinence • Summary • References

3. What is urinary incontinence?? - Passing urine when you do not mean to (an involuntary leakage of urine). • It can range from a small dribble now and then, to large floods of urine. • Incontinence may cause physical and mental distress as well as being a hygiene problem.

4. Types of incontinence

5. Risk factors • Pregnancy – if you developed stress incontinence during pregnancy, you are more likely to have stress incontinence five years after the birth   • Vaginal birth – giving birth vaginally, rather than with a caesarean linked to stress incontinence • Recreational drug use (current or past) • Obesity - having a body mass index (BMI) of >30 may be associated with urinary incontinence • Family history – there may be a genetic link to urinary incontinence, particularly stress incontinence  • Disability – conditions affecting your brain or spinal cord, such as multiple sclerosis or dementia, may increase your risk of urinary incontinence  • Increasing age – urinary incontinence is most common in women over 70    • Lower urinary tract symptoms (UTIS) – symptoms that affect the bladder and urethra

6. History • Whether the urinary incontinence occurs when you cough or laugh- Urge • Whether you can or cannot make it to the toilet on time - Stress • Asking about the risk factors • Whether you need the toilet frequently during the day (>8) or night (>1) • Whether you have any difficulty passing urine when you go to the toilet  • Any haematuria or dysuria? • Any bowel symptoms or incontinence • Prolapse symptoms: dragging sensation/ sensation of lump/ worse at end of day/standing up? Frequency? Difficulty bowels, e.g. put a finger in? Disrupting sex/ bleeding/ discharge • Whether you are currently taking any medications – old or new and including non prescription • How much fluid, alcohol or caffeine you drink 

7. History continued O&G Hx • Any other menstrual probs/ pelvic pain/ abnormal discharge? • Obs: details PMH • Childhood enuresis • Diabetes/ neuro conditions • Recent weight change/ coughing conditions? • Post menopausal? HRT?

8. History continued • Part of the history should also cover the psychosocial impact of incontinence in day to day life. Often women report: • Low self esteem • Embarrassment • Planning trips based on toilet stops • Avoiding certain activities and family trips • Sexual dysfunction and relationship problems

9. Bladder diary Asking patients to keep a diary of bladder habits for at least three days, so you can get as much information as possible about the pattern and nature of their condition is a useful tool. This should include details such as: • how much fluid you drink • the types of fluid you drink • how often you need to pass urine • the amount of urine you pass • how many episodes of incontinence you experience  • how many times you experience an urgent need to go to the toilet

10. Examination • General: weight with BMI • Abdo: Exclude masses, urinary retention • Pelvic: Inspection, pt in left lateral position ask to cough, or on standing. PV to assess for pelvic floor muscle damage/weakness. • Speculum: to look for prolapse of bladder neck, feel for any pelvic masses • If UTI or STI suspected – urinalysis / GUM samples may be done

11. Investigation • Urine dip • Blood • Nitrites/leucocytes • Glucose • Consider U&Es • Assessment of residual urine • Bladder scan – preferable • Catheter

12. Urodynamics • NICE advise conservative management first • Often pre-surgery • Use water to assess • Urine flow - ?obstruction/poor detruser function • Filling and voiding pressure – can detect detruseroveractivity and neurological problems • Abdominal leak point pressure – Pressure at which the urine leaks – stress incontinece • If tests remain inconclusive can try videourondynamics (contrast/US) or ambulatory urodynamics

13. Other Investigations • Cystoscopy is not recommended for investigation of urinary incontinence alone • MRI/CT/XR are not recommened. US not routinely recommended but may be useful for further assessment of the renal system

14. When to refer • Urgent • Microscopic haematuria >50yrs • Macroscopic haematuria • Persistent or recurrent UTI with microscopic haematuria >40yrs • Suspected malignant mass or urinary tract • Refer • Palpable bladder after voiding • Prolapse visible at/below introitus + symptomatic

15. Consider referral • Persisting bladder/urethral pain • There are clinically benign pelvic masses • There is associated faecal incontinence • There is suspected neurological disease • There are symptoms of voiding difficulty • Urogenital fistulae are suspected • Previous continence surgery has taken place • Previous pelvic cancer surgery has taken place • Previous pelvic radiation therapy has taken place

16. Management • Depends on type of incontinece • Stress • Urge • Mixed – Treat the predominent type • Lifestyle • Decrease caffeine • Manage fluid intake • Weight management

17. Stress Incontinence • Pelvic floor exercises • 3 months supervised • 8 contractions 3 times/day • Consider electrical stimulation in women with neuroprolblems • Secondary care • Duloxetine (SNRI) • Surgery • Eg TVT • Prevention • Pelvic floor advise given to all first time pregnant women • Weight control

18. Urge incontinence • Bladder training • Pelvic floor exercises • Scheduled voiding with stepped increases • Suppression of urge – distraction • Minimum of 6 weeks • 2nd line – consider adding anticholinergic

19. Urge incontinence • Anticholinergics • They reduce involuntary detrusor contractions and increase bladder capacity • Can take 4 weeks to work • Side effects – dry mouth, constipation • Start low dose • Tablets and patches • Oxybutynin, tolterodine, darifenacin • Try different ones • Start with a low dose and review every 4 weeks until stable, then annually (6 monthly if >65yrs)

20. Stress incontinence • Vaginal oestrogens – if vaginal atrophy • Secondary care • Botox injections • Desmopressin for nocturia • Nerve stimulation • Sacral nerve • Percutaneous posterior tibial nerve stimulation • Surgery • Augmentation cystoplasty

21. Stress incontinence • Prognosis • Behavioural therapy combined with drug treatment is often effective with up to 80% of cases improved and with excellent long-term results.

22. Overflow incontinence • Overflow incontinence due to bladder outlet obstruction should be managed by relieving/treating the obstruction. • Intermittent self-catheterisation may be carried out • Indwelling catheters (either urethral or suprapubic) may be indicated if: • There is chronic urinary retention and the person cannot perform self-catheterisation. • Skin wounds, pressure sores or skin irritations are being contaminated by urine. • There is distress or disruption caused by changing clothes and the bed. • A woman would like this form of management